It would be nice if we could at least provide everybody with simple surgical masks. It would surely help flatten the curve a lot if we could make masks in public mandatory. As far as I understand it those are basically just paper and a nose clip. They should be very simple to mass manufacture.
The main problem I see regarding masks is, besides price, distribution. Now that Chinese manufacturers are running again, they are producing 24/7. Sure prices are way higher than before. But the masks are there.
Problem is, Chinese suppliers sell FOB, meaning export cleared delivered to a (air)port terminal in China. Customers in Germany want to buy DDP (import cleared and delivered a specified location in Germany). There you have a structural problem. One that would be easy to overcome, if it wasn't product liability. The importer of record takes product liability in case the manufacturer is outside the EU. Good luck getting that insured (I tried). Ultimately, it will get sorted out.
The easiest way to get supplies going would be if the government did these two things:
- grant interest free loans for these products to allow importers to pay suppliers upfront (that's how this business works) for government orders
- take the product liability risk for products wutyh the proper (paper) certification
That would allow a lot of people to get this stuff. Rigjtt now it is a pain the ass.
"The main problem I see regarding masks is, besides price, distribution."
There's a crap ton of unused aircraft right now. You would just need heads of state to direct the airlines to fulfill that need, simplify clearance, customs, etc. Treat it like wartime.
Both are kind of true. The air freight / train / sea freight part would ve easy enough to solve. Getting the masks distributed locally is already a little bit trickier,but I am working on something right now. Basically a regional hub, supplied by air train or sea, and a couple of Kanban loops to local distribution centers (hospitals, practices, whatever).
Maybe I can convince someone to give it a try. If not, I'll just go back building my company as planned. Would still suck so, to have look at the mess from the sidelines.
That is completely fair. I have little insight into the local issues. The country level issues are fairly easy to bypass with war level rules. From real level experience with Turkey, Germany, Belgium, Denmark, etc.
The importer is considered to be the manufacturer in case something bad happens, caused by the product. Meaning, worst case,you import a mask. It fails. Patients in the practice you supplied the mask to get infected and some die. Now we are talking tens of millions.
I asked the Allianz and Munich Re (the insurers insurer). Both declined to insure that at the moment.
Which sucks. Because the gap between FOB and DDP would otherwise just be logistics. Ignoring prices, that is rather easy to solve. I try to get hold of someone at the armed forces department charged with that. Hopefully it leads somewhere.
EDIT: Product liability is th problem. Transport insurance is easy to obtain and no problem.
Imagine to be a e-commerce launching itself into masks now. Without insurance, proper due Diligence of suppliers and potentially no way to track batch numbers. And then something like that happens. You are in for a lot of pain.
Apparently you can get coverage, or rather a waiver, from the government if you are a non-profit.
As a side note, the government is now seriously launching itself into procurement. For example German states are starting procurement themselves.
My concern is the rush to acquire PPE, rules be damned, a decent amount of counterfeit masks will make it into circulation, and will provide a false sense of security.
We're not talking about FFP2/3 masks here, but simple masks that mostly prevent droplets produced by the wearer from spreading as far and slightly reduce the probability of inhaling the larger ones other people produce. Basically anything that covers mouth and nose.
N95 masks, as far as I know, are fairly difficult to manufacture, so I think it's unlikely that we can scale up production to hundreds of millions per day. I'd be happy to be proven wrong though :)
Nothing money or waivers cannot solve, as long as masks are being made and China allows export. I doubt Germany, USA, Italy etc care about chartering dozens of planes just for that.
I'm not so sure. We have an ongoing toilet paper crisis that is in it's third week now and the government is unable or unwilling to do anything about it, despite ensuring everyone that there's plenty of toilet paper somewhere in some storage of some company. If a somewhat trivial problem like coordinating a few trucks is beyond their ability, I have no hope for coordinating planes and import/export.
You might say "but that's toilet paper, who cares", but empty shelves in super markets in Germany are a great way to make people remember the past and go into panic mode.
What people do right now is buy masks individually from Chinese vendors on Amazon, and they are getting shipped. If you want them quickly, you can pay for airmail. China can deliver, but for some reason, Germany doesn't take them.
Where do you have a toilet paper crisis?
In north Germany at least shelves are refilled all the time. I’m back from groceries, Edeka, Lidl, and Rewe had all their shelves full.
Friends from Berlin tell me they still have empty shelves, so do the super markets in (western) Hamburg. They get refilled every few days early in the morning and are empty an hour or two later, only to sit empty for another day or two.
It's gotten so bad where I live that Aldi has apparently decided to just give up and use the space for potting soil.
The pasta shelves are re-stocked though, as is bread. Berlin isn't quite there yet.
Cause and effect, it will settle down in week or two and those who overstocked won't be buying more and those who are responsible and now short due to the hoarders of panic are slowly getting back to normal.
But certainly an insight into the culture and humanity of some people. Alas we have a society that seems to always see good responsible people suffer at the hands of the irresponsible.
I believe that the important lesson is that when government steps back, people will resort to ingrained behaviors, and "stock up when a crisis begins" is one of those. The wrong answer to that is to limit the amount anyone can buy, because you're just increasing the crisis-feel. The right answer is to make sure that people calm down, and the easiest way to do that is to demonstrate that the supply of goods is not affected. You do that by adding a fleet of trucks to transport goods to super markets and add a temporary night shift to re-stock shelves. If people see that there is no shortage, they will calm down.
The opposite is happening, you have (local, temporary) shortages and some politician who hasn't bought their own groceries in the last decade says "I assure you, there are no shortages", while everybody sees the empty shelves on a daily basis.
I'm in Hamburg, only spaghetti and hand sanitizer are still sometime missing in my neighborhood. During the past 2 weeks you could see some empty shelves depending on the time of the day, but it seemed to be temporary, due to the rapid increase in demand.
But now that people filled their shelves, I guess that store supplies are back to normal.
In America,I’m in Silicon Valley so people have money and space in their relatively large houses to store lots of stuff. Stores did not limit purchases early so there was panic buying early even here. Popular stores like Trader Joe’s and Costco have lines out the door for several hundred feet (they limit the number of people inside and everyone outside is six feet apart) but less popular grocery stores/green grocers do not based on my limited excursions on bike. Now purchases are limited but still some items run out because it takes more time for someone to stock items on shelves versus people just pulling it off.
Makes sense. I didn't consider that people in the US have way more place at home to store food. And I understand that people don't have grocery stores that close to their house/apartment, so they fill the car as much as they can.
Same in UK, least form my experience - was a blip and all those who overstocked now saturated and with that, not an issue - just the run hit supply chain demand and gave the impression of a shortage when it was only a short-term shortage due to panic buyers over-stocking.
But people worried about non-fire safe cladding seemed equally happy to fill their homes with flammable paper - the hypocrisy of madness plays out in many ways.
People aren't pooping more than usual and toilet paper production is not lower than usual. There is just an irrational run on toilet paper. There is no crisis.
There may be enough toilet paper somewhere but it's not where people want it: on the shelves.
People aren't rational actors, and by saying "they don't really need toilet paper", you're not solving the issue that is people seeing empty shelves for toilet paper, bread and soap and thinking that the system is failing.
You don't want the public to become nervous, ever. Nervous people make terrible decisions. And for a government to look uncaring/impotent is the way to make the population nervous.
It doesn't really make sense to increase toilet paper production though. There's no long-term increased demand, so the problem will probably sort itself out in a couple of weeks once everybody who has been panic buying already has a stockpile.
The trust damage will be done by then. It's like a stock market crash because of some irrational behavior. Sure, "it'll sort itself out in a few months", but you'll have companies going under, mass layoffs etc by then.
Also, I don't know whether they'd actually need to increase production. According to super market chains, they have more than enough but it's in their storage centers and they have issues/aren't prioritizing getting it into the stores.
Exactly, it's akin to a run on a bank - if all account holders of any bank withdraw all their money at once - NO bank would cope with that. Though a run on toilet paper just hit the supply chain, so you get these bumps. Come mid to end of summer, there will be a surplus of toilet paper due to the run of panic buyers fueling panic buyers all over-stocked.
My personal theory is, that the German entity tasked with procurement has no idea how international commerce works.
I saw a intriguing change in conversations I had over the last couple of days. First it was, like, no need, we got this. Just yesterday I found a call for an offer from the Armed Forces procurement department in my Inbox, while you now find direct contact details for these kind of things online. Not sure what happened, but there sure is a change in how authorities are approaching this.
Making oxygen is easy. I’m sure half the people on this site can fill a soda bottle with pure oxygen using a machine hacked together from just things found in an average kitchen.
Industrial scale production, transport, making sure it doesn’t set everything on fire, and supplying a medically appropriate quality without risking hyperoxia? That’s hard.
At least there is industrial oxygen production that could be repurposed.
Also oxygen enrichers could be made and distributed, they could also help some people. I know of a person who made one themselves in a week.
Both should be a lot easier than ventilators (which of course also should be pursued).
If you read the reports from Italy, they first ran out of ventilators, then CPAP machines and finally even oxygen.
But for some reason the talk is very concentrated on ventilators for now.
Also other equipment saves lives. Pulse oximeters so those needing help breathing can be identified. Protective equipment. A lot of things that save lives and are a thousand times easier to make than ventilators.
If a sick person wears a masks and keeps coughing into it. Does that person go around during the day with a mask filled with phlegm and spit. sounds disgusting and stupid.
I love the complete lack of bullshit in this article. Everything I read about this crisis seems to be full of hedging, massaging, unquestioned vagaries and coddling of sources. Here, it just straight to the point with a knowledgeable source.
“ It shows that common sense is more important than we all thought. This situation is so new and complicated that the problems can only be solved by people who carefully weigh their decisions. Artificial intelligence, which everyone has been talking so much about recently, isn't much help at the moment.”
"I spoke with Daimler over the weekend. They would also like to help. But it’s unfortunately not so simple..."
It would be interesting to hear more precisely why. We've heard more than a few well-respected industrialists essentially saying "Scaling up ventilator production ? How hard could it be?"
Edit. Of course I am not suggesting that car assembly lines are suitable to build ventilator parts. That's clearly not what Daimler suggested either. The question is 'what are the actual bottlenecks to ventilator production?', and nobody seems to really be willing or able to say.
Precisely what I was looking for in the article as well. Outside of logistic planning snafus, parts situation, and post production operator issues, it was silent as to why we can not scale up cranking out these machines.
Next line is "We can’t build cars either." It would be interesting to hear industrialists explain how car assembly lines make them able to produce any particular hi-tech equipment.
Or are you saying "why not just equip the buildings next door and quadruple everything"?
I am fascinated by the notion of factories just changing what they make. In my imagination a factory is a highly specialized machine for making one thing alone...
I guess that factories have workers, space, skills, and networks of suppliers. And maybe a few machines that can produce parts by design (injection molds, 3d printers). That's it: they're not going to set up automated production lines for ventilators instead of cars or washing machines.
At least car manufacturers consist of more than one production line. They make smaller series and prototypes too. And they have lines (and suppliers) that supply parts to other lines.
Remember they also have to build the ECUs, dashboard and AC plumbing. If you squint that might be about what you need for a ventilator.
Exactly. Also looking at German car manufacturers, their production lines are almost completely automated and rely on robots. Reprogramming them, if they would fit the job in the first place, would require weeks of testing and calibration alone.
Of course, but that's surely not what Daimler's CEO was suggesting. What he might have been offering may be assembly workers, or factory space, or privileged contacts with Daimler's supplier base, or something else. My point was that it would be interesting for the general public to understand the actual issues. Right now we're all left guessing a bit.
We also regularly hear (otherwise very sensible) software engineers saying stuff like "Clone twitter? How hard could it be?". It's not very hard to see how manufacturing life-saving medical equipment in a rush without proper testing could go catastrophically wrong. Even if you get known-good schematics from another company, retooling (say) a car production line to make something else needs a lot of planning to make sure all the supply lines and trained workers are in place.
That analogy is only partially accurate. For instance, injection molding machines are pretty flexible these days, parts are almost exclusively drawn in CAD and molds are commonly cut with EDM. Every injection molding house has to have the ability to maintain those molds too. So if you wanted auto manufacturers (or more likely one of their suppliers) to produce a plastic part, it could almost be hands off. Send them the CAD files and specifications, produce a short run with heavy QA and once they're started, you can almost have as many parts as you need.
Modern cars have such a huge variety of parts with varying materials and characteristics that I'd guess almost all the ventilator parts could be out-sourced. I don't know enough to say what the specialized skills or parts could be but let the ventilator manufacturers build those, do final assembly and QA and you'd at least increase production to some degree. My guess is that the quoted manufacturer has ramped up their existing parts manufacture beyond their ability to do final assembly were Daimler to provide more parts.
You are assuming (edit: actually you aren't, see below) that the car manufacturers are producing these parts themselves. It is a lot more complicated for Daimler to produce plastic parts for ventilators (for example) if small plastic parts in Daimler cars have been produced in China for the last 25 years and delivered just-in-time to the assembly line in Stuttgart.
I don't think I was assuming that ... but your point is valid. Certain car parts have indeed been the same for a long period of time. You'd certainly want to avoid the suppliers that are resistant to change or that have historically taken many iterations to get to the point where they can produce 10s and 100s of millions consistently. There are however manufacturers that specialize in smaller runs and more precision (two within 20 minutes of where I type this which is NOT considered a traditional manufacturing area). I'd be willing to bet those managing the supply chain for the car companies know exactly which type of company is which (where do their engineering departments have short-run prototypes made?)
Europe is full of plastic moulding factories, big and small. Capability is there. Not everything is made in China. My friend has a small plastic moulding factory back home with 15 machines and his father is a tool maker. They themselves could produce 50,000 plastic parts a day if needed.
The issue with cloning Twitter is primarily the network effect, not the technology. That's different in ventilators, unless you're looking at long term investments, e.g. when this is over and you've invested heavily into scaling production, you might not be in a good spot.
I agree, and I don't understand the reasoning not to. This almost-complete-shut-down has a gigantic price tag attached, I'd guess that anything that will make it pass easier or quicker will be an easy decision.
Any government could clone Twitter if they must. It's not rocket science and Twitter is actually quite open about their architecture and technologies choice.
Plastics are very easy if you have in house tooling capability. In 2002 I was working in a plastic moulding part of the factory that produces commutators. We went from 0 to fully developed product in 24 hours and were ready to mass produce. Hundred parts on three machines per minute. And this was 2002. I imagine today it's even easier. So, indeed this is not a hard problem because it was solved decades ago.
Dyson in UK is ready to produce their own version of ventilators already.
Machines that produce raw materials for cars, like frames, can't simply be repurposed to produce ventilator frames (to my knowledge) as the tools that are attached to the machines (e.g. the stencils) are specialized, intricate parts themselves, so designing one for a new task can take years.
The assembly lines / workstations also look very different, in general. You can see in the picture how the ventilators are assembled, it's not a factory line but more a workshop.
Then you have all the supply chain issues that the article discussed. Companies like Dräger have been optimizing their supply chains and processes for literally over 100 years (the company was founded in 1889), so to think another company could just replicate all of that within a few months or weeks is unrealistic. Even with Dräger's help this would be challenging, as building up a new factory location usually takes several years as well.
I think we have a strong bias to think that all problems can be solved with technology or engineering. Some need to be solved on a social and political level though, at least initially as technological developments take time. For Covid-19 we need to change our behavior now to allow technology to catch up.
It's a good question. Probably would also need the automotive parts suppliers to change to ventilator parts. And their sub-suppliers etc.
Controlling quality would take time.
It would be hard to make reliable properly working machines fast. Faulty ones would kill patients.
(Not an expert on ventilators, but I have been working on software side of medical devises.)
Producing semi-mechanical Bag-valve-masks (BVM) would be relatively easy, but you need professional to sit there and monitor the patient. That's not ICU ventilator. BVM is very crude tool for short term use. If the rules and legislation are relaxed so that hospitals could use non-certified crude devises that help. You would almost certainly see ventilator-induced lung injuries.
If the system is automated life support, it generally has to maintain homeostasis of the patient and _dynamically_ adjust. If you are just tiny amount off from the optimal and there is drift in the dynamical adjustment it accumulates over time and you can kill the patient or cause immense pain or discomfort.
Oxygen is poison if you get it too much and if you get it too little, you die. Pushing air into the lungs can damage them and the oxygen mix should adjust. If lungs are filling with fluids, you might need more oxygen and less volume. The system must be connected to instrumentation that monitors the patient's state continuously.
There is the question of medical staff using the thing correctly. Medical UI/UX is safety critical in the same level as it is in aviation. If just 5% of users use it wrong it, can negate all benefits from using the device.
Generally you need deep knowledge transfer to scale up production of critical components or testing and calibration, just emailing the specs is not quick enough. You need to test it with real environment and refine the device to see how it works in practice. I'm sure that ventilator manufacturers have already outsourced every component that is easy to manufactured and produce to others. There are some bottlenecks that involve testing, special machines, materials and calibration that is not easy to scale quickly.
(edit: the time-frame of ICU overflow seems to be between May-Sep in the most countries in most models If you ramp up deliveries 3 months from now, you could catch the tail end of the need)
Thanks, I'm interested too why people think car manufacturers are the best place to make ventilators. What are the difficult/bottleneck parts to build?
I think that choice wasn't based on any particular logic, but rather the fact that car manufacturing is one of the few manufacturing industries that haven't been completely outsourced by most countries, and is somewhat compatible with the demands of building ventilators.
A friend of mine is coordinating Airbus effort to build ventilators. I know Airbus manufacturing base, and theoretically possible. Getting a design together that works, and can get certified for medical use, is the difficult part as far as I understood. But they are in contact with various universities and so on.
One big issue can be IP. Dräger put a lot of money behind that. Just opensourcing the design and specs would kill the company. But why not negotiate liscense agreements or sub-contracting production out. Could be a solution. Just shows how everybody is still trying to adopt to the new reality.
I am also concerned that Draeger refusing to share crucial IP might be an unspoken bottleneck. Of course, if that's the case, the right solution is for the government to acquire said IP for a large amount of money, but it may fail to happen for purely bureaucratic reasons.
I would just liscense it out for a certain amount of time. Fees can be paid for by the government. But I understand that Dräger might be concerned. No idea if that's the case so.
I read somewhere that it could be dangerous to wear one when you're infected, because then the virii have a much bigger chance to be inhaled again and get deeper into the lung.
There are studies out there on the use of cloth masks vs medical ones [0].
Tho it should be noted that both, cloth and surgical masks, are mostly worn to protect others from accidental discharge by the wearer.
So if you the wearer wants to protect themselves, then a respirator is actually needed. But respirators should be prioritized for at risk-groups who wouldn't survive infection or work with infected people.
The non-respirator masks are mostly to reign in the spread by people who could be infected without symptoms yet or as the "we got nothing else" option.
Except they're very hard to breath through. I also wonder what kind of dish towels, exactly, since I have different towels with very different permeability.
"Before we invest too much thought into this, we should focus on getting devices that are sitting around in a basement somewhere back into working order."
I'm mechanically and electrically handy but don't have a basement full of ventilators. I'm going to send an email to my local hospital ... we'll see how that goes. Anyone have know where else to find ventilators that need to be serviced?
The primary difficulties are establishing medical consensus on what kind of pressure therapy is best (continuous vs bi-level) because that affects the availability of machines a lot and there's some disagreement. Secondary is how to stop patients on CPAP machines spraying virus into the air through the masks, however, at least one CPAP machine manufacturer thinks that concern is actually overblown and points to a study showing CPAP masks don't aerosolise to the extent current medical consensus seems to think.
Something very clear is that doctors are still figuring out treatment for this and there's some disagreement over what the right way to do things is. Disturbingly it may be that current medical consensus makes things worse for COVID-19 patients rather than better i.e. bi-level pressure therapy hurts the lungs in that state rather than helps (perhaps contributing to a high death rate?).
I hear GM and now Daimler are all offering to help. How easy are these to manufacture? Also setting up the manufacturing plant takes time doesn’t it? All these companies make it seem like it’s trivial to create the infrastructure needed to manufacture them in bulk. Or does auto manufacturers somehow have the equipment to do this already? Is that the case?
Cars are many orders of magnitude more complex than ventilators so it's not unimaginable. A ventilator is basically a motor/small turbine connected to a few sensors and air filters, all linked together with some fairly sophisticated software. The software can obviously be 'manufactured' at infinite speed. That leaves an assembly of pipes, valves and flow sensors - but only a few. Especially if you customise the machine to only what COVID-19 patients need and don't go general purpose, it can be done.
"Dräger: In Europe, the number of intensive-care beds per capita is very unequally distributed. In Italy, it is three times lower than here. In England, five times lower. The challenge in England will be greater than in Spain. And the situation in the U.S. is very alarming. The reporting system there is also underdeveloped."
I’ve wondered about this for a little while. Why does Germany have five times as many ICU beds than England? Until now, I’ve never heard a suggestion that England had fewer ICU beds than it needed generally, and assuming England and Germany use beds at the same general capacity, why on earth is Germany running five times more beds that it generally needs? (please don’t answer “for a case like this” unless you have some hard evidence)
As I understood it, a lot of countries have dismantled part of their hospital and healthcare infrastructure in the past 20 years (mostly to save money). Some countries have gone further than others in that pursuit. In Germany some of those measures have been decided, but not implemented yet.
Not saying a case like this, but don't forget that West and East Germany were supposed by the strategists to be main battlefield in eventual non nuclear WWIII ...
that's somewhat disingenuous, taking away agency and ascribing it to other nations - some of which haven't done so great in their own coronavirus efforts. so that doesn't really make sense to me, at least not in the 21st century.
in my experience, Germany is quite conservative (lagging behind in smoking bans, preferring cash over cards until the coronavirus hit), but wants to do the right thing (look at e.g. solar power subventions). them being a federal republic means they have similar jurisdictional issues as the US, but less hamstrung by a crippling fear and distrust in the federal government. those traits, if i'm accurate, would also explain it.
(what is still there as a disparity between some western states and eastern states.)
It is only disingenuous if you take it out of context from the parent I was replying too.
Which said infrastructure has no legacy from that era and completely overlook the cold-war build up and associated facilities and infrastructure of that era born out of that period. Equally let us not forget that Germany was upto not long ago - curtailed in what it could invest in military and not having that burden saw a shift into area's they could and medical and industry did well. More so when in many parts they had a clean slate to build up from.
I'm sure many aspect you mentioned are true - , however the drive for solar was born out of a distrust in nuclear and saw a rise in coal plants - which still has an effect today upon the climate of Europe as many (near on all) are located upon the borders, so that issue shifted and needed to be addressed and solar/wind was the right logical direction for them. But then - NO country is perfect or doing it perfect.
But the Germans are trying and done wondrous progress in many area's, let us not forget when they reunified the impact upon their GDP was negligible - that in itself was impressive and whilst in some parts of Germany that legacy still has more of an impact socially, it's progressed a long way and probably more than other countries would of had they been in a comparable situation.
>(what is still there as a disparity between some western states and eastern states.)
Consider that in the last few weeks the NHS doubled its ICU capacity. The term "ICU bed" conjures up images of something surrounded by über-complex equipment but it can mean other things, which is why it seems able to flex so fast.
As far as I can tell, so far in this pandemic, there haven't been any stats that can be totally trusted or compared between nations - on anything at all.
> As far as I can tell, so far in this pandemic, there haven't been any stats that can be totally trusted or compared between nations - on anything at all.
this is correct in general.
i don't think we'll have a clearer picture until at least autumn by which time some basic data has been collected and analyzed.
then the multi-year governmental and private inquiries will surely follow, shedding even more light on the whole situation.
i expect to keep hearing about this disease for years and years from now. but this too shall pass at some point.
That doesn't surprise me culturally. I lived in Germany for a couple of years, and the deference to "rules that matter" was completely different than my US experience. Even for trivial stuff like waiting in line/queues. The Germans were much more literal in following the rules, versus my US and UK peers.
Which funnily contradicts my experience as a German in the US (interesting how cultural perception differs). I've been told in very harsh words to go in line in the US several times, once in a line for the IKEA ferry to Manhattan where I was threatened to be left behind if I do not go to the back of the line. Once in the Metropolitan museum in NYC when I skipped the ropes of an empty queue and was told to go back and follow the route through the zigzag ropes although noone was there.
Another anecdote, whenever I wanted something "unusual" I was denied, and the person "in charge" needed to ask a supervisor. E.g. in an (upscale) hotel I wanted to see a different room for my next stay, took some time to ask different supervisors but in the end it was "impossible". In Germany the person at the reception desk would decide if this is possible or not and most like show me a room.
(Yes all anecdotal and colored by my cultural perception).
Your frustration with US rules, to me, only emphasizes my point. You want the rules to work. Versus the US born/bred idea that they never will. Flippant, I know, but that's my observation.
It's also completly possibile that you're an outlier German that is frustrated with the current rules. For sure, I've seen that in spades. it isn't the mainstream though.
Different cultures play loose with different rules. I believe that for every two countries, you can find one rule that exist in both but are routinely ignored in one but religiously followed in the other and another where it is exactly reversed.
This is something I love about living in germany, actually. In the UK (where I was brought up) you're very used to the kind of absurd situations that develop from common sense not being applied to rules. If you talk to somebody in a position of authority, you absolutely expect them to pick the least reasonable, least constructive application of any rule they have at their disposal to ruin your day.
I don't know why this is so different in Germany. I've more often observed the inverse - where people (mostly well-dressed middle-aged men, for whatever reason) are extremely rude and condescending towards secretaries, ticket collectors, etc.
I don't think that's a contradiction: Germans police themselves so there is not as much of a need to police each other. And perhaps we subconsciously assume that someone who permitted themselves[1] to violate a rule did so for a good reason.
[1] I don't think that's idiomatic English, which illustrates my point.
Basically the principles of JustInTime inventory management system applied to ICU. England optimized bed usage to be around 95%, to reduce the cost associated with empty beds.
80% versus 95% occupancy while having 5 times more beds can only be explained by Germany using ICU beds when they don't really need it (ie: as regular beds).
You can use that mentality on things that are not safety critical.
How could anyone argue that once in a while there won't be enough beds to save everyone's life?
The closest things I can think of non healthcare is that airbags are designed for 5, 50, and somewhat for 95%ile individuals. But I think it's actually impossible to develop for everyone due to mechanical restrictions.
Note that the UK spends a lot less (per capita) on healthcare than Germany: (£2,989 vs £4,432 in 2017), and that funding for healthcare has generally be considered to be insufficient over at least the last 10 years in the UK, leading to cuts in service. This may account for at least some of the difference.
Insufficient by what measure? You're comparing against - it appears - the second highest spender in the world.
There have been no cuts in NHS service. Sometimes I think I need to assign this to a keyboard macro because it's such a frequently repeated myth. The NHS has more funding now than it's ever had, it has been explicitly protected from budget reductions when every other government department has seen massive real cuts, and just last year has been given enormous spending boosts. NHS "cuts" are a bit like the gender pay gap - they exist only when statistics are abused to meet political and ideological agendas.
Or, you could equally ask why Germany and the USA seem to spend so much on healthcare. After all the UK spends about average for the OECD. And the USA spends the most of all by far so it should barely notice COVID-19 compared to other countries? I guess we'll see.
I can't find stats to back this up either way; funding seems to have grown in real terms over time, but I can't see real funding per capita which is probably the more relevant factor.
It has grown in real terms, but not as fast as either demand or costs. Healthcare inflation is very high, and greatly outpaces the CPI index that we use for 'real-terms' comparisons. Basically, the same funding in 'real-terms' doesn't buy you the same level of care as last year in any country.
Plus Britain is getting somewhat older, and somewhat sicker (partly because of medical advances meaning that previously-fatal conditions are now chronic and need ongoing treatment). And we can treat more now, so there is more demand.
Bluntly, the proportion of GDP which needs to be allocated to healthcare to maintain a good quality service is rising unsustainably in all countries. The NHS is beating CPI inflation (and in doing so doing way better than other parts of government: local government has seen >25% real terms cuts, which has trashed the social care system amongst other things) but not nearly enough to keep up.
NHS spending has not dropped, but it has not grown at the appropriate rate. There are various discussions that we could have about nursing numbers and junior doctor hours, but instead I'd like to provide one hard data point:
Addenbrookes Hospital in Cambridge (technically Addenbrookes Hospital Trust, comprised of several hospitals on one site) is the largest hospital in the UK.
For the tax year 2019/2020, the available budget for capital expenditure (building, large equipment like MRIs etc.) was £0. (accurate prior to Covid-19)
Occasionally as a result of political manoeuvering (General Election campaigning) pots of money for very narrow purposes with a limited time window on them appeared, but in general things like ward refurbishments have been funded by charitable donations. Most worthwhile capital investments take more than a year, so a predictable capital budget is necessary to implement programs. Having no money for CapEx is not how you maintain a health service long term.
NHS spending has not dropped, but it has not grown at the appropriate rate
Yes, this is how such threads always go. It's a simple three step process:
1. Someone claims the NHS funding has been cut
2. I point out that's a lie, no such cuts have ever happened and in fact the budget has always gone up
3. Somebody else replies with: but it should have grown even faster.
The point I'm making is not about the correct level of healthcare spending, which is arbitrary and values-based as healthcare systems will consume however much money is given to them. Rather the persistent level of outright lying that accompanies any discussion of the NHS in Britain. It's absurd and quite obviously linked to a belief that misleading people is fine if it's for a 'good cause'.
But this behaviour has to stop. It isn't OK to lie even if the outcome might appear to be desirable (more political pressure for higher healthcare spending). People learn that they're being manipulated and support for the desired cause can collapse.
Having no money for CapEx is not how you maintain a health service long term.
I'll repeat this until I'm blue in the face. The NHS has more money now than it's ever had. Not only does the NHS have money for capex but it's been repeatedly allocated money specifically and only for capex, because NHS managers have a long history of preferring to divert spending on upgrades to other forms of spending - frequently salary increases.
It's bad management. The government attempts to combat this lack of forward thinking by earmarking of money specifically for upgrades (what you criticise here as "pots of money for very narrow purposes"). One of the first things Boris Johnson did is allocate a billion pounds to the NHS only for capex. Unfortunately it doesn't work:
"Capital spending was particularly tight with only £150.3m spent from £354.1m of allocated funding ... funding to help NHS trusts to become more digitally advanced accounted for most of this capital underspend. The DH planned to spend £116.2m of capital on these trusts in 2016-17 – instead it spent nothing."
The idea the NHS doesn't have money for capex is just another piece of misdirection. It refuses to spend on upgrades even when central government is trying to force its hand, because it knows that the result is No 10 will blink and give up, which is what happens:
"The money was not allocated elsewhere but “as with all Department underspends, was available to offset pressures in other parts of the system”, she said."
Inflation and population growth will force spending increases no matter what, and if the increases don’t track with those two variables, then service will obviously have to decline.
Doctor and nursing salaries are pretty low in the UK, if management is diverting capital expense money to salary increases, they are doing a poor job of it.
"Looking at the wider UK, the amount spent on health has been increasing over the long-term. That’s true whether it’s expressed in cash, cash adjusted for inflation, per person, or as a proportion of the size of the economy."
Population growth puts pressure on public services. The British people have been asking for reduction in population growth for a long time, partly out of concern for the state of the NHS, yet of course have been repeatedly denied by the EU and their own political classes. 4 years after voting to leave the EU largely to get a grip on the ever-increasing cost of public services they still haven't been allowed that.
Doctor and nursing salaries are pretty low in the UK
They're extremely high. The average pay for specialist consultants in the NHS is £120,000 or approximately 6x the average salary. This is dramatically higher than in say, Germany, where specialists earn 80,000 Euro on average. That's £71,600 or a bit less than 60%.
"Billions of pounds spent on improving NHS hospitals has mostly gone on staff salaries while productivity has fallen over the last decade, a key National Audit Office (NAO) report has found."
"Between 2000 and 2009 the NHS workforce grew from 1.1 to 1.4 million - almost a 30 per cent rise. That included an extra 12,500 consultants, whose average pay rose from £71,900 to £120,900 over the same period - a 68 per cent increase. Doctors' pay rose by 48 per cent, nurses' and midwives' by 36 per cent and managers' by 34 per cent"
That's some selective (mis-)quoting. First the fullfact reference you give directly stated in 2013 there was a predicted funding gap of 30 billion pound by 2020. The conservative government gave them 10 and said you need to find 20 billion in cuts. That is an effective cut.
Health costs have been rising everywhere in the world and this has little to do with population growth (that's actually good because young people pay taxes), but more with rising life expectancies and the resulting average age. Every country has been experiencing the same trend (the US being an exception likely because of privatized healthcare):
https://en.wikipedia.org/wiki/Healthcare_in_Germany
and those country have pretty different population developments.
That looks awfully similar to what a Facharzt earns (actually with the current rates the German earns significantly more more):
70.000 – 95.000 Euro
https://www.praktischarzt.de/arzt/gehalt-arzt/
there was a predicted funding gap of 30 billion pound by 2020 ... That is an effective cut.
Please, just stop this. Departments asking for more money than they know they'll be allowed and then getting less is a universal truth of organisations, both governmental and corporate. It's called negotiation. Being given more money than you had before is not, and never will be, a "cut" in the English language. That word has a precise meaning and it simply doesn't apply here.
Likewise the NHS wasn't asked to find 20 billion in "cuts". That doesn't even make sense. You can't increase your own budget by reducing it. They were told that if they really needed that much they would be expected to find it through increased efficiency. Keeping a check on NHS waste is a key function of elected governments which voters expect them to fulfil, simply writing them blank cheques has been tried before and didn't work (as in costs went up, but healthcare outcomes didn't or didn't by anywhere near as much).
Health costs have been rising everywhere ... more with rising life expectancies and the resulting average age
And the NHS budget has been rising too.
Also you are comparing a Facharzt salary to a consultant, that's not a fair comparison
Alright, fair enough, then focus on the original statement - doctors and nurses get anywhere between good and extraordinarily good pay relative to the average salary in the UK. There are doctors in the UK earning significantly more than the Prime Minister, and their pay went up significantly during the last Labour government (not sure about this one, didn't look, but I assume pay inflation has been only slightly lower).
The point is that significant amounts of the money given to the NHS ended up being spent on increased OpEx like salary increases, rather than CapEx like capacity increases or efficiency improvements. Obviously the NHS must raise salaries at least in line with inflation, and really more in line with global healthcare inflation to avoid brain drains. But the idea its hospitals are run down because evil central government keeps cutting its budget is just far wrong.
Maybe that they count them as beds and have more that can cater for ICU than others.
However, let's not forget historical factors and was case of many countries having armies in Germany for legacy war reasons and that may well of seen the mentalities to have a higher number of such beds than most places.
I am not an expert here but it seems dangerous to assume as you do that the baseline of “correct number of ventilators” is the UK number. They could be...
-Under provisioning for surges (not even Covid, even just a sudden emergency of another sort, a bad flu season, big accident, terror event, whatever)
-Going longer between maintenance intervals than is recommended
-Delaying ICU admission longer than is strictly recommended
-Relocating ICU equipment as needed more than other countries feel comfortable doing
-Using more reliable ICU equipment (does the German figure include any older and potentially less reliable gear in the former communist east?)
-Have less need among population for ICU
On the last point, Germany has accepted by far more refugees from MENA war zones than any other European country and I would not be surprised if this resulted in higher emergency medicine use.
Also a quick Google shows Germany is a bit older with 22% of the population over 65 vs 18% in UK.
None of this is to say Germany isn’t over provisioned but it is probably not 5X over provisioned, if it is.
Queuing Theory 101: you can either optimize for usage or for availability, not for both at the same time.
Investing in availability costs, and the UK has been brutally cutting NHS funding in the past years or even decades.
Another aspect is that health care in Germany is much more decentralized, and so local hospitals have to absorb spikes in demand more by themselves, distributing patients to other facilities is only done in very rare cases (usually when specialist treatment is necessary). You cannot operate at > 80% utilization and still be able to absorb spikes in demand.
One explenation I heard is that hospitals in Germany perform more surgeries than any other OECD country per 100k inhabitants [1]. Not sure if it actually explains difference in the number of ICU beds.
> why on earth is Germany running five times more beds that it generally needs?
I feel like that question is asked the wrong way around because you are assuming England has "exactly enough", that's how you end up with Germany supposedly "running five times more beds than it needs".
But there's good reason to believe England has not enough ICU beds, even outside of a pandemic, the result of years of austerity cuts to the NHS [0].
There's also the fact that Germany is a healthcare powerhouse. Often forgotten among all the "cars and engineering" exports, but pharma and vaccines are the other two German top exports [1]
These are fields you can only really innovate in if you have a matching clinical and medical infrastructure behind it, which Germany has.
It's this combination that allows Germany to have such low fatality rates [2]. To put them in numbers: The UK right now sits at 11 deaths per 1m population, Germany at 5, and that's with Germany having tens of thousands of more cases [3].
> he UK right now sits at 11 deaths per 1m population, Germany at 5, and that's with Germany having tens of thousands of more cases [3].
The UK has done around 110k tests, Germany more than 400k. Don't confuse positive test results with actual infections. If the UK tested more, it'd very likely have more "cases".
Very very true of many countries, the level of testing and how they record deaths has been done at the discretion of individual countries and in many ways, makes comparing data not as clear-cut as you would think. THough if you don't know that, you end up comparing, what are hard numbers that you take as golden and end up down many wrong turns.
With that, who really thinks Russia has so few cases compared to the rest of the countries?
Even deaths, which you would of thought would be pretty clear cut, some countries will not count deaths with underlying conditions when many do. Then you have those who died at home and nobody knows about it.
I do know one thing, I feel for the postal workers in months ahead as there job will become a lot more morbid seeing who's letterbox is rammed and with that, possible dead people inside that nobody knows and for those postal workers - they will be the ones raising the alarms.
> Don't confuse positive test results with actual infections.
I don't, I'm mostly going by deaths/1M pop, and afaik even if the UK tested more, that number wouldn't change and still be more than double that of Germany.
So Germany must do something right that the UK doesn't.
Maybe it's the extra ICU beds, maybe it's the rapid testing, most likely it's a combination of both of those in addition to the better funding?
> So Germany must do something right that the UK doesn't.
... or wrong. Italy e.g. tests dead people for Coronavirus, Germany might conclude in many cases that people with prior issues died from those issues. I know Austria is very reluctant about this.
But the testing is somewhat part of the picture. Germany is now testing 400k a week (I think that is what your number is referring to). Again that is a reflection of the German healthcare system.
Another poster mentioned the decentralised nature of the German system, that has been mentioned as one of the reasons why Germany was able to test so much.
> Another poster mentioned the decentralised nature of the German system, that has been mentioned as one of the reasons why Germany was able to test so much.*
Seems to be, but that makes Austria's excuses look a bit poor. Here they have a similar decentralised system, but they're claiming that they don't get enough test kits on the market and that's why they're now testing 3k-5k a day despite having lab capacities >15k/day. If Germany can get them, Austria can, too - money shouldn't be an issue.
NHS hospitals have a completely different set of incentives than German hospitals that exist at a boundary between market capitalism and something entirely different. Terminal ICU patients are the health care equivalent of a billable hours fountain.
It's definitely not a deliberate "for a case like this" precaution but an emergent outcome of the specifics of how hospital funding is done and had been decried as a problem to be solved by should of the usual suspects.
Two reasons: Germany's much higher per capita income than England and it's federal structure. I won't comment on the first claim, it's self-evident. Germany is a federation of states: each state needs to provide adequate healthcare; states can't absorb spikes by distributing excessive patients to other states' hospitals (unless in a crisis) so they must over-provision infrastructure.
Is that still true? These reported numbers for the US are very much outdated. Would love to see a source younger than a decade.
All seem to come from the same sources, a 2009 and a 2012 study. The Forbes article actually mentions an alternative source, an article from 2015 [2] which is actually looking at regional 2000-2009 data. You can also follow the links at Wikipedia [0].
For Germany, there are numbers from 2017: The German Office for Statistics is reported in 2019 28.031 ICU beds which is a rate of 33.7 per 100,000 inhabitants.
EDIT:
This [3] WoPo article references data from 2016-2018: 93,000 ICU beds in total in the US. That's about 36 ICU beds per capita (aged 16 or older).
For comparison, Germany, based on the 28031 ICU beds and 70976000 inhabitants 16 or older [4] has 39,49 ICU beds per capita.
The number of beds per capita is one thing, how many are free or can be freed in the next few days/weeks is another. At least in Germany it was reported that a lot of them were in use and less than half were available for coronavirus patients.
We can't. It's not just a number of beds. It's also how long people stay there (which really depends on healthcare system). E.g. in countries with poor healthcare level people tend to stay in bed longer than in countries with good healthcare. Plus the average "normal" level of ICU occupation might be different (e.g. one country has 70% threshold, while another one 40%).
Just yesterday on German news they reported that Germany had most ICU beds per capita in the world. No idea if it's true. I guess no one ever knows the correct current numbers.
> The median number of full-feature mechanical ventilators
per 100,000 population for individual states is 19.7 (interquartile ratio 17.2–23.1), ranging from 11.9 to 77.6
Edit: WSJ opinion linked to a NIH study from 2012.
> A 2012 review [1] in the journal Current Opinion in Critical Care found that the U.S. has 20 to 31.7 ICU beds per 100,000 people compared to 13.5 in Canada, 7.9 in Japan and between 3.5 and 7.4 in the U.K. Differences in how countries define “ICU” account for some of the disparity, the article notes, and the U.S. needs more ICU beds because it has a higher incidence of chronic conditions like heart disease.
Since I looked around a lot for newer numbers, I thought I'd point out some newer numbers in my reply to the sibling comment [0].
In summary:
Data for the US from 2016-2018 suggest 93,000 ICU beds total, that is a ratio of 28.43 per 100,000. (research referenced in WoPo article linked in the comment below).
For comparison, Germany (official 2017 data) has 28031 ICU beds total, a ration of 33.76 per 100,000.
Both countries likely have the highest ratio in the world at this time.
By reporting, I suspect he means testing, as the actual reporting is working as expected. As for testing the United States did 120k tests yesterday and is accelerating. The CDC test failing really set things back.
In terms of ICU beds, for once this is where the us health care system is in reasonable shape. iCU beds are very profitable and we spend way more then Europe on health care, so there is a abundance of them in many regions. New York and georgi look constrained, but California, Florida and Colorado look solid from numbers I saw yesterday.
General beds are better in Europe then in the USA.
The USA also had the highest ratio of ventilators to people - in fact the number that he gives as impossible to produce in a year was in the US reserve at the start of the year - but it’s unlikely to be enough.
As for as scaling up production for ventilators.... just watch. I think you will see a similar effort to the tests scaling up. There will be a lot of press on it, but I would not be surprised to see new machines scale within this month. Probably not enough to save all lives, but more this this individual thinks is possible or conceivable will me from China and the US.
For whatever reason, Germany has historically been very bad about scaling production in emergencies, even during life and death moments (is, wars).
By reporting, I believe they mean how many ventilators the US has. See my peer comment to yours that has data from 2010 and 2012, which is the newest the US seems to have.
"What are the lessons to be learned from this crisis?
Dräger: It shows that common sense is more important than we all thought. This situation is so new and complicated that the problems can only be solved by people who carefully weigh their decisions. Artificial intelligence, which everyone has been talking so much about recently, isn't much help at the moment."
So, they have a prototype and are ready to produce 500. Impressive. And it looks like that each and every country is now designing and producing their own ventilator. Also, a lot of them outsourcing the design which is great. In unfortunate events people come together and do great stuff!
Right, they are also flying the parts and the people around in small passenger planes to speed up deliveries, and to keep key people from getting infected because of unnecessary travel. It's quite a project.
Bit of an aside, but Dräger is a fascinating company. Aside from their core medical devices, serious scuba divers know them for their rebreathers, which collect, scrub and reuse the air you breathe, instead of just venting it out like typical scuba regulators. Rebreathers are notoriously expensive, fiddly and dangerous, because there are all sorts of ways things can go wrong if the gas mix isn't just right, but Dräger's kit is the gold standard.
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[ 6.7 ms ] story [ 251 ms ] threadProblem is, Chinese suppliers sell FOB, meaning export cleared delivered to a (air)port terminal in China. Customers in Germany want to buy DDP (import cleared and delivered a specified location in Germany). There you have a structural problem. One that would be easy to overcome, if it wasn't product liability. The importer of record takes product liability in case the manufacturer is outside the EU. Good luck getting that insured (I tried). Ultimately, it will get sorted out.
The easiest way to get supplies going would be if the government did these two things:
- grant interest free loans for these products to allow importers to pay suppliers upfront (that's how this business works) for government orders
- take the product liability risk for products wutyh the proper (paper) certification
That would allow a lot of people to get this stuff. Rigjtt now it is a pain the ass.
There's a crap ton of unused aircraft right now. You would just need heads of state to direct the airlines to fulfill that need, simplify clearance, customs, etc. Treat it like wartime.
Maybe I can convince someone to give it a try. If not, I'll just go back building my company as planned. Would still suck so, to have look at the mess from the sidelines.
Ideally you would import it from a vetted manufacturer
I don't think anything but FOB is common, except in specific cases.
I asked the Allianz and Munich Re (the insurers insurer). Both declined to insure that at the moment.
Which sucks. Because the gap between FOB and DDP would otherwise just be logistics. Ignoring prices, that is rather easy to solve. I try to get hold of someone at the armed forces department charged with that. Hopefully it leads somewhere.
EDIT: Product liability is th problem. Transport insurance is easy to obtain and no problem.
Apparently you can get coverage, or rather a waiver, from the government if you are a non-profit.
As a side note, the government is now seriously launching itself into procurement. For example German states are starting procurement themselves.
The masks you are talking about, we already have citizens sewing them in a large-scale volunteer effort.
(Let’s present solutions, HN. Don’t just tell people things won’t work.)
These help with droplets and with reducing face touching.
You might say "but that's toilet paper, who cares", but empty shelves in super markets in Germany are a great way to make people remember the past and go into panic mode.
What people do right now is buy masks individually from Chinese vendors on Amazon, and they are getting shipped. If you want them quickly, you can pay for airmail. China can deliver, but for some reason, Germany doesn't take them.
It's gotten so bad where I live that Aldi has apparently decided to just give up and use the space for potting soil.
The pasta shelves are re-stocked though, as is bread. Berlin isn't quite there yet.
But certainly an insight into the culture and humanity of some people. Alas we have a society that seems to always see good responsible people suffer at the hands of the irresponsible.
The opposite is happening, you have (local, temporary) shortages and some politician who hasn't bought their own groceries in the last decade says "I assure you, there are no shortages", while everybody sees the empty shelves on a daily basis.
Equally, once many heard news of something was being brought up, the net effect was to drive others into panic and drive them to do the same.
Panic begats panic. So you start to enter into the aspect of https://en.wikipedia.org/wiki/Crowd_psychology
But now that people filled their shelves, I guess that store supplies are back to normal.
But people worried about non-fire safe cladding seemed equally happy to fill their homes with flammable paper - the hypocrisy of madness plays out in many ways.
People aren't rational actors, and by saying "they don't really need toilet paper", you're not solving the issue that is people seeing empty shelves for toilet paper, bread and soap and thinking that the system is failing.
You don't want the public to become nervous, ever. Nervous people make terrible decisions. And for a government to look uncaring/impotent is the way to make the population nervous.
Also, I don't know whether they'd actually need to increase production. According to super market chains, they have more than enough but it's in their storage centers and they have issues/aren't prioritizing getting it into the stores.
I saw a intriguing change in conversations I had over the last couple of days. First it was, like, no need, we got this. Just yesterday I found a call for an offer from the Armed Forces procurement department in my Inbox, while you now find direct contact details for these kind of things online. Not sure what happened, but there sure is a change in how authorities are approaching this.
There are so much more things than ventilators that are much easier to scale.
Industrial scale production, transport, making sure it doesn’t set everything on fire, and supplying a medically appropriate quality without risking hyperoxia? That’s hard.
Also oxygen enrichers could be made and distributed, they could also help some people. I know of a person who made one themselves in a week. Both should be a lot easier than ventilators (which of course also should be pursued).
If you read the reports from Italy, they first ran out of ventilators, then CPAP machines and finally even oxygen.
But for some reason the talk is very concentrated on ventilators for now.
Also other equipment saves lives. Pulse oximeters so those needing help breathing can be identified. Protective equipment. A lot of things that save lives and are a thousand times easier to make than ventilators.
People who are handy with a sewing machine can even make pretty decent ones themselves [0]
[0] https://smartairfilters.com/en/blog/best-materials-make-diy-...
This material is extremely difficult to produce, which makes it hard to scale on short notice, so its price in China shot up 50 times.
“ It shows that common sense is more important than we all thought. This situation is so new and complicated that the problems can only be solved by people who carefully weigh their decisions. Artificial intelligence, which everyone has been talking so much about recently, isn't much help at the moment.”
I want to work for this guy!
It would be interesting to hear more precisely why. We've heard more than a few well-respected industrialists essentially saying "Scaling up ventilator production ? How hard could it be?"
Edit. Of course I am not suggesting that car assembly lines are suitable to build ventilator parts. That's clearly not what Daimler suggested either. The question is 'what are the actual bottlenecks to ventilator production?', and nobody seems to really be willing or able to say.
Or are you saying "why not just equip the buildings next door and quadruple everything"?
The industrialists I mention are not just in automotive, but oil and gas, etc
- health laws forbidding veterinarians to help (animal standard != human standard)
- companies not allowed to help because some administrative formality
Many systems are not ready to switch gears fast in times of crisis.
However, project management and engineering setup takes a long time.
Remember they also have to build the ECUs, dashboard and AC plumbing. If you squint that might be about what you need for a ventilator.
There are also extremely high standards to be met for medical devices.
Modern cars have such a huge variety of parts with varying materials and characteristics that I'd guess almost all the ventilator parts could be out-sourced. I don't know enough to say what the specialized skills or parts could be but let the ventilator manufacturers build those, do final assembly and QA and you'd at least increase production to some degree. My guess is that the quoted manufacturer has ramped up their existing parts manufacture beyond their ability to do final assembly were Daimler to provide more parts.
I don't think I was assuming that ... but your point is valid. Certain car parts have indeed been the same for a long period of time. You'd certainly want to avoid the suppliers that are resistant to change or that have historically taken many iterations to get to the point where they can produce 10s and 100s of millions consistently. There are however manufacturers that specialize in smaller runs and more precision (two within 20 minutes of where I type this which is NOT considered a traditional manufacturing area). I'd be willing to bet those managing the supply chain for the car companies know exactly which type of company is which (where do their engineering departments have short-run prototypes made?)
Dyson in UK is ready to produce their own version of ventilators already.
The assembly lines / workstations also look very different, in general. You can see in the picture how the ventilators are assembled, it's not a factory line but more a workshop.
Then you have all the supply chain issues that the article discussed. Companies like Dräger have been optimizing their supply chains and processes for literally over 100 years (the company was founded in 1889), so to think another company could just replicate all of that within a few months or weeks is unrealistic. Even with Dräger's help this would be challenging, as building up a new factory location usually takes several years as well.
I think we have a strong bias to think that all problems can be solved with technology or engineering. Some need to be solved on a social and political level though, at least initially as technological developments take time. For Covid-19 we need to change our behavior now to allow technology to catch up.
It would be hard to make reliable properly working machines fast. Faulty ones would kill patients.
Producing semi-mechanical Bag-valve-masks (BVM) would be relatively easy, but you need professional to sit there and monitor the patient. That's not ICU ventilator. BVM is very crude tool for short term use. If the rules and legislation are relaxed so that hospitals could use non-certified crude devises that help. You would almost certainly see ventilator-induced lung injuries.
Ventilator-associated lung injury https://en.wikipedia.org/wiki/Ventilator-associated_lung_inj...
Ventilator-Induced Lung Injury Review (Part 1 of 2) https://pulmccm.org/review-articles/ventilator-induced-lung-...
If the system is automated life support, it generally has to maintain homeostasis of the patient and _dynamically_ adjust. If you are just tiny amount off from the optimal and there is drift in the dynamical adjustment it accumulates over time and you can kill the patient or cause immense pain or discomfort.
Oxygen is poison if you get it too much and if you get it too little, you die. Pushing air into the lungs can damage them and the oxygen mix should adjust. If lungs are filling with fluids, you might need more oxygen and less volume. The system must be connected to instrumentation that monitors the patient's state continuously.
There is the question of medical staff using the thing correctly. Medical UI/UX is safety critical in the same level as it is in aviation. If just 5% of users use it wrong it, can negate all benefits from using the device.
Generally you need deep knowledge transfer to scale up production of critical components or testing and calibration, just emailing the specs is not quick enough. You need to test it with real environment and refine the device to see how it works in practice. I'm sure that ventilator manufacturers have already outsourced every component that is easy to manufactured and produce to others. There are some bottlenecks that involve testing, special machines, materials and calibration that is not easy to scale quickly.
(edit: the time-frame of ICU overflow seems to be between May-Sep in the most countries in most models If you ramp up deliveries 3 months from now, you could catch the tail end of the need)
One big issue can be IP. Dräger put a lot of money behind that. Just opensourcing the design and specs would kill the company. But why not negotiate liscense agreements or sub-contracting production out. Could be a solution. Just shows how everybody is still trying to adopt to the new reality.
Bureaucracy can be a bitch.
https://www.researchgate.net/publication/258525804_Testing_t...
Is this true?
Tho it should be noted that both, cloth and surgical masks, are mostly worn to protect others from accidental discharge by the wearer.
So if you the wearer wants to protect themselves, then a respirator is actually needed. But respirators should be prioritized for at risk-groups who wouldn't survive infection or work with infected people.
The non-respirator masks are mostly to reign in the spread by people who could be infected without symptoms yet or as the "we got nothing else" option.
[0] https://bmjopen.bmj.com/content/5/4/e006577
I'm mechanically and electrically handy but don't have a basement full of ventilators. I'm going to send an email to my local hospital ... we'll see how that goes. Anyone have know where else to find ventilators that need to be serviced?
Ventilator is a BiPap on steroids.
https://blog.plan99.net/cpap-for-covid-d47886bf978c
https://blog.plan99.net/more-cpap-for-covid-b6911f806c89
The primary difficulties are establishing medical consensus on what kind of pressure therapy is best (continuous vs bi-level) because that affects the availability of machines a lot and there's some disagreement. Secondary is how to stop patients on CPAP machines spraying virus into the air through the masks, however, at least one CPAP machine manufacturer thinks that concern is actually overblown and points to a study showing CPAP masks don't aerosolise to the extent current medical consensus seems to think.
Something very clear is that doctors are still figuring out treatment for this and there's some disagreement over what the right way to do things is. Disturbingly it may be that current medical consensus makes things worse for COVID-19 patients rather than better i.e. bi-level pressure therapy hurts the lungs in that state rather than helps (perhaps contributing to a high death rate?).
https://www.ncbi.nlm.nih.gov/pubmed/27910706
https://www.medicalnewstoday.com/articles/247295
Not a physician, but sounds like a more rapidly scalable method - if it works.
"Dräger: In Europe, the number of intensive-care beds per capita is very unequally distributed. In Italy, it is three times lower than here. In England, five times lower. The challenge in England will be greater than in Spain. And the situation in the U.S. is very alarming. The reporting system there is also underdeveloped."
in my experience, Germany is quite conservative (lagging behind in smoking bans, preferring cash over cards until the coronavirus hit), but wants to do the right thing (look at e.g. solar power subventions). them being a federal republic means they have similar jurisdictional issues as the US, but less hamstrung by a crippling fear and distrust in the federal government. those traits, if i'm accurate, would also explain it.
(what is still there as a disparity between some western states and eastern states.)
Which said infrastructure has no legacy from that era and completely overlook the cold-war build up and associated facilities and infrastructure of that era born out of that period. Equally let us not forget that Germany was upto not long ago - curtailed in what it could invest in military and not having that burden saw a shift into area's they could and medical and industry did well. More so when in many parts they had a clean slate to build up from.
I'm sure many aspect you mentioned are true - , however the drive for solar was born out of a distrust in nuclear and saw a rise in coal plants - which still has an effect today upon the climate of Europe as many (near on all) are located upon the borders, so that issue shifted and needed to be addressed and solar/wind was the right logical direction for them. But then - NO country is perfect or doing it perfect.
But the Germans are trying and done wondrous progress in many area's, let us not forget when they reunified the impact upon their GDP was negligible - that in itself was impressive and whilst in some parts of Germany that legacy still has more of an impact socially, it's progressed a long way and probably more than other countries would of had they been in a comparable situation.
>(what is still there as a disparity between some western states and eastern states.)
Yes - that is a product of legacy.
Consider that in the last few weeks the NHS doubled its ICU capacity. The term "ICU bed" conjures up images of something surrounded by über-complex equipment but it can mean other things, which is why it seems able to flex so fast.
As far as I can tell, so far in this pandemic, there haven't been any stats that can be totally trusted or compared between nations - on anything at all.
this is correct in general. i don't think we'll have a clearer picture until at least autumn by which time some basic data has been collected and analyzed. then the multi-year governmental and private inquiries will surely follow, shedding even more light on the whole situation. i expect to keep hearing about this disease for years and years from now. but this too shall pass at some point.
Another anecdote, whenever I wanted something "unusual" I was denied, and the person "in charge" needed to ask a supervisor. E.g. in an (upscale) hotel I wanted to see a different room for my next stay, took some time to ask different supervisors but in the end it was "impossible". In Germany the person at the reception desk would decide if this is possible or not and most like show me a room.
(Yes all anecdotal and colored by my cultural perception).
It's also completly possibile that you're an outlier German that is frustrated with the current rules. For sure, I've seen that in spades. it isn't the mainstream though.
I don't know why this is so different in Germany. I've more often observed the inverse - where people (mostly well-dressed middle-aged men, for whatever reason) are extremely rude and condescending towards secretaries, ticket collectors, etc.
[1] I don't think that's idiomatic English, which illustrates my point.
How could anyone argue that once in a while there won't be enough beds to save everyone's life?
The closest things I can think of non healthcare is that airbags are designed for 5, 50, and somewhat for 95%ile individuals. But I think it's actually impossible to develop for everyone due to mechanical restrictions.
Source: https://www.ons.gov.uk/peoplepopulationandcommunity/healthan...
There have been no cuts in NHS service. Sometimes I think I need to assign this to a keyboard macro because it's such a frequently repeated myth. The NHS has more funding now than it's ever had, it has been explicitly protected from budget reductions when every other government department has seen massive real cuts, and just last year has been given enormous spending boosts. NHS "cuts" are a bit like the gender pay gap - they exist only when statistics are abused to meet political and ideological agendas.
Or, you could equally ask why Germany and the USA seem to spend so much on healthcare. After all the UK spends about average for the OECD. And the USA spends the most of all by far so it should barely notice COVID-19 compared to other countries? I guess we'll see.
Plus Britain is getting somewhat older, and somewhat sicker (partly because of medical advances meaning that previously-fatal conditions are now chronic and need ongoing treatment). And we can treat more now, so there is more demand.
Bluntly, the proportion of GDP which needs to be allocated to healthcare to maintain a good quality service is rising unsustainably in all countries. The NHS is beating CPI inflation (and in doing so doing way better than other parts of government: local government has seen >25% real terms cuts, which has trashed the social care system amongst other things) but not nearly enough to keep up.
Addenbrookes Hospital in Cambridge (technically Addenbrookes Hospital Trust, comprised of several hospitals on one site) is the largest hospital in the UK. For the tax year 2019/2020, the available budget for capital expenditure (building, large equipment like MRIs etc.) was £0. (accurate prior to Covid-19)
Occasionally as a result of political manoeuvering (General Election campaigning) pots of money for very narrow purposes with a limited time window on them appeared, but in general things like ward refurbishments have been funded by charitable donations. Most worthwhile capital investments take more than a year, so a predictable capital budget is necessary to implement programs. Having no money for CapEx is not how you maintain a health service long term.
Yes, this is how such threads always go. It's a simple three step process:
1. Someone claims the NHS funding has been cut
2. I point out that's a lie, no such cuts have ever happened and in fact the budget has always gone up
3. Somebody else replies with: but it should have grown even faster.
The point I'm making is not about the correct level of healthcare spending, which is arbitrary and values-based as healthcare systems will consume however much money is given to them. Rather the persistent level of outright lying that accompanies any discussion of the NHS in Britain. It's absurd and quite obviously linked to a belief that misleading people is fine if it's for a 'good cause'.
But this behaviour has to stop. It isn't OK to lie even if the outcome might appear to be desirable (more political pressure for higher healthcare spending). People learn that they're being manipulated and support for the desired cause can collapse.
Having no money for CapEx is not how you maintain a health service long term.
I'll repeat this until I'm blue in the face. The NHS has more money now than it's ever had. Not only does the NHS have money for capex but it's been repeatedly allocated money specifically and only for capex, because NHS managers have a long history of preferring to divert spending on upgrades to other forms of spending - frequently salary increases.
It's bad management. The government attempts to combat this lack of forward thinking by earmarking of money specifically for upgrades (what you criticise here as "pots of money for very narrow purposes"). One of the first things Boris Johnson did is allocate a billion pounds to the NHS only for capex. Unfortunately it doesn't work:
https://www.hsj.co.uk/technology-and-innovation/exclusive-qu...
"Capital spending was particularly tight with only £150.3m spent from £354.1m of allocated funding ... funding to help NHS trusts to become more digitally advanced accounted for most of this capital underspend. The DH planned to spend £116.2m of capital on these trusts in 2016-17 – instead it spent nothing."
The idea the NHS doesn't have money for capex is just another piece of misdirection. It refuses to spend on upgrades even when central government is trying to force its hand, because it knows that the result is No 10 will blink and give up, which is what happens:
"The money was not allocated elsewhere but “as with all Department underspends, was available to offset pressures in other parts of the system”, she said."
Doctor and nursing salaries are pretty low in the UK, if management is diverting capital expense money to salary increases, they are doing a poor job of it.
https://fullfact.org/health/spending-english-nhs/
"Looking at the wider UK, the amount spent on health has been increasing over the long-term. That’s true whether it’s expressed in cash, cash adjusted for inflation, per person, or as a proportion of the size of the economy."
Population growth puts pressure on public services. The British people have been asking for reduction in population growth for a long time, partly out of concern for the state of the NHS, yet of course have been repeatedly denied by the EU and their own political classes. 4 years after voting to leave the EU largely to get a grip on the ever-increasing cost of public services they still haven't been allowed that.
Doctor and nursing salaries are pretty low in the UK
They're extremely high. The average pay for specialist consultants in the NHS is £120,000 or approximately 6x the average salary. This is dramatically higher than in say, Germany, where specialists earn 80,000 Euro on average. That's £71,600 or a bit less than 60%.
https://www.google.com/search?hl=en&q=average%20salary%20for...
https://www.medscape.com/slideshow/2019-uk-doctors-salary-re...
if management is diverting capital expense money to salary increases, they are doing a poor job of it.
They've done an excellent job of it. From 2010:
https://www.telegraph.co.uk/news/health/news/8206972/Billion...
"Billions of pounds spent on improving NHS hospitals has mostly gone on staff salaries while productivity has fallen over the last decade, a key National Audit Office (NAO) report has found."
"Between 2000 and 2009 the NHS workforce grew from 1.1 to 1.4 million - almost a 30 per cent rise. That included an extra 12,500 consultants, whose average pay rose from £71,900 to £120,900 over the same period - a 68 per cent increase. Doctors' pay rose by 48 per cent, nurses' and midwives' by 36 per cent and managers' by 34 per cent"
Health costs have been rising everywhere in the world and this has little to do with population growth (that's actually good because young people pay taxes), but more with rising life expectancies and the resulting average age. Every country has been experiencing the same trend (the US being an exception likely because of privatized healthcare): https://en.wikipedia.org/wiki/Healthcare_in_Germany and those country have pretty different population developments.
Also you are comparing a Facharzt salary to a consultant, that's not a fair comparison. You should compare to a specialist and look what do they earn in the UK? £40,037 to £74,661. https://www.healthcareers.nhs.uk/explore-roles/doctors/pay-d...
That looks awfully similar to what a Facharzt earns (actually with the current rates the German earns significantly more more): 70.000 – 95.000 Euro https://www.praktischarzt.de/arzt/gehalt-arzt/
Please, just stop this. Departments asking for more money than they know they'll be allowed and then getting less is a universal truth of organisations, both governmental and corporate. It's called negotiation. Being given more money than you had before is not, and never will be, a "cut" in the English language. That word has a precise meaning and it simply doesn't apply here.
Likewise the NHS wasn't asked to find 20 billion in "cuts". That doesn't even make sense. You can't increase your own budget by reducing it. They were told that if they really needed that much they would be expected to find it through increased efficiency. Keeping a check on NHS waste is a key function of elected governments which voters expect them to fulfil, simply writing them blank cheques has been tried before and didn't work (as in costs went up, but healthcare outcomes didn't or didn't by anywhere near as much).
Health costs have been rising everywhere ... more with rising life expectancies and the resulting average age
And the NHS budget has been rising too.
Also you are comparing a Facharzt salary to a consultant, that's not a fair comparison
Alright, fair enough, then focus on the original statement - doctors and nurses get anywhere between good and extraordinarily good pay relative to the average salary in the UK. There are doctors in the UK earning significantly more than the Prime Minister, and their pay went up significantly during the last Labour government (not sure about this one, didn't look, but I assume pay inflation has been only slightly lower).
The point is that significant amounts of the money given to the NHS ended up being spent on increased OpEx like salary increases, rather than CapEx like capacity increases or efficiency improvements. Obviously the NHS must raise salaries at least in line with inflation, and really more in line with global healthcare inflation to avoid brain drains. But the idea its hospitals are run down because evil central government keeps cutting its budget is just far wrong.
If Germany have provisioned 5 times more ICU beds than they generally need, I can see why their costs might be higher
However, let's not forget historical factors and was case of many countries having armies in Germany for legacy war reasons and that may well of seen the mentalities to have a higher number of such beds than most places.
-Under provisioning for surges (not even Covid, even just a sudden emergency of another sort, a bad flu season, big accident, terror event, whatever)
-Going longer between maintenance intervals than is recommended
-Delaying ICU admission longer than is strictly recommended
-Relocating ICU equipment as needed more than other countries feel comfortable doing
-Using more reliable ICU equipment (does the German figure include any older and potentially less reliable gear in the former communist east?)
-Have less need among population for ICU
On the last point, Germany has accepted by far more refugees from MENA war zones than any other European country and I would not be surprised if this resulted in higher emergency medicine use.
Also a quick Google shows Germany is a bit older with 22% of the population over 65 vs 18% in UK.
None of this is to say Germany isn’t over provisioned but it is probably not 5X over provisioned, if it is.
Investing in availability costs, and the UK has been brutally cutting NHS funding in the past years or even decades.
Another aspect is that health care in Germany is much more decentralized, and so local hospitals have to absorb spikes in demand more by themselves, distributing patients to other facilities is only done in very rare cases (usually when specialist treatment is necessary). You cannot operate at > 80% utilization and still be able to absorb spikes in demand.
[1] https://www.gesundheitsstadt-berlin.de/oecd-studie-deutschla...
I feel like that question is asked the wrong way around because you are assuming England has "exactly enough", that's how you end up with Germany supposedly "running five times more beds than it needs".
But there's good reason to believe England has not enough ICU beds, even outside of a pandemic, the result of years of austerity cuts to the NHS [0].
There's also the fact that Germany is a healthcare powerhouse. Often forgotten among all the "cars and engineering" exports, but pharma and vaccines are the other two German top exports [1]
These are fields you can only really innovate in if you have a matching clinical and medical infrastructure behind it, which Germany has.
It's this combination that allows Germany to have such low fatality rates [2]. To put them in numbers: The UK right now sits at 11 deaths per 1m population, Germany at 5, and that's with Germany having tens of thousands of more cases [3].
[0] https://www.theguardian.com/politics/2019/jun/01/perfect-sto...
[1] https://oec.world/en/profile/country/deu/
[2] https://apnews.com/ad9a6af47c3b55fd83080c9168afaaf4
[3] https://www.worldometers.info/coronavirus/#countries
The UK has done around 110k tests, Germany more than 400k. Don't confuse positive test results with actual infections. If the UK tested more, it'd very likely have more "cases".
With that, who really thinks Russia has so few cases compared to the rest of the countries?
Even deaths, which you would of thought would be pretty clear cut, some countries will not count deaths with underlying conditions when many do. Then you have those who died at home and nobody knows about it.
I do know one thing, I feel for the postal workers in months ahead as there job will become a lot more morbid seeing who's letterbox is rammed and with that, possible dead people inside that nobody knows and for those postal workers - they will be the ones raising the alarms.
I don't, I'm mostly going by deaths/1M pop, and afaik even if the UK tested more, that number wouldn't change and still be more than double that of Germany.
So Germany must do something right that the UK doesn't.
Maybe it's the extra ICU beds, maybe it's the rapid testing, most likely it's a combination of both of those in addition to the better funding?
... or wrong. Italy e.g. tests dead people for Coronavirus, Germany might conclude in many cases that people with prior issues died from those issues. I know Austria is very reluctant about this.
Another poster mentioned the decentralised nature of the German system, that has been mentioned as one of the reasons why Germany was able to test so much.
It's over 400k total as of March 23rd and 100k in the week of 20th. https://www.zeit.de/wissen/gesundheit/2020-03/coronatests-de...
> Another poster mentioned the decentralised nature of the German system, that has been mentioned as one of the reasons why Germany was able to test so much.*
Seems to be, but that makes Austria's excuses look a bit poor. Here they have a similar decentralised system, but they're claiming that they don't get enough test kits on the market and that's why they're now testing 3k-5k a day despite having lab capacities >15k/day. If Germany can get them, Austria can, too - money shouldn't be an issue.
It's definitely not a deliberate "for a case like this" precaution but an emergent outcome of the specifics of how hospital funding is done and had been decried as a problem to be solved by should of the usual suspects.
The standards for "it's good enough" are vastly different in these countries.
https://www.forbes.com/sites/niallmccarthy/2020/03/12/the-co...
https://en.wikipedia.org/wiki/List_of_countries_by_hospital_...
Based on these numbers and in light of the current situation in Spain, the situation in the UK will indeed get very difficult.
All seem to come from the same sources, a 2009 and a 2012 study. The Forbes article actually mentions an alternative source, an article from 2015 [2] which is actually looking at regional 2000-2009 data. You can also follow the links at Wikipedia [0].
For Germany, there are numbers from 2017: The German Office for Statistics is reported in 2019 28.031 ICU beds which is a rate of 33.7 per 100,000 inhabitants.
EDIT: This [3] WoPo article references data from 2016-2018: 93,000 ICU beds in total in the US. That's about 36 ICU beds per capita (aged 16 or older).
For comparison, Germany, based on the 28031 ICU beds and 70976000 inhabitants 16 or older [4] has 39,49 ICU beds per capita.
[0] https://en.wikipedia.org/wiki/List_of_countries_by_hospital_...
[1] https://www.sciencemediacenter.de/alle-angebote/fact-sheet/d...
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4351597/
[3] https://www.washingtonpost.com/business/2020/03/23/map-place...
[4] https://www-genesis.destatis.de/genesis//online?operation=ta...
Why would this be unique to germany. Can we just assume this is more or less identical everywhere?
https://www.cambridge.org/core/journals/disaster-medicine-an...
> The median number of full-feature mechanical ventilators per 100,000 population for individual states is 19.7 (interquartile ratio 17.2–23.1), ranging from 11.9 to 77.6
Edit: WSJ opinion linked to a NIH study from 2012.
https://www.wsj.com/articles/americas-intensive-care-dividen...
> A 2012 review [1] in the journal Current Opinion in Critical Care found that the U.S. has 20 to 31.7 ICU beds per 100,000 people compared to 13.5 in Canada, 7.9 in Japan and between 3.5 and 7.4 in the U.K. Differences in how countries define “ICU” account for some of the disparity, the article notes, and the U.S. needs more ICU beds because it has a higher incidence of chronic conditions like heart disease.
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3551445/?mod=ar...
In summary: Data for the US from 2016-2018 suggest 93,000 ICU beds total, that is a ratio of 28.43 per 100,000. (research referenced in WoPo article linked in the comment below).
For comparison, Germany (official 2017 data) has 28031 ICU beds total, a ration of 33.76 per 100,000.
Both countries likely have the highest ratio in the world at this time.
[0] - https://news.ycombinator.com/item?id=22711215
In terms of ICU beds, for once this is where the us health care system is in reasonable shape. iCU beds are very profitable and we spend way more then Europe on health care, so there is a abundance of them in many regions. New York and georgi look constrained, but California, Florida and Colorado look solid from numbers I saw yesterday.
General beds are better in Europe then in the USA.
The USA also had the highest ratio of ventilators to people - in fact the number that he gives as impossible to produce in a year was in the US reserve at the start of the year - but it’s unlikely to be enough.
As for as scaling up production for ventilators.... just watch. I think you will see a similar effort to the tests scaling up. There will be a lot of press on it, but I would not be surprised to see new machines scale within this month. Probably not enough to save all lives, but more this this individual thinks is possible or conceivable will me from China and the US.
For whatever reason, Germany has historically been very bad about scaling production in emergencies, even during life and death moments (is, wars).
I've seen estimates everywhere between 90 to 99.9% of cases going untested.
Dräger: It shows that common sense is more important than we all thought. This situation is so new and complicated that the problems can only be solved by people who carefully weigh their decisions. Artificial intelligence, which everyone has been talking so much about recently, isn't much help at the moment."
https://www.corovent.com/ https://www.medrxiv.org/content/10.1101/2020.03.24.20042234v... ...
https://en.wikipedia.org/wiki/Rebreather