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This is how often you should wash your cloth face mask.

USA TODAY

Treating coronavirus patients in one of the busiest emergency rooms in Manhattan, Dr. Jason Hill wore the same disposable respirator mask for up to four shifts in a row.

He’d take the mask home from Columbia University Medical Center, his coffee-flavored breath clinging to its fibers. Then he’d bake it in an oven to kill any viral hitchhikers. A half-hour at 140 degrees.

For months as the virus filled hospitals in New York and across the nation, doctors, nurses and other medical workers risked their lives in similar ways – sharing protective gear, reusing masks or going without – simply because there weren’t enough to go around.

Thousands of health care workers got sick, and hundreds died.

Nurses at Mount Sinai West hospital in New York City wore Hefty trash bags to protect themselves. Doctors at a California veterans hospital were handed one single-use disposable respirator in a brown paper bag at the beginning of the day to use for an entire shift. 

The stories spawned a massive volunteer network to make cotton masks and donate supplies. The Federal Emergency Management Agency, under the direction of President Donald Trump,created an airlift to bring in emergency supplies from around the world. U.S. companies that had never made personal protective gear filled in as pinch-hitters, all in an effort to ease shortages.

Six months into the nation’s battle with the coronavirus, doctors and nurses still face a dearth of supplies as coronavirus cases rise nationwide. Nearly 45% of those surveyed by the American Nurses Association said they experienced protective gear shortages as late as May 31. Almost 80% said their employers encouraged or required them to reuse disposable equipment. 

More: Tracking the coronavirus outbreak in the USA

Things have improved since the severe shortages in March. Major mask manufacturers increased production. Federal officials eased some rules for masks and other personal protective equipment, commonly known as PPE, allowing reuse and cleaning. But those efforts haven’t matched, much less gotten ahead of, the demand.

The USA TODAY Network analyzed dozens of government reports and interviewed more than 50 experts – including health care administrators, traders and lawmakers – about the PPE shortages, especially the disposable masks that cost a few pennies to a dollar. 

The blame, experts agreed, goes beyond any single person or agency but is the culmination of decades of change in the nation’s manufacturing capabilities, a worldwide shift in how goods are delivered and the country’s long battle with medical costs. Warnings about how these factors set the stage for shortages during a worst-case scenario went unheeded, leaving the country unprepared for a pandemic. 

By the time the coronavirus arrived, it was too late. The nation was left with massive shortages and a ruptured supply chain that won’t be an easy fix. 

Michael Alkire, president of Premier, one of the nation’s largest hospital purchasing organizations, is optimistic the supply chain problems can be corrected.

“Nothing is insurmountable,” Alkire said. He and others recommended moving manufacturing of critical supplies out of China and closer to home, better coordinating supplies during emergencies and ramping up emergency manufacturing when needed. 

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National Nurses United protest in front of the White House calling attention to the health care workers lacking PPE.

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Will the country be ready if a second surge of the virus hits this fall? It’s too soon to say, Alkire said. Much depends on how many hospitalizations occur and where.

“If we get another New York City that goes all over the country,” he said, “obviously we’re going to be in short supply, even though everybody is working like the dickens to get product.”

Some of the PPE shortages are being addressed by U.S. manufacturers who continue to add manufacturing lines and capacity, Alkire said, but fully resolving the situation could take years. 

The problems span multiple federal administrations.

Federal pandemic planners, scholars and some manufacturers warned for at least 15 years that shortages of respirator masks and other supplies, including prescription drugs, were likely during a pandemic. They warned billions of masks would be needed.

“All of us knew how desperate the need was,” said Dr. Sonja Rasmussen, a University of Florida professor who co-wrote a federal study at the Centers for Disease Control and Prevention in 2017 on the lessons learned about personal protective equipment from public health responses. 

Multiple studies had warned: 

  • Decades of pressure on hospitals, businesses and governments to cut costs and make more money left the country ill-prepared for a pandemic.  
  • A shift of manufacturing overseas, especially to China, meant more than 90% of the world’s masks and respirators are made outside the USA, far away and difficult to reach, especially during a global crisis. 
  • Hospitals wouldn’t have the supplies they needed. In a 16-state survey in 2014, not a single hospital reported having a stockpile or emergency cache. 

As the Asian Development Bank put it in a briefing statement, “The combination of offshoring, lean manufacturing and just in time inventory to cut costs may have stretched the global supply chain to a breaking point.”

A pandemic begins

Troubles began with mask production weeks after China, which produces more masks than any other country, reported the first coronavirus cases Dec. 31.

Chinese provinces near the outbreak went into lockdown. For weeks, the government required most masks produced in China to stay there. The filtering fabrics factories used to make masks ran low. 

Dozens of countries limited or banned the export of masks and supplies. 

By late January, masks began disappearing off shelves in the USA, and stores had a hard time restocking.

Hospitals found their supply lines drying up by early March. They dug into reserves designed to buy them a little time during normal surges in activity. It quickly became apparent the coronavirus was nothing like a bad flu season.

Production in China rebounded a few weeks later, but it was too late. The demand for masks was so high the world’s shipping industry couldn’t keep up. Hospitals across the USA reported acute shortages.

Fierce competition for protective gear among hospitals, clinics, states and the federal government drove up prices and attracted con artists.

“The magnitude and speed of the spread of coronavirus just overwhelmed the entire supply chain from A to Z,” said Mike Crotty, an Ohio-born Shanghai textile broker with more than 35 years in the business. “It was a madhouse.”

‘Mass exodus’

China’s move toward manufacturing dominance began more than 30 years ago when the country adopted a series of economic measures. Congress granted China permanent normal trade relations status in 2000, and in 2001, China joined the World Trade Organization. As trade restrictions were lifted, China attracted investors and companies looking to lower manufacturing costs. 

U.S. companies were among those setting up shop in China, including maskmakers 3M and Honeywell.

By 2011, China’s exports had grown by more than 500% while manufacturing employment in the USA dropped by almost 20%, at least 2 million jobs. China became the biggest supplier of imports to the USA, about $452 billion worth in 2019. 

“America’s maskmakers left America in an uncoordinated mass exodus,” said Mike Bowen, CEO of Texas-based Prestige Ameritech, one of the nation’s few domestic mask manufacturers. 

Less than 10% of the masks used in the USA are made here. China makes almost half the world’s masks, gowns, gloves and other PPE. 

When China nationalized its factories in February and directed all mask production to domestic use, that left much of the world in a quandary. 

A USA TODAY Network investigation showed imports of goods to the USA plunged in the category that includes masks. 

As other parts of the world began battling the coronavirus in January and February, China rushed to import millions of protective items. Exports to China from the USA surged. 

Emails among U.S. Department of Health and Human Services officials in late January and early February, released as part of a whistleblower complaint, showed a flurry of confusion, delays and debates as the virus began to spread. The complaint was filed by Rick Bright, who was director of the department’s Biomedical Advanced Research and Development Authority.

Bowen sent near-daily emails to the department in late January. “If the supply stops,” he warned on Jan. 25, U.S. hospitals would run out of masks.

Speaking about the virus on Jan. 30, Trump said, “We think we have it very well under control.”

On Feb. 7, Secretary of State Mike Pompeo announced the United States had shipped 17.8 tons of donated medical supplies – including masks and respirators – to China.  

Two days later, according to a memo included in the whistleblower complaint, Peter Navarro, a senior adviser to Trump on trade, recommended the United States halt the export of respirator masks and try to ramp up production.

In mid-February, the U.S. Commerce Department published a flyer with tips for U.S. companies that wanted to ship face masks, ventilators and other supplies to China, which had temporarily lifted some registration requirements for imports.

China pushed factories to increase production. New companies jumped in to start producing masks. “Everybody was moving fast,” said Crotty, president of Golden Pacific Fashion and Design in Shanghai. His company started to sell masks in the midst of the pandemic.

As production increased, manufacturers encountered shortages of the specialized, nonwoven fabric called polypropylene, used to make the masks, said Renaud Anjoran, a China-based quality engineering consultant and auditor with Sofeast. The material is “melt blown” to create small, electrically charged fibers that trap small particles and prevent the spread of infectious diseases.  

#GetUsPPE

In the USA, supplies were running low in March – even before COVID-19 cases began to multiply – because of the busy flu season, said Valerie Griffeth, a doctor with specialties in emergency medicine and intensive care at Oregon Health and Science University. Griffeth works with GetUsPPE.org, an effort organized by health care workers in response to the coronavirus-driven shortages to match providers with supplies and raise awareness.

Before the pandemic, emergency room doctors rarely used the disposable N95 respirator masks, Hill said. Hill had worn one only a few times over his nine-year career, usually to protect himself while treating a patient with tuberculosis.

By mid-March, some hospitals were using up to 17 times more masks and gloves than normal. 

The N95 disposable respirator is essential for controlling infectious diseases such as the coronavirus. It filters out 95% of the harmful particles in the air and is more comfortable to wear and less scary for patients than masks that provide greater filtration. 

When the coronavirus struck, use of the N95s in the USA shot from 50 million per month, 10%-15% of which were used in health care, to 300 million a month, mostly for health care, said Gary Gereffi, who directs the Global Value Chains Center at Duke University. 

That’s almost 1 billion masks over three months, as experts had predicted. Nested in a row, that’s enough masks to reach from Seattle to Miami, and back.

Some East Coast hospitals used 40,000 masks a day, said Mike Schiller, senior director of supply chain for the Association for Health Care Resource and Materials Management.

Almost half the hospitals that answered a survey in March by the Association for Professionals in Infection Control and Epidemiology were either out of N95 respirators (20%) or almost out (28%). 

When the coronavirus hit a rural, predominantly African American community in Georgia in March with devastating consequences, a stockpile at Phoebe Memorial Hospital that normally would have lasted six-months was gone in a week, Dr. Shanti Akers told a U.S. House subcommittee. 

“We were and still are forced to make that supply stretch,” Akers said in late May.

‘Just in time’

The critical supply shortages across the country illustrated the pitfalls of the lean ordering systems hospitals put into place over three decades to cut costs.

“It’s no secret that the margins in hospitals are being tightened,”  Schiller said. For years, hospitals have faced constraints on reimbursement levels from insurers. 

They eliminated warehouses full of supplies and equipment and adopted “just-in-time” practices to keep stockpiles as low as possible to cut costs, ordering supply shipments to arrive as needed instead.

In turn, distributors don’t carry as much inventory and depend on deliveries from their own suppliers, who rely on shipments from the countries making masks, including China, Taiwan and India. 

“Just like everywhere across the country, I think it’s pretty clear that we are not prepared for these types of pandemics, and that’s showing itself in spades right now,” said Joseph Fifer, president and CEO of the Healthcare Financial Management Association.

Most hospitals keep five to nine days of N95s in stock, said Dr. Stephen Kates, a chair of orthopedic surgery at Virginia Commonwealth University’s Medical Center and a professor.

One night in mid-March, when Hill’s hospital was “awash in a sea of COVID,” he had to intubate a patient, forcing a breathing tube into the patient’s airway. The coronavirus spreads through fluids from the nose and mouth, but no one in the emergency room could find a face shield, so Hill performed one of the riskiest procedures without one. 

He rounded up a group of 3D-printing friends and the Columbia University Design Center to make face shields. Working around the clock for weeks, the volunteers printed thousands.

‘The Wild West’

As the shortages grew more severe, states and hospitals looked for help from the federal Strategic National Stockpile, a collection of drugs, antitoxins, respirators, ventilators and other supplies overseen by the Department of Health and Human Services.

Former officials and other experts said the stockpile was never adequately funded as congressional priorities and budgets shifted from year to year. By early April, 90% of the stockpile’s PPE supplies were gone.

That left the marketplace, where purchasing officials for states and hospitals encountered extreme competition and soaring prices. Many vendors, scenting profits, looked to break into the business.  Many sellers required cash up front before they would ship masks and other supplies. 

Dr. Andrew Artenstein, an infectious disease specialist for Baystate Health in western Massachusetts, wound up in an out-of-state parking lot in April, wheeling and dealing to buy masks. Just when he thought the supplies were safely rolling away in disguised trucks, he said, federal agents arrived, demanding to know where they were headed.

Some state officials dubbed it “the Wild West.”

“It’s pretty chaotic and difficult,” said William Tong, Connecticut’s attorney general as he helped to find supplies and check vendors’ backgrounds. “I am aware of offers to sell PPE to hospitals at exorbitant prices.”

In Louisiana, emergency officials put together a list of potential vendors for masks and other supplies. Prices for N95s were as much as 28 times higher than before the pandemic. Three companies on the list showed prices higher than $10 per mask, more than 10 times higher than normal. State records show the highest quote, from a company named Deera Bituach, was $14.63. Per mask.

Other proposed contracts so alarmed Louisiana officials they turned them over to the attorney general’s office for further investigation. 

Businesses also faced a chaotic environment. Mask manufacturer 3M filed four lawsuits across the nation against vendors it said tried to sell tens of millions of nonexistent 3M N95 masks. 

Amazon removed 6,000 accounts it identified as price gouging attempts, and the company said it was working directly with state attorneys general “to prosecute bad actors and hold them accountable.”

The online retailer proved a boon for volunteers throughout the nation looking for elastic, cotton fabric and other supplies to make homemade masks for health care workers and first responders. 

Elizabeth Townsend Gard, a law professor at Tulane University in New Orleans, launched the MillionMasksADay.com website with friend and fellow quilter Seth Hackler. They were among dozens of groups across the country that donated tens of thousands of colorful cotton masks.

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“We knew people who were sick and people who died,” Townsend Gard said. “How could we not be making masks?” 

‘A cluster’ 

Even for states and hospitals that managed to find supplies, getting freight from China to the USA became “a cluster,” said Steve Keats of Miami, a partner in Kestrel Liner Agencies, an international shipping company. 

Cargo comes from China in two ways, Keats said: a 12-20-day journey on a cargo ship or in a matter of hours in the belly of a jet.  Everyone wanted their mask deliveries via air, but fewer passenger jets were flying across the Pacific, and that meant less space in their cargo holds for shipments. 

Air-freight wait times increased to almost a week, Keats and others said. They watched in shock as shipping costs quadrupled.

Passenger airlines American and Delta started making cargo-only flights, in some cases stowing cargo in space normally used for passengers.

Eventually, the Federal Emergency Management Agency intervened to speed things up and get supplies where they were needed most. Dubbing the effort “Project Air Bridge,” FEMA worked with commercial cargo companies, including UPS and FedEx, to pick up supplies from manufacturers in Asia and Latin America and deliver to U.S. distributors for sale at market prices. 

Through mid-May, the project distributed 768,000 N95 respirators and 75.5 million surgical masks to areas prioritized by FEMA and HHS. FEMA said it would build up a 90-day supply of masks, respirators and other items.

‘A complete and utter train wreck’ 

As deaths mount and the fight against the virus continues, lawmakers, manufacturers and others say it’s time for the United States to heed the years of warnings and develop the ability to respond more quickly. 

The situation this spring was “a complete and utter train wreck,” said Sen. Chris Murphy, D-Conn. “It was ‘Lord of the Flies’ out there.”

Overseeing purchasing for more than 4,000 hospitals, Premier President Alkire is keenly aware of every failure and bottleneck in the supply chain. He worked with FEMA on the air bridge.

He and others said three big things need to happen:

  • Some manufacturing of essential raw materials, medical supplies and prescription drugs, should return to the USA, or at least Canada and Mexico. 
  • A high-tech coordinated national system should locate products and determine where they’re needed during emergencies.
  • The federal government needs to provide incentives to companies to maintain the ability to ramp up emergency production of masks and other medical supplies when needed.

Murphy and other federal lawmakers launched legislation aimed at correcting some of the problems. 

But some experts noted disasters tend to fade quickly into memory when a new disaster occurs.  

That’s a natural response in part, said neuroscientist David Rock, founder of the NeuroLeadership Institute. Humans unconsciously let one threat fade into the background and move on to the next. “Something that feels far away – like it happened 100 years ago or in another country – just isn’t given importance.”

The role of leaders in any organization, he said, “is to think at longer-term horizons and make sure the important, not just urgent, things get done.” 

Contributing:  Dian Zhang and Emily Le Coz 

Dinah Voyles Pulver, Erin Mansfield and Katie Wedell are investigative reporters for USA TODAY. Contact Dinah at dpulver@gatehousemedia.com, Erin at emansfield@gatehousemedia.com and Katie at kwedell@gatehousemedia.com.  Dian Zhang is a data journalist for USA TODAY. Contact her at dzhang@gatehousemedia.com. Emily LeCoz is the regional investigations editor for USA TODAY. Contact her at elecoz@gatehousemedia.com.

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