As she waited for the results of her rapid COVID-19 test, Rachel de Cordova sat in her car and read through a stack of documents given to her by SignatureCare Emergency Center.

Without de Cordova leaving her car, the staff at the freestanding emergency room near her home in Houston had checked her blood pressure, pulse and temperature during the July 21 appointment. She had been suffering sinus stuffiness and a headache, so she handed them her insurance card to pay for the $175 rapid-response drive-thru test. Then they stuck a swab deep into her nasal cavity to obtain a specimen.

De Cordova is an attorney who specializes in civil litigation defense and maritime law. She cringes when she’s asked to sign away her rights and scrutinizes the fine print. The documents she had been given included disclosures required by recent laws in Texas that try to rein in the billing practices of stand-alone emergency centers like SignatureCare. One said that while the facility would submit its bill to insurance plans, it doesn’t have contractual relationships with them, meaning the care would be considered out-of-network. Patients are responsible for any charges not covered by their plan, it said, as well as any copayment, deductible or coinsurance.

The more she read, the more annoyed de Cordova became. SignatureCare charges a “facility fee” for treatment, the document said, ranging “between five hundred dollars and one hundred thousand dollars.” Another charge, the “observation fee,” could range from $1,000 to $100,000.

De Cordova didn’t think her fees for the test could rise into the six figures. But SignatureCare was giving itself leeway to charge almost any amount to her insurance plan — and she could be on the hook. She knew she couldn’t sign the document. But that created a problem: She still needed to get her test results.

Even in a public health emergency, what could be considered the first rule of American health care is still in effect: There is no set price. Medical providers often inflate their charges and then give discounts to insurance plans that sign contracts with them. Out-of-network insurers and their members are often left to pay the full tab or whatever discount they can negotiate after the fact.

The CARES Act, passed by Congress in March, includes a provision that says insurers must pay for an out-of-network COVID-19 test at the price the testing facility lists on its website. But it sets no maximum for the cost of the tests. Insurance representatives told ProPublica that the charge for a COVID-19 test in Texas can range from less than $100 to thousands of dollars. Health plans are generally waiving out-of-pocket costs for all related COVID-19 treatment, insurance representatives said. Some costs may be passed on to the patient, depending on their coverage and the circumstances.

As she waited, de Cordova realized she didn’t want to play insurance roulette. She changed her mind and decided she’d pay the $175 out-of-pocket for her test. But when the SignatureCare nurse came to collect the paperwork, de Cordova said the nurse told her, “You can’t do that. It’s insurance fraud for you to pay for our services once we know you have insurance.”

Dr. Hashibul Hannan, an emergency room physician, lab director and manager at SignatureCare, told ProPublica his facility is an emergency room that offers testing, not a typical testing site. He said de Cordova should have been allowed to pay the $175 cash price. The staff members were concerned about being accused of fraud because they had already entered her insurance information into the record, he said. So they didn’t want it to appear she was being double-billed. Hannan also said he regrets that she was upset by the disclosure forms that are now required under state law.

Unable to pay cash and unwilling to take a chance on the unknown cost, de Cordova decided to leave without getting the results of her COVID-19 test.

“I Would Have Signed Anything”

Later that day, de Cordova couldn’t get past what happened. She wondered what happened to patients who didn’t read the fine print before signing the packet.

Then she realized she and her husband, Hayan Charara, could investigate it themselves. In June, the couple’s 8-year-old son had attended a baseball tryout. They thought the kids would be socially distanced and that precautions would be taken. But then the coaches had crowded the players in a dugout, with no masks or social distancing, and a couple days later the boy said he wasn’t feeling well.

So just to be safe, on June 12, Charara took their son to the same SignatureCare, the Heights location, for a COVID-19 test. The line was so long they had to wait for hours, go home, come back and wait for hours again in their car in the 100-degree heat. Charara, a poet who teaches at the University of Houston, said he didn’t take a close look at the financial disclosure paperwork. De Cordova wasn’t with them. It had been 10 hours of waiting by the time the boy was tested, so “I would have signed anything,” he said. (The child tested negative.)

Charara, de Cordova and their children are covered by the Employees Retirement System of Texas, a taxpayer-funded benefit plan that covers about half a million people. They hadn’t received any notices about the charges for their son. So they contacted the SignatureCare billing department and asked for an itemized statement. The test charge was indeed $175. But the total balance, including the physician and facility fees associated with an emergency room visit, came to $2,479.

The facility fee was $1,784 and the physician fee $486.

The couple were dumbfounded. Their son’s vital signs had been checked but there had been no physical examination, they said. The interactions took less than five minutes total, and the child stayed in the car. “You’re getting a drive-thru test, and they’re pretending like they’re giving you emergency services,” de Cordova said.

The SignatureCare charges shocked experts who study health care costs. Charging $2,479 for a drive-thru COVID-19 test is a “nauseating” example of profiteering during a pandemic, said Niall Brennan, president and CEO of the Health Care Cost Institute, a nonprofit organization that studies health care prices. “It’s one of the most egregious examples of giving the fox the keys to the henhouse I’ve ever seen and yet another example of the absurdity of U.S. health care pricing.

“Imagine a vendor in any other walk of life being allowed to bill a third party for whatever amount they wanted,” Brennan said.

Insurance companies in Texas typically pay between $100 and $300 for drive-thru COVID-19 tests, said Jamie Dudensing, CEO of the Texas Association of Health Plans. But the association’s members have seen hundreds of out-of-network COVID-19 test charges come in far higher, some in the thousands of dollars.

“There’s no excuse for that, especially in a public health crisis,” said Chris Callahan, spokesperson for Blue Cross and Blue Shield of Texas, which likewise has seen high charges for COVID-19 tests from out-of-network providers.

The reimbursement rates negotiated between insurance companies and in-network providers are much lower, but they still vary, according to data provided by the nonprofit FAIR Health, which tracks spending by private insurers. For the same test billed by SignatureCare, an in-network insurer pays a median price of $23 in Utah and $75 in Wisconsin, according to FAIR Health estimates.

Texas is notorious for its high-priced out-of-network emergency bills and free-standing emergency departments. Some of the facilities appear to be using COVID-19 testing to draw in patients so their insurance plans can be charged for additional services, said Blake Hutson, associate state director for AARP Texas, the advocacy organization for older Americans. “It’s not a surprise they would be racking up the charges and adding on everything they can and billing the health plan,” he said.

In some cases, insurers do pay the exorbitant out-of-network charges, Hutson said, but they typically get reduced. In 2019, Texas lawmakers voted to ban billing patients in state-regulated insurance plans for charges not covered by their policy, Hutson said, which is known as “balance” or “surprise” billing. But consumers may still be responsible for any deductibles and other cost-sharing under their health plan. And the costs covered by the health plan get passed back to the consumers over time in the form of higher premiums, he said. “It’s all problematic for the cost of care,” Hutson said.

Hannan defended SignatureCare’s high out-of-network charges by blaming insurance companies for refusing to give what he considers to be fair in-network rates. The charges are a starting point for negotiating a fair deal from out-of-network insurance plans, he said. He described SignatureCare, which has 18 locations, as “small players. When it comes to negotiating with insurance companies, we have no luck.”

Was the Bill Accurate?

The medical record portrays the visit as an emergency and contains details that are not consistent with how Charara and de Cordova describe their son’s condition. The chief complaint in the record is “body fluid exposure,” and elsewhere it says “confirmed COVID exposure.”

But that’s not accurate, according to the parents. No one had coughed or sneezed on their son, and they knew of no one from the tryout who had tested positive for COVID-19, they said. The child’s temperature is registered in the record as 102.8, which is high. But Charara said that could have been caused by sitting in the Texas heat, waiting for the test.

Shelley Safian, a Florida health care coding expert who has written four books on medical billing, examined the bill and medical records of Charara and de Cordova’s son at ProPublica’s request. She said the medical records don’t justify the charges. SignatureCare billed the case as if the exam were an emergency that required an “expanded problem focused history” and “medical decision making of moderate complexity,” she said.

In order to qualify for reimbursement of an exam at that level, the encounter would need to include examining the affected organ system, Safian said. But the medical records do not document any check of the respiratory system, which would be indicated for suspected COVID-19.

Much of the medical record appeared to be cut and pasted from other electronic records, Safian said. “This is boilerplate B.S.,” she said, “and I don’t mean ‘bachelor of science.’”

Hannan, the SignatureCare doctor and manager, stands by the charges associated with the child’s COVID-19 test. The facility has to treat every case like a possible emergency, and that requires an examination, he said. He pointed out that the charges are in line with what other out-of-network providers would charge in the area, according to FAIR Health, though they are far higher than in-network prices.

A doctor’s examination may not be as hands-on during COVID-19, but, similar to a telemedicine visit, a lot can be examined visually, Hannan said. Hannan said the company he uses for coding said COVID-19 requires a higher level of care and vigilance because it’s an infectious disease.

In light of the questions raised by ProPublica and Safian, Hannan said he asked his billing company to audit the charges. Sharon Nicka, president and CEO of Nicka and Associates, the billing company used by SignatureCare, took issue with Safian’s assessment and said the billing codes used were justified by the medical record. She said the charges are high for a drive-thru test, but those are set by SignatureCare.

ProPublica identified several apparent errors and contradictions in the medical record and billing documentation. For example, the notes in the medical record alternatively refer to the boy as “symptomatic” and “asymptomatic.” The record also says the physical exam showed a skin wound that “was not red, swollen or tender,” but the child had no wound of any kind, the family said. And the billing documentation shows a charge for an antibody test when the medical record showed that the patient actually received a diagnostic test, which is something different.

In response to ProPublica’s questions, a SignatureCare medical director reviewed the record. The error about the “wound” may have been caused by a software template adding something that was not in the physician chart, the reviewer wrote. The facility now uses a different template. The charge for the antibody test is likely a billing error, as the physician had ordered the correct test, the reviewer wrote. “We will continue to update and improve our (electronic medical records),” the reviewer said.

Hannan stressed that SignatureCare is upfront with patients about the possible fees associated with its treatment, including the disclosure paperwork and explanations on its website. It’s an emergency room, he said, so patients should expect emergency room fees. Patients who do not have a medical emergency should not come, he said, though the ER allows patients to book appointments a day in advance for a COVID-19 test.

Dudensing, the chief executive of the Texas Association of Health Plans, said she’s heard Hannan’s contention before and it’s true that freestanding emergency rooms have a license that allows them to charge more. But she still believes that they handle many nonemergency cases and are forcing facility fees of thousands of dollars on them. “They’re hiding under the guise of emergency rooms when they’re really dressed-up urgent care,” she said.

Diana Kongevick, director of group benefits for the Employees Retirement System of Texas, said the health plan had only recently received the bill for the 8-year-old’s test. It hadn’t been processed, so she could not speak to it directly. But, in general, the health plan will pay 100% of the cost of the test, in this case $175, she said. The claim would be processed using out-of-network provisions, she said. So for the other charges, the patient may be responsible for paying in the range of $600, she estimated, for the out-of-network copay and deductibles. “This is a nonemergent patient self-referral to an out-of-network provider,” Kongevick said.

“Testing Should Be Free”

Even if the Employees Retirement System of Texas determines that Charara and de Cordova should pay $600 for their son’s test, SignatureCare will not be sending the family a bill, Hannan said. He said insured patients are not being sent bills for COVID-19 treatment beyond what their insurance companies cover.

De Cordova never did get her test results, and she didn’t seek a test elsewhere. She felt better later and now believes she had just been suffering from allergies. But what if it had turned out to be COVID-19, she wondered. Might she have gone on to infect others, she’s asked herself.

From a public health perspective, the haggling about out-of-network charges and payments puts patients in the middle, and it might discourage them from getting tested for COVID-19 during the pandemic, said Stuart Craig, an economist at the University of Pennsylvania who studies health care costs. “It’s another part of the fragmentation of the health care system that makes patients’ lives miserable,” Craig said.

It’s especially frustrating, he said, because COVID-19 testing is so essential to making it safely through the pandemic. Craig said he believes there should be a nationally mandated price and government subsidies to make sure medical providers and manufacturers are motivated financially to provide tests. “Testing should be free,” Craig said. “In fact, we should probably be paying patients to get tested.”

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When police discovered the woman, she’d been dead at home for at least 12 hours, alone except for her 4-year-old daughter. The early reports said only that she was 42, a mammogram technician at a hospital southwest of Atlanta and almost certainly a victim of COVID-19. Had her identity been withheld to protect her family’s privacy? Her employer’s reputation? Anesthesiologist Claire Rezba, scrolling through the news on her phone, was dismayed. “I felt like her sacrifice was really great and her child’s sacrifice was really great, and she was just this anonymous woman, you know? It seemed very trivializing.” For days, Rezba would click through Google, searching for a name, until in late March, the news stories finally supplied one: Diedre Wilkes. And almost without realizing it, Rezba began to keep count.

The next name on her list was world-famous, at least in medical circles: James Goodrich, a pediatric neurosurgeon in New York City and a pioneer in the separation of twins conjoined at the head. One of his best-known successes happened in 2016, when he led a team of 40 people in a 27-hour procedure to divide the skulls and detach the brains of 13-month-old brothers. Rezba, who’d participated in two conjoined-twins cases during her residency, had been riveted by that saga. Goodrich’s death on March 30 was a gut-punch; “it just felt personal.” Clearly, the coronavirus was coming for health care professionals, from the legends like Goodrich to the ones like Wilkes who toiled out of the spotlight and, Rezba knew, would die there.

At first, seeking out their obituaries was a way to rein in her own fear. At Rezba’s hospital in Richmond, Virginia, as at health care facilities around the U.S., elective surgeries had been canceled and schedules rearranged, which meant she had long stretches of time to fret. Her husband was also a physician, an orthopedic surgeon at a different hospital. Her sister was a nurse practitioner. Bearing witness to the lives and deaths of people she didn’t know helped distract her from the dangers faced by those she loved. “It’s a way of coping with my feelings,” she acknowledged one recent afternoon. “It helps to put some of those anxieties in order.”

On April 14, the Centers for Disease Control and Prevention published its first count of health care workers lost to COVID-19: 27 deaths. By then, Rezba’s list included many times that number — nurses, drug treatment counselors, medical assistants, orderlies, ER staff, physical therapists, EMTs. “That was upsetting,” Rezba said. “I mean, I’m, like, just one person using Google and I had already counted more than 200 people and they’re saying 27? That’s a big discrepancy.”

Rezba’s exercise in psychological self-protection evolved into a bona fide mission. Soon she was spending a couple of hours a day scouring the internet for the recently dead; it saddened, then enraged her to see how difficult they were to find, how quickly people who gave their lives in service to others seemed to be forgotten. The more she searched, the more convinced she became that this invisibility was not an accident: “I felt like a lot of these hospitals and nursing homes were trying to hide what was happening.”

And instead of acting as watchdogs, public health and government officials were largely silent. As she looked for data and studies, any sign that lessons were being learned from these deaths, what Rezba found instead were men and women who worked two or three jobs but had no insurance; clusters of contagion in families; so many young parents, she wanted to scream. The majority were Black or brown. Many were immigrants. None of them had to die.

The least she could do was force the government, and the public, to see them. “I feel like if they had to look at the faces, and read the stories, if they realized how many there are; if they had to keep scrolling and reading, maybe they would understand.”

It’s been clear since the beginning of the pandemic that health care workers faced unique, sometimes extreme risks from COVID-19. Five months later, the reality is worse than most Americans know. Through the end of July, nearly 120,000 doctors, nurses and other medical personnel had contracted the virus in the U.S., the CDC reported; at least 587 had died.

Even those numbers are almost certainly “a gross underestimate,” said Kent Sepkowitz, an infectious disease specialist at Memorial Sloan Kettering Cancer Center in New York City who has studied medical worker deaths from HIV, tuberculosis, hepatitis and flu. Based on state data and past epidemics, Sepkowitz said he’d expect health care workers to make up 5% to 15% of all coronavirus infections in the U.S. That would put the number of workers who’ve contracted the virus at over 200,000, and maybe much higher. “At the front end of any epidemic or pandemic, no one knows what it is,” Sepkowitz said. “And so proper precautions aren’t taken. That’s what we’ve seen with COVID-19.”

Meanwhile, the Centers for Medicareand Medicaid Services reports at least 767 deaths among nursing home staff, making the work “the most dangerous job in America,” a Washington Post op-ed declared. National Nurses United, a union with more than 150,000 members nationwide, has counted at least 1,289 deaths among all categories of health care professionals, including 169 nurses.

The loss of so many dedicated, deeply experienced professionals in such an urgent crisis is “unfathomable,” said Christopher Friese, a professor at the University of Michigan School of Nursing whose areas of study include health care worker injuries and illnesses. “Every worker we’ve lost this year is one less person we have to take care of our loved ones. In addition to the tragic loss of that individual, we’ve depleted our workforce unnecessarily when we had tools at our disposal” to prevent wide-scale sickness and death.

One of the most potentially powerful tools for battling COVID-19 in the medical workforce has been largely missing, he said: reliable data about infections and deaths. “We don’t really have a good understanding of where health care workers are at greatest risk,” Friese said. “We’ve had to piece it together. And the fact that we’re piecing it together in 2020 is pretty disturbing.”

The CDC and the Department of Health and Human Services did not respond to ProPublica’s questions for this story.

Learning from the sick and dead ought to be a national priority, both to protect the workforce and to improve care in the pandemic and beyond, said Patricia Davidson, dean of the Johns Hopkins School of Nursing. “It’s critically important,” she said. “It should be done in real time.”

But data collection and transparency have been among the most glaring weaknesses of the U.S. pandemic response, from blind spots in the public health system’s understanding of COVID-19 in pregnancy to the sudden removal of hospital capacity data from the CDC’s website, later restored after a public outcry. The Trump administration’s sudden announcement in mid-July that it was wresting control over hospital coronavirus data from the CDC has only intensified the concerns.

“We’d be the first to agree that the CDC has been deficient” in its data gathering and deployment, said Jean Ross, a president of National Nurses United. “But it’s still the most appropriate federal agency to do this, based on clear subject-matter expertise in infectious diseases response.”

The CDC’s basic mechanism for collecting information about health care worker infections has been the standard two-page coronavirus case report form, mostly filled out by local health departments. The form doesn’t request much detail; for example, it doesn’t ask for employers’ names. Information is coming in delayed or incomplete; the agency doesn’t know the occupational status of almost 80% of people infected.

The data about infections and deaths among nursing home staff is more robust, thanks to a rule that went into effect in April that requires facilities to report directly to the CDC. The agency told Kaiser Health News that it is also “conducting a 14-state hospital study and tapping into other infection surveillance methods” to monitor health care worker deaths.

Another federal agency, the U.S. Occupational Safety and Health Administration, investigates worker infections and deaths on a complaint basis and has prioritized COVID-related cases about the health care industry. But it has suggested that most employers are unlikely to face any penalties and has issued only four citations related to the outbreak, to a Georgia nursing home that delayed reporting the hospitalization of six staffers and three Ohio care centers that violated respiratory protection standards. Of the more than 4,500 complaints OSHA has received about COVID-19-related working conditions in the medical industry, it has closed nearly 3,200, a ProPublica analysis found.

Data problems aren’t just a federal issue; many states have fallen short in collecting and reporting information about health care workers. Arizona, where cases have been surging, told ProPublica, “We do not currently report data by profession.” The same goes for New York state, though a report in early July hinted at just how devastating the numbers there might be: 37,500 nursing home employees, about a quarter of the state’s nursing home workforce, were infected with the coronavirus from March through early June. Other states, including Florida, Michigan and New Jersey, provide data about employees at long-term facilities but not about health care workers more broadly. “We are not collecting data on health care worker infections and/or health care worker deaths from COVID-19,” a spokesperson for the Michigan Health Department said in an email.

This problem is global. Amnesty International, in a July report, pointed to widespread data gaps as part of a broader suppression of information and rights that has left workers in many countries “exposed, silenced [and] attacked.” In Britain, where more than 540 medical workers have died in the pandemic, the advocacy group Doctors’ Association UK has begun legal action to force a government inquiry into shortages of personal protection equipment in the National Health Service and “social care” facilities such as nursing homes. And in May, more than three months after the first known medical worker’s death, the International Council of Nurses called for governments across the world to start keeping accurate data on such cases, and for the records to be centrally held by the World Health Organization. The WHO estimates that about 10% of COVID-19 cases worldwide are among health workers. “We are closely following up (on) these cases through our global networks,” a spokesperson said.

“Governments’ failure to collect this information in a consistent way” has been “scandalous,” said the council’s CEO, Howard Catton, and “means we do not have the data that would add to the science that could improve infection control and prevention measures and save the lives of other healthcare workers. … If they continue to turn a blind eye, it sends a message that [those] lives didn’t count.”

So regular people, like Rezba, have stepped up with their makeshift databases.

Rezba, 40, initially wanted a career in public health. While finishing her master’s degree at Emory University in Atlanta and for a few months afterward, she worked as a lab tech at the CDC, analyzing nasal swabs to track cases of MRSA, the flesh-eating bacteria. But she decided she cared more about people than bugs, so she headed to Virginia Commonwealth University medical school in Richmond, graduating in 2009 with plans to specialize in the treatment of chronic pain.

During her residency at VCU, her first rotation was in the neonatal intensive care unit. “There was a little baby I helped take care of for three weeks. And the very last day of that rotation, his parents withdrew care. … He was the first little person I pronounced dead. I went and cried in the stairwell after that.” Her next rotation was in the burn unit, then the emergency department. “It seemed like death was just everywhere,” Rezba said. Witnessing it “is something very separate from the rest of your life experiences. People look different when they’re dying. It’s not like TV. They don’t look like they’re sleeping. CPR is pretty brutal. Codes are pretty brutal.”

She began keeping a list as a way to process the grief. “In residency, you record everything — your case logs, the procedures you do. It was just sort of second nature to record their names.” Whenever a patient died she would make another entry in her notebook, then “I would kind of perseverate” — ruminate — “over their names.” At the end of the year, she took the notebook to church. “I lit candles for them. I prayed. And then I let it go.”

A decade later, Rezba was working full time as an anesthesiologist and raising three small children, her list-compiling days long past her, she thought. Then COVID-19 hit. The onetime infectious disease geek became obsessed with the videos leaking out of China — the teams of health care workers in full protective gear, the makeshift wards in tents, the ERs in chaos: “I knew early on that this was going to be a big problem.” In her job, Rezba was often called upon to do intubations. “The possibility of not having enough PPE caused a lot of anxiety for her,” said her husband, Tejas Patel, whom she met in medical school. “She would be the one, if we did hit that level of New York, who could potentially be at risk and bring it home to the kids.”

As it turned out, Rezba’s hospital wasn’t inundated, nor did it experience the PPE shortages that plagued many health care facilities. But her anxiety didn’t disappear; it just took a new shape. If health care workers were front-line heroes, she decided, her role was to search the trenches for the bodies left behind.

Rezba is the first to admit she’s not great at technology; she rarely uses a computer at home. Patel discovered what she was doing because their iPhones and iCloud accounts are linked. “Whenever she saves a picture to the phone, I can see it. And I noticed a bunch of pictures of, you know, these strangers.” He remembered how, in their student days, Rezba had insisted on humanizing the cadaver in their anatomy lab: “It upset her that it was just this anonymous person. Knowing his birthday and little things like that would make her feel better.” Patel figured the photos were part of a similar coping strategy. “It wasn’t until much later that I found out she was putting them up on Twitter.”

Much of Rezba’s digging happens in the middle of the night, when she can’t sleep. She usually starts by Googling for local news stories; if she’s still not tired, she turns to the obituary site Legacy.com. The hunt for a person’s occupation and cause of death invariably takes her to Facebook, where she follows the trail to relatives and co-workers, to vacation slideshows and videos of old men serenading their grandkids on the guitar. Every few days, she checks GoFundMe, where she’s recently been struck by the number of people who linger for weeks or months before dying. She’s still discovering deaths that occurred in April and May. Anyone under 60 gets special scrutiny. “If the obit says, ‘They died surrounded by family,’ I usually don’t bother trying to find out more, because those people didn’t have COVID. The people with COVID are mostly dying alone.”

Doctors and nurses are the easiest to find. “If someone worked in the laundry service at the nursing home, the family doesn’t put that in,” Rebza said. Yet it’s the nonmedical staff that she feels a special obligation to uncover — the intake coordinators and supply techs, the food service workers and janitors. “I mean, the hospital’s not going to function if there’s nobody to take out the trash.” Every so often, a news story mentions that several staffers from a particular nursing home or rehab center have died, without mentioning their names, and Rezba feels the rage start to bubble. “What it comes down to is, these are people that are making $12 an hour. And they get treated like they’re disposable.”

If she can’t find someone’s identity right away, or if the cause of death isn’t clear, she’ll wait a couple of days or weeks and try again. Because she comes across them anyway, she’s started to keep track of other categories of COVID-19 deaths, like kids and pregnant women, as well as health care workers in their 30s and 40s who don’t appear to have the virus but suddenly perish from heart attacks or strokes or other mysterious reasons. “I have a lot of those,” she said.

Once she’s certain she’s found someone who belongs on her list, she selects a photo or two and writes a few words in their honor. Sometimes, these read like a scrap of poetry; sometimes, like a howl.

He enjoyed crazy-dancing at home to Bruno Mars, with the moves becoming wilder the more his family laughed.

As a child, she would wrap her clothes around Dove soap so they would smell like America.

This poor baby should have his mother in his arms. Instead he has her in an urn.

A preprint study out of Italy last week hinted at the kind of lessons researchers and policy makers might glean if they had more complete data about health care workers in the U.S. The study pooled data from occupational medical centers in six Italian cities, where more than 10,000 doctors, nurses and other providers were tested for coronavirus from March to early May. Along with basic demographic information, the data included job title, the facility and department where the employee worked, the type of PPE used and self-reported COVID-19 symptoms.

The most important findings: Working in a designated COVID-19 ward didn’t put workers at greater risk of infection, while wearing a mask “appeared to be the single most effective approach” to keeping them safe.

In the U.S., many medical facilities are similarly monitoring employee infections and deaths and adjusting policies accordingly. But for the most part, that information isn’t being made public, which makes it impossible to see the bigger picture, or for systems to learn from each other’s experiences, to better protect their workers.

Imagine all of the opportunities it would present if everyone could see the full landscape, said Ivan Oransky, vice president for editorial content at Medscape, where a memorial page to honor global front liners has been one of the site’s best-read features. “You could be doing some real great shoe-leather epidemiology. … You could go: ‘Wait a second. That hospital has 12 fatalities among health care workers. The hospital across town has none. That can’t be pure coincidence. What did this one, frankly, do wrong, and what’s the other one doing right?’”

To Adia Harvey Wingfield, a sociologist at Washington University and author of “Flatlining: Race, Work, and Health Care in the New Economy,” some of the most pressing questions relate to disparities: “Where is this virus hitting our health care workers hardest?” Is the impact falling disproportionately on certain categories of workers — for example, doctors vs. registered nurses vs. nursing aides — on certain types of facilities, or in certain parts of the country? Are providers who serve lower-income communities of color more likely to become ill?

“If we aren’t attuned to these issues, that puts everybody at a disadvantage,” Wingfield said. “It’s hard to identify problems or identify solutions without the data.” The answers are especially important in Black and Latino communities that have suffered the highest rates of sickness and death — and where health care workers are themselves more likely to be people of color. Without good information to guide current and future policy, she said, “we could potentially be facing long-term catastrophic gaps in care and coverage.”

The near-term consequences have also been enormous. The lack of public data about health care workers and deaths may have contributed to a dangerous complacency as infections have surged in the South and West, Friese said — for example, the idea that COVID-19 is no more dangerous than other common respiratory viruses. “I’ve been at this for 23 years. I’ve never seen so many health care workers stricken in my career. This whole idea that it’s just like the flu probably set us back quite a way.”

He sees similar misconceptions about PPE: “If we had a better understanding of the number of health care workers infected, it might help our policymakers recognize the PPE remains inadequate and they need to redouble their efforts. … People are still MacGyvering and wrapping themselves in trash bags. If we’re reusing N95 respirators, we haven’t solved the problem. And until we solve that, we’re going to continue to see the really tragic results that we’re seeing.”

The misconceptions appeared to stretch to the highest reaches of the federal government, even as infections and deaths started surging again. At a White Houseevent in July focused on reopening schools in the fall, HHS secretary Alex Azartold the people gathered, “health care workers … don’t get infected because they take appropriate precautions.”

Even some medical workers have continued to be in denial. A few days before Azar spoke, Twitter was abuzz over an Alabama nurse who worked the COVID-19 floor at a hospital by day and decompressed at crowded bars by night, where she often went maskless. “I work in the health care industry,” she was quoted as saying, “so I feel like I probably won’t get it if I haven’t gotten it by now.”

Piercing that sense of invulnerability — making the enormity of the COVID-19 disaster seem real — isn’t only Rezba’s mission. From The New York Times’ iconic front page marking the first 100,000 American deaths to the Guardian/Kaiser Health News project “Lost on the Frontline,” news organizations and social media activists have grappled with how to convey the scale of the tragedy when people are distracted by multiple world-shattering crises and the normal rituals for processing grief are largely unavailable.

“The point at which accountability usually happens is when our leaders have to reckon with the families of those who’ve been lost, and that has not happened,” said Alex Goldstein, a Boston-area communications strategist behind the wrenching @FacesOfCOVID Twitter account, which has posted almost 2,000 memorials since March. With COVID-19, “no one has had to look in the eye of a crying parent who wants to show you a picture of their child or listen to someone telling you about who their mom or dad was. There has been no consequence. What would our policy decisions have looked like if [the people making them] had to come face to face with that death and loss in a more visceral way?”

It’s a question that weighs especially heavily on health care professionals, who have seen, in the most visceral way possible, the worst that COVID-19 can do. Erica Bial, a pain specialist in the neurosurgery department at a Boston-area hospital, fell dangerously ill from COVID-19 in March, her respiratory symptoms lingering for more than six weeks. She lived alone and opted not to go to the hospital, in part because she worried about infecting other people. “At that point [in the outbreak], they would have intubated me, given me hydroxychloroquine and azithromycin and probably killed me.” As her recovery dragged on, she wondered how other doctors were faring: “I couldn’t believe that I was the only physician I knew who was sick.” But as she searched online, “I could not find any data. I just started getting really frustrated at the lack of information and the disinformation. … And then I started thinking about, well, what happens if I die here? Will anybody know?”

Like Rezba, Bial has a background in public health; the Facebook page she created, COVID-19 Physicians Memorial, was an attempt to build “a network where there’s accountability. I wasn’t necessarily trying to create, you know, reverence or memorialization. I was trying to understand the scope of the problem.”

Rezba soon began posting memorials on the page; as it grew to include more than 4,800 members, Bial asked her to help moderate it. Among the things the two women share is a determination to stick to facts. “I didn’t want any politics and I didn’t want any garbage,” Bial said. “(Rezba) was 100% like-minded and trustable.” She was also someone Bial could talk to, doctor to doctor, as she recovered. “It wasn’t just two people obsessed with something kind of morbid,” Bial said. “She was a source of support.”

Emergency room doctor Cleavon Gilman also gained a following for his posts on Facebook, a diary about what he witnessed as an ER resident in the NewYork-Presbyterian hospital system, battling the virus as it engulfed Washington Heights. “It was just … overwhelming,” he recalled. “We were intubating 20 patients a day. We had hallways filled with COVID patients; there was nowhere to put them.” In the space of a few brutal days in late April, three of Gilman’s colleagues died, including one by suicide. “When it’s a colleague that you’re taking care of and you know them as a person you’ve been on a journey with … man, that’s hard.”

Though much of the media focus was on the risks faced by older patients, Gilman was struck by how many of the critically ill were in their 20s, 30s and 40s. In mid-April, his own 27-year-old cousin, a gym teacher at a New Jersey charter school, suddenly died; he went to the ER twice with chest pain but was diagnosed with anxiety and sent home, according to his relatives, only to collapse in his car on the side of the road.

As the crisis in New York City ebbed, Gilman could see trouble ahead in other parts of the country, including in Yuma, Arizona, where he was about to start a new job. It seemed vitally important to help younger people understand the risks they faced — and that they created for others — by not adhering to physical distancing or wearing masks, not to mention the dangers that health care workers faced from continuing shortages of PPE. So Gilman began gathering the memorials he saw on Twitter and Facebook, many of them found by Rezba or on @FacesOfCOVID, and organizing the dead on his website in the type of gallery that he knew would pack an emotional wallop. Then he went a step further, making the photos and obituaries — more than 1,000 people — sortable by age and profession.

“You begin to see a pattern here,” he said. “When someone says, ‘Oh people aren’t dying, they’re not that [young],’ you can come back with actual names, actual articles, quickly. It’s more powerful. You have your evidence there.”

One of the most overtly political projects is Marked by COVID, formed by Kristin Urquiza in honor of her father, Mark, after her “honest obituary” of him went viral in early July. To Urquiza, who earned her master’s in public affairs from the University of California, Berkeley, and works as an environmental advocate in the San Francisco area, “the parallels between the AIDS crisis and what is happening now with COVID are just mind-boggling [in terms of] the inaction by governments and the failure to prioritize public health.” She and her partner, Christine Keeves, a longtime LGBTQ activist, hope the project will be both “a platform for people to come forward and share their stories” and the COVID-19 version of the anti-AIDS group Act Up.

They’re also raising money on GoFundMe to help other families pay for obituaries; the second honest obit on their site was for a respiratory therapist in Texas named Isabelle Odette Hilton Papadimitriou: “Her undeserving death is due to the carelessness of politicians who undervalue healthcare workers through lack of leadership, refusal to acknowledge the severity of this crisis and unwillingness to give clear and decisive direction to minimize the risks of coronavirus. Isabelle’s death was preventable; her children are channeling their grief and anger into ensuring fewer families endure this nightmare.”

It’s a trend that Rezba supports wholeheartedly. By the end of July, she had posted almost 900 names and faces of U.S. health care workers who had perished from COVID-19. She fantasized about what it would be like to leave the counting behind her. “It would be great if I could stop. It would be great if there was nobody else to find.” But she had a backlog of dozens of stories to post, and the number of deaths kept climbing.

In late April, as an escalating pandemic shut down most of the country and the federal government shelled out billions of dollars to untested contractors for protective masks, Juanita Ramos got a call from a friend in the marijuana business.

Her friend and some other ganjapreneurs were buzzing over a potentially huge payday. They had in their possession a $34.5 million purchase order from the U.S. Department of Veterans Affairs. A contractor hired by the VA to provide 6 million N95 respirators to the nation’s largest hospital system had searched for weeks but found none of the potentially life-saving masks. So he had reached out far and wide for help, offering to cut in anyone who could help him finance, purchase and deliver masks by his deadline.

His PO, as it’s commonly called, had made its way to players in the cannabis industry, where deals are made quickly and often in cash. The friend asked Ramos: Did she want in on the action?

Ramos had modest connections in the medical supply chain through her work in legal marijuana and thought perhaps she could help terrified health care workers get urgently needed protective gear while also pocketing a little extra cash. Ramos, 66, enlisted her daughter, Dawn, 50, and both hit the phones, calling moneyed folks they knew in the marijuana business.

Marijuana retailers, operating in the no man’s land between state legalization and conflicting federal law, often get financing outside of traditional banks from private-equity firms and wealthy individuals. A famous example from The Before Time: Last fall, two indicted Soviet-born businessmen working for President Donald Trump’s personal attorney, Rudy Giuliani, tried to finance a pot business with cash from a Russian investor.

In the marijuana space, Ramos thought, there are people with deep pockets who can move money around fast, avoiding the hang-ups that might slow such an urgent purchase.

“It’s quick money,” Ramos told ProPublica. “And the broker game in the marijuana and industrial hemp industry — it’s exactly the same.”

For working the phones, Ramos and her daughter said they only made about $200, but their experience and the records they kept tell a cautionary tale for hospitals, agencies and schools that are still scrounging for masks ahead of a potential second wave of coronavirus.

Contracts, emails and spreadsheets that Juanita and Dawn Ramos shared with ProPublica detail how domestic and foreign investors, many with marijauna industry ties, have seized upon the nation’s public health disaster.

They show that some brokers attempted to use forged documents to gain access to masks coming off production lines of 3M, the manufacturer that makes the gold-standard masks capable of filtering 95% of particles that could transmit the novel coronavirus.

In one exchange, the owner of a Swiss nutritional supplement company detailed his plan to buy millions of 3M masks at $3.71 apiece and resell them to the Federal Emergency Management Agency, whose purchase order priced masks at $7 each.

The emails include bogus U.S. Food and Drug Administration certifications; videos and photos of real or imaginary mask stockpiles; bank statements claiming to reflect billions of dollars that could be wired instantly; and, of course, nondisclosure agreements to keep participants quiet.

These coronavirus-era artifacts were collected by a self-described medicine woman who lives with her daughter in Austin, Texas. It took only a few months for her to grow disgusted with what she saw in the rogue personal protective equipment market and decide to tell her story.

The Mystery Woman

I had first heard of Juanita Ramos back in April as I reported the other side of the VA deal.

I had accompanied VA contractor Robert Stewart Jr. on a private plane to Chicago, where he promised I could watch him deliver medical-grade masks to a VA warehouse. But the reporting trip yielded something different: a close-up look at the frenzy the federal government created when it agreed to pay obscene prices for masks to just about anyone claiming they could deliver. The only procurement I witnessed that day was of McDonald’s fast food.

Several times as his deal fell apart, Stewart cryptically referred to Ramos, whom he’d met on a phone call with various mask brokers. He believed Ramos had a connection to Vice President Mike Pence, the head of the federal coronavirus task force, and was greasing the wheels to help Stewart get a contract extension.

He didn’t have a number for this mythical Ramos, and I had turned up nothing about her on deadline. Ramos remained a mystery after the story ran, but a non-journalist friend of mine texted what I thought was a random joke about a nonexistent person: “Juanita Ramos is either a stripper in Atlanta or a Native American medicine woman.”

Ramos had a common name, and I was pre-filtering based on what little I knew, scouring LinkedIn and other databases for someone with Washington connections. But my friend, Crizno (don’t ask), had gone down a random late-night Google hole and found a photo of Ramos holding a dead eagle, bestowed upon her by a Cherokee Nation chief when she completed spiritual medicine training.

Weeks later, I finally contacted the correct Ramos and shared my story of Stewart’s unsuccessful VA deal. I told her he believed she was a conduit to the vice president.

“I’m reading this and I’m like holy hell — what?” she said as she saw the article for the first time. “First off, I don’t even like Mike Pence.”

Ramos insisted she has no White House connections.

“I help write legislation for medical marijuana,” she explained, referring to her work with the Utah Association for Responsible Cannabis Legislation and Sacred Roots Healing, an educational group that helped skeptics accept that non-THC cannabis products don’t make children with autism, like, super high. She’d also worked for a major CBD company in Colorado, the first state to legalize recreational pot.

“I mean, I’m down for the farmer. And believe me, Mike Pence ain’t gonna do shit for the marijuana industry or the farmer.”

“I don’t know how I became the mystery woman,” she quipped, “But this was a great ha-ha.”

It was true, as Stewart said, that she had joined a call with him and Troy King, a former attorney general of Alabama who had apparently become a mask broker. In the final hours before the VA axed Stewart’s contract, King had been helping him track down potential mask sellers and financiers.

“I said, lookit, I will do what I can to contact people that may have access to masks, but I don’t know if it can happen,” she explained, but that was the extent of her role. In retrospect, she’s not sure why she was even on the call. She said she had no connections, no masks, no funding. She complained that after that phone call, she was inundated with offers from mask brokers, which sometimes included client needs lists and “proof of life” videos of secret stockpiles of masks.

“I’m getting emails from these guys saying, lookit, I have 10 million masks or I have, you know, gloves, or we have what was the other thing? Gowns. Let us know if you need any. And I’m like, I don’t want anything to do with these guys.”

I asked her to send me examples of the emails she had collected. She forwarded an April 25 purchase order that suggests King had planned to flip the masks, buying them from a foreign seller and reselling them to Stewart, who would then sell them to the VA. In mask trade parlance it was a “broker chain,” wherein inventory switches ownership multiple times until the end buyer, in this case the VA, pays a price high enough for everyone to get a cut. Once the buyer pays up, money drips down.

That purchase order, included in an email thread with brokers I’ve independently found to be involved in the deal, suggested King, through his limited liability company, intended to buy the VA’s would-be masks from JV Tock Trading Corp., a Canadian distributor.

Chris Kruger, a managing partner at JV Tock, said the company got a call from King and other brokers just hours before the VA deal was about to implode.

The company execs were asked “if we could try and help them save their purchase order that they’re about to lose.”

Kruger said JV Tock got a call the next day saying that “the attorney general’s gonna pull some strings to help them out.”

The company decided not to work with King and was unaware of the purchase order, Kruger said. His company is on the up and up, he said, and hasn’t made much money in its efforts to get more masks to Canadian and U.S. buyers, which have led to countless dead ends.

“The entire industry is one of the most frustrating headaches I have ever dealt with,” he said. “Greed and dishonesty run rampant.”

Through a spokeswoman, King denied any involvement with JV Tock.

“The document you attached to your email is not one of my company’s purchase orders,” his statement said.

Three days later, a different purchase order showed another broker in Arizona offering to buy millions of the same type of 3M masks for $3 apiece from — wait for it — another broker. At the time, 3M’s list price was about $1.27. The VA, however, had agreed to pay about $5.75 apiece, a 350% percent markup, which left plenty of profit for a successful broker chain.

I wanted to see more. So I flew down to Texas at a critical moment in the state’s struggle with COVID-19. Hospitals were near capacity because of an explosion of new infections following Gov. Greg Abbott’s mixed signaling on the importance and enforcement of wearing masks.

“Blood Money”

Ramos lives in Circle C Ranch, a master-planned maze of cedar trees and stone facades southwest of downtown Austin, where residents enjoy a golf course and an Olympic-size pool that is, inexplicably, heated.

She’s definitely not the shrewd, White House-connected capitalist I had been led to expect. She refers to her higher being as “creator” and places colorful stones at the bottom of all sinks so that when you wash your hands, bad energy washes off and returns to the earth.

From her brown leather sectional, Ramos outlined her dream of helping people while making a modest profit, and how it was scuttled by bogus documents, misinformation and greed.

“I told my daughter, ‘Hey, if we were to look at doing this, we would do like maybe a penny or 2 cents,’” she said, referring to the potential profit margin on each mask.

The plan fell apart when friends in the marijuana industry connected her to Drew O’Malley of Boston Capital Consultants, Ramos said. Emails and records show O’Malley, whose background is in Connecticut real estate, was trying to broker multiple high-dollar deals involving foreign investors and private-equity groups, including the VA deal with King and others.

Ramos said her alarming conversations with Boston Capital Consultants eventually led her to sever ties.

“This Drew guy was telling me that they put, like, $1.25 on top of a mask,” Ramos alleged. “And I’m like: ‘What are you talking about? People are dying, and you guys are ripping people off for a buck twenty five?’ It’s like broker-broker-broker-broker for, like, 15 people in the middle, right? And then that dollar mask turns into eight bucks, or seven bucks or whatever.”

“I don’t want to get caught up in the ripping people off,” she added. “That’s blood money to me.”

Emails Ramos shared show O’Malley passed along a few letters of intent, commonly referred to as LOIs, in which prospective buyers outline how much they’ll pay for masks that are either sitting in a warehouse or on a manufacturer’s production line.

On April 29, Ramos received an LOI showing that a Zurich investor named Stephan Schmid, who runs a dietary supplement company, hoped to buy 100 million N95 respirators a week from 3M at $3.71 each. The end buyers for the deal included FEMA and hospitals.

This happened at the same time King and Stewart were trying to sell the same type of masks to FEMA at $7 apiece. Like the VA deal, the FEMA arrangement was ultimately nixed.

Schmid didn’t respond to questions.

O’Malley, who didn’t return calls and emails, is no longer employed by Boston Capital Consultants, according to his former boss, Aaron Marcy Sells.

Sells founded Boston Capital Consultants in 2018 after a career that involved marketing work for New England Patriots owner Robert Kraft, real estate investing through firms branded with his initials, launching bars and liquor brands and, more recently, trading through AMSCAN Inc., a holding company for cannabis ventures.

“They’re all big marijuana guys,” Ramos said.

Sells claims to have played no part in his company’s well-documented negotiations in the PPE trade. “If you asked me under oath what happened, I couldn’t tell you,” Sells told ProPublica.

“I don’t think Drew did anything wrong,” he added. “I think he got pulled in with some bad people. … The minute I smelled it, I pulled everyone away from it, and Drew left the company.”

Sells insisted that he shouldn’t be named in this story. “I am not involved in this Ramos and Troy King nightmare,” he said. And while I asked him multiple times if Boston Capital Consultants was as involved in the PPE game as emails sent out by his employees suggested, he provided only opaque dismissals.

“We do a lot of different business,” he said.

Ramos’ emails show the company was soliciting masks and gowns consistently through June, including in email blasts labeled “Deal of the Day.” For instance on June 5, Boston Capital Consultants sent out an email that’s an alphabet soup of PPE trade terms.

“DEAL OF THE DAY: 5.87 million KN95 Masks (FDA) – .95 cents per mask on the ground in L.A. PO/POF gets POL …”

KN95s are the Chinese version of the N95. The PO is a purchase order from a hospital or government agency. A POF is a proof of funds, such as a bank statement or letter of assurance from a bank. POL is proof of life — video showing the stock.

“THESE WILL MOVE FAST SO PLEASE DO SO AS WELL,” the email ends.

On July 14, Massachusetts business filings show Sells founded his latest venture: Safe and Clean Protection LLC. Its stated business purpose is to “manufacture and sell personal protective equipment (PPE).”

Three Paths to Masks

Resellers pursue three avenues to attain masks, according to interviews with brokers across the country and the dozens of emails Ramos shared.

The first is the all-cash spot buy, done fast to keep the feds from confiscating inventory.

A seller broadcasts that they have a mask lot on the ground, stashed in a warehouse or at a customs inspection hub. A potential buyer bids for the product and provides either a purchase order or bank records to show there’s money backing the deal. In return, the seller provides a proof of life. The money usually goes into an escrow account, similar to a real estate deal — released to the seller upon mask inspection.

Dawn Ramos said she saw brokers reselling inventory over and over in these spot buys just to keep it moving — technically not hoarding — so the federal government wouldn’t snatch it up. One broker “would get it and if he can’t sell it, and if it’s not gone by a certain time, they have to move it somewhere else, because otherwise it would be seized,” she said. Under the Defense Production Act, FEMA has stepped in to compel owners of mask lots to sell to the federal government at market prices if the broker is hoarding or price-gouging.

In late April, as its hospitals were inundated with COVID-19 cases, the VA’s top doctor expressed frustration that FEMA had swooped in and taken shipments the VA had ordered from vendors. FEMA has denied seizing supplies from other government branches.

The second type of deal is a direct buy from a manufacturer such as 3M. To pull this off, a purchase order must come directly from a hospital or government agency. This approach is less attractive to brokers because it requires more paperwork, oversight and the masks sell for near the list price.

The third type of deal is to purchase a production line, as the Swiss investor proposed. As one broker recently told me, “It’s basically futures trading.”

This is where the rampant fabrication comes into play. Getting a connection to a distributor or manufacturer is all but impossible right now, brokers say, and to even be heard you have to prove you have backing. Several companies, including JV Tock, have reported their brands being used in phony letters to help sell an illegitimate deal.

One exchange that dropped into the Ramoses’ emails illustrates the magical thinking pervading the mask trade.

In early May, a potentially existent English investor, using an obscure international charity, was working with a London-based consulting firm to establish that he should be a 3M distributor. His proposal included a letter purportedly from HSBC Bank reflecting more than $2 billion in available funds. The package also came with a letter of support from a California-based energy company that, he claimed, vouched for his bona fides.

Emails show this proposal floating between Boston Capital Consultants, including its owner, and Joseph Ingarra, who identifies himself as the “head rainmaker” at Apex Growth Solutions LLC, based in Palm Beach Gardens, Florida. Ingarra’s company appears to do some sort of marketing and claims to leverage the “world’s leading science of how people make choices.”

“I’m aware of a huge fckn lot 1-2B range in the UK,” Ingarra wrote to O’Malley and Sells in early May, referring to a large mask transaction.

“Get this shipped in one big shot and get paid quickly,” he said in bold letters.

But the proposed deal and documents raise questions. First, it’s coming from Florida. Second, the investor’s Delaware business address connects to a residential home valued at less than $200,000. Third, even in late April and early May, brokers say it was very unlikely such a large stock of masks, which weren’t being made in great abundance beyond pre-pandemic demand, ever existed.

Then there’s the letter vouching for the buyer on letterhead from UDECM, the California firm that designs and builds solar energy rigs primarily overseas. I sent the letter to the firm’s owner, Albert Rau, who called immediately to tell me he believes it was forged like dozens of others that he’s batted away in recent months.

“The letter is 100% fake,” he said. “We don’t know the people listed.”

Why pick his firm? Rau said he didn’t know, but early on in the pandemic, his firm was leveraging its international supply chain connections to help some nonprofits find masks. After UDECM dipped its toes into the sea of brokers, “it went viral,” he said.

“Everybody’s got documents out there being forged now,” he said.

Ingarra said he had no idea the document he shared wasn’t real.

“I have zero idea of who drafted that letter,” he said in an email. “I hope they catch the scumbag.”

“It’s Coming”

So what exactly did we learn here?

Ramos ponders the question as she scratches the ears of Sherlock and Inspector Clouseau, two old fluffy-white toy dogs whose longevity she credits to daily doses of CBD oil.

History is about to repeat itself, she said, and she hopes hospitals, schools and governments don’t waste time with middlemen and profiteers. If they must, she said they should run background checks and do more vetting.

“I want to see your business license,” Ramos said. “I want to know who your attorney is. I want to see that you have the right to represent a hospital, and show me where it’s going.”

While life has slowed for Ramos and her daughter, brokers and importers say the global mask shortage remains. Many brokers told me they’ve moved on from masks — “too much trouble” — to focus on other PPE like gloves, which are becoming harder to source and thus more expensive.

But masks remain the best safeguard for workers and hospitals praying to block a respiratory killer, and the U.S. is still largely reliant on middlemen importers and brokers who are jacking up prices.

Two hours away, in Houston, the country’s fourth-largest city, several hospitals have reached the capacity of their intensive care units to treat the sickest patients. Statewide, the number of daily infections has jumped to about 10 times the April figure.

Nationwide, the COVID-19 death toll has surpassed 150,000 people. With the pandemic nowhere near under control, schools are reopening without plans to equip teachers and staff with life-saving masks. It’s the perfect storm all over again — low supply, intense demand, money to be made.

“It’s coming,” Ramos said. “It’s going to be repeated.”