After India: The countries on the brink of another Covid oxygen crisis

Dozens of countries face severe oxygen shortages because of surging Covid-19 cases and low vaccination rates, with campaigners warning many could soon reach the crisis point seen in India.

Oxygen is one of the only treatments for severe Covid-19 infections. Without it, patients can suffocate. As supplies fell short in India, ordinary people with no medical experience found themselves begging or bartering for oxygen cylinders on social media.

The Bureau analysed data provided by the Every Breath Counts Coalition and non-governmental organisations PATH and Clinton Health Access Initiative (CHAI), as well as global vaccination data, to find the countries most at risk of devastating death rates from running out of oxygen.

As of this month, 19 countries around the world – including Argentina, Colombia, Iran, Nepal, the Philippines, Malaysia, Thailand, Pakistan, Costa Rica and South Africa – need more than 50,000 cubic metres a day for coronavirus patients. That need has risen rapidly between mid-March and mid-May. In nearly all of these countries, fewer than one in 10 people have received a dose of a vaccine.

The combination of high and rising oxygen needs with low vaccination rates leaves nations extremely vulnerable, said Leith Greenslade, coordinator of the Every Breath Counts Coalition. Overall, the need for medical oxygen to treat Covid-19 patients across low- and middle-income countries has more than doubled in the past two months. Many of these countries faced oxygen shortages before the pandemic, Greenslade said, adding that the extra needed for Covid-19 patients is pushing health systems to the brink.

Oxygen change month by month

Beautiful, easy data visualization and storytelling

“The situation last year, and again in January this year, in Brazil and Peru should have been the wakeup call,” she said. “But the world did not wake up. We should have known India would happen after seeing what happened in Latin America. And now looking at Asia, we should know this will happen in some of the big cities in Africa.”

Robert Matiru, who chairs the Covid-19 Oxygen Emergency Taskforce, told the Bureau, “We could see the total collapse of health systems, especially in countries with very fragile systems.”

A man kneels in the street cleaning oxygen cylinders
An oxygen vendor in Pakistan Farooq Naeem/AFP via Getty Images

The next oxygen crisis

Thousands of people have been dying every day in India over the past month as the country suffers a devastating second wave. Oxygen shortages have played a large part in that toll. By the middle of May, India needed an extra 15.5m cubic metres of oxygen a day just for Covid-19 patients, more than 14 times what it needed in March, according to the Bureau’s analysis.

A patient hospitalised with the virus needs between 14 and 43 cubic meters of oxygen per day for roughly two weeks – an amount so great that hospitals in Europe struggled to cope.

In response, India has banned all exports of liquid and cylinder oxygen. But as the virus spreads across borders, the need for oxygen follows. Now experts are worried about India’s neighbours – Pakistan, Nepal, Bangladesh, Sri Lanka and Myanmar – particularly as some of these rely on Indian-made oxygen and equipment.

“You’d imagine if they start to see peaks of the same degree, then it could be even worse, because India needs all the supply,” said Zachary Katz, vice president of essential medicines at CHAI.

Nepal shares a border with five Indian states and thousands of workers travel between the two countries. Oxygen shortages have already been reported, and the Bureau’s data shows that Nepal needs more than 100 times as much oxygen as it needed in March. Earlier this month, an official asked climbers tackling Everest to bring back their empty oxygen bottles so they could be refilled and used in hospitals.

In Sri Lanka, demand for oxygen has risen seven-fold since mid-March. Pakistan and Bangladesh’s demand for oxygen seems steady, but some doctors and campaigners fear their national case numbers may be an underestimate, as official cases may lag far behind reality.

In Pakistan, which is suffering its third wave of cases, almost 60% more patients are on oxygen in hospital than during the country’s previous peak last summer, a government minister warned in late April, adding that pressure on the oxygen supply was reaching dangerous levels.

But even those numbers may not show the full extent of Pakistan’s oxygen need. Doctors report that some patients have been reluctant to seek help at hospitals, where treatment is expensive. “They come to the hospital only when the situation gets out of their control,” said Dr Fazal Rabbi, a critical care specialist in Swat, in the north of the country.

Pakistanis are overwhelmingly reliant on private hospitals, where they must pay for cylinders and oxygen. The prices are often well beyond what most families can afford, and the competition is desperate. Some private vendors have more than doubled their prices over the past month; a foundation that provides free oxygen received 400 calls a day.

In Islamabad, Zahid Ali Khan’s sister-in-law died in a public hospital after the family were unable to secure a bed in a private one. The family had scrambled to find oxygen for her. They were charged Rs30,000 (£140) as a security deposit for a cylinder, and Rs2,500 (£11) to fill it by a private vendor.

Cases have begun to subside in Pakistan, but demand for oxygen continues, as people try to stockpile, or treat their sick relatives at home. “The mood is extremely grim,” says Dr Fyezah Jehan, a doctor in Karachi. “I think we are very scared of an India-like situation. We're hoping that some magic happens, and this [current] lockdown can prevent a new onslaught of cases.”

The pattern in south Asia is being repeated around the world. Greenslade warns that Latin America is still “at crisis level”, and there are four other clusters that are either already experiencing or at risk of experiencing oxygen shortages: in east Asia, the Middle East, Africa and central Europe.

In many cases, the key indicator is not just how much oxygen is needed, but how quickly demand rises. For example, Laos’ current oxygen need is a modest 2,124 cubic metres per day, but this is a nearly 200-fold increase from mid-March. The Bureau’s data shows more than 30 countries now need at least twice as much oxygen as they did two months ago, including Fiji, Vietnam, Afghanistan, Cambodia, Mongolia, Angola and Kyrgyzstan.

On the other end of the scale, Brazil, Russia and Peru all have a huge daily demand for oxygen coupled with low vaccination rates, but Covid-19 cases and overall oxygen demands there are falling.

“Rapidly rising need for oxygen puts pressure on the health system, which it can’t meet, and we see patient deaths,” said Greenslade. “And that will keep happening week after week, month after month, if the vaccine rollout is slow, because at this point, in many of these countries, it’s only increases in vaccine coverage that will bend the curve on transmission.”

The health systems of many poorer countries “could not be more ill prepared”, Greenslade said. “From the head of state, the health minister, the finance minister… these countries haven’t prioritised oxygen as an essential medicine,” she said. “As we see in India, many, many people have died and continue to die every day for lack of oxygen.”

A patient in intensive care and two doctors in scrubs
A Covid-19 patient in Iran Morteza Nikoubazl/NurPhoto via Getty Images

Demand outstripping supply

Oxygen may be one of our only defences against Covid-19, but medical oxygen makes up just 1% of global liquid oxygen production, according to Gasworld Business Intelligence. The rest is used by a vast range of industries, including mining, petrochemicals, aeronautics, industrial chemistry and water treatment. Several nations, including India and Pakistan, have demanded that gas companies divert oxygen from their industrial clients to hospitals.

However, data obtained by the Bureau from Gasworld shows that many of the countries most in need would still suffer shortages even if all local oxygen production was diverted to hospitals.

Some of the shortfalls are stark. Iraq’s gas companies can produce about 64,000 cubic metres of liquid oxygen a day, a third of what the country’s Covid-19 patients need. In Colombia, the industry can only provide 450,000 cubic metres a day, less than two thirds of what is needed.

Even small shortfalls put patients at risk. In Peru, gas companies can only make 80% of the oxygen it needs if all oxygen was diverted to healthcare. “Currently, Peru is registering a drop in [Covid] cases,” said Dr Jesús Valverde Huamán, who works in an ICU in Lima. “However, we are still in need of medical oxygen, especially for hospitals.” It has been a constant struggle to find enough oxygen for patients, he said, apart from a short stretch in November and December last year, when cases dipped. Soon, they surged again.

By late March, 15,000 people were hospitalised with Covid in Peru, but there was only oxygen available for up to 12,000 patients. In April, the country reached more than 400 deaths per day. Huamán said oxygen shortages “might be one of the causes of the surge of the mortality rate”. He added: “We must prepare for a third wave.”

Even in countries where gas companies appear able to meet demand, there are shortages in medical oxygen. This could be because oxygen earmarked for industry is not being diverted, or there are difficulties getting liquid oxygen from the gas plant to the patient.

Liquid oxygen production by region

Beautiful, easy data visualization and storytelling

In Argentina, hospitals struggled with severe shortages during a Covid-19 surge in late April. Many hospitals in major cities rely on their own liquid oxygen tanks and pipe oxygen directly to patients’ beds. “In a normal situation, the tanks were filled once a week in each clinic. Now they have to be filled up to four times a week,” Jorge Cherro, president of the Association of Clinics, Sanatoriums and Private Hospitals of Argentina, said.

In extreme cases, shortages may have led to deaths. Medical sources told the Bureau that between 18 April and 29 April at least a dozen clinics in Buenos Aires had to move patients because of lack of oxygen. Authorities are investigating the deaths of six Covid-19 patients at a hospital in Ensenada, south of Buenos Aires, on a night when the hospital’s central oxygen tank ran dry.

In the final days of April, the government froze oxygen prices for 90 days, prohibited its export to other countries and ordered suppliers to stop manufacturing the product for industrial use and instead supply only hospitals. “It is a concentrated market,” one government official, who did not wish to be named, told the Bureau; three companies – Air Liquide, Linde and Induracontrol most of the country’s oxygen market. “In a situation as delicate as this one, the state should take action.”

Ukraine’s gas industry has the capacity to deliver 570,000 cubic metres of oxygen per day, more than its hospitals need right now. But last month there were reports of medical facilities experiencing “acute shortages”, echoing late 2020.

Dr Ivan Chernenko, an anaesthetist near Odessa, said oxygen shortages last winter led to difficult clinical decisions when triaging patients. “We sacrificed one to save, say, ten,” he said. “It certainly didn’t happen all the time, but there were moments when it did.”

In early April, with hospitalisations for Covid again rising, the Ukrainian government allowed oxygen manufactured for industrial use to be used in medical settings, if it met strict standards.

Greenslade said: “We have to ask a very critical question: Why such an essential resource as oxygen is locked up in mining, steel, oil and gas when the poor public hospital system can't provide enough to keep babies, adults and the elderly alive.

“These countries have to take a good look at how they’re investing in medical oxygen in the health system. If oxygen capacity is there for mining companies to extract, the capacity must be there for the health system to save lives.”

It can be hard to even judge a country’s oxygen production. While liquid oxygen is a major source for medics in many countries, it does not account for all of the supply. Hospitals can also get oxygen from pressure swing adsorption (PSA) plants – on-site factories that turn ambient air into oxygen – and oxygen concentrators: portable suitcase-sized machines that carry out the same function. (Read our explainer on how medical oxygen is made.)

There is no comprehensive data on how much oxygen countries can get from plants and concentrators, and it can be especially difficult to calculate capacity when many plants lie dormant, or operate only some of the time, as they must in places with intermittent electricity supplies.

Plants and concentrators also require trained staff and spare parts, which are in short supply. The World Health Organization, Unicef, the World Bank and other donors and NGOs have shipped hundreds of thousands of concentrators to hundreds of countries to help them deal with surges in oxygen needs, but manufacturers are running short of parts.

A large oxygen tanker with clouds of oxygen behind it
An oxygen tanker being refilled in Ukraine Aliona Nikolayevych/Ukrinform/Barcroft Media via Getty Images

For this pandemic – and the next

In the panic of the early pandemic, oxygen was frequently overlooked. The World Bank has warned that many countries have not applied for emergency loans available to help them upgrade oxygen systems. Last year the Bank made $160bn available for countries to prepare for Covid-19 and added an additional $12bn this month. Both funds, it said, can be used to import oxygen or shore up production.

But Mickey Chopra, a senior official at the Bank, said countries had applied for loans for ventilators and PPE but not for oxygen supplies. “The variants and the sudden spikes that we've seen now have caught people by surprise, to a large extent, and the weakest point in the system has turned out to be the oxygen supply system.”

He told an Every Breath Counts Coalition meeting that some countries were unwilling to take on loans when NGOs were donating plants and concentrators, and that there was a mistaken belief that oxygen supplies would not be needed after the pandemic.

Chopra told the Bureau that the crises in India and Brazil had spurred some countries into action, but it was “challenging” to seek support so late in the day. “To put in more sustainable systems such as oxygen plants or to rearrange industrial oxygen systems takes much longer than the emergency response required,” he said.

Unitaid and Wellcome have donated $20m emergency funding for oxygen in the global south. The Global Fund has also made $3.7bn in grants available for countries to use on their Covid-19 response programs, including to buy oxygen concentrators and build public oxygen plants. But the majority of funding will likely help increase oxygen capacity in the medium and long term – not immediately.

Experts say the money is still not being given out quickly enough. Campaigners want fast-tracked emergency funding for oxygen supplies anywhere in the world, building on the mechanism that allowed the Global Fund to send $75m to India within days.

It is help like this that is needed in Nepal, which right now lacks not only oxygen, but also the cylinders to store and transport it. “They can’t access fast financing from the global players that can translate into product in-country quickly,” Greenslade said. “Now, if we had an emergency financing, we could immediately negotiate directly with cylinder makers to buy those cylinders, and transport them into Nepal within days.”

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Oxygen is not used only to treat Covid-19. It is an essential medicine for pneumonia and sepsis, in anaesthesia and childbirth, and to treat trauma and accident victims. About 2.5m people – including 670,000 children under five – die of pneumonia every year when experts say better sanitation and access to vaccines, oxygen and antibiotics could save their lives.

Greenslade believes oxygen has been a “blind spot” among health ministries. She would like to see governments create comprehensive national medical oxygen strategies that take capacity and strategic deployment into account, with workers trained up to give patients oxygen safely and maintain and fix equipment.

Zachary Katz, of CHAI, hopes governments use the funding available during this pandemic to invest in infrastructure, such as piped systems in hospitals, which will be cheaper and easier to maintain in the long run. He also hopes countries will aggregate their facilities nationally or regionally, so that they can negotiate cheaper prices for liquid oxygen, PSA plants and maintenance services.

The next big challenge will be working out how to set up oxygen systems so that they serve Covid-19 patients and continue to benefit the health system for years afterwards. “Hopefully when we all normalise a little bit more with vaccines, we can reallocate that equipment to other places that still have 650,000 kids per year dying from childhood pneumonia,” he said.

Greenslade said that countries need to have surge plans in place for unexpected rises in demand. “What they’re doing at the moment is when a crisis hits, [governments] scramble to bring a group together to come up with some way of managing it,” she said. “But they need to get ahead of the game.”

Improving oxygen systems now will not only save the lives of people with Covid-19, but will also bolster a country’s defences against future respiratory pandemics. “Countries must do what they need to do to prepare for the next one,” she said. “Scientists are saying this is not the first, and it may not be the worst.”

Reporters: Madlen Davies and Rosa Furneaux
Additional reporting: Oksana Grytsenko, Anmol Irfan, Ivan Ruiz, Rizwan Shehzad, Claudia Chavez, Ralph Zapata and Natalie Vikhrov
Desk editor: Chrissie Giles
Global editor: James Ball
Investigations editor: Meirion Jones
Production editor: Frankie Goodway
Fact checker: Alice Milliken
Legal team: Stephen Shotnes (Simons Muirhead Burton)

This article is part of our Global Health project, which has a number of funders including the Bill & Melinda Gates Foundation. None of our funders have any influence over the Bureau’s editorial decisions or output.

Header image: A worker filling oxygen cylinders at a hospital oxygen plant in Lalitpur, Nepal, earlier this month. Credit: Sunil Pradhan/NurPhoto via Getty Images