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Bangkok workers produce masks at the Thai Hospital Product Company factory, which mostly exports to the US and Europe. | Jonathan Klein via Getty Images

The US government stockpiles medical supplies like ventilators and PPE. Here’s why it failed. 

One of the biggest reasons the federal government failed in its initial response to the coronavirus pandemic is that it lacked the medical supplies necessary to deal with the outbreak.

Because of that failure, states like New York and New Jersey, which were hit especially hard by the virus, scrambled to locate desperately needed masks, other protective equipment, and ventilators for their front-line medical workers.

The obvious question is: How did this happen?

There’s an office of the government called the “Strategic National Stockpile” that’s specifically tasked with managing the nation’s stock of emergency medical equipment and other materials that might be needed in a disaster — like, for example, a global pandemic. This stockpile should’ve been the backstop the states needed when their supplies ran out.

To learn why the national stockpile failed so badly in this pandemic, I reached out to Andrew Lakoff, a professor at University of Southern California who studies the politics of global health and disaster response. He’s also the author of Unprepared, a 2017 book that explored how the world responds to public health emergencies.

We discussed why the federal government wasn’t ready for this crisis, what went wrong, and how we can better prepare for the next one.

A lightly edited transcript of our conversation follows.

Sean Illing

What is the Strategic National Stockpile and when was it created?

Andre Lakoff

The Strategic National Stockpile was first established in 1999. Basically, it’s a series of federally managed storage facilities designed to have essential supplies available to be distributed to states and localities in case of a range of different kinds of potential emergencies.

Sean Illing

What kind of emergencies or disasters was it designed to backstop?

Andrew Lakoff

From its inception the stockpile has mainly been focused on health emergencies. There are supplies that could be used for other kinds of emergencies, but if you look at where its major efforts have been focused, its emphasis from the beginning was on bioterrorist attacks, and then it broadened to encompass naturally occurring infectious diseases like a flu pandemic.

Sean Illing

Why was a bioterrorist attack the biggest concern in 1999 as opposed to, say, a flu pandemic or nuclear war?

Andrew Lakoff

The government became worried about this for a couple of reasons. One was the result of the defection of a bioweapons scientist from the former Soviet Union who told US biodefense specialists about large stockpiles of weaponized anthrax and smallpox that had been somehow lost or misplaced after the collapse of the Soviet Union. Then, along with that, there were a number of speculative narratives, for instance a best-selling novel called The Cobra Event about a potential bioterrorist attack, that Bill Clinton read and found convincing.

After that, high-level security officials began to run simulations that showed what might unfold in the US after a bioterrorist attack. One thing that they recommended was that we have a lot of biomedical countermeasures at the ready in advance of such an event. And then, of course, the anthrax letters of 2001 added urgency to this effort.

Sean Illing

So who funds the stockpile? And has it been a priority for Congress and the various administrations?

Andrew Lakoff

The level of prioritization has ebbed and flowed. Its funding level depends on congressional appropriations. Until recently it was managed by the Centers for Disease Control, and then it was transferred to the Office of the Assistant Secretary of Preparedness and Response within the Department of Health and Human Services.

But to answer your question about funding, it depends on health and security officials convincing Congress that these threats are a high priority. For example, around 2005, 2006, there was a lot of worry about the possibility that H5N1, Bird flu, might mutate to become easily transmissible among humans.

At that point Congress held a number of hearings on the pandemic threat, and a significant amount of funds were allocated for stockpiling antiviral medications that would be effective against influenza as well as other pandemic preparedness supplies. But that anxiety faded over the ensuing years. You could tell a similar story about stockpiling ventilators. That’s the discussion that we’re having today.

Sean Illing

Right, and a lot of people who aren’t familiar with this background are wondering how in the hell do we end up in a situation where a state like New York is paying 15 times the normal price for masks and other supplies because it’s not getting what it needs from the federal government?

Who’s responsible for this failure?

Andrew Lakoff

It’s really a terrible situation and I would say that question goes beyond the stockpile per se and it’s much more broadly about what role the federal government can and should play in an emergency situation.

I think most preparedness planners have always thought that in a major public health emergency the federal government would really play a strong coordinative role in the response. That includes being very aggressive about providing essential medical items where they are needed. That could involve using the Defense Production Act (DPA), it could involve finding other sources of supply, but in any case ensuring that states don’t have to bid against each other.

The federal government could have played a much more proactive role in creating a fair, efficient system that would deliver critical supplies to the places that need them most.

Sean Illing

The entire world has known something like coronavirus or a comparable flu pandemic was inevitable for decades. Why weren’t we prepared for this?

Andrew Lakoff

On the one hand, there are a range of different threats that come to the center of planners’ attentions at different moments and there are different factors as to why one threat rather than another is prioritized. A tremendous amount of money has been spent on things like having enough doses of smallpox vaccine to inoculate the entire United States population, or on acquiring thousands of caches of nerve gas antidote.

So choices are constantly being made about which are the most dire threats given a limited amount of resources. Then as it turned out, the event was not a smallpox attack, it was not nerve gas. It was a coronavirus and it wasn’t pandemic influenza. And in terms of pandemic preparedness, a lot of the effort focused on rapid vaccine development and on stockpiling antiviral medications that are known to be effective against influenza.

Sean Illing

But pandemic influenza would require medical equipment like ventilators and masks just as a coronavirus pandemic does, so it still boggles the mind that we weren’t prepared—

Andrew Lakoff

Right, and there were strong recommendations that the stockpile increase its supply of those things for years but it just didn’t happen.

One thing that happened is that after the 2009 H1N1 pandemic there were a lot of masks distributed to states and localities and they simply weren’t replenished. Then there was a plan to purchase thousands more ventilators. A contract was signed with a small medical equipment company in Southern California. That company was then bought by a different medical equipment company, and in the end the contract wasn’t fulfilled. The new ventilators never came in.

So there are these matters of prioritization and inattention that can affect whether in fact we have the supplies that have been recommended in the stockpile.

Sean Illing

Again, who’s responsible for that failure? Who decided not to replenish those supplies?

Andrew Lakoff

There are probably different stories in each case. In the case of ventilators, it’s partly about how the medical industry changed over the last decade. But more generally it is up to the officials who manage the stockpile to make decisions about where to invest their resources and whether they have enough of a given item. I imagine that we’ll be learning more in the coming weeks and months about how certain decisions were made.

Sean Illing

I want to be as clear as possible on this point, because there’s a lot of confusion about whether we lacked the supplies we needed in the stockpile, or whether we had the supplies we needed and this administration failed to distribute them fairly and quickly.

How do you see it?

Andrew Lakoff

I think it is probably a combination of both of those. There’s a key period that a lot of people are now focusing on, which is late January to mid-February. This is a point at which we were already aware of what had happened in China, and the World Health Organization had declared Covid-19 a “global health emergency of international concern.”

That was really the time to consider whether we had the supplies we needed of these essential items and to figure out whether the stockpile needed to be replenished rapidly and do whatever it took to make sufficient supplies available — whether that meant purchasing supplies from other sources or even using the DPA to force manufacturers to shift to production of ventilators, for example.

So even if it had not been replenished prior to this administration, there was a chance to do a better job at the outset.

Sean Illing

What did our preparedness system look like before the National Stockpile? You mentioned in a recent article that it was tied to the Cold War era. Why is that history relevant?

Andrew Lakoff

There are two distinct periods to look at it. The first I would date from 1950 to 1975. That’s the period of Cold War preparedness and in terms of medical stockpiling, the focus was on what kinds of supplies the population would need to survive a thermonuclear attack. There were something like 32 storage facilities around the country that had radiation dosimeters, surgical supplies, burn treatments, all the things you might imagine you would need in the aftermath of a nuclear attack at the ready.

By the late ’60s and early ’70s, if not before, the public was disillusioned with the idea that we should be spending a lot of money preparing for the aftermath of a thermonuclear catastrophe — mainly because nobody believed we could survive a massive thermonuclear war. So we should mainly try to avoid having one. By the mid-’70s that stockpile was disposed — hundred of millions of dollars worth of medical equipment was sold off or given away.

There was no medical stockpile for a couple of decades, but then in the mid-’90s after the collapse of the Soviet Union, this new concern arose about a novel biological threat, and that’s when the second stockpile came into being, what is now called the Strategic National Stockpile.

Then, just as during the Cold War, it was difficult to convince Congress to allocate resources to maintain the stockpile, to indefinitely store things that might or might not ever be used. So even though the current stockpile is a different one than the Cold War stockpile, they suffered from similar neglect.

Sean Illing

It’s become popular to talk about our response to this virus as a “war.” Is that the wrong framework for thinking about preparation for a public health crisis like coronavirus?

Andrew Lakoff

The idea that we should be able to mobilize to address a dire emergency is not necessarily a bad one. It’s important to have in place tools and capacities for dealing with acute events — whether it is an enemy attack, a major hurricane or a pandemic — that are difficult to predict. The challenge is to maintain the attention of the public and policy makers in between these events, to keep thinking about what we’ll need, and to stay flexible in terms of our policy measures and responses for all kinds of events, not just the once-in-a-generation disasters like this one.

Sean Illing

Can you give me an example of what you mean there?

Andrew Lakoff

Well, there’s something called a syndromic disease surveillance system, which is a system for detecting anomalous disease events in a city. The system can be used to detect outbreaks of food poisoning, seasonal flu, or alternatively something like an emerging pathogen. The more you spend resources on tools that are flexible in this way, the better you’re prepared for a wide range of threats.

Sean Illing

So how can we better prepared for the next pandemic or the next shock event?

Andrew Lakoff

We should think carefully both about which threats are most plausible but also which methods of preparing have the widest range of potential application, so that we can be much more responsive and flexible when an event that was not anticipated occurs.

Sean Illing

In the end, though, there may just be some events for which we can never fully prepare, even if we know they’re coming.

Andrew Lakoff

I think that’s right.


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Author: Sean Illing

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