Winter's Shadowy Fingers

January is when systems creak

Photo by Fabrice Villard on Unsplash

Cold Homes, Cold Bodies

Every winter, fuel poverty affects millions of UK households. It disproportionately affects older adults, single parents, and, owing to their reduced capacity to earn, people with chronic illness.

People living in cold housing are at increased risk of respiratory infections, including pneumonia, cardiovascular events, including heart failure, hypothermia and excess winter mortality.

Of course, other factors, such as the winter viruses, take their toll.

In the UK, excess winter deaths (EWDs) are calculated by comparing the number of deaths in the winter months (Dec–Mar) with the average of non-winter months (Aug–Nov and Apr–Jul). Historically, England and Wales saw 20,000–50,000 excess winter deaths per year before the pandemic, rising with severe seasonal conditions. In one recent winter (2020–21), there were about 60,760 excess winter deaths, partly due to COVID-19 alongside cold exposure.

Estimates attribute around 4,700–5,000 excess winter deaths per year directly to cold, damp homes in England, Scotland and Wales — a marker of fuel poverty and deprivation. Previous analyses suggest about 10% of excess winter deaths are directly linked to fuel poverty and 21.5% to cold homes specifically.

A UK analysis found that in the last decade, a quarter of a million older people died from cold-related illness — roughly one older person every 7 minutes — with poor housing a key driver. A Europe-wide study estimated approximately 363,500 deaths annually from cold exposure.

Winter places stresses upon healthcare systems. The sometimes critical increases in respiratory virus infections mean that the services are less able to cope with diseases associated with cold housing. There is a knock-on effect.

Further, children from cold homes have higher rates of asthma exacerbations and missed school days.

Winter in the Northern Hemisphere involves some of the richest countries on Earth. Still, there is fuel poverty, homelessness, suffering, morbidity and increased mortality. Resources that could help the poor and unsheltered are being hoarded by a small percentage of the population.

The excess deaths seen in winter are not a meteorological or even a purely medical phenomenon. They are a social problem.

Like poverty, cold is not a lifestyle choice.

Deprivation as a Multisystem Disease

The effects of poverty upon health can be seen as poverty behaving like a chronic inflammatory state. Poverty is associated with poor nutrition and reduced access to health care. Each has drastic effects upon the well-being of the poor.

Nutritional deficiencies can lead to poor health. Calories are cheap, so obesity is more likely among the poorer population. Dietary inadequacies can lead to poor tissue repair, immune system inefficiencies and specific vitamin and amino acid deficiencies.

The everyday problems of poor accommodation, poor nutrition, inadequate clothing and fuel poverty lead to chronic stress. The consequent rises in cortisol and sympathetic tone can lead to an increased risk of cardiovascular disease and diabetes.

Reduced access to preventative care makes common diseases more likely and delayed presentation leads to more advanced disease when help is sought.

Of course, the poor are more exposed to seasonal changes.

Why are there more deaths in winter?

Cold makes things worse.

When cold exposure contributes to excess mortality, it typically does not appear on the death certificate as “cold”, but acts as a trigger or exacerbating factor for other conditions.

The main causes associated with cold exposure are increases in cardiovascular deaths, such as heart attacks and strokes, and in respiratory deaths, such as from pneumonia and COPD exacerbations (cold stress and indoor crowding in winter facilitate respiratory infection and airway strain).

Influenza and other seasonal viruses contribute significantly to winter mortality.

Lower temperatures, icy conditions, and decreased mobility increase fall risk in older, more frail adults. Falling might mean a fractured hip, and, unless help is quickly to hand, a simple fall might lead to hypothermia.

Vulnerable populations.

Cold-related mortality is heavily concentrated in groups with less capacity to adapt. By far the majority of cold victims are from the 65 and over age group. People in poor housing, with a higher indoor exposure to cold, and those with heart and lung problems are also at risk from the cold.

Homeless people and people with insecure housing living in an exposed environment without adequate protection are a further risk group (exact UK homeless cold-death statistics are sparse but clinical and shelter data indicate a very high vulnerability).

Long COVID: what we understand better now.

With greater experience of the Long COVID syndrome comes a clearer definition and a clearer sense of scale.

The WHO now frames “post-COVID-19 condition” as symptoms starting within 3 months of infection and lasting at least 2 months, and estimates about 6 in 100 infected people develop it. A key shift is accepting that “long COVID” is likely to be several overlapping conditions, not one illness.

Several clinical presentations are now recognised, such as dysfunction of the autonomic nervous system (dizziness on standing, heart-rate changes), neurocognitive impairment, and exercise intolerance.

There are several possible ways that COVID can cause long-term health problems. Damage to the immune system and a subsequent chronic inflammatory response can keep symptoms going after the initial infection has resolved. Viral persistence or antigen persistence in some tissues is another possibility under serious consideration.

Damage to the linings of, and micro clots within, small blood vessels has been suggested as one possible contributor to fatigue, breathlessness, and exercise intolerance. Disruption of the autonomic nervous system would explain dizziness, palpitations, temperature intolerance and fatigue often seen post-COVID.

Management of the various Long COVID presentations needs to be tailored not only to the presentation but also to the individual. Symptoms often improve over months, but a meaningful minority have prolonged impairment.

Antimicrobial drug resistance.

Resistance to antibiotics and similar drugs used to fight infection is growing. This puts everybody at risk.

The UK health Security Agency reports that in England 2024 there were nearly 400 antibiotic-resistant infections per week, with estimated deaths in people with a resistant infection rising from 2,041 in 2023 to 2,379 in 2024.

This is not a theoretical problem. It means longer hospital admissions, fewer oral options, more IV therapy, and “routine” infections becoming complicated and possibly fatal.

We need better antimicrobial stewardship in order to slow the development of resistant infections and to allow our current antibiotics to remain effective.

The UK’s AMR National Action Plan 2024–2029 aims to reduce the need for antibiotics, optimise their use, and support new treatments and diagnostics options.

Think of stewardship as preventing avoidable exposure and protecting future effectiveness, while still treating serious infection promptly.

This means choosing the right drug, right duration, right indication. Shorter effective courses are preferable where evidence supports their use and we must avoid “just-in-case” antibiotics for clearly viral infections.

Without these measures, currently manageable infections can become much more serious and surgical operations at present made possible by of the availability of effective antibiotics will become unsafe or impossible to undertake.

What can we all do to help?

• Don’t seek antibiotics for colds/flu-like illness unless red flags develop.

• Don’t keep leftovers.

• Don’t share antibiotics.

• Finish the prescribed course.

• Accept offered vaccinations.

• Make sure your indoor environment is well-ventilated.

New Flu strain emerging.

Reports in the British Medical Journal have shown an increase in flu cases in the UK, mainly among young adults and school children. This appears to be due to a new H3N2 strain, which has mutated several times over the summer and so increased in severity.

Though this is not an entirely new strain, there are sufficient differences for it to side-step community immunity and vaccine cover. That is side-step, not dodge. Existing acquired immunity still offers some protection, and this can be ‘topped up’ by this year’s vaccine.

The advice remains as before: take sensible precautions to avoid spread, use masks in public places, wash your hands and ... get vaccinated.

Resources:

Keeping People Warm

Fuel poverty is one of the most preventable winter health risks.

• National Energy Action - Advice, advocacy, and direct support for households struggling to heat their homes.

• Citizens Advice - Eligibility checks for energy grants, benefits, debt advice, and crisis support.

• GOV.UK – Winter Fuel Payment & Cold Weather Payment - Direct financial support for older people and low-income households during cold spells.

• Energy Saving Trust - Advice on insulation, heating efficiency, and grants that reduce long-term cold exposure.

Health, Ageing & Vulnerability

• Age UK - Winter warmth programmes, befriending services, benefits advice, and local outreach.

• NHS – Stay Well This Winter - Vaccination, respiratory illness prevention, and advice for carers and vulnerable adults.

• Royal Voluntary Service - Volunteers delivering food, companionship, and support to isolated older people.

• Trussell - Volunteers delivering food parcels, foodbanks around the UK

Small actions matter.

Keeping one home warm, reporting one person sleeping rough, or helping one older person access support does not solve poverty, but it can prevent illness, hospitalisation, or death - and it matters to that one household, that one person.

Cold is a risk factor we know how to treat.