Silent hypoxia and black fungus cases amid oxygen shortages during Covid-19 crisis overstretched Indian healthcare system to breaking point
There are several factors behind the second Covid-19 wave surge in India. Religious (Kumbh Mela), political (election campaign), and social (Sikh strike) gatherings contributed to surge in second wave. Black fungus, silent hypoxia and oxygen supply disruptions in hospitals further fueled the Covid-19 crisis in India [Soutik 2021, Chandra 2020].
Silent hypoxia affects the blood flow in lungs of Covid-19 patients. Black fungus may cause vision loss in recovered diabetic patients. Mucor mould is found in soil, plants, manure, decaying fruits and vegetables which affects eyes, nose, lungs and the brain. Black fungus may be life threatening for diabetes and immunocompromised patients. Dr. Nair said, “diabetes lowers the body's immune defenses, coronavirus exacerbates it, and then steroids which help fight Covid-19 act like fuel to the fire.”
SARS-CoV-2 in India is infecting on average 400,000 people and killing 4000 Covid-19 victims every day. World community is sending liquid oxygen tanks, oxygen generators, concentrators and cylinders to help Covid-19 victims in India [Mike 2021]. Fresh air has 20.95% oxygen in which ±12% deviations may kill by hypoxia (shortage of oxygen) or hyperoxia (excess of oxygen).
The earth was formed 4.5 billion years ago and water evolved out of forming process 4.37 billion years ago. Earliest single cellular life started 4 billion years ago which started photosynthesis process 3.5 billion years ago. Earth’s atmosphere experienced first rise in oxygen 2.4 billion years ago triggering multicellular life 1.6 billion years ago. Aquatic plants were there more than 1 billion years ago and animals evolved 750 million years ago. Oxygen surge to 33% in atmosphere caused mass extinction some 445 to 485 million years ago [Cole 2007].
Natural air consists of 78% nitrogen, 21% oxygen and 1% other gases. Our lungs filter oxygen from the air we breathe. When lungs start malfunctioning the doctors put patients on oxygen in hospitals. Medical oxygen is extracted on large scales from air using cryogenic distillation and pressure swing absorption methods. Portable 2 to 10 liters oxygen concentrators may be used at small scales. Patients must not administer oxygen at their own, without doctor’s advice, to avoid oxygen toxicity.
Oxygen is one of the most abundant substance in nature yet thousands of people are dying in India due to shortage of oxygen supplies. There is global shortage of medical oxygen and coronavirus crisis has made supplies even worse due to high demand. Covid-19 victims were reported suffocating due to disruption in oxygen supply in Brazil and India [Janhavee 2021; Charlotte 2021]. Oxygen supply was disrupted in USA last year yet restored well in time [AP, 2020].
Brazil, Congo, Peru and Venezuela had faced similar situation during peak of covid-19 cases. At start of 2021 global demand of medical oxygen was 1.20 million canisters for 500,000 patients which now have increased due to covid-19 runaway in India. Twenty countries including Malawi, Nigeria and Afghanistan need $1.6 billion support for oxygen [AFP 2021].
Doctors and nurses need training for safe handling of oxygen cylinders. Oxygen is a life-saving substance, yet leakages may cause fire hazards. Oxygen is administered through thin tubes to patient nose. Surplus oxygen and exhaled air are removed by ventilation system to avoid build up. Minor leakages may not affect but catastrophic leakages can enhance fire. Cryogenic supply spills may cause fire by reaction of oxygen with floor materials. Oxygen fire hazards have increased during Covid-19 pandemic.
Oxygen leakage and fire incidences in 3rd week of April 202 took lives of more than one hundred patients admitted in healthcare facilities. An oxygen leakage incidence in Zakar Hussain Municipal Hospital, Nashik in India, took lives of 24 Covid-19 victims on high pressure flow ventilators [ET Bureau 2021]. Three days later, on 24 April 2021, an oxygen tank explosion killed 82 and injured more than 100 in Ibn Khatib Hospital in Baghdad, Iraq [Reuters 2011]. Oxygen needs more care than other compressed gases. In another fire incidence in Covid-19 Ward of Welfare Hospital in Bharuch, Gujrat, 18 patients died in India. However, in Batra Hospital, New Delhi, 12 Covid-19 patients died due to disruption in high flow ventilators. Media and opposition chiding incumbents [Ashok 2021].
Oxygen is an integral part of all hospitals and its uninterrupted supply of liquid oxygen is essential for critical Covid-19 patients breathing last on ventilators. Oxygen training of doctors and nurses is necessary as its presences increases fire risk in hospital environment. An oxygen fire incidence happened in Great Ormond Street Hospital London on 29 September 2008. Nobody died in this incidence as plastic burning smell and fire alarms had alerted evacuation, yet this ward was ruined in explosion. Oxygen leakages enriches soft materials around which burn more violently. Lesson learnt was to turn off cylinder right after use. Leaked oxygen may catch fire by minor spark [Mike 2008].
Keep oxygen cylinders away from combustible materials. Refrigerated oxygen may cause frostbites. It reacts violently with grease and oils. Liquid medical oxygen is non-flammable gas and a strong oxidant that intensifies combustion. Oxygen is an oxidizing agent that reacts with other materials to form oxides. Oxygen is the third most abundant element in universe, after hydrogen and helium. Oxygen constitutes 21% of atmosphere and half of earth’s crust in form of oxides. Oxygen molecules release energy in combustion process [Weiss 2008]. Oxygen and water distinguish earth from other planets.
Nature furnished the planet with plants and animals before evolution of humans. Photosynthetic archaea and bacteria in oceans started producing oxygen 3.5 billion years ago. Free oxygen began to outgas from oceans about 3 billion years ago. Great oxygenation catastrophe drove most of the anaerobic species into extinction 2.5 billion years ago. Cellular respiration in plants and animals started more than 1 billion years ago. Humans evolved about 315,000 years ago. The average healthy individual with a basal oxygen consumption has no more than four minutes supply of oxygen in the blood.
Plants use light energy to produce oxygen from water and carbon dioxide. Oxygen is used in oxygen therapy and life support systems in aircrafts and submarines. It is also used in steel mills, plastics, textiles and welding industries. When Covid-19 cases increased some countries started diverting industry grade oxygen to supplement medical grade oxygen in hospitals. Flu virus (H1N1) outbreak in 1918 killed 50 million and infected 500 million people when world population was 1.5 billion. Pyres had no wood and graveyards were full so people started throwing dead bodies in flowing waters which choked all the Indian rivers. Covid-19 has so far caused 3 million deaths and 150 million infections.
Traders hide health and food items during emergency to cause inflation for windfall profits. Pakistani traders sell oxygen at Rs80-90/L and cost of 10 liter cylinders was Rs1,400. Media reported some retailers selling 5L cylinder on Rs2,000 to Rs4,000 prices [Web 2021]. However, prices of 8Kg (240 L) oxygen cylinders on OLX were seen varying from Rs4,500 to Rs17,000 during third wave of Covid-19 in April 2021, when oxygen prices in India were reported to be $600 to %1300 per cylinder in 4th week of April 2021. Daily new cases were 379,359 on 29 April 2021 in India. CNN and BCC claim actual cases are far more than this. More than 150 people are dying in one hour in India and Brazil.
Acute shortage of oxygen supplies in India made the Covid-19 pandemic a nightmare [Marianne 2021]. Hundreds of Covid-19 victims died due to shortage in oxygen supplies. Police convoys started escorting oxygen tanks to ensure safe oxygen supply to hospitals [Alasdair 2021]. Indian oxygen demand peaked at 2,800 MT/day in first wave which surged to 5,500 MT in second Covid-19 wave. INOX Air company has medical grade oxygen production capacity of 2,200 MT/day which supplies to 800 hospitals from 25 plants. Privy sources claim Indian oxygen production capacity is 7,287MT which is still higher than peak demand. More than two dozen industrial plants supply 1,500 MT of oxygen to maintain supply line [BBC 2021]. Indian graveyards are full and crematoriums pyres reveal war like situation reflecting collapsed healthcare system as patients were crying on roads [Sheikh 2021].
United States, United Kingdom, Germany and Russia started sending oxygen, tests, treatment, PPE, concentrators, ventilators, oxygen supplies and medical aids to India when daily covid-19 cases surpassed 350,000 in second wave. Imran Khan prayed for earlier recoveries, Edhi Foundation and Government offered ambulances, digital x-ray machines, oxygen supplies and medical aids to deal with rampant rise in Covid-19 cases [Ciara 2021, Geeta 2021; Reuters 2021; Ayaz 2021]. UK was the first country to send the oxygen concentrators in India. China has also offered help to India.
Pakistan had hardly 420-ton daily oxygen production capacity which has now been increased to 800-ton by adding 380-ton capacity. We use 80% of available oxygen capacity in hospitals and 20% in industries. Steel mill oxygen plant can produce 520-ton oxygen which was shut down long ago and 40 plant operators removed from service. Government can arrange water and 165 MW power supply connection to restore it. Pakistan Ordinance Factor, Port Qasim Plant Karachi and Tarbela also produce oxygen. Pakistan Oxygen was the first oxygen production factory setup in 1949. Estimated oxygen supply capacity of Pakistan Oxygen was 133-tons per day in 2018. Government of Pakistan is buying 5,000 oxygen cylinders and 6,000 tons of oxygen in view of rising cases and deaths in third wave.
ICU beds Lahore are 90% full and, oxygen beds in Multan and Gujranwala have reached their 85% to 88% capacities [Sama 2021]. Oxygen capacity utilization used to be 80% of capacity before start of Covid-19 pandemic. Medical oxygen demand used to be 250-ton per day before start of Covid-19 which increased to 300 to 500 tons per day in 2020. Estimated oxygen demand in third wave of Covid-19 seems to be more than 700-tons per day in 2021 [Molly 2021]. Government is arranging to import oxygen from Iran and China by road as it can’t be imported by air.
Oxygen is produced either by chemical reaction or fractional distillation. Hospitals use liquid oxygen that is stored in chilled tanks and boiled at -182.96°C in gas phase. Oxygen may be compressed in gas cylinders for subsequent use through regulators. Oxygen concentrators may separate oxygen from air for use of one person at home. Oxygen delivery system include pressure regulators, flowmeters and Thorpe tubes. However, scuba divers, aircrafts and submarines need natural breathing gas (air). Medical grade oxygen cylinders are painted white (shoulder) and black (body).
A single piston liquid oxygen pump is used to fill cylinders at 165 Kg/cm2 pressure. Oxygen is produced by separation method direct from air with 99.5% purity at production rates of 80 to 600 m3/h. A typical cylinder stores 7 m3 oxygen at 150 bar (15 MPa) pressure. A typical oxygen and nitrogen plant of 11-ton oxygen capacity costs Rs70 to Rs80 millions [SMEDA 2012]. Industrial gases are mostly extracted from air through distillation. Pure gases are separated from air by first cooling to liquefy then selectively distilled at their various boiling temperatures. Global industrial gases business was $85 billion in 2019.
Oxygen is compressed into cylinders at about 20 MPa. When the cylinder bursts the temperature rises from 25 to 250-350°C and pressure from 150 to 300 bars. Fire is direct hazard yet major hazards are cylinder metal debris and fragments which fly around with high speed. Oxygen cylinder valves often get rusted and mediate gas leakage. Keep cylinders up right at secure places [Bożena 2018].
Air pollution had already made the New Delhi a gas chamber and covid-19 explosion has made it horror chamber with terrible death scenes without oxygen and ventilators. India is a global pharmacy for planet yet caste system and poverty has made health care in accessible to poor. High caste Hindus have access to healthcare low caste untouchables and minorities left to mercy of nature [TNN 2019, Vidya 2021].
Face masks are used to protect against entry of viruses and bacteria through nose and mouth. However, some industries place graphene coating on face masks. Graphene incapacitate viruses and bacteria by sharp edges mechanically as well as electrocuting them electrostatically. It produces oxygen free radicals which incapacitate the viruses [Pawan 2021]. It observed the coronavirus can survive for days on graphene coated face masks and inhaling of graphene particles do on lungs what the asbestos does [White 2021].
Several stories report coronavirus attack on brain causing memory loss and brain fog. A basic question is how SARS-CoV-2 gets there. Brain is separated by semipermeable barrier stopping bacteria and viruses as air sacks in lungs don’t allow pathogens and particles enter blood streams. Once the coronavirus makes way to brain it can attack the central nervous system. Coronavirus invades human cells in throat, lungs, heart, liver and kidneys by attaching to ACE2 receptors which are not there in brain cells. A recent study shows both neurons and astrocytes have ACE2 receptors [Boldrini 2021].
Runaway coronavirus cases have caused shortage of oxygen supplies, ventilators, personal protective equipment, testing and diagnostic systems in hospitals in India. UK, USA, Germany, France, Russia and many others have started sending emergency medical aids to India. China and Pakistan have also offered medical aid to India during peak of pandemic [UP 2020].
A pernicious form of social distancing was already in practice long before Covid-19 pandemic which now has become even worse. Untouchables and minorities from seven sister states face hard times during covid-19 outbreak. The curse of caste system has become more exposed at public places. Not speak of Covid-19 vaccines the minorities have no equal access to ICU and oxygen facilities [Sumit 2020]. The Covid-19 lockdown disproportionately hurt marginalized communities due to loss of livelihoods and lack of food, shelter, health care, and other basic needs. Curfew was even more tightened in Kashmir [WR 2021].
However, global medical aid could not reach so far to minorities in villages. People in rural areas are dropping like flies, says local media [Arunbah 2021]. Many countries have sent oxygen generators, oxygen concentrators and cylinders to India yet people especially minorities claim to have got nothing [Arunabh 2021]. Covid-19 has exposed the curse of caste system in India.
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