Oxygen and hospitals: What lies ahead of Bangladesh in second wave?

As grim reports continue to surface about India's turmoil and impacts of its second Covid-19 wave, Bangladeshi public health experts, hospital officials, doctors – and recently oxygen supply companies – are taking stock of the country's medical resources to tackle the second wave.

Oxygen is a key element in the treatment of Covid-19 patients, and Bangladesh is presently producing and supplying oxygen to hospitals at full capacity. Linde Bangladesh Ltd and Spectra Oxygen Ltd account for the majority of the oxygen being supplied to the healthcare facilities.

Hospital authorities claim that the demand for oxygen is still manageable and the influx of Covid-19 patients has dropped in recent days owing to the stricter lockdown measures, but they are clueless about what to do in case of a further spike in severe cases.

"In the last two months, demand for medical oxygen has increased by about 40% in Bangladesh," said Linde Bangladesh Ltd spokesperson Saiqa Mazed, adding, "We are already operating at full capacity and our two plants are producing about 90 tonnes of oxygen per day."

"We are yet to face a serious crisis, but we are already treading very carefully to sustain the demanding supply chain."

Commenting on the present demand for medical oxygen, Mugda Medical College Hospital's Director Dr Asim Kumar Nath told The Business Standard, "Our oxygen demand has gone up by 20% since last month, and we are now refilling our 12,000 cubic metre tank daily.

"But we have not faced any shortage of this gas so far."

Now with India's ban on oxygen export in place since 22 April, the companies are on high alert. Both Linde and Spectra import oxygen from India. For example, Spectra used to import 150 tonnes of oxygen from India per week.

Spectra presently supplies 580 cubic metres of oxygen every day and has another plant awaiting paperwork to produce an additional 400 cubic metres of the gas to supply the hospitals. In addition, they are already supplying 25 tonnes of liquid oxygen to hospitals daily.

"We are doing our best to ensure continued oxygen supply to hospitals across the country," a Spectra official said on condition of anonymity. "We now provide 24/7 customer service to tackle the ever increasing demand of medical oxygen, but things may go downhill if the demand increases further."

Linde Bangladesh is an international company that has its own plant in India too. They supply liquid oxygen in tanks to government hospitals and oxygen in cylinders to some private healthcare facilities.

"For now, the supply of medical oxygen has taken precedence over industrial oxygen and if we cannot import oxygen from India because of India's ongoing oxygen crisis, it is the supply of industrial oxygen that will take a hit," Linde's spokesperson Saiqa Mazed said.

Over the last year, the company had imported oxygen from its plant in India when deemed necessary to "strike a balance" between medical and industrial oxygen supply. But that will likely no longer be the case.

Bangladesh may be on a new precipice of Covid-19 management challenge. Hospital officials however are now claiming that they are not facing a shortage in oxygen supply, owing mostly to a decline in patient load at the end of last week.

The second wave had put a strain on medical resources in the country, but for the first time in weeks, officials from Covid-19-dedicated hospitals say they are witnessing a drop in the patient influx.

"There are 159 seats [beds for Covid-19 patients] vacant as of Saturday morning," said Dr Nath of Mugda hospital, adding, "It has been five to six days, that we are seeing a gradual dip in Covid-19 patients, which is giving a much-needed breather to our oxygen support system."

Besides, beyond hospitals, the demand for oxygen cylinders also increased in the retail market. "More people are definitely buying and renting oxygen cylinders again – and it started at the beginning of the second wave," said Linde spokesperson Mazed.

Similar to last year, there is an uptick in oxygen cylinder purchase. In some cases, it is only a precautionary measure, to have oxygen support at home if a family member falls ill. 

Shohrab Hossain, advisor to the Chattogram-based Associated Oxygen Ltd, said, "We are mainly producing oxygen for industrial purposes. Our daily production capacity is 9,600 tonne. But in some cases, we have refilled oxygen cylinders for local hospitals."

"Due to a surge in medical oxygen demand due to the Covid-19 outbreak, we are now trying to supply more oxygen in the hospitals. In this regard, we are working to upgrade some equipment of the factory and transportation system."

Another company named Islam Oxygen Ltd also supplies oxygen to government hospitals, and there are other small local companies which produce oxygen at a small scale, industry insiders have said.

Why is the second wave different?

Bangladesh is all too familiar with the shortage of oxygen supply that overran the Covid-19-dedicated hospitals in the country last year.

Earlier in April, hospital officials and patients had also faced a stark shortage of Intensive Care Unit (ICU) beds, ventilators and other medical equipment – as though nothing has really changed in the healthcare system since the first wave.

However, in the backdrop of the fresh wave, hospital officials say doctors and facilities are more prepared now in terms of administering treatment for the virus and resources too, compared to the first wave.

They also pointed out that increasing the number of ICU beds is no easy task because it requires trained manpower and special set up, along with the monetary cost.

Within months of the first wave, the government, medical professionals and stakeholders recommended that the dire state of medical facilities in Bangladesh be rectified as soon as possible.

To this end, a number of efforts have been successfully made to ensure oxygen supply lines, insiders claim.

For example, Kurmitola General Hospital and Shaheed Suhrawardy Medical College Hospital – along with a number of facilities – now have central oxygen supply systems to support their Covid-19 wards.

Central oxygen supply systems guarantee uninterrupted oxygen supply to the beds of Covid-19 patients when necessary by converting liquid oxygen to gas. Otherwise, a patient would have to rely on oxygen cylinders, which can only provide a maximum of six litres of oxygen per minute.

One kilolitre of liquid oxygen produces 960,000 litres of gas. A Covid-19 patient, depending on the severity of the case, requires far more oxygen than any cylinder could provide. One five-kilolitre tank can supply oxygen to 350 patients at a much higher rate for 24 hours on one refill.

Coronavirus, especially because of the new variants, affects the lungs and consequently cripples the breathing system, leaving critically infected patients gasping for their life.

"A stark difference between the two waves is the severity of this year's infection," said Mugda Medical College Hospital's Director Dr Asim Kumar Nath, noting, "We are seeing how a Covid-19 patient's health drastically deteriorates, owing to the new variants in the mix."

Dr Nath highly recommends that instead of treating the virus at home in isolation, which many people who show mild symptoms continue to do, it is wise to consult with a doctor for treatment.

In doing so, we can separate the infected population and substantially control the spread, he told The Business Standard.

A silver lining on the Covid-19 cloud

This is not to say that all of the healthcare system's flaws and vulnerabilities had been amended, as the reality is far from expectations. But the hospital officials say some measures have been taken since the first wave to address the shortcomings.

Responding to a query, Kurmitola General Hospital's Consultant Dr Shahnewaz Dewan said, "We have designated three wards to Covid-19 patients, and yes, the wards have a central oxygen supply line now. It was installed in September last year."

According to him, there is a substantial difference in preparedness and management between the two coronavirus waves in the country.

"Primary difference lies in our preparedness," Dr Dewan explained. "We now have categories of treatment wards, including more tests in Covid-19 treatment – such as lung CT scans – and we have expanded our medical resources.

Is Bangladesh doing enough?

When asked if Bangladesh is taking adequate measures to ensure that our healthcare system does not face a fate similar to that of our neighboring country India, Dr Nath said, "This pandemic is such that every country has to devise its own methods to tackle the virus, and there is not much of a model, per say, to follow, given how unique the circumstances are."

Registrar of the Impulse hospital Covid ICU unit Dr Abdullah Asef Akhond also spoke with The Business Standard on the issue after getting off a late night shift on Friday, saying "We are doing the best we can, the doctors are overworked and exhausted.

"For most of April, we had the ICU unit almost at full capacity. But the situation improved at the end of last week."

The hospital – which has a central oxygen supply line – managed to expand its number of ICU beds from merely 12-14 in late 2019 to 56 now.

Dr Akhond believes that the hospital has taken adequate measures since the first wave, but "If there is an increase in the influx of Covid-19 patients, we simply do not have the vacancy to accommodate them."

With lockdown soon to be lifted, most public health experts and doctors echo the same concern – an increased infection rate and an overburdened healthcare system.

"Regardless of what the decision is, positive or negative in terms of imposing or lifting the lockdown, from observations we now know that such a decision will take 8-10 days or more to show its result," Dr AM Zakir Hussain, former regional advisor of the World Health Organisation (WHO) said.

Dr Zakir is a former director of Primary Health Care and Disease Control under the Directorate General of Health Services (DGHS).

The reason why hospitals saw a dip in Covid-19 patients at the end of last week is possibly a result of the government's name-only lockdown that began on 14 April, he said.

"This is to say, once the lockdown is lifted altogether, we will see its grim outcome within one or two weeks' time – unless the border with India is kept sealed completely and air travel from India and other heavily infected countries remain halted."