As the ongoing Covid-19 pandemic continues to threaten vulnerable communities across the globe, grave concerns have been raised over the lack of medical oxygen preparedness faced by low and middle-income countries.

Perceived by some as a sign of global inequity, the medical oxygen supply issues faced especially by developing nations over the past 18 months or so have exposed weak links not only in pre-existing stocks of medical oxygen, but also in both the domestic and international oxygen supply chain and the lack of onsite oxygen generation capability in areas that need it most. 

As part of its vision to both increase health equity and save lives across low and middle-income countries (LMICs), non-governmental organisation (NGO) Direct Relief has committed to supplying healthcare providers with funding of $5m (£3.7m) to acquire much-needed medical oxygen systems. 

The commitment adds to more than $15m (£11m) already invested by the organisation for the mitigation of global oxygen shortages, realised through schemes such as its provision of more than 35,000 oxygen concentrators for international healthcare providers. 

Funding has also been utilised to build and restore seven pressure-swing adsorption (PSA) plants that are used to generate medical-grade oxygen onsite at hospitals. In addition to medical oxygen, Direct Relief provides other medical supplies to healthcare providers across the world in the form of PPE and cold chain technology such as medical fridges and freezers.

Daniel Hovey – Director of International Emergency Response & New Initiatives at Direct Relief – spoke with gasworld in an exclusive interview, revealing the extent of the organisation’s drive to supply medical oxygen to the country’s that need it the most. 

How does the organisation deliver its medical oxygen? 

Founded in 1948 by two Estonian immigrants who had fled Nazi Germany, Direct Relief originally sought to raise support from local businesses to provide their communities in Europe with essential clothing, food, and medicine. 

Over time, the focus of the organisation shifted primarily to the provision of medicines and medical supplies. This medical focus has seen the NGO work in over 100 countries and throughout all 50 US states. 

“Direct Relief is the only nonprofit organization in the United States that has received the accreditation and licensing that allows us to act as a pharmaceutical wholesale distributor at the national level,” said Hovey. “We essentially have the same drug distribution licencing as a CVS and Walgreens, two of the big four pharmacies here in the U.S.” 

The humanitarian supply chain works through a collaboration with the pharmaceutical industry, which makes donations free of charge to Direct Relief before the NGO opens its inventory for viewing to its network of hospitals and health clinics around the world.

Hovey explained, “Our healthcare provider partners make specific requests from our medical inventories here in California or abroad and then we ship it to them free of charge, that’s our model of support during normal times and it’s then ramped up to scale in response to a health crisis like Covid-19.” 

He revealed that the origins of the NGO’s Covid-related response dates back to its epicentre in Wuhan, China. 

“…anywhere there was a Covid outbreak we saw people dying due to critical shortages in medical oxygen.”

“From the very beginning we received requests to respond in Wuhan, China, where this whole thing started. Originally we were equipping health workers with personal protective equipment, but we saw very early on that the demand for medical oxygen was spiking and far outpacing the local supply. 

“We were put in touch with a pulmonologist in Wuhan who had seen what was going on in the hospitals there and he was the first to share with us that a reliable supply of oxygen was a vital treatment to this unknown respiratory disease. This would be the unfortunate theme for the next two years, anywhere there was a Covid outbreak we saw people dying due to critical shortages in medical oxygen.” 

From that point, hospitals in Wuhan had begun to request oxygen concentrators – devices that Direct Relief had already been starting to stockpile due to the rise in wildfires in its home-state of California. This gave the NGO an opportunity to provide oxygen concentrators early in the pandemic when local supplies in the US were overwhelmed. 

The continual surge in US cases revealed a degree of inequity in communities with either poor or no medical insurance. 

Hovey revealed, ”We provided oxygen concentrators to serve those communities in need, and then it was just everywhere.” 

As an emergency response team member, Hovey would typically respond to calls for aid due to hurricanes or earthquakes which affect a specific confined area. 

“But with Covid, it was everywhere all at once. We have a 130k sqft warehouse filled essential medicines and supplies and the logistics support to ship nearly anywhere in the world, this is what we do all the time. But being able to meet the needs everywhere, including at home in the U.S, it was definitely a major challenge.” 

A 25-ton shipment of medical aid including 860 Direct Relief-purchased oxygen concentrators arrived via air charter in Kathmandu, Nepal

A 25-ton shipment of medical aid including 860 Direct Relief-purchased oxygen concentrators arrived via air charter in Kathmandu, Nepal

Source: Source: Pranjal Sharma/Direct Relief

However, supplies were not affected solely by Covid, other essential applications such as neonatal care, the management of COPD, anaesthesia, and the management of pneumonia also require medical oxygen treatment. 

With supplies dwindling further and sensing an opportunity to improve the sustainability of its medical-grade oxygen relief efforts, the organisation began to fund the construction of PSA plants – facilities that enable the production of oxygen gas onsite, usually at a hospital or other healthcare facility. 

Having contacted Leith Greenslade of the Every Breath Counts Coalition (EBCC), Direct Relief was made aware of a large network of oxygen plants in LMICs that were operating either massively under capacity or not functioning at all. 

“Oxygen plants require technical expertise to manage and maintain, if they break, and no one is properly trained on how to fix it or if spare parts aren’t available in the local market, then they will just sit there and don’t provide benefit to anyone. It’s a chronic issue, especially in low resources settings.” 

This has proven to be a chronic issue around the world, compounded by backed-up supply chains for new plants, which can take between four to eight months just to buy. To mitigate this long lead time, Direct Relief has focused on fixing existing plants by supplying new parts – which are usually delivered within a month or two – and making sure staff receive adequate training in maintenance and management. 

Cases of Covid-19’s delta variant continued to rise in Nepal last summer and the Dhulikhel Hospital in capital city Kathmandu was inundated by hospitalisations. As patients in rural areas of the Himalayan hill region were airlifted to city hospitals, doctors providing in-flight treatment were told to bring their own oxygen supply. 

Covid-19 patients being treated outside a hospital in Kathmandu, Nepal

Covid-19 patients being treated outside a hospital in Kathmandu, Nepal

In a conversation with Direct Relief in February, Dr. Aban Gautum, President of the aid organisation Mountain Heart Nepal spoke of the medical-grade oxygen shortages, saying, “It was a very challenging time for us to refill just one cylinder, we had to wait in a very long queue.” 

Upon reaching the hospital, there was no guarantee of oxygen. 

Despite Dhulikhel having a PSA plant onsite, it was operating far below capacity. The hospital needed to produce between 150 and 200 oxygen cylinders every 24 hours to supply enough medical oxygen for its 136 designated Covid-19 beds. 

Due to poor plant maintenance, the facility was only generating around 60 cylinders per day and – according to Hovey – even if it had been producing 100 per day, the demand still wouldn’t have been met. 

A collaborative effort was then initiated by the organisation. “We got in touch with another group via zoom to look at the plant from the US and were able to identify the issue and the solution to fix it. They had the plant up and running just like new. ” said Hovey.

Future preparedness 

To help identify areas encountering issues with non-functioning oxygen plants, Direct Relief in conjunction with EBCC developed a ‘find and fix’ map. The map allows users to assess the status of plants in their community, in addition to data surrounding current oxygen needs of specific areas.  

Every Breath Counts ‘find and fix’ map

Every Breath Counts ‘find and fix’ map

Source: Source: Direct Relief

The map has also reinforced the idea that a certain degree of inequity exists when it comes to medical oxygen supply. During gasworld’s Medical Gases Summit 2022, Leith Greenslade, Coordinator of EBCC and Founder and CEO of JustActions, spoke of the need to increase the equitable access to medical oxygen across the globe. 

“Studies suggested shockingly high levels of under treatment of patients needing oxygen across Africa and Asia,” she said. 

“There is no question that lack of oxygen is one of the reasons that pneumonia has been the leading infectious killer in Africa and Asia for so long.” 

According to Greenslade, all LMICs need approximately 4m2 of oxygen every day just to treat Covid patients. Africa and Asia comprise about 70% of that number. To help meet this number and also prepare for future oxygen shortages, Direct Relief is continuing to focus its efforts on installing new plants and fixing existing ones. 

Emphasising the fact that oxygen plants are essential to treat a broad spectrum of health issues, Hovey added, “This is not an issue that is new to Covid, it’s not going to go away after Covid, and it’s not just a therapy for Covid, it’s an essential medicine for any hospital or ICU.” 

“These investments are worthwhile. The project in Nepal, for example, we spent $100k on oxygen plants now treating a population of 450,000 people and it will continue to support them for 10, 15, 20 years with proper maintenance,” he said. 

Closer to home 

The ongoing Russia-Ukraine war has brought with it concerns over oxygen availability. With infrastructure either damaged or destroyed and supply chains heavily impacted, the World Health Organisation (WHO) announced in February that Ukraine was running ‘dangerously low’ on its supplies of medical oxygen. 

Shortages were compounded by a scarcity of zeolite – a key mineral used to separate gases in molecular sieves when generating oxygen through pressure-swing adsorption (PSA) systems. 

Spheres of zeolite

Spheres of zeolite

Having been cited earlier this year in Forbesgasworld’s Business Intelligence department revealed that the country’s medical oxygen demand more than doubled during the pandemic, increasing from between 140 – 150 metric tonnes per day to 350 – 380 metric tonnes per day. 

At the time, WHO and Ukrainian health authorities identified an approximate 20-25% increase over previous pre-crisis medical oxygen needs. 

Showcasing the importance of data during a crisis, Direct Relief partnered with colleagues from the Harvard School of Public Health to form a partnership called CrisisReady. The aim of the project was to carry out analysis of anonymised data collected from mobile devices – primarily through social media such as Facebook – to understand population dynamics in near real-time during crisis events. 

Following the invasion of Ukraine by Russia, the data enabled organisations such as WHO and UNICEF to observe the movement of people, allowing them to make rapid decisions on where and how much of their services and supplies are needed.

The importance of such coordinated efforts to ensure adequate medical oxygen supplies cannot be understated. Lessons must be learned from international events such as the Covid-19 pandemic and the ongoing Russia-Ukraine conflict to help mitigate future shortages.