On the night of April 17, Ram Kumar Jaiswal went to sleep relieved that his elder brother Raj Kumar was recovering.

It had been a week since Raj Kumar, 28, had been admitted to the government medical college and hospital at Shahdol in Madhya Pradesh after he had tested positive for Covid-19. With his oxygen levels falling, he had been moved to the intensive care unit. But that night, he seemed better, he even ate dinner by himself.

At 4 am, however, Ram Kumar, who was sleeping outside the ICU, woke up to commotion. He heard hospital workers say repeatedly, “Get the cylinder.”

He tried to enter the ICU but the guards did not let him. He pushed past them only to watch his brother’s body go cold. “Tadap raha tha.” He was struggling, said Ram Kumar.

He alleged he saw six others die in the ICU unit. “The oxygen supply was low, we all found out,” said Ram Kumar. “How else did seven people die in one go?”

The hospital authorities have refuted the allegation. The pressure of oxygen from the centralised system that stores 12 metric tonnes had dropped, said Dr Milind Shiralkar, dean of the college. But the hospital had 245 jumbo cylinders, he claimed.

At least 255 Covid patients were admitted in the hospital of which 62 were in the ICU and 110 were on oxygen beds. “The use of oxygen also went very high and it started getting exhausted very quickly, it was going to finish,” Shiralkar said. But he insisted the deaths were not caused by oxygen shortage. “It is unfortunate six people died but had it been a lag in oxygen, then the number of deaths would have been disastrous,” he said. “The deaths would have been more.”

A tanker carrying 16 metric tonne of oxygen was on its way from Modinagar, Uttar Pradesh, more than 900 kms away. It was supposed to reach on the morning of April 17, but got delayed to 4 pm on April 18.

“A day before an oxygen tanker had met with an accident because the driver was tired, so the company asked the driver not to drive at night,” Shiralkar said. “I have also heard that political workers are stopping tankers to do puja. I really do not know the cause of the delay.”

Rickshaw drivers hold oxygen cylinders outside a private refilling station during the coronavirus crisis in New Delhi. (Credit: Adnan Abidi/Reuters)

A last minute purchase order

India’s ferocious second wave of the coronavirus pandemic has left it facing a grave oxygen emergency. Based on current levels of daily demand and production of medical oxygen in the country, its oxygen reserves could get exhausted in two weeks, unless all oxygen is diverted to medical use and is quickly supplemented by imports, as this Scroll.in report explains.

But the gap between demand and supply is only one part of the crisis. The other is geography and logistics: oxygen production is unevenly distributed through India and moving stocks from eastern India to states in the west and the north is proving to be a huge challenge.

Madhya Pradesh, with over 73 million people, is among the worst affected, partly because it barely has any oxygen production capacity of its own. The state has 82,268 active Covid-19 cases currently, which means at least 44,000 patients need oxygen therapy, according to an estimate based on data of cases in the second wave released by the health ministry.

On Wednesday, oxygen cylinders were allegedly looted on the way to a hospital in Damoh district. In Ujjain, hospital officials told reporters they were running out of the life-saving gas.

Madhya Pradesh is entirely dependent on other states for the supply of medical oxygen, said Waji Ud Din, the state nodal officer for oxygen supply and deputy chief controller, Petroleum and Explosive Safety Organisation.

Currently, it receives around 330 metric tonnes of medical oxygen daily from Jharkhand, Odisha and Chhattisgarh. Reliance Industries in Gujarat sends an additional 120 metric tonnes of liquid oxygen, he said. On April 18, Madhya Pradesh officials accused Maharashtra of scuttling their supply of oxygen concentrators because of restrictions imposed in the latter state.

Over the past year, however, the state has done little to augment its own oxygen production capacity, and authorities have woken up rather late to the need to ramp up infrastructure.

On April 13, as the number of active cases in Madhya Pradesh rapidly rose to 43,539 from 4,512 a month ago, the state road development corporation floated a tender to install and maintain PSA oxygen generation plants in 10 district hospitals.

These oxygen plants use Pressure Swing Adsorption technology, which separates gases from a mixture in the atmosphere to generate concentrated oxygen that can be supplied to hospital beds through a pipeline, negating the need for hospitals to buy pressurised liquid oxygen from other sources.

The next day, however, the state government made an emergency purchase of PSA oxygen plants for those 10 districts and three others at a cost of Rs 15 crore from an Aurangabad-based company called Airox Technologies. The nodal officer Waji Ud Din said it will take another 15 days to install the plants.

Each PSA oxygen plant would have a production capacity of 618 litres of oxygen per minute, according to the tender document. Assuming one patient is administered 6-10 litres of oxygen per minute, each hospital with a PSA oxygen plant can provide oxygen to 60-100 patients simultaneously.

This capacity, had it been created on a war footing in Madhya Pradesh, would have reduced the dependence on oxygen transported over long distances. Questions emailed to the Madhya Pradesh government asking why it delayed augmenting capacity went unanswered. This article will be updated if there is a response.

But the Madhya Pradesh government is not the only one to have overlooked this localised solution for creating on-site medical oxygen capacity. Even the Central government took eight months into the pandemic to float a tender for 162 PSA oxygen plants across India, of which only 33 plants have been installed so far, as another Scroll.in investigation revealed.

What makes the delay more egregious is that the cost of a PSA oxygen plant comes to an average of Rs 1.25 crore, according to the central government tender document, and Rs 1.5 crore, as per the Madhya Pradesh purchase order.

Oxygen-deficit states

Another state that is hobbled by lack of production capacity is Delhi.

It has by far the highest population-wise caseload of Covid-19 in the country, but does not have a single oxygen production unit.

With cases rising to 24,638, the Delhi government has been left making appeals to the Centre on Twitter asking for more oxygen to be allocated to the state. It has accused both Uttar Pradesh and Haryana of blocking oxygen supplies. The matter even reached the Delhi High Court on Wednesday, which ordered that the Centre allocate 480 metric tonnes of oxygen to Delhi and deploy paramilitary forces to provide the tankers safe passage.

On Thursday, however, the crisis escalated and Chief Minister Arvind Kejriwal said that Delhi’s daily oxygen demand was 700 metric tonnes. He said that his government was also exploring options of air lifting the oxygen supply coming from Odisha.

Scroll.in contacted the Delhi government’s spokesperson and the nodal officer for oxygen supply to ask what the state had done in the past year to augment its own oxygen producing capacity. But the calls and texts went unanswered.

Another state that does not have its own liquid oxygen manufacturing capacity is Bihar.

Currently, the state has only seven Air Separation Units, an older technology of using a cryogenic plant to generate oxygen from the atmosphere, that produce a total of 34 metric tonne of oxygen daily, said Basudeo Basak, the state’s nodal officer for oxygen supply and controller of explosives, PESO. “This is not sufficient now,” he said. “The requirement is two times more of this.” Bihar currently has over 63,000 active cases.

But unlike Delhi and Madhya Pradesh, Bihar is confident that it can depend on steel plants in Jharkhand for its supply, Basak said. “We have arranged for seven tankers so it will be easy to bring it,” he said.

Workers in Punjab on Thursday refill cylinders with medical oxygen for supply to hospitals. (Credit: PTI)

Oxygen producing states

States in eastern India like Jharkhand, Odisha and Chhattisgarh, hubs of the country’s mineral and steel industry, are currently diverting oxygen from industries like steel for medical purposes. These states are currently supplying oxygen to Maharashtra, Madhya Pradesh and Gujarat among others that are seeing a surge in Covid-19 cases.

Among these states, Chhattisgarh has seen the highest surge in Covid-19 cases in the second wave, with 1,22,751 active cases as of April 22. Yet it has been able to meet the rising demand because it produces around 210 metric tonnes per day from its two steel manufacturing plants, and has 35 cylinder refilling plants with a capacity of 178 metric tonnes, said Ayyaz Tamboli, the state’s nodal officer for oxygen supply.

The state is currently consuming 144 metric tonnes of medical oxygen per day, he said. “Our major issue is our oxygen bed capacity is increasing, we have to increase [manufacturing] capacity to meet that load,” he added.

But at the moment, Chhattisgarh has surplus supply. On April 20, the state had supplied 74 metric tonnes to Maharashtra, 87 metric tonnes to Madhya Pradesh and 22 metric tonnes to Telangana. These figures fluctuate on a daily basis, Tamboli said.

Odisha produces around 6,000 metric tonne per day from five major steel plants, said Dr Ruab Ali, the state’s nodal officer and deputy chief controller of explosives, Petroleum and Explosive Safety Organisation. “The demand within the state is moderate and we are not in a crisis as other states,” said Ali.

Another state that is self-sufficient is Kerala, which has come to the aid of Goa by sending it around 22 metric tonnes of oxygen.

Kerala has 12 gas refilling plants, 11 privately-run Air Separation Units, and two gas manufacturing plants. One is a privately-run plant of Inox Air in Palakkad that produces 149 metric tonne per day and the other is a plant of the Kerala Minerals and Metals Limited, a state-run undertaking that started producing six metric tonnes per day four months ago.

In total, the state produces around 155 metric tonnes of oxygen per day, said Dr RC Venugopal, the state’s nodal officer for oxygen supply and deputy chief controller of explosives at the Petroleum and Explosive Safety Organisation. In addition, the state has diverted industrial gas from the Bharat Petroleum refinery in Kochi and was allotted five PSA oxygen plants by the Central Medical Services Society tender in October of which three have been installed, he said.

Ample manufacturing capacity aside, what has worked in favour of the state, said Venugopal, was close monitoring of the need for medical oxygen among each of its Covid-19 patients, said Venugopal. The state officials used the World Health Organisation’s Essential Supply Forecast tool to predict and prepare for their future oxygen needs.

For instance, Venugopal calculated that the state would need an estimated 99 metric tonnes of the gas by April 25 for Covid-19 patients as well as those who require it for other purposes. By April 30, if the number of infected patients rises to 1,15,000, the state would need around 104 metric tonnes of the gas. “This process has not been very rigorous in other states,” he said.

Also read:

How grave is India’s oxygen emergency? Worse than the government admits