A Simple Way to Save Lives as Covid-19 Hits Poorer Nations

As the coronavirus pandemic hits more impoverished countries with fragile health care systems, global health authorities are scrambling for supplies of a simple treatment that saves lives: oxygen.

Many patients severely ill with Covid-19, the illness caused by the coronavirus, require help with breathing at some point. But now the epidemic is spreading rapidly in South Asia, Latin America and parts of Africa, regions of the world where many hospitals are poorly equipped and lack the ventilators, tanks and other equipment necessary to save patients whose lungs are failing.

The World Health Organization is hoping to raise $250 million to increase oxygen delivery to those regions. The World Bank and the African Union are contributing to the effort, and some medical charities are seeking donations for the cause.

The W.H.O. estimated on Wednesday that with about one million new coronavirus cases worldwide per week, the world will need 620,000 cubic meters of oxygen per day, or 88,000 large cylinders.

By a stroke of luck, the W.H.O., UNICEF and the Bill & Melinda Gates Foundation in 2017 began searching for ways to increase oxygen delivery in poor and middle-income countries — not in anticipation of a pandemic, but because oxygen can save the lives of premature infants and children with pneumonia.

The organizations began ordering equipment in January, but within weeks suppliers were swamped by the sudden surge in demand created by the pandemic.

The W.H.O. has purchased 14,000 oxygen concentrators, which filter oxygen from the air, to be sent to 120 countries, and the agency hopes to buy 170,000 more concentrators over the next six months at a cost of $100 million.

Dr. Tedros Adhanom Ghebreyesus, the director-general of the W.H.O., warned that “80 percent of the market is owned by just a few companies, and demand is outstripping supply.”

Although the machinery needed to generate oxygen is relatively simple, it must be sturdy enough to withstand the dust, humidity and other hazards common in rural hospitals in poor countries. Some companies produce relatively rugged equipment, but prices are rising and restrictions on international flights are complicating deliveries.

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The machines cannot come too soon, doctors working in the field said.

ImageA health worker replaced an oxygen tank in a tent set up in a hospital parking lot for coronavirus patients in Manila in April.
A health worker replaced an oxygen tank in a tent set up in a hospital parking lot for coronavirus patients in Manila in April.Credit…Eloisa Lopez/Reuters
In May, the Alliance for International Medical Action, or Alima, treated 123 Covid-19 patients in the Democratic Republic of Congo, said Dr. Baweye Mayoum Barka, the charity’s representative in Kinshasa, the country’s capital. Fifty-six of them needed oxygen, but not enough equipment was available.

“So, unfortunately, there were 26 deaths, 70 percent of them in less than 24 hours,” Dr. Barka said. “I can’t say they were all from a lack of oxygen, but it played a role.”

Alima needs 40 oxygen concentrators, but the agency has just eight, he said. Because it is hard to move patients from one hospital to another, some die waiting, gasping for air.

In Congo, many Covid-19 patients arrive at hospitals with critically low blood oxygen levels — sometimes as low as 60 percent, a level at which patients must normally be put on a ventilator to survive. (Normal oxygen saturation levels are 95 percent or more.)

One such patient was a doctor who had for a while refused to go to the hospital and instead stayed home, taking chloroquine, which is still in Congo’s national treatment guidelines.

“Then, when his condition deteriorated and he did come, just as he was nearing the Covid building, he developed convulsions,” Dr. Barka recalled. “They stopped to give him a drug for them, and he died just at the gate.”

Nigeria is also grappling with an oxygen shortage, said Dr. Sanjana Bhardwaj, UNICEF’s chief of health there. Since May, hospitals in Lagos and Kano have seen a steady stream of older patients with Covid-19 symptoms who need oxygen.

In nearly every country the virus has hit, rich or poor, about 15 percent of all symptomatic patients develop pneumonia severe enough to require extra oxygen, the W.H.O. estimates, but not so dire that they must be put on a ventilator.

Ventilators are rare in poor countries; they can cost up to $50,000, and patients must be heavily sedated the whole time the breathing tube is lodged deep in their airways; also, the pressure must be constantly monitored to prevent lung damage. That requires anesthesiologists and trained respiratory technicians, positions that many hospitals lack.

Oxygen can be delivered in two ways. Tanks contain nearly pure oxygen. For patients who need large volumes and help keeping the air sacs in their lungs open, tanks can deliver oxygen at high pressure through a mask strapped tightly over the nose and mouth.

But tanks are heavy, must be refilled at central stations and delivered by truck, and they pose some risk of explosion and fire. While many poor countries have plants making industrial-grade oxygen for construction jobs like welding, it cannot be used on patients because the tanks often contain rust or oily water that could lodge in the lungs, said Paul Molinaro, chief of operations support and logistics at the W.H.O.

An alternative is an oxygen concentrator, which is usually the size of a suitcase or even a briefcase. Concentrators pull oxygen out of ambient air by forcing it under pressure through a “molecular sieve” filled with the mineral zeolite, which adsorbs nitrogen.

Most concentrators cost only $1,000 to $2,000. They need electricity but can run on a generator or batteries, using about as much power as a small refrigerator.

Typically concentrators can produce about 90 percent pure oxygen. They do not deliver it under pressure, but the thin tube through which the oxygen streams can be connected to a continuous positive airway pressure machine, or CPAP, to enrich the air it blows into the lungs.

Alima has started a campaign, “Oxygen for Africa,” to raise money to send about 500 concentrators to six poor countries, Jennifer Lazuta, a spokeswoman, said.

UNICEF has ordered about 16,000 concentrators for about 90 countries, but thus far has been able to deliver only about 700, said Jonathan Howard-Brand, an innovation specialist at UNICEF’s procurement center in Copenhagen.

The W.H.O. has ordered another 14,000, of which 2,000 have been delivered and 2,000 are in transit, Mr. Molinaro said.

Pallets of health supplies delivered to UNICEF workers in Nigeria, including 15 oxygen concentrators, in April.
Pallets of health supplies delivered to UNICEF workers in Nigeria, including 15 oxygen concentrators, in April.Credit…UNICEF
He and Mr. Howard-Brand described severe delivery problems created by the epidemic, including delays of up to five weeks. When possible, the aid agencies ship through the World Food Program, which has dozens of planes. But the concentrators must compete for space with shipments of food, personal protective gear and other lifesaving goods.

Also, some countries are far from cargo hub cities, while others restrict all flights, even those containing aid, for fear of the virus being introduced.

“We need more planes in the air,” Mr. Howard-Brand said.

UNICEF is also buying tens of thousands of pulse oximeters, fingertip devices to measure blood-oxygen saturation.

In deciding how much equipment to buy, the aid agencies are, to some extent, flying blind. As New York State learned when it was desperately collecting ventilators in March, how great the need will be is unpredictable.

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Younger Covid-19 patients and those without other health problems often survive without supplemental oxygen. Populations in Africa skew younger, because vaccination and anti-malaria campaigns over the past two decades have saved many children who otherwise would have died. Wide swaths of older Africans died of AIDS before H.I.V. therapy became widely available in the mid-2000s.

(It is still unclear whether being on H.I.V. treatment increases risks of death from Covid-19, according to the Centers for Disease Control and Prevention. But U.N.AIDS, the U.N. program fighting the disease, worries that lockdowns and border closings will disrupt supplies of H.I.V. medicines, which would undoubtedly put H.I.V. patients at high risk.)

People lined up to refill medical oxygen tanks in Lima this month.
People lined up to refill medical oxygen tanks in Lima this month.Credit…Raul Sifuentes/Getty Images
The agencies seek advice from other aid personnel in each country to estimate how much equipment is needed, Mr. Molinaro said. If he had more money and time, he added, he would concentrate on ways to increase supplies of tanked oxygen, which is dangerous to ship and so must be produced on site.

In recent years, some public-private partnerships have sprung up to do that. In East Africa, for example, an aid organization, Assist International, set out several years ago to break local corporate monopolies producing medical oxygen that many public hospitals in Africa could not afford.

With equipment supplied by the GE Foundation and money from Grand Challenges Canada and other donors, Assist now has a network of oxygen-making plants in Rwanda, Kenya and Ethiopia.

The U.N.’s oxygen-concentrator procurement effort, begun in April, was a natural extension of the U.N.’s Oxygen Therapy Project, which began in 2017 with Gates Foundation support in an effort to save babies and children.

By January, the project had found four manufacturers — two in China and two in the United States — whose machines could stand up to harsh conditions and which could add voltage stabilizers to prevent damage from power spikes, which are common in the electrical systems of poor countries and anywhere that relies on generators for power.

The agencies were just beginning to place orders when the pandemic began.

“Our timing was immaculate,” said Mr. Howard-Brand, who helped write the specifications for the new machines. “Now maybe the market will open up.”

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