Thirteen people <a href="https://edition.cnn.com/2023/04/18/asia/india-heatstroke-deaths-award-ceremony-intl-hnk/index.html">died </a>and <a href="https://timesofindia.indiatimes.com/city/navi-mumbai/11-attendees-of-maharashtra-bhushan-award-ceremony-die-of-heat-related-health-issues-in-navi-mumbais-kharghar/articleshow/99539090.cms?from=mdr">over 600</a> people suffered from heat stroke after attending a state award ceremony in Navi Mumbai, India in the month of April in 2023. More than 1 million people reportedly showed up to the event. The high temperatures, lack of available drinking water, and an unforeseen disaster led to the fatalities.&nbsp;

This fatal incident is a sad reminder of India and the broader region&rsquo;s vulnerability to climate change. After the country&rsquo;s <a href="https://weather.com/en-IN/india/news/news/2023-03-01-february-2023-was-indias-hottest-in-its-122-year-recorded-history">hottest</a> February on record, April brought a severe heat wave last year. Last year, Indian officials issued heat warnings for several states, with temperatures reaching 109 degrees Fahrenheit in some parts of the country. Despite this, the existing Heat Action Plans in the country are <a href="https://cprindia.org/wp-content/uploads/2023/03/Heat-Report_27March-23_Updated-Table.pdf">inadequate</a> in terms of funding, transparency, and legal foundations.&nbsp;

The public health implications of soaring temperatures are bluntly seen in the case of the event that happened at Navi Mumbai. According to the National Family Health Survey 2019-21(NFHS 5) <a href="http://rchiips.org/nfhs/NFHS-5Reports/NFHS-5_INDIA_REPORT.pdf">report,</a> only 1 in 4 people in India have air conditioning or cooler facilities in their households. Out of which nearly 25% of households belong to urban settlements and only 15% belong to rural areas. The rest of the population lacks access to air conditioning and other cooling devices. This increases their risk of developing heat-related illnesses, especially for young children and older people. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6950623/">lack</a> of awareness about prevention and first aid for heat-related illnesses, as highlighted by the Navi Mumbai incident, also is a major concern.&nbsp;

What are heat-related illnesses and why do they occur?

Heat-related illnesses are a spectrum of illnesses that can manifest as something as mild as a Heat Rash, Heat Cramps, Heat Exhaustion, Heat Oedema, to more dramatic complications like Heat Syncope, and Heat Stroke.

A heat-related illness can occur either due to exposure to hot weather or excessive physical exertion without fluid and electrolyte replacement. When the body is exposed to extreme heat, the body&rsquo;s normal mechanism to lose heat to maintain optimal temperature fails. There is an imbalance between heat loss from the body and heat gained due to high ambient temperatures. Consequently, the body temperature continues to rise, leading to a direct toxic effect of heat on the body which further impacts the body&rsquo;s heat regulation mechanism. This creates a vicious cycle and causes failure of multiple organs in the body. If not addressed urgently, it leads to death.&nbsp;

What are the symptoms of these illnesses?

Heat rash is a skin irritation that can manifest as red clusters of pimples or small blisters across the body. It is caused when the ducts of the sweat glands get blocked after getting damaged by high temperatures and humidity.

Heat cramps are painful cramps in the muscles caused due to dehydration due to excessive sweating during strenuous activity or high temperatures. The sweating depletes water and salt in the body which leads to cramps. If fluids and salt are not replaced then this can progress to heat exhaustion. Such people tend to develop a low-grade fever along with tiredness.

Some people can also develop swelling of their legs as the vessels in the foot become leaky in high temperatures. This is known as heat edema. Pooling of fluids in the legs can also result in a sudden drop in blood pressure and fainting when a person stands for too long or stands up from sitting or lying down. This is known as heat syncope.&nbsp;

Heat stroke is the most serious heat-related illness. It occurs when the body can no longer control its temperature: the body&rsquo;s temperature rises rapidly, the sweating mechanism fails, and the body is unable to cool down. When heat stroke occurs, the body temperature can rise to 106&deg;F or higher within 10 to 15 minutes. Heat stroke can cause permanent disability or death if the person does not receive emergency treatment. Patients with heat stroke can also develop seizures, irrelevant talk, or become unconscious.&nbsp;

It is essential to look for dark yellow/brown coloured urine, especially in the elderly, as it is a sign of dehydration which predisposes to all the above-mentioned conditions.

Who is at a higher risk of developing heat-related illnesses?

People working in hot and humid environments like brick-kiln workers, construction site workers, and athletes are at a higher risk of developing a heat illness. The risk is even higher if the person does not adequately replace the water and salt lost from the body as sweat. Older people, children, people recovering from a viral illness, people with other long-term diseases like diabetes, heart disease, and hypertension, and people with inadequate sleep are also a higher risk as their body&rsquo;s coping mechanisms to tackle heat are weak.

First aid treatment for heat-related illnesses

One of the first steps is to keep the person hydrated by giving them cool fluids like water, oral rehydration solution (ORS), or fruit juices. Secondly, it is important to lower the person&rsquo;s body temperature. This could be done by either using fans or air conditioners or by taking the person to the shade or any well-ventilated place and wetting their clothes. The clothes should be loosened in order to allow the body to lose its heat.&nbsp;

In case of rashes keep the skin &ldquo;cool and dry&rdquo; by recurrent baths and application of lacto-calamine lotion that helps in reducing skin irritation. In case of muscle cramps or heat exhaustion, the person should avoid any physical exertion and should adequately hydrate themselves in order to replenish the lost fluids and electrolytes. If the person is having altered sensorium (talking irrelevantly), is comatose (not responding), has seizures, or feels irritable, kindly take them to the hospital as soon as possible.&nbsp;

People with a history of other chronic conditions like heart disease, hypertension, cancer, or diabetes should be rushed to the hospital if a kind of heat-related symptom is noticed. Similarly, people belonging to extremities of age such as children and the elderly should receive urgent care if any heat illness symptom develops owing to their low coping ability with high temperatures.

Precautions to be taken to avoid heat-related illnesses

It is important to stay well hydrated and eat at frequent intervals to maintain an electrolyte and fluid balance in the body. The colour of the urine is a good indicator that can help in assessing the hydration status of the body. The darker it is, the higher the level of dehydration, and vice versa.&nbsp;

It is also important to maintain a cool environment. For those indoors, fans, air conditioners, and proper ventilation will help in tackling the heat. However, for those working outdoors, it is important to provide them with a cool resting place and allow them to take frequent breaks from the heat. If possible, direct exposure to the sun should be avoided by providing outdoor workers with a tent or at least caps or hats.&nbsp;

Relationship between diet and heat illnesses

Consuming food rich in non-esterified fatty acids like <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146300/">almonds</a>, flaxseeds, and fish that contain omega-3 fatty acids and using plant oils like flaxseed oil, soybean oil, and canola oil can be helpful. As alcohol, tea, coffee, and carbonated soft drinks dehydrate the body, they should be avoided. Instead, ORS, and homemade drinks like lassi, torani (rice water), lemon water, buttermilk, etc. should be consumed. Fruits and vegetables <a href="https://indianexpress.com/article/lifestyle/health/diet-foods-increase-decrease-risk-heatstroke-summer-season-8570338/#:~:text=Foods%20that%20are%20high%20in,prevent%20heat%2Drelated%20illnesses.%E2%80%9D">high</a> in water content such as watermelon, and grapes among others should be consumed as they can help replenish lost nutrients and fluids.

To summarize, staying hydrated and avoiding high outdoor temperatures and strenuous exercise during summer is key to avoiding heat-related illnesses. It is important to understand that climate change forms the core of this problem and a permanent solution to this problem would be to address factors causing environmental destruction and climate change.

Edited by Parth Sharma.

Image by Janvi Bokoliya.

Temperatures are on the rise and so are heat related illnesses.

Heat-related Illnesses: A Rising Public Health Concern In India

&quot;The digital space has evolved in leaps and bounds in the last two decades. After the pandemic, the digital space became an inescapable part of everyone&rsquo;s lives. From many urban businesses being Google listed to online shopping, buying groceries, and online banking, the presence of the internet has been prominent. This has resulted in India experiencing the largest number of real-time transactions in 2021 (48.6 billion). Technology has therefore enabled knowledge and information sharing, has brought markets to our fingertips, and increased access to basic services. Yet this is just one side of the story&mdash;of the privileged who have gadgets and uninterrupted internet connection at their homes and on their smartphones to reap the benefits of being online.&rdquo; - <a href="https://www.oxfamindia.org/knowledgehub/workingpaper/india-inequality-report-2022-digital-divide">India Inequality Report 2022: Digital Divide, Oxfam India</a>

India is taking giant leaps in digitizing health systems with the introduction of the Ayushman Bharat Digital System (previously named National Digital Health Mission). The digital revolution in the health sector is intended to help resolve the existing disparities in the delivery of services. India is a country with a diverse population with multi-layered inequalities related to gender, social and economic status, geographical location, and, most importantly in this context, digital literacy. Therefore, we need to ponder whether the need for digitization is uniform and if it will really address existing inequities.&nbsp;

The India Story is quite ironic. We have huge disparities existing within the digital realm -&nbsp; rural and urban; privileged and marginalized. The digital literacy rates in most the metropolitan cities are over 61%,&nbsp; which is at par with some of the most developed countries. But predominantly rural states like Bihar and Orissa are worse off than several of the least-developed countries with only 25% of people being digitally literate.

According to the National Sample Survey Office (NSSO) 75th round, only one-fifth of India&rsquo;s population can operate a computer or use the internet.&nbsp; Among the poorest one-fifth of households, only 2.7% have access to a computer and 8.9% to internet facilities. On the contrary, among the richest one-fifth of households, 27.6% have access to a computer and 50.5% to internet facilities.

<a href="https://www.oxfamindia.org/knowledgehub/workingpaper/india-inequality-report-2022-digital-divide">The Oxfam India Digital Inequality Report 2022</a> refers to the digital divide as &ldquo;the gap between individuals, households, businesses, and geographic areas at different socio-economic levels with regard to both their opportunities to access information and communication technologies (ICTs) and to their use of the internet for a wide variety of activities.&rdquo; It reflects differences among and within countries.&nbsp;

&ldquo;It is not just about people who have access and those that do not; it is not just about haves and have-nots. It is about people becoming knowers and know-nots; and doers and do-nots; those who can communicate with the rest of the world and those that cannot.&rdquo; - Sumanjeet Singh, Associate Professor in the Department of Commerce, Ramjas College, University of Delhi, writes in his <a href="https://www.researchgate.net/publication/220136939_Digital_Divide_in_India_Measurement_Determinants_and_Policy_for_Addressing_the_Challenges_in_Bridging_the_Digital_Divide">paper</a> on the digital divide in India.

In a recent talk titled &ldquo;Digital Divide: A Perspective From the Other Side,&rdquo; Dr. John Cherian Oommen from Christian Hospital, Bissamcuttack emphasized how digitalization has excluded the underprivileged and widened the gap of the existing inequalities. He cited the example of the Cowin portal. The COVID-19 vaccine was made available through appointments through the digital platform. This deprived the digitally poor of accessing a life-saving vaccine.&nbsp;

Citing another example from the same community, he highlighted how online education during the COVID-19 pandemic had failed to consider people from his remote community. He rightly pointed out how most solutions (existing policies and schemes) that are introduced or formed are affected by &ldquo;Capitalitis&rdquo;, a term he invented. He describes Capitilitis as &ldquo;an ophthalmic disease that prevents one from seeing beyond the capital.&rdquo; Through the talk, Dr. Johny instilled the need of enlarging the viewpoint of policymakers, and public health professionals beyond the four walls of the capital.

&nbsp;&ldquo;Our understanding of reality depends on where we are looking from.&rdquo;-Dr. John Oommen

The effects of the digital divide were <a href="https://www.oxfamindia.org/knowledgehub/workingpaper/india-inequality-report-2022-digital-divide">classified</a> by Dewan and Riggings into two groups. First-order effects include inequalities due to differential access to technology and second-order effects include inequalities due to the difference in the ability to use the technology among those who have access to them. These two effects need to be considered before digitizing anything in the country.

The Oxfam India Inequality Report 2022 on the Digital divide has extensively covered and discussed the existing disparities in various fields including health. The Government has been trying to digitalize schemes to increase accessibility.&nbsp;

&ldquo;Often the beneficiaries of the government belong to the economically backward and socially marginalized sections of the society. Evidence suggests that they have remained digitally disconnected. As such, when compulsory digital methods are used to provide government benefits and services, it fails the very people it intends to serve&rdquo;. - <a href="https://www.oxfamindia.org/knowledgehub/workingpaper/india-inequality-report-2022-digital-divide">India Inequality Report 2022: Digital Divide, Oxfam India</a>

For instance, let&rsquo;s look at the initiatives that mandate an Aadhar card. The One Nation One Card (ONORC) launched in August 2019, made it mandatory for individuals to get their Aadhar Card linked with the Ration Card to avail benefits of this scheme. Though the deadline to link the card was extended twice, officials in many states immediately started insisting on linkage and denied ration to those who could not.&nbsp;

For many with the linkage, the ration is denied since the thumbprint could not be authenticated as in the case of fading thumbprints in the elderly and finger deformities in people with leprosy. At a village in Jharkhand, it was <a href="https://www.ndtv.com/india-news/no-aadhaar-no-food-11-year-old-girl-died-begging-for-rice-says-jharkhand-family-1763863">reported</a> that an 11-year-old died after months of starving as the administration stopped giving her family subsidized food. This is just one story among others, many of which go unreported or are brushed under the carpet. Similarly, pension was also <a href="https://www.ndtv.com/india-news/millions-denied-pension-as-finger-prints-dont-match-aadhaar-data-bjp-lawmaker-1793558">denied</a> to people whose identity was lost due to missing fingerprints.

Another case is that of the Mahatma Gandhi National Rural Employment Guarantee Act (NREGA) which is an Indian job guarantee scheme. The scheme guarantees 100 days of employment in every financial year to willing adult members of any rural household at the statutory minimum wage of Rs 100 per day. From <a href="https://rural.nic.in/en/press-release/national-mobile-monitoring-system-nmms-app-mgnregs">January 1st</a> onwards, the National Mobile Monitoring System (NMMS) digital attendance application was made compulsory for the workers across the country.&nbsp;

The Application requires two &ldquo;time-stamped and geo-tagged&rdquo; photographs of the laborers before the attendance can be uploaded onto the server. Many times due to poor network issues or lack of access to digital technologies, the photos do not get registered on time. From February 1, 2023, the Ministry of Rural Development made it <a href="https://thewire.in/rights/aadhaar-payments-compulsory-nrega">mandatory</a> that all payments to the Mahatma Gandhi NREGA beneficiaries would be made through Aadhaar Based Payment System only. According to the Ministry of Rural Development&rsquo;s <a href="https://rural.nic.in/en/press-release/difficulties-under-aadhaar-based-payment-system-national-mobile-monitoring-system">report, </a>currently, only 43% of NREGA workers are eligible for the Aadhar Based Payment System. This means that more than half of the workers are not getting paid even though they are working.

The above examples clearly show that digitization has not helped in addressing the inequity but made it worse. Before digitizing any existing process the officials should consider the following questions - Does the community have the necessary skills and technologies needed to effectively survive digitization? Are the internet download and upload speeds sufficient for the needs of the users? How does the cost of using digital devices compare to the cost of essential goods? What percentage of a person&rsquo;s income will be spent on making the process accessible? Are there mobile applications available in the local language relevant to the people in the community?

Health experts insist that broadband internet access must be recognized as a social determinant for health. We need to build an inclusive, resilient, and sustainable digital environment. However, to achieve this goal and bridge the existing digital divide in India we need to bring in more inclusive solutions that consider all socio-economic aspects of the most vulnerable groups.

Edited by Parth Sharma.

The wave of digitization is sweeping India but are the citizens ready to live in a digitized India?

Is India Ready For Digitization Of Services?

Chithra Maria Alexander is a behaviour change and health communication enthusiast who is working in health promotion through research, scientific writing and communication methods. She is currently a postgraduate scholar at the Johns Hopkins Bloomberg School of Public Health, Baltimore.

Chithra Maria Alexander is a behaviour change and health communication enthusiast who is working in health promotion through research, scientific writing and communication methods. She is currently a postgraduate scholar at the Johns Hopkins Bloomberg School of Public Health, Baltimore.

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Chithra Maria Alexander

Chithra Maria Alexander

Heat-related Illnesses: A Rising Public Health Concern In India

Is India Ready For Digitization Of Services?

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