Remember the N95 mask shortage? It’s still a problem.

Texas broke records for Covid-19 hospitalizations six times last week, including a record 2,504 hospitalizations in a single day on June 10.

South Carolina, North Carolina, Alaska, Florida, Mississippi, and Arkansas have also all broken records of new cases reported in a single day. Alabama saw a 92 percent increase in its seven-day average of new cases, and more than a quarter of Arizona’s total Covid-19 cases have been reported in the last week. Overall, 21 states have seen an increase in their daily average cases.

As these states have loosened lockdowns and people have come back into close contact, the virus is spreading rapidly again, and hospital ICUs are filling up. And public health experts say health care providers and essential workers remain at high risk of infection for the same reason they have since March: there’s a shortage of critical supplies, including personal protective equipment (PPE).

As of April 14, the Centers for Disease Control and Prevention (CDC) estimated that 9,200 medical professionals had been infected in the US; it’s not known how many have died.

An ongoing problem with PPE is that supplies still aren’t being distributed equally around the country and even within hot spots. Better-resourced hospitals have more supplies while other facilities struggle to find enough.

The federal Centers for Medicare and Medicaid say that one in five Florida nursing homes do not have a one-week supply of gowns or the N95 masks needed to care for Covid-19 patients and prevent transmission. According to WCNC Charlotte, North Carolina ran perilously low on gowns and masks in May even before its recent surge in cases, receiving only 99,000 of the 27 million N95 masks it had ordered. An internal report from the Federal Emergency Management Agency (FEMA) suggests “[t]he demand for gowns outpaces current U.S. manufacturing capabilities” and that the government plans to continue to ask medical staff to reuse N95 masks and surgical gowns intended to be disposed of after one use into July.

Val Griffeth is an emergency and critical care physician in Oregon and the co-founder of Get Us PPE, a grassroots organization that finds and donates PPE to health care workers who don’t have enough. (Project N95 is another organization that works with institutions who can afford to buy supplies but are having trouble procuring them.) Griffeth says Get Us PPE has seen a recent uptick in requests, particularly for gowns and gloves.

“I worry there hasn’t been a true fix to the supply-chain issues,” Griffeth says. “Our government has basically said that we’re going to allow the free economy to fix the issues. Unfortunately, it takes time and capital to ramp up production, and because the government has not devoted capital to helping solve the situation, we’re seeing a delay in its resolution.”

Griffeth argues the Defense Production Act (DPA), which Trump has deployed selectively, could be used more broadly to increase production of essential protective gear. The lack of federal leadership and coordination, the lack of a central agency prioritizing distribution based on need, Griffeth says, has led to difficulty procuring supplies, with states and hospitals often bidding against each other and elevating prices.

Now, as cases surge in several states, grassroots efforts are filling the vacuum. Here’s a closer look at a few of the country’s hot spots, and the people organizing to try to help protect their communities.

Why is PPE important?

A May preprint study, conducted by researchers at Massachusetts General Hospital, King’s College London, and Zoe Global Ltd., looked at data from the Covid Symptom Tracker app. It found that front-line health care workers were at nearly 12 times higher risk of testing positive for Covid-19 compared with members of the public, and those workers with inadequate access to PPE had an even higher risk.

“The limited availability of adequate PPE, such as masks, gowns, and gloves, has raised concerns about whether our health care system is able to fully protect our health care workers,” said senior author Andrew Chan, chief of the Clinical and Translational Epidemiology Unit at Mass General, in a statement.

Carri Chan, an associate professor at the Columbia Business School and an expert in hospital operations management, explains that PPE is essential not just to reduce transmission in hospital settings but because studies have shown that in a respiratory disease pandemic, trained health care workers are the bottleneck. If they get sick, patient care suffers. “You can have all the ventilators in the world, and if you don’t have specially trained people to provide care, it doesn’t matter how many machines you have,” she says.

It’s not only hospitals that need more staff and PPE; many other areas of health care do too, including primary care facilities, homes for the disabled, and nursing homes — a fifth of which reported at the end of May that they had less than a week’s supply of critical PPE. Chan notes that other essential workers, including grocery store clerks, delivery workers, and those “who don’t have the luxury to work from home” also need PPE to protect themselves and others.

Because a large portion of the masks, gowns, and gloves the US uses come from China, and because of the overnight global demand, supply chains have been disrupted. “Due to limited access, as hot spots grow, some more underserved communities could be again hit disproportionately,” she says.

This is yet another area where the lack of federal leadership hindered the Covid-19 response. As a New York City resident, Chan compares Elmhurst — a hospital in Queens that saw “apocalyptic conditions” — to better-resourced and well-connected facilities in other parts of the city, saying that “because of the decentralized manner in which PPE procurement occurred, some [hospitals] were much worse off than others.”

In her hospital, Griffeth is currently given one N95 respirator mask and one face shield per day. She wears the face shield both as eye protection and to decrease droplets contaminating the respirator. N95s are placed in a paper bag between uses while face shields are cleaned with sanitizing wipes between patients. Best practices would involve using a new mask and face shield with each potentially infectious patient. “Both masks and respirators continue to be an issue,” she says, “despite falling out of the nightly news cycle.”

Chan says, so far, there have been few national efforts to ensure PPE is distributed equally. “At Elmhurst, people were dying just waiting to get access to care. There’s a lot of imbalances about the way the system is set up.”

Florida: “Left out to the wolves”

Rebekah Jones, a scientist and former manager of data and surveillance at Florida’s Department of Health, says that, back in January, the CDC told the department it needed to prepare for a widespread pandemic.

Jones was in charge of the state’s public tracking of Covid-19 cases until May 19, when she allegedly refused a superior’s request to alter numbers so that the coronavirus positivity rating would drop below the state’s threshold to reopen. Before she was fired, Jones says she saw requests for PPE rolling in from around the state — requests for shoe covers and hand sanitizer and masks — suggesting many places in Florida still didn’t have the equipment they needed to stay safe. Since mid-May, 24 health care workers in St. Petersburg have been infected, prompting at least one nurse to quit, and firefighters and first responders in Immokalee recently reported they are running out of PPE.

Desiree Ann Wood, a truck driver and founder and president of Real Women In Trucking, says that Florida’s need for PPE extends far beyond hospital doors. She’s been organizing donations of PPE for truck drivers, who have struggled to maintain the country’s supply chains during lockdown.

Wood reports that rest stops truckers normally rely on to go to the bathroom, sleep, and eat have been closed, and many drivers are no longer allowed inside the places they deliver. “You’re like a social pariah,” she says, but “we are part of the logistical supply chain, and no one’s thought that the people restocking shelves are being left out of the equation.” She says with the temporary suspension of regulations limiting long-haul driving hours, “Drivers can drive more for less money, and for less services, and no one ever thought, ‘What about them?’ It doesn’t even occur to you to give them a mask, too.”

Wood started handing out donated masks in early March. “I couldn’t get permission initially. I’d just show up at a truck stop and pass masks out till I was asked to leave.” But though she’s met skepticism — truckers “assume I’m going to hassle them, or I’m a working girl in the parking lot” — the Real Women in Trucking network has now handed out more than 8,000 masks, gloves, and bottles of hand sanitizer.

Thanks in part to a donation by Uber Freight, as well as donated supplies and a cash donation from the freight company DDC FPO, Wood is now handing out PPE in Florida, Kentucky, Mississippi, Iowa, Georgia, and Michigan.

Jones, the former Florida state data scientist, has also developed her own dashboard, which, unlike the state’s, shows the total number of positive cases for everyone tested in Florida regardless of their legal address. “If you live here and are sick here and die here, your information should be included,” she says.

Wood agrees that it doesn’t seem as though the state is considering everyone. “We see this over and over again,” she says. “We’ve really been left out to the wolves.”

Georgia: “We’re not united anymore.”

On June 11, Georgia saw a single-day increase in Covid-19 cases of more than 26 percent. The increase in cases isn’t surprising to Edward Aguilar, Shourya Seth, and Manu Suresh, juniors in high school in a suburb of Atlanta. They’ve been busy after school, building software to get PPE to hospitals that needed it.

“It’s been frustrating seeing cases rise, and the lack of government response,” says Aguilar. “It really does point out the weak points of the whole supply chain,” Seth says. “It’s almost like a confederacy. We’re not united anymore.”

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After talking to Seth’s cousin who works at Emory University Hospital, the teens called five maker spaces — collaborative workspaces that often have shared tools — in early March to see if they could find a way to get additional PPE to medical workers. They created a grassroots organization, Paralink, and since April 1 have delivered donated PPE supplies, primarily face shields, to health care providers around the South. “FEMA has delivered 180,000 face shields to Georgia,” says Aguilar. “We’ve delivered 190,000.”

At first, the teens were calling hospitals to make a list of who needed what, but now the group uses Get Us PPE’s database to prioritize shipments. It’s been a crash course in logistics: Paralink now coordinates more than 50 maker spaces to 3D-print face shields, and relies on 150 volunteer drivers to distribute them.

Aguilar recalled one shipment of 3,000 face shields that urgently needed to get to Albany, New York; within a day, they used Facebook groups to find seven volunteers, who each drove the shipment for several hours in a human chain between Georgia and New York.

As they’ve scaled up, the teens have run into some of the same stop-and-go problems as larger corporations. While Georgia was locked down, there was a drop in requests for PPE, so Paralink called some of the volunteers to tell them their help was no longer needed making face shields. “Now we need to call back and say we need more,” Aguilar says. “We’ve had some really tough conversations.”

Paralink’s requests for face shields have recently doubled. “It’s scary to see we’re not able to keep up production — and we know we can move faster than the federal government. What happens when the government has to make these phone calls to massive companies? How do you tell [manufacturers] that after retooling, they have to stop, or then start again? The backlash won’t be in favor of the manufacturers,” says Aguilar.

“People call us and say we’re inspiring — and it’s scary. The focus, as it should be, has been on health care workers, but a lot of [them] are in the same position now and aren’t getting any help,” Aguilar says. “It’s not just people in hospitals. Everyone needs this protection.”

Arizona: “It’s been heartbreaking”

Over the last week, Arizona’s Covid-19 cases surged by 54 percent. Saskia Popescu, a senior infection prevention epidemiologist at the University of Arizona, says she was “surprised and deeply worried when the state opened so prematurely. We’re seeing the fallout of that right now.”

Northern Arizona in particular has been hard-hit, seeing hospitals approach capacity, and the largest care system in the state, Banner Health, warned that the number of patients on ventilators has quadrupled since May 15. The Arizona Department of Health Services told hospitals to “fully activate” their emergency plans.

Because it’s so hot in Arizona — it hit 112 degrees Fahrenheit in Phoenix twice in late May after the stay-at-home order lifted — it’s more difficult to follow recommendations to socialize outside instead of inside. That may help explain why Arizona’s case numbers have been spiking after lockdown was lifted, says Popescu.

But it’s not just increased transmission that’s putting a strain on the state’s PPE supplies. The Arizona Department of Health Services has recently allowed elective surgeries to restart, adding traffic to hospitals and creating what Popescu calls “a perfect storm for rapid case growth, and a very stressed health care system.”

Popescu says that she’s seen a widespread shortage of even basic supplies like disinfecting wipes, as well as disposable stethoscopes and laryngoscope blades — “things people don’t think are big deals, but that show that the supply chain problem is not resolved.”

Watching people become increasingly lax about prevention while knowing that hospitals are increasingly full has “been heartbreaking,” Popescu says.

Lois Parshley is a freelance investigative journalist and the 2019-2020 Snedden Chair of Journalism at the University of Alaska Fairbanks. Follow her Covid-19 reporting on Twitter @loisparshley.