Budget cuts mean painful choices for managers of the US Strategic National Stockpile, a medical repository initially designed to aid the country’s response to terrorist attacks.

Congress created a national stockpile in 1998, and this has grown into an all-purpose resource that can deliver supplies to a disaster site within 12 hours. But the federal budget crisis has reduced the stockpile’s funding by 18% over the past four years (see ‘Running low’), raising doubts about whether the United States can afford to be prepared for every pandemic or natural disaster, from bird flu to hurricanes.

At a 3 April meeting, advisers to the Department of Health and Human Services (DHHS) unanimously endorsed a report recommending that the stockpile rely on science to guide decisions about what threats are most likely, what supplies are needed to respond and whether local officials can actually use them. “The [stockpile] will be buying less. There’s no doubt about it,” said Ali Khan, who directs the public health and preparedness office at the US Centers for Disease Control and Prevention in Atlanta, Georgia, which oversees the stockpile.

Federal officials are struggling to weigh up competing priorities. State and local disaster-response agencies increasingly rely on the stockpile to compensate for cuts to their own budgets. But the national programme is also the only buyer for expensive, specialized treatments developed after the 2001 World Trade Center and anthrax terrorist attacks. It is spending increasing amounts on therapies that are unlikely ever to be used.

“There has clearly been mission creep,” said Steve Krug, director of emergency medicine at the Ann & Robert H. Lurie Children’s Hospital of Chicago in Illinois at the 3 April meeting.

The DHHS has already sharply reduced orders for some items, including a new botulism antitoxin that costs US$1,250 per dose. Such decisions alarm companies making biodefence products, says Maureen Hardwick, executive secretary of the Alliance for Biosecurity in Washington DC, which represents many of those firms. “If they’re researching and developing things that will not be procured, that sends a negative signal,” Hardwick says.

But just replacing expired medications already in the stockpile will exceed the repository’s projected budget by 20% next year. And the programme will eventually be asked to restock other high-priced anti-bioterrorism drugs first purchased by a separate agency, the Biomedical Advanced Research and Development Authority (BARDA), which supports the development of medications considered priorities for biosecurity.

BARDA has purchased 2 million doses of an anti-smallpox drug for more than $150 per dose, even though the stockpile already contains enough smallpox vaccine to immunize the entire US population.

The stockpile will also foot the bill for two biological products to neutralize the toxin produced by anthrax bacteria, first purchased by BARDA at costs of $2,900–3,500 and $8,100 per dose. Meanwhile, the country continues to invest in biodefence research.

Fewer purchases may mean that the United States will be less prepared for unlikely events, such as bioterrorist attacks, than officials would like. But other nations made this trade-off long ago. Only two other countries — Japan and Israel — are thought to have enough smallpox vaccine to vaccinate their entire populations. And no other country has anything like the anti-bioterrorism arsenal of the United States.

“There has to be a thoughtful analysis of what we’re willing to do without, which is a very painful discussion in our society,” Krug said at the meeting.