Issue 12: What's behind the global search for ventilator supply

There are plenty of logistical, regulatory, and supply-chain obstacles to securing adequate supply. Technological innovation offers hope, but ethical questions remain

The COVID-19 pandemic has challenged global policy makers in ways unheard of in most of our lifetimes. This newsletter provides short, accessible briefings on as many of the relevant policy challenges as possible. Today’s briefing is written by Sebastian Muermann (SM), a graduate student at the Max Bell School of Public Policy who is riding out the pandemic in Montreal.

Early indications show that nearly 1 in 6 people will require hospitalization following an infection of the COVID-19 novel coronavirus. Somewhere between 30 and 40 per cent of these patients are estimated to require mechanical ventilation at some point. Hundreds of thousands of people will need a ventilator, but these devices are currently only stockpiled by the hundreds, and in some cases, by the dozen. 

Some quick facts:

  1. COVID-19 damages healthy lung tissue, making oxygen delivery to the blood difficult.

  2. Pneumonia and acute respiratory distress syndrome (ARDS) can develop, which begins to damage other organs. 

  3. Mechanical ventilators feed pure oxygen into the lungs through a tube inserted down the throat, or via a mask worn topically. 

  4. Machines usually contain humidifiers, which add heat and moisture to the air to match body temperature.

  5. It is also possible to pressurize a mouthpiece device to slowly emit oxygen if the patient is strong enough to breathe on their own.

In terms of their core function, ventilators are basically sophisticated pumps, “not extraordinarily complicated machines”. However simple they may appear, under no circumstances can they be allowed to malfunction. “If they fail, the patient is very likely to die,” explains Mauricio Toro, an engineer design lead developing three different open-source ventilators in Colombia. 

Under normal circumstances, reliability comes as a result of extensive testing — up to two years for commercial manufacturers. Coincidentally, this matches the 18-month timeline needed to develop viable vaccines. “This is what makes them so challenging to build.” says Toro. World wide ventilator shortages have led to the launch of wartime-like production efforts, with countries looking to procure a large supply at almost any cost. But shortages and competition for the scarce resource are not the only challenges facing the advancement of this technology.  Increasing the supply of available ventilators is hindered by a critical two-part supply chain problem:

First, prior to COVID-19, many component parts for ventilators and most other kinds of personal protective equipment (PPE) were made, at least in some degree, in China. Given the widespread use of available medical supply stocks in the region, it is unlikely that adequate production could reach capacity in time to meet global demand, or even just the areas that have a significant anticipated need. 

Second, if  innovations bear fruit and ventilator production increases, distribution could become a complicating concern. Ventilators range in size and can be difficult to transport, deliver, and install quickly. Their delivery would be concentrated in production zones and would have to be green-lit across and between whole countries. Transportation network lines have been stalled due to a global slowdown, and countries could be left waiting on shipments that do not arrive. 

An additional challenge is ventilator safety regulations. Companies as varied as Dyson Vacuums, Formula 1, and the Montreal-based flight simulator company CAE have volunteered to produce component parts or entire designs in their facilities. They are all bound by restrictive regulations, requiring ventilators to endure extensive wear and tear, not be likely to additionally spread infection, and hold up under varied heavy-duty cleaning methods, such as chemical use or UV radiation. Interestingly, fire codes for hospitals are another barrier, because compressed oxygen use is highly regulated. Stringent but highly necessary health and safety requirements seriously entangle the design and engineering process. 

A fourth challenge raises complex political and ethical challenges: the trade in ventilators, the question of international distribution, and the impact on social inequality. High-income countries are seeking out additional ventilators and there are reports that prices are skyrocketing as demand rises globally. But while high-income countries may be able to scale up industrial production in weeks, most countries, especially those with weaker healthcare systems, do not have that luxury. For example, in the West African country of Mali, home to some 19 million people, there are only a total of 56 ventilators.

Still, innovation is providing some hope. Designers and engineers are currently working at breakneck speed — at least a dozen ventilator prototypes at different stages have been developed in March 2020 alone by teams in different countries. They are organising on Slack channels, in Facebook groups, and via GitHub to provide open source concepts for ventilator components. They think they can help solve the bottleneck with very replicable tools, particularly in parts of the world with less capability to respond to the crisis, like Africa or South America.

Training to use a ventilator is the final piece of the puzzle. For medical professionals in a hospital setting, machine operation is relatively simple. Doctors and nurses simply need to be able to clean, install, and operate the device. The ensuing ethical dilemmas around prioritization, risk, and end-of-life questions are, though, a different kettle of fish, and possibly the subject of another briefing. (SM)

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Policy for Pandemics is produced and edited by Andrew Potter and co-edited by Charlotte Reboul and Paisley Sim (bios here). If you have any feedback or would like to contribute to this newsletter, please send an email to andrew2.potter@mcgill.ca