Of all the coronavirus-induced problems facing America, the mask shortage might be the most baffling. Masks are now so hard to find that health-care workers are reusing theirs multiple days in a row. Grocery-store workers, who are at high risk of contracting the virus, have been denied masks for months. Everyday people are making their own out of fabric scraps.
One reason the U.S. ran short of masks is that many of them are manufactured in China; the country slowed mask manufacturing and stopped shipping them to the U.S. during its own coronavirus outbreak. But America was supposed to have its own supply of masks in the Strategic National Stockpile, a secretive stash of emergency supplies held in an undisclosed number of warehouses around the country. As of April 1, it was almost out.
The stockpile has been a consistent target of criticism throughout the COVID-19 pandemic, and there’s an obvious logic to that criticism: How did the richest country on Earth fail to hoard enough masks for a pandemic flu? One reason is that the Strategic National Stockpile distributed 85 million N95 respirators during the 2009 swine flu pandemic, along with millions of other protective masks. That distribution effort contributed to what is largely seen as a successful federal response to that outbreak. But those masks were never replenished.
At the beginning of the coronavirus outbreak, the stockpile contained only about 12 million of the 3.5 billion N95 masks that federal officials estimated the health-care system would need to fight this pandemic back in March. “I’m not aware of a major effort to restock the stockpile with N95 respirators after the 2009 drawdown,” Charles Johnson, the president of the International Safety Equipment Association, told me.
But the stockpile was never intended to be the nation’s great savior. It wasn’t supposed to provide all of the nation’s medical-supply needs for a multi-month pandemic. Congress never doled out enough money for it to do so. Instead, the officials who monitored the national stockpile were hopeful that hospitals were making their own stockpiles. But to save money, they largely weren’t. In that context, the skimpy mask supply in the Strategic National Stockpile is not the thing that derailed the American response to COVID-19. Rather, it’s one of a series of planning failures that created the crisis we’re in today.
Just like everything else in the government, the Strategic National Stockpile is funded through congressional appropriations. That means there’s a limited amount of money to be spent, and the people in charge of the stockpile have to decide how to spend it. Officials bought millions of N95 masks and other flu-type preparations with supplemental congressional funding that trickled in from 2005 to 2007, says Greg Burel, who was the director of the stockpile from 2007 until January 2020. But then that supplemental money dried up.
With the remaining money, the officials in charge of the stockpile had to decide whether they wanted to plan for a hurricane, flood, tornado, pandemic, or terrorist threat. All of those disasters require the stockpile to be stocked with different stuff. “It isn’t like comparing apples and oranges,” says Tara O’Toole, a former homeland-security official who chaired an advisory committee on the stockpile and who is now executive vice president at In-Q-Tel. “It’s like comparing apples and Volkswagens and bird food.”
After 9/11, the people in charge of the stockpile were concerned about bioterrorism—threats like anthrax—and sudden, mass-casualty events like, say, a bombing at the Super Bowl. This made some sense, but in the process officials took their foot off the pandemic-preparedness gas pedal. The response to the 2009 swine-flu pandemic was seen as a success, and the stockpile-minders moved on to the next item on their disaster checklist. “I think as human beings, we sometimes, not that we get complacent, but it’s like, Oh, we’ve got this. And we did. We had it,” says Deborah Levy, who oversaw the stockpile as acting division director for the Centers for Disease Control and Prevention in 2013 and 2014, while Burel was in another role.
Because officials weren’t as worried about pandemic flu, they stocked fewer basic medical supplies, like masks, that would come in handy during an infectious-disease outbreak. Officials thought the stockpile should have bioweapon antidotes and other drugs that aren’t easily available on store shelves, rather than common items you can buy at CVS. “The Strategic National Stockpile was built to respond primarily to chemical, biological, radiological, and nuclear events, whether by a terrorist, or a state actor, or something that might happen along those same lines that was accidental,” Burel told me.
Since then, other changes to the stockpile might have made it less capable to handle crises like the one we’re living through. In 2018, the stockpile was moved out of the jurisdiction of the CDC and into a different domain of the Health and Human Services Department—the assistant secretary for preparedness and response. While some of the experts I spoke with saw this as a harmless change, most worried that institutional memory was lost in the process. The CDC, they say, was better at doing operational things like mobilizing a stockpile. Having it at the CDC “puts everybody who’s working on different aspects of being prepared and able to respond together,” Levy said. (HHS did not immediately respond to a request for comment, and I will update this story if I hear back.)
Still, the fundamental mission of the stockpile remained the same: A stopgap, not a safety net. Jared Kushner drew opprobrium last week for appearing to say that the states were on their own when it comes to medical supplies. “The notion of the federal stockpile was, it’s supposed to be our stockpile. It’s not supposed to be states’ stockpiles that they then use,” he said.
Although Kushner’s wording was undeniably inartful, the former stockpile directors said he sort of has a point. “Kushner doesn’t know exactly how to phrase it, but the stockpile was never designed to be for everybody all at once, anything that you might need for as long as you need,” Levy said.
The stockpile, Burel and Levy told me, was never meant to provide masks for the entire nation for months at a time. The idea was instead that hospitals and states would create their own stockpiles, and under extenuating circumstances—when they ran out of supplies, or if they were incapacitated for some reason—they could fall back on the national stockpile.
One could argue that we are living through just such an extenuating circumstance—states are running out of supplies, after all. But the former stockpile directors I talked to said that if anything, governors and hospitals should have been warned sooner about how few masks were in the national stockpile and told to make their own arrangements. “It was never viewed as something that would supply the whole nation with medical supplies for a long period of time,” said Richard Besser, who led the CDC office that oversaw the stockpile during Hurricane Katrina. “If you just look at the number of masks and gowns the nation is churning through, it would be impossible and cost-prohibitive to store that in perpetuity for a global pandemic.”
Hospitals, too, could have been keeping their own stockpiles. But Burel and others told me that rather than keep stockpiles, hospitals have what’s called “just in time” stock, in which supplies are delivered right as they’re needed. So do the distributors. And so do the manufacturers. It’s cheaper that way, because you don’t need space to store extra supplies or to test the masks to be sure they’re not expired. Hospitals stay open and pay their staff by staying profitable, and they do that by not spending money on a big room full of unused masks. One could say that hospitals should focus less on amenities and big salaries than pandemic preparedness, but this has not, historically, been a compelling argument to most businesses. To save lives, hospitals ultimately have to stay afloat. “We’ve made health care into a business where cost and profit matters more than the capacity to surge,” O’Toole told me.
When reached for comment, a spokesman for the American Hospital Association said, “In addition to our just-in-time inventory to cover day-to-day operational needs and consumption, hospitals and health systems also have surge inventories, which typically contain one to four months of supplies that would likely be needed during localized man-made or natural disasters. However, just-in-time inventory and surge inventory are unable to provide long-term support during a global pandemic such as COVID-19.”
The mask shortage is just another example of America’s failure to invest in pandemic preparedness, former stockpile officials say. Everything in our health-care system runs with just enough resources, and we have reached a point where “just enough” isn’t enough. “Public health is not well funded at the state level, the locality level, or at the federal level in the United States,” Burel told me. “It is a chronic problem.”
There are, of course, lessons we could take from this debacle. The federal government could move the manufacturing of crucial medical supplies like masks back to the U.S. Congress could fund all types of public-health efforts, including the stockpile, more generously. Johnson suggested the government could pay manufacturers to maintain stockpiles of various items, including masks. Rather than sending them to sit in a government warehouse, mask-makers could keep thousands of masks on hand, allow them to gradually get used up, and replenish them as they expire.
But any of these steps would require taking the threat of pandemic flu seriously, and spending money on it accordingly. And that isn’t something the U.S. has been doing, with the stockpile or otherwise.