As President Donald Trump came under criticism that his administration had failed to manage the coronavirus pandemic, he cited one area of success: his plan to donate thousands of ventilators to other countries.

“Now we’re the king of ventilators,” Trump told reporters on April 18.

White House officials have pushed the U.S. Agency for International Development to purchase thousands of the expensive devices from U.S. companies and donate them abroad, according to internal documents, emails seen by or described to ProPublica and interviews with officials. One USAID official recently referred to the project in an internal email as “the POTUS donation of ventilators,” using an acronym for president of the United States.

But the effort has been marked by dysfunction, with little clarity on how countries are chosen or how the ventilators are allocated. A USAID memo seen by ProPublica shows equipment donated to wealthy nations that typically do not get foreign aid, such as NATO countries, and to a few locations ill-equipped to use devices that require round-the-clock staffing and regular maintenance.

The administration’s decisions on ventilator distribution appear to have little correlation to the number of coronavirus deaths or infections in a country. Honduras, which is receiving 100 ventilators, had about 72 confirmed cases per 100,000 people on June 11, the day the plan was approved by a senior State Department official, according to World Health Organization data. Neighboring El Salvador, which is set to receive 600 ventilators, had about 51 cases per 100,000 people at that point. And Vietnam is set to receive 100 ventilators, though the country has had just a few hundred cases in all and no deaths.

“These numbers are too round,” said Richard Sullivan, co-director of the Conflict and Health Research Group at King’s College London, noting that the numbers of ventilators listed in the document are, with just one exception, multiples of 5. “No one has done a proper needs assessment.”

The administration has said it is spending more than $200 million on donating ventilators, a little less than one-fifth of its promised coronavirus-related foreign aid.

But public health experts said that without carefully assessing each country’s health care expertise — and following through to ensure hospitals can keep the machines running — the donations could go to waste or even risk patients’ lives.

“I see it all over the world. They call it medical graveyards,” said Dr. Berend Mets, chair of the American Society of Anesthesiologists’ Committee on Global Humanitarian Outreach. “All the equipment is stored in a room and they don’t know what to do with it, they don’t know how to fix it, and it’s a tragedy.”

Most low- and middle-income countries struggling with the pandemic have less need for ventilators than they do for oxygen supplies delivered through simple devices or funding for nurses and doctors, said Dr. Rebecca Inglis, an intensive care doctor who researches care for critically ill patients in places with few resources.

“Politicians and any other big donor bodies are seduced by the glamour and the glitz of donating high-tech equipment that captures the public imagination,” she said. “People like a fancy-looking donation which they can put a plaque on.”

Acting USAID spokeswoman Pooja Jhunjhunwala said the agency is providing the ventilators in response to country requests and is working with countries to assess hospitals’ ability to “use ventilators safely and appropriately.” She said the agency is offering “targeted technical assistance where needed,” as well as access to a “distance-learning portal for health providers.”

White House officials declined to answer specific questions about the donations. A spokesman for the White House National Security Council, John Ullyot, said in a statement that Trump “continues to reach out to our partners, allies, and those in need to provide American-made, life-saving ventilators to countries around the world.”

The USAID memo, which was approved June 11 by senior State Department official James Richardson, offers details of one of the administration’s highest profile international efforts to fight the pandemic. Trump has come under criticism for his May announcement that the U.S. would withdraw from the World Health Organization over its coronavirus response, a decision that alarmed public health experts and put the U.S. at odds with its allies. But the administration has pointed to the ventilator donations and other foreign aid as evidence that it is still leading the global coronavirus response.

The White House’s National Security Council and USAID’s acting administrator, John Barsa, have frequently posted about the donations on Twitter, sharing pictures of USAID-branded boxes headed to Russia, Paraguay, Brazil and elsewhere.

The U.S. is proud to donate ventilators to #Paraguay, supporting their fight against #COVID19. This donation delivers on the commitment made by President @RealDonaldTrump to President @MaritoAbdo, and shows the generosity of the American people. #AmericaActs pic.twitter.com/mpkjOW8zTL

— JBarsaUSAID (@JBarsaUSAID) July 14, 2020

But an internal email sent last month and described to ProPublica indicates the process is plagued by confusion and miscommunication. A USAID official on the agency’s coronavirus task force wrote to other officials that to execute the “vent work,” the agency needed to address “team communications,” “leadership expectations” and “need for senior engagement.” The first ventilator shipments had gone out more than a month before the email was sent.

“You’re partway through a process where you’ve already sent stuff and you want to be sending more and you don’t know what you’re doing,” said a USAID official with knowledge of the agency’s coronavirus response. “It just suggests that you’ve got a group of people working in dysfunction.”

And public health experts said that basic equipment such as masks, gloves and diagnostic tests were more urgently needed, although health care workers in several countries with few ventilators said they would welcome donations. Early in the pandemic, USAID restricted the purchase of personal protective equipment by recipients of its funds, and current rules still place limits on such purchases.

“It is probably even more important that we have PPE out there (in African health systems) than ventilators,” said James Pfeiffer, executive director of Health Alliance International, a public-health nonprofit organization that works in Mozambique, Ivory Coast and East Timor.

The ventilator funding comes from a congressional appropriation to respond to the pandemic. In some countries, the USAID resources being spent on ventilators make up nearly half or more of the funds the agency is spending, according to a separate budget document from mid-June seen by ProPublica. In Indonesia, 66% of USAID funds being spent there are going toward ventilators, while in Rwanda, the proportion is nearly half, and in Sri Lanka, it is 44%.

The ventilators being donated by USAID are made by three companies, ZOLL Medical Corporation, Vyaire and Medtronic, an agency spokesman said. Jhunjhunwala said the agency is working with companies identified by the Department of Health and Human Services and the Federal Emergency Management Agency.

The ventilators are being purchased through an existing multibillion-dollar agency contract with a consortium led by Chemonics, a Washington, D.C.-based development consulting firm. A Chemonics spokeswoman referred questions to USAID.

A spokesman for Vyaire, Patrick O’Connor, confirmed that 150 Vyaire ventilators were sent by USAID to Russia, and that at least 50 ventilators were going to South Africa. He referred other questions to the Trump administration.

A spokeswoman for ZOLL, Diane Egan, said the company is “honored to be part of the response effort to help meet this urgent need.” She declined to answer questions.

A Medtronic spokesman referred questions to USAID. All three companies have also signed contracts to make ventilators for HHS.

As the coronavirus pandemic spread in the U.S. this spring, states scrambled to buy ventilators, fearing that hospitals would be overwhelmed and that virtually all hospitalized COVID-19 patients would need mechanical ventilation. Within a few weeks after the outbreak, more than half of the approximately 13,000 ventilators in the U.S. Strategic National Stockpile had been sent to states.

Over time, medical providers have used ventilators more conservatively because of concerns that machines delivered too much pressure and oxygen and could actually harm patients’ lungs.

But with cases once again surging in the U.S., officials and experts say hospitals may soon again scramble for the machines. Congressional aides said they want to know how the administration analyzed domestic and international needs.

“USAID’s procurement of ventilators for other countries will in no way affect the availability of critical supplies for the American people,” Jhunjhunwala said.

Democratic Sen. Bob Menendez, the ranking member of the Senate Foreign Relations Committee, wrote to Barsa last month voicing concern that the initiative “interjects political agendas into how USAID allocates” funding.

Throughout the spring, as Trump repeatedly asserted that the U.S. would help other countries in need of ventilators, USAID missions and U.S. embassies routed machine requests through the NSC, the USAID official said.

“Everything went to the NSC,” the official said. Then, “the NSC would come back and say, ‘Here are our priorities.’” The NSC made those decisions with the White House’s coronavirus task force, the official added.

Mozambique appears twice on the list and is slated to receive 100 ventilators, according to the document.

Isaias Ramiro, the Mozambique country director for Health Alliance International, said his country had only 44 ventilators when the pandemic began and is now up to 150 after donations from China and elsewhere and purchases by the government. The country has seen nearly 1,300 cases and nine deaths, according to figures from Johns Hopkins University’s Coronavirus Research Center.

The ventilators “will make a huge difference for the government,” Ramiro said.

Though the estimated costs given in the memo include “ventilators and related support,” the average cost varies widely — from as little as $400 each for the 250 ventilators destined for Peru, to more than $77,000 each for the 60 ventilators going to the Maldives. Global health experts said that at least some of the variation is likely explained by differences in shipping costs.

(After this story was published, USAID pointed to a State Department press release that gave the value of the ventilators donated to Peru as over $3 million, which would put them at around $12,000 each, far more than the figures given in the internal document seen by ProPublica.)

The document states explicitly that USAID intends to donate ventilators based not just on need, but also to achieve other objectives. Donations to Panama and St. Kitts and Nevis, both defined as high-income countries by the World Bank, are being made to “further the U.S. national-security interest of addressing the COVID-19 pandemic” and are covered under a “wealthy-country waiver.”

In May, the White House NSC Twitter account quoted Robert O’Brien, Trump’s national security adviser, as saying Trump would send St. Kitts the ventilators “as a sign of appreciation of our key partnership.”

The U.S. is also donating 200 ventilators to NATO, made up largely of relatively wealthy European countries, the document states. Asked about the donation, a NATO spokesman said the alliance is setting up a “stockpile of medical equipment” to prepare for a possible second wave of COVID-19.

Public health experts questioned whether several of the countries receiving ventilators would have the supplies and expertise needed to safely use them. To be put on a ventilator, patients must first be sedated so a respiratory therapist or other clinician can insert a breathing tube. Health care workers must know how much oxygen and pressure to deliver to avoid lung damage. Throughout a patient’s days or weeks on a ventilator, specialists must monitor blood pressure, oxygen levels, kidney functions, caloric intake via feeding tubes and neurological symptoms, said Daniel Rowley, president-elect of the International Council for Respiratory Care and a critical care respiratory therapist.

Hospitals should also have basic disposable items like the corrugated tubes that deliver oxygen to patients, known as circuits, and access to quality drugs like opiates, antibiotics and neuromuscular blockers.

Jhunjhunwala said USAID’s ventilator donations include warranties, accessories and “limited amounts of consumables.”

“I’m very concerned (about the USAID donations) because we know internationally in general people are undertrained in mechanical ventilation, which then puts people in harm’s way,” Rowley said.

A paper by Inglis and her colleagues published last year stated that mortality rates for ventilated patients in low- and middle-income countries are much higher than in high-income countries, and ventilated patients in poorer countries are at greater risk of complications.

Another common problem is equipment breakdown. O’Connor, the Vyaire spokesman, said the company could repair its donated ventilators if they are shipped back to its facility in Palm Springs, California. A congressional aide said USAID officials did not answer questions about funding for equipment maintenance.

Jhunjhunwala said the agency is “negotiating service contracts for the donated ventilators if a host government wishes us to do so.” It is unclear if USAID would cover those costs. The State Department said last month that the U.S. ventilator donation to El Salvador included “one year of training on their correct use and maintenance.”

Inglis said there may be a handful of places, such as South Africa and Brazil, that have adequate staff and supplies and are genuinely stymied by a shortage of ventilators in the midst of the pandemic. USAID plans to donate 1,000 ventilators each to the two countries, according to the document.

Ten ventilators each are headed to Nauru and Kiribati, tiny Pacific island nations with no reported coronavirus cases. Officials from both countries did not respond to requests for comment. The WHO said in a 2017 report that Kiribati has “significant gaps in health services delivery” including “deteriorating health facilities with limited bed capacity and frequent shortages of medical equipment and drug supplies.”

Nauru, with a population of around 13,000, has an “extremely limited” intensive care capability and “would not be able to ventilate more than two people at a time,” said Nick Martin, a doctor who worked there in 2016 and 2017.

Afghanistan is set to receive 100 ventilators. The country has a shortage of health care workers, though it could find personnel to operate more ventilators if they were donated, said Dr. Masood Nasim, deputy medical coordinator for Doctors Without Borders in Afghanistan. Still, the country’s hospitals face dire drug shortages, with patients and their families often forced to purchase high-priced medicines on the private market, he said.

Sullivan, of the Conflict and Health Research Group at King’s College London, said he doubts Afghanistan could effectively use 100 new ventilators.

The vast majority of Afghanistan’s hospitals don’t have “the medicines, they’ve not got the ancillary kits, they’ve not got the technical capacity or capability to utilize” ventilators, he said.