Coronavirus response: Stockpile for me, not for thee

Welcome, dear readers, to the second installment of my coronavirus roundup. If you all find it helpful, I’ll post these every Friday in addition to Lost in the Sauce on Mondays.

Housekeeping:

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More warnings ignored

On March 6, President Trump said the coronavirus crisis was “an unforeseen problem” that “came out of nowhere.” On March 11: “We’re having to fix a problem that, four weeks ago, nobody ever thought would be a problem.” Trump insisted on March 19 that “nobody knew there would be a pandemic or epidemic of this proportion. Nobody has ever seen anything like this before. … Nobody ever thought of numbers like this.”

As we saw in last week’s round-up, this is not true. Trump’s administration ignored recurring warnings that spanned his entire time in office and originated from varied sectors. This week, we learned of even more instances of overlooked and rejected alarm signals.

2003-2015: As evidence that part of the government’s failure to respond to the coronavirus outbreak is systemic, there were at least 10 government reports on ventilator shortages that pre-date the Trump administration. In 2003, the Government Accountability Office warned that “few hospitals have adequate medical equipment, such as the ventilators that are often needed for respiratory infections … to handle the large increases in the number of patients that may result” from an infectious disease outbreak.” In 2015, DHS and CDC modeled a scenario in which a high severity influenza outbreak would “need approximately 35,000 to 60,500 additional ventilators, averting a pandemic total 178,000 to 308,000 deaths.”

2017: The Defense Department created a pandemic influenza response plan that specifically referenced the possibility of a dangerous coronavirus outbreak. The plan foresaw the medical supply shortages we’re now facing: “Competition for, and scarcity of resources will include…non-pharmaceutical MCM [Medical Countermeasures] (e.g., ventilators, devices, personal protective equipment such as face masks and gloves), medical equipment, and logistical support. This will have a significant impact on the availability of the global workforce.”

June 2017: A study by the CDC advised public health agencies to “stockpile critical medical resources,” warning that the Strategic National Stockpile “might not suffice to meet demand during a severe public health emergency.” On Wednesday, DHS officials said the emergency stockpile was “nearly exhausted” of medical supplies like masks and gloves. While there are reportedly about 9,500 ventilators in the stockpile (see more below), governors and experts predict the nation will need tens of thousands more in order to keep infected patients alive and breathing.

2019: Last fall, the White House Council of Economic Advisers published a report estimating the health and economic losses associated with a potential influenza pandemic. In the most serious scenario, the report determined that over half a million people could die from a pandemic in America and warned that “healthy people might avoid work and normal social interactions… incapacitating a large fraction of the population.” Critically, the report cautions against conflating the seasonal flu with a pandemic disease, which is exactly what Trump did as the coronavirus spread across the country.

  • Trump news conference Feb. 26: “This is a flu. This is like a flu.”
  • Trump tweet on March 9: “So last year 37,000 Americans died from the common Flu. It averages between 27,000 and 70,000 per year. Nothing is shut down, life & the economy go on. At this moment there are 546 confirmed cases of CoronaVirus, with 22 deaths. Think about that!”

Mid-January 2020: At a March 30 House Oversight Committee briefing, “HHS admitted that the Department knew as early as mid-January based on 2015 models that the United States would not have enough N95 respirator masks to respond to an infectious disease outbreak.”

January and February 2020: National security adviser Robert C. O’Brien and his deputy, Matthew Pottinger, were pushing for “strong action” earlier than others in the administration. Pottinger, who lived in China during the SARS crisis, knew that the Chinese government was underplaying the outbreak in their country and, with O’Brien, “repeatedly pressed other top [U.S.] officials to take the threat more seriously.” According to the Washington Post, then-acting White House Chief of Staff Mick Mulvaney and Treasury Secretary Steven Mnuchin were among the officials who were not convinced.

Feb. 3, 2020: The Daily Beast reported: “An unclassified briefing document on the novel coronavirus prepared on Feb. 3 by U.S. Army-North projected that ‘between 80,000 and 150,000 could die.’ …if the White House had heeded an Army warning nearly two months ago, it might have prompted earlier action to prevent an outbreak that threatens to kill more Americans than two to four Vietnam Wars.”

Feb. 5, 2020: Health and Human Services Secretary Alex Azar asked the Office of Management and Budget (OMB) for $2 billion to buy respirator masks and other supplies for the depleted Strategic National Stockpile. The request turned into a “shouting match” on Feb. 5 between Azar and an OMB official, who alleged that Azar improperly lobbied Congress for money for the stockpile. The White House cut the $2 billion down to just $500 million in the final budget request sent to Congress.

  • More details: In February 2019, the White House was planning for a presidential executive order on preparing for a potential flu pandemic. HHS requested a more than $11 billion investment over 10 years for [the stockpile]…some of those funds would go toward “better protective devices, manufactured faster.” But the executive order issued by Trump in September 2019 did not include that money.

Feb. 5, 2020: While Azar was trying to secure funding via the White House OMB, he was simultaneously denying additional funding from Congress. Sen. Chris Murphy (D-CT) tweeted on Feb. 5 about a coronavirus briefing he had attended, saying “Notably, no request for ANY emergency funding, which is a big mistake. Local health systems need supplies, training, screening staff etc. And they need it now.” In an interview last week, Murphy explained that numerous lawmakers demanded to know why the administration wasn’t asking Congress for funding for medical supplies. “Their position was that this wasn’t the moment to start panicking, staffing up and buying supplies,” Murphy continued.

  • More details from WaPo: “Crucially, several lawmakers were already telling administration officials that ‘our local public health systems were fundamentally just not ready,’ Murphy told me. ‘States were beginning to grapple with some of the most thorny questions, and it was clear the administration didn’t understand the scope of what was going to be necessary.’”
  • Yahoo News: “Had we appropriated money in February to start buying re-agent, we would be in a position to do many more tests today than we are,” Murphy said. ”It was just so clear to us that the administration didn’t think this was going to be a problem. We begged them in that meeting to request emergency funding from the Congress and they told us … that they had everything that they needed on hand, which was false.”

Late February: The Daily Beast reported: “A high-ranking federal official in late February warned that the United States needed to plan for not having enough personal protective equipment for medical workers as they began to battle the novel coronavirus, according to internal emails obtained by Kaiser Health News.”


Testing still an obstacle

On March 10, Vice President and leader of the coronavirus task force Mike Pence told the country that “over a million tests have been distributed” and promised “more than 4 million more tests” would be available across the country by the end of that week. Three days later, on March 13, Trump said we would have “1.4 million tests” within the following week “and 5 million within a month.”

However, at the end of March, the COVID Tracking Project reported only 964,865 total tests had been conducted, including available data from private labs. This number is far short of the promises made by the White House. When asked about the discrepancies last month, Trump said: “I cannot explain the gap. I’m hearing very good things on the ground.”

Just days ago, on a conference call with Trump and other governors, Gov. Steve Bullock (Montana) told the president that his state doesn’t have enough tests to trace the spread of the virus (audio). “Literally we are one day away, if we don’t get test kits from the C.D.C., that we wouldn’t be able to do testing in Montana,” Bullock said. “I haven’t heard about testing in weeks…I haven’t heard about testing being a problem,” Trump responded, also repeating the inaccurate claim that “We’ve tested more now than any nation in the world.”

  • Fact check: The U.S. has tested only 1 in 366 people. South Korea has tested 1 in every 124 people.

Bullock’s complaint that states were struggling with a lack of testing kits was backed up by Maryland Gov. Larry Hogan, who told NPR that Trump’s claim that states have adequate testing supplies is “just not true,” adding that “no state has enough testing.” Washington Gov. Jay Inslee told CNN last week that his state has “a desperate need for the testing kits” and lacks “the materials to take the test itself… things as simple as the swabs.”

  • Reminder: Washington scientists wanted to test for the coronavirus in January, when the first U.S. case was confirmed (in a man who arrived from Wuhan). But the FDA prevented local labs from performing the tests. A professor at the University of Washington became exasperated mid-February trying to get approval, saying “This virus is faster than the F.D.A.” On Feb. 25, a Seattle team began testing without government approval, confirming the first instance of community-transmission of COVID-19 in the nation. “It must have been here this entire time,” Dr. Chu recalled thinking with dread. “It’s just everywhere already.”

There is evidence to suggest that the federal government has shipped out more tests than the COVID Tracking Project reports. CNN and The Atlantic have reported that commercial labs have a huge backlog of coronavirus tests to process. These pending results would not be captured by the Tracking Project. For instance, New Jersey-based Quest Diagnostics had about 160,000 coronavirus test orders waiting to be processed on March 25 from across the country. California apparently has the largest backlog in its private labs, with over 57,400 people waiting for results at the end of March.

Drive-through testing

Another Trump promise that never materialized: During one of the corporate showcases masquerading as a coronavirus briefing, the president brought the executives of Target, Walgreens, Walmart, and CVS before the TV cameras to announce a network of drive-through COVID-19 testing sites across the country (video). Despite having a combined 26,400 U.S. stores, these four retailers have only opened four testing sites, none of which are open to the general public:

Walgreens and CVS have opened one site each, while Walmart last weekend opened two drive-through testing locations near Chicago. Target hasn’t opened any. Rite Aid, which joined the effort later, has opened one drive-through facility in Philadelphia.

Why is widespread testing important?

Iceland, a country of just 360,000 people, has tested 5% of its population for coronavirus. A biopharma company has screened the wider population, not just those with symptoms, and found that around 50% of those who tested positive said they were asymptomatic. This is critical because it confirms that people without symptoms can spread the virus. Right now, in America, we’re only testing those with severe symptoms (and even then, some states are unable to test anyone except healthcare workers). Until we have the capacity to test asymptomatic people as well, we’ll never know who should be self-quarantining.

States plead for supplies

A prediction from the past

I’d like to open this section with a quote from President Trump about his interactions with governors desperate for medical supplies for their states: “I want them to be appreciative. I don’t want them to say things that aren’t true. I want them to be appreciative. We’ve done a great job.” Later, Trump said he has told Pence not to call the Governor of Washington or the Governor of Michigan because “if they don’t treat you right, I don’t call.”

Now, a quote from Stanford Law Professor Pamela Karlan during her testimony in the impeachment inquiry on Dec. 4, 2020: “What would you think if, when your governor asked the federal government for the disaster assistance that Congress has provided, the President responded, ‘I would like you to do us a favor. I’ll… send the disaster relief once you brand my opponent a criminal.’”

Can we really say that the scenario we’re living through today is different from what Karlan predicted? ‘I would like you to do us a favor. I’ll send the coronavirus aid once you publicly praise me.’ Trump was impeached for holding aid hostage to his selfish, venal demands and Republicans refused to convict. Now, he is repeating the same behavior in the middle of a pandemic.

Unequal distribution

Some states seem to have better luck at getting supplies from the national stockpile than others. Occasionally these disparities occur along ideological lines, but just as often there seems to be no (visible) pattern to which states receive aid and which miss out. This leaves us with two equally disturbing conclusions: Either the federal government is playing favorites with life-saving medical supplies, or the federal government is too incompetent to fulfill basic orders from the states.

One instance that piques suspicions of partisan bias: Florida, headed by Trump-ally Ron DeSantis, has received 100% of its requests with a third surplus shipment on the way. Meanwhile, Democratic-leaning Massachusetts has only gotten 17% of the personal protective equipment (PPE) it requested and Colorado, led by a Democratic governor, received “enough for only one full day of statewide operations.”

Officials in Florida have pointed to the close relationship between DeSantis and Trump as a helpful tool in shaping federal policy. The two speak almost daily… Trump will probably need the 29 electoral votes of his adopted homestead to win reelection… “The president knows Florida is so important for his reelection, so when DeSantis says that, it means a lot,” said the official, who spoke on the condition of anonymity to be frank. “He pays close attention to what Florida wants.” (WaPo)

Yesterday, the House Oversight Committee released confirmation from DHS and FEMA that states are not receiving enough supplies from the stockpile – aside from Florida, apparently:

The Oversight Committee released documents suggesting dramatic shortfalls of equipment requested by states in FEMA’s Region III, which includes Virginia, Maryland, Pennsylvania, West Virginia, Delaware and Washington, D.C. Collectively, the states and D.C. sought 5.2 million respirator masks, but received less than 10 percent of their requests. And they received less than 1 percent of their request for 194 million pairs of gloves. A request for 15,000 body bags went unfulfilled as well.

To rebut evidence that the federal supply is not being used correctly, Jared Kushner, leader of a shadow task force, made the extraordinary, and inaccurate, claim that the federal stockpile “is supposed to be our stockpile, it’s not supposed to be states’ stockpiles that they then use.” The website for the Strategic National Stockpile clearly spells out the opposite: “When state, local, tribal, and territorial responders request federal assistance to support their response efforts, the stockpile ensures that the right medicines and supplies get to those who need them most during an emergency.”

  • Kushner also repeatedly advised Trump in the early days of the outbreak that the media was exaggerating the threat. That Google website that Trump falsely announced was coming? That was Kushner, too. Meanwhile behind the scenes a Kushner family health insurance company (Oscar Health) built the website that was promised. A senior official described Kushner’s “shadow” task force as “a ‘frat party’ that descended from a U.F.O. and invaded the federal government.”

eBay for supplies

The President and the task force have directed states not to rely on the stockpile and to turn to the private sector instead. However, simultaneously the president has refused to take control of the supply chain, instead encouraging an eBay-like bidding war between itself, all 50 states, and private hospitals.

“It’s like being on eBay with 50 other states, bidding on a ventilator,” a frustrated Gov. Andrew Cuomo, D-N.Y., said Tuesday morning, adding that the Federal Emergency Management Agency’s bids are pushing the cost of medical supplies higher. “I mean, how inefficient. And then, FEMA gets involved! And FEMA starts bidding! And now FEMA is bidding on top of the 50 [states]. So FEMA is driving up the price. What sense does this make?”

Elizabeth Warren: Trump told states they were on their own to purchase medical equipment, so that’s what MA tried to do. But then the federal government outbid MA at least 3 times – and reports show two of our orders were seized by federal authorities. This is unacceptable. MA requested supplies from the Strategic National Stockpile nearly a month ago. Only a fraction ever came. Without Trump’s full & consistent use of the DPA, state officials are still scrambling to find essential equipment but the federal govt has created a logistical black hole.

Defective equipment

Even when the federal government has sent supplies to states, sometimes the materials are defective or simply not what’s needed.

  • After criticizing Trump’s response to the outbreak, Illinois Gov. J.B. Pritzker (D) was sent surgical masks instead of the 300,000 N95 masks the White House promised. “I can’t emphasize enough how much we need the federal government to step up and amplify the size of their PPE [personal protective equipment] deliveries to Illinois and frankly across the nation,” Pritzker said.
  • Last Saturday, California Governor Gavin Newsom (D) announced that “LA received 170 broken ventilators from the national stockpile,” the entire shipment. “Rather than complaining about it, rather than pointing fingers about it…We got a car and a truck, we had those 170 taken to a facility” to be refurbished, Newsom said.
  • Almost 6,000 masks that Montgomery County (AL) received from the national stockpile were rotted and had a 2010 expiration date, according to Christi Thornton, the local emergency management director. Thornton said they received a replacement shipment Wednesday.

Ventilators

I’m addressing the problems with ventilators in a separate section, because it is a uniquely expensive piece of medical equipment desperately needed across the country.

First, there are not enough ventilators in the reserve for all the states. This is complicated by the fact that Trump and Pence do not believe states need as many machines as they’re requesting:

Officials in Illinois say they asked for 4,000 and got 450. New Jersey sought 2,300 and got 300. New Mexico has only 370. Virginia requested 350 ventilators but has not received any. The governor of Illinois asked Vice President Mike Pence for 4,000 ventilators this week and was told the state would not need that many. (NYT)

Video: Trump told.Sean Hannity. ‘I don’t believe you need 40,000 or 30,000 ventilators. You know, you go into major hospitals sometimes, they’ll have two ventilators. And now all of a sudden they’re saying can we order 30K ventilators?’”

Video: ABC News’s Jonathan Karl asked Trump if “everybody who needs one will be able to get a ventilator?” To which Trump responded, “Look, don’t be a cutie pie, okay? Nobody’s done what we’ve been able to do.”

Second, as Gov. Newsom discovered, many ventilators in the stockpile do not work. The New York Times reported that apart from the 9,500 Trump has spoken about being in the reserve, “an additional 2,109 lifesaving devices are unavailable after the contract to maintain the government’s stockpile lapsed late last summer, and a contracting dispute meant that a new firm did not begin its work until late January.” Presumably, Newsom did not receive 170 of the 2,109 that are out of commission, revealing that a certain percentage of the 9,500 ventilators do not work, either.

As White House officials have for the first time looked at a supply they had not thought about, they have discovered it is not only far smaller than what they need — it is also in constant need of maintenance.

Third, Trump is belatedly using the Defense Production Act (DPA) in a very limited fashion to compel one company, General Motors, to begin mass-producing ventilators… or is he? In a Politico interview, the president’s top trade official, Peter Navarro, said the administration has not been able to verify whether GM has made any progress since the Defense Production Act was invoked

Fourth, the confusion about ventilators exceeds just the use of the DPA. According to the House Oversight Committee, FEMA reported that most of the 100,000 ventilators promised by President Trump will not be available until late June at the earliest.

Fifth, a ventilator manufacturer is negotiating with Jared Kushner to build complex and expensive ventilators when taxpayers have already paid $32.8 million for 10,000 low-cost, portable, easy-to-use ventilators that were never delivered. ProPublica’s investigation found that Health and Human Services has been “remarkably deferential” to the company, Royal Philips N.V., even during the pandemic when Philips has prioritized commercial sales over beginning the government’s order.

Had government officials insisted that Philips first produce the ventilators that taxpayers paid to design, the government could conceivably be distributing all 10,000 to hospitals now.

The Defense Production Act

“The government’s not supposed to be out there buying vast amounts of items and then shipping, we’re not a shipping clerk,” Trump said. “As with testing, the governors are supposed to be doing it.”

A “shipping clerk” is exactly what is needed, though. The federal government could help by using the Defense Production Act (DPA) to procure resources and direct production to resolve supply shortages:

The federal government could get involved and place an order for masks, which would get fulfilled first because a DPA order takes priority over all others. Then, because the government knows which areas have the most need for those masks, it can distribute them appropriately… The federal government can find other sources of those materials and then put in an order to have the company sell the materials to the federal government instead of using them to make their own products.(Vox)

Trump’s resistance to using the DPA at its full force is especially puzzling considering the federal government’s long history of using the act… for weapons of war. The New York Times reported last week that Trump himself has used the DPA to “place hundreds of thousands of orders” for equipment before the pandemic struck.

Invoking the Defense Production Act is hardly a rare occurrence. As recently as last summer, the Department of Defense used it to obtain rare earth metals needed to build lasers, jet engines, and armored vehicles. The Defense Department estimates that it has used the law’s powers 300,000 times a year.

As has already become obvious, Trump recognized the problem too late, ignoring January warnings from medical experts that the U.S. will face a critical shortage of ventilators. Had the president acted sooner, thousands of new ventilators would probably be coming off production lines next month. Even after the problem was recognized, under the leadership of Jared Kushner, the White House and FEMA “struggled to define what was needed, who would pay for it and how to solve the problem of supply chains that stretched across more than a dozen countries.”

Now, with Trump beginning to use the DPA for (some) ventilators, there are new challenges.

  1. The president needs to use the DPA for PPE like masks
  2. The federal government needs to direct manufacturers on where to deliver their newly-produced supplies. CNN reported last week that “medical and ventilator manufacturing companies said they have pressed the federal government to take on the role of deciding where to place their supplies. But those calls, these companies said, have gone unanswered.” Abbott Labs, which developed the rapid-response tests Trump showcased last week, is asking the administration where to deploy the tests. Some White House officials reportedly want to ship the tests to rural areas, while officials in hard-hit areas argue that the tests are most useful for first responders and health-care workers in hotspots.
  3. FEMA is importing medical supplies from overseas, but only a portion is being delivered to hospitals in coronavirus hotspots. “The rest will resupply the private market, where competition between states and the federal government has been a source of frustration for governors,” according to CNN. “Everything that’s brought, 80% of it, is just dumped into the private market. So then governors are competing against one another, at times the federal government, to try to get these supplies,” Montana Gov. Bullock (D) said

Wrap up

There have been a ton of news stories that deserve coverage here. Unfortunately, I am but one person with a 40,000 character limit. So here are some links to articles that would appear above in an ideal world:

  • NYT: The 1,000-Bed Comfort Was Supposed to Aid New York. It Has 20 Patients. | “It’s a joke,” said a top hospital executive, whose facilities are packed with coronavirus patients.
  • NYT: Jared Kushner Is Going to Get Us All Killed
  • Buzzfeed News: Coronavirus Cases Have Surged, But The US Is Refusing To Take The World’s Most Available Masks
  • USA Today: U.S. exported millions in masks and ventilators ahead of the coronavirus crisis
  • Politico: Last week, a Trump administration official working to secure much-needed protective gear for doctors and nurses in the United States had a startling encounter with counterparts in Thailand. The official asked the Thais for help—only to be informed by the puzzled voices on the other side of the line that a U.S. shipment of the same supplies, the second of two so far, was already on its way to Bangkok. Trump aides were alarmed when they learned of the exchange, and immediately put the shipment on hold while they ordered a review of U.S. aid procedures.
  • Salon: Study: Republican governors “slower” to adopt coronavirus restrictions, causing “significant” harm; The study itself from the University of Washington.
    • Axios: Florida’s slow response may have made its coronavirus outbreak worse
  • Tampa Bay Times: Hours after Florida’s Republican Gov. Ron DeSantis issued a statewide stay-at-home order, he quietly signed another one that appeared to override restrictions put in place by local governments to halt the spread of coronavirus.
    • NBC News: Georgia Gov. Brian Kemp admits he just learned asymptomatic people can spread coronavirus
  • NBC News: Navy relieves captain who raised alarm about coronavirus outbreak on aircraft carrier
  • Stars and Stripes: Pentagon orders installations to stop reporting coronavirus cases as military-linked infections eclipse 1,000
  • Washington Post: Trump blames hospitals for mask and ventilator shortages
  • NYT: Philadelphia Hospital to Stay Closed After Owner Requests Nearly $1 Million a Month
  • ProPublica: Trump Congratulates Businesses for Helping Fight Coronavirus. But His Own Company Has Been Absent.
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