As COVID-19 Cases Increased, Oxygen Beds Fell, Data Show

"Need oxygen bed hospital in Delhi for friend," tweeted one doctor who volunteers with several relief networks this week. She said the patient she is in touch with is "delirious and disoriented and not eating or talking". A tweet from a senior journalist's handle said, "My oxygen is 31 when some will help me (sic)". He died shortly after, unable to get a hospital bed. Another Delhi-based journalist had been tweeting for days this week, trying to organise a hospital bed for a patient. On April 21, she said that the patient had found a bed, but the hospital was running out of oxygen. The patient's wife had also just died from COVID-19 earlier this week.

As surging COVID-19 cases overwhelm the medical-grade oxygen supply chain, the Supreme Court of India on April 22 issued a notice to the central government over the supply of oxygen, asking for a national plan, after noting that at least six high courts are hearing the matter.

India had ramped up its infrastructure for COVID-19 care substantially between March 2020 and September 2020, when the first wave peaked in most of the country. So what went wrong? Post-September, despite warnings of more severe cases and deaths from mutant strains from public health experts, the pace of adding dedicated COVID-19 facilities and oxygen-supported beds for severe COVID-19 cases slowed, our analysis of government data shows.

Then, between December 2020 and April 2021, these facilities fell 6%. Doctors told us this decrease was not surprising since case numbers had reduced, but the government should have retained the capacity to ramp these up quickly in case of a surge. This turned out to not be the case, and the government--both the Centre and state governments--were caught napping.

The view from a hospital

The 1,000-bed Kasturba Hospital in Sevagram, in rural Wardha district in north-east Maharashtra's Vidarbha region, is getting a functional oxygen plant this week. The equipment was delivered two weeks ago, but the hospital is still awaiting technicians to connect the oxygen plant to the hospital beds. "Perhaps the plant will be ready in a week," S.P. Kalantri, medical superintendent of Kasturba Hospital, told IndiaSpend. Meanwhile, the hospital is facing shortage of oxygen for all kinds of patients, and no one is sure whether there will be enough oxygen in the days ahead.

IndiaSpend had spoken to Kalantri a year ago, in April 2020, to learn how this large rural Maharashtra hospital, run on low cost, was preparing for the COVID-19 pandemic. At the time, we reported that the local administration had told the hospital to increase its oxygen beds from 200, as a precaution. By April 2021, it had doubled its oxygen beds for COVID-19 patients to 400, yet today is unable to admit all COVID-19 patients who need oxygen because cases have grown a lot faster.

While India's active cases in 2020 peaked on September 17, active cases were still on the rise in Wardha and some rural Vidarbha districts around the state's winter capital Nagpur. Maharashtra currently contributes 30% of India's total active cases of nearly 2.3 million cases, as of April 21, 2021.

The caseload through to February this year was not unmanageable, said Kalantri. The staff at this hospital "were absolutely having a respite", he said. At one point in late January 2021, they had only 26 COVID-19 patients with nearly 90% of their beds for COVID-19 empty. "But we celebrated prematurely," said Kalantri. "The virus is having the last laugh."

Kasturba Hospital just about managed its oxygen needs until February 2021 with cylinders. But in early March, as the increase in cases became exponential along with the second wave in the rest of the country, the oxygen cylinders they need daily has doubled to 500, at a further cost of Rs 1 lakh per day. For a charity-run hospital, this is a big expense.

The new oxygen plant has cost the hospital about Rs 1 crore, Kalantri said. Although the state government had said it would partly fund it, the hospital has not received the money yet, he said. IndiaSpend contacted the Maharashtra government for confirmation. The article will be updated should they respond.

Not enough oxygen

Early on in the pandemic, in April 2020, IndiaSpend reported that oxygen was going to be vital for managing patients with severe COVID-19, in which the SARS-CoV-2 virus, which causes COVID-19, attacks the lungs and other organs, and can cause them to fail. With a limited kitty of drugs available to treat the disease, doctors depend on treating patients with oxygen therapy to prevent escalation to a stage where they may need to be on a ventilator.

Doctors on the frontlines of the second surge in Ahmedabad told IndiaSpend this past week that the SARS-CoV-2 virus, or a variant of it, is more virulent in this ongoing second wave, and more patients' lungs are getting affected compared to the first wave. As state governments flag oxygen supply shortages despite capacity additions, civil society groups and volunteers involved in COVID-19 relief say the price of oxygen cylinders has rocketed compared to last year.

On April 15, amid widespread oxygen shortage, the central government said supply had outstripped demand on April 12, and announced measures to increase production and ease distribution. But experts told us that if oxygen production is adequate, the shortages imply a lack of planning for effective distribution. They say lessons must be learned from the current shortages so that India is better prepared if there is a third COVID-19 wave.

The government's response has been to counsel "rational use" of oxygen. On April 21, a health ministry release quoted doctors to discuss "unnecessary demand" to put COVID patients on oxygen, and said the country has enough oxygen if used judiciously. Yet, that same evening, the central government told the Delhi High Court that the daily oxygen requirement in the country has exceeded daily production capacity.

On April 21, India reported over 315,000 new COVID-19 cases, the highest in any country since the start of the pandemic.

Decrease in facilities between December 2020 and April 9, 2021

When COVID-19 cases first began rising in India in March 2020, the government began identifying and adding dedicated COVID hospitals, dedicated COVID health centres and COVID care centres, public and private. From time to time, the government also put out data on how many COVID-19 beds were available in these facilities across the country, including ICU beds and oxygen supported beds for severe cases, and isolation beds for mild and pre-symptomatic cases. Only COVID hospitals and health centres offer all three types of beds.

By the time of the second wave, the health minister said, "the country has substantially ramped up the hospital infrastructure for management of COVID". There were 2,084 dedicated COVID hospitals, 4,043 COVID health centres and 9,313 COVID care centres in the country, per the accompanying Ministry of Health and Family Welfare (MoHFW) press release on April 9. These numbers all represent substantial increases since April 2020 (see chart below).

However, the pace of adding COVID hospitals and health centres decreased after the first wave peaked in September 2020, our analysis of health ministry data submitted to parliament and in press releases shows. Between December 2020 and April 2021, the number of dedicated COVID hospitals fell by 6%. Similarly, there was a 6% reduction in the number of dedicated COVID health centres, falling to 4,043 in April from 4,300 in December 2020. Only the number of dedicated COVID care centres increased by 5%, from 8,857 in December 2020 to 9,313 in April 2020. COVID care centres, however, are not equipped for severe cases, only COVID hospitals and health centres.

There were 255,168 oxygen-supported beds in the country on April 9, 2021, per the ministry. This is more than double the 115,134 million beds in May 2020, but 6% fewer since December 2020.

The decrease in itself is not necessarily a problem, say experts. "The key issue here is whether the government had capacity to ramp it up when we hit a surge, and so there needs to be flexibility in the system for this," said T. Sundararaman, former dean of the School of Health System Studies at the Tata Institute of Social Sciences in Mumbai, told IndiaSpend.

"If beds were shifted to non-COVID purposes in December when COVID cases went down, that is actually a good thing, because otherwise, why should beds be kept empty just for COVID-19," Sundararaman said. The government, however, would still have had to ensure that they have planned for both "peak and non-peak situations" of the pandemic.

In December 2020, the curve of the pandemic was continuing to flatten in India. By April 2021, it was eclipsing the first wave.

"If cases were reducing, the excess capacity could have been dismantled but they should have had a contract that as and when needed, we will have to open it immediately. You can temporarily close things, but you do not dismantle it. You preserve it," Dileep Mavalankar, director of the Indian Institute of Public Health in Gandhinagar, told IndiaSpend.

State governments have since scrambled to add or repurpose infrastructure for COVID-19 care (see Box). While the central government procured medical equipment including 102,400 oxygen cylinders and nearly 39,000 ventilators and distributed these among states from its COVID-19 emergency response plan by January 24, the responsibility of installing health infrastructure lies with state governments, as health is a state subject. The state governments had installed 35,269 ventilators, 91% of the 38,867 allocated by the central government between March 24, 2020 and March 3, 2021, according to health ministry data, by the time the second wave hit. The performance of states has been mixed. Where most states and UTs have installed close to or 100% of their allocated ventilators, Assam and Goa (80%), Odisha (75%), Punjab (62%), Karnataka (61%), Madhya Pradesh (57%) and Arunachal Pradesh (56%) have installed 80% or less of their allocated ventilators. Sikkim had installed none.

Volunteer groups step in, prices rise exponentially

"We have run out of cylinders for today. We are waiting for the refill which may happen around 10 a.m. tomorrow," Harteerath Singh, a volunteer at Hemkunt Foundation in Delhi told IndiaSpend. The foundation is one of several civil society groups and volunteers in India who are organising oxygen cylinders for COVID-19 patients. Hemkunt has been working in Delhi throughout the pandemic.

By the next day when we checked with him, Singh said they had actually got the refill of 20 cylinders around 1 a.m. that day. At 1.48 a.m., they tweeted that they had oxygen cylinders. By noon, they had distributed them all. "We are responding round the clock," they tweeted.

The foundation has been depending on donations to fund their COVID-19 relief work, and has purchased 186 cylinders so far through donations. The price of oxygen cylinders, however, has increased by at least 75% compared to last year. "The price of cylinders has gone up. It is now more than Rs 7,000, but last year when we were buying them, it was Rs 4,000," said Singh.

Syed Tousif Masood has been working with the Mercy Mission collective in Bengaluru, which has also been supporting COVID-19 relief work throughout. Last year, they also realised that oxygen was going to be vital and began buying oxygen cylinders. "We have 500 cylinders now, which we drop to people's houses on request, and pick up when they have finished using it," said Masood. "We give them oxygen cylinders until they find a hospital bed."

Learnings for a third wave

India's daily production capacity for oxygen is around 7,127 metric tonnes (MT) while the consumption of medical oxygen on April 12 was 3,842 MT and India's stocks of oxygen were 50,000 MT, thus India's oxygen capacity and stock was "comfortably more than daily consumption", the government said on April 15, 2021.

"Along with the ramped up production of the oxygen manufacturing units and the surplus stocks available, the present availability of oxygen is sufficient," the government said, while telling states to ensure "rational use" of oxygen. At the same time, it instructed India's foreign missions to look for foreign vendors to import 50,000 MT of oxygen from and announced plans to purchase another 100,000 oxygen cylinders. The government also announced that production capacity will be enhanced by 154 MT with 162 new oxygen plants in different states at a cost of Rs 201 crore. Of these, 33 have already been installed. Another 100 hospitals would get oxygen plants via the PM CARES fund. The government also said that oxygen made in steel plants will be diverted to hospitals, and 14,000 MT of oxygen has already come through this capacity.

The government subsequently announced steps to ease distribution by exempting oxygen tankers moving between states from needing permits, and asking states to ensure that tankers can move round the clock. Cylinder-filling plants have also been allowed to work 24 hours a day, and industrial cylinders could now be used for refilling oxygen for medical purposes.

If production of oxygen was adequate, the issue was of poor distribution management by the government, experts tell us. "The government said that India's consumption of oxygen is well within its production. So if production was not a problem, then clearly distribution was the problem. The government cannot be absolved of its responsibility, even if it says that production has been sorted… because handling logistics means handling production as well as delivery," said Sundararaman.

"Next time, we should be better prepared. Otherwise if there is a third wave, we will again be caught napping," said Mavalankar.

By April 21, as a hospital moved the Delhi High Court in light of imminent exhaustion of its oxygen supplies and the danger to 400 patients, the central government reportedly informed the court that the country's production capacity for both industrial and medical oxygen was around 7,200 MT a day, but that the requirement was now over 8,000 MT daily.

(Lesley Esteves edited this story. Shreya Khaitan, a writer and editor, and Gautam Doshi and Priyanka Gulati, interns with IndiaSpend, contributed to this story.)

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