India likely underestimates heat deaths and therefore responds more cautiously, officials say

BENGALURU, India (AP) — Months of scorching temperatures that exceeded 50 degrees Celsius (122 Fahrenheit) in parts of India — the worst heat wave in more than a decade — left hundreds dead or sickened. But the official death tolls listed in government reports barely scratch the surface of the true toll, and that hampers future preparations for similar heat waves, health experts say.

India has now recovered somewhat from the intense heat and is battling a number of other weather extremes as monsoon rains hit the northeast of the country. But for months, the extreme heat has been hitting much of the country, especially in the north, where government officials reported at least 110 heat-related deaths.

Public health experts say the true number of heat-related deaths is likely in the thousands. But because heat is often not listed as a cause of death on death certificates, many heat deaths are not included in the official figures. The concern, they say, is that undercounting deaths means the heatwave issue is not being given the priority it deserves and authorities are missing opportunities to prepare their citizens for the scorching temperatures.

The warmest years in India on record have all occurred in the last decade. Studies by health experts have shown that up to 1,116 people died each year between 2008 and 2019 due to heat.

Difficulties in registering heat-related deaths

As part of his work in public health, Srinath Reddy, founder of the Public Health Foundation of India, advises state governments on how to take heat into account when recording deaths.

He noted that heat-related deaths across the country were significantly underestimated due to “incomplete reporting, late reporting and misclassification.” Despite national guidelines on recording deaths, many doctors – especially in overcrowded public hospitals where resources are already scarce – were not complying, he said.

“Most doctors only record the immediate cause of death and not environmental factors such as heat,” Reddy said. That’s because heat deaths can be divided into exertion-induced and non-exercise-induced deaths: Exercising-induced deaths are deaths caused by direct exposure to high temperatures. Non-exercising-induced deaths are deaths in which young children, the elderly or people with underlying medical conditions become seriously ill or sometimes even die indoors.

“For the second category of people, the heatwave is the last straw,” says Dileep Mavalankar, former director of the Indian Institute of Public Health in Gandhinagar. “Most people who die during a heatwave belong to this category, but their deaths are not recorded as being related to the heat.”

Mavalankar agreed that the official number of heat deaths this year is too low. He said 40,000 cases of heat stroke were recorded, but only 110 deaths. “This is only 0.3% of the total number of heat stroke cases recorded, but normally heat deaths should account for 20-30% of heat stroke cases,” he said.

“We need to count deaths more accurately,” said Mavalankar. “That is the only way we can know how severe the consequences of extreme heat are.”

Planning for future heat

In his previous role at the Indian Institute of Public Health in Gandhinagar, Gujarat, Mavalankar was instrumental in developing India’s first heat action plan for the city of Ahmedabad in 2013, three years after more than 1,300 people died there during a heatwave.

The heat plan includes measures such as improving access to shaded areas for outdoor workers, converting relatively cool public buildings into emergency shelters for people without homes or access to electricity, and ensuring hospitals have adequate medical supplies and staff during heatwaves.

In subsequent years, Mavalankar and his team studied the impact of the heat plan by counting the number of deaths in subsequent hot summers. Since there was no specific data on heat deaths, the team looked at deaths from all causes, which spike during heat waves, and used the number of excess deaths to determine how many deaths were likely caused by heat.

They estimate that the Heat Action Plan has helped reduce deaths during heatwaves by up to 40%.

While that data isn’t perfect, Mavalankar said, it allows the city to adequately prepare for extreme heat and do more of what worked in the future.

However, he said that due to the lack of data from other countries, it would be difficult to reproduce the Ahmedabad results at the national level.

“Not reporting these deaths and not sharing data is like the Indian Meteorological Department not sharing weather data,” he said. “We could easily do this across the country, but we have not decided to do it yet.”

Improving government data

The Indian government collects data on heat-related deaths through the National Centre for Disease Control under the Ministry of Health. These are then forwarded to the National Disaster Management Authority. The authority then reports the data as a national total for the year, but a state-by-state breakdown is not publicly available.

The National Crime Records Bureau also collects data on heat-related deaths as part of its recording of deaths due to “forces of nature” and publishes these figures.

But there are major discrepancies. In 2020, the last year with publicly available data on heat deaths from both official sources, the Criminal Registry recorded 530 deaths from heat stroke, but the Civil Protection Agency reported only four heat-related deaths.

The Associated Press has contacted the Indian Health Ministry spokesperson, the NCDC and the NDMA for comment on the discrepancy but has not received a response.

Better data could answer a whole range of questions about who is most at risk and how best to help those people, says Bharghav Krishna, a public health expert and member of the Sustainable Futures Collaborative think tank. “Especially in terms of finding out who is dying, where they are dying and what they are doing when they die.”

Krishna believes that while the data currently collected is insufficient, it could at least provide some insights for policymakers and researchers and at least compel action if made available to the right people.

But Malavankar said the data collection problems were more systemic in nature and needed to be addressed urgently.

“We have not conducted a census since 2011. The fact that we do not have figures is our national weakness,” he said.