Recommendations For the Homeless and Hypothermia
There are many different factors that determine an individual’s vulnerability to hypothermia. The result is that health experts cannot predict how long a person can safely remain outdoors at various temperatures. According to Dr. James J. O’Connell from the Boston Health Care for the Homeless Program (BHCHP), the most dangerous cases of hypothermia do not occur when the ambient [surrounding] temperature is far below freezing. Instead, Dr. O’Connell says, the worst cases they see arise when the days are warm (between 40o F and 50o F) and the nighttime temperature drops to the mid-30s.

Life-threatening cases of hypothermia often occur when the ambient temperature is between 32o F and 40o F. For example, the most drastic case ever seen at the BHCHP, in which a homeless man was brought in with a body temperature of 57 o F, occurred when the temperature was greater than 50o F during the day and fell to 36o F at night.

In order to protect their homeless citizens from extreme cold, cities must organize and fund a winter response plan that provides enough extra beds to accommodate the increased need of the season. Dr. O’Connell asserts that “all cities should have a plan well in place” before the cold weather arrives. Temperature cut-offs should be avoided, since the effectiveness of a shelter is decreased when the population it serves does not know, from night to night, whether the shelter will be open. If a temperature cut-off is necessary, due to financial or other reasons, the cut-off should be at least 40o F in order to prevent the most dangerous cases of hypothermia, according to Dr. O’Connell. If it is possible to keep services open every night during the winter, regardless of temperature, the winter season should be defined as October through April. This allows homeless people to find shelter during the transitions from fall to winter and from winter to spring, which Dr. O’Connell acknowledges is a very dangerous period for homeless people.

A comprehensive approach is necessary in order to make city-funded winter response plans as effective as possible. When a homeless population has nowhere to take refuge indoors, it is threatened by low daytime temperatures as well as nighttime cold. Winter services must be available throughout the day, and cities must have adequate space in day centers to accommodate people who would otherwise remain outside until nightfall. If there is no day center in an area, shelters in that area must open during the day, at least when the temperature falls below 40o F.

Additionally, winter services must be available to all homeless persons, without restrictions. Naturally, people who are violent, threatening, or exceedingly disruptive may be excluded from shelters for the safety of others. However, past bans and other restrictions should be waived on nights when the temperature is lower than 40o F. Most importantly, every city must make winter shelter space available for people who have been consuming alcohol or other drugs. The risk of developing hypothermia is greatly increased for those who have been using substances, especially alcohol. People who are inebriated must be allowed to spend the night indoors during cold weather. If needed, they may be separated from those who are sober, as long as they can remain safe and warm.

Local governments should play a large role in the improvement of winter homeless services. Every state and every major city should have a winter plan in place detailing options for shelters, day centers, and emergency transportation, as well as increased outreach and distribution of blankets and warm clothing. This plan should be revised yearly, before the start of the winter season. Additionally, the government should allocate funds to winter services if there is not enough shelter space to meet the nightly demand.

It must be understood that we do not write this report to criticize existing winter services that are imperfect due to funding or other circumstances out of their control. Limited services that cannot be open reliably or cannot accommodate everyone whose needs are certainly better than no services at all. However, all homeless service providers must be constantly trying to improve.

Conclusions
The homeless population is at greatly increased risk for hypothermia and other cold- related conditions. This risk is even higher from those who suffer from substance addictions, mental illness, or other physical illnesses. Even if they do not die from these conditions, their risk of death from future unrelated conditions is greatly increased.

Homeless service providers and governments have the responsibility to protect their homeless citizens through state- and city-wide winter plans and increased shelter availability. An exemplary winter shelter would be open 24 hours each day between October 1 and April 30, regardless of temperature, as well as any other days during the year when the temperature falls below 40o F. It would also admit all homeless people, regardless of sobriety status or past bans, unless they are violent or causing an extreme disturbance.

Though many of the providers we interviewed had impressive winter services, many others were inadequate in some way. In some cases, this is a challenge that must be met by providers themselves; in others, it is the result of a lack of funding. In such situations, both the state and federal government must provide sufficient and lasting resources and services to its homeless constituents.