As the coronavirus crisis deepened in April, Georgia officials circulated documents showing that to get through the next month, the state would need millions more masks, gowns and other supplies than it had on hand.
The projections, obtained by KHN and other organizations in response to public records requests, provide one of the clearest pictures of the severe PPE deficits states confronted while thousands fell ill from rising COVID-19 cases, putting health workers at risk.
Georgia on April 19 had 932,620 N95 respirator masks — one of the best protections for health workers against infection — and expected to burn through nearly 7 million within a month. It urgently needed to buy 1.4 million more, according to documents obtained by the Brown Institute for Media Innovation and shared with KHN. For gowns, officials expected to go through 16.1 million in 30 days, a staggering amount compared with the 21,810 the state had at the time.
"Making progress with PPE needs. Biggest challenge now is gowns and we are working it," Georgia Emergency Management and Homeland Security Agency Director Homer Bryson wrote on April 19 to two of Gov. Brian Kemp's senior-most aides.
Even so, one day later, the first-term Republican governor announced he would begin to reopen the state's economy, including gyms, restaurants, hair salons, theaters and a host of other businesses.
"We have relied on data, science and the advice of health care professionals to guide our approach and decision-making," he said at a news conference, "putting the health and well-being of our citizens first and doing our best to protect lives and livelihoods."
"Our state agencies and the governor felt confident in the state's ability to meet daily PPE requests from our local emergency preparedness partners and medical facilities when Georgia began implementing its measured reopening plan," Cody Hall, the governor's spokesperson, said in response to questions. "We have continued to meet those needs since April." He noted the state is now building a PPE stockpile.
A matter of life or death
After Georgia eased its lockdown, COVID cases spiked. Requests for PPE from health workers in the Atlanta area escalated through April and May, according to numbers provided by the nonprofit Atlanta Beats COVID-19, which makes face shields for health workers and other residents.
According to public data on the Georgia Department of Public Health's website, at least 80 Georgia health care workers have died from COVID-19, including after the state reopened its economy.
One was John "Derrick" Couch, a nurse practitioner who worked in Fort Oglethorpe, Georgia. Shortly after graduating with his master's degree in nursing on May 10, the worker at Med First Immediate Care Medical Center grew sick with COVID-19. His wife, Karol, cared for him at home for a time before he was hospitalized. He died after 36 days on a ventilator, according to a GoFundMe page set up to help his family cover his health care expenses.
"Karol wants everyone to know that Covid-19 doesn't care or discriminate. She says John would want all of his colleagues and friends in healthcare and community to demand proper equipment and protection," it said. Med First Immediate Care did not respond to a request for comment.
Between March 16 and Aug. 9, 48 COVID-19-related complaints regarding inadequate PPE in Georgia health care facilities were closed by the Occupational Safety and Health Administration, the federal agency responsible for workplace safety. The PPE complaints accounted for the majority — roughly 6 in 10 — of Georgia's COVID-19 complaints submitted to OSHA during the four-month period.
In April and May, "we received thousands of requests for N95 masks, but we couldn't get our hands on the right materials to even make an N95 mask," said Caroline Dunn, Atlanta Beats COVID-19's communications coordinator.
Nationally, health workers continue to express alarm about protective equipment supplies as COVID-19 hot spots reemerge across the country. A National Nurses United survey in July found 87% of nurses working in hospitals reported reusing at least one piece of single-use PPE. Only a quarter of nurses surveyed felt their employers were providing a safe workplace.
"There's really been this normalization and this acceptance that some people are going to be expendable. And that's completely unacceptable," said Dabney Evans, director of the Center for Humanitarian Emergencies at Emory University in Atlanta.
Another document projecting PPE supplies, dated April 10 and developed by Georgia health and emergency management officials, relied on a calculator from the U.S. Centers for Disease Control and Prevention to estimate how quickly Georgia would burn through supplies across hospitals, nursing homes, dialysis clinics, jails and prisons. The state had 527,424 N95 respirators but needed a total of nearly 1.1 million to get through the ensuing seven days. The projected need grew to 4.8 million masks when estimating supplies for the following 31 days.
It had 196,500 gloves on hand but would need more than 12.1 million to get through a week, and 54 million for 31 days. The state had about 122,000 face shields but required more than 458,000 for the coming seven days. For a month, the projected need ballooned to over 2 million.
The April 10 estimates — a day when Georgia's new COVID-19 case count rose by about 1,000 people — were sent to the U.S. Department of Health and Human Services and Federal Emergency Management Agency as part of a broad effort to assess what states needed across health care settings to operate for at least seven days and up to a month. Federal officials asked state public health and emergency management officials to submit PPE projections daily, according to emails among state personnel, HHS and FEMA.
PPE estimates would be used "to determine projections for our region and the next hot spots within each state," Jeanne Eckes, an HHS official working with FEMA on the federal government's COVID-19 response, wrote in an April 3 email to officials in multiple states throughout the South, according to correspondence obtained by KHN.
Georgia officials contend the state's estimated PPE deficits were larger early in the pandemic because projections accounted for all COVID-positive cases. Once the state had more information on how many of these positives were asymptomatic cases and how many led to hospitalizations, it could better gauge what was needed, they argued. Multiple changes were made to its burn-rate calculations, including a May 8 adjustment that replaced the total case count with hospital-based COVID cases, which reduced the projected demand for PPE.
However, multiple experts disputed the idea that knowing the number of asymptomatic patients would be relevant for PPE projections. In facilities like nursing homes and jails — both of which were accounted for in the Georgia estimates — asymptomatic individuals could spread the virus if not quarantined immediately.
"Because there's not on-the-spot, point-of-care testing available for the most part, you have to use PPE throughout the hospital all the time," said Dr. Eric Toner, a senior scholar with the Johns Hopkins Center for Health Security. "In this day and age, you just have to presume that everyone has COVID."
When the state's case count began surging in March, many COVID-19 patients treated at Tift Regional Medical Center in Tifton, Georgia, needed ICU-level care and were from nearby Dougherty County, a Georgia hot spot where hospitals were quickly overwhelmed.
"There were times to which we were down to only having a few days of PPE left," said Dr. Kaine Brown, a physician and medical director at Tift, adding that the hospital was partly saved by donations of N95 and cloth masks. Gowns were the biggest problem. PPE supplies have since improved — as of early July, the hospital had stockpiled more than eight months' worth of surgical masks and enough N95s and gowns to last six months and about three months, respectively.
Georgia's stay-at-home order for most residents expired April 30; it remains in place for individuals at higher risk of severe illness.
"We were very apprehensive about [easing restrictions]," Brown said. "Those of us who had been working on the front lines knew how infectious this was."
Since May, Georgia has reopened a broad swath of businesses. In early July, more than 1,000 health care workers signed a letter to Kemp urging him to institute a statewide mandate requiring face coverings, to close bars and nightclubs, and prohibit indoor gatherings of more than 25 people. Georgia currently bans gatherings of more than 50 people if social distancing cannot be observed.
State officials say PPE supplies have "greatly improved" since the start of the public health emergency. As of Aug. 14, the state had distributed 3.9 million N95s, 13.1 million surgical masks, 36.6 million gloves, 4.6 million gowns and 1.6 million face shields, among other items, according to the Georgia Department of Public Health. Early on, Georgia also relied on donations to bolster PPE supplies when many items were unattainable through normal supply channels, which have since become more reliable.
However, even with the increased stocks, workers still reuse protective equipment and many fret over the uncertainty about how long they can do so safely. Another community-based organization, the Atlanta chapter of Sewing Masks for Area Hospitals, said that from April to June the organization gave out over 59,000 cloth masks to 152 health care facilities in the Atlanta area, including large hospitals, such as Children's Healthcare of Atlanta and Emory St. Joseph's Hospital. Kayla Hittig, a co-founder of the sewing group, said that health care workers were using the cloth masks to cover their N95 or surgical masks to make them last longer.
"That's the thing we hear the most — how often do we have to use these and how protective are they, for how long?" said Richard Lamphier, president of the Georgia Nurses Association.
Lamphier wasn't critical of the state officials' efforts to ensure health workers are protected.
"I think they've done the best they could with the situation they had," he said.
It wasn't enough to protect John Couch, whose family is reeling from his death.
"He was my whole life," Karol Couch said. "My life is shattered."