One of the leading producers of rapid tests purged supplies and laid off workers as sales dwindled. Weeks later, the U.S. is facing a surge in infections with diminished capacity.For weeks in June and July, workers at a Maine factory making one of America’s most popular rapid tests for Covid-19 were given a task that shocked them: take apart millions of the products they had worked so hard to create and stuff them into garbage bags.Soon afterward, Andy Wilkinson, a site manager for Abbott Laboratories, the manufacturer, stood before rows of employees to announce layoffs. The company canceled contracts with suppliers and shuttered the only other plant making the test, in Illinois, dismissing a work force of 2,000. “The numbers are going down,” he told the workers of the demand for testing, saying it wasn’t their fault. “This is all about money.”As virus cases in the U.S. plummeted this spring, so did Abbott’s Covid-testing sales. But now, amid a new surge in infections, steps the company took to eliminate stock and wind down manufacturing are proving untimely — hobbling efforts to expand screening as the highly contagious Delta strain rages across the country.Demand for the 15-minute antigen test, BinaxNOW, is soaring again as people return to schools and offices. Yet Abbott has reportedly told thousands of newly interested companies that it cannot equip their testing programs in the near future. CVS, Rite Aid and Walgreens locations have been selling out of the at-home version, and Amazon shows shipping delays of up to three weeks. Abbott is scrambling to hire back hundreds of workers.America was notoriously slow in rolling out testing in the early days of the pandemic, and the story of the Abbott tests is a microcosm of the larger challenges of ensuring that the private sector can deliver the tools needed to fight public health crises, both before they happen and during the twists and turns of an actual event.BinaxNOW, a rapid antigen test made by Abbott, can provide results in 15 minutes.Abbott, via Agence France-Presse — Getty Images“Businesses crave certainty, and pandemics don’t lend certainty to demand,” said Stephen S. Tang, chief executive of OraSure Technologies, which in the midst of the testing slump in June received emergency F.D.A. authorization for its own rapid test, InteliSwab, long in development. But the company is not yet supplying retail stores.Meanwhile, Dr. Sean Parsons, chief executive of Ellume, the Australian manufacturer of a competitor rapid test, said this week that demand was 1,000 times greater than forecast and the company was racing to set up a U.S. plant. Abbott’s decisions have ramifications even beyond the United States. Employees in Maine, many of them immigrants from African countries, were upset at having to discard what might have been donated. Other countries probably could have used the materials, according to Dr. Sergio Carmona, chief medical officer of FIND, a nonprofit that promotes access to diagnostics.“This makes me feel sick,” he said of the destruction, noting that more than a dozen African nations have no domestic funds to buy Covid tests.In an interview, Robert B. Ford, Abbott’s chief executive, argued that the discarded materials — finished test cards — should not be viewed as tests. Kits for sale also include swabs, liquid buffer and instructions. “I would just caution in terms of using the word ‘destroy’ because it kind of gives a sense here that we’ve got all these tests that were in packages and we threw them away,” he added.Asked why the materials needed to be thrown away, Mr. Ford cited a limited shelf life. But photographs of some of the estimated 8.6 million Abbott test cards that employees said were shredded show expiration dates that were more than seven months away.Workers had their own conjectures. Some figured layoffs were imminent and there would be no employees left to dispose of the excess, while others thought the company did not want to flood the market and decrease the value of its product: A box of two home tests carries a retail price of $20 to $24.As for donating BinaxNOW, it is a U.S. product that is not registered internationally, Mr. Ford said. “We couldn’t just ship it there.” But he acknowledged that the company did in fact send a million tests to India in May, paid for by the U.S. government.Dr. Mariangela Batista Galvao Simao, an assistant director general at the W.H.O., said the agency was not made aware of the BinaxNOW surplus. While some countries might have had regulatory barriers, the W.H.O. “would have worked to facilitate whatever is needed.” Donating tests would probably have required considerable extra work for Abbott, she added.Addressing the challenges ahead in the U.S., Abbott’s public affairs director, Aly Morici, said in an email that it was “difficult to scale up on a dime, but we’re doing so again.” She acknowledged that “there will be some supply constraints over the coming weeks.”Abbott invited workers back to the plant in Maine this month to meet what it described in a letter as “unexpected manufacturing needs.” But it is unclear how many employees will return. They would forgo weeks of being paid for doing no work, as provided for in their severance packages, with only a two-week “thank you” pay extension and no guarantee that their jobs will last.The company was not in this position in early 2020. Anticipating the need for quick, reliable tests that required no specialized equipment, Abbott assembled a team of about 100 scientists, supply-chain experts and engineers to design BinaxNOW in a highly compressed time frame. “Everybody was working nonstop,” Mr. Ford said. “This is ultimately what Abbott was built for.” The test strip, resembling the one on a pregnancy stick, is less sensitive than PCR but delivers results on the spot, allowing a company or school to take immediate action.The F.D.A. granted BinaxNOW emergency authorization last August. A day later, the U.S. government announced plans to buy 150 million of the tests for $760 million — $5 a test, plus shipping — to be used in settings including nursing homes and schools.Friendship Public Charter School in Washington received 20,000 government-purchased BinaxNOW tests free of charge as part of a pilot program supported by the Rockefeller Foundation. Patricia A. Brantley, the school’s chief executive, said that 70 percent of students’ parents opted in for them to undergo weekly testing. Children as young as 3 submitted to a swipe in the nose in exchange for a sticker. “Testing is still an important part of the strategy not only to reopen schools but to keep them open,” Ms. Brantley said.Northwestern University also adopted BinaxNOW early, testing students twice a week. The university performed up to 5,000 rapid tests a day, according to Luke Figora, the school’s vice president for operations.After the F.D.A. authorized BinaxNOW for at-home use, Northwestern bought 150,000 kits, handing them out to students, faculty and staff. “We wanted to give them one more tool to stay safe,” Mr. Figora said. Abbott met its initial production goals by keeping manufacturing lines running 24 hours a day and emphasizing speed to an extent that some employees said made them uncomfortable.On a January conference call, investors learned the hard work was paying off: Abbott had sold $2.4 billion in coronavirus tests, mostly rapid ones, in the final quarter of 2020. “I expect testing demand is still going to remain high, even as the vaccines roll out,” Mr. Ford said on the call.“The big point here is the sustainability of this.”For a while, it appeared he would be right. In March, the federal government announced $10 billion to support testing in schools. By April, Abbott had reaped another $2.2 billion in testing sales. The same month, the F.D.A. extended BinaxNOW’s shelf life, originally six months, to a year.But then the C.D.C. came out with a game-changing announcement: Vaccinated people without symptoms no longer needed to be tested, even after exposure.“We couldn’t have anticipated what has occurred over the past several weeks,” Mr. Ford told investors on another call, describing “a sharp and rapid decline in demand,” particularly for rapid tests, and dropping the company’s earnings forecast.“Are you not thinking that there’s going to be any kind of, you know, resurgence or ramp-up of screening testing in the fall?” Matt Taylor, a managing director at UBS, asked on the call. “What are you to do with all the capacity that you’ve built up?”The destruction that followed lasted about a month. A list of “lots to be destroyed” appeared on a white board at the plant in Westbrook, Maine, and some of those batches had recently been labeled with new expiration dates.Boxes of BinaxNOW test cards that employees said they were told to destroy. A board indicating lots to be purged.An expiration date in February next year. Several employees, not authorized to speak on behalf of the company, said they were told to eliminate 25 lots of about 345,000 test cards each at the Westbrook factory. Mr. Ford would not confirm that number.Test pouches were dumped onto tables, one former employee, Steven Hall, recalled. “Some people ripped them open singly, and some people used the scissors and did four or five at a time,” he said. They stuffed foil wrappers and desiccant packets into trash bags and boxed the test cards for shredding.Test cards in Maine that were to be put through a shredder.As the Delta variant drives a new appreciation for screening programs, and the C.D.C. again recommends testing vaccinated people who are exposed, Abbott’s inability to meet demand is causing pain in the business world.The U.S. Rapid Action Consortium, which buys BinaxNOW on behalf of more than a dozen workplace testing programs, including Air Canada and Scotiabank, has seen increased interest, according to Darren Saumur, chief operating officer at Genpact, a founding member. But when the group asked to bump up its purchases, an Abbott sales representative said that she could only provide what was already committed, adding that the company had been unable to fulfill 14,000 requests from new clients, Mr. Saumur said. (Abbott declined to comment on the figure.)The group’s negotiations with Abbott to lower the cost of the tests were also halted. “The price points we were talking about they definitely don’t want to talk about anymore,” Mr. Saumur said.For many Abbott employees, especially those from African countries, the most troubling aspect was the waste of it all. “I was hurting, seeing that,” said Aristoteles Landa, a worker from Angola.Abbott representatives said the company was able to meet demand for its rapid Covid tests outside the U.S. through sales of a South Korean-manufactured version called Panbio.Last fall, the W.H.O. approved that test for emergency use, and the Global Fund committed an initial $50 million to allow low- and middle-income countries to buy Panbio and another company’s test at a maximum price of $5 each (a malaria test based on similar technology sells for about $0.20). A coalition of international organizations announced a goal of securing a half-billion tests within the year.But more than 10 months after the announcement, only a fraction of that number — under 60 million — has been procured under the plan, according to the W.H.O., with cost being one constraint.Amal Barakat, a virologist at the W.H.O.’s Eastern Mediterranean regional office, shook her head when she heard about the destruction in Maine. “My heart,” she said, “it hurts.”Students at College des Saints Coeurs Ain Najm in Lebanon. The W.H.O. has had trouble buying tests for schools in the country.Mohamed Azakir/ReutersIn many countries, Dr. Barakat said, “we can’t fulfill all their demand.” Lebanon recently requested rapid tests for children in schools, she said, but her agency lacks the funds to procure them. Laboratories there were importing “whatever,” regardless of regulatory status.She dismissed the idea that the test could not go to other countries because it had not been approved. “This is just paperwork,” she said.Emily Anthes contributed reporting.

While ventilator shortages have been largely averted in the U.S., this lifesaving therapy is scarce. How to choose which critically ill patients get it?During a surge of coronavirus cases at Houston Methodist Hospital last summer, a patient in his 40s on a ventilator was declining. There was one more option, a last-resort treatment that can mechanically substitute for badly damaged lungs.But that day, the slots designated for the intensive treatment, called ECMO, were filled. One patient, a man a decade older, had been receiving the therapy for over a month. Doctors had concluded he had almost no chance of recovery, and had recommended several times stopping the treatment, but his relatives were not ready to let him go.“We have to push some more,” said Dr. Sarah Beshay, a critical care physician, because the younger patient “needs a chance too.”That afternoon, she called the older man’s daughter, who had not been allowed to visit because of Covid restrictions. Explaining that the therapy was in scarce supply, the physician said, “It’s a matter of using the available resources in the wisest way possible.”The daughter interrupted, bluntly asking if the doctors were trying to remove the equipment from her father to give it to someone else. Dr. Beshay said no, adding that it was a physician’s duty to inform a family that persisting with treatment was “not the right thing from a medical perspective” when chances of recovery were minimal.The next day, the family agreed to withdraw ECMO and he died. A day later, two patients were successfully taken off the treatment after improving, and others started on it, including the man in his 40s. A month later, however, doctors were having a difficult conversation with his family.Throughout the pandemic, such scenes have played out across the country as American doctors found themselves in the unfamiliar position of overtly rationing a treatment. But it was not ventilators, as initially feared: Concerted action largely headed off those shortages. Instead, it was the limited availability of ECMO — which requires expensive equipment similar in concept to a heart-lung machine and specially trained staff who can provide constant monitoring and one-on-one nursing — that forced stark choices among patients.Doctors tried to select individuals most likely to benefit. But dozens of interviews with medical staff and patients across the country, and reporting inside five hospitals that provide ECMO, revealed that in the absence of regional sharing systems to ensure fairness and match resources to needs, hospitals and clinicians were left to apply differing criteria, with insurance coverage, geography and even personal appeals having an influence.“It’s unsettling to have to make those kinds of decisions,” said Dr. Ryan Barbaro, a critical care physician in Michigan and head of an international registry of Covid-19 patients who have received ECMO — short for extracorporeal membrane oxygenation — about half of whom survived hospitalization.“Patients died because they could not get ECMO,” said Dr. Lena M. Napolitano, co-director of the Surgical Critical Care Unit at the University of Michigan. This spring, she was overwhelmed with requests to accept patients considered good candidates for the therapy. “We could not accommodate all of them,” she said.And despite the progress the United States has made against the virus, some doctors are still having to ration ECMO, which is offered in less than 10 percent of hospitals.“It’s something we’re balancing every day,” said Dr. Erik Eddie Suarez, a cardiovascular surgeon at Houston Methodist. If the hospital accepts too many Covid patients for ECMO, he said, “we can’t do cardiac surgery,” because some of those patients also need the treatment.Dr. Erik Eddie Suarez, center, a cardiovascular surgeon at Houston Methodist Hospital, was among those who faced impossible choices about whether to put patients on ECMO.Erin Schaff/The New York TimesOf the more than 185 million known coronavirus cases worldwide since December 2019, close to 8,000 patients have received ECMO to date, including nearly 5,000 in North America, according to a registry maintained by the Extracorporeal Life Support Organization.Among them were a family doctor and a police sergeant nearing death in Southern California whose cases demonstrate both the promise and the clinical and ethical challenges of the therapy.Dr. David Gutierrez, 62, cared for patients with the coronavirus in a high desert town northeast of Los Angeles before catching it last winter. But the hospital where he was gravely ill did not offer ECMO, and others nearby that did were full or would not take him. “My father had no options,” said Dr. David Gutierrez Jr.The elder Dr. Gutierrez was beyond the age cutoff established by Providence Saint John’s Health Center in Santa Monica, Calif., during the coronavirus surge and had underlying health conditions that decrease ECMO’s chances of success. Physicians there accepted him in January anyway, partly because of the risks he had taken caring for patients, said Dr. Terese Hammond, head of the intensive care unit. During the peak, the hospital had 11 Covid patients on ECMO at one time; as of Sunday, it had three.Dr. Terese Hammond, right, head of the I.C.U. at Providence Saint John’s Health Center in Santa Monica, Calif., celebrating a patient’s improvement.Isadora Kosofsky for The New York TimesDuring surges there and elsewhere, securing a precious ECMO slot often required extraordinary advocacy by a patient’s family, colleagues or medical providers.That was the case for the Los Angeles police sergeant, Anthony Ray White, an athletic, 54-year-old father of two with Type 2 diabetes whose department sent him for coronavirus testing after a potential exposure on the job in late December. When he fell ill, he was treated first at a Kaiser Permanente hospital that did not offer ECMO. The medical team there told his family that he would die, that it was time to withdraw care and say goodbye.His wife and sister refused to accept the prognosis. The medical director of the Los Angeles Police Department intervened, persuading the hospital to allow Sergeant White to be transferred to Saint John’s. “They’re my family so I advocate for them,” Dr. Kenji Inaba said of the police department. He said he had pushed to get ECMO for several other officers who almost certainly would have died without it.“A person shouldn’t have to be a police officer or have connections to get health care,” said Twila White, the sergeant’s sister.Finding the ‘Goldilocks’ momentAfter the coronavirus struck China, some doctors there used ECMO to treat Covid-19 patients, but they reported poor outcomes — 80 percent of patients in one Hubei, China, study died. When the disease exploded next in Italy, doctors were overwhelmed and did not try it much. That March, the Swiss Academy of Medical Sciences recommended against giving the treatment to Covid patients.ECMO involves a bedside surgery to connect major blood vessels with equipment that adds oxygen and removes carbon dioxide from the blood before pumping it back to the patient, allowing the lungs or heart to rest. One to two highly trained nurses care for each patient, with respiratory therapists and often with technicians known as ECMO specialists or perfusionists.ECMO, short for extracorporeal membrane oxygenation, adds oxygen and removes carbon dioxide from a patient’s blood before pumping it back in.Victor J. Blue for The New York TimesWhen cases began rising in New York last March, ECMO teams were “flying blind,” said Dr. Mangala Narasimhan, a director of critical care services at Northwell Health, New York’s largest medical system. Unsure of whether to offer ECMO, staff members debated potential risks and benefits.While a course of ECMO often lasts four or five days for respiratory failure, doctors learned that Covid patients could require weeks. “You’ve got to figure out, do they really need it and is it really enough,” Dr. Narasimhan said. Out of roughly 14,000 Covid patients treated in the hospital system during the initial surge — close to 2,500 in intensive care — only 23 were put on ECMO, with about 60 percent surviving, she said.One day last April at Long Island Jewish, a flagship Northwell hospital, Dr. Narasimhan was called multiple times to consider potential ECMO patients. That week, roughly 900 suspected or confirmed coronavirus cases packed a facility whose usual bed capacity was 583. One bad day, 84 patients died.Across the hospital system, seven patients were on ECMO for lung failure; normally there would be one or two. Dr. Narasimhan went to evaluate a 60-year-old with diabetes and heart disease who had Covid and was faring poorly. The physician turned the patient down for ECMO, given the age and underlying conditions.Dr. Narasimhan then discussed a 20-year-old at a hospital roughly an hour away. “The patient’s already dying,” she told a colleague. Team members could go get the patient, but “they don’t think they can get up there fast enough.”Putting a critically ill patient on ECMO requires finding what Dr. Subhasis Chatterjee of Baylor St. Luke’s Medical Center in Houston called the “Goldilocks” moment — not too early, when less intense therapies may still work, but also not too late, when too much damage has occurred.As coronavirus patients flooded Houston Methodist Hospital last summer, officials set a cap of eight Covid patients on the therapy at any time, even though there were additional ECMO devices — in part to reserve capacity for heart surgery patients, and because nurses reported that they could not safely care for more. But the prospect of watching good candidates for ECMO die was excruciating. In mid-July, Dr. Suarez, the cardiovascular surgeon, started a patient on the treatment despite having been told not to because the ceiling had been reached. “The man was dying in front of me, and we had the machine,” he said. The patient survived and made it home. As cases continued to rise, the hospital created a daily process to triage ECMO, which included input from ethicists. Doctors specializing in end-of-life care worked with family members to help prepare them for the possibility that their loved ones would not recover, and they were allowed to visit before a dying patient was taken off ECMO. A patient on the ECMO unit last May at Long Island Jewish hospital, part of New York’s largest medical system.Victor J. Blue for The New York TimesStill, the dilemmas have persisted. Houston Methodist, which has treated 90 Covid patients with ECMO, turned down roughly 120 requests for it just this year, mostly for lack of capacity, according to the head of critical care, Dr. Faisal Masud. He said he expected demand to remain high because of unvaccinated residents and the treatment’s broader utility for lung failure.Dr. Jayna Gardner-Gray, a critical care and emergency physician at Henry Ford Health System in Detroit, said during a surge this spring she kept asking herself how long to keep patients on ECMO when it appeared, but was not certain, that they would never recover. “If no one else was waiting, would I let them go?” she said.Dr. Antone Tatooles works at two Chicago-area hospitals that initially had good success with ECMO. But when one of them took on more Covid patients, survival rates fell. “We got overwhelmed,” he said. “We can apply technology, but we need appropriate human resources.”Outcomes vary widely among hospitals. Overall, however, survival has decreased over time, including at major U.S. and European hospitals. From January to May of 2020, according to the international registry, less than 40 percent of Covid patients died in the first 90 days after ECMO was started. But in the months after that, more than half died. “The patients seem to be doing markedly worse,” Dr. Barbaro said.He and his colleagues are analyzing whether that relates to factors like new virus variants, less experienced centers providing care or changes in the treatments patients receive before ECMO.Who can pay, and who can’tECMO is offered in few community hospitals, where most Americans get care. Saint John’s, the Santa Monica facility where the doctor and police sergeant received the treatment, is an exception.It started an ECMO program about a year before Covid-19 emerged. The 266-bed hospital has provided the therapy to 52 Covid patients during the pandemic, about the same as the entire Northwell health system in New York, which has more than 6,000 hospital and long-term-care beds.The Saint John’s charitable foundation, supported by the area’s wealthy donor base, helped fund the ECMO program and its expansion. The hospital accepted some uninsured Covid patients for ECMO, whereas elsewhere these patients were often turned down despite a federal program that reimburses hospitals for their care.“There are just so many inequities,” said Dr. Hammond, Saint John’s I.C.U. director. And for every Covid patient who survived with ECMO, there are “probably three, four, five people that die on the waiting list.”She and other doctors said the pandemic highlighted the need for ECMO to be made more widely available and less resource intensive. Until then, “we really need to have a system for sharing,” she said. Allocation systems do exist for transplant organs and trauma care.Getting patients moved to a hospital with ECMO often depends on relationships between doctors and having a case manager “who really knows how to push,” said Dr. Michael Katz, a critical care specialist at St. Jude Medical Center in Fullerton, Calif., who has transferred patients elsewhere for ECMO. In multiple cases, he said, by the time a hospital had financially evaluated the patient’s insurance status, it was too late.By contrast, Minnesota’s ECMO centers formed a consortium and issued standard eligibility criteria to help ensure that every patient had “the same shot” at getting the therapy, said Dr. Matthew Prekker, the ECMO medical director at Hennepin County Medical Center. “There weren’t any double standards. No one had to go ECMO shopping.”Centralized ECMO triage systems also exist in Britain and the Paris metropolitan region.Melissa Peters, a speech therapist working with Dr. Gutierrez at Saint John’s. The hospital accepted him for ECMO even though he was beyond its age cutoff for the treatment.Isadora Kosofsky for The New York TimesThroughout the world, the main considerations for selecting patients have been medical ones, and the organization that maintains the ECMO registry offers guidelines. During a surge in cases, individual institutions often tightened the criteria.That mostly involved lowering age limits — as Saint John’s did, moving its cap from 70 to 60 — because the treatment tends to be less successful in older patients.There were some exceptions, like 62-year-old Dr. Gutierrez, who loved Netflix and Korean dramas and was soon to become a grandfather.Dr. Gutierrez had a rocky course on ECMO. Fluid collected around his heart. He bled easily, developed other infections and required kidney dialysis.In February, he improved enough for the medical team to stop ECMO. Still, he faded in and out of consciousness and continued to require a ventilator.Dr. Gutierrez’s daughter, showing a family photo, visited the hospital, as did his wife and son.Isadora Kosofsky for The New York TimesHis wife and his two adult children visited, and other relatives joined a daily prayer call. Over several months, his lungs began to heal. He spoke between huffs, closing his eyes with the effort. Without ECMO, he said, he would probably be dead.In June, medical staff at his rehabilitation facility clapped as he was discharged home in time for Father’s Day. He remains weak, but aims to be treating patients again by January.Dr. Gutierrez celebrated Father’s Day with his family after being released from the hospital. Isadora Kosofsky for The New York TimesSergeant White improved after transferring to Saint John’s for ECMO. Doctors woke him up, and he engaged in video calls with his school-age children and his wife, Tawnya White.But his lungs did not recover, and in late February, he was transferred to U.C.L.A. for a transplant evaluation. To qualify, he had to get strong enough to walk, and test negative for the coronavirus and other infections. He wrote on a white board that he was hoping to “get well for retirement.”Back at their family home in Eastvale, about 50 miles from the city, Sergeant White’s 11-year-old son recalled his father teaching him to play chess. His 15-year-old daughter spoke wistfully of going out for fast food with him after soccer practice. He and her mother would sing as they cooked together, near a sign that read, “This kitchen is for dancing.”Tawnya White visiting her husband, Sgt. Anthony Ray White, at Saint John’s. He improved after being put on ECMO.Isadora Kosofsky for The New York Times“He is a beautiful person with a beautiful heart,” his wife said.Soon he could sit in a chair, and in March, he stood for the first time in months. He even took a few steps, and doctors hoped that his lungs might yet heal.But setbacks chased every milestone. A chamber of his heart malfunctioned. His oxygen levels dipped. He developed an unusual fungal infection.The weeks passed in a painful limbo for Ms. White, who was not allowed to visit. “I go to bed thinking about him, I wake up thinking about him,” she said.At last, in April, the hospital loosened its no-visitor policy. Her husband took her hand, and she read his lips as he tried to speak: “How do I get stronger?”Two days later, Sergeant White had his second consecutive negative coronavirus test. He had finally cleared the infection. But two days after that, his 100th day of hospitalization, doctors told Ms. White her husband was dying. He had developed an aggressive bacterial pneumonia. Within days, he was gone.His wife takes comfort that he was given his best chance at survival. “I’m still at peace that everything possible was done for him,” she said. But she feels it is unfair that was not the case for other patients. “Everyone should have access to everything that Anthony had,” she said.Isadora Kosofsky

Swift mask mandates and travel restrictions, an international treaty and the creation of new bureaucracies are among the recommendations presented to the W.H.O.The next time the world faces an outbreak of a fast-spreading and deadly new pathogen, governments must act swiftly and be ready to restrict travel or mandate masks even before anyone knows the extent of the threat, according to a pair of new reports delivered to the World Health Organization.The studies are intended to address missteps over the past year that led to more than 3.25 million deaths, some $10 trillion in economic losses and more than 100 million people pushed into extreme poverty.“Current institutions, public and private, failed to protect people from a devastating pandemic,” concluded one of the reports, released on Wednesday, which called the Covid-19 pandemic “the 21st century’s Chernobyl moment.”“Without change,” it said, these institutions “will not prevent a future one.”The reviews, released in advance of this month’s meeting of the W.H.O.’s governing assembly, were written by appointees who donated countless hours in the midst of their own countries’ pandemic fights to interview hundreds of experts, comb through thousands of documents, gather data and seek counsel from public and private institutions around the world.Pandemics, the authors concluded, are an existential threat on the order of a chemical or nuclear weapon, and preparing for them must be the responsibility of the highest levels of political leadership rather than only health departments, often among the least powerful of government agencies.N95 masks being decontaminated last spring, when protective equipment was in short supply in the United States.Brian Kaiser for The New York TimesThe reviews also called for nations to provide predictable and sustainable financing to the W.H.O. and to their national preparedness systems.“W.H.O. is underpowered and underfunded by its member states,” Helen Clark, a former prime minister of New Zealand and an author of one of the reports, said at a media conference this week.Whether the recommendations lead to lasting change is an open question. Ms. Clark’s group, the Independent Panel for Pandemic Preparedness and Response, pointedly noted that since the H1N1 pandemic in 2009, there have been 11 high-level commissions and panels that produced more than 16 reports, with the vast majority of recommendations never implemented.These reports “sit closed gathering dust in U.N. basements and government shelves,” said Ellen Johnson Sirleaf, another author of that report, who served as president of Liberia during the Ebola outbreak there in 2014 and 2015.Under the current international health regulations, “there’s no enforcement mechanism,” said Dr. Lothar H. Wieler, president of the Robert Koch Institute in Berlin, who led the second major review, in which scientists scrutinized how those regulations functioned in the pandemic.Both reports supported the creation of an international pandemic treaty that would establish consequences if countries failed to live up to their commitments. Those might include quickly sharing samples and sequences of emerging pathogens, providing rapid access to teams deployed by the W.H.O. for early investigation and response, and ensuring equitable distribution of vaccines, medicine and tests around the world.Both reviews also noted that early in the coronavirus pandemic, many countries all but ignored the formal warning issued by the W.H.O., known as a Public Health Emergency of International Concern. Its unfortunate acronym, Pheic, is often pronounced “fake,” one of the reports noted. (Whether the proposal to change this to “Phemic” will prove more stirring remains to be seen.)The independent panel also concluded that the warning could have been declared at least a week earlier than it was — on Jan. 22, 2020, instead of Jan. 30.Even then, “so many countries chose to wait and see,” only taking concerted action once intensive care beds were filled, Ms. Clark said.Family members said goodbye to a grandmother dying from Covid-19 last year at North Shore University Hospital in New York.Victor J. Blue for The New York TimesHer group contends that if its recommendations on political leadership, financing and surveillance systems had been in place, the coronavirus outbreak would not have become a pandemic. It also said that digital tools, such as those that scrape social media for rumors of new outbreaks, should be better incorporated into official responses.Notably, the panel did not delve into individual countries’ failures in its report, determining that blame would not be “a very useful approach,” said Dr. Anders Nordström, who helped lead the effort.But the group did commission a study of 28 countries with high, medium and low Covid death rates. Some of the countries with the lowest tolls had previously invested in outbreak control systems after experiencing SARS, MERS and Ebola, the report said. Successful countries acted quickly, coordinated across multiple government agencies, meticulously isolated people with the virus and quarantined those exposed to it.The worst performing countries had underfunded, fragmented health systems and “uncoordinated approaches that devalued science.” Those with the highest death tolls, including Brazil and the United States, denied the seriousness of the pandemic and discouraged action, the panel members said in interviews.On some key points, the reports came to different conclusions. The Independent Panel for Pandemic Preparedness and Response argued that the international health regulations governing how countries are supposed to prepare for and report emerging outbreaks “serve to constrain rather than to facilitate rapid action.”A grave prepared in New Delhi last month for a man who died from Covid-19.Atul Loke for The New York TimesBut the other group, which spent months reviewing those regulations, found that many could have helped but were “simply not implemented by various countries,” Dr. Wieler said.Some countries were not even aware that the regulations existed, his group reported. Others lacked laws vital to responding to outbreaks, such as those authorizing quarantines.Changing those regulations would require “negotiations for years,” Dr. Wieler said, noting that the latest set took a decade to finalize. Instead, one of his committee’s major recommendations was to increase countries’ accountability for their obligations, including though a pandemic treaty and a periodic review of their preparedness that would involve other countries.The independent panel also proposed creating an international council led by heads of state to keep attention on health threats and to oversee a multibillion-dollar financing program that governments would contribute to based on their ability. It would promise quick payouts to countries contending with a new outbreak, giving them an incentive to report.“There’s only going to be the political will to create those things when something catastrophic happens,” said Dr. Mark Dybul, one of the panel members. These recommendations stemmed in part from his experience leading the President’s Emergency Program for AIDS Relief, known as Pepfar, and the Global Fund to Fight AIDS, Tuberculosis and Malaria, he said.But Dr. Wieler, who led the other international review, said that in general, creating new institutions rather than focusing on improving existing ones could increase costs, complicate coordination and damage the W.H.O.The recommendations of panels after global emergencies have sometimes been embraced. The Ebola outbreak of 2014 and 2015 led to the creation of the W.H.O.’s health emergencies program, aimed at boosting the agency’s role in managing health crises as well as providing technical guidance. A report released this month noted that the new program had received “increasingly positive feedback” from countries, donors and partner agencies as it managed dozens of health and humanitarian emergencies.The W.H.O. before the Ebola outbreak and after it are “two different agencies basically,” said Dr. Joanne Liu, a former international president of Doctors Without Borders and a member of the independent panel. Dr. Liu was one of the W.H.O.’s most trenchant critics during the Ebola response, and she noted a “marked improvement” in how quickly the agency had declared an international emergency this time.A health worker with a dose of China’s Sinopharm vaccine last week in Colombo, Sri Lanka.Dinuka Liyanawatte/ReutersDr. Liu said her biggest fear was that as wealthier countries gained an upper hand on the virus because of vaccines, they would leave low- and middle-income countries behind, with Covid-19 becoming “a neglected pandemic because they are going to be the only ones fighting it — a bit like H.I.V. and T.B.”To avert that, the panel released a slew of urgent recommendations and called for the world’s entire population to be immunized within a year.Wealthy countries with a good vaccine pipeline should commit to making at least a billion doses available to the poorest countries by September through programs like Covax, a global effort to provide vaccines equitably throughout the world, the group said.

They survived serious cases of Covid-19, sometimes spending weeks on a ventilator, but not without complications. Now, a special clinic at an L.A. hospital is helping them get back to their lives.LOS ANGELES — Three days after being released from Martin Luther King Jr. Community Hospital, Gilbert Torres returned on a stretcher, a clear tube snaking from his nose to an oxygen tank. It was the last place he wanted to be.But Mr. Torres, 30, who had just spent two weeks on a ventilator in the intensive care unit, wasn’t there because his condition had worsened. He was there to visit a new outpatient clinic for Covid-19 survivors, intended to address their lingering physical and psychic wounds — and to help keep them from needing to be readmitted.Several medical centers around the country, including Massachusetts General Hospital, have created similar clinics, a sign of an increasing appreciation of the need to address the long-term effects of Covid. Other hospitals that already had I.C.U. aftercare programs have added large numbers of Covid patients to their rolls: Indiana University Health Methodist Hospital, for example, has treated more than 100. And some institutions, like Providence St. Jude in Fullerton, Calif., have recovery programs that also serve coronavirus patients who were never hospitalized.“We put a thousand percent of our energy into these patients,” said Dr. Jason Prasso, one of the intensive care doctors at M.L.K. Hospital who created the clinic there. “We feel accountable for them getting better even after they leave the hospital.”Dr. Jason Prasso, who treated Mr. Torres in the I.C.U., started the clinic with his colleagues when they realized many of their patients were getting little follow-up care.Isadora Kosofsky for The New York TimesWell before the pandemic, doctors knew that some patients recovering from critical illness developed a constellation of symptoms known as post-intensive care syndrome that can include muscle weakness and fatigue. Depression, anxiety and cognitive impairments arise in about half of people who have spent time on ventilators in an I.C.U., studies suggest. About a quarter of these patients develop post-traumatic stress disorder. The risk is higher among those who have had respiratory failure, long hospital stays and treatment with drugs to sedate or paralyze them — all common in the sickest coronavirus patients.Dr. Prasso and his colleagues created the clinic at M.L.K. after realizing that many patients whose lives they had fought to save were getting little follow-up care. The hospital is in a low-income neighborhood where health services, inadequate even before the pandemic, have grown more scarce.Since opening in August, the clinic has seen more than 30 patients. Visits, which happen on Tuesday mornings and include a physical exam and a mental health screening, often entail discussions of housing, food security and employment problems that can arise because of long-term symptoms. Patients are also offered spiritual care.The first to walk into Mr. Torres’s examination room in February was Rudy Rubio, a hospital chaplain who had visited him often in the I.C.U. The pastor asked if they could pray together and offered to get him a Bible.Mr. Torres, whose parents fled war in El Salvador, grew up in the neighborhood and worked cleaning big rigs at a Blue Beacon Truck Wash. Although he was morbidly obese — a risk factor for severe Covid — he enjoyed running and biking and rarely needed to see a doctor. He had no idea how he contracted the coronavirus or became so sick that doctors needed to insert a breathing tube within hours of his arrival at M.L.K. For days before he began showing signs of improvement, they feared he would not survive.“You were spared,” the chaplain told him at the clinic. “What are you going to do with this opportunity?”When Dr. Prasso entered the room, Mr. Torres did not recognize him at first without his protective gown and helmet. “It was you,” he said when the realization dawned.As the doctor examined him, Mr. Torres said he was able to walk short distances but was worried that if he did his oxygen levels would drop. “It is a little bit of a mind game,” Dr. Prasso said. “You may feel short of breath, but your oxygen can still be totally normal.”The clinic would arrange to get Mr. Torres a portable oxygen machine because small tanks were in short supply nationally, the doctor said. He explained that it could take anywhere from a few weeks to several months for patients to wean off; some might require it indefinitely.Mr. Torres brought up another problem. A physical therapist assigned to visit him had canceled. “A lot of the agencies are a little bit resistant to going into people’s homes right now because of Covid,” Dr. Prasso told him. He said the clinic could enroll Mr. Torres in a pulmonary rehabilitation program instead, so that he could work with therapists focused on the recovery of his lungs.Mr. Torres in the intensive care unit in January.Isadora Kosofsky for The New York TimesMr. Torres shared that he was anxious and haunted by memories of beeping I.C.U. monitors and a sensation of choking. He had barely slept since returning home and had not yet seen his 5-year-old son, who was staying temporarily with grandparents. Mr. Torres was afraid of breaking down in front of him.“Everything that you’re feeling is normal,” Dr. Prasso reassured him. “Just know that what you went through was a trauma. It takes time for that to heal.”The two exchanged memories of the moment Mr. Torres’s breathing tube was removed. “You begged me to get the tube out, and as soon as we took the tube out, you asked to have it put back in,” Dr. Prasso said.“It was hard to breathe,” Mr. Torres said. “I didn’t want to be awake.”“This guy had a vise grip on my hand,” Dr. Prasso told Mr. Torres’s partner, Lisseth Salguero, who had joined him in the exam room. Family members, themselves at risk for mental health problems, are encouraged to accompany patients to clinic. Ms. Salguero had developed Covid symptoms the same day as Mr. Torres had, but recovered quickly. Since he had returned home, she had been waking up to check Mr. Torres’s oxygen level at night. “I’m happy as long as he’s OK,” she said.Mr. Torres hours after his breathing tube was removed. He would later recall that “it was hard to breathe” and “I didn’t want to be awake.”Isadora Kosofsky for The New York TimesThe extraordinary stress of an I.C.U. stay in the era of Covid-19 is often compounded by near-unbearable loneliness. Visitor restrictions meant to reduce transmission of the virus can mean weeks separated from loved ones. “I kept asking for someone to hold my hand,” Mr. Torres recalled. “I wanted contact.”The staff members became de facto family. “You have nobody except for your nurses,” Mr. Torres said.For those I.C.U. nurses, caring for Covid patients while being among the few conduits to their family leads to deep emotional attachments. Nina Tacsuan, one of Mr. Torres’s nurses, could not hold back her tears when she saw him in the clinic.“Thank you for keeping me alive, giving me a second chance,” Mr. Torres told her. “I’m grateful.”“You’re my age,” Ms. Tacsuan said. “It was just really hard the whole time.”Nina Tacsuan, wiping tears, and Anahiz Correa, who both work in the I.C.U., joked in the clinic that Mr. Torres was not welcome to return to the unit.Isadora Kosofsky for The New York TimesOften, the experience ends in heartbreak: At the time Mr. Torres was hospitalized, only about 15 percent of Covid patients at M.L.K. being treated with ventilators had survived to go home.Those who do survive, like him, inspire the staff to keep going. But usually I.C.U. workers lack opportunities to see their former patients once they get better. The clinic has changed that.Ms. Tacsuan and a nurse manager, Anahiz Correa, joked that Mr. Torres was no longer welcome in their I.C.U.By the time the transport ambulance picked him up to go home, Mr. Torres said he was feeling much better than when he had arrived. He reunited with his young son, Austin, a couple of days later, and he has continued to improve in the weeks since.Mr. Torres with his partner, Lisseth Salguero, and their 5-year-old son outside their home.Isadora Kosofsky for The New York TimesMr. Torres visited the clinic twice more, in February and in March. Although he ended up declining outpatient rehabilitation — opting instead to climb stairs and do other exercises on his own at home — he said he felt cared for and was glad to have gone.A social worker there connected him with a primary care doctor in M.L.K.’s system for more follow-ups. An osteopath manipulated his back and taught him stretches to help relieve lingering discomfort from his time in the hospital bed. And last week, at his most recent appointment, the clinic staff strung up a congratulatory banner and shouted “Surprise!” as he entered, to mark his “graduation” from having to use an oxygen tank.He still needs more strength and stamina to be able to return to his physically demanding job at the truck wash, he said, but “I’m doing a lot more stuff.” And he is no longer haunted by anxiety, he added. “I feel great.”