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A breath of fresh air: Bringing life-saving services to doorsteps

Authors: Pranab Chatterjee, Anita Shet

As the second wave of COVID-19 coursed through India the world is waking up to the reality of the enormous toll the infection is taking on the gasping nation. With reported cases crossing 400,000 daily, health systems across the country are overwhelmed, hospitals are running out of beds, medicines, healthcare workers – and oxygen.

One of the most tragic outcomes is the depletion of oxygen supplies. Among those with severe lung involvement due to COVID-19, additional oxygen support is the mainstay of treatment. Oxygen is life. More than food, water and sunlight, we tend to take oxygen for granted, thinking that air is free and always available. Such complacency, as we are learning under the grimmest of circumstances, can kill.

Although one may argue that the oxygen shortage in India is a ‘black swan’-like outlier event, an unpredicted occurrence with a major impact, evidence points towards this being more like a gray rhino, a highly probable but neglected event that also has an enormous impact. Many would agree that given the scale of the pandemic in 2020, there was an urgent need to bolster immediate response needs such as ambulances and essential medicines such as oxygen. Although the magnitude of the current crisis has caught the whole system unawares, worrisome signals emanated as early as September last year. Even during the early phase of the first wave, experts recognized the challenge of scaling up oxygen-equipped beds in rural Indian hospitals. As India went through stages of opening up towards the end of 2020, concerns of a second wave were recognized by experts. While the first wave predominantly affected urban areas, policymakers had apprehensions of a more intense second wave affecting smaller towns and rural areas.

An important lesson may be learned from a high-burden state, Kerala, that transformed overnight from being oxygen-insufficient to being an oxygen provider to other states. Kerala leveraged industrial oxygen production to replenish medical needs by convening policy dialogues as early as March 2020. Public and private entities were brought together and investments were made to scale up daily oxygen production to 204 tons – a 60% increase in a single year.

One short-term approach to circumvent the shortage of oxygen tanks is the use of an oxygen concentrator. This is a medical device that takes in ambient air and filters out nitrogen, resulting in higher concentration of oxygen to support patients in distress. Portable oxygen concentrators have been around since early 2000s and are effective in those with low-flow oxygen requirements due to the ease of use and minimal maintenance needed.

The shortage in oxygen supplies galvanized members of the private sector and civil society to devise oxygen-based solutions. Tech companies mobilized their networks to airlift concentrators from around the world. Logistics and supply chain start-ups joined hands and started importing thousands of oxygen concentrators every week. Mission-mode projects sprung up all over the country; Mission Oxygen looks to equip hospitals with oxygen concentrators, and Oxygen for India is raising money to source oxygen cylinders and concentrators. Other efforts, like the Oxygen on Wheels Initiative in West Bengal, with support from the Johns Hopkins India COVID relief task force, is establishing a fleet of oxygen concentrator-equipped ambulances to serve oxygen-requiring individuals in home care or transit.

Providing oxygen therapy at the patients’ doorsteps can reduce inequities in healthcare access. When the entire family is suffering from COVID-19, caregiving responsibilities of women members get multiplied, even if they themselves are sick. Further, women often end up prioritizing healthcare needs of other family members over their own. Given the rapid progression of desaturation and decompensation in some individuals, this gender-specific delay can be fatal for many. Urgent and nimble implementation of initiatives such as the Oxygen on Wheels program will provide a mechanism to access life-saving oxygen. In addition to helping the scores of individuals as they worsen clinically and need to be transported to a hospital under oxygen cover, this will also provide succor to many women who are unable to seek formal healthcare.

With the pandemic exacting a heavy toll, the exponential increase in the demands for healthcare services has exposed the cracks in the system. As we scramble to respond, we need to think of this as a marathon and not a sprint. As with any other infectious disease outbreak, this lethal wave too shall pass, leaving a trail of pain, suffering and death in its wake. Once the acute needs reduce, we must remember the collective ordeal we endured. Before we forget how our cities and villages struggled to breathe, we must motivate ourselves to invest in our people, our leaders and our health systems so that we are better prepared for the next, inevitable public health emergency to arrive.

Dr. Pranab Chatterjee, is a public health physician pursuing his doctoral studies at the Department of International Health, Johns Hopkins Bloomberg School of Public Health

Dr. Anita Shet is Director of Child Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health and Director of the Maternal and Child Health Center, India

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