If America is at war with covid-19, it’s doing a bad job of fighting

Many times during the past few weeks Donald Trump has called the outbreak of covid-19 an "invasion" by an "invisible enemy," and referred to himself as a "wartime president." The message that the White House is trying to get across is clear: America is at war with covid-19.

He's not the only politician who has compared fighting the virus to fighting a war: On March 17, Massachusetts Senator Edward Markey co-wrote a Boston Globe op-ed calling for a "Manhattan Project-type approach" to deal with nationwide shortages in essential medical gear like ventilators, protective masks, and diagnostic test kits.

"Just as the Manhattan Project engaged the expertise of academia, science, industry, military, and government in a massive effort that led to the development of the atomic bomb, we, too, can marshal the kind of far-reaching collaboration that can produce meaningful results," Markey wrote along with Massachusetts General Hospital president Peter Slavin.

But if America is really at war, it does not appear to be winning. The fight is raging inside health care facilities across the country, and those on the front lines are going into battle without the defenses they need. The enemy caught the government flat-footed, and the country is already running out of vital supplies even though the fighting has only just begun.

So what would it look like if America was on a real war footing?

Proper preparation-and a bullet dodged

The first step would have been to properly prepare-and ensure that the equipment and supplies needed to fight a war were in hand.

A month ago, there were dire predictions that the US would run out of hospital beds and ventilators, and would need to urgently manufacture tens of thousands of new ventilators. President Trump had come under intense pressure to mobilize industry to produce them.

There was an obvious way to do this: under the much talked-about Defense Production Act, a 70-year-old wartime law, the president has the power to make manufacturers to sell products to the government at a low price (often just above the cost of production), and move government orders to the front of the line. It also lets the government finance additional "surge" production capacity if necessary. This is specifically aimed at dealing with national security threats, and the power is defined broadly enough to include responding to a pandemic.

But political positioning quickly saw the use of the DPA devolve into partisan conflict, with pro-business groups like the US Chamber of Commerce coming out against it. This caused dangerous delays, and by the time Trump finally invoked the law on March 18, he did so reluctantly and compared using it with socialism. "Call a person over in Venezuela, ask them how did nationalization of their businesses work out?" he said during a press briefing on March 22. "Not too well."

In reality, however, the federal government routinely uses the DPA. The Defense Department uses it to build up the nation's strategic stockpiles; the Federal Emergency Management Agency has used it while responding to hurricanes. Last year, the Trump administration itself invoked the law to "strengthen the industrial base and supply chain for rare earth elements," which are used in weapons systems but are mostly produced in China.

The Defense Production Act is routinely used by the federal government" but it is typically used in anticipation of a potential crisis, not in reaction to a catastrophe.

The provisions of the DPA are a "standard feature" for companies that contract with the Defense Department, says Joshua Gotbaum, who administered the law while serving as assistant secretary of defense under President Bill Clinton. It is not about nationalizing private businesses, he says, calling the Trump administration's approach to the DPA "bizarre."

Importantly, the Defense Production Act is typically used in anticipation of a potential crisis-part of that wartime planning-not in reaction to a catastrophe. Gotbaum says the White House should have started the process of increasing federal stockpiles at the first indication that the virus could possibly spread to the US-back in January. Instead, it waited months, and in the end has resorted to using the DPA as a cudgel.

Ultimately, however, the White House, and the nation, seems to have dodged a bullet: apparently due to the effectiveness of widespread social distancing measures, the latest projections for ventilator demand are much smaller than they were just two weeks ago. Whereas before it appeared the nation would have to manufacture new ventilators, now it appears the existing supply is sufficient, as long as the supply can be effectively moved around the country as needed to respond to new hot spots. (That's of course subject to change, for example if restrictions on large gatherings are lifted too early.)

Unfortunately, the same cannot be said for the body armor of the fight against covid-19: personal protective equipment, or PPE.

Frontline fighters in danger

The most urgent need right now is to protect those doing battle with covid-19 every day. Doctors and nurses are frontline troops who require protection, although instead of helmets and body armor, they need PPE: gloves, gowns, and masks.

But the market for medical-grade protective gear has descended into chaos. A report from the Health & Human Services inspector general, published April 6, described "widespread shortages," orders being delayed months, and a dangerously disrupted supply chain. Without central administration from the federal government, desperate hospitals and state governments have been left competing with each other for supplies. As one administrator told the inspector general, everyone is "trying to pull [PPE] from the same small bucket."

The problem stems from three main causes: A failure to stockpile enough supplies to meet the pandemic-scale demand, a heavy dependence on Chinese manufacturing, and the lack of an authoritative information source that can reveal bottlenecks in critical supply chains.

In a normal year, health-care facilities in the US place orders between one and two billion respiratory masks, including surgical masks and n95 respirators, says Prashant Yadav, a senior fellow at the Center for Global Development. Meanwhile, a 2015 study from government infectious disease experts suggested in the event of a pandemic similar to this one, demand for n95s alone would be at least between 1.7 and 3.5 billion, and could rise to greater than 4 billion if the infection rate stays high after the epidemic peaks.

There is a reserve supply, in the form of the federal government's strategic national stockpile and stockpiles held by individual states. But these supplies apparently weren't nearly enough. On April 9, the Associated Press reported the Strategic National Stockpile was "nearly out" of n95 respirators, surgical masks, face shields, gowns, and other surgical supplies.

Uncertainty about the availability of PPE from federal and state sources was a consistent concern voiced by hospital administrators, according to the IG's report. One administrator said the supplies the hospital received from the stockpile "'won't even last a day." Another hospital reported getting thousands of masks from a state reserve that were unusable because the elastic bands had dry rotted, and yet another reported that a federal agency sent it two shipments of PPE that had expired in 2010.

According to the IG report, this has led many hospitals to reuse PPE, which is only supposed to be worn once. Some are exploring ultraviolet sterilization techniques, while others reported bypassing normal sanitation processes. "We are throwing all our PPE best practices out the window," one administrator said. "That one will come back and bite us."

Supply and demand

This has all been compounded by bad information that has made it difficult to precisely quantify either supply or demand, says Yadav. Not only government leaders, but PPE manufacturers, distributors, and purchasers that might otherwise be able to collaborate on sourcing and distributing materials are flying blind.

Three quarters of the n95 respirators and surgical masks that US healthcare facilities order are made in China, he says, with major medical product distributors often using contract manufacturers there instead of paying a premium for a brand name. (On April 6, 3M, the largest US manufacturer of n95s, agreed-days after the White House invoked the DPA to give FEMA the authority to acquire as many masks as necessary from the company-to import 166.5 million n95s over the next three months from its own factory in China.)

But how much supply is available in China? No one seems to know the answer, and the chaos of the past month has made suppliers less inclined to reveal their true stocks. If an effort to capture this information had been launched a month ago, Yadav argues, it would have been easier to collect accurate information.

It's also hard to know what the demand really is because orders are being double- and triple-counted. Desperate hospital purchasers are repeating the same orders with multiple potential sources, hoping for one to come through amid the shortage.

Without a more complete and accurate picture, it is difficult to figure out how to most efficiently match supply and demand. In a real war, if the military was facing a shortage of critical supplies, "the first thing that such an effort has to depend on is a rich information set about what is in stock, what is in demand, and what are the links in the supply chain," says Yadav.

Where are the bottlenecks? And what is coming next? President Trump, in his daily meetings with the press, has consistently cast managing medical supply chains as primarily the responsibility of the states, not the federal government. "We're a backup," he said on April 2. "We're not an ordering clerk."

Besides tracking information about manufacturers and distributors, a true wartime dashboard would also track the supply and demand of the raw materials used to make n95 masks. Indeed, Yadav anticipates that the US will "quickly" run into supply constraints for a specialized fabric called melt-blown nonwoven polypropylene-and it's neither easy nor cheap to scale up the production of this critical material. If the nation were to run out of fabric, any added production capacity would have to sit idle anyway.

The coming storm

All evidence suggests that even after covid-19 deaths in America reach a peak-and even if the issues of PPE and ventilators are taken out of the equation-there will still be other problems building in the background.

After all, winning this war will require more than just finding a way to protect the soldiers or help the victims. The ultimate weapon, a vaccine, is many months if not years away-and developing and deploying it is something that would benefit from central coordination. Once it's actually developed, it will need to be administered to millions and millions of people in all 50 states. In the meantime, and before the US can begin to relax social distancing measures and restart its economy, the nation will need not only to test massive numbers of people but also track and restrict the movements of all those people who came into contact with everyone who tests positive.

Such a technically and logistically complicated effort would benefit from some sort of cohesive national strategy, even if not the full-blown Manhattan Project-style effort that some envisaged. But the White House's approach to the pandemic response thus far suggests it won't jump at the opportunity.

"States are supposed to be doing testing," President Trump said during a press conference April 10. "We're the federal government. We're not supposed to stand on street corners doing testing."

And that is where we stand today. Despite Trump's wartime rhetoric, America is sending its troops into battle without proper protection and forcing them to haggle with each other over resources. Its government has no clear long-term plan for vanquishing the virus. And to truly fight off the enemy, America will need weapons it doesn't yet have. And even the small victories that have happened seem to be the result of local action and luck rather than coordinated effort from the center.

There may still be a small window of time to reverse course. Near-term PPE shortages may not be averted, but through efficient mobilization of US manufacturers the stockpiles can be replenished and built up to proper levels in time to face potential new outbreaks in the fall. Perhaps the 50 states can come together to pull off a massive testing and contact tracing effort. But who will lead it?

"Daunting perhaps, but there are impressive examples of times when a serious threat to a nation inspired patriotism and led to creative thinking and achievement," Markey and Slavin wrote, citing the efforts of Franklin D. Roosevelt and Winston Churchill to quickly mobilize their respective nations to prepare for World War II. "This is the same kind of leadership we need right now as we struggle in the midst of a pandemic."