The Silver Lining
Dr. Rajendra Bharud an Indian Administrative Services (IAS) officer of 2013 batch presently Collector Nandurbar in the tribal area of Maharashtra started setting up a liquid oxygen plant way back in September 2020 when the first wave of Wuhan virus had commenced ebbing. Today the district hospital has a capacity of 1800 liters of liquid oxygen per minute. The hospital is increasing its capacity to 3000 liters per minute with five plants. Each plant produces 600 liters per minute with an installation cost of Rs 87 Lakhs (8.7 Million). They have pioneered another management technique of ensuring proper use of medical oxygen by instituting the practice of ‘Oxygen nurse’. She decides who gets oxygen support and for how long. Obviously the hospital must have laid down appropriate guidelines for the oxygen nurse.
By Brig (Dr) Ashok Pathak
Raised by a single mother at Dhule in Maharashtra Dr. Bharud approached Western Railways of India to help him with railway coaches as isolation wards. In no time the Indian Railways sprang into action and provided him 21 coaches, each coach has facility for 16 patients equipped with coolers and two oxygen cylinders. The Indian Minister for Railways and Commerce promised all support to Dr. Bharud1.
Nandurbar with a population slightly over three lakhs and literacy rate of 55.77 percent is anobscure taluka on the Maharashtra- Gujrat border 446 kilometers from Mumbai on the National Highway 48, with travelling time of around nine hours. It must be much below the national average on almost all counts. But no one died in the district hospital for want of oxygen. Nandurbar also woke up to the need of medical oxygen much before the crisis blew up on us. They also identified the managerial requirement of its appropriate usage and cut down wastage. Dr. Bharud’s achievement as a district collector was highlighted on page 14 of the Times of India dated 28 April 21. No one found it fit for the headlines. What did the headlines of newspapers cover for a full week?
Oxygen Crisis Leading to an Emergency Situation!
The second wave of the Wuhan virus infections in India commenced in mid-March 21. The Indian Prime Minister said that ‘it has shaken the country’. By third week of April 21 most newspaper headlines started flashing oxygen crisis. Patients were dying, people were in distress, judiciary was in anguish, and hospitals’ administrations were in helpless panic, some of the elected leaders made political statements. Here are some sample headlines.
‘City hospital gasps for oxygen on hour to hour basis’. ‘Horror story from sharing O2 cylinders to halting admissions’. ‘Delhi NCR in Chokehold still, four die at Gurgaon Hospital’. ‘Gurgaon and Rewari eight patients die due to shortage of oxygen’. National Health Emergency: Supreme Court asks center for plan today; How will you bolster supply of O2; Ensure O2flow or face criminal action (Delhi High Court to authorities). Will hang anyone obstructing oxygen supplies, Warns Delhi HC. With Oxygen running out Delhi -NCR hospitals start asking patients to leave.
The Chief Minister of West Bengal told center that oxygen manufactured in Bengal is meant for the state and should not be diverted to other states (UP and Madhya Pradesh). The Chief Minister of Delhi requested the Prime Minister that all oxygen manufactured in the country must be taken over by the Army and Army should be made responsible to ensure supply of O2 to hospitals in all the states.
Special trains were running from the Oxygen producing states in India to the states facing shortage medical oxygen. The strategic lift aircraft of the Indian Air Force – Globe Trotter and IL 76 were ferrying cryogenic oxygen containers from across the globe and within India. Some state governments declared that sanctions for establishing new hospitals will be given only if theyinstall oxygen plants as part of its infrastructure.
How Big and Complex is the Problem?
For the people of Nandurbar and for Dr. Bharud producing medical oxygen for the district hospital was ‘another job in a day’s work’. They anticipated the need much in advance and never let the problem grow to monstrous proportions. They adopted new managerial techniques to prevent wastage and ensure timely action. They collaborated with central agencies and got prompt help. For rest of India the situation was different. Why has the problem become so big and complex for rest of India? Is it because of science and technology involved or some other reasons?
The Science and Technology of Medical Oxygen
Identified as a new element by Joseph Priestley of UK in 1774 oxygen was first produced in 1885 by Karl Paul Gotfried Von Linde of Germany and William Hamspen of England by careful distillation of liquid air. 18 Its first use was in industry for welding -mixed with acetylene. Later liquid oxygen was used in rocket engines as fuel. Today it is one of the key components of many industrial processes19. Before the crisis struck India produced 7500 metric tons of oxygen per day (out of this 6600 metric tons are being allocated for medical use to fight the pandemic).
Though distillation from liquid air is the most prevalent method of producing purest form of oxygen there are other methods that can produce about 90 percent pure oxygen is good enough for medical use. These methods include cryogenic processes where oxygen is produced by fractional distillation of liquefied air, Pressure Swing Adsorption (PSA) based medical oxygen plants, Vacuum Pressure Swing Adsorption (VPSA) as also by normal electrolysis of water and electrolysis at zero gravity. All these technologies developed almost a century back have been refined over time to make production of high purity oxygen cost effective.
Indian State Galvanized to Fight the Oxygen Crisis
Government of India had ordered 162 such plants to be installed in October 2020, as on date 33 are operational at the cost of about Rs1.24 crores per plant that includes maintenance for next seven years. By end May eighty plants will be operational. As the crisis blew up additional funds were allotted from the PMCARES (Prime Minister’s Citizen Assistance and Relief in Emergency Situations) fund to install medical oxygen plant for more hospital. The DRDO has also pitched in with its expertise. From the pre Covid-19 production of about 700 to 800 tons per day of medical oxygen production in India may touch 6000 to 8000 tons per day. With the current momentum it is quite likely that very soon all hospitals in India will have their own captive oxygen plants. The nation has the capability to overcome the crisis. But we need to look at some very pertinent questions on the way ‘we the people’ nurture our democracy.
Pertinent Questions and Analysis
The most relevant question here would be, ‘Who is responsible for the oxygen crisis?’ Simple answer is, ‘those who are responsible for treating the sick’. We may argue that how can doctors ensure installation of oxygen plant? The same way that hospitals get the MRI machines, joint replacement, angiography machines installed. Hospitals today are full of appliances running on principles of pure science and technologies. We need to ask the Chief Medical Officers, Chief Executive Officers and owners of hospitals what did they do to foresee the problem and fix it before it blew up. There can be many reasons why the hospital administrations did not act in time. May be the doctors in the government hospitals do not have appropriate authority or they do not know the managerial processes as to how to go about it. It can be that they think it is someone else’s job- may be the Prime Minister, the Health Minister or some bureaucrat who has all the perks and power. There is a need to enlighten, empower and cajole this first line of defence. Had all the district hospitals acted the way Nandurbar hospital did no one would have died for want of oxygen and even for want of beds, isolation wards.
The second and most obvious question is if Dr. Bharud sitting in an isolated tribal area could do it why not others? After all installation of medical oxygen plant did not require some path breaking research or awfully superior knowledge. It did require commitment to work, sincerity of purpose, foresight and will to fight the odds. Apparently these ‘essential qualities’ in an average district head are rare to find. The reason for this could be excessive job security, tendency to reward ‘play it safe’, mark -your -time-approach that breeds in- efficiency and mediocracy. We saw this strange behaviour in the national capital.
The third question could be why the PMCARES fund when allotted as early as October 2020 could not be utilized before the current crisis came over us. This is where the eternal lack of coordination among various government institutions and agencies becomes the root cause of our failure. During the hearing of this case in Delhi High Court the central government officer confirmed that though eight plants were sanctioned for Delhi, site clearance of only one plant was received on 19 April 21. He also informed the court that in some cases the site allotted by the hospitals was not appropriate. In some other cases the paper work was still pending. Apparently we are a long way from proper coordination, collaboration and commitment in most serious of the issues. Even the 1991 liberalization has not helped us cut the red tape and speed up our processes.
Lastly the din and noise raised in the public domain represents the way we think and function. Some of the statements coming from the most respected institutions in the country could have been avoided. The elected representatives of the democracy could have been more circumspect in saying what they said. The public discourse could have focused on the likes of Dr. Bharud way back in September 2020. Someone could have raised the issue of the slow pace of utilization of PMCARES fund for the oxygen plant way back in November 20. This would have alerted the authorities and Delhi would have had all the eight oxygen plants running in March 21, much before the time when the first death took place due to lack of oxygen. We have several pillars of democracy. Each pillar must strive to collaborate in constructive manner. Instead these pillars appear to be consistently antagonistic of each other in an obstructive manner.
We appear to have become habitual of blaming the ‘system’ finding convenient scapegoats, suggest new structures and rules and occasionally run down ourselves, our nation and our culture. In the bargain we very frequently ignore the fact that officers like Dr. Rajendra Bharud achieve seemingly impossible results in the same system with the same set of rules in much more trying conditions than most of his other compatriots working in highly endowed metros in close proximity with people in power.
Democracies function on ‘people’ who make the systems and make them work. A system is as good as the people who are responsible to run it. These people need not be at the top. They can be anywhere, at bottom of the pyramid, in the middle or at the apex level. In each case the relevant systems are not as important as the people are. It is time that ‘we the people’ start making positive contributions in whatever positions we are.
This article first appeared in www.vifindia.org and it belongs to them. The author is a research associate with VIF.