Guinea's best hope for coronavirus patients lies inside a neglected yellow shed on the grounds of its main hospital - an oxygen plant that has never been turned on.
The plant was part of a hospital renovation funded by international donors responding to the Ebola crisis in West Africa a few years ago.
But the foreign technicians and supplies needed to complete the job can't get in under Guinea's coronavirus lockdowns — even though dozens of Chinese technicians came in on a charter flight last month to work at the country's lucrative mines. Unlike many of Guinea's public hospitals, the mines have a steady supply of oxygen.
As the coronavirus spreads, soaring demand for oxygen is bringing out a stark global truth: Even the right to breathe depends on money.
In much of the world, oxygen is expensive and hard to get — a basic marker of inequality both between and within countries.
In wealthy Europe and North America, hospitals treat oxygen as a fundamental need, much like water or electricity. It is delivered in liquid form by tanker truck and piped directly to the beds of coronavirus patients. Running short is all but unthinkable for a resource that literally can be pulled from the air.
In Spain, as coronavirus deaths climbed, engineers laid 7km of tubing in less than a week to give 1500 beds in an impromptu hospital a direct supply of pure oxygen. Oxygen is also plentiful and brings the most profits in industrial use such as mining, aerospace, electronics and construction.
But in poor countries, from Peru to Bangladesh, it is in lethally short supply.
In Guinea, oxygen is a costly challenge for government-funded medical facilities such as the Donka public hospital in the capital, Conakry. Instead of the new plant piping oxygen directly to beds, a secondhand pickup truck carries cylinders over potholed roads from Guinea's sole source of medical-grade oxygen, the SOGEDI factory dating to the 1950s. Outside the capital, in medical centres in remote villages and major towns, doctors say there is no oxygen to be found at all.
The result is that the poor and the unlucky are left gasping for air.
"Oxygen is one of the most important interventions, (but) it's in very short supply," said Dr Tom Frieden, former director of the Centres for Disease Control and Prevention in the US and current CEO of Resolve to Save Lives.
For many severe Covid patients, hypoxia — radically low blood-oxygen levels — is the main danger. Only pure oxygen in large quantities buys the time they need to recover. Oxygen is also used for the treatment of respiratory diseases such as pneumonia, the single largest cause of death in children worldwide.
Yet until 2017, oxygen wasn't even on the World Health Organisation's list of essential medicines. In vast parts of sub-Saharan Africa, Latin America and Asia, that meant there was little money from international donors and little pressure on governments to invest in oxygen knowledge, access or infrastructure.
"Oxygen has been missing on the global agenda for decades," said Leith Greenslade, a global health activist with the coalition Every Breath Counts.
The issue got more attention after British Prime Minister Boris Johnson narrowly survived a bout of coronavirus, crediting his recovery to the National Health Service and "litres and litres of oxygen." But Johnson is a prominent figure in one of the world's richest countries.
After the AP report came out today, the WHO said it is working with partners to increase access to medical oxygen for people infected by the new coronavirus in developing countries. Director general Tedros Adhanom Ghebreyesus said that at the current rate of about a million new Covid-19 cases every week, the world would need about 88,000 large cylinders of oxygen every day.
"One of the most effective ways of saving lives is providing oxygen to patients who need it," Tedros said.
Unlike for vaccines, clean water, contraception or HIV medication, there are no global studies to show how many people lack oxygen treatment — only broad estimates that suggest at least half of the world's population does not have access to it.
In the few places where in-depth studies have been carried out, the situation looks dire. In Congo, only 2 per cent of health care facilities have oxygen; in Tanzania, it's 8 per cent, and in Bangladesh, 7 per cent, according to limited surveys for USAID. Most countries never even get surveyed.
In Bangladesh, the lack of a centralised system for the delivery of oxygen to hospitals has led to a flourishing market in the sale of cylinders to homes.
Abu Taleb said he used to sell or rent out up to 10 cylinders a month at his medical supply shop; now it's at least 100. Courts have sentenced about a dozen people for selling and stockpiling unauthorized oxygen cylinders, often at exorbitant prices.
In Peru, which recently surpassed Italy in its number of confirmed Covid-19 cases, the president has ordered industrial plants to ramp up production for medical use or buy oxygen from abroad. He allocated about US$28 million for oxygen tanks and new plants.
Some hospitals have oxygen plants that don't work or can't produce enough, while others have no plants at all. In the city of Tarapoto in northern Peru, relatives of Covid patients who died from lack of oxygen protested outside a hospital with a plant that does not work, banging pots and pans. The Government has flown in tanks of oxygen by air and is expected to install a new plant.
Annie Flores has lost two relatives to Covid oxygen shortages. She said the family embarked on a desperate quest to buy oxygen after being told the hospital didn't have any. Price gouging was rampant, with tanks going for six times the usual amount.
In Sierra Leone, neighbouring Guinea, just three medical oxygen plants serve 17 million people. One inside the main Connaught Hospital broke down for nearly a week, as Covid cases mounted. Even now, with the plant working again, there are shortages of cylinders to fill.
Everywhere that oxygen is scarce, pulse oximeters to measure blood-oxygen levels are even scarcer, making it nearly impossible for doctors and nurses to know when a patient has been stabilised. By the time lips turn blue, a frequent measure used, a patient is usually beyond saving.
Some places have made progress, largely thanks to local activists who have pushed for more oxygen plants and better access outside just the largest cities. Kenya, Uganda and Rwanda all have made it a priority, according to Dr Bernard Olayo of the Centre for Public Health and Development in East Africa.
But in Guinea, not a single hospital bed has a direct oxygen supply, and the daily deliveries of cylinders are taking their toll on budgets, with each one costing US$115. A standard cylinder costs on average US$48 to US$60 in Africa, compared to the same amount of oxygen for between US$3 and US$5 in wealthy countries, Olayo said.
Medical oxygen comes in liquid and compressed forms
Liquid oxygen is what wealthy countries largely use. Air is chilled to minus 186 degrees Celsius, so that the oxygen condenses into a liquid in much the same way dew forms in cool night air. It is then pumped into a truck-sized double-thick vacuum flask on wheels and sent to hospitals. There, pumps warm it back into a gas.
Compressed oxygen is pressurized into cylinders about the size of a small adult. Each weighs about 50kg.
Before the coronavirus crisis, the Donka hospital in Conakry went through 20 oxygen cylinders a day. By May, the hospital was at 40 a day and rising, for a total of more than US$130,000 a month, according to Dr Billy Sivahera of the aid group Alliance for International Medical Action. Oxygen is the hospital's fastest-growing expense.