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Good morning. Wendy Cox in Vancouver today.

On Tuesday, the BC Coroners Service delivered the final word on what happened last year at the end of June, when temperatures soared to record-breaking, reaching into the mid-30s in Vancouver and shattering a national high in Lytton at 49.6 degrees. The coroners service’s death review panel found 619 people died, most of them elderly and frail, most of them alone and almost all of them in their homes.

The coroners report notes the heat dome, which began June 24 and lasted a week, revealed gaps in warning systems and emergency preparedness, and underscored the growing risk of extreme weather because of climate change. Justine Hunter and Andrea Woo write today that people faced delays in reaching 911 operators and paramedics, the review found, but almost one-third of those who died were simply discovered by someone during a routine visit. In a province in which building codes are fixated on keeping warmth in, the danger of heat stroke – particularly for vulnerable populations – was not widely recognized.

But if the report did an efficient job of revealing what happened, it was far more vague about why it happened. How is it possible that, in one of the wealthiest regions of an already rich country, there was not the infrastructure in place to protect the vulnerable and lonely?

Dr. Jatinder Baidwan, Chief Medical Officer for the BC Coroners Service, said the death review panel’s report deliberately didn’t single out any agency that was not ready for the heat dome last year.

“We were specifically vague about the public agencies because we’re talking about all agencies,” he said. Cities can provide more shade and cooling centres, and official heat-warning systems need to improve. But, he said, people also need to be made aware of the dangers of heat stroke.

“It’s not a failure of the health system. It’s a failure of the way that we live,” he told reporters.

The report calls on the province to co-ordinate a heat alert response system, and to identify and support vulnerable populations. In a pre-emptive news conference on Monday, the B.C. government announced it would do just that.

Last year, British Columbia did not use the direct-to-cellphone alerting system in any of the catastrophes the province faced – heat, fires or floods – and the government was heavily criticized. Public Safety Minister Mike Farnworth now says there will be protocols for warnings about all three.

For heat, he said British Columbians will get two types of alerts: heat warnings and extreme heat emergencies. The temperatures that will trigger the heat warnings will vary, ranging between 28 degrees in the northwest to 35 degrees in the Okanagan.

The death review panel also confirmed last year’s accounts by terrified residents who tried repeatedly in vain to get through to 911 during the worst of the crisis. The panel found calls to 911 doubled, and half of them were not answered within the benchmark of five seconds. In 17 instances, 911 callers were placed on hold for an extended period of time. In 50 instances, paramedics took 30 minutes or longer from the time of the call to attend. In six instances, callers were told there was no ambulance available.

Health Minister Adrian Dix said his ministry has added 125 paramedics and 42 dispatchers since last June, but he acknowledged that COVID-19 is taking its toll on the health care system, with roughly 15,000 health care workers off at least one day last week.

The coroners’ report recommended that by next year, the provincial government provide rebates to anyone renovating their homes to include cooling measures and that by 2024, the BC Building Code incorporates cooling measures as mandatory in new housing construction.

Some of that is already being done, at least in Vancouver and North Vancouver where those cities will require either air-conditioning or cooling through heat pumps within a few years. That has meant that kind of equipment is already in short supply for builders, Frances Bula reports.

Preserving and increasing the tree canopy and park space – another report recommendation – within cities such as Vancouver, which are aggressively trying to densify, is also proving a challenge.

A green parasol of trees can reduce a street’s temperature by 10 to 15 degrees, but it takes time for a tree to mature enough to provide real protection. In Vancouver, even the space for enough dirt to support large trees is being squeezed out by other demands. In an effort to speed permitting for new housing, the city embarked on a pilot project that made it easier for developers to remove smaller trees. This week, city staff recommended the project be halted after reporting that 640 trees had been removed in a single year of the pilot.

Health columnist Andre Picard writes today that events such as a heat dome can be a deadly gut punch, especially to seniors.

“In the coming years, climate change will likely prove our single biggest public health challenge. In our aging society, that will be especially dangerous to elders. We owe them more than retrospective reports cataloguing the body count. We need to invest in prevention and mitigation, and urgently.”

This is the weekly Western Canada newsletter written by B.C. Editor Wendy Cox and Alberta Bureau Chief James Keller. If you’re reading this on the web, or it was forwarded to you from someone else, you can sign up for it and all Globe newsletters here.