JACOBABAD, Pakistan—Sajjad Ali lies semi-conscious in the heatstroke center at Civil Hospital here, an intravenous line in his wrist delivering fluids to his dehydrated body.

Ali, 15, operates a tractor in the fields on the outskirts of Jacobabad—one of the hottest cities on Earth—and was carried to the hospital after his temperature remained at 102 degrees Fahrenheit for a week. 

On the opposite side of the ward, kept at a cool 78 degrees by a whirring air conditioner, Muhammad Musa occupies another bed, its cobalt blue frame contrasting starkly with his face, which is drained of color. A farm worker in Jacobabad’s rice fields, Musa, 65, arrived with a 102 degree temperature, body aches and severe dehydration. 

Jacobabad, a landlocked city in Pakistan’s Sindh Province nearly 340 miles north of Karachi, is pushing the limits of human livability on a warming planet. Since the beginning of March, an unprecedented heat wave has gripped India and Pakistan, affecting more than a billion people on the subcontinent. And Jacobabad has been among the cities worst hit, experiencing temperatures in excess of 100 degrees for 51 straight days. Last month, the temperature here reached 123.8 degrees and before that, reached 122 degrees on three separate occasions. 

Rising temperatures and humidity, coupled with electricity shortages, water stress and the absence of heat adaptation measures, have exceeded thresholds that experts say the human body can stand, with more intense summers arriving earlier in the year, and some experts say that going forward, those extreme conditions could last for 10 months each year. 

The 2022 heat wave in South Asia is already estimated to have caused more than 90 deaths in India and Pakistan, and to have resulted in glacial melts in northern Pakistan and reduced wheat crop yields in India. According to a recent report published by the World Weather Attribution Initiative, the onset of the heat wave was made 30 times more likely by climate change. 

Back at the heatstroke center, Bashir Ahmed, a duty nurse, asked Ali how he was feeling. But the 15-year-old struggled to gather enough energy to speak a full sentence, his lips dry and half parted. 

Ahmed did not seem worried. The medical staff in the hospital is not easily fazed by heat stroke patients. In May alone, more than 100 people were admitted to the center for heat-related illnesses, but no deaths have been recorded so far. 

Two hours later, both patients were recovering. Musa’s body temperature had gone down to 100 degrees, but he would still need another hour to regain enough energy to sit up. Despite the fever, this was the first time in weeks he had been in a room with temperatures low enough for him to relax. 

Musa kept a checkered black and white linen scarf over his eyes and drifted into a light sleep. He is among 70 percent of Jacobabad’s population of roughly 200,000 who live below the poverty line, primarily farm workers and daily wage earners in factories or brick kilns. 

Above Musa’s bed was a large banner that listed preventative measures against heat strokes. The first item: Stay indoors or under a shade during the hot hours of the day. It is a luxury he and other farm workers here cannot afford. “If we stop working every time it gets too hot,” he said, “how will we eat?”

Named after Brigadier-General John Jacob of the East India Company, Jacobabad developed a primarily agrarian economy after Jacob’s arrival in 1847. He ordered the excavation of a canal to bring water from the river Indus for agriculture and irrigation. Jacobabad is a nine-hour drive from Karachi. 

Pakistan is headed towards 3.5 degrees Celsius warming by the end of the century, according to projections from Berkeley Earth, a nonprofit focused on environmental data. Heat wave-like conditions are expected to become even more frequent. In Pakistan’s Sindh province, more cities are experiencing 120 degree weather earlier than expected.

Pakistan has contributed less than 1 percent of global greenhouse gas emissions but is one of the top 10 most vulnerable nations threatened by climate change. In 2009, at the United Nations climate change conference known as COP15, held in Copenhagen that year, developed countries agreed to provide $100 billion in climate funding to developing nations by 2020, a promise that to date remains unfulfilled. Pakistan, currently undergoing an economic crisis as the rupee plummets to a record low against the U.S. dollar, needs billions in aid to address its adaptation and mitigation needs. “Developed countries have to start putting in at least a billion dollars every year into Pakistan’s mitigation and adaptation,” said environmental policy consultant Dawar Butt. 

In 2015, a then-unprecedented heat wave resulted in more than 1,500 deaths in Karachi. Since then the city has had a heat wave management plan in place that calls for alert systems, setting up of cooling infrastructure and addressing urban heat islands in densely populated areas across the city. 

But Jacobabad, despite the history of extreme heat, has no such plan. Here, residents come together in small ways to help each other survive the city’s unbearable heat. On Friday afternoons every week, groups of young men set up stations on the side of the road, outside mosques and near the national highway, handing out bright pink, green and orange plastic glasses of cold drinking water to passersby. 

Last month, when temperatures rose above 123 degrees, Hakim Ali, a 22-year-old who works at an ice factory in the city, lost consciousness in the middle of the day. His friends and co-workers doused him in a barrel of cold water to help alleviate the symptoms of heat stroke. 

The city’s residents know how to handle heat stroke, bringing out cold water buckets and placing patients in the shade at the first sign of a heat-related symptom. But healthcare infrastructure in the city is not prepared to handle prolonged and frequent heat waves. The heat stroke center where Sajjad and Musa were admitted, established by the local health department and the Community Development Foundation, a non-governmental grassroots organization engaged in aid work in the city, has only four beds. But coordinated planning among health and disaster management departments, heat adaptation measures specific to Jacobabad’s unique weather and cooling infrastructure for communities that work outdoors in the heat are largely absent from policy. 

Every morning at the crack of dawn, when the temperature is usually at its lowest for the day, men crowd around concrete tanks in the city where groundwater is privately pumped, stored and sold to distributors. Deep-blue jerricans loaded on carts are a common sight on the dusty streets, where motorbikes outnumber cars by a wide margin. 

In 2019, the U.S. government spent $2 million for a water support program in Jacobabad, but a USAID report published last year confirmed that a clean water supply to Jacobabad remains limited due to frequent power cuts at the water filtration plant, a lack of technical staff on site and little to no coordination among local government bodies.

So in the water-stressed city, residents continue to buy water from private distributors. A five-gallon can is sold for 1 cent, and a family of five spends up to $6 a month buying water for drinking and cleaning. “Most families in the city earn less than $2 a day,” said Jan Muhammad Odhano, director of the Community Development Foundation. 

The warmer the day gets, the fewer men there are in sight in the fields that surround the city. Male farm workers take a break during the hottest hours of the day and return to work later in the evening. 

But for women, social norms, safety concerns and household responsibilities all keep them from such flexible work schedules. Between noon and 4 p.m., when the temperature is the highest, they can still be seen, hard at work. 

For Jacobabad’s Women, a Crushing Routine

Noor Bibi and the women from her village, five miles east of the city, spend much of their days in June standing knee-deep in water, planting rice as temperatures reach 115 degrees or more.

Bibi said she lost consciousness in the fields last year after working through a week-long 100-degree fever. Women in rural areas are largely responsible for household needs, including securing adequate water and food, and perform more labor intensive tasks both in agricultural fields and at home. All of this labor makes them more vulnerable to the impacts of climate change, according to the United Nations.

At the heatstroke center, where record keeping is limited, doctors and nurses agree that women face a greater risk of suffering health impacts from the heat and make up a larger percentage of the patients. 

Bibi wakes up at 5 a.m. every morning and makes her way out of her room into the courtyard where the family’s cattle–two water buffaloes–are tied under a tree on one side and the kitchen is set up on the other. She places herself on a small wooden stool in front of the stove and reaches for a half-filled sack of dried-up cow dung. Solid fuels and firewood are among the most commonly used sources of energy for cooking in Jacobabad. 

Bibi does much of her cooking early in the morning while her husband and three children are still asleep. During the summer when the children are at home, her daughter Zahida, 19, who dropped out of school at the age of 13, manages housework and takes care of her younger brothers, while her mother goes to work in the fields. Her husband, Imdad Ali, like many other men in the community, is unemployed. 

At 6:30 every morning, Bibi and eight other women walk two-and-a-half miles to get to the fields. During late May, a few weeks before rice cultivation begins across the Sindh province, the women prepare the fields, filling cracks in the soil and helping build temporary boundary walls to minimize water loss. To cultivate rice, the fields are then filled with water, which remains standing during the summer months and adds to the humidity across the province. 

“We’re worse off than our buffaloes,” said Bibi. “At least they can soak themselves in water when the heat gets unbearable.” 

Hot Nights

Ameeran Baloch, 35, lives with her husband, Zaheer, their five children and an aging mother-in-law, about a mile away from the city entrance. Zaheer works at a nearby bakery and is one of the few men in their neighborhood with a running monthly income. 

By mid-May of every year, most of Ameeran’s neighbors, including her sister Zahida’s family, start getting ready to migrate to Quetta, a city roughly 200 miles west of Jacobabad where summer temperatures rarely cross the 100-degree threshold. During summer months, those in Jacobabad who are able pack up their homes and belongings and migrate to colder cities. Some migrate all the way to Karachi. According to a report published by Action Aid, by 2030 climate change-induced disasters will force more than 600,000 people in Pakistan to migrate. 

But for Zaheer and his family, leaving a steady income to escape the city’s harsh heat is not an option. Those who remain in Jacobabad during its long and intense summer months are faced with power cuts lasting 10 to 12 hours a day. 

While Zaheer works at the bakery, where a battery-operated fuel generator keeps the fans running, Ameeran’s time at home is spent finding ways to protect herself, her mother-in-law Jan Bibi, who suffers from diabetes, and her five children, Asifa, Bashir, Tahira, Mudassir and Benazir, from the heat. 

On a recent afternoon, Bashir, Ameeran’s youngest, dressed in a black shirt and orange pajamas, sat under a hand pump for water in a corner of their home. The 2-year-old laughed as his mother pulled down the metal lever and drenched him in cold water. Jan Bibi joined them, taking some water in her hands to splash her face. 

After Bashir had his turn under the pump, Ameeran repeated the exercise four more times for her other children, all of whom joined their grandmother on the charpaai, a traditional bed made of a solid wood frame and ropes that allows air to pass through, in the courtyard. The intermittent gusts of wind provide a naturally cooling effect, although this will abate toward the end of June, as the weather shifts and the heat and humidity increase. “This is our air conditioning,” Bibi laughs. 

Ameeran, who has to cook lunch for the family now, waited for her turn under the pump until the chores of the day were completed. The power has already been out for more than five hours and she doesn’t think it will be restored by day’s end. 

In 2019, the provincial government, in partnership with The World Bank, announced a $100 million project to increase power generation and improve electricity access across Sindh Province. While a portion of the money was intended to provide solar power access to more than 200,000 homes across rural Sindh between 2019 and 2020, the project is still in its assessment phase. 

Last week, a maintenance problem caused a three-day power outage in Ameeran’s neighborhood. Today, she and her two eldest children, Benazir, 10, and Mudassir, 8, will move the three other charpaais to the courtyard before sundown, as they often do. Whether they sleep indoors or in the courtyard, uninterrupted hours of rest for residents of Jacobabad are becoming infrequent. Late last month nighttime temperatures in the city went as high as 110 degrees. 

But when the power is out the family sleeps in the open. “We would suffocate inside,” Ameeran said.