The TLDR: “Patients waiting for beds gasped for air on stretchers and in ambulances, while sobbing relatives stood by their sides. Some sat with oxygen cylinders they had bought themselves out of desperation. Others died waiting in the hospital car park.” That’s The Guardian’s description of scenes of the ‘Covid hell’ playing out across the country. We look at why hospitals are running out of oxygen, and what the government plans to do about it. 

Why does oxygen matter?

Covid is a respiratory illness that attacks the lungs—depriving cells in key organs like heart, brain etc. of oxygen. Hence, oxygen therapy is one of the only proven methods of treatment. It is typically recommended for moderate cases with signs of pneumonia plus  severe cases with acute respiratory distress, hypoxaemia, or shock. 

Point to note: Medical oxygen is at least 82% pure oxygen and free from contamination, including that of other gases. In contrast, the air we breathe contains various gases like nitrogen, argon, carbon dioxide etc—and only 21% oxygen. 

How bad is it?

Bad. Private hospitals have been telling patients they need to move out because they are running out of oxygen—which is catastrophic since hospital beds are also scarce. In Gujarat, doctors are forced to choose between patients in a “triage-like-situation.” In Nashik, 24 people died because the hospital’s oxygen tank developed a leak—which you can see below (leak not deaths). 

Earlier this week, two private hospitals in Nalasopara reported 11 deaths due to lack of oxygen. In Delhi, a number of hospitals were on the brink of running out on Wednesday—but were saved by a late night refill. Quint has a full list of hospitals issuing an SOS. Indian Express reports on which states are the worst hit. 

Delhi court steps in: Max Healthcare network urgently moved the Delhi High Court, saying its hospitals only had three hours of oxygen. And if it runs out, it would threaten the lives of 400 patients—including 262 Covid cases—and that’s in just one of its seven hospitals. It also said that its established suppliers could not meet the rising demand. The court was furious at the union government—and ordered it to ensure the supply of medical oxygen by “whatever means required.” The judges said: “Beg, borrow, steal, it’s your job to get oxygen.” (Bar & Bench has more on the scathing ruling)

Point to note: Even back in September, hospitals were running out of oxygen—at a time when we only had about 9.4 lakh active cases compared to our current total of 22-plus lakhs.  

Why are we running out of oxygen?

For a number of complex reasons: 

Rising demand: More patients are complaining of shortness of breath in the second wave—47.5% compared to 41.7% last year. We also have more severe cases this time around: “1.75% of the patients are in ICU beds, 0.40% are on ventilators, and 4.03% are occupying oxygen beds. Those may seem like small percentages, but given the high number of active cases—2,291,428—they represent significant numbers. And more that overall case total grows with each passing day, the greater the demand. Data point to note: The daily demand for oxygen in the first wave was 2,800 metric tonnes. The daily demand today: 5,000 metric tonnes.

Supply chain problems: The reality is that we have more than enough oxygen to meet our demands—as the infographic below shows:

But as an expert notes, “When we talk about availability of oxygen, we also talk about the ability to deliver and distribute—organise logistics, to have enough cryogenic (tank) trucks, cylinders and refilling facilities.” Sadly, that supply chain is currently in shambles! We do not have enough cryogenic tankers to ensure 24×7 road transport of medical oxygen. And smaller suppliers are running out of larger-sized tanks to ensure continual supply. 

Adding to the problem: Geographical distribution. States that most need the oxygen do not have oxygen manufacturing plants. Example: Delhi, which depends on plants in Uttar Pradesh and Haryana. As one major supplier told MoneyControl:

“The only problem is the excess supply that is there in the market is in East India like in Odisha and Jharkhand, whereas the demand is mostly coming from Western India—Maharashtra, Gujarat and Madhya Pradesh. Now, demand has also started picking up in Delhi and Uttar Pradesh. The issue is that supply is available in places that are very far away from the demand.”

Not helping at all: interstate jhagdas. Delhi hospitals nearly ran out of oxygen yesterday because the Haryana authorities were blocking tankers headed for the capital. Haryana’s health minister said:

“We are being forced to give our oxygen to Delhi. First, we’ll complete our needs, then give to others. Yesterday, one of our O2 tankers was looted by Delhi Govt that was going to Faridabad. From now, I've ordered police protection for all tankers.”

The Delhi High Court case also cited the risk of law and order situation surrounding UP tankers supplying Delhi. The union government finally had to step in and get UP and Haryana to back off. 

Bureaucratic apathy: One way to ensure hospitals have their own independent supply of oxygen is to set up a Pressure Swing Adsorption plant—which converts atmospheric air into medical oxygen—at the hospital location. But the government took eight months after the pandemic started to finally invite tenders to set up such plants in 150 district hospitals. As of today, only 11 such units have been installed—and only five are operational! Though now the government insists the number of installed plants is 33. Scroll has more on why this happened. A counter example of excellent government management: Kerala.

Oxygen exports: Complacent about our own needs, we’ve been energetically exporting our oxygen to other countries. Our exports jumped by 734% from January 2020 to January 2021. And between April 2020 and January 2021, India exported over 9,000 metric tonnes of oxygen. Of course, the government has furiously denied this is a problem: “This is absolutely false and industrial oxygen exports are being mistaken as medical oxygen.”

But, but, but: that claim isn’t exactly true either. The government just issued an order banning the sale of industrial oxygen—and diverting it to meet medical demands. And a number of big companies are channelling their industrial oxygen stocks to help relieve the shortage. In its ruling, the Delhi High Court also demanded that steel and petroleum plants be temporarily shut down to utilise their oxygen supplies. So it isn’t exactly apples and oranges. 

High flow nasal therapy: Doctors are also deploying new high-use treatments to save patients: 

“The problem is once a patient goes on high flow then a single patient requires 130 litres per minute of oxygen, so it sucks out the capacity. Even if one patient requires high flow, we have to balance the benefits with 50 others who are surviving on oxygen at 16 litres per minute.”

So what are we doing now?

• As mentioned before, the government has banned the use of industrial oxygen across a swathe of industries—while making exceptions for steel, petrol etc. 
• Next on the agenda: importing 50,000 metric tonnes of oxygen. 
• Tata Group plans to import 24 cryogenic containers to transport oxygen.
• The government is setting up ‘oxygen express’ trains to quickly transport oxygen—the first recently left from Mumbai to Vizag to pick up seven tankers. The next one will go from Lucknow to Bokaro for a similar pick-up.
• There are new plans to set up another 100 Pressure Swing Adsorption plants at hospitals—though it would be nice if they focused on first meeting the initial goal of 162.

The bottomline: In India, every crisis of scarcity inevitably reveals a tale of gross mismanagement and apathy.

Reading list

• BBC News and Guardian have the big picture on our healthcare hellhole. 
• Indian Express has a good explainer on oxygen therapy.
• Times of India offers an overview of how we ended up with a shortage—and what the government plans to do about it.
• A must read: Scroll’s investigation into Pressure Swing Adsorption plants—and how government complacency undermined a plan that could have saved lives right now. 
• Bar and Bench and Quint have everything you need to know about the Delhi High Court ruling.
• MoneyControl has a list of steps that the government plans to take to resolve the crisis.  
• FactChecker has a useful list of verified Covid helplines.
• Dangerous WhatsApp forwards are advocating the use of camphor tablets to help those undergoing oxygen therapy. This doctor’s blog post is a useful way to rebut the same.