On 25 July 2023, staff at Cervello Hospital in Palermo, the capital of the Italian island of Sicily, watched anxiously as wildfires that had ravaged a nearby hilltop inched closer to them and their patients.
“The firefighters were all as busy as we were,” says Dr Ilaria Dilena, Emergency Director at Cervello Hospital. “The whole area around Palermo was in the throes of fire.”
While wildfires were being extinguished just metres from the clinic and pharmacy, staff at the hospital worked on. They were battling to manage the impact of 10 days of record-breaking heat. With more people suffering from serious hyperthermia (excessive heat) and dehydration, the hospital had to run 2 fully staffed shifts instead of 1.
The condition of these patients could rapidly deteriorate, and many needed urgent medical attention to replace lost fluids and prevent serious outcomes. Despite health workers’ heroic efforts, during the heatwave the mortality rate in the emergency room rose by a third.
As temperatures outside reached a peak of 47 degrees Celsius, entire departments were without electricity because of heat damage to cables. Bed space was limited, but discharging some of the older patients became impossible.
Ilaria and her colleague Dr Tiziana Maniscalchi, Health Director at Cervello Hospital, are both shaken by the experience of working through this period of scorching heat and wildfires.
“Only now, 10 days later, are we seeing a return to near-normality. It’s only July now, so we’re worried about what the future holds, also in the long run,” says Tiziana.
They recount how extreme heat impacted their hospital, and share thoughts on adaptions to health systems struggling to respond to a warming world.
The effect of heat on health
“Temperatures have been gradually rising in past years, but the difference this time around was how long the heatwave lasted – for 10 days in a row, also during the night. I have no recollection of that in the past, never,” says Ilaria.
In Sicily, older people have been most impacted by the heat, alongside other vulnerable individuals with pre-existing medical conditions. Many presented in the emergency room with confusion, headaches, respiratory disorders and seizures. Cases of renal failure due to dehydration rose, as did cases of hyperthermia, which is when the body absorbs or generates more heat than it can release.
“During the 30 years I’ve worked as a doctor, I saw 4 or 5 cases of hyperthermia. During those 10 days, I saw 5 or 6 cases a day,” says Tiziana.
Hyperthermia can cause heat cramps, but it can also progress to more severe heat exhaustion and potentially life-threatening heatstroke. Heat also exacerbates pre-existing conditions such as cardiac problems and can interfere with the absorption of medication.
“On a normal day, we have a code red 30 times per day, when a patient’s life is really at stake, but during those days, we had 50 per day – so, a major increase,” recalls Tiziana.
Outdoor workers
Ilaria and Tiziana also treated a number of younger people, many of whom were outdoor workers exposed to the sun. “They were arriving in a critical state due to excess exposure to heat. They need to be much better protected, less exposed to the sun, to be allowed to cool down,” says Ilaria.
Tiziana believes more thought should be put into how work is carried out during the hottest parts of the day: “Cities must make plans over the summer months and suspend some of the work going on outdoors when it’s this hot, to decrease risks for all of us.”
The new normal?
Both doctors stress the urgent need to adapt to the threats posed by climate change. “We can’t continue to ignore the way climate change is a threat to our health. We must prepare – us health workers in particular,” urges Ilaria.
Tiziana believes urgent health information and advice campaigns are necessary, to warn people about the dangers of going out during the hottest period of the day. Noting that traditional Sicilian family structures are changing, she believes changes to the delivery of health services are also necessary to protect older people, many of whom now live alone.
“People are unable to cope with the care of elderly relatives. We’ve never had such a huge request to transfer the elderly from a home to a facility as during the heatwave,” Tiziana points out.
She suggests that telehealth could reduce the need to visit doctors and pharmacies during hot summer weather, and regular home visits by health-care workers to older people could prevent many heat-related conditions from becoming life-threatening.
The heat emergency also highlighted social challenges. “It was extremely difficult, if not impossible, to send elderly people home,” Tiziana continues. “We were managing patients that maybe weren’t at a grave risk in that very moment, but would be soon because they had nowhere safe to go, no option of transport other than walking in the heat, nor anyone to take care of them, other than us.”
Although Cervello was a COVID-19 hospital with experience managing crises, staff were intimidated by the challenge of providing for patients during the extreme heat. “We got together, the emergency room and intensive care, and repurposed services, reorganized, in order to cope. What we felt in those days was fear, precisely the same fear many of us felt when COVID-19 first hit,” says Ilaria.
The impact of heat this summer has persuaded both doctors that health systems cannot afford to be complacent in the face of rising temperatures. “This is a serious emergency and it’s not one we can ignore,” says Ilaria. “It is on par with COVID-19. We need to do better, work harder on prevention.”
Heat–health action
Climate change is leading to an increase in extreme weather events, including heatwaves. Recent heatwaves in the WHO European Region have led to a rise in related mortality, but the adverse health effects of hot weather and heatwaves are largely preventable.
Prevention requires actions at different levels, including meteorological early-warning systems, timely public health and medical advice, improvements to housing and urban planning, and efforts to ensure that health and social systems are ready to act.
Effective prevention can be integrated and systemized in a defined heat–health action plan (HHAP). WHO/Europe, with support from the European Commission, is currently updating its guidance on HHAPs. The guidance aims to direct the efforts of decision-makers and practitioners from health and other sectors to develop national, subnational and/or local HHAPs that frame and guide preventive and remedial interventions for avoiding or reducing heat exposure. This includes a focus on risk communication and the protection of vulnerable population groups.