NU733 Unit 1 Issue Analysis, Homelessness Deaths Example

Seventy-One Deaths, Nine From Cold: An Issue Analysis of Mortality and Cold Injury Among People Experiencing Homelessness in Composite Port Hadley, With the Numbers First and the Ethical Questions Last

[Student Name]

Purdue University Global

NU733: Ethics, Policy, and Advocacy for Population Health

Unit 1 Issue Analysis

[Instructor Name]

[Date]

Port Hadley and every local figure are composite; numbers are bracketed placeholders for the values the named local sources would supply.

Deaths

The county medical examiner records deaths of people known to be experiencing homelessness at the time of death. From [2019] through [2024], the annual count rose from [38] to [71]. In [2024], overdose caused [41] of the [71] deaths, hypothermia [9], trauma [8] and medical causes the remaining [13]. Overdose has been the largest single cause in every year since [2020].

The pattern resembles what has been found elsewhere. A study of homeless adults in Boston over fifteen years found that drug overdose, cancer and heart disease were the leading causes of death, with overdose accounting for a third of deaths among adults under 45 and opioids implicated in most overdoses (Baggett et al., 2013). A review of health among homeless people in high-income countries described markedly higher mortality than in the general population, driven by infectious disease, substance use, mental illness and chronic conditions often diagnosed late (Fazel et al., 2014).

The medical examiner's count has limits. It depends on investigators recording housing status, which is sometimes unknown, and deaths of people who were recently housed or staying with others may be missed. The count is therefore more likely to be low than high.

How Many People Are Homeless

The federal point-in-time count, taken on one night in late January, found [1,904] people homeless in Port Hadley in [January 2025], [612] of them unsheltered. The county's coordinated entry list, which records everyone assessed for housing services over a year, shows [1,140] people who were unsheltered at some point in [2024]. The two figures answer different questions. The point-in-time count is a snapshot of one cold night, when some people who usually sleep outside find shelter; the annual list captures movement in and out of homelessness. Using only the snapshot would understate how many people experience unsheltered homelessness over a year.

Cold Injury

The county hospital recorded [23] admissions for frostbite among patients experiencing homelessness over the [2024 to 2025] winter, and [11] of them ended in amputation of fingers or toes. Most occurred on nights when the temperature fell well below freezing, which matches research elsewhere. In Toronto, a study of hypothermic events among homeless individuals found that the odds of an event rose by about 1.64 times for every 5 degrees Celsius drop in the day's minimum temperature (Zhang et al., 2019). Hospital data capture only those who reached the hospital; cold injuries treated in the field or not treated at all are missing.

Shelter Capacity

The city's emergency shelters had [1,180] year-round beds in [2024], plus [150] seasonal beds opened when the overnight temperature is forecast below [15] degrees Fahrenheit. On the point-in-time night, [1,292] people were sheltered, which exceeded year-round capacity and filled most seasonal beds. Occupancy data from the two largest shelters show that single-adult beds were full on [81] percent of winter nights, while family units had occasional vacancies. Outreach logs for the same winter record [340] occasions on which a person declined an available shelter bed, and the reasons given, which Unit 4 will examine, included separation from a partner, rules about pets and curfews that conflict with night work.

Capacity figures matter to this analysis because they limit what any enforcement policy can achieve. If beds are full on most winter nights, moving people from one outdoor location to another does not move them indoors. The figures also show that the problem is not only the number of beds but whether available beds fit the people who need them.

How the Count Has Changed

The rise from [38] to [71] deaths did not occur evenly. Deaths were roughly flat from [2019] to [2021], then rose sharply in [2022] and [2023], the same years in which the county's overall overdose deaths increased and the unsheltered count grew by about [40] percent. Hypothermia deaths ranged from [three] to [nine] a year without a clear trend, but the [nine] in [2024] followed a winter with [eleven] nights below zero degrees Fahrenheit, more than in any of the previous five winters. Year-to-year changes in small counts should be read with caution, since a difference of a few deaths can reflect chance.

A Rough Comparison of Death Rates

Dividing the [71] deaths by the [1,140] people on the annual unsheltered list, or by a broader estimate that includes people in shelters, gives a crude death rate far above the city's adult rate of about [1,050] per 100,000. Using the annual list alone yields about [6,200] per 100,000. That figure is unadjusted for age, sex or the true size of the population at risk, which is uncertain, and it should be labeled as a rough indicator of scale rather than a precise rate. Because the homeless population is younger on average than the city's adults, an age-adjusted comparison would likely show an even larger gap.

The numbers show a rising count of deaths, most of them preventable, and a winter that cost eleven people part of their hands or feet.

What the Numbers Do Not Show

The data do not show why deaths rose between [2019] and [2024]. Possible explanations include a more potent drug supply, a growing unsheltered population, changes in shelter capacity and changes in how the medical examiner records housing status. The data also do not show which deaths might have been prevented by any particular policy. Those questions require analysis beyond counts.

Four Questions the Evidence Raises

Only now does the analysis turn to ethics, because the figures raise questions that data cannot answer.

First, what does a city owe people who sleep outside on nights cold enough to cost them fingers and toes? Second, when a public health measure such as clearing an encampment protects some residents, how should its costs to the people displaced be weighed? Third, who should decide how enforcement of camping laws is carried out, and whose voices are missing from those decisions? Fourth, when the most common cause of death is overdose, how should harm reduction be balanced against the goal of moving people indoors?

These questions shape the rest of the course, and each will be taken up with an ethical framework, the relevant law and the people with power to act.

References

Baggett, T. P., Hwang, S. W., O'Connell, J. J., Porneala, B. C., Stringfellow, E. J., Orav, E. J., Singer, D. E., & Rigotti, N. A. (2013). Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Internal Medicine, 173(3), 189-195. https://doi.org/10.1001/jamainternmed.2013.1604

Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high-income countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. The Lancet, 384(9953), 1529-1540. https://doi.org/10.1016/S0140-6736(14)61132-6

Zhang, P., Wiens, K., Wang, R., Luong, L., Ansara, D., Gower, S., Bassil, K., & Hwang, S. W. (2019). Cold weather conditions and risk of hypothermia among people experiencing homelessness: Implications for prevention strategies. International Journal of Environmental Research and Public Health, 16(18), Article 3259. https://doi.org/10.3390/ijerph16183259