The Covid-19 pandemic was a preventable disaster with weak links at every point in the chain of preparedness and response.
That was the summary of findings from a report from the Independent Panel for Pandemic Preparedness and Response, titled Covid-19: Make it the last pandemic. The report concluded that the alert system was too slow, the World Health Organization (WHO) was underpowered, and global political leadership was absent.
According to an article published by the BMJ on 13th May 202193, the 13-member panel spent eight months reviewing the evidence on the spread, actions, and responses to the pandemic, culminating in the report commissioned by the WHO Director General in May 2020. It described Covid-19 as a terrible wake-up call and “the 21st Century’s Chernobyl moment.” Further still, it damningly says that the system, as it stands now, is unfit to prevent another novel and highly infectious pathogen, which could emerge at any time, from developing into a pandemic.
The question is, was our oxygen preparedness one of the key weak links in that response?
Medical oxygen shortages around the world have been a tragic feature of the pandemic, seen in both the advanced and emerging economies, but undoubtedly 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 on 29th June 2021, 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 (LMICs) need two million oxygen cylinders (14.2 million cubic metres) per day at present. These are needs that are simply not being met, still, well over one year into the pandemic.
Leith Greenslade, Founder and CEO of JustActions and Coordinator of the Every Breath Counts Coalition, has been vocal in her belief that we were woefully unprepared to deal with the Covid-19 pandemic. Further still, she believes 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 vaccines, tests and treatments like oxygen ‘from the get-go’.
The Every Breath Counts Coalition is an instrumental part of the Covid-19 Oxygen Emergency Taskforce – a group of partners led by Unitaid and Wellcome under the ACT-Accelerator Therapeutics pillar – that announced unprecedented medical oxygen agreements with Air Liquide and Linde, respectively, on 15th June (2021). The coalition has been striving to coordinate greater access to oxygen in LMICs as far back as 2013 and had identified a lack of access to medical oxygen – liquid, plants, and concentrators – as a significant risk to life in the global south and the cause of a large number of deaths especially among children with severe pneumonia.
When the Covid-19 pandemic hit, this risk was escalated to tragedy across almost all age groups 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,” she told gasworld in an exclusive interview94.
“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.
Affirming how unprepared we were, she explained, “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 just 3% vaccine coverage. 97% of Africa is not vaccinated, and they don’t have oxygen either.”
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 and 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,” she said.
“If we’d had that data and if there had been plans in place, we could have moved much more quickly.”
There has been a widespread view conveyed by those in the industry that the supply chain was unprepared for such demand, noted across many interviews with gasworld since March 2020. Wherever that sense of unpreparedness lies, the common acceptance is that industry and governments globally have been scrambling to assemble the extreme levels of oxygen and related equipment required. Let’s look at a handful of randomly selected examples.
In May 2020, AirSep Corporation, a keen proponent of onsite generators, was asked by gasworld if this unwanted crisis had shone a light on the role of oxygen generators in the medical sector. Lawrence J. Hughes, Vice-President and General Manager, responded, “Yes, definitely…Initially there was a lot of emphasis placed on ventilators at the beginning of the crisis, but globally we are seeing clinicians and relief workers raising awareness about the need for adequate oxygen supplies for the communities that have been hit hard with the virus.”
“We have seen a global increase in demand for stationary oxygen concentrators, liquid oxygen storage vessels and medical oxygen generators from customers, and particularly those providing emergency aid in pandemic hot zones.” 95
Fellow PSA systems manufacturer INMATEC shared this sentiment in an August 2021 interview with gasworld. Dr. Peter Biedenkopf, General Manager of INMATEC, said, “Yes. The rising demand for oxygen led to a shortage of liquid oxygen in numerous countries due to limited logistics. Hospitals around the world have realised that it is key that oxygen supplies will have to be designed redundantly in the future in order to secure patient care.”
“In regions where LOX (liquid oxygen) med is not available at all or only at high costs, pure PSA supplies comprising a redundant design with two systems and an additional storage tank will be the future technology.” 96
Nippon Gases Europe is a more traditional supplier of bulk liquid oxygen and was among those on the frontline of meeting mammoth oxygen demand in Europe during the height of the pandemic last year. Asked what lessons we have learned in the medical oxygen supply chain, Pasquale Di Chio, European Leader for Healthcare & Homecare at Nippon Gases Europe, told gasworld in an August 2021 interview, “We understood how important is everyone’s commitment to managing a crisis and how essential it is to work flexibly, with team spirit, in compliance with safety rules and with great confidence in one’s own means.”
“Hospitals have also understood the importance of the oxygen supply chain and the need to maintain the medical gas piping systems. I think in the future each hospital will define an emergency management plan with the suppliers and make the appropriate maintenance or improvements to the medical gas piping systems.”
“Hospitals were able to understand how important strategic stocks are and how easily the supplies of oxygen can increase: it was an important weapon in responding to the pandemic, but not all hospitals were prepared for such an attack, so a lesson to be learned is the need for prevention, the need to have state-of-the-art oxygen storage and distribution facilities, and the knowledge that together with collaboration between supplier and demander we can win.”
“The importance of oxygen in hospitals will grow,” he added. “For a long time there has been talk of using self-producing oxygen in hospitals, but now it has been found that delivery solutions such as liquid oxygen are more efficient, reliable and safer in terms of flexibility and quality – especially when it is necessary to increase the quantity and having a high quality drug to fight respiratory diseases such as Covid-19. High flow oxygen therapy has proved very useful for Covid patients in hospitals and will play an increasingly important role not only in hospitals but also in homecare.” 97
This is just a straw poll of tens of interviews that gasworld has published since the pandemic began, but clearly supports the argument that the oxygen supply chain was unprepared for such a scenario as unfolded. So what of the wider oxygen infrastructure? It was seen in Europe at the height of the pandemic in spring-summer 2020 that hospitals were struggling to cope with the flow rates of oxygen required, even when that oxygen was available and delivered, as referenced by Di Chio above.
This is a lesson learned that has recently been in the news, though it could easily have gone largely unnoticed. gasworld reported only in July 2021 how an investigation has been completed by the Healthcare Safety Investigation Branch into the provision of piped oxygen gas supplies to UK hospitals, concluding that improvements could be made to existing infrastructure in order to ensure that hospitals meet oxygen flow needs98.
The report, titled Oxygen issues during the Covid-19 pandemic, endeavoured to investigate limitations in piped oxygen supply to hospitals and explore the role of engineering specialists and medical gases committees in piped oxygen supply. The investigation explored a reference event where a major incident was declared by an acute hospital trust (Trust) when oxygen supply demands, delivered via its medical gas pipeline system (MGPS), led to patients being diverted to different hospitals, elective (planned, non-emergency) surgery being cancelled, and a need to reconfigure ward environments.
Further to this, the report states that the Trust began identifying mitigating measures that would allow it to carry out a test on the MGPS in the High Dependency Unit (HDU). It also states that the Trust carried out a pressure test on the MGPS to identify failures, with the results identifying several areas where there was a reduced ability to provide the anticipated flow of oxygen from the MGPS.
Despite the Trust understanding that the HDU should have been capable of providing a specified flow of oxygen to a certain number of patients, the report discovered that the anticipated flow of oxygen to the HDU, and other wards, was impacted by an influx in earlier oxygen demand from the MGPS system before the pipeline reaching the HDU. It was found that the Trust had spare capacity to generate oxygen as the overall demand on the MGPS never exceeded more than 56% of its total capacity. Therefore, the investigation concluded, the limitations in the Trust’s existing pipework infrastructure contributed to the lack of oxygen flow available to the HDU.
Other contributing factors included the distribution of patients across the hospital, and the types of oxygen therapy required to treat patients across the hospital.
From the investigation, the report suggests several solutions that could be examined in order to prevent future oxygen shortages from occurring when needed most. One of the key findings was the lack of investment into the MGPS itself, with one safety observation suggesting it ‘may be beneficial if medical gas pipeline systems were prioritised for financial investment and ongoing management where they may not be effective for future anticipated clinical needs.’
It was also suggested that key technical documents should be updated to reflect recent developments in healthcare. The report noted that the last update to the MGPS health technical memorandum was 2006.
Dr. Stephen Drage, Director of Investigations at HSIB, said, “Our investigation highlighted just how critical the MGPS is and that if it fails the impact is significant.”
“Any uneven demand in the pipework could mean that a concentration of oxygen in one area – for example to Covid-19 patients – could lead to a reduction elsewhere. Patient wellbeing can be at further risk as may have to make tough decisions about prioritisation of care to ensure that sufficient oxygen is distributed across the hospital.”
“We recognise the speed at which the NHS had to adapt to this unprecedented demand.”
Expecting the unexpected?
For a balanced discussion on the preparedness of oxygen supply chains, one has to question how feasible it is to expect the unexpected – and be able to respond to it under such pressure.
As this author wrote in a column back in May 202199, there are several factors of industrial gas economics at play when considering oxygen preparedness, not to mention the practicalities related to those, all of which are underpinned in this instance by a huge sense of unpredictability.
In any story of shortage there is of course always a question of supply and demand. The impact of Covid has pushed us to the brink (and beyond) of demand for oxygen, ventilators, ICU beds to name a few fundamentals, and all of the necessary infrastructure and supply around those. This has all been seen on a scale not witnessing for almost a century. Supply chains were simply not designed for this; how could they be?
When it comes to the oxygen supply chain more specifically, generally speaking it’s not for the lack of production capacity. We’re so often going to come back to the same fundamental: cylinders and delivery. In the majority of hospitals the world over, oxygen supply is dependent on the use and supply of cylinders. This is particularly true of makeshift field hospitals and even overspill wards at dedicated healthcare facilities.
Even in well-developed, advanced economies, where bulk oxygen is supplied direct to the facility’s pipeline systems, that same hospital infrastructure is often unable to cope with ramped up off-takes from bulk cryogenic supply. It simply wasn’t designed to cope with such demand/scenarios, as discussed earlier.
In instances where bulk supply hasn’t been as readily available and is shipped in – whether by road, rail or river – it is still often a question of getting that extra bulk supply into cylinders. And therein could lie other complexities, some also Covid-induced. Are there enough cylinders in local circulation? Are there pinch points in the logistics of delivery or cycling of cylinders, with various aspects of infrastructure disruption as Covid hits workforces across transport and industry? Are empty cylinders flowing back effectively from hospitals or crisis centres, ready to be turned around and refilled?
The argument that it is not simply the production capacity of oxygen but the preparedness of the entire distribution and value chain that requires questioning, was made by former industrial gas professional and now consultant, Stephen B Harrison, Managing Director of sbh4 consulting. With over 30 years’ experience of the global industrial and specialty gases business, Harrison was a panellist on gasworld TV’s 23rd April webinar, Covid-19 & Medical Gases: Lessons Learned One Year On.
The webinar was held on the same day that gasworld reported India was turning to the international industrial gas community for urgent help to meet its oxygen needs. Whilst India was naturally an area of focus as a result, Harrison focused his discussions on Europe and how the continent has been dealing with the pandemic, just over one year on.
“The fortunate thing here in Europe is that we overcame the shock of the challenge last year,” he said. “That was really when we had to put all of the infrastructure into place to increase the amount of oxygen that we can supply to hospitals. And I think it reminded us that the industrial gas sector is a gas distribution business as well as a gas production business.”
“Furthermore, it also reminded us that the molecules and what we do is only one link in the chain, which is also absolutely essential. From molecule production through to liquid storage cylinders, through to the patient, we have to look at all of those links in the chain and any one of those could be a bottleneck. Maybe we can’t make enough molecules, maybe we don’t have enough storage tanks to put the molecules into, or maybe the gas pipelines inside the hospitals themselves need to be of a high capacity.”
“Working through all of those challenges and fixing them is really what we were doing in the first six months of last year. The oxygen availability, to be honest, is the least of those problems here, and we need to reflect that.”
“Europe is an extremely industrialised part of the world and the amount of oxygen that’s produced for use on refineries or steel making or other heavy industrial applications is tremendously large, and the amount of oxygen that is routed into medical applications in comparison to that is quite small.”
“So even if the oxygen demand for hospitals rises by a lot, as it has done, [it is] only eating into that overall oxygen availability here in Europe. For other parts of the world that are not quite so industrialised, a doubling in the oxygen demand in some countries means literally a doubling of the national oxygen demand. So in Europe for many, many reasons, we’ve been a very good place, much better placed than a lot of other parts of the world.” 100
It’s a complex supply chain, with multiple potential intersections for bottlenecks during a societal and industrial crisis, as has been demonstrated in even the most advanced and industrialised of economies, as Harrison alluded to.
Even the realm of PSA and VPSA systems, as well as oxygen concentrators, while proven promising during this pandemic in particular, is not without its own important considerations – not least, those lead times for orders and factors of physical sizing to be taken into account for containerised or skid-mounted units. This is another challenge in unpredictability.
We have to remember that this was a pandemic like no other for over a century. This was a point made by Martin Litvik, Commercial Director at Czech Republic-based Cylinders Holding a.s. in an interview with gasworld in April 2020. At that time, Cylinders Holding was one of only a handful of companies manufacturing medical oxygen cylinders in Europe during the Covid-19 crisis and Litvik said, “Quite frankly, we have never seen such a high requirement and demand for oxygen cylinders. The demand is somewhere between 30-40 times more than usual. Oxygen is more than ever absolutely essential to any patient diagnosed with the Covid-19.” 101
This might seem like a very obvious point, but the scale of at least a 30-fold increase in oxygen cylinder demand is huge. In pure numbers, this translates to around 35,000 finished medical cylinders for the month of April, compared to around 1,000-1,500 medical cylinders on a ‘normal’ monthly basis.
Asked if the company saw any lessons learned from the crisis, even in those early days of the pandemic in April 2020, Litvik said, “It’s a very difficult question as, in the modern age or era, we don’t have enough experience with pandemics/disasters on a scale of this. I think it is quite essential to remember that we need to be prepared more than ever to be able to accept any changes. Quite literally anything and everything is possible now.”
“Companies need to be structured in a way that they will be more flexible, effective and easily adaptable in order to react to any challenges.”
It could be argued that the oxygen industry was let down by a lack of recognition of the gas’ importance as a medical treatment by governments and leaders the world over.
Indeed, Litvik said the biggest lessons are arguably to be learned at a political level and in the preparedness for such circumstances in his April 2020 interview. “We can say it is an unprecedented situation, but again right now we have a chance to get ready. States, governments should invest and create a state material reserve of medical cylinders in case of a disaster or emergency.”
“They say ‘If you want peace, prepare for war’. Oxygen cylinders have proven fundamental in the treatment of Covid-19. As we know, even the Prime Minister of the UK, Boris Johnson, said ‘they saved my life’. He was given oxygen treatment, so it speaks for itself.”
“We have to invest into a retail structure so that anyone can buy the cylinder with oxygen.”
If this is a common thread of the conversation, as it seems to be, could we question then whether health leaders and political leaders had a ‘blind spot’ when it came to oxygen supply, as Greenslade had described?
Litvik observed in April 2020 that even though the pandemic had hit some regions and supply chains, ‘right now we have a chance to get ready’. And yet, we were still not ready with either oxygen product or the cylinders to transport it in for second and third waves of the virus, in various parts of the world, as has been proven in Africa, Brazil and India for example. So could it also be levelled that the industry was compromised by the relative inaction and/or sluggishness of those governments or leaders in how they have responded to Covid-19?
As alluded to earlier in this chapter, when we opened with the findings of the WHO-commissioned report into the pandemic, it has been suggested that the pandemic was a preventable disaster with weak links at every point in the chain of preparedness and response. The report – titled Covid-19: Make it the last pandemic – from the Independent Panel for Pandemic Preparedness and Response says that clinicians in Wuhan, China, were quick to spot unusual clusters of pneumonia of unknown origin in late December 2019. But the formal notification and emergency declaration procedures under international health regulations were too slow and time was lost. WHO should have declared a global emergency a week earlier than it did on 30th January, the panel found.
Too many countries then took a ‘wait and see’ approach and as a result February 2020 was a ‘lost month’ when steps could and should have been taken to contain the spread of SARS-CoV-2. Only a minority of countries set in motion comprehensive and coordinated measures that managed to contain and stop the spread of the virus. Many countries only started to act when hospitals began to be overwhelmed. Countries with the poorest results had uncoordinated approaches that devalued science and denied the potential impact of the pandemic102.
That appears a damning conclusion from a report specifically commissioned to examine the global response to Covid-19. Further still, Panel co-chair Ellen Johnson Sirleaf, former president of Liberia, reportedly added, “The shelves of storage rooms in the UN and national capitals are full of reports and reviews of previous health crises. Had their warnings been heeded, we would have avoided the catastrophe we face today. This time must be different.”
The report makes several recommendations to halt the current spread of Covid-19 and to prevent a future outbreak from becoming a pandemic. Among them, particularly of interest where oxygen supply chain preparedness is concerned, is the recommendation that the G7 group of international leaders should immediately commit to provide 60% of the $19bn (£14bn; €16bn) needed for the Access to Covid-19 Tools Accelerator in 2021 for vaccines, diagnostics, therapeutics, and strengthening of health systems.
The oxygen roundtable
It is clearly evidenced then, that the oxygen supply chain was unprepared for the Covid-19 pandemic. It seems that it can be argued that all sides of the oxygen roundtable were unprepared.
If this was to an extent foreseen by the Every Breath Counts Coalition and oxygen taskforce, who had for years prior to Covid been campaigning for greater access to oxygen in LMICs, as we have heard, then doesn’t that bring into question why there was not in fact an oxygen roundtable to speak of at all?
Is that the biggest question here, both now in the continuing midst of the pandemic but also in terms of the lessons to take forward?
“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?” said Greenslade in another interview with gasworld, reflecting on the significance of recent breakthrough oxygen agreements with Air Liquide and Linde, respectively103.
“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. 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 added, “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.”
The question remains, even at the time of writing this report, why are there still only two ‘big giants’ in oxygen round that table and committed to those partnerships. Are there market competition issues, regional dynamics or perhaps even inherent reluctances/misconceptions to be overcome to faciltate a truly joined-up, global oxygen emergency response? If oxygen is a pre-requisite, an essential medicine as has been so painfully demonstrated, then evidently greater preparedness is a fundamental.
|93||BMJ 2021;373:n1234, published 13 May 2021. (https://www.bmj.com/content/373/bmj.n1234)|
https://www.gasworld.com/covid-19-and-medical-gases-lessons-learned-one-year-on/2020806.article / https://gasworld.tv/covid-19-medical-gases-lessons-learned-one-year-on/
BMJ 2021;373:n1234, published 13 May 2021. (https://www.bmj.com/content/373/bmj.n1234)