More than 1200 people have died in Karachi during the recent heat wave. Fingers are being pointed in different directions to determine responsibility. Sometimes bad things happen and no one can really be blamed. This was a natural calamity that was compounded by human error and legally enforced piety.

A few weeks ago (Surviving Summers, May 24, 2015) I had gone over some of the basic points about the need for and the importance of adequate water/fluid intake during summer. Instead of repeating myself I want to reiterate a couple of points. First, the human body is truly like a furnace that keeps producing heat at all times. This heat has to be ‘dissipated’ to survive. In hot weather the body gets rid of heat through perspiration (sweating) and the evaporation of that perspiration. The water that is lost has to be replaced or else the person cannot survive.

For those of us that might remember some of our high school physics, heat loss is greatest when the heat difference is the greatest, and heat loss diminishes as the temperature difference diminishes. When the ambient temperature approaches or exceeds that of the body then sweating and evaporation of sweat are the only methods by which body loses heat. But then again if the area around the body is relatively saturated with moisture (high humidity) then sweating becomes less efficient and ventilation or air moving around allows some evaporation and cooling -- that is why we use fans and fanning.

What happened in Karachi was due to a mixture of all these factors. It was hot and humid with little natural breeze. Many of the ‘homeless’ that died had no access to fans and sadly also no access to drinking water. Muhammad Hanif in a New York Times article published on June 26, 2015 tells how he and many other people in Karachi that provide ‘free’ drinking water to the public stop doing that in Ramzan. The reason he gives is respect for those that fast but he also points out that it is against the law to provide water or to feed anybody in public during fasting hours. Hanif also mentions the fact that with urban ‘development’, many spaces where people could cool off like public parks have also disappeared.

It is important to understand that heatstroke (also called sunstroke) is not the same thing as dehydration. Heatstroke usually occurs due to exposure to extreme heat or the sun in summer. This can damage the heat regulation system of the body. Under normal circumstances the body temperature is maintained in a narrow range around 37.5 degrees Celsius. In people suffering from heatstroke this heat regulation system is damaged and the body heats up leading eventually to death. The afflicted person will arrive at the hospital with a high fever. Heatstroke is much more dangerous than dehydration or plain loss of water.

Dehydration occurs relatively slowly and its major manifestation is thirst. The common cause is obviously an inability to replenish body water that is lost in sweat and in normal body functions. The inability to replace lost water can be involuntary especially in those that for reasons mentioned above do not have access to drinking water and at the same time are forced to live in places where electric fans are not available.

Self inflicted dehydration is seen in patients fasting during periods of extreme heat aggravated by prolonged ‘loadshedding’ where fans or air conditioning is not available. Patients with dehydration are weak, almost comatose and have low blood pressure and many even while at home might be ignored on the presumption that they are just sleeping.

In all likelihood more people died from ‘forced’ dehydration rather than heatstrokes. The few that died from heatstroke were probably workers that spent time in the sun while they avoided drinking water because they were fasting or else were afraid of being considered ‘bad’ Muslims. As a physician I think that most of those that died were victims of dehydration. Instead of trying to set up Joint Investigation Teams (JITs) to affix blame, the much more important thing is for physicians and public health officials to determine the major cause of death and sickness and then publish the derived statistics and medical insights for the medical and bureaucratic communities to see and understand.

Such understanding is vital since with the rapidly changing climate, future heat waves just might be hotter and more prolonged. It might be easy to blame Karachi and its government but it is quite possible that in the future, even other big cities especially those in the Punjab might also be affected. Also for at least another five years Ramzan will fall during the warm summer months. So it is important to think of the present tragedy also as a warning for the future. Steps must be taken to prevent future repetition, however difficult theses steps might seem.

First step is to register the homeless and create ‘shelters’ for them during periods of extreme weather. This applies to both winters and summers. Shelters should be permanent especially if the number of homeless in a given city is large enough to merit a major investment. However, many of the homeless will avoid living in permanent shelters for different reasons but may use them only for specific purposes. Any visit to the shrine complex of Data Sahib in Lahore will show that a large number of homeless find shelter there during extreme weather as well as for the food that is freely available at all hours. It is important that such shelters have electricity and drinking water available for most of the day.

The other thing that needs to be done is to decriminalise the provision of food and water to those in need during the fasting hours. I realise that many of the religious laws promulgated during the ‘Islamisation’ of the eighties have become like millstones around our collective necks. But the large number of people that died during Ramzan this year suggests that it is time to modify those laws. It might be appropriate to create ‘way stations’ at regular intervals in the city where those in need can find water and perhaps food during the fasting hours. And no I am not suggesting that restaurants and eateries should be open throughout the day. The ideal situation would be if local mosques provided such services.

Finally, who should be in charge of long term national planning to avoid such climactic disasters in future? The obvious answer is the Federal Ministry for Climate Change. Yes we actually have such a ministry headed by a very pious looking gent. At present I am sure that most of the senior bureaucrats as well as the minister in this ministry are in a perpetual search mode for international conferences on climate change that they can attend at public expense. Assuredly there are many such conferences going on all the time especially in cool climates. Perhaps it is time to give all of these fine representatives of Pakistani bureaucracy and our elected politicians a chance to do some real work.