Can earlier training for India’s frontline health workers help combat rising heat risk?
By Amitha Balachandra
Dressed in a bright pink sari, her hair tied in a bun, 39-year-old Vishaka Patil was ready to start her day as a community health worker. It was mid-March and temperatures were already heating up in Khanivali, a village in India’s western Maharashtra state.
As the accredited social health activist (ASHA) was about to step out her door, however, she received a call from the medical officer for the area’s main health center, asking her to check on a man treated for suspected heat stroke a few days earlier.
Yogesh Bhanushali, 44, had just returned from a tiring trip to Mumbai, where he had been walking around the city all day looking for wholesale goods to stock his utensil shop back home. During the trip, temperatures had climbed over 40 degrees Celsius, with Mumbai issuing a yellow heatwave alert.
Feeling terrible after returning, he went to a primary health care center near his home, where he was quickly admitted and ice packs placed under his arms and thighs to reduce his body temperature.
“I was feeling dizzy. I had a fever and weakness. They put me on IV fluid and kept me under observation for 24 hours,” said Bhanushali, who was later discharged with a list of precautions to ensure he was not overwhelmed by heat again, such as staying hydrated and not going out in the hottest parts of the day.
But Patil, the community health worker who checked on Bhanushali, said she and other local frontline health workers at the time had never received instruction on helping their patients manage worsening rising heat risks. That came only at a monthly meeting at the end of April, backed by the medical officer of the primary health centre.
The lack of guidance until that point limited their ability to begin early surveillance at a time when heat extremes are being reported more often and earlier each year, she and health experts said – a problem for workers considered the first point of contact between community members and health services.
“We were informed about the precautions one must take for critical cases in a meeting on April 28,” Patil said, such as encouraging anyone traveling to carry both water and oral rehydration packets, measures that can “help the patient till they reach the hospital in serious cases,” she said.
ASHA workers in other districts and cities – including Mumbai, Satara and Dharashiv – said they had also received instructions in April, despite heatwaves affecting the region as early as February and March this year.
But health officials said heat training for health workers, which is relatively recent in India, is naturally taking time to percolate to the front lines - and that lengthy training modules still need to be distilled for frontline use.
"Other national programmes like vaccination, malaria and tuberculosis are old programmes and they have budgets, they have officers, they have systems, whereas this is a very new programme,” said Dr. Dileep Mavalankar, who led India’s first heat action plan in Ahmedabad and who is the former director of the Indian Institute of Public Health in Gandhinagar.
Still, getting heat training to frontline workers tasked with providing primary medical care and creating awareness about government healthcare programmes is important as temperatures rise in India, experts said.
RISING HEAT RISK, RISING AWARENESS?
Climate-change-driven heat extremes are now the deadliest of weather-related disasters. Nearly half a million people died of heat-related causes each year, on average, between 2000 and 2019, according to a study in the medical journal The Lancet, and global temperatures have risen substantially since then.
But understanding of how significantly heat health risks are rising – and what should be done to reduce them – is limited, health officials say, including in already hot countries where many people feel they know how to handle stifling days.
Frontline health workers, who go door-to-door in communities, could help spread awareness of rising risks and how to manage them, but around the world many have not yet received adequate training themselves, experts say. India has over a million ASHA workers, according to the National Health Systems Resource Centre.
In India, which like many countries is facing worsening heat extremes, doctors go through periodic in-person or online training sessions on heat, at the national, state and district level.
“We train them on how to report it, how to do a post-mortem and so on. We expect them to percolate this training in their respective districts,” said Dr. Ajay Chauhan, a director-professor of medicine who is in charge of the heat stroke clinic at New Delhi’s Ram Manohar Lohia hospital. He regularly trains doctors under the government’s National Programme on Climate Change and Human Health (NPCCHH).
The NPCCHH has heat training modules for state and district health and medical officers, including community health workers, last updated in 2023. A module for ASHA community health workers describes their key role in spreading heat awareness in communities, looking for signs and symptoms among the vulnerable, and reviewing cases after the heat season. But the training is not always reaching frontline workers in a timely way, experts say.
barriers to training
In Palghar district, where the village of Khanivali is located, doctors said heat training for medical officers began as early as February this year – but ASHAs were not included in those discussions on spreading heat awareness, heat-related surveillance, tackling heat stroke cases, first aid and hospital preparedness.
One problem is that heat training modules are long and so can be intimidating to absorb, especially for those without formal medical training, said Vidhya Venugopal, a public health professor at Sri Ramachandra Institute of Higher Education and Research in Tamil Nadu. She is now working to simplify them.
“These modules are so big that even the doctors don't want to go through them. So it has to be a couple of pages that the ASHA can have in her hands to see that these are the signs and symptoms, something that's pictorial,” Venugopal said.
ASHA workers are also not formal medical employees, but instead are considered volunteers and paid a monthly honorarium and incentive, which varies depending on the state government and is usually between 5,000 and 15,000 rupees ($58 to $176). That can leave them outside formal systems.
In several Indian states, including Kerala in southern India, community health workers are demanding pay increases and retirement benefits. Some states, including Maharashtra, in western India, have given ASHAs pay rises over the last year, but some workers complain of delays in payments.
The Palghar district health office, Maharashtra health department, and the National Centre for Disease Control, did not respond to requests for information about heat training for community health workers.
But Dr. Vikas Desai, an urban health specialist, said hard-working ASHAs are key “messengers” in sharing health advice with communities.
When it comes to rising heat risk, “citizen adaptation is very important,” said Desai, technical director of the Urban Health and Climate Resilience Centre of Excellence in Surat.
quick cooling
While ASHAs are required to refer serious cases to hospitals, health experts say giving them more training on providing immediate care for heat-affected patients could save lives.
India’s training guidelines for heat health emphasise the importance of cooling overheated patients quickly, even before they are transported to the hospital.
“The most important thing a peripheral worker can do is pour cold water, below the neck at least, on the patient. Fan him, put the person in shade, and then ferry him to the nearest hospital or the health centre for further management,” Chauhan said.
Some non-profit groups are starting to train ASHA workers, hoping they could play a larger role in preventing heat stroke cases.
The Mahila Housing Trust, in partnership with local civic bodies, conducted a one-day training for community members, including 26 ASHAs in Rajasthan, in mid-May. In Ahmedabad in late May, the trust – which aims to help poorer urban women manage the challenges they face – trained about 1,500 ASHAs on heat, with a focus on solutions to lower heat risks.
ASHAs were encouraged to persuade every household to paint their roof white, for example, to reflect more heat and keep the inside cooler.
HeatWatch, another Indian non-profit group, brought in a medical professional to conduct heat training for ASHAs in Rohtak, in Haryana state, towards the end of March, in collaboration with the Centre for Indian Trade Unions. The session looked at how community health workers can identify heat-related illnesses and provide emergency care.
“Many ASHAs noted that a lot of the information that was given to them about, say, heat-related exhaustion or cramping or heat stroke was brand new information. A couple of ASHAs also mentioned that they have come across cases where a person has fainted at a construction site or a labourer has fainted, and they have not been aware of how to help,” said Apekshita Varshney, HeatWatch’s founder.
STRUGGLING IN HEAT
India’s NPCCHH heat guidelines acknowledge that community health workers face significant heat risks themselves as they walk long distances in rural areas or through crowded lanes in urban areas.
Government health centers advise them to take precautions, but the ASHAs say they are developing their own coping mechanisms as well.
“When we go out for visits, we carry a water bottle with our kit. We step out early and try to finish early. (But) in case of emergencies, we don’t have a choice,” Patil said. Their kit does not include particular heat safety equipment such as an umbrella to provide shade, or a cap, she said.
The mental stresses of sustained heat exposure are also a concern. Swati Kurne, 42, an ASHA in Mumbai who is starting menopause, said she found it particularly difficult to work on very hot days.
“It affects me mentally. I get irritated a lot, even for small things sometimes. Whenever I have severe pain, I need to take a day off,” she said.
Kurne’s colleague, Anjali Girkar, 43, also an ASHA, said she felt a little dizzy when she was out working one hot morning this April.
“This is the first time I experienced this during summer,” she said, noting that the severity of the heat had increased.
But ASHA workers say they are already beginning to use the training they have received.
Anita Bhagalpuri, 54, an ASHA from Haryana state, remembered how just days after she attended the HeatWatch training she used what she learned to help a 58-year-old farmer who had fallen ill in hot conditions.
Bhagalpuri discovered the woman she was treating was severely dehydrated as there was little drinking water available.
“We gave her lemon water because she was vomiting. We put a wet cloth on her head to cool her down. Then she was taken to the hospital and was given glucose,” Bhagalpuri said.