On the early hours of June 10th, a nine-year-old boy from Kifri in Kurdistan Region of Iraq (KRI) died from apparent respiratory distress. His family told media outlets that the district general hospital he was taken to did not have enough oxygen supplies to save his life. They also claimed that his father had to bring an oxygen cylinder from his private cooling business to give his son Oxygen in hospital. Few days after his death, his family stormed the hospital and destroyed most of its equipment.The family referred to the “I can’t breathe” protests in the United States and their resulting destruction as a justification for their violent actions (personal correspondence).
Around the same time, an ICU nurse in Slemay in KRI told reporters that mother who was in intensive care because of COVID-19 has died because the CPAP machine she was on has run out of Oxygen. More recently, a lawyer issued a statement on social media accusing one of the hospitals in KRI of killing her father because their oxygen supply ran out.
These tragedies are emblematic of disastrous consequences of unaddressed issued related to medical Oxygen which the WHO considers an essential medicine. WHO has recently also warned of shortages of oxygen therapy and equipment in countries experiencing an increase in the case of COVID-19. As far as KRI is concerned, those issues can be approached as one of demand, supply and management.
As cases of COVID-19 soar in KRI, the demand for medical Oxygen, an essential treatment for the disease, becomes increasingly evident. Recently the numbers of confirmed COVID-19 cases in KRI have exceeded the 5,000 marks. During June, the number of cases has increased by 600% in Iraq (including KRI). Furthermore, more than 67% of COVID-19 cases are hospitalised in KRI, albeit inappropriately for some. Conservatively estimating that around 20% of admitted patients need Oxygen, the massive influx of patients will inevitably put strains on this essential medicine.
Seemingly, the increased demand for medical Oxygen is not limited to public hospitals. Some well-off people in KRI have purchased oxygen cylinders and concentrators for their private use at home. The price of a single oxygen cylinder went up to US$110, while one oxygen concentrator was sold for US$1700. Unconfirmed reports also claimed that people in the position of power in political parties and the government had obtained oxygen cylinders from public hospitals for their private use.
However, oxygen related issues in KRI are not limited to increased demand or abuse but also shortages in oxygen supplies. Medical oxygen is supplied through varies methods in KRI. Some large hospitals have onsite oxygen tanks (for example, Rizgary Teaching Hospital in the Capital city of Erbil). More commonly, compressed oxygen cylinders are provided by public and private manufactures. Similar to other settings, the provision of oxygen by private providers is accompanied by several difficulties. During the ongoing COVID-19 crisis, the supply of oxygen from one of the leading private supplier was reduced by 25% in Slemany governorate. The director of the supplier claimed that an essential piece of its machinery has malfunctioned and has to be replaced. He also reported that this particular piece was ordered for the United States, which will take several weeks to arrive.
Also, it appears that some in the private market are trying to abuse the COVID-19 emergency to make profits by restricting the supply and increasing prices. The Iraqi Ministry of Interior, for example, issued a statement reporting that it arrested businesspersons who withhold 150 oxygen cylinders and demanding ID 500,000 for each.
KRI is not the only region in the world with issues related to the oxygen supply. The WHO has recently estimated that 88,000 oxygen cylinders would be needed around the world daily. The shortage of this essential medicine is alarmingly becoming a widespread phenomenon, particularly in similar LMIC settings. For example, oxygen is available in less than half of hospitals at any given time in Africa and Asia-Pacific. As COVID-19 tightened its grip, oxygen shortage has become evident in countries from Peru to Guinea and India.
KRI, however, seems to be one of the few regions in the world where private use of oxygen at people’s houses is becoming increasingly common. Boycotts by healthcare workers, lack of trust in public health facilities and the limited capacities of the health system are only a few of the drivers of such a trend. It is essential to introduce policies that limit such practices and ensures the safety of patients and their families for home oxygen use.
Like many other LMICs, the regulatory function for oxygen resides with the Ministry of Health (MoH). Similar to various LMIC settings, the MoH’s capacities to undertake such duty to regulate the expanding private market is nascent. While the mix of oxygen sources is perhaps a strength for the health system in KRI, it is necessary to enhance the capacity of the MoH in to regulate and coordinate the supply of oxygen.
Organisations and countries have provided life-saving assistance to KRI during the COVID-19 crisis. Recently, for example, WHO has provided 300 oxygen concentrators to Iraq. But as some rightly argued obtaining equipment and “dumping it on hospitals”, will unlikely be useful in the long run. These concentrators are also unlikely to be helpful for the management of severely affected patients who require more than the usual 5 litres per minute supply that these machines can provide. Furthermore, unreliable power supply in KRI will likely put patients who require an uninterrupted flow of Oxygen at risk. Therefore, more efforts are needed to ensure sustainable and sufficient volume of Oxygen during this crisis and beyond.
About the authors
Goran Abdulla Sabir Zangana is a physician and non-resident research fellow with the Middle East Research Institute.
Shayan Kaka Salih is a physician and a member of the Kurdistan Parliament’s Health, Environment, and Consumer Rights Committee
We have read BMJ Group declaration of interests and declare we have no competing interests to declare.