Ahmedabad, India’s Heat Action Plan, the first in South Asia, saving lives

As climate change fuels more frequent, more extreme, and longer heat waves across a wider swath of the globe, health and health systems are increasingly impacted.

A heatwave in Europe in 2003 is estimated to have caused 70,000 deaths. In India, the National Disaster Management Agency estimated that between 1992 and 2015, heat waves caused 24,223 deaths across the country.

“There is an urgency to act and respond to the heat health emergency, as there will be serious consequences of inaction,” noted the Integrated Research and Action for Development in a recent report.

The challenge, explained Dr. Gulrez Shah Azhar, an epidemiologist and public health researcher, “is that we are all the frog in a pot of water. We don’t realize that the water is coming to a boil.”

Indeed, Dr. Azhar moved to Ahmedabad, India’s fifth largest city, with a population of over five million, in 2010, months after a record-setting heat wave caused temperatures to top 46 °C (116 °F) for days.

“People joked with me,” recalled Dr. Azhar, who was working at the time for the Indian Institute of Public Health, Gandhinagar. “They said, ‘there are two seasons in Ahmedabad: hot and very, very hot.’”

When he asked about the death toll, locals shrugged and said that about a dozen people died. Dr. Azhar and colleagues dove into the data and eventually estimated the excess death toll during the single heat wave was more than 1,300.

His data on deaths and heat-related illnesses shocked authorities and proved a galvanizing moment for Ahmedabad. Health leaders recognized heat as a serious public health hazard and a threat to the city’s development. The city became the first city in India and South Asia to develop a Heat Action Plan (HAP).

HAPs are comprehensive extreme heat early warning systems and preparedness plans. They typically include a range of mitigation and adaptation measures aimed at reducing health impacts in both the short and longer term. Their goal is to improve public awareness, expedite community outreach, facilitate coordination across sectors, support capacity building for health care professionals, promote adaptation efforts, and reduce heat exposure, illness, and death.

Early research by Dr. Jeremy Hess, director at Center for Health and the Global Environment, University of Washington, has credited Ahmedabad’s HAP, launched in 2013, with averting approximately 1,190 deaths each year in the nearly decade since.

Climate change and extreme heat can feel overwhelming and too large of a problem for a single city or region to do much about, said Dr. Hess. The Ahmedabad experience illustrates that isn’t the case. “Ahmedabad’s leaders were open to the idea that, as with other disasters, they could prepare for extreme heat and do better,” said Dr. Hess.

There is currently limited research comparing the impact of the various HAPs that have been adopted by cities and states around the world. Experts in the field have highlighted the need for more research, including data on what works. A few within India have been held up as models: Odisha’s HAP, which is noted for using vulnerability assessment and socioeconomic data to identify and protect the most vulnerable; Rajasthan’s HAP, the first HAP focused on rural areas in India; and Ahmedabad’s HAP, which has been lauded by the Natural Resources Defense Council (NRDC) as a "leading example of urban heat adaptation," that "serves as a template for many cities and states across India, and internationally."

Key takeaways from Ahmedabad’s experience may be useful for health leaders struggling with the impact of climate change on health outcomes and considering developing their own Heat Action Plan.

Ahmedabad’s HAP focuses on four key strategies, first developed, said Dr. Azhar, as an expansion of local traditions communities have long practiced to beat the heat.

The HAP expanded and codified these behaviors and incorporated best practices from plans around the world, from Europe to California, said Dr. Dileep Mavalankar, director of the Indian Institute of Public Health, Gandhinagar, who also led the development of the HAP.

First, leaders developed and implemented an early warning system. Ahmedabad’s uses a simple color-coded early warning “heat alert” system to alert residents, city officials, and the health system of forecasted high temperatures. This early warning, which can provide up to five-days’ notice before a heatwave, kickstarts inter-agency coordination and preparation through formal, specially designated communication channels that reach the media, community groups, relevant agencies, medical providers, and first responders. The health department leads and coordinates the overall response.

When a heat alert is issued, a system of interagency coordination kicks into effect. A wide variety of agencies and groups launch a well-defined response that includes: ambulances strategically placed where they can most easily respond to vulnerable areas identified in previous heat waves; hospitals and clinics ready extra ice packs and other resources; water tanker trucks deliver drinking water to slum areas; school hours and work hours for outdoor laborers may be adjusted; and community groups establish drinking water stations, distribute public awareness materials, and take efforts to provide shade in high-traffic areas.

Second, the HAP outlines community outreach to build public awareness of the dangers of heat and tips for preventing heat-related illnesses and deaths. This outreach emphasizes simple, low-cost ways to avoid heat-related illnesses such as drinking water and shifting outdoor work to cooler hours. It also outlines similarly easy strategies for cooling when overheated, and explains when to seek medical care. At the launch of the HAP, authorities also held a workshop to emphasize and educate the media about their key role during such emergencies. Officials use pamphlets, billboards across the city, regular radio campaigns, and social media in local languages to ensure broad reach. The city also installed digital temperature displays in high-traffic areas to increase awareness. Awareness workshops are conducted for heat-exposed workers such as traffic police, laborers, street vendors, and others.

Third, the HAP outlines and supports training for health care providers to improve their ability to accurately educate, diagnose, and manage patients during a heat wave. Trainings include a broad spectrum of health force workers. This includes health system administrators’ decision making regarding surveillance, reporting, and staffing to address surging demand for health care during heat waves. Trainings extend to frontline community health workers, who learn how to recognize heat related dangers, educate their communities, and identify cases of heat-related illnesses.

Fourth, the plan outlines efforts to reduce heat exposure and promote adaptive measures over the long term. This includes, for example, practical and low-cost strategies such as painting roofs with reflective material as a way to reflect sunlight and cool indoor temperatures without the need for air conditioners.

“It is important for each heat action plan to be tailored to local circumstances and speak the local language,” said Abhiyant Tiwari, Lead at Climate Resilience and Health at NRDC, India, who, along with Dr. Azhar, Dr. Hess, Dr. Mavalankar, and other partners at the Ahmedabad Municipal Corporation, the Indian Institute of Public Health, Public Health Foundation of India, Mount Sinai School of Medicine, and Rollins School of Public Health at Emory University developed and supported the launch of the HAP. (Resources and recommendations related to the development of the HAP can be found here, including a brief for supporting slum communities and recommendations for health providers.)

Several factors make Ahmedabad high risk – high population density, a tropical climate, low access to air conditioning, and a high number of people regularly working outside. Those same factors can be found in hundreds of other cities across the global south.

“Before our work, people thought we are acclimatized and used to heat,” said Dr. Mavalankar, a lifelong resident of Ahmedabad. “India, after all, has been hot for thousands of years. But people believed that because they were not looking at the data on daily deaths and admissions to hospitals during the heat waves and comparing them with non-heat wave periods.”

Most cities in low- and middle-income countries, Dr. Mavalankar explained, do not have statisticians or epidemiologists, so even diagnosing the problem of heat-related illness and death can be a challenge.

Leveraging the capacity of local universities and international partners helped Ahmedabad quantify the problem, which includes increased neonatal mortality, said Dr. Mavalankar. “Medicine has recognized for a long time the risk of hypothermia to newborns in winter. But pediatricians in Ahmedabad demonstrated the risk of hyperthermia in neonates during extreme heat. Neonates become dehydrated and overheated and can’t survive.”

Many researchers are now urging the adoption of heat action plans to protect "vulnerable populations in tropical latitudes, where the effect of climate change could be very severe on economically disadvantaged communities in crowded cities.

“Most HAPs are not in low- or middle-income countries,” said Dr. Hess. “It is a great shame. We should do these everywhere there is significant heat risk.”

Even today, when heat is finally recognized as the largest environmental driver of mortality, many disaster management agencies and plans don’t consider heat within their purview. Dr. Hess and Dr. Azhar emphasized that HAPs can be used as the foundation for early warning and emergency preparedness for a broad array of health threats and disaster management. “If you abstract and generalize the process, you can use it for everything from tsunamis to storms,” said Dr. Hess. “It is, at a fundamental level, about making the community and health system more resilient.

India’s National Disaster Management Authority is currently working with 23 of India’s 28 states to develop and implement heat action plans and, last year, held a national webinar to support the development of HAPs. Dr. Azhar has also created a district level heat vulnerability index for India.

The partners who developed Ahmedabad’s HAP created a toolkit for other interested cities and states to adopt their own heat preparedness plans. It features learnings from across India and beyond and includes tips, like the importance of regularly updating HAPs, the importance of breaking silos and including the labor, transport, and power supply agencies in any HAP, assessing socioeconomic factors that create vulnerabilities, and the value of analyzing the impact of urban heat islands. For example, explained Dr. Mavalankar, currently Ahmedabad relies on one official temperature reading taken from a weather station near the airport. It doesn’t capture the increased heat in the city center or that surface heat on the hot tarmac, where people are walking, might be 10 degrees Celsius warmer.

“HAPs create a cultural shift,” said Dr. Hess. “They help people understand that heat is a problem we can do something about.”