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Saturday, May 08, 2021

The oxygen chain: Why India is falling short of the life-saving gas

Amid a crippling shortage of oxygen across several states, The Sunday Express maps the supply chain that brings the life-saver gas, a vital component in the battle against Covid, from the manufacturers to hospital beds, and identifies key bottlenecks along the way.

Written by Tabassum Barnagarwala | Mumbai |
Updated: April 25, 2021 6:02:17 pm
A worker sorts oxygen cylinders to be used for Covid-19 patients, at Jawaharlal Nehru Hospital in Ajmer, Friday, April 23, 2021. (PTI Photo)

Afzal Shaikh is catching up on his sleep in his cluttered shop, ‘All India Healthcare Medical Equipment’, in Jogeshwari, a Mumbai suburb.

All around him are cylinders, concentrators, BiPAPs and ventilators. For over a fortnight now, Shaikh has hardly got more than two hours of sleep, his time awake spent coordinating medical equipment for Covid-19 patients. Sometimes he rushes out at midnight to fix an oxygen cylinder for a patient. Shaikh says he goes home just once every day — for sehri, since it’s Ramzan month.

“For the last two days, I have been getting more space to sleep here. My entire stock is rented or sold. I am hardly getting oxygen supply, and the phone doesn’t stop ringing. There is always someone crying for oxygen on the other side,” he says.

The second wave of Covid-19 has exposed glaring gaps in the country’s health infrastructure and the government’s preparedness in dealing with a crisis that came with enough warning signs. Nowhere is that vacuum more evident than in hospitals across Delhi, Mumbai and other urban centres where people have been struggling for something as basic as medical oxygen.

The oxygen chain

Patients under home isolation have been unable to get cylinders, and the cost of refilling a cylinder or renting an oxygen concentrator has, in the absence of any regulation, sky-rocketed.

On April 9, in Mumbai’s suburb Kandivali, when Vinod Naik complained of breathlessness, his family tried to find him a hospital bed, but failed. A doctor advised them to get an oxygen cylinder at home. The hunt led to a supplier, who was ready to rent out an oxygen concentrator for Rs 10,000, double the market price. The Naiks did not think twice. The elderly patient was saved.

But 10 km away, in a Dahisar slum, Ramnath Tupseinder’s story ended differently. The same night, the 60-year-old’s oxygen saturation dipped to 89. His son rushed to two government-run Covid centres, but found no bed. “He had no money to afford a concentrator or a cylinder,” says Sandhya Fernandes, a social worker who says she rang all hospitals to find Tupseinder a bed. So they used the limited oxygen left in a cardiac ambulance to sustain him. Two hours later, Tupseinder died, gasping for breath.

In Gujarat’s Palanpur, five patients died in a private hospital after oxygen dried up on April 21. Up north in Uttar Pradesh, five patients died in a private Aligarh hospital before fresh oxygen could be supplied.

covid oxygen crisis A paramedic assisting Covid patients with oxygen support as they wait inside an Ambulance outside Civil Hospital in Gujarat. (Express Photo by Nirmal Harindan)

Since the second wave began in early February, India has recorded close to 35,000 Covid deaths, but the country hasn’t kept a record of Covid deaths due to oxygen shortage.

Officially, India’s daily oxygen production capacity is 7,127 MT and its medical oxygen requirement has increased by 76 per cent in 10 days — from 3,842 MT on April 12 to 6,785 MT on April 22. On paper, that leaves the country with a few hundred metric tonnes still to spare, but state after state has been complaining of acute shortage.

Until 2019, before the pandemic hit the country, India required just 750-800 MT liquid medical oxygen (LMO), the rest was for industrial use. Since April 18 this year, industrial supply has been completely disrupted.

The supply chain

Among India’s big oxygen manufacturers are Inox Air Products, Linde India, Goyal M G Gases, National Oxygen Ltd and Taiyo Nippon Sanso Corporation.

An Inox official claims the company meets around 60 per cent of the country’s LMO demand, manufacturing 2,000 MT per day and supplying to 800 hospitals. The company has 550 transport tankers and 600 drivers, who, the official says, have been on the road 24×7.

LMO is manufactured in large plants using cryogenic distillation techniques to compress atmospheric air, feed it into distillation columns and get liquid oxygen. It has 99.5 per cent purity. This process, an industry expert said, can take two-and-a-half days for lakhs of litres.

The liquid oxygen is filled into jumbo tankers for storage, from where special cryogenic tankers, that maintain temperatures of -180 degrees Celsius, travel hundreds of kilometres to smaller distributors in the hinterland.

Oxygen crisis India covid-19 Among India’s big oxygen manufacturers are Inox Air Products, Linde India, Goyal M G Gases, National Oxygen Ltd and Taiyo Nippon Sanso Corporation. (Express Photo by Vishal Srivastava)

The distributors convert liquid oxygen into gaseous form, compress it, feed it into cylinders and transport them to their final destination: hospitals. Some stock is sold to local vendors, who supply to home patients. Officials say that with longer distances to cover, end-to-end transport takes anywhere between five and 10 hours.

Government data show India has 1,172 oxygen cryogenic tankers for road transport. The tankers served the purpose well until before the pandemic, but now they are scarce and take painfully long to cover hundreds of kilometres.

India is converting tankers for nitrogen and argon into oxygen-carrying vehicles. It’s also importing tankers, manufacturing new ones, and using the Air Force to airlift empty ones to speed up one-way travel.

To speed up oxygen delivery, trains have also been pressed into service to ferry tankers. On April 23, the first rake from Visakhapatnam travelled with 105 MT LMO to Nagpur, offloaded three tankers, and sped to Nashik to supply four tankers on Saturday.

With several states reaching full utilisation of their oxygen production capacity, they have been relying on the Centre to divert oxygen from states that have surplus. This week, Delhi, Uttar Pradesh, Haryana and Gujarat complained of less allocation than their daily requirement. Karnataka, Rajasthan, Maharashtra are scraping the bottom of their oxygen barrels.

As Saket Tiku, president of the All India Industrial Gases Manufacturers’ Association (AIIGMA), puts it, “Production is just one problem. Transporting oxygen over long distances, especially to rural and remote parts, is the bigger problem.”

Then, there is another, seemingly intractable problem — the black market.

Hoarding and price rise

Local vendor Shaikh says several families, especially those with the elderly and others at risk to Covid, have been panic hoarding oxygen concentrators and cylinders, leading to shortage and price rise.

A small 100-litre cylinder now costs Rs 8,000 and above, up from Rs 4,500-5,000, and its refilling cost has risen from Rs 150-250 to Rs 500-800 in Delhi, Mumbai, Pune and other cities. In Tier-II and Tier-III cities, refilling costs range from Rs 400 to Rs 600.

A 5-litre oxygen concentrator, which until two months ago cost Rs 45,000-50,000, now costs Rs 80,000-90,000, its monthly rent up from Rs 5,000 to Rs 10,000-20,000.

Covid oxygen supply crisis With several states reaching full utilisation of their oxygen production capacity, they have been relying on the Centre to divert oxygen from states that have surplus. (Express Photo by Vishal Srivastava)

“Once a customer takes a concentrator on a monthly rent, he wants to keep it for the entire month even if they don’t need it any more. I call up customers every day to convince them to return the cylinder for another patient. Some agree, some don’t. Batao, main kya karoon… yahan log mar rahe hain (Tell me, what do I do? People are dying here),” Shaikh says.

Exploring other avenues

India is tapping into all resources. With supply to industries cut since April 18, oxygen produced in iron and steel plants being diverted for medical use, and industrial oxygen manufacturers being encouraged to produce medical oxygen. With these measures, the government claims to have increased LMO capacity by 3,300 MT.

The Health Ministry has also sanctioned the installation of 162 Pressure Swing Adsorption (PSA) plants to directly use atmospheric air and separate it under pressure to filter out nitrogen. The oxygen that remains — 92-95 per cent pure — is compressed and fed into oxygen pipelines. The government plans to install 59 of these by April end in hospitals across 17 states and Union Territories, but together, they will only provide 154.19 MT oxygen.

covid oxygen India has 24.28 lakh active Covid-19 cases, of whom only 20 per cent have some symptoms and only 5-10 per cent end up needing oxygen.

In Maharashtra, the government has even tapped four thermal power plants. Since these plants can supply oxygen but do not have a bottling unit to fill oxygen in cylinders, there are plans to set up 500-bed hospitals near these plants and lay a direct oxygen line to all beds. “We have reached a point of desperation and all solutions are being worked out,” says Dr Sudhakar Shinde, IRS officer who is part of Maharashtra’s committee to manage oxygen and Remdesivir shortage.

All eyes are now on the 50,000 MT of oxygen that India is expected to receive through the import route. “We are evaluating and soon will do an allotment. In normal circumstances, it takes three weeks to despatch the oxygen,” Health Secretary Bhushan said.

Doctors rise up to challenge

Amid the surging numbers, the National Clinical Covid-19 Registry has identified a key data point: 54.5 per cent, or more than one out of two people admitted in hospitals, need oxygen support during treatment this time. This is a 13.4 percentage point increase from last year’s peak during September and November, according to data from 40 centres across the country.

A Covid patient with oxygen support waiting outside a hospital in New Delhi. (Express Photo by Tashi Tobgyal)

India has 24.28 lakh active Covid-19 cases, of whom only 20 per cent have some symptoms and only 5-10 per cent end up needing oxygen. Yet, as numbers surge, the 5-10 percentage have translated into a huge number of patients needing oxygen beds.

Mumbai-based intensivist Dr Gunjan Chanchalani, who has been treating Covid-19 patients at their home, says not every senior citizen needs oxygen or hospitalisation. “Only if the fever persists for five days or more and oxygen keeps falling below 94 do we consider hospital admission,” she says. Most are easily treated at home, she says, adding that she recommends the prone position (lying on the stomach) as first aid for those with oxygen saturation levels between 92-96.

India covid oxygen People waiting in long queues to buy Oxygen cylinders from suppliers in Lucknow. (Express Photo by Vishal Srivastava)

On the role of oxygen therapy

Dr Chanchalani explains, “Atmospheric air has 21 per cent oxygen. Inflamed lungs are able to filter very little quantity of oxygen. If we give 4-5 litres per minute oxygen therapy to someone with 85-90 saturation, the oxygen saturation improves by 26-28 per cent. If we increase oxygen supply to 15 litres, saturation rises to 90 per cent. Direct supply of pure oxygen puts less pressure on the alveoli, but overdose can scar lung tissues.”

Nursing homes and hospitals, falling short of oxygen, are also triaging. “We now admit people with oxygen saturation below 85-90 instead of 94, and try to advise prone position at home for those with 90-95 saturation. There aren’t enough oxygen beds,” a government doctor says.

With inputs from Kaunain Sheriff M

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