Vinay Srivastava’s oxygen saturation level was dangerously low when he tweeted around 8 pm on April 16 to say that no hospital in Lucknow was responding to his phone calls.
Oxygen saturation in the blood below the level of 94 is considered a matter of concern for people suffering from Covid-19. Srivastava said his level was 52.
As the 65-year-old freelance journalist’s complaint went viral on Twitter, the Uttar Pradesh chief minister’s media advisor responded to him next afternoon, asking for more details. By then, Srivastava’s oxygen levels had fallen to 31.
At 4.20 pm on Saturday, his son, Harshit Srivastava, tweeted to say his father had died—waiting for an ambulance. “We did not get anything,” he told Scroll.in on the phone. “I called every number for an oxygen cylinder but no one picked up.”
About 7 km from their home, the government-run Shyama Prasad Mukherjee Civil Hospital has been waiting for an oxygen generation plant. It is one of 150 district hospitals across India for which the central government floated tenders in October, eight months into the coronavirus pandemic, to create units that can produce medical oxygen on site.
But six months later, the oxygen plant is yet to be installed. Had it been in place, breathless Lucknow residents like Srivastava would have stood a better chance of surviving Covid-19. The city of three million people currently has 44,485 confirmed coronavirus cases.
“My father could have been saved,” said Harshit Shrivastava, who was still awaiting his father’s Covid-19 report, hours after his death. “It is entirely the government’s fault.”
About 1,200 km away, in Navsari, Gujarat, another district hospital due to get an oxygen generation plant has had to refuse admission in the last few days to several Covid-19 patients who required oxygen.
“There is a full shortage of oxygen,” said Avnish Dube, the chief medical officer of the district’s 175-bedded MGG General Hospital. Last week, five Covid-19 patients died in a private hospital reportedly due to lack of oxygen—despite the district’s official case load being barely over 500.
Had the oxygen plant been in place, Navsari could have even catered to patients from Surat, one of the worst affected cities in Gujarat, less than an hour away. But, currently, when nearby hospitals contact him, Dube said, “I have had to tell them, ‘Don’t send them here.’”
Eight months to float tenders worth Rs 200 crore
India declared the coronavirus pandemic to be a “disaster” on March 14, 2020. Ten days later, over a billion people were put under the world’s most severe lockdown, with the government arguing it needed time to expand the country’s healthcare capacity.
Early in the pandemic, it became clear that oxygen would be one of the most precious commodities in the battle against the virus. Yet, it took the Narendra Modi government eight months to invite bids for new oxygen generation plants.
On October 21, the Central Medical Services Society, an autonomous institution under the Union health ministry, floated a tender online calling for bidders to establish Pressure Swing Adsorption oxygen plants in 150 district hospitals across the country. The PSA technology 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.
It seems unlikely that the delay in kickstarting the tender process was caused by a lack of funds: the outlay for 162 oxygen plants (12 plants seem to have been added later) is just Rs201.58 crore. The money has been allocated from the PM-Cares corpus—the Prime Minister’s Citizen Assistance and Relief in Emergency Situations fund, which had received over Rs 3,000 crore in donations within four days after it was set up on March 27, 2020.
Now, with a deadly second wave of the Covid-19 pandemic sweeping through the country, the Modi government said in a statement on Thursday that another 100 oxygen plants will be established out of the PM-Cares fund. On the status of 162 oxygen plants for which contracts were given in 2020, all it said was that they were “being closely reviewed for early completion of 100 percent of the plants.”
Questions sent to the Central Medical Services Society and the union health ministry enquiring about the status of the 162 oxygen plants, went unanswered at the time of publication.
But an independent investigation by Scroll.in revealed a disturbing picture of mounting delays. We called more than 60 hospitals across 14 states where the new oxygen plants are expected to come up. Only 11 units had been installed and just five were operational, as per interviews with hospital officials.
Update: Two hours after this article was published, the health ministry put out a series of tweets, confirming that most new oxygen plants were not functional. “Out of 162 PSA Oxygen plants, 33 have been installed,” it said. “By end of April, 2021, 59 will be installed. By end of May, 2021, 80 will be installed.” It is likely the ministry meant a total of 80 plants will be installed by end of May—less than half the number of new sanctioned plants—because the numbers would otherwise add up to 172 plants.
With nearly two million people currently infected with coronavirus in India, oxygen is running out, despite many states redirecting all industrial oxygen production to medical purposes. The government said on Thursday it would import 50,000 metric tonnes of medical oxygen.
The new oxygen plants would have added a capacity of over 4,500 metric tonnes of oxygen per month. This would still have proven inadequate to meet the demand currently seen in the second wave but every additional capacity could have saved lives.
“Even if Covid-19 had not been there, these plants should be there,” said T Sundararaman, former director of the National Health Systems Resource Centre, an advisory body of the union ministry of health and family welfare.
Public health experts like him have argued that the pandemic is an opportunity for India to fill the glaring gaps in its healthcare systems, one of them being the absence of piped oxygen in district hospitals that cater to lakhs of people.
“We have had tragedy after tragedy because of lack of oxygen,” Sundararaman said. This includes deaths due to snake bites, encephalitis, road accidents, among other causes.
Hundreds of thousands of such deaths could have been avoided had piped oxygen been available through on-site generation plants, which as the recent bids have showed, come at a small cost—just Rs 200 crore for over 150 hospitals.
But now Covid-19 is adding to this death roll.
Mounting delays as hospitals and companies trade charges
What explains the delay in installing the oxygen plants when infrastructure should have been ramped up on war footing during a pandemic?
Scroll.in spoke to hospital officials in 14 states—Assam, Bihar, Chhattisgarh, Delhi, Gujarat, Jharkhand, Kerala, Madhya Pradesh, Maharashtra, Telangana, Uttar Pradesh, Uttarakhand and West Bengal. Most officials blamed the companies that had won the contracts for the delays.
In the tender document for the new oxygen plants, district hospitals were listed along with the total number of beds in the hospital and the capacity of the plant. Out of these, Uttar Pradesh was allotted the highest number of plants with varying capacities in 14 districts. It was followed by Maharashtra, which was allotted plants in 10 districts. Delhi was allotted eight plants with a total capacity of generating 7,700 litres of oxygen per minute.
The contracts were awarded to at least three companie—Uttam Air Products, Airox Technologies and Absstem Technologies—according to the information provided by district officials at the hospitals Scroll.in contacted.
In Uttar Pradesh, not one of the 14 hospitals reported having a functional oxygen plant.
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.”
Gyanendra Kumar of Meerut’s LLRM Medical College said: “We allocated a site for the plant, but the machine is yet to come. I have phoned the company several times, but there is no response.”
In both cases, the contract had been won by Absstem Technologies, a company registered in Delhi. Even MGG general hospital in Navsari, Gujarat, identified Absstem as the company that won the contract but failed to show up. “We keep calling them, they keep saying they would call back,” said Avnish Dube, the chief medical officer of the hospital. “I don’t know what the problem is.”
Scroll.in was unable to contact any official of Absstem since phone numbers and email addresses mentioned on the company website were unresponsive. This article will be updated if the company responds.
Another company that bagged orders to install the new oxygen plants is the Aurangabad-based Airox Technologies. Its founder Sanjay Jaiswal claimed the company had finished all procedures on its end. But the new units were delayed because hospitals, he claims, were yet to provide the infrastructure needed to connect the generation units to the beds.
“From our side, our 60 engineers were aggressive, it is almost done,” he said. “But states need to provide us all copper pipeline connection and electricity. That is not in our hand. Unless they give us that, we cannot start the system.”
Across the states, however, most hospitals insisted they had all the infrastructure ready. “On January 13, I sent the company a mail saying the site is ready,” said Niyati Lakhani, a doctor at GMERS Medical College and General Hospital, Gandhinagar. “I have not heard back despite several follow-ups. We desperately need it up and running. We just are not being able to manage with cylinders.”
The company contracted to carry out work in Gandhinagar was Delhi-based Uttam Air Products, which Scroll.in found had been blacklisted by the Central Medical Services Society on April 13. A letter by Central Medical Services Society, reviewed by Scroll.in, states the company had not submitted its security deposit or accepted letters of acceptance after winning the contract.
When we broke that news to Lakhani, she said in resignation: “If Uttam is blacklisted then where should I get oxygen from?”
The company’s founder Manish Kapoor declined to comment on the matter. “You already have the letter from CMSS,” Kapoor said. “I think they will be the better people to answer that. We are vendors and we have assisted them in various technical inputs related to those tenders.”
As the delays escalate, smaller hospitals in fur-flung areas are particularly impacted. It is extremely difficult for them to procure oxygen cylinders when supply lines are choked. They are simply unable to compete with bigger players with deeper pockets. These hospitals would have been better equipped to care for severely-ill patients had a local source of production been up and running.
As Ungender, the medical superintendent of the Area Hospital in Telangana’s Bhadrachalam, a district that is home to a large Adivasi population, put it: “When we are purchasing oxygen from outside, we are running huge bills. But if we produce at site, it will reduce our burden.”
After all, as Ungender said, all it took to produce oxygen, once a plant was functional, was air.
Shortages lead to death spiral
Doctors across India say the second wave might prove more lethal, not because new variants of the virus were causing more severe disease (there is no clear evidence on this yet), but simply because a higher case-load would make it harder for patients to get admission to hospital. And even those admitted to hospitals might have to go without oxygen.
The lack of medical oxygen, said doctors in Gujarat, had forcing 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.
“Last time we were able to meet the requirements,” said Roopam Gupta, a doctor at CU Shah Medical College and Hospital in Surendranagar district in Gujarat, “but this year the wave has come so suddenly with a steep rise so at the moment we are only making our ends meet.”
The hospital has 700 beds out of which nearly 200 were occupied on Friday by Covid-19 patients and almost all of them needed oxygen, Gupta said. The hospital has kept two trolleys with 100 oxygen cylinders on standby along with fire engineers manning the vicinity. “It [oxygen] is in such high flow that we are afraid that a disaster [could] take place,” he said.
This time around, doctors were using a new treatment termed high flow nasal therapy, which requires higher amounts of oxygen per patient. “The problem is once a patient goes on high flow then a single patient requires 130 litres per minute of oxygen, so it sucks out the capacity,” Gupta explained. “Even if one patient requires high flow, we have to balance the benefits with 50 others who are surviving on oxygen at 16 litres per minute.”
Many doctors at the district hospitals which are waiting for the new oxygen plants conceded they had stopped following up with the companies because for a while it seemed the worst was over. After reaching a daily-high of about 1 lakh cases in September, Covid-19 cases in India had been falling steadily till February.
“We became a little less serious,” said Sanghamitra K Phule, civil surgeon at Ratnagiri district hospital in Maharashtra. “But now in April, things have become even more serious.”
The oxygen plant at the hospital is now its final stages of installation—a result of soaring demand. “Our requirement has increased by four times,” said Phule. “So even if the plant is not enough by itself to meet our demand, something is better than nothing.”
Running on empty cylinders
While oxygen generation plants are not adequate to serve the needs of bigger hospitals with a higher number of critical patients, they could be a useful tool in the armoury in times of high demand, said doctors. This is especially the case when there is an acute shortage of commercial oxygen across the country.
Ten manufacturers and oxygen cylinder suppliers in Maharashtra, Tamil Nadu, Kerala, Andhra Pradesh, Gujarat, Punjab and Uttar Pradesh told Scroll.in that the demand was much higher in the second wave than it had been during the first wave of Covid-19 cases last year.
“Medical oxygen is in shortage,” said Sunil Gupta who runs Raigad Carbides, an oxygen manufacturing firm that has buyers in western India. Before the pandemic, Gupta’s firm would supply oxygen mostly to industries. But now the entire production was being diverted for medical use, he said.
Subasish Guha Roy of Universal Air Products said his firm, which supplies 60 metric tonne oxygen within Karnataka to cities like Bengaluru and Mysore, was running at its full capacity. “It will be difficult to meet daily needs if a high demand continues,” he said.
Even cylinder suppliers said their stocks had run out quickly. “In the last 15 days the demand was three times what it usually is,” said Chirag Vasani of Laxmi Gas Suppliers in Surat, Gujarat. Vasani has been supplying at least 200 cylinders daily within Surat. “This is only because of coronavirus,” he said.
A medical oxygen cylinder supplier in Lucknow did not respond to calls when Scroll.in contacted him on Thursday (April 15). Within a minute, he sent a text message: the cylinders were sold out.
Another supplier in Lucknow, Kaushal Katiyar, said he had lost count of the number of cylinders he had sold over the past week. “If there is a patient in every house then you can just imagine what the demand is like,” he said. “I have stopped picking calls.”