Lack of medical oxygen affects millions, report reveals

Six out of every 10 people globally lack access to safe medical oxygen, resulting in hundreds of thousands of preventable deaths each year and reducing quality of life for millions more, an international report co-authored by the University of Auckland has found.

Associate Professor Stephen Howie, from the University’s Faculty of Medical and Health Sciences (FMHS), was an adviser to The Lancet Global HealthCommission on Medical Oxygen Security and co-author of its report “Reducing global inequities in medical oxygen access.”

A key finding shows global access to medical oxygen is highly inequitable. Five billion people, mostly from low and middle-income countries, don’t have access to safe, quality, affordable medical oxygen.

Associate Professor Howie, child health researcher and a specialist pediatrician, says he hopes further lives will be saved because of this work, and that children and adults will not only survive but thrive.

The Auckland University team are leading the field to improve access to medical oxygen. Howie recently gave a plenary address at the World Lung Health Conference in Bali, spelling out the challenges and opportunities to tackle the global issue.

“I have been working in the area of oxygen treatment for oxygen-starved (hypoxic) illnesses for two decades, particularly in Africa and the Pacific. My first priority was children (naturally, as a pediatrician) but we learned soon enough that solving the problem has to involve catering for all ages.

“It is such an obvious need. I saw it at the hospitals I worked at in Africa where needless death from diseases like pneumonia happened because oxygen supplies were short, and this hit families and staff very hard. It was at that time that we made it our goal that ‘no child should die for lack of oxygen’ and this applies to adults too.”

Fiji was particularly hard hit when the first waves of the COVID-19 pandemic arrived. At one point, it had the highest rate of COVID-19 in the world. A close partnership between the Fiji Ministry of Health, the University of Auckland, Cure Kids and Fiji National University, played an important role in supporting the pandemic response, says Howie.

Dr. Sainimere Boladuadua is Lancet Commission's Western Pacific Region ambassador

On the ground during that time was Dr. Sainimere Boladuadua, a public health medicine specialist, now a doctoral student at the University of Auckland and currently undertaking a Fulbright fellowship at Johns Hopkins University in Baltimore.

Boladuadua (Somosomo, Cakaudrove, vasu i Levuka-i-Yale, Kadavu/Fiji) also has the honor of being The Lancet Commission’s Western Pacific Region ambassador and will spearhead advocacy for improving access to medical oxygen in the region.

“I remember those days, the adrenalin was pumping and it was scary. It was very difficult before the vaccine arrived. We had very little sleep trying to get everything set up,” she says, recalling the period of the country organizing itself and the national response which included setting up field hospitals.

Boladuadua met Howie in Fiji where he helped to lead the Fiji Oxygen Project, supporting the vital work of health leaders like Dr. Luke Nasedra and Dr. Eric Rafai.

“The project was just doing exactly this, trying to improve and ensure that all the health facilities had access to medical oxygen, facilities to deliver them. That no child or adult should die for lack of oxygen, and it’s such a simple medical therapy that you expect to be available but often it isn’t, says Boladuadua.

“The reality was that rural health facilities sometimes had to ration the oxygen. You have a limited supply, the cylinders that come in every month you have your quota, and if you run out, then sometimes you have to prioritize who gets it, who doesn’t. Which is just so heartbreaking.”

The Fiji Ministry of Health, supported by the project, was in the midst of covering those gaps when COVID hit, and Boladuadua says the one silver lining was that it shone a light on the gaps, putting the issue on the radar.

“You saw the images around the world, hospitals running out of oxygen in India, family members hauling oxygen cylinders on motorcycles. I guess that made it really come to the forefront.”

This was the entry point for Boladudua to start work on her doctoral studies at the University with Howie as her primary academic supervisor, and unsurprisingly, her Ph.D. has a focus closely related to her previous work.

“My research question is how to improve access to care for children with acute respiratory infections in Fiji and obviously links to the supply of oxygen as well.”

She says respiratory conditions are rising and pneumonia is still one of the leading causes of death and disease, particularly in under-five-year-olds across the Pacific and even in New Zealand.

“Within New Zealand, our Pacific children experience a larger acute respiratory burden than children of any other ethnic group.”

Boladuadua says she’s grateful to Professor Cameron Grant, Head of Pediatrics, Child & Youth Health at FMHS, who encouraged her to apply for the Fulbright Scholarship. As well as support from her friends, doctoral candidates Alehandrea Manuel (who has since completed her Ph.D.) and Ashlea Gillon.

“Professor Grant was a Fulbright scholar 30 years ago and he said it would be life-changing, and it has been in so many ways,” she says of working closely with the team at Johns Hopkins and the opportunities presented, such as the lecture she’s been asked to present next month at the School of Public Health: “Decolonizing Global Health—a Pacific perspective.”

“What appealed to me was they had a Center for Indigenous Health that worked very closely with Native American communities. And although Johns Hopkins is in Baltimore, their work is very much within the communities themselves, in the tribal lands of the Navajo and White Mountain Apache peoples in the Southwest of the US.

“They’ve got sites in all these communities and the staff—data collectors, researchers, the research nurses and everyone in those teams. The majority are Native American. So it’s about responding to their health needs and also building local capacity.”

Learning how the Indian Health System has accommodated traditional medicinehas inspired Boladuadua and she’s brimming with ideas that she’s eager to bring back to Aotearoa later this year when she returns.

“I wanted to see how you can use traditional knowledge and practices with western knowledge. I wanted to learn how that happened. They’re just doing it so beautifully here. I am learning so much and it has been life-changing with all the different perspectives, exposure and the incredible people I’m able to work with.”

• Research is ongoing about the potential health benefits of cold-water immersion, which involves taking cold showers or ice baths. 
• One systematic review and meta-analysis found that cold-water immersion may help decrease sick day absences, improve sleep and quality of life, and reduce stress.
• More research is needed to examine the long-term benefits of cold-water immersion.

A recent systematic review and meta-analysisTrusted Source published in PLOS OneTrusted Sourceexamined eleven studies to evaluate whether cold-water immersion, also called cold plunges or cold water therapy, was actually beneficial to health. The researchers specifically looked at its effects on cognitive, psychological, and physiological health.

According to the findings, people who use cold-water immersion may experience stress reduction for a limited time after exposure, have a decrease in sickness absences, and experience improvements in quality of life and sleep. 

The review authors encourage future research to look at the cold-water immersion’s long-term effects, include large and diverse samples, explore diverse outcomes, and examine dose-response relationships.

Cold-water immersion includes a broad range of actions that allow for exposure to cold water. Authors of the current review note that it has become more popular in recent years among athletes and the general population. 

Dylan Colbert, PhD, a Performance Psychologist & Lecturer at Carlow College, who was not involved in the study, told GMHCN that despite there being a lack of consensus on what conditions are necessary for optimal cold immersion, there are three main factors.

“Firstly, the ideal water temperature appears to be between 10 and 15 degrees Celsius. While many practitioners use water considerably colder, the additional physiological and/or psychological benefits of this have yet to be demonstrated empirically. Secondly, it is advisable to submerge only up to neck level, as dunking one’s head has been associated with some adverse health consequences, and may even undermine some of the positive effects of CWI. Finally, while short sessions are of benefit, research has indicated an optimal CWI duration of approximately 12 minutes for experienced practitioners,” Colbert explained.

For this review and analysis, the authors defined cold-water immersion as showering, ice baths, or immersion in cold water that was 15 degrees Celsius or less for 30 seconds or more. 

They only included studies with cold water immersion to chest level or higher and excluded studies where participants wore protective clothing. Ten of the studies involved bath cold-water immersion, and one involved cold showers.

The authors of the current review wanted to understand more about the effects of cold-water immersion. They used ten databases to search for eligible randomized controlled trials. They assessed methodological quality based on components like between-group comparison, blinding, and adequate follow-up. Seven studies were of moderate quality, and four were of high quality. 

The researchers looked at a number of outcomes related to cold-water immersion including sleep quality, stress, mood, and immunity. They conducted meta-analyses when two or more studies reported on a cold-water immersion outcome. They conducted a narrative synthesis for outcomes that didn’t meet this and additional meta-analysis criteria. They were then able to conduct meta-analyses for inflammation, stress, and immunity. 

For this paper, researchers included eleven studies, allowing them to examine information from 3,177 participants. Only one of the included studies had a group of mixed participants; all the other studies only included male participants. 

The researchers excluded studies that included “highly-trained and elite athletes competing at a national level or higher.” 

They found that cold-water immersion increased inflammation immediately and one hour after the intervention. 

However, study author Tara Cain, the Project Manager for Dialling Up Health, Alliance for Research in Exercise, Nutrition & Activity (ARENA), Allied Health & Human Performance, University of South Australia, explained why this could still mean positive effects in the long-term.

Regarding other outcomes, researchers found that cold-water immersion helped reduce stress 12 hours after exposure but not immediately after, one hour after, 24 hours after, or two days after. 

They did not find significant immunity changes immediately or one hour after cold water exposure. However, the certainty of evidence was fairly low. 

Narrative syntheses revealed potential additional benefits of cold-water immersion. For example, one trial found that cold-water immersion reduced sickness absence by 29%. However, there wasn’t a significant difference between the number of illness days reported by the control and intervention groups. 

This same trial also found an increase in quality of life for participants who engaged in cold-water immersion, but the change was no longer significant three months later. 

Another trial found that cold-water immersion may improve sleep quality, but the intervention only lasted five days. Additionally, researchers did not find that cold-water immersion affected mood. 

This review does have certain limitations. First, it focused on the effects of cold-water immersion in healthy adults. Thus, the results may not be applicable to people with certain health conditions or children. 

Additionally, only one study included women, which limits how much of the findings can be applied to women. Many studies also had small sample sizes, which also limits generalizability. 

Second, there was a lot of variation in the protocols that the trials used for cold water immersion, and this most likely added to the result heterogeneity. 

Six of the eleven studies only looked at the impact of single immersions, which doesn’t allow for conclusions regarding the long-term impact of cold-water immersion. Five of the trials involved cold-water immersion after exercise, which introduces confounding risk. 

Some outcomes were only reported by a single study, so the authors encourage caution regarding these results.

Each of the included trials had limitations. For example, researchers acknowledge a risk for confounding in the trial that assessed sleep quality. Similarly, the study evaluating the effects on sickness and quality of life relied on self-reporting, which introduces bias risk. This study also had struggles regarding cold-water immersion adherence over time.

The authors also point out that the effects of cold-water immersion seemed to be greatly dependent on time, so additional research regarding this factor may also be helpful. The authors note that future studies can also evaluate the safety of cold-water immersion and the participants’ experiences.

Overall, the results indicate the need for more research in this area to examine long-term effects and confirm effects related to various outcomes. 

“Right now, there isn’t enough high-quality research to say exactly who benefits most or what the ideal approach is to cold-water immersion. More long-term studies, among more diverse populations, are needed to understand its lasting effects and practical applications,” Cain noted.

David Merrill, MD, PhD, a board-certified geriatric psychiatrist at Providence Saint John’s Health Center in Santa Monica, CA, and Singleton Endowed Chair in Integrative Brain Health, who was also not involved in the study, noted that long-term studies are needed to assess its full impact.

“The question is whether those effects translate into long-term improvements in mood and resilience. We need studies that track people over time to see if regular cold exposure has lasting mental health benefits, especially for those with clinical depression or anxiety,” he added.