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Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Page 71
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Page 72
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Page 73
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Page 74
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Page 75
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Page 76
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Page 77
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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Page 78
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
×
Page 79
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
×
Page 80
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
×
Page 81
Suggested Citation:"7 The Impact of Mitigation and Preparedness." National Academies of Sciences, Engineering, and Medicine. 2019. Implications of the California Wildfires for Health, Communities, and Preparedness: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25622.
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7 The Impact of Mitigation and Preparedness Key Points Highlighted by the Speakers • Partnerships between colleges and universities and local organizations provide a way to understand community needs and build resilience. (Errett) • Creating resilient communities requires that everyone at risk from wildfires has the knowledge, information, and tools to reduce those risks. (Shew) • A better understanding of fire behavior and impacts on structures, better design and detailing, and better land use planning can have major implications for survivability. (Shew) • Mitigating the impacts of wildfires calls for a new wildfire management paradigm in which communities coexist sustainably with wildfires. (Medley-Daniel) • Climate and health adaptations based on risk and sensitivity can effectively protect public health. (Thie) • The Smoke Sense app is an example of how to leverage citizen science to effectively engage populations affected by smoke. The app makes smoke and health resources easily available and is designed to create a personal connection between environmental changes and health, and to emphasize the importance of changing behaviors during smoke events. (Rappold) Communities can do much to prepare for wildfires and mitigate their effects. But wildfires are part of the landscape and cannot be suppressed forever, which requires that communities learn to live with fire—a point made by each of the five workshop speakers who spoke on issues related to mitigation and preparedness. ENGAGING WASHINGTON COMMUNITIES TO BUILD RESILIENCE TO WILDFIRE SMOKE In Washington State, the summers of 2017 and 2018 were characterized by extensive smoke from wildfires (see Figure 7-1). In August 2018, for example, the air quality over almost PREPUBLICATION COPY: UNCORRECTED PROOFS 7-1

7-2 IMPLICATIONS OF THE CALIFORNIA WILDFIRES FOR HEALTH, COMMUNITIES, AND PREPAREDNESS the entire state ranged from unhealthy to hazardous. “These events are having significant health impacts for our communities,” said Nicole Errett, lecturer in the Department of Environmental and Occupational Health at the University of Washington School of Public Health. “Our communities in Washington are grappling with what they should do.” The University of Washington has been partnering with organizations in Okanogan County, which is the largest county in Washington, including the Methow Valley Clean Air Project, the Okanogan River Airshed Partnership, and the Confederated Tribes of the Colville Reservation, as well as local health departments and others, to figure out what communities can do to address wildfire smoke risk.1 Okanogan County is a very rural part of the state, with only 7.8 people per square mile compared with Washington State’s average of 101.2. Adjacent to the Colville Reservation, 13 percent of its 42,132 residents are American Indian or Alaska Native, compared with just 1.9 percent for the state as a whole. The median household income is $42,598 compared with $66,174 in Washington State overall.2 “This community has been dealing with five-plus years of wildfires and wildfire smoke impacts,” Errett pointed out. The Carlton Complex Fire of 2014 destroyed more than 350 homes, and followed the massive Okanogan Complex Fire in 2015.3 Subsequent mud/debris flows (Errett et al., 2019) were in turn followed by fires that led to significant smoke impacts in 2017 and 2018.4,5 Errett reported that in 2018, one of her colleagues who works in the area said that the community experienced approximately 40 days of visible smoke. Furthermore, smoke is a four-season issue in Okanogan County, said Errett, with prescribed burns, agricultural and backyard burning, and woodstove use in the fall, winter, and spring. As part of the Methow Valley Clean Air Project, the community developed priorities for dealing with wildfire smoke: • Target sensitive populations and those who care for them, including schools, senior centers/homes, and health care providers • Promote the importance of clean indoor air • Make finding cleaner outdoor and indoor air easier • Address mental health and well-being impacts of prolonged smoke episodes • Coordinate and enable key partners to build disaster preparedness and response systems • Improve risk communication from fire management agencies • Build self-sufficiency through emphasis of how to protect health The University of Washington’s partnership with organizations in Okanogan County is designed to understand community needs and build resilience. The partners have engaged in a variety of activities: 1 Some statistics in this section have been updated from those presented at the workshop. 2 U.S. Census Bureau. QuickFacts Okanogan County, WA. https://www.census.gov/quickfacts/okanogancountywashington (accessed June 4, 2019). 3 For more information, see http://www.okanogancountyrecovery.com/the-fires (accessed October 22, 2019). 4 See https://kozi.com/mud-rock-and-debris-flows-covered-several-roadways-in-3-counties (accessed October 22, 2019). 5 See https://wasmoke.blogspot.com/search?q=diamond+creek+fire and https://wasmoke.blogspot.com/search?q=crescent+fire (accessed October 21, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

THE IMPACT OF MITIGATION AND PREPAREDNESS 7-3 • They have surveyed community members outside grocery stores about how they were receiving smoke information and how they would like to receive smoke information. • They have facilitated the establishment of a low-cost sensor network with the goal of generating more spatially specific air quality data so that community members could more easily find cleaner air. • They have hosted community and stakeholder conversations to understand communities’ needs and priorities. • They have analyzed the content of daily emails distributed by the U.S. Forest Service during the 2017 Diamond Creek Fire for the presence of wildfire smoke risk information with the goal of making practice-based recommendations about how best to include smoke risk and efficacy information. • They have conducted interviews with people who hosted clean-air sensors to understand why they wanted to participate in this citizen-science endeavor and to determine how the monitors helped them understand and minimize the risks they were facing.6 • They have hosted community outreach events. • They are planning future work to prospectively assess the impacts on health and well- being of wildfire smoke exposure and to evaluate strategies to minimize risk. From this work, the partnership has developed a list of questions that the community wants answered, which Errett said aligns with some of the scientific questions raised by others throughout the workshop: • Is the smoke going to make me sick? • How do I survive indoors during wildfire season? • What do I do with my children? Should I really keep them inside? • Should I have my child or baby wear a mask? • How do I know my indoor air is clean? • Where can I go to find clean air? • Why are the air quality numbers I look at online different? • What does several weeks of bad air per year from wildfires mean for our long-term health, including lung, cardiovascular, neurologic, mental? • Am I going to have to move away from my home? The smoke issue does not just affect Okanogan County, Errett pointed out. Many parts of the state have been affected by smoke, including the Seattle metropolitan area. These parts of the state have different populations, such as immigrant and refugee communities, facing different issues. People living in the wet, western part of the state also tend not to have air conditioning, which can make it more difficult for them to escape smoke conditions. They, too, “want to know how can risk be controlled and how can risk be communicated for wildfire smoke,” said Errett. In October 2018 the University of Washington hosted the Wildfire Smoke Risk Communications Stakeholder Synthesis Symposium, which brought together 76 regional 6 Hosting clean-air sensors involves allowing researchers to attach clean-air sensors to citizens’ homes, which then monitor surrounding air quality for a predetermined amount of time. PREPUBLICATION COPY: UNCORRECTED PROOFS

7-4 IMPLICATIONS OF THE CALIFORNIA WILDFIRES FOR HEALTH, COMMUNITIES, AND PREPAREDNESS stakeholders, including practitioners and academics, to talk about the evidence needed to build resilience to wildfire smoke (Errett et al., 2019). In four facilitated World Café discussions, participants discussed four questions: • Who is uniquely susceptible to wildfire smoke in this community? Why? • How can we effectively communicate risk to this population? • How can we reduce the risk to this population? • How can research improved preparedness and responses to future wildfire smoke events?7 Participants at the symposium identified research priorities across exposure science, health risk research, risk communication research, behavior change and intervention research, and legal and policy research. “We need a plan,” said Errett. “We need research infrastructure. We need to be able to figure out how we are going to measure exposure, how we are going to leverage measures from different cohort studies. We need to figure out how to all work together in advance of the event to be able to do this in real time.” FIGURE 7-1 In the summers of 2017 and 2018 on 15–20 percent of the days, there was moderate-to- hazardous air quality in Washington State according to the Washington Air Quality Advisory. SOURCES: Washington Department of Ecology. Presented by Nicole Errett. 7 For more information, see http://www.theworldcafe.com/key-concepts-resources/world-cafe-method (accessed January 15, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

THE IMPACT OF MITIGATION AND PREPAREDNESS 7-5 “We need to figure out how to all work together in advance of the event to be able to do this in real time.” Nicole Errett STRUCTURE IGNITION ISSUES IN WILDFIRE PREVENTION California has always had large fires, observed David Shew, consultant at Wildfire Defense Works, but that does not mean that natural disasters are inevitable. As Jack Cohen, a retired researcher from the U.S. Foreset Service in Missoula, Montana, has put it,8 Shew said, “Wildfires are inevitable, but wildland urban disasters don’t have to be.” Shew, who was a licensed architect before transitioning to a career with CAL FIRE for the past 32 years, said that the real problem involves structures and infrastructure. “How do we live more resiliently and more successfully in the middle of a wildfire environment and try to minimize the impacts of those fires when they occur?” he asked. To a fire, everything is fuel. “Vegetation, structures, vehicles, unfortunately human beings, anything that is in the way is fuel for that fire. We are not going to fix this by simply hiring more firefighters and buying more fire engines.” The energy being released by a catastrophic fire is so great that nothing in the human arsenal can stop it. Firefighting resources become overwhelmed and have to focus simply on saving lives. Nor is there a single solution to preventing or putting out fires. Dealing with wildfires requires “an entire combination of things,” Shew said. It also requires a collaborative effort across local, state, and federal lands, which is always a challenge, but “fires pay no attention to those dotted lines on a map.” One important point is that fires have a tendency to repeat themselves, Shew observed. The footprints of recent fires often closely match the footprints of past fires. Today, however, these areas contain more structures, which partly accounts for the steadily increasing toll of structures destroyed by wildfires. Many communities are aware of their fire histories. In 2008 the Humboldt Fire just to the east of Paradise threatened the town and burned down a number of houses, though no one died. After that, Paradise put together an aggressive Community Wildfire Protection Plan (CWPP), which had what Shew called “one of the best evacuation plans that I have ever seen a community develop.” The community practiced this plan, most recently just a few months before the Camp Fire. “Had they not done the aggressive work of putting their CWPP together and practicing their evacuation routes, as bad as that fire was, I would argue that it could have been much, much worse.” Shew pointed out that perhaps the single most important factors for structures destroyed in wildfires are embers. Approximately 80 percent to 90 percent of all structures damaged or destroyed by wildfires are the result of ignitions due to embers, with radiant heat and direct flame contact responsible for the remainder. Moreover, if embers ignite a structure, it generally has only a 5 percent to 10 percent chance of surviving the fire. Creating resilient homes and communities requires a coupled approach, said Shew. The materials and design features of a home can make it far less susceptible to embers. The selection, location, and maintenance of vegetation and other combustibles on the property also provides protection. In particular, a noncombustible zone extending five feet from the edge of a house reduces the odds of a structure burning down. 8 See https://community.nfpa.org/community/fire-break/blog/2016/02/03/firewise-how-to-qa-an-interview-with- jack-cohen-offering-perspective-on-current-wildland-fire-conditions (accessed on November 8, 2019) PREPUBLICATION COPY: UNCORRECTED PROOFS

7-6 IMPLICATIONS OF THE CALIFORNIA WILDFIRES FOR HEALTH, COMMUNITIES, AND PREPAREDNESS The National Fire Protection Association’s (NFPA’s) Wildfire Division provides resources to residents and stakeholders to help ensure that everyone at risk from wildfires has the information, knowledge, and tools to reduce those risks, Shew said. The goals of the division are to provide community engagement programs, training and certification, resources and tools, and research and technology. The NFPA’s Firewise USA® program has more than 1,500 participating sites in 42 states and has seen increased growth in areas recently affected by wildfires. The program encourages individuals to look at their property and to work with their neighbors to reduce the risks to themselves, to their communities, and to first responders. Shew helps with this program as a Wildfire Field Rep for NFPA. For their part, NFPA teaches a 2 day class called Assessing Structure Ignition Potential from Wildfire; it communicates risk to residents with a focus on fire science. People can also receive training to become certified wildfire mitigation specialists, after which they have the knowledge to look at individual structures and determine the risks of that structure from wildfire. It is aimed at fire services, forestry agencies, insurance professionals, and others and involves an exam and practicum. In addition, NFPA offers a variety of preparedness tips, fact sheets, online workshops, research publications, and other resources that people can use to prepare their homes to resist wildfires. For example, “how many of you like to have your nice wood pile stacked up on your deck so that it is easy to get to?” asked Shew. “Thank you for putting a lot of kindling on the side of your house.” Though California has been hit hard, wildfires are a global problem, he pointed out. A better understanding of fire behavior and impacts on structures, better design and detailing, and better land-use planning can have major implications for survivability around the world. “This is an all-hands-on-deck” situation, Shew argued. “We can’t keep thinking of this as a fire department problem.” Many industries, including the insurance industry, are involved in the issue. Elected officials need to have the political will to enforce fire safety regulations. Homeowners need to understand their responsibilities for maintaining their properties. Shew concluded by again referencing Jack Cohen,9 saying “It is not rocket science. It is a lot more difficult. It is social change. It is changing how people think and how people will act.” “Fires pay no attention to those dotted lines on a map.” David Shew IMPROVING SOCIETY’S RELATIONSHIP WITH FIRE Around the small town of Hayfork in northwestern California, the fire return interval is just 5 to 15 years, observed Michelle Medley-Daniel, deputy director of The Watershed Center and director of the Fire Adapted Communities Network. “Putting out every fire is just going to pass the buck onto the future,” she said. “We need to be thinking about how we can accept more fire and manage and mitigate for the impacts.” Doing so requires a new wildfire management paradigm, she continued. In the past, the dominant fire paradigm has been a war on fire (see Table 8-1). The new paradigm has to be to work with fire as an agent in landscapes, to “sustainably coexist with wildfire.” That requires taking action before, during, and after fires occur. “We need local capacity and a culture that 9 See https://www.npr.org/2018/11/24/670581508/to-prevent-wildfire-devastation-look-at-building-design (accessed November 8, 2019). PREPUBLICATION COPY: UNCORRECTED PROOFS

THE IMPACT OF MITIGATION AND PREPAREDNESS 7-7 includes a relationship with fire. We have to acknowledge that every community’s experience with fires is going to be different. . . . [And] to get to this prize [of a new relationship with fire], we need to have people working together and sharing different ideas,” Medley-Daniel said. In 2013 the Fire Adapted Communities Learning Network was launched to bring together community leaders from around the country that are trying to live better with fire. The network, stewarded by The Watershed Center and The Nature Conservancy, has connected these community leaders and is supported by agencies that manage wildfires, including the U.S. Forest Service and agencies of the Department of the Interior. Several state networks have grown out of the initiative as well, and related networks include the Fire Learning Network and the Indigenous People Burning Network. This broad coalition of organizations has focused on three questions: • How are different people, from different kinds of places and working with different institutions, approaching fire adaptation? • How can the network be encouraged to work at the edge of current practice? How can it co-create more knowledge and practice? • How might the network grow and help catalyze a movement of people who want a different relationship with fire? An important component of the network has been a program called TREX, which is a prescribed fire training exchange program developed by The Nature Conservancy. Communities need training to learn how to use fire, said Medley-Daniel. “It is hard if you are not a federal fire manager in our country to have access to training and become qualified to use and engage with fire. TREX helps provide that access to other people.” The Fire Adapted Communities Learning Network also provides experiential learning, develops materials that describe models people have developed and demonstrated for living with fire, engages with federal land managers and fire managers, publishes a blog written by community leaders, and fosters connections between researchers and practitioners. As an example of on-the-ground work, Medley-Daniel outlined the work led by the Western Klamath Restoration Partnership, which she described as “the embodiment of co- management of fire and landscapes.” With leadership from tribal communities and the cooperation of other residents, the partnership has created intergenerational learning opportunities designed to foster a culture that values fire across generations. Values-based planning has helped the partnership overcome potential conflicts. Using what is called the open standards process, the partners have sought to figure out how fire can play its role in the landscape without people being negatively impacted. The process provides an opportunity for community members to identify what they care about. These values are overlaid on a map, “and pretty soon you start seeing that your environmentalist community members who are concerned about spotted owls are caring about the same place that ranchers are concerned about. You start to see opportunities where you have shared interests and the opportunity to design treatments and take some actions together.” The partners are now working with the U.S. Forest Service Southwest Research Station on implementing landscape-scale projects that integrate operational and ecological information on thousands of acres in the Mid-Klamath. Values-based planning, in which people gather, honor, and use local information, could benefit many communities, Medley-Daniel said. For example, such planning can be used to PREPUBLICATION COPY: UNCORRECTED PROOFS

7-8 IMPLICATIONS OF THE CALIFORNIA WILDFIRES FOR HEALTH, COMMUNITIES, AND PREPAREDNESS design proactive projects in which people can agree where and under what conditions a prescribed burn might benefit the community. The second example Medley-Daniel explored involves her hometown of Hayfork. When the lumber mill in the town shut down, the town entered a period of crisis. “We needed to reimagine what we are going to be if we were not going to be a logging town. We have been on that journey for the past 20 years,” she explained. Part of the task was to convert former loggers into landscape stewards. Another major factor in that transition has been an evolution in thinking about fire—and the roles it can play and the jobs that might be created to manage it. Medley- Daniel noted that many of the students in the town do not want to go to college. Rather, they want to be in technical careers. One way to meet this need has been to cross-train workers so that they can do more than one thing. “We need these people to know how to do everything in the woods. We need people to be able to clean up the clandestine trespass marijuana grows that are going on in our national forests. To put fire on the ground, and to thin the forest and create fuel breaks.” This kind of training contributes to cultural change, she said. People “are making the care and stewardship of a landscape their life’s work.” When the next fire happens, this cross- trained workforce will already have worked on the landscape and will be ready to respond to the fire without needing as much outside support. Medley-Daniel touched upon some of the other work going on in the network. Member organizations have held evacuation drills, living-with-fire events, and harvesting demonstrations. They have promulgated the Fire Adapted Community Self-Assessment Tool to help communities think about the work they need to do and where to prioritize their time and resources. Community ambassador programs have helped build neighborhood leadership and have connected people to one another. People have worked with their chambers of commerce to think, for instance, about how smoke is impacting their economies. Other groups are expanding tribal engagement and thinking about cultural fire practices. Finally, other states are thinking about how to densify this network and get more people engaged and excited about new ways to live with fire. Doing that requires investing in local capacity, redistributing power in the fire management system, and recognizing the roles that local communities and economics can play in ecosystem stewardship, she said. “Putting out every fire is just going to pass the buck onto the future.” Michelle Medley-Daniel CREATING CLIMATE AND HEALTH ADAPTATIONS North Carolina is a place where people should be able to exercise their pets, connect with their neighbors, and otherwise engage in outside activities in ways that are healthy and limit their exposure to air pollution, observed Lauren Thie, a public health epidemiologist from the North Carolina Department of Health and Human Services. However, the southeastern portion of the state depends on prescribed burning for a healthy ecosystem, for care of endangered species, and for general land management. For example, the state is a part of a regional effort seeking to restore about a million acres of longleaf pine, which is an ecosystem that depends on regular fire, and regular fire is necessary for the continued existence of a variety of pollinators, plants, and ecosystem services. The pollution from these prescribed burns can have impacts that include asthma, heart conditions, and other symptoms, Thie observed. As a result, the North Carolina Department of PREPUBLICATION COPY: UNCORRECTED PROOFS

THE IMPACT OF MITIGATION AND PREPAREDNESS 7-9 Health and Human Services, with funding from the Centers for Disease Control and Prevention (CDC), has been developing a set of climate and health adaptations. The department has used a five-step framework from CDC known as Building Resilience Against Climate Effects (BRACE): 1. Anticipate climate impacts and assess vulnerabilities 2. Project the disease burden 3. Assess public health interventions 4. Develop and implement a climate and health adaptation plan 5. Evaluate impact and improve quality of activities With this framework, the department has identified heat-related illnesses and air pollution as the primary areas of focus, with a particular focus on wildland fires. Drawing as well on the research literature on effective public health interventions, the department has developed a climate and health adaptation that combines a vulnerability index around wildland fire, with community input, to develop a map of smoke vulnerability in North Carolina (see Figure 7-2). The green dots on the map denote the amount of exposure to smoke based primarily on data from the U.S. Environmental Protection Agency (EPA) along with information from the North Carolina Forest Service on the number of acres burned and how many wildfires happen on average in each county. The sensitivity component combines CDC data relevant to wildfire smoke exposure and socioeconomic status data. The hash marks in the map indicate that low numbers of people in those areas are accessing AirNow information from EPA. In Hoke County, which Thie used as an example, about 20,000 acres are burned nearly annually on average, with about half being prescribed burns. This land is largely owned by the second largest military base in the United States, so burns are done for land management in accordance with the federal Endangered Species Act. Burning also sometimes occurs as a result of artillery practice. Interventions noted in the literature include information on evacuations, air filtration, personal air masks, forecast systems, and public service announcements, though as Thie noted “in the field of environmental health there’s a paucity of data on what is effective in intervening and protecting people’s health.” This information was combined with input from stakeholders on such factors as ease of implementation and cost. This input also indicated the need for an educational campaign that would accompany the Smokey the Bear program that is provided in elementary schools. This campaign has several components, including a game played in an auditorium setting in which students learn what steps to take to protect themselves from wildland fires. Another activity is a bingo game for classrooms in which students try to match the terms they heard in a preceding talk on fires. The campaign also includes asthma education tools for teachers and nurses. From January through May 2019, four different elementary schools with about 1,600 students participated in the program, and about 50 teachers or school nurses received the asthma education programming. The department also has been working with EPA to identify potentially vulnerable communities, with the overall goal of creating an ecosystem that is well managed by fire. In response to a question from a viewer of the webcast, Thie noted that one part of the community’s feedback was to broaden the description of the map from wildfire smoke to smoke in general because of sensitivity toward the term wildfire, which might have implications for PREPUBLICATION COPY: UNCORRECTED PROOFS

7-10 IMPLICATIONS OF THE CALIFORNIA WILDFIRES FOR HEALTH, COMMUNITIES, AND PREPAREDNESS insurance coverage, emergency response, or perceptions of the county. People saw the most important issue “as smoke exposure, as opposed to talking about the wildfire itself.” “In the field of environmental health there’s a paucity of data on what is effective in intervening and protecting people’s health.” Lauren Thie FIGURE 7-2 A map of smoke vulnerability in North Carolina combines information on exposure, sensitivity, and how often people access air quality information. SOURCES: North Carolina Department of Health and Human Services. Presented by Ana Rappold. LEVERAGING CITIZEN SCIENCE FOR RESEARCH AND ENVIRONMENTAL PUBLIC HEALTH In response to the health effects of wildfire smoke exposure, EPA developed a project called Smoke Sense that takes a citizen science approach to the issue. Led by Ana Rappold at the EPA National Health and Environmental Effects Research Laboratory, Smoke Sense addresses “the gap between what we know about risk and ways to protect our health and the observed public health outcomes.” The research objective behind the project is to learn more about personal motivations in adopting health protective behaviors and to develop a greater understanding of health risk messaging. “A successful health risk communication strategy is an essential part of helping people adopt new behaviors, which can be very difficult and takes time,” said Rappold. PREPUBLICATION COPY: UNCORRECTED PROOFS

THE IMPACT OF MITIGATION AND PREPAREDNESS 7-11 Smoke Sense is facilitated through the use of a free app that can be downloaded to iOS and Android mobile devices. The app makes smoke and health resources easily available when and where people need them, making it easier for participants to make a personal connection between changes in their environment and changes in their health and to raise personal awareness about the salience of changing behavior during smoke events. Through participation in the study, citizen scientists and researchers explore the gaps that exist between resources and health outcomes. The insights gained from participation are expected to provide an innovative way of acquiring knowledge that can lead to better communication skills at the national level. In the app, users can participate in different ways. They can report their health and smoke observations. They can say what they did to reduce their personal exposure or in response to exposure to wildfire smoke. They can access resources, such as maps of smoke plumes, the status of fires, and forecasts of smoke movement and intensity. The app also incorporates educational elements. For example, Air Quality 101 provides lessons derived from a wildfire public health resource designed for public health officials; these have been rephrased to be inviting and easy to identify with. After the app was launched in the latter half of 2017, more than 5,000 people, mostly from California and Washington, downloaded it during the remainder of that year. One-third of these participants reported observations, and 92 percent kept using the data and educational modules on the app. Users tended to be younger and more educated with a higher proportion of females and whites. The vast majority of users downloaded the app during smoke episodes and their reports of smoke correlated with the National Oceanic and Atmospheric Administration’s (NOAA’s) satellite images more than 80 percent of the time. Additionally, the vast majority of participants clearly recognized smoke as a hazard. Participants also completed a brief profile of their preexisting health concerns. These responses indicate that participation was largely motivated by a personal concern for health. People with preexisting conditions were more likely to engage with the app, and they stayed engaged longer. However, the symptoms that they were reporting were not necessarily related to the health conditions that they reported in their profiles. Additionally, participants did not consistently evaluate personal risk. While 91 percent of the individuals considered pollution a risk to other people, only 72 percent of participants recognized air pollution as risks to their own health. Of the participants in this initial year, 89 percent engaged in exposure-reducing behaviors. Some of these behaviors were easier to adopt than others, Rappold reported, probably reflecting social, physical, and financial circumstances. The more symptoms users were experiencing, the more likely they were to adopt exposure-reduction behaviors. However, preexisting health factors did not modify the likelihood of such behaviors. Rappold concluded with two broad insights regarding ways to make health risk messages more effective. The first is to emphasize personal relevance, with a particular focus on health factors and outcomes that may be salient to individuals in the focal audience. “We should consider talking about what people are actually experiencing rather than what their vulnerability status is, because a lot of people are not identifying their own vulnerabilities, and even if they are, that is not modifying their action,” she explained. The second is that messages should provide compelling evidence that behavioral change is beneficial. In the absence of clear statements, people tend to stick with the status quo and do not try to adopt new behaviors, she said. PREPUBLICATION COPY: UNCORRECTED PROOFS

7-12 IMPLICATIONS OF THE CALIFORNIA WILDFIRES FOR HEALTH, COMMUNITIES, AND PREPAREDNESS Currently, Smoke Sense has more than 25,000 users, with more than 200,000 sessions launched. News media have reported on the app, and it was featured as one of the top 10 downloads in the Apple store. EPA works with partners in state agencies to help develop communication strategies that use parts or all of Smoke Sense. EPA is also developing a K–12 curriculum, and it is beta-testing the app in Spanish. Finally, it has conducted interviews in state- level organizations that respond to smoke about the perceptions of what their constituents are experiencing. One of the take-home messages of these interviews is that people want data and visualization in real time. The result has been a portal where people can access data visualization and sharing tools. In response to a question about whether the Smoke Sense app could be used to measure the behavioral changes and health outcomes of people using the app, Rappold said that it could. The users of the app are anonymous, and EPA does not interact with them directly. But “you can certainly envision the types of studies that intervene . . . enroll a cohort of people, and follow them through time to measure their health outcomes.” In response to a question, Rappold recommended having all the data from such studies available to researchers so that they can derive results with different datasets using the same exposure metrics and then compare outcomes, though organizing a platform for that kind of data sharing will require substantial foresight. She also pointed to a “huge growth opportunity” with the amount of new data that are coming online, both from remote sensing and from personal wearable and low-cost sensor technologies. Sensors also provide good opportunities to better understand smoke exposure and a few have been tested for use during wildfire episodes. Again, comparing different sensor data would allow results to be compared, though some produce proprietary data that would need to be made available. In the past, epidemiology has concerned itself with overall measures such as exposures averaged over a 24-hour period, but new questions are arising about acute exposures, such as when people need to be helped or evacuated. Rappold asked, “What do sub-daily or sub-hourly exposures mean, and when do we make those cut off points where you have to act to protect someone’s health?” Sensor data would be good indicators of when people need to start changing their behaviors, she said. She also mentioned the challenges of measuring mental health effects, which is another issue that has become much more prominent recently. For example, what are the effects on individuals who rely on tourism as a main source of income, when their communities are inundated with smoke during tourism seasons? She added that there are potentially other kinds of health impacts of smoke that we are just beginning to have conversations about. Her final point was that one way to prevent wildfires is to introduce more fires into the landscape. But smoke is not good for anyone. “Can we be, as a community, ready to help guide the conversation, can we do ecological benefit and yet protect our health?” Federal agencies have been working to develop communications on that topic, “but there’s no quick solutions,” she concluded. “A successful health risk communication strategy is an essential part of helping people adopt new behaviors, which can be very difficult and takes time.” Ana Rappold PREPUBLICATION COPY: UNCORRECTED PROOFS

THE IMPACT OF MITIGATION AND PREPAREDNESS 7-13 DISCUSSION In response to a question from Kizer, Shew pointed out that large fires have happened throughout the United States. In the lower 48 states, the largest fire in recorded history was the 1872 Peshtigo Fire in Wisconsin, which may have killed thousands of people. But because it occurred at the same time as the Great Chicago Fire, it has received less attention. All 50 states have had fires. “I am convinced that Paradise is not the worst we will ever see. It will be worse,” Shew said. As a specific example, Shew noted that the Oakland and Berkeley hills have a history of fire, including the 1991 Tunnel Fire that burned down about 3,000 structures and killed 25 people. “Another fire in the Oakland–Berkeley hills is only a matter of time,” he said. New knowledge from research and better steps to protect properties can reduce the risk to structures and lives, he said, so that “fewer homes [are] lost the next time.” When asked how to incentivize people to do that, Shew observed that many people have insurance, especially those with high-cost homes in the Oakland–Berkeley Hills. At the same time, the insurance industry has realized the importance of this issue. In the past, wildfires did not represent a large dollar loss for them. Hurricanes, tornadoes, flooding, and even hailstorms could produce much greater losses. But wildfires have recently risen toward the top of their list of concerns, “and they are struggling to catch up and understand.” Insurance companies are for- profit organizations, and they have been caught off guard by wildfire losses. “Because wildfires have been historically a very low risk for them, the cost of wildfire insurance has been artificially kept low for a long time, because they subsidized it with the cost of other insurance. That is all going to change very rapidly.” Even as insurance rates rise, these companies will learn how to look at individual structures on a more detailed level and to create incentives for homeowners to protect their properties. Medley-Daniel added that people want to know what they can do to keep themselves and their families safe. Many programs exist to help them figure out what actions to take, how to work with their neighbors, and the basic community organizing that needs to be done. “We have tremendous opportunities, especially with some of these big, tragic fires, where we have some attention to say, ‘Here are some things you can do that will help you.’” Shew observed that California is the only state in the country that has Wildland–Urban Interface (WUI) building codes. Maps identify high and very high-risk areas across the state, and structures in those zones have to be built according to the codes. However, the codes were put into place in 2008 in the state, and new science is rapidly overshadowing them. Insurance companies are using new technologies and new risk assessment models to look at properties on a parcel-level scale and give home owners a snapshot of what they can do to improve their homes, he continued. For example, at the time of the workshop, the city of Redding was partnering with a national program called the Community Planning Assistance for Wildfires, which advises jurisdictions about their codes and ordinances. At the same time, new research is producing much more fire-resistant materials. “Of course, that requires the contractors and builders to change the way they are doing business. But it has to happen for us to be more resilient in these fire-prone areas.” In response to a question posed to Eisenman about why the risk posed by wildfires has not become a more prominent national issue, Errett responded that the wildfire researchers have been behind other types of disaster science. But as more people are affected, studying wildfires PREPUBLICATION COPY: UNCORRECTED PROOFS

7-14 IMPLICATIONS OF THE CALIFORNIA WILDFIRES FOR HEALTH, COMMUNITIES, AND PREPAREDNESS will become easier. For example, epidemiological studies have a statistical power that they have not had in the past. Medley-Daniel pointed to a shift in the conversations that are happening in California and across the country. “People recognize that what we are doing is not working and we need to adopt some new strategies. Recognition of that can lead to change.” People are also starting to think in terms of whole systems, including economic systems. “We have to take a broad view of how we want to live as people on a landscape. What do we want community to mean to us? How do we want to relate to each other? How do we want to relate to the natural processes that are shaping our environment? . . . If we think about all [the] things we can do, it gives me hope.” PREPUBLICATION COPY: UNCORRECTED PROOFS

Next: 8 Reflections on the Workshop »
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California and other wildfire-prone western states have experienced a substantial increase in the number and intensity of wildfires in recent years. Wildlands and climate experts expect these trends to continue and quite likely to worsen in coming years. Wildfires and other disasters can be particularly devastating for vulnerable communities. Members of these communities tend to experience worse health outcomes from disasters, have fewer resources for responding and rebuilding, and receive less assistance from state, local, and federal agencies. Because burning wood releases particulate matter and other toxicants, the health effects of wildfires extend well beyond burns. In addition, deposition of toxicants in soil and water can result in chronic as well as acute exposures.

On June 4-5, 2019, four different entities within the National Academies of Sciences, Engineering, and Medicine held a workshop titled Implications of the California Wildfires for Health, Communities, and Preparedness at the Betty Irene Moore School of Nursing at the University of California, Davis. The workshop explored the population health, environmental health, emergency preparedness, and health equity consequences of increasingly strong and numerous wildfires, particularly in California. This publication is a summary of the presentations and discussion of the workshop.

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