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Will India go down in history as responsible for threatening the world’s pandemic recovery?

While China is where the COVID-19 virus originated, some scientists have linked India’s fresh wave to a more virulent strain, with the out-of-control outbreak providing a petri dish for further mutations to evolve that could challenge the vaccines now being distributed from Europe to the US.

The world’s second-most populous country is now struggling to contain a second wave of infections much more severe than its first last year. As of now, India is a living hell. COVID-19 has spread like wildfire, leaving the citizens absolutely helpless and bewildered. Hospitals are inundated by patients due to the surge of COVID-19 cases nationwide. People are gasping for breath, literally.

Hospitals are operating on a day-to-day basis when it comes to oxygen availability. Average stock level in hospitals of several states have declined to one day and sometimes just a few hours as compared to 3 days before the pandemic. Social media is overflowing with appeals from individuals and hospital administrators regarding the sourcing of oxygen. High courts in several jurisdictions, including the Delhi High Court, have been the location of appeals from large hospitals and hospital chains to get the supply chain moving.

This has forced individuals and hospitals to shop around for oxygen, companies to divert and donate their stores of industrial oxygen, and the government to urgently import tens of thousands of metric tons of medical oxygen.

The national demand before COVID-19 outbreak last year was about 700 MT/day. This jumped to 2800 MT/day in the first spike of COVID-19 last year and currently the demand is estimated at about 8000 MT/day in the second wave.

It seems to have become a struggle at an inter-state level. The states that have the manufacturing facilities have enough supply, while the others are struggling. The state governments have territorial jurisdiction over the oxygen producers. Large oxygen plants are being prevented from satisfying their contracts to hospitals in other states. Andhra Pradesh and Delhi provide a striking contrast.

Within Andhra Pradesh, there are three producers of medical oxygen — Rashtriya Ispat Nigam Limited (RINL) (or Vizag steel plant), Ellen Berries in Visakhapatnam, and Liquinox of Srikakulam, all three suppliers concentrated in the north Andhra region. The state government is currently distributing oxygen to 146 hospitals which have a total of 26,446 beds with an oxygen pipeline. The government has projected a maximum consumption of around 416 metric ton per day, so far, the consumption has been a maximum of 360 metric tons. Other private hospitals that are not dependent on the government also get their supply from the same three suppliers. The two private suppliers other than RINL have ramped up production in order to meet government requirements as well as existing commitments. Across districts, the storage capacity of various forms of medical oxygen is up to 515 metric ton.

On the anvil are five oxygen plants sanctioned by the union government to come up at government hospitals in Vizag, Kakinada, Kurnool, Guntur, and Tirupati. Three of these hospitals, in Kakinada, Kurnool, and Vizag have received the machinery and are awaiting installation of the plant, expected by end May. Guntur GGH and the Ruia GGH, Tirupati are yet to receive the machinery. Each of these Pressure Swing Adsorption (PSA) plants is expected to generate 900 to 2000 liter per minute of liquid oxygen. These PSA plants or concentrators, however, would function at a smaller scale to meet emergency demand of 1 to 2 metric ton a day. And on the standby is the possibility of oxygen production at Andhra Pradesh Medtech Zone, a medical equipment manufacturing facility. Even with the rising COVID-19 caseload, the current demand for medical oxygen is less than the supply.

Ministry of Steel tweet

“Medical oxygen supply per day from steel plants crossed 3000 MT mark with 3650 MT dispatched on April 27 and 3122 MT on April 26. The steel fraternity has stepped up to meet the nation’s requirement of medical oxygen and is fully geared up to meet the call of the nation.”

In contrast, with Uttar Pradesh, Haryana, and Rajasthan having blocked tankers from reaching Delhi, the capital is under siege. Hospitals are grappling with oxygen scarcity. Scary reports are coming in regularly from hospitals across the city. Twenty critically ill patients died overnight at Jaipur Golden Hospital; Batra Hospital, with 350 patients somehow managed to get emergency oxygen supply from the Delhi government since the supplier stopped responding to calls; Sir Ganga Ram Hospital, which requires a minimum of 11,000 cubic meter of oxygen daily had only 200 cubic meter, as they waited for a tanker delivery with 1.5 tons of oxygen. Max Hospitals had to approach the High Court last week after 1400 COVID-19 patients were put at risk due to dangerously low levels of oxygen supply. The late-night courtroom drama, with the state and federal government lawyers bickering over oxygen supplies to the national capital, which has among the best health care infrastructure in the country, is a grim indicator of a worse situation in the
hinterlands.

And prices have gone through the roof. Four days ago, a 10-liter oxygen tank, which lasts around five to six hours for one patient, was filled for ₹6000. But the very next day, after issues about oxygen supply were raised by the Delhi government the same tank cost ₹16,000. Ditto for devices. Earlier an oxygen concentrator retailed at around ₹40,000-50,000, with the surge in demand, is now sold for as high as ₹100,000.

BS Yediyurappa
Chief Minister,
Karnataka

“I have already requested the union commerce and industry minister as well as union health and family welfare minister to increase our allocation to 1471 tons per day from April 25 and 1471 tons of oxygen per day from April 30.”

The government took quite some time to appreciate that there is an oxygen shortage crisis in the country. As recently as April-December 2020, liquid oxygen figures stand at 9294 MT, more than double the total 4502 MT of exports in the previous year. It took the ministry over 8 months, after the pandemic started for a directive to increase the number of oxygen-processing plants to be turned into an actual tender. As a consequence, only 33 of 162 planned plants have been installed.

Having said this, the government has now been making a serious attempt to get the situation under control. The Prime Minister, Narendra Modi and Union Home Minister, Amit Shah have been directly involved in augmenting the oxygen supply on a war-footing and implementing innovative measures. Efforts are being made to import oxygen not only through diplomatic channels but also personal intervention of political executive.

Several steps are being taken to increase oxygen production, which includes issuing licenses to industrial gas manufacturers to manufacture medical oxygen; enhancing production in steel plants and other initiatives through Ministry of Steel; enhancing production of medical oxygen from other manufacturers; restricting industrial use of oxygen; augmentation in availability of tankers; and commissioning of Pressure Swing Adsorption (PSA) plants.

In addition to the earlier sanctioned 713 PSA plants under the PM CARES Fund, 500 new Pressure Swing Adsorption (PSA) oxygen plants have been sanctioned. Established with transfer of the indigenous technology developed by DRDO and CSIR to the domestic manufacturers these dedicated plants will be established in identified government hospitals in district headquarters in various states/UTs. The procurement will be done through Ministry of Health and Family Welfare. These 500 PSA plants will be established with transfer of the indigenous technology developed by DRDO and CSIR to the domestic manufacturers.

Such an in-house captive oxygen generation facility addresses the day-to-day medical oxygen needs of these hospitals and the district. In addition, the liquid medical oxygen (LMO) serves as a top up to the captive oxygen generation. Such a system will go a long way in ensuring that government hospitals in the districts do not face sudden disruption of oxygen supplies and have access to adequate uninterrupted oxygen supply.

A further procurement of 100,000 portable oxygen concentrators from the PM Cares Fund is being done. These are to be provided in states with high case burden.

HLL Lifecare has floated a global tender for procuring medical oxygen with at least 99.5 percent purity in 20-ton ISO containers for hospitals in states and under the central government. The tender will close on April 28. The tender was invited on April 21 and the Indian embassies followed it up with letters. The Center floated a tender for the import of 50,000 tons of oxygen on April 16. However, it received a firm commitment for only 3500 tons. At the state level also, procurement is being planned. Maharashtra floated an expression of interest to procure 40,000 oxygen concentrators, 132 PSA plants, 27 oxygen storage tanks, and 25,000 tons of liquid oxygen.

A mapping exercise is being undertaken jointly by the Department for Industry and Internal Trade (DPIIT), the ministries of health and steel, critically affected states, and the Petroleum and Explosives Safety Organization (PESO), along with representatives of the All India Industrial Gas Manufacturers Association (AIIGMA) to get clarity on the oxygen that needs to be supplied over the next few weeks.

Various new permissions have been given by the government, especially in 12 hard-pressed states including Delhi, Maharashtra, Uttar Pradesh, and Chhattisgarh, to ensure adequate supply of medical oxygen. The government has exempted all inter-state movement of oxygen tankers from the requirement of registration and permits. They can operate round the clock. Cylinder-filling plants are operating 24 hours to fill the gaps with necessary safeguards.

The central government has also directed states that there be no power cuts at the plants manufacturing oxygen and that district/local administrations be told that there be zero interference so as to ensure smooth functioning of the plants. Also, the Center is attempting to convert most tankers presently carrying nitrogen and argon into oxygen-carrying tankers. There are 1199 – 434 argon and 765 nitrogen – tankers in the country and 516 LMO tankers spread across 11 major states.

The Supreme Court has now taken suo motu cognizance of this problem and called for a national policy. Overall responsibility for this state of affairs rests with the union government, which should indeed make it clear immediately how it intends to ease the oxygen shortage, what its estimation of demand and supply are, and how it will preserve the oxygen supply chain to hospitals. The SC has appointed senior advocate Harish Salve as an amicus curia to assist it in the suo motu proceedings.

Expedited customs clearance for import consignments relating to COVID-19 without any hurdle is being given at airports. Priority berthing to ships calling at the port for unloading oxygen and oxygen-related equipment is being granted.

Special trains are being run for faster movement of oxygen tankers and the home ministry has been coordinating efforts to deploy empty tankers and containers in various filling stations across the country to speed up its distribution.

Since the first train of empty tankers left from Mumbai on April 19 for Vizag, Indian Railways has safely transported more than 510 metric tons of LMO have been delivered to Maharashtra. So far, the PSU has delivered 202 metric tons to Uttar Pradesh, 174 metric tons to Maharashtra, 70 metric tons to Delhi, and Madhya Pradesh 64 metric tons. Haryana has also requested the Railways for
oxygen.

According to the Railways, transportation of oxygen through trains is a lot faster than road transport. Also, due to restrictions of height of Road Over Bridges and Over Head Equipment (OHE) at certain locations, T1618 model tanker with height of 3320 mm is found feasible to be placed on flat wagons with height of 1290 mm.

The central government has enlisted the help of steel firms, which have been given state-wise quotas to ensure adequate supply. The government’s Empowered Group 2 (EG2), which reviews the production, consumption, and stocks available at all the steel plants in the country, has allocated distribution of liquid medical oxygen from each steel plant to various states.

The Indian steel industry has the capacity to supply 3000 tons a day of medical oxygen. Tata Steel, Steel Authority of India (SAIL), and Jindal Stainless are among those that have already started supplying medical oxygen to states. Besides, Vedanta’s Sterlite Copper has received Supreme Court’s permission to reopen its Tuticorin plant to produce oxygen. The Tata Group will import 24 cryogenic containers through a group company to transport liquid oxygen to meet the logistic requirement. Both SAIL and Tata Steel have enhanced their capacities.

SAIL has already supplied 36,747 tons since August 2020. With the increase in demand across the country. SAIL has been supplying 660 tons per day from its plants on an average. It has reduced the production of gaseous oxygen, nitrogen, and argon besides optimizing process parameters in its plants to boost production of liquid medical oxygen.

Tata Steel is currently supplying 300-400 ton of LMO daily to Uttar Pradesh, Madhya Pradesh, Andhra Pradesh, Telangana, Jharkhand, Odisha, Bihar, and West Bengal, and hospitals through its manufacturing units in Jamshedpur, Kalinganagar, and Dhenkanal.

Hindustan Zinc has supplied 1500-liter oxygen to the Udaipur health administration. The company transported a 1000-liter liquid oxygen tanker from its industrial oxygen plant at Rajpura Dariba Complex. HZL is supplying industrial oxygen, which will undergo a clinical procedure to be used for medical treatment.

ESL, the Vedanta group’s steel maker, has registered its plant near Bokaro for LMO. It has committed to supply up to 10 tons of oxygen daily, based on the steel ministry’s requirement. Jindal Stainless, which produces LMO at its Hisar facility in Haryana for industrial purposes, has been supplying 8 ton a day to nearby medical facilities. This includes Jindal Institute of Medical Sciences, Hisar; Maharaja Agrasen Medical College, Agroha; Maharishi Markandeshwar Institute of Medical Sciences, Mullana; and the rest is being supplied to cylinder re-fillers. Jindal Stainless recently began supplies to Medanta, Gurugram; and Moolchand Hospital, Delhi.

Rashtriya Ispat Nigam Limited (Vizag Steel Plant) has also been supplying liquid oxygen to Andhra Pradesh and other states. The steel plant’s air separation facility has five units of oxygen extraction plants for its steel plant. Of this, three units have the capacity to produce 550 tons per unit per day and two units have the capacity to produce 600 tons per unit per day. It produces 2600 tons of oxygen in gas form, and 100 tons in liquid form every day. The liquid form gas is now being supplied for medical purposes for the past few days.

Piyush Goyal
Additional Secretary,
Ministry of Home Affairs

“Do not worry, do not panic. We have enough stock of oxygen. The issue is transportation. Transportation is a major challenge which we are trying to resolve by active involvement of all stakeholders”

UPL Ltd., a crop protection company, plans to convert four of its nitrogen production plants in Gujarat to produce oxygen for four hospitals in Gujarat and Madhya Pradesh. These plants will then be skid-mounted and delivered directly to the hospital sites.

A host of large private sector firms in the manufacturing sector are repurposing their factories to produce medical oxygen in times of scarcity. Reliance Industries Ltd., has tweaked manufacturing at its Jamnagar oil refineries to produce over 700 tons a day of medical-grade oxygen which is being supplied free of cost to states badly affected by COVID-19. The company’s Jamnagar refineries in Gujarat initially producing 100 tons of medical-grade oxygen has now been ramped up to over 700 tons. The company plans to raise medical-grade oxygen production capacity to 1000 tons.

The On-Board Oxygen Generation System (OBOGS) developed for the Tejas light combat aircraft has been translated into a civilian-use oxygen generation plant that can produce 1000 liter of oxygen every minute. The technology has been transferred to the private industry and the Uttar Pradesh government has already placed an order for five such plants.

According to the DRDO chairman, Satheesh Reddy, more plants can be supplied by the industry to cater to the burgeoning hospital requirements. Reddy offered a supplemental oxygen delivery system that the DRDO had developed for soldiers posted at extreme high-altitude areas could be used for COVID-19 patients as their medical conditions were similar in both cases. The DRDO expects the product, which is based on SpO2, to be available in the market soon.

Reliance Industries comes to the rescue. Reliance has once again risen to occasion. Its contribution to making telecom tariffs affordable is well documented. Traditionally, Reliance not a manufacturer of medical grade liquid oxygen, started from nil before the pandemic, has now become India’s largest producer of this life-saving resource from a single location. RIL engineers quickly reconfigured and optimised current operations – designed for refining and petrochemicals grade oxygen – to produce high-purity medical grade oxygen. Medical grade liquid oxygen has to be produced in liquid form at -183°C with almost 99.5 percent purity, which poses extraordinary challenges and risks in production and maximising tonnage. Reliance engineers worked tirelessly and, through process optimisation and modifications of Cryogenic Air Separation Units, were able to maximize production of medical grade liquid oxygen in a very short span of time. At its refinery-cum-petrochemical complex in Jamnagar and other facilities, RIL now produces over 1000 MT of LMO per day. This oxygen is being provided free-of-cost to several state governments across the country to bring immediate relief to over 100,000 patients on a daily basis.

In addition to the production of high-quality medical grade liquid oxygen, the other challenge has been to quickly overcome the transportation bottleneck in supply of liquid oxygen to various parts of the country. This necessitated increasing the loading capacity for its safe and quick transportation. To achieve this, Reliance engineers made smart logistical modifications to rail and road transport, such as laying parallel lines, using hoses, and loading up liquid tankers through pressure differential, since liquid oxygen pumps cannot be installed at short notice.

In another innovation, Reliance converted nitrogen tankers into transport trucks for medical grade oxygen, through innovative and safe processes that were approved by the Petroleum and Explosives Safety Organization (PESO), the relevant regulatory body of the Government of India.

Reliance organized the airlifting of 24 ISO containers into India from Saudi Arabia, Germany, Belgium, The Netherlands, and Thailand adding 500 MT of new transportation capacity for liquid oxygen. These ISO containers will help in removing the transport constraints for medical grade liquid oxygen in the country. In addition, Reliance is airfreighting more ISO containers over the next few days.

International efforts are under way to help India ride through this crisis. India expects to receive supplies from about 17 countries including the US, UK, France, Germany, Ireland, Belgium, Romania, Luxembourg, Portugal, Sweden, Australia, Bhutan, Singapore, Saudi Arabia, Hong Kong, Thailand, Russia, and UAE among others, to help tide over the current crisis for oxygen at hospitals.

The first batches of high-capacity container shipment that included 250 oxygen concentrators landed in New Delhi were from Singapore. Another batch of containers was brought in from Dubai. Containers from Thailand were the third such consignment to be flown to the country in the Indian Air Force’s (IAF) transport aircraft by the home ministry.

The UK has begun sending oxygen concentrator devices. EU members are also due to send aid including 495 oxygen concentrators. In Brussels, the European Commission said it planned to send oxygen and medicine too. Its head Ursula von der Leyen said the organization is pooling resources to respond rapidly to India’s request for assistance.

The US is also sending supplies worth more than USD 100 million, including 1000 oxygen cylinders. Air India had brought in 318 oxygen concentrators on its New York-Delhi flight on April 26. Likewise, from Chicago too.

Riyadh is providing liquid oxygen as well as tanks and oxygen cylinders. Linde-SIGAS is working with the Adani Group and Tata Group. Facilitated by the Adani Group, the first shipment of 4 ISO cryogenic tanks with 80 tons of liquid oxygen and another 5000 medical-grade oxygen cylinders is to arrive from Dammam to Mundra.

India is also procuring oxygen cylinders and containers from Abu Dhabi. Most of the transportation is being coordinated by the Ministry of External Affairs in tandem with the Ministry of Home Affairs and the Indian Air Force.

Japan may come to India’s aid by providing 10 tankers. 23 mobile oxygen generation plants are to be airlifted from Germany for use in Armed Forces Medical Service hospitals with COVID patients. Each plant has a capacity to produce 40 liter of oxygen per minute and 2400 liter an hour.

Bhutan will supply liquid oxygen from a new plant being set up at the Motanga Industrial Estate, Samdrup Jongkhar district by SD Cryogenics Gases Pvt. Ltd., a Bhutanese company. Every day, 40 metric tons of liquid oxygen produced by the oxygen plant will be exported to Assam using cryogenic tankers.

Maersk, a Danish shipping major is transporting tanks as well as other medical supplies. They will be used for storing, transportation of oxygen. Maersk is assisting India through MEA.

Ireland is to send 700 oxygen concentrators, one oxygen generator, and 365 ventilators.

France has offered significant extra oxygen capacity in two phases; eight large oxygen generating plants that can be installed quickly, liquid oxygen in Phase-I, and five liquid oxygen containers in Phase-II.

As many as 800 oxygen concentrators have been airlifted from Hong Kong to Delhi. 10,000 more will be dispatched soon.

Russia has also offered help by providing medical-grade oxygen concentrators and tanks from Moscow.

Australia will send oxygen and other essential equipment as part of an immediate support package to the country.

Canada will provide USD 10 million for humanitarian assistance to the Canadian Red Cross to support the Indian Red Cross Society. This contribution will support the procurement of essential supplies and medicines, including oxygen cylinders.

The Norwegian government will contribute USD 2.4 million to be channeled through the World Health Organization (WHO) and International Federation of Red Cross and Red Crescent Societies (IFRC). The support will be used to scale up medical services, buy equipment such as oxygen tanks for ambulances.

Romania will send 80 oxygen concentrators and 75 oxygen cylinders.

Portugal will 20,000-liter oxygen per week.

South Korea plans to provide India with oxygen concentrators.

The private sector, with a large number of multinational and Indian companies is also pitching in as supplies at hospitals dwindle.

Google is funding ₹135 crore to GiveIndia and UNICEF.

US-India Strategic Partnership Forum (USISPF) is assisting with 12 ISO containers to help transport oxygen in India. USISPF is sourcing 100,000 portable oxygen concentrators for use at home and hospitals to be shipped to India immediately.

Deloitte is working with the US-India Strategic Partnership Forum, the US-India Business Council, the Business Roundtable and India’s Ambassador to the US to mobilize resources. More than 40 CEOs of multinational companies came together to focus on immediate needs including oxygen concentrators, and oxygen cylinders It has provided 1000 oxygen concentrators so far and an additional 11,000 are being sourced.

FICCI, and its partner association BVMW (German Association of Small and Medium sized Enterprises) have extended their support by procuring 1500 oxygen concentrators for private entities in the Indian healthcare industry. The first batch of the freight containing the medical devices and accessories was airlifted from Frankfurt Airport on April 28 and made available in various hospitals across the country.

Microsoft will continue to use its voice, resources, and technology to aid relief efforts, and support the purchase of critical oxygen concentration devices.

Amazon has joined hands with ACT Grants, Temasek Foundation, Pune Platform for COVID-19 Response (PPCR) and other partners to urgently airlift over 8000 oxygen concentrators and 500 BiPAP machines from Singapore. Additionally, Amazon India is also procuring over 1500 oxygen concentrators and other critical medical equipment that will be donated to hospitals and medical facilities.

Xiaomi India has pledged to donate ₹3 crore to procure over 1000 oxygen concentrators for hospitals across states in India. The oxygen concentrators will be donated to hospitals and state governments where the need is the highest, for example, Delhi, Maharashtra, Karnataka, and few other states.

Paytm has placed an order for 21,000 oxygen concentrators, which will be made available from the first week of May. The company has raised ₹5 crore contribution from the public and matched the same amount taking the total kitty to ₹10 crore for procurement of oxygen concentrators (OCs). These devices would be immediately sent to government hospitals, COVID care facilities, private hospitals, nursing homes as well as Resident Welfare Associations.

CRED has partnered with healthcare fundraising platform Milaap to procure and distribute oxygen concentrators in the country. The company plans to distribute a billion liters of the life-saving gas through this partnership.

Zomato and Delivery have announced an initiative, Help Save My India, and the firms are raising ₹50 crore for sourcing oxygen concentrators and other medical supplies.

EaseMyTrip’s co-founder Rikant Pitti has offered to import 150 oxygen concentrators and sought logistics help for the same.

Larsen & Toubro, ITC, and Bharat Forge have also stepped in with offers. Allcargo Logistics has offered to ship 500 oxygen concentrators from Singapore.

State-run oil firms are setting up Pressure Swing Adsorption (PSA) medical oxygen generation plants at 93 locations. Bharat Petroleum Corporation Ltd’s Bina refinery in Madhya Pradesh will supply 10 ton per day of gaseous oxygen of 90 percent purity to the1000-bed temporary hospital being built by the state government for COVID-19 patients. Indian Oil Corporation Ltd is procuring cryogenic containers for transporting liquid medical oxygen and has contracted nine such containers.

With COVID cases on the rise, the need for oxygen is by far more than the allocation. As per Empowered Group II, India’s daily production capacity of medical oxygen is 7287 MT and there is an availability of a buffer stock of approximately 50,000 MT. But that was in the first week of April. The daily requirement has now gone up to 8000 MT and each state is grappling with the shortage.

For instance, as on April 30, Maharashtra’s daily requirement is 1646 MT against an allocation of 2000 MT, and UP needs 800 MT, whereas 751 MT is allocated. Similarly, Tamil Nadu gets 360 MT, whereas the requirement is for 465 MT and Delhi 378 MT against 445 MT needed. Hospitals are refusing to admit patients if they are not able to give oxygen to them.

The inability to map demand and supply accurately is continuing to play havoc. And a huge challenge of logistics, of transporting the oxygen from the facilities to the hospitals, after having converted from industrial to medical oxygen remains.

With the mass attendance at political rallies and the Kumbh Mela, not to forget the holy dip in the Ganges, the virus is no longer confined in the major cities but has spread to the Tier-II and Tier-III towns and travelled to the villages. The cylinders are coming into play here.

In the underserved areas, hospitals do not have copper pipelines to seamlessly supply oxygen and they simply use cylinders as an alternative, with which come many issues. Cylinders are in shortage, it is not easy to transport them, they cannot be used on multiple patients, they are heavy to replace so two attendants are required, to list a few.

And last but not the least, while the availability of oxygen is being mapped and supplies streamlined, the nightmare of storage has begun. The hospitals need replenishments on a regular basis. This is very akin to having enough oil, but no place to store it. The storage capacity limits will be tested within the near future.

All the stakeholders are coming together to save the nation. Is it too late? Only time will tell.

 

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