While 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 the 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 were forced to risk their lives in similar ways – sharing protective gear, reusing masks, or going without – simply because there weren't enough to go around.
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 shocked the nation and 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. Meanwhile, companies in the U.S. that had never made personal protective gear filled in as pinch-hitters, all in an effort to ease shortages.
But six months into the nation's battle with the coronavirus, doctors and nurses still face a dearth of supplies as coronavirus cases continue to 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.
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, for example allowing reuse and cleaning. But those efforts haven't matched, much less gotten ahead of, the demand if the nation sees a big resurgence in coronavirus hospitalizations.
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 anywhere from 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 we deliver goods, 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 Akire, 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. Among the steps he and others said it would require are moving manufacturing of critical supplies out of China and closer to home, better coordinating supplies during emergencies and ramping up emergency manufacturing when needed.
Will the country be ready if a second surge of the virus hits this fall? It's really too soon to say, said Alkire and others. 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 already are being addressed by U.S. manufacturers who continue to add new manufacturing lines and capacity, Alkire said. But he and other experts USA TODAY interviewed said fully resolving the situation could take years.
While many have argued about whether one federal administration or the other is to blame, the problems span multiple administrations.
Federal pandemic planners, scholars and even some manufacturers warned for at least 15 years shortages of respirator masks and other supplies, even 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 at the CDC in 2017 co-authored a federal study on the lessons learned about personal protective equipment from previous public health responses.
Multiple studies had warned:
Decades of pressures on hospitals, businesses and governments to cut costs and make more money left the country ill-prepared for a pandemic.
A dramatic shift of manufacturing overseas, especially to China, meant more than 90% of the world's masks and respirators are made outside the United States, far away and difficult to reach, especially during a global crisis.
Hospitals -- under pressure to contain costs -- 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 recent 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."
Troubles began with mask production just weeks after China, which produces more masks than any other country, reported the first coronavirus cases on Dec. 31.
Chinese provinces near the outbreak went into lockdown. For weeks the government required most masks produced there to stay in China. Then, the filtering fabrics their factories use to make masks ran low.
Dozens of countries also limited or banned the export of masks and supplies.
By late January, masks began disappearing off shelves in the U.S., and stores had a hard time restocking.
Hospitals, too, 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. But 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 U.S. 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."
China's move toward manufacturing dominance began more than 30 years ago when the country adopted a series of economic reforms. Congress granted China permanent normal trade relations status in 2000, and in 2001, China joined the World Trade Organization. As additional trade restrictions were lifted, China attracted new investors and companies looking to lower manufacturing costs.
U.S. companies were among those setting up shop in China, including mask makers 3M and Honeywell.
By 2011, China's exports had grown by more than 500% while manufacturing employment in the U.S dropped by almost 20%, at least two million jobs. China became the biggest supplier of imports to the U.S., about $452 billion worth in 2019.
Bill Merkle works on making protective masks in Warren, Mich., Thursday, April 23, 2020. General Motors has about 400 workers at the now-closed transmission plant in suburban Detroit. All over the country, blue-collar and salaried workers have raised their hands to make medical equipment as companies repurpose factories to answer calls for help from beleaguered nurses, doctors and paramedics who are treating patients with the highly contagious new coronavirus COVID-19.
"America's mask makers 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.
Today, fewer than 10% of the masks used in the U.S. are made here. And China makes almost half the world's masks, gowns and gloves and other PPE.
So, when China nationalized its factories in February and directed all mask production to domestic use, that left the U.S. and much of the world in a quandary.
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 until recently was director of the department's Biomedical Advanced Research and Development Authority.
Bowen, the Texas mask maker, 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 January 30, President Donald Trump said: "We think we have it very well under control."
On Feb. 7, Secretary of State Michael Pompeo announced the U.S. had shipped 17.8 tons of donated medical supplies -- including masks and respirators -- to China.
Just two days later, according to a memo included in the whistleblower complaint, Peter Navarro, a senior advisor to Trump on trade, recommended the U.S. halt the export of respirator masks and try to ramp up production.
Still, 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.
At home, China pushed factories to increase production. And 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 had not previously sold masks, but started in the midst of the pandemic.
As production increased, manufacturers encountered shortages of the specialized, non-woven 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.
Back in the U.S., 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, said Hill and others. 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.
That N95 disposable respirator is essential for controlling infectious diseases like 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 U.S. shot from 50 million per month, with only 15-10% 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, exactly as experts had predicted. Nested in a row, that's enough masks to reach from Seattle to Miami, and back.
Some east coast hospitals were using 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 who answered a March survey 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.
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," said Schiller. 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 between five and 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 "just awash in a sea of COVID," he had to intubate a patient, forcing a breathing tube into the patient's airway. When no one in the emergency room could find a face shield, he performed one of the riskiest procedures for a disease that spreads through fluids from the mouth and nose without one.
He immediately 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.
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 Health and Human Services department.
Former officials and other experts said the stockpile was never adequately funded, with priorities and budgets shifting from year to year, driven in part by the changing priorities of Congress. 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 new 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.
Several 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, state 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 non-existent 3M N95 masks.
Amazon removed 6,000 accounts it had identified as price gouging attempts, and the company stated it was working directly with states 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 have donated tens of thousands of colorful cotton masks.
Elizabeth Townsend Gard, a law professor at Tulane University and co-founder of Millionmasksaday.com works on one of the many masks she's created since the coronavirus pandemic started.
"We knew people who were sick and people who died," said Townsend Gard. "How could we not be making masks?"
Even for states and hospitals who managed to find supplies, getting freight from China to the U.S. 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, said Keats and others. 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 also stated it would build up a 90-day supply of masks, respirators and other items.
As deaths mount and the fight against the virus continues, lawmakers, manufacturers and others say it's time for the U.S. to heed the years of warnings and develop the ability to respond more quickly in the future.
The situation this spring was "a complete and utter train wreck," said U.S. Senator Chris Murphy, a Connecticut Democrat. "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 also 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 U.S., or at least Canada and Mexico.
A high-tech coordinated national system to 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 legislators already have launched legislation aimed at correcting some of the problems.
However, several former federal officials 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 tend to unconsciously let one threat fade into the background and move onto 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 senior leaders in any organization, he said, "is to think at longer-term horizons and make sure the important, not just urgent things, get done."