It’s been less than two weeks since the Chinese government quarantined 35 million people in the city of Wuhan and surrounding regions to control the fast-spreading coronavirus, but the images coming from there already have a grim familiarity: empty shops and streets, long queues at hospitals, and on every face, a surgical mask covering everything below the eyes.
The masks’ ubiquity is a signal of people’s panic over the disease, and also of official actions to control the outbreak. Wuhan and several other jurisdictions are now requiring they be worn in public, and footage originally posted to the Chinese social network Weibo shows police officers using drones with loudspeakers to scold people who venture out without one.
But for people who anticipate a pandemic—an expanding epidemic that rapidly crosses borders—the masks blanketing China have an unsettling second meaning. They are a reminder that Chinese manufacturing is the source of most of the world’s masks and respirators. Now that the vast country is using more masks than it ever has before, fewer of them will likely be available to the countries that have been China’s regular customers.
That includes the United States. According to data compiled by the US Department of Health and Human Services, 95 percent of the surgical masks used in the US and 70 percent of the respirators—thicker, tight-fitting masks that offer better protection against viruses—are made overseas. That leaves the mask supply vulnerable to labor disruption if a pandemic sickens manufacturing workers, as well as to flat-out diversion if a government decides to keep its own stock at home.
“This is 100 percent a vulnerability,” says Saskia Popescu, a biosecurity expert who is the senior infection-prevention epidemiologist in an Arizona hospital system. “Personal protective equipment is always going to be a problem when there is an outbreak of something novel, because public health guidance will be unclear at first and there will be a run on supplies. Masks being made offshore is one more stress on the system.”
Demand for masks is enormous in China. Manufacturing has ramped up rapidly, according to the state-affiliated China Global Television Network, with factories churning out 20 million masks a day. Yet on Monday morning, the Chinese foreign ministry said masks and safety goggles that protect doctors’ eyes were running out within the country, and it issued an international appeal for more.
The demand has spilled over to the rest of the world, even though only a small fraction of all known cases of coronavirus—185 out of 17,494 cases as of Monday afternoon, according to a real-time dashboard maintained by Johns Hopkins Center for Systems Science and Engineering—have occurred outside China. There are reports of masks selling out in stores and online in Europe and the US, and factories in Europe and Asia running 24/7 to keep up.
A supply chain gap won’t only pose a risk if the novel coronavirus spreads beyond the 11 cases that have so far been identified in the US. It could become a risk immediately, because masks and respirators are essential to everyday health care. Surgical teams wear masks to protect their patients, and people with infectious diseases wear masks to protect health care workers and other patients. Right now, at the height of flu season, many emergency departments offer stacks of masks at their sign-in desks and ask new arrivals to pop them on to contain sniffles and coughs while they wait. (It’s worth remembering that when SARS tore through Toronto in 2003, one of the places it spread first was an emergency room.)
So leaders of US health care organizations are worried. “Because China produces such a large proportion of the US’ drugs and medical supplies—especially personal protective equipment (like masks, gowns and gloves) that are used by hospital caregivers to protect themselves and their patients from infection—our members have expressed concern that the already fragile supply chain will break with the worsening conditions in China,” Tom Nickels, executive vice president of the American Hospital Association, wrote by email. “The AHA and hospitals are working with the appropriate emergency preparedness officials at the Department of Health and Human Services to keep them informed about the potential impact that worsening shortages could have.”
“All over the country, our members are talking to their supply chain managers, who are calling in additional masks and respirators to make stockpiles,” agrees Connie Steed, a South Carolina nurse who is president of the Association for Professionals in Infection Control and Epidemiology. If shortages occur—and she emphasized that she isn’t aware of any yet—hospitals would have to think through what they could sacrifice, from postponing elective surgeries to asking workers to wash and reuse their gear.
But in some parts of the health care system, supplies are already patchy. “We have a member listserv, and people are asking each other how to get masks,” says Sean McNeeley, a physician who, until recently, was president of the Urgent Care Association. McNeeley is medical director for a Midwestern network of urgent-care clinics associated with a large hospital, which buys its stock from most of the major wholesalers in the US. “I am hearing from all these vendors that they are having issues with things on back order,” he says.
Like hospitals, urgent-care clinics, which account for an increasingly large slice of US medical care, might also have to adapt their businesses if they can’t get enough supplies. McNeeley hypothesized that they might have to convert from walk-in service to call-in triage, assessing patients over the phone to sort out who is most likely to carry in a dangerous virus. Subsequently, they might divert possible coronavirus cases—or just bad flus—to an emergency room that has respirators on hand.
The need to provide respiratory protection in an epidemic hasn’t been a secret. For the past 15 years, a group of federal agencies including the US Department of Health and Human Services and the Department of Homeland Security have had official plans for a pandemic, though the pandemic they envisioned was flu. The original National Pandemic Strategy, published in 2005, was prompted by the worldwide outbreak of the H5N1 flu that began in Hong Kong in 1997, as well as the 2003 SARS outbreak, which began on the Chinese mainland.
From the start, the strategy paid close attention to the need for respiratory protection, especially for health care workers, who are at higher risk for infection because they treat so many patients in close quarters. It laid out plans for developing new masks and respirators that would provide better protection and be easier to wear for long periods.
What the strategy didn’t specify was where those devices would come from. Since 2009, when an epidemic of H1N1 flu swept the United States, a small group of US manufacturers has been insisting that this lack of specificity has been a mistake. Four manufacturers who dubbed themselves the Secure Mask Supply Association—all competitors who buy their materials in the US and make their masks there—have jointly been urging the government to find a way to bring production back within US borders. “We have been saying all along that the big one will come from China, and China controls the mask supply,” says association founder Mike Bowen, who is also the executive vice president and co-owner of the Texas mask company Prestige Ameritech.
But the companies that make up the association are relatively small. Larger domestic companies are based in the US but have production sites overseas—such as 3M, which said last week that it would ramp up production at its factories in China. That allows the association’s members little flexibility to drop prices to account for the lower labor costs offshore, and little ability to scale up to meet demand.
Bowen, for instance, says that back during the H1N1 outbreak, when masks were in short supply and US health care providers were clamoring for stock, he ramped up production to 24 hours a day, buying a new building, adding a third shift, and hiring 150 additional workers. H1N1 was an authentic pandemic, widespread and fast moving. But it was not virulent, and public alarm quickly ebbed. Bowen ended up laying off all of the extra workers he had hired. “One of my biggest customers didn’t place another order for 5 months,” he said. “It was brutal.”
As he spoke on Friday morning, Bowen’s phone kept pinging, an indicator of how many orders are flowing to Prestige right now. Over four days, he said, they had done an additional $300,000 in one-time business, which is as much as their largest regular customer usually buys in a month. But at the same time, he noted, their credit card processor had declined 1,000 cards for fraud, a measure of how perilous this new spot market might be.
Bowen said he had no hope of reading every incoming email. But among them, he’d seen requests from Chinese wholesalers seeking huge numbers of masks. There were others, which made him tear up, from people hoping to donate to Wuhan schools and hospitals, and to send supplies to protect their families in China. Two, he said, were from government departments in Pacific Rim nations. The requests, Bowen estimated, were arriving every few minutes.
And unless the epidemic changes course, he expects the pressure on companies like his to only get worse.
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