HEAT’S HIDDEN RISK

The Washington Post

By Shannon Osaka, Erin Patrick O'Connor and John Muyskens

Sept. 6, 2023

PHOENIX

On an isolated street a few steps from the looming, cactus-peppered slopes of South Mountain, there was nowhere to hide from the heat. It was one o’clock on a Thursday in July 2022, and temperatures had already climbed to around 109 degrees. The sun scorched the surface of the road, sending waves of heat up into the stagnant air.

And Stephan Goodwin was walking right through it.

Goodwin, a 33-year-old with schizophrenia, was heavyset with a bald head that had already begun to blister from the sun’s rays. Two days earlier, he had left the home he shared with his girlfriend and her father, carrying a gallon of water and a drawstring bag with some clothes, a pillow, deodorant and two guns. Now, the jug of water was empty, the last drops evaporating in the midday sun. He had taken off his shirt, perhaps in a misguided attempt to stay cool.

He took a step forward, then back. His feet seemed to catch on each other. On either side of the road, sprawling suburban homes sat quietly behind fences, their air conditioners humming.

A local real estate agent, who spoke on the condition of anonymity, saw him from her car as she drove around the neighborhood searching for her cat. “Hey, do you need help?” she recalled asking.

As she watched, Stephan turned, slowly, stiffly, as though his limbs hung on strings. His eyes didn’t register her presence. Then he turned away and kept walking, toward the mountainside with its cactuses standing at attention.

The agent called 911, and then, a few minutes later, called again. “Where are you guys?” she asked. “I think he’s going to die.”

By then, Stephan had been wandering through Phoenix for over 24 hours. His final days, pieced together through police and medical examiner records, videos from the scene, text messages and interviews with family members and witnesses, show how extreme heat, even in a country as rich as the United States, turns into a lethal threat.

A photo of Stephan Goodwin with a family member at his parents' home.

Phoenix is one of the hottest cities in America. Every year, dozens of people in this Southwestern city suffer second- or third-degree burns just from coming into contact with the pavement; thousands more are hospitalized with heat-related illnesses. While air conditioning, water stations, and heat warnings shield many residents from rising temperatures, hundreds of people still die of heat here every summer — including over 300 suspected deaths so far this year.

And one factor stands out as potentially the most dangerous preexisting condition in a rapidly warming world — not just because it makes people struggle to find safety in moments of extreme heat, but also because it makes their bodies physically more vulnerable to the heat. It’s the condition that Stephan was diagnosed with in his late 20s: schizophrenia.

10 P.M. | 100 DEGREES

Stephan set out from near this neighborhood on the evening of July 12, 2022.

No one knows exactly why Stephan left home. There was an argument with his girlfriend; according to his family, he also may have been experiencing paranoia from his illness. On July 12, 2022, Stephan placed some of his belongings into a gray bag that had once held an air mattress. Around ten o’clock in the evening, he called his grandfather, Ralph Goodwin, saying that he needed to spend the night.

Ralph — a tall, deep-voiced 82-year-old — agreed. But it was late: Stephan didn’t have a driver’s license and Ralph’s eyes were too poor for nighttime driving. “Do you have any water?” Ralph recalls asking. Temperatures had fallen from the heat of the day, but it was still over 100 degrees. Stephan promised that he had a gallon of water with him, and set out on foot. He ended up spending the night at his grandfather’s house — before abruptly disappearing the next morning.

When temperatures surge, the effects of schizophrenia can be profound.

During the record-breaking heat wave in British Columbia in Canadain 2021, for example, researchers found that an astonishing 8 percent of the people who died in the heat had been diagnosed with schizophrenia — rendering it more dangerous, when combined with heat, than any other condition studied. Michael Lee, an epidemiologist at the British Columbia Centre for Disease Control and one of the study’sauthors, said people with chronic kidney disease were 36 percent more likely to die during the heat wave than in normal conditions. In people with schizophrenia, it was over 200 percent.

People with schizophrenia are more likely to be unhoused or economically vulnerable — but that’s not the only reason they are at greater risk. Drugs prescribed for schizophrenia and other serious mental illnesses dehydrate patients and make it harder for their bodies to manage high temperatures. There is also evidence that thesepatients have inherent difficulty dealing with temperature changes.“People with schizophrenia have more difficulty thermoregulating,” said Joshua Wortzel, a psychiatrist at Brown University.

In 2022, the year Stephan stumbled down the South Phoenix street, people diagnosed withschizophrenia made up 4 percent of all heat-related deaths and 4 percent of all hospital visits for heat-related illness, according to the medical examiner’s office and the public health department of Maricopa County, which encompasses Phoenix and its suburbs. Data from the public health department shows that when factoring inother serious mental illnesses — such as schizoaffective disorder or bipolar disorder — the numbers are likely to bemuch higher.

Death records and interviews with medical practitioners and family members reveal how acutely vulnerable people with schizophrenia are. There was John Bernal Jr., a 49-year-old man whose family worked hard to get him into a group home, only to have him wander away. Three days later, on Aug. 30, 2021, he was found with an internal body temperature of 108 degrees. There was Sailaja Boyilla, amiddle-aged woman recently diagnosed with schizophrenia, who was found in her car in a parking lot, having recently purchased a bottle of juice.

Their deaths show the struggle that countries like the United States face when grappling with extreme heat. In poorer countries, the battle against heat is largely about resources: access to air conditioning and electricity cheap enough to run it. But in richer countries, it’s about protecting those who can’t or won’t have access to shelter: outdoor workers, unhoused people, drug users, and those with mental illness.

The city of Phoenix’s 27-page heat response plan doesn’t include any mentions of mental illness or schizophrenia — despite the fact that David Hondula, the city’s director of heat response, co-authored a paper showing that heat is boosting hospital admissions of people with schizophrenia in the Phoenix area. Hondula declined to be interviewed for this article. The Maricopa County Department of Public Health also did not offer comment after multiple requests.

Nonprofits and medical groups struggle to help those in need. Tara Ankrah, a registered nurse at a Phoenix nonprofit called Circle the City, spends her days delivering medications, water, and care to the thousands ofpeople living on the city’s streets — many of whom have schizophrenia, bipolar disorder, or another serious mental illness. The heat, she says, is a “recipe for disaster” for those patients — and it’s getting worse. “It feels more and more hopeless every year,” she said. “More and more heat. More and more unbearable.”

12 A.M. | 100 DEGREES

A street corner near Stephan’s grandfather’s house, where Stephan spent the night.

When Stephan arrived at his grandfather’s house around midnight on the evening of July 12, he did so with a gun in each hand: a Canik semiautomatic pistol in one and a Taurus 0.357 Magnum revolver in the other. “Like it was a gunfight,” Ralph recalled.

Ralph had dealt with erratic behavior before. His son, Stephan’s uncle, had also been diagnosed with paranoid schizophrenia. He stayed calm: He placed the guns in a safe, and he set his grandson up in the spare roomfor the night.

Like many people with schizophrenia, Stephan’s symptoms began in adulthood. His mother, Darae Goodwin, remembers him as a very happy child. He was slow-moving but often smiling, prone to saying whatever popped into his mind. When he was 7 years old, he had his appendix removed, and was treated by a surgeon with a ski-jump nose. As the doctor examined him, Stephan, not known for his politeness, turned to Darae. “Mom, look at his NOSE!” he shouted.

Darae Goodwin, Stephan Goodwin’s mother, at home on the day of the first anniversary of his death.

He did not excel in school, preferring to play video games, camp in the open spaces around Phoenix, or smoke weed. He had a longtime girlfriend whom he met through a mutual friend. (She did not respond to multiple requests to comment for this story.)

In his mid-20s, though, things slowly began to unravel,family memberssaid. Stephan struggled to hold down a job, sometimes working as a landscaper, other times sorting items at the Goodwill Warehouse. He felt anxious around other people and was struck, sometimes, by unpredictable moods or fits of paranoia.

Once, when Ralph came to pick him up from a temporary job at the local Whataburger, Stephan shouted angrily at him for several minutes, spitting out combinations of words that his grandfather said he struggled to understand. Then, just as suddenly, the moment passed. “Are you all right?” Ralph remembers asking, taken aback.

“Yeah,” Stephan responded. “I’m just goofy.”

Hebegan to see and hear things that weren’t there. He told his mother that he had seen the body of a burned child in the field behind their family home. His closest friends and family, he believed, were trying to hurt him: his childhood best friend, his sister’s boyfriend, his girlfriend’s father and brothers.

“He thought everybody was out to kill him,” Darae said.

In his late 20s, Stephan checked himself into a psychiatric clinic for three days. He came out with two diagnoses: paranoid schizophrenia and post-traumatic stress disorder.

The diagnosis provided clarity but, ultimately, little help. A doctor prescribed lithium but, like many psychiatric patients, Stephan quickly stopped taking his medication. It made him feel “like a zombie,” Darae recalled him saying. She urged him many times to return to the doctor to adjust his dosage, but Stephan demurred. If he went back to the hospital, he told her, they would never let him out.

He spent his days turning over cans and bottles to the recycling center to earn enough money to buy a bit more weed,spending time with his girlfriend, or offering food and water to the homeless who roamed Phoenix’s streets. Although he still visited his family, he couldn’t stay for more than a half-hour at a time — he would pace the living room of their small trailer, mumbling to himself.

“He was scared to death,” Darae recalled.

In August of 2021, as his paranoia grew, Stephan arranged to be baptized for the second time. Darae recalls that he told his younger sister, Korina, that he was going to die soon. The baptism would help him get right with God.

7 A.M. | 97 DEGREES

A park a few blocks from where Stephan’s grandfather returned his guns.

The next morning, Stephan behaved strangely. When Ralph and his wife were eating breakfast, Stephan stood in the front yard, staring at the neighbor’s house. Then he wandered off without saying goodbye. A few minutes later, he called his grandfather from a nearby intersection: He wanted his guns back.

Ralph drove his pickup truck to the intersection, where two sprawling four-lane roads met next to a railway track. There was no shade; across the street in a vacant lot, half a dozen RVs were clustered in the hot sun.

“Get in,” Ralph said. He offered to take Stephan anywhere — to his mother’s house, to his girlfriend’s house.

Stephan refused. He just wanted his guns. But as he took both firearms from his grandfather, he seemed to understand that something was wrong. “I’m going to check myself into the hospital,” he said, suddenly. Then he turned away.

 “Stephan, wait a minute, I’ll take you to the hospital,” Ralph said desperately.

Briefly, Stephan looked his grandfather in the eyes. “Grandpa, I’m so sorry,” he said. Then he set off down the street in the hot sun. He had no water. It was early morning, and the temperature was already over 100 degrees.

Stephan may not have known it, but his body was more vulnerable to the heat baking the four-lane road.

For almost a century, scientists have known that people with schizophrenia struggle to regulate their body temperatures. In the 1930s, two doctors in Worcester, Mass., placed people with and without schizophrenia in a small, windowless room with eight electric heaters. Under hot conditions, the researchers noted,the patients with schizophrenia’sbody temperatures rose farther and faster than the control group. “Schizophrenic subjects,” they wrote later, “are unable to comply normally … with the regulation of heat.”

The precise reasons why people with serious mental illnesses — and those with schizophrenia in particular — struggle to deal with higher temperatures remain somewhat murky. Some doctors hypothesize that schizophrenia affects the hypothalamus, the brain’s inner thermostat. Schizophrenia has also been linked to problems regulating dopamine, the chemical that makes the body feel good; altered levels of dopamine can also prevent the body from effectively cooling itself off.

Some things, however, are clear. Many antipsychotic medications, which provide a lifeline to people afflicted with paranoia or delusions, also make their users more sensitive to heatstroke. Some have a side effect of suppressing sweating, which prevents the body’s natural air-conditioning system from functioning normally. Other medications, like lithium — which is often prescribed to patients with bipolar disorder or schizoaffective disorder — can become toxic and deadly if the user is dehydrated.

Then there is the tendency of patients with schizophrenia to wrap themselves in layers upon layers of clothing, even in boiling temperatures. “If you’ve ever been completely perplexed when you see someone when it’s really hot out, sitting there all bundled up — that is likely a schizophrenic person,” said Robin Cooper, an associate professor of psychiatry at the University of California, San Francisco.

Beth Darling is the medical director of a treatment team at Valleywise Behavioral Health that serves around 100 schizophrenic patients.

Beth Darling, the medical director of a treatment team in the Phoenix area that serves around 100 patients with schizophrenia, says that people with the illness are also more likely to be unhousedthan members of the general population, or to be estranged from family members or friends. They are also more likely to self-medicate with methamphetamine, fentanyl, and other drugs — substances which can also alter the body’s ability to sense and respond to extreme heat.

Shaun Dekutoski, a primary care provider in Peoria, Ariz., says the situation for people with schizophrenia is akin to a perfect storm. “The more of those risk factors you have stacked on top of each other, the more vulnerable the person is.”

And psychosis — the state in which patients lose touch with reality — is itself alsoa risk factor. Patients may experience delusions or hallucinations, forget where they are, or believe that others are attempting to harm them. Experts alsosay that people withschizophrenia lack insight into themselves and their condition — in medical terms, this is known as “anosognosia.” In the midst of a psychotic episode, patients do not know or believe that they are sick. Darlingsays that she’s seen patients check themselves out of emergency rooms and wander the streets in scorching temperatures. “They get lost, they get confused,” she said.

Under psychosis, a patient might walk for miles engaging only with the voices and characters in their own mind. Under normal conditions, that might simply be dangerous. In Phoenix, it’s deadly.

11:45 A.M. | 104 DEGREES

A witness saw Stephan wandering in a field in Laveen, Ariz.

When Darae picked up the phone, her son’svoice sounded thick. “Mom, I’m dying,” she recalls him saying. “You need to come get me.”

“Where are you?” Darae asked. Nobody had seen Stephan for almost 24 hours; the previous day, after leaving his grandfather’s house, he had made a brief stop at the home he shared with his girlfriend and her father, and then disappeared again.

More forcefully, she said, “Where are you, Stephan?”

The police incident report on Stephan Goodwin, summarizing a call his girlfriend made to the police on July 14, 2022.

Stephan didn’t know — he was confused and disoriented. But he told Darae that he could see a sign that mentioned South Mountain, a 25-square-mile park on a mountain that looms over Phoenix’ssouth side. Before Darae could ask any more questions, the line went dead.

When the body is trying to cool itself off, a few things happen at once. Sweat glands begin to work, pumping a salty liquid from beneath the skin to the surface, where it evaporates and cools the skin. At the same time, the brain sends signals to the blood vessels to dilate, pushing blood away from the hot center of the body and toward the skin to cool off. These two systems working in tandem can keep the body around 98.6 degrees — for a time.

Prolonged exposure to severe temperatures, however, tests the body. The heart has to pump faster, to circulate blood for cooling. Blood pressure drops, depriving the brain and vital organs of oxygen. The person can become dizzy or disoriented; thinking slows. As body temperatures climb to 106, 107 degrees, the proteins in the cells of the body start to break down, or denature. Intestines develop holes and leak their contents into the bloodstream. Kidneys stop functioning. The body cooks.

The medical examiner’s report on Stephan Goodwin. In both this report and one from the police, his name was misspelled ‘Stephen.’

After Stephan’s calls, the Goodwins and his girlfriend rushed to send helicopters and police officers to search the network of trails that crisscrossed South Mountain. But Stephan wasn’t on South Mountain; he was less than half a mile away from the park, stumbling through an isolated residential neighborhood.

The agent who spotted Stephan called the police around 1:15 p.m. Initially, the 911 dispatcher told her that the fire department would arrive in three or four minutes. But then the agent noticed that Stephan had a gun in his waistband. The dispatcher told her they would have to send the police instead.

The agent was still on the phone with the dispatcher when Stephan wandered off the asphalt street and onto a vacant lot belonging to her neighbor. She watched him stumble over small rocks and pieces of dirt. Then she watched as he fell, face-first, onto the hot ground.

One black tennis shoe slipped off and lay in the dirt nearby. His body twitched.

“What do I do? What do I do?” the agent asked. She wondered if she could somehow shade Stephan to protect him from the punishing sun. The dispatcher warned her not to approach. For 21 minutes, she watched and waited for the police to arrive.

The police and EMTs arrived at 1:48 p.m. The police removed Stephan’s semiautomatic pistol and turned his body over, according to a police report obtained by The Washington Post. Blood was already beginning to pool in his face and stomach, but for about 15 minutes, emergency responders attempted to revive him. They placed his head on the pillow thathe had carried with him for the past two days. Later, the medical examiner’s report showed that the ground where Stephan fell was 136 degrees.

At 2:16 p.m. — less than 36 hours since he apologized to his grandfather on a busy street — Stephan Goodwin was pronounced dead.

1 P.M. | 115 DEGREES

The empty lot in Laveen, Ariz., where Stephan collapsed.

On a Friday afternoon this July,the Goodwin family gathered atDarae’s two-bedroom trailer in Glendale about 15 miles north of the vacant lot where Stephan died. It was the first anniversary of Stephan’s death, and the family was planning to remember him by watching one of his favorite Disney movies: “The Fox and the Hound.” Four dogs scampered in and out of the trailer — three mutts, including Stephan’s old dog, Eve, and a pit bull puppy that kept nervously peeing on the kitchen floor.

The city of Phoenix was in the midst of another deadly heat wave: Over a dozen people had already died of extreme heat, and hundreds more deaths were under investigation.

The temperature was 115 degrees.The blinds were closed to keep out the sun and the afternoon heat — in one corner, an air conditioner whirred. Low couches and a few small cots filled the room; with only two bedrooms, Stephan’s nephew and niece sleep in the living room most nights.On one wall of the room, just across from the front door, a small shrine hung in Stephan’s memory: a photo of him, his urn decorated with green trees, and a vase with a fake lemon stem — his favorite fruit.

For the Goodwin family, Stephan’s final days feel like an endless series of “what-ifs.” What if he had let Ralph take him to the hospital? What if Stephan and his girlfriend hadn’t argued that night? What if the police had come earlier?

Asked about the case, the Phoenix Police Department said it took about 17 minutes for them to reach the site. “Available officers from the precinct responded from their most recent location,” the department said in a statement.

Sitting at the kitchen table, Darae flipped through photo albums, looking for Stephan’s baby pictures. She has suffered from acute anxiety since Stephan’s death — her hair has turned gray, and she struggles to sleep at night. Twice, she went to the hospital with panic attacks.She has found comfort in crocheting blankets for the homeless — she believes Stephan would have wanted her to do it. Stephan never lived on the street, but she sees in unhoused people some of the samemental health challenges that her son faced.

Sometimes she feels a sense of peace — perhaps God was relieving Stephan of the suffering caused by his schizophrenia. Other times, the weight of his death, and all of the circumstances leading up to it, threatens to overwhelm her. Surely, she feels, help could have come from somewhere: abottle of water, a ride, another call to 911. “If only one thing had changed that day, he would still be here,” Darae said.

“He could have been saved,” she added, almost to herself. Then, louder: “I believe he could have been saved.”