As Covid Cases Surge, India May Need More Than Double The Medical Oxygen It Produces

As India faces a deadly second Covid-19 wave, 392,488 new cases were reported on Sunday by the health ministry. So far, less than 2% of the country’s 1.3 billion population has been fully vaccinated and hospitals are running out of supplies. “It's absolutely equivalent to a war,” says Rahul Tambe, an internal medicine doctor 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 across the country. 

 Low vaccination rates and a potentially more contagious variant coupled with a lax government and public response could explain the vengeance of the second wave. “There were just so many political gatherings, religious gatherings, social gatherings,” says Anant Bhan, a public health and bioethics researcher in Bhopal. “Everyone was taking it a bit casually.” But as cases surge and dead bodies pile up in graveyards, healthcare facilities struggle to provide medical oxygen, a basic supply, to Covid-19 patients gasping for breath. “I don't think I've seen anything of this type in living memory in India,” says Bhan.

Since cases began skyrocketing, several hospitals have said patients died because oxygen supplies ran out, according to local media reports. One public health non-profit estimates India’s daily need for oxygen is more than double what the country manufactures domestically per day, and the country’s oxygen manufacturers have also been struggling to distribute it to hospitals located hundreds or thousands of miles away from factories. Fortunately, help may be on the way thanks to international aid, which is providing not only needed oxygen supplies, but also technologies to help hospitals make their own. 

Even though it’s a gas that makes up 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 that is piped through to patient rooms, while certain government-run facilities and those in rural areas are less likely to be equipped, says Prashant Yadav, an expert on healthcare supply chains and a professor at INSEAD. The current situation, he says, is a “double whammy” because it’s affecting both hospitals with and without oxygen infrastructure. 

India’s Supreme Court has ordered Prime Minister Narendra Modi’s government to deliver an oxygen supply plan, but even with a plan in place, it will still be difficult to predict just how much oxygen each Covid patient will need. It depends on the severity of individual cases in terms of the number of minutes, hours or days of oxygen required. “Estimating that using an epidemiologic model is challenging,” says Mike Ruffo, who directs a program to improve access to medical equipment for children at the global health nonprofit PATH. “Oftentimes we'll revert to the number of beds, but there's a lot of room for error there. It's hard to quantify.” 

Nevertheless, a team at PATH has developed a global tracker to try and approximate medical oxygen needs in low- and middle-income countries during the Covid-19 pandemic as a way to draw attention to the issue (but  they caution these figures shouldn’t 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 isn’t the problem, instead citing logistics and transportation, but given the ever increasing number of cases, there’s no surefire way to determine how much oxygen is sufficient, says Yadav. “We have to match it against ever increasing demand, right? So when someone says there is sufficient supply, they're assuming the current number of beds and cases.” For now, the case numbers keep rising, setting new records each day.

An important first step, which the government already initiated, is to direct that all industrial oxygen be diverted for medical use. There isn’t a huge difference between the two, says Yadav, 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. India’s air force is flying empty tanks to be filled up at plants to cut down on travel time and also utilizing the railways. Additionally, multiple countries, international aid agencies and others have begun shipping thousands of oxygen cylinders and ventilators to India. 

For hospitals without tanks and piping, there are two main options: concentrators or PSA plants. Concentrators are portable devices, about the size of a large microwave, that suck in air and remove the nitrogen to provide highly concentrated oxygen. Think of PSA plants, which stands for pressure swing adsorption, as enormous 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 big capital investment. And while facilities rush to set up oxygen infrastructure in the short-term, there needs to be training for staff on how to maintain and clean these devices. 

The international community has been supplying India with thousands of new oxygen concentrators, and the hope longer term is that whatever oxygen technologies hospitals acquire “can be redeployed post-Covid,” says Ruffo. While treating Covid patients is the immediate priority, oxygen is needed across the health system to treat issues among children and adults like asthma, pneumonia and heart failure. 

Tambe in Mumbai says the government needs to enforce stringent lockdowns to curtail the spread of the virus and ramp up the vaccinations on a massive scale. “Otherwise, with mutant virus, I will admit, I don’t even want to think of it,” he says. “We will have issues.”