New Approach to Avoid Health Risks From Wildfire Smoke

Some pulmonologists and other experts are not breathing easy over projections of a potential global health crisis due to wildfires. The United Nations projects a 14% global increase in extreme fires by 2030, a 30% jump by the end of 2050, and a 50% increase by the end of the century. Federal agencies warn that as more of us are exposed to wildfire pollution, our risk also increases for cardiopulmonary effects, especially in the elderly, children, and those with clinical diagnoses.

“Global leaders must support climate adaptation,” wrote the authors of a guide to improving performance during wildfire season in response to the emerging scenario. Such changes take time and money to implement, however, as they do away with the current system, relying instead upon a cross-discipline approach, informed by social determinants of health because those most affected by wildfire pollution tend to be populations underserved medically, socially, and economically.

For pulmonologists and their patients, these developments raise questions about how best to avoid wildfire smoke harms both now and in the future.

Taking a Population Health Approach

“Pulmonologists need to be advocates within their health systems,” Brooks T. Kuhn, MD, an assistant professor of medicine in the Pulmonary and Critical Care Division at the University of California Davis School of Medicine in Sacramento, California, wrote in an email. “For effective prevention and interventions, pulmonologists need to collaborate with public health, population health, and other colleagues through their health systems to develop a comprehensive approach.”

In a perspective, Kuhn and his co-author, Reshma Gupta, MD, chief of Population Health and Accountable Care at UC Davis School of Medicine, suggest a five-pronged population health plan for protecting those most vulnerable to wildfire pollution.

Their model leans heavily on public health data to identify who in the community is most at risk from wildfire smoke. Subsequently, multidisciplinary teams are sent to visit and assess the needs of those identified by the data as most at risk. The assessments are then used to create wildfire risk stratification action plans. Next, communication and care pathways are developed by risk tiers such as disease, access to care, risk of exposure, etc. These pathways might include personalized text message reminders when the air quality is dangerous for persons with asthma, or in-person visits for the delivery of chronic obstructive pulmonary disease (COPD) and asthma “go-bags” with basic items such as inhalers, to ensure people with lung disease are protected. Finally, outcomes are measured and future interventions are refined accordingly.

“Identifying at-risk populations and targeting them with interventions is probably the most effective approach to take,” Christopher Migliaccio, PhD, a toxicologist and research associate professor at the University of Montana in Missoula, Montana, said in an interview. “The key is having the resources — people, funds — to do something like this. It’s not an easy ask in a rural state like Montana, but maybe it’s more feasible in a place like California.”

In fact, Gupta and Kuhn’s plan has yet to be stress-tested by Californians, although Gupta previously collaborated with others at the University of California, Los Angeles, using this model to successfully reverse the high cost of treating people with unattended chronic conditions.

Still, many other governments also have not found proactive preparation for wildfires to be an “easy ask.” The Lancet Planetary Health reports that while stated global intentions are robust, the mobilization of the necessary resources supportive of sustainable health is “lagging.” As of 2022, only 11 (17%) of the 64 countries that pledged a commitment to the Alliance for Action on Climate Change and Health to build climate-resilient health systems had even completed a vulnerability and adaptation assessment.

Finding Intermediate Solutions

What can be done in the meantime to ensure optimal health outcomes during wildfire season? In some states, the Department of Environmental Quality is taking a community-based approach to protect against wildfire smoke harms.

This might include offering in-home high-efficiency particulate air (HEPA) filters to those already risk-stratified, in the event of elevated PM2.5 matter. Doing so has been shown to lower health costs and death rates for at-risk populations, such as the elderly or people with asthma or COPD. It also has been shown to be more cost-effective than distributing HEPA filters to all affected residents.

Creating public safe air spaces, however, is also a strategy some states like Washington are implementing, running HEPA filtration systems in public buildings such as community centers and homeless shelters. PurpleAir, makers of a hyper-local air quality data app for community scientists, has teamed with states like Montana to provide air filtration in public high schools.

“The goal is to make the indoor air quality better in general, and especially during wildfire events,” said Migliaccio.

Get the Message out

Dissemination of data about the dangers of wildfire smoke is another proven prevention strategy, according to Mohit Bhutani, MD, a clinician and professor of pulmonology at the University of Alberta in Edmonton, Alberta, Canada.

During the unprecedented fires that ravaged Canada last year, Bhutani said he was often asked by the national media there to specify for citizens the exact dangers they faced and how to mitigate them.

“Maybe the public doesn’t actually know how bad the air is for them. They might not be aware that if you have asthma, you are 40% more likely to go to the emergency department on a smoky day than on a non-smoky day,” Bhutani said in an interview. “Or that a blue mask is not as good as an N95 mask that will keep out the particulates.”

Gupta and Kuhn’s population health strategy also endorses creating targeted public message campaigns about the dangers of wildfire smoke, broadcast in different languages, to different cohorts, as doing so, they write, is supportive of creating “wildfire preparedness on the individual, system, and community levels through equity-focused, proactive outreach and education.”

Short of concerted efforts to advise the public at large, educating colleagues about the health impacts of wildfire smoke on all people, not just those already diagnosed at risk. “It’s becoming a norm within the healthcare community to discuss the overall effect of these fires,” said Bhutani. “It’s a discussion I increasingly am having with primary care doctors, general internists, hospitalists, and other specialists.”

This is especially important, according to Bhutani, whose research has centered on the underdiagnosis of lung disease in the general population. “If you don’t know whether you have one of these conditions, maybe you are less likely to pay attention to the air quality. Then you expose yourself to poor air quality that might trigger asthma or COPD symptoms,” Bhutani said.

“Everyone should check the air quality index before they go out, not just people already diagnosed with a lung disease.”

Help Patients Plan Ahead — and to Stay Home

Kuhn said the best protection pulmonologists can offer their patients is to help them think ahead. “Developing a plan for wildfires is the key. This can include having extra inhalers/medications on hand in the event patients cannot access pharmacies for a period, having an action plan for self-management, and education on how to make their home a safe environment to breathe despite poor external air quality,” Kuhn wrote. “While a predominantly respiratory concern, there are other aspects of health that are negatively impacted by wildfires, such as the heart and pregnancy.”

To help with these conversations, the World Health Organization has created an evidence-based toolkit for health professionals, rich with conversation starters: “Communicating on Climate Change and Health.”

All experts interviewed for this story agreed the best protection for patients at-risk from wildfire smoke harms is to stay inside to avoid exposure as much as possible.