Months into the coronavirus pandemic, front-line health care workers still don’t have enough personal protective equipment to keep them safe , a Washington Post-Ipsos poll found this week. Nearly two-thirds of workers didn’t have enough masks in early May. More than 4 in 10 reported shortages of surgical masks, which are even less protective, and about a third said they were running low on hand sanitizer. About 70 % of workers had to wear the same mask for more than a day.

That persistent shortage of medical supplies has made it difficult — and dangerous — for U.S. health care workers to care for infected patients during the coronavirus pandemic. One health system recently described efforts to obtain essential protective gear that included a legal, but unusual, deal with a Chinese supplier, a covert trip to an industrial warehouse, respiratory masks loaded into trucks labeled as food delivery vehicles, an interaction with federal agents, and the intervention of a congressman to ensure that the shipment arrived at its destination.

The Post’s poll results, let alone a story like this — which sounds more like an action movie plot than the way hospital supply chains usually operate — would have strained credibility a few months ago. But it now sounds painfully familiar to health systems, hospitals and state governments that have tried to secure protective gear for doctors, nurses and other health care professionals during the pandemic.

Generally, health care supply chains employ strategies similar to those used by other industries. In normal times, medical equipment manufacturers aim to match their supply with the market’s demand. Hospitals and health systems do not stockpile materials (e.g., ventilators or protective gear) for emergency situations, but use “just-in-time” ordering to limit excess inventory. While this results in efficiencies and reduces costs, it also renders manufacturers and customers vulnerable to supply disruptions and shortages when needs surge.

By late January, it was clear that these normal procedures wouldn’t be sufficient to maintain enough medical supplies — a global pandemic was looming. So why didn’t manufacturers increase the production of necessary supplies? Why didn’t hospitals begin stockpiling items they would soon need? And as the scale of the pandemic came into sharper focus, why did we continue to face shortages? And why have these shortages persisted despite calls to increase production?

Manufacturing medical supplies is a low-margin business. To survive, factories prioritize efficiency over adaptability, which limits their ability to boost production quickly. Manufacturers also have little incentive to produce beyond their just-in-time orders — if the surge in demand never materializes, they would be stuck with extra masks, gloves and other items. Most health care protective equipment used in the United States is imported; making it domestically costs more. But since several of the countries that manufacture protective gear — particularly China, which produces the majority of it — were struck by the virus early in the pandemic, supplies from those manufacturers went to these early hot spots, leaving the United States more reliant on limited sources of domestic manufacturing.

Once shortages became apparent, hospitals and health systems were unable to easily find the existing supply because there’s no national tracking system for protective gear. This meant that purchasers were blind to what was potentially available or where it was, limiting their ability to coordinate distribution of existing supply or anticipate future needs. Regulations that in normal times are necessary created additional barriers.

In the longer term, the government may need to subsidize the market to maintain a more constant supply of the medical supplies needed during a pandemic.

Tara Lagu is an associate professor of medicine at the University of Massachusetts Medical School-Baystate. Rachel Werner is executive director of the Leonard Davis Institute of Health Economics and professor of medicine at the University of Pennsylvania. Andrew Artenstein is chief physician executive and chief academic officer at Baystate Health and a professor of medicine at the University of Massachusetts Medical School-Baystate.

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