Why doctors are struggling to certify heat deaths even in this brutal summer

On June 1, government teacher Wasi Akhtar, 48, walked to the Baluadih Urdu medium government school in Bihar’s Jamui and logged his attendance before 9 am.

A day before, the maximum temperature had soared to 44 degrees in Jamui. The India Meteorological Department had sounded a heat-wave alert for parts of Bihar since May 29, warning of hot nights which gives no time for the body to cool down. Schools had been shut because of the heat wave. But teachers were still asked to report for duty.

“After a while, Akhtar went to inform the headmaster that he was not feeling well,” his elder brother Mohammed Shamim said. “He collapsed there.”

Shamim rushed to the school and saw that other teachers were spraying water on Akhtar to revive him. “His body was very hot when I touched it,” he said.

Akhtar was rushed to a local doctor who said he could not treat a case of heatstroke.

A second private doctor, Dr Tasneem Ahmed, put him on intravenous saline drip for some time and then asked the family to take him to a bigger hospital. Akhtar’s blood pressure was high but the ECG report was normal, the doctor observed.

The family then travelled to Durgapur, over 80 km and two hours away, but Akhtar died before they could reach a hospital.

His death caused an uproar. Government teachers in Jamui staged a protest against the rule that makes it mandatory for teachers to report for duty even during heat-wave conditions.

Local activist Pushpraj Shastri said the protest forced the police to send Akhtar’s body for a post-mortem at the government-run Sadar hospital.

The verdict of a heat-related death would entitle Akhtar’s family to Rs 4 lakh ex-gratia, but Shamim said they have “little hope”. “Usually government doctors label such cases as heart attacks.”

Many teachers in southern Bihar suffered heatstroke, and some died in the three days between May 30 and June 1 due to extremely high temperatures, according to Markandey Pathak, president of TET-STET Uteern Niyojit Teachers’ Association. “But most have not been counted as heatstroke victims,” Pathak told Scroll.

The association has recorded the deaths of eight teachers between May 1 and June 10. “Most of them died during a heatwave,” Pathak said.

In cases when an autopsy was done or treatment was given, hospitals have been reluctant to provide medical documents, said Jagat Bhushan from Ekta Parishad, a non-governmental organisation in Bihar. “This is the administration’s attempt to undercount heatstroke deaths,” Bhushan said.

How to label a heat death

This summer, fierce heat waves struck large parts of northern, eastern and western India, leading to several deaths. The India Meteorological Department recorded more than double the number of heat-wave days than what these regions experienced last year.

Across India, the health ministry has recorded 24,849 suspected heatstroke cases and 56 deaths between March and May 31 this year.

The actual number may be higher. To take the case of Bihar alone. Local media reports from Bihar pointed to 60 deaths in a span of 24 hours on May 30.

Heatstroke deaths are undercounted not only because of bureaucratic hurdles, as activists allege, but also because they are very difficult to be medically labelled so.

To ensure that heat-related deaths are duly notified, the Union health ministry issued new guidelines to help doctors identify deaths caused by heat.

A person could be said to die of heatstroke, when heat directly contributes to the death – or when a pre-existing health condition such as heart or lung disease has been exacerbated by heat stress, the guidelines said. Examining the clinical history of a person’s demise – from the ambient temperature at the time of falling ill to the conditions in which he or she was exposed to heat – could also help ascertain a heat death, the guidelines said.

“A significant number of these deaths will occur in persons having some preexisting disease known to be exacerbated by heat stress,” the guidelines said. “These deaths can be certified as heat-related, with the disease being considered a significant contributing condition, or vice versa.”

However, doctors and health officials in several states told Scroll that they were either unaware of the new guidelines or that the expert advice is not helping, because it is not attuned to the reality on the ground. Many continue to avoid certifying deaths as caused by heatstrokes because not doing so is considered a safer option.

When medical attention comes too late

The new guidelines on heat deaths were framed by the National Centre for Disease Control along with the National Programme on Climate Change and Human Health.

To confirm a death due to heat, they suggest that a medical officer must look for more evidence, such as the body temperature at time of collapse, ambient environment temperature, and surrounding circumstances.

If the body temperature was more than 40.6 degrees at the time of collapse, it is categorised as a heatstroke case. But in rural areas, where medical facilities are inaccessible, by the time a person is brought to a tertiary-level hospital, the body temperature dips. This is what likely happened in the case of Akhtar, the school teacher.

“If the body reaches us in a state of hyperthermia (high body temperature), it is easier to label it as a heatstroke,” said Dr Naushad Ahmed, deputy superintendent in Sadar hospital. “But Akhtar’s reached us much later.”

However, there are other clinical symptoms that doctors can rely on in cases where body temperature is lower or the information is not available.

Extreme exposure to heat forces the heart to pump faster and harder. For heart patients, this may lead to cardiovascular collapse due to reduced oxygen supply. For respiratory illness patients, it can affect lungs and cause heat-related hyperventilation. It could also lead to kidney injury, especially in alcoholics. All of this can show up in an autopsy.

But an autopsy does not always provide conclusive answers. Dr Indrajit Khandekar, professor of forensic medicine in Mahatma Gandhi Institute of Medical Sciences in Wardha, said that an autopsy may provide “non-specific findings”. “For instance, there may be brain edema [swelling] or organ necrosis or kidney damage due to heat. But this can also be caused by other health conditions,” he said. “To pin down heat as the cause becomes difficult.”

There are more definitive indications. For example, the presence of myoglobin protein in urine, which indicates muscle breakdown due to heat, or presence of high sodium and chloride levels in the vitreous fluid present in the eyeball, which indicates loss of water or dehydration in case of heat exposure.

The National Centre for Disease Control guidelines state that during an autopsy blood, urine, and vitreous samples must be preserved to carry out the above tests.

“But these tests are not readily available in rural areas,” Khandekar pointed out.

“Removing vitreous fluid is not possible unless doctors have expertise,” said Dr Aditya Saxena, forensic expert from the Medicolegal Institute in Bhopal, referring to biochemical analysis where fluid is extracted from the eye to check for sodium and chloride levels, as mandated by the National Centre for Disease Controlguidelines.

In the absence of awareness and facilities, doctors remain reluctant to certify a heat death.

“These guidelines have been framed by experts who do not know the ground situation,” said Khandekar.

In Akhtar’s case, such samples have not been sent for biochemical analysis, which can be carried out by forensic labs or medical colleges.

Dr Ahmed told Scroll that they do not have forensic experts and rely on regular doctors to do postmortems. “We need to train them to ascertain heat-related deaths,” Ahmed said.

Akhtar’s brother Shamim said it has been a fortnight since the autopsy. “I am yet to receive any medical document or cause of death certificate,” he said.

Dr Jasvinder Kaur Bhatia, chairperson of committee that framed the National Centre for Disease Control guidelines, and Dr Aakash Shrivastava, the convenor of the report, refused to comment over the difficulty doctors are facing in implementing the National Centre for Disease Control guidelines.

A member from the committee, who requested not to be identified, said that as autopsy findings may not be enough, clinical findings could be the only way to suggest a heat-related death. “By that I mean investigating the circumstances in which the person collapsed, the surrounding temperature and their symptoms,” the committee member said.

This would mean the doctor will have to also record the statement of family members to understand how the patient fell ill. Such a process is not being followed in rural regions, said Ekta Parishad’s activist Jagat Bhushan.

What doctors do

In several rural areas, awareness about assessing heat-related deaths is negligible.

Moreover, as notifying a heat-related death is not compulsory, private doctors seldom report it, Khandekar said.

In Gujarat’s Palanpur, where average temperatures this summer hovered around 40 degrees Celsius, Dr Ramesh Chaudhary said doctors in his private hospital have mostly relied on what they had learnt in medical college when diagnosing heat-related deaths.

“We have not seen the fresh guidelines,” he said, referring to the National Centre for Disease Control report. “The kind of heat people are getting exposed to is also higher this year. Doctors need to be given fresh training to handle wide-ranging complications related to it,” he added.

While the National Centre for Disease Control guidelines focus on both – heatstroke death and heat-related deaths – several doctors only label a death as one caused by heat if there is direct evidence of heatstroke.

Chaudhary said if a patient has a history of heart ailment and suffers a cardiac arrest from heat stress, his hospital labels it as a death due to heart disease, making no mention of heat.

This is common in other states, too.

In Sagar, part of the Bundelkhand region, Dr Manish Jain, professor of medicine in Bundelkhand Medical College, said doctors in his hospital have not come across the ministry’s new guidelines.

For a patient who suffers a cardiac event due to heat stress and may have pre-existing diabetes, he said that doctors usually attribute primary cause as heart attack and antecedent cause as diabetes. “We usually don’t add heat in the cause of death certificate,” Jain said.

Moreover, Jain said doctors “avoid post-mortem unless there is a medico-legal case.”

Saxena, the forensic expert from Bhopal, said this year he received a few bodies that he certified as heat-related deaths. Most either had existing heart problems, or alcohol addiction, or diabetes. “These are the people who get affected by heat the worst,” he said.

In several cases, Scroll found that medical officers shy away from labelling heatstroke cases and want the police to attest that there was no foul play as well as corroborate the family’s version that the deceased was exposed to extreme heat.

For example, Dr Ahmed said that since Akhtar was brought dead, doctors will have to rely on the police to confirm his brother’s account of him collapsing in school during a heat wave.

‘I know heat led to her death’

The lack of due certification process forces many to skip the bureaucratic hurdle.

Over 100 hundred years, Janki Devi was nonetheless fit and would do household chores in the house she shared with her son Upendra Prasad in Masaurhi, Patna district.

On May 30, the India Meteorological Department had issued an orange alert for severe heatwave in Patna district. At 42 degrees Celsius, Patna’s temperature was 4.2 degrees higher than normal that day.

Prasad said the heat was discomforting enough to force him to move his workstation to the ground floor. “The roof of the house was heating up, the cooler was throwing hot air at us and my mother continued to rest on the top floor,” he said. “It felt like 46 degrees that day.”

At 3.30 pm, he found her collapsed. He tried to administer her oral rehydration salts. “But her body was extremely hot and it wasn’t cooling down,” he said.

He called a family physician at home but before he could initiate treatment she had stopped breathing.

“My mother was active and had no health problems,” Prasad said. “I know heat led to her death. I was also feeling dizzy that day. We heard similar incidents of people collapsing in our colony that day.”

He did not visit the government hospital to certify her death as a heat stroke. “The government is intentionally avoiding certification as heatstroke,” he maintained.

This reporting was supported by a grant from the Thakur Family Foundation. Thakur Family Foundation has not exercised any editorial control over the contents of this article.