A conservative business group founded by a prolific Republican political donor is pressuring the White House to greenlight an unproven COVID-19 treatment, saying in an online petition that the country has plants in the U.S. ready to produce a drug but can’t because of “red tape, regulation, and a dysfunctional healthcare supply chain.”

In recent days, Home Depot co-founder Bernard Marcus’ Job Creators Network has placed Facebook ads and texted supporters to sign a petition urging President Donald Trump to “CUT RED TAPE” and make an anti-malarial drug called hydroxychloroquine available for treating those sickened with the virus, one such message obtained by ProPublica reads.

Hydroxychloroquine and another related drug, chloroquine, are approved by the U.S. Food and Drug Administration to treat arthritis and lupus but not for COVID-19. (Doctors, however, are able to prescribe approved drugs for off-label uses.)

The campaign follows the president’s own endorsement of the treatment plan. On Saturday, Trump tweeted that hydroxychloroquine when taken with a commonly used antibiotic “have a real chance to be one of the biggest game changers in the history of medicine.” The JCN ads appeared on Facebook on Monday and its text messages went out on Tuesday. It’s not clear how much JCN has spent on its influence campaign.

There’s currently a shortage of hydroxychloroquine, a generic sold under the brand name Plaquenil. ProPublica reported this week that a nationwide run on hydroxychloroquine and chloroquine is being driven in part by doctors inappropriately hoarding it by prescribing it for themselves, their families and their friends. Lupus patients are having trouble getting prescriptions filled. In Arizona, a couple who heard the president tout the drugs this week ingested chloroquine phosphate — a chemical they’d used to treat their koi fish — mistakenly believing it would prevent COVID-19. The man died and his wife was hospitalized, according to NBC News.

There is no vaccine or cure yet for COVID-19, the disease caused by the novel coronavirus. One small French study this month found the cocktail tweeted by Trump reduced the viral loads of COVID-19 patients in a handful of cases. Dr. Anthony Fauci, the country’s top infectious disease doctor, has called that study “anecdotal” and told reporters last week that it “was not done in a controlled clinical trial, so you really can’t make any definitive statement about it.”

In its petition, JCN claims big-name drugmakers are willing to “donate” millions of tablets and plants are ready to produce the drug “if they can secure the active ingredient.” Ami Fadia, an analyst at investment bank SVB Leerink, wrote in a report published Tuesday that about 450 million doses of hydroxychloroquine were sold last year, generating about $140 million, but that demand has grown in recent weeks.

“Overall, we don’t believe hydroxychloroquine will have major financial implications for generic companies, but the efforts by these companies to step-in to help combat the COVID-19 pandemic would be a good reminder for various constituents of the important role generic companies play in the healthcare system,” Fadia wrote.

JCN, a 501(c)(4) nonprofit, says in tax filings that its purpose is to “educate Americans on the vital role of free enterprise in creating jobs that will spur innovation and help ensure America’s future economic success.” The group reported $13 million in contributions in 2018, according to its most recent tax form. A related entity, the Job Creators Network Foundation, is listed as the petition’s sponsor with another nonprofit group, Physicians for Reform.

Neither JCN nor Physicians for Reform have returned requests for comment. Spokespeople for the White House, Treasury Department and the White House Coronavirus Task Force did not respond to emailed questions. Marcus hasn’t responded to a request for comment relayed through a representative at his foundation.

There’s currently a clinical trial underway in New York to treat COVID-19 patients with the cocktail, but Gov. Andrew Cuomo has banned any other “experimental or prophylactic use” of hydroxychloroquine or chloroquine. A small study of 30 patients published by the Journal of Zhejiang University in China found that hydroxychloroquine alone was no more effective for COVID-19 patients than traditional treatment.

The drugs’ potential side effects include fatal heart problems, according to the FDA.

The “coronavirus petition” is being promoted by a coalition of groups organized by JCN called Healthcare For You, which has sought to undo the Affordable Care Act. It tells doctor members their signatures “will go directly to President Trump,” and it urges the president to “protect physician autonomy and medical decision-making as we stand in harm’s way to care for the American public.” It asserts there is “clear and ever mounting” evidence of hydroxychloroquine’s effectiveness against COVID-19. (As yet, there isn’t such evidence.)

Among the coalition’s members are a range of conserviative medical and business groups, such as Americans for Fair Taxation, the American Hotel and Lodging Association, Young Americans Against Socialism and the Colorado Business Roundtable.

As lawmakers and the administration negotiated a huge rescue package to stand up the U.S. economy, JCN’s president, Alfredo Ortiz, told Bloomberg News that he’d had three direct calls with Treasury Secretary Steven Mnuchin last week about the administration’s plan.

Among the group’s ideas, Ortiz told Bloomberg, was to extend quarterly April tax payments by two or three months, a move that would allow businesses to defer paying some 2020 taxes as well as taxes owed in 2019. He also said he discussed with Mnuchin a plan to streamline Small Business Administration loans.

Speaking to Fox News host Maria Bartiromo on Sunday, Breitbart News co-founder and former Trump adviser Steve Bannon said that “Bernie Marcus’ Job Creators Network has a plan of forcing cash into the system.” He didn’t elaborate on it.

Job Creators Network paid Breitbart News Network $1.1 million for advertising in 2018, according to the group’s 990 tax form from that year, the most recent publicly available. The news outlet wrote last week that JCN had launched an ad campaign airing on Fox to advocate for its members.

Marcus is a generous donor to Republican groups and causes. During the 2016 presidential campaign he gave $5 million to a pro-Trump PAC and has said he’ll support the president’s reelection campaign.

In the 2018 midterms, tax filings and campaign disclosure reports show, JCN gave $213,000 to the American Potential Fund, a political action committee that spent most of that sum on digital ads targeting then-incumbent Sen. Bill Nelson of Florida during the last month of the election. Nelson, a Democrat, was defeated by Republican Rick Scott in a tight race.

Gunshot victims with massive blood loss and failing lungs packed the emergency room of Sunrise Hospital in Las Vegas late on the night of Oct. 1, 2017. A man had opened fire on a music festival from the 32nd floor of the Mandalay Bay Hotel, spraying more than a thousand rounds of ammunition into the crowd, wounding hundreds.

The hospital soon ran out of ventilators, machines that breathe for patients who can’t. Dr. Kevin Menes, a critical care physician, had several patients in respiratory failure. Menes remembered that a colleague from his medical residency had studied how to connect multiple people to a single ventilator. When a respiratory therapist said to Menes, “‘We don’t have any more ventilators,’ I said, ‘It’s fine,’” he later recalled. He asked for tubing and began splitting one machine’s oxygen flow into two patients, saving their lives.

Now, Menes’ makeshift strategy may well be adopted by desperate caregivers worldwide. As hospitals anticipate more COVID-19 patients with respiratory failure to arrive than they have ventilators to hook them to, the idea of using one ventilator for two or more patients has gained widespread attention and support, including at two prominent Manhattan hospitals.

But interviews with critical care workers and a review of the medical literature show that plugging more than one person into the same ventilator is a stopgap that risks harming patients’ lungs. At best, many doctors say, it’s a last resort for patients who have stopped breathing on their own and have no other prospect of surviving.

A ventilator is designed and can be set for only one patient at a time. Since two patients are unlikely to require oxygen at the same amount and pressure, one might get too little oxygen while the other receives too much, injuring their lungs either way. Also, the air tubes might distribute contaminants between patients. Reflecting these concerns, one major ventilator manufacturer and the American Association for Respiratory Care both discourage hospitals from connecting machines to multiple patients. Some hospitals are reluctant to try it under any circumstances and are looking for other backup plans.

“This is not a panacea,” said Dr. Lewis Rubinson, chief medical officer at Morristown Medical Center in New Jersey and a longtime critical care physician. “We don’t want a solution that’s a distraction, and that’s what this has become.”

Some see it not as a distraction but as a lifesaver at a time when the U.S. health care system has about 160,000 ventilators available, less than half of the number most statistical models estimate it will need to treat gravely ill coronavirus patients. A YouTube video posted by a critical care doctor in Detroit, demonstrating how to connect up to four patients to one ventilator, has been viewed more than 800,000 times in the past 10 days. A physician at a rural hospital in Canada told reporters he has doubled the number of patients he can ventilate at one time by following the video’s directions.

In New York City, which has almost 30% of the nation’s coronavirus cases, intensive care units at NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center are testing how to use “split-ventilation,” Dr. Craig Smith, the hospitals’ chief surgeon, said in a note to staff this week. Smith lauded plans to care for multiple patients with one ventilator as a critical innovation, and he wrote, “Today a technique forged in the crucible of mass trauma is helping our medical colleagues manage COVID-19.”

New York Gov. Andrew Cuomo on Tuesday endorsed its use. “We are going so far as to try an experimental procedure where we split the ventilators,” he said. “We use one ventilator for two patients. It’s difficult to perform, it’s experimental, but at this point we have no alternatives.”

Some hospitals are already on the brink of running out of ventilators. A critical care physician in New Jersey, who asked not to identify herself or her employer, said the facility was treating dozens of patients who had tested positive for COVID-19, while several dozen others awaited test results. A young patient arrived, struggling to breathe, and “suddenly there was panic around where we were going to get the next ventilator from,” the doctor said. Eventually, a ventilator was found for the child.

A ventilator pumps oxygen into a patient’s airways when the lungs are too injured or sick to breathe on their own. Typically, for COVID-19 patients, physicians and respiratory therapists first run tubes into the airway to deliver oxygen to the lungs. Then they set how often the machine breathes for the patient and how much oxygen it sends. Using sensors, the ventilator tracks everything about the breaths — their length, the amount of resistance the air hits in the body and how much the lungs expand and contract. Medical staff use the information to determine whether the treatment is working and to make adjustments.

With multiple patients connected, a ventilator becomes a blunt instrument. The tubes are adjusted so the air the ventilator pumps out is divided between two or four tubes, each going into a different set of lungs. It moves air in and out of each person, or at least tries to. Doctors and therapists must choose carefully which patients to pair, matching them by gender, body size and diagnosis.

This is highly inexact, Rubinson said. Sicker patients, whose lungs resist more, take in less of the oxygen. Stronger patients take in more air, which can cause its own problems. The machine cannot adjust, and it is difficult for the critical care staff to do so either.

Early studies of whether ventilators could work on more than one patient involved testing them on artificial lungs that simulate the function of actual lungs. In 2006, a pair of emergency doctors at St. John’s Hospital and Medical Center in Detroit, anticipating “a large outbreak of botulism” or other disaster for which hospitals would not have enough ventilators to go around, found that a ventilator could inflate and deflate multiple artificial lungs, but could not address whether there would be adequate oxygen or any potential for lung injuries. A follow-up study on animals found that ventilators struggled to distribute air evenly. There has never been a controlled test on human subjects.

The flaws are well understood on most intensive care units. Even hospitals including the technique in emergency plans for COVID-19 plan to use it only as a last resort. “In a short term scenario, it would be a potentially lifesaving choice” when a hospital has run out of ventilators, said Dr. Gregory Martin, head of critical care at Grady Memorial Hospital in Atlanta.

However, “there isn’t a way to necessarily decide how much oxygen, or how much carbon dioxide removal, or what size breath to give” to multiple patients on one ventilator, Martin continued, adding, “We wouldn’t use this solution if we had really any other options.”

At the University of California-San Francisco, the intensive care units are working on ways to cope with a shortage and avoid using the multiple patient technique, said Dr. J. Matthew Aldrich, the system’s executive director of critical care. It is unproven and “I’m not aware of any successful use in this kind of situation.”

Anesthesia machines in operating rooms have ventilators built in, which could at times be used to treat ICU patients, Aldrich said.

The American Association for Respiratory Care, which represents more than 40,000 respiratory therapists, discourages hospitals from connecting two or more patients to a single ventilator, said Tim Myers, an executive at the association. The technique does not allow caregivers to ensure patients are receiving the right amount of air, or to track their respiration.

“How will we know that your lungs are getting better?” Myers said.

Hamilton Medical AG, one of the largest ventilator manufacturers, warns against the multiple patient technique. “Ventilators use sensors to adapt ventilation to every individual patient. This is important with critically ill patients — like COVID-19 patients,” a spokeswoman for Hamilton Medical said in a written response to questions. “If there were several patients on one ventilator, to whom should the ventilator adapt?”

When one patient’s lungs resist the airflow, it travels to the other patients, who then receive more than their lungs need and potentially more than they can tolerate, said Audrey Mak, a retired respiratory therapist in south Texas.

“Say you have a balloon and you’re blowing it all the way, the balloon is going to get weak,” Mak said. “You can do the same thing with lungs.”

Maya Miller contributed reporting

On Feb. 13, the U.S. Centers for Disease Control and Prevention sent out an email with what the author described as an “URGENT” call for help.

The agency was struggling with one of its most important duties: keeping track of Americans suspected of having the novel coronavirus. It had “an ongoing issue” with organizing — and sometimes flat-out losing — forms sent by local agencies about people thought to be infected. The email listed job postings for people who could track or retrieve this paperwork.

“Help needed urgently,” the CDC wrote.

This email is among hundreds of pages of correspondence between federal and state public health officials obtained by ProPublica through a records request in Nevada.

During the period in which the correspondence was written, from January to early March, health officials were trying to stay ahead of the coronavirus outbreak underway in China. By mid-February, when the CDC job postings email went out, the virus had a toehold in the United States, where there were already 15 confirmed cases. In another two weeks, the first case of community transmission would be reported in California, followed shortly by cases in Washington.

The documents — mostly emails — provide a behind-the-scenes peek into the messy early stages of the U.S. response to the coronavirus, revealing an antiquated public health system trying to adapt on the fly. What comes through clearly is confusion, as the CDC underestimated the threat from the virus and stumbled in communicating to local public health officials what should be done.

The same week the CDC sent out the email about the job openings, the agency sent Nevada officials alerts about 80 potential coronavirus patients to monitor, documents show. Four were not Nevada residents.

A state epidemiologist, in each instance, corrected the agency, informing the CDC that the person was from New York, not Nevada. (The CDC then redirected each report to New York, the documents show.)

The confusion sometimes went both ways. On March 4, a program manager in the Nevada Health Department reached out to the CDC to ask about congressional funding for COVID-19, the disease caused by the novel coronavirus.

“There seems to be a communications blackout on this end,” the program manager wrote, wondering if funds would be distributed based on the number of cases in each state or by population.

“Unfortunately, there is no clear answer to your questions,” responded a CDC staffer, apologizing for the lack of information. “We are hearing all of the rumor mills as well.”

“Thank you,” the Nevada program manager replied. “It’s good to be confused together.”

Chaotic Coordination

For much of February, the CDC kept a tight grip on who should be tested for the coronavirus, a strategy that has been criticized by epidemiologists for limiting the ability to track the spread of the disease.

In a Feb. 19 presentation to state health officials, the CDC described the definition of a person who ought to be tested: You had to have had close contact with someone confirmed to have COVID-19, or to have traveled from China and then had respiratory symptoms and a fever at the same time.

However, the CDC’s own guidance from a month prior, distributed to the states on Jan. 17, had a footnote that said that “fever may not be present in some patients,” such as people who had taken fever-lowering medications, according to one of the documents obtained by ProPublica. That caveat was not on the slides presented to the states in mid-February.

In a statement to ProPublica, the CDC said clinicians could always use their judgment to decide who received a test. “CDC never declined a request for testing that came from a state or local health department,” the agency said.

In mid to late February, the CDC was trying to move responsibility for coronavirus testing from itself to state health departments — a critical step, since the CDC does not have the capacity to be the nation’s testing lab. Slides from the Feb. 19 presentation describe the process for transitioning from “Phase 1,” in which the CDC determined who was a potential COVID-19 patient and conducted all the testing, to “Phase 2,” in which local health departments would do that work and report data back to the CDC.

Because of delays with test kits, Phase 2 had to be “redesigned,” the presentation said, so the CDC would continue to test specimens and return results. The CDC told ProPublica that all states have now transitioned to the original Phase 2 plan, where they can run their own tests.

The CDC presentation also directed the states to use a web platform called DCIPHER, which the agency was already using for food-related outbreaks, to report potential COVID-19 patients and confirmed cases.

But it wasn’t until the week of Feb. 24 — the same week that the U.S. would discover its first case of community-acquired COVID-19 — that the CDC scheduled a training for states on how to use the platform, according to the documents.

On March 1, the CDC emailed Nevada’s Health Department, requesting that it send a list of users and email addresses to connect to the DCIPHER system, to “ensure that we can onboard your jurisdiction.”

“We sent a spread sheet a couple weeks ago which I thought covered this,” a state epidemiologist responded.

Four days later, Nevada announced its first confirmed case of the coronavirus. It’s unclear when the state managed to successfully get on the DCIPHER system. Officials from Nevada declined to comment.

“Maybe Just Kidding”

A key part of the CDC’s strategy during the early days of the outbreak was identifying infected travelers returning from China. The process for screening passengers arriving at Los Angeles International Airport did not go smoothly, the correspondence obtained by ProPublica indicates.

On Feb. 16, a CDC staff member sent a message to colleagues about a buggy electronic traveler screening questionnaire that wouldn’t save correctly, among other issues. Also, the tool’s drop down field auto-populated with “United Kingdom” instead of “United States,” forcing users to type “United States of America.”

The CDC staffer also said the agency was struggling to interview non-English speakers in a timely manner and needed additional interpreters.

“Hello Team,” another CDC staff member responded, offering a solution: “The Google translate App has a real-time voice translation option.”

The screening protocol also wasn’t always clear. On Feb. 29, a CDC officer at LAX sent an email to her colleagues, saying: “In case this comes up again, we are not screening private flights. These would be flights that land at LAX but don’t arrive into the regular terminal … mainly for rich people.”

Just over two hours later, the officer emailed again. “And, maybe just kidding,” she wrote. Information from headquarters seemed to contradict what she had said about private flights, she said.

The CDC told ProPublica that it scaled up the screening almost overnight, so it focused on vetting the largest segment possible of high-risk passengers coming from places like Wuhan, China. The agency trained staff and dealt as best it could with limited staffing and translation services, it said.

“Protecting Americans Is What We Do”

The CDC’s initial response to COVID-19, particularly its failure to initiate swift, widespread testing, has drawn intense criticism.

Nonetheless, the correspondence ProPublica obtained shows that the CDC director, Dr. Robert Redfield, exuded confidence in communications with others at the agency.

On Jan. 28, when the CDC had confirmed five cases of the coronavirus, all in travelers who arrived from outside the country, he emailed colleagues to acknowledge it posed “a very serious public health threat,” but he assured them “the virus is not spreading in the U.S. at this time.”

That actually may not have been the case. The CDC confirmed the first case of COVID-19 in Washington on Jan 20. Trevor Bedford, a computational epidemiologist at the Fred Hutchinson Cancer Research Center in Seattle, has said he believes that the virus could have begun circulating in the state immediately after the traveler arrived in mid-January, based on his analysis of genetic data from the initial Washington cases.

The CDC said in its statement that Redfield’s comments were based on the data available at the time. “At no time, did he underestimate the potential for COVID-19 becoming a global pandemic,” the agency’s statement said. “He stated consistently that more cases, including person to person spread, were likely.”

On March 3, Redfield wrote to his staff again, stressing the agency’s readiness, despite the growing evidence that it wasn’t. “We anticipated and prepared for the possible spread of COVID-19 in communities across the United States,” he said in an email.

The CDC said in its statement that Redfield was telling staffers that the agency would continue to be engaged in a sustained response to COVID-19. Redfield’s email was not characterizing the state of the outbreak, the CDC said.

By that point, it was clear that the coronavirus was gaining ground within the country, even if the inability to test for it was obscuring the true numbers. Physicians and public health experts begged for more tests while warning that thousands of cases would soon emerge.

Still, Redfield’s March 3 email struck a reassuring note.

“Confronting global outbreaks and protecting Americans is what we do,” Redfield wrote in the message. “More and more, people are turning to us for guidance, and we respond consistently with evidence-based information and professionalism.”