Explained: Why There Is An Increase In Oxygen Demand And Supply Shortage In The Second Wave
From production capabilities to supply chain management to government policies, here is a comprehensive look at the issues plaguing demand and supply of medical oxygen in India.
The clamour during India’s first wave was for ventilators, ventilators and ventilators. In the second wave, it’s about oxygen, oxygen and oxygen.
After India locked down in March-end last year, there was a mad rush to procure as many ventilators as possible to augment grossly insufficient infrastructure. The Central government made plans to buy thousands of ventilators for hospitals and local industry ramped up production capacity. The Centre had ordered over 58,000 ventilators chiefly financed through the PM Cares Fund in May and had started receiving deliveries in June which were then sent to the States based on need.
But soon it was clear that most of the patients were recovering with oxygen support due to less severity of the disease and not needing ventilation. Patients are given different therapy based on their oxygen needs. For example, nasal cannula-based oxygen therapy for those with 2-5 litre requirement of oxygen per minute, mask-based for those with 6-15 litre requirement, high frequency nasal cannula oxygen therapy for those with 15-50 litres and ventilator support above that.
“We have been talking for a long time about ICU care and ventilation, but if you look at the patient profile, the critical thing today is oxygen and our entire hospital preparation is to provide oxygen to patients,” C.K. Mishra had said in a press briefing on 23 April last year. This was seconded by All India Institute of Medical Sciences (AIIMS) director Randeep Guleria who said that ’20 per cent of the patients need oxygen therapy and five per cent need ventilation.’
Medical experts were increasingly preferring non-invasive oxygen therapy over ventilation as doubts over effectiveness of ventilator increased after overwhelming majority of Covid-19 patients on ventilator were dying in India and abroad. It was thought that ventilators were worsening the lung damage caused by Covid-19.
Dr Animesh Arya, senior consultant in respiratory medicine at Delhi-based Sri Balaji Action Medical Institute, had said that their understanding had also changed with the evolution of the disease. ‘While initially, intensive care units had patients on ventilators, now we have explored other options and use of ventilators has now been limited for severe cases,’ he said.
Perhaps this explains why the need for ventilators has come down in the second wave. As per National Clinical Covid-19 registry, 27.8 per cent of admitted patients were put on mechanical ventilation as opposed to 37.3 per cent during the first wave.
‘This is because doctors have stopped using ventilators for management of COVID-19 (except very late) as early ventilation was said to increase the chances of death,’ Dr Anupam Singh, MD Internal Medicine and Assitant Professor at SMC Ghaziabad, tells Swarajya.
While mechanical ventilation usage is down, the demand for oxygen has jumped many-fold. Percentage of hospitalised patients needing oxygen support during treatment increased by 13.4 percentage point from 41.1 per cent at the first wave’s peak to 54.5 per cent now.
‘In this wave, since surge is fast, many people stay at home till late and approach hospitals for admission at a stage when oxygen demand is pretty high (five-six fold) as compared to low flow stage,’ explains Dr Singh.
This is a major causes of concern because this, combined with sudden surge in hospitalisations, has caused demand to skyrocket while the governments are struggling to meet the requirements of hospitals.
The consumption of medical oxygen in the country has already shot up over eight-times from normal levels, reaching almost 7,500 tonnes per day.
SOS pleas, distress calls for help if you will, regarding oxygen beds or cylinders from individuals and even hospitals have flooded social media over the last 10 days. Reports of deaths attributed to unavailability of oxygen abound along with news of hospitals running out of supply desperately shifting patients to other facilities.
This has implications on mortality too, researchers say. As baseline O2 saturation decreases, the chances of mortality rise exponentially. Dr Anupam Singh who is involved in the study which looked at data from 1499 individuals (254 deaths) says that ‘late presentation (low presentation baseline oxygen saturation) can exponentially increase risk of death. Hence we need early care and therapy (oxygen/steroid/heparin) in pulmonary phase (90-95 per cent saturation).
But how did we come to such a point that we are falling short of oxygen needs? It’s certainly not the case that no one anticipated this situation.
Dr Dhruv Chaudhary who heads the department of Pulmonary and Critical Care Medicine at Post Graduate Institute of Medical Sciences in Rohtak had advocated for ensuring that there are enough manufacturers of oxygen and enough trucks to carry it.
“At the moment, we first need to focus on getting the oxygen delivery systems and supply chains rather than on ventilators. We need to increase our oxygen capacity and more ways to deliver oxygen and to train people on it. For me, getting good quality and continuous supply of oxygen is very important as it is needed for oxygen therapy and ventilators,’ he had said in April last year.
Additionally, the Central government wasn’t blind to the changing needs. It had sanctioned money from PM-CARES fund to build 162 pressure swing adsorption oxygen (PSA) plants in States.
Tendering process was concluded in December and the contracts were given to vendors which were supposed to install these plants in 45 days but only 33 plants have been setup so far thanks to mismanagement at all levels - centre, states, districts.
In the latest efforts, the union government has decided to increase PSA plants to 551 which it promises to make functional in next three months but it will have to ensure that past mistakes aren’t repeated. This will add capacity of around 500 MT of medical oxygen per day.
To meet the needs in the short term, the government floated a tender on 21 April to import 50,000 MT of medical grade oxygen. While this should provide some cushion, if cases continue to rise, even this will prove insufficient as more and more states are finding themselves in the grip of the second wave.
The Central government told Supreme Court that on 21 April, it had 16,000 MT of medical oxygen while the demand was less than third of that. Also, the steel sector has increased supply from 1000 MT per day from first week of April to 21 April. Moreover, the government is in process of receiving tens of thousands of oxygen concentrators which are best suited to meet the oxygen demands of mild to moderately ill patients as they can generate 5-10 litres of oxygen per minute. All this should help in meeting the surging demand.
Meanwhile, India’s problem is said to be more on the transport and supply infrastructure side rather than production and availability of the oxygen.
“The production of oxygen, mostly captively used, is concentrated in far-off areas. Oxygen in liquid form is traded and transported through heavy, safe tankers, each of which costs Rs 45 lakh. Worse still, oxygen worth Rs 300 is stored in a cylinder that costs Rs 10,000! The distant production and multiple trade chains in oxygen, transport in tankers and stocking in cylinders created huge logistic issues even in normal times,” S Gurumurthy argues.
This view is endorsed by Saket Tiku, president of the All India Industrial Gases Manufacturers’ Association (AIIGMA) who says that ‘Transporting oxygen over long distances, especially to rural and remote parts, is the bigger problem.’
To speed up the transportation, the government has pressed the Railways and Air Force (IAF planes are ferrying empty tankers back to production plants) into action so that time taken to supply oxygen to hospitals is reduced.
Another problem is that India only has 1,172 oxygen cryogenic tankers which can maintain a temperature of -180 degrees needed to transport the liquid medical oxygen (LMO). Oxygen producing plants send LMO to local distributors who convert it into gaseous form and fill in the cylinders after compressing.
Due to unprecedented surge in demand and limited supply, black market emerged which has made matters worse as cylinders to concentrators are being hoarded. While the governments can crack as much as they want, this problem will truly be solved only when the supply exceeds the demand and people are able to get the oxygen they need without struggle.
Meanwhile the Centre is importing tankers from abroad (20 have already come and distributed to States). Local manufacturing is set to increase and tankers for nitrogen and argon are being converted into oxygen-carrying vehicles.
One of the lesser talked about reasons for oxygen mismanagement is the State-level maladministration and ad-hoc policies which are creating more problems for hospitals.
A doctor in Mumbai who runs a private clinic and has been treating Covid-19 patients since the beginning of the pandemic narrated how municipal commissioners and collectors, instead of working in tandem with each other, are running their districts like little fiefdoms in which incursion of the other is not allowed.
“Recently an oxygen supplier informed me that the municipal commissioner of the area in which oxygen filling stations are located personally entered the plant to get the vendors supplying oxygen to their area served preferentially over those waiting in line for several hours from across neighboring districts. Battles over oxygen tankers are commonplace, with collectors diverting oxygen tankers passing through their area to their district at the first opportunity,” he told Swarajya on the condition that his identity is not revealed for he might be targeted by workers of the ruling regime.
‘It is the first time in the history of Mumbai that a major municipal hospital such as Bhagwati has run out of oxygen not once but twice. No less than six major public hospitals ran out of oxygen, and critically ill patients had to be shifted to other municipal hospitals in a major operation. Each of these is a major public hospital and not some small nursing home with limited resources. What sort of incompetence is on display here by a state government and its municipal corporation that allows its own hospitals to reach such a crisis point?,’ he wonders.
The doctor says that the shortage is now starting to affect treatment in ways not even fathomed by authorities.
“Due to low resources, several well-equipped hospitals are hesitant to take in extremely critical patients with high oxygen requirements, preferring to concentrate on relatively stable patients with lesser requirements. And you cannot blame them for making this cold decision to "save oxygen" because a hopelessly incompetent government cannot ensure critical supplies needed for patient care. This will eventually add to the overall mortality in the state as more and more desaturating patients do not get the beds they desperately need,” he says squarely blaming the State government for mishandling the situation with high-handedness.
Hospitals are being harassed no end which is making it hard for them to treat patients even if they want to.
‘The municipal corporations send out various teams that enter the COVID hospitals completely unannounced, at random times, and demand voluminous data to be provided to them at once. Instructions have even been issued to provide a cabin for them to be permanently perched inside your hospital and check every bill made by your establishment, to make it comply to the completely arbitrary and unworkable government prescribed rates. Never mind the fact that oxygen cost has increased ten times from January 2020 to April 2021: they will still adamantly state that you cannot charge the patient for oxygen".
"The government made a big pomp and show about fixing oxygen cylinder charges at Rs 150/- per cylinder. The fact on ground is that it is selling officially for between Rs.1000 and Rs 2500 per jumbo cylinder for hospitals and as much as Rs 6500/- per day for home oxygen. Several companies have also serially hiked the cost of oxygen concentrators from around Rs 30,000-35,000 per unit to above Rs 80,000/- per unit".
"Rental cost of oxygen concentrators has shot up from Rs 4000/- per month to above Rs 15000/- per month. No action has been taken against these "looters" while all attention is focused only on bills of hospitals that are already struggling to manage patients, costs, supplies, relatives and local leaders of all hues".
"If input cost is sky-high, how can hospital bills expected to be low? If the government cannot fix their astronomically high input costs, it must not interfere in their bills as well,” says the doctor explaining how the mentality of simply passing diktats without understanding the ground reality is worsening the situation.
”If hospitals have to survive, they must allow the running cost of hospitals to be recovered along with appropriate compensation for the extreme risks they have faced and bravery in the face of a raging pandemic that has already killed millions,” he says.
It’s not just the Maharashtra government that is at fault. Many State governments are trying to put pressure on already burdened hospitals officially and unofficially. In Uttar Pradesh, the government has warned hospitals that National Security Act may be slapped against them if they raise false SOS requests.
Some may not see anything problematic in this. Some might even applaud such an order. But put yourself in the shoes of a hospital owner.
As soon as you put out request, you open yourself to investigation. It’s the government babus that will decide whether request for more oxygen is justified or not. The hospitals will obviously try to ensure that they don’t make too many requests and save oxygen which means that critical patients with very high oxygen needs will not be entertained.
The governments must be very careful and not think that waving the magic wand of orders or threats will solve the problems. They will make them worse.
Lastly, the governments should seriously ponder over the suggestion of Dr Anupam Singh who is of the opinion that we need to setup massive field hospitals like we did in the first wave but this time they be equipped with oxygen. “One of the biggest oxygen wasters is decentralised and inefficient use at individual hospitals. It’s time to call the army, ensure triage and set up massive stadiums (open air field) with Level-2 facilities (low flow oxygen support). We set up level-1 Hospitals (not requiring oxygen) earlier as well. We can replicate the same for Level-2 Hospitals. Patients who are sicker wits high flow oxygen/ventilation requirement can be referred to hospitals. It will ensure triage/early care,” he says.
Moreover, if these can be located near Airports or train stations, it will help solve some of logistical challenges as well.
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