Across the previous eight parts of this series, we have explored the various constructs at play in the global response to the outbreak of Covid-19 and as it developed into a true pandemic, the dire shortages of medical oxygen that have been witnessed around the world – in advanced and developing economies alike.

The consensus across the series is that we were clearly unprepared to deal with the pandemic; a WHO-commissioned report has decisively concluded as much. We were also lacking in oxygen supply chain preparedness, for a variety of reasons; not only is there visible and tragic evidence to support this, there are informed comments on record to suggest that too. 

All of which begs the question, if we were woefully unprepared for this pandemic, how pandemic-prepared will we be going forward? 

Healthcare and political preparedness

All things considered and appropriately balanced, it is of course hard to make any judgements or predictions about our future pandemic preparedness. As alluded to earlier in this series, when we examined the findings of that report commissioned by the World Health Organization (WHO), it was starkly concluded that the pandemic was ‘a preventable disaster with weak links at every point in the chain of preparedness and response’. 

It was also very pertinently pointed out that the WHO should have declared a global emergency a week earlier than it did on 30th January, that too many countries then took a ‘wait and see’ approach, and how there was already a catalogue of learnings from previous disasters and epidemics that seemed to go unheeded. Indeed, Panel co-chair Ellen Johnson Sirleaf, former president of Liberia, said of the learnings, “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.” 115 

Fellow Panel co-chair Helen Clark, the former prime minister of New Zealand, added, “The tools are available to put an end to the severe illnesses, deaths, and socioeconomic damage caused by Covid-19. Leaders have no choice but to act and stop this happening again.” 

Perhaps with such conclusions and such robust messaging, we will be wiser to the warning signs now. 

Will a less divided and terse political climate also pave the way for a less distracted and more cohesive pandemic response? The report – titled Covid-19: Make it the last pandemic – was clear in its findings that 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 pandemic116

With all of this in mind, how do we move forward? 

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, it recommends that: 

  • A Global Health Threats Council should be created with the power to hold countries accountable 
  • A global disease surveillance system should be established with the authority to publish information without the approval of countries concerned 
  • The independence, authority, and financing of WHO should be strengthened, including increasing member state fees 
  • All national governments should update their preparedness plans against targets to be set by WHO. 

If all such recommendations were taken on board, then perhaps we would go some way to ensuring we are better prepared in future. 

Also among the recommendations, as we explored in a previous part of this series and of particular interest where oxygen supply chain preparedness is concerned, is the suggestion 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. 

Perhaps we will move forward, then, without a so-called ‘one-legged stool’ of defence built around vaccines alone? 


Oxygen: Now part of the public health architecture 

Amidst the lessons learned from the Covid-19 pandemic and the chronic oxygen shortages witnessed, Leith Greenslade – Founder and CEO of JustActions and Coordinator of the Every Breath Counts Coalition – believes a core outcome is the oxygen industry’s role in the public health architecture moving forward. 

The clear observation is that there had not previously been enough recognition either from the industry or global health leaders that oxygen is part of this global public health architecture. 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 healthcare systems the world over. 

Explaining that players in the industry likely didn’t consider themselves ‘public health actors’ before, she added, “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 industry associations. You need to get public health expertise inside the companies, 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.” 117 

Kevin Lynch, Senior Vice-President of Industrial Gases at Anova, also believes the expertise in oxygen and related technologies resides in the industrial gases business, and that it has to be more of a partner with healthcare systems in the future. That does not mean oxygen supply alone; it encompasses the whole infrastructure of tanks, cylinders and asset management technologies too.

Lynch was a panellist on gasworld TV’s webinar titled Covid-19 & Medical Gases: Lessons Learned One Year On on 23rd April. He reflected on the Covid-19 crisis and the lessons learned one year on from an Anova perspective, with advanced monitoring solutions the focus of discussion. 

He explained, “What we [Anova] were able to do for some of our customers and partners during the Covid era was provide them with advanced monitoring systems that we provide to monitor not just what’s happening inside an oxygen tank, but what’s the loading on the vaporizer and even what is the flow that the hospital itself can take into its own piping network to get the oxygen to the different wards where it needs to go.”  

“With that, our customers were able to use real time information related to tank levels and oxygen flow rates to manage the hospital loading in partnership with the hospital staff and, in some cases in partnership with the medical authorities and the local or the county where they work.” 118

Explaining how such technology can advance operations, Lynch explained that it provides hospitals and other facilities with the heads-up they need if they’re going to run out of oxygen, or for any other reason. “I think has been remarkable and has really committed to saving lives,” he enthused. “It’s almost hard to believe, but in the early days, there were quite a few hospitals that did not have remote monitors on their on their medical oxygen tanks. With that, it caused a spike in demand in different localities at different times.” 

“There were also quite a few and have an ongoing there have been temporary hospital solutions, pop-up hospital supplemental oxygen systems, and in most cases, if not all those, those were swept with remote monitoring and telemetry. I think that also drove some demand, and it’s ongoing.” 

With this learning at Anova in mind, coupled with Lynch’s own decades of experience in the industrial gases industry, he offered the view that, “This is the time for the industrial gases business to really show its expertise and be a partner in this healthcare system and in the infrastructure related to the healthcare system. This industry is where the experts reside.” 

One would be led to believe that both Air Liquide and Linde, respectively, share this sentiment of the oxygen industry being both more prominent and prepared in the future, given their commitments to ensuring greater access to oxygen for all in the years ahead. 

In the official statement announcing those agreements, as reported by gasworld, Jean-Marc de Royere, Senior Vice-President and member of the Air Liquide Group Executive Committee in charge of social programmes, reflected, “Striving to improve oxygen access in LMICs is an integral part of our sustainable development commitments announced in March 2021. Today’s announcement is also in line with Air Liquide teams’ mobilisation since the beginning of the pandemic in the countries where the group operates.” 

“Leveraging on its technical expertise and know-how, the group will work along with Unitaid and CHAI, contributing to solutions to increase oxygen access in LMICs countries where demand is high and operational conditions are challenging.” 119 

Linde plc COO Sanjiv Lamba

Linde plc COO Sanjiv Lamba

Likewise, Sanjiv Lamba, Chief Operating Officer at Linde, had added, “The Covid-19 pandemic highlighted the importance of access to healthcare for all. Linde’s employees stepped up in these extraordinary times to produce and deliver medical oxygen, playing a critical role in supporting healthcare systems across the world. All these efforts will be in vain if we cannot work together to improve access to medical oxygen in low and moderate income countries, overcoming the many challenges.” 

“Linde is proud to partner with Unitaid and the Clinton Health Access Initiative and we look forward to working together to increase access to oxygen on a fair and equitable basis.”120 

A lasting pathway of access to medical oxygen

The hope now is that we will see a long-term path forward emerge in the medical oxygen supply chain or rather, a long-term pathway of access to medical oxygen. 

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 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 among children (with pneumonia for example) that were simply not getting access to oxygen.

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 when they actually require 50 plants. What we’re trying to do here is hook-up hospitals all across the global south with liquid oxygen and PSA plants, of the same standard as you would get in a hospital in a rich country,” she affirms121

“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, and install oxygen plants where that is the best option.” 

“So when the next respiratory pandemic comes – we’re told there will be more respiratory pandemics and two years from now we could be in another pandemic – we’re ready with oxygen. The need for oxygen in this way could be long-term. 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.” 

“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 think that the liquid medical oxygen market should be a growth market for industry in emerging markets for at least the next decade.’ 

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.” 122 

“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.” 

PSA production in future preparedness… 

It would also appear to make sense to embrace more the role of PSA oxygen generator systems, as has previously been alluded to in this series by many stakeholders – and not just those in the PSA systems business. 

France-based 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 in July 2021, why are recent oxygen agreements such a breakthrough? Acknowledging the significance of those agreements, he explained too the key role that he feels is now well and truly proven for PSA oxygen generators.

“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 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.” 123 

“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.”


More still to be done 

There appears wide agreement then, that there can and needs to be greater preparedness in the oxygen supply chain in the future. There is also the view that this should be taken one step further, with oxygen and the industry behind it considered part of the public health architecture moving forward.

Whether it is industrial or medical-grade oxygen, bulk liquid oxygen or via PSA generator systems, both debates for another day, there is unilateral acceptance that there simply hasn’t been access or availability to enough of this precious, life-sustaining resource. A veritable body of evidence and reports appear to back this up, as we have explored across this series. 

Perhaps further, damning evidence can be seen from one of the sadly highest-profile case studies of Covid-19 and oxygen supply: India, spring 2021. An article from the publication India Today, first published on 5th May (2021) and subsequently updated on 6th May reported that at that time, India accounted for a quarter of the world’s deaths owing to Covid-19. The morgues are running at full capacity. Patients are dying of Covid-19 and lack access to healthcare, it explained124

“The statistics are mind-numbing. India’s record is beyond dismal when it comes to the total number of deaths we have recorded in the second wave of the pandemic. There has been a seven-fold increase in deaths reported in the last one month in India. The country has seen more than 50,000 deaths in the last 20 days alone,” the report continued. 

“India Today’s Data Intelligence Unit has found that if you take May 1, 2020, as the beginning of the first wave of the pandemic – the deaths reported on this day were 77. Compare this with 118, on February 1, 2021, considered the beginning of the second wave.  What is the reason behind this? Medical experts say that severely-ill patients are not receiving the healthcare they need.” 

The article in question went on to question both whether these deaths were preventable, and/or whether the emergence of the Delta variant of Covid-19 was causing more severity. India Today was able to quote two doctors that told the publication at the time, that pressures on the healthcare system and a lack of access to the required healthcare was causing preventable deaths. 


For the purpose of this series, it would be too simplistic to even attempt to measure ‘preventable deaths’ as a result of a lack of oxygen availability; however, it is a stark observation in the case of India alone, that a nation was so visibly crippled by a lack of oxygen (as reported by the world’s media) and at the same time, leapt up the order in terms of Covid-19 fatalities and at one point accounted for around a quarter of the world’s deaths. 

A coincidence? We have also seen well-documented instances of lack of oxygen availability and rising death rates in many other countries, not least Brazil and Peru in South America. Further still, let’s look at a timestamp of simple facts from Africa’s deadly third wave of Covid-19. gasworld reported on 29th June 2021, that ‘Africa is reportedly ‘losing the battle’ with a brutal third wave of Covid-19 as the Delta variant of the virus sweeps across the continent and shortages in its oxygen supply chain are seriously exposed.’ 125 

The WHO announced on 25th June that the pandemic was resurging in 12 African countries; meanwhile the highly contagious Delta variant of the coronavirus had been detected in 14 African countries. It also admitted that third wave came as Africa was experiencing a vaccine shortage. It said, at that time, just slightly more than 1% of Africans had been fully vaccinated. 

At around the same timeframe, the Every Breath Counts Coalition said that as many as 50 LMICs were dealing with oxygen shortages or are at risk of facing the crisis, with clusters in Asia, Latin America, Africa, the Middle East and even central Europe. Further still, the COVID-19 Oxygen Needs Tracker from PATH, the Clinton Health Access Initiative (CHAI) and Every Breath Counts, affirmed the severely sharpening need for oxygen across various African countries. Data correct as of 28th June 2021, suggested the Democratic Republic of Congo (DRC), for example, had a current need for 16,138 cubic metres of oxygen per day – up from well below 5,000 cubic metres per day on 1st June. There were far more extreme examples. Zambia had a need for 121,732 cubic metres of oxygen per day, up from a baseline of almost zero need on 1st June; Tunisia, 134,301 cubic metres of oxygen per day; Uganda, 50,259 cubic metres of oxygen per day; South Africa, a huge 620,769 cubic metres of oxygen per day. 

Could we say those needs were all being met? How prepared were we, and how prepared will we be in future? Is it now time for a global estimate of the number of deaths attributable to lack of access to medical oxygen? Though an undoubtedly arduous task, some certainly believe so. The Every Breath Counts coalition is among those calling for such a study, as are sources in India.

MicrosoftTeams-image (5)

Source: gasworld / Unitaid

The WHO now acknowledges on its website that more is still to be done in access to medical oxygen for all. “Medical oxygen is lifesaving and an essential medicine. It can be used at all levels of the health system and is crucial for the treatment of Covid-19 and other life-threatening conditions such as severe pneumonia, severe malaria, sepsis (from bacteria and viruses), trauma and complications of birth or pregnancy. It is essential to ensure safe surgical, emergency and critical care services. These are just a few examples, of the many conditions for which oxygen is life-saving. Unlike other medicines, it doesn’t have a substitute,” it says.126 

“Although vast work has been done in the medical oxygen ecosystem over the years, especially in its safe production and clinical use, it remains limited in its access and availability in many countries. The Covid-19 pandemic has highlighted this inequity.” 

“Only a strong and collaborative action can scale up access and availability to oxygen quickly. That is why WHO, together with other global entities, have joined efforts to find context appropriate, sustainable solutions.”

Furthermore, it is clear that not only is strong and collaborative action the continued order of the day, but we must not lose the momentum that had been built in medical oxygen access for all. This was the view of Robert Matiru, Director of the Programme Division at Unitaid, in an October (2021) interview with gasworld.127 Matiru explained that in the context of the Covid-19 pandemic, the lack of access to medical oxygen is threatening entire health systems in countries around the world.

Even before Covid-19, oxygen supply in LMICs was inadequate, demonstrated by the fact that pneumonia is the world’s biggest infectious killer of adults and children, claiming the lives of 2.5 million people in 2019. Against this backdrop and the onset of the pandemic, the aforementioned Covid-19 Oxygen Emergency Taskforce was launched (in February 2021) to bring together key partners to address these critical oxygen gaps, co-led by Unitaid.

Matiru believes the Taskforce plays a critical role in bridging those gaps in the supply chain. “The Taskforce plays a critical role in improving the coordination of the global response and mobilising resources to address the needs in the most acute way,” he said. “The Taskforce focuses on achieving four key objectives as a part of an emergency response plan: measuring acute and longer-term oxygen needs of LMICs ; connecting countries to financing partners for their assessed oxygen requirements; and supporting the procurement and supply of oxygen, along with related products and services; reinforcing advocacy efforts to highlight the importance of oxygen access in the Covid-19 response.”

“Other areas in the scope of the Taskforce include addressing the need for innovative market-shaping interventions, as well as reinforcing advocacy efforts to highlight the importance of oxygen access in the Covid-19 response.”

Matiru admits he is ‘somewhat’ disappointed that we have not seen more major medical oxygen agreements signed since those groundbreaking announcements in June, but says “we continue to hold talks with other companies and are cautiously optimistic that they too will sign such framework agreements, to facilitate fairer access.”

There is certainly still work to be done and further steps to be taken, and Matiru is clear that we cannot afford to lose momentum in medical oxygen, with 40 countries still at risk of oxygen shortages at the time of writing. A number of these countries are considered ‘code red’ – countries at serious risk.

“We cannot afford to lose momentum,” he urges. “During the UNGA in September, at a summit convened by President Biden, the resounding message was that Covid-19 is far from over. And as regards oxygen access, that many LMICs are seeing, and will likely continue to see, surges in case numbers – largely driven by the Delta variant and low vaccine rates.”

On that very clear and pressing note, the need for more action, more collaboration and more urgency, our series is brought to a close.