We were woefully unprepared to deal with the Covid-19 pandemic, and the oxygen industry now needs to accept that it’s part of the public health architecture of the world, says Leith Greenslade of the Every Breath Counts Coalition.

Further still, the Covid-19 pandemic response was handicapped by a predominant focus on vaccines at a time when there needed to be an equal focus on vaccine tests and oxygen ‘from the get-go’.

That verdict came after groundbreaking new agreements were announced earlier this month that see both Air Liquide and Linde plc commit to providing greater access to medical oxygen in low and middle-income countries (LMICs).

Medical oxygen shortages around the world have been a tragic feature of the pandemic, impacting the poorest countries disproportionately. These access difficulties were entrenched in many parts of the world before Covid-19, and have been exacerbated by the pandemic, putting strain on fragile health systems and resulting in preventable deaths.

Estimates from PATH, a global non-profit organisation for improving public health, suggest that around one million critically-ill Covid-19 patients in low and middle-income countries need two million oxygen cylinders (14.2 million cubic metres) per day at present.


Source: Exposure Visuals / Shutterstock

On 15th June, Unitaid and the Clinton Health Access Initiative (CHAI) revealed that unprecedented medical oxygen agreements had been reached with Air Liquide and Linde, respectively. These agreements – non-binding and non-exclusive Memoranda of Understanding (MoU) – came after months of intense engagement with the world’s major oxygen suppliers by the Covid-19 Oxygen Emergency Taskforce, a group of partners led by Unitaid and Wellcome under the ACT-Accelerator Therapeutics pillar.

The taskforce also includes the WHO and the biomedical consortium it coordinates, as well as Unicef, The Global Fund, the World Bank, UNOPS, the Every Breath Counts Coalition, CHAI, PATH, Save the Children, The Bill & Melinda Gates Foundation, and the Access to Medicine Foundation.

Read more: Pioneering oxygen agreements: What do they constitute?

A key proponent in the taskforce, even prior to the emergence of Covid-19, is the Every Breath Counts Coalition – the first public-private partnership to support governments in LMICs to reduce pneumonia deaths by 2030.

Coalition members had been striving to coordinate greater access to oxygen in LMICs as far back as 2013 and had identified this as a risk to life in the global south, where there were already many hospitals without any kind of oxygen – liquid, plants or concentrators – and a large number of fatalities in those regions were in children (with pneumonia for example) that were simply not getting access to oxygen.

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When the Covid-19 pandemic hit, this risk was escalated to tragedy and pulled the question of oxygen supply sharply into focus.

“We knew this was going to be a nightmare [with oxygen]. We just knew and we were watching,” says Leith Greenslade, Founder and CEO of JustActions and Coordinator of the Every Breath Counts Coalition.

“We watched as international agencies all mobilised around the subject of vaccine. It was clearly critical: we needed a vaccine and they put so much effort into that. And we thought well that’s good, but what about oxygen?”

“If you don’t put the same amount of effort into oxygen and you have countries waiting for vaccines for a long time, this is a recipe for mass fatalities – and that is tragically how it’s played out.”

Greenslade believes global health leaders and political leaders alike had a ‘blind spot’ when it came to oxygen supply and likens their response to the pandemic as a vaccine-focused ‘one-legged stool’.

As if the casualties and statistics of the last 15 months were not enough, this approach is now under the spotlight yet again with ‘concerning surges’ of Covid-19 reported in several countries across Africa, Latin America and South-East Asia.

“We needed an equal focus on vaccines, diagnostic tests and treatments from the get-go, equal money going into each, equal partnerships with industry – and we didn’t have that…”

Affirming how unprepared we were, she explains, “It’s not just industry’s fault, the global health leaders and political leaders that were underwriting the global Covid response had a blind spot when it came to oxygen. I don’t think they knew that it wasn’t available in hospitals in Africa, Asia and Latin America. I think they just took it for granted.”

“The global community has been extremely vaccine-focused and we’ve been critical of that. I’ve said publicly that during a pandemic you never put all of your eggs into one basket, ever, because these pandemic beasts are unpredictable – you don’t quite know what you’re dealing with or which way it can turn. You need to be active on prevention, diagnosis and treatment equally.”

“We needed an equal focus on vaccines, diagnostic tests and treatments from the get-go, equal money going into each, equal partnerships with industry – and we didn’t have that. We had a kind of one-legged stool, which was vaccine-focused, and they’re now just realising the error of their ways as Africa is dealing with a third wave and has a 3% vaccine coverage rate. 97% of Africa is not vaccinated, and they don’t have oxygen either.”

Oxygen – part of the public health architecture

There is good reason to believe a blind spot did exist where oxygen supply was concerned.

We were all familiar with high-profile headlines over oxygen supply in both Europe and the US 12 months ago, when both regions were the epicentres of the pandemic. Established hospital infrastructure seemed unprepared for the sheer volumes it was required to deal with at the height of the pandemic, while new field hospitals demanded significant additional supply and the onus was also on ramping up medical oxygen cylinders and the gas to fill them.

In the last 12 months, scenes of oxygen crises have also been seen in Peru and Brazil in South America, as well as in India and Nepal in recent months in particular – when the world mobilised to get oxygen into the country by road, rail, river and air.

But Greenslade also points to the simple lack of data underlining this sense of a blind spot.

“The lack of data on oxygen is the fault of the global health leaders, the WHO, UNICEF for example – none of them had good oxygen data. The first six months of the pandemic were spent scrambling to get the data on what countries did and didn’t have in terms of oxygen access in their hospitals.”

“If we’d had that data and if there had been plans in place, we could have moved much more quickly.”

She believes Covid-19 has changed the role of the oxygen industry forever – an industry that now needs to accept and embrace its position in the world’s public health architecture.

Explaining that players in the industry likely didn’t consider themselves ‘public health actors’ before, she adds, “Maybe prior to Covid, they really weren’t. Covid has changed the role of the industry forever. You are now, just like pharma companies. The oxygen industry is part of the public health landscape now and will be forever.”

“I think that means you’re going to need different kinds of leaders, and different kinds of associations. You need to get public health expertise inside the organisations, just as pharma had to do 10 years ago and before. It was the HIV/AIDS pandemic that really brought pharma into a public health framework and transformed the way they operate.”

“I think the oxygen industry now needs to accept that it’s part of the public health architecture of the world, and that the medical gas business is going to be a much bigger part of the industry moving forward – and that’s a good thing for everyone.”

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Every breath counts

For Greenslade, every breath counts really is a mission statement as much as a coalition name. She explains with great passion that there is a long-term vision to the coalition, the oxygen taskforce and the new breakthrough agreements that it has fought so hard to secure.

That vision is to create a lasting pathway of access to medical oxygen for all, not just in response to the current Covid-19 pandemic, but in anticipation of future pandemics and diseases.

“At the moment, a lot of hospitals in poor countries are being asked to make do with little (oxygen) concentrators that were designed largely for the homecare market in rich countries, or maybe they get a PSA plant at best. What we’re trying to do here is hook-up hospitals all across the global south with liquid oxygen, of the same standard as you would get in a hospital in a rich country,” she affirms.

“We’re talking about a 10-year minimum agenda, to pipe liquid into hospitals – certainly in the major cities and towns – of Africa, Asia and Latin America.”

“So when the next respiratory pandemic comes, we’re ready with oxygen. Scientists are telling us Covid-19 won’t be the first respiratory pandemic and maybe not even the worst.”

“This is a long-term agenda where we want to keep the public financing available for as long as it takes to get this done, so that hospitals aren’t high and dry again when the next oxygen surge comes.”

“This is a long-term business proposition for the industry; if they can serve these markets in the long-term, there’s business growth here…” 

“Some people still say, ‘oh liquid oxygen, forget about it, you can’t do that in Africa – it’s just not possible’. We don’t agree with that, we absolutely agree that the liquid medical oxygen market should be a growth market for industry in emerging markets for at least the next decade.’

Herein lies the final key point. Greenslade is as pragmatic as she is impassioned, and keenly points out that for the gases industry, there is a cold, hard business case here as much as an exercise in global benevolence. 

“Every Breath Counts is a public-private partnership – and industry is equal in that. It has equal seats at our table and the coalition is set up that way. We’re very appreciative and understand the role of industry, we’re not the kind of group that screams at those players. We want to work with them.”

“This is a long-term business proposition for the industry; if they can serve these markets in the long-term, there’s business growth here. And there’s also public money on the table now too, the money that can finance that expansion. It makes no business sense not to sit down with us.”