In the past week, four U.K. doctors have died from Covid-19; the youngest was 55. There will be more to come if the government does not 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 unspoken bonds of trust that have kept the country’s under-resourced health service punching above its weight.
Doctors around the country are still reporting lacking enough 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 U.K.: Bloomberg reported earlier this week that doctors and medical staff in the U.S. have also been told by hospitals they will be fired if they speak out about shortages.)
But doctors are right to advocate publicly 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 over 50% – largely depended on the preparedness of the facility receiving patients. It has 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 U.S. 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 since March 11. When I first wrote about the issue last week, 24 Italian doctors had been named as fatalities from Covid-19. The list had grown to 69 by the following Thursday, just 10 days later.
Most of the 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 medical staff 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 World Health Organization recommendations. Their thick suits are waterproof. Those inside the treatment rooms with patients communicate through a window to those on the outside. Medicine is passed through a compartment.
Today’s PPE shortage in the U.K. and U.S. is one consequence of years of underinvestment in pandemic preparedness, despite many warnings. It will take time to fix. “The typical supply chain, where U.S. 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 U.S. They have logged over 335 million requests for units of PPE for the next 30 days.
Large-scale Chinese factories like 3M’s are focused on supplying the Chinese government and Asian countries, so any masks coming from them and arriving in the West are “leakage,” or excess coming through side businesses the factories have, says Devika Daga, the supply director of ProjectN95. Meanwhile, there is a cottage industry of home-made and repurposed kit to meet the need (as my colleague Frank Wilkinson recently described in the U.S.). But there is also plenty of poor-quality PPE being produced in China too, making vetting essential. The Netherlands recently had to recall a large shipment of Chinese masks which were discovered to be faulty.
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 whom I spoke to for last week’s article on surgeons’ concerns, has resigned himself to this reality in order 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 again 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 is 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 is not be 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 with planes grounded; he wasn’t sure why or how long he would have to wait. Another doctor who had ordered supply directly from contacts in China also hadn’t received delivery.
In the U.K., the problem hasn’t been simply an issue of supply. Guidance was confusing and inadequate. On Thursday, after much 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. But they still don’t meet the Cotugno Hospital gold standard.
For orthopaedic surgeons and their teams, who are often engaged in long procedures using heavy power tools, having powered air-purifying respirators (PAPR) — contained 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 how infectious Covid-19 is even in non-surgical settings.
Because Covid-19 has not been established to be “airborne,” the guidance for GPs and many other front-line staff is much lighter. While new research has not yet been peer-reviewed, there is 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; and the U.K. government is struggling with delivering the supplies it has promised already.
The PPE shortages have underscored the extent to which the U.K.’s taxpayer-funded National Health Service relies on the goodwill of medical staff and their families to remain among the country’s most revered institutions. 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 is meant to have their backs? The consequences, at a time when so many doctors have already been leaving the NHS for private practice earlier than planned, would extend beyond this particular crisis. –Bloomberg