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Vinay Srivastava said on Twitter at around 8pm on April 16 that when there was no hospital in Lucknow to answer his call, his oxygen saturation level was dangerously low.

Oxygen saturation in the blood below the level of 94 is considered a concern for Covid-19 patients. Srivastava said his level is 52.

As the 65-year-old freelance journalist's complaint went viral on Twitter, the media adviser to the Chief Minister of Uttar Pradesh replied to him the next afternoon asking for more details. At that time, Srivastava's oxygen level had dropped to 31.

At 4:20 pm on Saturday, his son Harshit Srivastava tweeted that his father had passed away-waiting for an ambulance. "We got nothing," he told Scroll.in on the phone. "I dialed every number of the oxygen cylinder, but no one answered it."

About 7 kilometers away from their home, the government-run Shyama Prasad Mukherjee Civil Hospital has been waiting for an oxygen plant. It is one of 150 regional hospitals across India, and the central government tendered it in October eight months after the coronavirus pandemic to create a device that can produce medical oxygen on site.

But six months later, the oxygen generator has not yet been installed. If it is in place, Lucknow residents who are breathless like Srivastava will be more likely to survive Covid-19. This city of 3 million people currently has 44,485 confirmed cases of coronavirus.

"My father could have been saved," said Harshit Shrivastava, who was still waiting for his father's Covid-19 report hours after his death. "This is completely the government's fault."

About 1,200 kilometers away, in Nafsari, Gujarat, another regional hospital had to refuse admission to several Covid-19 patients who needed oxygen in the past few days due to the installation of an oxygen generating device.

"There is a total shortage of oxygen," said Avnish Dube, chief medical officer of the 175-bed MGG General Hospital in the area. Last week, it was reported that five Covid-19 patients died in a private hospital due to lack of oxygen-even though the official number of cases in the area was just over 500.

If the oxygen plant is in place, Nafsari can even cater to patients from Surat, one of the worst-hit cities in Gujarat, less than an hour away. However, at present, when the nearby hospital contacted him, Dubey said, "I have to tell them,'Don't send them here.'"

India declared the coronavirus pandemic to be a "disaster" on March 14, 2020. Ten days later, more than 1 billion people were placed under the worst lockdown in the world, and the government believes that it will take time to expand the country’s health care capabilities.

In the early stages of the pandemic, it is clear that oxygen will become one of the most valuable commodities in the fight against the virus. However, it took the Narendra Modi government eight months to bid for the new oxygen plant.

On October 21, the Central Medical Service Association, an autonomous organization under the Federal Ministry of Health, opened an online tender for bidders to establish pressure swing adsorption oxygen plants in 150 regional hospitals across the country. PSA technology separates the gas from the mixture in the atmosphere to produce concentrated oxygen that can be piped to hospital beds, eliminating the need for hospitals to purchase pressurized liquid oxygen from other sources.

It seems unlikely that the delay in starting the bidding process was due to lack of funds: 162 oxygen plants (it seems that 12 plants were added later) cost only Rs 201.58 crore. The money was allocated from the PM-Cares Corpus (Prime Minister’s Citizen Aid and Relief Fund in Emergency Situations), which received more than 3,000 crore donations within four days of its establishment on March 27, 2020.

Now, with the deadly second wave of Covid-19 pandemic sweeping the country, the Modi government said in a statement on Thursday that it will use the PM-Cares fund to build another 100 oxygen plants. Regarding the status of the 162 oxygen plants that signed contracts in 2020, it only said that they are "closely reviewing, with a view to completing 100% of the plants ahead of schedule."

Questions sent to the Central Medical Service Association and the Ministry of Health of the Trade Union were not answered at the time of publication, asking about the status of 162 oxygen plants.

But an independent investigation by Scroll.in revealed a disturbing delay. We called more than 60 hospitals in 14 states, and we expect to build new oxygen plants in these states. According to interviews with hospital officials, only 11 units were installed and only 5 were in operation.

Update: Two hours after this article was published, the Ministry of Health issued a series of tweets confirming that most of the new oxygen plants were not working properly. “Of the 162 PSA oxygen plants, 33 have been installed,” it said. "By the end of April 2021, 59 will be installed. By the end of May 2021, 80 will be installed." The ministry is likely to mean that a total of 80 factories will be installed by the end of May-less than half of the number of newly approved factories ——Because otherwise these numbers will add up to 172.

At present, nearly 2 million people in India are infected with the coronavirus. Although many states re-use all industrial oxygen production for medical purposes, the oxygen is running out. The government said on Thursday that it would import 50,000 metric tons of medical oxygen.

The new oxygen plant can increase the production capacity of more than 4,500 metric tons of oxygen per month. Facts have proved that this is still not enough to meet the current demand in the second wave, but every additional capacity can save lives.

"Even if Covid-19 does not exist, these plants should exist," said T Sundararaman, the former director of the National Health System Resource Center, an advisory body of the Federal Ministry of Health and Family Welfare.

Public health experts like him believe that this epidemic is an opportunity for India to fill a clear gap in the healthcare system. One of them is the lack of pipeline oxygen in regional hospitals to meet the needs of hundreds of thousands of people.

"Due to hypoxia, we have experienced tragedy after tragedy," Sundararaman said. This includes deaths caused by snake bites, encephalitis, traffic accidents, etc.

If pipeline oxygen were provided through an on-site power plant, hundreds of thousands of such deaths could have been avoided. As the recent bids show, the cost is very low-more than 150 hospitals only cost 2 billion rupees.

But now Covid-19 is joining this death list.

What explains the delay in installing oxygen plants when infrastructure should be strengthened on the basis of war during a pandemic?

Scroll.in talked with hospital officials in 14 states-Assam, Bihar, Chhattisgarh, Delhi, Gujarat, Jharkhand, Kerala, Madhya Pradesh, Maha Rashtra, Telangana, Uttar Pradesh, Uttarakhand and West Bengal. Most officials attribute the delay to the company that won the contract.

In the bidding documents for the new oxygen plant, the total number of beds in the district hospitals and hospitals and the capacity of the factory are listed. Among them, Uttar Pradesh has the largest number of factories with different capacities in 14 regions. It is closely followed by Maharashtra, which has factories in 10 districts. Delhi is assigned to eight factories with a total capacity of 7,700 liters of oxygen per minute.

According to information provided by hospital area officials contacted by Scroll.in, these contracts were awarded to at least three companies-Uttam Air Products, Airox Technologies, and Absstem Technologies.

In Uttar Pradesh, none of the 14 hospitals reported having a fully functional oxygen generator.

SR Singh of Shyama Prasad Mukherjee Civil Hospital in Lucknow accused the company that won the contract of “fleeing after installing the factory”.

"After that, they did nothing," he said. "We will now connect the pipeline and make it run on its own."

Gyanendra Kumar of Meerut LLRM School of Medicine said: “We have allocated a site for the factory, but the machine has not come. I have called the company many times, but no one answered it.”

In both cases, the contract was won by Absstem Technologies, a company registered in Delhi. Even the MGG General Hospital in Nafsari, Gujarat, identified Absstem as the company that won the contract but failed to show up. "We keep calling them and they keep saying they will call back," said Avnish Dube, the hospital's chief medical officer. "I don't know what the problem is."

Scroll.in was unable to contact any Absstem official because the phone number and email address mentioned on the company website did not respond. If the company responds, this article will be updated.

Another company that received an order to install a new oxygen plant is Airox Technologies in Aurangabad. Its founder, Sanjay Jaiswal, claimed that the company has completed all procedures. But he claimed that the new unit was delayed because the hospital had not yet provided the infrastructure needed to connect the generator set to the hospital bed.

"On our side, our 60 engineers are very active and are almost done," he said. "But the states need to provide us with all the copper plumbing connections and electricity. That is not in our hands. Unless they give us this, we can't start the system."

However, in each state, most hospitals insist that they have all the infrastructure in place. "On January 13, I sent an email to the company saying that the site was ready," said Niyati Lakhani, a doctor at the GMERS Medical College and General Hospital in Gandhinagar. "Despite a few follow-ups, I haven't received a response. We desperately need it to be up and running. We just can't manage it with gas cylinders."

The company contracted to carry out work in Gandhinagar is Delhi-based Uttam Air Products. Scroll.in discovered that the company was blacklisted by the Central Medical Services Association on April 13. A letter from the Central Medical Services Association reviewed by Scroll.in stated that the company did not submit a deposit or accept an acceptance letter after winning the bid.

When we told Lakhani of the news, she reluctantly said: "If Uttam is blacklisted, where should I get oxygen?"

Manish Kapoor, the company's founder, declined to comment on the matter. "You have received a letter from CMSS," Kapoor said. "I think they will be better candidates to answer this question. We are the supplier and we have helped them with various technical inputs related to these tenders."

With the escalation of delays, small hospitals in the fur district have been particularly affected. When the supply line is blocked, it is difficult for them to obtain oxygen cylinders. They simply can't compete with big players with deep pockets. If local production sources had been up and running, these hospitals could have taken care of seriously ill patients better.

As Ungender, the medical director of the Bhadrachalam Regional Hospital in Telangana, said: “When we buy oxygen from the outside, we have to pay a huge amount. But if we produce it on site, it will reduce our burden.”

After all, as Ungender said, once plants are running, all they need to produce oxygen is air.

Doctors across India said that the second wave may be more deadly, not because new variants of the virus caused more serious illness (there is no clear evidence), but simply because the higher number of cases will make it more difficult for patients to enter the hospital. Even those who are admitted to the hospital may have to be deprived of oxygen.

Doctors in Gujarat state that the lack of medical oxygen forces them into a “triage-like situation”-which means they have to choose between patients. Everyone needs oxygen, but only some people.

"Last time we were able to meet the requirements," said Roopam Gupta, a doctor at the CU Shah School of Medicine and Hospital in Surendranagar District, Gujarat. "But this year's wave came so suddenly and rose sharply, so now we are just making our break even more than we can achieve."

Gupta said that the hospital has 700 beds, of which nearly 200 beds were occupied by Covid-19 patients on Friday, and almost all of them need oxygen. The hospital has two trolleys with 100 oxygen cylinders on standby at all times, and there are fire engineers nearby. "It [oxygen] has such a large flow that we are worried [may] be a disaster," he said.

This time, the doctors used a new treatment called high-flow nasal therapy, which requires each patient to use more oxygen. Gupta explained: “The problem is that once a patient has a high flow rate, then a single patient needs 130 liters of oxygen per minute, so it will run out of capacity.” “Even if a patient needs a high flow rate, we have to communicate with 50 patients at 16 per minute. A liter of oxygen keeps the surviving patient in balance."

Many doctors at the regional hospitals that are waiting for the new oxygen generators admitted that they have stopped following up with these companies because the worst situation seems to have passed for some time. After reaching a daily high of approximately 100,000 cases in September, the number of Covid-19 cases in India has been steadily declining until February.

"We have become less serious," said Sanghamitra K Phule, a civil surgeon at the Ratnagiri District Hospital in Maharashtra. "But now in April, things are getting worse."

Due to the surge in demand, the hospital’s oxygen equipment has now entered the final stage of installation. "Our demand has increased fourfold," Phule said. "So even if the factory itself is not enough to meet our needs, it is better than nothing."

Doctors say that although oxygen generators are not enough to meet the needs of large hospitals with a large number of critically ill patients, they can be useful tools in the armory when the demand is high. This is especially true when there is a severe shortage of commercial oxygen across the country.

Ten manufacturers and oxygen cylinder suppliers in Maharashtra, Tamil Nadu, Kerala, Andhra Pradesh, Gujarat, Punjab and Uttar Pradesh told Scroll.in that the second wave of demand Much higher than the first wave of Covid-19 cases last year.

"Medical oxygen is in short supply," said Sunil Gupta, who runs Raigad Carbides, an oxygen manufacturing company that has buyers in western India. Before the pandemic, Gupta’s company mainly supplied oxygen to industry. But now the entire production is diverted for medical use, he said.

Subasish Guha Roy of Universal Air Products said his company supplies 60 metric tons of oxygen to cities such as Bangalore and Mysore in Karnataka and is currently operating at full capacity. "If high demand continues, it will be difficult to meet daily needs," he said.

Even cylinder suppliers said that their stocks were quickly used up. “In the past 15 days, demand has tripled as usual,” said Chirag Vasani of Laxmi Gas Suppliers in Surat, Gujarat. Vasani supplies at least 200 steel cylinders in Surat every day. "It's just because of the coronavirus," he said.

When Scroll.in contacted him on Thursday (April 15), a supplier of medical oxygen cylinders in Lucknow did not respond to the call. In less than a minute, he sent a text message: The cylinders are sold out.

Another Lucknow supplier, Kaushal Katiyar, said he could not remember the number of cylinders sold in the past week. "If there is a patient in every house, then you can imagine what the needs are like," he said. "I have stopped answering calls."

This article first appeared on Scroll.in. We welcome your comments via idea.india@qz.com.

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