R.K. Himthani was known as the doctor who was always smiling. The head of gastroenterology at Batra Hospital in New Delhi, who had worked through the COVID-19 pandemic and earned a reputation for going the extra mile, contracted COVID and was admitted to his place of employment as a patient this spring, according to local media. On May 1, Himthani’s name appeared on a list of 12 patients who had died when the hospital ran out of oxygen for an hour and 20 minutes as India’s monstrous second wave of COVID squeezed supply of the precious gas. He was 62.

The sudden surge of COVID infections and the subsequent need for supplemental oxygen in late March blindsided India’s health care network. The country had assumed the worst of the pandemic was over. But within two weeks, the daily demand for medical oxygen spiked to 12 times pre-COVID levels, leaving hospitals like Batra struggling to treat the rush of patients who were showing up, gasping for breath.

It wasn’t just acute need that caused the run on oxygen. Panic drove people to buy oxygen cylinders and machines like oxygen concentrators at three times their regular rate on the black market, even if the buyers didn’t immediately need them, according to anecdotes from consumers and media reports.

The apparent shortage led to Indians begging for oxygen on social media and to stories like Himthani’s, in which COVID patients died because their need was never met.

In truth, India always had enough oxygen. But as the second wave hit, it was being used for industrial—not medical—purposes.

Ordinarily, India produces 9,000 tons of liquid oxygen each day. Only 10% to 15% of that goes toward medical supplies. The rest is used in industry, such as steelmaking.

At the height of India’s second wave, which is still ongoing, COVID patients needed between 9,000 and 11,000 tons of oxygen. India had the capacity to meet that demand, but it would require diverting up to 90% of the country’s oxygen supply from industrial sites.

Pulling that off took weeks—and government intervention.

The biggest turning point in the national oxygen crisis came in late April when the federal government banned the use of liquid oxygen for industrial purposes, with a few exceptions.

The ban “will help in augmenting supply for medical oxygen in the country and save precious lives,” India’s Home Secretary, Ajay Bhalla, wrote in a letter to state governments, which was published in India Today.

India’s largest producers of oxygen can be separated into two camps: dedicated producers of industrial gas, such as INOX Air Products, Linde, and Praxair, and industrial giants, such as Tata Steel and JSW Steel, which own plants that supply the oxygen used in manufacturing.

Since the government order was issued, oxygen that’s typically used for industry has fulfilled around 80% of the medical oxygen demand. The rest is being met by oxygen generation plants at hospitals, small generation plants that supply oxygen cylinders to hospitals, and imports, said Seshagiri Rao, joint managing director of JSW, one of India’s largest steelmakers and oxygen consumers, who also heads the Confederation of Indian Industry task force on oxygen supply.

Steel companies are diverting more oxygen than they usually produce. In the past three weeks, they have upped oxygen output by 172% to supply 4,100 metric tons per day, nearly half of current demand countrywide.

India’s largest private company, Reliance Industries, a conglomerate, is also producing around 1,000 metric tons per day.

Consumer major ITC, which generally has a limited need for liquid oxygen, has supplied medical oxygen from its paperboard unit to nearby hospitals in the southern state of Telangana.

“The current health crisis is indeed of concern and calls for every section of society to join hands in addressing the challenges,” said Sanjiv Puri, chairman of ITC.

India’s leading oxygen producer, INOX Air Products, said it has increased its production capacity to 2,700 tons per day from a pre-COVID average of 400 tons.

“Our tankers are logging three times more kilometers…and three times more tanker [truck] refills than last year,” said Siddharth Jain, director at INOX Air Products.

The Indian government currently operates 74 oxygen plants on its own, and a government program will expand that number to 1,594, meaning India will need to rely less on industrial players if demand surges again in the future.

What’s more, the Indian government says it has already imported 5,800 metric tons of oxygen; it plans to import 50,000 metric tons in total, though it hasn’t specified a timeline.

After being taken aback by the sharp rise in demand, India is now producing enough oxygen for medical purposes—9,524 tons of oxygen per day as of May 9—to meet the needs of its COVID crisis.

“There is no demand-supply gap as of now,” said Rao.

Critics say the government is trying to solve a problem of its own creation. K. Srinath Reddy, president of the Public Health Foundation of India, argues that government officials across the country were too quick to deprioritize medical oxygen after India’s first COVID wave in 2020. “Large hospitals in Delhi should have set up their own oxygen plants, but they did not,” he said. “Some states [that] did not prepare well got caught off guard.”

The federal government deserves blame too for assuming it had conquered COVID and not preparing for a second wave, Reddy says. He admits that virtually no one could have expected the second wave to be so ferocious. Even if the government had prepared, oxygen still would have been in short supply. But shortages “would have been less and temporary,” he added.

And the government action to divert all oxygen to medical uses has not solved the shortage entirely. What remain are logistical snarls that are crimping the oxygen supply chain and keeping patients in places like Delhi, parts of southern India, and the western state of Goa from getting the oxygen they need.

India’s main oxygen production centers are located in the country’s eastern region, home to oxygen-intensive industries like steel. Normally, getting oxygen from these sites to population centers in northern, western, and southern India takes from three to 12 days, depending on the location.

The lengthy journey is made all the more arduous by another ongoing shortage: that of specialized tanker trucks that need to keep liquid oxygen at a temperature of minus 183 degrees Celsius.

T. V. Narendran, president designate at the Confederation of Indian Industry (CII), a trade group, cited the shortage as an especially challenging bottleneck, but said that industry and government are trying to address it.

INOX has expanded its tanker truck fleet to 380 from 270 by repurposing tanker trucks that normally carry nitrogen and argon.

Abhijit Banerjee, managing director of Linde India, says that his company started renting standardized containers from abroad. The containers that usually hold liquids, gases, and powders can be hoisted onto trucks for oxygen transport or to serve as stationary storage. Tata Steel and ITC, Banerjee says, are picking up the rental tab.

Linde India has also established a railway system to deliver medical oxygen from eastern India to Delhi in a tie-up with the state-run Container Corporation of India (Concor) and Indian Railways.

To speed up a tanker truck’s usual roundtrip—driving with a full oxygen supply to local distribution facilities, then returning to production sites with no load—the government has started transporting oxygen tanker trucks by air force planes and rail. (Planes cannot carry full tanker trucks because of fire risk.) Speeding up the return journey reduces the full travel time by at least half on rail and by as much as 90% by plane.

The government has also invoked a National Disaster Management Act so oxygen tankers receive the same priority on roads as ambulances on national highways. A government unit is digitally tracking the movement of tanker trucks to ensure that drivers do not make unscheduled stops or divert from the shortest routes.

“The government brought in significant steps by mobilizing [the] Indian air force and railways for speeding up the transport of oxygen from production plants to deficient areas. The government also helped in importing liquid oxygen from Asian and Middle Eastern countries by air and sea routes,” said Asit Gangopadhyay, managing director of PCI Gases. “All these have contributed significantly to easing the supply crunch.”

The diversion of industrial oxygen is not without its tradeoffs, Gangopadhyay said; it’s slowing the production of components for making certain medical equipment and oxygen generation equipment. Still, he’s urging the government to ramp up supply even further, in case India faces a third wave.

So is Reddy.

“There is a saying: ‘Hope for the best and prepare for the worst.’ We have to follow that.”

(聊城荣恒医疗器械有限公司)