The arduous path for oxygen to reach the sick in one of Brazil’s most remote regions

The desperate words of Thalita Rocha went viral on Jan. 14. “We are in a deplorable situation,” she said in a video posted to Instagram. “Whoever has oxygen availability, bring it here to the polyclinic. Many people are dying.” Rocha’s mother-in-law, who had tested positive for the coronavirus, was hospitalized in Manaus, the isolated city in the Brazilian Amazon, when the oxygen supplies ran out that day.

When Rocha learned of the shortage, she asked when the hospital would get more oxygen, only to hear that the director didn’t know. She watched as some patients were resuscitated in the hallways and others suffocated to death. She saw doctors cry. She dropped to her knees and prayed. “It looked like the end of the world.”

On Jan. 14 and 15, dozens of Brazilians asphyxiated as authorities scrambled to get more oxygen to Manaus. Rocha’s mother-in-law was one of them.

“There is a collapse in the health-care system in Manaus. The line for hospital beds is growing by a lot,” said Brazilian Health Minister Eduardo Pazuello on a Jan. 14 live stream. Over the next few days, the government started transporting critical patients to other states. But lines for hospital beds are still long — there are more than 360 people waiting.

A woman hugs a covid-19 patient before she is flown out from a hospital in Manaus to one in Maceió, Alagoas state. There are almost no free public hospital beds and intensive care beds left in the city.
A woman hugs a covid-19 patient before she is flown out from a hospital in Manaus to one in Maceió, Alagoas state. There are almost no free public hospital beds and intensive care beds left in the city. (DPA/Picture Alliance/Getty Images)

Oxygen consumption in Amazonas

Last year, oxygen consumption in Amazonas state doubled within 30 days in April, when the first wave of the coronavirus struck. But demand grew even more quickly last month, nearly tripling in two weeks.

Amid the discovery of a virus variant in the state, Amazonas reported 66,000 cases in January, more than a third of the total reported there in 2020. With hospitals full, oxygen consumption has skyrocketed, creating a logistical nightmare for local authorities.

Amazonas needs about 86,000 cubic meters of oxygen daily to serve its hospital load.

The state has managed to increase local production by setting up new oxygen plants. This has boosted daily oxygen production from 30,000 cubic meters to 40,100 cubic meters.

The remaining 46,000 cubic meters must be transported by land from Venezuela or by sea and air from other Brazilian states.

Even with these shipments, the state can’t meet demand. A deficit of 6,000 cubic meters means that about 70 critical patients per day will not get oxygen.

And increasingly crowded ICUs are expected to drive the daily need up to 130,000 cubic meters, creating an even larger deficit.

An isolated metropolis

Brazil is not the only country short on oxygen. Surges of coronavirus cases in January challenged cities from Lisbon to Mexico City and Los Angeles. In Egypt, patients posted videos of a hospital that appeared to have run out of oxygen, though the government denied any shortages.

The challenge in Amazonas is aggravated by the difficulty in accessing its capital, Manaus, which contains all the intensive care units in the state.

Vanda Ortega, center, a nurse and member of the Witoto Indigenous tribe, speaks to a covid-19 patient at the Indian campaign hospital in the Parque das Tribos neighborhood of Manaus.
Vanda Ortega, center, a nurse and member of the Witoto Indigenous tribe, speaks to a covid-19 patient at the Indian campaign hospital in the Parque das Tribos neighborhood of Manaus. (Bloomberg News)

The city of 2.2 million people is isolated from the rest of Brazil. The two main highways are impassable because of a lack of maintenance. You can only get here by boat or by plane. There isn’t another access connecting the city to the rest of the country,” said Marcellus Campêlo, the state secretary of health.

Common routes for oxygen transportation

In the past couple of weeks, the virus started spreading rapidly from Manaus to rural areas of the state, worrying authorities about transportation logistics to remote areas that can be accessed only by boat. The trip from the capital is, in some cases, days long.

A transportation challenge

Oxygen is transported in two forms: gas, transported in cylinders, and liquid, carried in big tanks kept at minus-300 degrees Fahrenheit.

Only certain aircraft are fitted with the equipment required to carry oxygen. The Brazilian Air Force has been using three planes to ferry oxygen to Manaus from other state capitals. The plane with the largest capacity, a KC-390 Millennium, can carry only about 6,000 cubic meters of oxygen in cylinders or cryogenic tanks at a time, less than 7 percent of the daily consumption in Amazonas state.

Oxygen cylinders are loaded onto a Brazilian Air Force transport to be flown from the city of Belém to Manaus.
Oxygen cylinders are loaded onto a Brazilian Air Force transport to be flown from the city of Belém to Manaus. (Sipa USA/AP)

Oxygen is also being shipped to Manaus by boat. Although this allows for larger shipments, the trip up the Amazon River from Belém takes at least a week.

A long boat journey

One shipment of about 90,000 cubic meters, roughly equivalent to a day’s consumption in Amazonas, arrived in Manaus on Feb. 6, several weeks after it left São Paulo state.

The oxygen is then transferred to vehicles that can reach hospitals — a process that takes three days, according to the local supplier White Martins. After that, the tank returns to Belém, where it is refilled, and repeats the journey to Manaus.

To expand local production, the state government has installed 20 small oxygen plants in Manaus, which together generate about 10,100 cubic meters of oxygen daily. Another 44 will be installed in the capital and in rural areas of the state, according to the government. A donation of $300,000 from the U.S. government will be used to build more oxygen production plants across Amazonas.

Although most hospitals in Manaus now have sufficient oxygen, many lack the capacity to admit new patients. As of Feb. 10, coronavirus ICUs are 93.5 percent full, leaving patients to treat themselves at home. “Today I got three calls from people who needed oxygen and couldn’t find it,” Rocha, who has volunteered to distribute supplies across the city, told The Washington Post. “The situation is far from normal.”

Warnings of the shortage

White Martins, the government’s local oxygen supplier, said it warned the government of the shortage on Jan. 7 and asked for the Air Force to transport more oxygen to Manaus. In a statement, the company said it also alerted the government in July and September that “the oxygen consumption supplied to the state no longer reflected the contracted volume.”

People wait in line to refill oxygen tanks in Manaus.
People wait in line to refill oxygen tanks in Manaus. (Bloomberg News)

Campêlo, the state health secretary, acknowledged receiving the company’s request on Jan. 7, but said authorities didn’t see it as a sign the health system was about to collapse.

President Jair Bolsonaro has weighed in.

“We did what we could to solve the crisis,” he said. But Brazil’s attorney general has opened an investigation authorized by the supreme court on the federal health minister’s response to the crisis. He noted that federal authorities didn’t start transporting oxygen to Manaus until Jan. 12.

Bolsonaro has denied federal negligence. He said it is not the government’s “competence or responsibility to send oxygen to Manaus.”

Alex Machado Campos, a director of the country’s health regulatory agency, called the situation in Manaus a human tragedy. “It’s the saddest and most revolting expression of government failure at all levels.”

A man holds an oxygen tank in Manaus on Jan. 15.
A man holds an oxygen tank in Manaus on Jan. 15. (Michael Dantas/AFP/Getty Images)

To Rocha, the oxygen shortage is just a small piece of the health crisis in Manaus. “The oxygen crisis was the final straw, because hospitals are still full, there are no ICU beds, no medication, not even water in some hospitals. The problem is much bigger,” she said.

“We are fighting to survive.”

Armand Emamdjomeh and Terrence McCoy contributed to this report. Photo editing by Chloe Coleman.

About this story

Notes: Oxygen consumption data as of Feb. 8. Ship and plane routes are not exact. Flight duration varies depending on load size.

Sources: State Department of Health of Amazonas, Brazilian Air Force, White Martins, Amazonas Health Surveillance Foundation. Human illustration is from ProPublica’s Wee People typeface.

Júlia Ledur is a graphics reporter covering foreign news at The Washington Post. Before joining The Post in 2021, she worked as a graphics editor at the COVID Tracking Project at the Atlantic. Previously, she was on the graphics team at Reuters, covering Latin American politics, the environment and social issues with data and visuals.