At the beginning of the workshop’s second day, Kenneth W. Kizer, distinguished professor in the University of California (UC), Davis, School of Medicine and the Betty Irene Moore School of Nursing and director of the Institute for Population Health Improvement, sought to tie together some of the issues discussed at the workshop in a broader context (see Box 8-1). This discussion set the stage for some of the discussions during the final session.
In the final session, nine members of the workshop steering committee and of the roundtables and forum that held the workshop commented on what they had heard and on the workshop’s implications for the future. They were Kenneth Kizer; Wayne Jonas, executive director of the Samueli Integrative Health Programs; David Eisenman, professor-in-residence at the David Geffen School of Medicine and the Fielding School of Public Health at UCLA; Julie Baldwin, director of the Center for Health Equity Research and professor of health sciences at Northern Arizona University; Colleen Ryan, professor of surgery, Harvard Medical School, American Burn Association; Winston Wong, medical director of community health and director of disparities improvement and quality initiatives for Kaiser Permanente; Michelle Bell, the Mary E. Pinchot Professor of Environmental Health from the Yale School of Forestry & Environmental Studies; Octavio Martinez, executive director of the Hogg Foundation for Mental Health and associate vice president in the Division of Diversity and Community Engagement, The University of Texas at Austin; and Antonia Villarruel, professor and Margaret Bond Simon Dean of Nursing at the University of Pennsylvania School of Nursing.
Kizer began by pointing out that more fire disasters will occur in the future, which will initiate a cascade of environmental and population health effects. Furthermore, even relatively short-term exposures can have long-term and even intergenerational effects, he said.
Kizer also observed that wildfires, and disasters in general, expose the disparities, structural biases, and inequities that are embedded in societal systems and in response and recovery mechanisms. Communities and populations at risk from California wildfires already face inequities ranging from pesticide exposure to heat exposure. However, the exposure of inequities also provides opportunities to reengineer processes and reimagine communities so as to remove biases and disparities.
Wong also called attention to the equity issues that were highlighted during the workshop, pointing out that vulnerability is not equally distributed when disasters occur. When the Titanic sank, people sailing in first class had a better chance of surviving than those in second class, who had a better chance of surviving than those in third class. Perhaps the smoke from wildfires does not discriminate, Wong acknowledged, but the suffering is “disproportionally borne by those individuals in the lower segments of our socioeconomic structure.”
Discrimination can mark access to housing, material support for people who are undocumented, the availability of mental health and trauma services, and resources for the frail and the elderly. Furthermore, discrimination can extend far downwind to communities nowhere near a fire. “If you are an inner-city kid living in East Oakland, your chances of having a mask, or a safe place to go, or a network to care for you, is probably less than for those kids that lived in a relatively well-sheltered townhouse or single-family dwelling in Walnut Creek,” said Wong.
Summarizing the available scientific evidence, Bell drew the overall conclusion that limited but growing data indicate that smoke and other forms of environmental contamination from wildfires are very harmful for human health. Furthermore, the implications of these results extend to distant communities, and “if we really want to understand the overall impact of wildfires on human health, we have to include everything.” But some of the results are conflicting and uncertain and will require more research to resolve, she said. “If we understand the science, we can help save lives and reduce the public health burden.”
Scientific results are also critical for planning, she observed. Summing up the burden of wildfires will be critical in gaining more resources to pre-
pare for, mitigate, respond to, and recover from wildland fires. This burden includes loss of school days, loss of work days, hospital admissions, and mortalities caused by contaminants. The impacts of wildfires on human health are much larger than might be indicated from watching the news, she said, which is the bad news. “The good news is that people in the scientific community want to look at this.”
Martinez emphasized the need to provide for continuity of care. Health care has taken steps in this direction, but continuity needs to extend beyond health care so that it includes all the determinants of health, Martinez said, “everything outside of the brick and mortar of the clinic that impacts an individual or community.” As such, the need for continuity of care extends from well before a disaster to well after. Understanding needs throughout this span calls for more than biomedical research; it also requires translational research and implementation science, according to Martinez. Exemplars exist, but they are not being shared. “We have this silo effect that diminishes the impact that we can have,” he said. “We need to work together as a community.”
Regarding health effects, Eisenman specifically cited the need to measure the levels and effects of indoor smoke. “All the measurements and exposures we heard about the last 2 days were outdoor exposures. We need to develop the science of indoor exposures assessment and bring that into our public health models.”
The inequalities that exist in communities and populations are relevant across the spectrum of response, recovery, and preparedness. Ryan, for example, as a burn surgeon, reiterated that “there are 300 burn surgeons in North America. Burn beds are limited. Burn nurses are limited. Burn staff is limited. It is clearly a bottleneck in the national defense system. . . . One spark the wrong way, and it could be a tremendous disaster.” She recommended codifying at a national level the current self-organized and unfunded regional disaster response system, which is an effort that is currently being undertaken. “We need to move forward with that,” Ryan emphasized.
She also pointed out that the design, organization, and delivery of recovery efforts must address the intersecting vulnerabilities of populations. Race, ethnicity, age, gender, language, disability, and other factors all affect how individuals and communities experience a trauma, and this trauma then extends to receiving communities. “All these people are stakeholders,” and they need to be represented in discussions of the issues that affect them. For example, if before a fire the simple message to “cool the burn” could be translated into all of the languages spoken in an area and then disseminated immediately after a fire, the messaging and ensuing responses could be optimized, Ryan said.
Less visible vulnerabilities should also be addressed, she observed. For example, children who have been burned or have experienced a fire can have difficulty watching television, because so many shows feature fires, even cartoons. What to tell children about a fire could be prepared beforehand so that communities and populations do not have to reinvent appropriate messages every time.
More generally, Ryan pointed out, prearranged policies such as rent control could snap into place after wildfires. Survivors of fires should be involved in formulating these policies because they have a unique perspective, she added. For example, is having a low level of benzene in water more important than putting food on the table?
Baldwin also emphasized the need to look at response, recovery, and preparedness through a health equity lens. Plans tend not to be in place for helping vulnerable populations, who sometimes cannot even afford to evacuate. “We have to think about that much more carefully.” For migrants who speak indigenous languages and for those who are undocumented and fear even trying to access services, disasters pose particular hazards. “We need trusted partners to be able to communicate this information,” she noted.
Wildfires and other disasters are much more than a public health or medical issue, Jonas said. Many nonmedical organizations provide necessary support, from faith-based communities to beauty shops to trauma-informed yoga practitioners. In addition, people from communities that have experienced disasters and have bounced back know what the issues are and can be great assets. On this subject, Eisenman also emphasized the roles of universities and colleges, as demonstrated by Chico State. “That needs to be written about and developed.”
In addition, Eisenman recalled the challenges of receiving communities. Experiences in small communities may bear lessons for receiving communities for much bigger events, where much larger numbers of displaced peoples are coming into communities. Taking one of the worst possible disasters, Eisenman pointed out that a nuclear war would generate huge numbers of displaced persons, whether internally within a single country like the United States or across international borders. The challenges of receiving communities today, even on a much smaller scale, may provide data for future events, he said.
Wildfires are unlike other kinds of disasters, Eisenman observed. Many workshop participants spoke about the return of fire to ecologies and environments, which is not how people talk about other disasters. “We don’t invite floods. We don’t invite tropical storms.” Preparing for the return of
fire creates a new paradigm, he said, about how communities recover from and prepare for wildfires.
Jonas, too, mentioned the need to reframe the issue from putting out fires to adapting to fires. This is also a reframing from deprivation to assets. Deprivation is related to a medical model that says: You have needs. We are going to come in and provide services to meet those needs. “What we have heard over and over again is that communities have resources. They have learnings in those areas. They know what they want. . . . We can provide power to those communities.” A good example, he said, is the well-being in the national index framework, released right before the workshop, which focuses on positive social determinants rather than negative ones like a deprivation index. In doing so, it looks toward the country’s assets and how to build and connect those across silos. Examples from England and elsewhere show very large returns on investments that can be achieved through that framing, Jonas said. “This is not a fire issue. This is a resilience issue. . . . [If] you could create a learning and self-care community and focus on that, that kind of reframing would go a long way in getting us the return on investment we need.”
Part of preparedness is knowing in advance about vulnerabilities, Jonas added. For example, he mentioned an initiative in both the United Kingdom and the United States to map vulnerability at the neighborhood level and use that map in risk management and in resource investment. These maps and related efforts could even go farther upstream to indicators of both vulnerability and resilience that could be used to shape behaviors.
Jonas also mentioned the need to bring vulnerable communities into the heart of the discussion. The video shown at the workshop demonstrated how much they have to contribute, he said. Baldwin particularly cited the contributions that Native communities can make to preparedness and recovery. Traditional views of fire and the landscape could bear on new models of fire adaptation that are being explored, she said.
On this point, Wong called attention to the need to incorporate into planning and recovery the voices of those who are most vulnerable and who are impacted the most. The UndocuFund, for example, should be part of the planning for wildfires, not just a reaction to a disaster. People who speak different languages, have a different cultural perspective, or embody the traditions and knowledge of the past have much to offer to disaster planning. Acknowledging this fact can be especially difficult in places that are largely white, he added.
Communities also have much to learn from each other about disasters and trauma. They have common experiences about systems letting them down, understanding their shared destiny, dealing with displacement, and recovering from their experiences. “The trauma of a wildfire is not that dissimilar from the trauma of kids that experience gun violence in their
neighborhoods every day,” Wong said. Such experiences and events generate narratives of historical significance, of how a family lost its home or its sense of place. “Those are the stories and the fabric through which we can find a path toward healing.”
Eisenman pointed out that wildfires occur in places that offer special opportunities for recovery and preparedness. People move to the forest for the joys it brings them. Thus, the same thing that poses the hazard provides opportunities for learning to live with fire. Perhaps that is also “a model, potentially, for living with climate change,” he said. The same sorts of ideas will arise when shorelines start to be overcome by sea-level rise.
Finally, Villarruel broadened the discussion from wildfires to other disasters like hurricanes that are more common in other parts of the United States. From a distance, the media pays more attention to the Hollywood homes in southern California than to vulnerable populations and communities. “The opportunity to elevate and amplify the voices of vulnerable communities throughout is critical.”
She emphasized the need and opportunity to apply a health equity lens to not only wildfires but all disasters, explaining that “the inequities that we have in all locations are the real disasters,” she said. “We have to attend by working with those communities.” Much more can and should be done in reaching out to these communities and also in reaching out to mainstream organizations so that they can be made aware of the needs of disenfranchised populations.
The workshop could not touch on all of the vulnerable communities that are involved in disasters, she noted, pointing to the brief mention of prisoner firefighters. “To me, that raises all sorts of issues. Did they volunteer? They are also a vulnerable group, so what are the health effects on prisoners?” Another vulnerable group might be veterans, she added. “What was the effect on the veterans? Can and should the resources of the Veterans [Health] Administration be mobilized?”
“We don’t know more than we know,” Kizer reminded the workshop participants. “There are so many areas that are begging for research to be done, to establish the databases, to even establish the research infrastructure so that research can be done.” When he was director of the California Department of Health Services, he was often struck by how meager the evidence was on which government advisories and other recommendations were based. “We need a substantial amount of work to determine the effectiveness of these public health interventions that we recommend.”
Much basic biomedical research is still needed, Ryan pointed out. For example, the physiological mechanisms of smoke inhalation are still uncer-
tain. “Until we can understand the dose–response curve and what it is, we are not going to truly understand” smoke inhalation.
Ryan also called for a conceptual framework for understanding disaster. “If we can measure it, we can improve it.” For example, what is the essential information needed for us to benchmark disaster responses? How can this information be measured and used to improve responses?
Bell cited research questions related to how to estimate exposure to wildfire smoke or other contaminants from wildfires. Satellite imagery, chemical transport models, and a variety of models and methods each have benefits and limitations. Other health outcomes also need to be investigated, she said, such as mental health outcomes, low birthweights among mothers exposed to wildfire smoke during pregnancy, and exposures other than smoke, such as contaminants in water.
Bell also emphasized the links of environmental and social justice to research. Furthermore, these issues of environmental and social justice do not start with a disaster response. People with different socioeconomic backgrounds, ages, races, ethnicities, and other distinguishing characteristics are exposed to different levels of environmental contaminants before a disaster occurs, on both an individual level and a community level. “Even if a disaster response were somehow made equal, we still would have people who, due to their baseline health status, their compromised health status, their occupations, their access to health care, and other factors, may still have a more severe response to contaminants such as wildfire smoke or water quality from wildfires than other populations,” she said. This is an active area of research, she said, but much more research will be needed to understand which communities and individuals need attention.
Jonas pointed to the lack of research on recovery as a community process. “Recovery research on disasters has been historically difficult to do,” he said, and its relative neglect “is a glaring absence.” He also pointed to the need for more research on structural inequities at the local levels in recoveries. “We would like to see models of how these structural inequities can be addressed in recovery plans in communities.” This is an opportunity for equity researchers to promote and participate in conversations in communities, Eisenman said.
Finally, several speakers lauded the multidisciplinary approach taken at the workshop. Both Jonas and Wong pointed out that bringing together four different groups within the National Academies’ models the intersectional thinking that needs to be applied to wildfires. As an example of such thinking, Jonas mentioned the training the Department of Defense has provided in battlefield acupuncture to treat pain nonpharmacologically, which
is now being used in the field. It is relatively simple and can be learned in a few hours, he said. “There are lots of examples like that.”
Jonas also emphasized the need for cross-silo “meta-leadership.” Perhaps a new kind of professional is needed who is trained and has the authority to integrate across silos. This kind of professional is emerging in health care, which is also characterized by the need to work across systems. Examples include health coaches and care coordinators who are focused on trying to get the system to work better. “Maybe we need something like that, perhaps a PhD in system integration.”
Both Bell and Eisenman remarked on the variety of disciplines and professions represented at the workshop. As Eisenman noted, it brought together fire researchers, practitioners, community organizers, public health experts, disaster researchers, health equity experts, and even climate change researchers. “I would hope that the National Academies or others might think about how to tap this kind of transdisciplinary energy and move forward.” Bell made a similar point: “We had medical and health care professionals, disaster planning, community organizations, scientists, government organizations, and many others with different perspectives. I found that very useful. I am sure it will impact my own work positively.”
On a related point, Ryan emphasized the importance of convergence science, which “is exactly what we need to solve this problem.” Inaccuracy in burn-size determination, for example, could be resolved through interdisciplinary collaborations, such as using artificial intelligence to determine burn sizes from photographs taken with a smartphone. Economists could work on the best ways to transfer patients and which hospitals should remain open while others are closed. Engineers could figure out ways to more efficiently treat burns. “How [can] a burn surgeon in Boston guide a fireman or an emergency room physician . . . to save the limb of somebody in Alaska? This is what we need to figure out how to do.”
Baldwin observed that systemic challenges require operating across silos. “How do we come out of these silos and collectively work together?” One need is to work across sectors and bring in people who are most impacted to hear their stories and perspectives, she said. Meaningful solutions need to be constructed over time, “fostering relationship building, increasing language access, and enhancing how messages are communicated to reach all of the people in our communities.” Arriving at such solutions will require reframing issues; collaborative planning; gathering, honoring, and integrating local and cultural knowledge; and mobilizing communities.
Everyone has a responsibility and opportunity to extend and broaden the conversation, said Villarruel at the end of the workshop. “We as roundtables, and as the Academy, need to be thinking about what are the next steps, either in promoting additional research or in using the Academy to bring attention to this particular issue.”