While here in the US some are tentatively removing their masks and resuming small outdoor gatherings, others around the world are searching for air. In India, people need oxygen, and they need it now.  

Last week, Covid-19 became India’s No. 1 killer. One million people in a country with a population of 1.3 billion are predicted to die of Covid-19 by August. As of May 7, 150 people were reportedly dying every hour, and while 29 million have been fully vaccinated there, vaccines are not what is most urgently needed right now. 

When people are sick with Covid-19, many have trouble breathing, and the most important treatment is oxygen. But in India there is debate over whether there’s an oxygen shortage or a problem with accessing the existing supply.

Regardless, many people can’t get the lifesaving treatment they need just to breathe. Some oxygen systems, whether for hospitals or for individuals, require refills. Global systems of production, movement of goods, and tariffs all regulate who can get oxygen. In this case, people waiting outside hospitals are dying for oxygen, and this is perhaps why some in India are calling death from lack of oxygen a genocide. 

The shortage of oxygen in India is not an unusual event. It is a reminder of interconnected networks that regulate production and supply, and that inequality means life for some and death for others. 

Calls for solutions to the oxygen shortage from India’s top court and elsewhere continue, as do urgent messages like #SOSoxygen on Twitter and other social media where people list what they need.  

As Ruchit Nagar, founder of Khushi Baby, an Indian NGO headquartered in Udaipur, Rajasthan, explains, “smaller hospitals are pleading, saying, ‘We only have a day of oxygen left and [many] people at risk of dying if we don’t get it in 24 hours.’ In some cases, that cry for help is met on time, but in other cases people literally run out of oxygen. … There’s no easy solution.”  

All this is set against a backdrop of climate change, environmental racism, and poverty causing a scarcity of clean air. Poor air quality in India and elsewhere causes childhood asthma and adult lung disease. Housing shortages, overcrowding, and inadequate access to sanitation infrastructure contribute to fine particulate matter, raising risks for poor outcomes from Covid-19 and even increase the likelihood that the virus will spread. This combined with the lack of oxygen creates a dire threat. 

As a group of researchers, writers, and medical providers in the US, we are watching these events unfold with grief, horror, and a painful sense of déjà vu from when the US experienced its own horrible surges in hospitalizations and deaths. This will not be the last crisis. But the steps we take to stem the suffering and devastation will inform how we handle future Covid-19 surges and other disasters in other countries. Today the lesson is about oxygen, something none of us can live without.  

Why some Covid-19 patients need oxygen

Oxygen is a critical resource because Covid-19 can inflame the lungs and sometimes fill them with fluid, making it hard to breathe. Even asymptomatic people with Covid-19 can have signs of lung infections in X-rays and CT scans that may contribute to a sudden worsening of symptoms. The virus may also bind to hemoglobin, the protein in red blood cells that transports oxygen through the blood and delivers it to the body. 

A person’s oxygen level should be 95 to 100 percent at sea level, though patients with chronic lung problems, like emphysema, can live at an oxygen level of 88 to 92 percent. But the National Institutes of Health considers people with Covid-19 who have oxygen saturation levels less than 94 percent to have “severe illness.” 

Why? Lower oxygen levels force the body to work harder to supply enough oxygen to vital organs like the heart and brain. Death from Covid-19 is often from hypoxia — a form of tissue suffocation where the lungs are unable to absorb enough oxygen from the air being breathed — or respiratory failure, when the body is unable to get enough oxygen and basically exhausts itself trying. By contrast, early access to oxygen can help prevent patients from becoming critically ill.  

How we get oxygen for medical use

The New York Times recently reported on a looming global oxygen crisis, but there were concerns about India’s oxygen supplies dating back to September.

In areas with more resources, oxygen is purified off-site into a liquid form, transported by trucks with massive tanks, and stored in hospitals. This oxygen is then delivered as a gas through piping built into hospitals. Patients receive oxygen through nasal cannulas (plastic tubes that go directly into their noses), masks on their faces, or ventilators. 

Some remote hospitals have small plants that can continuously purify oxygen on-site. However, many lower-income communities globally are dependent on smaller individual tanks that need to be refilled. This is the most expensive form of oxygen delivery, costing about 10 times as much as the large-scale liquid version.

Individuals can purchase oxygen tanks, or “cylinders,” which don’t require electricity for use but need to be refilled when they are empty. Tanks last anywhere from less than one hour to nearly 40 hours, depending on how much oxygen the person needs.

Another option — one people are desperately seeking in India — is oxygen concentrators, smaller machines that can provide oxygen to one or a few patients. They are easy to use, are portable, can be placed near bedsides in homes and clinics, and can make oxygen on the spot from air and water. They are ideal for less severe cases of Covid-19.

Since they draw oxygen from the surrounding air, concentrators can cut down the need for constant refilling of oxygen cylinders and free up supply for more severely ill patients. They require batteries or an electrical source, but some designs can supply oxygen 24/7 for five years or more.

The response so far isn’t enough

The Indian government and the international community have been scrambling to increase the supply of available oxygen through multiple means. By the beginning of May, New Delhi’s daily oxygen demand surged to 976 metric tons, more than double its current supply.

Other countries have been donating liquid oxygen, and the Indian government announced plans to dramatically expand oxygen manufacturing abilities, but as of April 24 there were only 33 oxygen plants out of 150 requested. Hence, the majority of the country is relying on the more expensive, single-use forms of oxygen.  

The biggest problem may not be the supply itself as much as access. Most oxygen production is on the coast, and special tankers are required to deliver it in larger quantities to population centers. The Indian Army and the Railways Ministry are assisting with the logistics of transporting oxygen tankers to the worst-hit areas. 

Previously, hospitals might need a refill once a week, but now they need it daily.  Unfortunately, it can take six to seven days for one tanker to make a round trip, and with increased demand, government officials and oxygen plant leaders expressed concerns about tanker shortages during the surge as well.  

India temporarily exempted importing personal oxygen concentrators from customs clearance until July 31, paving the way for efficient donation and capacity for better crisis response. While the country’s finance ministry removed both customs fees and the goods and services tax (GST) for oxygen cylinders, the GST of 12 percent — down from 28 percent — still applies to oxygen concentrators, priced at $550 to $4,000. The courts are arguing that concentrators should be treated the same as oxygen cylinders and the GST removed.

With lockdowns creating barriers, raw materials imports are challenging. On top of that, the fractious to and fro between the central and local government on supply and demand worsens oxygen delivery gaps.

Meanwhile, on social media, families and communities are using #SOSOxygen and #OxygenShortage to make requests. With over half of India living without access to the internet, these requests are coming from those with the resources to ask, and they’re taking a significant risk to do so.

In Uttar Pradesh, India’s most populous state, individuals and hospitals can be punished for speaking out about the oxygen shortage, and at least one person has been arrested for tweeting a request for an oxygen cylinder, though this hasn’t stopped people from turning to this last resort. 

“Some of the damage can be mitigated, but it’s a bleak situation,” says Nagar. “We’re not going to be able to stop the tsunami. We can try to save some lives, but the tsunami is going to hit. It already has.”

A quicker response to India’s crisis requires flexibility and knowledge from the ground

Today’s oxygen crisis in India feels similar to last year’s personal protective equipment (PPE) shortage in the US and Europe. But wealthier countries are no longer in desperate need of supplies. This gives the US an opportunity to renew its commitment to global health.

More oxygen doesn’t solve the pandemic, but it does save lives. And, in partnership with substantial prevention measures, it is part of a toolkit of strategies to stem the surge. 

Technology has facilitated access to some oxygen and other supplies, including crowdsourcing of cylinders and hospital beds. Rural areas with high cellphone use now play public service announcements before each call encouraging the use of masks. And Nagar explains that some local and international organizations, like Khalsa Aid, “have been procuring oxygen concentrators, and some have been able to set up a drive-through situation, where … you can get access to a cylinder or refill your own.”

Perhaps most important to long- and short-term solutions is the ability to listen to on-the-ground needs and work with organizations, like Give India, that are already using locally appropriate tools to address the problems.

Effective international collaboration, like waiving regulations to speed up thoughtful production, helps. So does shipping and distributing the right kinds of technologies for acute care, such as oxygen concentrators, suction tubing, pulse oximeters, antibiotics, and PPE.

China and India, often at odds with border disputes, are collaborating to increase the supply of oxygen concentrators, Nagar says. The World Health Organization Covid-19 Essential Supplies Forecasting Tool can be used for country-level detailed supply calculations. Khushi Baby is also helping with data collection to predict the demand for oxygen and other supplies in upcoming weeks, and it is part of a network of NGOs collaborating to bring support where it is needed most. 

The need for global solutions 

The surge in India highlights our global interconnectedness, and the need for both global and local solutions to stem the pandemic. India was previously the primary manufacturer of vaccines but now is desperately trying to re-import them.

Meanwhile, other countries are waiting on contracts from India that can’t be filled. At the same time, the new variants that appear with each new surge of cases put all of us at risk, including the variant recently found in four states in India. These variants may lower the efficacy of our vaccines over time. India’s problem is everyone’s problem. 

Gaurab Basu, a physician and global health leader at Harvard University, explains that we must shift from thinking about charity to thinking about justice, “not chasing global tragedy with oxygen containers.” He adds that our global experience right now parallels “the lack of federal government in the US for much of 2020 and how the states suffered from that.” 

Global leaders and local health care workers can continue to improve triage and clinical care driven by local data. This, coupled with interventions like screening, testing, contact tracing, quarantining, and public service announcements focused on individual behaviors, provides a comprehensive, proactive approach to save lives. 

These courses of action pave the way for a proactive and collaborative response to disasters in the future. There is a need for interconnected global systems designed to allow for listening to what’s needed on the ground. And right now, that’s oxygen.

Lisa J. Hardy is an associate professor of medical anthropology and director of the Social Science Community Engagement Lab in northern Arizona conducting international research on Covid-19.

Lawrence Weru is a consultant and digital storyteller who illustrates the sciences for a more just and sustainable world.

Nazia Sadaf is a family physician at PISES Riyadh, integrating patient care with artificial intelligence as a Forbes Ignite Impact fellow and change maker.

Jennifer Kasper is an assistant professor of Global Health and Social Medicine at Harvard Medical School with expertise in health and human rights issues in India.

Francesca Decker is a family physician with a master’s in public health who works in student health at Cornell University.