The No. 1 lesson from the 2021 JP Morgan Healthcare Conference: Healthcare is ‘too vital to fail’

Chronic Conditions | HENRY KOTULA

The annual J.P. Morgan Healthcare Conference is one of the best ways to diagnose the financial condition of the healthcare industry. Every January, every key stakeholder — providers, payers, pharmaceutical companies, tech companies, medical device and supply companies as well as bankers, venture capital and private equity firms — comes together in one exam room, even when it is virtual, for their annual check-up. But as we all know, this January is unlike any other as this past year has been unlike any other year.

You would have to go back to the banking crisis of 2008 to find a similar moment from an economic perspective. At the time, we were asking, “Are banks too big to fail?” The concern behind the question was that if they did fail, the economic chaos that would follow would lead to a collapse with the consumer ultimately picking up the tab. The rest is history.

Healthcare is “Too Vital to Fail” 

2020 was historic in too many ways to count. But in a year when healthcare providers faced the worst financial crisis in the history of healthcare, the headline is that they are still standing. And what they proved is that in contrast to banks in 2008 that were seen by many as “too big to fail,” healthcare providers in 2020 proved that they were “too vital to fail.” 

One of the many unique things about the COVID-19 pandemic is we are simultaneously experiencing a health crisis, where healthcare providers are the front line in the battle, and an economic crisis, felt in a big way in healthcare given the unique role hospitals play as the largest employer in most communities. Hospitals and health systems have done the vast majority of testing, treating, monitoring, counseling, educating and vaccinating all while searching for PPE and ventilators, and conducting clinical trials. And that’s just the beginning of the list.

Stop and think about that for a minute. What would we have done without them? Thinking through that question will give you some appreciation for the critical, challenging and central role that healthcare providers have had to play over the past year.

Simply stated, healthcare providers are the heart of healthcare, both clinically (essentially 100 percent of the care) and financially (over 50 percent of the $4 trillion annual spend on U.S. healthcare). Over the last year they stepped up and they stepped in at the moment where we needed them the most. This was despite the fact that, like most businesses, they were experiencing calamitous losses with no assurances of any assistance. 

Healthcare is “Pandemic-Proof”

This was absolutely the worst-case scenario and the biggest test possible for our nation’s healthcare delivery system. Patient volume and therefore revenue dropped by over 50 percent when the panic of the pandemic was at its peak, driving over $60 billion in losses per month across hospitals and healthcare providers. At the same time, they were dramatically increasing their expenses with PPE, ventilators and additional staff. This was not heading in a good direction. While failure may not have been seen as an option, it was clearly a possibility. 

The CARES Act clearly provided a temporary lifeline, providing funding for our nation’s hospitals to weather the storm. While there are more challenging times ahead, it is now clear that most are going to make it to the other side. The system of care in our country is often criticized, but when faced with perhaps the most challenging moment in the history of healthcare, our nation’s hospitals and health systems stepped up heroically and performed miraculously. The work of our healthcare providers on the front line and those who supported them was and is one thing that we all should be exceptionally proud of and thankful for. In 2020, they proved that not only is our nation’s healthcare system too vital to fail, but also that it is “pandemic proof.” 

Listening to Front Line at the 2021 J.P. Morgan Healthcare Conference 

There has never been a more important year to listen to the lessons from healthcare providers. They are and were the front line of our fight against COVID-19. If there was a class given about how to deal with a pandemic at an institutional level, this conference is where those lessons were being taught.  

This year at the J.P. Morgan Healthcare Conference, CEOs, and CFOs from many of the most prestigious and most well-respected health systems in the world presented including AdventHealth, Advocate Aurora Health, Ascension, Baylor Scott & White Health, CommonSpirit Health, Henry Ford Health System, Intermountain Healthcare, Jefferson Health, Mass General Brigham, Northwell Health, OhioHealth, Prisma Health, ProMedica Health System, Providence, Spectrum Health and SSM Health.

I’ve been in healthcare for 30 years and this is my fifth year of writing up the summary of the non-profit provider track of the conference for Becker’s Healthcare to help share the wisdom of the crowd of provider organizations that share their stories. Clearly, this year was different and not because the presentations were virtual, but because they were inspirational. 

What did we learn? The good news is that they have made many changes that have the potential to move healthcare in a much better direction and to get to a better place much faster. So, this year instead of providing you a nugget from each presentation, I am going to take a shot at summarizing what they collectively have in motion to stay vital after COVID.

10 Moves Healthcare Providers are Making to Stay Vital After-COVID

As a leader in healthcare, you will never have a bigger opportunity to drive change than right now. Smart leaders are framing this as essentially “before-COVID (BC)” and “after-COVID (AC)” and using this moment as their burning platform to drive change. Credit to the team at Providence for the acronym, but every CEO talked about this concept. As the saying goes, “never let a good crisis go to waste.” Well, we’ve certainly had a crisis, so here is a list of what the top health systems are doing to ensure that they don’t waste it and that they stay vital after-COVID:

1. Take Care of Your Team and They’ll Take Care of You: In a crisis, you can either come together as a team or fall apart. Clearly there has been a significant and stunning amount of pressure on healthcare providers. Many are fearing that mental health might be our nation’s next pandemic in the near future because they are seeing it right now with their own team. Perhaps one of their biggest lessons from this crisis has been the need to address the mental, physical and spiritual health of both team members as well as providers. They have put programs in place to help and have also built a tremendous amount of trust with their team by, in many cases, not laying off and/or furloughing employees. While they have made cuts in other areas such as benefits, this collective approach proved incredibly beneficial. And the last point here that relates to thinking differently about their team is that similar to other businesses, many health systems are making remote arrangements permanent for certain administrative roles and moving to a flexible approach regarding their team and their space in the future. 

2. Focus on Health Equity, Not Just Health Care: This was perhaps the most notable and encouraging change from presentations in past years at J.P. Morgan. I have been going to the conference for over a decade, and I’ve never heard someone mention this term or outline their efforts on “health equity” — this year, nearly everyone did. In the past, they have outlined many wonderful programs on “social determinants of health,” but this year they have seen the disproportionate impact of COVID on low-income communities bringing the ongoing issue of racial disparities in access to care and outcomes to light. As the bedrock of employment in their community, this provides an opportunity to not just provide health care, but also health equity, taking an active role to help make progress on issues like hunger, homelessness, and housing. Many are making significant investments in a number of these and other areas. 

3. Take the Lead in Public Health — the Message is the Medicine: One of the greatest failings of COVID, perhaps the greatest lesson learned, is the need for clear and consistent messaging from a public health perspective. That is a role that healthcare providers can and should play. In the pandemic, it represented the greatest opportunity to save lives as the essence of public health is communication — the message is the medicine. A number of health systems stepped into this opportunity to build trust and to build their brand, which are essentially one in the same. Some organizations have created a new role — a Chief Community Health Officer — which is a good way to capture the work that is in motion relative to social determinants of health as well as health equity. Many understand the opportunity here and will take the lead relative to vaccine distribution as clear messaging to build confidence is clearly needed.

4. Make the Home and Everywhere a Venue of Care: A number of presenters stated that “COVID didn’t change our strategy, it accelerated it.” For the most part, they were referring to virtual visits, which increased dramatically now representing around 10 percent of their visits vs. 1 percent before-COVID. One presenter said, “Digital has been tested and perfected during COVID,” but that is only considering the role we see digital playing in this moment. It is clear some organizations have a very narrow tactical lens while others are looking at the opportunity much more strategically. For many, they are looking at a “care anywhere and everywhere” strategy. From a full “hospital in the home” approach to remote monitoring devices, it is clear that your home will be seen as a venue of care and an access point moving forward. The pandemic of 2020 may have sparked a new era of “post-hospital healthcare” — stay tuned.

5. Bury Your Budget and Pivot to Planning: The budget process has been a source of incredible distrust, dissatisfaction and distraction for every health system for decades. The chaos and uncertainty of the pandemic forced every organization to bury their budget last year. With that said, many of the organizations that presented are now making a permanent shift away from a “budget-based culture” where the focus is on hitting a now irrelevant target set that was set six to nine months ago to a “performance-based culture” where the focus is on making progress every day, week, month and quarter. Given that the traditional annual operating budget process has been the core of how health systems have operated, this shift to a rolling forecast and a more dynamic planning process is likely the single most substantial and permanent change in how hospitals and health systems operate due to COVID. In other words, it is arguably a much bigger headline than what’s happened with virtual visits.

6. Get Your M&A Machine in Motion: It was clear from the presentations that activity around acquisitions is going to return, perhaps significantly. These organizations have strong balance sheets and while the strong have gotten stronger during COVID, the weak have in many cases gotten weaker. Many are going to be opportunistic to acquire hospitals, but at the same time they have concluded that they can’t just be a system of care delivery. They are also focused on acquiring and investing in other types of entities as well as forming more robust partnerships to create new revenue streams. Organizations that already had diversified revenue streams in place came through this pandemic the best. Most hospitals are overly reliant on the ED and surgical volume. Trying to drive that volume in a value-based world, with the end of site of service differentials and the inpatient only list, will be an even bigger challenge in the future as new niche players enter the market. As I wrote in the headline of my summary two years ago,It’s the platform, stupid.” There are better ways to create a financial path forward that involve leveraging their assets — their platform — in new and creative ways. 

7. Hey, You, Get into the Cloud: With apologies for wrapping a Rolling Stones song into a conference summary, one of the main things touted during presentations was “the cloud” and their ability to pull clinical, operational and financial dashboards together to monitor the impact of COVID on their organization and organize their actions. Focus over the last decade has been on the clinical (implementing EHRs), but it is now shifting to “digitizing operations” with a focus on finance and operations (planning, cost accounting, ERPs, etc.) as well as advanced analytics and data science capabilities to automate, gather insight, manage and predict. It is clear that the cloud has moved from a curiosity to a necessity for health systems, making this one of the biggest areas of investment for every health system over the next decade.

8. Make Price Transparency a Key Differentiator: One of the great lessons from Amazon (and others) is that you can make a lot of money when you make something easy to buy. While many health systems are skeptical of the value of the price transparency requirements, those that have a deep understanding of both their true cost of care and margins are using this as an opportunity to prove their value and accelerate their strategy to become consumer-centric. While there is certainly a level of risk, no business has ever been unsuccessful because they made their product easier to understand and access. Because healthcare is so opaque, there is an opening for healthcare providers to build trust, which is their main asset, and volume, which is their main source of revenue, by becoming stunningly easy to do business with. This may be tough sledding for some as this isn’t something healthcare providers are known for. To understand this, spend a few minutes on Tesla’s website vs. Ford’s. The concept of making something easy, or hard, to buy will become crystal clear as fast as a battery-driven car can go from zero to 60.

9. Make Care More Affordable: This represents the biggest challenge for hospitals and health systems as they ultimately need to be on the right side of this issue or the trust that they have will disappear and they will remain very vulnerable to outside players. All are investing in advanced cost accounting systems (time-driven costing, physician costing, supply, and drug costing) to truly understand their cost and use that as a basis to price more strategically in the market. Some are dropping prices for shoppable services and using loss leader strategies to build their brand. The incoming Secretary of Health and Human Services has a strong belief regarding the accountability of health systems to be consumer centric. The health systems that understand this are working to get ahead of this issue as it is likely one of their most significant threats (or opportunities) over the next decade. This means getting all care to the right site of care, evaluating every opportunity to improve, and getting serious about eliminating the need for expensive care through building healthy communities. If you’re worried about Wal-Mart or Amazon, this is your secret weapon to keep them on the sideline.

10. Scale = Survival: One of the big lessons here is that the strong got stronger, the weak got weaker. For the strong, many have been able to “snapback” in financial performance because they were resilient. They were able to designate COVID-only facilities, while keeping others running at a higher capacity. To be clear, while most health systems are going to get to the other side and are positioned better than ever, there are many others that will continue to struggle for years to come. According to our data at Strata, we see 25 percent operating at negative margins right now and another 50 percent just above breakeven. They key to survival moving forward, for those that don’t have a captive market, will be scale. If this pandemic proved one thing relative to the future of health systems it is this — scale equals survival. 

When Will We Return to Normal?

Based on what the projections that these health systems shared, the “new normal” for health systems for the first half of 2021 will be roughly 95 percent of prior year inpatient volume with a 20 percent year-over-year drop in ED volume and a drop of 10-15 percent in observation visits. So, the pain will continue, but given the adjustments that were already made in 2020, it looks like they will be able to manage through COVID effectively. While there will be a pickup in the second half of 2021, the safe bet is that a “return to normal” pre-COVID volumes likely won’t occur until 2022. And there are some who believe that some of the volume should have never been there to begin with and we might see a permanent shift downward in ED volume as well as in some other areas.

With that said, I’ll steal a quote from Bert Zimmerli, the CFO of Intermountain Healthcare, who said, “Normal wasn’t ever nearly good enough in healthcare.” In that spirit, the goal should be to not return to normal, but rather to use this moment as an opportunity to take the positive changes driven by COVID — from technology to processes to areas of focus to a sense of responsibility — and make them permanent.

Thanking Our “Healthcare Heroes”

We’ll never see another 2020 again, hopefully. With that said, one of the silver linings of the year is everything we learned in healthcare. The most important lesson was this — in healthcare there are literally heroes everywhere. To each of them, I just want to say “thank you” for being there for us when we needed you the most. We should all be writing love letters to those on the front line who risked their lives to save others. Our nation’s healthcare system has taken a lot of criticism through the years from those on the outside, often with a blind eye to how things work in practice vs. in concept. But this year we all got to see first-hand what’s happening inside of healthcare — the heroic work of our healthcare providers and those who support them. 

They faced the worst crisis in the history of healthcare. They responded heroically and were there for our families and friends.

They proved that healthcare is too vital to fail. They proved that healthcare is pandemic-proof.

Thank you to our healthcare heroes.

This terrible year taught me something about hope

The first month of the pandemic was also supposed to be the month I got pregnant, but my clinic closed and plans changed. Doctors and nurses needed personal protective equipment to tend to patients with covid-19, not women with recurrent miscarriages.

When the clinic reopened several months later, it turned out my husband and I had only been delaying yet another loss: In late August, he obeyed the medical center’s strict coronavirus protocols by waiting anxiously in the car while I trudged inside, masked and hand-sanitized, to receive a miscarriage diagnosis alone. I searched the ultrasound screen for the rhythmic beat of a heart, and then accepted that whatever had once been there was now gone.

But that was 2020 for you, consistent only in its utter crappiness. For every inspiring video of neighbors applauding a shift change at the hospital, another video of a bone-tired nurse begging viewers to believe covid was real, it wasn’t a hoax, wear a mask.

For every protest organized by activists who understood racism is also a long-term crisis, an appearance by the Proud Boys; for every GoFundMe successfully raising money for a beloved teacher’s hospital bills, a bitter acknowledgment that online panhandling is our country’s version of a safety net.

Millions of citizens stood in line for hours to vote for the next president and then endured weeks of legal petitions arguing that their votes should be negated. The basis for these legal actions were conspiracy theories too wild to be believed, except that millions of other citizens believed them.

And that was 2020 for you, too: accepting the increasingly obvious reality that the country was in peril, built on iffy foundations that now buckled under pressure. My loved ones who worked as waiters or bartenders or physical therapists were choosing between health and paychecks, and even from the lucky safety of my work-from-home job, each day began to feel like watching America itself arrive at a hospital in bad shape, praying that doctors or clergy could find something they were able to save.

Is there a heartbeat?

You want the answer to be yes, but even so, it was hard to imagine how we would come back from this.

What kind of delusional person would even try to get pregnant in this world? In my case it would never be a happy accident; it would always be a herculean effort. And so it seemed I should have some answers.

How do you explain to a future child: Sorry, we can’t fix climate change; we can’t even get people to agree that we should wear masks in grocery stores? How do you explain the frustration of seeing brokenness, and then the wearying choice of trying to fix it instead of abandoning it? How do you say, Love it anyway. You’re inheriting an absolute mess, but love it anyway?

I found myself asking a lot of things like this in 2020, but really they were all variations of the same question: What does it mean to have hope?

But in the middle of this, scientists worked quietly in labs all over the world. They applied the scientific method with extraordinary discipline and speed. A vaccine was developed. Tens of thousands of volunteers rolled up their sleeves and said, Try it out on me.

It was approved, and a nurse from Long Island was the first American televised receiving it. Her name was Sandra Lindsay, an immigrant from Jamaica who had come to the United States 30 years ago and who had spent the last year overseeing critical care teams in back-to-back shifts. She said she had agreed to go first to show communities of color, long abused, brushed-off or condescended to by the medical system, that the vaccine was safe.

Here was hope. And more than that, here was hope from a woman who had more reason than most to be embittered: an exhausted health-care worker who knew too well America’s hideous racial past and present, who nonetheless also knew there was only one way out of the tunnel. Here she was, rolling up her own sleeve, and there were the lines of hospital employees ready to go after her, and there were the truck drivers ferrying shipments of syringes.

I can’t have been the only person to watch the video of those early inoculations, feeling elated and tired, and to then burst into tears. I can’t have been the only person to realize that even as 2020 revealed brokenness, it also contained such astounding undercurrents of good.

The scientific method works whether you accept it or not. Doctors try to save you whether you respected public-health guidelines or not. Voter turnout was astronomical because individual citizens realized they were all, every one of them, necessary pieces in a puzzle, even if they couldn’t see what the final picture was supposed to look like.

The way to believe in America is to believe those things are passed down, too.

Sometime in October, a couple of months after my last miscarriage — when the country was riding up on eight months of lonely and stoic birthdays, graduations, deaths and weddings — I went into the bathroom and saw a faint second line on a First Response pregnancy test. It was far from my first rodeo, so I knew better than to get excited. I mentioned it to my husband with studied nonchalance, I told him that I’d test again in a few days but that we should assume the worst would happen.

Two weeks after that, I had a doctor’s appointment, and then another a week later, each time assuming the worst, but each time scheduling another appointment anyway, until eventually I was further along than I’d ever gotten before — by one day, then three days, then thirty.

I am not a superstitious person. I don’t believe that good things always come to those who deserve them. I believe that stories regularly have sad endings and that it’s often nobody’s fault when they do, and that we should tell more stories with sad endings so that people who experience them know that they’re not alone.

But 2020 has taught me that I am, for better or worse, someone who wants to hope for things. To believe in the people who developed vaccines. In the people who administered them. In Sandra Lindsay. In the people who delivered groceries, who sewed masks, who have long cursed America’s imperfect systems and long fought to change them, who still donate $10 to a sick teacher’s GoFundMe.

At my most recent appointment, the doctor’s office was backed up in a holiday logjam. I sat in the exam room for nearly three hours while my husband again waited anxiously in the car. I texted him sporadic updates and tried to put hope in a process that so far had not seemed to warrant my hope.

It all felt precarious. The current reality always feels precarious.

And yet there we all are together, searching for signs of life, hoping that whatever we emerge to can be better than what we had before, and that whatever we build will become our new legacy. The sonographer finally arrived and turned on the machine.

There was a heartbeat. There was a heartbeat.

The disturbing surge in Covid-19 hospitalizations, in one chart

https://www.vox.com/2020/11/12/21560902/covid-19-risk-hospitalizations-chart-texas-illinois

More people in the US are hospitalized with the coronavirus than at any other time.

More Americans are currently hospitalized with Covid-19 than at any other point in the pandemic, a grim indicator that the third big wave of cases in the US may be the worst wave to date.

On November 11, 65,368 people across the United States were in the hospital after testing positive for the novel coronavirus, according to data reported by the Covid Tracking Project. That’s significantly higher than the last peak of 59,940 recorded on April 15, when the New York City area was the epicenter of the US outbreak. (As the Covid Tracking Project notes, the national and state hospital data have been erratic and incomplete, and reported totals may continue to shift.)

What’s clear from the data is that Covid-19 migrated across the country to new hot spot regions this fall. In the spring, hospitalizations were overwhelmingly concentrated in the Northeast. In the summer, more than half of hospitalized Covid-19 patients were in the South and West: states like ArizonaCaliforniaFlorida, Georgia, and Texas.

Now the Midwest, Great Plains, and Mountain West are the new hot spots, but some former hot spots are warming back up as well, with cases and hospitalizations surging again. “There’s so many places, with so many people, that the numbers are just drastically higher,” said Daniel McQuillen, an assistant professor of medicine at Tufts and a senior physician in the division of infectious diseases at Beth Israel Lahey Health, at a Wednesday Infectious Diseases Society of America briefing.

As of November 11, Texas had the highest number of hospitalizations of any state (6,779), and Illinois was in second place with 5,042 people in the hospital; other Midwestern states like Michigan, Indiana, and Wisconsin have seen record spikes in cases in recent weeks and now have more than 2,000 people hospitalized each.

“The hospitalization number is the best indicator of where we are,” Eric Topol, a professor of molecular medicine and director of the Scripps Research Translational Institute, told Vox this summer. That’s because it’s a better measurement of the severity of the pandemic than Covid-19 testing, which only finds a fraction of cases and includes more mild cases. “We’re going to go to new heights in the pandemic that we haven’t seen before. Not that what we saw before wasn’t horrifying enough.”

Some states like Utah and North Dakota have lower total hospitalizations but also fewer hospitals and hospital beds — and they’re now reaching a woeful tipping point of hospitals stretched to maximum capacity.

“Here in Salt Lake City, we provide a lot of [specialized infectious disease and ICU care] to people in four states as far away as Montana, Arizona, and Wyoming … and our hospitals and caregivers are extraordinarily stressed,” Andrew Pavia, the chief of pediatric infectious diseases at the University of Utah School of Medicine, said at the IDSA briefing. “Our ICUs are full, but that includes overflow ICUs that have been purpose-built, taking advantage of the time we’ve had to plan.”

This was, unfortunately, to be expected (although it wasn’t inevitable). As the weather has turned cooler and states failed to fully control their outbreaks, transmission picked up when people moved indoors. Nearly all the states currently experiencing an increase in new cases and hospitalizations also did not experience major outbreaks in the spring or summer, so residents were less fearful and took less action to prevent the spread of the virus.

“There was a political climate where there’s distrust of government and reluctance to take harsh measures,” in places like Utah, said Pavia. “Many of these states did not have mask mandates until very recently, and some don’t even have them today and have very limited restrictions on mass gatherings.”

Deaths are ticking up again too, reaching 1,592 on November 11, reversing a steady decline that had begun in early May after the first wave and in August after the second wave.

Cumulatively, 10.2 million Americans have tested positive for Covid-19 since the pandemic began, and more than 233,000 of them have died. With hospitalizations surging and several states reporting thousands of new cases a day, experts say we are in for a difficult late fall and winter.

The new hospitalizations, and the untenable pressure they’re putting on the health care system, are also a reminder of how critical it is for states to implement and enforce measures like mandatory face masks, restrictions on bars and restaurants, and for the federal government to fix testing and contact tracing problems. “It should be an all-points bulletin to really bear down on this, because otherwise there’s no limit on where this might go,” said Topol.

Hospitals are running out of staff and beds for Covid-19 patients

The good news is that infectious disease experts think many hospitals are better prepared to handle surges in Covid-19 patients than they were in the spring. For the most part, they have the equipment they need and they know how to deploy it. They also have more standardized protocol for treating the sickest patients.

Yet hospitals in hot spots across the country are maxing out their staff, equipment, and beds, with doctors and nurses warning that the worst-case scenario of hospital resources being overwhelmed is on the horizon if their states don’t get better control of the coronavirus.

“The surge of Covid-19 patients takes away from our ability to care for the sick patients that are already in Arkansas,” said a nurse at a major health system in Little Rock, who asked to go unnamed fearing retaliation from her employer. “We have so many nurses quarantined that we’re not able to staff our oncology unit appropriately, and our patients are being negatively affected. Covid-19 is right now overburdening our healthcare system in Arkansas.”

Hospitals in several states are also straining to find enough specialists to treat the very sick Covid-19 patients. “ICU beds don’t take care of people — you need staff,” said Pavia of the University of Utah School of Medicine. “And one of the things that many of the Western states have in common is a relative shortage of the people we need to take care of very sick people during a pandemic like this: ICU doctors, probably most importantly ICU nurses, and infectious disease physicians, respiratory therapists. These folks have been working flat out for eight or nine months, and three months into the surge, they’re exhausted, they’re stressed.”

Staffing is a universal problem in hot spots. Gov. Gary Herbert of Utah said the state will have to bring in out-of-state nurses to help with the surge, and officials and health care providers in South Dakota, Tennessee, Arizona, and Wisconsin are requesting them too:v

In Texas, officials are setting up medical tents in El Paso and Lubbock in response to the rapid rise in hospitalized Covid-19 patients and a dwindling number of hospital beds. “El Paso, Texas, is almost completely out of ICU beds; Lubbock, the same thing,” said McQuillen.

“We are the 11th-largest city in the state of Texas and we have two field hospitals on their way to town,” Jarrett Atkinson, Lubbock’s city manager, told KCBD on Tuesday. “I can absolutely assure you that never in my career did I think we would be deploying field hospitals to Lubbock, Texas.”

According to McQuillen, both El Paso and Lubbock have been “much less stringent with their populations [mandating] simple things like wearing masks, and socially distancing.” He compared that to Massachusetts and other Northeast states where he says strict measures during the spring surge made a big difference in reversing the steep climb in cases and hospitalizations. Yet too many states ignored that critical lesson, and now are paying the price.

Daily deaths are creeping up again but are still far below the earlier peak

While daily Covid-19 hospitalizations are surging, another key metric, daily deaths, reached 1,562 on November 11, the highest it has been since May during the first surge, according to the Covid Tracking Project. It’s an ominous sign that deaths could reach unprecedented levels in the coming weeks and months, given that cases and hospitalizations are now at new highs.

It’s possible, experts say, that fewer people who are hospitalized will end up dying in this winter stage of the pandemic as compared to the spring. As Vox’s Julia Belluz reported, there have been significant improvements in mortality in the US and Europe in the past several months, as doctors’ understanding of Covid-19 and how to treat it has improved:

Now, there’s strong evidence that common steroids like dexamethasone can reduce the risk of mortality in severely sick inpatients. Putting patients to rest on their stomachs instead of their backs (a practice known as proning) also seems to help.

Though there’s still a lot of progress to be made, the treatment approach has become more standardized over time, said Jen Manne-Goehler, an infectious disease doctor at Brigham and Women’s and Massachusetts General hospitals. When she started treating Covid-19 patients in the spring, it felt like practice was changing every few days. Now it’s more streamlined — and that’s undoubtedly helping with survival, too.

That said, if hospitals in the hard-hit states run out of beds and staff to treat the incoming flow of patients, more people who could have been saved may die. When ICU staff were stretched in the spring, “ICU patients just didn’t get the same attention,” intensive care doctor Lakshman Swamy, who works with the Cambridge Health Alliance, told Belluz.

Hospitals Are Reeling Under a 46 Percent Spike in Covid-19 Patients

The number of people hospitalized with the coronavirus has climbed significantly from a month ago, straining cities that have fewer resources to weather the surges.

The patient who died on Tuesday morning at Aurora St. Luke’s Medical Center was rolled out of her room under a white sheet. One nurse, fighting back tears, stood silently in the hall as the outline of the body passed by — one more death in an eight-month-old pandemic that has no end in sight.

“Those moments, they hit the soul,” said Jodie Gord, a nurse manager who oversees a team of about 120 people at the hospital in Milwaukee.

Aurora St. Luke’s is far from alone in coming under strain. Hospitals around the United States are reeling from the rampaging spread of the coronavirus, many of them in parts of the country that initially had been spared the worst.

Approaching the eve of the election, President Trump has downplayed the steep rise in cases, attributing much of it to increased testing. But the number of people hospitalized for the virus tells a different story, climbing an estimated 46 percent from a month ago and raising fears about the capacity of regional health care systems to respond to overwhelming demand.

A coronavirus testing site at El Paso Community College.

The exploding case numbers point to a volatile new phase in the pandemic, coming after earlier waves hit large cities such as New York, then Sun Belt states like Florida and Arizona. While some of those places have begun to bring the virus under control, the surge of hospitalizations is crippling some cities with fewer resources.

In El Paso, where the number of people hospitalized with Covid-19 has more than tripled over the past three weeks, doctors at University Medical Center have started airlifting some patients to hospitals as far away as San Antonio while treating others in a field hospital in a nearby parking lot. Across the border in Mexico, the mayor of Ciudad Juárez, himself hospitalized after testing positive for the virus for the second time, is urging a temporary ban on U.S. citizens crossing into his city.

“We have never seen this in El Paso,” said Dr. Joel Hendryx, chief medical officer at University Medical Center, one of the largest hospitals along the border. Citing the need for field hospitals, Dr. Hendryx drew a sharp contrast to the city’s earlier surge in July, when mitigation measures drove case numbers down.

Dr. Hendryx’s hospital had 195 inpatient coronavirus cases as of Tuesday compared with about 30 a month ago. In addition to the parking lot tents, officials in El Paso are converting the downtown convention center into a 50-bed hospital. Hundreds of health workers from other parts of Texas are deploying to El Paso, including an ambulance strike team with paramedics from the Houston area.

The situation is also becoming critical in states such as Idaho, Missouri, New Mexico and Utah, with frontline workers exhausted and hospitals struggling to find replacements for those testing positive each day.

At St. Luke’s Magic Valley Medical Center in Twin Falls, Idaho, where more than one-third of patients have Covid-19, administrators are sending children to a hospital in Boise, two hours away. The influx of patients from rural areas with little health infrastructure is similarly straining hospitals in Wisconsin, where cases have increased 53 percent from two weeks ago.

Across the country, case numbers have risen to fearsome new levels in recent days, with the seven-day average for new cases exceeding 70,000 for the first time in the pandemic. Twenty-six states are at or near record numbers for new infections. More than 500,000 cases have been announced in the past week. And exactly zero states are seeing sustained declines in case numbers.

On a per capita basis, smaller cities and rural counties in the Upper Midwest and Mountain West are struggling most acutely. North Dakota, South Dakota, Wisconsin and Montana lead the country in new infections per capita. Of the 12 metro areas with the highest rates of new cases over the past two weeks, 10 are in North Dakota or Wisconsin.

But the dismal trend lines are not confined to those regions. North Carolina, New Mexico, Pennsylvania, Rhode Island and West Virginia have recently set seven-day records for new cases. And more big cities are starting to spiral, with alarming trends emerging in Chicago, Milwaukee and Newark.

And while the escalating case numbers had not been accompanied by a steep rise in deaths, that trend is starting to change. About 800 deaths are now being recorded across the country each day, far fewer than in the spring but up slightly from earlier this month.

Cities and towns nationwide are rushing to impose new restrictions. In Idaho, Gov. Brad Little backtracked on reopening but stopped short of a statewide mask mandate. Mr. Little limited indoor gatherings to 50 people, required masks at long-term care facilities and placed new restrictions on how bars and restaurants could serve their customers.

In Newark, all nonessential businesses will have to close at 8 p.m. beginning on Tuesday. Mayor Lori Lightfoot of Chicago imposed a curfew under which nonessential businesses must shut down from 10 p.m. to 6 a.m., and bars without a food license are no longer allowed to serve customers indoors.

In Fargo, N.D., Mayor Tim Mahoney used his emergency powers to pass the first mask mandate in the state. The mayors of Nixa and Ozark in Missouri imposed mask mandates after appeals by nearby hospitals overwhelmed by coronavirus hospitalizations.

On one of the I.C.U. floors at Aurora St. Luke’s in Milwaukee, the mood was somber on Tuesday morning as doctors and nurses made their rounds. Twenty of the 24 beds were filled, and many of the patients were on ventilators.

But the staff put on a brave face. They gave thumbs-up to patients from the hallways, walked into rooms to greet others and assisted one woman as she ate her breakfast.

Before noon, an older woman was transferred to the I.C.U. from the Covid-19 floor. Within 30 minutes of her arrival, loud beeping sent staff members running to her room, frantically grabbing personal protection gear.

The patient’s oxygen levels had plummeted to dangerously low levels, and she was going into cardiac arrest. A nurse practitioner called the patient’s family, making it clear there was a possibility she would not make it.

A staff member performed compressions on the woman in hopes of keeping her alive. After several minutes, her condition stabilized — for the moment.

She was the second patient who needed such care in just three hours. When the nurses and doctors stepped away for a breath, the woman lay on the bed, now intubated, eyes glazed over and her face pale. It was hard to see any clear signs of breathing.

Some staff members patted each other on the back. Others took deep breaths. A health care worker walked out of the patient’s room, holding a small plastic bag in her hand. Inside was jewelry to give to the family, said Ms. Gord, the nurse manager, in case the woman died.

Staff members still seemed in shock over the death of the other patient from that morning. She had become dear to the I.C.U. team, said Ms. Gord, who stood quietly and with obvious emotion as the stretcher slipped past. “Bless her soul,” she murmured. “Sweet little lady.”

Staff members said they were fighting constant exhaustion. “What’s going to happen when we cannot take care of these patients?” said Dr. Pedro Salinas, a critical care specialist, who worries about how much longer the staff can endure. “They are emotionally and mentally exhausted.”

The prospect of ending up in an overcrowded hospital ward is making some who are sick with the virus hesitant to check in. At the hospital in El Paso, staff members said some Covid-19 patients were arriving in the emergency room so debilitated that they required intubation almost immediately.

Sandra Garcia, 31, an El Paso resident who tested positive for the coronavirus last week, said she had been grappling with fatigue, shortness of breath and a loss of taste and smell, but had refrained from seeking care in the city’s crowded hospitals.

In the meantime, she is caring for a 13-year-old who also has Covid-19 and 5-year-old twins, who are all studying online from home. Ms. Garcia said she questioned why Dee Margo, El Paso’s mayor, had failed to order a shutdown of the city to curb the spike in cases.

“He’s just trying to get re-elected and it’s disgusting,” Ms. Garcia said.

Last week, Mr. Margo announced new restrictions such as closing parks to league and tournament play, but he said an order for a full city shutdown would need to come from the governor of Texas.

Dr. German Hernandez, a nephrologist who has been caring for patients at several hospitals in El Paso, said the situation was so acute that patients on oxygen were being kept in rooms in the trauma area of University Medical Center. He said that could be devastating in the event of a disaster such as the August 2019 mass shooting at a Walmart in the city that left 23 people dead.

“God forbid we have another Aug. 3 shooting because we can’t handle it right now,” Dr. Hernandez said. “We have no buffer.”

Into the COVID fray again, or for the first time

https://mailchi.mp/45f15de483b9/the-weekly-gist-october-9-2020?e=d1e747d2d8

Addressing Workforce Needs for COVID-19 | University at Albany

While it sometimes seems like the coronavirus has been with us forever, it’s worth remembering that there are still parts of the country that are only now experiencing their first big spike in cases—that’s the nature of a “patchwork” pandemic working its way across a vast country.

One of our health system members in the Midwest, with whom we recently spent time, is in just this situation: they’re seeing their highest inpatient COVID census to date, just this month. As they shared with us, there are advantages and drawbacks to being a “late follower” on the epidemic curve. The good news is that they’re ready.

Back in March, like most systems, they stood up an “incident command center”, and began preparing for a wave of COVID patients, designating a floor of the hospital as a “hot zone”, creating negative pressure rooms, cross-training staff, developing treatment protocols, stockpiling protective equipment, and securing a pipeline of critical therapeutics and testing supplies. There was a moderate but manageable number of cases across the late spring and summer, but never to an extent that stressed the system.
 
Eventually, recognizing that they couldn’t ask their doctors, nurses, and administrators to stay on high alert indefinitely, they “stood down” to a more normal operational tempo, only to watch with dismay as the surrounding community seemingly forgot about the virus, and lessened precautions (masking, distancing, and so forth), wanting life to return to “normal”. And now, the post-Labor Day, post-return-to-school spike has arrived.

The challenge now is getting everyone, inside and outside the system, to stop talking about COVID in the past tense, as though they’ve already “gotten through it.” The preparations they’ve made are paying off now. Hospital operations continue to run smoothly even with a high COVID census, but the workforce is exhausted, and citizens aren’t stepping outside to bang gratefully on pots every night anymore.

Asking the team to return to war footing is no easy task, given the fatigue of the past seven months. A question looms: what is the trigger to restart “incident command”? As cases begin to increase again in some of the original COVID hot spots—New York, New England, the Pacific Northwest—healthcare leaders there will need to learn from the experiences of their colleagues in the newly-hit Midwest, about how to take an already virus-weary clinical workforce back onto the battlefield.

The N95 shortage America can’t seem to fix

https://www.washingtonpost.com/graphics/2020/local/news/n-95-shortage-covid/?utm_campaign=wp_post_most&utm_medium=email&utm_source=newsletter&wpisrc=nl_most

Nurses and doctors depend on respirator masks to protect them from covid-19. So why are we still running low on an item that once cost around $1?

The patient exhaled. She lifted her tongue for a thermometer. She raised her finger for a blood sugar test, and that’s when she started coughing. One cough can send 3,000 droplets into the air, one droplet can contain millions of coronavirus particles, and now some of those particles were heading for the face of emergency department nurse Kelly Williams.

The nurse inhaled. Strapped over her mouth and nose was an N95 respirator, the disposable filtering mask that has become the world’s most reliable and coveted defense against the virus.

N95s were designed to be thrown away after every patient. By this July afternoon, Williams had been wearing the same one for more than two months.

To get to her, the N95 had traveled from a British factory to a Baltimore warehouse, in a supply chain as tangled and layered as the web of microscopic fibers inside the mask’s filter.

It was purchased by Johns Hopkins Hospital, the famed medical institution that has tracked cases of the novel coronavirus around the world since the pandemic’s start. When its map of dots marking clusters of infections began to show pools of red across the United States, Hopkins was quietly unpacking a stock of personal protective equipment it had been building for over a year — a literal lifesaver when the onslaught of covid-19 cases led to a massive shortage of N95s.

Six months later, that shortage persists, leaving health-care workers exposed, patients at risk and public health experts flummoxed over a seemingly simple question: Why is the world’s richest country still struggling to meet the demand for an item that once cost around $1 a piece?

At Hopkins, nurses are asked to keep wearing their N95s until the masks are broken or visibly dirty. Williams, a 30-year-old from Georgia with a marathoner’s endurance and a nurse’s practicality, went into health care after working for three years in the corporate offices of retailers Abercrombie & Fitch and Under Armour. She understood supply chains. She believed that the makers of N95s, anticipating the pandemic’s eventual end, would invest only so much in expanding production. She believed it was her duty, on top of risking her life for her patients, to make her disposable respirator mask last through as many 12-hour shifts as she could.

When the country was short of ventilators, the companies that made them shared their trade secrets with other manufacturers. Through the powers of the Defense Production Act, President Trump ordered General Motors to make ventilators. Other companies followed, many supported by the government, until the terrifying problem of not enough ventilators wasn’t a problem at all.

But for N95s and other respirators, Trump has used this authority far less, allowing major manufacturers to scale up as they see fit and potential new manufacturers to go untapped and underfunded. The organizations that represent millions of nurses, doctors, hospitals and clinics are pleading for more federal intervention, while the administration maintains that the government has already done enough and that the PPE industry has stepped up on its own.

As the weather cools and the death toll climbs, America’s health-care workers fear that when winter comes, they still won’t have enough respirators. And the longer the shortage lasts, the longer N95s will remain largely out of reach for millions of others who could be protected by them — teachers and day-care workers, factory employees and flight attendants, restaurant servers and grocery store clerks.

While the pandemic that has killed almost 200,000 Americans drags on, Williams will keep trying to conserve her respirator, wearing it as she rushes in and out of virus-filled rooms, touches virus-shedding patients, and now, comforts a covid-positive woman who is having a coughing fit.

“How can I help you feel a little more comfortable?” Williams asked her patient, who was in her 80s. The woman was about to be admitted to the hospital. Her oxygen level was too low, so they had to run tubes of air into her nostrils. If her situation didn’t improve, a ventilator could come next.

This was the routine in the part of the emergency department Williams called “Covidland.” She’d just risked exposure to care for this woman, but she would never get to find out what happened to her.

She could only take a deep breath through her N95, roll her patients upstairs and hope that she would never become one of them.

‘The gauntlet’

Before the N95 was on her face, it was in a plastic wrapper, in a box, on a shelf inside an East Baltimore warehouse four miles from the hospital. The 165,000-square-foot building had concrete floors, rolling doors, overhead lighting — unremarkable, except to a man named Burton Fuller.

Fuller, a 38-year-old father of three, had once planned on becoming a doctor. Instead, he went into hospital supply chains. It was the kind of job that didn’t earn many follow-up questions at dinner parties. But six months after Fuller was hired at Hopkins, the pandemic made him the person that everyone relied on and no one envied. It was up to him to keep 40,000 employees in six hospitals safe.

Even before covid-19, masks were key to that equation. There are surgical masks, which protect a patient from a nurse’s germs, and respirator masks, which protect a nurse from the patient. Humans have recognized the need for protective masks since at least A.D. 77, when Pliny the Elder wrote about wearing animal bladders as face coverings to make breathing easier in lead-filled mines.

The evolution of early masks brought leather beaks stuffed with straw and herbs to ward off the bubonic plague, and long beards that firefighters would wet and clamp between their teeth. Once the far more effective gas mask became standard for coal miners breathing in silica and soldiers facing chemical weapons, engineers at the Minnesota Mining and Manufacturing Company, better known as 3M, started trying to make a protective respirator that wasn’t so bulky. They realized in the 1960s that the technology used to make pre-made gift bows could also make a mask that was a lightweight, molded cup. And so began the single-use respirator as it exists today.

Inside that cup, and more recently, inside the flat-fold versions, is the key component: fibers 1/50th the width of a human hair, blown together in an intricate web that creates an obstacle course for dangerous particles. An electrostatic charge works like a magnet to trap the floating menaces and attach them to the fibers. If an N95 is fitted properly — a metal nose piece folded snugly, no beard in the way — less than 5 percent of even the most difficult-to-catch particles will make it into the lungs.

At Hopkins, Fuller’s job was to get manufacturers to deliver N95s and other equipment directly to the warehouse, rather than through a distributor. In 2019, the shelves started to fill up, and on one of them was the N95 that would make its way to nurse Kelly Williams. The respirator had been made by 3M at a plant in Aycliffe, a town of 7,000 in northern England.

But this Hopkins stockpile was rare in the world of hospitals, where costs were cut by using medical supply companies to provide equipment when it was needed, rather than letting PPE pile up.

Hospital administrators knew that in cases of natural disaster, chemical warfare or what global health officials used to call “Disease X,” the federal government had its own warehouses in secret locations, filled with PPE.

Except that in 2009, while Fuller was in his first job out of college, the H1N1 flu epidemic depleted 85 million N95s from the national stockpile — and the supply was never replenished. In 2013, 2014, 2016 and 2017, public health officials published alarming reports warning of a “massive gap” in what remained. Even more concerning, they said, the vast majority of N95s and the materials needed to manufacture them were now being made in Asia.

The Department of Health and Human Services did fund the invention of a “one-of-a-kind, high-speed machine” that could make 1.5 million N95s per day. But when the design was completed in 2018, the Trump administration did not purchase it.

This year, as the virus spread from Wuhan to Washington state, HHS turned down a January offer from a manufacturer who could make millions of N95s. The agency didn’t start ordering N95s from multiple companies until March 21. Paul Mango, deputy chief of staff for policy at HHS, would later call that timeline “friggin’ light speed … the fastest this has ever been done.”

By then, the United States had 8,000 reported coronavirus cases and 85 deaths, and health-care workers were panicking over PPE shortages.

Fuller’s orders began being canceled. As the Hopkins emergency department was being readied for covid-19 patients, and Williams was being told she would need to start wearing an N95, the hospital’s administration decided not to reveal how many N95s were in the warehouse.

“Only a half a dozen people know,” Fuller said. “Behavioral economics say that if we communicate a number someone perceives as high, they will use the supply more gratuitously. If we communicate a number they perceive as low, they may hoard to ensure there is enough.”

As the boxes of N95s were loaded into trucks headed for Hopkins hospitals, Fuller and a dozen staff members entered what he would come to call “the gauntlet.” Every hospital and health department in the country was competing for N95s and other PPE, a mess of bidding wars, price gouging and worthless knockoff masks. Fuller uncovered one scam when a company CEO, claiming to be based in Indianapolis, didn’t recognize the name of the city’s most famous steakhouse.

“For every mask shipment we have been able to bring in,” Fuller said, “there are 10 or 15 transactions we have had to terminate.”

He worked so much that his wife, home with their children, received flowers from Hopkins executives. He joked about the other crucial stockpile in his life, his wine collection.

Fuller was desperate to make the stockpiled N95s last as long as possible. He wanted every employee wearing one to also wear a face shield, but those, too, were impossible to find.

So at the end of March, the warehouse filled with folding tables spaced six feet apart. Volunteers were given foam strips, elastic straps and sheets of plastic to make homemade shields. At one of the most prestigious medical institutions in the country, they were trying to fix the problem for themselves, with scissors, staplers and hot glue guns.

‘Bracing yourself’

A face shield was clipped to Williams’s belt in the middle of May, when for only the fourth time during the pandemic, she unwrapped a new N95.

After nine weeks in and out of Covidland, she had come to trust in her disposable respirator. It hurt her nose, gave her acne and made breathing hard. But the power of its protection was starting to give her back the feeling of safety she’d lost in March when she and the dozens of colleagues who worked alongside her each shift watched the areas where they’d cared for gunshot victims and heart attack patients turn into isolation rooms. They were tested to make sure the N95s fit their faces and taught to use other respirators that looked like gas masks or blew clean air into a hood.

And then, they were slammed. The first covid patient to go on a ventilator at Hopkins was a 40-year-old who worked out every day. The ambulance bay became a testing center. Williams’s co-workers were crying in the break room. Her patients couldn’t breathe, and then tubes were going down their throats, and then it felt like she couldn’t breathe, like everything she knew about nursing would never be enough.

“Our lives changed overnight,” she said. “You’re bracing yourself for people to die.”

She started silently saying a prayer she knew, every morning, every few hours, then sometimes 20 times a day in Covidland.

God, grant me the serenity to accept the things I cannot change, it began. She said it before her patient started violently shaking and flailing, seizing in his bed. She couldn’t run out the door to ask for help, because to leave the room without potentially taking the virus out, she had to sanitize her gloves, trash them, take her gown off, trash it, exit into an antechamber, take off her first layer of gloves, sanitize her hands and wipe down her face shield. So she ran to the window and banged on it, then ran back to her patient, trying to hold him down, her face inches from his.

Courage, to change the things I can, the prayer continued. Williams said it in the car that she drove to work and wouldn’t let any member of her family touch. Its speakers blared Lizzo-filled playlists she used to pump herself up for what she told her friends was an “awesome learning experience.” She had been a nurse for only two years. Her job in merchandising at Under Armour had brought her to Baltimore, where she met her husband, Sean, and his two children. They were the ones to make her realize that she wanted a job where she could actually see the impact of all those hours she worked. Now, every day might be the day she took the virus home to them.

Grant me the serenity to accept the things I cannot change, courage, to change the things I can, and wisdom to know the difference. Another day in Covidland, and Williams was wearing her new N95, pumping her palms into an unconscious man’s chest, not thinking of all the particles flying out of his airways. Another, and her face shield popped off and clattered to the floor. Another, and a young Latina mother told Williams she couldn’t self-quarantine because she could not afford to stay home from work.

Another, and Williams was watching the chest of a middle-aged man rise and fall by the force of a ventilator. Outside the walls of the hospital on this day in July, America seemed to have moved on from the conversation about the shortage of N95s. Instead, people were fighting over simple cloth masks.

Maybe this patient had worn one. Maybe he’d said he didn’t believe in them. Either way, it was her job to take care of him. Williams suctioned virus-filled fluid from his airways, and breathed in again.

‘Not profitable’

The radio advertisements could be heard across South Dakota, playing inside cars passing billboards plastered with the same message: 3M is hiring in Aberdeen. In a state that hosted 460,000 people at an August motorcycle rally and requires no one to wear a mask sits the largest respirator plant in the United States.

Its N95 manufacturing lines have been running 24 hours a day, 7 days a week since Jan. 21, the same day public health officials announced the arrival of the coronavirus in Washington state.

Plant manager Andy Rehder hired 200 new employees this year and was still looking for more this summer so he could staff another N95 line being built. Rehder, whose wife wears an N95 as a hospital social worker, had a Bloomberg Magazine article from March displayed in his office. The headline asked, “How do you make more masks yesterday?”

The question still hangs over the plant, and the entire country, nearly six months after that article was published.

Ask the Trump administration, and the N95 shortage is nearly solved. Rear Adm. John Polowczyk, whom Trump put in charge of securing PPE, said that by December, 160 million N95s will be made in the United States per month. By his calculations, that will be enough to handle a “peak surge” from hospitals, clinics, independent physicians, nursing homes, dentists and first responders. The Strategic National Stockpile has 60 million N95s on hand, and states are rebuilding their stockpiles.

“I’ve got production up to what we think is the limits of what we need,” Polowczyk said. “I believe now that hospital systems are making management decisions that might lead to an appearance that we still don’t have masks, which is the farthest from the truth.”

But ask the people inside hospitals, and the shortage is far from over. An August survey of 21,500 nurses showed 68 percent of them are required to reuse respirators, many for more than the five times recommended by the CDC, and some even more than Kelly Williams. One Texas nurse reported she’s still wearing the same five N95s she was given in March.

Many health-care facilities that ordered KN95s, Chinese-made masks meant to have a similar filtering efficiency, gave up on them after realizing that the looser fit left workers in danger. The N95 shortage is more acute for primary care physicians, home health aides and hospice workers. But even for many hospital systems, the situation remains “fragile and challenging,” the American Hospital Association said this month.

“Maddening, frustrating, mind-blowing, aggravating, that’s the polite language for it,” said American Medical Association President Susan Bailey, who still hears from doctors who do not have respirators. “There has been such an outpouring for support for ‘health-care heroes.’ Everybody knows now how important it is for our front-line health-care workers to be able to work in a safe environment. … And yet, that desire doesn’t seem to be turning into a reality.”

The AMA, AHA, American Nurses Association and the AFL-CIO all point to the same solution: broader use of the Defense Production Act, which gives the president power over funding for the production and distribution of critical supplies during crises.

In August, Trump stood before a group of socially distanced reporters, praising himself for using the DPA “more comprehensively than any president in history.”

“There was a time,” he said, “when the media would say, ‘Why aren’t you using it? Why aren’t you using it?’ Well, we have used it a lot, where necessary. Only where necessary.”

That’s not what it looks like to the man who used to run Trump’s DPA program within the Federal Emergency Management Agency. Larry Hall, who retired last year, said the authority has been executed in an “ad hoc, haphazard fashion.”

Along with ordering 3M to import 166.5 million masks from China, the administration has used the DPA to invest $296.9 million in bolstering the N95 and filter-making supply chains. The Department of Defense, which oversees that funding, spends more per year on instruments, uniforms and travel for military bands.

“By not having a national strategy,” Hall said, “we have fewer masks.”

Ask the PPE industry and the refrain is that without long-term guarantees that the government will keep buying respirators, N95 manufacturers are wary of investing too much, and other companies that could start making respirators or the filters for them are hesitant to do so.

Peter Tsai, the scientist who invented a method to charge the fibers inside the respirator filter, knows why: “It is not profitable to make respirators in the United States,” he said. It can take six months just to create one manufacturing line that makes the N95′s filter.

But there is a workaround, Tsai said. Companies that already make similar filters — for vehicle emissions, air pollution and water systems — can modify their equipment to make N95 filters.

While Tsai, 68, has been fielding hundreds of calls from hospitals and researchers trying to sanitize N95s with heat and ultraviolet light, he has been working with Oak Ridge National Laboratory in Tennessee to woo the 15 to 20 American companies that have the potential to produce respirator filters more quickly.

The government has funded just three of these companies through the DPA.

Others have gradually joined in on their own. But then those filters have to be made into respirators, and those respirators have to be approved by NIOSH, the National Institute for Occupational Safety and Health.

The entire process has moved at a glacial pace in comparison with the flurry of activity that rid the country of its ventilator shortage. Ventec, a company known for its efficient, toaster-size ventilators, handed its plans over to General Motors so that the auto company, under the DPA, could mass produce a product that was known to work. Other ventilator companies followed, handing over their trade secrets to Ford, Foxconn and other major manufacturers.

But when GM started making N95s, engineers with expertise in car interiors and air bags were charged with figuring out the process from scratch, the company said. Although they received advice from major mask makers, there were no groundbreaking corporate partnerships this time. The first N95s GM made were rejected by NIOSH. The second design didn’t correctly fit most people.

Other potential manufacturers went through the same challenges as GM, failing tests and making flat-fold N95s that experts worry do not offer a tight enough seal.

“If there was some kind of intellectual sharing, they wouldn’t be doing that,” said Christopher Coffey, who was the associate director for science in the NIOSH approvals program before retiring in January.

The DPA does have a provision that would allow manufacturers to work together without being subject to antitrust laws. But it has yet to be used for N95s.

Instead, established U.S. makers of N95s, whose products have been successfully protecting miners, construction workers and health-care professionals for decades, have continued to protect their processes as intellectual property.

Though 3M helped Ford make the far more expensive powered respirators, which blow clean air into a hood, the company has not entered into any major partnerships with outside manufacturers to make N95s. Asked why, 3M declined to explain, instead pointing to its other pandemic partnerships.

Ford gained its own approval to manufacture disposable respirators but has made just 16,000 of them while focusing instead on face shields and surgical masks. Other major U.S. manufacturers of N95s, including Honeywell and Moldex, have kept their manufacturing in-house, too.

“Folks aren’t likely to share that information outside of their own company,” said Jeff Peterson, who now oversees NIOSH approvals. NIOSH employees may know how 3M makes its respirators and the filters inside them. But by contract, they can’t tell other manufacturers how to do the same.

Meanwhile, 3M continues to dominate the American N95 market. While other parts of its business, such as office supplies and industrial adhesives, have struggled during the pandemic, 3M has invested $100 million to expand domestic production of respirators from 22 million to 50 million per month. Once the new production line is up and running in South Dakota in October, that number is expected to reach 95 million per month in the United States.

It still won’t be enough.

“Even though we are making more respirators than ever before and have dramatically increased production,” 3M spokeswoman Jennifer Ehrlich said, “the demand is more than we, and the entire industry, can supply for the foreseeable future.”

‘I just don’t get it’

Her N95 was already on, but Williams’s hands were slipping as she tried to force on a pair of gloves. She could hear the alarms going off. One of her patients was crashing, and she had to get into the room.

She should be able to just go, her runner’s legs carrying her to the bedside. But in Covidland, there were two closed doors standing in her way. She had started wearing her N95 all day so she could be ready for this moment. She pulled on her gown and another set of gloves and her face shield, reached for the door — and realized the patient inside was her 13-year-old stepson Kellen.

She jolted awake. She was in her bed. Her husband was asleep beside her. She slid out from her sheets and went downstairs to check on her stepchildren. Kellen and 19-year-old Alle were sleeping, too.

The nurse inhaled. She could still hear the alarms.

This is what it meant now, to be a health-care worker: across the country, nurses and doctors were reporting increased sleeplessness, anxiety, depression and post-traumatic stress.

Williams reminded herself that she’d always had an N95, and the heavier, more protective respirators she sometimes wore instead.

But she knew, too, that covid-19 had taken the lives of more than 1,000 health-care workers, including a New Jersey primary care doctor who, determined to keep his practice open, doubled up on surgical masks when his N95 orders didn’t come. And a California nurse who rushed into a covid patient’s room to perform chest compressions. She saved his life, then doused her hair in hand sanitizer. She hadn’t been given an N95 at the beginning of her shift.

And then there was the news that shook every health-care worker Williams knew: Less than two miles from Hopkins, the head of the ICU at Mercy Hospital died after contracting the virus in July.

Joseph Costa was one of the people who’d guided the hospital through its PPE shortage early in the pandemic. His husband, David Hart, remembered him coming home and saying, “This is my mask for the week.” Neighbors pushed N95s through their mailbox slot.

“This is the United States of America, and we can’t seem to get factories built to deliver this stuff? I just don’t get it,” Hart said.

He will never know exactly how his husband, who insisted on caring for covid patients alongside his staff, became infected. Costa died in the ICU, the gloved hands of his colleagues on him as he went. Minutes later, they returned to caring for other patients.

At Mercy, at Hopkins, at every hospital that had found a way to get N95s, health-care workers wore their PPE to try to save the lives of people who contracted the virus because they had none.

Williams and her colleagues didn’t need to see the statistics to know that the pandemic was disproportionately affecting Black and Brown people, especially those deemed essential workers. They saw it in their patients and heard it from their families and friends.

Williams worked side by side with Shanika Young, a nurse whose brother seemed to have every known covid-19 symptom before he started to recover.

Afraid of infecting anyone in her community, Young went weeks without seeing her parents and newborn niece. She adopted a hound-mix puppy to have a friend when she couldn’t see her own. In the weeks that followed the killing of George Floyd, she agonized over her decision to stay away from the protests. She knew there wouldn’t be N95s there.

On a sweltering August morning, she left her dog in her apartment and packed her respirator in her car. She, too, re-wore her mask, but usually for four or five 12-hours shifts.

Now Young was taking it across Baltimore, not toward the hospital, but to a predominantly Hispanic neighborhood with one of the worst infection rates in the city.

During the pandemic, Baltimore has seen outbreaks in its homeless shelters, its trash-collecting facility and its jail. Now every place Young drove by fell on one side or the other of a new dividing line in America: those who have PPE and those who don’t. Bodegas, restaurants, nail salons and funeral homes. Downtown, a nonprofit’s dental clinic remained shuttered. She passed a mental health counseling center where sessions were still conducted only by video, and a physical therapist who wore KN95s to see clients. She parked near a school that, without N95s, had no way of ensuring its teachers were protected. It serves primarily Latino children, all of whom would be forced to learn online.

In the parking lot of the church, a booth that used to sell $1 snow cones had been transformed into a coronavirus testing center run by a team of Hopkins doctors and nurses.

On her day off, Young volunteered to work with them, spending hours sweating in her scrubs, sending swabs deep into nose after nose. She wore a surgical mask on top of her N95.

“I don’t think there’s any science that says this is actually safer,” she said. “But it’s just a mental thing.”

The line of people sweating on the asphalt was so long, Young couldn’t see the people at the end: a man in painter’s clothes, a mother pushing a stroller and a woman who, like Young, was wearing scrubs. Stitched onto the chest was the name of a retirement home.

‘Hazard’

The coughing patient was starting to fall asleep when Williams left her in the covid unit. Her shift had been over for more than 30 minutes. She checked in to make sure there was no one else who needed her help and headed for the locker room. She washed her hands twice. She used alcohol wipes to sanitize her phone, glasses, ID badges and pens.

She took off her N95, and she inhaled.

For the first time in two months, she decided that this respirator was done. Its straps were starting to feel too stretched. The shape of it looked just a little too warped.

Instead of hanging the N95 from a hook in her locker to air dry, she stuffed it in a bag marked “hazard.”

A new mask, still in its plastic packaging, was waiting for her next shift. She would wear it as long as possible, especially after learning that the Hopkins stockpile had run out of the British-made mask she wore and couldn’t get any more. She needed to change to a different type of N95, one that felt unfamiliar once again. She told herself that she was grateful just to have it. She told herself that it would protect her just the same.