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The N95 shortage America can’t seem to fix

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?

By Jessica Contrera
Sept. 21, 2020
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BALTIMORE —

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?

This N95 was made in Aycliffe Village, England and worn by emergency department nurse Kelly Williams for weeks of treating coronavirus patients. 3M is now manufacturing a similar model of this respirator in the U.S.
This N95 was made in Aycliffe Village, England and worn by emergency department nurse Kelly Williams for weeks of treating coronavirus patients. 3M is now manufacturing a similar model of this respirator in the U.S. (Amanda Voisard/for The Washington Post)

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.

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Williams prepares to administer a coronavirus test to a patient in the Hopkins emergency department. (Will Kirk/Johns Hopkins)
Williams prepares to administer a coronavirus test to a patient in the Hopkins emergency department. (Will Kirk/Johns Hopkins)

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.

 

Burton Fuller, the chief supply chain officer for the Johns Hopkins Health System, was responsible for finding a way to conserve Hopkins’s stock of N95s and other PPE.
Burton Fuller, the chief supply chain officer for the Johns Hopkins Health System, was responsible for finding a way to conserve Hopkins’s stock of N95s and other PPE. (Johns Hopkins)

‘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.

An engraving, circa 1656, shows a beak mask, which would have been filled with herbs and straw in the belief that the wearer would be protected against the plague.
A 1917 photo shows a German officer wearing a gas mask as protection against chemical agents. (Stefan Sauer/picture-alliance/dp)

LEFT: An engraving, circa 1656, shows a beak mask, which would have been filled with herbs and straw in the belief that the wearer would be protected against the plague. (Hulton Archive/Getty Images). RIGHT: A 1917 photo shows a German officer wearing a gas mask as protection against chemical agents. (Stefan Sauer/picture-alliance/dp) .

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.

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