Come with me to a busy outpatient clinic at a public hospital in rural Andhra Pradesh. There is a sea of waiting patients. Some are on chairs, most on the floor, waiting to be called in by the doctor. People on the floor talk, eat, and some even nap as they wait. Oppressive heat, along with the smell and feel of sweat, pervade the atmosphere.
In a small consultation room two doctors attend to a patient. In the corner, another doctor treats a patient. Outside the door stand a multitude of patients. Every now and then someone peeks in and asks, “Doctor, when will my turn come?”
Looking around, we notice there are no windows. An old fan rattles overhead, recirculating the same overheated air. While the doctors can take breaks in their air-conditioned duty room, patients have no such respite.
A similar stifling environment is replicated in many places across the country, as Mr. Joseph can testify.
“I accompanied my relative to his appointment at the B. Baruah cancer centre in Guwahati,” says Mr Joseph (name changed). “The hospital waiting room was overcrowded and extremely humid because everybody there was sweating. Soon enough, I started having a headache and muscle cramps. My temperature rose too. I had to go out to a different clinic to consult a doctor and they diagnosed me with heat exhaustion. I was admitted and given paracetamol along with saline injections. Only after some time did I feel better,” he adds.
Failing infastructure
India’s public health infrastructure is crumbling under the sheer volume of sick people and this might have unintended consequences for people in the current heatwave India is experiencing.
This year, India is experiencing its longest and deadliest heatwave in the past 15 years with some parts of North India hitting record-high temperatures. This heat wave disproportionately affects the poor and marginalised communities who have no access to cooling devices. While several forms of inequalities have been exposed by the current heatwave – such as occupational inequality and gender inequality, it is also important to talk about how economically-weaker sections of the community who seek healthcare from the public sector are exposed to heat-related illnesses within the premises of these clinics and hospitals.
“My father was admitted to the general ward of a hospital because he had a fever and stomach pain sometime back,” says Muniamma, a daily wage labourer from Vellore, South India. “The doctors told me that he had a kidney infection and they were treating it with injections with which he was getting better. Suddenly his fever returned and he started speaking incoherently. Initially, the doctors did a lot of tests but then they realised that it was heat related as it was peak summer.”
Muniamma’s father, though he was admitted with a different ailment, developed a heat-related illness as he lay in the hospital bed in the overcrowded and poorly ventilated hospital ward. “The doctors tried their best,” says Muniamma who had to then sit with her father day and night spraying cold water from a spray bottle onto every bit of exposed skin. “They gave him saline injections which were cooled in a refrigerator. They asked us to bring a few table fans which we placed around him. We also kept trying to cool him by placing ice cubes in his armpits and such. But he did not get better. His kidneys failed due to the heat and he died,” she recounts sadly.
Killer heat
Just like Muniamma, Kumari from Vellore too has lost an uncle to heat illness in a poorly-ventilated general ward. “He had some mental illness and would always be sad or crying, so we showed him to a psychiatrist and got him some medicines. However, after a suicide attempt, we rushed him to a hospital where they put a tube in his nose and gave him injections and medications. He started gaining consciousness and was getting better when he started having a fever. Considering that he was in a hospital, the doctors initially said that he might have caught an infection from one of the other patients. But all the tests came back negative. That is when we realised that it might have been the heat, as it was scorching. He was treated for heat-related illness but he did not recover,” she says, “I am truly sad that my uncle died of something that was not even his initial problem. But what can we do? We can only afford to come to a government hospital and we know how overcrowded and hot it can get,” she adds.
While the news of heat-related deaths is making it to the headlines daily, there is reason to believe that the numbers may be underreported due to several logistical reasons. Known reasons include decreased knowledge among healthcare professionals about when to report and inadequate autopsy services to conclusively prove heat-related deaths, patients developing heat-related illness after admission to a hospital for a different illness are lesser-known reasons for the underreporting. For instance, in the past two examples, the causes of death may be mentioned as urinary tract infection and suicidal poisoning despite the actual reason being heat.
According to Anand Zachariah, consultant physician, CMC Vellore, people who come to hospitals for certain illnesses are more vulnerable to heat-related illnesses. “Especially when someone has a fever due to any infection, it is very important for them to dissipate heat from their bodies via sweating. However, if the ambient heat in the hospital ward is high, they will not be able to do so. This puts them at a very high risk for developing heat exhaustion or heat stroke,” he says. Alongside this, older individuals, individuals with any longstanding illnesses and skin conditions which cause issues with sweating may also be at risk of developing heat-related illnesses in the hospital according to a paper co-authored by Dr. Zachariah.
According to Aditi Dandawate, a paediatrician working at Cooper Hospital, Mumbai, such issues can be very common in newborns and children admitted for other reasons as well. “Considering the high temperatures in Mumbai in summer, we always keep our eyes peeled for dehydration in children. In the ward, we advise mothers to dress their children in the bare minimum clothing required to prevent issues. We also ensure adequate hydration in our patients as a priority, providing them with IV fluids, ORS or even coconut water to proactively ensure that heat does not worsen the child’s health,” she adds.
Improving amenities
While these are individual measures taken at the level of the treating doctors, it is not enough to combat the systemic failings of poor infrastructure of the healthcare system and the ever-looming problem of climate change at large. Hospitals, for one, need to have a strategy in place every year as to how they would deal with such occurrences. This year some hospitals including Tirunelveli Medical College, RML Hospital Delhi, GRH Madurai etc. have started air-conditioned wards to admit and treat heat stroke patients, but these measures fall short on the prevention front. CMC Vellore has prepared a protocol for its doctors which disseminates information about how heat stroke can develop while in hospital. The document shows the signs the doctors must look out for and cautions them as to which kinds of patients are at risk for the same.
“On top of this, it is important to ensure further changes at the level of the hospital like providing shady areas for patients to wait, keeping pots of water or water dispensers in outpatient areas, measures to cut the time patients must stand in queues etc,” says Dr. Zachariah. “Hospitals must also ensure adequate spacing between beds and ensure every patient has a fan, but in resource-limited settings, one can ask the patient bystanders to bring table fans for the patient. It is also important to store saline and some other IV fluids in the refrigerator as a precaution as administering cold saline can help bring down the body temperature of a person about to go into a heat-related illness soon,” he adds.
The other solutions that can be considered are conducting outpatient clinics during cooler hours of the day such as early mornings and evenings, creating awareness among patients regarding the development of heat-related illnesses in hospitals and advising patients who come for just general check ups or regular check ups for their diabetes or hypertension to not to do so in the summer months and to come only if they have any troubling symptoms.
In the current scenario of climate change as we all adapt to “the new normal” it is time that healthcare providers, clinics and hospitals also adapt to ensure that people seeking treatment from them are not subjected to heat-related ailments due to poor planning and infrastructural concerns.
(Assistance for overcoming suicidal thoughts is available on the State’s health helpline 104, Tele-MANAS 14416 and Sneha’s suicide prevention helpline 044-24640050. Helplines across the country can be accessed here.)
(Dr. Christianez Ratna Kiruba is an internal medicine doctor with a passion for patient rights advocacy. christianezdennis@gmail.com)
