This year marks 20 years since Congress established the Strategic National Stockpile (SNS), originally named the National Pharmaceutical Stockpile, in preparation for the year 2000. The intent was to arm the country against possible terrorist threats that could disrupt the U.S. medical supply chain. With a $51 million appropriation and a handful of public health staff based at the Centers for Disease Control and Prevention, the stockpile began in 1999 with a sole focus to protect the American people from biological and chemical attacks.
In those early days of what is now the SNS, the ability to move a 12-hour Push Package to any location in the United States within 12 hours of a decision to do so was the measure of success. The 12-hour Push Package is a 50-ton load of a variety of medical supplies that might help public health and emergency management respond to a variety of threats. Today, the SNS still holds 12-hour Push Packages because they might be useful if the federal response community knows there is a problem, but the actual problem is not clear. Because of tremendous advancements in threat detection technology, the 12-hour Push Package that represented the SNS’s most important response asset is now the most well-known but least critical response asset. They make up less than 5% of the modern-day SNS inventory.
The SNS’s early beginnings as a small logistics capability have given way to an exceptional response asset. The stockpile is now a robust medical supply chain and logistics operation with a formulary valued at more than $8 billion. The professionally, scientifically governed formulary provides the nation with capabilities to respond to a wide array of threats, including bioterror agents like anthrax, smallpox, and plague, as well as naturally occurring disasters. The stockpile is prepared to respond to chemical events with the fielding of almost 2,000 forward-placed installations of chemical nerve agent antidotes ready at a moment’s notice to be used by state and local hazmat responders. The SNS holds countermeasures that allow the U.S. government to respond to nuclear and radiological events. Established relationships and experience in crafting immediate response capability allow SNS experts to underpin the supply chain requirements for many emerging infectious disease responses.
The annual appropriation has grown to $650 million and the staff has expanded to nearly 200 members with expertise in not just public health but also supply chain management, medical logistics, facility management, transportation, pharmaceuticals, emergency management, quality control, and more. The organization and its scope have evolved, but the mission remains the same: to get the right materiel to the right place at the right time to secure the nation’s health. The space in which the stockpile delivers its mission continues to evolve and change. New threats emerge regularly, and new technologies are introduced daily that can change how SNS responders work while not changing the task at hand.
Stockpile personnel have achieved much since the early days of moving a small 12-hour Push Package to the point of responding with vast amounts of materiel in far less than 12 hours in many cases to the site of any health emergency in the United States and its U.S. territories. The value of the stockpile goes far beyond just what is held in warehouses; the value is found in its capability to bring a range of professional disciplines to craft a supply chain-based response to unpredicted health emergencies. SNS experts are constantly working toward improving those capabilities further.
Uniting Federal Medical Countermeasure Response Efforts
In October 2018, the SNS joined the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services. This move unites the SNS’s capability to acquire and deliver medical materiel to the site of any public health emergency with ASPR’s ability to provide vital staffing at disasters and its imperative to manage all federal medical response efforts. This move allowed ASPR to re-evaluate response assets and its positioning and management across the entire medical response framework.
The SNS is positioned to take full advantage of ASPR’s capabilities and support to achieve future success. Working with the Biomedical Advanced Research and Development Authority (BARDA) to jointly develop all new development contracts will ease the transition of novel medical products from BARDA development to SNS sustainment and use. The SNS is working with the National Disaster Medical System (NDMS) to find new ways to leverage the buying power of the stockpile to improve access to medical materiel purchasing and management at lower cost.
In just its first year with ASPR, the most concrete example of the improvements the SNS is making is the assumption of responsibility for NDMS materiel management. This development allows the federal government to streamline its medical countermeasure (MCM) logistics operations by consolidating the warehouse footprint for medical materiel readied for public health responses. Now, during an emergency response, the SNS can move both MCM needed to protect and treat the affected public and the medical supplies required by the disaster response medical professionals in the field treating those who are exposed or injured. This also gives the SNS the opportunity to make acquisitions jointly for the separate organizations, thus creating better purchasing capability and more supply chain influence.
Future opportunities exist to strengthen federal purchasing power and offer pathways for product use in other settings than just disasters. The various operating elements of ASPR can work more directly together on collective needs. SNS has long partnered with other federal agencies, but the direct connection with ASPR opens new doors and allows the stockpile to improve interagency partnerships at a higher level. Now, as part of ASPR, the SNS can unite with other parts of the U.S. government to enter into longer-term contracts and use more creative contracting mechanisms. As a result, the federal government will realize better integration with other product development and procurement activities under ASPR.
Innovations for the Future
Technology improvements continue to change the world at rapid speed. The challenges of today that limit federal, state, and local capabilities to distribute and dispense MCM in a public health emergency may be a distant memory in the next 20 years. Perhaps robots are delivering medicine door-to-door or drones are dropping packs of MCM to precise locations based on GPS data. Many of these advancements are here today and the challenge exists to improve them and integrate them into response operations. To exploit all the new and emerging technology that can help the SNS keep pace with its future, SNS personnel are working hand in hand with ASPR’s innovation team. Together these two entities are planning, researching, and developing new technology-driven capabilities that can get the right thing to the right place at the right time. BARDA continues to develop new MCM and now the SNS can better engage in the innovation space together to deliver response assets in a better way.
Think of a scenario where a medicine is needed at a disaster site but, for many reasons, moving that medicine is an incredible challenge in itself. For example, moving large quantities of fluids is expensive and difficult. Considering how to improve and shorten the cycle for movement of materiel has led the SNS to invest in early efforts to manufacture critical care products on demand at or near the scene of an emergency. The thought is that if something can be made at the time it is needed and where it is needed, then critical time is saved in moving huge volumes of materiel. This may account for a fraction of what will ultimately be needed, which can allow the federal government to start its response efforts and simultaneously begin to continuously manufacture additional product on site throughout the response.
Consider chronic conditions that some of the most vulnerable citizens deal with every day. In disasters, reaching those vital therapies to sustain these individuals may become impossible. Considering how to help these individuals, the SNS has worked with ASPR to invest in mobile hemodialysis capability and continues to look at new advancements. Taking the therapy to the patient versus moving the patient far from home and far from his or her regular environment and support network might lead to better response and far superior health outcomes.
Robotic capabilities to load and unload materiel are in beginning stages of testing, and SNS experts have begun to consider how robotics might actually be used to deliver medicine directly to an individual. If a robot or drone or something not yet envisioned can bring medicine to the community without risking human life, then citizens might be able to stay home in a safer environment during an emergency. The opportunity exists for even more impressive innovations, some of which have not yet been imagined. The key is to find those partners that have the great imagination to conceive the future.
The SNS has arrived at the forefront of advancements in medical logistics and is poised to make use of the newest technology available. In current operations, the SNS uses modeling to explore better solutions for deploying product as quickly and efficiently as possible. By bringing on professional staff who are in the top of their fields and by partnering with thought leaders, industry, academia, IT, and others, the SNS can make use of those advancements to further the availability and use of MCM in public health emergencies.
Strengthening Partnerships for the Future
Just as those technological advances are key to moving the SNS forward in the next 20 years, so are the partnerships that the SNS has fostered with private industry. The current collaboration with manufacturers, distributors, and other medical supply industry partners must continue to inform both the government and the commercial market of supply-and-demand concerns both in normal operations and during emergencies. The SNS invests in vital assets to secure the nation that include more than just the materiel in the warehouses. Those vital assets include SNS experts and the partners across government and industry that can mean the difference between success or failure.
Since its inception, the SNS has engaged with state and local public health partners on planning for the worst imaginable public health scenarios. But with each response, and especially during the 2009 H1N1 pandemic influenza response and the domestic efforts for the 2014 Ebola epidemic, it was clear that both public and private interests must work together for the best possible outcomes. Knowing what product is available in the marketplace, what is available from the government, and the current picture of supply and demand is invaluable when making decisions on whether to deploy MCM from the SNS and in what quantities. This planning and relationship building between the government and commercial partners is best done in advance of an emergency, just as the planning efforts underway between federal, state, and local public health and emergency management.
There is much work still to be done with public/private partnerships. The SNS’s Strategic Logistics Branch, still growing and maturing, is charged with leading efforts to establish and nurture new and unique partnerships that will allow the whole of the United States to improve its response capability. SNS experts work together with personnel across ASPR to connect with partners – healthcare organizations, manufacturers, and distributors, for instance – to better understand their operations, challenges, and opportunities and to work with them on needs anticipated during emergency responses. This is work that was not even conceptualized 20 years ago when the SNS was established as that small logistics capability to deliver 50 tons of supplies that might be useful in a disaster.
The future is bright for the SNS and overall medical response operations in the United States. By working together, both government and private industry can do more and do it better. No one can do this kind of work alone. The SNS is poised to continue and advance its key role in working with critical partners to: share information; collaboratively develop solutions; encourage advancements in warehousing, distribution, and transportation; and strengthen and streamline federal MCM operations for effectiveness and efficiency. The SNS will continue to make progress in new and exciting innovations that can improve response efforts and just might make day-to-day healthcare and the lives of all Americans just a little better, too.
This article is the third of a three-part series:
Part 1 (published in October 2019): The Early Years: Shaping a National Stockpile for Preparedness
Part 2 (published in November 2019): Evolving the Scope of the Strategic National Stockpile
Author’s personal note: It has been the greatest honor of my career to work with the incredible and dedicated staff of the SNS in making us who we are in this instant. From our rather humble beginnings, we have pushed hard for years to reach the scope and scale of capability we can provide the nation today. I will depart my role as SNS Director at the end of 2019 leaving behind a capable and robust organization filled with truly amazing people with the skill and drive to keep SNS on a forward path. I know that as I move to my own future of retirement, the SNS will continue to grow, change and improve. I look forward to watching that as the biggest fan and cheerleader of our nation’s Strategic National Stockpile!
Greg Burel is director of the Strategic National Stockpile, managed by the Department of Health and Human Services’ Assistant Secretary for Preparedness and Response. As head of the nation’s largest stockpile of medicines and supplies available for emergency use, he is a leading expert on medical supply chain management in the United States. With more than 35 years of civil service, he has risen through the ranks of the federal government, beginning his career at the Internal Revenue Service and serving in leadership roles in both the General Services Administration and the Federal Emergency Management Agency. In 2006, he assumed the helm of Strategic National Stockpile operations. He was awarded the Samuel J. Heyman Service to America Medal for Management Excellence and selected as a National Academy of Public Administration fellow in 2016.