Habib Motahir, a 42-year-old farmer, or Ann Noyens, a 50-year-old Belgian tourist, are among the few people whose deaths due to high temperatures have been confirmed in Spain. Although the daily mortality monitoring system (MoMo) of the National Epidemiology Centre of the Carlos III Health Institute in Madrid, the reference register in this field, estimates that in the warm months of last year there were 3,009 deaths attributable to heat. This is an estimate made with statistical models based on the excess deaths that occur in the country when temperatures soar. In reality, it is very difficult to find where these deceased are, since in the vast majority of cases nothing about heat appears on the death certificates. Many of these people died without even knowing that high temperatures would mean the end of their lives.
At the beginning of this summer, in a house in the centre of Mazarrón (Murcia), the relatives of El Habib Motahir remember how the tragedy happened exactly a year ago, while they were on holiday in Morocco. His wife looks on with sad eyes without saying a word, she does not speak Spanish, and his three children – a 15-year-old boy, a 9-year-old girl and a 2-year-old baby – are also silent. It is his brother who explains what happened on Tuesday, July 18, 2023. El Habib, a farmer of Moroccan origin, “from near Casablanca”, who arrived in Spain by boat 27 years ago, had been picking tomatoes in a greenhouse in the nearby village of La Majada in the morning. It was difficult to work because the heat was suffocating, the air was burning. However, in the afternoon he returned. “That day he returned to work after lunch and soon after he started to feel dizzy.” No one forced him or pressured him, as he was a self-employed person who had rented the property. “The ambulance took more than 40 minutes and he died in the hospital,” laments his brother. “The papers said it was due to heat stroke.”
As Juan Blázquez, Secretary of Occupational Health for CC OO in Murcia, points out, the farmer from Mazarrón is one of only three workers who appear in the advance data from the Ministry of Labour as having died due to heat in Spain in 2023, after the corresponding investigation that is being carried out with workplace accidents. The other two are also farmers, who died in June in Castilla-La Mancha and Andalusia, according to the unionist, in a town in Ciudad Real and in Seville. “These figures do not match those given by the Carlos III Health Institute for excess mortality attributable to heat,” Blázquez insists. “We believe that there is an underreporting of worker deaths,” says the CC OO representative, who believes that there are more deaths from this cause that are going unnoticed. “If a worker falls from scaffolding due to heat, the death is not attributed to high temperatures but to the fall,” he argues. “And there are deaths due to heat that occur days after the high temperatures.”
Heat kills in different ways. Eneko Barbería, director of the Institute of Legal Medicine and Forensic Sciences of Catalonia, stresses that most deaths are caused by the worsening of pathologies in vulnerable people. These can be circulatory diseases, strokes or even neurodegenerative diseases. These deaths are very difficult to trace, since the causes listed on death certificates have nothing to do with temperatures. However, sporadically, deaths can occur due to heat stroke, in which this link is more evident. “In these cases, there is direct exposure to heat, causing the body to reach extreme temperatures. It is a serious illness, a life-threatening emergency, and is characterized by a central body temperature of over 40 degrees, with alterations in the nervous system that can cause delirium, convulsions or coma. The skin is hot, dry, reddish, without sweating, there is tachycardia, hypotension and hyperventilation,” explains Barbería, who specifies that it is in these deaths that a forensic doctor intervenes.
![A man cools off on the inland beach of the Breña reservoir, in the municipality of Almodóvar del Río (Córdoba).](https://imagenes.elpais.com/resizer/v2/ZNRIUO6REICVPPGQYVZDAEMFHY.jpg?auth=0a2321c66342f1b0343e4f3fbbbdf7b7a3cee5855645aa91e6733afb5388c4aa&width=414)
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But even in deaths initially linked to heat stroke, there is also a wide margin of uncertainty. Only a few days after the loss of El Habib Motahir, the death of a gardener aged only 24 also occurred at a campsite in Mazarrón, which was initially attributed to high temperatures. In this case, the autopsy was inconclusive, and as Blázquez points out, “it was rejected by the authorities”. [compañía de seguros de la] Mutua as heat stroke”. Also, in August the media reported the death due to extreme temperatures of a grape picker in Montilla (Cordoba), who felt unwell, with dizziness and difficulty breathing (dyspnea). But later this death was attributed to a heart attack. On the other hand, the Canary Islands Health Service does confirm four deaths due to heat last year on the islands, three of them tourists who were hiking, Guillermo Vega reports. One of the victims was identified as a Dutch woman, but in fact she was Ann Noyens, a Belgian holidaymaker who runs a fruit shop in Geel, who was walking with her husband on 13 August along a mountainous route in Guía de Isora, south of Tenerife. According to what he later told the Belgian media, she fainted after about three kilometres of walking and could not make herself understood on the telephone to call for help. Unable to carry her either, he reluctantly had to leave her there alone to go and get help. He managed to get a helicopter to come and pick her up, but it was too late.
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Beatriz Lozano Arias, representative of the National Association of Forensic Doctors (ANMF), explains that diagnosing heat stroke death can sometimes be complicated, especially if it is a report that has legal consequences, as in the case of work accidents. “To declare a death by heat that can later involve legal considerations, you must be very clear and documented,” the coroner insists. As she details, although there are specific signs that make one suspect the influence of the climate in a death, to confirm the diagnosis it is essential to exclude other options and, even if there is such a relationship, the final cause of death that will appear on the death certificate can be very different. “To speak of death by heat, the person must have almost no medical history [médicos] and that from the information available at the time of the removal of the body it is evident that the heat has had a fatal effect, either because there is an increase in body temperature or, if it comes from the hospital, because there are analyses that point in that same direction.” According to Lozano Arias, it has been seen that there are heart attacks, cerebral infarctions or respiratory problems that can be associated with excessive heat, “but on the medical death certificate what will be recorded as the final cause of death is not the heat, but those pathologies,” he emphasizes. “If you have data that support that there has been an acute myocardial infarction, then that is the cause of death, although there may be an influence of the heat.”
As explained by Julio Díaz, a researcher at the Carlos III Health Institute and one of the specialists who works with statistics on deaths attributable to heat, these estimates are made based on the excess of deaths that occur when temperatures exceed certain levels (or when they fall below certain levels, in the case of deaths due to cold) compared to the normal values of historical records. This is not a count of real deaths, but rather a statistic taken from a very real increase in deaths. “Only between 2 and 3% of these deaths due to high temperatures are related to heat stroke,” stresses the researcher, who explains that the vast majority of deaths related to rising temperatures are due to the worsening of other diseases. According to MoMo statistics, this particularly affects very elderly people, since two thirds of the 3,009 deaths estimated last year correspond to people over 85 years of age. Regarding geographical incidence, the autonomous communities where the most deaths attributable to this cause occurred were Madrid (409), Andalusia (397) and Galicia (307).
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As with deaths from air pollution, where even fewer real cases are known, without statistics these deaths from heat would go unnoticed, hidden by other pathologies, which does not help society to be more aware of the risk of high temperatures for health. “We use ecological studies, which cannot say whether an individual has died from heat, but they do allow us to analyse the incidence in entire populations,” says Díaz about the statistical models. Although the real cases are not known, the researcher explains that a cause-effect relationship can be established with temperatures and deaths, given that certain conditions are met, such as the existence of a statistically significant association, which has been confirmed in different places in the world, that there is a biological mechanism that explains it and that a dose-response correspondence has been proven, so that as the degrees of warming increase, the number of deaths also increases. “The heat is devastating,” stresses Díaz. “Deaths usually occur one, two, three or even four days after a rise in temperature. It could be an old person who is at home at 38 degrees, does not hydrate, becomes ill, is taken to the hospital and dies three days later.” Nowadays it is very difficult for a death certificate to contain any reference to heat, but it will be a number that will jump out in the statistics.
Forecast increase in deaths
In 2024 the daily mortality monitoring system (MoMo) has estimated 128 deaths attributable to heat in Spain since May. As Diana Gómez-Barroso and Inmaculada León, heads of this service at the Carlos III Health Institute in Madrid, comment, these are considerably fewer than last year at this time, 408, which is explained by the milder temperatures recorded so far this season. However, with the first heat wave of 2024 hitting these days, deaths are expected to begin to increase. At this point, another application of these statistics is interesting: the Kairos indexwhich makes predictions about where mortality may increase by province. “This index calculates the probability that deaths will exceed the 10% rate in the following five days,” says Gómez-Barroso, who in the middle of this week warned of an increase in deaths due to heat expected in Madrid and Zaragoza.
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