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agricultural workers in punjab who have to labor in 45°C (113°F) plus heat are losing their teeth as their bodies prioritise cooling through respiration and minimise saliva production.

“My mouth is always dry,” he said quietly in Urdu. “Even when I drink water until I feel sick. My mouth stays dry.”

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Saliva is not just moisture. It’s a physiological fortress, a sophisticated system that most people take entirely for granted until it fails them. For anyone, but especially for people doing physically demanding work in extreme conditions, saliva performs three critical functions that are absolutely essential to tooth survival: It buffers acids from food and stomach reflux that would otherwise erode enamel; it holds calcium and phosphate minerals, which actively remineralize tooth enamel when microscopic damage occurs; and it contains enzymes and antibodies that fight bacteria, helping prevent infection and decay.

Without adequate saliva flow — and I mean genuinely adequate, not just the minimal amount needed to swallow — teeth begin to demineralize within weeks, a process that becomes increasingly difficult to reverse.

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Increasingly erratic monsoons — along with land degradation and other issues — have also been impacting crop yields in Pakistan’s agricultural belt. (In 2025, the country’s output of major crops dropped by 13.5 percent.) Malnutrition among agricultural families has worsened significantly. According to data from Pakistan’s National Nutrition Survey, roughly 28.9 percent of children under five were underweight in 2018, and about 40.2 percent of children in the same age group were stunted. Agricultural wages for outdoor workers have stagnated while food prices have skyrocketed in recent years. Almost half of all rural agricultural families are now undernourished, struggling with food insecurity, and unable to provide adequate nutrition to their children.

One farmer described the economic reality with painful clarity: “Twenty years ago, we ate what we grew: wheat, vegetables, milk from our animals. Even in difficult years, we had this. Now I can’t afford that anymore. And I chew betel nut because it keeps me alert through the heat, keeps me working longer. My teeth pay the price for all of it. But what choice do I have?”

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My research that when workers in their late twenties and early thirties lose functional teeth, they don’t just lose the ability to chew solid food, though that’s devastating enough. They are fundamentally unable to do their jobs effectively. Agricultural and other manual labor is physically demanding, and, since tooth loss makes it hard for them to eat properly during long work days, their energy levels drop. Physical endurance diminishes. Productivity decreases significantly. Wages drop accordingly.

Additionally, there’s a stigma associated with having bad or no teeth. One of my patients, a 26-year-old construction worker in Faisalabad, who has lost four front teeth and has six others that are showing severe decay, described it this way: “Contractors see you and assume you’re weak, unreliable, physically breaking down. I lost three job opportunities after they saw my teeth. They literally told me they couldn’t hire someone who looked that ill.” He’s now unemployed, living with his parents at an age when he should be establishing his independence. “My friends joke that I look like I’m 60,” he said, with the weariness of someone who’s heard that comment one too many times.

Nasreen, another patient from Lahore, who used to work in construction but shifted to domestic work as her tooth loss progressed, says her condition, which has affected her speech (the loss of front teeth disrupts the ability to pronounce labiodental sounds like “f” and “v”), is costing her domestic work opportunities as well. Households hiring for in-home roles have turned her away, telling her she appeared “unclean.” Nasreen told me she stopped going to the market — the central gathering place for her community. “People stare,” she said. “In my community, a woman without teeth is considered unmarriageable. It’s not stated explicitly, but everyone knows it. My younger sister’s marriage prospects are affected too, because people talk. They wonder if there’s something genetically wrong with our family.” Nasreen used to earn 800 Pakistani rupees (about $2.85) a day as a construction worker; now she makes 400 rupees (roughly $1.45) a day, a 50-percent reduction that her family can barely absorb.

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When a 28-year-old loses the ability to eat, speak clearly, smile, and work because of a climate crisis created primarily by high-emission countries on the other side of the world, that’s not just a dental issue, it’s a manifestation of environmental racism and climate apartheid. And it demands urgent recognition and immediate response.

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What gives me genuine hope amid this, however, are the community responses emerging organically without government support.

In 2023, in the Punjab village of Chak Beli Khan, for instance, a local health worker named Shabana Khan started organizing work shifts that avoided peak heat hours — a simple intervention based on understanding that the worst heat occurs between 11 a.m. and 4 p.m. Shifting work hours from the traditional 6 a.m. to 2 p.m. schedule to 4 p.m. to midnight helped farmworkers reduce their peak heat exposure significantly. Crucially, it also improved their hydration capacity; workers can actually retain fluids better when working in cooler hours, when their bodies aren’t in constant crisis mode trying to cool down.

I’ve documented the results of this intervention over a period of two years: Two workers reported improved oral health six months in. More significantly, their saliva pH readings improved from an average of 5.1 — dangerously acidic — to 6.2, moving into healthier territory. Word spread through the region. By the following harvest season, eight surrounding villages had adopted similar work schedules. It’s not a perfect solution — the work remains physically demanding, and wages haven’t increased — but it’s a real improvement from their previous work situation, and it emerged from on-the-ground wisdom.

Similarly, in Faisalabad, a local microfinance and community health organization operating with limited resources began providing subsidized water stations and electrolyte solutions to agricultural laborers during harvest season to help their bodies retain fluids and maintain proper chemistry. It has made a measurable difference.

One patient told me, “My mouth felt different within weeks — less dry, less burning sensation, like my mouth was actually producing moisture again.” His saliva test showed improved chemistry across multiple markers. After I documented results in 15 workers there and helped the organization understand the clinical significance of what they were observing, the organization began lobbying provincial agricultural authorities to fund the work as an official worker-safety program. The group is now building the case for funding by compiling clinical evidence and lived testimony.

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But even these emerging solutions are, in truth, band-aids applied to a systemic wound that requires major intervention, both nationally and at the global level. What’s genuinely needed is policy change on multiple fronts: government-supported mobile dental clinics in agricultural zones with expertise specific to climate-related oral disease; binding workplace regulations for shade structures and mandatory hydration protocols during extreme heat; food-security programs that support truly nutritious food access in rural communities and don’t depend on cheap, processed foods; targeted health insurance, specifically for agricultural and other outdoor workers, covering both preventive and restorative dental care; and finally, climate-adaptation planning that centers human biology and human dignity, not just infrastructure and economic metrics.

Rashid came back to my clinic recently, his face showing the toll of another harvest season. We discussed implants as a long-term solution, knowing full well that he cannot afford them — the cost is prohibitive for an agricultural laborer earning 400 to 500 rupees a day. Before he left my clinic that day, I asked him what he’d want people to know about what’s happening to him and others like him.

Yayoi Kusama