s Covid-19 spreads throughout Africa, a potentially deadly lack of oxygen is leaving doctors unable to offer essential treatment. Some experts put considerable blame on two multinational gas suppliers that dominate the market for oxygen cylinders across much of the continent, saying that their high prices and systems make the treatment unaffordable. Ex-employees, industry insiders and hospital staff point to the processes and prices Linde Group and Air Liquide have for medical oxygen and say they are leaving hospitals struggling for supplies. In European and US hospitals, liquid oxygen is delivered by tanker, stored in tanks, converted to gas and piped directly to bedsides. But for nations without this infrastructure, cylinders have to be bought in. As a result oxygen in sub-Saharan Africa is around to five times more expensive by volume, according to an investigation by the Bureau of Investigative Journalism (BIJ) One nurse in Ouagadougou, Burkina Faso, says that in her hospital doctors frequently have to choose who receives oxygen and who does not. The Linde Group did not comment on any of the allegations but said it would “do everything possible to continue to reliably supply our customers”. Air Liquide says: “We have done everything we can to secure supply through the pandemic.” It added: “We are committed to making sure as many patients as possible in sub-Saharan Africa receive treatment and work with Unicef and a range of other international institutions, governments and NGOs to increase access to oxygen in the region.” Grace Anya’s father Obiefula was diagnosed with pneumonia and sent for a coronavirus test at Gbagada general hospital in Lagos, Nigeria, on 12 May. He had been vomiting and excreting blood, but was given medication and sent home. Over the next two days he became too weak to speak. The family took him to nine different hospitals, only to be told that they had no oxygen, or were not admitting people over 50 years old, or could not treat people without a positive test result. He died at home. It was hell to watch, says Anya. Oxygen is the key treatment that patients with the virus are taken into hospital for and is used when weaning patients off ventilator support. As lungs become damaged, blood oxygen levels can drop alarmingly, a condition called hypoxaemia, which can be fatal. While the majority of sufferers have mild symptoms, 14% of Covid patients will need oxygen in hospital and 5% mechanical ventilation in intensive care. Across countries including Nigeria, Kenya, Burkina Faso, Guinea, South Africa, South Sudan, Cameroon, Ethiopia and Tanzania, many hospitals and dedicated Covid-19 isolation centres have oxygen shortages. According to the BIJ, the price of a 6.8-cubic metre cylinder of oxygen (a “J” cylinder), enough to treat an adult for roughly a day, ranges from $112 in Guinea, including transport, to $23 in Kenya. Air Liquide says that comparisons of prices between countries were unfair because production costs vary. Additional costs can include a cylinder deposit fee of about $300, a monthly cylinder rental fee of about $25, and paying to transport cylinders to the gas company’s depot. As some big hospitals need up to 80 cylinders a day, the costs quickly spiral. Air Liquide and the Linde Group, European companies whose African subsidiaries include Afrox and British Oxygen Company (BOC), also supply “industrial oxygen” to the mining, chemical, welding and food industries. Globally the Linde Group and Air Liquide made revenues of $28bn and $24.5bn respectively in 2019. Ex-employees and analysts suggest some gas companies have likely made profit margins of between 45% and 88% on medical oxygen. Air Liquide – which does not operate in Kenya – has charged up to a third more for medical oxygen than industrial oxygen. According to the BIJ, both come from the same gas plant; BOC/Afrox has charged up to seven times more for its medical oxygen. Air Liquide told the BIJ: “The 88% margin claim is totally inaccurate and does not reflect the economic reality of our business in Africa or the competitive nature of the market. “The market for oxygen in sub-Saharan Africa is competitive, with more than 15 medical oxygen suppliers across the region, and your claims about Air Liquide’s market practices are simply not backed up by the facts. “The pricing model in Africa is the same as the one used worldwide – customers pay a fee for cylinder deposit, rental and transport. The price of oxygen for hospitals in each country is set through competitive tender processes and reflects the production and regulatory costs in each country.” Unlike industrial cylinders, medical cylinders are emptied and cleaned every time they are refilled. Some former employees say that these extra steps explain why medical oxygen costs more. As oxygen is regulated as a pharmaceutical drug, companies producing it have to register with the local medical authority, test for impurities and record its journey, so that it can be recalled if necessary. Air Liquide says medical oxygen “cannot be produced or distributed in an offhand manner. It needs to be fully traceable and of the highest quality.” But others suggest that, in practice, this process does not significantly increase production costs. One former gas company employee, who wanted to remain anonymous, complained about the big price difference between medical and industrial oxygen. “There’s no justification for it one way or another,” they say. “The Covid-19 crisis highlights the need for governments to treat medical gases as strategic and not be at the mercy of foreign owned suppliers.” The chronic shortage of oxygen across Africa affects more than Covid cases. In 2018, almost half a million children died of bacterial pneumonia in sub-Saharan Africa. Better access to oxygen and antibiotics could reduce that number. Studies from Malawi and Nigeria show that fewer than a third of adults and children who needed oxygen actually got it. Trevor Duke, director of the Centre for International Child Health at Australia’s University of Melbourne, found that improving access to oxygen reduced early deaths in children by 35%. And hospitals cannot simply shop around for a better deal if their oxygen supply is too expensive. “There are many countries with a gas company monopoly,” Duke said. “In some countries,” he added, “the oxygen bill is the largest single drug purchase by ministries of health.” For children with pneumonia in Nigeria, oxygen accounted for half the cost of an admission, says Dr Hamish Graham, a consultant paediatrician who researched improving oxygen access. “Oxygen was a really big driving force of catastrophic health expenditure for those families.” “These prices are completely beyond the reach of most public hospitals across sub-Saharan Africa,” Leith Greenslade, an activist from the Every Breath Counts coalition, says, “which is why the hospitals have been passing the cost on to patients. “You can imagine how desperate that situation can be for a family, when they have just put a family member in hospital and they have had to find the oxygen to help keep them alive and come up with these huge, huge amounts of money.” Air Liquide accepts that patients were charged for oxygen in Nigeria, Ghana and Cameroon, but says: “In most countries where we operate … patients are not charged for the oxygen supplied by public hospitals.” Air Liquide and BOC have faced criticism in the past. In 2002, the European commission fined them and five other gas companies for participating in a medical and industrial gases cartel in the Netherlands, which prompted other investigations across Europe. The companies held regular meetings to fix prices between 1993 and 1997; the commission recognised that BOC and German supplier Westfalen had played an exclusively passive role in the infringement and had not participated in all aspects. Between 2001 and 2011, Air Liquide and Praxair – which later merged with the Linde Group – were investigated for perceived cartel-like behaviour in a series of cases in Latin America. The Argentinian competition authority fined Air Liquide, Praxair and two other companies $24.3m in 2005 for price fixing and allocating customers. Praxair and two other companies were fined $8m in 2010 for bid-rigging in Peru. The Linde Group’s subsidiary Afrox is currently being investigated by the South Africa Competition Commission for concerns over alleged price-fixing over liquid petroleum gas cylinder rental schemes. Maria Teresa Da Piedade Moreira, of the United Nations Conference on Trade and Development, says “It’s one of those sectors where the investments to enter the market are so high that you will never have a competitive market.” Before 2013 Linde Group’s Kenyan subsidiary BOC Kenya was charging about $58 per J cylinder, plus transport, a cylinder deposit and a leasing fee on top of the refill cost. Dr Steve Adudans and Dr Bernard Olayo, of Kenya’s Centre for Public Health and Development, acquired funding and built their own oxygen plant under the name Hewatele – “abundant air” in Swahili. They devised a system to drop off and pick up oxygen cylinders directly from hospitals and clinics for free, providing rural areas with oxygen for the first time. A year after setting up the business the doctors say they were approached by a BOC Kenya representative who met them at a restaurant and asked them to shut down their plant and distribute BOC Kenya’s oxygen instead. They declined. They built two more oxygen plants. “If you’re a dominant player, you probably want to protect your market share,” Olayo says. “If someone wants to take it away you better convert them or you aggressively compete against them.” Hewatele charges $25 for a J cylinder; BOC soon reduced its prices for some hospitals, Olayo says. One of Hewatele’s plants was built in the grounds of the Rift Valley general hospital in Nakuru. According to Dr John Murima, then the area’s medical superintendent, the hospital had previously suffered shortages. BOC orders had to be driven three hours from Nairobi. Switching to Hewatele meant a cheaper, steadier supply, says Murima. “We were able to cut the costs of oxygen by 40%.” The doctors say BOC tried to tempt Rift Valley general back, offering a 5% discount for refills and other incentives, but the hospital stuck with Hewatele. Other hospitals found it harder to switch, says Olayo. Their valves only fit BOC Kenya’s cylinders. It is “completely wrong” that gas companies can use cylinders to seek to tie hospitals to their product, because they cannot always deliver all the oxygen a hospital needs, says Temie Giwa-Tubosun, founder of LifeBank, a business enterprise in Nigeria working with hospitals. After seeing a news story about a man who died after being sent to five different hospitals, none of which had oxygen, she set up AirBank, to distribute free emergency oxygen cylinders to Nigerian hospitals, a project funded by corporate donations. AirBank has to supply a full adaptor kit, worth $129, to hospitals so its cylinders can be used. “By tying hospitals to this one system you’re actually putting people at risk,” she says. After turning down BOC’s offer, Olayo did not hear from it directly until July last year when he says he received a letter that accused Hewatele of illegally filling up BOC Kenya’s cylinders at its plants, an allegation he denies. “We have never filled their cylinders,” he says. His perception was that BOC was seeking to put pressure on him. Some hospitals report that oxygen companies have occasionally limited supply. Usually, 35 cylinders were delivered every day to Yalgado Ouédraogo University hospital in Burkina Faso, says Idrissa Ouédraogo, in charge of buying the hospital’s oxygen. But in March, Air Liquide said that the hospital could only order more cylinders if it had returned 60% of those already provided. But those cylinders were still in use. Now only 10 cylinders a day are delivered. On a day when the delivery did not arrive at all, Ouédraogo says he told Air Liquide he was concerned he might not have enough to last until morning. Air Liquide says it needed the cylinders: “Given the unprecedented increase in demand, leaving empty cylinders in one hospital would result in a shortage elsewhere – creating an unacceptable risk to patients. No hospital ran out of the supplies they needed from us. “The price of oxygen in Burkina Faso has declined because Air Liquide invested in a larger, more efficient production plant in Cote D’Ivoire [Ivory Coast] that reduced costs. Prior to this, oxygen was imported from Europe or produced by small, high-cost local producers. We remain committed to improving access across the country and have managed to do so this year despite Covid-19 and the very difficult security situation.” As the coronavirus crisis deepens, the WHO, World Bank and Unicef are shipping thousands of oxygen concentrators to 120 countries. Portable, suitcase-sized machines convert air into oxygen and can be used at a bedside in place of cylinders. In a meeting about acquiring concentrators for Kenya, the Kenyan Health Federation, whose oxygen division is led by BOC, appeared to have ruled them out for Covid-19 patients, saying that only 99.95% concentrated oxygen should be used. That concentration is only possible with oxygen made cryogenically – air is frozen to separate oxygen and nitrogen to form liquid oxygen. This is the method used at BOC’s African plants. The other two methods to make oxygen – the concentrators and pressure swing adsorption (PSA) plants (like those built by Hewatele) – produce concentrations of between 93% and 99%. The WHO defines medical oxygen as anything above 82%. There is no clinical reason to raise this recommendation, says Graham. “There is a common misconception that 99% is ‘better’,” Graham says. Nigerian technicians and healthcare workers have told him that gas companies and cylinder distributors contributed to the perpetuation of this misunderstanding, claiming that cylinder oxygen is more appropriate than concentrator oxygen. Whichever type of oxygen is supplied, the gas given to patients is mixed with air, reaching the lungs at concentrations of up to 50%. Oxygen concentrators would help hospitals to be more independent of gas companies and give access to hospitals not accessible by truck, says Dr Hans Lang, a paediatrician working for Alima, a global health NGO. He added that oxygen production needs to be “decentralised” – produced near patients rather than at a city gas plant. Alima has ordered 280 concentrators to be distributed around Guinea on top of 50 that have been sent to Donka hospital in Conakry, the capital. At present, the hospital spends between $2,800 and $9,000 a day on cylinders from Sogedi, a former Air Liquide subsidiary. A concentrator costs about $1,000 to $2,000. The WHO and Unicef have bought more than 30,000 concentrators to send to countries in need, although more recently the WHO warned of shortages. Concentrators are not a perfect solution. Electricity is not always available, and they were not built for dusty or humid conditions, so are prone to breaking down. Prof Roger Rasool, a physicist at the University of Melbourne, has developed concentrators that can run on solar or river power and have a “bladder” that stores oxygen and continues supply in a power cut. In a trial at Mbarara hospital in Uganda, the machines eliminated oxygen shortages and cut the number of cylinders used in three months from 77 to two. A longer-term solution is for hospitals to build their own oxygen plants. It is expensive – plants can cost from $100,000 to $1.5m, with electricity and staffing on top – but can improve oxygen supply across a large area. The Ugandan ministry of health used donations to build an oxygen plant at every regional hospital. “There’s been great improvement,” says Sheillah Bagayana, a biomedical engineer who helped install the first plant. “Oxygen used to be a huge, huge challenge. You’d literally have no option … just watch the patient die. Now, at least doctors don’t have to decide which patient gets oxygen.” There are challenges: plants run at half capacity at night and power cuts shut off the supply. But Duke argues that by most calculations the expenditure can be regained within three to five years. “Ministries of health and governments have to realise they have to invest in health systems to save money,” he says, adding that this was too important to be left to big businesses but “requires a sort of multidisciplinary effort”. For the thousands who have died without access to oxygen that might have saved them, any changes will come too late. But, Leith Greenslade of Every Breath Counts says, if there was ever a time for discussions and negotiations with the gas companies, it is now. “In Africa, now we’re in the middle of a pandemic,” Greenslade says, “and medical oxygen at the moment is the only thing available to really keep patients who get very sick alive.” • Additional reporting: Rosa Furneaux, Nasibo Kabale