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The Supply Chain System

The current supply chain system that supports the deployment of medi- cal products is not well matched to the demands that a health security threat would create—a gap that represents a significant vulnerability. For everyday needs, the medical and public health sectors have come to rely on a just-in-time delivery system. Less a delivery system than an inven- tory strategy, such a system aims to supply a small amount of products as needed. The resulting limited stockpiles of medical products are the most notable aspect of this vulnerability, and the supply chains for these stockpiles only contribute to the problem. The United States, for example, currently imports 75–80 percent of the raw materials for drugs meant for the U.S. domestic market (GAO, 2007), which increases susceptibility to the effects of a public health emergency should an outbreak occur in an exporting country. Supply chain issues are not limited to raw materials, but also apply to widely used medications themselves. A 2009 study, for example, found that 100 percent of 30 identified essential generic life-saving medicines3 were manufactured overseas—mainly in India or China—with long supply chains and no significant stockpiles. In the event of a pandemic in these countries or a disruption at any point along these supply chains, U.S. hospitals would lose the ability to provide these drugs to patients (Osterholm and Olshaker, 2017). Similarly, according to a 2016 report by the Trust for America’s Health (TFAH), 40 percent of states lack backup medical supplies to cope with a pandemic influenza or other major outbreak should their supplies be low (Segal et al., 2016). Because of the just-in-

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3 The list of 30 drugs was based on responses from hospital pharmacists about what drugs were absolutely needed in their specialty. These included albuterol, heparin, insulin, nitro- glycerine, and various other drugs and antibiotics (Osterholm and Olshaker, 2017).

 

 

Global Health and the Future Role of the United States

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54 GLOBAL HEALTH AND THE FUTURE ROLE OF THE UNITED STATES

BOX 3-3 Case Studies of Infectious Disease Resurgence

Dengue and yellow fever resurgence in Brazil: Brazil spent much of the 20th century trying to eradicate the Aedes aegypti mosquito, responsible for car- rying dengue fever, yellow fever, and now the Zika virus, understanding that the threat of multiple diseases could thereby be addressed. Brazil declared success in 1958 and again in 1973, but given the regional territory of the mosquito, long-term eradication was not possible without concurrent effort in all of the Americas, and Brazil’s success did not last. Mosquito control services were drastically reduced in the 1990s, and in 2002 Brazil suffered the worst outbreaks of dengue fever in its history. Eventually, the Zika virus followed. Furthermore, as the result of a combination of relaxed mosquito control, low immunization rates for yellow fever (only 46 percent in 2015), and other factors, Brazil saw a resurgence of yellow fever in February 2017, which has become one of the worst outbreaks the coun- try has seen since the 1940s. Many are now concerned that the outbreak could spread to cities and become an urban phenomenon, possibly spreading to other countries in the region.

Malaria resurgence in Venezuela: In 1961, Venezuela was certified by the World Health Organization (WHO) as having eliminated malaria, 9 years ahead of the United States. However, economic turmoil in Venezuela led to a resurgence of the disease not just in remote wooded areas but across the entire nation. Because of this economic turmoil, people resorted to working at gold mines (where mosqui- tos and malaria thrive) and then returned to urban areas after being infected. This pattern was compounded by shortages of medicines and cessation of preventive interventions, such as spraying, in the cities, allowing malaria to be passed from infected individuals to others. While this represents a daunting problem for Ven- ezuela, it also poses a threat to neighboring countries.

Polio resurgence: WHO launched the Global Polio Eradication Initiative in 1988, with the goal of achieving eradication by 2000. By 2003, most of the 126 polio-endemic countries (the exceptions being Afghanistan, Egypt, India, Niger, Nigeria, and Pakistan) had been able to eradicate the disease. Sadly, the break- down of interventions in Nigeria resulted in the resurgence of polio there, which eventually spread to 21 other countries, 13 of which were reinfected after previous elimination of the disease. Continued spread was eventually contained because of immunization efforts. Now, polio remains endemic in only three countries: Afghani- stan, Nigeria, and Pakistan. While polio eradication is still technically feasible, budgetary constraints and fatigue can endanger success. Most important, efforts in these three countries are threatened by conflict.

SOURCES: Akil and Ahmad, 2016; Atchon, 2016; Beaubien, 2017; Casey, 2016; Ghafoor and Sheikh, 2016; GPEI, n.d.; Lowy, 2017; Rey and Girard, 2008; Simpson et al., 2014; WHO, 2016d.

 

 

Global Health and the Future Role of the United States

Copyright National Academy of Sciences. All rights reserved.

GLOBAL HEALTH SECURITY IS NATIONAL SECURITY 55

time delivery system, many health care systems can be one local supply breakdown away from an emergency for their patients. Box 3-4 provides examples of the effects of these limitations in supply chains during previous public health emergencies.

As evidenced by the examples in Box 3-4, the supply chain systems currently in place are not always capable of meeting a surge in demand. Because ensuring surge capacity and adequate stockpiles will likely result in financial losses for manufacturers, governments must incentivize them to do so. For example, Canada purchases flu vaccines from manufacturers annually—10.4 million in 2013 (The Canadian Press, 2014)—to ensure the production of a reserve supply (Public Health Agency of Canada, 2017). The U.S. Office of the Assistant Secretary for Preparedness and Response (ASPR) has begun to take similar action through its partnership with the Centers for Innovation in Advanced Development and Manufacturing, focused on assisting in addressing the shift in vaccine production capabili- ties overseas by the biopharmaceutical industry (see Chapter 7). However, this vaccine initiative addresses just one part of the problem; and additional solutions are needed even for such items as saline, gloves, masks, and other routine health supplies.

BOX 3-4 Examples of Stockpile Shortages and

Supply Chain Breakdowns

2003 severe acute respiratory syndrome (SARS) outbreak: Nurses in Canada experienced shortages of N95 masks, most of which had been shipped to Asia. As the main manufacturers of the masks (3M and Kimberly-Clark) lacked existing stockpiles, nurses instead had to use less-protective masks.

2014 Ebola outbreak and personal protective equipment (PPE): The need for highly robust PPE, the thousands of cases, and high levels of panic as every hospital tried to prepare for incoming patients caused the demand for adequate PPE to outpace the supply. While Dupont, Kimberly-Clark, and 3M in- creased their production in an effort to keep pace with the demand, the capacity to meet the need was lacking. Furthermore, the U.S. Centers for Disease Control and Prevention spent $2.7 million on PPE supplies for the United States, even though there were only a handful of cases in the country, exacerbating shortages for those fighting the outbreak in West Africa.

SOURCES: Hinshaw and Bunge, 2014; Northam, 2014; Wysocki and Lueck, 2006.

 

 

Global Health and the Future Role of the United States

Copyright National Academy of Sciences. All rights reserved.

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