She was 53. The family could not find her a bed in any of the hospitals in Delhi where they lived when her oxygen levels plunged on April 26. The next day, they found her one in a private hospital in neighbouring Uttar Pradesh’s Greater Noida. But the hospital had an oxygen shortage – as most facilities in north India at the time.
A young family friend, all of 24, took it upon himself to help. On April 29, he dialled “easily 200 numbers” looking for an oxygen concentrator for her, a device that can produce oxygen from the atmosphere. “I got two hits,” said the young man, an engineer by training.
One of them proved to be genuine – a volunteer in Haryana’s Yamuna Nagar, who connected him to a family that had an old concentrator and were now willing to sell it. It would cost more than Rs 1 lakh, he was told. But the sellers said they would not be able to provide a bill for the purchase. The family decided against it.
The next day, some oxygen was arranged for at the hospital, but it was already too late. The patient’s lungs had been infected beyond repair. She died on May 3.
In Uttar Pradesh’s Ghaziabad, a media professional recounted a similar ordeal. An acquaintance, infected with the virus, started gasping for breath April 19 onwards. A cylinder with an underwhelming capacity of 15 litres was arranged for with much difficulty but refilling it was next to impossible. “This was the time when things were at its peak in Uttar Pradesh,” said the media professional, who, like the engineer, did not want to be identified in this report. “Not only were there no hospital beds, the police would not let anyone get oxygen for home use either. It was a massacre.”
On April 21, the Uttar Pradesh administration banned the supply of oxygen to individuals except for those in a “serious condition” – an arbitrary category left to the whims of mid-level bureaucrats, say those who have tried to avail of the exemption.
The only option, the family was given to understand, was to procure an oxygen concentrator. “I had a contact who told me the first batch of concentrators he had got were over,” said the media professional. “They insisted I pay an advance of Rs 25,000 for a concentrator that would only arrive after a week and with the most basic specifications.”
They decided to wait, only to find the cost of the concentrator continued to rise over the next few days. Before they could procure a concentrator, the patient, who was 53, died on April 28 in a private hospital in Haryana’s Jhajjar district. Her lungs had collapsed.
After dramatically shooting up in April, India’s Covid-19 curve may be showing signs of slowing down over the last couple of days, but the crisis is far from over. People continue to die because of lack of access to oxygen, the shortage of which has been further exacerbated by the fact that the country’s production capacities aren’t uniformly distributed and moving oxygen from one part to another is a logistical nightmare.
The shortage could have been reduced had oxygen generator units been installed in hospitals on a war footing but as Scroll.in reported this did not happen.
As a result, those who can afford to pay for a concentrator have realised that it is their best bet of accessing life-saving oxygen. Visualise it as a miniature mobile oxygen generation. Size and weight vary, depending on the model and capacity but usually its dimensions are that of a mid-size stroller. Embedded inside the machine are zeolite crystals that absorb nitrogen from atmospheric air. The output is concentrated oxygen which can be administered to a patient short via tubes connected to nasal prongs.
But concentrators are hard to come by as the experiences of the two families in Delhi and Uttar Pradesh reveal. They could be prohibitively expensive and yet of suspect quality and dubious make.
With barely any domestic production capacity of its own, India is largely reliant on China-made concentrators. While there is a rush to import the concentrators, the costs are high and the hurdles are many, including hazy regulations that have led to dramatic raids on concentrator dealers in Delhi, resulting in a murky economy that desperate families are navigating with few signposts.
Concentrators that are useless
A common glitch with most concentrators is the decline in purity at high flow.
These devices are usually distinguished by its maximum flow rate measured in litres per minute. The three most common variants have a maximum capacity of five, seven and ten litres per minute. A machine is considered reliable only if it produces sufficiently pure oxygen at its highest promised flow rates.
Over the last month, several desperate families have realised that few devices currently available in the market do that – despite their inflated rates. For instance, if a five litres per minute concentrator produces more than 90% pure oxygen only when it is pumping oxygen at one litre per minute, it is as good as a nebuliser and virtually useless for most Covid-19 patients who require oxygen support.
A dependence on China
Not only does India depend on China for concentrators, even the few Indian companies that make concentrators depend on China for their raw materials.
BPL Medical Technologies, a company based in Bengaluru which is arguably India’s most well-known manufacturer of oxygen concentrators, had a production capacity of just 600-700 concentrators a month before the pandemic struck, said Praveen Nagpal, its chief operating officer. Much of it is lying unused now. Because of Covid, it is having some impact,” said Nagpal.
Nagpal said the company was currently in the process of tying up with the government-run Bharat Electronics Limited to “expedite our capacity by 10-15 fold”. Nagpal did not specify a timeline for when that would materialise.
Oshocorp Global, a Delhi-based company, is another local manufacturer. The company, which has a monthly capacity of 3,000-4,000 concentrators a month, was plagued by a similar problem as BPL, said Ashutosh Khate, the company’s managing director.
“Our production line has been drastically curtailed because global supplies have been disrupted,” said Khate. “We are not able to do much as of today because a lot of components are imported.”
This surge was not anticipated and hence there was no planning put in place to import raw materials in advance, said Khate. “Why would anyone invest in expanding capacity when the prime minister and health minister of the country are saying the pandemic is over?” he asked.
This seems to be the story across the board. Manufacturers of other medical devices that had the required infrastructure in place tried setting up production lines for concentrators only in the last two months. By then it was already too late.
SS Technomed, a Ghaziabad based manufacturer of neonatal medical equipment, for instance, set out to manufacture concentrators in March. “We thought we already had everything, but it is impossible to source raw materials,” said the company’s owner. “All supply chains are shut, no one is even willing to talk in these times.”
Even those who are seeking to import concentrators from China are struggling too to keep pace with demand.
“Chinese companies have increased prices,” said Prashant Sharma, managing director of the Delhi-based Acer Biomedicals, a long-time importer of oxygen concentrators from China. “A 5 litres (per minute) is up by 30-40%; a 10 litre (per minute) one by 60-70%.”
Before the pandemic, concentrators would come by sea but that is no longer an option given the time-sensitive needs. Air freight charges have shot through the roof in recent times. “Freighters have increased their price by 200-250%,” said Nagpal of BPL Medical Technologies.
Acer Biomedicals’s Sharma said that amounted to $5-7 per kilogram of cargo. “Depending on the weight of the concentrators, we are paying Rs 12,000-17,000 per piece on just freight,” he said.
Even those who have imported concentrators for non-commercial purposes complained of predatory freight charges. Mukund BS, a Bangalore-based social entrepreneur, recently imported some from China. “The biggest challenge”, Mukund said, was “getting cargo space out of China”.
“At any point of time, there is a backlog of eight-ten days,” he said. “I am surprised why the Indian government is not sending in cargo flights because at least concentrators will keep people alive before they find a bed.”
Given these escalating costs, it is perhaps no surprise that inferior quality products are flooding the market.
Most dealers Scroll.in spoke to in Delhi and Bangalore said despite the government waiving off customs duties, prices were so high that they were compelled to buy products from dubious Chinese manufacturers as opposed to the regular brands they would stock earlier.
“Whatever is available is Chinese – those products we used to buy for around Rs 35,000 earlier, but now they are above Rs 50,000 now,” said a dealer in South Delhi. “The reliable brands are just not available because they are just too expensive.”
In Bangalore’s Jayanagar, a dealer said he was selling a “Chinese brand” concentrator of 5 litres per minute for “Rs 62,000 plus tax” that would earlier cost around Rs 42,000 in total.“We are not getting stock of established brands,” he said.
But these prices appear conservative compared to people’s lived experiences. “Two weeks back, a five litres was around Rs 60-70,000,” said Suhas Motwani, a Bangalore resident who has been helping people get access to care and medicines. “Now it’s Rs 1 lakh.”
In Delhi, Sonali Vaid, a public health professional, bought a five litres per minute concentrator for Rs 47,500 in the last week of April. Last week, she bought the same model for Rs 72,000.
Some activists have asked why a regulatory mechanism has not been put in place to control the prices of these devices – a question that the Delhi High Court has asked too.
A court in Delhi recently pointed out that the government could easily do so since a regulatory framework was already in place. In March 2020, the government passed an order stating that all medical devices are to be considered drugs. Which means their prices can be capped by the National Pharmaceutical Pricing Authority, the agency that regulates the prices of drugs in India.
The police in Delhi have arrested and detained people on several occasions in the last couple of weeks, accusing them of hoarding and black-marketing concentrators. However, detractors say that the crackdowns were arbitrary and counter-productive.
Even a Delhi court was of a similar opinion. On May 12, as it granted bail to a several people accused of hoarding concentrators, it observed:
Mere booking of the manufacturers/importers under the criminal law without a regulatory regime in place and without any evidence just to show that the state is concerned about the problems of citizens in procurement of life saving medical devices, in my considered opinion, will be counterproductive and shall create a further scarcity of already scarce medical devices as it will discourage the manufacturers and importers from pushing their resources so as to make the essential medical devices available to the needy citizens.
Indeed, that seems to be already happening.
Late evening on May 8, representatives of Paramount Surgimed, a Delhi-based medical devices company, on their way to Gurgaon to deliver concentrators to patients were intercepted by the police who then landed up at the company’s premises. This despite, according to the company’s owner Shaily Grover, the representatives furnishing bills to the police officials.
“We had imported 100 units from China, paid GST and were selling at MRP and providing bells,” said Grover referring to India’s Goods and Services Tax. “We thought, what is the point of being in this line if we can’t help people, that’s why we went out of our way and placed orders. But not anymore. This is the price you get for trying to help people.”
Volunteers say the police action had resulted in several suppliers, who had once helped, switching off their phones of late. “I am not vouching for them – that is not my job – but the fact is they did live up to their word and delivered concentrators and cylinders in the past that helped save people’s lives,” said a 27-year-old volunteer who has been helping families in Delhi.