Author name: ikakar@georgeinstitute.org.in

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Heat stress worsens chronic health conditions, residents of informal settlements hit hardest

Heat stress worsens chronic health conditions, residents of informal settlements hit hardest Climate change is increasing the frequency, intensity and duration of heat extremes worldwide. In India, the average maximum temperature increased by ~0.5°C by 2000, and by ~1.0°C by 2020, as per a study published recently. Heat extremes put more individuals, communities and health systems at risk of illness, and death.  People with pre-existing chronic illnesses such as diabetes, hypertension, renal disease among others are more vulnerable to heat-related illnesses. Extreme heat is known to exacerbate health risks of those living with chronic diseases and can trigger hospital visits and mortality risk as the body struggles to regulate itself under heat stress.  Urban SHADE’s Hemanth Chandu and Pavani Pendyala recently wrote an article about informal settlements residents who live with chronic diseases. Urban SHADE’s Menaka Rao spoke to Dr Vivekanada Jha,  executive director at The George Institute for Global Health, India, and a nephrologist and public health researcher. He is Professor, Faculty of Medicine, Imperial College London, and the past President of the International Society of Nephrology. A prolific writer and editor, Dr Jha has worked with many global organisations including the World Health Organisation to develop clinical practice guidelines and advocacy papers. His research interests include understanding the health and societal impact of kidney diseases around the world and the development of affordable, scalable and sustainable primary and secondary prevention tools. Here are the excerpts of the interview: Menaka: How does extreme heat affect persons with chronic diseases such as hypertension, diabetes? In your clinical experience, what changes have you seen among those living with chronic health conditions , especially among poor patients and those living in informal settlements? Dr Jha: Heat affects both basic biology and the response of the body to external stimuli for people with chronic diseases including hypertension, diabetes, cardiovascular disease, kidney disease, etc. As temperatures go up, we sweat more. While the sweating is perceptible when humidity is high, it is not perceptible when the heat is dry. Sweating leads to a loss of water and salt from the body, reducing the total water and salt concentration. This can lead to a reduction in blood pressure. We have seen in clinics that people with well-controlled hypertension suddenly experience low blood pressure during extreme heat. They become giddy and weak. So during the summer months, we have to reduce the number of blood pressure medicines then, especially diuretics, which have the property of increasing urine flow, further worsening fluid and salt loss. We also have to warn our patients to check their blood pressure more frequently and pay attention to how they are feeling. Many people with diabetes require insulin, which is taken in the subcutaneous region. During the heat, the body does not absorb insulin well from that site, leading to uncontrolled blood sugar levels, even if it had been previously controlled. The build up of sugar concentration in the blood leads to spillage in the urine, which draws more water with it, causing dehydration. We ask patients to avoid injecting on the limbs before physical activity in heat. The abdomen is more predictable. They should also monitor blood sugars more frequently during heat waves, especially after meals. Insulin is a protein that denatures in hot weather. It should therefore be stored in a fridge.  Many in informal settlements don’t have access to a fridge. Practical solutions include using insulated pouches with ice bags or clay pot coolers. The effects of heat on kidney function have been extensively studied. When people lose salt and water through sweat, the blood flow to the kidneys decreases, and the kidneys lose some function. Let’s say a manual worker works in extreme heat from morning to evening. By evening, their kidney function becomes lower than normal. The kidney function may recover after the worker returns home and has water for the day, but repeated insults to the organ can result in long-term irreversible injury, which can progress to kidney failure. This has been well documented in many geographies around the world, including rural agricultural communities, outdoor workers such as construction workers, people who work in salt pans, and others. A population that is overlooked is women in informal settlements who have to cook indoors using coal or wood-fired stoves and therefore are exposed to high heat for prolonged periods. The body’s homeostatic mechanisms, which help us adapt to changes in our external environment, such as high heat, are impaired in those with chronic diseases like hypertension and diabetes. A younger person without any of these diseases, for example, will respond much more resiliently to heat stress. Menaka: What is the kind of advice for people with chronic diseases? Dr Jha: We warn our patients with hypertension that their blood pressure may go down during summer and that they should be mindful of any new symptoms that they develop. For example, if they start feeling giddiness or weakness, they should either check their blood pressure wherever they are or come to the clinic, where it can be checked. In that situation, we may need to reduce the number of blood pressure medications. Similarly, when the summer season ends, their need for blood pressure drugs may increase again. People with diabetes who are taking insulin, we have to advise them to keep their insulin in a cold environment, in a fridge, etc. We also tell them that when they are taking insulin, they should make sure they don’t inject it into the same site of the skin every day, especially over the limbs before physical activity. Finally they need to increase the frequency of blood sugar monitoring especially after meals. For people with kidney disease, we tell them to drink extra water and take salt when they step out. Not just one single one-litre bottle, as it’s not sufficient. We also ask them to try to avoid going out during the peak summer hours, so they go out early in the morning. For example, we tell farmers to try to

Events, Uncategorized

Consulting with stakeholders in Freetown

Consulting with stakeholders in Freetown Starting this February, the Urban SHADE team in Sierra Leone conducted meetings with various stakeholders to discuss the interventions of the project. The Urban SHADE Sierra Leone partners include Sierra Leone Urban Research Centre (SLURC), Institute of Gender and Children’s Health Research (IGCHR) and The Centre of Dialogue on Human Settlement and Poverty Alleviation (CODOSAPAH).  The teams engaged with institutions mostly government-based that work directly with climate risk management, disaster preparedness and health systems in Sierra Leone at national and city-level. The Urban SHADE team presented the findings of the project on how extreme weather affects people living in informal settlements, particularly their health. The Urban SHADE team will co-design interventions with communities and stakeholders to find interventions that are practical, scalable and sustainable.  The organisations the team met are: Sierra Leone Meteorological Agency (SL MET), National Disaster Management Agency (NDMA), Ministry of Health, National Public Health Agency (NPHA), District Health Management Team (DHMT), Freetown City Council (FCC), National Early warning and Response Mechanism Coordinating Centre (NEWRMC) and National Fire Force (NFF).  While the Urban SHADE team appealed to the stakeholders for their support in further activities, it also became increasingly clear that effective responses to climate-related health challenges require strong coordinated multi-sector collaboration. The Urban SHADE team is gearing up to form a Stakeholder Working Group which will include representatives of these stakeholders and will aim to coordinate effectively in the future.  The Urban SHADE team will share these research findings and proposed interventions with the three communities (Susan’s Bay, CKG, Moyiba) and seek suggestions from the community as well, and representatives and leaders from these communities will also be part of the Stakeholder Working Group. The Urban SHADE team will have workshops with the Stakeholder Working Group where the interventions can be co-designed, and particular roles and responsibilities of different stakeholders during extreme weather events (extreme rainfall and extreme heat) can be clarified. The team is currently in the process of formalising partnerships with these stakeholders through Memoranda of Understanding (MoUs). 

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Living with diabetes during extreme heat

Living with diabetes during extreme heat Hemanth Chandu By 11:00 AM in the morning, 32-year-old Sandhya sits outside her home with her female neighbours sitting under the tree shade. The women chat and laugh, relieved to escape the March summer heat inside the house. Within hours of sunrise, their two-room flats in the government constructed apartment in New Rajarajeshwari Peta in Vijayawada feels like a pot on a stove. “Ee vadagaalpula valla intlo baaga aaviri vachesthundi. During this hot summer, the heat builds up in the house like steam. I find it difficult to breathe sometimes,” she says. But Sandhya, it’s more than just physical discomfort. She has diabetes and feels her condition worsen during the summer.  About 57 percent of Indian districts, home to 76 percent of the country’s population, are at high to very high heat risk, a 2025 study by Council on Energy, Environment and Water (CEEW) showed. Andhra Pradesh is one of the top most heat-prone states. Vijayawada and Guntur, where the Urban SHADE  project works, are at very high risk of heat risk. Extreme heat is known to exacerbate health risks of diabetics. 77 million adults live with type-II diabetes in India. Studies done from some countries have shown that higher temperatures are linked to diabetes related complications related to cardiovascular or renal ailments among others, increased hospital visits and mortality risk, as the body struggles to regulate itself under heat stress. For Sandhya and other residents of informal settlements, who are already more vulnerable to the effects of climate change, the additional burden of having diabetes poses further risk. Mounting health problems A couple years ago, Sandhya used to run a food cart cooking and selling breakfast items such as dosa and idli, when she met with an accident. Hot oil spilt on her leg, and refused to heal for a long time. She finally had to go to a private hospital in the city where the doctors had to remove one of her toes. The surgery cost her Rs 1.2 lakhs which was borrowed from an informal lender for 10 percent interest. She continues to have a persistent wound.  “Everyday I put on the glove and do the dressing of this wound myself,” she said. She was first detected with diabetes when she was pregnant with her second child more than a decade ago. She goes to the Primary Health Centre near her house every month, where her blood sugar levels are checked and she gets her medicines. The PHC staff with whom around 200 diabetics are registered informed us that the blood sugar levels among the diabetics rises above their usual levels during summer.  Diabetes tends to place individuals at greater risk for heat-related illness during heat waves and physical activity due to an impaired capacity to dissipate heat, which can have an impact on cardiovascular health and blood sugar control. Those who already have poor glycemic control and are affected by diabetes related complications are particularly vulnerable. “I follow everything the doctor says. I take the medicine and follow the diet. But my sugar levels are never/often not  in control,” she says. Because of her uncontrolled diabetes and the persistent wound on her leg, Sandhya had to give up working outside home.  No relief at home Staying home provides little comfort. Though it is sometimes perceived that homes can provide protection, in informal settlements such as RR Peta, the indoor temperature is often higher than outdoors, a 2022 study showed. The qualitative study, which had RR Peta as one of its study sites, was led by architects trying to understand how the community copes with heat, and its coping mechanism to deal with heat stress. For roughly 17.4% of urban population living in informal settlements, this heat stress is far more acute. Houses in informal settlements are rarely built with thermal comfort in mind, leaving residents with limited access to cooling, clean water and heat alerts. Government affordable housing schemes continue to overlook basic passive cooling measures such as cross ventilation and insulated roofing and adequate shading making indoor temperatures as dangerous as outdoors during a heatwave.The minimum standards for constructing government affordable housing such as RR Peta is extremely low in the Indian context. In the tiny apartment, Sandhya lives with her husband and five children. The eldest who is a construction worker has moved out and lives with relatives. Two of her other older children work as delivery gig workers, while the youngest two still go to school.  Even basic household work is difficult for her now. “Even if I am sweeping the house, I need to rest for 15 minutes,”she says.   During summer, her legs swell, and she often gets headaches and back pain. She says,“This house barely has any ventilation and I end up sweating continuously while working. I have to do all the household work in this heat and through pain. It is so frustrating.” During the 2024 floods in Vijayawada when RR Peta was affected, their washing machine, fridge, and air cooler got destroyed. During these floods, homes were submerged, families displaced to relief camps, and livelihoods disrupted.  The machines are now sitting in the house like fossils for want of repair, as the family cannot afford to repair them. Meanwhile Sandhya has to wash the six people’s clothes and cook fresh meals everyday while trying to cope with the heat. Financial precarity Since Sandhya gave up working outside, her family finances have become precarious. The household depends largely on her husband Srinivas’s income. He is an autodriver and earns around Rs 10,000 per month.  Srinavas too feels the heat acutely while working, but brushes it off saying, “It’s common for us.” He has seen his own customers, mostly elderly people  faint in his auto.  He has pain in his right hand, but has not been able to tend to it, because of the family finances. The doctor had recommended a surgery (costing Rs one lakh) and rest for two months.  This was not

Events

Community meetings in Kenya on proposed interventions

Consulting the community on proposed interventions in Kenya The Kenya team of Urban SHADE project is having community meetings explaining the findings, and talking about possible interventions.  The intervention proposed for all three communities– Tudor Moroto and Matopeni in Mombasa and Mibuyu Saba in Kilifi is co-designing training modules and protocols for health workers and community health workers with the health department on flood and extreme heat management.  One of the additional proposed interventions for Mombasa’s Tudor Moroto is the establishment of a community resilience hub which is intended to serve both as a community health facility, as well as a community centre. The proposition is that this hub can help increase access to healthcare during extreme weather events as well as become a hub for community meetings, support community activities and interventions and also serve as a rescue centre during disasters. The Urban SHADE team had several meetings with the community members starting with the local administration and village elders in February to get their buy-in on the interventions and support in mobilizing and organizing the community meetings. In the community meeting at Simitini village in Tudor Moroto, there was a discussion on the access road to the identified building for the resilience hub. The access road is currently narrow, and rudimentary. The access road to this building also becomes too muddy after the rains. The community members said that if they have the right material, such as cement, they can fortify the access road. They were unsure about involving the government as there were worries that the government could ask people to move out of their homes, without compensating them. On developing modules for health workers to tackle health-related issues of flood and heat, the community members from all three settlements said that they would like community members to be also involved in the training workshops and other activites related to disaster management, and health-related interventions. The Urban SHADE team will discuss this further in stakeholders meetings which are underway.

Musings, Uncategorized

The Combermere nalla

The Combermere naala Inayat Singh Kakar The Combermere naala is one of the five natural streams that flow down central part of Shimla city. These streams are natural drainage channels that carry excess water down the mountainsides. The Combermere naala originates mid-way on the Jakhu hill, making its way down the hillside to form the Eastern boundary of our field site, Krishna Nagar and ends at Lal Pani where taxi drivers use the water to wash their vehicles. Old pictures of Shimla city show the naala flowing down pristine hillsides. Now when you hear the gushing of the water, you see a channel choked with garbage. The water tumbles over the garbage, desperately makes its way down, slowly changing its path as it cuts through the hillside. As the naala reaches Krishnanagar it becomes even more choked with garbage. Krishnanagar’s residents whose houses are constructed along the naala describe it as a health and safety hazard. In the summer, the wet garbage cooks in the harsh sun and becomes a swampy breeding ground for flies and mosquitoes. In the rains, the water thunders down the hillside, gushing so loud that it keeps nearby residents awake from the anxiety of flooding. Ramu, whose house is built right next to the naala says that he is afraid it will one day sweep his house down with it. He says that infrastructure built by the Municipality has created choke points in the path of the naala, instead of towards the end of its course at Lal Pani (near where the 2023 landslide took place) where it could be cleaned regularly. Right now, the choke points which are inaccessible to human beings. The naala is built in a way that it gets obstructed, and damages the hillside where Krishnanagar is located, increasing risk of landslides. With a sigh, Ramu says that the story of the naala is emblematic of a cruel irony faced by the residents of Krishnanagar, home to the majority of city’s sanitation workforce.

Events

Consulting with the communities

Consulting with the communities “What did you have for tiffin (breakfast)?” This question brings a smile to the faces of the people sitting in for community meetings of the Urban SHADE project. In these meetings that started in February 2026 are conducted in the community, the Vijayawada-Guntur team and the Shimla team discuss the findings and the proposed intervention of the Urban SHADE project.  The meetings have been set up in people’s houses within the community which they have generously opened for the Urban SHADE team, despite houses being small and cramped. In Guntur and Vijayawada, the hosts removed the cot from the house to make space for the duration of the meeting. In Shimla too, a friendly person’s house, public spaces such as grounds, or Anganwadi centres or even the lobby of a residential building were used for these meetings.  We are grateful to everyone who helped us organise these meetings. The meetings were conducted with different groups from different sites of the settlement- women, old persons, persons with disabilities, outdoor workers and those with chronic illnesses. In Shimla, meetings were also determined by the location- such as upper part of settlement, and the lower parts, and some occupational groups such as municipal sanitation workers. In Vijayawada and Guntur, the team hung relevant photos and distributed some photos among the participants that helped spark discussion among them. There were photos of cracked walls of houses, hospitals, garbage on the road, newspaper headlines of floods, flood warning messages or illustrations depicting heart illness among others. This technique helped a great deal in communicating the findings of the qualitative research including focus group discussions and in-depth interviews, especially since many of the participants were illiterate or semi-literate. Persons who participated in these meetings discussed the garbage in their areas, what happened during the floods, or their experiences in public hospitals or private clinics. Many people who attended the meetings said that they saw the messages sent by the government on flood warnings for the first time. They spoke about how they barely got food or water during the heavy floods in 2024. The community members also suggested their ideas for possible interventions.  In Shimla, the team presented an illustrated flow chart with the findings, gaps and the planned intervention activities. The team explained that the qualitative study presented cardiovascular diseases, musculoskeletal problems, skin disease, alcohol and drug addiction as problems facing the community. There are also increased out-of-pocket expenditures due to lack of ambulances and unavailability of medicines in government hospitals. The distance of the hospitals deters people from going there, especially older persons who are unable to walk up to main road, often leading to them missing out on follow-ups. Both informal settlements in Shimla do not have functional Primary health centres. Pregnant women and children have to go to hospitals further away to get basic check-up or immunisation. People reflected on how they are unable to sleep when during heavy rains. While they do get flood messages, they have no idea what action should be taken. The team also presented a general lack of awareness about the diseases caused due to extreme rainfall, and suggested interventions. These meetings helped validate the findings and also get buy-in from the community for the intervention activities still being planned. In Andhra Pradesh the team includes researchers Pavani Pendyala and Hemanth Chandu, field coordinator Satyanarayanamma Methukulla and community co-researchers Dasari Madhavi and Maddela Siva Parvathi. In Shimla, the team includes researchers Inayat Singh Kakar, Dr Yetika Dolker, and field coordinator, Sahil Kumar. 

Musings

Nowhere to go

Nowhere to go Dr. Abu Conteh It’s 12pm on a bright beautiful Monday morning, and the sun is beginning to get ahead of me. I am visiting the Soja town section of the Moyiba community to talk to Sia, whose house was recently destroyed by a mudslide. Moyiba is one of the most deprived informal settlements in Freetown, which is also exposed to multiple hazards including mudslides. Sia is a single mother of three who makes a living from stone mining. As I ascend the over 600-meter-high hill, I couldn’t help but wonder how women in this rugged part of the community deal with climate hazards and access healthcare. In the past years, women in this section of the community have had to deliver babies by the side of the road as they couldn’t make it to the only government health clinic in time about 3 kilometers away. Transportation here is a challenge, as motor bike riders complain of rugged roads. As I arrive at Sia’s home, she greets me warmly and offers me a seat in her delipidated single bedroom mud house that was destroyed by a huge boulder (in 2025). The house is now a relic of the original two-bedroom house built by her husband who died two years ago. “The destruction of the house has changed my life so badly”, she said. She recounted her daily horrors of having to live in a leaking house or rebuilding it withher meagre income. “I can barely feed by children, let alone rebuild this house.” As I looked around, I could see that most houses here are built with mud bricks, which makesthem vulnerable to extreme weather events such as flooding and mudslide. Sia recounts she is not the only woman affected. ‘‘Last year, one woman lost two children because of a mudslide,” she said. While she feels the community is not safe, she is worried about having to leave a whole life behind that she has built for over a decade. ‘‘I have nowhere to go. We are not offered any help by the ‘’big ones.’ No one has helped me since my house got destroyed,” she said.

Musings, Uncategorized

No future

Menaka Rao Ashu waited for me outside the hotel. He is a skinny man, and was visibly uncomfortable standing in the lobby of the hotel. He insisted on meeting me in the hotel, and not in Krishna Nagar, where he lives. He says his father was a municipal waste worker. But he drank so much that the children could not go to school. Ashu dropped out of school in his 7th standard. He became a contractual waste picker after his father’s death.  “There is no future in this work, Madam,” he told me, shaking his head. He feels the futility of his job, while not being able to see a way out. “I just don’t want to go to work, especially during the monsoon. The waste which I carry on my back just gets right into my clothes and trickles down my body. There is dal, curry, all kinds of food,..,” he said, trailing off and making a face full of disgust. His school-going son asked him one day why he did waste work. “I felt very bad that day,”he said. During one monsoon, about ten years ago, his family had to leave the house, built by his grandfather, because it got dangerous. The floor of his house cracked further and further, threatening to collapse. “We kept thinking the floor would stop caving, but it kept getting worse,” he said. They now live in a rented premise, cutting into their meagre income. So when he fractured his leg this year because of an accident at work, he had to borrow nearly Rs 20,000. He was out of work for three months.  “There is no future in this work, madam,” is his only refrain.

Blog

Lessons from margins: Insights from visit to Shimla’s Krishna Nagar

Lessons from margins Insights from Urban SHADE team visit to Shimla’s Krishna Nagar Looking at the paved roads and cemented houses at the beginning of Krishna Nagar settlement in Shimla, the first reaction of Urban SHADE members from Sierra Leone and Kenya was- “This place does not look like an informal settlement.” Krishna Nagar is an informal settlement at the heart of Shimla city. The Urban SHADE consortium visited Krishna Nagar during the Annual General Body Meeting on November 30. The consortium members were first trying to size up the differences and similarities between their field sites and Krishna Nagar. The settlement was built during the colonial times to house waste workers and other labourers. People in Krishna Nagar do not have land tenure.  “The structures in Krishna Nagar looked stronger. The houses in our settlements are not as strong. In fact, even with a bit of heavy wind, the houses can be destroyed,” said Tena Kabba from Institute of Gender and Children’s Health Research (IGCHR) in Sierra Leone, which works with three informal settlements in Freetown for the project. The consortium members from Sierra Leone felt that Krishna Nagar with its steep slopes and steps resembled Moyiba a little.  But as the members walked down towards the lower part of the settlement which is right at the edge of the hill, the challenges became apparent. Though the houses look well taken care of, some of them even have a small garden in front of them, many of them have big cracks.  “My first thought was, is this really an informal settlement?,” said Michelle Koyaro from Slum Dwellers International, Kenya. “We then saw the housing conditions. The walls of many houses are full of cracks. It places them in a vulnerable state. They are not sure if they will be able to live in the house next monsoon. I realised that if someone does not know the context definition of informal settlement, they will quickly cancel Krishna Nagar as informal settlement. ” And indeed, many houses have collapsed at the edge of the hill during the 2023 landslide when the Slaughterhouse collapsed. The consortium members met a man who sent his family to his native place but continued to live in a house perched at the edge of the hill. He said he had no option because he had to make a living in Shimla.  What struck many Urban SHADE members is how much people invested in the houses. The houses are by and large cemented, and many have taken effort to even have a garden in a small strip of land. The roads in the upper part of the settlement were built by the municipal authorities. The consortium members then saw older persons trying to walk up the stairs, as well as houses with big cracks perched precariously at the extreme lower part of the settlement, at huge risk of being washed out by rains. Dr Jiban Karki, from Liverpool School of Tropical Medicine (LSTM) said that the lower parts of the settlement were revealing. “I visited Krishna Nagar twice. But this time we went further down, where we saw all the cracked houses. We found that people were still living there despite the danger. There was another vulnerable population who were living in rented houses. Towards the top of the hill in Krishna Nagar people were relatively better off, then those in the lower range.” Dr Karki spoke about meeting some Nepali origin people in the lower parts of the settlement who lived on rent, in houses that were more precarious. As the consortium members tried to climb up the stairs they realised how difficult it is. ”I kept thinking about how many elderly people live there. As young as I am, I was barely able to climb the stairs. Even if there is a car available, it is hard to get to the main road,” said Dr Desta Ali, from IGCHR. Many wondered how pregnant persons and those with disabilities climb stairs everyday.  Some of the Urban SHADE team members met an elderly lady who had great difficulty climbing a steep flight of stairs. She took breaks sitting down at the side of the stairs while walking up with a stick.She sought help from some teenagers passing by.  The consortium also saw the building of the primary health centre (PHC) which is currently non-functional. The older PHC which was there earlier collapsed more than a decade ago during the monsoon. The team from Sierra Leone and Kenya observed that they had a functional health facility within most of their settlements they are working with for the Urban SHADE project. The ASHA workers present in the meeting also raised various problems people in the community faced because of PHC.  Dr Ijeoma Onyeahialam, who works with LSTM observed, “In relation to Sustainable Development Goals (SDG), the community falls short because of the community’s lack of access to health care. The PHC is not working. After going into the community more, you can see how pregnant women are disadvantaged. This also helps various country teams to see how they can compare and see similarities.”  The consortium members also had a meeting with community leaders and ASHA workers at Valmiki temple said to have been established in the early 1900s. Valmiki is a patron saint for Dalits. The discussions ranged from lack of land tenure, caste discrimination and access to healthcare.  The community leaders of Krishna Nagar spoke about how the government keeps trying to evict them, as it falls on prime land. “Just before the elections, the political leaders promise that they will ensure we will be granted land tenure. But after elections, these promises vanish,” said Kuldeep, who is with the Valmiki Sabha  The teams from Sierra Leone and Kenya said that it’s just the same situation in their hometowns with informal settlements. Except, the people working in the settlements there refrain from investing their money in building a better house because of the fear of eviction.  “People

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