8 N THE NEW YORK TIMES, SUNDAY, JULY 26, 2020Tracking an OutbreakU.S. Fallout
Expired surgical masks. Isola-
tion gowns that resemble oversize
trash bags. Extra-small gloves
that are all but useless for the typi-
cal health worker’s hands.
Nursing home employees
across the country have been dis-
mayed by what they’ve found
when they’ve opened boxes of
protective medical gear sent by
the federal government, part of a
$134 million effort to provide facil-
ities a 14-day supply of equipment
considered critical for shielding
their vulnerable residents from
the coronavirus.
The shipments have included
loose gloves of unknown prov-
enance stuffed into unmarked Zi-
ploc bags, surgical masks crafted
from underwear fabric and plastic
isolation gowns without openings
for hands that require users to
punch their fists through the
closed sleeves. Adhesive tape
must be used to secure them.
Health regulators in California
have advised nursing homes not
to use the gowns, saying they
present an infection-control risk,
especially when doffing contami-
nated gowns that must be torn off.
Some nursing homes have re-
ceived masks with brittle elastic
bands that snap when stretched.
None of the shipments has includ-
ed functional N95 respirators, the
virus-filtering face masks that are
the single most important bul-
wark against infection.
“People hate to complain about
personal protective equipment
they’re getting for free but many
of these items are just useless,”
said Brendan Williams, president
of the New Hampshire Health
Care Association, which has been
fielding a flurry of calls about the
defective gear from nursing
homes it represents. “It’s mystify-
ing that the government would
think this is acceptable.”
The Federal Emergency Man-
agement Agency began shipping
the masks, gowns and gloves this
spring to 15,000 nonprofit nursing
care facilities whose limited fi-
nances have made it difficult to
buy protective equipment on the
open market. The first cache of
shipments was completed in mid-
June, and the second round will
wrap up by early August.
In a statement, FEMA said it
had addressed the complaints
about the first shipment and had
asked the private contractor that
is providing the supplies to re-
place the tarp-like gowns. The
agency said, however, that the
original gowns sent out meet fed-
eral and industry standards.
“We have received complaints
on less than 1 percent of the total
P.P.E. shipments to nursing
homes,” the statement said. “We
continue to engage with nursing
homes to keep lines of communi-
cation and feedback open at all
times.”
FEMA subsequently acknowl-
edged in an email that the contrac-
tor has been sending out a small
number of the older gown models.
The controversy over inade-
quate and low-quality protective
equipment has come to embody
what public health experts and
nursing home executives call a
halting and haphazard federal ef-
fort to protect the 1.5 million peo-
ple who live in nursing homes and
long-term care facilities.
More than 40 percent of all coro-
navirus deaths in the United
States have been tied to nursing
homes, according to a New York
Times analysis, which found that
the virus had infected 316,000 peo-
ple at 14,000 facilities as of July 15.
The virus has been particularly le-
thal to those in their 60s and older,
more so for those in poor health,
and it can rapidly spread through
buildings where residents live in
close quarters and workers movefrom room to room.
“The federal response to pro-
tect one of the most vulnerable
populations in the country has
been a dismal failure,” said Ta-
mara Konetzka, a health econo-
mist at the University of Chicago
who has been studying the pan-
demic’s outsize impact on nursing
home residents.
The Trump administration’s
largely hands-off approach to per-
sonal protective equipment, or
P.P.E., has forced states, cities and
big hospital chains to compete for
limited supplies, leaving nursing
homes at a disadvantage as prices
have soared.
The recent spike in caseloads in
the South and West has reinvigo-
rated calls for President Trump to
use his authority and compel do-
mestic manufacturers to producedesperately needed gear.
“We’re extremely disappointed
with the government’s response,”
said Katie Smith Sloan, the presi-
dent of LeadingAge, a group rep-
resenting nonprofit senior care
providers. “Folks on the ground
are desperately trying to save
lives and protect their staff, but
we’re leaving them in the dust.”
The crisis is likely to intensify
as the virus gains a foothold in the
Sun Belt. Infections at long-term
care centers in hot-spot states
have jumped by 18 percent since
late June, according to an analysis
by the Kaiser Family Foundation.
Florida saw a 51 percent rise, and
Texas had a 47 percent increase.
The Centers for Medicaid and
Medicare, which oversees nurs-
ing homes, earlier this month said
it would supply every adult care
facility in the country with rapid,
point-of-care test kits, but the roll-
out is expected to take months. In
the meantime, the vast majority of
nursing homes in the United
States is unequipped to regularly
screen employees and residents
for the coronavirus.
Without widespread testing,
health experts say medical-grade
gowns, single-use gloves and res-
pirator masks are among the few
tools that can protect nursing
home residents from devastating
outbreaks that often begin with
asymptomatic staff members whounknowingly introduce the virus
from the surrounding community.
“It’s really mind-boggling and
frustrating that five months into
this pandemic we still can’t get fa-
cilities the P.P.E. they need,” said
David C. Grabowski, a professor
of health care policy at Harvard
Medical School. “I don’t know
whether it’s a matter of incompe-
tence or just indifference about
older adults and the people who
care for them.”
In a call with nursing home
providers last month, Col. Brian
Kuhn, director of operations at the
Defense Logistics Agency,
blamed Federal Resources Supply
Company, the private contractor
that is providing the goods.
The contract calls for 1.2 million
pairs of protective eyewear, 13
million medical gowns and 66 mil-
lion pairs of nitrile gloves.
“They just kind of carte blanche
shipped them all out,” Col. Kuhn
said, according to a recording of
the call posted online. He said that
the masks made from underwear
fabric were not intended to be
used by staff members — only by
nursing home visitors — and that
the expired respirator masks
never should have been distribut-
ed. “It was one of those things, I’ll
be honest, that just slipped
through the cracks,” he said.
In response to the complaints,
FEMA directed the Federal Re-sources Supply Company to
produce an instructional video ex-
plaining how the gowns should be
donned and doffed. The contents
of each shipment are determined
by the number of employees at
each care center.
Federal Resources, which is
based in Stevensville, Md., did not
respond to emailed questions.
Nursing home executives and
employees that have received
their second shipments say the
contents are an improvement
over the first batch but that many
problems remain.
Nursing homes in New Hamp-
shire have received face masks
with flimsy paper ear loops in-
stead of elastic bands. In Arizona,
some facilities have been sent
gloves that are either all large
sizes or all extra small.
At Los Angeles Jewish Home,
workers were heartened two
weeks ago to receive about 1,
disposable gowns, 187 pairs of eye
goggles and 12,000 gloves in a
range of sizes. But they were dis-
mayed to also find 2,000 of what
employees dismissively referred
to as “trash bag gowns.”
“It’s outrageous that they are
still sending these gowns,” said
Dr. Noah Marco, the chief medical
officer of Los Angeles Jewish
Home, which has 1,200 beds and
50 employees. “And it’s insulting
and inappropriate for the federal
government to say we just don’t
know how to use them.”
Even nursing homes express-
ing gratitude for the supplies say
they are often mismatched to
their needs, while others say the
amounts are paltry given how
quickly employees churn through
single-use protective gear as they
tend to dozens of patients a day.
“If I’m being totally honest, I’d
describe these as a token offer-
ing,” said Sondra Norden, the
chief executive of St. Paul’s Elder
Services in Wisconsin. “If we had
a major outbreak, we’d burn
through these supplies in a few
days.”
Virginia Mennonite Retirement
Community, a 120-bed nursing
home in Harrisonburg, received
its second shipment two weeks
ago. It contained several hundred
of the standard and highly cov-
eted isolation gowns and a similar
amount of the problematic gowns.
“I’m not sure how we would
even use those,” said Jan Em-
swiler, a nurse educator who
trains employees on the proper
use of protective gear. She was es-
pecially confounded by a packing
slip claiming the boxes contained
3,500 pairs of gloves. There were
only 1,000 pairs, she said.
“Oh God, even before Covid, we
were going through 3,000 pairs in
a day,” Ms. Emswiler said. “We ap-
preciate what we’ve gotten, but
we could really use a lot more.”
As for the gowns without arm
holes, Ms. Emswiler said they had
been placed in a storage closet.
“I hope we never have to use
them,” she said.FEDERAL RESPONSE
Much of the Protective Gear FEMA Sent Nursing Homes Is ‘Just Useless’
By ANDREW JACOBSVice President Mike Pence helped deliver protective gear sup-
plied by FEMA to a senior center in Alexandria, Va., in May. At
left, nursing homes in New Hampshire have received face masks
with flimsy paper ear loops, top, instead of elastic bands.PETE MAROVICH FOR THE NEW YORK TIMESVIA NEW HAMPSHIRE HEALTH CARE ASSOCIATIONBOSTON — The sign is easy to
miss in the waiting room of the
emergency department at Massa-
chusetts General Hospital, next to
the reception desk and a hand
sanitizer pump. “Register to vote
here,” it says, above an iPad at-
tached to a podium.
The kiosk has stood there since
November, before the pandemic
began and stayed there through
the worst weeks of April, when 12
gasping patients were put on ven-
tilators during a single grueling
12-hour shift.
Now, as the number of coro-
navirus patients has slowed to a
trickle, Dr. Alister Martin, the 31-
year-old emergency room doctor
who built the kiosk, is determined
to keep trying to register voters.
“There will be a time where,
above the din of suffering we ask,
‘How can we use this to make
something better of our situa-
tion?’ ” vowed Dr. Martin, who al-
ways wears a “Ready to Vote?”
badge around his neck.
Dr. Martin’s project, VotER, has
taken on new urgency as the pan-
demic has curbed traditional in-
person voter-registration efforts,
and as the link between public pol-
icy failures and death has become
especially clear.
Now, despite a global pandemic
— or perhaps because of it — his
project is spreading across the
country. Since May, more than
3,000 health care providers have
requested kits to register their
own patients to vote, including at
flagship hospitals across the coun-
try in Pennsylvania, Kansas and
Arizona.
VotER is part of a larger move-
ment that pushes medical profes-
sionals to address the underlying
social conditions — such as
hunger, drug addiction and home-
lessness — that make their pa-
tients sick in the first place. At its
core, it amounts to nothing less
than an effort to change the cul-
ture of medicine by getting doc-
tors and nurses to view the “civic
health” of their patients as part of
their professional duties.
Supporters of this movement
say the health care system tends
to work best for communities that
vote, so encouraging voting is a
strategy for improving patient
health in the long term. Jonathan
Kusner, a fourth-year medical stu-
dent who is co-chair of Med Out
the Vote, a get-out-the-vote initia-
tive started by the American Med-
ical Student Association, said his
group was encouraging primary
care doctors to include “Are you
registered to vote?” in intake
screening questionnaires.
“Just as we ask people to behav-
iorally modify their diet or their
exercise or their health, we could
ask people to modify their civics,”
said Mr. Kusner, whose organiza-
tion has teamed up with VotER to
promote voter registration in hos-
pitals around the country.
But some health care profes-
sionals frown on voter registra-
tion efforts, fearing that they
could be viewed as partisan. After
years of being dependably Repub-
lican, doctors are now more likely
to be Democrats.
Others worry that registering
voters is beyond the scope of what
medical professionals should be
asking their patients. Few doctors
have been trained to discuss voter
registration in a nonpartisan way,
and many emergency room doc-
tors already feel overwhelmed by
their work as it is.
“There is an enormous voice
that says, ‘Not our job,’ ” said Dr.
Harrison Alter, the founding exec-
utive director of the Andrew Lev-
itt Center for Social Emergency
Medicine, which helped popular-
ize a new medical field called “so-
cial emergency medicine” that
trains doctors to tackle social con-ditions that make patients sick.
But newly minted doctors tend
to be more outspoken about the
need to get involved in enfranchis-
ing patients, and trying to fix a
broken health care system.
“Previously, physicians taking
a political stance was seen as pos-
sibly unprofessional,” said Kelly
Wong, a medical student who is
part of Patient Voting, a Rhode Is-
land-based effort to provide hospi-
talized patients with information
that can help them navigate the
gantlet of voting from a hospital
bed. “Civic engagement of our pa-
tients and our communities is re-
ally important to changing health
outcomes.”
Dr. Martin, who grew up in New
Jersey with a single mother, said
he identified with his emergency
room patients who struggle to
make ends meet. At Harvard
Medical School, he became disillu-
sioned realizing how much time
doctors spent on paperwork and
the power of insurance companies
to dictate what treatments are
prescribed.
He considered leaving medi-
cine for good and earned a mas-
ter’s degree in public policy. Then
he worked as a health policy aide
to the governor of Vermont during
that state’s experiment with sin-
gle-payer health care.
Eventually, he returned to
medicine, finishing his residency
last year. He is already full of
stories about public-policy fail-
ures that make patients sick. He
speaks with passion about the 19-
year-old woman who came in
twice in one week with a life-
threatening condition related to
diabetes.
In medical school they called it
noncompliance. She was not tak-
ing her insulin as instructed. But
Dr. Martin realized after talking
with her that she had been ra-
tioning insulin because she had
lost her health insurance.Then there was the woman who
came in on Christmas Eve with
stomach pains. Her urine sample
revealed high levels of ketones, a
sign that she had not eaten in
days. That, too, was not the kind of
problem he had been taught to
solve in medical school.
“Gunshot wound? Save them.
Heart attack? Diagnose it.
Stroke? Fix it,” he said of his train-
ing. “Really the thing that keeps
you up at night is, ‘This woman
was here for abdominal pains be-
cause she was starving.’ I don’t
have an answer for that.”
Last year, just a few months af-
ter Dr. Martin was hired as a full-
fledged emergency room doctor
and a faculty member at the Har-
vard Medical School Center for
Social Justice and Health Equity,
he asked hospital administrators
for permission to put up voting ki-
osks. They agreed, as long as the
effort was nonpartisan and did not
infringe on treatment.
Dr. Martin installed TurboVote
software on a few iPads and af-
fixed them to podiums that hebought online. He also put up post-
ers with QR codes that patients
can scan with cellphones, auto-
matically bringing up a website
where they can register to vote.
The project was just getting
started — with about one patient a
day registering to vote and about
a dozen hospitals expressing an
interest in the kiosks — when the
pandemic struck. Emergency
rooms filled with terrified people
demanding tests. The iPad touch
screens became a source of possi-
ble infections. Hospitals that had
ordered kiosks stopped returning
his calls.
Massachusetts General took on
the look of a military camp, with a
tent for the homeless who awaited
their results. In April, at the peak
of surge, Dr. Martin noticed that
most of the sickest people were
low-income Spanish speakers —
essential workers who could not
shelter in place.
The virus was laying bare the
disparities in the health care sys-
tem that Dr. Martin was already
trying to combat.Instead of sidetracking VotER,
the pandemic has only raised in-
terest in it. After months of watch-
ing the mismanagement of the re-
sponse, and fearing for their own
lives as well as their patients’,
many doctors and nurses now see
the connection between their
work and politics more clearly.
The kits have already arrived in
Lawrence, Kan., where Dr. Sherri
L. Vaughn has arranged for the
QR code posters to hang in the
emergency room, radiology wait-
ing rooms and the cafeteria at
Lawrence Memorial Hospital, as
well as at primary care offices in
town. Dr. Vaughn also serves on
the board of the Kansas Hospital
Association, which embraced the
effort as the logical extension of
its earlier efforts to register doc-
tors and nurses to vote.
“It has gone out to every hospi-
tal in Kansas,” she said.
So far, this month about 500
people have registered to vote us-
ing the QR code on VotER posters
and badges worn by health care
providers, about twice as many as
had registered during the previ-
ous three months. And Dr. Martin
has received so many orders that
he isn’t sure how his small team of
volunteers will fill them all.
The pandemic has put an edge
in his normally cheerful demean-
or that was not there before. If
health care providers want a sys-
tem that works, he said, they have
to “step up.”
“The time for us being impartial
and apolitical and standing on the
sideline is over,” he said.
The virus has also given Dr.
Martin another avenue to bring
up the topic of voting with his pa-
tients. He advises his patients, es-
pecially the most fragile, that it is
safest to vote from home in No-
vember. “Do you already have
your mail-in ballot?” he asks
them, pointing to the QR code on
his badge. “You can get one here.”HEALING AN AILING SYSTEM
Doctors’ Advice: Rest Up, Drink Plenty of Fluids and Don’t Forget to Register to Vote
Dr. Alister Martin, 31, on his way to Massachusetts General Hos-
pital, where he built a voter-registration kiosk in a waiting room.TONY LUONG FOR THE NEW YORK TIMESBy FARAH STOCKMAN