NEW DELHI (BLOOMBERG) - Hospitals in several Indian states are struggling for medical oxygen as the country's pandemic surges at the fastest rate in the world and manufacturers scramble to plug the gaps in supply and transportation.
Most plants producing medical oxygen are concentrated in eastern and western India, leaving large areas of the densely populated north and centre without quick access to the essential medical supply.
The capital, New Delhi, and the states of Bihar and Madhya Pradesh, with a combined population of some 200 million - nearly as many people as Brazil - don't have a single unit manufacturing oxygen.
In March, when India had some 1,300 confirmed coronavirus infections, the country was using around 750 tonnes of oxygen a day, said Mr Saket Tiku, president of All India Industrial Gases Manufacturer's Association.
"Now in September, it has gone up to 2,800 tonnes per day," he said. "It has put a lot of stress on our supply chain logistics."
Apart from the pressure to produce more medical grade oxygen, manufacturers are dealing with a limited number of mobile cryogenic tankers, he added.
While the country is managing so far, "going forward we need to be careful and very, very sensitive to oxygen use", he said.
With more than six million reported infections, India is now one of the world's main virus hot spots.
The country imposed a strict, six-week lockdown in March and April to flatten the curve and build capacity for growing infections. But as the outbreak keeps surging, its public hospital system - woefully inadequate even before Covid-19 struck - has struggled to keep up.
That it's now experiencing oxygen shortages comes as a surprise to experts like Dr Ramanan Laxminarayan, the director of the New Delhi and Washington DC-based Centre for Disease Dynamics, Economics and Policy.
"We had many months to prepare," he said. "The hope would have been that this calculation would have been done, because the oxygen was at the very top of the list of things critical to controlling a pandemic."
The administration of Prime Minister Narendra Modi was forced to step in earlier this month, with the federal health ministry asking states to ensure there were no restrictions on the movement of tankers carrying medical oxygen.
Earlier, hospitals had supplies for six days; now, they are able to maintain only four days of stock, said Mr Tiku.
"It creates a panicky situation if your oxygen is about to get over and your stock hasn't reached you."
Dr Amit Thadhani, a surgeon at Niramaya hospital in Mumbai experienced this panic first hand. For a week earlier this month, oxygen supplies at his hospital - with 55 beds and 10 intensive care spots earmarked for Covid-19 patients - went cold.
"We had to shift two patients because we were running dangerously low," he said.
The hospital was considering shifting more critical, oxygen-dependent patients when supplies stabilised but at much higher costs. From about 350-400 rupees (S$6.50-S$7.40) per cylinder, it is now 650-700 rupees a cylinder.
Shares of Linde India, the country's biggest manufacturer and distributor of industrial gases, including oxygen, have surged about 50 per cent since March, the start of India's pandemic.
"Sudden surge of medical oxygen in the last couple of weeks is impacting availability of industrial oxygen in some states," the Kolkata-based unit of Linde said in a presentation made to shareholders on Sept 18.
Coronavirus patients who require hospitalisation experience a dip in blood oxygen levels, making medical oxygen crucial for treatment. Each critically ill patient can need up to 10 jumbo cylinders a day, Dr Thadhani said.
Those needing oxygen increased sharply over the past weeks, with more people coming in with severe illness, Dr Thadhani said, partly because doctors from rural hospitals without adequate facilities are sending patients to bigger cities.
"We had a chat with manufacturers association also," he said. "They are saying that as of now, we have enough to manage but we need to use judiciously so that the situation doesn't go out of control. The fact is supplies were not forthcoming for many days."
Several states including Maharashtra, home to the financial capital Mumbai, have issued advisories to hospitals to use their oxygen supplies with care.
Meanwhile, its price has also soared despite a government cap on the cost of cylinders. While most large public hospitals have annual contracts with oxygen manufacturers, the price hike has hit smaller hospitals that don't have existing tie-ups.
"This is unprecedented - there's nothing absolutely in the last so many decades which comes close to this," said Dr Thadani.