Access to medical oxygen: a glaring global inequity

Since the World Health Organization declared Covid-19 a global pandemic more than six months ago, we have passed many grim milestones — worldwide, there have now been more than 35 million cases and 1 million deaths from the disease.

As the virus continues to expand its reach, it is worsening the public health disparities and inequities that advocates have been warning about for decades and making the devastating consequences of inaction harder and harder to ignore.

One of the glaring global inequities creating enormous quality-of-care challenges for doctors, nurses, and other health care providers, especially in countries with fragile health systems, is limited access to medical oxygen. In low-resource settings around the world, where many lack access even to electricity and clean water, oxygen availability is severely limited.


The disparity in safe, reliable access to medical oxygen — which is needed to treat a range of diseases and health conditions, and is absolutely essential for treating Covid-19 — is further compounded as health systems are overwhelmed by surges of patients.

The consequences of limited access to oxygen are too dire to go unchecked: It causes preventable deaths every day. In 2010, an international team made a call for international action to make medical oxygen an “essential medication” and improve access to it. In 2017, a group of experts from the WHO wrote that “safe and effective provision of oxygen is a challenge for doctors, hospital administrators, and government officials globally.” A study in Papua New Guinea showed that providing reliable systems for delivering oxygen in health care settings could reduce child pneumonia deaths by as much as 35%.


Approximately 20% of people with Covid-19 infections require hospitalization. For many of them, the delivery of supplemental oxygen is the principal treatment. In many cases, this single intervention saves lives.

In the United States, with the most modern, robust health care infrastructure in the world, the pandemic has threatened to push certain health care providers and systems to the brink of collapse. In countries with fewer hospital beds and little or no access to medical oxygen, the challenge is exponentially greater.

As public health officials, policymakers, and nonprofits grapple with how to support efforts to combat the Covid-19 virus and build more resilience into local health care systems in resource-limited settings, it’s imperative that we prioritize equitable, sustainable access to life-sustaining oxygen and work closely with local leaders and health care providers on the ground to design oxygen-delivery solutions that are appropriate to local contexts.

Medical oxygen comes in several forms. Advanced hospitals rely on liquid oxygen, which is delivered in its gaseous form directly to patients via piping threaded through the walls. Liquid oxygen, however, requires complex production and distribution networks that don’t exist in many low-income countries.

Alternative methods of delivering oxygen also present challenges. On-site pressure swing adsorption plants — commonly known as PSA plants — can produce oxygen that is then piped through the hospital. Bedside oxygen concentrators are self-contained units that provide up to 97% pure oxygen.

But both of these systems rely on a combination of strong and dependable electricity and expert personnel.

Even oxygen options that don’t rely on electric power, such as large cylinders of compressed oxygen, have barriers in these regions: Long distances between suppliers and hospitals can disrupt the supply chain, costs can be prohibitive, and monitoring and replacing the cylinders can require enormous staff capacity.

Ox Box
The OxBox is designed to address the cost and electricity barriers to providing patients with oxygen. Build Health International

To address the challenges and bridge existing gaps in treatment, our organization, Build Health International, has been working in partnership with local officials and others to develop and implement short- and long-term solutions that overcome the challenges involved in providing patients with oxygen.

To meet the immediate needs of hospitals and doctors treating an influx of Covid-19 patients, one solution is our OxBox, which intentionally addresses both cost and electricity barriers. Designed to be rapidly delivered, implemented, and easily operated, the OxBox includes proven, time-tested components: bedside concentrators capable of delivering oxygen at an effective and continuous rate; a solar array or generator to supplement the energy supply where electrical grids are unreliable; and a battery that converts intermittent power to a continuous flow, allowing the system to run 24/7.

Covid-19 represents an urgent call to scale up efforts to improve and implement more sustainable and resilient oxygen infrastructure in countries around the world. In many settings, investments in repairs and training are essential. Our team was recently in Central Haiti, working alongside local staff members to repair the on-site PSA plant at Cange Hospital. This work not only restored access to medical oxygen but also helped provide local workers with the skills to diagnose and repair the PSA plant in the future, ensuring greater continuity in the supply of oxygen. In some places, the construction of new oxygen infrastructure is necessary to ensure a sustainable supply.

When national health systems are in danger of being pushed beyond the breaking point by a virus that wreaks havoc in the lungs, and millions of lives are at stake, equitable access to medical oxygen is more important than ever. The global response must include meeting the immediate needs of hospitals and doctors who require rapid access to oxygen to treat patients with Covid-19 and creating reliable, sustainable oxygen infrastructures in low-resource settings around the world. This will improve care not just during the time of coronavirus, but long after the pandemic has faded.

The expertise and technology exist to deploy effective solutions in countries most at risk. It’s time to fund and implement these basic solutions to save lives in communities around the world.

David Walton is a physician in the Division of Global Health Equity at Brigham and Women’s Hospital in Boston and a co-founder of Build Health International. Jim Ansara is a retired general contractor who founded Shawmut Design and Construction and a co-founder of Build Health International.

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