MUMBAI, India — Sanchi Gupta was running around, trying to get her hands on an oxygen cylinder — even an empty one.
Her mother was one of 140 COVID-19 patients in Saroj Hospital, one of the best-equipped hospitals in India's capital, New Delhi. She was on a ventilator in intensive care. Then the hospital told Gupta and other families that its oxygen supply had run out. So they had to go out and find oxygen cylinders to bring to the hospital to keep their loved ones alive.
"We are not getting full cylinders, so we are trying to find empty cylinders, because we can still get those filled," Gupta explained to local media outside the hospital last month. "We're in contact with NGOs [in the hope that they have tanks that can fill cylinders], everybody! We're using every kind of pressure, every contact. We are desperate."
She pleaded for answers from strangers on the sidewalk outside the hospital.
"What is happening with the government? Why don't we have oxygen?" Gupta cried. "Why? Why is this happening?"
In India, procuring oxygen is a task that normally doesn't fall to patients' families. But with the country confirming more than 300,000 coronavirus cases a day for the past two weeks, medical supply chains have broken. In addition to oxygen shortages, there are shortages of hospital beds, antiviral drugs, coronavirus test kits — virtually all the tools any country needs to fight a pandemic.
It's a consequence, experts say, of decades of neglect and lack of spending on public health in a country of nearly 1.4 billion people — one that is now hit by the biggest coronavirus wave in the world.
"It is disheartening. We are not a rich country. There has always been an inadequate health budget," says Dr. Vineeta Bal, an immunologist at the Indian Institute of Science Education and Research in Pune.
Bal notes that India invests less on public health — just above 1% of its gross domestic product — than most of its peers. Brazil spends more than 9% of its GDP on health; in the United States, the figure is nearly 18%.
"One percent of GDP is a pathetic state of affairs," Bal says. "It's nothing!"
At Saroj Hospital, local government officials eventually got a giant tanker to deliver oxygen, replenishing stocks for Gupta's mother and other patients. In the end, they didn't have to rely on the small cylinders that families were able to scrounge up.
Other hospitals have not been as fortunate.
Hospital SOS: "Kindly help us in procuring [oxygen]"
On Tuesday, as many as 24 patients died after the Chamarajanagar district hospital in the southern state of Karnataka allegedly ran out of oxygen. On Saturday, 12 COVID-19 patients died at Delhi's Batra Hospital after an oxygen delivery was delayed by just 90 minutes. Several more such incidents have been reported across the country.
And it's not just COVID-19 patients. A children's hospital near the capital put out an SOS notice Saturday, warning that it was running out of oxygen and that six babies in critical care might suffer "severe consequences."
"Kindly help us in procuring [oxygen cylinders] for the sake of the babies and mankind," a news release from the hospital said, which was shared on social media. The notice was addressed "to whom it may concern."
The Allahabad High Court in northern India on Tuesday declared that hospital deaths from oxygen shortages amount to "genocide." In India, courts frequently work in a suo moto capacity (the term means "on its own"), investigating issues of public concern without the need for a lawsuit to first be filed. In this case, the Allahabad High Court began investigating oxygen shortages because of viral videos showing such shortages in its jurisdiction.
"This wave [of infections] happened so fast! So it was very difficult to manage all the things. People at home also bought [oxygen] cylinders and started using them," says S.D. Mishra, who oversees COVID-19 oxygen supply at the Petroleum and Explosives Safety Organization, a government agency that regulates the transport of oxygen and hazardous substances. "So because of this panic situation, there was a sudden increase in demand in oxygen supply."
"We actually have excess production and storage [of oxygen] in eastern India and other areas, but Delhi is having problems," Mishra told NPR by phone from his agency's headquarters in Nagpur, in central India.
These shortages have been happening even as the U.S. and many other countries pour aid into India. That includes empty cylinders and oxygen concentrators — machines that extract oxygen from the air and concentrate it for medical use.
On April 28, the U.S. dispatched to the Indian capital its first shipment, which included more than 400 oxygen cylinders and 960,000 rapid-testing kits. Since then, at least four more shipments from the U.S., carrying more than 200,000 vials of the antiviral drug remdesivir and additional oxygen support, have arrived in Delhi and Mumbai. Countries around the world, including the United Kingdom, the United Arab Emirates, France, Uzbekistan, Thailand and many others, are sending ventilators, liquid oxygen and oxygen concentrators.
Much of that aid has become mired in customs queues. State officials told Indian media that some of it began to be dispatched on Monday night — more than a week, in some cases, since it had arrived. During that time, COVID-19 patients were dying of shortages in hospitals only a few miles from these stockpiles.
Late Wednesday local time, the Indian government issued a news release saying a "streamlined and systematic mechanism for allocation" of foreign aid supplies had been implemented. "Cargo clearance and deliveries are facilitated without delay," the release stated. All donations received by May 4 have already been allocated to recipient states or institutions, and a "substantial part of it stands delivered," it added.
"The challenge now is to transport the oxygen"
The Indian government says it has ramped up oxygen production. It has banned the use of oxygen for industries, with a few exceptions — for the military, for example — and is diverting most of it for medical use.
But the problem has been getting the oxygen to medical facilities.
"The challenge now is to transport the oxygen," Piyush Goyal, a spokesperson for the Home Affairs Ministry, said in a news conference on April 26.
Liquid medical oxygen is flammable and in most cases can't be flown. It has to move by road, rail or sea freight.
"The demand for tankers [that can be filled with oxygen] has gone up, and we do not have enough tankers available," said Goyal.
Mishra, the oxygen supply official, says lots of oxygen-tanker drivers got sick with COVID-19 right at the moment when oxygen demand skyrocketed. Officials had to arrange replacement drivers, and it took time.
In some parts of the capital, oxygen demand is up as much as 700%. According to the Delhi government, hospitals are asking for close to 1,000 metric tons of liquid oxygen per day on average, but only 40% of that is being supplied.
Most of India's oxygen-generating plants are in the country's east and south. But demand right now is mostly in the north. That means 18-hour trips by tanker truck. India's Air Force has been airlifting empty tankers back to the factories to cut travel time. It has also been picking up extra containers from abroad. On Tuesday night, an Indian Navy ship arrived in Kuwait to pick up donations of liquid oxygen and other supplies.
Indian Railways has run at least 27 special trains delivering more than 1,500 metric tons of liquid oxygen to several states. Two such "Oxygen Express" trains pulled into Delhi on Wednesday, Railways Minister Piyush Goyal (no relation to the Home Affairs Ministry spokesperson) announced on Twitter.
This week, the government announced that two oxygen plants would be quickly constructed inside two big Delhi hospitals. They're expected to begin supplying oxygen by Wednesday evening.
"Crucial lessons ... were simply not learned"
Mad scrambles for oxygen at so many hospitals underscore one of the biggest problems: how bureaucracy has slowed things down. The Indian government has taken over oxygen distribution but still does not have the systems in place to deliver. Dr. Sumit Ray, the critical care chief at Delhi's Holy Family Hospital, has experienced that firsthand.
"There are patients dying who come in ambulances, searching from hospital to hospital, and they are brought in dead because they did not find oxygen — or the oxygen in the ambulance ran out," he tells NPR.
His 275-bed hospital was instructed by the government to handle only COVID-19 patients. It has since expanded to 390 beds by squeezing two or three beds into rooms that were previously for one. Corridors have been sealed off and lined with beds, oxygen cylinders and monitors. In the intensive care unit, stretchers have been placed in between permanent beds. The hospital has run out of ventilators, so technicians have repurposed anesthesia machines from operating rooms to help COVID-19 patients breathe, Ray says.
On April 23, Holy Family Hospital came within 30 minutes of running out of oxygen. Ray describes a mad scramble to hook up patients two to a cylinder and to triage who could be saved. He put in frantic calls to local government officials.
"It's not that they were not trying to help, but they themselves didn't know how to go about it. The systems were not in place," Ray recalls. "All the logistics of large-enough tankers moving fast enough, and also coordinating! Because the demand has gone up. So you have to coordinate much more on who gets how much."
Local governments are relatively new to this. Most Indian hospitals used to procure their own oxygen directly from suppliers. But in March 2020, when Prime Minister Narendra Modi put India under the world's biggest coronavirus lockdown, the government got involved in regulating essential medical supplies, including oxygen. Hospitals now have to send refill requests to their state government, which in turn asks the central government. The process is overseen by a committee called the Empowered Group 2, a government-appointed body.
Last year, Ray says, his hospital was asking for refills once a week. Now he says it's using "10 to 12 times as much oxygen" — which means he's calling for refills more than once a day.
The requests to the government quickly pile up.
On April 23, an oxygen tanker eventually pulled up to replenish Ray's hospital, when he had just 30 minutes' supply left. Disaster was averted. And tankers have since been arriving on time, he says.
But the close call that his hospital experienced last month says something about India's pandemic preparedness more than a year after the pandemic began. Experts say the country did not use its time wisely, when its coronavirus caseload dropped to record lows in early 2021.
"There was a sense of complacency, and many crucial lessons that we could and should have learned — what we needed to do to strengthen the health system to prepare for a second wave — were simply not learned," says Yamini Aiyar, president of the Centre for Policy Research, a Delhi think tank. "Perhaps no one could have predicted how virulent this surge is."
"But our complete lack of preparedness has brought this already-broken system to its knees," she says.