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“We were told to bring our own oxygen supply,” Gautam recalled. But medical-grade oxygen was scarce all over the country. “It was a very challenging time for us to refill just one cylinder…we had to wait in a very long queue” at a local oxygen plant.
Even medical support and in-flight oxygen weren’t enough. When a patient reached a hospital, there was no guarantee of enough oxygen to support them.
“We could not take any [more] patients because of oxygen shortages,” recalled Pramesh Koju, public health officer at Dhulikhel Hospital in Kathmandu, Nepal’s capital city.
Dhulikhel had onsite a pressure-swing absorption (PSA) oxygen plant. But it was operating far below capacity. “We cleaned all the filters, cleaned the room… but it couldn’t generate enough oxygen for demand,” said engineer Sanil Shrestha.
To care for patients in its 136 designated Covid-19 beds, Dhulikhel needed between 150 and 200 oxygen cylinders every 24 hours. Its PSA plant could only produce about 60.
Shrestha would wait overnight at a local oxygen factory to secure enough oxygen to treat hospital patients to make up the difference.
Dan Hovey, Direct Relief’s emergency response director, hears similar stories every time a country experiences a Covid-19 surge, beginning with China.
“We learned that a spike in demand for oxygen was completely overwhelming the local supply. And we’ve seen that in every outbreak since then,” Hovey said.
This isn’t a new problem. Even before the pandemic, a lack of oxygen was killing children with pneumonia and others who needed it, said Leith Greenslade, the coordinator of the public-private coalition Every Breath Counts – it numbers UN agencies, businesses, nonprofits, and academic institutions among its participants – and an expert on oxygen supply shortages.
“Oxygen was really rare in hospitals” in settings across sub-Saharan Africa and South America, Greenslade said.
In wealthier countries, where road systems are more reliable and commercial oxygen more available, hospitals are most likely to purchase oxygen from a medical distributor dispensing liquid or gas oxygen, explained Sarah Sceery, director of external relations at Build Health International, a nonprofit organization working to improve health care infrastructure in low-resource settings. The oxygen is delivered in large tanks and incorporated into a facility’s system in these cases.
“Oxygen is almost a no-brainer” in many wealthier countries,” Sceery said.
However, in low-resource settings, purchasing a large tank of oxygen isn’t always an option, whether because of poor-quality roads, seasonal conditions, or a lack of local suppliers, Sceery said. The global supply chain issues caused by the pandemic have only exacerbated the problem, especially in many low-income countries that rely exclusively on imported oxygen.
Instead, many hospitals rely on PSA plants, which separate oxygen from other gases onsite, said Eric Buckley, Build Health International’s director of oxygen engineering. But many such PSA plants are broken or not working at full capacity. They’re often donations from an external entity, but local staff are not provided with sufficient training to maintain the plant or troubleshoot problems.
Buckley emphasized that underfunded and overburdened hospital staff are not to blame for the situation.
“The bad guy here is not the facilities person in the hospital, who’s been given nothing more than a screwdriver and a roll of tape, and asked to maintain the PSA plant,” he said.
But there’s no question that the pandemic has severely worsened global oxygen shortages, even as it has drawn attention to the issue. And untold numbers of people have died – sometimes publicly, on the street – as a result.
“Oxygen is also needed for neonatal care, maternal care, surgical care,” Sceery said. “When [hospitals] become overrun with Covid and with Covid patients, it becomes even more disastrous.”
“We first started hearing about the vast quantities of oxygen” needed to care for severely ill Covid-19 patients, Greenslade recalled, “and we just knew it was going to be a horror story.”
At the China Friendship Hospital in the Caribbean country of Dominica, Covid-19 cases stayed low until the summer of 2021. Then the delta variant surged, and case levels remained high, said Nicole Laville, the director of engineering services for the Dominica Hospitals Authority.
“What we found is that, since August, the demand for oxygen has gone up,” she said.
The hospital had a PSA plant, but it had been damaged by Hurricane Maria, the Category 5 storm that caused widespread damage to Dominica and Puerto Rico in 2017. “We’re kind of walking on glass with regards to this oxygen plant,” Laville said. “In an emergency situation, people need oxygen, so they had to run the plant, so it caused further damage to the plant.”
When Laville spoke to Direct Relief in late December, one particular patient was going through 10 cylinders of oxygen a day. The demand was so great that China Friendship Hospital could no longer afford to share with other hospitals in Dominica.
“A lot of those island nations have been in oxygen crisis, but they’re small and tend not to be able to get the attention of the large international agencies,” Greenslade said.
Addressing this oxygen crisis requires a multifaceted approach. Oxygen concentrators, which have received widespread media attention, have proven to play a valuable role in the fight against Covid-19, allowing patients to recuperate at home while opening up vital hospital beds for the sickest cases.
But they’re generally not suitable to treat the sickest patients. A typical concentrator might provide five liters of oxygen per minute, Greenslade said. A patient with a severe case of Covid-19 could require as much as 60 liters per minute.
A way forward
For Greenslade, oxygen is the missing link in the global response to Covid-19. “Early on in the pandemic, a wrong path was taken, and we’ve been on the wrong way ever since then.”
The problem is an over-reliance on vaccines to solve the problem. “They are amazing vaccines, but all the effort was put into bringing them to market quickly,” without taking vaccine uptake adequately into account, she said. “A lot of people would just decide, ‘We’re not going to take them and you just can’t make us.’”
In the meantime, Greenslade explained, “we didn’t focus enough on preventing deaths, on taking care of people who were getting sick.” That meant that the vital role oxygen plays in treating Covid-19 wasn’t emphasized enough.
Part of the solution is making sure that hospitals and health organizations have access to reliable sources of medical-grade oxygen. With this in mind, Direct Relief has already funded oxygen plants in several countries.
While a PSA plant is often the best solution, Hovey explained, an unreliable electrical grid and lack of access to spare parts make it the wrong solution in countries experiencing conflict, such as Syria. Instead, the funding will go toward a liquid oxygen filling station.
With funding from Direct Relief, Build Health International worked with Dhulikhel Hospital to figure out why their PSA plant wasn’t working well, diagnosed the problem, and got the plant running at full capacity.
For China Friendship Hospital, Build Health International recently traveled to the site to evaluate the plant and issued a full report within days.
“We need very nimble humanitarian agencies that can almost operate in a parallel universe” from that of governments and other official bodies, Greenslade said. With a government, she explained, an official report on a broken PSA plant might take four to six months – and more deaths.
“The advantage of a group like Direct Relief is lives saved,” she said.
Dan Hovey and Alycia Clark contributed reporting to this story.
Direct Relief has committed $5 million to the oxygen supply problem and is joining the Every Breath Counts coalition. The organization will work with the coalition and with Build Health International to build and restore PSA plants or other effective, resilient oxygen sources in countries such as Dominica, India, Madagascar, Nepal, and Syria. Direct Relief will also receive guidance on oxygen strategy and prioritization from the Society of Critical Care Medicine, which is the largest nonprofit medical organization devoted to critical care and has members in 100 countries.