Because every breath counts

Investing in medical oxygen security will not only help us face the next pandemic, but also help us treat a wide range of medical conditions

Let us start with a question: What is the one thing we all take for granted in this world? How about the air that we breathe in and breathe out every living moment? 


Imagine yourself lying on a hospital bed, gasping to breathe, and fighting for life. Would you still take your breaths for granted? 


It's all too easy to take the air we breathe for granted -- it can feel like a given that we will receive enough oxygen. It is the oxygen in the air that our bodies want and need while we breathe. Fortunately, 21% of the air around us is oxygen, and most of us only require 19.5% to survive. However, this is not the case for those with less oxygen in their blood, a condition known as hypoxemia. Those with this ailment require oxygen as a critical medical intervention. 


Additional oxygen is also a crucial treatment commodity for various acute and chronic conditions across all age groups, from newborns in respiratory distress to children and adults with pneumonia, malaria, sepsis, and tuberculosis, to adults with chronic obstructive pulmonary disease (COPD), heart disease, and asthma, and many more. Medical oxygen is also essential for almost all major surgeries with anesthesia.  


Unfortunately, medical oxygen is often unavailable in health facilities in low-resource settings. In places where it is available, it is often inaccessible and unaffordable to lower income populations. 


Each year, approximately seven million children are admitted to hospitals in countries like Bangladesh with hypoxemic pneumonia requiring medical oxygen therapy. However, only 20% of them receive it. Healthcare providers must make the excruciating decision as to who receives oxygen therapy and who does not. People with more financial resources often receive oxygen, creating inequity, inequality, and injustice in global health. This occurs alongside the acute shortage of skilled workforce needed to install, operate, and maintain the lifesaving oxygen equipment.


When the Covid-19 pandemic hit the world, a surge of patients was admitted to hospitals requiring oxygen. Facilities of all sizes around the world, especially in low- and middle-income countries (LMICs), could not meet the skyrocketing demand, resulting in hundreds of thousands of unfortunate deaths. A study in 64 intensive care units across 10 African countries showed that one in two patients died without receiving medical oxygen during the pandemic. 


Bangladesh and many other resource-poor countries were no exception. During the pandemic, we saw patients lying on trolleys on the veranda or outside the facilities, in the backseat of a van, or at home waiting for someone to bring oxygen. 


Covid-19 did not create this gap. It was always there, but it remained largely unnoticed and unaccounted for. Issues related to the availability, accessibility, and affordability of medical oxygen intensified during the pandemic, revealing the health systems' inadequate capacity to produce, deliver, and distribute oxygen adequately and appropriately. 


We must prepare ourselves for the future. Investing in medical oxygen security will not only help us face the next pandemic, but it will also help us treat a wide range of medical conditions. 


Pneumonia -- the largest killer among children -- and chronic obstructive pulmonary disease -- a major chronic disease among the adult population -- can improve with the assistance of oxygen. 

To secure the necessary oxygen supplies, we need meticulous planning and concerted efforts that must start now.

 

The first step is to ascertain the total need for medical oxygen in Bangladesh, presently and in the future. We must gauge how much oxygen we may require when there is a surge in demand, like the next pandemic due to a respiratory pathogen. We need a precise estimate, but we do not have adequate data for it yet. 


Next, we need the necessary equipment and tools to rapidly identify patients suffering from hypoxemia who have various respiratory diseases and conditions. Unfortunately, very few health facilities in Bangladesh have pulse oximetry in the outpatient and emergency departments, which involves a simple device to instantly assess and identify hypoxemia. Our country needs to include it as a standard of care. 


Next, we must ensure timely and adequate oxygen to those who need it. We must invest in increasing our capacity to produce, deliver, and distribute medical oxygen throughout the country. 


Although the government of Bangladesh is taking some measures to increase production capacity and improve the supply chain in medical colleges and district hospitals, the upazila health complexes, the primary point of contact for most of the population in rural Bangladesh, are left behind. We have a long way to go to ensure comprehensive oxygen security. 


Lastly, we need knowledgeable and skilled personnel responsible for supply, maintenance, and administration of the oxygen systems. It is as important to have available well-maintained oxygen as it is to provide it to patients. Having both requires an educated support staff as well as clinician training. 


It is essential to know when to give oxygen, in what flow and for how long, depending on the status of the individual patient. Few healthcare providers in Bangladesh currently have adequate knowledge and training in medical oxygen therapy.


Significant advancements in underlying support structures, processes, and personnel are thereby needed if the medical oxygen system is to be sustainably integrated into health systems and achieve a meaningful impact. The biggest challenge that could hinder this process is data gaps on oxygen needs, access, and use. 


Around the world, few health information systems and surveys assess and track data on medical oxygen consumption or functional access. Such a paucity of data severely impairs the ability to plan effectively and implement solutions efficiently. This lack of data occurs not just in Bangladesh but also in most resource-poor countries. 


Fortunately, gaps in strategic thinking and data will be addressed by the Lancet Global Health Commission on Medical Oxygen Security, scheduled to be published in 2024. The Commission will shed light on the burden of hypoxemia, how to define and measure oxygen access, which oxygen solutions work best in different settings, and how to generate the financing and political will to achieve transformational change. 


It will address all levels of care from home to hospital, all age groups from neonates to the elderly, all health conditions where hypoxemia is a risk, and how access to oxygen can contribute to health system strengthening. 


The Commission will be led by three organizations, one being our very own icddr,b from Bangladesh. The other two are Makerere University in Uganda and the University of Melbourne and Murdoch Children's Research Institute (MCRI) in Australia. Every Breath Counts, the global platform working to avert pneumonia related deaths, will provide auxiliary support.  


We know that strong oxygen systems rely on health systems' “hardware,” including a skilled health workforce, appropriate technology, supply chains, and financing of operational expenses, especially maintenance. But while managing the hardware, we often forget about the contribution of health systems' software -- power dynamics, values, and norms that can support and ensure medical oxygen security. 


The good news is that governments, multilateral and bilateral agencies, and donors are more compelled than ever to invest in medical oxygen. Because everyone has the right to breathe.


Shusmita Khan works as the Knowledge Management and Communications Specialist for the Data for Impact project of the University of North Carolina at Chapel Hill. Dr Ahmed Ehsanur Rahman, PhD, works at the Maternal and Child Health Division of icddr,b as an Associate Scientist. 

This article was produced with the support of the United States Agency for International Development (USAID) under the terms of USAID's Research for Decision Makers (RDM) Activity cooperative agreement no. AID-388-A-17-00006 and of Data for Impact (D4I) associate award no. 7200AA18LA00008. Views expressed herein do not necessarily reflect the views of the US Government or USAID. To learn more, please email Shusmita Khan at [email protected]