Centering on Coronavirus Podcast: Interview with former SNS Director Greg Burel

On this episode of Centering on Coronavirus, The New Center interviewed Greg Burel, the former Director of the Division of the Strategic National Stockpile. Mr. Burel served in this capacity for 12 years, from March 2007 up until his retirement this January. Today, he serves as president at Hamilton Grace, a consulting firm focused on preparedness and response. 

Aleksandra Srdanovic: So I thought to frame the discussion, it’d be worthwhile to address the current narrative around the Stockpile. Since the onset of the pandemic, there’s been criticism of the shortages of supplies in the stockpile and its inability to meet requested needs from states. So I’m wondering, given this criticism, what exactly is the Stockpile’s role in a crisis like this, and how would you rate its performance in carrying out that mission?

Greg Burel: So I’ve actually published quite a bit on this that you might want to go take a look at, the most recent was an op-ed in The Hill. But, the Strategic National Stockpile was established a little over 20 years ago now with a mission to be able to respond to chemical, biological, radiological and nuclear events that were either tied to individually acting terrorists or terrorist cells, all the way to a state actor. 

The primary purpose is to store the drugs and materials that you need to respond to even large scale terrorist events, but more focused on sort of a regional response. So we think about the theoretical bioterror attack on, maybe, Washington, D.C., New York City, and some other city at the same time, and we’re prepared to respond to those with a variety of materials that nobody else could move as quickly as we could to the area to cover all the people that might need to be taken care of, and in many cases to move the material from us to those locations where there is no other source for that kind of material, because it’s very unique in terms of drug product and so on. There is no commercial market for most of the things that one stocks to deal with bio-terror events, or chemical nerve agent attacks, or large scale radiation releases, or in the worst case, a nuclear detonation. 

In 2005 or 2006, the Bush administration was trying to get better prepared for potential pandemic influenza events. So there were some supplemental appropriations from Congress that allowed us to build some stock of antivirals and personal protective equipment designed to respond to a pandemic influenza event. When we looked at models that suggested what we would need to deal with a 1918-type event in today’s United States population, the numbers of things that you might have to have are staggering. And there would really be no way even with almost unlimited funds to stock those and manage that material. 

So, we used most of the material that we purchased for pandemic influenza in fighting the 2009 H1N1 pandemic influenza. Congress never gave us additional funds to revive that material. So, what I would say in terms of narrowing this down for you, the Stockpile was intended to respond to chemical, biological, radiological, and nuclear events. Over time, because it’s clear that one of the most capable medical logistics institutions around, we’re saying what we call at this point mission gallup. So, we went from a plan to be able to respond to CBRN in multiple cities simultaneously based on data that can’t be disclosed, to being asked to be engaged in a response to natural events, to being asked to be engaged in response to emerging infectious disease, and we’ve never seen a commensurate increase in funds to do that. 

So, based on all of those factors, I think that what the Strategic National Stockpile had, at the beginning of this, was a limited quantity of specific material that could be used to respond to a pandemic or any other emerging infectious disease. Our plan has been always, because we’ve not been able to secure additional funding from the Congress, to get really ready in those areas as we would like-to be able to draw from the private sector supply chain at the time of an event. We’ve done that very successfully as well, for example, when we had to prepare on the fly for Ebola. But the reality is, the money is not there to be prepared as we should be for pandemic emerging infectious disease. 

I would say that the Stockpile’s response has been outstanding based on what it has and the funds it’s received to be prepared for this. But I think what this raises is, if the nation expects the Strategic National Stockpile to continue to grow its mission, and it expects it to be prepared for these kinds of events, then it’s going to have to fund it to be able to do that.

AS: You suggested that [the Strategic National Stockpile] had some mission creep and it expanded into other areas aside from chemical, biological, nuclear incidents. So, would you say that it’s more of an issue of, the SNS just really needs more funding from Congress, or do you think that it would be better suited to have a more contracted mission or to have some internal reorganization?

GB: Congress has to fund it. SNS is fully capable of executing the mission that it needs to execute, whether it’s where the mission currently sits, really built around CBRN, or if you really want to expand it and make it do all of these other things. SNS is fully capable of doing that. And I would say it’s more capable than any other organization, not just because I worked there, but other government people will tell me, “SNS can do things that nobody else can do.” People look to us from, even, DOD to help support their mission requirements in many spaces. And the Strategic National Stockpile is the envy of the world. People are routinely coming to the SNS asking us, “How do you do this? How would we set this up in another country?” And so on. I don’t think there’s any benefit really from reorganization.

It needs more funds, and it would be nice if there were some additional authorities. So, for example, the issue here is not necessarily that the SNS didn’t have what it needed, although we would love to have seen the SNS have more material. But the reality is, the normal operating medical supply chain in the United States runs on a very lean, just-in-time paradigm. And while that does a great job of optimizing for the best value, the best profitability, the least funding that’s needed to do that, what it does is it sub optimizes that entire system to be prepared for anything. So if we have just enough of, let’s say, whatever drug it is in the supply chain, all the way from the manufacturer to the point that it would be dispensed to someone to cover a 30-day requirement for the entire United States, you can see there’s no flexibility.

Let’s exacerbate that a little bit. Probably 90% or [more] pharmaceuticals and a similar range of medical surgical supplies like gloves, gowns, face shields and so on, are made outside the United States. Any geopolitical problem can disrupt that supply chain. A number of years back, there was a longshoreman strike on the West Coast, and there were many container ships sitting off the coast with gloves, gowns, and they couldn’t make port and drop those off. So, it’s a combination of factors and to fix this problem. 

First, the normal operating supply chain is going to have to create some flexibility in itself. Because it shouldn’t have been necessary with four or five cases in Washington state for Washington state to come ask the federal government for help.

Secondly, states and locals, well, primarily state public health, has to be better funded. Because state public health needs to be prepared to respond to it’s piece of this. The Strategic National Stockpile, even when we think about it in terms of CBRN, was always instead intended to supplement and resupply states just like the rest of the disaster response mechanisms in the United States are. The federal government is never supposed to be the first responder. The problem is, because there isn’t funding for public health as it should exist at the state and local level, they’re not prepared to be the first responder and the second responder either. So when you get back to the Strategic National Stockpile, it has to be funded if you want it to do this. But realistically, if we said that to respond to a 1918 type flu, you would need 3.7 billion N95 masks in stock, and that’s not realistic.

So everybody has to give a little in this. The supply chain has to be more flexible. We’d have to encourage manufacturing to come back into the United States so that we’re not reliant on easily disrupted supply chains from other nations. And I wouldn’t say everything, but there has to be a higher manufacturing capability in the US. And then, those government agencies that are responsible really, and they should be the fall back, on this kind of thing, have to be funded in such a way that they can have a valid way to deal with these things.

AS: Do you have any thoughts on how Washington could ensure that we augment some of these supply chains so we’re making more of these products at home, or just making importing it easier? A followup to that being, in the wake of a lot of previous pandemics, the American public and Congress became really focused on public health preparedness, but obviously as these threats recede, so too does the attention and the funding. Do you have any strategies or ways do you think that we could prevent that from happening again? Or making public health preparedness more conscious in people’s minds?

GB: I think the only way that you’re going to get manufacturing to increase in the United States is if you see, at least initially, some government incentives to bring that manufacturing back. The reality is that the cost to manufacture these products in the US is significantly higher than it is to manufacture them in foreign nations. You can get into all of the why’s and wherefores and politics and goods and bads about that whole thing. But, in reality, it costs more to make these in the US. A company that attempts to make product like this solely in the United States is, on price, always going to compete poorly with somebody that’s bringing in most of those from foreign sources. There are actual real examples of this out there; there is a company in Texas that has a great desire to make a lot of N95s, and they do have a number of customers and they make N95s. But the reality is, their product is significantly higher priced than their nearest competitor’s.

So if people are buying on price alone, which tends to be the case with this kind of thing, then they’re going to be driven away from that higher priced product, simply because it’s higher priced. Not because it’s a better product, but only because it’s made in the US. There’s going to have to be some kind of government incentive somewhere to bring that manufacturing back on shore, or at least a bit of it. Maybe that takes the form of tax incentives, maybe it takes the form of some relaxation of whatever stricture is causing some of the additional costs. There are risks associated with that as well. But, another thing that could be done is to fund the Strategic National Stockpile with, say, a special reserve fund that’s just designed to say, “We want to be able to have another 5 million masks a day manufactured in the United States.” So we put out a contract that we’re not really buying masks, but were buying capacity, and funding the cost to build that capacity. So, there are some potentials to think about there.

To your second question, I think that your articulation of the problem is very clear, and I would’ve said it the same way. Public health has often been, and frankly, much emergency response in general has been a matter of, if there is an event, we throw tons of money at that event. Typically, it’s too late at that point for that money to make a difference in that event. But we beat our chest and say, “This will make a difference in the future.” But the reality is, as we move further away from that event and it recedes in the mind, less and less money is available.

When I look at the supplemental funds that have been awarded under CARES [the Cares Act of 2020] and that we expect to see more of under other acts, the reality is that money is good to get a start on what you need for the future. If you don’t make that a regular investment, you’re going to have the same problem we have here. You’re going to buy this stuff, and it’s going to be used for an event, and you’re going to have no way to replace it. Or you’re going to buy this stuff, and it’s going to sit on the shelf for five or six years until the next event pops up, and then we’re going to get complaints because, “the mask is out of date” or “the drug is out of date” or whatever it is. Well, if you’ve got no money to rotate it after that initial investment to buy it, it was potentially a huge waste.

So, I think that’s a problem, but it’s a problem that affects the state and local level as well. After 9/11, a huge amount of money got poured into public health preparedness as well as other emergency preparedness across the country. And then you can look at the funds that were provided in subsequent years, and the further you moved away, those funds were diminished. This is something that has got to be at the forefront of the mind for forever. To suggest how to change that, I think, is difficult, because this has been the pattern of emergency response and public health preparedness in the United States for hundreds of years.