Just the name, Strategic National Stockpile (SNS), evokes the image of a huge warehouse, or a series of warehouses spread across the U.S., strategically stocked with all the medical supplies, diagnostics and drugs that will be needed nationwide to respond to any health emergency brought on by terrorists, nuclear attacks, pandemics or other public health hazards.

The reality is so much more – and so much less. While the stockpile had an $8 billion inventory as of December 2019, it was ill-prepared for the demands of COVID-19 as global competition for basic medical supplies and drugs created shortages across the nation.

Testifying before the Senate Homeland Security Committee Wednesday, Greg Burel, who served as SNS director from 2007 until his retirement in January, provided a brief history of the development of the stockpile and the challenges facing it today.

Originally formed in 1999 as the National Pharmaceutical Stockpile, the SNS was intended to develop an inventory of drugs to respond to chemical, biological, radiological and nuclear threats. For the most part, these were drugs that had no market outside of government. Commercially available drugs and medical supplies needed in emergencies were often stockpiled by states. And before the advent of just-in-time manufacturing/supply chains, they were held in hospital and manufacturer inventories.

Over time, Burel said the SNS’ highly specialized material and medical logistics capabilities became apparent, and its mission was expanded to all hazards, including pandemics and natural events. “Instead of mission creep, SNS experienced mission gallop,” he said.

But congressional funding hasn’t kept pace. Subsequently, the SNS must balance risk-based needs across various threats to purchase the best mix of medical products, Burel said, adding that the stockpile is required by law to prioritize products unavailable in the commercial market. Personal protection equipment (PPE) – such as masks, gloves and gowns – was assumed to be commercially available, so by law, it was not a stockpile priority.

Making matters worse, Congress has ignored the need to replenish SNS inventories used to respond to public health emergencies. Thus, despite the advice of a federal task force, Congress provided no funding to replace the PPE distributed in 2009 in response to H1N1. “Public memory fades, and funds often decrease with that,” Burel said. Consequently, when states were desperate for PPE for health care workers on the frontline of the COVID-19 pandemic, the SNS had little to offer.

Julie Gerberding, former director of the CDC, agreed that adequate funding is a big problem for the stockpile. When the SNS is stocked based on its funding rather than the other way around, “it’s the tail wagging the dog,” she said.

She and Burel recommended that the SNS be funded as part of national security, with mandatory spending much the same as the Department of Defense. Burel also suggested that instead of having it dispose of expired inventory, Congress give the SNS the authority to sell products before they expire and then allow the stockpile to use that money to replenish the inventory.

Mission confusion

Another problem facing the SNS is external confusion over its mission. As COVID-19 hit pandemic levels in the U.S., several states expected the SNS to provide PPE and other necessities. But according to the agency’s current mission statement, the role of the stockpile is to supplement state efforts, committee Chair Ron Johnson (R-Wis.) said, stressing the word “supplement.” He also noted the mission statement describes the SNS as a “short-term, stop-gap buffer,” with no mention of addressing the massive levels of supplies needed for a pandemic.

Going forward, Congress needs to think about the mission of the SNS and then codify it, Johnson said. For instance, should the SNS supplement state efforts? Should states be responsible for their own stockpiles? Or should the SNS have everything that would be needed in any public health emergency?

States need to create their own stockpiles, Sen. Rick Scott (R-Fla.) said, recounting his experience as governor of Florida and state preparations for hurricanes. “You can’t expect that someone else is always going to take care of you,” he said.

If there is no clear, consistent strategic intent that the federal, state, tribal and local governments can agree to, “we’ll just be bouncing from one crisis to another,” Gerberding told the committee. Since “Congress is the bill payer,” it must provide clarity and consistency for the SNS, she said.

Along with addressing the mission statement, Congress also might want to rethink the name “Strategic National Stockpile,” Johnson said, adding that it’s misleading. The name shouldn’t imply that there’s all this PPE and other supplies sitting in a national warehouse somewhere, because the SNS just doesn’t have the volume of supplies to address such an enormous need as the COVID-19 pandemic, he said.

In the know

The SNS also should go beyond warehousing drugs and supplies to figuring out manufacturing capability and looking at the entire supply chain and its flow. It’s a “pretty complex logistics problem,” Johnson said.

Daniel Gerstein, a senior policy researcher at the RAND Corp., agreed. While the SNS is essential, preparedness planning depends on thinking beyond stockpiling to figure out how to procure large quantities of products in an emergency, he said. That includes identifying where supplies and resources will come from, what is manufactured in the U.S. and what other sources are available. That knowledge must go beyond the finished product to include the manufacturing of ingredients and components necessary for critical drugs and devices, Gerstein added.

Much of the supply chain that precedes the finished product is “extremely opaque to the federal government,” Burel said. While that’s proprietary information, preparedness planners must know where those ingredients and components originate so they can ensure supplies in an emergency. While the FDA has much of that information, it can’t share it.

Sen. Gary Peters (D-Mich.), ranking member of the Homeland Security Committee, said he has drafted legislation that would require the FDA to share that information with the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services.

People in the supply chain know who their suppliers are. ASPR needs to know that too, Gerstein said.

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