Inside the Chaotic, Cuthroat Gray Market for N95 Masks - Health, Medical and Fitness News Blog

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Tuesday, November 17, 2020

Inside the Chaotic, Cuthroat Gray Market for N95 Masks

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In his 30 years as a doctor, Andrew Artenstein had never worried about N95 respirators. The chief physician executive of Baystate Health, he ran his four hospitals in western Massachusetts exactingly, and an essential face covering being out of stock was inconceivable. His doctors, nurses and other responders went through about 4,000 a month, usually for treating patients with airborne diseases. There were always more in the warehouse, just outside the city of Springfield, where Baystate is based. But on April 6, as the novel coronavirus stampeded through the Northeast, Artenstein rose in predawn darkness, on a mission to secure about a quarter-million masks for his thousands of staff members. Baystate Health was just days away from running out.

For the next five hours, he was chauffeured down highways drained of normal traffic, while overhead a private plane bearing four specialists, who would vet the authenticity of the delivery, headed toward the same destination: a warehouse in the Mid-Atlantic, where the masks were being stored by a third-party dealer. A driver had been hired separately for Artenstein, because his frequent interactions with Covid patients meant he might expose the rest of the team to the virus. Two semitrailers were also converging to convey the delivery back to Massachusetts.

But it wasn’t actually clear yet how many N95 respirators there would be to pick up — the night before, the dealer confessed that he could only deliver a quarter of what had been promised, after canceling another pickup the previous week. (Because of an agreement between Baystate Health and the dealer, The Times has agreed not to identify him; he also declined to respond to questions.) Baystate Health had been forced to turn to unproven entrepreneurs like this after the corporate distributor it had once depended on ran out of N95s, when national and international supply chains collapsed at the beginning of the pandemic. Their predicament wasn’t unique. Many hospitals, states and even federal agencies were also desperate, transforming the normally staid market for health care commodities into a Darwinian competition of all against all.

Artenstein and his team had no choice except to pursue this tenuous lead. In the past two weeks, the number of Covid cases nationwide had grown about sevenfold. Nurses complained of having to improvise face coverings, even using modified ski goggles. Within a few weeks, the Centers for Disease Control and Prevention would calculate that at least 9,282 health care workers had tested positive for the novel coronavirus, and 27 had died — a fatality count that would pass 1,700 by mid-September. Artenstein knew that his own safety, and that of his doctors and other health care workers, might depend on the success of his mission.

He finally pulled up to the warehouse a little after 10 a.m. The Baystate Health equipment specialists picked several boxes at random, and sliced them open to verify that the cargo was authentic. Artenstein was flooded with relief; the masks sealed to a person’s face. The respirators could be loaded into the semitrailers. The Baystate team had hired trucks normally used by the food-service industry so that their cargo would appear to be nothing more than refrigerated meats and vegetables. This precaution was taken to help keep the respirators secure; stories were circulating of federal agencies, also struggling to get respirators, appropriating shipments.

Artenstein was about to direct Baystate headquarters to wire the payment when the dealer tapped him on the shoulder and said that the F.B.I. wanted to talk. Artenstein thought this was a joke. But then, he says, he was led to a glassed-in conference room deeper in the warehouse, where a pair of agents stood up from their laptop computers and showed him their badges. They explained that they were part of a new nationwide effort to make sure that medical equipment was getting to health care workers and not being hoarded by exploitative middlemen. Artenstein furnished proof that the respirators were destined for his hospitals. He was dismissed without a clear answer of what was going on. Hours ground past as he paced in the vast warehouse, developing contingency plans and checking in with the agents until it became clear they didn’t want to hear from him again. Finally, he was informed that the federal government was considering reallocating the shipment elsewhere.

Artenstein had to wonder: How had the U.S. medical system devolved to this? The Baystate Health team was just at the beginning of a monthslong battle to secure P.P.E. from an out-of-control market that the Trump administration would avoid closely managing — despite bipartisan calls to do so from mayors, governors, congressional representatives and the leaders of some of America’s largest health care workers’ unions and industry associations. Indeed, during the initial outbreak, the federal government would sometimes be the most feared player in that market, acting not in an oversight capacity but as its most powerful buyer and disruptive agent. Though the Trump administration would subsequently take action to improve the P.P.E. supply, the result of its efforts was a characteristically American, ongoing experiment in whether local governments and health care systems can fend for themselves during a deadly pandemic — an experiment that may have left the country unprepared to deal with a record-shattering “third wave” of infections this winter.

Credit...Christopher Payne for The New York Times

The N95 respirator is emblematic of globalized capitalism: It is made out of fossil fuels, manufactured at enormous scale, often in developing nations by cheap labor, and distributed on the shipping lanes that bind together the far-flung corners of the world; it is used by urbanites to keep pollution expelled by their own factories from their lungs, construction workers raising clouds of concrete dust as they build ever-growing cities and doctors treating patients coughing from the diseases multiplying among increasingly urbanized populations. It is meant to be tossed after a single use.

These lightweight scoops of breathable plastic — the shape of which was inspired by the cup of a 1950s molded bra — are simple to use. A person sets a respirator over the nose and mouth, and a tensioned headband seals it against the face. When someone inhales, air passes through tightly woven, electrostatically charged mesh, which snags the vast majority of microscopic airborne particulates — 95 percent, hence the name. The masks are made by melting huge quantities of specialized plastic pellets and then blowing the molten liquid through perforated metal to produce a tangle of filaments that cools and fuses into a dense mat of fibers: the all-important filter. An electrostatic charge is added to help capture microscopic particulates. Then the filter is sealed between two protective layers, and a headband is welded or stapled on. Tens of millions of masks can roll off a factory’s conveyor belts in a month.

It was not preordained that the United States would have a shortage. In 1998, President Bill Clinton read a Richard Preston novel, “The Cobra Event,” about a bioweapon wreaking havoc across the country. Horrified, he subsequently established what would become the Strategic National Stockpile, which has since cached tremendous quantities of P.P.E., ventilators, vaccines and medicines. The S.N.S. eventually developed into a network of warehouses strategically located near transportation hubs, prestocked with 50-ton pallets of supplies that could be delivered anywhere in the nation within 12 hours.

The George W. Bush administration created a pandemic plan that called for the federal government to oversee the initial distribution of P.P.E. from the S.N.S., and later coordinate public and private efforts to provide America with more equipment. In 2009, the Obama administration disbursed 85 million respirators from the S.N.S. while combating the H1N1 pandemic, and then failed to effectively replace them, despite being warned to do so. The Trump administration also did not refill the stockpile, ignoring admonitions from public health officials and a pandemic-simulation test that showed America would run disastrously short of P.P.E. if the real thing occurred.

In late 2019 and the first two months of 2020, the Trump administration was inundated with red alerts about the incoming pandemic from internal entities like the National Security Council and external sources like the nation’s biggest medical-supply corporations. Some of those warnings — including memos addressed directly to the president — highlighted how America’s P.P.E. supply would be overwhelmed. As a whistle-blower report would later reveal, in January, Department of Health and Human Services officials effectively dismissed an offer from one of America’s few remaining N95 manufacturers, Prestige Ameritech, to expand its production lines. And when the head of an H.H.S. agency responsible for preparing the nation for pandemics tried to expand his budget to increase domestic respirator production, he was overruled by a senior H.H.S. official, Robert Kadlec. (H.H.S. says Kadlec was forced to make the decision because of appropriations rules.)

On March 3, Kadlec was pointedly questioned by the Senate’s committee on health about the nation’s supply of N95s. He referenced a C.D.C. estimate that, in a pandemic, America would need as many as 3.5 billion N95s for its health care workers and emergency medical workers — but, he confessed, the government’s stockpiles held only 10 percent of that. Shortly after, H.H.S. clarified that Kadlec had misspoken: The S.N.S. had a tenth of the figure he’d cited, or one one-hundredth of what the country would need. On March 12, about two months after warnings began about the pandemic, and one day before President Trump declared a national emergency, the federal government finally placed its first large-scale order of N95 respirators. But by then it was too late, as global supply chains were breaking down. Domestic production of N95s was far too small to provide the nation with what it needed. Within weeks, numerous hospitals were running short of N95s, just as Covid-19 cases were exploding, leading to Artenstein’s desperate mission — and his run-in with the federal agents.

Before the pandemic, Pat Sheehy, a 61-year-old vice president at Baystate Health, had been in charge of its supply chain for around 15 years without ever needing to consider how N95s arrived at his warehouse. He estimated that he only had to spend a few hours per week directly overseeing procurement. A computerized inventory-management system monitored his warehouse’s supply of medical commodities like N95s, hand sanitizer, gloves and isolation gowns and then automatically reordered whenever they were running low. But in March, as the pandemic exploded, he was shocked to find that the normal channels for getting respirators were, he says, “like a faucet without a stream of water.”

In early 2020, many of the N95s used in the United States were produced in Chinese factories. Medical-supply vendors bought massive quantities of these respirators, which were then loaded into shipping containers and hauled by colossal ships on a monthlong journey to the United States. The distributors knew from historical sales data how many N95s hospitals would need during a given month, and strategically timed their orders to ensure that the new product arrived at their warehouses just as old product went out to customers. This balletic relay delivered N95s so seamlessly that it was largely invisible to hospital administrators. Each respirator cost about 65 cents. It was a textbook example of the win-win power of globalization.

But as the coronavirus rapidly rode the channels of international commerce between continents, it turned the advantages of globalization into vulnerabilities. Right when the United States needed masks most, there were severe shortages. Chinese production had ground to a halt as the country locked down to stop the virus’s spread — and just-in-time supply chains dependent on their manufacturing quickly disintegrated. Baystate Health was consuming about 15 times more respirators monthly than during pre-pandemic times, and had no easy way of finding new suppliers. It would take months for American companies to build out new production lines.

The economy abhors a vacuum, however, and since N95s were soon selling for more than 10 times what Baystate Health had been paying, fly-by-night speculators swiftly established a gray market for remaining stocks of respirators. To navigate this treacherous bazaar, Sheehy expanded his team’s ranks from a dozen to 30 individuals, looking for supply-chain expertise and what he called a “runs toward accidents” personality. Days started with an early-morning conference call, during which the team discussed what was running low at the warehouse. Then everyone, most working from home, began plumbing personal networks for leads. An inbox was set up to consolidate the unsolicited sales pitches cascading in, many of which were little more than a Gmail handle and a list of P.P.E. at grossly inflated prices.

Normally, Baystate Health vetted new suppliers and conducted cost-effectiveness analyses in a process that could take weeks. But now it had to decide within a few hours, lest another hospital or a government agency claim the N95s first. The team members did their best to check out potential sellers, splitting leads up among five teams of six, which would search dealers’ backgrounds, check their tax forms and request “proof of life” pictures of the product. Then Sheehy and the five team leads would debate whatever information they had gleaned. Answers, they found, were usually not “black-and-white,” and came down to a gut feeling: “Does the broker’s story make sense?” In the first month of the pandemic, they would sift through some 2,000 leads, seriously investigate 368 of them and place 99 orders — of those, only 25 resulted in goods being delivered by mid-April.

This was because the marketplace was being bum-rushed by freelancers whose previous experience in international logistics was, say, importing bat guano as organic fertilizer for cannabis. Some were expat hustlers who conjured ideas over drinks in a Shanghai bar, drawn by the potential for huge paydays. Some were just inept, making promises they couldn’t keep: One man who had received a $34.5 million order from the Department of Veterans Affairs, despite having no relevant expertise, allowed a ProPublica reporter to ride along with him on a hired private jet to pick up his shipment — only to have it fail to materialize. But others were accused of outright criminal behavior, such as two Californians charged with conspiracy to commit wire fraud for trying to sell millions of dollars in masks that didn’t exist. By early May, the Department of Homeland Security would open 370 cases and arrest 11 people for mask-related fraud. Steve Francis, a special agent in an investigatory division of the D.H.S., told me that the illicit P.P.E. market was so profitable that some transnational criminal organizations turned from smuggling humans and narcotics to moving masks.

Even the government struggled in these conditions. The Miami Herald reported in April that of the 10 largest mask contracts signed by Florida, five of them, worth $170 million, were canceled, including one inked with a consulting firm owned by one of the stars of “Shark Tank.” That same month, a review of federal contracting data by The Wall Street Journal would find that federal agencies had ordered more than $110 million in masks from vendors with scant experience, who then had trouble delivering.

For several weeks, Baystate Health’s efforts yielded little more than dead ends. But then, on the morning of March 30, as yet another important deal had just collapsed for Baystate, an email arrived in the inbox of Kelly Salls, one of Sheehy’s team leads, who was trying to help her four children with remote-schooling while also scouring the globe for P.P.E. In the email, a friend of a friend claimed to have KN95 respirators, a technical equivalent to N95s, certified to a Chinese standard. Web searches showed that this company had long manufactured specialized medical products in China. When Salls spoke on the phone to the dealer, he agreed to rush-deliver samples to her — something no one else had done. After the samples were authenticated, Salls placed an order for about half a million KN95s and half a million three-ply medical masks, to be picked up the next day.

Soon, however, the dealer called back, saying that wouldn’t be possible. Two days passed. Finally, on the night of April 5, the dealer announced that Baystate could pick up a quarter of the original shipment the following morning — the rest he had divvied up among equally desperate health care systems. Salls and Sheehy monitored the mission from Springfield, while Artenstein went down in person. When the F.B.I. held up the release of the respirators, Artenstein telephoned Mark Keroack, the C.E.O. of Baystate Health. It was clear to Keroack that he needed to call in “the biggest favor I’ve ever asked.”

Credit...Christopher Payne for The New York Times

Across the street from Baystate Health’s flagship hospital, a phone rang. Representative Richard Neal, chairman of the powerful House Ways and Means Committee, picked up at his house, where he had been self-isolating. During his three decades representing the district, Neal had been a patron of its hospitals, which were vital to the region’s economy, and he immediately agreed to help Keroack. At first, thinking it was a routine intramural conflict, he dispatched his chief of staff, William Tranghese, to unstick things. Tranghese, however, reported back that not only were the F.B.I. and H.H.S. involved, but the Department of Homeland Security was, too. This made Neal even more concerned.

Federal officials have denied appropriating legal shipments of N95s and other P.P.E. headed to American hospitals. But in the spring, the stories of them doing so were widespread enough that the Baystate Health team figured that’s what was happening to them. They even had a similar experience the week before, when a shipment was withdrawn because the V.A. had exercised its precedence over Baystate Health — or so the dealer claimed. (The V.A. declined to respond to questions.)

Similar incidents made news all over the country. The mayor of Los Angeles described cutting a check for a shipment of masks, only to have FEMA swoop in at the last moment. The governor of Montana complained on a conference call to President Trump that his state lost four or five orders in the previous week to federal agencies. After Massachusetts officials came to suspect that the federal government had snatched supplies already in transit, the state’s Republican governor arranged for over a million N95s to be flown in from Shenzhen on the New England Patriots’ private jet. Illinois officials similarly spent nearly $1.8 million chartering flights from China to airlift P.P.E. in secret, afraid that the Trump administration might otherwise commandeer it. And when the federal government was not reportedly seizing shipments, it was outbidding its less resourced competitors and compelling domestic N95 manufacturers and importers to prioritize its orders, making it extremely hard for anyone else to get P.P.E.

The Federal Emergency Management Agency denied ever commandeering P.P.E., and referred me to a media briefing in which these events were described as misunderstandings and a result of unscrupulous dealers’ blaming FEMA to cover up for their own inability to deliver promised supplies. It also emailed the following statement in May: “This is a global pandemic — demand continues to outweigh supply across the globe, not just in the U.S. Considering that, FEMA and H.H.S. are both working hard to ensure federal contracting efforts don’t compete with states’ abilities to acquire P.P.E. and other supplies.” (The F.B.I. declined to comment on Baystate Health’s claims.)

The widespread belief, in the face of its protestations to the contrary, that the Trump administration was appropriating P.P.E. shows the extent to which the federal government came to be seen as part of the problem rather than the solution. Public-health experts generally agree that the federal government alone has the power to coordinate a comprehensive response to a nationwide pandemic, and throughout the last century it has usually taken the lead during national disasters. Indeed, according to a detailed internal plan the administration produced in March, just as the virus was gaining a foothold in the United States, it identified one of the “Key Federal Responsibilities” as buttressing “medical supportive equipment, supplies and P.P.E. needs” across the nation.

The Trump administration, however, appeared to do the opposite. On March 19, President Trump declared at a press briefing: “The federal government is not supposed to be out there buying vast amounts of items and then shipping. You know, we’re not a shipping clerk.” This was what resulted in the chaotic P.P.E. marketplace, described by Andrew M. Cuomo, the Democratic governor of New York, as “50 states competing against the states, and the federal government competing against the states,” which he said drove up the cost of masks for New York from 85 cents to around $7 apiece. To solve this “madness,” he asked for the federal government to step in and take control of all buying to suppress bidding wars and to direct P.P.E. more efficiently toward hot spots — as the Bush administration’s previous guidelines, the administration’s own planning and numerous public-health experts, mayors, governors and congressional representatives suggested.

It wasn’t just the political opposition, as well as a small number of conservatives, asking the administration to provide more leadership — the private sector was also pleading for direction. Starting in late January, representatives from six of the largest medical-supply companies and members of the Health Industry Distributors Association, a trade group, had raised concerns about supply-chain problems. They requested guidance from senior administration officials on what became daily calls, according to documents released by the House oversight committee. Bafflingly to some high-level industry leaders, however, after nearly two months, they were still trying to get the administration to take straightforward actions — all while the supply chain was visibly fracturing.

An industry leader, who met with the president and the vice president, and requested anonymity to avoid retaliation, described widespread frustration among private-sector health care leaders at the administration. He recalled a “shocking” and “galling” White House sit-down in March, in which the vice president, Mike Pence, started by discomfiting the health care professionals with handshakes, and then tried to smooth over an hour of criticism they had unloaded on a senior H.H.S. official by simply asserting they’d get the problems solved. “It was like we were in two different realities,” the individual said. “I could see the vice president was in a bubble.”

The administration’s attempts to deal with the P.P.E. crisis reportedly emanated from a team of unpaid consultants, many in their 20s with little to no experience in health care, assembled by Jared Kushner, the president’s son-in-law. After distributing the dregs of the Strategic National Stockpile, the federal government focused on procuring whatever supplies it could from corporate medical distributors and the gray market, distributing them through FEMA. An analysis by The Associated Press suggested that rural states with less serious outbreaks were awarded more P.P.E. per confirmed case than states with significantly more dangerous outbreaks. This raised accusations of political favoritism in a life-or-death situation — though the administration has strongly denied this.

Kushner’s team, meanwhile, was also starting Project Airbridge, a program that expedited the delivery of P.P.E. from Asia to America by paying for it to be flown rather than shipped. During the first four months of the outbreak, Project Airbridge would help bring in 5.3 million respirators and 122 million medical masks. These figures, though large, represent just a tiny fraction of the 3.5 billion respirators that Kadlec said were needed. In June, Project Airbridge would be wound down without fanfare.

At the outset of the pandemic, at least from Baystate Health’s point of view, what the administration’s response succeeded in creating was a feeding frenzy. In this kind of chaos, everyday citizens had little chance, and so Keroack reached out to Representative Neal. At first, this seemed to accomplish nothing, and Artenstein left the federal agents and the masks, and drove home. But that evening, when he was back at the hospital, he got word that the shipment had been loaded onto the trucks. Representative Neal had managed to get on the phone with the Department of Homeland Security, and delivered a strongly worded message to release the respirators. Still, as Salls monitored the trucks on their long drive north, she was nervous each time they stopped for gas. The masks finally hit the guarded warehouse well after midnight, and pictures of them were giddily shared. Over the next few days, the remaining three-fourths of the order arrived in chunks, with Representative Neal’s chief of staff, Tranghese, ushering each portion through customs. But Baystate’s ordeal was far from over.

Many in the health care industry encouraged the president to make use of the Defense Production Act, which allows him to exert control over domestic manufacturing during national emergencies. But for weeks during the initial phase of the pandemic, the administration resisted invoking the D.P.A. Eventually, at the end of March, it began to make limited use of the act, ordering companies like 3M, the largest remaining American producer of N95s, to increase respirator production in the United States. (The company had already taken many of the steps to expand production at the outset of the pandemic that the administration would later mandate.) It would never take a primary role in distributing P.P.E. nationwide, instead directing supply mostly to hot spots and letting the market work out the rest.

A key reason for the administration’s hands-off approach was ideological. “Our role is to be able to deploy assets and resources into areas that have an unusual surge in demand, based on things like Covid or hurricanes,” and not to meet “daily needs,” said a senior administration official who helped lead the P.P.E. response, and requested anonymity so he could speak candidly. Rear Adm. John Polowczyk, who eventually took over the P.P.E. supply-chain response, described it as “locally executed, state managed, federally supported” — which effectively meant that health care systems would largely be responsible for securing their own provisions on the market, with states being the first to step in during emergencies and the federal government last. That this decision was influenced by political philosophy is unsurprising. (By contrast, the Biden campaign was promising that, if elected, it would essentially nationalize the P.P.E. supply chain and appoint a “supply commander” to oversee distribution.) But the Trump administration’s decision to duck the responsibility may have had strategic elements as well; as an administration official explained to Politico, “No matter how well you did, we also knew it was never going to be considered good enough.”

The oddity of this seemingly laissez-faire approach is that the P.P.E. shortages provided the administration a perfect chance to fulfill its “America First” campaign promise, to return manufacturing jobs to the United States. In the spring and summer, Peter Navarro, assistant to the president, director of his Office of Trade and Manufacturing Policy and a longtime advocate of returning manufacturing jobs from China, helped shape the P.P.E. response. “This was an opportunity to make sure production was on-shored and to break our dangerous dependence on foreign P.P.E. sources,” he said in an October interview. It was an important shift in strategy, but also one that had come too late to help Baystate and others through the initial chaos. By this point, agreement on the importance of onshoring the P.P.E. supply chain had become bipartisan, and the Biden campaign was calling for similar measures.

Starting in April, the Trump administration made a series of high-profile onshoring announcements, such as awarding a billion-dollar contract to 3M to manufacture medical supplies domestically. The company began rapidly building out production lines. In 2019, it produced about 22 million N95s monthly in America; by June 2020, this leapt to around 50 million monthly; by the end of the year, it expected to be producing about 95 million a month. Six other large American manufacturers, such as Honeywell, also received substantial respirator orders from late March through July. According to data provided by H.H.S., domestic production would more than double over the summer, hitting around 160 million respirators monthly in November. In total, the administration would invoke the D.P.A. at least 30 times to expand the domestic medical manufacturing base, for respirators as well as other items. And after operating with limited visibility at the beginning of the pandemic, H.H.S. developed tools that integrated data from manufacturers and health care systems so it could better track where supplies were and who needed them.

These actions would both increase the total supply and somewhat improve the distribution of it. As the catastrophic outbreak waned in the Northeast and cases throughout the rest of the nation saw only modest gains, hospitals were soon reporting going from having a few days’ supply on hand to one or two weeks’ worth. In June, Admiral Polowczyk appeared to declare victory in a presentation to the Senate Homeland Security committee, claiming that expanded domestic industry would largely address the nation’s acute N95 shortages by July. And come October, the administration predicted, the problem would largely be resolved, with the six American companies producing about 140 million respirators monthly, and the remaining 40 million N95s that were needed being provided through imports and a novel decontamination system.

But by the end of June, tens of thousands of new Covid cases were being registered daily and hospitalization rates were rising significantly throughout the South and the West, again straining the nation’s P.P.E. supply. In July, smaller doctor’s offices and private health care providers complained about lacking enough P.P.E. to safely reopen, as they couldn’t compete with bigger purchasers, who were snapping up the increased domestic P.P.E. output. In August, a nationwide survey of nurses reported that 68 percent of them were reusing N95s for days or weeks at a time, often in violation of C.D.C. guidelines. Supply and demand for respirators were locked in a life-or-death race.

Like the Trump administration, the Baystate Health team came to consider domestic production as the answer to the shortages. Springfield had been one of America’s original industrial centers and its economy had been rebuilt around the health care services industry. Baystate already had a business initiative, TechSpring, that sought to revitalize the area’s once-proud manufacturing base by developing specialized medical equipment and software. In May, TechSpring decided to establish a Massachusetts-based N95 factory and furnished a long-term contract to Marc Etchells, a medical-equipment entrepreneur, which would guarantee him steady demand — if he could get a production line running.

Etchells had overseen a factory that made similar products in the past, but he found himself stymied: The materials were impossible to get because of overwhelming demand worldwide. Other business owners were also trying to pivot to N95 production, and they, too, were finding the terrain unnavigable; the Trump administration was mostly interested in providing direct support to a small number of corporate giants like 3M. The administration had used the D.P.A. to compel experienced ventilator producers to share their production techniques with neophytes, leading to one of its signature supply-chain successes in rapidly expanding ventilator production. But it declined to do the same with N95 masks, forcing new producers to reinvent the wheel. In the end, the Trump administration invested a relatively small amount in improving the N95 supply chain: $280.6 million, according to figures it provided. An analysis by The Washington Post found that the Department of Defense, which administers the D.P.A., has spent more money annually on musical instruments, outfits and travel for military bands.

After making its initial investments in the N95 supply chain, the Trump administration turned its attention elsewhere. It made a few investments in the manufacturing of other crucial P.P.E., such as isolation gowns and nitrile gloves, which are also produced largely overseas and subject to similar shortfalls. Baystate Health would come within days of running out of medical gowns, and had to enlist the help of a local furniture factory and a prison manufacturing line to engineer backups. Other hospitals were dressing nurses in rain ponchos, a fate Baystate Health ultimately avoided by finding domestically made gowns produced from materials like airbag fabric, by American businesses that had pivoted into P.P.E. manufacturing. Sheehy and his team also landed several huge orders of Chinese-made surgical-isolation gowns on the gray market, which were cheaper and better than some of their American counterparts. All of which meant that despite Baystate Health’s efforts to create its own supply, and the Trump administration’s labors to expand domestic production, Sheehy and his team were still partly reliant on foreign P.P.E.

Because China had quickly brought the pandemic to heel, its factories reopened relatively quickly, and businesses were converting facilities into new P.P.E. production lines, with government support. Throughout the summer, American health care systems and states increasingly tapped back into this booming Chinese production. Miranda Tan, a broker whom Baystate Health had come to rely on, had transformed a business that had placed Western products with Chinese social media influencers into one procuring P.P.E. from all over Asia for American customers. She estimated that “hundreds” of Americans had gotten into the market, and saw no signs of domestic production replacing her line of work.

By the end of October, Etchells had finally managed to secure raw materials for Baystate Health’s N95 factory, and he had ordered two respirator-production machines, as well as one for medical masks, which would arrive by the end of the year. Each factory line would cost him in excess of a million dollars to buy and install, meaning he would be deep in the red long before the machines started churning out masks in the first quarter of 2021. And meanwhile, the influx of supply from overseas had depressed prices to a still-inflated but more reasonable $2 apiece. Though it increasingly seemed possible that Baystate Health might one day again spend just quarters for N95s manufactured great distances away, Keroack, the Baystate Health C.E.O., remained committed to paying a premium for some P.P.E. to support a modest local industry, as a hedge against future pandemics or other supply-chain-snapping disasters.

As October turned to November, the United States entered a “third wave” of the pandemic. Soon, it would break numerous daily records for the number of Covid infections, adding in excess of 100,000 cases a day. Around 10 months after the Trump administration was first warned that P.P.E. shortfalls could hinder its ability to corral the virus, the lack of basic equipment was still endangering Americans. Baystate Health was receiving just enough domestically made N95s to get by, but not enough to store many away. Sheehy was still hunting for supplies on the gray market. Shortages persisted. Get Us P.P.E., a nonprofit that gives away protective gear nationwide, had analyzed nearly 17,000 requests in October and found that the United States was still in a crisis, especially among long-term-care facilities, like nursing homes. For the first time since April, the organization said, P.P.E. requests were once more rising nationwide. Not long before, the Government Accountability Office published a report warning of ongoing constraints in the market.

Admiral Polowczyk said the G.A.O. report was “absolutely wrong.” Pointing to increased domestic production, he blamed health care systems for asking workers to reuse P.P.E. when there actually was enough supply nationwide — an incongruity he explained by suggesting that management was stockpiling unnecessarily because they were traumatized by running short of P.P.E. earlier in the pandemic. At the beginning of November, FEMA and the S.N.S. had on hand about 136 million N95s and 45 million KN95s — a significant buffer that Polowczyk hoped would sustain the country through a potentially nightmarish winter, but also less than half of what officials projected to have earlier this year.

In total, H.H.S. said that over the course of the pandemic, federal agencies and the private sector delivered about 318.5 million N95s — a substantial number, and one made possible by the administration’s success at expanding the domestic production. But it’s a number that still fell far short of the 3.5 billion that Kadlec had estimated were needed — a figure that was actually the “base” scenario the C.D.C. study laid out; it had calculated that a “maximum demand” situation could require more than twice as many respirators. Like much of the rest of the administration’s response to the virus, its P.P.E. successes relied partly on redefining reality: Perhaps the most consequential decision it made in expanding respirator supply was loosening safety guidelines, over the protests of health care worker advocates, so that a respirator designed for seeing a single patient could be worn for days or even weeks.

Ultimately, Admiral Polowczyk felt that the Trump administration had done what it had set out to do — lead a “locally executed, state managed, federally supported” response. “I beg to differ about putting the full weight of all that responsibility for every office worker and grocery store clerk who thinks they need an N95 mask on my shoulders,” Polowczyk said. “There’s a lot of people who should be accountable for their own preparedness for the pandemic.”

For those on the front lines, the Trump administration’s decision to be the last line of response felt a lot like abandonment. The nation’s largest health care and labor organizations, such as the American Hospital Association, the American Medical Association and the A.F.L.-C.I.O. have continued to plead for the administration to more forcefully invoke the D.P.A.

Artenstein, the chief physician executive at Baystate Health, emailed me in October. “There still does not appear to be a coherent, organized and effective (or even potentially effective) plan by this administration to address ongoing P.P.E. shortages,” he wrote. “Trust me, these are ongoing and will only worsen.” Indeed, the shortages have already returned as the virus runs rampant through the country once again. And though President-elect Biden has promised to federalize the P.P.E. response, he won’t take office until January 20 — and the current administration’s obstruction of the transfer of power may further delay his ability to act quickly.

The primary wisdom that Artenstein was providing to other health care systems asking for his advice was to not expect substantial help from the federal government. In a sense, the Trump administration had achieved one of its goals: It had trained Americans not to rely on it. Everyone was on his or her own in this pandemic, Artenstein warned. That was the American way.



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