“India lost around five weeks in the production capacity of PPEs. If we would have been provided with the specifications and the basic numbers of stockpiling required, we would have set targets and managed accordingly.”Sanjiiiv, Chairman of the Preventive Wear Manufacturer Association of India At a time when healthcare workers are repeatedly raising concerns about their lack of access to personal protective equipment, or PPE kits, there are several questions that have arisen about whether the Modi government has handled this aspect of the health crisis adequately.Over the past week, there have been various reports of doctors resorting to wearing raincoats, helmets and other alternatives due to the shortage of PPE kits.PPEs, Masks: How Protected Are India's Frontline Medics?To understand the measures currently being undertaken by PPE manufacturers to overcome this shortage, as well as the difficulties they are facing due to the lockdown and other circumstances, The Quint spoke to Sanjiiiv, the Chairman of the Preventive Wear Manufacturers Association of India (PWMAI).Both the PWMAI and Sanjiiiv have been working closely with the Centre in resolving the problems around shortage of PPEs.‘India Lost Around 5 Weeks’: Centre’s Delayed ResponseThe first concern around the shortage of PPEs was the delayed response by the Centre in countering the problem.PPE manufacturers including Sanjiiiv say they had contacted the health ministry in February and urged the government to stock up on PPE kits. But they say they did not receive any response from the Centre.Sanjiiiv: We never received a mail till 21 March. If the government had replied and provided the specifications by around 21 February instead, then we would have been able to make adequate arrangements.Would you say there was a delay in the government’s response to the crisis in terms of shortage of PPEs?SC Seeks Centre’s Stand on Plea for WHO-Graded PPE for MedicosSanjiiiv: Yes. It could have happened somewhere around 15 February. If that had happened, we wouldn’t have seen this problem (regarding the shortage of PPEs).As this is not a regulated sector, manufacturers don’t have any set guidelines as to what has to be followed under such outbreaks. So, we need to look forward to our government as to what they are saying, about what we have to make.As a result, nobody was coming up with a stockpile.At the end of the day, all of the manufacturers are businesspersons first. So they would look forward to having some sort of guidelines so they can come up with products which match those guidelines. And then they can stockpile. These guidelines were issued on 24 March, but before that the demand had started pouring in already.From when did you see the demand rising rapidly?Sanjiiiv: From around 5 to 8 March, tenders from state governments, Army hospitals, railway hospitals, those started flowing in.The Health Ministry has not responded to The Quint’s requests for a comment or clarification regarding these allegations of a delayed response by the Centre.The TimelineOn 31 January, India banned exports of all kinds of personal protection equipment, including clothing and masks used to protect people from air borne particles.However, around a week later, on 8 February, the restrictions were relaxed to allow shipments of surgical and disposable masks and some gloves.On 27 February, WHO guidelines noted, “The current global stockpile of PPE is insufficient, particularly for medical masks and respirators; the supply of gowns and goggles is soon expected to be insufficient also. Surging global demand − driven not only by the number of COVID-19 cases but also by misinformation, panic buying and stockpiling − will result in further shortages of PPE globally.”The Ministry of Textiles acknowledged shortages in a 18 March meeting, according to minutes seen by Reuters. India needed some 7,25,000 coveralls and 60 lakh N95 masks but "the rate of supply is not able to meet the rising demand", the ministry said in the document.On 19 March, the Centre issued a notification prohibiting the export of domestically manufactured PPEs as well as raw material for the same.Rahul Criticises ‘Delay’ in Banning Export of Ventilators, MasksLockdown Woes for PPE ManufacturersAccording to the World Health Organisation (WHO), PPE includes gloves, medical masks, goggles or a face shield, and gowns, as well as for specific procedures, respirators like N95 masks and aprons. Certain parts, like the overalls, are not usually required in the large numbers that are being demanded now.Sanjiiiv: If we’re talking about cover-alls or overalls, this is not a product which sells regularly. It is not even a seasonal product. This is something that sells (in large quantities) when there is an outbreak. Manufacturers were preparing for the crisis, but again, because this is not a regulated sector, they did not know what the requirements were.So when did the government spell out these specifications that the manufacturers needed?Sanjiiiv: On 24 March.[On the same day, Prime Minister Narendra Modi addressed the nation at 8 pm and announced a countrywide lockdown from 25 March, the very next day. The lockdown has amplified the woes faced by the PPE manufacturers.]Sanjiiiv: The conditions the government has come up with are virtually impossible for the manufacturers to follow due to the lockdown.You’re saying it’s a problem to even manufacture during the lockdown?Sanjiiiv: Of course, yes.We have around 20 manufacturers with a standard fabric and standard design, and without a lockdown, the cumulative output would be around 25,000 PPE kits a day. Due to the lockdown, their problems have intensified because half the labour is also gone. After 10 days, we may have even fewer workers coming in to work.Also, there are lots of components. When we talk about an overall, we’ll be needing non-woven, zippers, elastic. When we get permission for the non-woven manufacturer to operate, they’ll need permission for polymers, mechanics, parts. Under the lockdown, it is very difficult to get so many permissions. It is very tough.Has the government thought this through then?Sanjiiiv: The Central government has been listening to our problems and routinely coming up with revised guidelines. They are definitely helping us. But at the level of the local administration, there are still a lot of problems faced. For example, to obtain the requisite pass, if I have to go to the local authority, on the way, I am repeatedly stopped by policemen who are not ready to listen, that is the problem.Despite Reaching Home, Migrant Workers’ Problems Far From OverRajiv Nath, Forum Coordinator of the Association of Indian Medical Device Industry (AiMed), echoed Sanjiiiv’s concern, “We hope that the local administration of the town level DC/DM/police will facilitate (our efforts) as India cannot afford closure of any factories especially of PPE and masks, gloves and sanitizers.”Sanjiiiv: Till around 20 March, there was no panic situation. Those asking for PPEs were getting something from manufacturers - like gowns and all. But as soon as the guidelines came on 24 March, the manufacturers said that “we cannot supply this (immediately)“, then there was a problem. Now, what is available will not be purchased because that is not up to the guidelines issued by the Ministry of Health and Family Welfare. And what the government is asking, that is almost impossible for us to do under the lockdown.Doctors Highlight Growing Concerns About Lack of PPEsAt the moment, medical staff lack sufficient masks, gloves and coveralls, complained the United Resident & Doctor's Association India (URDA), in a letter addressed to Prime Minister Modi.The association wrote, "Asking a health professional to work without these essentials is like asking a soldier to fight without a gun.”In Bihar, doctors at Patna Medical College and Hospital (PMCH) told The Quint that they have taken to wearing raincoats as protective gear in the absence of PPE kits.In Haryana, Dr Sandeep Garg of ESI Hospital told Reuters that he had been using a motorbike helmet because he did not have any N95 masks.Across the country, there is a sense of concern among healthcare workers about whether they will be provided protective equipment, and if not, how vulnerable would they be while working during this healthcare crisis.For PPE coveralls, gowns, and PPE kits, the capacity reported by the 20 manufacturers of the AiMeD is of over 62.5 lakh pieces per year, that is over 5 lakh pieces per month, said a statement issued by the association on 31 March.But AiMed agreed that even that figure is “now being considered very less in terms of coronavirus preparedness should the disease spike.”What the Centre’s Guidelines SaySanjiiiv: You have to get both your fabric and the final garment tested. Because the manufacturers don’t require this kind of fabric on a daily basis, 90% of them didn’t have it in stock.So now, they will have to request their fabric manufacturers. Also, the manufacturers will not buy it in bulk immediately, because that fabric hasn’t been tested. So, they will be asking for a sample first and then seeking to get both the fabric and the garment successfully tested.The government has specified that the fabric must be fluid-resistant and pass the synthetic blood penetration test. Such fabric is domestically available, that is not a problem.(Read the document outlining the Centre’s guidelines on PPEs here.)A Lack of Clarity, Even NowThe government has centralised acquisition of PPE kits for use by healthcare professionals through the public sector healthcare product manufacturer HLL Lifecare. But there are still aspects on which PPE manufacturers claim there is a worrying lack of clarity.Sanjiiiv: We are asking the government to tell us how many healthcare workers are being planned to be there for the first set of contingency, so that we get an idea that these many healthcare workers are already there on the ground, and we can accordingly prepare for a 15-day inventory.We will then get a fair idea of our production target, and understand if we will be able to achieve that target in around 10 days. If not, then we can rope in other garment manufacturers also. We can send them the standard operating procedures, help them with raw materials, tell them the technicalities which are required to be followed. But for that, we need the numbers, the bare minimum quantities we are looking for as a country.So, as of now, you don’t have clarity on that?Sanjiiiv: That is amiss, yes. If that is there, we can still find a solution.You’re looking towards the government now to provide that?Sanjiiiv: Of course, yes.But why the delay?Sanjiiiv: We are clueless.On 5 March, the demand was of 3 lakh PPEs. On 18 March, it was 7.25 lakh PPEs. On 24 March, it increased to 10 lakh PPEs. So, how do you think any sector, and all these manufacturers are MSMEs - how do you think they will be able to ramp up their production like this? And it is all manual. On top of that, because the lockdown was unplanned, we were not ready with inventories. If we would have been given 48 hours...See what my problem is. Today, we are out of needles. So for that needle vendor, I need permission. How will I explain to the local administration that needle is a core component for me to manufacture? For them, “needle is not a PPE”. We need machine oil, and so much more.COVID-19 Reality Check: Bihar Doctors Wear Raincoats, Use HIV KitsJugaad the WHO Won’t MindWhat happens to the protective equipment that was being manufactured before the Centre’s guidelines on PPEs came in? Are those still being manufactured?Sanjiiiv: We are trying to tell our manufacturers that if they have gowns which are of the medical-grade, non-woven kind, but which are not fluid-resistant as the guidelines require, please do not worry. Please train the healthcare workers and the hospitals to whom you are selling to add a layer of plastic apron, so that the gown can be made impervious.So, in a way, you could call that a kind of jugaad?Sanjiiiv: This jugaad has already been announced by the WHO and the CDC (Centers for Disease Control and Prevention in the US).(The WHO has indeed, in a document titled ‘Rational use of personal protective equipment (PPE) for coronavirus disease (COVID-19)’, said, “Specifically, for aerosol-generating procedures, health care workers should use respirators, eye protection, gloves and gowns; aprons should also be used if gowns are not fluid resistant.”The WHO document also specified, “COVID-19 is a respiratory disease that is different from Ebola virus disease (EVD), which is transmitted through infected bodily fluids. Because of these differences in transmission, the PPE requirements for COVID-19 are different from those required for EVD. Specifically, coveralls (sometimes called Ebola PPE) are not required when managing COVID-19 patients.”)But not all healthcare workers approve of having to make do with “jugaad PPE”.For instance, AIIMS Resident Doctors’ Association general secretary T Srinivas Rajkumar told The Hindu, “We met with the administration on Wednesday (1 April) and requested that all personal protection equipment will have to meet the safety standards prescribed by the Health Ministry and that neither doctors nor other patients should be put at risk of catching the infection. “Jugaad” PPE will not work.”Not just in India, a shortage of PPE kits has forced healthcare workers across the world to use makeshift alternatives. However, from doctors in New York, America’s COVID-19 epicentre, to those in the United Kingdom under the National Health Service (NHS), the concerns being echoed are similar too.Hearing reports of these concerns raised by Indian healthcare workers, PPE manufacturers can’t help but rue the delay in ramping up production.Sanjiiiv: The government invited people from various organisations. . AiMed and PWMAI were working hand-in-hand with the concerned ministries in providing data of face mask manufacturers, we were attending all the meetings – related to health, textiles, etc. All the data of manufacturers was supplied by us. But for PPE technical specifications, they did not invite us. Neither AiMed nor PWMAI was invited.Why is that?Sanjiiiv: That ‘why’ can wait. If we start asking why at this moment, we’ll lose the focus to find the solution to the problem first. We have enough time (later) to discuss that lapse, because time is trickling away.In India’s Coronavirus Pandemic Response, Where Are Helicopters?Suggestions Looking AheadWhat are the steps you would suggest that the governments take now to ensure that enough PPEs can be supplied in time?Sanjiiiv: We are suggesting that the Central government come up with a fresh set of guidelines that clearly state - these are the people who don’t need any PPEs, these are the people who need some PPEs (some parts of the PPE), and these are the people who need full PPEs.We have also been suggesting to our member manufacturers that this is the time to stand with the nation so they should use rational margins. The surge in your selling prices should be equally proportional to the surge in your raw material prices. If your costs on components and raw materials have increased by 20%, that doesn’t mean you should increase your final prices by 30% or 50%.More Questions AriseOn 31 March, the Health Ministry seemed caught unawares when asked to explain how 90 tonnes of medical protective equipment from India had landed in Serbia a couple of days earlier, on 29 March, despite India having banned the export of PPEs with effect from 19 March.At the daily press conference on COVID-19 on Tuesday, Luv Agarwal, joint secretary, Ministry of Health, said he had no knowledge of the consignment, reported Business Standard.The United Nations Development Programme (UNDP) in Serbia had tweeted on Sunday, “The second cargo Boeing 747 with 90 tonnes of medical protective equipment landed from India to Belgrade today.”Even as the concerns and confusion about such steps continue, the Association of Indian Medical Device Industry (AiMed) and the Preventive Wear Manufacturers Association of India (PWMAI) say they are working closely with the government in seeking to overcome the shortage of PPEs.“The government has assured us all possible help and asked AiMeD not to worry about the restrictions imposed in the supply chain of essential commodities like medicines, raw materials, components to make masks, sanitizers, ventilators & other medical devices to the factories due to lockdown as within a short while, the whole supply chain that was there before should be up and running completely unobstructed as far as medical devices are concerned.”AiMed statementFor the sake of India’s healthcare workers, one can only hope that they are successful.(The Quint has reached out to the Health Ministry for comments. This article will be updated if and when they respond.) We'll get through this! Meanwhile, here's all you need to know about the Coronavirus outbreak to keep yourself safe, informed, and updated. The Quint is now available on Telegram & WhatsApp too, Click here to join.