• The need to streamline O2 supplies in Sri Lanka to avoid widespread crisis 

By Sumudu Chamara Since the end of the three-decade civil war, the Covid-19 pandemic has posed the largest challenge that Sri Lanka has had to manage – an unseen enemy wreaking havoc on the people, while crippling the economy with increased health expenditure alongside decreased production and income, making it difficult to fight back with the limited resources available. This scarcity has led to many parties, especially health workers, lamenting inadequate resource allocation from the Government. Inadequate stocks of vaccines, the insufficient conduct of PCR tests and rapid antigen tests (RATs), and the lack of proper facilities at treatment centres were prevalent among these allegations. The situation seems to be nearing boiling point, with concerns arising over a potential shortage of oxygen (O2) for critically-ill patients, triggered by increasing demand and overburdened hospitals.  Oxygen supply and hospital capacity Even though health workers had previously raised concerns about the adequate procurement of oxygen and its effective supply to Covid-19-infected persons, the discussion about oxygen stocks arose again during the course of this week, after the Health Ministry on Tuesday (27) stated that the need for oxygen in the treatment of Covid-19-infected persons has increased and that hospitals are nearing full capacity. Adding that the health authorities are seeing a higher percentage of patients with symptoms than ever before, Health Ministry Communications Director, Public Health Services Deputy Director General, and Disaster Preparedness and Response Division Head Dr. Hemantha Herath revealed that the need for oxygen has, therefore, increased considerably. He also told the media that under the prevailing circumstances, hospitals had reported that they were operating close to full capacity. However, just three months ago, the Health Ministry had assured the public of the continuous and adequate supply of oxygen from firms providing oxygen for medical purposes, and said that they were in a position to provide more than the required amount of oxygen. Dr Herath’s statement came a week after Sri Lanka Medical Association (SLMA) President Dr. Padma Gunarathne highlighted the demand for oxygen. She said that the National Hospital of Sri Lanka (NHSL) in Colombo records about 200 Covid-19 patients a day, and that about 100 of them require oxygen supply support.  Oxygen supply: The status quo To look into the present situation of the supply of oxygen to Covid-19 treatment facilities, we spoke to several persons who have knowledge of the situation. Emphasising that the growing demand for oxygen is a pressing concern, the Government Nursing Officers’ Association (GNOA) President Saman Rathnapriya said that there is also a risk of an oxygen shortage if the situation remains unaddressed. He added that even though the Intensive Care Units (ICUs) of some major hospitals possess wall-fitted oxygen facilities (providing oxygen through pipes running through walls), at least 60% of treatment facilities established for the treatment of Covid-19-infected persons do not possess such equipment. He explained: “Sometimes, the health situation of Covid-19 infected persons worsens all of a sudden, and the best way to treat them is using wall oxygen supply facilities because it helps provide an uninterrupted oxygen supply. However, we have not provided such facilities for a majority of hospitals, including the newly established Covid-19 treatment centres. Those treatment facilities usually use cylinders of oxygen, which require to be replaced when one cylinder finishes.  “This is a practical matter that negatively affects this method of supplying oxygen, because it is not very effective in a context where some treatment facilities treat a large number of Covid-19-infected persons, with very limited medical staff. It is difficult to manage when they have to keep track of the cylinders of oxygen in large treatment facilities and have to replace the cylinders on time.” Even though health sector trade unions have already brought this matter to the attention of the authorities, according to Rathnapriya, so far, no tangible measures have been taken to make the supply of oxygen more efficient. He also said that in addition to increasing the efficiency of supply, there is also an urgent need to increase the amount of oxygen provided for Covid-19-infected persons. However, when inquired about the importance of managing available oxygen supplies, the Government Medical Officers’ Federation (GMOF) said that they believe the health authorities are taking necessary measures to manage the oxygen requirement and supply, although the oxygen requirement is on the rise due to the increasing number of patients. GMOF President Dr. Rukshan Bellana told The Morning: “A shortage arises when the demand exceeds supply, and the requirement keeps increasing every day. If Sri Lanka does not manage the oxygen requirement properly by increasing the supply to meet the demand for oxygen, a severe shortage may arise, and it will put patients’ lives at risk. However, as far as we are aware, there is no such shortage of oxygen at present.” Meanwhile, in response to these growing concerns with regard to oxygen stocks, Dr. Herath yesterday (28) told The Morning that even though the demand for oxygen has not yet exceeded current supply, the rising demand has prompted health authorities to take steps to increase hospital-based treatment and oxygen facilities, as a precautionary measure in the event of an emergency. Speaking of the oxygen requirement in the country, Dr. Herath added: “Steps are being taken to expand the oxygen supply.” However, he emphasised that this does not mean that there is an oxygen shortage. “No patient can be allowed to die due to the lack of oxygen under the circumstances that are likely to arise in the future. The Health Ministry would take immediate action to expand the oxygen stocks in the country, and if the stocks of oxygen in the country are insufficient, steps will be taken to import the necessary stocks,” he assured.  Dr. Herath explained that as part of the said preparations, when there is a rise in the number of Covid-19-infected persons admitted to a hospital, steps would be taken to refer those patients to other locations, including intensive care units, depending on the need. As far as Sri Lanka’s situation is concerned, development of the relevant infrastructure was discussed in April. To meet the increasing demand, Ceylon Oxygen Ltd. (COL), the country’s largest oxygen supplier that supplies 60% of the local oxygen requirement, urged the Government to facilitate piped oxygen supplies connected to tanks, instead of cylinders of oxygen. Writing to the Health Services Director General (DGHS) Dr. Asela Gunawardena, the COL also urged the Government to establish dedicated Covid-19 hospitals with piped oxygen connected to a bulk oxygen storage tank, which would ensure a continued and reliable supply for Covid-19 infected persons in need of high-flow oxygen. Expressing confidence that Sri Lanka has sufficient manufacturing and distribution capacities that could, according to the estimates, provide three times the demand for oxygen (at the time of writing to the Government), the COL proposed to the health authorities to minimise the disruption in provision of medical supplies, as seen in countries like India and Bangladesh. The COL also proposed to the Government to divert the supply of 10 imported oxygen storage tanks intended for hospitals that already have bulk storage tanks to hospitals that, they claimed, were using cylinders of oxygen as a primary source. These hospitals, it noted, are the Colombo South Kalubowila Teaching Hospital, the Teldeniya Base Hospital, the Kalutara General Hospital, the Puttalam Base Hospital, the Chilaw Base Hospital, the Kurunegala Teaching Hospital, the Minuwangoda Base Hospital, the Mulleriyawa Base Hospital, the Karawanella Base Hospital, and the Nawalapitiya Base Hospital. State Minister of Primary Health Care, Epidemics, and Covid-19 Disease Control Dr. Sudarshini Fernandopulle confirmed to The Morning that matters pertaining to supplying oxygen come under the purview of the Health Ministry, and not her State Ministry. However, attempts to contact DGHS Dr. Gunawardena and Health Minister Pavithra Wanniarachchi to inquire about measures being taken to increase the oxygen supply to meet increasing demand were unsuccessful. Global situation According to the Programme for Appropriate Technology in Health (PATH) – a global health organisation focusing on vaccines, diagnostics, and health devices and systems, among others – as of 27 July, the daily oxygen need for the treatment of Covid-19 infected persons in low and middle-income countries had risen to 16.4 million cubic metres, which is approximately 2.3 million cylinders of oxygen. The estimated annual cost for this requirement exceeded $ 3.25 billion.  Even though Sri Lanka is not facing a scarcity of oxygen at present – at least not officially – according to the World Health Organisation (WHO), the increasing demand for oxygen is affecting more than half a million Covid-19 infected persons who require oxygen treatment in low and middle-income countries, and affordable and sustainable access to oxygen has been a growing challenge in those countries. Based on research data, early this year, the WHO said that more than half a million people in these countries require 1.1 million cylinders of oxygen per day, with 25 countries reporting surges in demand, the majority in Africa.  Adding that Covid-19 has put a huge pressure on health systems, with hospitals in many low and middle-income countries running out of oxygen and resulting in preventable deaths and families of hospitalised patients paying a premium for scarce oxygen supplies, the WHO also said that the main reasons for such shortages are the cost, infrastructure, and logistical barriers. According to the researchers, a considerable portion of Covid-19-infected persons die of Covid-19-related pneumonia, a medical condition which most of the time requires oxygen supplementation. Therefore, the need for an effective and adequate supply of oxygen is a concern that requires attention. India’s situation during the past few months is a good example that shows how a shortage of oxygen supply could lead to not only more cases, but a national-level crisis. Despite concerns and allegations concerning a potential shortage of oxygen in Sri Lanka, or the emergence of a crisis creating excessive demand, health authorities have not confirmed any shortage so far, and remain hopeful that such an issue would not arise. However, being prepared is always better than being too late, especially with so many lives on the line.