Gasping For Breath

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In the absence of treatment, the basic requirement for managing the Covid-19 cases is oxygen. As the existing infrastructure in the health sector is witnessing a massive overload and a net shortfall in medical oxygen, the manufacturing sector and countless voluntary groups are working round the clock to ensure the patients do not gasp for breaths, reports Masood Hussain

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Have you seen the oxygen? It looks like this when it changes from its liquefied form to the gaseous form that humans breathe. High flow oxygen is key to the treatment of Covid-19 patients. KL Image: Masood Hussain

Amidst an abundance of pristine oxygen in the air, on the ground 5,000 Kashmiris are literally gasping for a lung full of it to survive. Can there be a bigger tragic irony? Nature’s bounty has been negated by nature’s calamity.

It all depends now on a handful of businessmen and a few samitarians. 

Mian Murtaza, proprietor of Mian Gases, Khonmoh, does not stop to breath at his facility which produces oxygen.  Every minute, there is a desperate telephone call; a worker accompanying a Covid-19 patient to his home to set up the life-saving contraption for him and needs oxygen immediately. Psychologically, Mian feels were he to take a deep breath at ease, a precious life may be lost for the lack of oxygen that his factory produces for the hospitals.

“For the last three months, we are working in three shifts and the plant rarely shuts for maintenance,” says Murtaza. “We supply oxygen to most of the health facilities in Kashmir including the 92-Base Hospital and the peripheral hospitals across Kashmir”.

Mian said the demand has gone through the roof. It has already tripled and is still soaring.

A long line of attendants queued up to get an oxygen cylinder in the SMHS premises. The hospital’s in house oxygen manufacturing is overloaded forcing it to purchase from the industry. KL Image: Bilal Bahadur

Generation Deficit

Though all the major hospitals own oxygen concentration plants, they run short of supply as the demand has phenomenally surged owing to the desperation for oxygen by the Covid-19 patients. Right now, Kashmir has more than five thousand active Covid-19 patients mostly admitted to hospitals. Oxygen is a key support in helping their lungs to stay alert and do not fall to the contagion destruction.

Initially, the Government Medical College, Srinagar run SMHS hospital was not supposed to be a Covid-19 facility. But the rush of the patient has literally converted major part of it into a Covid-19 care facility. Apart from the challenges that come with the Covid-19, Oxygen is at the top.

An inside view of a hospital ward dedicated to Covid-19 care in Kashmir. Watch the oxygen cylinders, now the basic requirement. KL Image: Bilal Bahadur

“We have two plants and both put together generate slightly more than 2000 litres per minute,” insider sources revealed. “The demand goes up to 6000 and sometimes 7000 litres per minute and that is where the deficit is.” Overloading the plant leads to low flow which is unhelpful to the patients.

The deficit is being managed by the private sector oxygen concentration plants that supply more than 600 cylinders a day to the SMHS alone.

Every morning, desperate attendants of the patients queue up near a rare door where a truckload stops with the fresh supply. They take these cylinders personally and keep alongside the beds of their patients. There is a sort of stampede among the attendants and they end up hoarding the supply in the wards.

Parts of the Covid-19 ward, sometimes, look like an oxygen cylinder warehouse. But there are no options, either. The hospital administration is not in a position to manage everything given the huge load of the patients that drives to the hospital, almost on an hourly basis.

However, the situation is better at the Chest Diseases Hospital, Kashmir’s main Covid-19 run by the GMC Srinagar. It has sufficient oxygen supply.

“There was one plant already and after the hospital was declared a Covid-19 hospital a spare plant of children’s hospital (that is coming up) was installed and with that, the supply increased to more than 1000 litres of oxygen a minute which is exactly the requirement of the hospital,” an officer said.

Kashmir’s major charity, the Athrout handing over six high-value ventilators to the management of Chest Disease Hospital in Srinagar in April. The hospital was the first designed Covid-19 Hospital. Pic: Special arrangement

Oxygen concentration plants are the basic requirement of any hospital that has an operation theatre. The SKIMS run Jhelum Valley Hospital in Bemina was having problems with its oxygen plant but it was readied on an emergency basis and is operational for the last two months. “We have the 750-litre facility and it is being completely consumed, “Dr Shifa Deva, the Medical Superintend of the hospital said. “Just to be sure that we do not face any problems, we use bulk cylinders as well.”

The requirement has more than doubled in the Sher-e-Kashmir Institute of Medical Science (SKIMS) Soura.

“We had a functional plant and in anticipation of the Covid-19, we installed another one and that makes us generate 3200 litres of oxygen per minute from our own facilities,” Dr Farooq A Jan, the SKIMS Medical Superintendent said. “But we also required around 450 cylinders a day that adds another 3000 litres per minute capacity.”

Dr Jan said the demand is soaring. “We have requested for installation of two more oxygen concentration plans and purchase of another 500 cylinders,” he said. This means the SKIMS foresee a requirement of almost 7000 to 8000 litres per minute in coming days.

A charity group SRO is leading a major campaign to ensure the Covid-19 patients get the oxygen supply in time. Pic: Special arrangement

The Situation In the Periphery

Not every hospital in the periphery has an oxygen concentration plant, District Hospital Pulwama, running four scattered Covid-19 facilities within the town, for instance, uses the mobile bulk cylinders. “Right now, we do not have any problem for oxygen and we have the capacity to even give high flow oxygen to more patients,” Dr Gowhar Ahmad said. “We have more than 210 cylinders and that helps us manage the patients with the entire requirement.”

Now the district administration is trying to install a plant. Doctors said they were told that it will be ready by September and the unit is sophisticated and modern and will be installed within 10 days.

In the GMC Anantnag, the medical superintendent, Dr Iqbal said they have a plant with 350 litres per minute capacity. “Recently the mechanical division has sanctioned another major facility with 3000-litre capacity but that will take some time in installation,” Dr Iqbal said. “Right now, we are managing our requirements from our own plant and in addition, we have almost 300 cylinders that we use to manage adequate supply.”

Dar ul Atta, a Srinagar charity was already working to manage the COPD patients and has now jumped to manage part of the Covid-19 load. Pic: Special arrangement

In Baramulla, also a GMC now, medical superintendent, Dr Syed Masood said they had an old 350 LPM plant and now an additional plant is being installed. “It will take a few days more and we will have double the capacity,” Dr Masood said. “Besides, we have almost 400 cylinders with us. Let me tell you that we can run the facility without any supply for at least 30 days.” The hospital, he said, has many mobile concentrators also.

 Oxygen Makers

 Kashmir has a small but sufficient oxygen generation facility. There were many stakeholders but the peculiar business model and the low industrial requirement did not permit at least two facilities to run profitably and shut down. Right now, there are three units manufacturing oxygen and these are vital in the battle against Covid-19.

At North End Enterprises, the empty cylinders being refilled. KL Image: Masood Hussain

In one of Kashmir’s oldest industrial estates at Sanat Nagar is North End Enterprises. The oldest oxygen manufacturer in Kashmir, it was installed almost 25 years ago. “The oxygen is used for industrial purposes in the fabrication of steel and for medical use,” Altaf A Baba, its promoter said. “For the three years, the demand for industrial oxygen has depleted to less than 25 per cent because nothing much is happening in Kashmir. But post Covid-19, the demand for medical oxygen has phenomenally increased.”

Baba’s 60-cubic meter facility is supplying the oxygen to the private nursing home and through a chain of non-government organisations to various hospitals and individuals. “The problem is that we have 400 cylinders and they are filled in 48 hours. Once these cylinders are supplied to the people, they take five to eight days in consuming them,” Baba said. “Till the cylinders reach back, the plant is closed.”

Unsung Fights: Altaf Baba and his team at the North End Enterprises that is one of the oldest facilities for making oxygen. KL Image: Masood Hussain

What is interesting in the oxygen manufacturing facilities is the plant, once closed, needs almost 12 hours of idle running to get the maximum concentration in the oxygen it produces. “That inflates the power bill hugely and this was one of the reasons why many plants closed in Kashmir,” Baba said.

That perhaps is the reason why Mian has hugely invested in the cylinders. He has almost 500 cylinders and they are being regularly exchanged with the empty cylinders of his clients, the hospitals. This is how the chain does not break and he runs his plant 24 x 7 in three shifts.

Mian’s 200-cubic meter an hour facility – the second largest in Kashmir, had rarely run full capacity ever since it was commissioned in 2015. “Since mid-June, we have been running 24 hours a day and we have stopped any supply for industrial use,” Mian said. “We supply almost thirty per cent of our generation to the SKIMS then we supply to almost all the district hospitals, the 108 facility and the 92 Base Hospital.”

Mian Murtaza’s Khonmoh factory works 24 x 7 as the oxygen requirement soared too much in last three montsh because of the Covid-19. He runs the second major facility in Kashmir and supplies to most of the health facilities. KL Image: Masood Hussain

Normally, the oxygen manufacturers were supplying most of their supplies for the industrial use in summers but now it is completely reversed. “During the fall, the patients with asthma and pneumonia would seek oxygen supplies but that was just a fraction. Now that private demand has soared to almost eighty per cent in comparison because most of the patients are treating themselves at home using the high flow oxygen,” Mian said.

Mian expects the demand will surge as the infections are not stopping. Given the locational disadvantage, not many individuals approach him for oxygen, but still, some people visit him with prescriptions. “This fall will be slightly chaotic because a lot of patients would require oxygen,” Mian said.

There is another facility in Rangreth, the biggest one, that is exclusively managing the demand from the SMHS hospital, the major consumer of the oxygen these days.

The Volunteer Circuit

With the health sector mandated to work and the private sector supposed to keep the supply lines well-oiled, the real heroes of the battle against the invisible contagion are the voluntary groups. They work with both and make a huge difference in how Kashmir is battling the menace.

As the winter was about to be over and the Covid-19 threat had started looming large over Kashmir, businessman Mohammad Afaaq Sayeed and some of his friends started a Facebook page CorovirusWatch JK. “It was supposed to be an awareness group and as people joined the group, the tensions started coming to the page with the requirements and deficit,” Afaaq said. “Gradually the page got sucked into the crises and we decided to fight back.”

The page-mangers started hunting for a group and they convinced Batamaloo based SRO, a reputed small NGO working for destitute for many years. Initially, hunger emerged as a challenge because of the lockdown so the group supplied 1500 food kits (a kit took care of a month’s requirements in a modest family kitchen).

In the second stage, we chipped in to help the patients suffering from Covid-19. Managing oxygen supplies to the patients was challenging especially in the wake of the crisis the hospitals were facing. “We have 150 oxygen cylinders and on a daily basis, we add up numbers,” Afaaq said. “These include 25 cylinders with a high-flow output which are given to patients requiring 4 litres per minute and these are being made available to hospitals only.”

Besides, the group has 150 mobile oxygen concentrators that are being provided to patients within and outside the hospital on loan. Normally a patient requires oxygen support for at least 10 days and in severe cases beyond that.

“When we start to work, we had 65 concentrators and 40 cylinders,” Afaaq said. “Now we have 150 each. Recently, we have ordered 50 more and the pan is to acquire 200 more because this winter would see oxygen requirements for not less than 5000 additional individuals in Kashmir.” People who even recover have some kind of damage to their breathing systems and in winters they are expected to face tensions in which oxygen concentrators are vital.

Complex Breathing

Breathing is more complex than it seems. Once it gets into a bad patch, it needs a lot of support. Certain patients lack the capacity to exhale carbon dioxide when unwell. Complex machines are required for managing them. One machine called CPAP (Continuous positive airway pressure therapy) is used to help a person with obstructive sleep apnea (OSA) to breathe easily during sleep. Another machine is called BiPap that is used to push air into the lungs. SRO has acquired eight of these machines each and all are in use of the people.

All these machines are very costly. A concentrator costs upward of Rs 40,000, a major high flow cylinder will cost will Rs 18,000 and breathing disorder machines also cost more than Rs 25-30,000 each.

“For all these months, the people donated generously. So far we spent Rs 71 lakhs and right now we have a debt of Rs 47.5 lakh,” Afaaq said. “But we know, people recognise the services and the donations will come.”

Interestingly, all the SRO people are volunteers, who worked tirelessly for all these months. “We identified half a dozen volunteers and decided to give them some Eidhi on the last Eid,” Afaaq said. “We gave them Rs 5000 each and once we rejoined after Eid, we were surprised that they pooled this amount and purchased a two-wheeler for the NGO.”

The group has created a website for bridging the gap between plasma donors and patients. So far it has helped arrange 148 matches. Now it has started funding the medical bills of very poor patients suffering from Covid-19.

Silent Workers

Since 2012, Shabir Ahmad and his friends are running Dar-ul-Atta Charitable Society, mostly a medical relief group. Funded by white-collar job goers on a monthly basis, the group rarely seeks any donation. Most of its requirements reach them in Ramzan, mostly the Zakaat money.

“Even before Covid-19, we were funding the medical bills of 750 patients suffering from serious ailments and helping kitchens in 200 cases,” Shabir said. “As part of the routine, we would visit SMHS every Sunday to check if somebody is in dire help and would manage that right away. Basically patients drive to the hospital where they are, in certain cases, detected with serious problems that require immediate financial help like for stents and all that. We fund these emergencies there on spot.”

Post Covid-19, the monthly help in food management reached 1800 families a month.

“We already had 100 oxygen concentrators with us for the use of needy COPD patients with CPAP and BiPAP machines,” Shabir said. “We have already placed an order for 60 more concentrators.” The group is already building a 12-bed dialysis centre that will offer its services free. “This year, so far, we have spent almost Rs 70 lakh on our activities, which is almost double of what we spent in last one complete year,” he asserted.

Athrout

Perhaps the grandest of the charities in Srinagar, the Athrout (Kashmiri word meaning holding the hand) knew the costs of the scourge that was coming the way of Kashmir. In the first instance, it spent Rs 39 lakh and procured six sophisticated ventilators and donated it to Chest Disease Hospital. The hospital administration took its time to make up its mind –it triggered a controversy, and finally accepted the donations.

(KL Image: Bilal Bahadur)

“For COPD patients, we already had almost 120 oxygen concentrators with us along with almost 32 CPAP and BiPAP machines and we started using them judiciously with the onset of Covid-19,” Bashir Nadwi, the NGO founder said. “In these months, we added 35 more concentrators and we have put a fresh order for 100 additional concentrators.”

Nadvi said his group had plans to start laying the foundation stone for a hospital but the Covid-19 forced us to face the pandemic challenge first. Right now the crisis is that everybody wants to have concentrators and it is short in supply.

The NGO has spent immensely in managing the personal protection equipment (PPE) for the medical staff initially. “We require more concentrators and the allied machines as we are aware of the fact that the situation is dramatically changing,” Nadvi said. “But the people who acquire these machines at individual levels must know that these should be up to the mark because there are bad manufactures also being sold in the market.”

Medical Equipment

The pandemic has forced a section of the masses to invest massively in the basics to manage the infection. A lot of people have acquired oxygen concentrators and the pulse-oximeters in recent days. The latter help in displaying the oxygen concentration levels in the blood, a key indicator of the Covid-19 morbidity.

“Earlier, the industry used to sell around 100 units of oxygen concentrators a month and now it is 1000 and the demand is much more than that. This is despite the companies have increased the cost because of the raw material and skilled workmanship issues,” Basharat Ahmad of the Srinagar Surgicals said. “The problem is that we get this equipment in short supply and usually every order is pre-sold.” There is a huge demand in flow meters, equipment that reads the oxygen flow when they are fixed on cylinders.

Outside view of SKIMS Srinagar.

Outside view of SKIMS Srinagar.

Basharat said equipment like the oxygen cylinders were not been sold because of the fewer margins and space constraints by the dealers. “But all of a sudden, everybody wants it and it is in short supply now,” Shabir said. “I was desperate to ensure everything is all right when my father-in-law tested positive.”

The situation, Basharat said, is that some of the equipment are now available over the counter. “The pulse oximeters are now being sold like thermometers,” Shabir said. “I think Kashmir market consumes almost 7000 oximeters in a month now.” No oximeter sells less than Rs 1500.

Though there is a surge in the numbers, Shabir said, the real business is in other items like the face mask, the sanitizers and the soaps. “Pre Covid, a mask would sell at Rs 1.90 apiece but I personally purchased one Rs 12, see the margins. There were people having idle funds who made the best of it despite not being in the medical line.”

At the same time, the hospitals invested in a lot of equipment. Every hospital has now two sets of basic diagnostic equipment like ECG machines and stethoscopes – one for Covid area and another for non-Covid.

“Demand is ok but you cannot imagine the way the suppliers met it because the lockdown interrupted movement and closed down the manufacturing facilities,” Junaid Ahmad of the Breathzone, another medical supply firm said. “These were the harsh times in getting the authorities convinced that they need movement permission.”

As they say, when the situation gets tough, the tougher get going. That is how the counter-Covid-19 show is going on.

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