Why America ran out of protective masks — and what can be done about it

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Doctors and nurses are now crying out for masks and other personal protective equipment as they’re forced to wear bandanas and scarves for masks, trash bags for gowns, and reuse all sorts of medical equipment — heightening the risk of coronavirus infection and possibly death as we all rely on these health care workers now more than ever to stem the outbreak.

But the government should have seen this coming. Many people did.

“When we have done exercises in the past for pandemic preparedness, supply chain issues were a well-documented challenge,” Saskia Popescu, an epidemiologist focused on hospital preparedness, told me. “This is something we’ve known about — maybe not to this extent, but this isn’t a shocker. It’s more surprising that we let it get this bad.”

Health care professionals and experts say we now have a shortage of masks, gowns, gloves, and other personal protective equipment (PPE) for doctors, nurses, and other medical staff. In this environment, health care workers worry they might get sick — perhaps forcing them to take up a hospital bed that would otherwise go to someone else — or die. Privately, some say they may not be able to show up to work at all under these conditions.

The situation not only threatens health care workers’ well-being, it could limit US health care capacity even as experts warn we need to scale up to confront the rise in coronavirus cases.

Different levels of government are now trying to take action — with cities, counties, states, and the federal government racing to get more PPE and send it to places and hospitals that have been hardest hit by Covid-19, the disease caused by the novel coronavirus. President Donald Trump recently activated the Defense Production Act, a once-obscure law that could let the feds dictate what equipment is produced and where it goes. And the federal government has started to send out some masks and other equipment from the Strategic National Stockpile, although state and local officials argue the response has still been too slow.

The problem, experts say, is that the federal government should have prepared for this months if not years ago — but it didn’t. It’s an issue that has been magnified by Trump but really transcends presidential administrations: America, along with the rest of the world, has never been ready for a major disease outbreak.

“Every serious look at US pandemic readiness and global pandemic readiness has identified PPE shortages as a major issue,” Jeremy Konyndyk, senior policy fellow at the Center for Global Development, told me. “This is a known issue. We’ve seen it before.”

We’re seeing the consequences of that now. Due to the lack of preparedness, we are still lacking testing capacity for coronavirus, and experts say we’re still in the dark as to how many cases there even are in the US, so the current estimate could be an undercount by many times over. The lack of testing has forced us to rely more on painful social distancing measures, requiring that everyone isolate to some extent to stop the spread of the virus.

And in hospitals, the lack of preparedness translates to a shortage of masks, gowns, and other PPE, among other problems. As health care facilities expect beds to overflow in the next few weeks of the pandemic, the shortage threatens to undermine how many doctors and nurses will be there to treat patients. More people could die as a result.

The PPE shortage is a very big problem for everyone, not just doctors

As coronavirus has spread, experts have talked up “flattening the curve.” The idea is to spread out the number of coronavirus cases — through social distancing, testing, contact tracing, and other protective measures — to avoid overwhelming the health care system. Here’s what that looks like in chart form:

The PPE shortage could make it harder to flatten the curve of new cases if doctors and nurses get sick. But the line representing health care system capacity also isn’t a constant. If we develop more capacity, it can handle more cases at once. If capacity falls — if doctors and nurses get sick because of a lack of protective equipment, or refuse to work without conditions that can ensure their safety — even a flatter curve will be hard for the system to handle.

“If you have health care workers who don’t feel safe, you may very well have people who don’t come to work,” Val Griffeth, an emergency and critical care doctor who’s helped lead #GetUsPPE, told me. “Worse, you have people who come to work, get infected, and end up in the hospital taking up a bed and also not seeing patients that day, that week, or that month.”

Despite recent government actions, experts and medical professionals warn that the protective equipment shortage is far from resolved. Report after report just in the past week found doctors and nurses having to ration and reuse medical equipment — or come up with homemade alternatives. One doctor, who asked to remain anonymous to avoid upsetting her employer, told me as she came off a shift this week that she still had to reuse masks and respirators on a regular basis.

Some hospitals are even considering do-not-resuscitate orders for dying Covid-19 patients out of fear that such intensive, close-up procedures could get health care workers without PPE infected with the coronavirus.

“Even with the infusion of supplies from the strategic stockpile and other federal resources, there will not be enough medical supplies, including ventilators, to respond to the projected COVID-19 outbreak,” a March 21 letter from the American Medical Association, American Hospital Association, and American Nurses Association stated. “We have heard of health care providers reusing masks or resorting to makeshift alternatives for masks.”

The problem is about both supply and demand. Prior to the coronavirus outbreak, China made half the world’s face masks. When the outbreak took off there, China started to use its supply and hoard what remained. This problem has only spread since, as more and more countries hoard whatever medical supplies they can get — with some, like Germany, even banning most PPE exports. So as demand increased due to Covid-19 — not just from health care workers but from a general public increasingly scared of infection — there was less supply to go around.

Some public health officials and experts tried to tamp down on public demand by suggesting face masks wouldn’t help laypeople avoid infection. But experts told me this messaging backfired: There is evidence that masks help people avoid infection, and once the public saw doctors and nurses were using and wanted more of the masks, that likely fueled distrust toward what public officials and experts were saying — and people bought up masks anyway.

The result, now, is a shortage that not only threatens doctors, nurses, and other medical professionals at the front lines of the coronavirus pandemic, but also puts us all at serious risk, since we’re relying on these same health care workers to literally save us if we get sick.

The risk is big: If those health care workers get sick and are unable to care for people, more patients are likely going to suffer and die — and not just from Covid-19, but just about any other medical issue, from heart attacks to car crashes, that we’ll need health care workers for in the next few months.

The government should have prepared for this. It didn’t.

In the years before the coronavirus pandemic, government officials and epidemiologists regularly ran simulations and exercises to see what would happen in case of a big outbreak. One of those simulations held by the federal government, as the New York Times reported, covered a pandemic that looked a lot like the one we’re facing now: a respiratory virus that started in China and made its way to the US and the rest of the world.

Among the many problems, the Times found, were “deficiencies ‘in personal protective equipment use.’” The exercise found that the US didn’t have the means to quickly produce more PPE. When states turned to the federal government for help in the exercise, there was “confusion” and “bureaucratic chaos” as requests and submissions hit multiple agencies at once.

This was far from the only simulation to produce these results, experts told me. Konyndyk, in fact, pointed to a real-world example that highlighted the failures: the 2014-2016 Ebola outbreak. While working in President Barack Obama’s administration at the time, Konyndyk quickly realized that America — and much of the world — was simply not ready for a major disease outbreak.

“I came away from that experience just completely horrified at how unready we would be for something more dangerous than Ebola,” he said, noting Ebola was, thankfully, relatively hard to transmit.

Indeed, experts and advocates argue that the US generally underfunds disease outbreak preparedness and public health programs more broadly. It’s these concerns that led the Obama administration, after the Ebola outbreak, to attempt to scale up preparedness by establishing a White House office dedicated solely to the issue and producing a 69-page playbook in case of an outbreak. The Trump administration, however, neglected and rolled back these efforts, eventually disbanding the White House office.

We’ve seen the results in the botched rollout of coronavirus testing, but PPE offers another example. America could have shored up its supplies of PPE in its strategic stockpile. It could have ensured that there would be surge capacity to boost production in case of emergency. And it should have been doing this all before the coronavirus pandemic.

But it didn’t. As of earlier this month, the US had 12 million N95 respirators and 30 million surgical masks in its Strategic National Stockpile — which officials acknowledged was just 1 percent of what the country needed in a full-blown pandemic.

“The US … was not prepared,” Jen Kates, a senior vice president and director of global health and HIV policy at the Kaiser Family Foundation, told me. “A good preparedness plan would have helped address this and had things in place to allow for that increased need to be met.”

The Trump administration could have started to do more in January when it became clear that Covid-19 could pose a threat to the entire world. But, Konyndyk said, the administration just didn’t do that: “What that prompted on our side was travel bans but no serious action to reinforce domestic readiness.”

So now doctors and nurses are forced to resort to bandanas, trash bags, and homemade equipment instead of actual protective gear.

There’s still some time to act

At this point, experts warn that the US is stuck playing catch-up. But there are some things different levels of government can do and are doing to make the situation on the ground a bit better.

For one, PPE production needs to be increased. Already, private companies are starting to do this — with even car manufacturers like Ford vowing to 3D print face shields and masks for health care workers. In the several bills Congress has passed and is working on to tackle the coronavirus pandemic, federal lawmakers have also committed more funds to boosting production of PPE.

But scaling up production will take time — maybe weeks or months — during which the coronavirus will continue to spread. That’s why the PPE that’s already out there needs to be reprioritized for doctors, nurses, and other health care workers.

The federal government says it’s now taking some action. In a statement, a spokesperson for the Federal Emergency Management Agency (FEMA), which is overseeing the response to the outbreak, said that federal agencies are “working to meet demands for personal protective equipment (PPE) through new acquisition, [Department of Defense] allocation, or Strategic National Stockpile sources.”

But experts say the federal government isn’t doing enough, with multiple people describing the current response as “a systemic failure.” Local and state officials complain that they now have to outbid each other, as well as other countries and the federal government, to secure dwindling supplies, even if they need PPE more than other bidders.

Much of the criticism has focused on Trump’s use of the Defense Production Act. The law probably can’t enable much more PPE production in the short term, since new production can take weeks or months to scale. But it does let the federal government reprioritize the production that’s already out there.

For example, the feds can tell factories making surgical masks to direct their products to New York — which is currently suffering the worst coronavirus outbreak in the US — over states that aren’t as hard hit. Or the federal government can buy up the supply and then direct it on its own accord. Or it can even order some factories that don’t normally make PPE to start producing it, while providing funds for these operations to get up and running (although, again, that can take time).

The idea: During normal times, companies are typically guided by profits and a “first come, first serve” basis. But during an emergency, that’s not good enough; some places will need certain products first, even if they don’t have more money or didn’t place the order first.

Trump signed an executive order invoking the Defense Production Act last week. But he’s wavered on fully activating the law and forcing manufacturers to scale up production in a specific, mandated way, instead arguing that he’s merely using the Defense Production Act as “leverage” to get companies to do the right thing. He’s compared fully activating the law to “socialism” — which experts say is false, because the Defense Production Act doesn’t let the government nationalize a private company or asset.

The administration did say it was going to use the Defense Production Act more fully earlier this week, but it then abruptly backed down.

This has led some public officials and advocates to criticize the administration for not going far enough. “I do not for the life of me understand the reluctance to use the federal Defense Production Act,” New York Gov. Andrew Cuomo said at a March 24 press conference.

Experts disagree on just how far the federal government should go here. James Hasik, a senior fellow at George Mason University’s Center for Government Contracting, said that the law should be used “more as a scalpel than an ax.” Rather than placing a mass order of products, he added, “You want to find where the particular problems are. You want to let industry mostly solve these problems. And when somebody is being a jerk and needs to be told, ‘No, you’re not cooperating, you’re not playing well during this national emergency,’ then you send a letter or make a phone call.”

Others take a more aggressive view. Steve Grundman, a senior fellow at the Atlantic Council, told me that “this is a whole different kind of crisis.” In his view, the current outbreak requires the federal government to get more hands-on than it has in the past, compared to when he oversaw Defense Production Act implementation in the 1990s as a deputy undersecretary in the Defense Department.

That could require more aggressive, broader orders about what should be produced and where it should go. At the very least, it should require much more coordination than the Trump administration appears to be providing so far — a point that Hasik agreed with.

That such aggressive action may even be needed, though, further exposes the underlying problem: America was not ready for the coronavirus pandemic. And the ongoing response to the current outbreak isn’t leading to more confidence that it’ll be ready for the next one, either.

“People want to be able to feel safe,” Griffeth said. “Because the government has been so slow in responding to this pandemic, people don’t feel safe.”