With the news in June that Air Liquide and Linde have entered into unprecedented agreements to provide increased access to medical oxygen in low and middle-income countries, a major milestone is achieved both in the fight against Covid-19 (coronavirus) and in the gases industry.

The agreements came after months intense engagement with the world’s major oxygen suppliers by the Covid-19 Oxygen Emergency Taskforce. A breakthrough in the provision of medical oxygen to low and middle-income countries (LMICs), it is a development of key significance lauded by the international community and yet still with only two signatories from the industry’s major players in oxygen production and supply.

Here on the eve of the upcoming Medical Issue of gasworld magazine, we explore why it’s considered such a breakthrough and perhaps therefore, why a wider collaborative effort could be so important – not just through what we hope is the tail-end of this pandemic, but in a world beyond Covid-19.

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A basic pre-requisite

“Think of it this way: how would we have been able to even agree on a Covid-19 vaccine, let alone develop and distribute it without sitting down with pharmaceutical companies like Pfizer and others?”

That’s how Leith Greenslade, Founder and CEO of JustActions and Coordinator of the Every Breath Counts Coalition, put the significance of the new agreements into context.

“A basic pre-requisite during a pandemic is that you have an ongoing dialogue with industry on one of the main solutions for reducing deaths,” she adds. And yet, it seems there was no such conversation when it came to oxygen. This alone underscores the sheer significance of the work of the taskforce and the agreements now in place.

Greenslade continues, “We’ve had that dialogue with vaccines, we’ve had that with diagnostic tests and other kinds of medicines like steroids, but we have not had a partnership with industry on oxygen – there just wasn’t one prior to Covid, or for the first year of Covid. This is the first tangible example of a direct partnership with the oxygen industry, for what the WHO now calls the most essential medicine to treat Covid-19 – oxygen.”

“It’s appalling when you put it that way,” she adds, “that we went into this pandemic, without any kind of partnerships for the essential medicine to treat Covid patients – oxygen. Now we have that, at least with two of the big giants in oxygen, and it’s great that we have those two players, but we really need active engagement and agreements with all of the leading oxygen providers in liquid, PSA plants and concentrators.”

A PSA perspective

On that note, let’s turn to PSA (pressure swing adsorption) plants – these systems utilise commonly available components that can greatly reduce the initial capital required compared to the cryogenic production of oxygen, and offer the kind of mobility that address the varying requirements of the hospital and healthcare sector.

Their rise in the medical market has been facilitated by ‘monographs’ that deem the use of oxygen in the range of 90-96% purity acceptable, and the spotlight was arguably shone on this means of oxygen production during the pandemic.

Read more: An opportunity for onsite oxygen generation

Novair was among the very first companies to introduce the oxygen generator as a source of medical oxygen supply to hospitals in Europe in 1994. It is also one of the few companies in the world to manufacture high pressure oxygen boosters which can fill oxygen cylinders up to 200 bar with oxygen produced by generators. Founder and President Bernard Zenou is also Chairman of MEDIGHAM, an association of onsite oxygen generator manufacturers, and gasworld asked him, why are recent oxygen agreements such a breakthrough?

“The agreement between the major gas companies and the main LMIC relief foundations shows the awareness of the responsibility of these companies in oxygen supply disruptions,” he responded.

“In heavily populated countries such as India and Brazil, which experienced the devastating effects of Covid-19 due to oxygen shortages, it has been reported that the pandemic was more the result of a failure in logistics than a lack of oxygen. In other words, oxygen was available but not where the hospitals needed it most.”

“This situation demonstrated the need to give autonomy in medical oxygen to hospitals thanks to PSA oxygen generators, the only solution to avoid the constraints of transport logistics. This is the reason why the New Delhi High Court has planned to make it mandatory for all hospitals above 100 beds to install a PSA oxygen generator.”

Zenou was referencing the news on 20th May (2021), that the Delhi High Court had asked all big hospitals in the Indian capital with 100 or more beds to install PSA oxygen plants as a measure of preventing the dependence on outside sources of oxygen supply. It also stated that those PSA plants should have a capacity of at least double their normal requirement.

“It is important that in the programme to support and reorganise the medical oxygen supply chain, the PSA solution should be properly considered. As an association of onsite oxygen generator manufacturers, MEDIGHAM would be willing to assist in the development of this programme.”

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Beyond Covid-19

To further grasp the significance of these new oxygen agreements is to better understand their origin and indeed their potential future impact. In many ways it’s a case of back to the future in medical oxygen access. This is as much about a world beyond Covid-19 as it is fighting the pandemic.

gasworld understands the foundations of the agreements goes back to 2012/13, when the Access to Oxygen initiative was about getting oxygen into LMICs where it simply wasn’t widely available and preventable deaths due to pneumonia, for example, were all too common. Air Liquide was at the forefront of this effort, from an industrial gas point of view.

Greenslade explains, “It’s been a long, long process. I’ve been working on Access to Oxygen since 2012/13, well before the pandemic when we identified this (access to oxygen) as a risk in low and middle-income countries (LMICs). Mainly we’re talking Africa, Asia and Latin America – so the global south – where we already had many hospitals without any kind of oxygen, liquid or plants or concentrators. Largely the oxygen-related deaths in those regions were among children – kids that we’re not getting access to oxygen, children with pneumonia for example.”

“We were working on it and that’s when I first reached out, years ago, to Air Liquide. I’d built a coalition, the Every Breath Counts coalition, and we were starting to talk to industry. And they’ve always been great. They’ve always been at the table, talking. But I think prior to Covid, there was no obvious way to engage companies – because governments weren’t funding oxygen, global health agencies weren’t funding it, and it was almost like industry didn’t have a partner on the other side of the table.”

Read more: Reflections on a new era in medical oxygen

In many respects, the rest is history, though nonetheless frustrating that it took so many years and a global pandemic for oxygen to be recognised in the public health architecture. When Covid-19 hit and the taskforce recognised access to oxygen was going to take on a whole new, even more pressing significance, it pushed hard and unrelenting in its pursuit of collaboration.

Access to oxygen agreements for LMICs are clearly a breakthrough for the remainder of this pandemic, the ‘big vision’ here is to create a lasting pathway of access to medical oxygen. Pneumonia will still be here long after Covid-19; the original reasons for Access to Oxygen back in 2012 will still be there a decade later, in 2022 and beyond. This is about a world beyond Covid.

Read more: Oxygen now part of public health infrastructure

Unitaid, a leader in the taskforce, alluded to this vision and the opportunity to ‘change the course of history’ at the time of the announcement in June. Dr. Philippe Duneton, Executive Director, said, “We welcome the engagement from Air Liquide and Linde. This is the first time such an agreement has been made to help facilitate equitable access to oxygen, an essential, lifesaving medicine. We hope that other oxygen suppliers will now follow suit and come to the table.”

“There is a real opportunity to change the course of history – both for the Covid-19 pandemic, and for other areas where medical oxygen is so vital but has been often lacking, including pneumonia control, treating women who develop complications in childbirth and trauma patients.”