What’s the health toll of 2023 Maui wildfires on firefighters? Long-term study aims to find out : Maui Now

When firefighters rushed into the flames in Lahaina town on Aug. 8, 2023, they were surrounded by toxic contaminants. 

The wildfire that started in a dry field of brush burned everything from old plantation-style homes to concrete-and-steel storefronts to highly flammable gas stations. Even a fire engine melted. 

“When it quickly transitioned into homes on fire, now you’re dealing with different types of combustibles, different types of chemicals, different types of exposures,” Maui Fire Department Chief Brad Ventura said. 

After the flames had been doused and the firefighters had finished sifting through the ash of the nation’s deadliest blaze in the last century, researchers with the Fire Fighter Cancer Cohort Study wanted to know the toll it took on the firefighters’ bodies. 

A team came to Maui two months after the fire and took blood samples from more than 100 firefighters. In October, they returned for another round of samples that will help them keep an eye on the firefighters’ health over time and screen for cancer and other diseases.

Researchers are looking at changes to molecules known as microRNA, which when disrupted can help flag disease. Already, early results from Maui firefighters who responded to the blaze are showing changes as high as 50% compared to those who didn’t, but researchers still have work to do to see whether the level of exposure they faced matches up with the changes in their bodies. 

Cancer is one of the leading causes of death for firefighters, but it’s still unclear exactly what exposures cause it and what’s most effective at reducing the risk.

“It’s really challenging when every fire is different … to really identify what is the driving cause of some of these increased cancers that we are seeing in the fire service,” said Shawn Beitel, research program administrative officer for the University of Arizona’s Firefighter Health Collaborative Research Program. 

“It goes beyond just the exposure at the fire itself that we’re investigating.”

On Maui, the fire department has upped its annual medical screenings and decontamination practices since the COVID-19 pandemic and the wildfires, but that still doesn’t remove the biggest risk of all — the job itself. 

SILENT KILLER

When Garrett Kim first became a firefighter on Hawai‘i island, he didn’t wash the turnout gear that he wore to his calls for the first five or so years. 

There was honor in having a dirty coat and scuffed-up boots. It meant you’d put yourself on the front lines of the smoke and flames. His station didn’t have an industrial washer; they just sent their gear to the local laundromat when it got really dirty.

But when Kim developed an extremely rare cancer in his sinuses in 2010 at the age of 42 — with no family history of cancer, an extremely active lifestyle and no penchant for smoking and drinking — he knew it had to have been caused by his exposure on the job. 

“We’ve known for awhile when you look at the research that firefighters have an abnormal rate of cancer, but … it wasn’t commonplace in the fire service to really accept that or understand that,” said Kim, now the Hawai‘i state director for the Firefighter Cancer Support Network.

The network points out that occupational cancer caused 65% of the career firefighter line-of-duty deaths from 2002 to 2021, according to data from the International Association of Fire Fighters. Firefighters have a 9% higher risk of being diagnosed with cancer than the general U.S. population and a 14% higher risk of dying from cancer. 

In 2022, the International Agency for Research on Cancer classified the occupation of firefighting as a carcinogen. 

But when Kim was diagnosed with esthesioneuroblastoma, a cancer so rare he had to seek surgery, chemotherapy and radiation at Stanford, there was so little awareness and focus on cancer among firefighters that there wasn’t even a support group he could turn to. Part of the problem is that cancer can be such “a long, drawn-out process,” that deaths occurring after the firefighter left the service weren’t considered line-of-duty deaths for many years.

But over the last decade, that’s changed, Kim said.

In 2016, the Fire Fighter Cancer Cohort Study was created with funding from the Federal Emergency Management Agency. The study gathers data over time on firefighter health nationwide, including surveys, biomarkers and exposure information related to cancer-causing substances. 

As of Oct. 1, the study includes 8,228 firefighters across 32 states. 

The long-term goal is to track the health of 10,000 firefighters over a span of 30 years, or the duration of their careers, said Jackie Goodrich, a research associate professor with the University of Michigan School of Public Health. Goodrich is the principal investigator on the study and has been collaborating with the University of Arizona since 2018. 

Because it can take cancer a long time to develop, biomarkers in their blood and urine can help measure the effects well before the disease arises. 

During the team’s first visit to Maui in 2023, they took samples from 108 firefighters, including a “control group” of 16 who hadn’t responded to the incident.

By the time researchers arrived, many chemicals firefighters would have been exposed to had likely already left their blood, so they were not tested for, Goodrich said. Instead, they took samples that they could compare over time.

The key is the microRNA, which regulates genes in the body. Exposure to a contaminant or appearance of a disease can disrupt microRNA, and those changes can help point doctors in the direction of the problem.

Early results showed some changes in microRNA, with firefighters who responded to the August 2023 fires seeing a difference of 25% to 50% compared to the control group who wasn’t exposed. The changes researchers found could be linked to some cancers and autoimmune diseases. However, Goodrich said they’ll get a truer picture of whether that’s fueled by the fire once they compare the length of time that firefighters were on scene.  

For example, if the results show a bigger change in a firefighter who was exposed for 30 days that included battling the fire and cleaning up as compared to someone who was only there for a couple of days or someone who was off island, then it gives researchers “confidence” that it might be caused by the exposure, Goodrich said.

Last month, they were able to follow up with 70 participants from the first study and added another 50, pushing the total number to about 160. They also were able to collect much more detailed information on where each of them was at the time of the fires.

Now, they’re working to factor exposure time into their analysis of the old and new samples. Goodrich said they hope to have results to share with firefighters in about six months, though publication of a peer-reviewed study could take about a year and a half.

Researchers involved with the cohort study have also looked into how fighting fires in the wildland-urban interface, where rural areas of vegetation run into development as they did in Kula and Lahaina, impacted the microRNAs of nearly 100 California firefighters. They found that 50 different microRNAs experienced noticeable changes, including one known to suppress tumors.

Other early studies have pointed to potential health impacts from the Maui fires, but with limited conclusions. In September 2023, the National Institute for Occupational Safety and Health visited Maui and took blood samples from nearly 300 responders with Maui County departments and the Hawai‘i National Guard. 

The study found elevated levels of certain chemicals in some of the responders, and it detected polyfluoroalkyl substances, also known as “PFAS” or “forever chemicals” because of how long they take to break down, in nearly all the responders, with the highest levels in firefighters.

But, the study pointed out, there were no clear patterns between the results and the first responders’ self-reported exposure times or personal protective equipment use. “More sophisticated analyses beyond the scope of this report” would be needed. 

Ventura said the higher exposures were from older firefighters with decades of experience, “so they had more time to accumulate those levels” and exposure to things like the old firefighting foam that contained PFAS and has now been phased out. 

PFAS is one of the more challenging chemicals to study because it’s in many things, including water bottles, nonstick cookware and waterproof barrier on firefighters’ gear. It’s common for there to be some level of these chemicals in just about anyone, Beitel said. However, the goal is to figure out how to keep them from building up and causing harm.

Regardless of the chemical, it’s difficult to figure out what causes cancer in firefighters because every fire is different in terms of the things they’re exposed to, Beitel said. 

“It’s not, unfortunately, like CSI, where you can put a sample in an instrument and it spits out … everything that was there,” he said. 

Plus, fires like the ones in Lahaina and the Palisades area were so much larger and had so many different exposures over a long period of time. It took nearly a month for the Lahaina fire to be 100% contained, and the fires in Olinda and Kula weren’t contained until late September 2023, though crews continued monitoring hotspots and dousing smoldering tree roots for months. 

Whether the Maui firefighters are at a higher risk of cancer given the intensity and duration of the Lahaina fire has yet to be determined. “That’s what we’re really trying to find out,” Beitel said.

The risk goes beyond the fire. Beitel pointed out that firefighters endure long shifts and little sleep as well as high stress and other job-related risk factors that can contribute to future health problems.

CHANGING PRACTICES & PERCEPTION

The challenge of pinpointing the risks firefighters face is not only because every fire is different. Ventura and Kim, both veterans with more than two decades of experience, agreed that what’s burning has also changed.  

Homes used to be made mostly of wood, which burns clean. But now they’re filled with items made of plastic, polyester, fake leather and other materials that release all types of carcinogens. 

“The fire service is constantly changing and we’re constantly having to evolve the way we protect ourselves, the way we clean ourselves, the way we do annual medical evaluations so that if we are exposed to something and we do pick up cancer, that we treat it as quickly as possible,” Ventura said. 

One big change to prevent exposure and reduce risk is reshaping the public image of the heroic firefighter. 

“The old-school firefighter who was covered in black soot and is a weathered and seasoned firefighter by the amount of black on his turnouts is a thing of the past,” Ventura said. “We’re looking for healthy firefighters who can have a healthy retirement, and that means cleaning all that off of your gear.” 

After a structure fire, crews pull down ceilings, get covered in charcoal and come out covered in carcinogens. 

About two years ago, not long before the Lahaina fire, the Maui Fire Department started doing on-scene decontamination. When they are finished inside a building, they use brushes and cleaners as well as water from the truck to clean off all of their gear “from head to toe,” including their helmet and their oxygen tanks, Ventura said. They also use Bullard wipes to remove carcinogens from the skin.

The gear is bagged to avoid contaminating the cab, and once they’re back in the station, they go into extractors, large commercial washing machines that have been placed at all of the stations since the 2023 fire. Firefighters have a second clean set of turnouts in case a call comes up while their first set is in the wash. 

When it comes to reducing risks, Ventura said, “the main thing is enforcing our industry standards.” After hours of fighting a house fire and cycling through several bottles of oxygen, he said it’s tempting to go back and mop up without a tank. But, he said, “let’s make sure everybody’s wearing their tank in that environment.” 

The department has a hazmat crew that can monitor air quality, and if it’s safe enough, firefighters don’t have to wear their tanks anymore. 

The department also started to change its medical screening during the COVID-19 pandemic.

For the last two years, they’ve implemented a new annual medical screening process. Phase 1 includes a blood draw, eye exam, hearing test and an ultrasound of their major organs, which Ventura said has helped identify some medical issues that firefighters needed to address.

A doctor reviews the results of the tests, and in Phase 2 a couple months later, everybody is brought back in to evaluate their blood work and undergo a stress test that looks at their heart. 

This year was also the first time they introduced the Grail cancer screening that tests firefighters’ blood for cancer markers.

Kim is currently traveling around the islands urging people to sign up with the National Firefighter Registry. When anybody in the U.S. gets cancer, their medical records go to a state database that gets shared with a national database to help doctors and scientists understand and prevent it better. If firefighters are in the national registry and diagnosed with cancer, it will help improve data on rates of the disease in the fire service.

“It is trying to ensure that no firefighters fall through the cracks,” Kim said.

Recalling the many firefighters who died years after responding to 9-11, Ventura said the department will be interested to see the results of the cohort study over time. But while they can make changes to protect firefighters and catch diseases early on, they can’t change that the job will always be dangerous.

On Aug. 8, 2023, Ventura said firefighters could have decided that the environment was unsafe, removed themselves from the area and tried to cut off the perimeter of the fire, but instead many were in the middle of it pulling people out of houses and battling the blaze. 

“I think that’s going to be a hard thing to tell firefighters not to do,” he said.