When the history of the COVID-19 pandemic is written, there will be a lot of ground to cover, from the virus’s source to the race to develop vaccines. But in almost every history, Chapter 1 will tell the same story: We weren’t ready.

Now is our chance to learn from the past. And a very important lesson deals with the Strategic National Stockpile. Founded in 1999, the Strategic National Stockpile stores medical supplies to combat pandemics, bioterrorism and other public health crises.

Despite this explicit purpose, the stockpile wasn’t ready when the novel coronavirus hit. While it did distribute some COVID-19 countermeasures, it couldn’t provide the masks and ventilators so desperately needed last spring. The stockpile is positioned for local threats, but is not anywhere close to adequate for nationwide or even worldwide threats like pandemics.

Fortunately, the White House’s proposed infrastructure bill includes a four-year plan to spend billions of dollars restocking the national stockpile. But while such a budget commitment is critical, tough decisions still have to be made about what to put in the stockpile.

The Strategic National Stockpile entered 2020 prepared for a nerve gas attack or smallpox outbreak, but neither of those things happened. It also has plenty of anthrax vaccine. The last anthrax attack in the United States happened 20 years ago and killed five people, which was a tragedy to be sure, but not on the scale of a pandemic. While we must be prepared for terrorist and man-made threats, the ongoing greatest challenge to humans is nature and the infections it produces. The worst epidemics and pandemics this world has seen, from the Spanish flu to COVID-19, stemmed from a tenuous relationship with nature, that risks widescale spreading on a regular basis.

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How you build a stockpile?

Some stockpile medications are barely effective. Oseltamivir, for example, was meant to treat H1N1, but has demonstrated no significant patient-oriented outcome with regard to decrease in admission, complication and death.

Of course, we can’t know for certain what the next biosecurity threat will be. Nonetheless, a couple of guiding principles stand out for building a truly strategic stockpile.

First, the stockpile needs to give great emphasis to respiratory diseases. COVID-19, which has killed about three million people worldwide, is of course respiratory. But so are many of our other novel contagions. In the 21st century alone, we’ve faced Severe Acute Respiratory Syndrome (SARS), first identified in 2003, which killed nearly 800 people; Middle East Respiratory Syndrome (MERS), which emerged in 2012 and has killed nearly 900 people; and the 2009 H1N1 flu pandemic, which has killed at least 75,000 people.

In short, even before COVID-19, we had every reason to believe that the next new virus to make the leap to humans would be a deadly respiratory disease. That is still the case. Our stockpile, therefore, needs not just plenty of ventilators and N95 masks, but also medicines to treat respiratory problems.

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The best medicines

Any list of such drugs would likely include corticosteroids like mometasone and dexamethasone, which reduce inflammation and are effective against asthma and chronic obstructive pulmonary disease. It’s also worth considering medications like sargramostim, which help boost immune response. In a study led by University Hospital Ghent, sargramostim showed great potential in alleviating severe respiratory symptoms in hospitalized COVID-19 patients. Such medications also increase survival rates against acute radiation syndrome, which make them ideal for treating patients in the event of a nuclear incident.

With the stockpile’s finite budget and limited space, whether a drug can do double or even triple duty should be a selection criterion. Indeed, one lesson scientists drew from the SARS outbreak was that to be prepared for future pandemics, governments must stockpile broad-spectrum antiviral drugs, which are those that have been found to be effective against more than one type of virus — like remdesivir, originally developed against hepatitis C and later found to help treat COVID-19.

It’s not clear that we heeded the lessons of 2003 or 2009. But we do know there will be future pandemics, acts of war and other disasters that require a reserve of medical supplies to protect the U.S. population. With an administration committed to rebuilding the Strategic National Stockpile, we have a great opportunity to get it right.

Dr. Ryan Stanton is an emergency physician in Lexington, Kentucky. Stanton serves as an EMS medical director and Fellow of the American College of Emergency Physicians.