AWARENESS AS AN ADAPTATION STRATEGY FOR REDUCING HEALTH IMPACTS FROM HEAT WAVES: EVIDENCE FROM THE DISASTER RISK

MANAGEMENT PROGRAM* Saudamini Dasa Abstract In recent years, one of the prominent and high frequency calamities due to climate change has been the mortality and morbidity due to heat waves. A heat wave is defined as an extended time interval of abnormally hot and humid weather extending from more than one day to several days. During heat wave, the dissipation of metabolic heat of human body stops due to the slowing down of the evaporation of body perspiration and body has to work extra hard to maintain normal temperature. Thus core body temperature goes up due to heat stress and if it exceeds 40C (tropical areas), the person collapses or may die. Now this is a global phenomenon affecting both developed and developing countries and the coastal states of Orissa and Andhra Pradesh are the worst affected ones in India. With changed climate, adaptation is a key and essential strategy to counter the immediate effects along with long term mitigation measures and one of the adaptive strategies has been to issue heat wave warning and undertake awareness campaign to bring behavioural changes in people to counter the health impacts. The state of Orissa has undertaken a massive awareness campaign on dos and donts during heat waves and this campaign has got intensified under the Disaster Risk Management (DRM) program of Government of India and United Nations Development Program that started in 2002. The DRM program is going on in 16 of the 30 districts of the state. This campaign aims to bring behavioural changes in people by telling them the dos and donts during heat wave period and there is report of such strategies reducing both mortality and morbidity in the state. The present paper is based on some initial results from the research project that is evaluating this awareness campaign in Orissa in reducing health effects due to heat waves. We use the heat wave index based on atmospheric temperature as defined by the Indian Meteorological Department and analyse the death toll for the period 1998 to 2010 using a district level panel data set. The districts where DRM program is going on are taken as the treatment units and the rest of the districts as control units. Initial results show the programmed districts to have witnessed some reduction in death toll compared to non-programmed ones after controlling for heat wave conditions. Though preliminary, these results do indicate that generating awareness on dos and donts during heat wave period does help people to change their behaviour and reduce the mortality due to heat stress. The results show the average death per year in the state that is witnessing more and more heat wave days in recent years would have doubled in the absence of the awareness campaign.
*: This paper is based on the ongoing research Adaptation to Heat Waves: Evaluating the role of Awareness Campaign as an effective strategy to avert health risk financed by South Asian Network of Development and Environmental Economics (SANDEE). The results are preliminary. a: Department of economics, SSN College, University of Delhi, Delhi 110036, India and Institute of Economic Growth, University of Delhi Enclave, Delhi 110007, India. Email: sdas_28@yahoo.co.in

AWARENESS AS AN ADAPTATION STRATEGY FOR REDUCING HEALTH IMPACTS FROM HEAT WAVES: EVIDENCE FROM THE DISASTER RISK MANAGEMENT PROGRAM

1. Introduction The global surface temperature is seen to have increased by 0.3 C to 0.6 C during the last century with 1990s being the hottest decade and 1998, the warmest year with a temperature of 0.57 C above the 1961 to 1990 average in the last 140 years 1 (Mohanty, 2006). The warming world has given rise to many weather and climate extremes like Heat Waves having adverse effect on human health. A Heat Wave is an extended period of abnormally and uncomfortably hot and humid weather during which the evaporation of perspiration that cools the human body slows down and the body has to work extra hard to maintain normal temperature. If core body temperature exceeds 40 C (tropical countries), heat stroke occurs and causes death. In recent years, severe heat waves have caused high mortality and morbidity in many parts of the world (Chicago1995, 1999; most part of Europe 2003; State of Orissa and Andhra Pradesh in India 1998, 2003 etc). Though human influence has been proved to be a big contributor to European heat waves (Scott et al. 2004), the impact of climate change to such tragedies is clear-cut. This scenario is likely to get aggravated in coming years (IPCC 2007a, 2007b, Kunkel et al. 2008) and WMO predicts the heat related fatalities to double in less than 20 years. Under the circumstances, adaptation is a key response strategy to minimize the potential impacts and adverse effects of heat waves on health (Menne and Ebi 2006). 1.1 State of Orissa and Disaster Management The State of Orissa in eastern India is disaster prone and has the history of witnessing cyclones, drought and floods very often. A recent addition to the list of natural disasters has been the casualties from regular heat waves, though unheard of in recent history. 2 Suddenly the state witnessed unprecedented heat waves in 1998, particularly in
1 2

With more recent data, 2010 may come out as the hottest year. Heat wave is not yet listed as a natural disaster by the central government of India, though the Orissa state government is strongly and regularly arguing before the central government to recognise heat waves as a natural disaster now.

the coastal areas and the administration and people were taken unaware resulting in a calamity situation. Compared to single digit casualties (range: 1 to 5) due to heat stroke in previous years, the death toll in 1998 rose to 2042 alarming the state administration (see table 1). The very next year, the state was devastated by a super cyclone with 356 km per hour landfall wind velocity and 7 metres of storm surge that killed 10, 000 people and caused colossal loss of other properties. After these calamities, the state government formed a special department, called Orissa State Disaster Mitigation Authority (OSDMA) in the year 2000 to handle the frequent disasters befalling the state. In 2002, the Disaster Risk Management (DRM) Project of the Government of India and United Nations Development Program was initiated with the aim of making sustainable reduction in disaster risk in some of the most hazard-prone districts in select states in India. This program was implemented in 16 of the 30 districts of Orissa with OSDMA as the nodal agency. DRM continued till 2007 and these districts have been covered by the Disaster Risk reduction (DRR) Program after that. Awareness generation was an important feature of DRM project and keeping with this objective, the disaster preparedness of the state under OSDMA took a paradigm shift by changing the focus from relief, restoration and rehabilitation to planning, preparedness and prevention. Generating awareness or knowledge on dos and donts during a disaster has become a core of OSDMA activities in making people prepared to face a disaster. Starting 1998, heat waves are a regular feature in the state and monitoring heat waves and preparing people to face the situation has also become an important and regular activity of OSDMA recently. One of the main strategies opted by OSDMA to counter heat attack has been to undertake awareness campaign on dos and donts during the heat wave period along with the broadcast of heat wave warnings. The awareness campaign has been in the form of giving precautionary instructions like not moving in empty stomach, drinking lots of water or ors solution, either avoiding travel during noon or carrying umbrella or wet towel along with, wearing cotton cloths, keeping ors solutions with oneself etc. Information is also given on symptoms of heat attack and the subsequent first aids to avoid serious consequences. Multiple mediums like electronic and print media, posters, pamphlets etc are being used and the type and number of mediums used has varied from year to year. Along with this campaign, other activities undertaken are

giving directions to various government departments to reduce exposure of workers during peak hot hours, ensuring smooth supply of water and electricity, etc. These other activities, however, were also being undertaken since 1999 (after 1998 calamity) by the calamity mitigation committee of the Government of Orissa when OSDMA was not in existence and are being done routinely since then. The novel addition to heat wave management under DRM by OSDMA is the awareness campaign that started systematically since 2003 and is continuing with different magnitude depending on the intensity of the problem. The mediums used for the dissemination of knowledge on dos and donts are mostly national medias and people in every district of the state are likely to get informed depending on their level of literacy (whether read news paper or not) and affluence (whether own television, radio or not). The DRM districts are expected to have advantage in this regard as the project is supposed to have trained local people or volunteers to help disseminate information and has appointed project officers in every district to continuously monitor and provide feedback during any calamity. Thus we expect the awareness index (if effective in reducing health effect or changing behaviour) to have a negative impact on the heat wave deaths for the whole state (as we cover years before and after the campaign) and a stronger impact in DRM districts compared to the non-DRM districts. Orissa being a poor and backward state where people are likely to be less alert on their own, awareness campaign should be more effective in changing peoples behaviour in DRM districts because of the volunteers and field officers. Personal communication with OSDMA officers and even some common people indicate awareness campaign to be very effective and managing heat wave is also being described as one of the most important and successful disaster management work of OSDMA (as seen from table 1 as well). If proved true, then changing behaviour through information campaign can be suggested as an effective adaptation strategy for areas facing heat waves. 2. Literature Review There are broadly two categories of studies on heat waves, the first category falling under the public health literature and the second under impact evaluation studies. The first set of studies have examined the link between mortality and temperature anomaly by studying either the daily fluctuations in mortality or the aggregate annual

death counts and have found a positive association between excess mortality and temperature, especially when temperature exceeds specified threshold (ONeill et al. 2003; Ramon-Medina and Schwartz 2007; Ramon-Medina 2006; Deschenes and Moretti 2007; Deschenes and Greenstone 2007; Deschenes 2010). Except the last two, the rest of the studies are based on daily mortality figures. Some of these studies have analysed individual events and some have used case cross over approaches. Studies analyzing specific heat wave calamities have found various death risk increasing factors like being black (live in impoverished neighbourhoods even if have same income) and having a high school education or less (ONeil et al. 2003), not having access to air-conditioning (Smoger 1998a), living alone and leaving home regularly (Semenza et al 1996, Naughton et al 2002) etc. These factors have amplified the effect of temperature on mortality. Old and people with heart or other health related problems are also reported to be more vulnerable to heat attacks (ONeil et al. 2009). Davis et al (2003) is the only study that suggests a decline in heat related mortality over the years due to physiological adaptation along with the use of air-conditioning. Using case cross over approach and pooled data, Michelle L Bell and others (2008) examined 754 291 heat related deaths witnessed in Mexico city, Sao Paulo and Santiago in between1998 to 2002 and found same and previous day temperature, and high age to be significantly related to deaths. The significance of factors like education and sex were found non-robust differing across communities and varying between cities. Both these categories of studies clearly indicate the existence of socio-economic gradients for heat related deaths along with factors like age, health history and the weather. Undoubtedly health impacts due to heat waves is a culmination of atmospheric, climatic, environmental, socio-economic, health history as well as awareness related factors and to identify the role of awareness in averting health risk by changing behaviour, one has to isolate the role of other factors. There is ample evidence that health education through mass media or public awareness campaign on environmental quality brings substantial behavioural changes in people, though it seems to depend on the structure, timing as well as the soundness of the theoretical content of the campaign (Cutter and Neidell 2009; Hornik 2001; Randolph and Viswanath 2004). However, there

is dearth of research on behavioural changes due to public education on heat waves or heat waves warning and also on how effective has been the behavioural changes in averting health risk, though educating people of appropriate behaviour during hot weather are thought to be an effective adaptation strategy by many government (WHO 1990, Menne and Ebi 2006). Early warning has been proved to be effective in saving lives during storms and complimentary to other death reducing factors (Das and Vincent 2009) and there are also evidences from studies doing impact evaluation of state intervention, mainly heat wave warning and other adaptive information to reduce mortality, that heat early warning do reduce deaths (Ebi et al 2004, Alberini et al 2008).

Alberini et al. (2008) analysed daily death counts for all non-trauma and other specific causes covering 86 US counties using regression discontinuity design and found heat stress to have resulted in appreciable increase in mortality of cardiovascular and respiratory patients and elderly. They found the heat alerts issued by National Weather Services (NWS) to have reduced the impact of heat stress appreciably, but the effects were different across regions of USA. It seemed to reduce excess mortality among elderly by 25% in mid-west, north-east and mid-atlantics, but neither heat nor heat warning seemed to have any effect on mortality in the south. Probably this is due to acclimatisation and behaviour. Ebi et al (2004) assessed the impact of the advanced Kalkstein heat/health warning system, named after its inventor Dr Laurence Kalkstein, in early years of its introduction in Philadelphia and found it to have saved 117 lives in between 1995 and 1998. The present paper assumes awareness campaign on heat waves to bring behavioural changes in people and the effect of heat early warning to be complimentary to awareness campaign as both are done simultaneously and wish to evaluate the awareness campaign in terms of its effect on reduced mortality3. The following logic chart explains the underlying ideas behind this impact evaluation study.

The full research, however, aims at using a scientifically defined index of heat wave like Heat Wave Index, Universal Thermal Climate Index (based on durability, temperature and humidity) or Comfort Index (based on temperature, humidity and wind speed) and bring out a more disaggregated picture of the effect of awareness on mortality for groups of people on the basis of rural, urban, age, gender, well-being etc.

Logic Model for Awareness Campaign Program input Program output 1.Do not go out of home in empty stomach, 2.Drink lots of water, carry water bottle and ors solutions 3.Avoid travel during noon 4. Carry umbrella or wet towels 5. Wear light colored cotton cloths 6. Small children, elderly, fat people and persons with diabetic, blood pressure, heart problem need extra care. 7. Do not give water to persons becoming unconscious and consult doctor 8. Avoid alcoholic drinks __________________________________ Mediums used: Television, News paper, Radio, Pamphlets, Panchayat Meetings, and volunteers 2. Awareness of consequences if do not follow the instructions. 1. Awareness on heat waves 1. Change in dietary habits 2. Carry umbrellas or cover head with wet cloths if traveling during noon. 3. Less exposure during noon or change in work plans 1. Less mortality or less hospitalization Program outcome Program impacts

Other factors impacting output and outcome 1. Climatic factors like temperature, humidity etc. 2. Economic well being 3. Relative alertness 4. Other defensive measures (use of air conditioners, water coolers, presence of medical facilities etc) 5. Natural adaptation (Vegetation cover, water bodies or wetland area)

The interventions are in the form of telling people what to do or not to do to avoid heat stroke during heat wave period and this is likely to create awareness in people on heat stroke, change their behaviour and ultimately the changed behaviour will help reduce the

mortality. The ultimate effect of these inputs on mortality, however, will depend on other intervening factors like heat wave conditions, peoples alertness, wellbeing, natural conditions present etc. 3. Study Area and Heat Wave The study area for this paper is the whole of the coastal state of Orissa in eastern India, the Bay of Bengal forming its eastern boundary. The state is economically backward with more than 7.5 million families, or 47 per cent of the total population of the state remaining below the poverty line as per the latest 2002 BPL census of the state, though expert groups are suggesting the government to revise the figure to 84.47 % from 47%. Agriculture and related activities constitute the main occupation catering to more than 76% of the population and more than 85% of the people live in rural areas, the percentage of urban population varying between as high as 42.93 for Khurda district to 4.29 for Nayagarh (Census of India, 2002). The average density of population is 236 per square kilometre for the state and it varies between 666 for Khurdha district to 81 for Kandhamal district. Thus the coping capacity of people to extreme events is limited and intervention is necessary at different levels to enable them to get over the extreme weather events. The state has 30 districts of which 16 have been covered under the disaster risk management project of Government of India and UNDP (the highlighted districts in figure 1). Figure 1: Location of districts covered under disaster risk management program in the state of Orissa.

As said before, though unheard of in recent history, the state is witnessing unusual increase in temperature and severe heat waves since 1998, when 2042 deaths occurred. Coastal towns and areas are more severely affected than the interior ones and as expected most of the coastal districts have been covered under the program. The state has 19 weather stations spread all over the state and has been divided into 10 agro-climatic zones. Using the heat wave definition given by the Indian Meteorological Department (IMD), the heat wave days are calculated for the state as a whole and for different district separately. Next the heat wave days are compared with the heat wave deaths 4 witnessed in the whole state as well as in the districts where DRM project is being implemented and the ones not receiving the program (see table 1, Figure 1 and 2). The IMD defines heat wave differently for different areas based on the prevailing normal temperature of the area. The formal definitions are the following: (i) The normal temperature is < 40 C. Any increase from the above normal temperature is called heat wave. + (5 or 6) C Moderate heat wave +7 C or more Severe heat wave (ii) The normal temperature is 40 C. Any increase from the above normal temperature is called heat wave. + (3 or 4) C Moderate heat wave +5 C or more Severe heat wave (iii) If the maximum temperature of any place continues to be 45 C consecutively for two days (40 C for coastal areas), it is called a heat wave condition Table 1 and both figure 2 and 3 show heat related deaths to have gone down over the years in the state in spite of similar heat wave condition prevailing compared to the year 1998 (in fact number of heat wave days going up in the state). However, if 1998 is ignored being an extreme year, the decline in death no longer looks striking (figure 2). There is decline in death both in DRM and non-DRM districts, may be because of physiological adaptation as human body does get used to increased temperature to some extent over time (Davis et al., 2003) or some other factors other than the awareness, but
4

The state has the provision to pay INR10, 000 as compensation for every heat wave casualty. Thus, every heat wave reported death is examined and certified by a doctor whether the death is due to heat stroke or not. The paper analyses those deaths which are certified by doctors to be due to heat stress.

the decline seems comparatively sharp for the DRM districts compared to the non-DRM ones (figure 3). This makes it an interesting case to find out if the intensity of awareness campaign did play some role in reducing the heat wave mortality. Table 1: The number of heat wave days and the number of human casualties in the state of Orissa
Year Heat Wave Days 1 2 1 1 1 2 28 25 18 12 21 28 8 29 4 8 12 29 38 Deaths in the state 3 1 22 1 9 3 2042 91 29 25 41 67 41 234 21 47 69 85 61 Deaths in DRM districts NA NA NA NA NA NA 1124 57 8 21 29 48 35 161 17 28 41 63 25 Deaths in non-DRM districts NA NA NA NA NA NA 918 34 21 4 12 20 10 75 4 19 27 22 35

1983 1987 1988 1989 1995 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Source: Indian Meteorological Department, Bhubaneswar and Orissa State Disaster Mitigation Authority, 2010

10

Heat wave and human casualties in Orissa

250

Deaths and number of heat wave days

200

150 heat_death heat_days 100

50

0 1999* 2000* 2001* 2002* 2003* 2004* 2005* 2006* 2007* 2008* 2009* 2010* Year

Figure2: Heat Wave days and number of human casualties in whole of Orissa

Heat deaths in treatment & control districts

Deaths in DRM & non-DRM districts
180 160 140 120 100 80 60 40 20 0

* 09 20

99

00

01

02

03

04

05

07

06

08

19

20

20

20

20

20

20

20

20

Year

20

death_DRM districts death_nonDRM districts

Figure 3: Heat wave related deaths in districts receiving DRM program and the ones not under the program

20

10

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4. Methodology The paper uses the Difference-in-Difference (DID) measure to bring out the impact of awareness generation on death (Pattnayak 2009; Wooldridge 2002; Card and Krueger 1994). DID is a non-experimental technique to measure the change induced by a particular treatment or program over a given period of time. The underlying idea is to examine the effect of the treatment by comparing the treatment group after the treatment both to the treatment group before the treatment and to some other control group not receiving the treatment. In program evaluation, the most important step is the measurement of counterfactual outcome, the outcomes that would occur in the absence of the policy being implemented. Deducing the effect of the treatment simply by looking at the treatment group before and after the treatment do not show the real impact as a lot of other things surely go on at the same time as the treatment and one has to control for it. The DID method uses a control group to subtract out the effect of these other changes, assuming that these changers are identical between the treatment and control groups. In other words, the control group provides the missing information or the outcome for the treatment group in the absence of treatment, the counterfactual. Along with the identification and measurement of counterfactual, the other important task is also the control and careful consideration of co-founders which are likely to be correlated with the interventions and thus are likely to impact the outcome. The simplest set up of DID is one where outcomes are observed for the two groups (A and B) for two time periods. One group (B) is exposed to a treatment in the second period but not in the first and the second group (A) is not exposed to the treatment at all. With repeated cross sections, the model for a generic member of any of groups is written as Y = 0 + 1 dB + 0 d 2 + 1 d 2 * dB + (1)

where y is the outcome of interest. The dummy variable dB (=1 for the treatment group) captures possible differences between the treatment and control groups prior to the intervention or policy change and d2 is a dummy variable for the time period. The time period dummy, d2, captures aggregate factors that would cause changes in y even in the 12

absence of a policy change. In equation 1 0 measures the baseline average; 1, the differences between the two groups in year 1, 0 represents the time trend in the outcome, and 1 represents the difference in the changes over time. The policy impact is captured by 1 , the coefficient of the interaction term, d2 *dB, which is the dummy variable equal to one for those observations in the treatment group in the second period. Thus difference-in-differences estimate is:

1 = ( y B , 2 y B ,1 ) ( y A, 2 y A,1 )

(2)

This simple set up can easily be extended to account for various subsets of treatment and control group (in which case we include further interaction terms and measure the difference-in-difference-in-difference), to add covariates to control for compositional changes in the groups, or use data on multiple time periods and groups etc. With multiple time periods and groups, the model to be estimated is written as

Yigt = t + g + X gt + Z igt gt + gt + u igt ,

(3)

where i represents individuals (=1, ., M gt ), g represents group, and t, the time. The full set of time effect is captured by t and the group effects are captured by g . X gt are the group/time period covariates (the policy variables), Z igt are the individual specific covariates, gt are unobserved group/time effects and u igt are the individual specific errors. In most cases, the unobserved group/time effects are ignored and suitable estimates are chosen depending on the nature of y to get , that measures the policy impacts. Hartwig and Grimm (2010) estimated such a model for measuring the effects of 2002 food crisis in some part of Malawi on the health of the children using a probit specification. With panel data, the model can be written as

Yit = t + Wit + X it + ci + uit = t + M it + X it + it ,

(4)

13

where i are the units (=1, ., M), t is time (=1, , T), and Wit is the binary indicator that equals unity if unit i participates in the program at time t. X it are the controls and the error it is defined to be having a time invariant component ( ci ) and a time varying component ( u it ) such that it = ci + u it . The coefficient is the treatment effect. Depending on the availability of data, Eq. 4 is estimated either by fixed effect or random effect using the suitable specification to get the accurate results. Many a times one has to use a combination of techniques like PSM and DID to control over the biases. The present paper uses a panel data and estimates the following equation: Yit = 0 + 1T + 2 drm _ period + 3 drm _ district + 4 drm _ pdXdrm _ dist +

5 populationit + 6 DNDPit + 7 awareness _ indext + 8 HWDit + 9 SHWDit + 10 Severity _ dummyit + 11 40 deg_ moreit + it
where the variables are the following:

(5)

Y: Number of human deaths for the ith district (1, .. , 30) in the tth year (1998, 1999, , 2010), T: time trend (to account for the physiological adaptation of human body to high temperature and other time variant changes), Drm_period: the treatment period dummy (=1 for 2003 and onwards), Drm_district: the treatment group dummy (=1 for 16 districts) Population: ith district population in the year t, DNDP: ith district net domestic product in the year t (account for well-being as well as urbanization), Awareness_index: number of mediums used in the year t to generate awareness (varies from 1 to 10 in different years), HWD: heat wave day as defined by IMD, SHWD: severe heat wave day as defined by IMD, Severity_dummy: dummy variable for the year t when the temperature deviation has been more than 10 C (exceptionally hot years) in the ith district as per the temperature recorded by the nearest weather station or by the one falling in its agro-climatic zone, 40deg_more: total number of days in the year t when the temperature has crossed 40C in the ith district (too many days with marginally more than 40C temperature may not be

14

captured by heat wave days, but may cause heat stress due to continuous high temperature), and is the error. Equation 5 is estimated with both fixed effect and random effect using a Poisson specification because of the count nature of the dependant variable.

4.1 Controlling for endogeneity biases Heat wave is a climatic phenomena and its impact is dissimilar over areas and over time. Though the awareness campaign is undertaken regularly starting with the month of March, its effect gets visible only if the temperature crosses some threshold. Areas with high heat wave index are likely to show high impact and vice versa. This bias in results is likely to be controlled as the model is using different measures of temperature deviations from the normal level which would be capturing the stress on human body from heat wave for each of the districts. After every calamity, people do change their behavior and undertake precautionary measures and such possibilities are also expected after the 1998 heat attack in Orissa. However, precautionary motive is strongly linked with income and the vulnerable population facing casualties due to heat wave are mainly the poor and marginal workers in the state 5 who spend little on averting activities. People who adapt to heat waves by using air conditioners or water coolers are less likely to face casualty. We hope to have controlled for this by using the district level net domestic product for different years that captures the degree of affluence or poverty in the district. 5. Data Data from multiple sources have been used to estimate the model. Data on human casualties was collected from OSDMA office where every death, reported to have been due to heat stroke, has been verified and certified by a medical officer. Daily maximum temperature data for the months of March, April, May and June (summer months for the state of Orissa) for the period 1998 to 2010 have been used to measure the different measures of heat wave index. This data source was the Indian Meteorology Department, Bhubaneswar. As mentioned before, the criteria suggested by the IMD have been used to calculate the heat wave and severe heat wave days for different district. The state has 30
5

Based on OSDMA report pasted on the web site.

15

districts, but only 18 weather stations (see figure 1) and thus, the agro climatic division of the state was used to identify the weather station that can capture the temperature of the district more accurately. The temperature of the districts having weather stations within its boundary was represented by the temperature recorded in the respective weather stations. The ones not having any weather station within its boundary were represented by the temperature recorded in the nearest weather station situated within its agroclimatic zone. Information on mediums used for awareness generation in different years was collected from OSDMA office. Though various mediums like different radio stations, television channels, print Medias and posters have been used and have been used for different duration in different years, the awareness index has been simply taken as the sum of the mediums used in a year. No weightage has been given to the duration or to the type of mediums, though their impact is likely to be very different. The same value of awareness index is used for both drm and non-drm districts as the channels and the news papers used are viewed and read state-wide depending on affordability. Population figures for non-census years were interpolated from the 1991 and 2001 census data using district wise decadal growth rates. District level net domestic product was collected from Planning Commission of India publications. District NDP was available only for the years 1992-93 till 2004-05 and for years beyond 2004-05, extrapolated values have been used. 6. Results The panel data used has 13 years of observations on 30 districts of which 16 districts are under drm, 14 are non-drm and of the 13 years, five are pre-drm years and eight are post drm years. The summary statistics of the variables are reported in Table 2.

Table 2: Summary Statistics

DRM districts (n= 208) Mean (std Min (Max) error) 7.97 0 (254) (26.78) 15.82 0 (77) (15.82) 5.67 0 (38) (6.57) Non_DRM districts (n= 182) Mean (std Min (Max) error) 7.50 0 (367) (32.79) 27.6 0 (77) (20.19) 8.71 0 (38) (7.77)

Variables Heatstroke_ death 40deg_more HWD

16

SHWD Severity_dummy Population DNDP Awareness_index

3.07 (4.53) 0.15 (0.36) 1622734 (691239) 242658 (174255) 5.38 (7.93)

0 0

(19) (1)

510199 (3674529) 39193 (955390) 0 (23)

4.55 (5.58) 0.143 (0.356) 910553 (471163) 129040 (94361) 5.38 (7.93)

0 0

(25) (1)

260349 (2118176) 24588 (585983) 0 (23)

The summary statistics show the average death per year per district to be little different between the drm and non-drm districts (7.97 and 7.5 respectively), but the nondrm districts to have been suffering from more severe heat attack, the average value of all the measures of heat wave being higher for these districts. These districts are also less populous and poor (the district net domestic product is nearly half of that of drm districts) compared to the drm districts. The vulnerable districts for implementation of drm project were decided on the basis of total number of hazards that included floods, droughts, cyclones and heat waves and thus, some of the poor districts more severely affected by heat wave may have been left out of the project. Two different specifications of equation 5 described above has been estimated with both gamma distributed random effect and district fixed effect. The dependant variable, number of deaths, being a non-negative count, Poisson estimates are used for estimating the equation 5. In one specification, the variable awareness index is used along with other variables and program impact is measured by interaction of the drm_period dummy with drm_district dummy and the awareness_index. In the other specification, the program impact is measured from the interaction of the drm_period and drm_district dummy without the awareness index. Both the specifications, as observed from table 3 and 4 confirm the drm program, through intensive awareness generation, to have reduced heat related death in Orissa significantly. 6 Of course, the second specification without including the awareness index shows the program impact to be much higher and this could be because of the reason that the awareness index has not been defined carefully in the model. The main activity to control heat stroke has been the awareness campaign and probably, it needs to be defined more carefully to capture the full impact of the intensive
6

The results are only preliminary.

17

drm interventions on heat wave. Both random effect and fixed effect estimates give similar results and confirm the positive effect of drm program in reducing extreme health impact from heat waves. Table 3: Random and Fixed effect Poisson estimates to explain Awareness Campaign effect on heat stroke death (Dep variable= number of human death due to heat stroke)
variables Drm_period Drm_district Drm_pdXdrm_dist Awareness_index Drm_pdXdrm_distXawareness_index 40deg_more HWD SHWD Severity_dummy Time_trend Population DNDP Constant Wald chi2 lnalpha Alpha Loglikelihood ratio test of alpha=0 Gamma distributed random effect Poisson estimates District fixed effect Poisson estimates

2.13*** (0.144) 0.02 (0.53) ----0.086*** (0.009) -0.018** (0.008) 0.042*** (0.003) 0.007 (0.006) 0.058*** (0.006) 0.553*** (0.065) -0.735*** (0.027) 1.37e-06*** (4.21e07) 1.81e-06*** (4.53e07) 0.853* (0.46) 5528.03 , Pro>chi2=0.00 0.389 (0.227) 1.476 (0.335) Wald Chibar2 = 2624.93, Pro>chibar2=0.00

2.12*** (0.144) --------0.086*** (0.009) -0.018** (0.008) 0.043 *** (0.003) 0.007 (0.006) 0.059*** (0.006) 0.542*** (0.066) -0.736*** (0.028) 1.48e-06** (6.05e07) 1.78e-06*** (5.01e07) ----5512.04, Prb>chi2=0.00

N=390

Table 4: Random and Fixed effect Poisson estimates to explain DRM project effect on heat stroke death (Dep variable= number of human death due to heat stroke) variables Gamma distributed random effect Poisson estimates 2.033*** (0.0151) 0.274 (0.552) -0.634*** (0.1136) ---District fixed effect Poisson estimates 2.03*** (0.151) ---0.635*** (0.1165) -----

Drm_period Drm_district Drm_pdXdrm_dist Awareness_index

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Drm_pdXdrm_distXawareness_index 40deg_more HWD SHWD Severity_dummy Time_trend Population DNDP Constant Wald chi2 lnalpha Alpha Loglikelihood ratio test of alpha=0

---0.055*** (0.003) 0.009 (0.006) 0.043*** (0.006) 0.683*** (0.063) -0.630*** (0.022) 1.15e-06*** (4.28e07) 3.26e-06*** (4.31e07) 0.482 (0.476) 5407.28 (Pro>chi2 = 0.00) 0.439 (0.225) 1.55 (0.35) Chibar2(01)= 2767.21, Pro > chibar2 = 0.00

----0.055*** (0.003) 0.009 (0.006) 0.043*** (0.006) 0.666*** (0.064) -0.629*** (0.024) 1.08e-06*** (6.05e07) 3.30e-06*** (4.63e07) -----5394.00 (Pro>chi2 = 0.00)

N=390 Notes: ***, **, * imply level of significance to be 1%, 5% and 10% respectively. Figures in parenthesis show standard errors. Most of the other variables show coefficients on expected lines. All the different measures of heat wave have positive and significant coefficient and the severity dummy (years or areas when the temperature increase deviates from the normal temperature by 10 or more degrees) seems to be the biggest killer. As expected, people get used to high temperature in course of time and time trend has a negative and significant coefficient. Against expectation, the district net domestic product has a positive and significant coefficient implying that richer districts are more vulnerable to heat stress. This could be because of activities where workers are more exposed, increased urbanisation leading to unhealthy surrounding and congestion etc. Though preliminary and based on macro data, the results show the heat related deaths in Orissa could have doubled in the absence of the drm program that used awareness generation to control heat stroke. 7. Conclusion Due to global climate change, the heat wave occurrences have become more regular, intense and wide spread in both developed and developing countries. Along with long term measures like changing housing structure, town planning, increasing green cover 19

etc, short run adaptation measures like warning, health education, advices on precautions etc are resorted to by policy makers to counter the impacts, but the effectiveness of these strategies is not researched. The paper analysed the deaths due to heat waves in Orissa and evaluated the impact of intensive awareness campaign undertaken by the Orissa State Disaster Management Authority in some of the districts of the state falling under the Disaster Risk Management Program of Government of India and United Nations Development Program. Under DRM program, the most important strategy to control heat wave impact has been to make people aware of the dos and donts during heat wave period. We found significant reduction in death in DRM districts and this could have been because of the fact that the DRM districts have witnessed more intensive awareness generation than the non-DRM districts. Results show the heat stroke casualties in the state could have doubled in the absence of this intervention. Though the research is ongoing and the paper quotes some preliminary initial results, the findings have significant policy implications. The problem of heat wave being recurring, the policy makers all over the world are looking for effective and economical strategies and awareness campaign could be one such adaptation measure.

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