NEW YORK (NYTIMES) - As the United States braces for an onslaught of coronavirus cases, hospitals and governments are confronting a grim reality: There are not nearly enough lifesaving ventilator machines to go around, and there is no way to solve the problem before the disease reaches full throttle.
Desperate hospitals say they can't find anywhere to buy the medical devices, which help patients breathe and can be the difference between life and death for those facing the most dire respiratory effects of the coronavirus.
American and European manufacturers say they can't speed up production enough to meet soaring demand, at least not anytime soon.
And while the acute shortages are global, not just in the United States, some European governments are deploying wartime-mobilisation tactics to get factories churning out more ventilators - and to stop domestic companies from exporting them.
The United States, by contrast, has been slow to develop a national strategy for accelerating the production of ventilators. That appears to reflect in part the federal government's sluggish reaction to the coronavirus, with President Donald Trump and others initially playing down the threat. This week, Trump urged governors to find ways to procure new ventilators. "Try getting it yourselves," he said.
That will be hard and in some cases impossible.
"The reality is there is absolutely not enough," said Andreas Wieland, chief executive of Hamilton Medical in Switzerland, one of the world's largest makers of ventilators. "We see that in Italy, we saw that in China, we see it in France and other countries. We could sell I don't know how many."
Wieland's company is shipping machines as fast it can get them off the assembly line. He has moved office workers to the factory and hired more employees. Even so, he can't keep up with the crush of orders. "Italy wanted to order 4,000, but there's not a chance," he said. "We sent them something like 400."
The coronavirus attacks people's lungs, in some cases compromising their ability to breathe. Ventilators, which deliver air to the lungs through a tube placed in the windpipe, are a crucial tool to keep these patients alive. The computerised, bedside machines can cost as much as US$50,000 (S$73,000).
Hospitals in the United States have roughly 160,000 ventilators. There are a further 12,700 in the National Strategic Stockpile, a cache of medical supplies maintained by the federal government to respond to national emergencies.
That probably won't be enough if the number of serious coronavirus cases keeps climbing.
"In a worst-case scenario it would be very difficult to have a sufficient number," said Thomas R. Frieden, the director of the Centres for Disease Control and Prevention during the Obama administration.
In the United States, roughly half of the intensive-care ventilators in use were made by foreign companies, including Dräger and Getinge, according to estimates by ECRI, an independent nonprofit group that evaluates medical technology.
There are fewer than a dozen American companies - including giants like General Electric and Medtronic - that make ventilators, according to Greg Crist, a spokesman for AdvaMed, the trade group that represents American medical device makers. They are scrambling to accelerate production.
But the machines are complicated, made up of hundreds of smaller parts produced by companies all over the world. There is no simple way to substantially increase the output.
"We are in a global supply chain situation, like it or not, so everybody making ventilators here or elsewhere is going to be looking for parts, often coming from the same suppliers," said Marcus Schabacker, chief executive of ECRI. "There's a domino effect coming into play."
Earl Refsland, chief executive of Allied Healthcare Products, a small ventilator manufacturer in St. Louis, said that ramping up production quickly was not possible. For his company, which makes about 1,000 ventilators a year, it will take at least eight months to sharply increase production.
"These are ventilators to keep people alive," Refsland said. "We aren't making wagon wheels. It takes a while."
Demand has spiked just as countries are forcing people to stay home to slow the coronavirus's spread. To bring more workers into factories, companies first need to buy protective gear for staff and spend money on cleaning services.
Without an adequate supply, doctors may have to make life-or-death decisions about who needs the machines most.
Johns Hopkins University's hospital system bought some new ventilators a few weeks ago, when the leadership saw the coronavirus spreading. But the Baltimore hospital network is struggling to find more to buy.
"We're scrounging," said Gabe Kelen, director of Johns Hopkins' office of critical event preparedness. "We're looking at every possible place we might get one."
The hospital system has considered whether it could work with the university's engineering department to build its own ventilators - an option that Kelen described as "extreme," given that they've never built the complex machines before - and has also convened a group of doctors and ethicists to figure out how to essentially ration the use of ventilators if there are more patients than machines.
As the initial epicentre of the coronavirus outbreak, China snapped up whatever slack there was in the market for the assisted-breathing machines. When the disease spread to South Korea and Italy, hospitals in those countries put their orders in. Now manufacturers are getting inundated with orders from all over the world.
The United States is toward the back of the queue, according to manufacturers.
Ventec, a small ventilator company with headquarters near Seattle, recently filled an order to sell 150 ventilators to Japan, said Chris Kiple, its chief executive.
Ventec is hustling to accelerate its production, adding employees and increasing their hours, he said. In an attempt to prevent the coronavirus from spreading among its staff, Ventec introduced mandatory temperature checks for everyone entering its factory. A janitorial staff works 24 hours a day to sanitize surfaces.
But even with the increased production, the company won't be able to quickly satisfy the surging demand.
For days, Kiple said, he has been getting nonstop phone calls from frantic hospital administrators, governor's offices and other government officials looking for more machines. He's even received inquiries from a number of wealthy individuals hoping to buy their own personal ventilators, a fallback plan in case the American hospital system buckles.
"I can tell you with a 100 per cent confidence that every single manufacturer is facing a backlog right now," Kiple said.
European countries - already reeling from tens of thousands of virus-infected patients - are responding forcefully. Some governments are restricting domestic medical supply companies from fulling international orders.
In Germany, where about 25,000 ventilators are now available nationwide, the government ordered 10,000 from a domestic manufacturer, Dräger, to be made over the next year. The company, whose stock has risen more than 50 per cent in the last week, said it was rushing to fulfill the orders, but faced constraints because of safety testing and the availability of components.
Italy, which has nearly 30,000 confirmed coronavirus cases and more than 2,100 deaths, is perhaps facing the gravest shortage of ventilators. In the northeast region of Veneto, officials are looking into whether ventilators designed for animals can be used on humans, local media reported.
The government has sent about 25 engineers and other staff members from the ministry of defence to help with production of ventilators at Siare Engineering, a manufacturer near Bologna. The company has quadruped production to make up to 150 ventilators a week. It delayed deliveries to other countries like India to meet the need in Italy.
"It's an urgent need for our country," said Enrico Tozzi, who leads Siare's export division. "We are completely in an emergency."
And in Britain, where the country expects to need far more than the 5,000 ventilators now available, Prime Minister Boris Johnson on Monday called on carmakers and other manufacturers to immediately begin helping make ventilators, a move reminiscent of the country's mobilisation to build Spitfire fighter jets during World War II. The government said it got more than 400 calls from businesses offering to help build ventilators.
The US government has considered, to some extent, a similar option. A federal report, obtained by The New York Times and dated March 13, noted that the president could invoke the Defence Production Act of 1950, which allows for the mandatory mobilisation of manufacturing lines to produce key supplies. (Trump announced on Wednesday that he would do so.)
So far, though, there have been no investments in technology to help manufacturers increase production, scant marshaling of federal resources and limited coordination to help distribute machines. Instead, it's essentially every state for itself, which leaves manufacturers having to decide which hospitals or governments need the machines the most - and, in theory, who is willing to pay a premium.
Some industry officials said they recently had been discussing production issues with members of the White House's coronavirus task force and officials at the Department of Health and Human Services.
Given the size of the United States, the problem is more complicated than raw numbers. An unused ventilator in Detroit, for example, does not help an overwhelmed hospital in Dallas.
"You may have more than sufficient resources close by or even across the country but face clustered outbreaks that exceed the capacity locally," said Dr. Greg S. Martin, president-elect of the Society of Critical Care Medicine and professor of medicine at Emory University in Atlanta.
There's also the question of finding enough trained personnel to staff the machines. Under normal circumstances, Martin said, physicians receive years of training before they are entrusted with operating ventilators in life-or-death situations.