The Oxygen Crisis
On Saturday (3/7/2021), the hospital reported that central liquid medical oxygen supply had been exhausted at 8 p.m. Its reserve of oxygen tanks would only last for another four to six hours.
In April 2020, the World Health Organization issued a method to calculate the need for oxygen.
Patients in a severe condition need 10 liters of oxygen per minute or 600 liters per hour, whereas critical patients need 30 liters per minute or 1,800 liters per hour.
When oxygen cylinders are scarce and offered at the price of Rp 6 million (US$413.58) — three to five times the normal price — for a 6,000-liter tank of oxygen (costing Rp 1,000 per liter), the pandemic indeed teaches how valuable oxygen is.
Oxygen and life
Lungs function to absorb oxygen and distribute it through blood circulation to all of our body’s cells, which then use oxygen to convert glucose into energy. When our oxygen intake is less than maximum, our energy supply is reduced and the body weakens.
When the body is in critical condition, oxygen intake has to be increased. Oxygen tanks have a higher degree of purity than oxygen in open air (above 99 percent versus 21 percent).
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When the supply of oxygen tanks is incapable of meeting demand, a loss of lives follows. The courage of healthcare workers in a hospital in Yogyakarta to reveal the fact of the consequence of oxygen supply scarcity has uncovered the curtain of its terrifying aftermath.
On Saturday (3/7/2021), the hospital reported that central liquid medical oxygen supply had been exhausted at 8 p.m. Its reserve of oxygen tanks would only last for another four to six hours. At midnight, 100 oxygen tanks as aid arrived from the local police.
The hospital’s oxygen orders from Central Java distributors were rejected because they were also short of supply. Aid came from East Java and Jakarta distributors totaling 14 tons and the first delivery arrived at 5 a.m. On Sunday (4/7), the hospital recorded 33 deaths in one day.
All of them were claimed to have received oxygen from oxygen tanks. However, it was later reported that four of them died while they were still connected to ventilators from the exhausted central oxygen supply and 15 died in the intensive care unit (ICU) while in serious clinical condition and lacking oxygen.
The boldness to be open should be appreciated to prompt authorities to acquire more oxygen so that the sacrifice of the 33 people will not be in vain.
It was unclear what had happened to the other 14 people. The boldness to be open should be appreciated to prompt authorities to acquire more oxygen so that the sacrifice of the 33 people will not be in vain.
Demand during pandemic
The WHO provided a guideline for policymakers and industries to calculate the needs for medical oxygen, identify oxygen sources and apply the best way of increasing production capacity in early April 2020.
Residents queue to refill oxygen cylinders on Jalan Swadarma Raya, Ulujami Village, Pesanggrahan District, South Jakarta, Sunday (4/7/2021).
Data in the early phase of the pandemic showed that 15 percent of COVID-19 patients had severe symptoms and 5 percent were in a critical condition. Both groups needed oxygen aid (20 percent). Patients in a severe or critical condition needed 10-30 liters per minute or 600-1,800 liters per hour.Oxygen needs are calculated by multiplying the estimated number of severe patients, critical patients and the hours of treatment that require oxygen aid. The calculation can be done for the levels of health facilities, regencies/cities, provinces and even the national level.
The global oxygen crisis has been cautioned against by the WHO since June 2020. For every million new cases per week, 620,000 cubic meters of oxygen per day will be needed, equivalent to 88,000 large oxygen cylinders. Brazil and India have experienced this crisis.
In Brazil, the danger signs of oxygen supply shortage began to arise in early April 2020 when 1,000 to 2,000 cases were listed daily. India underwent its oxygen crisis in the first wave of the pandemic in August-September 2020, when it was overwhelmed by 50,000 to 100,000 new cases per day. India was again hit by an oxygen crisis in the second wave in April-May, with 100,000 to 390,000 cases per day.
Indonesia has joined the move to overcome the oxygen crisis in India since early May. The Industry Ministry along with associations and players of gas, petrochemical and textile industries delivered 200 oxygen concentrators on May 8, 1,400 oxygen cylinders on June 8 and 2,000 oxygen cylinders on June 28. The aid funds were accumulated from industrialists and the state budget.
At the end of June, the Indonesian Industrial Gas Association (AGII) claimed to own reserves totaling 2,000 medical oxygen cylinders and deemed the supply sufficient for a case surge of up to 15 percent. In reality, the spike in cases has reached 500 percent.
Recalculation
Central and regional governments should recalculate oxygen needs for emergency and oxygen scarcity conditions. For instance, the Yogyakarta regional administration prepared 20 cubic meter tons that were later distributed to 27 COVID-19 referral hospitals. But in line with the rising number of patients, the oxygen supply ran out faster.
Finally, the regional administration requested extra supply from the central government and was approved to obtain an additional 47.6 tons per day, as well as reserves of 50 percent of its daily needs.
At the distributor level, the demand was even reported to rise two to sevenfold
The Industry Ministry indicated that medical oxygen demand had increased by 69 percent to 800 tons per day. At the distributor level, the demand was even reported to rise two to sevenfold.
A government study has shown that the allocation of medical oxygen from the total national oxygen production is still low. The capacity of national oxygen production can reach 866,000 tons annually, but its realization is only 640,000 tons (74 percent).
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Around 459,000 tons (72 percent) is annually used for industrial purposes while medical needs only share 181,000 tons a year (28 percent).
The government should increase investments in state-owned enterprises capable of raising oxygen cylinder production. The government has decided that 100 percent of production will be allocated to medical oxygen. The Industry Ministry has obligated all producers to allocate their entire oxygen production to medical needs.
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A nurse feeds a Covid-19 patient at a hospital in Medan, North Sumatra, Monday (14/6/2021).
Of the national production of 1,700 tons per day, 1,400 tons per day will be allocated to Java. This allocation is to be immediately carried out within the next several weeks. At the same time, the government has opened the option of importing large oxygen cylinders for prompt delivery to hospital emergency rooms in the next few weeks.
Oxygen cylinder distribution lines should be added by increasing the transportation means of delivery to speed up arrivals. The chain of distribution begins with producers’ delivery of large oxygen cylinders (1-6 cubic meters) by trucks to distributors in regions. Oxygen from large cylinders is further divided into small tubes (1-2 liters) for individual needs.
Any attempt to hoard and sell oxygen cylinders beyond normal prices should be promptly dealt with. Oxygen cylinders can indeed be bought without doctor’s prescriptions and the public is also free to trade in them. People buy the cylinders to treat the sick at home.
Reports of oxygen cylinder scarcity in health facilities and the health equipment market have panicked people into buying the tubes themselves. The price of oxygen cylinder has soared three to five times the normal rate. Several people in Lampung needing oxygen tubes for ailing family members were forced to grab the cylinders when community health center (Puskesmas) officers refused to lend them. The government has labeled hoarders of oxygen cylinders a public enemy liable to criminal charges and fines.
Indonesia is facing a major COVID-19 wave, greater than the previous one. The number of cases today have doubled since early February. The proportion of people with SARS-CoV-2 constituting 40 percent (national) or 50 percent in Jakarta is an indication that those infected but not detected may even score higher.
Apart from increasing oxygen cylinder supply through both national production and imports, we can help by not getting sick, being treated and needing oxygen. In brief, avoid being infected or infecting others. Limit leaving home for two to four weeks. Policy consistence, strict field execution and public obedience become the yardstick of success in the restrictions currently imposed.
Iqbal Elyazar
Iqbal Elyazar, Eijkman-Oxford Clinical Research Unit, Indonesian Young Scientists Academy, Scientist Collaborator of LaporCovid-19
(This article was translated by Aris Prawira)
