A model of this text was initially printed in Undark Magazine.
On a late April afternoon, the Ngor Health Center in Dakar, Senegal, is serene. Sunlight spills via 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 middle eight months prior, in the summertime of 2021, when COVID-19 struck the West African nation in its third and deadliest wave. The solely reminder exists excessive up on the partitions: slim copper pipes skilled via roughly drilled holes. The pipes have been constructed as Ngor frantically retrofitted its ready space with further beds in a bid to increase the middle’s restricted oxygen community to deal with the inflow of COVID sufferers.
But to the pediatrician Idrissa Demba Ba, the scramble for oxygen—which, in many international locations, got here to represent the pandemic—was nothing new. In truth, it’s an indicator 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 kids beneath the age of 5 in 2019.
Pneumonia could be triggered when a pathogen—for example, 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. Children are extra susceptible to the illness as a result of their lungs and immune techniques are nonetheless growing. To deal with the situation, there are three predominant choices: antibiotics, antivirals, and oxygen. Every 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 National Children’s Hospital.
The World Health Organization lists oxygen as an essential medication, which appears intuitive for a significant, life-sustaining fuel. Yet in Senegal and plenty of different growing international locations, offering oxygen in its medical kind could be fraught: The medical-grade oxygen is pricey, getting it from one place to a different requires the development of pipelines and different infrastructure, and medical personnel should be skilled to manage it.
These supply-chain obstacles threaten, per one estimate, greater than 7 million kids in low- and middle-income international locations who get pneumonia annually and want oxygen to outlive. Limited provides are a part of the explanation the illness stays the most typical infectious explanation for dying in kids worldwide, claiming the lives of greater than 740,000 beneath the age of 5 in 2019. Younger kids are extra susceptible—29 % of pneumonia deaths happen inside the first month of life, and three-quarters inside the first yr.
Most of these affected stay in lower- and middle-income international locations like Senegal, the place the danger of pneumonia is exacerbated by malnutrition and different points, says Papa Birane Mbodji, the pinnacle of new child well being on the Department of Mother and Child Health in Senegal’s Ministry of Health and Social Action. Another 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 kids, 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. While the world’s consideration has been skilled on COVID, “you could basically say there is an ongoing pandemic of pneumonia mortality,” says Keith Klugman, an infectious-disease skilled who heads the pneumonia program on the Bill and Melinda Gates Foundation.
But 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 international locations 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—resembling growing oxygen infrastructure—to assist curb childhood pneumonia. The authors wrote: “The COVID-19 response provides opportunities to increase diagnostic and treatment services for respiratory infections.”
Ba and different specialists on the bottom share the sentiment. More and extra, they see COVID as a chance to get the important useful resource to extra kids, to deal with this forgotten epidemic.
Against 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 government of Senegal established an ambitious scale-up strategy 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 electronic mail to Undark. Then in 2017, she wrote, members of the Senegalese authorities attended a PATH-led assembly centered on widening oxygen entry. There, the federal government highlighted its work with a personal contractor to put in and preserve pressure-swing adsorption, or PSA, vegetation—which produce purified oxygen from ambient air on-site—at plenty of hospitals. After this occasion, Smith mentioned, PATH began working with the federal government to supply further assist to shut different gaps in Senegal’s oxygen-supply chain.
A yr into the pandemic, PATH printed a report based mostly on a nationwide survey of medical gear, centered 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 giant city areas, however a lot scarcer at smaller well being facilities and posts that serve the vast majority of the inhabitants. For occasion, of 29 COVID-treatment facilities surveyed throughout 13 areas, Dakar, Senegal’s capital, had the best focus of key medical instruments—62 % of pulse oximeters, which estimate blood oxygen ranges, and 84 % of useful ventilators—regardless of 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 offer a dependable provide of oxygen. Nearly half of the remedy facilities with entry to a PSA plant, which price upwards of $100,000 apiece, have been concentrated in Dakar to satisfy the wants of town’s dense inhabitants—such because the Ngor Health Center’s PSA plant, which was constructed there earlier than COVID hit and have become a boon throughout the pandemic.
Within 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 via a filtration system to take away nitrogen and permit oxygen to cross via. The oxygen is then transferred to holding tanks, able to be piped into the wards.
In distinction, at most different health-care amenities the place PSA vegetation are briefly provide, health-care staff depend on smaller items of apparatus resembling oxygen concentrators and cylinders to produce the essential fuel. These include their very own challenges: Most concentrators, that are transportable, suitcase-size machines, ship oxygen at a fee that’s too sluggish for extreme COVID sufferers, and cylinders could be refilled with new oxygen solely at centralized vegetation, which implies that provide could be disrupted due to unreliable transport.
Maintaining this piecemeal infrastructure may also 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 bins, mosquito nets, and an previous mat and metallic mattress body stripped naked—stacked beneath a zinc roof simply exterior 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, the vast majority of low- and middle-income international locations struggled to acquire medical oxygen. In sub-Saharan international locations, 31 % of amenities had interrupted entry, whereas 25 % 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 mission referred to as Tools for Integrated Management of Childhood Illness, or TIMCI—collectively run by PATH, Unitaid, and the Swiss Tropical and Public Health Institute—launched in August 2021 in a number of amenities in three international locations, together with the arid baobab-studded area of Thiès, an hour’s drive into the countryside past Dakar. Here, TIMCI equipped pulse oximeters to docs at 59 well being posts to diagnose incoming sufferers. As of September 2022, TIMCI has screened virtually 17,000 sick kids 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 means of detecting a situation by which oxygen saturation ranges dip dangerously beneath 90 %, referred to as hypoxemia. Hypoxemia will increase the danger of dying by pneumonia as much as 5 instances.
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, as a way to then assist kids get the pressing oxygen remedy that they want and save lives. But 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 “increase 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 occasion, the federal government, along with PATH, is now finalizing one other evaluation of its oxygen infrastructure, upkeep, and long-term sustainability. The overarching purpose is “to improve oxygen availability and utilization in each health facility,” Badiane wrote in a follow-up electronic mail.
This evolving evaluation laid the inspiration for the federal government’s most vital transfer: the plan to roll out dozens of latest PSA vegetation, the items that produce oxygen on-site at hospitals, says Amad Diouf, the director of the Department of Infrastructure, Equipment, and Maintenance at Senegal’s Ministry of Health and Social Action. These essential new oxygen vegetation, 5 of that are funded by UNICEF, are as a consequence of be put in by the top of 2022, with a concentrate on well being facilities throughout the nation. At the beginning of the pandemic, with assist 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 combat towards childhood pneumonia. A 2021 evaluation research discovered that bolstering oxygen infrastructure in lower- and middle-income international locations may reduce child-pneumonia deaths in hospitals by virtually half. And in Senegal, the pediatrician Mbodji says there was a notable improve within the availability of oxygen at well being amenities. Though it’s tough to attribute solely to this transformation, Mbodji says, pneumonia deaths in kids have declined over the previous two years.
The pandemic has additionally given pneumonia initiatives like TIMCI particular resonance. COVID-19 was “an opportunity” for the Ministry of Health to acknowledge the significance of oxygen infrastructure and speed up the unfold of lifesaving instruments like pulse oximeters via extra well being amenities, says Maymouna Ba, who leads the TIMCI mission in Senegal.
“Before TIMCI, before COVID-19, such equipment, such tools, were just available at higher levels like in hospitals, in health centers. But not in health posts where providers also need these kind of equipment, these kind of tools to better detect severe illness in the early stage,” Ba says. With the TIMCI trial ongoing, she provides, there are plans to ultimately present much more pulse oximeters to well being posts throughout the entire nation.
Other pneumonia interventions have obtained the same enhance in recognition—such because the SPRINT mission, or Scaling Pneumonia Response InnovaTions, a program run by UNICEF to broaden entry to antibiotics and oxygen remedy for pneumonia. The program 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 the complete nation.
Senegal’s oxygen response is emblematic of modifications unfolding elsewhere. COVID made plain that “you can’t wait for disaster to happen for the equipment to be here,” says Fatima Diaban, a critical-care doctor and member of the Every Breath Counts Coalition, an initiative by the nonprofit JustActions centered on supporting nationwide governments in decreasing pneumonia deaths by the top of the last decade. In May 2021, Senegal was amongst 9 African nations to start receiving assist from PATH and the Clinton Health Access Initiative to obtain new oxygen gear, funded by $20 million from Unitaid. The Global Fund, a global health-care-focused funding group, with assist from authorities and private-sector donors, additionally offered $475 million to 66 lower- and middle-income international locations for the same objective.
Now that the pandemic has eased, a few of these sources could be redeployed to deal with childhood pneumonia—one thing that’s already beneath means in different international locations resembling Ethiopia, the place the federal government introduced plans in 2021 to redistribute the heart beat oximeters and oxygen therapies it used for COVID elsewhere in its health-care system.
Large assist donations typically 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. “Each donor has unique requirements for accountability and responsible use of funds,” she wrote in an electronic mail. For occasion, her group labored intently with Senegal’s Ministry of Health and the Department of Infrastructure, Equipment, and Maintenance to distribute donated oxygen gear to amenities in want.
Overall, such initiatives may fast-track progress on pneumonia, a illness that’s nonetheless “very much neglected” within the world well being discourse, regardless of its world burden, says Klugman of the Bill and Melinda Gates Foundation. Pneumonia continues to be chronically underfunded, taking simply 5 % of the money dedicated to preventing infectious illness globally, and simply 3 % of the analysis funding allotted to infectious ailments from 2000 to 2017 by public and philanthropic funders in G20 international locations.
Prevention will probably be essential—and progress is beneath option to develop new, focused vaccines, which defend higher towards pneumonia in contrast with current vaccines, Klugman says. But for now, oxygen stays a uniquely environment friendly option to save lives. As such, the pandemic responses that many international locations have drawn up present a great framework for motion—a “foundation for continued declines in deaths from all-cause respiratory infections over the next decade,” in response to a 2021 report on pneumonia and the coronavirus pandemic produced by JustActions.
Indeed, it’s not simply kids with pneumonia who stand to profit from this unfold: Wider oxygen provisions will assist folks with infectious ailments, cardiovascular ailments, and bronchial asthma.
This bigger significance, laid naked and elevated by the pandemic, is behind the latest September 2022 launch of the Lancet Global Health Commission on medical oxygen safety, a brand new partnership of lecturers and NGOs, which can reportedly embody robust illustration from lower- and middle-income international locations. 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 middle, 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. Just 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 kids’s ward.
As Badiane places it: “In 2022, really oxygen should be available and affordable in every health facility.”