Transcript of webinar: Investing in oxygen to close the access gap during COVID-19 and beyond

This is a transcript of the Investing in Oxygen webinar that was broadcast on March 11, 2021. 

The webinar was moderated by President Bill Clinton and included panelists Anthony S. Fauci, M.D., Director of the National Institute of Allergy and Infectious Diseases (NIAID) at the U.S. National Institutes of Health, Dr. John Nkengasong, Director of the Africa Centres for Disease Control and Prevention, and Ms. Joy Phumaphi, former Botswana Minister of Health and co-Chair of the United Nations Secretary General’s Independent Accountability Panel for Women, Children, and Adolescent Health.


President Bill ClintonNo one, no matter where they live or what their income, should die for lack of oxygen, a condition we can diagnose easily, treat affordably, and prevent globally. If you live in a wealthy country, having too little oxygen in your blood is a problem doctors have the tools and training to treat.  

In other parts of the world, it still can be a death sentence. So, we have quite a health equity crisis on our hands now. Aggravated, obviously, by COVID.  

CHAI was founded to ensure that access to lifesaving antiretrovirals for vulnerable patients in low and middleincome countries would be there, something at the time many people thought was impossible. But today millions of people in sub-Saharan Africa and around the world have antiretroviral treatments thanks to a truly global effort involving governments, normative bodies, international donors, and private sector companies.  

Access to oxygen requires the same kind of partnerships between many of the same types of organizations. We need clinical and technical experts to show how to deliver it to patients, normative and political bodies to prioritize it, and the full weight of both national and international financing mechanisms to support it.  

While COVID-19 has recently increased attention and funding for oxygen in low and middleincome countries, the work will not be sustainable without long term commitments and funding to truly transform oxygen delivery and diagnosis and health systems everywhere. 

Today we’re very fortunate to be joined by three experts who will discuss this issue and then I’ll ask a few questions and hope to shed more light than heat.  

Let me first introduce Dr. Anthony Fauci – who needs no introduction as he has been the face of our sane efforts against COVID for more than a year now – the director of the National Institute of Allergy and Infectious Diseases at our U.S. National Institutes of Health. Dr. Fauci, thank you. The floor is yours. 

Dr. Anthony Fauci: Thank you very much, Mr. President. It’s really a great pleasure and an honor to be here with you and with our distinguished panelists.  

I was reflecting, when I was asked to be part of this panel, that in my now over 40 years of which I have been involved in the response to outbreaks – including HIV, Ebola, SARS, and now COVID-19 – I was not really, ever fully aware of the importance and the critical nature of a shortage of oxygen until I began to get deeply involved, which I am to this day, with COVID-19 right here in the United States. The medical oxygen shortages due to surges and hospitalizations that I first noticed in the spring of 2020 in New York City, New Jersey, and Connecticut; then in Texas in the fall of 2020; and then in California and the Navajo nation this past fall and current winter, it was impressed upon me how extraordinarily critical this asset is. 

And now taking care of COVID patients myself, literally across the street from where I’m sitting now at the NIH Clinical Center, which I know you visited multiple times, Mr. President, that it became clear to me the vital nature of having oxygen available, which prompted me to go back and take a look at the role of oxygen and oxygen shortages in the risk of death in the developing world. And it is stunning.   

WHO estimated that up to 500,000 newborn deaths per year are due to a lack of available medical oxygen, and 40 percent of adult and pediatric deaths from pneumonia can be prevented with medical oxygen. And so, it became so clear to me that we are dealing with an extraordinary problem that needs to be addressed.  

When I heard that we’d be on this panel and the kinds of things that CHAI and PATH and Every Breath Counts and others have been doing, I felt this would be something that I absolutely wanted to be a part of the discussion. So, with that, I look forward to a very fruitful discussion. Back to you, Mr. President. 

President Clinton: Thank you very much. Now I’d like to recognize Dr. John 

Nkengasong, the director of Africa Centres for Disease Control, who has a long and distinguished career in his native land, in his native continent, and in Europe and the United States. We thank him for being here and for what he’s doing. And I open the floor to you, sir.  

Dr. John Nkengasong: Thank you. Thank you, Mr. President. Good evening. To all from Addis Ababa and specifically from the Centres for Disease Control and Prevention in Ethiopia. My warmest greetings to everyone on today’s panel, including President Clinton, Dr. Fauci, and my friend Joy for joining us on this panel today to discuss this important aspect.   

I would like to first thank the President and the Clinton Health Access Initiative for the opportunity to discuss this very important need that is the global oxygen supply gap. This has been and continues to be one of the many challenges facing our institutions across Africa, which have been exacerbated by the ongoing COVID-19 pandemic, as Dr. Fauci mentioned.  

During the current pandemic we have seen extraordinary need for oxygen across Africa, placing a larger burden on health systems on all African Union member states.  

Through Africa – though Africa has been relatively less hit than other parts of the world, carrying about 3.5 percent of the world’s COVID reported cases – the continent continues to struggle with securing and sustaining the necessary oxygen due to several factors.  

First of all, one of the main challenges we are seeing includes proper investment and funding for oxygen plants. Prior to the COVID-19 pandemic, there were just 68 oxygen generating plants on the continent of Africa, a continent of 55 member states with 1.2 billion people, according to the World Health Organization. The numberanyway, has increased since then to about 119 oxygen generating plants. That represents an increase of 40 percent. Though the increase is promising, challenges continue, including the ability to maintain those oxygen plants across the continent and to provide continuous and predictable financing to support them.  

As my friend, Getinge [inaudible] puts it, the issues of underfunding and inefficiencies of the health sector, whereby if hospital needs to procure oxygen are refused, the procurement processes become prolonged and the necessary oxygen supply doesn’t arrive on time, resorting to fatal consequences for a patient.  

According to the World Health Organization, the need for more oxygen on the continent rose by 39 percent increase during the period in January alone, making the demand for treatment higher than was seen in the first wave of the pandemic. That’s why [despite] this figure, the many challenges brought on by the pandemic, opportunities exist that we must work in partnership to begin to fill these gaps. And we are particularly pleased that there are other foundations trying to come together, rally, work together with the Clinton Health Access Initiative to fill this gap.   

Thank you for the opportunity. And I look forward to an exciting discussion. 

President Clinton: Thank you very much. Finally, I’d like to invite Joy Phumaphi, who recently joined the board of CHAI and who had a very distinguished run as the minister of health for Botswana, to say a few words, from the government perspective.  

You know, a lot of countries are approached by a lot of donors that come in, come out, they’re in, they’re out, they’re up, they’re down. CHAI, as Joy knows, has tried to be involved with nations for the long run, to make a real difference. And we’ve been working, thanks to the Gates Foundation and ELMA and the IKEA Foundation and four African countries and India, in Nigeria, Kenya, Uganda, and Ethiopia, where Dr. Nkengasong is today, to try to dramatically increase the availability of oxygen.  

But once you get into the details, you run into things like how to maintain the equipment, how to train people to do it. All of this. And I thought we should ask Joy to make a few remarks at the beginning from her perspective, having been the minister of health – and I thought running a really laudable effort in dealing with HIV and AIDS and other challenges. So, Joy, the floor is yours.  

Ms. Joy Phumaphi: Thank you so much, Mr. President. It’s really a privilege to have this opportunity to join this panel, under your leadership, together with Dr. Fauci and Dr John Nkengasong 

You know, oxygen shortage in developing countries, particularly in Africa, has been a real, real challenge. Low blood oxygen is a major cause of deaths. In fact, one million deaths could be avoided if we addressed the challenge of low blood oxygen.  

Dr. Fauci already talked about the challenge with newborns, but 16 percent of underfives that are admitted into hospitals actually suffer from low blood oxygen. And 13 percent of these children are children who have pneumonia; 10 to 15 percent are children who have got malaria, meningitis, convulsions and oxygen is a consistent challenge.  

One of the biggest challenges as well is misdiagnosis or failure to actually diagnose patients who have got low blood oxygen.  

It is estimated that 80 percent of the patients with low blood oxygen are actually not diagnosed with low blood oxygen, primarily because of lack of access to a simple way of testing blood oxygen. Whereas we do know that there are pulse oximeters which are very, very simple tools which can be used. So, the first thing is the diagnosis, the misdiagnosis, and then the next is the lack of access to oxygen.  

One of the biggest challenges I faced when I was a minister was trying to make enough oxygen available for the patients whom we had already diagnosed as needing oxygen  without a pulse oximeter, that is, patients who were diagnosed just by, you know, looking at symptoms, which leads to 40 percent failure in diagnosing.  

I was constantly challenged with the lack of oxygen, and this is a challenge which faces ministers consistently. One of the most important interventions that are required right now is to improve oxygen administration practices. First of all, you need policy change. You need to update clinical guidelines and protocols and then you need to update the patient charts and registers, and you need equipment maintenance. But you also need to train your health professionals on how to diagnose and how to equip them with the pulse oximetersand then there’s also the markets and the financing issue.  

So, what I would strongly like to propose and something that has already been proposed by other partners, is a roadmap that partners such as CHAI, could then use to support countries; partners such as a Unitaid could also use to support countries. A road map that will actually address the training, the maintenance, and the need for plants.  

There are lots of best practice examples that we could take from: There are countries, for example, like Malawi, like Papua New Guinea, like Nigeria, that have experimented on a small scale. And they’ve been able to demonstrate huge improvements, save lots of lives by making oxygen concentrators available, by using solar powered concentrators. Sometimes a government manufacturer in Ethiopia, for example, sharing the oxygen that it was using for bleaching with the hospital. So, there are many best practices that we can learn from, but it is something that is absolutely urgent. And it has been made even more urgent by COVID.  

President Clinton: Dr. Fauci, do you have a response to that?  

Dr. Fauci: No. I mean, I could not agree more with her. Joy just nailed right down the importance of being able to make the product available at the local level. I think one of the things that we always get concerned about in medicine is that when you have to have things brought to you from an outside supply. I mean, obviously that’s extremely helpful and can be lifesaving. But when you’re in a situation where you have a constant, continual, and consistent need, we have to have the facilities and the capabilities in place at the local level. Just as Joy has strongly suggested.  

President Clinton: Dr. Nkengasongdo you have anything to say about that?  

One of the things that strikes me – let me just back up – is that this really is a lot like other things CHAI has dealt with. We need to, yes, we need donors to give money to buy oxygen, but there has to be an infrastructure there. People have to be trained on the use, maintenance of the equipment, distribution, the follow up. So, what from your point of view, what should be the funding source to give oxygen to everybody?  

I mean, I realize we can ask all these groups, Unitaid and all the foundations and the usual suspects, to give money. But how should it be funneled and organized so that we get maximum benefit with whatever money we have?  

Dr. NkengasongThank you, Mr. President. A few months ago we wrote an op-ed with a professor, Peter Piot, the director of the London School of Hygiene and Tropical Medicine, on this topic, and my take on that in that op-ed was that we have to have country leadership and commitment to invest national resources into building the capacity for oxygen supply, including maintenance, the issues that we have been discussing. 

To ensure sustainability, our partners funding and other sources of funding from donors should only be able to supplement and complement those efforts from within the national resources. That is the only way, in my view, that will enable sustainability in a predictable manner. Such that I mean, those who deserve of that very critical medical intervention should have it.   

So, there are two things we need: policies at the national levels and we need political commitment and political will that will enable the hospitals to, as Joy rightly described, be able to properly equip, at least minimally, to provide basic services for oxygen.  

President Clinton: Joy, let me follow up on that. When we started CHAIa long time ago now, after I left the White House in 2002 or 2003, we decided we wouldn’t go anywhere where we weren’t first invited by the national government; that we had to have support and they had to be involved. So, we didn’t just show up.  

 But within just a few years, we realized that we also had to help build the capacity of the national government, to use the antiretrovirals, to use the testing, to use the diagnosis, to use all kinds of things.

So how do you think this should be set up? I realize we have emergency oxygen needs now, but it occurred to me just looking at what we’ve been involved with CHAI for the last year or so that there is a lot of structural help and support that needs to be offered to governments, low income countries, too.  

Ms. Joy Phumaphidefinitely believe that we have to focus on sustainability. Yes, we have the short term – hopefully, short term – demands that have been created by COVID-19. But even as we’re responding to the emergency situation that we’re dealing with now, we have to build sustainable systems, focus on oxygen plants, focus on skills training, focus on ensuring that we enhance solar powered oxygen concentrators since that will be sustainable, that can be part of long-term supply and distribution delivery systems that the countries can rely on long term. That is really what we need to focus on.  

And I think the major funders, funding partners like the World Bank, should actually be focusing on these long term, sustainable type of systems investments rather than giving money to buy oxygen cylinders. In fact, technology is becoming more and more easily accessible. Senegal, for example, has been developing 3D printed ventilators, so you can actually get local technology to meet the demand of the hospitals, if it is properly coordinated and structured.   

President Clinton: But Dr. Fauci, let me ask you a question and also Dr. NkengasongI’m trying to put myself in the position of what if I were, you know, president of Malawi, or Ecuador, Bolivia or any country similarly situated. How do we figure out how much oxygen needs to be deposited on a permanent basis? How much? How does every country figure that out – and then realize that this COVID-19 is probably not going to be the last problem like this, given the way the world is working. And as you pointed out in your opening remarks, we’ve even had some pretty serious oxygen shortages in the United States. Our neighbors in Mexico and Brazil have had some serious problems. So how should just looking at this? 

What’s the optimal level of organization? We decide how much capacity you need in country now and how much should be available through an international bank, if you will, in the event of emergencies? 

Dr. Fauci: Well, thank you for that question, Mr. President.  

You can actually model that. For example, WHO has recently estimated that in low and middle income countries, when you have about a half a million COVID patients, that you would need about 1.1 million oxygen cylinders a day. So, if you can do that, you can project by what you think the current and future surging, for example, with COVID or with any disease – you can do the same thing with malaria and you can do the same thing with tuberculosis. So, I think that’s one of the ways that we can get the ministers in the countries to do that.   

I just want to also mention one other thing, Mr. President, that I was thinking of when you were asking the questions about infrastructure and Joy spoke about the sustainable infrastructure. I believe research organizations like my own, the NIH, when we go to countries to do studies, that I think sustainable infrastructure building has to be an important commitment. Let me give you an example that I think you’d relate to.  

During the Ebola outbreak in West Africa, in Guinea, Sierra Leone, and Liberia, we went there to do clinical trials. And what we did is that in order for the individuals, the physicians, and health care providers in Liberia to adequately take care of the patients and to do a clinical research protocol, we did something besides training. We actually left what falls under the category of sustainable infrastructure: things like CT scans and other instruments that otherwise you wouldn’t want to leave there because you don’t necessarily need it for the research. And right now, those same clinics that were totally dependent on us are now selfsufficient. If we build in oxygen requirements when we do research there, I think we could help build some of the sustainable infrastructure, which would not really be that expensive. I mean, certainly not expensive as a couple of MRI machines.  

President Clinton: Dr. John, you have a comment on that? 

Dr. Nkengasong: Absolutely. First of all, I agree with Joy and Dr. Fauci that we need to quantify the problem, which for now I will submit that is poorly understood and actually poorly quantified on the continent until COVID hit the continent. The statistics that I mentioned earlier I can speak to, that before COVID, as a continent, we had 68 oxygen generating plants across the entire continent of Africa. But the good news is that because of COVID, that number was able to be increased by 40 percent in a very short time, which suggests to me that if we committed to that process, if we qualified our needs and better articulated [them], I think we will be able to build capacity starting with local resources.  

And then, of course, we have partnership. The key thing, as others have said, is that understanding what the problem is, and what the relative importance of that problem vis a vis the other challenges that the countries are dealing with on a routine basis, then now COVID became an emergency, and because of that, it exposed, even for them, the need for oxygen, oxygen facilities, and systems to be put in place. So, I think this is an opportunity, as I said earlier, to step back as a continent and actually do a proper evaluation of what our needs are, and where do we get from point A to point B and what kind of partnerships are required to carry us forward.  

President Clinton: You know, it seems to me, and correct me if I’m wrong here, but as compared with a lot of the major health challenges we’re facing, even within the COVID space where I think there’s been an amazing speed of development of the vaccine and you know, where we need to make sure it’s equitably distributed and where we are stumbling in that direction. But this problem seems to me to be relatively inexpensive compared to a lot of these other problems we have in the global health system, and particularly in infectious diseases and other problems that require more oxygen. All right, why do you think that these oxygen shortages are so chronic? Do you think it’s just that it hasn’t seemed as important as it is now that COVID put this into high relief? Or is it because it’s never been involved in a bucket list like AIDS, TB and Malaria? For PEPFAR, the Global Fund or whatever to deal with. What can we do to fix this? Because I don’t think it’s so much a money problem as almost an oversight and a function of the lack of established systems ina lot of low-income places.  DrFauci, you want to go first?  

Dr. Fauci: Yeah, sure. Well, I think you hit the nail on the head, Mr. President. It really is an issue of awareness. When you get involved with all of the diseases that we get involved with, oxygen is almost something that’s taken for granted, and that’s what I think the situation is.  

It really is an awareness issue. I gave you my couple of minute opening statement, and I hit it right there when I said, you know, I’ve been doing this for now 40 years, and the thought of oxygen shortage never really crossed my mind until all of a sudden it hit me right in the face when we were seeing shortages right here in the United States. And only then did I go back and take a look at what was going on in some of the low and– middle income countries, and it became clear to me that it was just an awareness issue. You just don’t think about it. You think about all the other important things that we do. But something as simple as oxygen supply somehow falls off the radar screen. 

President Clinton: Yeah, I agree with that. You know, I’ve been – obviously as a lay person – not only through CHAI, but through the Clinton Foundation, where we’ve been feeding hungry kids, and homeless people, and older people, not in nursing homes. All the things that you think about.  

didn’t think about oxygen in this context until a few weeks ago, my two high school classmates, who grew up on the same little one block street with me. We had, lived on a one block dead end street, and we had several kids, but two of them were in my class. One, my next door neighbor, who’s a very close friend of mine to this current day, and the other lived down the street, and I really liked him, and his mom and dad. On one day, my next door neighbor was going to get her COVID vaccine in a hospital, where the other guy who lived down the street from us and his wife were on ventilators upstairs. And she sent him a note saying we were all pulling for himand he passed away two days later. But that’s just a typical American experience. I’m just one person who was in one place, and 50 years later this happened. But I never thought about it in a deeply personal way until then.  

And I think that one of the things we’re trying to do with this panel is to make sure everybody is thinking about it, because we do have really sensitive, smart people who are willing to give money to this. As I mentioned, we had , just in the five countries we’ve started in, a third of the known cases in low- and middle-income countries of oxygen shortage. We were able to raise quite a lot of money, thanks to the Gates Foundation, and ELMA, and IKEA, and Unitaid. And I’m very grateful, but I hope that all of you [who] are doing this will make a difference.  

Does anybody else have anything to say about this? Why you think this has not been prioritized, or whatever we can do more to make sure people know it is a problem.?  

Ms. Phumaphi: Yeah, I just had one commentMrPresident. In addition to Dr. Fauci’s point that it is underdiagnosed and that, you know, sometimes up to 80 percent of the cases, are never detected. One important factor, is that it’s a cross cutting issue. And the consistent problems we have in health systems and particularly at primary health care level, is that when an issue is cross cutting, it is underappreciated because it’s going to affect children who are suffering from malaria, from pneumonia, children who are suffering from meningitis, convulsions, and newborns.  

So, it is a cross cutting issue. It is underestimated primarily because it is in every single sector. So, when you look at newborns alone, you miss how significant it is because you have not factored in the malaria, the pneumonia children, and the convulsions and the meningitis. So, that is one of the issues that makes it so missed as a critical issue. And another issue is just the lack of adequate training in this particular area. We don’t train our health workers enough for them to be able to appreciate how critical this is for the various diseases that that I’ve just mentioned.  

President Clinton: Thank you. Dr. Nkengasong, do you have anything else to say?  

Dr: NkengasongI was saying that we, given the competing nature, as Joy mentioned, of other disease burden and other disease,[and]  inadequacies on the continent, there are usually three things that we need to begin to consider here. Sustained advocacy for this particular problem to me is very important. And we have to do that at multiple levels, as we we’ve done for other diseases, including HIV/AIDS. Effective partnerships – partnerships that include the private sector, philanthropies and of course, donors – are extremely valuable [and]will be very critical going forward. And lastly, championship. The kind of championship , Mr. President that you exercised in addressing the issues related to HIV/AIDS, especially access to treatment.  

I think we all recorded the continent of Africa was challenged with access to ARVs until you have effective championship from people like you, from people like Dr. Fauci. I remember working in Côte d’Ivoire in 2001 when Dr. Fauci and the rest were going through Africa trying to map out and design the programs for PEPFAR. I remember vividly studying in my lab with Dr. Fauci and others, with Secretary Thompson. That kind of championship will be required for us to be able to turn the tides and address this very critical area of interest.  

President Clinton: I think we should wrap up, but I wanted to make one final comment because when you mentioned PEPFAR, it got me thinking about it;we were able, before PEPFAR, and then PEPFAR totally speeded up the process, to drive down the price of antiretrovirals and dramatically increase the volume of quality medicine available by using the fact that we could raise a lot of money for AIDS medicine. And since the marginal cost of a new pill was negligible, CHAI was able to negotiate all these agreements with the producers of medicine, and later with testing and diagnostic equipment of all kinds to drive down the per patient costs.  

One of the things that we [at] CHAI think is important is to get the price of oxygen down in the developing countries. But we have to get enough money into it to aggregate volume so that the t unit price can be driven down, and it’s still economically feasible to produce the oxygen. So, I’d like to give all of you the chance to close by saying what you think of that. Should this be a priority for, you know, wrapping up the way we handle COVID and looking forward? Because it’s not going to be enough just to have the emergency supplies of oxygen for COVID. You need it every day for all kinds of things in all kinds of settings, and there are a lot of people now who know how to bargain to get lower prices. But you have to have a certain amount of volume in a certain cash flow that’s predictable before you can get them. So, well, I‘ll just open to the panel for any closing comments you have about this. But it’s really importantI’m like Dr. Fauci. I never thought about it until I had friends, and family members gasping for breath, and I’m ashamed of that. But I didn’t. Tony.  

Dr. FauciYeah, MrPresident, you just hit the nail right on the head. There is a consistent demand., And you had said that first you have got to establish the fact that there is a demand so that when people make investments, they know that this is something that’s going to be sustainable over time. History has taught us with diseases that go back decades and decades: childhood mortality, infant mortality, malaria,[and] tuberculosis. Now it’s been put on all of our radar screens right in front of us because of COVID-19. But this is something that I agree with you completely. We can get the price down dramatically, because this is something that is totally a sustainable need. Joy?  

Ms. PhumaphiI absolutely agree with you, Mr. President. We are at a stage where COVID-19 has alerted us to this challenge, which existed pre COVID-19, but it has, alerted us to the enormity of the challenge. But there are also solutions that are affordable out there. Solar powered systems can turn,ambient air into medical grade oxygen with battery banks enabling uninterrupted services even on cloudy days. So, we have these examples that we can tap into. And we have an opportunity now to build a long-term sustainable system, with proper maintenance backed training, partnering with institutions, local technical institutions in, developing countries. So, it is an opportunity, and it is- It can be made cost effective. And there is really no excuse for us not to do it, because we’ll be saving one million lives a year.  

President Clinton: Thank you. Dr. Nkengasong, do you have anything else to say? 

Dr. Nkengasong: My final remarks, Mr. President is that sustainability is key, and the key element for their sustainability is local solutions. Like Joy just mentioned, I think if you do that and then we do the right partnerships, then we will be able to achieve the appropriate goals 

President Clinton: Well, thank you. I want to thank you all so much. I hope we’ve made a dent in this, and I hope your voices will be heard. And this is one problem that you won’t have to worry about as we hopefully, as we’re looking – on the downhill path on COVID. Although I suspect Dr. Fauci withhow disciplined we areand how we open, and how we in the United States, how we understand what we can and cannot do. Even when we’re vaccinated, will determine that. In the meanwhile, we’ve got people all around the world, and in particularly hard-hit places at home that need oxygen. And I hope we can get it to them[and] teach people how to take care of the equipment to maximize its longevity, train people to use it efficiently and get a longer-term funding stream and thank you for helping to support that goal. 

Thank you all. Have a good dayand God bless you for what you’re doing.