Medical oxygen: Why is it vital and does India produce enough?

India is facing the brunt of oxygen shortage with serpentine lines seen outside oxygen manufacturing units as the second wave of COVID-19 has completely overwhelmed health infrastructure of the country.

The world's second-most populous nation is in deep crisis, with its hospitals and morgues overwhelmed as healthcare professionals struggle to cope with streams of patients.

Apart from the megacities, medical oxygen and beds have become scarce in smaller cities, with major hospitals putting up notices saying they have no room for any more patients and asking relatives to arrange for medical oxygen.

Long queues were seen at oxygen plants in several cities of India's most populous Uttar Pradesh state, including its capital Lucknow, with people from private hospitals, isolation centres, and even individuals visiting the plant with their empty cylinders in the hopes of getting some life-saving gas for patients.

Oxygen production and filling facilities in rural India are also overburdened with high-demand. They have shut regular industrial filling of oxygen and are only focused on filling up cylinders for medical oxygen.

Why is medical oxygen vital? 

Oxygen therapy is crucial for severe Covid-19 patients with hypoxaemia when oxygen levels in the blood are too low.

According to community health specialist Rajib Dasgupta, "Some clinical studies show that up to a quarter of hospitalised (Covid-19) patients require oxygen therapy and upwards to two-thirds of those in intensive care units."

"This is why it is imperative to fix oxygen supply systems in hospital settings as this is a disease that affects lungs primarily."

India's toll from the coronavirus surged past 200,000 on Wednesday, the country's deadliest day, as shortages of oxygen, medical supplies and hospital staff compounded a record number of new infections.

What is an oximeter and oxygen concentrator?

Pulse oximetry is a non-invasive and painless test that measures your oxygen saturation level or the oxygen levels in your blood. It can rapidly detect even small changes in how efficiently oxygen is being carried to the extremities furthest from the heart, including the legs and the arms.

During a pulse oximetry reading, a small clamp-like device is placed on a finger, earlobe, or toe. Small beams of light pass through the blood in the finger, measuring the amount of oxygen. It does this by measuring changes in light absorption in oxygenated or deoxygenated blood. This is a painless process.

Meanwhile, in the case of oxygen concentrator, air is filled with various gases such as carbon dioxide, oxygen, hydrogen and nitrogen. So to separate oxygen from these gases Oxygen Concentrator comes into being, it is a medical device that supplies pure oxygen. As per the WHO report published in 2015, this device was developed to help patients admitted to hospital with respiratory illness. Oxygen Concentrator produces oxygen for 24 hours, seven days a week, for up to five years or more. Also, they can supply five to ten litres of oxygen per minute. Unlike the oxygen cylinder, this device doesn't need to get refiled, is portable and can run with the help of an inverter. However, they are quite expensive, compared to oxygen cylinders.

Does India produce enough oxygen? 

Yes. Experts say the vast nation of 1.3 billion people is producing enough oxygen, just over 7,000 tonnes a day. Most is for industrial use but can be diverted for medical purposes.

The bottlenecks are in transport and storage.

Liquid oxygen at very low temperatures has to be transported in cryogenic tankers to distributors, which then convert it into gas for filling cylinders.

But India is short of cryogenic tankers.

And such special tankers, when filled, have to be transported by road and not by air for safety reasons.

Most oxygen producers are in India's east, while the soaring demand has been in cities including financial hub Mumbai in the west and the capital Delhi in the north.

According to the head of one of India's biggest medical oxygen suppliers Inox Air Products, Siddharth Jain, "The supply chain has to be tweaked to move medical oxygen from certain regions which have excess supply to regions which need more supply."

Meanwhile, many hospitals do not have on-site oxygen plants, often because of poor infrastructure, a lack of expertise and high costs.

Late last year, India issued tenders for on-site oxygen plants for hospitals. But the plans were never actioned, local media report.

Why the long waits for oxygen in developing nations? 

India is only the latest country to confront a lack of medical oxygen supplies. Earlier in the pandemic there were similar scenes of long lines in countries such as Brazil, the Democratic Republic of Congo, Peru and Venezuela. 

Unitaid, a global initiative that helps low- and middle-income countries confront public health challenges, puts the lack of supplies of medical oxygen down to its cost, limited infrastructure and logistical difficulties.

Medical oxygen is key to treating people in respiratory distress, whether at home or in hospitals. According to the World Health Organization (WHO), one person in five suffering from Covid-19 needs medical oxygen to ensure that the level of oxygen in their blood is sufficient.

How much is needed in countries facing shortages? 

In February, the WHO estimated that half a million people needed 1.2 million oxygen canisters a day.

Unitaid put the price tag of helping the countries facing the greatest need at $1.6 billion this year.  

"This is a global emergency that needs a truly global response," said Unitaid's Executive Director, Dr Philippe Duneton, in February.

It has identified some 20 countries facing the greatest difficulties with oxygen supplies, including Malawi, Nigeria and Afghanistan.

How is oxygen made? 

Oxygen is made in two ways:

Medical oxygen: is made by separating the oxygen from other gases and impurities found in air by repeated steps of compression, filtration and purification, according to Air Liquide Sante France.

Such medical oxygen reaches more than 99.5 percent purity and is rigorously tested.

It can be highly compressed into a liquid form, but has to be maintained below -182°C, which according to Air Liquide Sante France is the best way to meet variations in demand as one litre of liquid oxygen is the equivalent to around 800 litres when it is in normal gas form.

Canisters that can travel with patients with one litre of compressed litres of oxygen contain about 200 litres of normal oxygen.

- Compressed oxygen: machines that can separate out nitrogen from ambient air can raise oxygen levels to around 93 percent. The machines can be portable or larger to serve a hospital. However, these machines cannot meet surges in demand -- which rose by a factor of five or six in French hospitals as waves of Covid patients peaked. They are require lots of electricity and need to be regularly maintained by a technician.

Who are the main producers? 

Outside of China, the three main producers of medical oxygen are the German firm Linde, which is allied with Praxair in the US; the French firm Air Liquide and the US company Air Products.

But there are a large number of local and regional producers of medical oxygen given that it is difficult to shop long distances.

Industrialised countries are better served as production facilities were designed to serve more than just the medical sector, such as the steel and chemicals industries.

What's being done for India? 

The Indian military has used its cargo aircraft to transport oxygen tanker trucks where supplies are lacking, and a train called the Oxygen Express was put into service on April 22.

The military has also said it plans to import 23 mobile production units from Germany.

France plans to send eight such units that will be able to produce enough oxygen to serve 10,000 patients a day. It also plans to ship 200 tonnes of liquid oxygen to Indian hospitals.

What's happening on the ground? 

Oxygen shortages are still affecting badly hit regions despite the measures to boost supply, transport and storage.

Reports have emerged of hospitals asking patients to arrange for their own cylinders and of people dying even after being admitted due to low oxygen supplies.

Social media platforms have been filled with posts by desperate families hunting for cylinders and refills.

Meanwhile, there is a growing black market for cylinders and concentrators sold far above their usual retail prices.

(With inputs from agencies)