On 19 April, Narayanaswamy, the head of Athreya Hospital in Anekal, a town in Bengaluru urban district, sounded an alarm with government and health officials, oxygen suppliers, and the media: his hospital was running out of oxygen. His patients, several of whom were severely ill with COVID-19, would not survive without it. “I have eight patients who are in critical condition and their family members are falling on my feet asking me to save them at any cost. But I am helpless. I can’t do anything,” Narayanaswamy, who is also the president of the Indian Medical Association in Anekal, told reporters with the Bangalore Mirror when they met him that night.
A 69-year-old COVID-19 patient overheard the doctor while he was making appeals for oxygen over the phone. Narayanaswamy recalled that he went to replenish the man’s oxygen, which was running out, he found him hugging the empty cylinder, refusing to let go. “He thought I was stealing his oxygen supply for another patient,” Narayanaswamy told me. “I had to convince him, he was not listening, even as his oxygen was dropping from 70 to 65. That’s when I broke down.”
At around noon on 20 April, about 24 hours after Narayanaswamy made his frantic calls, district health and government officials visited Athreya Hospital. They assured Narayanaswamy that they would facilitate the provision of oxygen for the hospitals in Anekal facing shortages. But, Narayanaswamy said, they were also worried about public perception. He recalled one official saying, “We are in the public, whatever is happening, we should not worry the families. We should avoid panic…even if don’t have something in our pockets, we should say our pockets are full.”
Soon after the meeting with health officials, Narayanaswamy sent a member of his administrative staff to the government-recommended supplier to get cylinders refilled. The truck going to the supplier had close to 72 empty cylinders from different hospitals in the area, including Athreya Hospital. Narayanaswamy found the suppliers resistant to refilling the cylinders and government officials, unresponsive. “Till midnight, none of them were picking up calls, I started calling again, putting messages everywhere possible, I started the same hungama”—fuss.— “When the situation was going to burst, they answered,” Narayanaswamy told me. The oxygen eventually arrived at Athreya Hospital a few hours past midnight, but for the 69-year-old patient, it was too late. He had died earlier that day. “I am honestly telling you, we didn’t have uninterrupted oxygen supply,” Narayanaswamy said, “I put my hand on my heart and tell you, there were interruptions. If it was continuously flowing, maybe he could have made it. Maybe, who knows, I am not God.”
I spoke to the 13 private and public health doctors from Bengaluru, most of them from small-to-medium-sized private hospitals. Nine among these doctors faced at least one oxygen crisis since the beginning of the surge of COVID-19 infections in April. Of these, two said that they received timely help from government officials, while the rest bought oxygen at marked-up prices, either directly from suppliers or on the black market, or got help from the medical fraternity. Most of these hospitals had either stopped admitting new patients or restricted COVID-19 admissions till they could ensure consistent oxygen supply.
“In very big hospitals…there is a liquid oxygen system and oxygenators, so an oxygen-generating system is in place,” a member from Karnataka’s COVID-19 Technical Advisory Committee, who did not want to be identified, told me. “But in smaller hospitals and nursing homes, we are finding that there is a definite shortage.”
I spoke to the head of a private hospital in the Shivajinagar locality of Bengaluru, on 24 April, who compared the situation in the city to the on-going crisis in Delhi, particularly the deaths of 25 patients at Gangaram hospital earlier that day due to an oxygen shortage. “That situation is there, it is just at the doorstep,” the doctor said. “One of the reasons it hasn’t happened is that we’ve refused a lot of admissions, and those people have already died on the street.” The head of a hospital in east Bengaluru told me, “the system is collapsing. There is a forest fire and we are trying to fight it with sprinklers.”
Karnataka has been among the worst-affected states in the rise of COVID-19 infections in March and April in India, described as the country’s second wave. On 30 April, it registered 48,296 new cases, the highest single-day rise since the beginning of the pandemic. On 1 May, the state registered 40,990 new cases, taking the number of active cases to 4,05,068. The state reported a test positivity rate—the number of positive cases among those tested—of 23.03 percent. Bengaluru Urban district alone accounted for 2,70,993 active cases, which was nearly 66 percent of the state’s case-load. By 1 May, the city had officially recorded 6,537 COVID-19 deaths since the beginning of the pandemic in March 2020.
ML Giridhar, the treasurer of Karnataka’s Private Hospitals and Nursing Homes Association and the head of Tejas Hospital in southwest Bengaluru, told me, “I think the death rate in the media is less.” According to him, it did not account for cases in which patients came to casualty wards in severe conditions, without RTPCR reports, and died. In such cases, Giridhar noted, a patient’s family was often unwilling to wait to confirm whether or not a patient was COVID-19 positive through a test, which meant that the death was attributed to another cause.
Bengaluru’s medical infrastructure has been bursting at its seams. Doctors have been negotiating a precarious balance of shortages between intensive care unit beds, oxygen, and ventilators. Meanwhile, the state government went from claiming preparation in mid-March to fire-fighting in mid-April.
On 22 April, the Karnataka government directed all hospitals with more than 30 beds to dedicate 80 percent of their beds and ICU facilities for patients infected with the coronavirus, instead of the previously mandated 50 percent. It announced that eight modular ICUs, with a capacity of 200-250 beds, would be set up in eight zones across Bengaluru. To mitigate the shortfall of beds, the state is contemplating asking hospitals to admit patients only if their oxygen saturation levels are below 90 percent. On 26 April, the government announced a 14-day-long lockdown across the state.
On 27 April, a division bench at the Karnataka High Court observed that the situation was “quite alarming.” The court was hearing a case that had been registered suo moto after it received two letters detailing problems that COVID-19 patients in the state were negotiating. The court was informed that Bengaluru had only 74 high dependency unit beds, 20 intensive care unit beds and 14 ICU beds with ventilators available at the time. Addressing the counsels representing the centre and the state, the court asked, “There is a huge gap between the requirement and availability of oxygen in the state. How are you going to bridge the gap?” Two days later, the bench passed an order in which it noted that while there had been a marginal improvement in the availability of beds, the state needed to take more stringent measures to account for its lack of preparation.
“The government has been responding very retrospectively, even though they should be planning far ahead for a pandemic,” Sylvia Karpagam, a public health doctor and researcher, said. The second wave should not have taken the Karnataka government by surprise. The state’s technical advisory committee on COVID-19 comprising epidemiologists, doctors and public policy experts warned the government of a second wave in a report it submitted on 30 November 2020.“The authorities under-estimated the scale of the problem,” the technical advisory committee member told me. On 23 April, the Times of India quoted an unnamed senior minister saying, “We basically wasted three months of crucial time due to politicking and by-polls.” K Sudhakar, Karnataka’s health minister admitted to the New Indian Express on 25 April that, “The TAC had advised us about a second wave and also suggested strict measures. I agree that if we had perhaps taken the measures that we took now about three weeks ago, we would have been in a better position.”
On the evening of 23 April, standing in the compound of Victoria Hospital, it was hard to fathom what the “better position” Sudhakar alluded to could have looked like. Victoria Hospital is Bengaluru’s largest public hospital located in the heart of the city. By the second week of April, it had been converted into a dedicated COVID-19 facility. The hospital was still in the process of converting all of its buildings into wards for COVID-19 patients at that time. ICU facilities were stretched thin.
That evening, four ambulances crowded the small compound of its trauma care centre, occupied by patients and attenders who were waiting to be called on. In one such vehicle, a frail-looking woman kept dropping the oxygen mask she was breathing into as she slipped in and out of consciousness. Inside, doctors and nursing staff in PPE kits were working at a frenetic pace. “The main thing is that the patient intake is so much,” a member of the hospital’s nursing staff, who wished to remain anonymous, said. “We have had a tremendous shortage of beds. We have had to turn some people away.”
A junior resident, who asked not to be identified, lost a patient in his mid-forties in the emergency ward that day. “He had no co-morbidities previously, but his saturation was constantly dropping,” he recalled when we spoke on the phone the next day. “We gave him everything possible in terms of initial care in the emergency ward—oxygen mask, high flow oxygen.” The patient’s only hope was intubation, but the doctors did not have a ventilator available. “I was helpless, I couldn’t save him, I did everything in my hands to save him,” the junior resident said. “It was traumatising.”
The high rate of infection in the second wave has also been putting healthcare workers at increased risk, and systems under increased strain. “We might run out of manpower in the near future,” the junior resident doctor from Victoria Hospital told me. “Most of the doctors are turning positive, most of the nursing staff are turning positive.” Even through multiple oxygen crises, doctors see a looming crisis of healthcare workers. “We can produce oxygen tomorrow, we can’t produce a nurse, we can’t produce a doctor…where are you going to get them from overnight,” the head of the east Bengaluru hospital said.
As I was leaving Victoria Hospital compound on 23 April evening, a middle-aged man was sitting outside and quietly sobbing into his phone. His 31-year-old nephew had tested positive earlier that week and was admitted at St John’s Hospital in Koramangala. A day before, the doctors there had said that his oxygen saturation levels were dangerously low. He would not survive without a ventilator but they did not have one for him. Since then, the man had called everyone he could think of and travelled to numerous hospitals within the city, but to avail. “I don’t know what to do,” he said, “I have done everything I could.”
Since the first week of April, doctors in Bengaluru have been issuing warnings of shortages in oxygen supply. On 17 April, Vijay Raghav Reddy, the head of Swastik Hospitals in Marathahalli uploaded a video appeal for oxygen on Facebook, saying that his patients were in grave danger and could not be shifted out because there were no other hospitals that would provide them with oxygen support. That day, Karnataka’s Private Hospitals And Nursing Homes Association or PHANA addressed a letter to the Sudhakar, the state’s health minister. “If the current situation of oxygen shortage continues, we may have a major medical disaster of loosing [sic] precious lives on oxygen support,” the association noted. “Time is running out and we pray with utmost urgency to your good self to take this on TOP priority and address the situation.”
On 19 April, Karpagam and Tousif Masood from Mercy Mission, a coalition of non-governmental organisations that works on issues related to COVID-19, wrote a letter to the state government as well. “Those who are seriously ill are forced to run from pillar to post to even secure admission,” the letter noted. “Moreover, those admitted have received exorbitant bills ranging from Rs 3-5 lakh. There is no clarity on what the expenses are and whether rational treatment is being followed.” The letter emphasised the “critical shortage of oxygen supply so that even those patients who can be managed with home care with clinical tele-support, medications and oxygen supply are succumbing to the illness.” Karpagam and Masood called for the government to ensure that “all liquid oxygen must be routed towards hospitals rather than industrial uses,” and that “private hospitals do not turn away COVID positive patients and, at the very least, life-saving treatments are not denied to patients.”
After a spate of statements in which it claimed that Karnataka’s oxygen production capacity and supply were sufficient to meet its demands, the state government, on 22 April, began operating a war-room staffed by 26 government officials to co-ordinate the supply of medical oxygen and the anti-viral drug Remdesivir to hospitals. Subsequently, the state government requested the centre to increase its daily oxygen allocation from 300 metric tonnes to nearly 1,500 metric tonnes. The centre sanctioned 800 metric tonnes on 24 April, although the details of when or how this supply will be distributed remain unclear.
Several doctors said that the war-room had brought little change. The managing director of the hospital in east Bengaluru said that when his staff faced an oxygen shortage about a week ago, they depended on their own resources. He added, “There was one day in between when we could get a few cylinders through government support, so I can’t completely say the government did not participate. But essentially if there is no supply, there is nothing they can do also.” On 26 April, I asked the head of the hospital in Shivajinagar whether government support had improved. “There is one officer sitting in the gates of every oxygen supplier 24/7. Poor man, he has good intent, but where is the oxygen,” he messaged in reply. Two doctors told me that when they approached the war-room for help, nodal officers told them, “Why are you admitting so many patients? Just admit as many your stocks will allow.”
On 19 April, when Giridhar, the PHANA treasurer, realised that his hospital was going to run out of oxygen in a few hours, he approached government officials who directed him to a supplier in Peenya, an industrial area on the outskirts of Bengaluru. “I myself, and my driver went with a truck,” Giridhar told me. “There was nobody, and I was trying like mad. I waited for three hours, nobody was responding, there was no oxygen.” Meanwhile, the doctors in Giridhar’s hospital kept calling him with dire updates. “They were saying that the cylinder needed to reach in 45 minutes, there was nothing in my hands at that time.” Desperate, he reached out to colleagues from neighbouring hospitals and borrowed two cylinders each from three organisations. “If I had not been able to get the cylinders from my colleagues, those six cylinders, at least minimum eight people would have died,” he said. “I am a treasurer for PHANA, I have so many contacts, I have been working for 30 years in this industry. With all this influence, I am still facing these problems, you can imagine how it is for smaller doctors.”
When I met Athreya Hospital’s Narayanaswamy on 23 April, a staffer from his maintenance department had just returned from a similar wild-goose chase. It was 3 pm and Narayanaswamy said he had oxygen till about 8 pm for the 28 patients in his hospital who needed it. That morning, health officials had directed him to a filling station, where, Narayanaswamy said, all the cylinders were empty. “There was no activity happening, because there was not a drop of oxygen.” As we were speaking, Narayanaswamy’s original supplier was carting 20 empty cylinders from the hospital across the city in the hunt for oxygen.
I called and left messages with a nodal officer from Karnataka’s oxygen war room asking about the government’s plans for helping hospitals in distress and about doctors making appeals for oxygen to the media and on social media. He did not respond to my queries.
Several doctors reported that because patients infected with COVID-19 were deteriorating at a quicker rate than in the first wave, and displaying symptoms of happy hypoxia—in which the patient does not feel the symptoms of low oxygen saturation levels till there is significant depletion—the requirement for oxygen far exceeded a hospital’s original capacity. While some were still able to procure the quota that had been allotted to them before the pandemic, it was not enough. Sudhindra Kanevahalli, a critical care specialist at Apollo Hospital, pointed out that although “bigger hospitals have better supplies so we have not had an oxygen crunch yet, it is a matter of time when everyone will be hit.” Normally, he said, oxygen would be used by some patients in the ICU, some in the HDU and only a few in the wards. “Now the situation is that every bed in the hospital needs oxygen. From 10-15 percent of patients in a hospital needing oxygen it has become 70-80 percent,” he said.
He outlined the measures that hospitals such as his had taken, including the creation of oxygen surveillance teams. These teams made rounds of wards every two to four hours and inspected oxygen pipelines for leaks. They also checked for leaks from oxygen ports and whether ports had accidently been left running at unused beds. “Clinically, we have decided to accept a lower oxygen saturation limit if the patient is comfortable,” the doctor added. “From insisting on an oxygen saturation of 94-95 percent earlier, we are now accepting that a patient is stable between 88-92 percent, provided the patient is comfortable and not breathing at a faster rate.”
Many private hospitals said they were turning to the black market to bridge the disparity between their allotted oxygen quota and what they need. “We are paying 300, 400, 500 percent the cost and getting it from various places,” the head of the hospital at Shivajinagar said. “It is partially illegal, because the cylinders we have are leased out from an oxygen supplier company and it is not legal to fill it up from any other supplier. You have to get those from the same company you have leased it out from. We are getting it filled it up from somebody else.” The doctor said that they had refilled cylinders at Rs 6,000 before the pandemic, and then an escalated price of Rs 13,000 during the first wave of the pandemic. This year, they were paying around Rs 40,000 for each refill. However, he said, even paying these exorbitant prices bought only a few cylinders at a time. “It’s not like if I pay they’ll give me 10 cylinders.”
A volunteer at an NGO that has been helping patients and hospitals procure oxygen, who requested anonymity, told me that there had been a shortage of regulators of oxygen cylinders as well. “This was [priced at] Rs 850-Rs 900 till two weeks ago,” he said. “I just purchased them for Rs 1,800 each, and a supplier I reached out to now, is asking for Rs 1,950.” When I spoke to HM Prasanna, the president of PHANA, on 22 April, he said, “Of course there is a mark-up. The attitude is if you want to buy it, then buy it, otherwise get lost. Whatever the government fixed pricing is there, we are paying three to four times that.”
A report in the Bangalore Mirror pointed out that these increased costs were being borne by patients of private hospitals, some of whom were left with no choice but to pay Rs 37,800 for the continued supply of oxygen. This was more than five times the price that they were earlier charged of Rs 7,500 per day.
On 25 April, the central government imposed a complete ban on the use of liquid oxygen for industrial or non-medical uses, directing that there would be no exemptions. A report in the News Minute noted that since all seven of Karnataka’s privately-owned liquid oxygen manufacturing plants were located between Bengaluru and Ballari, a district in north-east Karnataka, “it is not just a question of supply keeping up with the demand. Even if all oxygen production is diverted to be used for medical purposes, there is a massive logistical challenge of transporting and storing the oxygen...because the production is not evenly distributed in Karnataka.” Despite the shortage of oxygen in the state, none of the six Pressure Swing Adsorption oxygen plants that were sanctioned for Karnataka’s hospitals under the PM-CARES fund are operational yet.
“People are also hoarding cylinders, because they’re panicking, there is a huge amount of public health education that needs to go out,” Karpagam said. According to her, a lack of proper triaging—the process by which the treatment plan of a patient is decided according to the severity of the disease—was also resulting in unnecessary hospitalisation. Karpagam had encountered cases in which private hospitals were encouraging patients to seek admissions even if their symptoms were manageable, by pointing out changes in their CT scans, some of which she said were natural in a COVID-19 infection. “Evidence-based medicine is taking a hit. Those who need tertiary care are running looking for hospitals,” she said, “I tried counselling people who are in this situation, they are in just so much panic. But if you try and talk to them as soon as they’re positive, they’re much more receptive. We are managing a lot of people at home with tele-visits and home consultation.”
People who were not able to consult doctors remotely and were isolating at home without adequate care were far more likely to regress to serious conditions. Prasanna, the president of PHANA, said monitoring patients in home isolation needed to be supplemented with effective medical consultation to prevent their conditions from worsening. “We need to identify patients who are going to develop complications. Most of these patients, who are developing complications and getting into the ICU, can be brought down by 50 percent,” he told me.
The oxygen shortage brought on by a combination of factors—the inadequate preparation, absence of triaging and tele-consulting, and the quick regression of patients’ health—had directly impacted the ability of hospitals to admit patients. “I can wait for a day if I don’t have medicine,” Reddy of Swastik Hospital said. “But if I don’t have oxygen, how will I answer to the attendants? This is not a reason to die, right? I could have treated them and they could have not responded, I have no problem…but I cannot tell them oxygen not being available is the reason for death.” Prasanna told me, “It is our ethical responsibility to see patients get adequate medicine and oxygen supply, and if we can’t do that, what business do we have taking more patients.”
A private hospital in Rajajinagar found a compromise to this conundrum. The hospital had run out of ICU beds. But on the afternoon of 23 April, COVID-19 patients with serious symptoms were being provided oxygen at its fever clinic, a small room at the end of a lobby in the basement of the hospital. One of the patients was Nagendra’s mother, a 59-year old woman, whose oxygen saturation levels had been fluctuating between 45 and 50. When Nagendra could not find an ICU with a ventilator, he brought her to the hospital. “I begged them for two hours of oxygen,” he said. In the meantime, he tried to secure oxygen cylinders for his home as a temporary measure, but the only facility that responded asked him to bring an empty cylinder of his own, which he did not have. It had been 24 hours since he came to the hospital looking for oxygen. His mother spent the night on a spare cot in the clinic.
Nagendra said he tried the government helplines “every 15 minutes, from last night 9 pm till today morning, 7.30 am.” He had no luck. Finally, at 2 pm, after what he felt were five hundred phone calls, his mother was allotted a bed equipped with a ventilator at the government-run KC General hospital in Malleswaram.
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On the afternoon of 21 April, I visited the Jayanagar office of Mercy Mission. Across three floors of the building, scores of volunteers, many of whom were fasting for Ramzan, fielded calls at a relentless pace. The organisation, which had been founded in 2020 to assist migrant workers during the lockdown, had expanded its mandate. Over the past year, it had provided oxygen for patients and hospitals, counselled patients, identified plasma donors, run ambulances, conducted funerals, and facilitated bed allotments. In April, Mushtaq, one of the mission’s volunteers, died of COVID-19.
Through the early months of 2021, the number of calls on the organisation’s helpline reduced to between 30 and 40 a day. Since 10 April, they began to shoot up and by 25 April, Mercy Mission was receiving close to 5,600 calls. “There is so much panic,” Masood, the volunteer who co-wrote the letter to the government, told me. “The severe shortage of oxygen supply, that is the most critical and top priority for which we have to do something.” During the second wave, Mercy Mission has tried to maintain a stock of about 500 cylinders divided across five of its centres, for hospitals and for patients who needed them for home-care, he said. Every time they stocked up, supply ran out within hours. “Yesterday, I travelled about 400-500 kilometres to refill the empty cylinders we had,” Masood told me.
“The previous year, we saw people calling us for advice on what was to be done if they were COVID-positive,” Nabeela, a young woman who has been volunteering with Mercy Mission for about a year, said. “This time, it’s only distress calls: ‘My mother is not able to breathe, my father is not able to breathe, my brother is not able to breathe,’ and saturation is in its forties or fifties. It’s always below seventy.” Sharif, a managing trustee of Project Smile, one of the NGOs that form Mercy Mission, said, “Sometimes after a shift, the volunteers break down, they just can’t take it anymore”.
Nabeela told me of a fifty-five-year-old woman she had been in touch with. The woman had not been tested, but her symptoms were consistent with Severe Acute Respiratory Infections. According to the BBMP rules, she could not get admitted as COVID-19 patient without a Bengaluru Urban, or BU number, which would be generated only after she got a positive RT-PCR report. “It took three days, she waited with oxygen on a general bed,” Nabeela said, “She got tested, her BU number came, she got an ICU. On the way in the ambulance, she died.” The absence of a BU number, especially as a back-log of tests built up and results were delayed, was a stumbling block for a number of patients who had approached Mercy Mission.
Outside the office, a clutch of people collected cylinders for friends and relatives who were COVID-19 patients. Mercy Mission charged a refundable deposit of Rs 8,000 to ensure that the empty cylinders would be returned without damage, and a price of Rs 500. Syed Abdullah’s aunt, whose saturation levels were dropping to the seventies, had not been able to get a hospital bed because her RT-PCR test result had not come in yet. Abdullah hoped to tide over the waiting period with the cylinder that he was taking home. A woman from Koramangala was there to take a cylinder for her mother, whose saturation level was perilously low, at 35. “It has been very difficult we have been trying since 9 am, we haven’t been able to manage even a general bed for her,” she said, relief writ large on her face as she loaded the cylinder into the boot of her car.
The next evening, I dropped by the Mercy Mission office again. The mood there was buoyant. Over 45 patients at the HBS hospital in Shivajinagar were on oxygen support and the hospital had run short of oxygen earlier that day. The team had been able to help them procure oxygen from Hosur, on the outskirts of Bengaluru. But given the traffic in the city, transporting the re-filled cylinders back in time was no guarantee. The volunteers contacted Bengaluru police officials, who created a green corridor for the truck and cleared vehicular traffic on the route. “It was a last ball match!” Masood exclaimed. Khalid, the ambulance driver who had ferried the cylinders, broke his fast with water and a vada and described the drive in breathless detail.
As we were talking, the woman from Koramangala entered the office to return the cylinder she had taken the day before. She seemed much calmer than she had the previous afternoon. “How is your mother now?” I asked her. When she adjusted her mask to speak, I realised she was crying. “She died, she died before we could get the oxygen cylinder to her, we were too late,” she said.