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In Poor Countries, Many Covid-19 Patients Are Desperate for Oxygen

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.

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.

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.

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

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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, which filter oxygen from the air, 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.

Credit…Sylvain Cherkaoui/Alima

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.

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.

  • Frequently Asked Questions and Advice

    Updated June 22, 2020

    • Is it harder to exercise while wearing a mask?

      A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.

    • I’ve heard about a treatment called dexamethasone. Does it work?

      The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.

    • What is pandemic paid leave?

      The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.

    • Does asymptomatic transmission of Covid-19 happen?

      So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • How does blood type influence coronavirus?

      A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.

    • How many people have lost their jobs due to coronavirus in the U.S.?

      The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.


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.

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.”