
In Pursuit of PPE - erwan
https://www.nejm.org/doi/full/10.1056/NEJMc2010025
======
sailfast
This is insane. 5x markup and federal seizure of privately procured masks that
will then get given to private companies to give to hospitals. Instead, the
government could institute price controls and distribute directly to those in
need or allow all private purchases to go through while controlling part of
the market. Absolutely crazy. Not to mention having to hope your governor
praises the federal government to get their masks back.

You could not have invented a worse scheme for this, but somehow they have,
AND they’re using federal manpower (in N95s, naturally) to intercept these
shipments.

~~~
pmorici
Whats even more nuts is that N95's have taken this level of importance in
healthcare at all instead of reusable P100 masks. I read a post on medium the
other day about a hospital in Texas that does that and it was being treated as
some kind of amazing discovery as if this was some unknown miracle device.

[0] [https://elemental.medium.com/a-tiny-hospital-in-texas-
might-...](https://elemental.medium.com/a-tiny-hospital-in-texas-might-help-
solve-the-mask-shortage-9ad3c0a7a861)

~~~
danenania
I've found that the P100s tend to make me feel lightheaded pretty quickly. I
tried to wear one on a very smoky drive from LA to SF during the fire season
last year, but had to take it off after ~45 minutes because I felt my ability
to concentrate on the road was being weakened too much. That would definitely
be an issue for healthcare workers. I haven't experienced anything similar
with an N95.

~~~
pmorici
You might not have been wearing it right. You might also want to get your
lungs checked with a spirometry machine a standard test that is done to make
sure peoples lungs are healthy before letting the wear a respirator.

[https://www.healthline.com/health/spirometry](https://www.healthline.com/health/spirometry)

~~~
danenania
I run 3-5 miles most days, so I don’t think it was a lungs issue. I was
wearing it very tightly—maybe I made a mistake, but I’m pretty sure it was on
right.

------
reggieband
When I read this kind of thing I am happy we live in a society that allows the
free discussion of information. It is no exaggeration to say this kind of
honest description of events by a senior health official could have lead to
imprisonment or worse in many historical and some modern contexts.

Given how many people are currently unemployed - how is it that we can fail to
ramp up our own ability to produce this needed equipment? There is no shortage
of labor. Forget about the failures to prepare in January, February and March
- what are we doing right now to prepare for the next 6 months?

I'm looking around for a leader who has that vision. Governors are blaming the
federal government. The federal government is blaming China and the WHO. Who
is organizing the effort to fill the gaps?

~~~
rhino369
>Given how many people are currently unemployed - how is it that we can fail
to ramp up our own ability to produce this needed equipment? There is no
shortage of labor.

Labor isn't the limiting factor. You need machines, raw materials, supply
chains.

There isn't an AWS for N95 mask manufacturing.

~~~
elihu
There are some surprisingly resourceful groups doing local manufacturing in
incredibly inefficient, seemingly-unscalable ways and actually producing masks
and eye-shields by the thousands.

[https://www.facebook.com/groups/pdx3dplab/](https://www.facebook.com/groups/pdx3dplab/)
[https://team2471.org/](https://team2471.org/)
[https://pdxhackerspace.org/](https://pdxhackerspace.org/)

This is just in the Portland area. I assume there are similar efforts around
the country and around the world.

Ideally this stuff should be made in factories rather than hundreds of bespoke
3d printers operated by volunteers, but if the need and motivation is there, a
lot can be accomplished. Maybe it's not enough, but it's a lot more than
nothing. And the longer this goes on, the more efficient the organization and
manufacturing gets.

Normally the regular supply chain would handle all this, but if the supply
chain is broken by hoarding behavior or the wrong kinds of active government
intervention, the alternative is to bypass the usual market and use whatever
local workforce volunteers or can be hired to make what's needed directly for
the institutions in need.

~~~
rckoepke
N95 masks don't require 3D printers, they require melt-blown fabric. My
girlfriend and I are chemical engineers, and took a look at the process that
turns bulk, cheap, and widely available plastic (PE, PP, PC, etc) into melt
blown fabric. She noted that it looked pretty nasty to her, and she wouldn't
want to be involved with the startup for a new plant, and we regularly work
with pretty nasty chemicals in large quantities. I was less hesitant, thinking
it doesn't look that awful but I tend to be far less risk-averse. With proper
safety precautions I think I'd be fine with it, but both of us feel that
companies are extremely likely to fail at fully protecting the workers near
the equipment from hazards. Here's an example of the machinery required:
[https://www.youtube.com/watch?v=897yTI6wXWY](https://www.youtube.com/watch?v=897yTI6wXWY)

You need a lot of capital for a melt-blown fabric facility, and some
specialized engineers. China and Taiwan managed to build new facilities of
huge size very quickly - it can be done, but apparently much harder for the
large American conglomerates to get off the ground as quickly.
[https://www.wfuv.org/content/covid-19-has-caused-shortage-
fa...](https://www.wfuv.org/content/covid-19-has-caused-shortage-face-masks-
theyre-surprisingly-hard-make)

If you can get >$10 million together, and a very dedicated and specialized
team of engineers, plant operators, machinists, and businesspeople - you might
be able to finish your factory before 3M's Rhode Island and Arizona plants, if
you start right now. But you won't do it in a distributed way with a bunch of
people with 3D printers.

However, it seems there's evidence that non N95 masks have some efficacy. Just
regular old cotton clothing cloth. You could start an MLM/Amway/Mary-
Kay/Avon/Vemma/Younique style thing to get out-of-work people to make these at
home and sell them to friends and family.

Sinopec decided on Feb 24 to built a melt-blown fabric plant
[https://www.youtube.com/watch?v=p9lchhBE7cE](https://www.youtube.com/watch?v=p9lchhBE7cE).
It was operating on March 6. It took them 10-12 days to build, from scratch, a
facility to produce 1.2 million N95 masks per day. One of my links above shows
another facility built in 11+ days making 200,000 N95 masks per day.

At the start of the outbreak, Taiwan could product 100,000 N95 masks per day,
but have built over 60 production lines, and now make enough melt blown fabric
to product over 20 million N95 masks per day. Notably, Taiwan had a HUGE
stockpile of masks, so even though making 100,000 masks per day wasn't enough
for their population, they had enough in storage to last them while they built
up their capacity. Now they make enough to send tons of masks the the USA
every week.

USA (3M) decided to build melt-blown fabric facilities around March 23:
[https://www.powderbulksolids.com/news/Honeywell-
Expands-N95-...](https://www.powderbulksolids.com/news/Honeywell-
Expands-N95-Respirator-Production-at-RI-Plant-03-26-2020) and to a much
smaller capacity. And none of the new lines in the USA are up and running yet.
"Before the onset of the COVID-19 pandemic, 3M was manufacturing about 50
million masks per month" ... "In its continuing effort to help meet demand, 3M
says it is working to double its global N95 mask production numbers once again
to 200 million units monthly." But they think that will take another YEAR to
accomplish. Only 35 million N95 masks are currently made in the USA, by 3M or
others. [https://www.nasdaq.com/articles/n95-mask-production-wont-
mee...](https://www.nasdaq.com/articles/n95-mask-production-wont-meet-demand-
for-another-year-3m-predicts-2020-04-02)

Ideally, each citizen would have a new N95 mask for every day. We'll get to 1
mask per citizen per month, sometime around a year from now.

------
fny
I'm actively on the hunt for PPE on behalf of hospitals and I can tell you the
mark up comes from several places:

\- First, manufacturers have marked up prices. What used to cost 5c from a
Chinese manufacturer now costs 30c or more. \- Aside from supply being keen on
the shortage, demanders are also willing to push prices even higher. I have
even had people /outbid/ my place in line for product. \- Airfreight costs
$14.50 a kilo. It's typically around $2-3 a kilo. \- Financing is hard. In
many cases, no one wants to pay up front at all or make deposits because of
all the scams and counterfeit products. Suppliers similarly want money up
front, often 100%. The transaction itself becomes a more risky proposition. I
can't find anyone willing to finance part of a 30 day transaction for 5%
returns.

The Federal seizures have made everything even more risky. Price controls will
not fix this. A manufacturer in China has enough demand from the rest of the
world to charge. (I was out bid from someone from France.)

The only thing we can do is ramp up supply.

~~~
Cynddl
> I was out bid from someone from France.

This is quite interesting to read. Most of the media coverage in France has
been very hostile against the US with little evidence to back it. We've seen
claims of Americans waiting on the tarmac to buy our masks and redirect
planes, cash in hand ready to be given. And in major newspapers [1, 2].

[1] [https://www.lefigaro.fr/actualite-france/coronavirus-les-
reg...](https://www.lefigaro.fr/actualite-france/coronavirus-les-regions-
redoutent-le-vol-de-masques-par-les-americains-20200402) [2]
[https://www.liberation.fr/france/2020/04/01/une-commande-
fra...](https://www.liberation.fr/france/2020/04/01/une-commande-francaise-de-
masques-detournee-vers-les-etats-unis-sur-un-tarmac-chinois_1783805)

~~~
nicbou
It doesn't help that the US tried to make some shady deals with a German
company for exclusive access to the vaccine, and allegedly rerouted PPE paid
for and headed to Germany.

------
gok
We should give US doctors lots of PPE for no cost.

Then a few months later, mail the hospitals bills for every person involved in
making those masks. Also separate bills for the "specialists" who packed them
into cardboard boxes. Then a month later we should send them another bill
explaining that we decided the original mask shipment actually wasn't covered
under their donation plan.

If they have trouble paying we should let them know we have payment plans
available.

~~~
0x00000000
Yeah it is rather ironic all this talk about price gouging in a state of
emergency when hospitals do it all the time, especially for emergencies where
the person has no choice.

Oh masks cost 5x as much now? What a tragedy, they are charging 1-3 orders of
magnitude markup on everything, all the time. But now people want to talk
about “ethics”?

I hope when this is all over that is sparks a serious conversation about the
healthcare mafia. A lot more needs to change before throwing tens of trillions
of dollars at them for Medicare for all.

------
hef19898
While I can only speak for Europe, more particularly for Germany, I learned
quite a lot about masks in the last couple if weeks when I tried to leverage
my logistics contacts to get masks and stuff from China.

IMHO we see what a complete brake down of an established supply chain looks
like. As end users in Germany are unable to source directly from Chinese
suppliers, and these suppliers are unable to import, the high demand, combined
with production shutdowns, resulted in a near global stock out.

While this is bad enough, the multi-tiered distribution chain (producer,
importer, wholeseller, local distributor) is by definition not capable or fast
enough to recover in any reasonable amount of time. And that is under ideal
conditions, and not during a global shortage and run on the product in
question.

One would be tempted to assume some central entity would be able to step in.
But in Germany, that fell to the armed forces and other government entities.
And those have not the slightest clue about international trade. So the
insisted on suppliers to import. Remember why the supply chain is the way it
is? So the only thing working is donations, because there logistics pros are
running things.

It is not a question of availability of masks nor transportation capacity or
lead times, just price.

Now it seems the import part is solved. I give the government 2 weeks tops to
realize distribution is not that easy neither. Just having masks in some
warehouse is only the first step of supplying the front line people.

~~~
rfoo
Sounds duly familiar to what I read about Wuhan back in late January and
February. Only donations work. Had massive trouble distributing things.
Fortunately at least you don't have to deal with another distraction named
"government redirected your donation shipment to Red Cross (ran by government
in China) and they sat on their stockpile doing nothing or malicious".

~~~
hef19898
So far, no. I guess we have to be happy about the little things, don't we?

------
ttul
It's absolutely insane that PPE isn't something that's being procured on a
national level. Why are hospitals and clinicians having to deal individually?
If there were a monopsony buyer (i.e. the Feds), suppliers could be bullied
into providing reasonable terms.

Well, I suppose the real answer is: Because that's not how healthcare works in
America...

~~~
nashashmi
I'm going to repeat your question: why isn't ppe being procured on a national
level, and instead why is dhs seizing supplies, and why is not a war supplies
act being declared when the national government is clearly needing them and
not able to procure them.

It is insane on multiple levels.

~~~
notagamedev
Is a war supplies act different from the Defense Production Act that has been
invoked?

------
tosser0001
I was certain by this point in the crisis we'd be seeing video akin to
WWII/"Rosie the Riveter" stuff of PPE flowing out of factories around the
country.

Is the U.S.A. simply not capable of this level of production any longer? What
the heck is going on? It's sobering.

~~~
bolasanibk
Because retooling is expensive and time consuming. And there is no guarantee
how long this level of demand will sustain. And no guarantees on cheap chinese
goods flooding the market and taking all your customers in a few months.

~~~
xienze
> And no guarantees on cheap chinese goods flooding the market and taking all
> your customers in a few months.

You might could fix that with strong tariffs. There was a guy recently, can’t
remember his name, who was very much in favor of domestic manufacturing and
tariffs against China. Seemed to catch a lot of flak for those policies! Wish
I could remember who that was...

~~~
mindslight
Bingo. It's amazing, this could have been _the shining moment_ for his
platform. Give domestic mask manufacturers immediate long-term federal
contracts and a promise of significant tariffs when the dust settles. Instead
he denied the problem even existed, encouraged people to get infected, and
delayed our response by six weeks.

------
somewhereoutth
What I fail to understand - where was the emergency planning? A global
pandemic is surely one thing that is a) foreseeable and b) possible to plan
for. PPE could have been stockpiled, essential industry identified, testing
infrastructure established, quarantine protocols put in place. We even had a
dry run with SARS!

I'm sure there are (or were) civil defence / continuity of government plans in
case of nuclear war, this must have been number 2 on the list of possible
national emergencies?

~~~
baybal2
Sure they were!

Some titles to Google:

National Security Council: National Biodefense Strategy 2018

H.R. 269 (116th): Pandemic and All-Hazards Preparedness and Advancing
Innovation Act of 2019

H.R. 6378 (115th): Pandemic and All-Hazards Preparedness and Advancing
Innovation Act of 2018

United States Government Accountability Office — Report on national bio
defence strategy

Bipartisan Commission on Biodefense Report 2019

------
sirsar
Serious question: If the FBI and DHS are seizing PPE, where is it going? Why
can't this hospital be a beneficiary of seized PPE, rather than an (almost)
victim?

~~~
cameldrv
Blue Flame Medical.

------
altoidaltoid
[https://www.businessinsider.com/fema-paid-bankrupt-
company-n...](https://www.businessinsider.com/fema-paid-bankrupt-company-no-
employees-55-million-n95-masks-2020-4)

No corruption here...

~~~
m0zg
Yeah, they should have spent a month or two vetting every single company out
of tens of thousands involved in the effort. This armchair quarterbacking is
tiresome.

~~~
untog
Come on. There's a middle ground. Of course the government can't be expected
to vet every company in absolute depth right now, but it can very easily check
a few criteria:

\- does this company have any experience making the product in question?

\- what size workforce does this company have to deploy once they receive
funds?

This is basic stuff. Very basic stuff. And the government is failing at it.

------
anxman
I wrote up instructions on how to buy KN95 Masks from China for $1.67
delivered. Please share it to anybody in need of KN95 masks. If you need
samples of the masks, I can send them to you for free, just shoot me a
message.

[https://docs.google.com/document/d/1BKUmZgwrvPG47VMR8SFvvSVh...](https://docs.google.com/document/d/1BKUmZgwrvPG47VMR8SFvvSVh7lrUiMv0dvrnzmrs1Is/)

~~~
pm_me_ur_fullzz
The price premium comes from shipping and the cost of time.

MOST suppliers and even stateside vendors are trying to use Fedex, UPS, DHL.
Many profiteers/altruists have _already seen_ the possibilities here, and it
is crowded but has irreconcilable limitations. You need your own cargo planes,
shutting out most of the market. Plenty of other pitfalls too. With the risk
involved, the "public health" ethical debate around pricing now falls flat,
there is fortune involved in overcoming these hurdles.

People IN THE US want supplies IN THE US, not 10-15 days later with threat of
seizure by CCP, by Customs in China, by Customs in US, by Federal Government
and questionable product validity. So there is still actual, irreconcilable
scarcity, because even the fastest trendiest entreprenuers just really cannot
tell and operate on assurances, whereas the people that can have a limited
supply that is bought instantly in a constant bidding war.

------
jhart99
If this sort of seizure is being conducted under the Defense Production Act
Section I, there should be greater transparency of what PPE materials are
currently subjection to allocation control. Otherwise, we might as well have
the National Guard protect shipments from seizure within the states.

------
syllable_studio
Fixing our PPE supply chain was/is a solvable problem that our governments
have utterly failed to address properly. It is shameful that our federal and
state governments haven't better organized and incentivized solutions to fix
this. I understand that it's hard. I understand that they're working hard to
address this problem. But it's unacceptable that we haven't just gotten this
done -- that we've instead put the burden on our medical workers to solve this
life-or-death problem. As if they didn't already have enough to worry about.

I feel much closer to this issue than I expected to be. Because I worked for
weeks with a volunteer group called helpfulengineering.org to help figure out
how to make face shields through local partnerships. I was helping organize
efforts for the city of Chicago. Our group made dozens of 3D printed face
shields, then hundreds. Each face shield was given to a medical worker who
sent back stories about how desperately important each one was to them.

[https://twitter.com/syllablehq/status/1247891099324051462](https://twitter.com/syllablehq/status/1247891099324051462)

In an effort to scale up faster, we got price quotes from local manufacturers
who could manufacture NIH vetted face shields in bulk using injection molding
or die cutting. These local manufacturers were very eager to help and work
with us. We were prepared to get our own investment to kick-start the
manufacturing as long as we had some confidence that we could get the products
to market and not lose tens of thousands of dollars. We were prepared to sell
them AT COST - not even for a profit. Next step: we just needed help to
connect these manufacturers with an organized supply chain.

We talked to government offices and offered to help them get this plan in
motion. But no one could do anything except direct us to generic websites and
phone numbers. We filled out forms and called numbers. Never heard back. One
government office told us they were working as hard as they could, and there
were numerous projects in the works... but they couldn't give us any more
information. No transparency.

Weeks later, the hospitals are still in desperate need. There is still no plan
to solve this problem. Corporations have stepped up to donate a million here
and a million there. This is great. But it's not a replacement for the war-
time effort we need to save thousands of lives.

Thank you to so many leaders who are working hard -- including those from
Chicago. But we've got to do better than this. If our medical workers were
soldiers, we would not send them to war expecting them to find their own
community donated helmets.

------
rckoepke
> As a chief physician executive, I rarely get involved in my health system’s
> supply-chain activities.

This seems crazy to me. Maybe it's because I came from manufacturing, where
even front-line managers are heavily involved in supply-chain activities. We
constantly have discussions about how this-or-that global/regional/local event
might affect x or y commodity and the tortuous potential paths that may have
to affecting our business niches. However, high functioning bars and
restaurants also generally seem to have an excellent grasp of their extended
supply chain and market forces.

It blows my mind that hospital executives didn't understand much at all about
where their necessary supplies came from.

------
nashashmi
Where is the ppe going? And why is dhs stepping in when hospitals are ordering
them? Why cannot health care workers order ppe directly? Hospitals are having
a difficult time time giving them out to workers because it is low.

------
Jemm
Time to start manufacturing in country which now means that, in North America,
we need to provide financial incentives to all manufacturing because you can’t
start building one product without the local supply chain to accomplish that.

The time of cheap Chinese made goods must come to an end.

------
learc83
My fiancee is an ER doctor and her hospital is now getting considerably more
N95s than they were a few weeks ago. It looks like the supply chain is finally
ramping up.

------
mhb
It's easy to test the fit of the mask. I wonder what made him confident that
the filter material actually worked.

------
lucretian
so many comments asking "how could this be?" and "what the heck is going on?"
and so forth.

the answer is obvious, but i guess it's too "political" for people to accept.

~~~
qqssccfftt
Or it conflicts with their worldview that what we have now is the best thing
possible and life cannot be better.

------
abinaya_remote
Good approach!

------
pm_me_ur_fullzz
so they still buying or what

------
pm_me_ur_fullzz
> Having acquired the requisite funds — more than five times the amount we
> would normally pay for a similar shipment, but still less than what was
> being requested by other brokers

Pay attention people, this IS the market price. Even most state's "price
gouging" laws are limited to 30 days after the State of Emergency because if
the emergency has lasted that long, it is probably external forces outside of
the state. Just like is happening here.

This equipment has to be provided to the whole population, eventually, and
each person needs a whole pack. So since this does not exist, the prices go up
as every state and organization has its needs and tries to prioritize health
care workers.

To those noticing you can wash N95 masks in certain procedures:

It is also possible to boil water from a stream to remove some impurities. Or
you could just have more clean water, maybe even bottled. I wonder what people
will choose?

We are still at the healthcare workers first, phase. The inventory
does.not.exist, the inventory is not re-usable, there is a market that has no
relation to what prices were before the state of emergency. Insatiable
quantity and people just catching on can't effectively be in this market
quickly. China limits factories and more.

