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Christine Garcia was scrambling.

As the San Francisco regional director at an agency for children with mental health and behavioral issues, Garcia and her colleagues had seen the latest guidelines from local health agencies mandating the use of masks at facilities like theirs. It seemed like common sense, except for one thing.

“There were no masks to be had,” Garcia recalled.

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The guidelines said that facilities like Garcia’s could request supplies from the city. Garcia was able to receive an initial batch of masks from the San Francisco Department of Public Health, but she knew her agency needed more, and the department said it had already provided what it could.

It took a stroke of luck to find more masks: A friend’s brother worked as a beauty product e-commerce entrepreneur, and used a manufacturer in China for some of his own supplies. In the spring, that manufacturer was abruptly contracted by the Chinese government to produce masks. So the entrepreneur brokered a deal between the  manufacturer and Garcia, and within a week, Garcia received 500 masks for her workplace.

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That episode, in March, revealed an overlooked reality of the Covid-19 pandemic in the United States: While major metropolitan hospitals have largely stabilized their supply chains for personal protective equipment such as masks, facilities and communities that serve some of the most vulnerable populations are still struggling to get what they need.

An analysis by Get Us PPE, a nonprofit group, found that while the PPE requests it received were almost evenly split between hospitals and nonhospital settings in April, in October over 90% of requests were from facilities such as homeless shelters, natural disaster relief groups, and nurses’ offices in schools. Smaller hospitals are also struggling.

“Even if there’s still inadequate supply, major hospital systems have been able to access that inadequate supply because they have the financial means,” said Megan Ranney, a co-founder of Get Us PPE, which organizes and distributes PPE donations to both hospital and nonhospital facilities across the country. “The clinics, safety net hospitals, the critical access rural hospitals, the smaller nursing homes are absolutely still lacking PPE.”

The failure of the federal government to procure adequate protective equipment for frontline workers is an ongoing tragedy. At the same time, a grassroots movement including organizations like Get Us PPE is trying to fill the void. With the pandemic projected to worsen in the coming months, the question is whether it will be enough.

Bridging the gap

The problem, of course, started at major hospitals.

Shafqat Islam, a tech entrepreneur in New York, remembers receiving emails that made clear the seriousness of the issue. They were written by the parents of students at his daughter’s school.

Some of you may know, I am a physician at [a local hospital] — … please, if you have any boxes of masks, especially N95 respirator masks, or other protective equipment that you can donate… please email…

Islam was confused. How could one of the city’s most well-funded hospitals be without protective equipment?

But the problem, it turned out, wasn’t just a financial one. It was an issue of supply. China — the source of over 40% of the world’s PPE imports — had shut down its factories in the wake of the first coronavirus surge. U.S. hospitals weren’t nimble enough to find new suppliers.

Islam had never worked in the medical industry. But as the CEO of a technology startup, he was used to building things from scratch, and he wanted to help. Within weeks, he had secured initial funding of $400,000 from the local startup community and formed high-level strategic and logistics partnerships to bring large quantities of PPE into the U.S.

His initial goal was ambitious: source and distribute 1 million masks to frontline healthcare workers in New York City. It was an enormous target, but Islam also knew it was merely a stopgap solution.

“Our goal was to provide the bridge to when the supply would be restored,” Islam said.

The same issues were popping up at major hospitals across the country. Many had detailed plans for dealing with supply shortages during emergencies. But most protocols were developed to focus on supplies for the treatment of patients, rather than the protection of the health care practitioners themselves. What’s more, hospitals typically braced for single, short-duration emergencies like plane crashes or natural disasters, rather than the monthslong slog of the coronavirus pandemic.

Like the hospital in New York, others were turning to local communities for help.

And donations were pouring in. Major metropolitan hospital systems received brand-name N95 respirators left over from home improvement DIY projects, boxes of gloves and masks from dentist’s offices — even supplies pulled straight from the cabinets of then-shuttered public school nurse’s offices.

Emory Healthcare in Atlanta opened a PPE donation site in late March, and received 40,000 N95 respirators and more than 100,000 surgical and homemade cloth masks.

“There was a full court press across Atlanta,” said Cheryl Iverson, corporate director of community engagement for the health care system.

While the system worked on stabilizing its supply chain, the Chinese American community, including overseas parents of Chinese students at Emory, rallied to find supplies independently. China had imposed limits on purchasing and exporting at the time, but by combining their efforts they were able to organize a large donation of masks to Emory Healthcare.

“They supplemented our supplies while we were scrambling to get [them] through our regular efforts,” recalled Iverson.

By April, Emory had adapted to the shortages — and found ways around them. It received a grant to build machines for sterilizing PPE for reuse, vetted donations, and strengthened its network of vendors. In May, it closed its donation center.

In New York, Islam was thrilled to see similar outcomes at nearby hospitals, thanks in part to his nonprofit, 1M Masks to NYC Healthcare Workers.

His “weekend project” had turned into “something better,” he said.

But even as the initial panic subsided at major hospitals, smaller clinics and other facilities were about to be left behind.

Stitch House masks
Stephanie Cave sews the mask seams and straps together to finish creating masks at Stitch House in Dorchester, Mass., in March. The store was responding to a call for donations from local hospitals dealing with a huge shortage of masks. JOSEPH PREZIOSO/AFP via Getty Images

In the United States, federal and state agencies are responsible for providing health care and public health services to federally recognized tribes. And beginning in the early summer, many tribes received an initial distribution of PPE.

But some tribes were experiencing worrying gaps in supply, said Susan Alzner, a co-founder of shift7, a company that works with communities, including Native American tribes, to develop solutions for systemic economic, social, and environmental challenges.

“They were saying to us, ‘Can you find [PPE] anywhere? We can’t find it,’” said Alzner. “So we just started looking around — literally, we started on Amazon.”

Alzner started with what she thought would be surefire purchasing channels, but none of her professional contacts had access to PPE, and the prices she found on Amazon were astoundingly high.

Eventually, Alzner found a dental supply company selling masks. At the time, she was focused on sourcing PPE to donate to the Havasupai Tribe of the Grand Canyon and then for their neighbors, the Hualapai Tribe. Each tribe had only one health clinic, and a coronavirus outbreak would have been devastating for either community.

“It was obscene, let me just say, what we paid for what we sent,” said Alzner.

But shift7 kept hearing from more communities about their needs for PPE. The company did what it could, seeking information about available supplies through emails, text threads, phone calls, and word-of-mouth. It even hired two consultants to handle outreach with tribal partners to figure out exactly which PPE was most needed.

Nothing about the process was linear. At some point, Alzner heard that the tech company Salesforce intended to distribute 1 billion units of PPE to organizations in need. So she sent in a proposal; it was approved within 24 hours.

Around the same time, Alzner was introduced to Shafqat Islam, of 1M Masks, via text. She was immediately struck by the group’s ability to navigate the complex logistics of the PPE supply chain. But she was most impressed by perhaps an even more important quality: integrity.

“They were able to get supply — vetted supply, and they were diligent about it, they were careful,” said Alzner.

Quality issues are a dangerously common occurrence in the world of PPE sourcing, as the insatiable demand for PPE creates ample opportunity for bad actors to flood the market with useless, counterfeit product.

In April, one of the samples that Alzner received was different from what 1M Masks had told her to expect. But it turned out to be a mixup on the part of the warehouse service that 1M Masks was using, and Alzner recalls that 1M Masks acted swiftly to address the mismatch.

In the chaos of the pandemic, it’s qualities like trust and fortitude that make it possible to do good, she said.

These days, Islam thinks a lot about his initial optimism for 1M Masks. He had launched the organization in April in the hopes of buying facilities enough resources and time to stabilize their PPE supply chains. He’d thought the organization would close its doors in June for good — July at the latest.

But, “I feel like there’s always a bridge to something,” he said. In the spring, 1M Masks was providing PPE as a Band-Aid for metropolitan hospitals’ supply chain. In the summer, as a stopgap for Native American communities. This autumn, their PPE was used by poll workers during the election.

Islam paused, thinking about all the bridges that America has yet to cross. “At some point we have to get back to a normal situation,” he said. But he has no illusions that normal is here yet.

“I’m wondering now — what’s the next bridge that we’re going to have to provide?”

Goodwill isolation gowns
Workers sew isolation gowns at the Goodwill South Florida facility in Miami in April for doctors working in hospitals. Joe Raedle/Getty Images

Preparing for the winter

Despite the tragic lessons learned from the spring and summer, the coronavirus pandemic is still not over in the U.S. Cases and deaths are increasing at an alarming rate.

The public’s focus has shifted away from PPE shortages to secondary effects wrought by the pandemic: the long-term impact on the economy, the mental health toll of shelter-in-place orders, the horrifying lingering effects of the virus.

But the PPE problem “is absolutely, positively not fixed,” said Ranney, of Get Us PPE.

Since launching in March, Get Us PPE has distributed millions of units nationally to hospitals, as well as community clinics, nursing homes, homeless shelters, and other frontline nonhospital facilities.

The organization has partnered with the National Association of School Nurses in order to gauge current need and help schools as more of them return to in-person instruction.

And still the requests keep coming in. As of early November, Get Us PPE has been able to fulfill only about 10% of PPE requests received since March. But Ranney is determined to find silver linings amid the slog. She said she’s found hope in the generosity of people, and the power of grassroots communities to create real change. She is also now a true believer in public-private partnerships between public health departments and corporations.

Islam agreed.

“I just hope that the hospitals use this as a learning opportunity,” he said — about the need for innovation in the supply chain process and the importance of flexibility and partnerships with nontraditional sources. “Otherwise, when this happens again — if we’re back to square one, that would be a shame.”

Organizations like Islam’s and Ranney’s are learning as they go. After initially focusing on managing donations of equipment from individuals, Get Us PPE has shifted to partnering with local community organizations, including “makerspaces,” to produce PPE items that remain difficult to source, like isolation gowns.

With their supply chains stabilized, some hospital systems have been trying to pay it forward. After closing its donation center, Emory Healthcare donated excess surgical and homemade masks to clinics in the Atlanta area. These donations, according to one clinic co-founder, are a godsend for vulnerable populations that might otherwise have to choose between buying food or buying PPE.

But at the end of the day, Ranney said, the struggle for PPE is indicative of “a host of other structural inequities that cause poor health in our country.”

Though many major hospital centers opened community donations centers in the spring, none of those that STAT spoke with intend to reopen their centers.

In contrast, shift7 is still working with 1M Masks and other organizations to source PPE. To date, shift7 has facilitated donations of more than 625,000 units of PPE directly to more than 100 tribes and tribal organizations, including the Great Plains Tribal Leaders Health Board, the Indian Pueblo Cultural Center, and the International Indian Treaty Council. The tribal organizations, in turn, have distributed the supplies to approximately 230 additional tribes.

“We shouldn’t have to be in a reactive situation to save lives,” said Alzner, of shift7. “We should be able to protect [vulnerable communities] proactively. There’s no excuse.”

What began as the disparate efforts of concerned Americans has turned into an ever-shifting — yet robust — patchwork of communities, donors, grassroots suppliers, and vendors trying to help.

These grassroots networks are made up of people like Islam and Ranney, who, in addition to working their day jobs, believe they have no choice but to mobilize manufacturers, makers, and logistics experts to help fix the PPE shortage.

These networks serve small health clinics, local museums, congregate care facilities, and countless other community organizations that have no choice but to face the uncertainty of the pandemic on their own.

These networks are, for many, the only choice there is.

  • There apparently and luckily still is a vast sense of community in the United States, that supports, takes action, and delivers. State and federal governments ought to be royally embarassed, and shape up. But in their favouring the holy “economy” they are the devils who cause needless deaths for lack of health care. And in another time they would hang for this. Americam leaders have failed their flocks.

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