Send 5 Billion Masks, Please

Hosted by Christina Ruffini and Sir Richard Dearlove

Guest

Paul Molinaro

Paul Molinaro is a WHO official tasked with trying to stop the virus in its tracks and securing payment for treatment.

Episode Summary

The pandemic spreading like fire, the WHO’s Paul Molinaro is faced with an all-consuming task: trying to stop the virus in its tracks. And get people to pay for it.

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Transcript

COLD OPEN

Molinaro: Coming up on One Decision. The tempo is bang, bang, bang, bang. You're in a race with a virus. We we first came up with a number that was just was so big. I don't know if I cried or laughed. I don't think we ever had a plan A work.

INTRODUCTION

Kosinski: Hi there. I'm Michelle Kosinski. Welcome back to One Decision, where we look at the tough ones. And sometimes one decision becomes an endless string of them. In this case, for a man named Paul Molinaro, his choices were, in a very real sense, the difference between life and death for an untold number of people around the world. COVID brought him there and took him to the edge of what he thought he could handle. His story takes us deep inside the behemoth global response to the pandemic. Have you ever thought about what it takes to get the things people need all over the planet, whether it's that little mask to guard your breath or a ventilator, the breath of life. But first, let's check-in with our guru of decision making, tradecraft, and global knowledge, the former head of Britain's MI6, Sir Richard Dearlove.

WITH SIR RICHARD DEARLOVE

Dearlove: Hi, Michelle. I regret face to face.

Kosinski: I know. Such is COVID. Nearly two years into this pandemic now. What are your takeaways? For me, it's how quickly things fall apart. We only have our together on this very narrow layer, this bubble film delicately surrounding all the potential for nothingness.

Dearlove: It's probably the most disruptive events since World War II. It's a global war against an invisible enemy, is the virus, and I sat on certain committees that talked about pandemics and I just don't think we even began to imagine how a serious pandemic like this one could just affect every facet of our lives. We should be all in this together as humans, right?

Kosinski: You know, I think a lot about my grandparents. They both survived the Spanish flu in the early 1900s, both lost their fathers to it, so it changed the rest of their lives. They left school after eighth grade to go to work, to help support their families. And they would tell us these stories, remembering the death and fear around them. And they said that there was this horse drawn cart that would go through town every morning, and they knew where to pick up the bodies because people would put out this black cloth outside their house. I know if they were alive today, they would look at this with disbelief. They would say, with all your technology and your instantaneous communication, you're fighting over wearing a damn mask? Like, this is the best you can do a hundred years later?

Dearlove: Our response in a way has been limited.

Kosinski: We live on a fragile planet. Do you feel like you've changed as a person through the pandemic?

Dearlove: Yeah, become more reflective, thought more about the state of the world, become more philosophical.

Kosinski: If you could rate on a scale of, let's say, one to ten, one being abysmal and 10 being excellent, humanity's response to the virus, how would you grade it? That's a tough question.

Dearlove: Well, think it started off at three, but it's gradually been climbing.

Kosinski: You just hope that humanity has learned from this pandemic in preparation for whenever the next one is going to be.

Dearlove: I'm sure that you know there will certainly be an inquiry in the UK and the lessons will be drawn.

Kosinski: Richard, there's always an inquiry in the UK.

Dearlove: Don't think I'm proud of. I mean I think you can think through how you will react next time, whether you can have the resources ready, I question. And you know, you can't sort of stockpile indefinitely for every eventuality.

Kosinski: Well, that is a perfect segue into our decision. The many decisions every single day of Paul Molinaro.

THE STORY OF PAUL MOLINARO

Molinaro: So I have been doing this kind of work since 1993, almost thirty years. I started off in Kenya. I grew up in Kenya. My father is Italian. My mother is a Brit.

Kosinski: Paul was a college student home on summer break from studying film and journalism in New York City when he saw refugees streaming into Kenya from Somalia facing a horrible trifecta of war, government collapse, and drought. Hundreds of thousands of people trying to survive. Paul's friend asked him to help out, helping them, and that one ask changed the course of his life.

Molinaro: I just sort of realized I had an aptitude for this. This was distribution of food and then basically never came back and just moved on from there.

Kosinski: He worked for an NGO, the UN in Rwanda after genocide, worked for UNICEF for eighteen years, opened schools in Afghanistan for girls that had never before had that chance. Well, you've had all the good jobs, Paul. I have had all the good jobs. He'd seen plenty of war and disaster, but never large scale disease. That was all about to change. Paul got a job with the World Health Organization in Geneva as the head of logistics. Two weeks after walking in that door, end of 2018, he was thrown right into Ebola in the Congo.

Molinaro: That was a very steep learning curve.

Kosinski: And then came COVID. He remembers the day, New Year's Eve 2019, a report of an unknown respiratory disease spreading in China. NEWS CLIP [6:24]
China has identified the cause of the mysterious new coronavirus. There are fears a rapidly spreading virus has reached Australia. This is a rapidly emerging situation where there is not a cause for alarm. The first US case has been detected. There's confirmation the coronavirus has reached Australia. China is urging its citizens not to travel abroad as it struggles to contain the virus.

Kosinski: So for you, when did this little flame of that alert turn into a fire?

Molinaro: So I think around the January 15, we started to look at and say, should probably start and and we had and there's a bit of luck here. In responding to the Ebola outbreaks, we had replenished our stocks of PPE. Let's just see what our stocks are and can we contact our vendors to see if we could put in some more orders just to kind of put up another set of buffer stock. Oh, that was smart. But there was still no kind of on fire. As we got into over the sort of mid January, it's really where we started to feel the heat and could feel the tension in the meetings. We also started to get back indications from our vendors that the lead times on the PPE were being affected.

Kosinski: The Chinese were ordering a lot of it. Where is most of it coming from, or is it coming from all over the?

Molinaro: Coming from all over the world. One of the things we were surprised about, we had a network of partners and companies established sort of four years ago post Ebola. And we sent out a survey just to try and take a temperature check on this particular market and what came out from that survey that the world was gonna have a serious issue around PPE.

Kosinski: And another surprise. They had expected that around half of all personal protective equipment, PPE, was made in China. Their survey showed it was more like up to 80%. Did you think, you know, how are we gonna handle this? How are we gonna do this? Yeah.

Molinaro: We needed to quantify this, which is not easy. And the rate in which it's spreading, we plugged all of that in and really focusing on core health care workers and no one else.

Kosinski: We came up with a number. Their forecast of need was staggering, like a 100,000,000 masks and gloves a month, likely far more.

Molinaro: And we transmitted that to heads of state and to CEOs of major companies and came and said, you will need to increase global production by 40% and you will need to do that as soon as possible.

Kosinski: Wow.

Molinaro: So really just focusing on the core workers who are at most at risk was a 40% ramp up of production.

Kosinski: Gosh. And 40%, what does that translate into?

Molinaro: We we first came up with a number that was just was so big that we we had to I mean, we laughed when when we saw it. But, you know, our boss, he came walking past, and he saw the number. He's like, we were saying you're going to need however many billion dollars of PPE. He's like, but this is. Yeah, this is like probably the six month budget of the entire Irish health system.

Kosinski: Gosh, gosh.

Molinaro: Now obviously it's hard for us to go out and say, we, WHO, need this number. But certainly we were frightened by the size of the number. So, you know, we have to be somewhat judicious in the number that we ask funding for. So we have to bring it down.

Kosinski: Now, normally what the WHO does is respond to localized emergencies, not like this. This required scaling up in ways Paul had never imagined.

Molinaro: Just to move fast, have no regrets, be agile, and do not wait and make a decision. Even if the decision is wrong and you have to adjust midstream, it's far better than pondering and doing nothing. And then you're behind the curve. We have a certain amount of dollars we have access to. We did mobilize partners like the Gates Foundation and others to provide credit lines because we saw on the market, if you weren't able to commit to a certain amount and a large volume, there's no way you are getting access to production.

Kosinski: When you saw that number that you had estimated and you're the one who has to organize this and procure it. What what goes through your mind?

Molinaro: Well, I I mean, swear words.

Kosinski: Did you think that it was even going to be possible?

Molinaro: We were definitely going to have to take risk. We were definitely gonna have to commit funding to manufacturers because if you didn't, someone else would, and you would just lose them the access to the production. And in this battle, you're conscious that you're representing countries and groups of healthcare workers who potentially won't have access unless you're able to place large financial commitments on their behalf.

Kosinski: Wow. So your red alert that companies are gonna need to up production by, like, 40%, do you think that really kick started the response to the pandemic in PPE? Was it you?

Molinaro: At the end of January into early February, there was a lot of countries and organizations sending PPE to China to support the Chinese response. If you can stop at source, it's better. We saw in that dynamic in the air cargo rates, a complete inversion. The cost of flying into China was becoming really, really prohibitive. That's where we start to understood that this was also gonna have severe impact on the air transport and shipping markets.

Kosinski: So how would you define your decisions during this insane time?

Molinaro: That we were gonna have to go big. It changes the type of funding we need access to. It changes how we approach markets. It changes how we take on risk.

Kosinski: Completely changes everything just because of the size of it. And you being so new on the job, what you were doing became key really to the entire COVID response.

Molinaro: It was, yeah, very weird and a bit disconcerting.

Kosinski: Paul and his team were in the thick of it. What were some of your worries at this point? Like you've overestimated and you'll have a million warehouses full of PPE. Were you getting any sleep?

Molinaro: No, sleep was hard to come by. You know, I ended up being dragged into press conferences, sat there next to Tedros, and you've got the family gleefully WhatsApping you, saying how miserable you look and how tired you look. You have buyers getting WhatsApps from so many different government people across the world. I had phone conversations with guys who worked in the response, say in Italy or in India or in other places, and many of them were crying. I mean, really desperate and not knowing what to do in so many different ways. And the pressure to, you know, we need so and so many test kits. We need so and so many pieces of PPE. I think at the time the big, big panic and concern and pressure was more on the diagnostics, because again, without the tests, you don't know what's happening in your country. We had that track that was ongoing as well. And I think that I'd never had that kind of direct exposure to that level of pressure before.

Kosinski: Paul describes it as months and months of running on panic and adrenaline, a mad race to procure what everyone was literally begging for. Plus the pressure to not accidentally source scams or junk.

Molinaro: Many of the manufacturers didn't even want to talk to you unless you could put maybe 50% down in advance. But even that in itself would take time because we would insist on third party lab analysis because the air networks were going down. It would take some time. The lab test itself would take some time. The results would take some time. And by the time you come back, that manufacturer has moved the product and you're back to square one. So you aren't going into 50,000,000, 60 million dollars in a single transaction. Is kind of a moment where, yeah, it's again probably inappropriate thoughts to go through my head. But yeah, that is difficult.

Kosinski: What Paul and his team were up against day to day, they ended up having to set up their own air network, teaming up with a World Food Program with a hub in Ethiopia. What we, the public, see are planes arriving. We don't see the scramble behind the scenes to get the stuff and then get that on those planes.

Molinaro: I don't think we ever had a plan A work. It was chaos. I mean, had documents coming in Chinese that then they needed to be translated. We need to issue a different document. Each country that you're sending this to has a different regulatory requirement in terms of the documents that are needed. In some cases, you didn't have a landing permit for the aircraft. Then you had to call the country that the airline was registered to and their ambassador would help pressure this country. So you were using the diplomatic network, you were using the commercial network, and every single day there was an issue. Planes were arriving that, you know, the country wasn't properly informed. We had some things stuck in the airport. It took time to customs clear. Obviously, in the amount of things we were moving, we had some things showing up to the wrong place, and we're having to then truck it from one country in Europe to another country in Central Asia. So this was continuous and continuous and continuous. And we had a team at that time of about 16 to 20 people who are then running that component of the operation.

Kosinski: Just just 20 people managing this entire?

Molinaro: On the networks.

Kosinski: Yeah. This is amazing. Were there just days when you thought, how are we gonna do this? Like, I'm only one person.

Molinaro: Yeah, there were. I mean, I have to be careful how into it I go. It's okay. We were struggling with the documentation needed to accompany each air shipment. We are dealing with some manufacturers who had not been used to export, that they were very much used to supplying domestically within China. This was a very steep learning curve, including the attempt to try and maximize space in aircraft themselves. And so we would have to receive, and it gets a bit technical, we have to receive items in pallets, but then to make maximize the air cargo is then strip the pallets and load it as loose cargo. Oh. But then obviously all our documentation is being designed around the pallet. So now what comes out at the other side in terms of the batch numbers and all of these different things is completely different from what went into the aircraft. Did you have to repallet them? No. We didn't have to repallet them. We had to redo the documents while the plane was in the air. This is fascinating, actually. So we had two or three guys. Honestly, I don't think they slept. They were constantly in the office. They were reprinting out the documents, PDF scanning them, and then sending them to the country that was gonna receive the plane before the plane arrived. We would know the documentation wasn't in order because it would come up as it was being loaded. If the packing list was created, first it was created in Chinese by the manufacturer. We have to change it at the pallet level into English. And then we are having to rechange it again once we realize what actually got loaded. It was hell. And I think what the time. And I don't know if I cried or laughed. I mean, some countries are very strict on this. And we got a call from the office, and it was like, look, the plane has just arrived, but look at one of your documents. It looks bad. And I think that was kind of the worst day. When when he showed me that, I honestly, I just laughed. It was hell.

Kosinski: Paul says of all those daily wild decisions he had to make with his hair and the world on fire, including who would get the desperately needed items first. What he's proud of now is moving quickly without second guessing. On that New Year's Eve, no one even knew what the disease was, but within a month, they had a diagnostic test ready to go. They built a network of partners, companies, donors, their own global delivery system.

Molinaro: Doing things collectively and sharing information that made sure we weren't competing for the same product. If three of us are going to the same manufacturer for the same 1,000,000 masks, all three of us are going to suffer.

Kosinski: Picture yourself back then watching the pandemic start to happen. I remember the eerie, quiet streets and then suddenly empty shelves and the unknown of how deadly this was going to be. And, you know, most of us in the West had never really experienced much of a shortage of anything before.

Molinaro: Never saw it was gonna get to that scale. Never realized how much data we were gonna generate and how much information we are going to have to provide to people. All of this was completely new. And if ever there was a cliche that you, you know, you drive the ship as you build it, this really for the first time really felt like that.

Kosinski: Because for a lot of the beginning, we weren't even floating. It all adds up to around a billion pieces of equipment that Paul and his team shipped, hundreds of millions of test kits, and who knows how many lives saved because of it.

Molinaro: When there is will to do it, okay, some of the will is through panic and fear, but that we can mobilize as human beings, and we can find solutions to things.

Kosinski: You know, when people think back to the shortages, and I almost forgot, like in the beginning, my first mask was one that I made myself with a sewing machine and some shop towels that I had from a painting project in my house.

Molinaro: Imagine that's what we got to?

Kosinski: Yeah, like I almost forgot that there was nothing to be found in all of Washington DC. I mean, there was not even toilet paper in Washington DC for god's sake. So some people looking at this will say, oh, well, in the critical stages, this was a failure because nobody had anything. But it's not the WHO's failure. It's each individual country not having any stockpiles. Right?

Molinaro: I think sometimes we can be a little bit too hard on ourselves. I think the word failure, who could have foreseen this scale? I mean, and again, there's also a realism. Stockpiles cost money and they cost money to have them. And I guarantee this, human beings have sometimes memories like ants. Once this has gone, voices sounding the preparedness trumpet will slowly start to disappear. And you ask for an investment in a stockpile, even say that you get that investment in the stockpile, after five years, you have to rotate and distribute that product and replenish it. Otherwise it becomes obsolete. It becomes out of date. And that also requires continued commitment, will and investment. And after ten years of doing this, if the thing doesn't happen that you built it for, slowly the support to maintain it fades away. I think if you have the mechanism that can move money quickly, that can access people and expertise quickly, and that can link in very quickly to manufacturing and the companies who make this product, that's what we need to develop further. And yes, looking on national self interest being a contributor to some of the shortages, I'd have to say it was. Understand where you come from as a government whose first duty is the duty of care to your own population, your taxpayers and the people who voted you in. I understand that, but by locking and requisitioning areas of your manufacturing, you had an unintended knock on effect on other parts of we're a global supply system. You have knock on effects that may end up coming to bite you in the bum. And we've had examples of that with a country saying we're stopping all export of this equipment, not realizing that one of the materials they stopped was actually needed to manufacture N95 masks that the same country was waiting for their order for and that the manufacturer couldn't fulfill because this country had stopped the export of a component. Interesting. These knock on effects are there. They're very hard to see or anticipate because there's a whole lot that's under the iceberg that you don't see and you don't realize. I spoke to companies that didn't even realize how much of their manufacturing was done in China. It is how it's being set up, and it is, I think, something that needs to be looked into.

Kosinski: It's it's both amazing. Like, it's an amazing feat of human collaboration, and it's depressing all at the same time. That's that's humanity. Yes. It is. Was there a decision that you made that you just felt like, oh my god. I'm so amazed that actually worked?

Molinaro: Allowing myself to be carried by the desire to bring about a result. Rather than question, oh, this we can't do. Just saying, we will deal with all of that later. We just need to move and we need to do it. If we need more people, we'll get more people. If we need this, we will just do it. But if we spend time analyzing all of these parts of what we need and how much it would cost and all of these kind of things, it would, a, either never have happened or, b, happened at a time where it was no longer relevant.

Kosinski: I think I find all of this fascinating, like weirdly fascinating. What what do you think people don't realize that you want people to know? It's not just PPE.

Molinaro: Right. The tests and then the things like ventilators also in short supply. They don't just come from from nothing. Each market completely different. If you look at something like oxygen, it's not that you can just buy a standard thing. Each hospital has a different piping system, it's going to it's different electricity, it has different this and that and the other, different setup in some of the hospitals. Let's say the wealthier countries. It's been so long that they've dealt with an infectious pathogen that they've forgotten how to deal with an infectious pathogen.

Kosinski: Do you sometimes think that every single item that you send out could be a life saved?

Molinaro: I think it's hard to have that attribution, but certainly, particularly desperate situation in in India, we managed, again, using the relationships we've had with vendors that we built off, managed to access small oxygen generation equipment and were able to ship that and did see pictures of that equipment in a hospital plugged into a patient, you can say, that action had a direct consequence in terms of saving a life.

Kosinski: Is there anything you wish you would have done better? Anything that stands out as a decision you made that you felt like, oh, we shouldn't have done that, or we could have done better.

Molinaro: I think we could have done better in bringing in regional bodies like the African Union or like ASEAN and like others, is bring them in and utilize their networks and coverage. For us, the time sensitivity was let's get hold of stuff and didn't devote a lot of time on well once you have stuff, what is the most effective way of moving stuff to where it's needed? And I think that could have been introduced a bit earlier. The other thing I think we failed to anticipate was the humongous information hunger for data, for numbers, and for reporting on what's going where and what we're doing. And that that was a humongous amount of data work that we had to scramble and bring.

Kosinski: So you must feel very ready for the next pandemic. I would hope so.

Molinaro: I would hope so. The tempo is bang, bang, bang, bang. You are in a race with a virus, and I have learned an astounding amount. Yeah.

Kosinski: You must feel like you've been through hell. It's been tough.

Molinaro: It's been tough. I have people in my team who lost both parents to COVID. Have people who lost both parents on the same day to COVID, and people who missed funerals. So I kind of think the scars of this in the society are going to be felt for a long time, more so than perhaps we realize right now.

Kosinski: Absolutely. Did you have moments of self doubt during this time?

Molinaro: Yeah. All the time. Yeah. All the time. Are we gonna get over the line? Are we gonna is this gonna work? When is all this gonna collapse? I mean, we sometimes sail very, very close to the edge. It's only that you're surrounded by very good people who want the result to happen and that will do anything to make it happen, that it happens. But obviously, to undertake such a kind of activity, you are always gonna come close to the whole thing falling apart.

Kosinski: Did you have a day where you realized or a moment where you said this the like, we made the right choices. Like, this is effing working.

Molinaro: Yeah. I think it all started to come together. You saw the numbers, you saw the volume, and where we had become kind of a machine, certainly by when we looked in September, October, even though we were tired and exhausted, you could actually see what we had built and how it was functioning and operating.

Kosinski: Today, Paul sees the whole thing with clearer, wiser eyes.

Molinaro: I'm optimistic. There's some aspects of this you look and go, what the hell are people thinking? The competitive instinct.

Kosinski: I think it's something that's within us as human beings. We're still apes, like, fighting all the time over everything. Exactly. People will fight each other over a roll of toilet paper, for god's sake.

Molinaro: But at the same time, every advance we made, be it in the diagnostics, be it in the vaccine, came as a response of sharing, of sharing risk, sharing knowledge and sharing capacity. That's the only way we get through these kind of events. Won't happen any other way.

Kosinski: What was the hardest decision making for you? The sequence of shipments.

Molinaro: Because everyone is a priority. Everyone is under political pressure. But we are unable to serve everyone at the same time. Those phone calls and conversations would could be extremely, extremely tough.

Kosinski: It seems like what you've learned is more of everything is needed, more ability to make things and move things.

Molinaro: I think we have to be able to be bigger fast. I don't think you need to be big as a constant. Flexibility, speed, and willingness to assume risk and having access to very quick finance to be able to go big when you need it and to be able to identify and target the priorities within that big. This is so fascinating. Been therapeutic. What do you feel best about? That we were able to do it. We did it. Could we have done it better? Yes. We fought like cats and dogs, but we achieved a common result.

ANALYSIS WITH SIR RICHARD DEARLOVE

Kosinski: Paul, we commend you. Let's check-in again with Sir Richard Dearlove. What a rare look inside that time.

Dearlove: I was quite moved, and the reason I was moved really was the sort of strength of his commitment and his determination to do a really great job in impossibly difficult circumstances.

Kosinski: I think most of us never consider what it took to get masks on faces, then tests, then vaccines.

Dearlove: Well, let's face it, I mean, some of the UN agencies have a great reputation. But you know large chance of the UN does not attract sort of heroic admiration. You have this discrepancy you know between the top elite and decisions around the top elite which are often charged with the complexities of international politics. And I think what's so extraordinary about this is you really see the commitment, belief, and unrestrained wish of people to do good at the working level. And it's a very timely reminder of why the UN, when it's good, is very, very good and, you know, does something pretty unique.

Kosinski: It also really highlights inequality, right? Simple access of rich countries versus poor. Like the vaccine sharing system was a lovely idea, but in reality.

Dearlove: You know, it's the struggle for survival. Yeah, I mean, weird things happened like, you know the AstraZeneca vaccine being talked down by politicians in Europe when it was clearly very adequately effective. That damaged the prospect of AstraZeneca being exported to certain markets in developing countries. Oh, I mean, you know, things that really, in retrospect, we really should be pretty ashamed of.

Kosinski: At least we know there is heroic effort out there. Decisions change things. Thanks, Richard. And thank you for joining us. Follow us wherever you find your podcasts and on social media. We'd love to hear from you. I'm Michelle Kosinski here at One Decision.