Canada, Pushing Back at Trump PPE Restrictions

"New Brunswick Power is the electricity provider to Northern Maine."

"There are at least three hospitals in Northern Maine that would get their electricity through New Brunswick Power."

Kirsten Hillman, Canadian Ambassador to Washington, D.C.

In April 2020, American firm 3M was ordered by President Donald Trump to stop sending N95 masks such as this one to Canada, but refused to comply. Photo by Angus Mordant/Bloomberg

Early in Canada's introduction to the pandemic the issue of personal protection equipment became a leading dilemma; Canada hadn't any to speak of. In a fit of generosity and compassion, the government of Canada had seen fit when China was in its early desperation stages of managing an 'epidemic' of SARS-CoV-2 -- when the rest of the world found difficulty imagining that the virus causing COVID-19 would speedily gravitate abroad -- to gratuitously send along Canada's supply of said PPEs.

 

And then Canada discovered it would need them, after all. It might even had made use of the PPE that had been warehoused past its use-before date which it decided to destroy just before Canada itself become embroiled in the predatory virus stalking through its population and panicking its hospitals traumatized over the notion it would never be able to cope with growing numbers of seriously ill people requiring ventilators, many of whom would soon be beyond medical help.

 

Mind, China returned the compliment; when Canada pleaded with Beijing to supply the country with PPE as the world's largest manufacturer of them, it sent along masks and other equipment leading to a big sigh of relief in Canada -- until it was discovered that the deliveries were next to useless; their specifications not up to par, and not worth the effort nor what it cost to access them.

 

Photograph: Nicholas Pfosi/Reuters

And then there was the trifling issue of Canada's relations with its 'best-friend' neighbour when then-President Donald Trump announced his 'America first' sentiments. And the Trump administration restricted shipments of N95 masks and ventilators early spring of 2020, when Canada was desperate for them. Even 3M protested against Mr.Trump's declared strategy of withholding and refusal to permit its masks to be shipped to Canada.

The result led to Canadian officials responding by politely pointing out there were some hospitals in the U.S. that were dependent on Canadian electricity, on Canadian medical personnel working in U.S. hospitals. Canada's U.S. ambassador produced a list of levers at Canada's disposal that could be extremely persuasive; medical equipment suppliers in Canada, the electrical supply for northern Maine among them.

Other Canadian officials met with their U.S. counterparts emphasizing that Canada had the potential should push come to shove, to cause problems for the United States, pointing out the items contained on the list of Canada's contribution to America's well-being. Including special filters for bio-containment suits from 3M produced in Canada; a requirement for the suits to be effective; a paper mill in Nanaimo, B.C. producing specialized fabric for surgical masks and gowns.

It took quite a bit of prodding to convince the Trump administration of the interoperability and interconnectedness of the two neighbours' economies; that neither country gained even a modicum of advantage from export restrictions. It seemed to work, since Mr. Trump relented, setting aside his trumped-up defence production act in prevention of critically needed items leaving the U.S. The resumption of the 3M shipments an adequate assurance of the message having had the requisite impact.

 

A CargoJet flight bearing tens of thousands of pounds of personal protective equipment landed in Hamilton, Ont., earlier this month as part of a made-for-Canada plan to deliver to medical supplies from China to front line workers across the country. Two cargo planes sent to China for pandemic supplies returned home empty Monday. (CargoJet/Twitter)

 

"As previously mentioned, there is a 40 entering the country, meaning aircrews cannot stay at the airport for an extended period of time to wait for supplies to be unloaded onto planes", explained an email between the prime minister's office staffers on the occasion when a Canadian flight had no option but to leave the Shanghai airport absent its order of masks, when Beijing too found reason to retain PPE internally rather than release the products through legitimizing exports.

A German company, Zoll, producing ventilators in the U.S. signed a contract with Canada early in March for the provision of 200 ventilators to arrive in early April. The ventilators were delayed as a result of the company having a supply relationship with the U.S. department of defense, and President Trump had used the defence production act to halt shipments abroad of medical devices.

"Zoll indicated that all its ventilator production will go to the U.S. [DOD/Department of Defense] for at least the next 60 -90 days", the then-Foreign Affairs Minister informed staff at the prime minister's office. An appeal by Canada's health minister to her U.S. counterpart exacted a promise to exempt Canada from the act, and though the shipment was delayed by a month, it was eventually received.

Best Friends; Neighbours and Trading Partners

"We consider that [U.S.authorities confiscating German orders for PPE from 3M, en route from China to Germany] an act of modern piracy."

"You don't treat your transatlantic partners like that."

"Even in times of global crisis, there should be no wild-west methods."

German Interior Minister Andreas Geisel

"We are receiving essential supplies from the United States but the United States also receives essential supplies and products and indeed health-care professionals from Canada every single day."
"I think of the thousands of nurses, for example, who cross the bridge in Windsor to work in the Detroit medical system every single day. These are things that Americans rely on. It would be a mistake to create blockages or reduce the amount of back and forth trade of essential goods and services including medical goods across our border."
Canadian Prime Minister Justin Trudeau

"I am just so, so disappointed right now. We have a great relationship with the U.S. and then all of sudden, they pull these shenanigans. Unacceptable."
"When the cards are down you see who your friends are, and I think it’s very clear over the last couple days who our friends are."
Ontario Premier Doug Ford

• U.S. President Donald Trump speaks during a coronavirus task force briefing in the Rose Garden of the White House, in Washington. (AP Photo/Patrick Semansky)
  

 Starting off on the wrong foot with someone of the nature of U.S. President Donald Trump is not a formula for good relations; rather spurning or scorning the man on the merits of his unstatesmanlike behaviour, his unpredictability, his hungry ego and boastful, threatening behaviour in an overt manner in the presence of others in a way that highlights the scorn in which other world leaders hold the man is to presage a predictable lash-back at the time and choosing of the man insulted.

Justin Trudeau, himself a preening egotist with pretensions of superiority as a 'woke' progressive, likes presenting himself as a world leader of a post-nationalist country, a man of his times and ahead of the times, contrasting himself as a sophisticated leftist feminist and champion of the underdog, to the autocratic belligerence and rough manner of someone like Donald Trump. Trudeau's immature posturing at the last NATO conference ridiculing President Trump would not be forgotten by a man who, like Trudeau himself, doesn't take slights lightly.

3M makes about 1.1 billion masks a year around the world, but currently none in Canada. (Romeo Ranoco/Reuters)

That situation did much to ensure that Canada has a small, very small voice in Washington. Leading Trump to have no qualms whatever when he decreed that 3M -- which had contracted with Canada to supply it during the global pandemic caused by the novel coronavirus with badly need N95 respirator masks for Canadian health professionals in an health-crisis-unprepared situation -- cease and desist. The U.S., much harder hit by the epidemic of infections and deaths than Canada, resulted in President Trump's America-first decision to ban export of vital medical products away from the U.S. and into Canada.

The ban did not start and stop with the critical masks alone, but was extended to include gloves and other medical equipment. And at the same time that President Trump excluded Canada from its contracted share of needed personal protective equipment, he generously extended an exception to his America-first rule to give aid to Italy and Spain, both particularly hard-hit, like the United States, with a surge of virus cases and a related shocking death rate.

N95 masks for COVID-19. (Nicholas Pfosi/Reuters

When 3M pushed back in favour of ensuring its masks would be shared to a degree with Canada citing humanitarian and contractual obligations, Mr. Trump declared he was "not happy with 3M". Following Canada's exclusion from 3M products, both Germany and France were also placed on the Trump "hit list" of unfavoured PPE recipients. In Canada, there sre those who advocate Canada should coolly respond to President Trump's decision-making.

Asserting that the thousands of Canadian health-care professionals who cross the border daily, including nurses, doctors and others in health care to work on visas in the United States, should be requested by the government to return to Canada and remain there, using their professional skills which are badly needed in the U.S., at home to respond to the anticipated crush of new cases requiring hospitalization and respirator treatment.

Ontario alone, the most populous province in Canada, and one of the hardest hit next to Quebec by the coronavirus, had ordered 2,200,000 masks from 3M, shipments which have been held up by American officials who in the end permitted 500,000 of the total number to be released into Ontario. Canada could also reciprocate to Mr. Trump's edict excluding Canada from 3M's deliveries by itself banning the exports of test kits, drugs and raw material required to produce medical supplies -- unless they prove surplus to Canadian needs.

N95 masks. | Thomas Wells/The Northeast Mississippi Daily Journal via AP Photo

Manufacturing Crises Over Crises

"Ceasing all export of respirators produced in the United States would likely cause other countries to retaliate and do the same, as some have already done."
"If that were to occur, the net number of respirators being made available to the United States would actually decrease."
"That is the opposite of what we and the administration, on behalf of the American people, both seek."
3M Statement

"We are receiving essential supplies from the United States, but the United States also receives essential supplies and products and indeed health-care professionals from Canada every single day."
"These are things that Americans rely on, and it would be a mistake to create blockages or reduce the amount of back-and-forth trade of essential goods and services, including medical goods, across our border."
Canadian Prime Minister Justin Trudeau

A 3M mask — one of the items of protective equipment health care workers around the world badly need to cope with the COVID-19 pandemic. (Nathan Denette/The Canadian Press)

"To say that I'm infuriated with the recent actions of President Trump of the United States is an understatement."
 "I cannot believe for a second, in a time of crisis, that President Trump would even think about banning key medical supplies to Canada."
Newfoundland and Labrador Premier Dwight Ball


"[Ontario has just one week's worth of critical personal protective equipment for front-line health-care workers as it waits for more shipments]."
"[Around three million masks ordered from the U.S. have been held up by American officials, but 500,000 masks are being released today]."
"We're putting pressure on the U.S. government from all sides. [Those 500,000 masks] will buy us another week."
"What I understand is we had three million masks that were stopped by U.S. officials coming out of 3M in South Dakota."
"I just was briefed not long ago saying we were able to get 500,000 N95 masks moving forward that should be released today coming into Ontario."
Ontario Premier Doug Ford

Pushing back against orders from the White House to stop its export of surgical-grade face masks to Canada and Latin America -- equipment critical to the effort to control COVID-19 -- 3M, which manufacturers protective medical gear and sells their products to Canada, is contesting White House orders. Defiance against U.S. President Donald Trump's refusal to allow medical equipment to leave the United States has consequences for the company, but the Trump order also has consequences for the United States. Firm neighbours and trade partners do not abandon the need of neighbours by reserving vital emergency supplies exclusively for themselves.

As a "critical supplier" of the N95 respirators among other badly-needed emergency medical supplies, the company pointed to the "significant humanitarian implications" inherent in denying protective equipment to health-care workers as they man the front lines of a struggle against a global pandemic. The reminder to the Trump administration that there was a long-standing agreement between the two countries on trade, much less a more recent one occasioned by the COVID emergency to maintain the movement of goods, services and commerce across the border, was a lesson in diplomacy.

The fact is that U.S. manufacturers of medical equipment are in turn dependent on materials sourced from Canada to manufacture their products. As in the case of a Nanaimo, British Columbia mill that makes a special recipe of pulp for surgical masks, gowns and other medical supplies which has had to double  its production for American customers amid the COVID-19 crisis. According to Harmac Pacific president, Levi Sampson, round-the-clock mill production was diverted to make the medical-grade pulp.
“We’ve never had a doubling for this grade of pulp, so you can tell that there’s some supply problems out there. Every day it seems to be more and more health-care professionals are talking about either lack of supplies or worried about it in future", noted Mr. Sampson. As he also noted that his 300 full-time workers at the mill take tremendous pride that the product they're producing is so vital to the medical community in its fight against the scourge of the global pandemic.

Well over a million confirmed cases of COVID-19 have surfaced in short order around the globe, with in excess 60,000 deaths, of which 7,000 deaths occurred in the United States alone; far greater numbers in Spain and Italy, the virus hot-spots of Europe. There is no country in the world, developed and wealthy or developing and hobbling along that hasn't been stricken with the virus, and that find themselves short on medical supplies and personal protective equipment for their medical staff.

A World Trade Organization study found that China, Germany and the U.S. together produced 40 percent of all exports of personal protective equipment in 2018, inclusive of masks, and soap, sanitizer and protective goggles. In addition to which the U.S. holds roughly16 percent of the export market for ventilators and respirators, second to Singapore, at 18 percent. Today, U.S. President Donald Trump announced a deal with 3M to produce over 166 million masks and the company confirmed that both Canada and Latin America would continue to receive N95 respirators.

The 166 million masks that 3M committed to producing for the U.S. market, will be imported from China, from 3M's manufacturing sites located there (“3M will import 166.5 million respirators over the next three months primarily from its manufacturing facility in China, starting in April”). The products produced in the United States by 3M on the other hand, will be exported under the agreement, to Canada and Latin America.

"The Administration is committed to working to address and remove export and regulatory restrictions to enable this plan. The plan will also enable 3M to continue sending U.S. produced respirators to Canada and Latin America, where 3M is the primary source of supply." Warning, the U.S.Administration under the Trump White House has a penchant for surprises and off-the-cuff 'solutions' to pressing problems that confound rational thinking.

"I am very pleased that a resolution has been reached between 3M and the U.S. administration. I want to thank 3M and officials on both sides of the border for their support to ensure Canada’s continued access to vital PPE", was Ontario Premier Doug Ford's last, relieved comments. Leaving President Trump to hug himself with self-congratulations for once again exercising his very special deal-making skills as outlined in his book "The Art of the Deal", where he doesn't mind gambling with life-and-death situations in search of a 'deal'.

The Taut Front Lines

"There are places that have shortfalls, there are decisions being made because we don't have the supply, period. Nobody at the moment has an understanding, a full Canadian understanding of how much PPE [personal protection equipment] is in stock at each facility."
"For every one patient who is on a ventilator, for every single day, you're talking somewhere in the order of hundreds of pieces of PPE when you add up the gowns, the gloves, the masks."
"When the prime minister says they have all this supply coming, how is it going to be distributed? How are they going to figure out where the need is? they have no idea, because nobody has done that work."
"We've started that work here; we're working on that frantically to figure that out. We're all on edge. This feels like the Viking ships are on their way, we don't know how many ships there are, we know that when they arrive they're going to pillage, destroy. We don't know how much we're going to be able to fend them off."
"We're just hoping they're just sending one ship, and we've got enough people to battle them. We just don't know."
Dr.Andrew Morris, infectious diseases specialist,Sinai Health System/University Health Network, Toronto

Doctors treat COVID-19 patients in an intensive care unit in Rome, Italy. Antonio Masiello/Getty Images

The community is agitated and concerned; no one wants to become infected with the novel coronavirus and most everyone is following recommendations to self-isolate, to practise great caution, to maintain a two-metre distance from others, to religiously wash and soap their hands for a protracted scrub, to be vigilant about what they come in contact with. The news -- all the news, everywhere -- is suffused with updates on the lightning speed of infection and the number of hospitalizations, much less deaths from respiratory collapse.

And then there are the health professionals, both doctors and nurses and others, those engaged in cleaning the hospital environment to make every effort to reduce the chances of a silent, lurking virus invading the closest human body, to replicate and to re-infect endlessly in a spiral of mass infection. Medical staff are in close contact with the ill; their profession demands it of them to serve the needs of the sick, leaving medical personnel in a moral quandary; what about their personal obligation to their own longevity, to their families?

Everything is hugely complicated by the fact that hospitals have insufficient personal protection equipment for their staff, leaving them vulnerable to infection while they tend to the needs of those infected. The rate of death of clinicians, of attending physicians, of caring nurses, of paramedics has astonished and frightened everyone in the medical fraternity. They are more exposed, the viral load they may be infected with may account for their increased mortality. This is their profession, one they are proud of and protective of. At a new, harrowing cost.

"Physicians may be permitted in exceptional circumstances to refuse to practice if they reasonably believe that the work environment creates a legitimate unacceptable hazard that is not inherent to their ordinary work."
"As always, members should document their rationale for decisions under crisis situations to assist in the event of medical-legal difficulties."
Canadian Medical Protective Association

"I think what [doctors are] really concerned about is, 'do I have the guidelines to make proper decisions and do I have the support structure to make an unthinkable rationing decision of two patients, and one ventilator."
"What they're looking for now is really some guidance, some standards on how to make those decisions should they be forced to do so."
"[Doctors] have questions about the reuse of protective gear, questions about what's appropriate with respect to the use of  homemade gear."
"Physicians can't refuse to see patients who are ill or who have an infection, but there would be some expectation that they would have the appropriate gear to be able to complete their task."
"And so that's what we're telling physicians, but that doesn't necessarily go far enough. Because at the end of the day, the building is still burning, patients are still sick and they need to be cared for and physicians feel that tremendous obligation to care for them."
"So it's really putting the doctors in a very difficult position, because they're concerned about their patients, they're concerned for their own health. They're concerned about transmitting the infection back to their family. And they're concerned about asymptomatic spread."

Dr.Todd Watkins, associate executive director, Canadian Medical Protective Association

Thanks to the new pestilence that is upon the world, and the many unknowns related to it, and its
virulence, medical professionals now have conversations with themselves that they never before contemplated having to indulge in, as introspection goes. How much exposure should they permit themselves given the very real risk of morbidity? Two nurses in New York City have died so far. "Doctors are getting sick everywhere", stated William P.Jaquis, president of the American College of Emergency Physicians.

Italy's experience has been telling. A first-world country with a first-rate medical system that has been overwhelmed by a firestorm of an infection rate that has exhausted them physically and psychologically, while taking a dreadful death toll of the medical community, on the verge of collapse. No fewer than 4,824 health-care workers were infected with the virus at last week's count, with 61 doctors having perished. That dread experience has informed Canadian doctors what the future may resemble for them, as well.

"My friends in Italy and Spain didn't seem to wrestle with it as much. We're a little less focused on the individual well-being here and more supportive of the social contract where we look out for each other."
"I just think Canadian doctors will be less likely to consider staying home if help is needed on the front lines of this battle."
Dr.Anand Kumar, critical care doctor, Winnipeg

A robot operated by medical teams helps treat patients suffering from COVID-19 in the Circolo hospital in Varese, Italy. Flavio Lo Scalzo/Reuters

In today's Canada where hospitals are concerned over their lack of equipment and doctors are exhausted before the real crush in intensive care units have even surfaced, doctors are isolating themselves, determined to avoid taking the novel coronavirus back to their families at home. The necessity of having to ration personal protective equipment places medical staff at higher risk of becoming infected themselves. And the scarcity of mechanical ventilators is the stuff of nightmares where doctors may be forced to make choices no one can morally contemplate.

To avoid over-use of PPEs, staff have begun using cellphones and baby monitors in communication with infected patients, hoping to limit face-to-face contact with the attendant need to fully suit up, using up scarce personal protective equipment. According to Public Services and Procurement, the federal government has placed on order 157 million surgical masks, 60 million N95 masks and 1,470 ventilators, while hoping to source even greater numbers.

Nightmare scenarios of having to decide in crisis situations whom to extend heroic care for, and whom to leave, haunts the medical profession, with the legal and ethical issues inherent in such dramatic decision-making. There's a brief window "during which they can be saved" reads an article published in the New England Journal of Medicine, when a patient's breathing deteriorates to the point where a ventilator is required. Should the ventilator be withdrawn the person will die within minutes.

"Unlike decisions regarding other forms of life-sustaining treatment, the decision about initiating or terminating mechanical ventilation is often truly a life-or-death choice." Should the  young leapfrog the old? How much time is given someone to recover before life support is removed? COVID-19 has become a global pandemic,"and the sad fact of the matter is that in most health systems around the world, physicians, nurses, health-care providers have limited-to-no access to personal protective equipment", noted Dr.Ross Upshur of the University of Toronto Joint Centre for Bioethics.