Surviving A Heat Stroke, Against All Odds

In the grip of a prolonged heatwave this summer season, Delhi’s hospitals were faced with a harsh reality: when a patient suffering from severe heat stroke was rushed into the emergency, the prognosis was poor. Most patients tended to be male, with mortality rates spiking to more than 70% on some days. It was touch-and-go for Dev Prasad Ahirwar, who spent six days unconscious and on a ventilator before what his family said was a miracle. He woke up and survived the worst.

Maximum temperatures were higher than usual across most parts of India this summer. The national capital endured its longest heat spell in 13 years, according to the India Meteorological Department. Labourers and outdoor workers from low-income groups, like Dev Prasad, were the worst hit. Hospitals were inundated with emergency heat stroke cases by mid-June, with the crisis abating after the weather turned on June 20.

The unusual heat and high heat stroke deaths reported in the national capital have prompted conversation on the need for effective heat action plans (HAPs) to mitigate impacts. But 54-year-old Dev Prasad’s story demonstrates that vulnerability to heat stress is woven by a complex web of factors that go beyond just central planning, and that survival for the poorest is driven, in part, by sheer luck.

It was on June 18, when maximum temperatures reached 44 degrees Celsius after two weeks of unrelenting heat, that Dev Prasad collapsed while on guard duty. He was posted in the posh neighbourhood of Noida Sector 50 and was rushed to Neo Super Specialty Hospital nearby at approximately 3:30 in the afternoon.

Gasping and unconscious with a fever of 106 degrees Celsius, the hospital announced a “code blue” according to his prescription – a medical emergency usually caused by cardiac or respiratory arrest. He was administered a cold saline drip, sponged to cool his body, intubated, and then sent to the Intensive Care Unit. “I don’t really remember falling unconscious, or anything from that day,” Dev Prasad said.

What heat stress does to the body

Unlike heat stress or other heat-related illnesses, heat strokes are life-threatening and time-sensitive conditions. Heat stroke can set in when exhaustion from heat is not treated, and the body’s thermoregulation limits are breached without any way to shed the excess heat. It can cause the central nervous system to dysfunction and organs to fail.

Dev Prasad reached the hospital in critical time, but others weren’t so lucky. “We saw four other people who were admitted due to heatstroke die within an hour of arriving,” said Vinod Kumar, Dev Prasad’s son-in-law. “We were so scared our father would die too.”

The primary treatment is to rapidly cool the body down without delay. Some hospitals in Delhi adapted by creating specialised heat stroke units to deal with the influx of patients. At Ram Manohar Lohia Hospital, a heat unit with two cement immersion tubs and a large ice dispenser had been set up under the leadership of Dr. Ajay Chauhan, a heat specialist who contributed to the national guidelines on emergency cooling for heat-related illness. “Early cooling can save lives, but when patients arrive after a delay, there’s very little that can be done. Despite our best efforts, we saw a mortality of 60 to 70 percent,” he said. “When someone collapses from heat stroke, the most important thing to do is to splash water on their bodies from the neck down.”

Bystanders who noticed Dev Prasad collapse had the presence of mind to splash water on him and grew alarmed when he didn’t respond. This small measure could have contributed to his survival, doctors where he was admitted said.

Making a poor prognosis worse

Marginalised caste groups like the Ahirwars dominate occupations requiring outdoor physical labour, a recent study found. An analysis of the role caste plays in heat stress and occupation revealed that these groups were less likely to have access to adaptation measures and were more exposed to heat stress and high temperatures compared to other groups. “Persistent caste-related disparities in education levels and social networks could also drive occupational segregation, with marginalised castes disproportionately represented in lower-paying jobs,” the study says.

The circumstances of Dev Prasad’s life and the events leading up to his collapse peel back the layers of how vulnerability to heat compounds. Originally from Madhya Pradesh’s Tikamgarh district, Prasad and his family have worked in the national capital region as migrant labourers for decades, without job security, health benefits, or liveable wages.

Last year, Dev Prasad took up a job with middlemen who supplied labour to establishments and was posted as a security guard in a bungalow in Noida Sector 50. No formal contract was involved, and according to Prasad, his employers would routinely delay the payment of his monthly salary of Rs. 12,000. “This time, even by mid-June, they paid Rs. 5,000 less. I had to continue working despite the heat to earn my money. I cannot afford to let Rs. 5,000 go, I was behind on rent,” he said.

Dev Prasad mentioned feeling uneasy for two days before he collapsed, his wife, Binodi Ahirwar said. When he finally did, his employers refused to help and took no responsibility for his working conditions. “They simply cut the call and have switched off their phones since then. They refused to help with his treatment and still have not paid the money they owed him,” said Dev Prasad’s son, Sanjay Ahirwar, who works as a construction labourer. “The only reason we think he survived is because the owner of the house he was guarding happened to be a senior IAS officer in the central government, who got him admitted and paid the hospital bill of Rs. 1.5 lakh,” he added.

The hefty medical bill for treating Dev Prasad’s heatstroke was not covered by any state or central government health insurance scheme, because neither Dev Prasad nor his family members were aware of the benefits under them. They were not registered for the Ayushman Bharat, Employees’ State Insurance Scheme, or any other health benefits. “We would have been turned away from the hospital for treatment because they said no beds were available, but the officer was kind and stepped in to help. We’re very grateful for that,” said Vinod Kumar.

Access to basic social safety nets can help reduce shocks from climate impacts, studies have found. “The basic indicators of poverty and wellbeing — nutrition, calorie intake, consumption, productive and non-productive assets, health and sanitation, literacy and education, and in some cases migration and crime — are not too different from those we use to measure climate resilience capacities. There is strong evidence of the positive impact of social protection on these indicators, and, hence on supporting resilience, especially absorptive and, to a certain extent, adaptive capacities,” the Global Centre on Adaptation says.

Apart from gaps in social protection and welfare, gaps in infrastructure exacerbated Dev Prasad’s condition. He would walk about 1.5 kilometres to work from his rented room under the hot sun. His quarter, in the congested neighbourhood of Barola, was a badly ventilated room made of concrete with a low ceiling and one small window. A small fan propped up on the ceiling provided a draught when electricity was available, but it didn’t adequately cool the room whose brick and concrete walls absorbed the heat from outside.

At work, a small cabin built from concrete, glass, and a plywood roof provided shade with a small wall fan. “But it was so hot inside that cabin that I preferred to sit outside,” said Prasad. To hydrate, he bought a large 10-litre water bottle made of plastic which would heat up, and he would drink from it till it needed to be replaced. There were no provisions for cold water nearby.

Despite these compounding factors – including his age and bidi smoking habit – Dev Prasad survived the heatstroke when many others didn’t. Deaths from heatstroke were reported to be over 200 in Delhi . In Safdarjung Hospital, where he was later admitted, around 50% of emergency heat stroke patients admitted in mid-June, died, the hospital administration told Mongabay-India. “His vitals remained stable, he responded to the medication and slowly he was able to breathe on his own,” said a doctor at Safdarjung Hospital, who did not wish to be named.

But the heatstroke has left him bedridden, and he cannot walk or go to the bathroom on his own. His speech is slurred, and recovery ahead is long, arduous, and expensive. “He’s got bedsores on his legs which will need treatment, but where should I take him? And how will we pay for it?” said wife Binodi.

Identifying vulnerability

An analysis of heat action plans by the Centre for Policy Research at the state, district, and municipal levels found that most were poor at identifying and targeting vulnerable groups. Only two out of 37 HAPs assessed carried out their own vulnerability assessments, while most identified vulnerable groups as those outlined in the National Disaster Management Authority’s guidelines.

The result is a lack of differentiation that leads to poor targeting of resources, the report said. It also found that HAPs missed out on integrating heat mitigation techniques through existing schemes and policies, including social welfare ones like MGNREGA. “None of the HAPs reviewed systematically explored policy integration across all listed interventions. Many actions in agriculture, water, housing, infrastructure, and urban design could usefully be linked to existing policies to unlock capacity and finances,” the report says.

The HAPs also lack legal and financial backing, which is among the biggest hurdles in their implementation, according to a recent analysis by think tank iFOREST. None of the cities assessed by iFOREST integrated HAPs into city planning.

Even with standard operating procedures in place, medical staff were taken aback by the number of heat stroke cases entering the emergency ward. Improving awareness of heat stroke symptoms so people seek emergency care without delay, and mandating rest periods between work to reduce heat stress are some of the biggest learnings for hospitals treating patients, said a doctor from Safdarjung hospital who did not wish to be named.

The work of effectively targeting vulnerable groups begins with making it a government mandate to compensate for the loss of work hours from heat stress, said Aditya Valiathan Pillai, fellow and coordinator of climate adaptation and resilience at think tank Sustainable Futures Collaborative. “There are institutional groups within each sector, like unions and large companies, through which the government can dispense education, work out insurance systems, and build forms of social protection. Identifying vulnerable groups across a geographical area is useful for HAPs, but there also has to be engagement with these institutional groups so the needs of vulnerable populations are met,” he said.

Even after he makes a full recovery, Dev Prasad’s family says they won’t let him go back to his security guard duties. “We’ll send him back to the village. He can do some farming there, or maybe be a shopkeeper. But we don’t want him to endure these types of conditions again,” said Sanjay.

(Published under Creative Commons from Mongabay-India. Read the original article here)