Mount Kilimanjaro stands nearly 20,000 feet above sea level, its snow-capped peaks providing a stark contrast against northern Tanzania’s otherwise equatorial backdrop. As Africa’s tallest mountain, it draws tens of thousands of climbers a year: some of whom reach the summit successfully, many of whom must stop short because of low levels of oxygen in their blood (the peak’s atmospheric pressure offers about half the breathable air as at sea level). The irony, however, is that in Tanzania – and nearly every country in sub-Saharan Africa – you don’t need to climb a mountain to reach an environment with too little oxygen; you just have to walk into a hospital.
Oxygen is one of the most frequently-required medical interventions in the world, yet it remains in critically short supply in low-resource hospitals. The World Health Organization (WHO) estimates that less than half of health facilities in Africa have reliable access to medical-grade oxygen – let alone the trained staff, supplies and infrastructure to deliver it.
Without medical oxygen, health providers are unable to treat critically ill patients with low levels of oxygen in their blood – an effect of conditions such as trauma, obstetric complications, heart failure and respiratory diseases like pneumonia, a leading cause of death for children globally. As one Tanzanian doctor recently explained to me, oxygen is essential throughout the entire hospital because low blood-oxygen levels – known as hypoxemia – can be both ubiquitous and, in many cases, fatal.
“Hypoxemia can occur in any patient at any point of care,” said Dr. Mwemezi Kaino, Head of Anesthesia and Intensive Care at Kilimanjaro Christian Medical Centre – a referral hospital at the base of Mount Kilimanjaro that serves an area with more than 10 million people. “For example, when lungs become diseased – like in patients with pneumonia – they lack the capacity to function optimally in normal air, which is roughly 21% oxygen. So we must be able to provide air with higher concentration and monitor its saturation in the blood.”
The challenge, according to Dr. Kaino, is that medical oxygen is expensive and often unavailable, particularly in rural health facilities. Unlike hospitals in the U.S. and Europe that manufacture oxygen on-site and pipe it through their walls, those in low-income countries rely on cylinders filled at oxygen generating plants. However, these plants are few and far between in Africa, meaning hospitals must incur expenses for cylinders, transport, accessories and the oxygen itself, plus any training, maintenance and inspection costs needed. This price tag is simply too steep for many hospitals. In the interim, whatever oxygen is available often becomes rationed, used primarily for surgical care and the most acute cases.
One Kenyan entrepreneur – Dr. Bernard Olayo – is working to change that. After analyzing existing oxygen plants and realizing how much hospitals were spending on fuel for transportation, he created a self-sustaining model for producing and distributing concentrated oxygen at a lower cost.
“We found a way of reducing costs by creating a local plant in Western Kenya, timing distribution to nearby hospitals based on projected oxygen consumption and sticking to efficient, routine delivery routes,” explained Dr. Olayo. “We also offer customers training, maintenance packages and accessories such as face masks, pulse oximeters and manifolds [piping devices that allow oxygen to be distributed throughout a hospital].”
Dr. Olayo’s enterprise is aptly named Hewa Tele (Kiswahili for “abundant air”), and has quickly become a paragon for supplying oxygen in low-resource settings. It is currently serving health facilities with a combined catchment area of six million people, and is expected to double in size in 2017 thanks to a new investment from the Canadian government.
But Dr. Olayo acknowledged one difficult reality that continues to prevent oxygen from reaching patients’ lungs and bloodstreams: a gap between need and priority. Millions of people in sub-Saharan Africa need oxygen therapy for life-threatening diseases and injuries, but donors, governments and hospital administrators have, to date, failed to prioritize it in their budgeting and policymaking.
One reason for this gap is that oxygen is not recognized as a standalone treatment on the WHO’s Essential Medicines List (EML), which guides donors and governments on safe, effective and affordable medicines needed for a basic health system.
“Currently, the EML only indicates oxygen for use during anesthesia,” said Bonnie Keith, a senior policy and program officer at PATH. “But the global health community must recognize oxygen’s importance as an independent treatment for hypoxemia and ensure that it’s widely accessible throughout low-resource settings.”
In collaboration with the WHO and other global health organizations, PATH submitted a proposal to create an additional listing of oxygen on the EML, specifying its use for managing hypoxemia. PATH believes this policy change – part of its broader HO2PE Campaign – could help improve the availability of oxygen therapy in settings that need it most.
The WHO’s Expert Committee on Selection and Use of Essential Medicines will make its decision on an updated list later this week in Geneva.
Dr. Olayo seems hopeful about this pending development. “The WHO is the engine that fuels national priorities, so this indication would give countries a new license to operate with respect to oxygen,” he noted. “But we still need implementers and advocates to see it through on the ground; in the meantime, 35-40% of patients with severe pneumonia will die simply because we can’t provide oxygen.”
Regardless of the WHO’s decision, it will still be an uphill battle to improve the production, distribution and delivery of medical oxygen. The ho(2)pe, however, is that unlike on Mount Kilimanjaro, this climb will end with a sufficient supply of oxygen, or, as Dr. Olayo might say, hewa tele.