At the Allentown, Pennsylvania, distribution center for a major supplier of personal protective equipment, President Trump lauded America’s doctors and nurses, calling them “warriors” charging into battle: “They’re running into death just like soldiers run into bullets,” said Trump, who avoided combat in Vietnam. “It’s a beautiful thing to see.”
The ugly truth is that, as commander in chief, Trump has left these frontline medical combatants without the proper defenses. As the pandemic loomed, the national stockpile of N95 masks — essential for preventing healthcare workers from catching COVID-19 — was all but empty, with less than one percent of 3.5 billion masks government models had long indicated would be needed in a pandemic.
The lack of protective masks — the equivalent of helmets or bulletproof vest for infantry — has put healthcare workers at needless risk of infection. Doctors, nurses, EMTs, nursing home attendants and other frontline workers have had to reuse N95 masks designed for single use, sometimes for weeks on end. Others have been forced to make do with less effective surgical masks. Hundreds are dead.
This is the story of another avoidable tragedy in the Trump administration’s bungling fight against the coronavirus. It draws from internal emails and memos, a federal whistleblower complaint, and congressional testimony by federal officials and private executives. That record provides a startling glimpse behind the scenes of an administration deaf to timely and dire warnings beginning in January about the need to accelerate N95 mask procurement and production to protect healthcare workers. Despite these urgent appeals the Department of Health and Human Services dragged its feet until the middle of March before signing contracts to buy significant quantities of masks. The president failed to use his powers under the Defense Production Act to require mask production until April — and even then in quantities far below the nation’s need.
The lack of PPE has turned caregivers into patients and, in some cases, casualties. An April CDC study suggests that healthcare workers could account for as up to 11 percent of U.S. cases. At the Henry Ford hospital system in Detroit alone more than 700 employees tested positive for the virus. A May paper in The Lancet found that healthcare workers accounted for five percent of critical care COVID patients at a pair of New York City hospitals. The National Nurses Union (NNU) has documented 100 nurse deaths from COVID-19, a body count executive director Bonnie Castillo blames on “employer and government disregard for nurses lives.” She adds: “Nurses signed up to care for their patients. They did not sign up to die needlessly on the front lines of a pandemic.”
IN MID MAY — on the same day Trump glorified the “beautiful” self-sacrifice of healthcare workers — federal whistleblower Rick Bright, testified that the nation’s frontline healthcare workers were put in danger, not because of a lack of insight into the critical N95 mask shortage, but because of an “unconscionable” refusal to fix it. Until he was ousted by the Trump administration in April, Bright served as director of a Health and Human Services department called BARDA, or the Biomedical Advanced Research and Development Authority. “Our people were aware of the urgency,” Bright said of top administration figures. “What was lacking was the action.”
N95 respirators are close-fitting face masks designed to trap microscopic particles, including pathogens like viruses, in their fibers — filtering the air that passes through the mask without leaking about the sides. The N95 masks used in medicine are usually made out of plastic fiber, cost about a dollar apiece in a normal market, and are used by health professionals who must work in proximity to highly infectious patients. Precisely because the N95 masks trap contaminants with their fibers, they are meant to be disposed of after a single use.
In normal circumstances, N95 mask usage is relatively uncommon; a typical hospital might only use 6,000 N95 masks over a full year, with national demand reaching about 25 million masks a year. But such supplies become woefully inadequate the moment a pandemic hits. The likelihood of a critical shortage of N95 masks has been spotlighted in government reports as far back as 2006, when a report from the National Academies’ Institute of Medicine warned “efforts to produce and stockpile sufficient supplies of disposable masks… may fall short in the event of a pandemic.” The report underscored that “no method of decontamination” exists that’s capable of “removing the viral threat” from the masks, while not compromising the integrity of the devices or the health of the wearer. It emphasized that N95 masks should “therefore be discarded after a single use.”
According to CDC best practice, circa 2015, every health care worker in a pandemic ought to dispose of a mask after each encounter with an infectious ICU patient, creating a burn rate of up to 16 masks per patient, per day. Need spikes outside of hospitals too. CDC recommended supplies of up to four masks per day for first responders (police, fire, and ambulance workers) as well an allotment of four masks per patient, per day at nursing homes. A CDC-sponsored study that same year calculated a need for up to 7.3 billion N95 masks across the scope of a severe pandemic lasting roughly a year. This same paper also established a “base case scenario” of up to 3.5 billion masks — a figure that has gained currency in the coronavirus pandemic.
The supply chain for N95 masks can’t instantly ramp up production to meet this need. The industry has few machines in reserve, limiting surge capacity. A run on mask materials can also create a choke point. “You can’t wait for the pandemic to happen before we do something about it,” Mike Bowen, CEO of America’s largest surgical mask company, Prestige Ameritech, testified to Congress in May. Bowen described his failed crusade to get the administrations of George W. Bush, Barack Obama, and Donald Trump to elevate domestic N95 production, supply and stockpiling as national security priority. “Nobody listened,” Bowen said. “We had thirteen freaking years to fix it, and that’s the travesty.”
Globalization has heightened the risk to America’s N95 mask supply. Production has shifted to overseas factories. (“I call it chasing pennies to China,” said Bowen of the profit motive that has driven mask manufacturing abroad, insisting, “It has cost us lives.”) Offshoring has left the U.S. reliant on an international supply chain that can seize up in a pandemic if producing countries begin hoarding for domestic need rather than supplying the global market, as happened with a significant portion of the Chinese supply in this pandemic. For-profit hospital systems have also exacerbated a national undersupply. Seeking to boost profits, hospitals have slashed their own stockpiles of emergency medical equipment, relying on just-in-time deliveries to sustain their operations.
There is ample blame to share in the lack of preparedness for the current pandemic. The Strategic National Stockpile of medical supplies does not have an ongoing pandemic preparedness budget. Its last major cash infusion came in 2006, under the W. Bush administration, when it added roughly 100 million masks to the stockpile. But the 2009 H1N1 outbreak, in the early Obama years, depleted this reserve. And amid the Republican-led budget standoffs that defined the Obama presidency, the masks were never significantly replenished. This inaction came despite a stark warning from the Association of State and Territorial Health Officials, which warned the CDC in a 2010 H1N1 postmortem report that: “There should be a central repository of N95s which is replenished for future events.”
The Obama administration did attempt to secure a work-around future N95 shortages. In 2015, BARDA contracted with Halyard Health to design a machine that could make up to 2 million N95 masks a day — creating surge capacity to meet demand in case of an outbreak. “Pandemic preparedness in the United States is imperative to protecting health and saving lives,” BARDA Director Robin Robinson said at the time, “and respirator manufacturing capacity remains a critical gap in that preparedness.”
But in 2018, under the direction of the Trump administration, HHS defunded the project, after being presented a viable design for such a machine. The project appears to have been swallowed up by a bureaucracy that saw little reward in furthering a pet project from the previous administration. HHS told the Washington Post it lacked the budget to build a prototype. Bright, who took over as BARDA director, testified that he was not in the loop on this project his predecessor deemed imperative. “I don’t know what the proposal was,” he told Congress. “The decision to end or continue that project was not brought to me.”
The Trump administration, itself, had clear and specific warnings that a pandemic could create N95 mask shortages, but took no evident steps to resupply. HHS ran a months-long pandemic war game called Crimson Contagion that, with eerie prescience, modeled the outbreak of a virulent respiratory infection originating from China. Bright revealed to Congress that the exercise showed “we would need 3.5 billion N95 respirators in our stockpile to protect our healthcare workers from a pandemic response.”
The “Crimson Contagion 2019 Exercise Draft After-Action Report,” circulated to participants in April, warns that “global manufacturing capacity will… be unable to meet domestic demand for medical countermeasures, including personal protective equipment… and it is anticipated that countries will keep their own stockpiled supplies for their own citizens.” The report also warns, specifically, that “domestic supplies of on-hand stock of… N95 respirators… are limited and difficult to restock, because they are often manufactured overseas.”
WHEN THE CORONAVIRUS OUTBREAK first reached U.S. shores in mid January, Bright and Bowen sounded the alarm to top Trump administration decisionmakers about the need to secure N95 mask supplies and ramp up domestic production. Bright’s federal whistleblower complaint contends he was retaliated against for these “unwelcome… demands for urgent action.” Rolling Stone requested interviews with key HHS leaders and staff named in Bright’s complaint and accompanying documentation. None agreed to answer questions. An emailed response from HHS did not mount a substantive defense against Bright’s charges, but attacked him, personally, for “trying to blow things up.”
Bowen, the CEO of the Texas-based mask company, emailed Bright on January 22nd offering the Trump administration the capacity of his company’s four idled lines of N95 mask production. These machines are capable of producing 7 million masks a month, and Bowen sought an ongoing contract that would keep the machines in use even after the pandemic. (Through May, they remained idled.) Bright put Bowen in contact with HHS’s director of critical infrastructure production, whom the CEO warned that “imported masks are subject to foreign confiscation during a severe pandemic.” The director responded that the administration was not “anywhere near” being able to make a commitment.
Bright says he brought the impending N95 mask deficit to the attention of Dr. Robert Kadlec, the assistant HHS secretary in charge of preparedness and response, who leads a key department known as ASPR, in a meeting on January 23rd. Kadlec, who had led the Crimson Contagion exercise, paid “short shrift to the concerns,” according to Bright’s whistleblower complaint.
Bright kept sending Bowen’s emailed warnings to his HHS colleagues. “As much as 50% of masks come from China,” Bowen wrote in one message, forwarded to the head of the national stockpile. “If the supply stops, U.S. hospital[s] will run out of masks. No way to prevent it.” Bright urged his colleagues to keep the N95 supply “at the top of the heap” of issues they were contending with.
Despite these warnings, the mask issue kept slipping. Near the end of January, Bowen wrote to Bright, reporting on a discouraging conversation he’d had with a preparedness director at HHS about the global supply chain seizing up. “Rick, I think we’re in deep shit,” Bowen wrote. Bright testified in May that this email left him despondent. “From that moment, I knew that we were going to have a crisis for our healthcare workers because we were not taking action,” he said. “That was our last window of opportunity to turn on that production, to save the lives of those healthcare workers, and we didn’t act.”
Bowen didn’t stop trying. On January 29th, he emailed top HHS decisionmakers warning that the Chinese were likely to start hoarding N95 supplies: “US hospitals are going to have a very rough time…. A horrible situation will become unbearable.” Within weeks China had, indeed, shut down much of its N95 exports.
At a February 7th meeting of senior HHS officials known as the “Disaster Leadership Group,” Bright again attempted to elevate the masks issue, reminding the group of models showing the need “for up to 3.5 billion N95 masks to respond to a pandemic.” According to Bright’s complaint, ASPR leaders “pushed back, insisting that there was no indication of a supply chain shortage or of issues with masks, and therefore there was no need to take immediate action.” They added that if shortfalls materialized, the CDC could update its guidance to urge the general public not to buy masks. Bright responded: “I can’t believe that you can sit there and say that with a straight face.”
Forging an alliance with Trump’s trusted trade adviser Peter Navarro — one of the few administration figures who reacted with appropriate alarm at prospect of a coronavirus pandemic — Bright began to move the needle. Navarro is the tip of the spear for Trump’s protectionist America First trade policy, which is reflexively anti-China. But in this case, Navarro correctly identified a national security risk in relying on a geopolitical foe for critical healthcare supplies, especially at a time when China was in the midst of its own health crisis. On February 9th, Navarro circulated a memo to the Coronavirus Task Force and top White House officials titled “REQUEST FOR IMMEDIATE ACTION.” Navarro’s top recommendation: “Halt the Export of N-95 Masks, Ramp Up U.S. Production.” The United States “faces the real prospect of a severe mask shortage!” Navarro wrote. “Inaction at this point risks losing…our N95 production capabilities.”
But even Navarro’s red alert did not produce quick results. “The pressure of Mr. Navarro… did not spur Dr. Kadlec and our Strategic National Stockpile into that urgently needed to action,” Bright testified. Navarro followed up with another memo on February 14th, slugged: “Status of the N-95 Face Mask Supply,” which exhorted the Coronavirus Task Force to secure the N95 mask supply. “These masks are the frontline defense for our health care professionals,” he wrote, “and we can’t waste time.”
Only ten days later did the mask issue appear to have risen to any level of urgency within the administration. HHS asked Congress for supplemental funding to prepare for the coronavirus, including funding for N95 masks. But in a symptom of broader disarray, HHS’s top brass couldn’t keep their numbers straight. In senate testimony on February 25th, Secretary Alex Azar cited an administration estimate of needing “possibly as many as 300 million masks for health care workers.” Days later that estimate had grown more than tenfold. ASPR chief Kadlec told Senators on March 3rd that America “would need 3.5 billion N95 respirators.”
“What percentage of what we would need for our medical professionals is in the Strategic National Stockpile?” Sen. Mitt Romney (R-Utah) asked. Kadlec described the stockpile as having 35 million N95 masks, and assured Romney this is “10 percent of what we need… if it were to be a severe event.” HHS quickly acknowledged that Kadlec’s arithmetic was flawed: 35 million is just one percent of 3.5 billion. (“Dr. Kadlec simply misspoke,” an HHS spokesperson tells Rolling Stone.) But HHS also revealed that the stockpile of N95 masks was barely one third of what Kadlec advertised, 12 million masks, and 5 million of these were past their expiration date, leaving the National Stockpile with just 7 million reliable masks.
Finally, on March 4th the administration published a notice that it would be seeking to purchase large quantities of N95 masks. But it wasn’t until March 21st — nearly two months after senior officials like Bright first raised the issue — that HHS signed deals to deliver 600 million masks over the next 18 months, a huge order, but still far short of meeting the national need.
Responding to questions from Rolling Stone, HHS provided a quote from the recently hired HHS Assistant Secretary for Public Affairs Michael Caputo, a staunch Trump defender and notorious Twitter troll who reportedly blamed the emergence of coronavirus on the “millions of Chinese” who “suck the blood out of rabid bats as an appetizer and eat the ass out of anteaters.”
Caputo took a broadside at Bright, accusing him of having “sat out the peak month of the coronavirus at home, trying to blow things up and charging the taxpayers $285,000 a year.” Following his ouster from BARDA in April, Bright was reassigned to the National Institutes of Health. According to his attorney, Debra Katz, Bright took medical leave after his departure from BARDA to treat hypertension under his doctor’s supervision; NIH then took two weeks to onboard him. “HHS should focus on finding a cure for this pandemic,” Katz said, “and stop taking shots at Dr. Bright, a dedicated scientist and civil servant.”
Another department spokesperson chided Bright for not staying in his lane: “Mr. Bright had no authority over the SNS [Strategic National Stockpile]” and “was not part of the broader inter-agency effort to procure masks.” The spokesperson added: “Bright didn’t have visibility into the enormous amount of work being done by Secretary Azar and Dr. Kadlec, much less by other components of HHS and the administration as a whole. Rick Bright’s assumption that others were not concerned with and working on various workstreams related to COVID-19 preparedness is bizarre and false.”
THE CRITICAL SHORTFALLS in N95 supplies — warned of in January — hit frontline workers as the coronavirus pandemic exploded in the United States in March. Deflecting blame, Trump shamelessly accused hospital staff experiencing shortages of needed N95 masks of pilfering: “Something’s going on. Where are the masks going?” Trump asked during a Coronavirus briefing on March 30th. “Are they going out the back door?”
In early April, the inspector general for HHS released a report showing the human toll of the Trump administration’s delay: “Hospitals across the country reported that a shortage of PPE was threatening their ability to keep staff safe while they worked to treat patients with COVID-19.” The report cites one hospital administrator saying: “We are throwing all of our PPE best practices out the window.”
The report found rationing of N95 masks in broad effect: “hospitals reported conserving and reusing single-use/disposable PPE, including … bypassing some sanitation processes,” it stated. “Hospitals also reported turning to non-medical-grade PPE, such as construction masks… which they worried may put staff at risk.” One hospital described “being in ‘war mode’… abandoning the typical standard of care” by reserving N95 masks only for “certain higher-risk procedures for COVID-19 patients” like intubations.
Trump blasted this watchdog report as “Another Fake Dossier!” But with public pressure building, the administration finally invoked its authority under the Defense Production Act in mid April to require production of N95 masks. Yet here again, the order was orders of magnitude too small — just 39 million masks, not the billions government reports indicated were needed.
In mid May, Bright testified to the impact of having failed to secure masks from domestic suppliers. “We were forced to procure the supplies from other countries without the right quality standards,” he said. Despite N95 labeling, the masks were often only 30 percent effective, he added, warning that “nurses are rushing in the hospitals thinking they’re protected and they’re not.”
The Trump administration has given emergency approval to and rich contracts for million-dollar devices that allege to sanitize single-use masks. Trump has repeatedly touted technology — “the masks can be sterilized up to 20 times!” But in practice, the devices, using a hydrogen peroxide vapor to neutralize the virus, appear to be compromising the integrity of masks after just two to four cleansings. In June, the Food and Drug Administration issued guidance warning that many Chinese made N95 masks should not be decontaminated and reused.
A May survey by the union National Nurses United found that 87 percent of nurses have been forced to reuse single-use masks, and that 28 percent had to use decontaminated respirators, which nurses allege can be harmful to their health. “These respirators are meant for single use,” says Jean Ross a president the union. “It’s improper infection control to wear them again. Before COVID-19, if we had reused our same N95 respirator mask all day, between multiple patients, and then put it in a paper bag as we’re being told to do, we would have been fired.”
Castillo, the NNU executive director, scoffs at a government that will call nurses heroes but fail to invest in the basic equipment to keep them healthy. “Dr. Rick Bright’s testimony to Congress came as no surprise to us. He calls it indifference – we call it willful negligence,” she says of the administration’s response. “We can’t even say they failed, because that would imply they tried.”
As insufficient as the infection-control practices with N95 respirators are in hospitals, in nursing homes they appear to be even worse. Despite CDC recommendations of four masks per patient per day, FEMA didn’t begin delivering N95 masks to nursing homes until months into the pandemic, May 7th, in a photo op by Vice President Mike Pence. The U.S. death toll from COVID-19 has been ballooned by outbreaks in such facilities, thought to be worsened by unknowingly infected staff. Nearly 26,000 nursing home residents have died in the pandemic, along with nearly 450 staff, according to federal data.
In mid May, the Coronavirus Task Force touted having delivered just 46.4 million N95 masks to America’s frontline workers. In his congressional testimony, Bowen the mask CEO, compared himself to Cassandra, the figure in myth who could see the future, but was cursed to be disregarded by those in the present. Bowen had scathing final words for the Trump administration: “I’m a Republican, lifelong Republican. I’m embarrassed at how that’s been handled,” he told Congress. “It’s the scientists we need to be listening to. And we’re not. That’s got to change. Or more lives are going to be lost.”