Healthcare workers wearing personal protective equipment (PPE).
The COVID-19 pandemic will not be contained without international solidarity and coordination, but not all high-level cooperation is productive — in fact, the politicization of some responses has critically compromised them. A particularly high-stakes example of this trend is the distortion of the personal protective equipment (PPE) supply chain in recent months. As demand continues to outpace supply, manufacturers are primarily offering PPE to their allies, states are taking hazardous shortcuts to produce and procure it, and some governments are being forced to choose between the wishes of their allies and the safety of their constituents. Crucially, these dynamics prevent healthcare workers (HCWs) in other high-burden regions from accessing high-quality PPE, and by extension, exacerbate the spread of COVID-19.
A new arena of politics — PPE politics — has emerged during the time of COVID-19 as a combination of “mask diplomacy” and the politicization of the PPE supply chain. Mask diplomacy is the “zero-sum geopolitical game” in which countries send PPE to their allies despite their domestic needs to appear altruistic and advance their political interests. The resultant political implications are distorting the supply chain because, depending on the supplier, nations might be reluctant, over-eager, or making deadly compromises when obtaining PPE.
PPE politics have successfully mended and strengthened diplomatic relations, and inspired global distribution in a time where over 50 countries have limited or banned their exports of PPE. Long-time adversaries Japan and the PRC have exchanged tens of millions of PPE items and publicly affirmed their “friendship” since the outbreak. Similarly, eight days after the US and Taiwan formally agreed to share equipment with one another, the US government signed into law the long-neglected “Taiwan Allies International Protection and Enhancement Initiative Act.” But politicizing the PPE supply chain has and will continue to have drastic public health implications by delaying its use, incentivizing sub-standard production, and preventing third parties from distributing it equitably.
Those in most urgent need of medical-grade PPE are HCWs not only because they are being disproportionately infected, but also because hospitals and clinics have been shown to be sites for the super-spread of infectious respiratory diseases. Much of the burden of diseases comparable to COVID-19, such as SARS-CoV-1 and MERS, have been attributed to outbreaks in healthcare facilities despite adequate supplies of PPE. Quality PPE is a strongly-supported, tangible way to protect them. Models have shown that the use of PPE among HCWs and patients would be more effective in slowing the spread of COVID-19 than comprehensive testing. Based on studies of SARS-CoV-1 and MERS, surgical masks can reduce one’s infectious viral load by up to six times. Further, given the unknown proportion of asymptomatic COVID-19 cases, PPE could be much more impactful than currently reported. Conversely, alternatives to medical-grade PPE put HCWs in danger. For example, unlike N95 respirators that protect wearers from 95 percent of respiratory disease particles, medical face masks block only 56 percent of them, and cloth masks — an increasingly popular alternative in American hospitals — stop only three percent. In order for front-line HCWs to access the equipment they need, the World Health Organization (WHO) estimates, global PPE production will need to increase by 40 percent.
PPE diplomacy is delaying much-needed deliveries of equipment to HCWs worldwide for at least two reasons. Firstly, strained diplomatic relationships are causing in-fighting that slow its purchase. Secondly, positive diplomatic relationships are resulting in exchanges of identical PPE, keeping it out of the hands of HCWs. A recent 60-ton shipment of PPE from Russia to New York, for example, was allegedly delayed. According to the Russian Press Secretary, some US officials made it “needlessly difficult” to coordinate. Objections had included general reluctance to diplomatically engage with Russia; the fact that the purchase would violate its sanctions against two of the producers; and the condition that the US would reciprocate, defying its four-month PPE export ban. Well-intended exchanges of PPE, instead, are keeping the life-saving equipment on planes and out of hospitals. Districts and towns in Japan and the PRC are sending thousands of face masks back and forth, Russia and the US plan to send one another ventilators, and the PRC has even sold Italy’s PPE donation back to them.
The race to produce and advertise the seemingly altruistic sale of PPE has also driven some countries to take deadly shortcuts. To meet demand for testing kits among prospective allies in Western Europe, Chinese companies — some without medical licenses — have begun to sell so many faulty testing kits that they have been discarded and recalled by the hundreds of thousands. The US also passed a law in March that protects new producers of N95s from lawsuits if they are substandard or “fail.” Similarly, Russia has been accused of selling substandard and “totally useless” PPE in the name of strengthening its political relationships. The resources needed to both purchase and test the quality of newly-acquired PPE are not only straining healthcare resources in endemic areas, but also, if untested or used anyway, putting HCWs at significantly higher risk of infection. In parallel, mask diplomacy is forcing politicians to choose between the wishes of their allies and the safety of their constituents. Recipient governments like that of Italy are reportedly feeling pressured to buy PPE of dubitable quality to maintain their political ties, while others like that of India are disregarding rampant public dissent because positive diplomacy with producers is foundational to their supply of PPE.
A politicized PPE supply chain is an unjust supply chain. HCWs in nations that produce and procure PPE alike are increasingly likely to face shortages or completely lack PPE. What if the representatives of desperate HCWs defy a political threat and they lose access to face masks, like Americans might? Or if politicians continue to send ventilators to allies before they supply HCWs in their endemic cities, like in Russia?
One of the greatest public health risks of PPE politics is its inherently unjust system of distribution. Because producers and buyers are prioritizing diplomatic interests over humanitarian ones, PPE is not distributed to HCWs in high-risk areas or among vulnerable populations. These inequities are compounded by other barriers to access like price gouging and transportation constraints.
Usually, vulnerable populations could rely on development agencies, inter-governmental organizations, and discerning philanthropists to get access to much-needed medical equipment. But PPE is less likely to be sold or donated to third-party organizations because there is no diplomatic incentive to do so. In fact, some nations have explicitly withdrawn funding from these third parties for political reasons. In mid-April, the US attributed its suspension of donations to the WHO for its “dangerous bias towards the Chinese government” in its handling of the outbreak. In practice, such cuts are disadvantageous to aid agencies as they compete with producers’ allies to collect PPE for just distribution. Particularly for organizations under PPE export bans, many are struggling to find other ways to support HCWs. The United States Agency for International Development, for one, was recently forced to prohibit grantees from using its funds to buy PPE. Similarly, to support Monaco — which had been unable to buy PPE from five major supplying countries throughout March — the Belgian Ministry of Health needed to publicly defy the EU PPE export ban.
There are a variety of means to undermine PPE politics that will not compromise its benefits. It would be wise, for example, to institute a centralized platform for information sharing, which would prevent price-gouging, connect underserved nations to reliable suppliers, and incentivize the production of high-quality PPE. Responsible reporting is also crucial to downplaying the appeal of PPE politics; outlets should not exaggerate the value or generosity of sellers, and should attribute faulty equipment to specific manufacturers rather than countries. If diplomacy is to remain a priority in the exchange of PPE, policy-makers should consider donating or selling equipment to high-burden, prospective allies, or prevent identical exchanges by sharing alternatives to PPE, such as HCW exchanges, logistical support, and miscellaneous healthcare supplies. Finally, and most importantly, third parties must receive adequate in-kind and financial support to equitably and comprehensively mitigate the pandemic.
Although the shared threat of COVID-19 has enabled remarkable strides in international diplomacy, the public health implications of these politically-motivated efforts must take precedence. Correcting for the injustices caused by PPE politics would be conducive not only to more stable diplomatic relationships, but also to a more coordinated and effective fight against COVID-19.
Image Credit: Creative Commons / Javed Anees