The overwhelming number of coronavirus patients flooding hospitals across the U.S. has resulted in a shortage of ventilators for those experiencing difficulty breathing. But while President Trump has faced criticism from states, like New York, for the short supply, federal agencies have been predicting the need for more ventilators for nearly two decades. Reports from various government offices have been sounding the alarm over the course of at least three successive presidencies dating back to the George W. Bush administration. “GAO found that most hospitals lack the capacity to respond to large-scale infectious disease outbreaks,” concluded the U.S. Government Accountability Office in a 2003 report after the SARS outbreak, noting that “few hospitals have adequate medical equipment, such as the ventilators that are often needed for respiratory infections such as SARS, to handle the large increases in the number of patients that may result.” A 2005 Congressional Research Service report examining avian flu also noted that the U.S. was unlikely to be prepared for a pandemic due to that virus’ effect on the lungs. “If this strain were to launch a pandemic and retain this trait, large numbers of victims may require intensive care and ventilatory support, likely exceeding national capacity to provide this level of care,” that report said. “In any event, such specialized care is not available in most developing countries, and access to it is uneven within the United States.” Later that same year, the Department of Health and Human Services released an extensive report on the plan for an influenza pandemic. A key item on their list of actions to take for a “health care and emergency response” was to “assess surge capacity” of medical systems including ventilators, noting the necessity for maintaining an emergency stockpile. “Despite planning and preparedness, however, in a severe pandemic it is possible that shortages, for example of mechanical ventilators, will occur and medical care standards may need to be adjusted to most effectively provide care and save as many lives as possible,” the report warned, noting the likelihood of a significant increase in the demand for ventilators in the event of a large-scale outbreak. The need for ventilators – and other resources – is repeatedly discussed in this report, even referencing a CDC spreadsheet that could help predict the potential need for ventilators at different stages of a pandemic. A CNN report last week detailed a number of these internal government reports. The mounting problem after nearly two decades of warnings, however, is not simply the product of a problem ignored. The government accepted bids from companies in 2008 planning to buy tens of thousands of additional ventilators for the stockpile after swine flu, avian flu, SARS, and MERS revealed the need. According to a New York Times report, the federal government contracted the small Japanese company Newport Medical Instruments to develop and produce inexpensive ventilators that the U.S. would purchase. Years later, after prototypes were developed, Newport was bought out by Covidien in 2012, and the project ground to a halt. By 2014, Covidien wanted out of the contract, former federal officials told the Times, and the government agreed to cancel it. A year later, Covidien was purchased by Medtronic, which told the Times that the ventilators Newport was developing would not have been usable on newborns and would have fallen short of the government’s requirements. The government entered into a new contract with Philips in 2014, and finally ordered 10,000 ventilators in December 2019, with delivery expected later this year. “We definitely saw the problem,” Dr. Thomas R. Frieden, CDC director from 2009 to 2017, told the Times. “We innovated to try and get a solution. We made really good progress, but it doesn’t appear to have resulted in the volume that we needed.” Meanwhile, reports sounding the alarm continued to pile up while that effort stalled. In 2006, the Congressional Budget Office warned that in the event of a flu pandemic on the level of the 1918 Spanish flu, the U.S. would be grossly underprepared when it comes to ventilators. The CBO noted that at the time there were an estimated 100,000 ventilators in the country, but “a severe influenza pandemic like the one in 1918 would require 750,000 ventilators to treat victims.” A 2007 flu pandemic plan published by the Department of the Interior also noted that in such an event: “A substantial percentage of the world’s population will require some form of medical care,” and that medical facilities would likely be “ overwhelmed, creating a shortage of hospital staff, beds, ventilators and other supplies.” Similar language was used in a 2009 OSHA report for influenza pandemic preparedness that also referred to instructions from the Department of Health and Human Services and the CDC for estimating the demand for ventilators and other equipment in the event of pandemics of varying scales. The same year, a report on preparedness for swine flu from the President’s Council of Advisors on Science and Technology warned then-President Barack Obama that “[c]ases requiring mechanical ventilation or intensive care could reach 10 to 25 per 100,000 population, requiring 50 to 100 percent or more of the total ICU capacity available in the United States and placing great stress on a system that normally operates at 80 percent of capacity.” In 2013, an avian flu outbreak in China led to a report from the National Institutes of Health on the demand for ventilators in the event of a flu pandemic. “There is a clear challenge to plan and prepare to meet demands for mechanical ventilators for a future severe pandemic,” the report said, estimating that in a “high severity scenario,” the U.S. would need “approximately 35,000 to 60,500 additional ventilators.” The Trump administration was also warned, as a June 2017 CDC report discussed the agency-managed Strategic National Stockpile (SNS) of ventilators, stating that “SNS ventilators might not suffice to meet demand during a severe public health emergency.” In 2006, the American Association for Respiratory Care recommended that the SNS increase its ventilator inventory to between 11,000 and 16,000. Earlier this month, Dr. Anthony Fauci told CNN that the stockpile currently has 12,700 ventilators. This is up from roughly 4,000 in 2006. Now that the country is in the midst of the coronavirus pandemic, the government is pushing for speedier delivery of the ordered ventilators that had been expected later on this year, as well as looking to other manufacturers for additional machines. General Motors has been working with medical device company Ventec Life Systems and parts suppliers to build more ventilators, and Trump invoked the Defense Production Act when he felt they were not moving fast enough. GM expects to produce ventilators at a rate of 10,000 per month starting in mid-April. Ford has announced that they and General Electric are also working together to produce “a simplified version” of an existing GE ventilator.