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Morally Indefensible PPE

Morally Indefensible PPE


When the pandemic hit, Caroline Criado Perez was inundated with messages from female healthcare workers telling her that their PPE – things like masks and goggles – didn’t fit. In this first episode of her brand new investigative series, join Caroline as she goes on the hunt for missing data and asks: can we fix PPE?


Caroline Criado Perez, narrating: There are probably a fair number of things I do that are morally indefensible. I buy single-use coffee pods instead of grinding my own beans. I have been known to chuck food waste into the black bin instead of the food caddy if the food caddy is full and I don’t want to take it out because it’s 11:00 PM and I just want to go to bed already. I’m not vegan; I’m not even vegetarian. And no, I don’t make sure all my food is seasonal, locally sourced, and organic.

All of these things are quite clearly morally indefensible, and I hold up my hand to them. I try to do better. But I have to admit, I did not have calling for PPE to fit women on my morally indefensible bingo card.

… because this is a new virus. The data continues to stream in. But my next guest argues….

Christiane Amanpour, on CNN

Caroline, narrating: Let me take you back. It was April 2020. Everything about COVID-19 felt new and terrifying. We had no idea of the scale of the coming pandemic. We were only one month in.

…In Italy, for instance, 70% of those…

Christiane Amanpour, on CNN

Caroline, narrating: My book, Invisible Women, had just come out in paperback. It was going down pretty well. It hit number one on the Sunday times, best seller list. As many of you might know, I set out to show how in a world built by and for men, we are systematically ignoring half the population, often with disastrous consequences. 

I went really deep on case studies and data and talked a lot about the gender data gap.

The gender data gap is basically a term that describes the fact that the vast majority of data we’ve collected historically and continue to collect, everything from medical data, to economic data, to urban planning data has been collected mainly in men. And this means that pretty much everything in the world from the car you drive to the medical treatment you receive has been designed for men.

Joining him to talk to us also is author and activist, Carolina Criado Perez. Her book…

Christiane Amanpour, on CNN

Caroline, narrating: So anyway, shortly after the first wave of COVID-19 had begun, I found myself on CNN along with another guest discussing sex differences in relation to COVID.

Yeah. I mean, so that’s why it’s so important that we are collecting sex disaggregated data right from the very beginning…

Caroline Criado Perez, on CNN

Caroline, narrating: After a few questions specifically about data in the pandemic, Christiane Amanpour, the presenter, asked me to talk about the gender data gap and the impact of a world designed mainly on male data. You know. My whole thing.

The vast majority of personal protective equipment has also been designed for men. The majority of those frontline workers are women…

Caroline Criado Perez, on CNN

Caroline, narrating: And then this happened.

The real data gap here, and that’s the one we really can’t ignore, is why are more men dying? So if she’s claiming that more women are becoming infected because they’re not having proper protective equipment, I should really remind her that most of the places around the world, women who are being infected don’t have any equipment, neither do the men.

Dr. Sharon Moalem, on CNN

Caroline, narrating: This is Dr. Sharon Moalem, the other guest on the show that day.

I think what I really have to take issue with what I hear your other guests saying, and I think it’s completely morally indefensible, is that to start speaking about properly fitting personal protective equipment, which is important actually for both sexes…

Dr. Sharon Moalem, on CNN

Caroline, narrating: Did he really just say that it was completely morally indefensible for me to be talking about PPE not fitting women? I mean, if it isn’t morally defensible to talk about properly fitting personal protective equipment during a deadly health crisis, then when exactly is it morally defensible?

I’m Caroline Criado Perez. And this is Visible Women, my new weekly podcast from Tortoise, which aims to investigate how we finally fix a world designed for men.

In this episode, when the PPE doesn’t fit and what we can do about it. And Dr. Sharon Moalem, if you thought that clip was bad, you’re not going to like the rest of this podcast.

The UK is on a three week lockdown until Easter Monday at the earliest-

ITV News

A very simple instruction: you must stay at home.

Boris Johnson’s lockdown statement, BBC News

Caroline, narrating: Let’s briefly remember how March 2020 felt. We didn’t know much about COVID. Remember disinfecting surfaces? Remember disinfecting food? But we did know that masks were an important defence. We knew that from related diseases like SARS. And speaking to doctors, they told us there was a sense that something quite scary was happening. There was a background sense of panic. It was all systems go overnight. By April 2020, just over 64,000 people were hospitalised with COVID in the UK. Frontline healthcare workers were wearing whatever PPE they could get their hands on; goggles, visers, gloves, and most importantly masks; but not everyone was being protected in the same way.

Dr. Mia van Manen: A large majority of my female colleagues and I all failed fit testing because we could not get a mask to fit our faces. And we worked nonetheless because we didn’t really feel that we had any other option.

Caroline, narrating: This is Dr. Mia van Manen, an intensive care and anaesthetic registrar based in Oxford.

Mia: Our special skill is the management of airways. So putting breathing tubes into sick patients.

Caroline, narrating: Mia says that during the first wave of COVID, she and her colleagues spent hours each day in intensive care treating patients that were known to be infectious, wearing masks that they knew didn’t fit them.

Mia: They’re supposed to have a snug fit, but they’re not supposed to be put on really, really tightly because that can actually interfere with how they work. But the problem was, in order to get them to fit or to stay on, you had to do the straps up very tightly. It was just unbearable. And you’re very hot, the skin gets bruised and damaged. People were having to put extra tape on to cover up gaps in the masks.

Caroline, narrating: And the reason the masks didn’t fit, as far as I can work out, is that female faces have not been sufficiently considered when masks are being designed and manufactured. According to a facial surgeon I spoke to, women’s faces are typically smaller than men’s, and of course less hairy, but they also differ in other important ways such as shape and movement. All of these things can impact mask fit.

This is not news. Researchers at NIOSH, that’s the body that regulates masks in the US, found significant differences in facial dimensions between males and females and all racial and ethnic groups back in 2010. And they even made a point of mentioning that this would be important information for designing and manufacturing masks. So 10 years later in 2020, why were we still having to make the case that this problem even existed? Mia says that the first few weeks, it was a case of grabbing what you could, which she says in her hospital was typically from a selection of heavy rubber, and plastic masks. And from very early on, there was a big issue with supply chains.

… that a lack of protective equipment or PPE is putting lives at risk.

… safety, because they fear their hospitals might run out of PPE.

An RAF aircraft has flown to Turkey to collect a shipment of 400,000 clinical gowns.

BBC News

Caroline, narrating: But what I wasn’t hearing on the news was that the supply chain issues were massively exacerbating women’s PPE problems. The masks that did fit women tended to be the smaller ones, and there were far fewer of these to begin with despite the fact that healthcare is a hugely female dominated industry. So the demand for the few smaller masks that were available was huge.

Mia: These masks are heavy and they come in a generic small, medium, and large size. And as was typical, there were not many small sizes and lots of medium and large sizes.

Caroline, narrating: Eventually, better PPE was sourced. Healthcare staff were meant to be using FFP3 masks. These are called N99 masks in the US. Staff were supposed to get what are called fit tests, a procedure to demonstrate whether or not a mask fits the wearer and will therefore protect her from breathing in any virus particles.

Mia: Fit testing procedures variable from hospital to hospital. Some trusts use more technologically advanced methods where you are on a sort of stepper and they have some sort of sampling technology that measures the particles. The trust where I was working used this kind of hood where you put the mask on and they sprayed sweet and bitter smells into the hood, and you just had to say when you could smell it and when you couldn’t smell it.

Caroline, narrating: And of course there was one group that was consistently more likely to smell the spray and therefore fail the fit test: women. 

I knew this from very early on in the pandemic because right from the beginning I started receiving messages from scared female healthcare workers telling me that their masks did not fit. So I wanted to discover what the scale of the problem was. Even before the pandemic, when I was researching PPE for Invisible Women, I found that the vast majority of women were wearing PPE that had been designed for a male body. 95% of women working in the emergency services, who responded to one survey, said PPE had actively hampered their work.

When I started looking into masks more closely, I found several studies proving that respiratory protective equipment is less likely to fit women, particularly those of Asian origin, as well as a lot of men from black and minority ethnic groups. One report explained that the equipment is designed using a so-called “standard” US male face. I sent out Freedom of Information requests to NHS trusts to ask them how often men and women failed fit tests. But most trusts did not sex disaggregate their data on fit test failures, as in they didn’t record the sex of the people failing the test, making it impossible to document the scale of the problem or even to prove the problem existed. And without that, it could all just be dismissed as anecdotal.

Mia: We were very much made to feel almost like failures. You know. “Well, I don’t know why this mask won’t fit you.” And the ones with the metal strip, in order to get it to fit, she had bent the metal strips at such an acute angle that I couldn’t actually breathe through my nose. She said, “Well, that’s how hard you have to do it.” I said, “I’m sorry. I can’t actually breathe.” And I think… The feeling I got was that she thought that I was sort of being difficult.

Caroline, narrating: A few months after I’d emailed basically the entire NHS, a UK study came out proving my suspicions right. Women were in fact twice as likely as men to fail their fit test. And let’s not forget poorly fitting PPE isn’t just an inconvenience. It can be fatal. One study from May, 2020 found that the mortality rate for female NHS employees aged 16 to 44 was estimated to be approximately twice that for those not employed in the NHS. Later in the year, another study found that healthcare workers and their families accounted for a sixth of hospital admissions for COVID 19 in the working age population. And ill-fitting PPE isn’t just dangerous for healthcare staff. It’s dangerous for patients too.

Mia: Because it’s very difficult to do a good job when you’re in pain, when you have got a mask that’s taped to your face, when your trousers are falling down, when you’re tripping over your gown. You know? It’s highly technical and specialised work that’s made incredibly difficult by ill-fitting, inadequate equipment.

Caroline, narrating: That’s not an exaggeration about the trousers falling down by the way.

Mia: My scrub trousers fell down whilst I was doing a tracheostomy, which is a really time critical, delicate procedure putting an airway in the front of someone’s neck. And I had to actually ask… I had a sterile gown over the top, but I had to ask one of my colleagues to pull my trousers up under my gown because they’d fallen down.

Caroline, narrating: Mia also told me about problems with one-size-fits-men face shields, which were too long and got stuck on female healthcare workers’ breasts if they looked down at a patient in bed – a pretty regular occurrence for a medic. She told me about gloves that were routinely stocked in sizes seven to nine, when she, as a six-foot woman, is a size six. Hands are one of those body parts that tend to differ by sex irrespective of height.

Let’s just take a moment to remind ourselves here that medicine is a hugely female dominated profession. About 70% of healthcare workers worldwide are female. It simply makes no sense to cater more to male bodies here. And while I’m focusing on masks in this episode, it’s not a problem that’s just in hospitals either. One-size-fits-men PPE plagues every industry where PPE is used from construction to policing, to transport, to the military. Stab vests, harnesses, gloves, eyewear, boots, hard hats, these are all PPE, and they all tend to be designed for men, leaving the female workers who wear them unprotected.

… to be the first female fire officer to be killed on duty.

Fleur Lombard was among 60 firefighters called to the crowded supermarket at lunchtime. As the flames rapidly gutted the store, she and a colleague went to check if anyone was trapped inside.

BBC News

Caroline, narrating: On the 4th of February, 1996, Fleur Lombard and a male colleague were caught up in what’s called a flashover. This is when everything simultaneously ignites in an enclosed area. The blast threw them both several metres across the floor. Fleur’s male colleague passed out, but survived. Fleur died. She was only 21 years old. Fleur’s death prompted investigations into the PPE she was using, which found that the temperature inside her fire gear had reached 600 degrees Celsius. Her PPE had not protected her. Seven years later, a report was published setting out the differences between male and female bodies and calling for an end to the practice of simply scaling down male PPE to fit women.

According to the International Association of Fire and Rescue Services, the upshot of this report was that PPE had to be tested on SOPHIE, a new female mannequin, who in 2003 joined RALPH, the original male mannequin which was developed in the 1980s. And all contractors involved in procurement had to supply specifically tailored PPE for women as well as men. Unisex was not allowed.

Banning unisex anything is of course music to my ears, but I can’t help thinking they managed to do this for firefighters 20 years ago in a highly male dominated industry. Why are healthcare workers, who are predominantly female, still having to put up with so-called unisex PPE? I needed to understand how manufacturers come up with the size and shape of their masks. And this meant I got to look at my favourite topic: standards. I have to confess, while we were making this podcast, I talked about standards so much that my producer suggested we have a special klaxon every time I mention them. So here it is.

Standards klaxon

Caroline, narrating: What I really wanted to know was what size specifications on manufacturers designing to. I set about trying to find out. I contacted manufacturers. I contacted standards bodies. I contacted PPE test labs. I even tried the Department of Health, but I just kept coming up against brick walls. No one wanted to talk to me about masks. No one wanted to talk to me about standards, which as you can imagine was very disappointing. So I enlisted some help in the form of Patricia Clarke, a data journalist at Tortoise. Think of her as my official data correspondent for Visible Women. We met and I told her all about my troubles.

Caroline: … also told me basically to take a hike. And no one seemed to want to engage with me on this topic. And to just answer what felt to me like a very, very simple question. You know? What are the specifications and what is the data you use to come up with them?

Patricia Clarke: That’s just amazing to me because it can’t… Surely those standards apply to more than just this massive… I mean, I say just. The fact that it’s 50% of the population-

Caroline: Yeah. But I mean, the data-

Patricia: … is another thing. But surely that you just need to know the standards for a bunch of other stuff for safety reasons.

Caroline: Yeah. I mean, the answer must be out there. You know? The manufacturers aren’t plucking masks out randomly from the ether. They have a size specification. They’re just not giving it to me.

Caroline, narrating: In the end, only one manufacturer replied: 3M. They’re one of the big ones. They made 2 billion masks in 2020. They pointed me towards the European standard for respiratory protective equipment, EN149:2001+A1, which is almost exclusively about filtration rather than fit. Although, there was one section, the Total Inward Leakage test, which was basically a fit test. And this test called for 10 clean-shaven persons. 

Hang on. Clean shaven? That doesn’t really sound like a standard that is making an active effort to include the female half of the population. Still, it didn’t really answer my question about size specifications and whether these accounted for female size and shaped faces.

So during one of our early recording sessions, I spoke to Patricia and our executive producer, Basia, about how we could get past the veil of silence.

Basia Cummings: But I think it’s that you would still run into the problem of, it’s not the standards that’s the problem, it’s how the standards get made. And it’s going one step further. And that I can’t quite figure out listening to you how we would get that.

Patricia: You want to trace it all back to just like one person…

Basia: Yeah. Yeah. One clean-shaven man 

Patricia: Yeah. One clean-shaven man who sat in his room, who was like, “My face is this big.”

Caroline: Well, you joke, but one of the parts of the EU Standard is that the mask should be placed on what’s called the Sheffield head. And the Sheffield head is the head of a man from Sheffield who happened to work in this lab. And they took a mould of his head, and that is what the masks are put on.

Basia: We have to do more on the Sheffield head. Oh my God.

Patricia: That’s it! The Sheffield head.

Basia: The Sheffield head is amazing.

Patricia: The one person I was picturing, I wasn’t expecting it to be that close to-

Caroline: I mean, he’s probably still alive. We might be able to speak to him.

Patricia: Yes.

Basia:  Can we find the Sheffield head?

Caroline, narrating: We had a plan. We were going to track down the Sheffield head. The Sheffield head is, well, a head. A dummy head. It’s a required part of the European standard for masks.

Standards klaxon

Caroline, narrating: In the simulated wearing treatment test, a mask is mounted on the Sheffield head and breathing is simulated. And it just seemed crazy to me that this important piece of the regulatory framework could be so unscientific, so based on happenstance. How could some random guy’s head become part of the legal process for getting a CE mark? That’s the sign that a product sold in Europe is safe to use.

I wanted to know how this decision had been made. And I wanted to know if anyone except for me thought this was a bit problematic. So Patricia began her quest to try to find the Sheffield head. She didn’t have much to go on. She fired out dozens of emails to wholesalers, manufacturers, standards bodies, anyone who might have a connection to mask manufacturing. She asked them all the same thing: Have you ever met the Sheffield head? After a few dead ends, she got a lead.

Patricia: I came out of the tube this morning to a missed call 8:30 AM which said, “Hello, Patricia. I have some information about the Sheffield head.” So obviously I ran to my desk and I phoned up the number. They were a person in their 70s and they said, “I know the Sheffield head.”

Caroline: Amazing.

Patricia: This person said, “Oh, I was on this panel when we were setting standards with the Sheffield head.”

Caroline: Oh, so the Sheffield head wasn’t just a head. He also had a brain.

Patricia: He also had a brain.

Caroline: And used it. That’s so interesting. I just sort of thought he was just a random head that they used.

Patricia: The person I spoke to was 75. They said, “He was older than me. So he might be dead,” was the way he phrased it. And I said, “Ooh.”

Caroline: Wow. Okay.

Patricia: Wow. But when I asked if I could have an interview and ask some more questions about what it was, they said, “No, no, no, no, no. You’ve asked your question.”

Caroline: Wow. They said that?

Patricia: I had someone else email me back just now saying they think the Sheffield head was modelled on someone in the 1950s. So I said, “Oh, that’s interesting. I’ve heard 1980s.” And they said, “You might want to speak to this other person…” And so I sent this other person a message. And it is just sounding increasingly sort of mysterious.

Caroline, narrating: And so the search continued. I should say here there does exist an updated set of five head forms called the ISO head forms. These are a set of digital 3D faces that are obviously a slight improvement on a random head from Sheffield. However, the data they are based on is male dominated and has not been sex disaggregated, which matters because the faces are supposedly unisex. And I have to say, at a glance, four out of five of them look very male indeed. And in any case, these head forms aren’t required in the standard. The Sheffield head is. I knew that standards much as I love them-

Standards klaxon

Caroline, narrating: … wouldn’t give me the whole answer, because while they set the legal minimum standard for masks, there was nothing in them really to prevent manufacturers from making masks to cater for the female half of the population. Women are, after all, pretty clean shaven on the whole. So why wasn’t anyone designing masks to fit them? But here again, I ran into more brick walls. No manufacturers wanted to engage. “We designed to the standard,” they said, ignoring my protests that the standard didn’t stipulate anything to do with size or shape.

So striking out on the supply side, I decided to try the demand side. Surely if hospitals demanded masks that fit their workforce, the manufacturers would have to produce them. So was the NHS thinking at all about the demographics of their employees when they ordered PPE? But here again, I got nowhere. The NHS refused to reply to my emails until I made a fuss on Twitter. At which point, they replied within a few minutes – to tell me to contact the Department for Health. Okay. You could have told me that weeks ago when I sent the first email, but fine.

I emailed the Department for Health, but they just told me that PPE is designed to be unisex and offer protection for both genders. And okay, that’s nice, but bodies aren’t unisex. And in any case, the evidence is clear that both genders are very much not being protected. They also pointed me towards Public Health England’s online guidance on the use of PPE, which makes no reference to sex or gender. So that didn’t answer my question at all. I needed to try another tack.

In 2021, the British Medical Association published the results of a survey of 7,000 UK doctors, which found that women were more likely to report that their PPE did not fit them. The British Medical Association, usually known as the BMA, is the trade union for doctors. Maybe they could help me.

Dr. Latifa Patel: The people doing the organisation, the people doing the buying, the government, right at the top, doing the ordering and the preparing went for the lazier approach. And they expected us to adapt.

Caroline, narrating: Dr. Latifa Patel is a paediatric respiratory doctor, but she’s also the interim chair of the BMA.

Latifa: We represent over 163,500 medical students and doctors across the UK.

Caroline, narrating: Latifa is 5’1″. So she’s used to adapting her PPE. By the way, 5’1″ is short, but not that short for a woman. The average height of a woman in the UK is 5’3″. So 5’1″ is well within the normal range. And yet, Latifa is very used to feeling like an outlier.

Latifa: All the way from when I was a medical student, I used to carry safety pins on me. I knew that scrubs were going to be too big, so I tightened them around the neck. I knew that the big aprons were going to be too big, so I just tightened them around the waist. I took belts with me. I can’t do that with my face though, can I?

Caroline, narrating: By the way, Latifa, like Mia, who we spoke to earlier, is also a size six in gloves.

Latifa: That won’t mean much to people who aren’t in the healthcare, but that’s one of the smallest sizes.

Caroline, narrating: And she is also used to not being able to find gloves that fit.

Latifa: Within wards, you find large, medium, small kind of size-fits-all. Small has never fitted me. I’m probably an extra small, but you don’t find that.

Caroline, narrating: And again, like Mia, Latifa also found that things got worse when the pandemic hit.

Latifa: It was frightening. And I know it was frightening for many of our members because they told us.

Caroline: Did the BMA receive a loss of complaints about the masks?

Latifa: Yes. Yes.

Caroline: And PPE in general?

Latifa: Absolutely. So we’ve been surveying our members, medical students, and doctors throughout the pandemic right from the offset because we needed to know very quickly what was going on on the ground. What we have found consistently when it comes to face masks and personal protective equipment is that our women members felt less protected. Our women members felt more worried. Our women members found it harder to access equipment that fitted them. And that’s been across the board. So there’s always been a discrepancy about how safe or how unsafe men felt and how safe women felt. The figures are stark. We have 1.3 to 1.4 million staff in the NHS. 75% of those are women. That’s almost  a million – 975,000 are women. And yet, women were the least protected because one-size-fits-all is prepared for men. It’s prepared for the average white man. So it’s not just women who weren’t protected. It’s actually lots of minority groups that weren’t protected as well.

Caroline, narrating: At this point, you’re probably wondering how could this carry on? Wasn’t anyone making a fuss? Well, no, not really. Here’s Mia again, the doctor from Oxford whose trousers fell down.

Mia: I think, and these things are all things which predated the pandemic and have been pervasive for the entirety of the NHS. So I think when then the pandemic happened, they weren’t things that were talked about because it’s just something that you accept as part of your daily working life.

Caroline: And is there any sort of pathway for a medic in the NHS to report issues like this?

Mia: Not really.

Caroline:  Right.

Mia: Well, honestly, I wouldn’t know really where to start because I think… I mean, particularly during the pandemic, we felt that we shouldn’t really complain because, it was harrowing awful work, but actually we weren’t the patients who were in intensive care, we weren’t the families that couldn’t be with our loved ones. So it almost felt like you couldn’t really… You know? It didn’t feel right to necessarily raise those issues. So I think when this happened, it was more the just resignation that you had to get on and do what you could to look after patients and deliver the best possible care.

Caroline, narrating: So if users of badly fitting PPE don’t feel able to complain, how can we solve this problem? I asked Dr. Katrina Hutchison, a bioethicist at Macquarie University in Sydney. She’s done some work on gender bias in medical devices. And she told me about something called moral aggregation problems.

Dr. Katrina Hutchison: So moral aggregation is the idea that you have small, on their own, sort of harmless or morally not noteworthy kinds of things. But when you get a lot of them or you get different types of them, they have a kind of cumulative or aggregative effect.

Caroline, narrating: Moral aggregation problems are particularly hard to solve because they’re so hard to pin down, as Katrina has found from her research into medical devices.

Katrina: So there are kind of regulators, there are device developing companies, there are doctors, there are local hospital areas that make their own policies about purchasing decisions. There are patients. So the structure is really complex and it contributes to us not being able to see that there’s a problem and also makes it difficult to think about how to intervene to solve it.

Caroline, narrating: This complexity makes tracking down data really hard. And the lack of data in turn makes it difficult to prove that the problem exists. And so you’re left with the person right at the end of the chain, the person who is being harmed by all the decisions that came before, unable even to vocalise the problem, because who should they even be complaining to? This seemed to describe exactly what was going on with PPE.

You had the standards, which didn’t seem to be data led at all and just vaguely gestured at clean-shaven persons. You had the manufacturers who just pointed at the standards and wouldn’t engage about data or size specifications. You had NHS procurement who ultimately ignored me or pointed me to the Department for Health, who in turn pointed me towards Public Health England, all while insisting that, “PPE was unisex anyway. So what are you complaining about?” Nobody seemed to have answers. Everyone seemed to blame everyone else. And the lack of data means that people are able to deny that the problem even exists.

Katrina thinks that the key to solving moral aggregation problems is to listen to the people at the end of the chain, like Mia.

Katrina: People have to be kind of emboldened, I think, to talk about experiences that they have that feel like they might involve prejudice or bias or might be affecting them because they’re a woman or because they’re from a minority group. Many years of socialisation might tell them to just get over it, keep quiet. Right? And I think once you’ve set up a kind of environment in which those sorts of things can be identified or people from kind of marginalised or oppressed or more vulnerable or less well represented groups in certain contexts can be heard, you’re much more likely to be able to make the features of the problem visible. And you also start to get the information that you need to be able to solve the problem.

Caroline, narrating: While I was knee deep in regulations and being stonewalled by, well, pretty much everyone, Patricia’s hunt for the Sheffield head – the head which is enshrined in the EU standard for masks – continued.

Patricia: I do want to reiterate that there’s really nothing sinister about this story. We’re not finger pointing or trying to accuse anyone of anything.

Hannah Varrall: We’d just love to understand what happened in the office on that day or something like that maybe.

Patricia: Yeah.

Caroline, narrating: That other voice you heard there is my producer, Hannah. 

So when we’re faced with such a complicated problem that no one wants to admit even exists, how can we go about fixing it?

Dr. Ambika Chadha: My name is Ambika Chadha. And I am a senior trainee in Oral and Maxillofacial Surgery.

Caroline, narrating: Dr. Ambika Chadha is part of a group that is putting together what might be a solution.

Ambika: We were just talking one day about how the PPE didn’t really fit women very well.

Caroline, narrating: When the pandemic hit, Ambika got together with a multidisciplinary team which included doctors, microbiologists, and engineers. They all knew there was a problem with masks and they wanted to fix it.

Ambika: And here’s the interesting thing, Caroline. It became evident that the manufacturer of FFP3 masks was rarely guided by data on facial shape and form, if at all. And where it may have been guided by data, this data was not universally applicable for a number of reasons or very historic. And there were flaws in it. And it really did become blindingly obvious that something of the utmost importance such as an FFP3 mask to prevent healthcare workers or anybody else for that matter from acquiring COVID was not being guided by data.

Caroline, narrating: Like me, Ambika first had to deal with the fact that the data to prove this was a substantial systemic problem simply didn’t exist. So she and her team designed a survey that was answered by 1,500 healthcare workers. And the data was clear. Women were far more likely to say that their mask fit was compromised by size. The masks didn’t fit their facial contours. The straps were too big. The masks were too big for their faces. Of course, Ambika knew about this before the results came in.

Ambika: Because anecdotally we were all experiencing this. Certainly in the female surgical fora, there was discussion about this. And within our own specialty, knowing the subtleties and the obvious differences between male and female faces, it came to no surprise to us that the fit was perhaps not going to be suited to certain ethnicities and perhaps less so to women.

Caroline, narrating: Ambika tells me that the level of data analysis we can do on faces has become much more sophisticated with the advent of 3D photography. This essentially involves compiling 360 degrees worth of photos into one. It has been a game changer for facial analysis.

Ambika: And if you photograph people from different backgrounds, ages, genders, and ethnicities, you will eventually compile data sets that can be used to identify trends in how facial differences manifest.

Caroline: So do those data sets exist yet?

Ambika: Oh yeah. They definitely exist.

Caroline, narrating: My heart sings. Detailed data disaggregated by sex, ethnicity, and age. This is how the world should be! And having collected this data, the team knew what they wanted to do.

Ambika: I thought, along with other colleagues, that if we could show that this was a problem, could we now not try to characterise faces on an individual basis and somehow use technologies like 3D printing, et cetera, et cetera, to customise masks? And research is currently underway as to how these masks can be better designed from the ground up.

Caroline, narrating: So Ambika and her team started to work on their idea of customising masks. A few months after they got going on this project, the British Medical Journal wrote about what they were doing. And then something amazing started to happen.

Ambika: We were contacted by some manufacturing firms, or sometimes we were contacted by firms that were supplying components to the mask firms.

Caroline, narrating: One of Ambika’s colleagues actually managed to speak to a manufacturer. Even better, the manufacturers were the ones who reached out. Maybe they are open to change. Still though, I worried about cost. Would any health system actually be able to afford this?

Ambika: So there is the ideal solution, and then there is the realistic solution, and then there is the commercial solution. So no, it’s not economically feasible, nor is it feasible in the supply chain to customise masks for everybody. And we were looking at it from an NHS perspective of healthcare workers. What we realised needs to happen is studies need to be undertaken to effectively generate what will probably be a bell curve of the range of different dimensions of the face and fit of the face, both on a static basis and a dynamic basis.

Caroline, narrating: Ambika’s bell curve would represent the spectrum of face shapes and sizes. The idea is that if you needed a mask, you’d have your face scanned using 3D technology, and you’d then be allocated a mask based on where your face sits on the graph.

Ambika: And maybe hypothetically it would fit in the mainstream where they could have adequate safety with a mainstream mask, or they would be highlighted as not being accommodating by that mask and in need of something that was more customizable.

Caroline, narrating: Of course, at the moment, it’s not just extremes of faces that aren’t managing to find a mask that fits. It’s really very average female faces. So what changes need to be made to the masks that most people will still be wearing?

Ambika: The answer to that is we don’t know. And the reason we don’t know is because that research hasn’t been undertaken. And I think part of this process of optimising mask fit was first an acknowledgement that it needed to be optimised, and then an acknowledgement that in order to make this a real scaled up solution, we were not going to be able to customise masks for everybody. And so what is it that we needed to do to improve fit? And the characterization of faces on that scale for the purpose of mask fit has not been done. And we know it needs to be done, but we also know that it’s going to need collaboration.

So to answer your question, we can’t answer it. But we know the questions now that need to be asked. That will then inform what tweaks we need to make to the off-the-shelf or stock masks that are available. And there has to be an effort to try and tweak it in such a way that it can accommodate a majority of faces in order to make this a realistic solution.

Caroline, narrating: Ambika estimates that it will be about four or five years before we could start to see any of this implemented in the NHS, but she feels pretty positive about it. So not the end, not even the beginning of the end, but maybe, just maybe, the end of the beginning.

Ambika: And it looks like, Caroline, COVID is here to stay. You know? We’re now a few years on in this pandemic and I don’t think any of us could have predicted the variants that ensued and the fact that we would be having multiple waves. We don’t know how long COVID is going to stay, but what we are sure of now is that pandemics are going to come and go. So the need for this is as strong as ever. And I really hope that that fuels the collaborations that we need.

Caroline, narrating: Latifa – she’s the doctor on the BMA board – agrees that data is critical. But she says that this push is going to have to come from NHS leadership.

Latifa: You know what? I treat it like all doctors treat medicine and treat their patients. I do the calculations. It’s simple, I keep going back to the fact 75% of the NHS workforce is women. Tailor it to women. Be more prepared. Do the calculations. Just, I know I keep going back to the word of being less lazy, be less lazy. Somebody has to put that effort in. You have to tailor it to the people. And all of this data is collected. NHS staff are surveyed periodically on their protected characteristics. We have this data. So we know someone has to invest in it. And someone has to say, “This becomes my priority.” And only then will that change. And that needs to happen right at the top.

Caroline, narrating: My journey into PPE has been a murky, torturous path filled with blind alleys and brick walls, but there was one thing we did manage to get to the bottom of.

Patricia: No one is as excited as me right now. We found the Sheffield head.

Caroline, narrating: Patricia had done it. After weeks of work, she had found the man who the Sheffield head was based on, the man whose faced would launch a thousand masks.

Jim: I was encased in plaster produced in an initial mould that was then sort of done out with fibreglass.

Caroline, narrating: The Sheffield head’s name is Jim. The recording isn’t very clear, but he’s telling Patricia about how his head was encased in plaster to make the mould that would become the infamous Sheffield head. And yes, he is from Sheffield.

Jim: I was born and raised in Sheffield. My father was a coal miner.

Caroline, narrating: Jim’s connection to the coal mines led him to his first job out of school at the Safety in Mines Research Establishment, which then got subsumed into the Health and Safety Executive. One of his first tasks there was to look at breathing apparatus to be used in mines. And part of that job involved trying the masks on for size.

Jim: I tended to get a good fit. And as a result of that, I was asked if I would be prepared for being a model for a new test headform. And that ultimately is how the Sheffield head started out. So it was simply because of that, because I tended to get a good fit. So they thought my head would be a good basis for producing a test head.

Caroline, narrating: So rather than creating masks that fitted a range of people, they just made ones that fitted Jim, who already fitted a lot of masks. You will find as this series continues that this really isn’t unprecedented. In the course of my research, I’ve come across this kind of back to front thinking in more than one sector. And it’s pretty crazy when you stop to think about it. I mean, why are we reverse engineering like this, fitting humans to masks instead of fitting masks to humans? What does this tell us about PPE?

Patricia: How did you take into account different people’s head sizes? And I’m thinking especially about women.

Jim: In those early days, it was just basically one-size-fits-all if you like.

Caroline, narrating: By this point, Jim was focusing on firefighters.

Jim: And the fire brigade at that time was basically all male in terms of firefighters. They had to be of a certain facial shape to wear the face mask to get a good fit. They would’ve had to have fit testing done at the time to make sure they could wear the apparatus. And they had to be clean-shaven.

Caroline, narrating: Clean-shaven. Where have I heard that before? And how does Jim feel about being the Sheffield head?

Jim: It’s kind of weird in some ways. But at the same time, I suppose there’s a bit of pride in it just to be honest, knowing that it’s out there and used. The main thing is it’s doing a job. It’s doing the job it was designed for, until something better comes along.

Caroline, narrating: Until something better comes along. That’s just it. Something better should have come along. It should be here by now, but it isn’t. We know what the solution is. Better data that feeds into actually data led standards that result in masks that fit everyone rather than just Jim, lovely as he is. And thanks to researchers like Ambika and her team, that work seems to be finally beginning. Oh, and Dr. Sharon Moalem, if you’re listening, I hope you don’t find that idea too morally indefensible.

This episode was written and produced by me, Caroline Criado Perez, alongside Hannah Varrall and Patricia Clarke. The executive producer is Basia Cummings. It features original music by Tom Kinsella and sound design from Studio Klong.