“High heat is one of the reasons for poor quality of care. That’s the bottom line and it can only get worse. We are having difficulty tackling climate change at present so we need to be ready, and we don’t have much time.”
Think about the hottest you’ve ever felt. That feeling of lethargy, the ‘need to lie down’, ‘grab me ice’, ‘I’ll NEED a cold shower’ kind of feeling, the creep of panic and suffocating sensation of breathing hot air into an already hot core, the smells and sensations that come with the heat…
Now turn that up a notch. And picture a busy maternal/newborn ward. You have to protect the mums, the babies, you’re on your feet all day, and water may be scarce. It’s not a pleasant mental image.
Yet, when we discuss ‘climate change’ and ‘heatwaves’, health workers are rarely front of mind. Extreme heat is taking a toll on those working in maternal and newborn health in hospitals. The conditions are hazardous for both the medical professionals and their patients. Now is the time for action.
Cue HIGH Horizons, a multidisciplinary, cross-country initiative funded by the EU and UKRI. Researchers from academic institutes across Europe and Africa are working together to measure and mitigate the impacts of extreme heat on pregnant women, infants, and health workers.
In this article, we focus on how Veronique Filipi, Isabelle Lange, Giorgia Gon and Nasser Fardousi from the London School of Hygiene & Tropical Medicine are studying this, what they hope to achieve, and why working as part of a wide collaborative adds immeasurable value to their work. I caught up with them over zoom for a fascinating discussion.
Q1. Let’s start by understanding a bit more about each of your roles. What’s your specific area of expertise, how did you end up working in HIGH Horizons, and how do you work together?
Veronique Filippi (VF): My expertise lies in interdisciplinary research to help improve pregnant women’s health in low- and middle-income (LMIC) settings. In HIGH Horizons, I’m involved in the health worker studies and in the evaluation of the interventions. But before this, I was involved in a project called Chamnha (Climate, Heat, Maternal and Neonatal Health in Africa) which has an overlapping theme and researchers, so HIGH Horizons was a natural follow on from that.
Giorgia Gon (GG): I have a similar story to Veronique. I have experience in behavioural change and evaluation design. I joined Chamnha when they needed to take action after realising high heat impacted on pregnancy and the postpartum period.
That naturally led to HIGH horizons. I was one of the co-investigators on the proposal and my role in this project is twofold. One is contributing to the evaluation tools, in particular something called time motion. Second, and this is led by Isabelle, is the design of messages to be given to pregnant and postpartum women around how they can manage heat waves better.
Nasser Fardousi (NF): I’m a research fellow and also the most junior in this team – this is essentially my first week! But I have been familiarising myself with this project for the past two months. I’m drawn to this because climate change is an imminent challenge to health care and I would like to bring my previous experience in evaluation and intervention development to help solve this challenge.
Isabelle Lange (IL): I come from a medical anthropology background. My interest really is in health facilities and the dynamics between health workers, the environment, systems, policies, guidelines, all of that. It’s really interesting here to look at the facility and maternal health workers in particular through the lens of climate change and extreme heat events, and to use an ethnographic approach to really understand how health workers move in their environment, and how they’re affected by hot temperatures or heat.
Q2. Why are healthcare workers in maternal and newborn settings important in the context of climate change? Have you got evidence to indicate this is a group at high risk?
VF: Yes, there’s evidence from South Africa that facilities are frequently 4-6°C warmer indoors than outdoors during the Summer months. It’s because the facilities are poorly-built – there’s no centralised air-cooling or ventilation systems. So you can imagine the temperature that health workers in these facilities are exposed to, day in, day out, in their work.
In terms of the impact on the workers, it can be extremely detrimental to their psychological and physical wellbeing. And it may mean that these people are then prone to making errors, and these errors are likely to take place in the maternal and newborn health units.
Another thing that interests me and is a very dominant theme in maternal and newborn health is respectful care. I would hypothesise that tough working conditions may be affecting the communications between providers and patients, leading to adverse outcomes.
NF: There’s also a health system perspective. It’s important to provide preferable working conditions for health care workers to retain them. This is especially true in countries with a high-turnover of staff because of the conditions. Improving their resilience is a non-financial incentive for them to stay.
Q3. And what are the risks if we were to do nothing to measure and mitigate impacts of heat on health workers in MNH?
NF: Heat is an occupational hazard, and that’s not something new. There’s a lot of research on other occupations like firefighters and farmers. And there’ve been many incidents of exhaustion and dehydration, in addition to the mental health issues in the long term.
Generally healthcare workers are overlooked when we talk about heat because people assume they’re working indoors in well equipped facilities. But now, with climate change and heatwaves, there’s a great need.
So if we do nothing, we are risking the wellbeing of the healthcare workers, and by extension the quality of care for the patients.
Q4. So when we say ‘extreme heat’, what are you referring to, what would the conditions be like?
VF: The thing with extreme heat is that it’s related to the setting. Me and you could agree now that a fixed degree counts as extreme heat, let’s say 35 or 40oC. But it’s also a question of what the normal average temperature is in that setting. There’s an absolute definition of extreme heat, but also a relative one.
GG: And that’s actually one of the objectives of HIGH horizons – to try and figure these thresholds out.
We want to know when a heat threshold corresponds to an adverse response. This may require a very personalised response based on individual characteristics, such as weight, age, and vulnerabilities. We’ll establish these indicators.
Hospital infrastructure will also play a big part in how heat is perceived. For instance, places in the desert may feel manageable because of good design and construction. Yet, a tiny container in 35oC may make you feel like you’re going to die. So we’ll be looking at that as part of the baseline.
Q5. Have any of you got experience of working in extreme heat yourselves? Or if not, how do the people you’re working with describe working in hospitals during heatwaves?
IL: When I was recently in Ghana for a different project, I asked maternal health workers who were based in the labour and postpartum rooms about their experiences with extreme heat and how they dealt with it.
They volunteered that they get very tired, more irritable and need to take more time. But it’s not just the heat, it’s also the smells. There are very textural scents that go along with extreme heat. It’s hard to articulate, but they’re part of the experience of a health worker in these settings.
In essence, this role is already difficult and challenging; dealing with bodily fluids, gear, and cleaning. But there’s an exacerbation in high heat and humidity which is challenging if you’re not prepared.
NF: I have worked as a pharmacist in Syria. Although Syria is not a ‘hot’ country, the Mediterranean climate can reach very high temperatures.
During the Syrian conflict there was very little power supply. We were working in a small pharmacy with four other team members and a high volume of patients. It was fast paced, and the conditions were not adapted to help us. It wasn’t a pleasant experience at all. It was very tiring.
One of my female colleagues was pregnant, and it was really hot for her. She had to step out now and then, and we would cover. So I personally see a direct benefit of this work for the productivity and the well-being of health care workers.
GG: When I spent 6 months in South Sudan, which was the hottest country I’ve ever worked in, I distinctly remember health workers around lunchtime and mid-afternoon, struggling to work. In fact, there was a high proportion of absences around those times, and it was a huge challenge in terms of hospital management.
If known in advance, it’s possible to cater for this. For instance, if it’s established that people are likely to need a break between 11 and 1 PM on warmer days, it’s possible to manage the hospital in a different way. It’s one of the things we can drill down into with HIGH Horizons.
Q6. Okay so onto the methods. How and where will you study the impacts of heat on health workers?
VF: We are working in health facilities in Zimbabwe, Sweden, and South Africa – there are about seven facilities, some are hospitals and some are health centres.
We’re using a range of techniques. The qualitative aspect is observation and discussions with key informants and providers to understand the impacts and potential interventions.
Then there is a time motion study, which is a quantitative approach to observation, I’ll let Georgia explain that.
GG: So briefly, all the health workers’ behaviours are captured and time stamped using a tablet. We’re hoping to use that as a way of thinking about strategies (by understanding their habits and workflow) with which they can use to improve their management or heat and make the work easier.
VF: Next, there is a piece where we have a questionnaire that would be delivered electronically to providers of MNH to ask how heatwaves affect their mental and physical wellbeing, how they perceive the change to quality of care, whether they perceive they suffer from the strain. And we do that in the cold and hot period, so that we can have a comparison baseline.
And we also extract information from medical records and do a time series to see how heat influenced access to, and quality of, care. Obviously we are working as part of a big consortium so we have a colleague from Denmark (Jorn Toftum) who is measuring the thermal conditions providers are exposed to on a continuous basis; they’ll analyse temperature and humidity in these facilities and also identify some biomedical markers.
GG: Yes, I think that’s actually one of the really ‘attention grabbing’ aspects of this work. One of our collaborators will measure physiological responses to heat. They’ll do that in real time and link it with productive care measures.
So the participant will be carrying something around their body, which would measure their core temperature, analyse heartbeats, and step counts. They’ll also analyse what the participant is wearing And what’s that other test we always forget?
NF: The osmolarity test! They look at the number of particles in the urine as a proxy for dehydration.
VF: Yes – that’s the one. So an important aspect of this is to measure what people perceive but also compare this to what they are experiencing physiologically and physically.
All of this will be built into modelling to see the potential impacts of interventions. For example, if you paint roofing white, open windows or close windows, use different types of insulation etc. – how is it likely to change the outcome?
IL: Another important aspect of the work is developing messaging that would be used in an early warning system. We contribute to that by thinking about what information can be given to health workers and women at the right time, so that they can make their lives easier in ‘concrete terms’ when heat waves are predicted.
But before developing anything, we need to figure out what the challenges or blockers are with regard to behaviour change. To do this, we’ve built in a participant observation component to this study, along with interviews, surveys and the time motion that Giorgia already mentioned.
Q7. And what is the plan after knowing the impacts – are you also developing solutions?
GG: So firstly with interventions, it’s important that we’re not ‘reinventing the wheel’. We should be working with existing norms and utilising local knowledge and solutions.
As an example, in Italy, if the heat goes above 40 degrees, you don’t bring out babies and you will never show up at the beach at midday. Everybody knows that – and people think you’re insane if you do differently!
Many hospitals in the Mediterranean and Africa have already built coping mechanisms to deal with heat. To be successful, we’ll need to work with whatever local solutions they found and facilitate that process. We also need to empower them to be able to take action.
NF: When thinking about interventions, it’s important we’re not exacerbating the problem. When people talk about health care, workers conditions and adaptation, they intuitively think of solutions like air conditioning. But it’s generally a misconception, right? It’s not an adaptation. It contributes to climate change.
One of the things we’d like to achieve with this research is to challenge this perception and offer an alternative that improves conditions while also mitigating the impact of climate change.
GG: I agree. And if we can build better infrastructures, we don’t need as much air conditioning. On the other hand, there are ways of providing energy for air conditioning that are more sustainable, like solar panels. So those alternatives could be considered.
One of the big challenges we face – heat waves are slightly unpredictable. But if it’s only a couple of weeks in a year when it’s truly unbearable, the thinking around interventions completely changes compared to something that’s occurring all year round. For example, implementing emergency responders for heatwaves.
It’s something that we need to have in our mindset when developing interventions. How often does this happen? Is it unpredictable? Okay, if it’s unpredictable, how can we make sure people are prepared to react when it does happen?
Q8. So if all goes to plan, and I were to interview you in a few years’ time about this work, what would you hope to have achieved?
VF: What do we plan to achieve? We want to change the world! But for me, first of all, is to put the impact of extreme heat on MNH in all settings, but especially low and middle income settings, on the agenda, so that more people will be working on this issue and hopefully build on our work. I would like to have developed a successful intervention that’s clearly evaluated so that it can be integrated in policies.
NF: I’d love to see a policy driven portfolio of intervention development and evaluations that can aid policymaking for this critical issue. In addition to that, I personally look forward to improving my knowledge and methodological expertise on various topics. It’s a very wide range topic, with a lot of activities to learn from.
GG: Interventions themselves are context specific, so I don’t foresee one specific universal solution as an outcome. But I’d like to see that the data we collected can be repurposed and relied upon in guiding intervention development. With clear guidance on which data is generalisable and which data they have to collect themselves.
I would like to use this as a roadmap that other groups can use to assess and implement the best interventions for them. And hopefully not spending a huge amount of money every time because that will not be sustainable!
VF: To build on that – context is incredibly important. I think the ultimate objective of HIGH horizons is really improving quality of care and health outcomes for mothers and babies.
High heat is not the only reason for poor quality of care, I don’t think that’s even the most important reason.
But it is one of the reasons.
Basically that’s the bottom line and it can only get worse. We are having difficulty tackling climate change at present so we need to be ready, and we don’t have much time.
It needs to be done now and we need to look at a range of issues. One of the pathways is improving occupational health for providers, which is what we’re doing.
Q10. How does working in a large consortium benefit the research? Is this kind of collaboration the way forward for climate health and action?
VF: I’m a big believer in group work. Our research questions are many, and the topic is super complex. So it’s something that needs to be tackled and explored from different angles. And we really have a lot of different disciplines and methods and approaches in this consortium which can help us progress on this issue.
IL: Like Veronique said, it’s different ideas from different institutions and inspirations that I think are the strength of the work.