How many more lives could be lost in India’s oxygen crisis?

The images on Indian television news in the past two weeks have been unprecedented. People queuing up for oxygen cylinders or refills, large hospitals tweeting in panic about their depleting oxygen tanks, patients in intensive care units dying due to a lack of oxygen.

How did it come to this?

Has a nuclear power with the ambition to build a $5-trillion economy really run out of oxygen? If so, by how much?

What we have seen so far

Before the pandemic began, India’s requirement of liquid medical oxygen was 700 metric tonnes per day, according to industry estimates. During the peak of the first Covid-19 wave, in September 2020, this went up to 2,800 metric tonnes. At the time, the country was adding around 100,000 new cases every day.

In the second wave, since April ’21, India has seen more than 3 lakh new cases every day, even crossing the 4 lakh-daily-cases mark on May 1. A simple extrapolation shows our requirement of liquid medical oxygen will be at least three times the amount we needed during the first wave, which comes to 8,400 metric tonnes.

But as of April 21, according to Union health secretary Rajesh Bhushan, the daily allocation of medical oxygen to states was 6,600 metric tonnes.

The Central government calculated the requirement at 6,600 metric tonnes per day using a formula of 10 litres per minute for a non-ICU bed and 24 litres of oxygen per minute for an ICU bed, according to an affidavit that it filed in the Supreme Court on April 29.

By April 26, India had almost 29 lakh active Covid-19 cases. The World Health Organisation says that 80% of Covid-19 cases are mild, 15% need oxygen support, and 5% need ICU beds.

However, in its April 29 affidavit in the Supreme Court, the Central government said an empowered group of medical experts has determined that 80% cases of all Covid-19 cases in India are mild and do not need oxygen, 17% need hospitalisation, of which only 50% or 8.5% of all patients need oxygen support, and the remaining 3% need ICU beds.

Even based on this assumption, India needed 7,473 metric tonnes of daily oxygen on April 26. However, on April 20, the Central government had allotted just 6,600 metric tonnes.

This means, assuming a lag of six days between allocation and use, given the time it takes to fill and transport oxygen across long distances, India was short of at least 873 tonnes of liquid medical oxygen on April 26.

Here it is worth noting that the demand for liquid oxygen projected by states itself rose rapidly, as per the Centre’s affidavit in the Supreme Court. On April 15, in their communication with the Centre, 12 states had projected a demand of 4,880 metric tonnes of liquid oxygen for April 20. By April 18, however, this was revised to 5,619 metric tonnes, with three more states joining in.

By April 27, the projected demand by 22 states and Union territories had shot up to 8,331 metric tonnes. The Centre claims to have allocated 8,410 metric tonnes but the states were able to arrange transport for only 7,334 metric tonnes on April 26.

This perhaps explains why we have seen such acute oxygen distress in the past few days.

What lies ahead

While the oxygen shortage witnessed in April appears to have been caused by actual demand exceeding the projected demand, with logistics exacerbating the crisis, future shortages could be due to a production constraint.

Let me explain.

Until April 15, the Indian government maintained that the country’s daily oxygen production capacity was 7,127 metric tonnes. On April 30, however, the government told the Supreme Court that the production had gone up to 9,000 metric tonnes. This appears to be largely because steel plants ramped up supply from 1,000 metric tonnes in the first week of April to 2,600 metric tonnes on April 21, as per the government’s court affidavit.

With daily production capacity at 9,000 metric tonnes, we assume 500 metric tonnes has been reserved for the three industries that are still allowed to use oxygen. Assuming the availability of 8,500 metric tonnes of daily oxygen, what does the forecast for May look like?

The various predictive models say this is just the beginning and the peak of the second wave will be anywhere between 3.5 lakh-4.4 lakh cases a day as per the IIT SUTRA Model, to 5 lakh new cases a day as per the Niti Aayog, to even 8 lakh-10 lakh cases a day as per Professor Bhramar Mukherjee of Michigan University. India could have as many as 38 lakh-48 lakh active cases between May 14-18.

Taking the most conservative model as a basis, and building on actual data till May 2, we have smoothened the curves of the new cases and recoveries to arrive at a projection of active cases till the end of May. The graph below shows a peak of 41 lakh active cases in the second week of May. We are still at 35 lakh active cases.

Taking this as the base, we have developed a prediction for liquid medical oxygen requirements using the government formula of 8.5% patients needing oxygen and 3% requiring ICU beds. The forecast is grim: the oxygen requirement could touch almost 11,000 tonnes per day in the second week of May.

The graph below represents the oxygen requirement (in green) versus the production capacity of 8,500 metric tonnes (in red).

Based on these assumptions, during the peak, India could be short by at least 2,200 metric tonnes per day. This translates into a cumulative shortage of at least 32,000 metric tonnes during the first three weeks of May 2021.

Assuming it takes 15 days of oxygen support for a Covid-19 patient to recover, the per patient requirement comes to 220 kgs of oxygen. A shortage of 32,000 metric tonnes means 1.45 lakh patients not getting the oxygen they need. For perspective, the total number of recorded deaths due to Covid-19 since the pandemic started in India is 201,190.

A Central government official told the Supreme Court on April 30 that it has stocks of 51,000 metric tonnes of industrial oxygen, out of which 19,871 metric tonnes is liquid medical oxygen.

This still places the country in a precarious position. It might not be enough to meet the demand for medical oxygen in the second wave.

So what can the government do?

Import liquid oxygen. The government has announced plans to import 50,000 metric tonnes of liquid oxygen. A tender was opened on April 28 by the central government-run HLL Lifecare Limited. This should be finalised immediately. Based on figures cited by officials last year when 1 lakh tonnes of medical oxygen was imported, the cost would come to about Rs 300 crore-Rs 350 crore, which is a pittance in the larger scheme of things.

Import oxygen concentrators. On April 28, the Central government authorised the procurement of 1 lakh oxygen concentrators through PM-Cares. In addition, the Maharashtra government has floated a tender to import 40,000 oxygen concentrators. This is a good step and should be done by all states. There should be emergency authorisations for the imports.

Increase production capacity. In Tamil Nadu, the Sterlite Copper plant, which has been lying shut for three years, is being revived to produce 1,000 metric tonnes of oxygen. More such avenues should be explored.

Set up oxygen plants in hospitals on a war footing. The government invited bids for 162 PSA oxygen generation plants in October 2020, but only 33 had been set up till April 26. These 162 plants would have added only 154 metric tonnes of daily capacity, but had the number of PSA plants been ramped up on a war footing, it could have made a difference. The government has now allocated funds for another 550 PSA oxygen plants. France has donated eight oxygen plants and the army will be sourcing 23 mobile plants from Germany. More such plants should be imported.

Listen to the specialists. Given that the country is facing a dire shortage of oxygen, a complete lockdown should be implemented immediately. There is no justification of not having a lockdown if the country’s medical facilities are stretched beyond limits and people are dying due to lack of oxygen. Both the Indian government’s Covid-19 Task Force and Dr Anthony Fauci of the United States are of this opinion.

Step up vaccinations. India needs to vaccinate its population on a war footing. Importing liquid oxygen and oxygen concentrators will only solve the problem temporarily. In the long term, vaccination is the solution.

Not all deaths due to Covid-19 are preventable. But deaths due to oxygen shortage certainly are. Solving India’s oxygen crisis should be the topmost priority of the government. This is the only essential service that is needed.

The author is a management professional with 20 years of experience.

Clarifications and corrections: This piece has been edited to remove a misstated reference to the conversion rate of liquid oxygen.