Supply notes April 4

The current overall chain of command for the national supply chain seems to be:

(1) Federal Emergency Management Agency (FEMA) supply chain task force, lead by Rear Adm. John Polowczyk.

(2) Jared Kushner’s private sector team, which also seems to be working closely with the FEMA team. Kushner is the liason with the FEMA team to the White House, and can relay requests from Trump / others to the team.

The supply chain task force is providing resources in several ways. It is coordinating the airlift of materials from abroad to the US from private supply firms. Some of the materials it is buying for itself, for the FEMA stockpile, but most of it is still in the possession of the medical supply firms. The medical supply firms are then filling orders like normal, with no priority system.

As to how FEMA is distributing supplies, it seems that they are tapping into the private data on where materials are going, and they can see a little bit which areas need more supplies. They are then sending supplies to the places that need them the most. Before sending supplies from the stockpile, i.e. ventilators, Kushner is asking about utilization rates.

On April 2nd, the White House gave an update of the supply situation at the daily press briefing. So far, the US strategic stockpile has sent out: 27.1 million surgical masks, 19.5 N95 masks, 22.4 million gloves, 5.2 million face shields, 7,600 ventilators.

Production in the US is usually 30,000 ventilators per year, but apparently by end of June we will produce 100,000. In April and May, several thousand will be available each month.

A deconstruction of the Jared Kushner Briefing

The link to the press conference is here.

When the Vice President first asked me to help on the task force with different tasks, I asked the President what he expected from the task force and how I can best serve him in the task force.

The task of the task force member is to perform the tasks which must be performed to complete the tasks.

What the President asked is that all of the recommendations that we make be based on data. He wanted us to be very rigorous to make sure that we were studying the data, collecting data. A lot of things in this country were happening very quickly and we want to make sure that we were trying to keep updating our models and making sure that we were making informed decisions and informed recommendations to him based on the data that we were able to collect and put together.

The task is clear: the data will be used to make informed decisions using data driven methods based on reliable data.

The President wanted to make sure that we had the best people doing the best jobs and making sure that we had the right people focused on all the things that needed to happen to make sure that we can deliver in these unusual times for the American people.

This was stated unironically.

The President also wanted us to make sure we think outside the box. Make sure we’re finding all the best thinkers in the country. 

Once again, unironically.

Just very early this morning, I got a call from the President. He told me he was hearing from friends of his in New York that the New York Public Hospital System was running low on critical supply. He instructed me this morning, I called Dr Katz who runs the system. I asked him which supply was the most supply he was nervous about. He told me it was the N95 masks. I asked what his daily burn was and I basically got that number. Called up Admiral Polowczyk. Made sure that we had the inventory. We went to the President today and earlier today the President called Mayor de Blasio to inform him that we were going to send a month of supply to New York Public Hospital System to make sure that the workers on the front line can rest assured that they have the N95 masks that they need to get through the next month. 

After using the word ‘data’ seven times, we now have an example of what data is being used and how. The president heard off hand from a friend in New York that they were having problems in the public hospital system, Trump told Kushner, who called the head of the public hospital system in NYC, and asked him for the one item that the hospital was having supply troubles with. Kushner then arranged for 200,000 masks to be sent the next day.

Updated N95 Supply Situation


 Survey data shows that active cases of COVID-19 create surge demand of 17X the typical burn rate for N95 respirators, 8.6X for face shields, 6X for swabs, 5X for isolation gowns and 3.3X for surgical masks.

According to the survey, hospitals ranked the supply of N95 respirators as their top concern. Comparing the number of respirators the hospital used before and after confirmed COVID-19 cases were admitted, Premier calculated a surge need of up to 17X. The survey also found that the average respondent had 23 days of N95 inventory on hand. However, those with active COVID-19 patients had an average of just three days’ worth.

“To date, most attention about supply shortages has focused on N95 masks, which was one of the first PPE items to fall into short supply as consumption surged to provide care to COVID-19 patients,” Alkire says. “Although this supply remains a top concern, backorders for surgical masks, isolation gowns, thermometers and disinfecting wipes are surging and quickly surpassing demand for N95s. This is an early warning signal of product shortages that may be on the horizon and need to be planned around.”

According to the survey, hospitals ranked the supply of N95 respirators as their top concern. While the largest number of respondents (about 39 percent) reported having more than 1,000 N95s on hand, a plurality of respondents (23 percent) are burning through more than 100 masks a day, meaning that many systems have less than 10 days’ inventory.

Despite these concerns and the fact that nearly all respondents have implemented at least some conservation protocols for PPE, there is still significant room to further improve conservation measures specific to N95 masks, including extending the wear of N95s (a measure followed by 60 percent of respondents), re-using N95s (40 percent), using expired N95s (33 percent) and using industrial N95s (20 percent).

Shortages for hand sanitizer were the second most concerning shortage for survey respondents, with 64 percent reporting an active shortage. An additional 25 percent have less than two weeks’ supply. However, clinicians do have alternatives, as proper hand hygiene with soap and water can be more effective than alcohol-based hand sanitizers.

Surgical mask shortages were the third most concerning shortage for survey respondents. While most respondents (56 percent) reported having more than 1,000 surgical masks on hand, a quarter (26 percent) burn through that amount every day, meaning that the mask supply is generally a day’s supply or less.

Half of survey respondents (50 percent) reported having more than 1,000 isolation gowns on hand, however, about 25 percent also burn through that same quantity each day. In addition, about 17 percent of respondents had fewer than 250 gowns available.

Viral swabs are another area of concern, as most respondents (60 percent) have fewer than 250 swabs on hand, while about 21 percent burn through more than 100 swabs a day. The swab shortage was largely due to the fact that one of the top manufacturers is based in Italy, which has been hit particularly hard by the virus. However, the U.S. Air Force has committed to making shipments of the swabs, so the problem may resolve in coming weeks.

According to the survey results, 20 percent of respondents report needing additional ventilators immediately. Approximately 27 percent can take on an additional one to five patients before they require additional ventilators. About 24 percent can accommodate six to 10 more patients, and about 30 percent can take 11 or more patients before they need additional ventilators.


3M and half a dozen smaller competitors are making 50 million N95 masks in the US a month.

3M has doubled production since January.

3M began ramping up mask production after the World Health Organization on Jan. 11 reported the first deaths from Covid-19, the disease caused by the coronavirus. By mid-March 3M had doubled its output to nearly 100 million masks a month globally, and 35 million a month in the U.S., at plants in South Dakota and Nebraska. the company also has said it would import 10 million masks this month from its factory in China, which earlier this year was restricted from sending goods abroad.

Smaller manufacturers Moldex-Metric Inc. and Prestige Ameritech Ltd. make about 10 million N95 masks each month combined, according to the companies. Their output plus 3M’s mask production represents the bulk of current U.S. capacity, according to industry leaders, augmented by smaller quantities from companies including Alpha Pro Tech Ltd. and Louis M. Gerson Co.

The agency in March ordered 600 million N95 masks from five companies to distribute to hospitals and augment the national medical-supply stockpile over the next 18 months. The purchase includes orders for 190 million masks each from 3M and Honeywell and 130 million from medical-supplies company Owens & Minor Inc., the agency said in an email.

Honeywell, which primarily made masks outside the U.S. before the pandemic, said it plans to hire 1,000 workers to make 20 million N95 masks a month by May at plants in Rhode Island and Phoenix. 3M said it will be making 50 million masks a month in the U.S. by June.

Moldex-Metric said it is making eight million N95 masks a month, and Prestige Ameritech said it is making two million masks a month. Dozens of smaller manufacturers are also buying equipment to start making masks.

But many of their new machines won’t be installed for months, manufacturers said. Some mask components, including a filtering material called polypropylene, are also in tight supply.

Total Petrochemicals USA, a division of France’s Total SA, is a major supplier of polypropylene to manufacturers including 3M, according to a person familiar with 3M’s supply chain. Total said it has boosted global production of polypropylene to meet rising demand.

Strong Manufacturers, a medical-equipment distributor, recently installed three mask-making machines at a factory in North Carolina, but can’t find enough raw materials to use them. The machines need a hard-to-find shape of elastic band, said Charles Fatora, the company’s head of global procurement.

Medicom Group, a Montreal-based mask maker, said it is opening a factory in Canada to make N95 and surgical masks after signing a supply agreement with the Canadian government. The company wants a similar commitment from officials in the U.S., where Medicom operates a surgical-mask plant, to buy its masks even after the pandemic ends.

“If we do not have a long-term agreement, how can we invest more and more dollars into equipment that is going to sit and rot,” said Medicom Chief Executive Ronald Reuben.


In the U.S., the 3M facility at Aberdeen, a city of 28,000, was built in 1974. The 450,000-square-foot factory and a sister plant in Omaha together produce 400 million respirators of myriad types annually. Within the next year, they will be producing many more.


Imports of N95 masks from China, the world’s top producer of medical gear, have resumed after a weekslong export stoppage as officials diverted production to fight the outbreak in the country where it began.

Lloyd Soong, chief executive of Singapore-based Pasture Pharma Pte, which makes one million N95 masks a day in China and other Asian countries, said raw material shortages have made it hard to boost output. A chunk of his output is still being requisitioned by government entities in China, leaving him with limited supply for eager customers in the U.S.

China makes half of the world’s N95 masks.

The most recent delivery of medical-grade N95 masks arrived from China about a month ago, on Feb. 19. And as few as 13 shipments of non-medical N95 masks have arrived in the past month — half as many as arrived the same month last year. N95 masks are used in industrial settings, as well as hospitals, and filter out 95% of all airborne particles, including ones too tiny to be blocked by regular masks.

Black Market/Exports

Tamer Abdouni is a Beirut-based consultant who facilitates the trade of, among other things, 3M respirators. Usually he can buy them for $1.25 apiece and resell them for a dime more. Lately the best purchase price he can get is $7.25. Even if he were willing to buy at that price, he says, selling respirators at multiples of his usual price during a pandemic would tarnish his reputation.

“3M makes the Rolls-Royce of masks,” Abdouni says. “People are holding stocks of masks and waiting for them to increase in value before selling them off. This is becoming very unethical. This is a war on coronavirus, and I don’t want to be a warlord.”

3M says it hasn’t raised respirator prices and can’t control what happens after it sells its products to distributors. Roman wrote to U.S. Attorney General William Barr on March 24 to offer 3M’s help in rooting out medical device counterfeiting and price gouging.

With demand soaring, 3M’s respirator sales could nearly double this year, to $600 million, according to William Blair & Co. analyst Nicholas Heymann. The company, despite its $32 billion in annual revenue, could use the boost.

Fortune: Most action seems to be done with shady sellers. Many masks being exported, apparently 280 million in one day.

Brooklyn — man arrested with warehouse full of medical supplies.

Supply Chain

First, the supply chain that served hospitals well in the past has broken down. For years, many hospitals bought supplies from the same suppliers. And for years, those suppliers relied on the same manufacturers. Trusted relationships were formed. Now the system isn’t working; suppliers and manufacturers are out of stock and flooded with requests. So hospitals have to find new sources of PPE, right when thousands of other hospitals are frantically doing the same thing. And once they do, they need to negotiate new agreements and payment terms — often with completely unknown suppliers sourcing PPE from known and unknown factories. As one person searching for hospital supplies put it, “It’s like the Wild West out there.”

Second, N95 masks, which offer extra protection, are particularly hard to procure right now because they’re almost entirely made in China, and trusted large-scale Chinese manufacturers like 3M are supplying China and other Asian countries battling their own pandemics. Often, the masks that U.S. hospitals are able to buy from them are “leakage” — extra supplies sold through side businesses that have launched to meet the rising demand. That’s not sufficient for the enormous need we have in the U.S.

Third, there’s a technical issue holding things up. The Chinese equivalent of N95 masks are called KN95s. They’re authorized by the CDC, but they aren’t yet authorized by the FDA for emergency use. That may change; those authorizations are updated regularly. But for now, U.S. hospitals following FDA rules — nearly all of them — aren’t buying KN95s, which means the pool of suitable masks is even smaller.

The crest of the wave: strategic situation on April 1st

Why haven’t you seen this poster?

The number of Covid-19 cases, hospitalizations, and deaths is growing, and the best estimates from epidemiologists and health policy experts say the overall peak for the country is two weeks away. With D-day fast approaching away, there will not be time to meaningfully increase the crucial medical supplies available to the health system: ventilators, masks and other PPE, virus testing materials. We must go to war with the army we have.

Although we are desperately short on resources, there are two aspects of the overall strategic situation which in principle greatly increase our chance of having the medical resources available to care for the coming crush of Covid-19 patients. First, not every state or locality will hit the peak at the same time. For example, California’s epidemic peak is expected to be April 28, while New York’s peak is April 9th. Second, not every area is expected to be equally affected. There are some areas which will be more affected, and areas which will be less affected.

Both these factors mean that it will be possible to concentrate resources first to the areas that need them the most. This includes (i) doctors and other health care workers (ii) ventilators and associated equipment (iii) masks and other PPE.

There is no shortage of aircraft to transport to transport the resources (passengers are not flying, so air craft are idle). In fact in order to secure their share of the stimulus, many airlines are flying empty planes around the country. There is no shortage of accommodation for the health care workers, hotel rooms across the country largely empty.

A trickier question is whether there are currently enough doctors available. But given the fact there are mass layoffs of doctors and healthcare workers around the country, it seems to be the case there is a large current reserve of current doctors that could be enlisted to help see patients. Different specialists can chip in. Recently retired doctors are another potential pool, however since the elderly are most affected it may be too risky to put them in the line of action. We could potentially import more foreign doctors, but this is potentially months down the line.

Doctors must be able to easily move between different hot zones: between different hospitals in a county, areas of a state, and even between different states. Ventilators and associated equipment must be able to move between different states.

It turns out there are actually existing organizations and systems to shift health care resources, but they are unknown, unorganized, ineffective, and poorly resourced. It is criminal that a national medical resources board has not been set up to organize the distribution of materials during the crisis, and a national medical labor board has not been set up to organize the medical workforce.

The US did have a strategic reserve of equipment, but unfortunately it was disbursed on the basis of political favor, and is now empty. There is a strategic reserve of 10,000 ventilators which is being held back, and which will undoubtedly be given to the right wing state which sucks up the most to the administration.

State governments are slowly trying to put into place systems to transfer health care resources, but from what I’ve read it doesn’t seem particularly organized. Andrew Cuomo has created a statewide command center, and apparently has convinced public and private hospitals to share resources.

Doctor reallocation

There is a federal system for signing up volunteers that is already in place which was set up after 9/11. But its website, which is designed to link volunteers to state-level registries, is little-promoted and recently had a major glitch. The separate website for the national medical reserve system has no mention of Covid-19 or our current crisis, and has not be updated for a year. There has been widespread advertising campaign for the reserve system and no general call to service for medical volunteers.

But even more crucially, there does not seem to be any plan in place to get volunteers to the places that need them the most.

Individual states are pursuing the following policies:

  1. New York has started a Medical Reserve Corps, with Governor Cuomo calling on volunteers from across the country to chip in. They have 11,000 volunteers so far, and so far 358 have signed up for shifts at health care facilities.
  2. Virginia’s Medical Reserve Corps has 11,000 members.
  3. Maryland’s corps has been activated, with its 5,000 volunteers.
  4. DC has approximately 1,600 members of its reserve corps.
  5. California is starting a Medical Corps.

Other Countries

Italy has recently formed a task force of 8000 doctors.