This is from a letter (and an email) I wrote today to Dr. Bob England, the Maricopa County Health Director:

Dear Dr. England:

When I talked with him over the summer, Supervisor Kunasek suggested that I relay to you my concerns about Maricopa County’s current plans for coordinating with the Strategic National Stockpile (SNS) in preparing for epidemics.

I first learned about the situation from Maricopa County SNS Coordinator Shawn Tennant, who spoke at a luncheon I attended on April 8. In an email I wrote to her that day, I expressed my concern that the SNS was apparently trying to create from whole cloth a distribution network of 150 emergency sites throughout the County. The SNS plan apparently relies mainly upon existing public facilities (public pools, public schools, etc.) and will rely on government workers to staff the facilities.

Using basic math, that’s over 26,000 residents for each SNS site in Maricopa County. If 26,000 people need to get to (or think they need to get to) a single site during a 48-hour period to get antibiotics to fight an anthrax attack, that’s 555 people per site per hour, or nine people per minute. In a real emergency, with tens of thousands of infected persons, with millions panicked, and the streets congested with panicked motorists, the County would be looking at a gigantic mess that would make the Hurricane Katrina/New Orleans situation look well-managed by comparison.

Before writing to Tennant, I checked the phone book, and found 150 Walgreens stores in the County. Walgreens and its competitors already have distribution networks set up, and their distribution points are located in rough proportion to population. If you add supermarket pharmacies, you have at least 500 distribution points. Those distribution points: 1) have refrigerators; 2) have security systems (to protect narcotics and other sensitive drugs); 3) deal with many kinds of drugs; 4) are staffed by persons who are used to filling out medical paperwork; and, 5) regularly update drug supplies to account for their expiration dates.

I suggested to Tennant that the SNS system could take competitive bids from pharmacy and grocery chains, to make sure that the system is paying pharmacies reasonable amounts for costs associated with complying with the program. For instance, the pharmacies will need to allocate resources to provide for a ready list of extra personnel who can be called upon to come to work with an hour’s notice to administer the distribution of drugs during an emergency. And officials might want to ensure that pharmacy refrigerators and security systems are hooked up to emergency generators in case of power failures. Permission for surprise inspections could be provided for in the contracts the pharmacies sign when they join the network. (We might even find that pharmacies will join the network for free. Perhaps they will get goodwill from doing a joint ad explaining to the public that “Even in the worst emergencies, Walgreens is there for you. We’re proud members of the SNS system...”)

It would be far cheaper--and far more effective--for the government to utilize the existing private distribution network, than to attempt to create and operate one of its own. One of the most important lessons we should have learned from the Katrina debacle is that private distribution networks such as WalMart were much quicker in reacting to the disaster and getting provisions on-site than FEMA and other government agencies (though the Coast Guard reportedly did a decent job in its limited sphere of activity).

As of this date, I have not received any response from Tennant. But apparently, my concern is not a new one. Back in August of 2006, the CDC published a webcast urging state and local planners to consider using private-sector distribution capabilities.

Here is a description of the webcast:

State and local SNS planners have suggested that it may not be possible to provide prophylaxis to the entire community in 48 hours using only the traditional Point of Dispensing (POD) model. Alternate methods of dispensing, such as using drive-through dispensing or pushing medications to businesses, nursing homes, or assisted living facilities, may be necessary in addition to PODs. This program describes several alternate methods of dispensing that planners can consider as they develop their comprehensive dispensing plans. Planners from state and local public health agencies will discuss the alternate dispensing methods they have devised and exercised in their communities. Subject Matter Experts identify the challenges and opportunities associated with pushing medication to large employers in the community or delivering medication to sheltered-in populations, such as those in nursing care or assisted living facilities.

Webcast link: http://www2a.cdc.gov/phtn/antibiotic6/default.asp

In a 2007 promotional piece called "Developing Business Partnerships," the CDC writes,

Increasingly, public health planners are reaching out to community businesses and organizations to assist in a mass antibiotic dispensing campaign. It is a logical choice.

Promo piece link: http://www2a.cdc.gov/phtn/business/BusinessFactSheet.pdf

“It is a logical choice.” Indeed. Unfortunately, given Tennant's comments to me on April 8th, and from what I can glean in the CDC's online materials, the private businesses known as pharmacies do not seem to be a big part of the initial 12-hour "push" campaigns. Rather, the "vendor managed inventories" are part of the follow-up plan.

The SNS is organized for flexible response. The first line of support lies within the immediate response 12-hour Push Packages. These are caches of pharmaceuticals, antidotes, and medical supplies designed to provide rapid delivery of a broad spectrum of assets for an ill defined threat in the early hours of an event. These Push Packages are positioned in strategically located, secure warehouses ready for immediate deployment to a designated site within 12 hours of the federal decision to deploy SNS assets.

If the incident requires additional pharmaceuticals and/or medical supplies, follow-on vendor managed inventory (VMI) supplies will be shipped to arrive within 24 to 36 hours. If the agent is well defined, VMI can be tailored to provide pharmaceuticals, supplies and/or products specific to the suspected or confirmed agent(s). In this case, the VMI could act as the first option for immediate response from the SNS Program.

At first glance, the Push Package system seems like a good idea. It seems to be a flexible response to an unknown threat. But we would still run into the distribution problem. From the viewpoint of basic economics, it would seem to be much more effective to have the most critical 12-hour supplies already positioned at pharmacies in communities, and then rely on the government to airlift and truck in large amounts of backup supplies. But the SNS clearly has a different notion. In a very interesting teleconference last July, Todd Piester explained how SNS envisions the use of private-sector distribution networks:

As I said earlier, whenever there’s a commercial market that offers us the opportunity to enter into a Vendor Managed Inventory agreement with partners where we pay them to have product on hand for us and then we pay them to rotate that product out into their commercial marketplace before it reaches shelf life and replace it with fresh dated product.

Well, that’s a great arrangement and it’s very cost effective and it works very well for us. However, the nation’s needs far surpass the commercial marketplace for many of our items. So for things like oral antibiotics, the nation, the world just doesn’t use enough of the product that would make it possible for us to enter into agreements for vendor managed inventory of our oral antibiotics.

Teleconference link: http://emergency.cdc.gov/coca/summaries/pdf/SNS_070108.pdf

As I see it, the government is gambling on creating a very expensive distribution system of its own—a system of questionable effectiveness—rather than incentivizing and subsidizing pharmacies (in a comparatively “cost effective” way) to stockpile and rotate the necessary materials.

So for everything that we can we prefer to enter into agreements for vendor managed inventory. Whatever we can’t, though, we then have in Stockpiled Managed Inventory or SMI. In response, really they’re both the same, doesn’t matter to the recipient whether a vendor managed it or whether we manage it; it’s coming to you, or it’s coming to the recipient; it’s palletized cargo. It’s very large quantities of specific items to meet specific needs.

Contrary to Piester’s claim, they’re not the same. A vendor-managed inventory is already on the ground, at hundreds of distribution points in the County. There is no need to forklift the cargo onto airplanes, fly those planes to PHX, forklift the cargo into delivery trucks, have the delivery trucks battle traffic (and a panicked citizenry) to the 150 distribution points, and then unload and unpack the cargo.

If the Department of Homeland Security insists, for political reasons, upon having the various steps in the distribution process run by (unionized) government employees, and to have government-run facilities serve as the distribution points (PODs), it will add exponentially to the inefficiency of the distribution process. That means huge delays in delivery, and huge extra costs to the taxpayer.

Back to Piester’s explanation:

So that’s the important thing to remember about our two types of inventory; it’s bulk cargo, it’s palletized cargo, specific items for specific needs. It’s not quite as fast as a 12-hour push package; it should arrive within 24-36 hours roughly from the decision to deploy. Again, not quite as rapid but it’s very large quantities, very specific items for specific needs.

The next slide - and this is entitled Stockpile Managed Inventory. And it just shows one of our warehouses. It shows an aisle at one of our warehouses with Stockpile Managed Inventory. And you can see there the racking where it’s palletized cargo, six racks high so we’re maximizing the footprint of each of our warehouses through racking that makes this as effective as possible to store all the product that we need.

This also can give you an idea of why it’s not quite as quick as that push package to deliver. You can see there that a lot of the product is going to have to be brought down with high lift forklifts. It’s got to be brought down off possibly the fourth, fifth, sixth rack to get down onto the floor. So it takes a specialized piece of equipment to even get it onto the warehouse floor.

And then every one of those pallets has to be moved around by material handling equipment, a pallet jack or a forklift, and that’s going to take an operator for each pallet. So it’s just not as quick to move.

“Not quite as rapid...” "...not as quick to move." Indeed. My concerns are expressed in one of the first questions asked of Piester in the teleconference:

Question: There’s 72 CRI cities, CRI areas across the country of varying size and complexity, yet a push pack handles antibiotics for, as I understand - I’ve seen different figures but 300,000 people plus or minus. There are 12 push packs. In a multi-CRI scenario event, if the Stockpile managed inventory won’t arrive for 24-36 hours and the push pack may be there earlier but 12 hours is a planning interval, how are we to meet the 48 hour deadline for complete prophylaxis if the time to get the materiels takes up three-quarters or more of the available hours?

Todd Piester: You’ve asked a very good question. For those on the phone that may not be familiar with the acronym CRI, Cities Readiness Initiative, really an effort by the government to enhance the ability of localities, cities to dispense prophylactic antibiotics to its citizens within 48 hours of an aerosolized release of anthrax.

And you’ve asked a very good question. Our general planning figures for managed inventory is 24-36 hours. We recognize the challenges of a CRI response and understand the 48 hour timeline. We believe that the push package, as our most responsive asset, may be of value for its rather limited antibiotic prophylactic capabilities to get first responders and other critical elements started on prophylaxis; that’s our most responsive asset.

It appears that the first responders will get the push package materiels, and the rest of us will just have to wait...

We are committed to providing the oral antibiotics for a CRI-type setting in enough time that we’re going to avoid the problems that you’ve brought up. So I didn’t go into detail with that, but we recognize the challenge that you’ve described and we have mechanisms in place to make those oral antibiotics deployable to meet those needs. And we continue to look at other alternatives to be able to do it better, faster to meet those needs.

I mean no slight to the valiant planning efforts of Piester and Tennant and many others in our public health system, from the local level to the national level. But there doesn't appear to be a sound plan to actually defend the entire population in a timely manner. Instead of utilizing the decentralized distribution networks of the private sector, the SNS plan is shaping up to be yet another catastrophic government failure of centralized command-and-control distribution.

For Liberty,

--Tom

Tom Jenney
Arizona Director
Americans for Prosperity
(Arizona Federation of Taxpayers)
www.aztaxpayers.org
tjenney@afphq.org
(602) 478-0146

cc: Supervisor Andy Kunasek