THE OXYGEN IMBROGLIO

Shortages of Oxygen has been a hot topic in India during the last several weeks. It started with a few Opposition-run State Governments blaming that India had exported the largest quantity of Oxygen from the country when the requirement was mounting in the country due to the Covid-10 pandemic. The Government and Industry clarified that it was Industrial oxygen that was exported and not medical oxygen. The Union Government pointed out that earlier this year, the PM-CARES Fund had allocated Rs 201.58 crores for the installation of an additional 162 PSA Medical Oxygen Generation Plants inside public health facilities and many states had not done the job. This is the context of this blog.

The mainstay of treatment for patients with COVID-19 is ‘supportive care’. Rather than treating the underlying viral infection, supportive care aims to maintain the function of the body’s vital organs to keep the individual alive while the disease progresses and eventually resolves. Severe bilateral pneumonia is the main feature of severe COVID-19. Supplemental oxygen is a first essential step for the treatment of severe COVID-19 patients with hypoxemia and should be a primary focus. Infected and damaged lungs are less effective at allowing oxygen to pass from the environment to the bloodstream.

The main reason for being admitted to a hospital with COVID-19 is to receive supplemental oxygen, to increase the amount of oxygen in the lungs and blood, which will be sufficient treatment before recovery in most cases. This can be administered in a number of ways, including into the nose using plastic tubing, or via a loose-fitting face mask: 1) Nasal cannula-based oxygen therapy for those with 2-5 litre requirement of oxygen per minute. 2) Mask-based for those with 6-15 litre requirement. 3) High-frequency nasal cannula oxygen therapy for those with 15-50 litres and ventilator support above that. AIIMS director Randeep Guleria said that ’20 percent of the patients need oxygen therapy and five percent need ventilation.

Medical experts were increasingly preferring non-invasive oxygen therapy over ventilation as doubts over the effectiveness of ventilator increased after an overwhelming majority of Covid-19 patients on the ventilator were dying in India and abroad. It was thought that ventilators were worsening the lung damage caused by Covid-19. Doctors have stopped using ventilators for management of COVID-19 (except very late) as early ventilation was said to increase the chances of death. Many people stay at home till late and approach hospitals for admission at a stage when oxygen demand is pretty high (five-six fold) as compared to the low flow stage. Late presentation (low presentation baseline oxygen saturation) can exponentially increase the risk of death. Hence medical community suggests early care and therapy (oxygen/steroid/heparin) in the pulmonary phase (90-95 percent saturation).

Cryogenic separation is most effective when any of the three criteria need to be met: high purity oxygen is required (>99.5%), high volumes of oxygen are required (≥10to the power of 2  tons of oxygen/day), or high-pressure oxygen is required. Cryogenic air separators take more than an hour to start up. Additionally, since cryogenics can produce such a high purity of oxygen, the waste nitrogen stream is of usable quality.

Pressure swing adsorbers (PSA) are a much newer technology as compared to cryogenic ASU. PSA devices are best suited for processes that do not require extremely high purities of oxygen (<95%). While PSAs can achieve as high as 99.9%, the cost associated with going above 99.5% in a PSA device rises tremendously. Furthermore, PSA devices are best suited for small volumes of oxygen production, typically on the order of 10 to the power of 1 ton/day. Since the output of oxygen is largely controlled by the bed size in the PSA systems, costs rise linearly when higher volumes of oxygen are required. PSA devices take only a few minutes for start-up.

Membrane Technology: Conventional membrane technology involves passing air over a membrane filter. The filter will allow fast gasses to pass and slow gasses will stay. Oxygen is considered a fast gas and nitrogen and argon are considered slow gasses. Varying levels of purity can be achieved by varying the time that the gas spends undergoing filtration. Previous membrane technology could only produce purity levels of less than 50%. But the recent The ion transport membrane (ITM) was developed by Air Products and Chemicals, in conjunction with the United States Department of Energy and Ceramatec can produce greater than 99% purity and high volume (equivalent to volumetric flow of cryogenic separation systems) Oxygen at much lower costs than cryogenic separation!

MEDICAL OXYGEN: The air we breathe is a mix of several gases, such as oxygen, nitrogen, carbon dioxide, and hydrogen. The term ‘medical oxygen’ means high-purity oxygen, which is used for medical treatments and developed for use in the human body. Oxygen is also used in industries for combustion, oxidation, cutting, and chemical reactions. The difference is that purity levels of industrial oxygen are not appropriate for human use. There can be impurities, which can make people ill. Medical oxygen cylinders should also be free of contaminants.

Years ago, gas supply vendors typically maintained two separate storage facilities for oxygen: "welding or industrial or technical" (a non-USP, or illegal to sell for human consumption label) variety and gas intended for human use in respirators or medical procedures (a USP label). Since most gas supply vendors have decided that it is simply not cost-effective to store separate grades of medical gases, almost all oxygen sold in the US is a USP grade- the United States Pharmacopoeia- (meets USP requirements for human consumption). However, there are distinct differences in how the cylinders are filled. Most vendors in the US are now filling all cylinders with USP gas. If the vendor fill station operator sees that a cylinder is labeled as a medical or emergency oxygen cylinder, or intended for human respiration, then the cylinder is evacuated and filled with USP/Medical oxygen. But most welding or Industrial grade oxygen cylinders are filled with USP oxygen without an evacuation-between-fills step. Grade 4.5 oxygen is USP oxygen that has a purity greater than 99.995 % oxygen Grade 5 (or "five nines") oxygen is USP oxygen that is certified 99.999 % pure. It is sometimes called research grade.  This is the highest purity of oxygen manufactured in the US and is typically found only in top-end chemical research facilities. Its non-research use is associated with specialty welding of titanium and titanium alloys for the nuclear or aerospace industry.

It is heartening to note that the Government of India has taken up the responsibility of supplying Oxygen to the states, and have requested/instructed industries to chip in producing medical oxygen stopping the production of industrial oxygen to the minimum. The Prime Minister's Office has approved funds for the installation of 551 dedicated Pressure Swing Adsorption (PSA) Medical Oxygen Generation Plants in public health facilities in the country.  The Indian Railways have done a great job of running Oxygen Expresses delivering as on today 9^th May 4500 MT oxygen across the country.

Countries like the United States, Russia, Ireland, Thailand, France, Italy, Germany, have been contributing to India’s medical requirement by building oxygen plants, sending ventilators, oxygen concentrators, rapid testing kits, and medicines. The Oxygen imbroglio has almost come to an end!

 

 

 

COVID  VACCINATION – FEARS and OBJECTIONS

It is a common fear more than an actual complaint that people  suffer common side effects of COVID-19 vaccinations like fever, experience fatigue (tiredness) and headache, feel nauseous, in addition to pain or swelling in the arm where the shot was administered. But statistically, in trials, most people didn’t have side effects. A little over 50% didn’t experience any side effects as monitored by hospitals after the vaccination drive began all over the world. I am 74, and I didn’t have any side effects after the first or the second dose. The nurse who administered the vaccine injection asked everyone to rotate their arms after the shots. I too did it, and the next morning did some digging in the garden without feeling any discomfort.

There are people who feel that the side effects mean the vaccine is doing its job. When the vaccine enters the muscles, the cells start making a spike protein, which makes our body think our muscle cells are infected with the coronavirus, and it tries to fight off the simulated infection in the cells, causing some inflammation that people experience.

The cells that have replicated the COVID-19 spike protein (RNA) generate antibodies specific for SARS-CoV2 When our innate immune system locates an infection and attacks it. That’s what can cause sore arms, fevers or muscle aches. These symptoms reveal that your immune system has been activated! Data from each clinical trial show younger patients tend to have more systemic reactions than older patients do. That is because, as a person ages, the ability of his/her immune system to recognize and quickly create antibodies and aggressively attack the intruder (infection), starts to get weaker. But those who are vaccinated are protected whether or not they have developed side effects. That is, you don’t have to feel terrible to prove that you’re protected from COVID-19!

In Johnson & Johnson’s clinical trial, more than 60% of younger patients had systemic reactions compared to about 45% of patients over age 60. Pfizer and Moderna’s studies show similar numbers, but not as large of a difference. The number of reactions increases with the second shot. Data also shows more women having a reaction to the shot than men. Details regarding COVISHIELD and Covaxin are not available at the moment.

Fear and anxiety about the vaccines can also create a reaction by making our body release adrenaline. Some might confuse that feeling with vaccine response. Adrenaline rush may increase the heart rate, and lead to a feeling of the heart racing, and redirect blood toward the muscles and a change in temperature as a result of the blood redirection, sweating as a reaction to stress, and feeling lightheaded due to changes in blood and oxygen supply. No harm in any or all these, it may be noted!

WHAT IS IMPORTANT TO REMEMBER IS THAT THE REACTIONS ARE NOTHING COMPARED TO ACTUALLY GETTING SICK WITH COVID!

Caste-based Reservations

(Reply to a friend)

I have serious objection to the Reservation policy which on the giver’s side is a sop or lollypop not to upset the vote bank already created in the pre-independence period and on the taker’s side mere entitlement psychology welling from the power of the block-votes.

Now let us look at those “right questions” the learned judges of the Supreme Court were expected to ask:

“When will caste-based discrimination come to an end? Why are the backward classes not represented in the higher positions of state services, including the judiciary? Why is reservation not being implemented in its letter and spirit? Why backlog vacancies of these classes are not filled in? What is the sanctity of economically weaker sections reservation when economic backwardness was not accepted as a stand-alone ground for providing reservation in Indra Sawhney (1992)? How can the Union government recruit directly to higher positions in civil services through lateral entry, bypassing the constitutional provisions? Why are public enterprises being privatized on such a large scale? Why is there no reservation in the private sector?”

These are notable for their shrillness just as much for their shallowness. The proponents of the caste-based reservation cannot swallow the ground reality that the poor Brahmin is as deprived as the poor Dalit. Likewise, there are no special difficulties for the poor Muslim or the poor Christan which the poor Hindu does not suffer. This is my view even as I agree that India does need welfare policies such as Reservations and quotas as there are millions in the bottom of the pyramid for not much fault of theirs. As Warren Buffett put it, they just did not win the ovarian lottery. So, affirmative action policies are needed.

I think a deprivation-based system should be applied for all reservations and the upper limit should be 50% and affirmative action such as good schooling, scholarships, financial growth, and hostels should be stepped up and eventually reservation should be gradually tapered off.

Now, though the caste system which is prevalent to date has been a fundamental part of Indian culture for time immemorial, I maintain after going through the literature on Caste system that it was the 1881 Census conducted by the British India Government which for the first time enumerated castes and arranged them in a hierarchy. To my knowledge India does not record a single caste war in its written history of 2000 years, or in its literature!

The philosophy of caste system had actually disappeared following the preachings of Sri Ramakrishna, Swami Vivekananda, and Dayananda Saraswati among others and only the morphology remained. As that too was crumbling, when the modern movements apparently rooted in progressive ideals have brought back the castes, (particularly recasting ‘Harijans’ as the oppressed classes-Dalits) into political toys through an attractive and addictive reverse discrimination. We now see clans and communities aspiring for ‘backward’ tag for reservations and other short-term benefits. These benefits have brought a special sense of competitive entitlement into the social system, making caste animosities deeper and more aggressive! “Jaathichoadippin” (ask for the caste) has come up as a slogan in the identity politics of recent years as against oft-quoted words of Shree Narayana Guru “Ask not, say not, think not caste”!

Unfortunately among the various identities an individual caries in India, the caste identity is the most potent one. On the positive side it facilitates group identity and helps in group activities. Many ignore its influence in business relationships in the Indian economy which is still predominantly “relationship-based”, not a “contract” or “value” based. It secures jobs and in many parts of Indiafacilititates initial capital formation and credit for doing business and also risk mitigation. Caste elders consider failure a part of the process of learning and don’t frown upon it.

Reservations for the SC/ST categories was a Constitutional provision that was "purposefully discriminatory". In law, it is a form of affirmative action whereby a percentage of seats are reserved in the public sector units, union, and state civil services, union, and state government departments and in all public and private educational institutions, except in the religious/ linguistic minority edu­cational institutions, for the socially and educationally backward communities and the Scheduled Castes and Tribes who are inadequately represented in these services and institutions. Parliament routinely extended reservation for SC/ST fixed at 10 years first, without any free and fair revisions. Later, reservations were introduced for other sections as well.

MISUSE OF 9^th SCHEDULE: The original intent behind creating the ninth schedule was to ensure that land reforms were not thwarted by judicial pronouncements in favor of the right to property, which would only have benefited landlords. But thanks to the desire of politicians to do everything without the judiciary having the right to review bad laws, governments have not only put land laws in this schedule, but an entire bunch of laws, including one to overturn a Supreme Court-mandated 49 percent limit on the reservation. Some states of the Union like Rajasthan have implemented a 68% reservation that includes a 14% reservation for forward castes in services and education, and Tamil Nadu made it 69%. These Reservations pose a systemic risk and they benefit more often the better-off among the lower strata!

In the modern context this unique institution – caste-  has been in use for political mobilization. Those social reformists and social engineers who argued for a “casteless society” fell on the wayside. They have perhaps been helpful in reforming the caste system, but not in abolishing it. Interestingly, the one-man-one-vote system of representative democracy has led to the integration of many sub-castes into a larger cast identity. The best example is Nairs! The caste system in its present form has become therefore a valuable social capital that gives a cushion from the shocks in dealing with the larger society, and more so in the interaction with the State for families and individuals! Everywhere else in the world, the individual is alone in the society with his constitutional/legal rights!