We all need oxygen to survive. When our lungs are sick, we need more oxygen to survive. This basic fact of biology – that oxygen is an essential medicine for individuals and for health systems – underscores the COVID-19 crisis facing India and many other regions of the world at this terrible time.
The availability of medical-grade oxygen that we can use for sick patients is not always straightforward.
There are many ways to get oxygen to patients who need it the most. The standard system in place in most hospitals with substantial infrastructure is through liquid oxygen, which is typically produced at oxygen manufacturing plants, transported to hospitals, vaporised through the hospital system and piped to patients who need it.
Some hospitals have local facilities to concentrate oxygen from the air through a technology called pressure swing adsorption. Cylinders are also used to store compressed oxygen gas, providing an ability to move oxygen around with patients as well as for in-hospital use. Portable oxygen concentrators use the air around us and produce medical grade oxygen, but are limited to generating the higher flows required for severely ill patients.
These technologies are well-established around the world and ensure that severely ill patients receive the oxygen that they need.
But in spite of this clear recognition, the idea of oxygen as an essential medicine is relatively recent, and much of the world lacks consistent supply.
A 2017 report estimated that by sufficiently improving access to oxygen, “up to 120,000 child deaths could be averted each year in the 15 countries with the highest pneumonia burden”. Many hospitals around the world don’t have the supply chains or local infrastructure to maintain a consistent supply of oxygen, particularly at higher flow.
Having a stable oxygen supply at all hospitals where patients are treated is a reflection of how coordinated and organised an acute-care health system is – in addition to the resources available overall. In short, how hospitals get their oxygen is a marker of their capacity to be resilient.
This is because of the substantial infrastructure that this system needs to reliably withstand distressing situations, and to be able to adjust to emerging health needs.
This requires, in addition to reliable suppliers:
* Robust supply chains from production plants to hospitals;
* Real-time monitoring of usage;
* Allocation frameworks across multiple hospitals with common suppliers; and
* Contingency plans in case of increased use
The COVID-19 outbreak in India right now has been expanding through tremendous surges, with lakhs of new cases daily and many thousands of patients requiring high volumes of oxygen just to survive.
But no matter how quickly the surge has expanded or how dire the situation, it is very difficult to scale up oxygen production capacity overnight. Given that doing so draws on multiple disciplines, including engineering, power systems, medical infrastructure and logistics, it can only be done with foresight and planning.
If a pandemic is underway, hospitals often count the number of hospital beds available as the metric with which to plan. But overlooked in this planning is what is capable within those beds – specifically, whether hospital staff members are available to care for the patients in those beds and whether the equipment and resources required to respond to each patient are available. The latter includes oxygen.
But policymakers like looking at ‘bed counts’, which is meaningless when you don’t know if those beds are going to be useful. This disconnect between the numbers that policymakers use and the numbers that clinical staff use has led many regions around the world to underestimate the crisis – India included.
Not having oxygen to treat patients reflects a systemic – not individual – problem. In the absence of coordination across facilities, oxygen supply will continue to be patchy and intermittent. In the absence of scaling up plant- and facility-based production weeks in advance, the total available amount will be lacking. And in the absence of a fair and equitable system for allocation, some facilities will get preferential access, leaving others without the resources required to save lives.
Irrespective of the total amount of oxygen available across a country, the important part is to get to those who need it when they need it. At times of scarcity, this requires an ability to coordinate supply and delivery logistics, which in turn requires careful oversight and planning. As the Indian health system has increasingly fractured with privatisation, this becomes even harder to implement.
So India’s current shortage is a systemic problem of planning, and it is not unique to any one place or region. Many countries around the world have failed to ready themselves properly for the worst case scenarios. India is currently reaping the consequences of one such failure.
Dr Srinivas Murthy is an investigator at the BC Children’s Hospital and a clinical associate professor in the Department of Paediatrics, Faculty of Medicine, University of British Columbia.