This pandemic is also an opportunity to close an oxygen divide that ranks among the greatest health injustices of our time, say Kevin Watkins and Adamu Isah

Last April Boris Johnson, the UK prime minister, emerged from his brush with covid-19 to deliver a tribute to his medical team and a celebration of the treatment that had kept him alive. “I was going through litres and litres of oxygen,” he said, adding: “I’m a very lucky man.” You can say that again. 

Covid-19 has provided a brutal reminder of the importance of medical oxygen. In severe cases, the disease attacks the lungs in the form of pneumonia, causing blood oxygen to fall to levels that compromise critical organs—a condition known as hypoxemia. Around one in five patients with covid-19 need oxygen—and lots of it. 

Boris Johnson had the good fortune to be treated in a health system that provides oxygen therapy in abundance, free at the point of use. That is what universal health coverage looks like in practice. 

Yet this stands in stark contrast to the crisis unfolding across much of the developing world. As the pandemic has spread, creaking medical oxygen systems have been overwhelmed. In India and Bangladesh public health facilities have struggled to provide oxygen for patients with covid-19. In Peru and Ecuador surging prices for oxygen have created flourishing black markets in oxygen cylinders, with public health providers squeezed out of markets. Lives have been lost due to shortages.

As in so many other areas, the uneven provision of oxygen has turned the spotlight on deep national and global inequities in health. Medical oxygen is universally available in rich countries. Yet in many developing countries, it is effectively a luxury item, which is available only to the wealthy through private hospitals. 

This oxygen divide has been neglected for far too long. That’s partly because most of those on the wrong side of the divide are poor—especially poor children. Pneumonia powerfully illustrates this. Covid-19, which poses the most immediate threat to older adults, has catapulted medical oxygen onto the global agenda. Meanwhile, the devastation caused by childhood pneumonia continues to escape the attention of policy makers.

Each year, around 4.2 million children in low and middle income countries are admitted to health facilities with pneumonia-related hypoxemia. Yet across parts of Africa, where child pneumonia is endemic, fewer than one in five receive the oxygen therapy they need. For many children, that is a death sentence. Childhood pneumonia is now the biggest killer of children, claiming more than 800 000 lives each year. 

Many of these lives could be saved.  A combination of pulse oximeters (simple, low cost devices that measure blood oxygen levels), training nurses, and basic oxygen therapy can cut death rates among hypoxemic children hospitalised with pneumonia by half. Yet in Nigeria, which tops the world league table for childhood pneumonia deaths, effective oxygen treatment is seldom available in the rural clinics and hospitals that serve poor families. That helps to explain why death rates from pneumonia are three times higher for children in the poorest 20% of households than they are for children in the richest households.

Universal access to medical oxygen would do more than save lives from pneumonia. Oxygen is vital for the treatment of malaria, sepsis, and neonatal respiratory problems (all major causes of death), as well as in childbirth. 

So, why is medical oxygen routinely available in rich countries and routinely inaccessible to poor people in developing countries? Infrastructure is key. The oxygen provided to patients in hospitals in Europe and the US is typically manufactured in large scale industrial plants, delivered in low cost bulk liquid form, stored, converted into gas, and channelled to bedsides through internal pipes. Economies of scale secure large volumes at low prices.

The infrastructure in poor countries looks very different. Hospitals typically buy oxygen in low volume, compressed gas cylinders, which are then transported, often over vast distances. Small rural hospitals in Kenya or Nigeria can pay 5-10 times as much per litre of oxygen as the London hospital that treated Boris Johnson. When demand surges, prices rise and supplies get diverted from rural clinics dealing with childhood pneumonia to urban hospitals responding to covid-19. 

Lacking the public finance to provide oxygen for free, health facilities invariably pass the cost of on to patients. Some of the world’s poorest people are left paying among the highest prices. Treating a single case of childhood pneumonia with oxygen in Nigeria can cost $50-60—and many people are just too poor to pay. 

The oxygen crisis is a symptom of market failure, inequity, and a paralysing neglect of oxygen as an essential medicine. The director general of the World Health Organization (WHO), Tedros Adhanom Ghebreyesus, has rightly called for new business models to close the yawning gap between oxygen supply and demand. 

Building these models is not rocket science. In Ethiopia, for example, the government has developed an ambitious roadmap for achieving universal oxygen access, bringing together investors, health authorities, and philanthropists. You can see the results in the Amhara Regional Oxygen Centre, an oxygen plant now supplying 40 hospitals. In Kenya, a social enterprise called Hewatele (Swahili for “abundant air”) has created three plants near clusters of hospitals, which have pooled demand and cut transport costs. Oxygen prices have fallen sharply. 

There are many examples of innovation with the potential to deliver oxygen to communities beyond the reach of hospitals. In Papua New Guinea an oxygen improvement programme providing training, solar powered oxygen concentrators, and pulse oximeters to 38 facilities in remote areas saw child death rates fall by 40%. 

International cooperation should be supporting efforts like these that tackle the systemic oxygen crisis. Unfortunately, the response to covid-19 has been a case study in misplaced priorities. Aid donors have focused on providing ventilators and oxygen concentrators for covid-19 wards, neglecting investment in the large scale oxygen systems that would not only reduce deaths from covid-19 but save lives from many other causes, including pneumonia. 

The Access to Covid-19 Tools Accelerator, the multilateral response vehicle targeting $38bn in covid-19 support, has not mobilised any resources for investment in oxygen infrastructure. That’s an outright dereliction of leadership. The Global Fund and the World Bank, who are responsible for oxygen in the Access to Covid-19 Tools Accelerator, should either be leading efforts to finance that infrastructure and operating with a sense of urgency on what is—quite literally—a life and death issue, or stepping aside.

We can and must do better. Covid-19 is a global crisis that has ruthlessly exposed and exacerbated health inequalities across the world. But it is also an opportunity to close an oxygen divide that ranks among the greatest health injustices of our time. 

Kevin Watkins, CEO of Save the Children UK.

Adamu Isah, Chief of Party, INSPIRING Project, Save the Children Nigeria. 

Competing interests: None declared.