When the first few cases of the coronavirus were reported in the country, health workers who cared for a 57-year-old man in Msambweni.
Kwale County, recounted the desperate moments when the life of their only patient at the time hung in the balance.
The patient, a French national, needed 15 cylinders of oxygen and without it, he might have had a tragic end.
The incident highlighted the critical importance of medical oxygen. Without it, the patient would have ended up like a health worker in Wajir County who waited for hours to access oxygen before his death.
Abdi Yussuf was a senior public health expert, and was facilitating a training in the remote villages of the county when he contracted Covid-19.
Yussuf was referred to Wajir Referral Hospital, which at the time lacked a functioning oxygen cylinder. He died while waiting for oxygen.
His is much like many of the untold stories in the country, where lack of oxygen has led to the death of Covid-19 patients.
As the country inches closer to the 40,000 mark, it has become evident that medical oxygen is the primary treatment for the majority of patients with severe Covid-19 symptoms.
Dr Majid Twahir, the Chief of Staff at Aga Khan University Hospital, said patients who require oxygen usually start at one to two litres per minute, which implies 60 to 120 litres per hour. If the patient is on oxygen the whole day, this will amount to 1,440 to 2,880 litres per day.
"This is for patients who are not very sick. For Covid-19 patients, we initially use between four to eight litres per minute of oxygen. On occasion, to try and delay the use of a ventilator, we use a high flow cannula set to deliver more oxygen. This consumes 50 to 60 litres of oxygen per minute," he said.
Dr Twahir said about 80 per cent of Covid-19 patients in Kenya are asymptomatic, slightly less than 20 per cent have moderate symptoms and may require not only an isolation bed, but ones that have oxygen. He added that about 2.5 per cent of the patients who are too critical are being treated in dedicated Covid-19 hospitals which have ventilators.
A majority of hospitals in the country lack the capacity to cope when numbers overwhelm the system. This is more so because for critically ill Covid-19 patients, oxygen is the difference between life and death.
A recent survey of emergency care centres across Kenya by the Emergency Medicine Kenya Foundation shows that over 30 per cent of the facilities do not have a regular supply of oxygen. In fact, close to 90 per cent of those with oxygen do not have piped oxygen in the emergency department and deliver oxygen directly from the tanks to the patient.
An investigation by the HealthyNation and The Bureau of Investigative Journalism reveals the biggest reason for this is the fact that two multinational gas suppliers dominate the market for oxygen cylinders in most African countries. Key stakeholders say the high prices of medical oxygen, make the treatment unaffordable.
Oxygen availability in Kenya varies depending on the location and the type of facility. Very few hospitals have liquid oxygen which is stored in tanks, converted to gas, and piped directly to bedsides. The majority of the hospitals, especially in counties outside Nairobi, lack the infrastructure necessary for this process.
The hospitals rely on oxygen cylinders, which in turn makes oxygen five times more expensive by volume, according to The Bureau.
Other than being more affordable, liquid gas can be transported in bulk quantities as it is denser than gas oxygen and is 99 per cent pure.
The cylinder technology generally averages 93 per cent pure oxygen. However, from a medical point of view, there are no serious issues to preclude the use of 93 per cent oxygen.
Previously, British Oxygen Company (BOC) was the only cylinder provider, but the number of private-sector suppliers has grown in recent years. There are now four main suppliers of oxygen in the country, Gas Africa, BOC, Hewatele and Nobel gas.
Before 2013, Linde Group's Kenyan subsidiary BOC Kenya was charging about $58 (about Sh6,300) per J cylinder, plus transport, a cylinder deposit and a leasing fee on top of the refill cost, found The Bureau.
However, with the expansion of the market and opening up of oxygen companies like Hewatele, which was founded by Dr Steve Adudans and Dr Bernard Olayo of Kenya's Centre for Public Health and Development, there has been an improvement in services and a drop in pricing of oxygen.
The difference is felt in small and medium-sized hospitals in the country who say they have cut their oxygen expenses by up to 40 per cent.
Dr Abdi Mohamed, the founder of Ladnan Hospital in Nairobi's Pangani, who also switched to a different company said the facility uses Gas Africa, whose large gas cylinder costs Sh2,500. "This company does not charge a deposit or rental fees unlike BOC and Nobel gas companies which makes it much cheaper for us," he said.
Health stakeholders say there needs to be a long-term solution and not just for Covid-19 patients, but also for future purposes.
Dr Wangari Waweru-Siika, a consultant in Anaesthesia and Intensive Care at Aga Khan University Hospital, explained that even after the government declared all counties need to have at least 300-bed capacity Covid-19 dedicated isolation centres, most have reported oxygen shortages. "We do not have oxygen in every one of these facilities," she said.
In fact, it is concerning from medics who have had to watch their patients gasp for air or even die from lack of oxygen that has pushed the Health ministry to announce the redirecting of about Sh1.2 billion allocated for the renovation of isolation centres to the purchase of piped oxygen.
The oxygen pipes are expected in 10 high-risk counties and will take a huge chunk of the remaining Sh4 billion from the Sh5 billion the Health ministry received from the World Bank to fight the pandemic.
Asked about the ministry's preparedness to handle severe Covid-19 cases in need of oxygen, Health Chief Administrative Secretary Dr Rashid Aman said this was a key area in the country's response. "This is an area we are actively looking at. We recognise that it is just not enough to have an ICU and a ventilator without having oxygen," he said.