Denver, CO. Health and CCH Health Send Letter to City Concerning Opening Warming Centers and Not Sweeping under Freezing

This letter (below and attached) was sent to City Officials yesterday. It includes data from these two hospitals regarding houseless cold related visits. In just the last 2 months (October and November) at just these two hospitals there were 54 houseless people in care for cold related injuries. 

The letter clearly explains through medical understanding that force displacements in cold weather significantly increase people’s likelihood of cold weather related illness and injury. 

May our City officials listen to the advice of these doctors. 

December 12, 2022 

Director Britta Fisher Department of Housing Stability (HOST) City and County of Denver Sent via email to Britta.Fisher@denvergov.org 

Director Bob McDonald Department of Public Health and Environment (DDPHE) City and County of Denver Sent via email to Bob.McDonald@denvergov.org

Dear Directors: 

As physicians caring for people experiencing homelessness in the Denver metropolitan area, recent patient care data from our facilities confirm that individuals experiencing homelessness still face too many medical risks of cold weather exposure. 

Given what is known about the interplay of ambient temperature, wind chill, and precipitation on medical risks for hypothermia, frostbite, and exacerbation of underlying medical conditions, as clinicians we recommend that officials with the City and County of Denver take immediate steps to address current deficiencies in 1) criteria used to determine when warming centers are open, and 2) policies and procedures related to forced displacements of unhoused individuals during cold-weather months. 

Health risks extend beyond hypothermia and frostbite 

Unhoused persons in encampments and other unsanctioned temporary dwellings face a variety of challenges during cold weather that limit their access to warmth and worsen their vulnerability to the harms of cold weather exposure. Hypothermia and frostbite may develop in minutes and often occur in the setting of risk factors for heat loss or decreased heat production including preexisting medical conditions, exhaustion, dehydration, substance use, and malnutrition, all of which are common among people experiencing homelessness. 

In addition to hypothermia and frostbite, the following injuries and illnesses are related cold-weather exposure: exhaustion, dehydration, and reduced neuro-cognitive functions. Cold weather sequelae (conditions that are a consequence of a prior illness or injury) often include respiratory illnesses, blood clots, bone and tissue infections, and loss of limbs, as well as cardiac dysrhythmias and heart attacks. 

Unhoused individuals’ risks for weather-related illness and injury increase exponentially when they suffer from chronic health conditions, including substance use disorder or traumatic brain injuries, or spend a prolonged amount of time in damp clothing and/or shoes as often occurs following forced displacement from tents. Cold weather also exacerbates existing medical conditions and may be a contributing factor rather than primary cause of hospitalization or death when it triggers an acute worsening of lung disease, cardiovascular disease, or diabetes, for example. 

DATA DENVER HEALTH (12/21-11/22) 

Complaint: Cold Weather Exposure 226 

Required admission for inpatient care 88 

Sought care in last two months (10/22-11/22) 39 

Complaint: Frostbite Injuries 58 

Required admission for inpatient care 18 

Sought care in last two months (10/22-11/22) 3 

COLORADO COALITION FOR THE HOMELESS (Winter 2020-2021) Complaint: Cold Weather Injury 77 

Sought care in last two months (10/22-11/22) 12 

Evidence-based cold-weather action plans to support seasonal strategies

Seasonal strategies should include expanded access to warm, indoor spaces that can be made available anytime the 24-hour low temperature is expected to be below 32 degrees Fahrenheit. Based on national standards, this standard mitigates the risks of overnight lows in the 30s. 

Cold-weather emergency options should detail how individuals who are suffering from substance use disorder, behavioral health conditions and/or neurocognitive conditions will not be adversely impacted by behavior policies and expectations that could lead to suspension or expulsion under non-emergency circumstances. Data clearly show that unhoused individuals disproportionately suffer from these debilitating conditions. 

Community-based organizations, frontline providers, and individuals with lived experience, can serve as an invaluable resource in developing and implementing strategies that are likely to mitigate increased risk for cold weather-related illness and injuries. As one example, we know that fear of loss of possessions often leads people to avoid leaving their tents to seek medical care or warmth, even in extreme cold. Forced removal from sleeping bags and tents causes people to face the elements without adequate covering, and loss of dry clothes to change into leads to prolonged time in damp clothing and shoes which significantly increases risk for hypothermia and frostbite. For these reasons, we recommend a policy of halting forced displacements when temperatures are projected to be below 32 degrees Fahrenheit. 

Moderately cold temperatures pose dangers to unhoused individuals, especially when they lack adequate shelter or clothing. Evidence shows that prolonged exposure to moderately cold temperatures (<45 degrees F) can lead to increased risk of hypothermia and/or frostbite.1 

We applaud the City and County of Denver for the steps they have taken so far on this issue including expanding emergency shelter access, re-evaluating temperature thresholds for activation of warming centers, limiting displacements of unhoused persons (“clean-ups”), and providing additional outreach for transportation, resources, and medical checks during these precarious times. Denver’s recent actions to designate recreation centers as overnight warming centers offered critically needed shelter, however, we are aware of only two days in November when these were available, despite multiple days of cold weather accompanied by freezing rain and snow. 

We encourage implementing a “Code Blue” system similar to what is used in other large metropolitan areas. These systems adopt evidence-based standards that are triggered when the overnight temperature, including windchill effect, is expected to fall below 32 degrees Fahrenheit. Standards should take into account Denver’s unique climate and weather conditions, which can change rapidly and with little notice to individuals who lack access to established communication tools, such as news and weather alerts. 

Thank you for your attention and leadership on these critical issues impacting our most vulnerable patients. 

Sincerely, 

Denver Health and Hospital Authority and Colorado Coalition for the Homeless Sarah E. Rowan, 

MD Sarah Axelrath, 

MD Sarah Stella, 

MD Edward Farrell, 

MD Jamaluddin Moloo, 

MD, MPH, Vice President, Integrated Health Services 

1 Zhang P, Wiens K, Wang R, Luong L, Ansara D, Gower S, Bassil K, Hwang SW. Cold Weather Conditions and Risk of Hypothermia Among People Experiencing Homelessness: Implications for Prevention Strategies. Int J Environ Res Public Health. 2019 Sep 5;16(18):3259. doi: 10.3390/ijerph16183259. PMID: 31491874; PMCID: PMC6765826.