Come with me to a busy outpatient department of a public hospital in rural Andhra Pradesh. It is teeming with waiting patients. Some sit on chairs, most sit on the floor, waiting to be called by the doctor. The people on the floor chat, eat, and some even take a nap while they wait. The atmosphere is one of oppressive heat, along with the smell and feel of sweat.
In a small consulting room, two doctors are caring for a patient. In the corner, another doctor is treating a patient. A large number of patients are standing in front of the door. Every now and then, someone looks in and asks: “Doctor, when is it my turn?”
As we look around, we notice that there are no windows. Above us, an old fan rattles, circulating the overheated air. While the doctors can take breaks in their air-conditioned office, the patients have no such rest.
A similar stifling environment exists in many places across the country, as Mr Joseph can attest.
“I accompanied my relative to his appointment at B. Baruah Cancer Centre in Guwahati,” says Mr. Joseph (name changed). “The hospital waiting room was crowded and extremely humid because everyone there was sweating. Soon I started getting headaches and muscle cramps. My temperature also rose. I had to go to another hospital to see a doctor and they diagnosed me with heat exhaustion. I was admitted and given paracetamol and saline injections. It was only after some time that I started feeling better,” he adds.
Failed infrastructure
India’s public health infrastructure is collapsing under the sheer number of sick people, and this could have unintended consequences for people in the current heatwave India is experiencing.
This year, India is experiencing the longest and deadliest heatwave in 15 years, with some parts of northern India reaching record high temperatures. This heatwave is particularly affecting the poor and marginalized communities who do not have access to cooling devices. While the current heatwave has exposed several forms of inequality – such as occupational inequality and gender inequality – it is also important to talk about how economically weaker sections of the population seeking medical care in the public sector are exposed to heat-related illnesses on 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 ache some time ago,” says Muniamma, a daily wage labourer from Vellore in southern India. “The doctors told me he had a kidney infection and they treated it with injections, which made him better. Suddenly his fever came back and he started slurring his speech. At first the doctors did a lot of tests, but then they realised it was related to the heat as it was mid-summer.”
Muniamma’s father, though admitted with another illness, contracted heat-related illness while lying in the overcrowded and poorly ventilated hospital bed. “The doctors did their best,” says Muniamma, who then had to sit with her father day and night, spraying every bit of exposed skin with cold water from a spray bottle. “They gave him saline injections, which were cooled in a refrigerator. They asked us to bring some table fans, which we placed around him. We also kept trying to cool him down by putting ice cubes in his armpits and the like. But he did not get better. His kidneys failed due to the heat and he died,” she says sadly.
Murderous heat
Like Muniamma, Kumari from Vellore also lost an uncle to heat sickness in a poorly ventilated general hospital. “He had a mental illness and was always sad or crying, so we took him to a psychiatrist and got him medicines. However, after a suicide attempt, we took him to the hospital where they put a tube in his nose and gave him injections and medicines. He slowly regained consciousness and started to improve when he developed a fever. Since he was in a hospital, doctors initially said he might have caught it from one of the other patients. But all the tests came back negative. That’s when we realised it might be because of the heat, as it was scorching hot. He was treated for the heat-related illness, but he did not recover,” she says. “I am really sad that my uncle died of something that was not even his original problem. But what can we do? We can only afford one visit to a government hospital and we know how crowded and hot it can get there,” she adds.
Although news of heat-related deaths makes headlines daily, there is reason to believe that the numbers may be underreported for a variety of logistical reasons. Known reasons include a lack of knowledge among health care workers about when to report cases and inadequate autopsy services to conclusively prove heat-related deaths. Less well-known reasons for underreporting include patients developing heat-related illness after being hospitalized for another illness. For example, in the last two examples, urinary tract infections and suicidal poisoning are listed as causes of death when the actual cause of death is heat.
According to Anand Zachariah, consultant physician at CMC Vellore, people hospitalized for certain diseases are more prone to heat-related illnesses. “Especially when someone has a fever due to an infection, it is very important that they release the heat from their body by sweating. But if the ambient temperature in the hospital ward is high, they cannot do that. This puts them at a very high risk of heat exhaustion or heat stroke,” he says. Moreover, according to a paper co-authored by Dr Zachariah, elderly people, people with long-term illnesses and skin conditions that cause sweating problems can also develop heat-related illnesses in hospital.
According to Aditi Dandawate, a pediatrician at Mumbai’s Cooper Hospital, such problems can be very common in newborns and children admitted for other reasons. “Given the high temperatures in Mumbai during summer, we always look out for dehydration in children. In the ward, we advise mothers to dress their children only in the bare essentials to prevent any problems. We also make it a priority to keep our patients hydrated and provide them with IV fluids, ORS or even coconut water to proactively ensure that the heat does not worsen the child’s health,” she adds.
Improving amenities
While these are individual measures taken by treating doctors, they are not enough to address the systemic deficiencies of the poor health system infrastructure and the increasingly threatening problem of climate change as a whole. Hospitals, for example, have to develop a strategy every year to deal with such incidents. This year, some hospitals, including Tirunelveli Medical College, RML Hospital Delhi and GRH Madurai, etc., have set up air-conditioned wards to admit and treat heatstroke patients, but these measures are not enough to prevent them. CMC Vellore has created a protocol for its doctors, disseminating information on how heatstroke can develop during hospitalization. The document shows the signs that doctors need to look out for and alerts them to the types of patients at risk.
“In addition, it is important to ensure other changes at the hospital level such as providing shaded waiting areas for patients, providing water containers or water dispensers in outpatient areas, measures to reduce patient waiting times, etc.,” says Dr. Zachariah. “Hospitals must also ensure adequate spacing between beds and ensure that each patient has a fan, but in resource-limited facilities, one can ask bystanders to bring table fans for the patient. It is also important to keep saline and some other IV fluids in the refrigerator as a precautionary measure, as administering cold saline can help lower the body temperature of a person who is about to experience a heat-related illness,” he adds.
Other possible solutions include holding outpatient consultations during cooler times of the day, such as early in the morning and in the evening, raising patients’ awareness of the development of heat-related illnesses in hospitals, and advising patients who only come for general check-ups or regular examinations for diabetes or high blood pressure not to do these during the summer months and to only come if they have worrying symptoms.
In the current climate change, where we are all adapting to the “new normal”, it is time for healthcare providers, clinics and hospitals to also adapt to ensure that people seeking care from them are not exposed to heat-related illnesses due to poor planning and infrastructural issues.
(Help to overcome suicidal thoughts is available through Government Health Helpline 104, Tele-MANAS 14416 and Sneha’s Suicide Prevention Helpline 044-24640050. Helplines across the country can be reached here.)
(Dr. Christianez Ratna Kiruba is an internist and passionate about patient rights. [email protected])
