Doctors are reporting a lack of PPE, despite govt assurances that the shortages were due only to temporary distribution hiccups and that millions of items have been delivered
In the past week, four UK doctors have died from Covid-19; the youngest was 55. There will be more to come if the government doesn’t quickly resolve the shortages of personal protective equipment, or PPE, in hospitals and medical centers.
The British Medical Association wasn’t being dramatic when it said this week that health workers treating Covid-19 patients face “life-threatening" shortages of PPE, and asked the Chancellor of the Exchequer for enhanced death-in-service insurance cover. A failure to protect medical personnel will not only threaten Britain’s ability to help those worst affected by Covid-19 — it could also undermine the bonds of trust that have kept the country's under-resourced health service punching above its weight.
Doctors around the country are still reporting a lack of PPE, despite government assurances that the shortages were due only to temporary distribution hiccups and that millions of items have been delivered. As the hashtag #GetMePPE was trending and young doctor couples were reportedly drawing up wills, there have been reports of doctors being punished or prevented from speaking out, as if out of some 1970s communist playbook. (And this was not just in the UK: Bloomberg reported earlier this week that doctors and medical staff in the US have also been told by hospitals they’ll be fired if they speak out about shortages).
But doctors are right to advocate for better protection. In examining the 2014-2016 Ebola outbreak in West Africa, the World Health Organization found that healthcare workers were up to 32 times more likely to become infected than the general population; the degree of health-care worker infection — which ranged from 2% to more than 50% — depended largely on the preparedness of the facility receiving patients. It’s been clear for some time that medical workers are at heightened risk from Covid-19 and that shortages of PPE were going to be a big problem.
There was the tragic death of 34-year-old Chinese doctor Li Wenliang, who was initially detained by police for “spreading rumors" after warning colleagues of the new virus. In February, Chinese and US media were reporting that Chinese medical professionals often had to source their own PPE, using tape to hold together items meant for single use and, inevitably, becoming ill. In mid-February, China reported that 1,716 medical workers had contracted the virus and six had died. Few doubt that this vastly understated the problem.
Italy began publishing statistics on doctor deaths on March 11. When I first wrote about the issue last week, 24 Italian doctors had been named as fatalities from Covid-19. Just 10 days later, the list had grown to 69.
Most fatalities have been older doctors, but that should be no comfort to younger physicians. An older person’s weaker immune system increases vulnerability; but doctors with prolonged and repeated contact with Covid-19 patients, and especially surgeons performing invasive aerosol-generating procedures, are likely to experience a higher viral load. This seems to increase the risk of contracting a more severe form of the disease, where the virus overwhelms even a younger person’s defenses.
The news from Italy isn’t all grim. Experience at the Cotugno Hospital in Naples, in which no medical staff have been infected so far, supports the view that correct PPE and procedures can save lives. The PPE there is more like Full Metal Jacket for the coronavirus era. A Sky News report from the hospital this week showed guards in the corridors and disinfectant machines that hose down all visitors. Staff protection at Cotugno Hospital goes beyond the standard WHO recommendations. Their thick suits are waterproof. Those inside the treatment rooms with patients communicate through a window to those outside. Medicine is passed through a compartment.
Today’s PPE shortage in the UK and US is one consequence of years of underinvestment in pandemic preparedness, despite many warnings. It will take time to fix. “The typical supply chain, where US healthcare providers purchase from known manufacturers, has broken down. Connecting supply to demand has become the Wild West," explains Nadav Ullman, one of the founders of ProjectN95, a non-profit set up to act as a national clearinghouse for Covid-19 equipment in the US. They have logged more than 335 million requests for PPE for the next 30 days.
Big Chinese factories like 3M’s are focused on supplying Asian countries, so any masks coming arriving in the West from them are “leakage," says Devika Daga, supply director of ProjectN95. Meanwhile, there’s a cottage industry of home-made and repurposed kit to meet the need (as my colleague Frank Wilkinson recently described in the U.S.). There is plenty of poor-quality PPE being produced in China too, making vetting essential. The Netherlands recently had to recall a large shipment of faulty Chinese masks.
In Britain, where health care is socialized and procurement largely centralized, the shortages have turned doctors into dealers, where they have to learn about getting VAT numbers and customs codes. Dr. Ricardo Petraco, a cardiologist at Imperial College NHS Trust, has resigned himself to this reality to ensure his team is protected and can keep working. “I’m just on Alibaba.com ordering 500 pieces of kit as a trial," he said when I checked in with him recently. “If it works well, we’ll order much more as a department."
Petraco said his department had run out of visors and other PPE: “I have read that millions of PPE have been delivered. I haven't seen that. We had to buy our own." That seems to be a problem around the country. Even U.K. schools have been asked to donate science goggles to be used as face shields.
I asked Petraco how the gatekeepers at his hospital and NHS Trust have responded to the new supply chains. “Normally we wouldn’t be able to buy kit independently. You have to go via procurement and they have to check and do quality control," he says. But the surgeons just want to keep working and the hospitals know there’s a supply breakdown. “They will fundamentally have to accept it as it’s for our protection. They can’t go inside wards and start removing people’s face masks and goggles," he says.
For prestigious institutions, securing funding for more PPE isn’t a problem. For less well-connected hospitals and medical centers, it may be another matter. And it’s unclear whether these ad hoc supply chains will work smoothly or hold up over time. Petraco later learned that the items he ordered were being held in China and Hong Kong. Another doctor who ordered supply directly from contacts in China also hadn’t received delivery.
In the UK, the problem hasn’t been supply alone. Guidance was confusing and inadequate. On Thursday, after an outcry from doctors and surgeons, Public Health England belatedly announced new guidance for PPE. The improved guidance is more specific and tailored to different medical settings. The standards have also been raised for anyone using devices in an aerosol-generating procedure. They still don’t meet the Cotugno Hospital gold standard.
For orthopaedic surgeons and their teams, often engaged in long procedures using heavy tools, having powered air-purifying respirators (PAPR) — stipulated in guidance from the American College of Surgeons but not in the NHS’s — would offer better protection and prevent the inflammation, pain and bruising that close-fitting masks and goggles often cause. The bigger problem may be that the new guidance doesn’t take seriously enough the infectiousness of Covid-19.
Because Covid-19 hasn’t been established as “airborne," the guidance for general practitioners and many other front-line staff is much lighter. While new research hasn’t yet been peer-reviewed, there’s enough to suggest high levels of “viral shedding" — that is, viral RNA finds its way onto surfaces and lingers in rooms where Covid-19 patients have been and in the air. This suggests that the practice in many Asian countries of widespread PPE makes a lot of sense. “There is a focus on aerosol generating procedures, but not on what you might call aerosol-rich environments," says Petraco. Accepting this level of threat, however, would require a much greater distribution of PPE in all medical settings.
The shortages have underscored the extent to which the taxpayer-funded NHS relies on the goodwill of medical staff and their families. The 223 or so devolved NHS bodies that run health-care facilities around the country are known, specifically, as trusts. But what if the professionals treating Covid-19 patients or performing emergency operations lose confidence in the system that’s meant to have their backs? The consequences, at a time when so many doctors have already been leaving the NHS for private practice, would extend beyond this particular crisis.
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