As India faces a second deadly wave of Covid-19, the Ministry of Health reported 392,488 new cases on Sunday. So far, less than 2 per cent of the country’s 1.3 billion people have been fully vaccinated and hospitals are running out of supplies. “It is absolutely equivalent to war,” says Rahul Tambe, internal medicine physician at Nanavati Super Specialty Hospital in Mumbai, India’s most populous city. A total of 215,542 deaths and nearly 19.6 million cases have been reported nationwide.
Low vaccination rates and a potentially more contagious variant, coupled with a lax response from the government and the public, could explain the Revenge of the second wave. “There were so many political meetings, religious meetings, social gatherings,” says Anant Bhan, a public health and bioethics researcher at Bhopal. “Everyone was drinking a little casual.”But as cases increase and corpses pile up in cemeteries, healthcare facilities struggle to provide medical oxygen, a basic supply, to Covid-19 patients who gasp for breathing. “I don’t think I’ve seen anything of this kind in living memory in India,” Bhan says.
Since cases began to skyrocket, several hospitals have said patients died because oxygen supplies ran out, according to local media reports. A public health nonprofit estimates that India’s daily need for oxygen is more than double what the country manufactures nationally per day, and the country’s oxygen manufacturers have also been struggling to distribute it to hospitals located hundreds or thousands of miles from the factories. Fortunately, aid may be on the way thanks to international aid, which is providing not only the necessary oxygen supplies, but also technologies to help hospitals make their own.
Although it is a gas that accounts for 20% of the Earth’s atmosphere, medical oxygen requires a complex delivery structure, one that only certain hospitals have. Larger hospitals in urban centers are more likely to have cryogenic tanks filled with liquid oxygen channeled through patient rooms, while certain government-run facilities and those in rural areas are less likely to be equipped, says Prashant Yadav, a health care supply chain expert and INSEAD professor. The current situation, he says, is a “double blow” because it is affecting both hospitals with and without oxygen infrastructure.
it will still be difficult to predict how much oxygen each Covid patient will need. It depends on the severity of the individual cases in terms of the number of minutes, hours or days of oxygen required. “Estimating that using an epidemiological model is a challenge,” says Mike Ruffo, who leads a program to improve access to medical equipment for children at global health nonprofit PATH. “We often go back to the number of beds, but there is a lot of room for error there. It’s hard to quantify.”
However, a PATH Team has developed a global tracker to try to approximate medical oxygen needs in low – and middle-income countries during the Covid-19 pandemic as a way to draw attention to the problem (but they warn that these figures should not be used for procurement). The tracker estimates that India needs nearly 16 million cubic meters of oxygen per day, or more than 21,000 metric tons, at current case rates. India’s daily domestic production is around 9,000 metric tons, according to local media reports. Despite these figures, a representative of the Ministry for Home Affairs reportedly said that “oxygen is available in adequate quantity in the country.”
Oxygen manufacturers have suggested that supply is not the problem, rather than citing logistics and transportation, but given the increasing number of cases, there is no sure way to determine how much oxygen is sufficient, Yadav says. “We have to face a growing demand, right? So when someone says there’s enough supply, they’re assuming the current number of beds and boxes.”For now, the number of cases continues to increase, setting new records every day.
An important first step, which the government has already initiated, is to order that all industrial oxygen be diverted for medical use. There is not a big difference between the two, Yadav says, except that medical-grade oxygen needs to pass additional testing requirements to certify that it is 95% pure and that the cylinders and equipment used are free of contaminants. The Indian Air Force is flying empty tanks to be filled in plants to reduce travel time and also using railways. In addition, several countries, international aid agencies and others have started sending thousands of oxygen cylinders and fans to India.
For hospitals without tanks and pipes, there are two main options: concentrators or PSA plants. Concentrators are portable devices, the size of a large microwave, that suck in air and remove nitrogen to provide highly concentrated oxygen. Think of PSA plants, which stands for pressure swing adsorption, as huge concentrators mounted on a frame that can provide oxygen to dozens of patients. These are easier to install than a tank and piping system, but still require a large capital investment. And as facilities rush to establish a short-term oxygen infrastructure, it is necessary to train staff on how to maintain and clean these devices.
The international community has been supplying India with thousands of new oxygen concentrators, and the long-term hope is that any oxygen technology hospitals acquire “can be redistributed after Covid,” Ruffo says. While treating patients with Covid is the immediate priority, oxygen is needed throughout the health system to treat problems among children and adults such as asthma, pneumonia and heart failure.
Tambe in Mumbai says the government needs to impose strict closures to reduce the spread of the virus and increase vaccines on a massive scale. “Otherwise, with the mutant virus, I’ll admit it, I don’t even want to think about it,” he says. “We’ll have problems.”