The workshop’s last session offered, in Tara O’Toole’s words, “a final chance for the committee members to synthesize and comment on their most vivid observations, impressions, and thoughts, after 2 years of hearing about, thinking about, and pondering the very broad mission of the Strategic National Stockpile.” Each participant’s comments (including planning committee members, Standing Committee members, and speakers), and O’Toole’s wrap-up statement, are summarized below. Box 5-1 presents attributed key points distilled from these comments.
Irwin Redlener expressed amazement at the extent of the stockpile’s agenda, and congratulated DSNS for executing it with remarkable competence. Based on insights and judgment accrued through experience, it seems that the agency’s mission may need to be modified to allow maximal and optimal preparation for major disasters, he observed. He advised DSNS to discuss how upstream and downstream issues could be better organized, and to consider their future mission in light of these issues.
The looming threat of Hurricane Harvey, Redlener noted, highlighted “every possible scenario of how people live in America all under one disaster umbrella.” The days ahead would offer important lessons for responding to future disasters, if carefully studied, he advised.
Equally astounding to Redlener as the extent and complexity of the SNS mission are the details of the supply chain, he said, and the realization that apparently arcane glitches can create widespread havoc. Finally, he
warned: “We will be judged ultimately by how well we do with respect to the vulnerable populations.”
Paul Petersen stated that Tennessee hopes for additional CDC and SNS support for pandemic readiness and also for radiation response. He noted that every state currently holds a large cache of crucial antivirals, of limited shelf life; their legislatures need to know whether to prioritize reinvestment to maintain those stocks.
Petersen also warned that state and local health departments, challenged by short staffing, cannot fully implement the SNS mission for disaster response. Proposed funding cuts to the Public Health Emergency Preparedness Plan and the Hospital Preparedness Plan will dramatically curtail already strained local preparedness efforts. He noted that volunteers who currently staff dispensing clinics could be better used in other emergency capacities in the “last mile.”
Linda Rouse O’Neill focused on the supply chain. She strongly advocated operationalizing the work begun on needles and gloves with HIDA, then expanding that model to thousands of products, each of which requires a plan based on knowledge of its specific supply chain. This development process needs to be institutionalized, she added, so that it continues no
matter who leads DSNS or the trade organizations involved, and so that the federal government maintains its interest in and support for the project.
O’Neill asserted that it will also be important to impart a working understanding of the supply chain and its role in national health security to other federal agencies involved in disaster response—not just directly, through HHS and ASPR, but also to those within the Department of State who influence the supply chain. She suggested that the Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA), which is again up for reauthorization in 2018, may provide a path toward this goal.
Skip Skivington applauded the depth and breadth of perspectives represented in the Standing Committee’s discussions, and the receptivity of DSNS representatives to the committee members’ ideas. “I took away a tremendous appreciation for the mission and your team,” he told Burel. “Your job [is not] easy given the expectations that the diverse groups of players expect and need or think they need. It is not going to get any easier.”
Margaret Brandeau took up the broadening of the SNS mandate, which continued over the course of the Standing Committee’s existence. She too congratulated the SNS for running smoothly, but worried that growing budgetary constraints would increase the stockpile’s reliance on the commercial supply chain, which as it grows leaner becomes less able to surge. Minimizing these limitations demands a detailed and strategic understanding of the supply chain in all its complexity, she suggested, as well as communication between the SNS and partners across the chain.
Support from the federal government may be needed to address weak points in the supply chain that interfere with the mission of the SNS, Brandeau observed. The SNS must advocate for resources such as maintaining inventory to compensate for the lean commercial chain. “The more you can advocate for resources for your mission and why it is important to the national security of the United States, the better off you will be,” she advised Greg Burel and his staff.
Lewis Grossman bemoaned a lack of consistency in emergency preparedness efforts at the state level, and in particular some states’ inability to carry out the “last mile” of the SNS supply chain. “I think that the [federal government] should throw [its] weight around a little bit more in this area, especially with respect to underperforming states,” he advised, although he confessed he did not know how legally or practically that could be accomplished.
The lean, just-in-time supply chain raises the importance of the SNS mission, Grossman observed. Warehousing for crisis surges is a public good, he insisted, but it has led the SNS to maintain ever-increasing inventories to compensate for supply chain weaknesses that would hinder the response to a growing range of emergencies. That sort of mission creep is worthwhile, and should be appropriately funded, he concluded.
Sheldon Jacobson observed that it is a supply network, rather than a chain, in which the SNS participates: too complex to be linear, and prone to produce unintended consequences. He also returned to the concept of the SNS as “Strategic National Strategy” and the strategic issues that underlie tactical challenges faced by the SNS. Whether the agency, its mission, or its budget grows or shrinks, he asserted, “there is a strategic issue that goes into defining the stockpile. Once the strategic issues are resolved, I believe some of the tactical issues actually may take care of themselves.”
Karen Remley insisted that society—not just the public and private sectors and NGOs, but every level of government—must embrace the responsibility to care for every victim of every disaster. “Everyone has to truly believe that we are our brother’s or sister’s keeper,” she said. “I think that is the hardest thing for all of us.”
Remley promised to spread this message as a leader of AAP, which enjoys strong media presence. She also advocated for greater attention to research on pediatric MCMs. “While children represent 25 percent of the population and 100 percent of the future, they are woefully underrepresented in the research and the efforts that have gone into medical countermeasures,” she observed. Children cannot be used as subjects for medical research, but there must be ways to gain information relevant to their emergency treatment, she argued, and she urged the pursuit of that goal through collaboration.
Lewis Rubinson praised the SNS for prioritizing effective action over involvement in policy. He noted that although the sort of mass-casualty CBRN event that the SNS was created to address has not occurred since its inception, the West African Ebola epidemic was similarly large in scale and overwhelming to the health care systems in the region. The inadequacy of the international response to that outbreak raises concerns about the ability of the SNS and its partners to address a domestic infectious disease outbreak or other disaster, he observed.
“There is nothing more catastrophic to a community than a secondary disaster,” Rubinson reflected. “The first is when something bad happens . . . the second is when we could have saved people and we fell short because the things that we had were just at the wrong place and there was no communication.” By continuing iteratively to improve based on such lessons, the SNS can reduce the risk that tragedy will follow disaster, he concluded.
Larry Glasscock recalled that during his first year on the Standing Committee, he focused on the leadership structure of the SNS and its partners in disaster response, and on strengthening that structure through drills and testing. After that, he came to prioritize medical supply chain disconnection between the stockpile and its global commercial partners. Commercial inventories are only going to get leaner, he predicted; the SNS will need to
adapt to that reality, and the price of doing so should be paid in the interest of national health security.
Panelists and other workshop participants other than Standing Committee members were then invited to offer comments and insights.
Michele Davidson had questions: How do we determine who actually gets life-saving medications when there are not enough? Will pharmacists have to make these decisions? Burel commented that pharmacists should not have to be involved in that type of decision making.
Anticipating Hurricane Harvey’s aftermath, Davidson predicted lingering health problems for the affected population due to mold and other diseases, as well as lack of access to medication. She urged careful study of the emergency response and attention to lessons learned.
James Hodge, Jr., professor of law at the Sandra Day O’Connor College of Law and director of the Center for Public Health Law and Ethics at Arizona State University, observed that the concept of a public health emergency recently expanded to include the steady attrition of the opioid epidemic, which cost approximately 60,000 American lives in 2016 (NCHS, 2017). How the SNS could play a role in addressing the opioid crisis is unclear, he acknowledged, but coping with opioid addiction and overdose could shape the stockpile’s content and mission once again.
Albert Romanosky challenged the SNS to seek out and integrate new technologies for inventory management.
As the workshop drew to a close, O’Toole and Burel thanked and praised the Standing Committee for shedding light on the daunting operational challenges involved in managing and deploying SNS assets within the complex context of the global medical supply chain. O’Toole offered the following observations on challenges facing the SNS and the nation’s health security as a whole.
The SNS is most likely to encounter obstacles to emergency response that would be interpreted as failure—despite the heroic efforts of its staff—at the stage of medical care delivery, O’Toole predicted. Her personal analysis of emergency responses to events ranging from the anthrax attacks of 2001 to the West African Ebola epidemic has led her to recognize the need for a channel through which the medical community at the scene of a crisis and the federal government can exchange information in near real time. She identified the SNS as the best organizer and executor of a strategy to strengthen and formalize communications between the medical community and government.
Second, O’Toole observed, “We need a much firmer grasp on the U.S. federal strategy for disaster response.” The plan has moved forward incre-
mentally since 2001 but is nevertheless “horribly outmoded,” she asserted, and she advocated sharpening the nation’s ability to respond to disasters by focusing on large, complex, mass-casualty emergencies. The SNS cannot effect this change on its own, she acknowledged, but she argued that it is within the purview of ASPR, the Federal Emergency Management Agency (FEMA), and the community of offices and agencies that make up PHEMCE.
From a management perspective, O’Toole said, she would move the SNS out of CDC and into ASPR, because operational programs tend to be more effective when linked to their “policy-making parents.” Whereas now the SNS “is kind of a sore thumb sticking out of the very able, very important, very professional CDC,” the distinct mission of the SNS would be better supported by ASPR, she asserted, although the cost of making such a move might outweigh its benefits. In any case, she continued, it would be wise to clarify the role of the SNS in disaster response as part of a much-needed effort to better define a national emergency response strategy.
“I do not think we can just continuously expand [the] SNS to cover everything,” O’Toole observed. “You have done a great job thus far, but it can’t go on forever,” she told Burel and his staff.
Finally, O’Toole lamented the fragility of the medical supply chain and the socioeconomic trends that led to its weakness. “I find it horribly upsetting that we are in a situation where our medical supply chain is so inflexible and so lacking in surge that we are worried, in the United States of America, about getting vital medical supplies on an ongoing, daily basis,” she stated. However, she added, this problem extends well beyond the supply chain, which merely manifests a dangerous fixation on efficiency and cost control. Noting that the federal government appears poised to dramatically reduce most forms of public health spending, she warned that an “obsession with cost and profit has now infiltrated our sense of public health and how we are going to take care of each other in the most dire circumstances.”
“I have been uniformly impressed and moved by all of the private-sector people who have come in and given their time to participate in [the activities of] this committee with their professionalism, with their vision, with their willingness to be straightforward in their views,” O’Toole announced, as she encouraged them to do more. “It is my conviction that the private sector has to step up,” she said, for they can best make the case to the policy makers who control funding for the SNS that it plays an essential, irreplaceable role in national health security. “We have to get the private sector to explain that we do need government capabilities to be there when [they] are needed,” O’Toole urged, and she predicted that the emergency response to Hurricane Harvey would illustrate those needs for better or worse.
Prior to concluding the workshop, O’Toole suggested that the SNS should continue to expand its engagement with the private sector, as exemplified by its work with HIDA, as a way to cultivate powerful advocates for the stockpile. “I don’t want you to get bigger and bigger and bigger,” she explained, “but a little bigger and a little bit more robust in your budget.”
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