Harsh Mander: As India gasped for oxygen in the second wave, those in power looked the other way

In a stunning reply to a question in Parliament last July, the Union government reported that it had no information about any deaths anywhere in the country because of the shortage of oxygen. Uttar Pradesh’s bellicose saffron-robed Chief Minister Adityanath went so far as to threaten to seize the property of anyone who alleged oxygen shortages, claiming that there was no shortage anywhere.

This, at a time when in every corner of the country, oxygen became incalculably more precious than gold. People begged every hospital, pleaded with everyone they knew, harvested any influence they could muster, for oxygen, and too many watched their loved ones choke to death. The BBC fittingly described this as “a nightmare on repeat, waiting for the terrifying moment when there is no oxygen left at all”.

The Times of India reported how a son watched his father gasp for oxygen on a wheelchair outside Bhabha Hospital in Mumbai’s Bandra and finally die. He said he would never forget those six harrowing hours. The hospital staff refused to admit him because they said they had run out of oxygen. That morning, when his oxygen levels had fallen, the family made the usual rounds.

They first called the official “war room” of the state government. The operator of the helpline there promised to look for a hospital bed. But they did not hear from them for two hours.

The family then headed for Bhabha Hospital, the newspaper reported. After they refused a bed for him, a cousin called six private hospitals, but to no avail. The son purchased a portable can that held about eight litres of oxygen, but this lasted less than ten minutes. His father gasped to death. “Had we found an oxygen bed, we could have saved him,” the son told The Times of India.

In the capital city of New Delhi, the director of one of the most prestigious upmarket private hospitals the Sir Ganga Ram Hospital made a sombre announcement on a melancholy day in April. He warned patients and their relatives that the hospital had oxygen supplies for only two more hours and that 60 patients were at risk of death. Following his forewarning, 25 of the “sickest” patients died.

Two other leading private hospitals, Max Hospitals and Saroj Super Specialty Hospital moved the Delhi High Court, seeking urgent assistance to sort out the oxygen crisis. The High Court responded with directions to the Union government to ensure that oxygen supplies and transportation were not disrupted, that special corridors be created for oxygen transportation and that security be given to the transporters to ensure that the oxygen was not diverted along the way.

“Enough is enough,” the judges declared. Using a popular Hindi proverb, they added, “Water has gone above the head. You have to arrange everything now.”

Deaths across India

A day later, at least 20 coronavirus patients died in another upmarket private hospital in Delhi, the Jaipur Golden Hospital, again after the hospital exhausted all its stocks of oxygen. “We lost 20 people amid an oxygen shortage last night,” the hospital’s Medical Director DK Baluja told the Hindustan Times. “Oxygen supply [will] last only half an hour now. More than 200 lives at stake.”

He told NDTV that the oxygen supply that was supposed to reach them by that evening arrived only at midnight. By then, these 20 patients had died. This hospital too petitioned the High Court. NDTV reported that in their plaintive plea, they said, “We are gasping for oxygen. We have our doctors before you. Please save lives. Please.”

According to a report published by Scroll.in, the third week of April saw an alarming “escalation of India’s oxygen emergency. Major hospitals in the national capital nearly ran out of oxygen for the third consecutive day. Oxygen cylinders were looted in a Madhya Pradesh town. Uttar Pradesh put restrictions on individual purchase of oxygen cylinders at a time when breathless Covid-19 patients have been unable to find hospital beds. An oxygen leakage in Maharashtra left 22 patients dead. States traded charges over oxygen blockades.”

Soon 12 more Covid-19 patients died in Delhi’s Batra Hospital. Six of them were in the intensive care unit. One of them was himself a senior doctor, gastroenterologist RK Himthani. The story was the same. The private hospital had run out of oxygen supply.

It told the High Court that it ran out of oxygen for 80 minutes at 1.30 pm. In a video message around 1 pm, the Executive Director of Batra Hospital, Sudhanshu Bankata, had circulated a terrifying message: “Currently we are surviving on some oxygen cylinders, but that will also run out over the next 10 minutes.”

SCL Gupta, medical director of the hospital declared, “It is a matter of shame that people are dying due to lack of oxygen in the capital of the country. One can only imagine the plight in other places.”

He was right also about the catastrophic consequences of an oxygen famine in every corner of the country. To list just a few instances instance, at least 22 patients who were on life-support ventilators at the Zakir Hussain Hospital in Nashik, Maharashtra, lost their lives after an oxygen tanker leaked outside the hospital. This resulted in disrupting the supply of oxygen to the hospital, with fatal consequences.

In just four hours one night, between 2 am and 6 am, 26 Covid-19 patients died at Goa Medical College and Hospital. Chief Minister Pramod Sawant and his health minister Vishwajit Pratapsingh Rane made contradictory statements about what caused the deaths.

On the one hand, The Hindu reported, Sawant insisted that “We have abundant supplies of [medical] oxygen. There is no scarcity in the state.” Rane on the other hand admitted that the hospital had indeed reported a shortfall of oxygen a day earlier.

The hospital, he said, needed 1,200 jumbo cylinders of oxygen, but the government was only able to supply the hospital with 400 cylinders. But after visiting the hospital following outrage and anguish about the deaths, Samant agreed that “availability of medical oxygen and its supply to Covid-19 wards in the Goa Medical College & Hospital might have caused some issues for the patients.”

“There are issues over the availability of oxygen in these wards which need to be sorted out,” the Goa chief minister added, according to Outlook. “Doctors, who are busy treating patients, cannot spend their time in arranging logistics like oxygen. I will hold a meeting immediately to set up ward-wise mechanisms to ensure that oxygen is supplied to patients in time.” But across five hospitals in Goa, the tiny state reported the largest number of Covid-19 deaths due to oxygen failures.

Authorities in denial

Thirteen patients died at the Chengalpattu Government Hospital in Tamil Nadu on a single night. Once again confusing denials emanated from the authorities, claiming the deaths were not due to oxygen shortages.

The dean of the hospital told The News Minute, “They died due to age, comorbidities and the condition of the diseases despite receiving treatment and not because of oxygen shortage.” District Collector John Louis also insisted, “There is no question of oxygen shortage.” But post-graduate doctors of the hospital denied this. They said that they had warned the hospital administration the morning before the deaths that the oxygen supply was depleting dangerously, but the dean and other senior doctors failed to act.

The hospital dean explained to The News Minute: “The Covid-19 ward is supplied with oxygen from the 10 kilolitres’ tank” at the hospital. “As several government and private hospitals are also in need of oxygen supply, our hospital has been receiving only around 4 kilolitres to 5 kilolitres to be filled in the three oxygen tanks, which would be enough to treat patients on regular days.” But clearly, this was not enough for the peak demand during the Covid surge.

The tragedy repeated itself in Chamarajanagar district hospital in Karnataka, where 24 patients died, apparently because the hospital ran fatally short of oxygen. The Deputy Commissioner of Chamarajanagar MR Ravi was again equivocal about the cause of the deaths. “We cannot say whether all have died due to lack of oxygen,” he told journalists.

This began a political slugfest. “Died or killed?” Congress leader Rahul Gandhi asked on Twitter. “My heartfelt condolences to their families. How much more suffering before the ‘system’ wakes up?”

Karnataka’s Chief Minister set up an enquiry into what caused the deaths, and his officers assured “strict action”. But little of this was later in evidence.

In Palanpur in Gujarat, five patients died in a private hospital after oxygen supplies ended. In Uttar Pradesh, five patients died in a private Aligarh hospital before oxygen supplies arrived. Meanwhile, Subhas Yadav, superintendent of a private hospital in Meerut, called the Anand Hospital said oxygen shortages had caused the death of three covid patients in his hospital on a single day.

Vinay Sharma, hospital superintendent of another private hospital, this one in Lucknow, announced to reporters that he himself was at an oxygen refilling centre because his patients urgently needed the gas to save their lives.

The BBC reported that in Uttar Pradesh, some hospitals put up boards announcing “oxygen out of stock” outside. In the state capital of Lucknow, and even in Delhi, hospital administrations asked families to move their patients elsewhere.

Anxious families bought oxygen cylinders in the black market, and when the oxygen ran out, converged in large numbers at the few oxygen refilling centres. One such centre in Hyderabad deployed bouncers to handle the surging crowds.

Hospitals everywhere struggled to take in patients whose oxygen levels were sinking or to keep alive with adequate supplies of oxygen those they had admitted. Many died outside hospitals because they could not get admission. Others died because the hospitals could not organise the oxygen needed to keep them alive.

Yet most senior politicians of the ruling party and senior officials remained in denial about the catastrophic shortage of medical oxygen in the country, resulting in numerous deaths.

To counter this ongoing scandalous official denial in government narratives of a reality that was playing out outside virtually every hospital across the country, a group of volunteers came together and established an open data tracker to “archive lost lives due to the lack of oxygen”.

They hoped that this documentation would provide lessons, now and in the future. They wanted to create this public record because the people who died gasping for oxygen “deserve to be noticed”, else this history will get lost a few years from now. Relying mainly on media reports, but also on information from social media and volunteer ground reports, they counted at least 512 oxygen deaths. Their figures are still likely to be gross underestimates because people who could not get hospital beds and died outside hospitals, in parking lots and in their homes would just not be recorded anywhere in the media and rarely even on social media.

According to their tracker, between April and May 16, the highest number of oxygen-related deaths (83 deaths) were in five medical colleges in Goa. Karnataka reported 54 such deaths. There were 59 deaths in Maharashtra, 30 in Madhya Pradesh, 59 in Delhi, 46 in Uttar Pradesh, 52 in Andhra Pradesh, 22 in Haryana, four in Jammu and Kashmir, six in Punjab, 37 in Tamil Nadu, 16 in Gujarat, five in Uttarakhand, nine in Rajasthan, eight in Bihar, 15 in Telangana, one in Chhattisgarh, one in West Bengal and five in Jharkhand.

Many courts sounded the alarm and directed officials to ensure adequate medical oxygen. The Delhi High Court warned that it would start punishing government officials if they failed to provide a steady oxygen supply – that it would initiate contempt proceedings if there was no compliance. In another hearing, the Allahabad High Court pronounced that those “failing to provide hospitals with oxygen were committing a criminal act no less than genocide”.

What went wrong?

What led to such a calamitous – or to use the apt phrase of the Allahabad High Court, a genocidal – collapse of the supply of an elementary life-saving resource like oxygen?

Firstly, why is medical oxygen therapy vital to save the lives of severe Covid-19 patients? Dr A Fathahudeen, a member of Kerala state’s Covid task force told the BBC: “You need high-pressure liquid oxygen for the smooth functioning of ventilators and bi-pap machines. When the pressure drops, the machines fail to deliver adequate oxygen into the lungs, and the consequences can be fatal.”

The medical oxygen crisis was unprecedented, and doctors could not do much to save lives if the oxygen supply was not secured. Some clinical studies, according to community health specialist Rajib Dasgupta who spoke to AFP, said 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.”

Oxygen is life-saving not just for Covid-19. For instance, it is critical if the lives of patients of severe pneumonia are to be saved. Pneumonia is the infection that snatches the largest numbers of lives of children under five years across the world.

Even before the Covid-19 pandemic, experts have long recommended the building of oxygen-producing infrastructure within large hospitals, but this was not heeded. It became apparent after the Covid-19 pandemic dramatically demonstrated the costs the enormity of the costs of human lives of this delay in building a crucial element of India’s healthcare capacity - to boost both the production and effective transportation of oxygen.

Not just governments, private hospitals that charge high fees should have also made investments to build captive oxygen units in large hospitals. This was indispensable if many serious patients of Covid-19 were to be saved from death. The World Health Organization, in a document of April 2020, said that “the ability to boost capacity to deliver oxygen therapy is the cornerstone of the overall approach to managing the Covid-19 outbreak”. World Health Organization estimated that nearly 15% of Covid-19 patients required oxygen therapy.

But a year later, amidst the agony of the horrific oxygen famine in India, when we saw images of one cylinder of oxygen being shared by six, sometimes ten patients outside a general hospital in Delhi, and news poured in of patients dying even inside hospitals because oxygen supplies had not reached, clear signs were visible of a failed state.

In a sterling clear-eyed investigation into the question of why India ran out of oxygen causing the preventable deaths of maybe thousands of Covid-19 patients, Vijayta Lalwani and Arunabh Saikia of Scroll.in had a simple answer. This happened simply because the government wasted time.

Lack of foresight

It was clear from the early days of the pandemic that since the virus attacked the lungs of the patient, oxygen would be critical in the battle to save lives. Yet the Union government took eight months to first invite bids for new oxygen generation plants.

It was in October when the Union health ministry floated a tender for erecting Pressure Swing Adsorption oxygen plants in 150 district hospitals across the country. The Pressure Swing Adsorption technology generates concentrated oxygen from the atmosphere.

This is supplied to hospital beds through a pipeline. The hospital then does not need to access pressurised liquid oxygen from other sources. The numbers were later raised to 162 plants, and the cost was an extremely modest at Rs 201.58 crore. This would be paid for from the PM-Cares fund, which raised more than Rs 3,000 crore in donations in just the first four days after it was set up on March 27, 2020.

But even by the end of April 2021, only 33 of these plants had been established. And even many of these were not operational. The government officially announced that by end-May, 80 plants would be installed: this would still be half the proposed number of units, 15 months after the pandemic broke out.

Mahesh Zagade, former health secretary of Maharashtra told the BBC, “When the first wave was tapering, that is when they should have prepared for a second wave and assumed the worst. They should have taken an inventory of oxygen … and then ramped up manufacturing capacity.”

Leading public health expert, Dr T Sundararaman, former director of the National Health Systems Resource Centre, an advisory body of the Union Ministry of Health and Family Welfare, went further. He said that even without the pandemic, public hospitals should have an assured supply of oxygen. “We have had tragedy after tragedy because of lack of oxygen,” he told Scroll.in. Hundreds of thousands of deaths due to pneumonia, snake bites, encephalitis, road accidents, among others, could have been prevented through piped oxygen supplied through on-site generation plants.

The costs of these are trivial, as the recent bids for 162 hospitals showed. I again underline the duty of high-end expensive private corporate hospitals to have made these investments to save lives. All major hospitals should invest in their own captive oxygen plants and tanks, so they do not depend on transported oxygen. But we have seen that although large private hospitals charged outrageous fees, most did not invest in their own capacities for oxygen production.

Triage situation

In Uttar Pradesh, the reporters found that not one of the hospitals earmarked for these units actually had functional oxygen plants. SR Singh of Lucknow’s Shyama Prasad Mukherjee Civil Hospital accused the company that won the contract of “fleeing after installing the plant”.

“They have done nothing after that,” he said. “We will now connect pipes and make it operational on our own.”

“We allocated a site for the plant, but the machine is yet to come,” Gyanendra Kumar of Meerut’s LLRM Medical College said to them. “I have phoned the company several times, but there is no response.”

The company that had been awarded the contract, Absstem Technologies, did not respond to questions from the reporters. A company in Maharashtra, Aurangabad-based Airox Technologies, did speak to them but laid all the blame on the hospitals.

The company had done its work, he said. It was the hospitals that had not provided the infrastructure needed to connect the oxygen plants to the beds. The states “need to provide us with all copper pipeline connection and electricity. That is not in our hands. Unless they give us that, we cannot start the system”. Many hospitals they spoke to denied this: they were ready, it was the contractors who refused to show up.

The lack of medical oxygen, said doctors in Gujarat to the reporters, forced them into a “triage-like situation” – by which they meant they had to pick between patients, all of whom required oxygen, but only some could be given it. “We now admit people with oxygen saturation below 85-90 instead of 94, and try to advise prone position at home for those with 90-95 saturation,” a government doctor said. “There are not enough oxygen beds.”

Rajabhau Shinde, who runs a small oxygen plant in Maharashtra, told the BBC, “As the saying goes, dig the well before you are thirsty. But we did not do that. We have been telling authorities that we are willing to increase our capacity, but we need financial aid for that.”

“Nobody said anything and now suddenly, hospitals and doctors are pleading for more cylinders,” Shinde said. “This should not have happened”.

Another question is: does India produce enough oxygen even for its peak needs in a Covid-19 surge? The answer, experts tell us, is both yes and no. Yes, because India’s peak needs were expected to be around 7,000 metric tonnes. India already produced more than this – at 7,127 metric tonnes.

Until 2019, before the pandemic hit the country, prior to the pandemic, India required just 750 metric tonnes-800 metric tonnes of liquid medical oxygen. The large remainder was for industrial use. But in just 10 days from April 12, demand for medical oxygen spiralled dizzily by 76% from 3,842 metric tonnes to 6,785 metric tonnes. There was still enough production in the country, in theory. Moreover, if the 162 units had been installed on time before the second wave hit us, we could have had added valuable additional on-site capacity.

Although a great part of the country’s oxygen production is for industrial and not medical use, calling on this in an emergency was a health and indeed a moral imperative. But officials argue that the possibilities of this were limited because diverting oxygen from industry to hospitals would mean that many vital industries like steel would be on hold.

Ominous picture

The Central government prohibited manufacturers from supplying oxygen for non-medical use but exempted nine industries: ampoules and vials, pharmaceuticals, steel plants, petroleum refineries, nuclear energy facilities, oxygen cylinder manufacturers, waste-water treatment plants, food and water purification – process industries that require the uninterrupted operation of furnaces. These account for around 2,500 metric tonnes of oxygen. Effectively, this left 4,600 metric tonnes for medical use. This made for an “ominous picture”.

And also, industrial oxygen does not have the purity that medical applications of oxygen require. Some experts fear that the new epidemic in India of black fungus cases during the Covid-19 second wave could have been caused, at least partially by the large use of industrial oxygen for medical purposes.

However, in truth the much greater bottleneck was transportation. Industrial oxygen is manufactured in large quantities in eastern India but the need for medical oxygen was highest in states like Maharashtra in the west, and Delhi in the north, requiring transportation for long distances.

The BBC explains that liquid oxygen is pale blue with a temperature of around minus 183 degrees Celsius. This cryogenic gas can only be stored and transported only in special cylinders and tankers. The tankers are not allowed to drive above 40 km per hour, and should not travel at night to avoid accidents.

For industrial oxygen to be reached to every hospital in every district required an elaborate and highly specialised transportation system that was entirely not in place. India had 1,172 oxygen cryogenic tankers for road transport of medical oxygen on April 25, 2021.

This was enough in normal times but fell drastically short when demand rocketed in the second wave. This again is something the government should have anticipated. Too little too late, it began after the second wave engulfed the country to refurbish 600 tankers that transported nitrogen and argon into oxygen-carrying vehicles, and import 162 more.

It also planned to manufacture 100 tankers in the next 4 months-6 months. The Air Force was called in to airlift empty tankers to speed up one-way travel. Special trains to transport the liquid oxygen were announced. By May 11, 2021, India had 1,750 oxygen tankers including the recently imported ones. All of this, and more, could have been anticipated and India’s oxygen transportation capacities enhanced well before the second wave.

It did not end here. India also faced a shortage of truck drivers who were equipped with the training and physical resilience to drive 1,500 km-2,000 km nearly at a stretch, and in a loop. Drivers died due to fatigue and fell into accidents on the way. The Goa Bench of Bombay High Court admonished the government, “People cannot die for reasons that we do not have a driver, technician and we did not get spanner.”

The Indian government fell back on ex-servicemen and trained specialist drivers as it scrambled to meet the crisis. A pool of 2,400 drivers who could drive the cryogenic tankers were eventually deployed to transport oxygen to the states. But the need was much higher.

In a country with a young labour force, the deployment of sufficient numbers of fit and trained cryogenic tankers should have not been difficult had someone in government simply anticipated the need and planned for this.

Desperation for oxygen

Since hospital beds, especially those linked to oxygen fell woefully short, patients went advised home isolation with regular monitoring of oxygen levels. This of course excluded most of the labouring and destitute poor, who did not have homes where a patient could isolate themselves.

But for those who could, what could they do when the oxygen levels of patients fell? Either their relatives made desperate rounds of hospitals that would turn them away until their loved one choked to death. Or they would look with equal desperation for oxygen cylinders and concentrators.

Hospitals had also run short of oxygen. They asked the families to arrange for oxygen from private suppliers. But there was an acute shortage of cylinders, leading as we have seen to a desperate scramble.

A local private oxygen supplier said, “until now we have been able to fulfil all demands and have not sent anyone back disappointed, but we do not have any more cylinders”. And even for those who managed somehow to get a cylinder (paying astronomical amounts in the black market or helped by private groups or even individuals), the next crisis was how to refill these cylinders when they were exhausted.

For patients with moderate oxygen needs, oxygen concentrators were useful and these did not require refilling. But again, they were expensive and hard to acquire. And the black market again kicked in. Hospitals and suppliers marked up their prices to two to four times higher than in normal times. The Indian Express reported that “A five-litre oxygen concentrator, which until two months ago cost Rs 45,000-Rs 50,000, now costs Rs 80,000-Rs 90,000, its monthly rent up from Rs 5,000 to Rs 10,000-Rs 20,000”.

And then, even as India choked, red tape still held up essential life-saving supplies. Around 40 countries came forward to help India during the crisis with medical supplies. Cumulatively, India has received (from April 27, 2021, to May 4, 2021) 1,764 oxygen concentrators, 1,760 oxygen cylinders, seven oxygen generation plants, 450 ventilators and more than 1.35 lakh Remdesivir vials and 1.20 lakh Favipiravir strips.

This was not much, given the countrywide tempest of need that the second wave unleashed. But at least some lives lost could have been saved. However, after the first consignments of foreign Covid-19 aid reached India on April 25, 2021, the Union government took seven days to frame and notify the “standard operating procedures” for distributing these crucial supplies to the states, even as the oxygen crisis deepened in the country. Many state officials complained about the foreign donations and aid being stuck at the airport and not delivered to the states.

In a slum in Mumbai’s Dahisar, 60-year-old Ramnath Tupseinder’s oxygen saturation dipped to 89. His son had learnt that this was a danger sign. He rushed him to two government-run Covid centres but found no bed in either of these.

Sandhya Fernandes, a social worker, phoned many hospitals to find him a bed but drew a blank. They had no money for a concentrator or a cylinder. Desperately they gave him the residual oxygen that remained in a cardiac ambulance. In two hours, he died, gasping for breath.

For those two dystopic months, this had become the story of India.

Read the other parts of the “Tsunami of suffering” series here.

Harsh Mander is a Richard von Weizsacker Fellow, Chairperson of the Centre for Equity Studies and convenes the Karwan e Mohabbat, a people’s campaign to fight hate crime with solidarity and atonement.