Heat and crowds strain health services at annual Black Nazarene feast in Manila

The Department of Health (DOH) has placed public hospitals in Metro Manila and nearby regions under Code White Alert from January 6 to 10 for the annual Feast of the Black Nazarene and its central procession, the Traslación, on January 9, health officials said.

According to the DOH, Code White means that health care facilities must be on heightened readiness with additional medical personnel, emergency equipment, and supplies to manage the expected variety of medical issues that may arise during the massive event.

The department also announced it will deploy about 200 health emergency response team members across the city and coordinate with local government units, the Philippine Red Cross (PRC), and other first responders to provide medical coverage along the procession route.

Meanwhile, the PRC said it will position over 1,200 personnel, ambulances, and foot-patrol teams to assist devotees and manage health concerns that typically accompany large crowds under hot conditions.

These preparations reflect a long-standing public-health approach to the event, which consistently draws millions of devotees into hours of movement and proximity, conditions associated with heat-related illnesses and crowd hazards according to health experts and recent research.

Massive crowd, predictable medical demand

The Traslación has repeatedly drawn millions of devotees across recent years, representing one of the largest annual religious gatherings in the Philippines.

According to official tallies released after the 2025 event, 8,124,050 devotees participated in the feast’s activities, including the procession itself, based on monitoring by Quiapo Church, with millions attending the procession that took more than 20 hours to complete.

The sheer scale of this crowd places sustained demands on emergency medical services in a relatively compact urban setting, where temperature, movement, and density converge.

Consequently, health authorities and emergency responders have long anticipated that hundreds of people will require medical assistance during the event.

During the 2024 Traslación, the Philippines Red Cross reported that nearly 400 devotees needed medical assistance during the procession day, according to ABS-CBN News.

Although this count alone does not capture all responses, it highlights the recurring pattern of heat- and crowd-related medical cases that surface yearly during the feast.

Heat, exertion, and the body’s limits

Medical science clearly explains why heat exposure, especially during continuous physical exertion, produces specific risks.

According to the US Centers for Disease Control and Prevention (CDC), heat-related illnesses encompass a spectrum of conditions including heat cramps, heat exhaustion, and heat stroke, all triggered by the body’s inability to cope with environmental heat and sustained exertion.

Symptoms range from heavy sweating, nausea, dizziness, headache, and fatigue (typical of heat exhaustion) to more critical signs such as confusion or loss of consciousness in heat stroke, which can be life-threatening without prompt medical care.

Heat syncope (fainting due to overheating) and dehydration are also common features of heat strain. CDC guidance underscores that heat stroke is a medical emergency requiring immediate cooling and medical attention, as delays can lead to organ damage or death.

Public health literature further explains that crowd density and limited airflow in mass gatherings can amplify heat stress by reducing heat dissipation from the body, increasing the risk of heat illness among participants.

Furthermore, the World Health Organization (WHO) highlights extreme heat as a significant health hazard worldwide, noting that heatwaves and hot weather can increase heat-related deaths and burden health systems.

WHO data indicate that thousands of heat-related deaths occur annually, and that extreme temperatures are becoming more frequent due to climate change, underscoring the broader public health context for outdoor mass events under hot conditions.

On the other hand, health authorities clearly understand and can predict the risks of heat exposure, which is why the DOH and other agencies emphasize readiness and prevention.

In the context of Traslación, both hydration and early recognition of symptoms, such as dizziness, nausea, thirst, and weakness, are key to preventing escalation to more serious conditions like heat stroke, as advised by public health authorities.

Crowds, density, and compounded risk

While heat exposure explains many physiological risks, crowd size and density introduce additional complexities.

A peer-reviewed study in the Philippine Journal of Science on the Black Nazarene procession documented the extreme crowd densities that can occur as devotees follow the moving icon, complicating both movement and emergency access.

Another academic analysis of the procession’s crowd dynamics highlighted how narrow streets and dense clusters of participants create “risk hotspots,” where minor injuries can escalate and where responders may find it difficult to reach a sick or injured person quickly.

These crowded conditions align with broader mass-gathering health research showing that increased population density in outdoor events correlates with higher incidence of heat stress and other health risks.

A 2024 review in The Lancet Planetary Health on heat-related illness at mass gatherings emphasizes that extreme heat significantly increases the medical burden at large outdoor events unless strategic planning, preventive services, and rapid response infrastructure are in place.

Analogous research on mass sporting events shows that high ambient temperatures and sustained crowd movement lead to measurable rates of exertional heat stress and heat illness among both spectators and participants.

These findings explain why organizers of the Traslación coordinate complex logistical and medical responses despite the event’s religious nature.

2026 readiness: planning for typical and atypical emergencies

For Traslación 2026, DOH’s Code White Alert instructs DOH-run hospitals in Metro Manila and nearby regions to maintain maximum readiness for a wide range of potential emergencies, including heat exhaustion, dehydration, fainting, respiratory distress, and complications among people with pre-existing conditions.

According to the DOH, hospitals will staff and equip their facilities to receive and treat patients around the clock during the feast period, while roughly 200 DOH health emergency responders will deploy at key points along the city’s streets to provide on-site medical support.

At the same time, recent coverage confirms that the Philippine Red Cross will support the operation with more than 1,200 personnel and auxiliary medical units, including ambulances, roving medical teams, and first aid stations strategically placed along the procession route.

In coordination with local government units and other agencies, PRC plans to provide immediate medical assessment, minor treatment, hydration support, and transport to hospitals if necessary.

The PRC deployment also includes psychological first aid and welfare desks, reflecting attention to both physical and mental stresses that can arise in crowded, heat-exposed environments.

This multi-agency preparedness model reflects lessons learned from past events and broader public health research on mass gatherings, where layered medical coverage, from street-level first aid to hospital readiness, reduces preventable emergencies and mitigates more serious outcomes when they occur.

Beyond heat: crowd injuries and access challenges

Although heat stress is a prominent driver of medical cases during the Traslación, it is not the only hazard.

Dense crowds and jostling among devotees can cause minor injuries such as cuts, blisters, sprains, and contusions, and they can hinder medical access when someone falls or succumbs to heat stress.

Mass-gathering health studies identify crowd pressure as a risk factor for injuries and delayed care, especially when emergency teams cannot quickly reach affected individuals in tightly packed areas.

In addition, respiratory irritations and skin issues can emerge when thousands of people move together for extended periods in proximity, particularly under hot, humid conditions.

Public health literature on mass gatherings notes that large crowds can increase opportunities for communicable disease transmission when hygiene and sanitation are inadequate, even though recent Traslación events have not reported major infectious disease outbreaks.

Public health guidance in practical terms

With these risks in mind, health authorities repeatedly stress actionable guidance for devotees.

DOH advisories recommend that physically vulnerable people, such as those with heart or lung conditions, the elderly, pregnant women, and young children, consider avoiding participation in the procession due to their higher susceptibility to heat stress and crowd pressures.

Health authorities advise all participants to hydrate early and often, carry enough water, wear loose and comfortable clothing, and watch for early warning signs of heat illness such as headaches, dizziness, nausea, or extreme fatigue.

Public health guidance from the CDC and WHO reinforces these measures, noting that early hydration and recognition of heat stress symptoms can prevent progression to more serious heat-related conditions.

If warning signs worsen or if an individual becomes confused, faint, or loses consciousness, immediate medical care is necessary, as delay can result in heat stroke or organ dysfunction.

On the other hand, such guidance must be culturally sensitive, given that many devotees interpret their physical efforts as part of a sacred commitment, sometimes leading them to overlook bodily distress until it becomes severe. Public-health messaging during the Traslación increasingly frames self-care as an expression of stewardship over one’s health and faith, a narrative that aims to bridge medical advice with devotional intent.

Latest global evidence on heat and mass gatherings

Recent international research underscores that the health challenges in Manila are not unique.

For example, a 2025 study published in Mass Gathering Medicine documented heatstroke deaths during an outdoor mass event with one million attendees in India, revealing how ambient heat combined with crowd mobility can have fatal outcomes in the absence of adequate heat-specific preparedness.

Similarly, analyses in peer-reviewed literature on heat at mass gatherings repeatedly show that elevated ambient temperature correlates with increased incidence of heat-related medical cases unless proactive mitigation strategies, including hydration access, shaded rest areas, and rapid medical response, are in place.

A 2024 study in The Lancet Planetary Health concluded that heat-related illnesses and deaths at mass gatherings could be significantly reduced through strategic planning and preventive services, including early warning systems, medical resource deployment, and crowd management, all of which are part of the DOH and PRC strategy for the Traslación.

Safety as part of devotion

The Feast of the Black Nazarene is one of the Philippines’ most beloved religious traditions, drawing millions in a collective expression of faith each January.

Nevertheless, the public-health record shows that heat stress, dehydration, crowd density, and related medical emergencies are foreseeable and manageable risks when proper preparation and response mechanisms are in place.

According to multiple sources, including DOH, PRC, and global medical research, early hydration, symptom awareness, and prompt medical care can substantially reduce preventable suffering, while layered emergency preparedness ensures serious conditions are treated rapidly.

Consequently, the strongest lesson from years of documented experience and international health science is that protecting one’s health is not separate from devotion but a necessary part of fulfilling it safely.

When devotees take care of their bodies and when emergency systems are fully prepared, the faithful can complete their vows and return home without avoidable harm , a tribute both to their personal devotion and to a public-health system attuned to the realities of mass gatherings under the sun.

Photo from Philstar Global_AFP_Ted Aljibe