TL;DR: It is what it sounds like: direct the US Federal Government produce N-95 (or higher NIOSH grade) respirators for all Americans. I believe that this would be a relatively low-cost policy with potentially huge benefits and little downside.

Note: I’m directing this policy proposal at the United States, but I think many large countries, especially those with an established manufacturing base in similar industries, could do something similar.

What I hope to get out of this post: More than anything, I just want to get the idea out there. I am currently quite busy with a lot of different projects for my PhD, but if anyone wants to run with this idea (e.g. lobby politicians, write out the proposal in more detail, get Joe Biden to add it to his plan) please do and I am happy to support! Also, feedback on what seems right or wrong about this is also helpful. The post generally stems from a frustration that we are now 10 months into this pandemic. Besides stomping out the disease before it becomes widespread (e.g. as Taiwan, New Zealand did), we don’t have many good implemented public policies to deal with community transmission besides widespread wearing of non-medical masks, physical distancing, and now new rounds of suggestions that we should just go for herd immunity. Cases are rising in the US and Europe, and indications are that this will probably continue getting worse as the weather gets colder. Meanwhile, pandemic fatigue has set in, making existing measures public health measures harder to implement. 

I believe we need some new ideas. This proposal seems like a simple way to get a possibly very large benefit in terms of lives saved and economic costs avoided at relatively very low cost. For months, every time I have a Covid discussion with friends and family, N-95 For All is the first thing I say we should do.  I figure that it is high time I write it up and maybe it inspires someone to try it out.

Motivation

At the beginning of the Pandemic in New York, I had some N-95 masks in my closet that I had bought a few years prior. I had done some research into biosecurity threats, and I realized that a big pandemic driven by respiratory-transmission was likely to happen sometime in my lifetime. I figured a stash of N-95s was good to have. When New York started going crazy in March 2020, however, my friend who is an Emergency Room doctor wrote a Facebook post saying that she desperately needed respirators because the hospital did not have enough. She was risking her life working on the front lines of the pandemic, so the least I could do was to donate those masks to her.

That was in March 2020, just while the pandemic was starting. It is now 7 months later, and you still generally cannot buy N-95 masks. I’ve also tried buying N-95 masks in France for a friend, and you can’t get them there either. In October 2018, I paid less than $1.50 for an N-95 mask. In October 2020, not only has market rate increased to $6 per mask, but you cannot buy an N-95 because they are being prioritized for organizations on the frontlines responding to COVID-19 (see picture below). Even so, N95s are still in shortage for the frontline medical workers that need them the most. 

The fact that the supply of these masks is still so constrained 7 months after the United States first started locking down is unacceptable. An estimated 92% of Americans say they wear a mask in public, and 74% say they “always” do. Along with physical distancing measures, this has helped to curb the spread of the virus. As the weather gets colder in the fall and winter and as more activities move indoors, however, it is important to provide an enhanced level of airway protection. Cloth and surgical masks provide some protection against droplets but are less effective against airborne aerosols that linger in the air indoors where there is less ventilation relative to medical-grade respirators like the N-95. A recent study suggested that N-95s, even when they are not properly fitted, provide far better airway protection than cloth and surgical masks. 

The Policy

My policy proposal is simple: the US should invest federal dollars as soon as possible to create N-95 or higher (N-95+ for short) NIOSH-rated masks that can filter aerosols for every American. The federal government would invest in the manufacturing capacity of medical-grade respirators such that everyone in the country would be delivered an N-95+ to their home and a new one would be delivered as often as is necessary (see the bullets below for more details). Every American that wants to protect their health and the health of others now would have the opportunity to upgrade their cloth masks for medical-grade respirators that would protect them with enhanced airway protection. Hospitals and essential workers would of course get access to these masks first, but the idea is to produce enough of these masks so that everyone in the country gets them. 

In short, the federal government would make sufficient investments such that N-95+ respirators would be widely available to everyone as soon as possible. 

This excellent article from the Washington Post provides a detailed description of the current US respirator policy and its consequences. The US has undertaken some policies to increase domestic production and international procurement of respirators, but these policies have not been sufficient to meet demand. There are a number of reasons for this, but more than anything, it comes down to a lack of investment. So far, the federal government spent $270 million dollars through the Defense Production Act to bolster the N95 supply chain. To put this in context, this is less than the government spends on the instruments, uniforms, and travel for military bands. PPE producers consistently state that they are wary about investing in further production capacity because they are unsure of continued demand for their products. In addition, there are at least 15-20 companies in related industries – such as filters for vehicle emissions, air pollution and water systems – that could modify their equipment to make N95s at the scale that would be required, but the government has funded just three of these companies through the Defense Production Act. In addition, 3M (the largest producer of respirators in the United States) has been largely unwilling to partner with other companies that could expand production to meet demand because it does not want to share its intellectual property with other manufacturers. This has made it difficult for other companies to successfully move into the respirator business and meet NIOSH standards for filtration.

While the details would have to be hammered out in more fine-grained detail, the goal of N-95 For All would be not just to make enough respirators to meet demand for front-line workers (which is the current goal), but to provide free respirators for all Americans. One possible way to meet this goal would be for the Federal Government to use the Defense Production Act more broadly to procure billions of respirators from domestic producers now and into the future. Through this act, the government would be able to force 3M to share its intellectual property with other producers (which they can then be compensated for) so that production of NIOSH-compliant respirators can be produced. This investment would likely be a few billion dollars. 

Regardless of the details, the larger point is that this investment of a few billion dollars would play a significant role in addressing pandemic that has now cost 220,000 lives in the United States and trillions of dollars in economic damage. Consider that in wartime, it would not be acceptable to send soldiers into battle without a rifle because the government wanted to save a few billion extra dollars or because one company couldn’t produce enough rifles and wouldn’t share their knowledge with other companies that could expand production. I believe that Covid-19 should be addressed with the same degree of seriousness and ambition as in war. Because of widespread community transmission that is now infecting at least 75,000 new Americans a day, Americans are on the frontline of the Covid-19 pandemic, and the Federal Government should provide its people with the best available protection, especially when the protection can be produced at relatively low cost.

Principal Benefits

• Better protection against Covid: Medical-grade masks provide much better protection against SARS-COV-2 than cloth or surgical masks (see this cool video for the physics of how these masks work). This is a respiratory virus that primarily infects people through the airway. Effectively protecting the airway significantly reduces an individual’s risk of contracting the virus.
• There seems to be little downside risk. At worst, you would give provide people that already choose to wear masks with better masks that they may or may not use to their full potential. A recent study suggested that N-95 masks provide much better protection than cloth and surgical masks even without a fit test (see figure 2 and note log scale), and when the masks are fitted properly they provide much stronger protection still.
• Potential benefits are huge. At best, this would play a significant role in driving down the number of cases down towards 0. If enough people have and use these masks to their full potential, the virus will no longer spread exponentially; it will decay exponentially.
  • To achieve exponential decay, it is not even necessary to have 100% compliance! The key thing is to drive the infection rate below 1, which implies that there is less than one new infection per existing infection (though the lower the infection rate is, the faster the decay). It is estimated that if 60-70% of the population is no longer available to be infected -- either because they have antibodies (i.e. herd immunity) or because they are wearing medical-grade respirators to their full potential -- then the virus would die out even if the other 30-40% of the population went about their normal lives. Right now, the infection rate is above 1, but not too far above 1 in most states. In addition to the other measures already being undertaken, N-95+ For All could be the catalyst in driving the infection rate below 1 to drive the number of cases towards 0.
  • Ironically, the more people that wear their masks effectively at a given point in time, the less time people may need to spend wearing these masks in total. If cases are driven low enough, people can start leaving their respirators at home (as is the case currently in countries that have very low case levels like New Zealand). If hot spots flare up again, authorities can ask communities to put their government-issued respirators masks back on for a period of time to again drive cases down.
  • As many economists have argued, the economic damage from coronavirus is primarily caused by the virus itself: people decide to socially distance by foregoing some economic activities to protect their own health. Government policy can further increase the degree of social distancing from the free market equilibrium. Either way, the presence of the virus itself is the root cause of economic damage. Therefore, measures that contribute towards driving cases down also have large economic benefits.
• A powerful tool against future pandemics: Highly contagious diseases are often airborne. Providing all citizens with N-95+ masks readily available to wear whenever the next pandemic emerges could help to stop it before community spread starts. In addition to providing the supply of N-95+ to meet this pandemic, the federal government should make sure that there is an extensive strategic stockpile in place for the next one, and it should work with industry to make sure that industrial capacity exists to produce large number of masks quickly when the next pandemic occurs.
• International trade could make the program pay for itself (or generate a profit and soft power): The Federal government could continue to produce N-95s beyond the level required to supply them to other Americans and export them to other countries. They could also make a profit doing this given the high demand around the world for these masks, perhaps enough to recuperate the cost of the program or even turn a nice profit. They could also just donate the masks to other countries or sell them at the (cheap) cost of production. This would certainly help American soft power.

Other Key Points

• It’s important to make sure it’s clear that this policy isn’t marketed as a panacea: It may be the case that if you can get enough people to wear masks and wear them correctly, it really may be a panacea. However, it is likely that it would take time and experience to get people to wear these masks and use them effectively (see next point). It is therefore important that N-95 For All is used in conjunction with other Public Health Measures.
• Learning, experimenting, and improving are key:
  • There have been some studies that have suggested that it can be tough to get people to wear the masks correctly and get a tight seal. Even so, as noted above, it appears that N-95s provide much better protection than cloth or surgical masks even without a fit test. Regardless, it is clear that medical grade respirators are effective when used correctly. One principal goal of this policy should be to learn how to maximize the number of people that are able to use their respirators effectively. This might come through design changes -- perhaps it is easier to consistently get a tight seal with N-99 or N-100 (these are essentially n-95s with extra material on the outside of the mask that provides a more consistent seal) and we learn we should focus on producing those. Perhaps we develop better fitting tests so that people can be consistently confidence that they are wearing the mask correctly. Along with providing N-95+ respirators to every American, we should also have randomized control trials with different equipment and different policies to see what works, and do more of what works as we go along.
  • I also think it is important not to take a static view that current performance is a deterministic predictor of future performance. I believe that we should prepare for this like we prepare for war: Covid-19 has already taken more American lives than all wars except the Civil War and World War II, and the daily rate of death exceeds any war in American history. For a wartime analogy, consider that when the British army first used tanks in the Battle of the Somme in 1916, most of them broke down and less than 20% of them made it across no man’s land. You might conclude from that result that tanks were a failure. However, despite the limited success, it was clear that the tanks had promise, and the allies kept improving both their design and tactics. By 1918, tanks played a large role in 100 Days Offensive that ultimately ended the war. They had success up and down the Western Front, and played a large role in ultimately breaching the Hindenberg line. It may be the case that the arc of success would be similar with N-95 For All.
  • Also, even if N-95 For All doesn’t work as well as expected to fight Covid-19, it may be the case that what we learn from an N-95 for all policy in this pandemic ends up being crucial information on how to implement this policy for future pandemics.
• It is critical to provide education and tools for using the respirators effectively: It is important not just to provide the respirators themselves, but to provide public service announcements, videos, interviews with experts, etc. on how to use the masks, how achieve a tight seal, and how to check for a tight seal.

Costs

• The cost would likely be a few billion dollars to set up and produce enough masks domestically: Consider that the government has now spent trillions of dollars in paycheck protection, unemployment benefits, and loans to businesses. This is important and addresses the downstream economic harm from the pandemic, but it does not address the underlying cause. N-95 For All costs just a few billion dollars and addresses the underlying cause.
  • The cost of a 3M N-95 before the pandemic on Amazon was $1.50. However, the cost of production seems to be way below that. For instance, Hollingsworth and Vose got a $1.9 million contract to produce 27.5 million N-95 masks (that’s ~$0.07 a mask). Also, as production gets ramped up, there may be additional economies of scale that are realized. Consider that in April, most Americans received a $1200 check from the Federal government to help us cover our bills in the wake of the unprecedented economic disruption. An N-95 mask in the mail is on the order of 1/20,000 the cost of that $1200 check, and it does much more to address the underlying cause.
  • The United States is good at producing a lot of stuff quickly, and frankly, this is a piece of cake compared to what we’ve done in the past. For instance, in World War 2, the United States produced over 77 pounds of artillery shells per American. The United States currently spends $2,112 per American every year on the military. N-95s are much simpler and cheaper than artillery shells, rifles, airplanes, or ICBMs, but they may be much more effective in saving American lives.

Potential Issues (and Response)

• N-95s only protect the user and not other people: A recent study suggested that N-95 masks are much better at protecting other people than surgical masks and cloth masks (figure 2c, note the log scale). It seems that this is the case because the thickly woven N-95 material is generally better at blocking particles. Still, there is some concern that N-95s with a breathing port may pose a higher risk to others than cloth or surgical masks. This breathing port exists because it allows the user to exhale air more easily so as not to build up too much CO² in the mask. However, basic design features that could easily be implemented in a nationwide standard would overcome this issue. Cloth and surgical masks block exhaled droplets, but you still inhale and exhale air out of the corners of the mask, so emitted aerosols can still be ejected out of the corners of the mask. Likewise, an N-95 with a tight seal could be built in such a way that there is a barrier that prevents air that you breathe out of the mask from going straight ahead, but instead go out of the corner of the mask like a surgical mask, or a breathing valve in the center of the mask with a barrier that then redirects the air downward.
• N-95s depreciate and lose their seal: Evidence suggests that this happens. The obvious response to this issue is to provide people with N-95+ on a regular basis to replace masks as they depreciate. This would raise the cost of the program, but due to the generally low marginal cost of producing these masks and economies of scale from nationwide production, I would expect this to be fairly modest. In addition, consistent with the learning and continuous improvement point from above, different types of equipment should be trialed, and the results monitored over time. Perhaps there are some design that depreciate more slowly. Perhaps it makes more sense to provide people with non-disposable masks, such as something like the GVS Elipse P100.
• Moral Hazard, i.e. people will take more risk because they feel protected: Moral Hazard often happens in situations when you protect people against some risk (e.g. insurance), but then they engage in riskier behavior than they normally would because they feel more protected from the downsides of risky behavior. E.g. if you give someone really good car insurance, then they’ll be more likely to go on reckless joy rides because they won’t pay the full cost of fixing a totaled car. You could imagine something similar happening here: people get their government issued N-95+ masks, they feel invincible while wearing them, and then they engage in risky behavior like hanging out at a crowded indoor bar because they feel protected by their mask (though it should be somewhat obvious that taking your mask off to drink defeats the purpose). This would end up counteracting some of the benefits from N-95+ For All. This is something that I would expect to happen to some extent, but the key thing is to limit the extent to which it is a problem. This further underscores the importance of not marketing N-95+ For All as a panacea, but as an additional public health tool in addition to other public health tools. It also further underscores the importance of education so that people wear their masks in such a way to maximize the chance that they have a tight seal, so that they are more likely to be protected even if they end up engaging in risky behaviors.
• A larger issue about the ability of the US government to successfully carry out any policy in the current political climate: You could argue that all policies in the current US political environment are set up to fail because politicians (and the politically motivated public) are more concerned with dunking on each other than making good policy.
  • One potential view of the current state of US politics: Politicians have become increasingly motivated by their reelection and the share of power that their political party controls compared to making good policy. Especially recently, politicians in the US view it as a best response to undermine and savage all policies that the other party implements when it is in power. There is now a thoroughly partisan media structure in place to help to magnify this savaging. Even if a policy is a very good policy from a cost-benefit perspective, the party not in power will invest heavily in savaging it because they view this as a best-response to maximize their chance of reelection and political control.
  • If this is true, the party not in power may try to undermine the N-95 For All and wage a propaganda campaign to discredit it. Instead of focusing on the average treatment effect, they will focus on anecdotal cases where people get the disease while wearing masks (which will inevitably happen due to imperfect wearing/fitting). These anecdotal cases will be used to undermine people’s trust and to discredit the whole program.
  • Honestly, I think this is the biggest risk. I hope it’s not true, but if it is, it probably suggests the US has bigger problems.
  • Also, there is no clear large constituency that benefits from devastating pandemics (except in the movie V for Vendetta) and the subsequent damage to many sectors of the economy. It is largely in everyone’s interest to make sure that a pandemic doesn’t happen, so hopefully this reduces the chance that some special interest derails the policy for reasons of self-interest.
• Politicians won’t want to pay for it
  • See above for discussions of cost-effectiveness. Also, consider that this year, the United States ran the biggest budget deficit in the history of our country at over $3 trillion, largely due to the effects of COVID-19. As a percentage of GDP, it is on par with the deficits ran during World War II.
• What about KN-95s that seem to be readily available? KN-95 is the Chinese standard that is similar to the N-95 NIOSH standard in the United States. Masks that are branded as KN-95 are widely available at reasonable prices on, for instance, Amazon.com. The FDA keeps a list of KN-95 masks that are not NIOSH approved to the N-95 standard, but are authorized for emergency use during the Covid-19 pandemic due to the shortage of N-95s. However, I spent a few hours going through the KN-95 models available from Amazon US and Amazon France, and none of the models that I were being sold appeared to be the models approved by the FDA. I have tried a few different brands of KN-95s (e.g. I bought this one, and I tried other KN-95 branded masks that bought by friends). It was clear to me that none of them provided nearly the tight seal that N-95+ masks provide, as I could feel leakage outside the sides of the mask (though some brands seemed to provide a better seal than others). Also, the KN-95 branded masks appeared to be made out of thinner paper-like material instead of the thicker weaving of the N-95 that allows it to have excellent particle filtration. My general takeaway from this little experiment is that non-NIOSH-approved masks branded as KN-95 appear to perform much worse than the NIOSH-approved N-95s. These KN-95s claim to meet the Chinese KN-95 standard (performance standard GB 2626-2006), but it is not clear to me how this standard is actually being enforced in the United States. The FDA has sent out a warning about the litany of counterfeit respirators on the market that falsely claim they are NIOSH N-95 approved, and how to spot them. They don’t even attempt to write something about KN95, since this is not a US standard. Personally, I don’t trust that these KN95 branded masks are actually performing up to the KN95 standard unless I can get verification from a US or Chinese agency that they have indeed been tested and passed the test (consider that many manufacturers who have attempted to make N-95s in the United States were not able to pass the NIOSH test). I personally may prefer a KN95-branded mask to a surgical mask if I feel that it is providing a tight seal, but I would certainly feel much more comfortable wearing a NIOSH approved N-95+ mask.

Conclusion

For the reasons described above, I would start implementing N-95 For All immediately if it were up with me. In short, I believe the potential benefits are very large, the costs are relatively small, and the risks are limited. 

The daily rate of death from the coronavirus already exceeds every war that America has ever fought in, and the virus has caused and will continue to cause trillions of dollars in economic damage. I believe we should mobilize and address this crisis with the same seriousness that we mobilized and addressed wars in the past. Taken from this perspective, a few billion dollar investment that could play a big role in saving trillions of dollars in economic damage and hundreds of thousands of lives is in my view something worth doing. 

Looking forward to everyone’s thoughts! I really would like to see this happen, so if you read this and like the idea and want to help to make it happen, I’d love to help!