Mobilizing extreme cold response plans for people experiencing homelessness

Although climate change is expected to lead to warmer winters in general, evidence shows that rapid arctic warming is contributing to an increase in extreme cold events. These events can be a challenge for anyone to stay safe and warm, but for those experiencing homelessness, extreme cold is more likely to be deadly. This blog explores factors that exacerbate the health risks of extreme cold events for people experiencing homelessness such as frostbite and hypothermia, discusses the evidence on mobilizing extreme cold response plans to reduce such risks, and examines additional environmental health risks that may arise during an extreme cold event.

What is homelessness?

According to a report from 2016, approximately 235,000 Canadians experience homelessness in a given year. Many advocates have acknowledged that this is likely an underestimate, as it fails to account for all individuals who experience homelessness but do not come in contact with the shelter system. The experience of homelessness is wide-ranging and far from uniform. Aside from those staying in shelter environments, homelessness can also refer to individuals who are:

1. Unsheltered: Living in vehicles, vacant buildings, parks, or other places not designed for permanent habitation
2. Provisionally Accommodated: Staying temporarily in transitional housing, hotels or hostels, friends’ or family’s places (“couch surfing”), or in institutional settings like hospitals and jails, without an immediate prospect for permanent housing

Why are those experiencing homelessness particularly vulnerable to extreme cold?

People who are unsheltered may face particularly severe risks during extreme weather, as they may be outside for longer and more frequent periods, resulting in increased exposure. However, all types of homelessness increase vulnerability to extreme cold due to a wide range of economic, social, biological, and behavioural factors. For example, individuals experiencing homelessness may lack access to things like seasonally appropriate clothing, food, or first aid items, which can leave people underdressed, malnourished, or dealing with an untreated injury or infection, reducing the capacity to tolerate cold exposure. People without cars and without money for transportation may have to travel long distances on foot to access basic needs services, increasing exposure to the cold. In terms of social factors, those without housing may be subject to laws, land-use regulations, and social stigma that force them out of public areas or prevent them from accessing safe places to shelter from extreme cold. Alcohol and medications for certain diseases can affect thermoregulation, and lead to greater susceptibility to extreme cold, as can some chronic illnesses. This is notable as individuals who are homeless are often at increased risk of chronic illnesses, including substance use disorders. Finally, the often stressful experience of homelessness can exacerbate mental health concerns which may increase vulnerability to extreme cold.

As people experience homelessness differently, these factors will be relevant to some more than others. Nonetheless, the interaction between these factors must be considered in any response to extreme cold.

How many people experiencing homelessness are affected by extreme cold?

While there is no cumulative data available as to how many people experiencing homelessness die from cold exposure in Canada, a study out of Toronto identified 79 non-fatal and 18 fatal cases of hypothermia among those experiencing homelessness between 2004 and 2015. However, this is likely an underestimate as the study only reviewed Emergency Department records from select hospitals in the city, and 19% of homeless individuals who presented to the hospital with apparent hypothermia left before being seen or formally diagnosed by a doctor. Few jurisdictions track the number of cold-related deaths among those experiencing homelessness; much of what is shared with the public comes from news reports.  As of February 2022, cities across the country, including Montreal, Toronto, and Windsor have already reported multiple deaths from extreme cold exposure this winter alone.

What are extreme cold weather response plans?

Extreme cold weather response plans vary from place to place and depend largely on the local climate and demographics. Often, smaller communities lack the resources to implement such plans. In places where they have been implemented, plans typically consist of one or more of the following elements:

• An extreme cold weather alert system that is triggered when certain meteorological conditions are met;
• Opening extreme weather response shelters and warming centers (also called “comfort centers” in some places);
• Extending outreach services (e.g., checking in on individuals who are unsheltered, encouraging them to seek shelter, providing safe transportation to shelters, and/or providing them with supplies to stay warm);
• Health promotion activities that promote awareness of the risks of extreme cold and educate the public on how to best prepare.

The groups involved in these responses and their roles in carrying out these plans often vary across provinces and municipalities. For example, in British Columbia, BC Housing (a provincial Crown corporation) manages the Extreme Weather Response (EWR) program and provides funds to community-based services to open temporary emergency shelter spaces during periods of extreme winter weather. In the event of extreme cold, a community representative will issue an extreme weather alert, enabling their community to activate their annual community plan to temporarily increase capacity of emergency shelters. The plan outlines the procedures for how to call an extreme weather alert, identifies who needs to be contacted during an activation, the roles and responsibility for community organizations and service providers, and describes the services EWR sites will provide and their hours of operation.  In BC, issuing an extreme weather alert also activates the Assistance to Shelter Act for the duration of the alert, which grants local police and RCMP the capacity to assist persons experiencing homelessness to a shelter.

In other provinces (e.g., Alberta), certain municipalities manage their own cold weather response plan. The City of Edmonton, for example, works in collaboration with Homeward Trust Edmonton and other community agencies to establish protocols and coordinate efforts to respond year-round to severe weather conditions. Activation of an extreme weather alert is part of the city’s Sector Emergency Response plan. One of the services the city provides is their Winter Warming Bus Route, which tr­ansports people from transit centers and other critical locations to emergency shelters during extreme weather conditions.

When should extreme cold response plans be triggered?

There is little consensus on when and for what criteria extreme cold response plans should be triggered. The threshold at which alerts are issued differs from place to place, and typically is determined by local temperature norms, population acclimatization to cold weather, and the overall preparedness of the public. Environment Canada’s wind chill hazard index is a good resource for better understanding the relationship between temperature and the risks of hypothermia and frostbite, though it is unclear whether particularly vulnerable populations are factored into their risk assessments.

There also remains a knowledge gap in terms of when alerts should be triggered ahead of the forecasted temperature. The few studies that have examined this suggest issuing triggers earlier and for a wider range of meteorological conditions to reduce cold-related injuries like hypothermia and frostbite in vulnerable populations like the homeless. For example, a study by Zhang et al. that examined the risk of hypothermia among individuals experiencing homelessness in Toronto found that 72% of all hypothermic events occurred when the minimum daily temperature was warmer than -15°C (the temperature at which extreme cold alerts are typically triggered in this city). While relative risk for hypothermia was highest for the coldest observed days, there were far more moderately cold days over the course of the winter seasons resulting in a greater number of hypothermic events overall. There has also been advocacy for shifting to a year-round extreme weather response plan (some plans are only in effect for a set period of time, e.g., November 15- April 15) as abnormal cold events have begun to happen more frequently outside of the typical winter season due to climate change.

What are the environmental health considerations during extreme cold?

In addition to addressing the risks posed by hypothermia or frostbite, cold weather response plans should also consider the environmental health risks that can arise during an extreme cold event. There are many individuals who may choose not to seek support through the traditional shelter systems. Those that sleep in their vehicles, tents or other make-shift shelters could face additional health risks, such as smoke inhalation, burns, or carbon monoxide poisoning, from trying to heat enclosed spaces through fires or other heating devices. The needs of these individuals must be considered during extreme cold response planning. Supports can include sharing educational resources, like this tip sheet, as well as direct outreach with supplies like warm clothing, blankets, hot beverages, and hand warmers before and during extreme cold events.

For individuals in the shelter system, environmental health risks can arise when an extreme cold event overlaps with severe winter weather like a snow or ice storm. Storms such as these can lead to staffing shortages and power outages, both of which can cause challenges to maintaining healthy and hygienic environments for service users and operators alike. Storms can also cause interruptions to waste disposal services, which can create health and sanitation problems if not addressed quickly.

Lastly, cold weather response plans must also account for the COVID-19 pandemic at present, other seasonal respiratory viruses that are more common during winter months, and respiratory diseases such as tuberculosis. Over the past two years, some shelters were forced to close due to outbreaks of the coronavirus, leaving many without shelter overnight during cold weather, and in one case, resulted in a death. While shelters and homelessness services have adapted their spaces and operations to reduce the risk of COVID-19 transmission, contingency plans should also be in place to support both populations served by shelters that have had to close due to an outbreak, and increased demand for services during an extreme cold event that might quickly lead to overcrowding.  

Summary

Those experiencing homelessness face a disproportionate impact from extreme (and even moderate) cold weather for a number of social, economic, physical, and ultimately structural factors. However, as data remains limited, it is unclear whether cold weather response plans are adequately and effectively serving those experiencing homelessness. Knowledge gaps remain as to when and for what criteria extreme cold response plans should be triggered to reduce cases of frostbite and hypothermia. More research and dissemination is necessary to determine best practices for extreme cold plans that address the specific needs of those experiencing homelessness.