A model of this text was initially revealed in Undark Journal.
On a late April afternoon, the Ngor Well being Middle in Dakar, Senegal, is serene. Daylight spills by means of architectural gaps within the ceiling and luxurious vegetation line cream-colored corridors. In a affected person ready space on the second ground, a employees member gently rolls a ball forwards and backwards with a toddler.
The calm belies the chaos on the well being heart eight months prior, in the summertime of 2021, when COVID-19 struck the West African nation in its third and deadliest wave. The one reminder exists excessive up on the partitions: slim copper pipes skilled by means of roughly drilled holes. The pipes had been constructed as Ngor frantically retrofitted its ready space with additional beds in a bid to increase the middle’s restricted oxygen community to deal with the inflow of COVID sufferers.
However to the pediatrician Idrissa Demba Ba, the scramble for oxygen—which, in lots of nations, got here to represent the pandemic—was nothing new. In actual fact, it’s a trademark of one other scourge he’s been battling for 18 years, childhood pneumonia. The illness, attributable to an an infection of the lungs that disrupts respiration, killed 2,400 Senegalese youngsters beneath the age of 5 in 2019.
Pneumonia might be triggered when a pathogen—as an illustration, a virus, micro organism, or fungus—enters the lungs, the place it inflames the air sacs, inflicting them to fill with fluid or pus and making it exhausting to breathe. Kids are extra susceptible to the illness as a result of their lungs and immune programs are nonetheless growing. To deal with the situation, there are three fundamental choices: antibiotics, antivirals, and oxygen. Day-after-day, there are kids who must be linked to an oxygen provide, says Ba, who’s head of pediatric pulmonology at Dakar’s Albert Royer Nationwide Kids’s Hospital.
The World Well being Group lists oxygen as a necessary medication, which appears intuitive for an important, life-sustaining fuel. But in Senegal and lots of different growing nations, offering oxygen in its medical type might be fraught: The medical-grade oxygen is dear, getting it from one place to a different requires the development of pipelines and different infrastructure, and medical personnel have to be skilled to manage it.
These supply-chain obstacles threaten, per one estimate, greater than 7 million youngsters in low- and middle-income nations who’re contaminated with pneumonia annually and want oxygen to outlive. Restricted provides are a part of the rationale the illness stays the commonest infectious explanation for demise in youngsters worldwide, claiming the lives of greater than 740,000 beneath the age of 5 in 2019. Youthful youngsters are extra susceptible—29 p.c of pneumonia deaths happen throughout the first month of life, and three-quarters throughout the first 12 months.
Most of these affected reside in lower- and middle-income nations like Senegal, the place the chance of pneumonia is exacerbated by malnutrition and different points, says Papa Birane Mbodji, the pinnacle of new child well being on the Division of Mom and Youngster Well being in Senegal’s Ministry of Well being and Social Motion. One other risk is the close by Sahara Desert, which sweeps in large quantities of mud that contribute to the area’s outsize world burden of younger sufferers.
When there isn’t sufficient oxygen to deal with these youngsters, their lungs fail, eliciting grunts as they struggle desperately to rake in additional oxygen from the air, Ba says—a symptom that echoes the devastating results of COVID-19. Whereas the world’s consideration has been skilled on COVID, “you can mainly say there’s an ongoing pandemic of pneumonia mortality,” says Keith Klugman, an infectious-disease knowledgeable who heads the pneumonia program on the Invoice and Melinda Gates Basis.
However there could also be an upside: The disaster of the coronavirus pandemic drew the world’s consideration to the essential significance of oxygen. Seeing how shortly nations galvanized to deal with COVID, Klugman and different specialists wrote a Lancet article in November 2020, calling for them to construct on the pandemic’s uncommon beneficial properties—reminiscent of rising oxygen infrastructure—to assist curb childhood pneumonia. The authors wrote: “The COVID-19 response offers alternatives to extend diagnostic and therapy companies for respiratory infections.”
Ba and different specialists on the bottom share the sentiment. Increasingly more, they see COVID as a chance to get the important useful resource to extra youngsters, to deal with this forgotten epidemic.
In opposition to this backdrop, Senegal provided fertile floor for enchancment. Even earlier than the pandemic, and within the midst of it, the nation was interrogating its medical-oxygen infrastructure.
“The federal government of Senegal established an formidable scale-up technique for oxygen as early as 2013,” wrote Lisa Smith, the access-to-medical-devices portfolio director for the market-dynamics program on the public-health nonprofit PATH, in an e mail to Undark. Then in 2017, she wrote, members of the Senegalese authorities attended a PATH-led assembly targeted on widening oxygen entry. There, the federal government highlighted its work with a non-public contractor to put in and keep pressure-swing adsorption, or PSA, vegetation—which produce purified oxygen from ambient air on-site—at a lot of hospitals. After this occasion, Smith mentioned, PATH began working with the federal government to supply further help to shut different gaps in Senegal’s oxygen-supply chain.
A 12 months into the pandemic, PATH revealed a report primarily based on a nationwide survey of medical gear, targeted on oxygen infrastructure, noting the place it was out there and the place it was most missing.
Key among the many findings of the ensuing report was that oxygen was closely concentrated at emergency facilities in massive city areas, however a lot scarcer at smaller well being facilities and posts that serve nearly all of the inhabitants. For example, of 29 COVID-treatment facilities surveyed throughout 13 areas, Dakar, Senegal’s capital, had the best focus of key medical instruments—62 p.c of pulse oximeters, which estimate blood oxygen ranges, and 84 p.c of useful ventilators—regardless of the town making up lower than 1 / 4 of the nation’s inhabitants.
The gear survey additionally revealed stark disparities within the distribution of PSA vegetation, which give a dependable provide of oxygen. Practically half of the therapy facilities with entry to a PSA plant, which price upwards of $100,000 apiece, had been concentrated in Dakar to satisfy the wants of the town’s dense inhabitants—such because the Ngor Well being Middle’s PSA plant, which was constructed there earlier than COVID hit and have become a boon through the pandemic.
Inside a big, sun-drenched courtyard on the hospital grounds, the PSA plant hums inside a locked concrete enclosure. As a part of the setup, there’s a black field referred to as a compressor, which sucks in exterior air and pressurizes it. From there, the pressurized air is scrubbed because it runs by means of a filtration gadget to take away nitrogen and permit oxygen to move by means of. The oxygen is then transferred to holding tanks, able to be piped into the wards.
In distinction, at most different health-care services the place PSA vegetation are in brief provide, health-care staff depend on smaller items of apparatus reminiscent of oxygen concentrators and cylinders to provide the essential fuel. These include their very own challenges: Most concentrators, that are moveable, suitcase-size machines, ship oxygen at a price that’s too sluggish for extreme COVID sufferers, and cylinders might be refilled with new oxygen solely at centralized vegetation, which implies that provide might be disrupted due to unreliable transport.
Sustaining this piecemeal infrastructure can be impractical. At one other well being facility throughout city, this was evidenced by a pile of discarded concentrators strewn amongst different objects—unused respirators in water-logged packing containers, mosquito nets, and an outdated mat and metallic mattress body stripped naked—stacked beneath a zinc roof simply outdoors the entry ramp for emergency sufferers.
Such infrastructural challenges aren’t distinctive to Senegal. A 2021 WHO technical session revealed that earlier than the pandemic, nearly all of low- and middle-income nations struggled to acquire medical oxygen. In sub-Saharan nations, 31 p.c of services had interrupted entry, whereas 25 p.c had none in any respect.
These wider findings on oxygen and COVID additionally helped inform child-pneumonia initiatives, together with a medical trial designed to check the worth of pulse oximeters in these sufferers. The trial, a part of a venture referred to as Instruments for Built-in Administration of Childhood Sickness, or TIMCI—collectively run by PATH, Unitaid, and the Swiss Tropical and Public Well being Institute—launched in August 2021 in a number of services in three nations, together with the arid baobab-studded area of Thiès, an hour’s drive into the countryside past Dakar. Right here, TIMCI provided pulse oximeters to medical doctors at 59 well being posts to diagnose incoming sufferers. As of September 2022, TIMCI has screened nearly 17,000 sick youngsters in Thiès.
The gadgets work by attaching to a affected person’s finger and painlessly measuring the extent of oxygen of their blood. It’s a fast and cheap method of detecting a situation by which oxygen saturation ranges dip dangerously under 90 p.c, referred to as hypoxemia. Hypoxemia will increase the chance of demise by pneumonia as much as 5 occasions.
The Senegalese trial—half of a bigger multicountry initiative additionally involving Kenya, Tanzania, India, and Myanmar—intends to guage the effectiveness of pulse oximeters in additional precisely and swiftly diagnosing hypoxemia, with a purpose to then assist youngsters get the pressing oxygen therapy that they want and save lives. However such initiatives will solely in the end be efficient if the important oxygen provides are readily available close by.
On a tree-lined avenue in downtown Dakar, Ndèye Astou Badiane sits contained in the PATH regional headquarters considering the pandemic’s legacy. In Senegal, though the well being system struggled with an actual “enhance in demand [for] oxygen,” says Badiane, who’s a respiratory-care coordinator on the nonprofit, some good got here out of it. The clear and pressing want, she provides, injected new momentum into nationwide efforts to deal with oxygen shortages.
For example, the federal government, along with PATH, is now finalizing one other evaluation of its oxygen infrastructure, upkeep, and long-term sustainability. The overarching intention is “to enhance oxygen availability and utilization in every well being facility,” Badiane wrote in a follow-up e mail.
This evolving evaluation laid the inspiration for the federal government’s most important transfer: the plan to roll out dozens of latest PSA vegetation, the models that produce oxygen on-site at hospitals, says Amad Diouf, the director of the Division of Infrastructure, Tools, and Upkeep at Senegal’s Ministry of Well being and Social Motion. These essential new oxygen vegetation, 5 of that are funded by UNICEF, are as a consequence of be put in by the tip of 2022, with a give attention to well being facilities throughout the nation. At first of the pandemic, with help from PATH and Unitaid, Senegal was capable of purchase 175 oxygen concentrators, 1,000 oxygen masks, and 250 pulse oximeters.
There are early indications that the trouble to strengthen Senegal’s oxygen gaps is translating into beneficial properties within the struggle towards childhood pneumonia. A 2021 assessment research discovered that bolstering oxygen infrastructure in lower- and middle-income nations might minimize child-pneumonia deaths in hospitals by nearly half. And in Senegal, the pediatrician Mbodji says there was a notable enhance within the availability of oxygen at well being services. Although it’s tough to attribute solely to this variation, Mbodji says, pneumonia deaths in youngsters have declined over the previous two years.
The pandemic has additionally given pneumonia initiatives like TIMCI particular resonance. COVID-19 was “a chance” for the Ministry of Well being to acknowledge the significance of oxygen infrastructure and speed up the unfold of lifesaving instruments like pulse oximeters by means of extra well being services, says Maymouna Ba, who leads the TIMCI venture in Senegal.
“Earlier than TIMCI, earlier than COVID-19, such gear, such instruments, had been simply out there at increased ranges like in hospitals, in well being facilities. However not in well being posts the place suppliers additionally want these sort of gear, these sort of instruments to higher detect extreme sickness within the early stage,” Ba says. With the TIMCI trial ongoing, she provides, there are plans to finally present much more pulse oximeters to well being posts throughout the entire nation.
Different pneumonia interventions have obtained an identical increase in recognition—such because the SPRINT venture, or Scaling Pneumonia Response InnovaTions, a program run by UNICEF to develop entry to antibiotics and oxygen therapy for pneumonia. This system was initially confined to sure areas, however for the reason that pandemic started, Mbodji says, the federal government has been engaged on plans to increase it to your complete nation.
Senegal’s oxygen response is emblematic of modifications unfolding elsewhere. COVID made plain that “you may’t watch for catastrophe to occur for the gear to be right here,” says Fatima Diaban, a critical-care doctor and member of the Each Breath Counts Coalition, an initiative by the nonprofit JustActions targeted on supporting nationwide governments in decreasing pneumonia deaths by the tip of the last decade. In Could 2021, Senegal was amongst 9 African nations to start receiving assist from PATH and the Clinton Well being Entry Initiative to obtain new oxygen gear, funded by $20 million from Unitaid. The International Fund, a global health-care-focused funding group, with help from authorities and private-sector donors, additionally offered $475 million to 66 lower- and middle-income nations for the same objective.
Now that the pandemic has eased, a few of these sources might be redeployed to deal with childhood pneumonia—one thing that’s already beneath method in different nations reminiscent of Ethiopia, the place the federal government introduced plans in 2021 to redistribute the heartbeat oximeters and oxygen therapies it used for COVID elsewhere in its health-care system.
Giant help donations usually include questions on whether or not such funding reaches the meant recipients in its entirety. PATH’s Smith mentioned there are safeguards in place to make sure it does. “Every donor has distinctive necessities for accountability and accountable use of funds,” she wrote in an e mail. For example, her group labored carefully with Senegal’s Ministry of Well being and the Division of Infrastructure, Tools, and Upkeep to distribute donated oxygen gear to services in want.
Total, such initiatives might fast-track progress on pneumonia, a illness that’s nonetheless “very a lot uncared for” within the world well being discourse, regardless of its world burden, says Klugman of the Invoice and Melinda Gates Basis. Pneumonia remains to be chronically underfunded, taking simply 5 p.c of the cash dedicated to preventing infectious illness globally, and simply 3 p.c of the analysis funding allotted to infectious illnesses from 2000 to 2017 by public and philanthropic funders in G20 nations.
Prevention might be essential—and progress is beneath solution to develop new, focused vaccines, which defend higher towards pneumonia in contrast with present vaccines, Klugman says. However for now, oxygen stays a uniquely environment friendly solution to save lives. As such, the pandemic responses that many nations have drawn up present a really perfect framework for motion—a “basis for continued declines in deaths from all-cause respiratory infections over the subsequent decade,” in response to a 2021 report on pneumonia and the coronavirus pandemic produced by JustActions.
Certainly, it’s not simply youngsters with pneumonia who stand to profit from this unfold: Wider oxygen provisions will help folks with infectious illnesses, cardiovascular illnesses, and bronchial asthma.
This bigger significance, laid naked and elevated by the pandemic, is behind the latest September 2022 launch of the Lancet International Well being Fee on medical oxygen safety, a brand new partnership of teachers and NGOs, which can reportedly embody sturdy illustration from lower- and middle-income nations. The Fee seeks to construct on the pandemic’s beneficial properties and supply coverage makers with data and instruments to shut the essential gaps in world oxygen-supply chains.
Already, the advantages of expanded oxygen entry are evident on the Ngor well being heart, the place the copper pipes are reminders of a traumatic time however now stretch past the emergency room, ferrying oxygen to those that want it most. Simply off the principle hall of the second ground, these pipes have been skilled right into a room with partitions adorned with cheerful stickers of Dora the Explorer, flowers, and birds—a youngsters’s ward.
As Badiane places it: “In 2022, actually oxygen must be out there and inexpensive in each well being facility.”