Amy Arlund, an intensive care unit nurse in California, starts every overnight shift hoping her supervisors will give her a fresh N95 respirator.
“You are asked to reuse them for weeks on end,” Arlund, 45, told NBC News. “You have to justify to your manager repeatedly why you need a new one.”
Nearly 100 days after the World Health Organization declared the coronavirus outbreak a pandemic, health care workers across the country are still facing major shortages of personal protective equipment, or PPE, including crucial equipment such as masks, gowns, gloves and N95 respirators. Amid an alarming rise in coronavirus cases across the United States, the situation is especially dire at hospitals serving communities of color or patients on Medicaid, NBC News has found.
"The issue of PPE for health workers has not gone away," Dr. Mike Ryan, head of the WHO's Health Emergencies Program, said Wednesday at a news briefing.
A new study out of Wuhan, China, is finding that health care workers who were appropriately protected with PPE did not get infected, despite being exposed to the virus.
Arlund is all too familiar with the frightening results of the crisis: a nurse at her hospital, Kaiser Permanente Fresno Medical Center, died of COVID-19 at the end of May.
“She was exposed from a patient who was not properly isolated and she had no PPE on her floor,” she said. “She spent almost two months in our ICU being cared for by her co-workers and her own friends and she passed away.”
In a statement, a Kaiser Permanente spokesman said the hospital is using a combination of new and reused N95 masks. “Like all health care providers, we continue to experience shortages of PPE, including N95 masks. We are aggressively managing our supply chain and working with existing and new manufacturers to increase these supplies,” the statement read.
A recent survey by the American Nurses Association found that 79 percent of nurses were encouraged, or even required, to reuse PPE, and 59 percent said they felt unsafe doing so. The survey included more than 14,000 nurses from all 50 states.
In the early days of the pandemic, PPE shortages were affecting many major hospitals. But most of those larger facilities have now been able to replenish their supplies. Now, health care workers say it’s smaller safety net hospitals and nursing homes serving the most vulnerable communities that are still facing horrific shortages.
“They are populations that are on Medicaid or have poor access to care and face greater barriers,” said Dr. Garth Walker, an emergency room physician in Chicago, who also works with the Buehler Center for Health Policy and Economics. “The common theme is that safety net hospitals are getting less money.”
Another ER physician in Illinois, who works at a safety net hospital, said they’re only getting new N95 masks every few shifts. And now the hospital is running out of gowns. So they are reusing them, which puts both the health care workers and the patients at risk.
Typically, doctors wear a new gown for each patient.
“What you end up doing is wearing the same gown for basically the whole shift,” said the doctor, who asked that her name not be used out of fear of losing her job.
The doctor said she doesn’t know what will happen when the hospital completely runs out.
“We'll have to make a decision as health care providers, whether to keep on working and marching on and caring for patients while risking our own lives,” she said. “Or we just put our foot down and say, ‘No, our health and the health of our family members is too important to risk it.’
Other health care workers said they were alarmed that they had recently been asked to use some PPE that was not allowed prior to COVID-19 -- including masks marked “for cosmetic use only” -- reflecting the Centers for Disease Control and Prevention’s evolving recommendations this spring.
And staff at some major hospitals are now being told that they can no longer wear N95 masks during their shifts if they work on floors that do not have COVID-19 patients, a new measure to conserve equipment.
One ER nurse at a New Jersey hospital, who declined to give her name because she could lose her job for speaking to the media, said the new policy was causing anxiety among staff.
“My worry is that with the widely publicized reliability of the [coronavirus] tests, there will be false negatives, and those people will end up on those ‘clean’ floors, further infecting others now unprotected” she said. “Any caregiver in the hospital should have the N95”.
Sal Rosselli, president of the National Union of Healthcare Workers, which represents 15,000 people, mostly in California and Hawaii, who work in acute care hospitals, nursing homes, outpatient and mental health clinics and some jails, said of the 200 institutions where they have members working, only one has adequate PPE.
“It’s a huge problem,” he said. “At almost all facilities, they are forcing health care workers to reuse. Some are given one N95 a week.”
Supply chain 'still broken'
Compounding the shortages at these hospitals is that the very population they serve are the ones most at risk for developing severe cases of COVID-19. A report from the CDC that looked at a snapshot of COVID-19 patients hospitalized in March found that more than 30 percent are African American.
“Whether it's the elderly, minority populations, populations affected by structural racism and historical injustice, those are the very groups that have the most difficult time getting adequate PPE for their workers,” Dr. Megan Ranney, an ER physician at Brown Emergency Medicine in Rhode Island, said.
Adding to the stress is the fear that the United States is on the brink of a second wave of the virus. Between some states perhaps reopening too soon, mass protests around the country and a possible reemergence of the virus this fall, facilities are under pressure to build up their supplies.
Dr. Patrice Harris, president of the American Medical Association, said she’s concerned that over the next few weeks, hospitals and doctors offices will see a surge of patients who were forced to delay care and those health care workers will need even more PPE.
“They delayed cancer and other screenings as well as surgeries, so it’s critical that practices reopen but we are hearing from our colleagues across the country that they are having challenges,” she said.
Ranney, who is also a co-founder of #GetUsPPE, a nonprofit dedicated to securing PPE for those in need, said getting more supplies is nearly impossible for many of these facilities.
“The biggest issue is that the supply chain is still really broken,” said Ranney, whose organization currently has close to 12,000 requests for PPE from around the country.
For example, she said, N95 respirators typically cost anywhere from 50 to 70 cents a piece. Now, the cost for each respirator is between $3 and $5.
“Few health care facilities have those kinds of financial resources,” she said. “We're in a scarcity situation. When there's something that's in high demand, they're supposed to charge more for it. That's the whole idea of capitalism, but it doesn't work for something like this.”
The solution is systemic change in the way PPE is distributed, something that needs to come at the federal level and something that should have happened months ago, both health care experts and union officials say.
“I hoped that the federal government would have stepped in to demand an increase in production and accountability so that we could deal with this,” said Deborah Burger, co-president of the National Nurses United and president of the California Nurses Association. “But five months in, it’s really immoral that they haven’t stepped up to the plate.”
Burger says there’s been little transparency in the way PPE from the Strategic National Stockpile, for example, has been distributed.
“We don’t know where they’re distributed to and how many we actually have in any given place,” she said.
In March, the Department of Health and Human Services said materials from the stockpile were distributed in proportion to the population in a given jurisdiction, calculated using 2010 data. Some areas of higher transmission of the coronavirus were eligible to receive extra supplies on top of their population-based quotas.
An HHS spokesperson said that the national stockpile has already deployed 90 percent of its original inventory of PPE in the COVID-19 pandemic response. The stockpile pushed its final products to states, four large metropolitan areas and territories April 23, she said, though there are ongoing efforts to distribute additional items.
To solve the confusion, Burger believes a solution lies within the HEROES Act, which while focuing on stimulus money, contains a provision that would establish a medical supplies resources coordinator. That person would track stockpiles, distribution and ensure increased production. The bill passed the House of Representatives, but is now stalled in the Senate.
“The unfortunate part of this epidemic is that it is showing the really ugly side of the American health care system and that is we don’t have a health care system,” Burger said. “We have markets and it is based on what we can afford to buy.“