L.A. Residents: Protect Yourselves From Ash

After a week and a half of unimaginable destruction, Los Angeles is at last beginning to look toward its recoveryfrom the Palisades and Eaton fires. Traversing that stage will take years, not only because of the significant economic and political implications of the fires, but also because of what they will mean for the health and well-being of the thousands of residents who live in or near the burn zones.

Los Angeles isn’t navigating the crisis alone, though. In the wake of the deadly 2023 Maui wildfire, researchers at the University of Hawaii launched the Maui Wildfire Exposure Study, a multi-year effort to track the disaster’s physical and mental health impacts on residents. Though the demographics of West Maui differ greatly from those of Pacific Palisades or Altadena — two of the most affluent zip codes in the country — California public officials, medical professionals, and wildfire survivors can still learn from the ongoing work of the MauiWES.

To that end, I spoke yesterday with Ruben Juarez, one of the study’s lead researchers. Our conversation has been edited and condensed for clarity.

What is the Maui Wildfire Exposure Study?

The Maui Wildfire Exposure Study follows a comprehensive cohort of people affected by the 2023 fires. We collected data six months after the fire, and typically, we’re looking for the long-term effects. For 60% of the individuals who came to the study, it was their first health check since the fires.

It is a pretty interesting population: They’re underserved and typically lack access to health care. We found three main trends: The first was mental and physical health issues. Access to care was a big issue in Hawaii, and I’m hoping that’s not going to be the case in California, but it definitely was here. Housing, job, and food insecurity were other big issues, as were the social impacts.

What have you learned about the mental and physical health of people exposed to the Maui wildfires?

Pre-wildfire we knew that the rate of depression symptoms in the Maui population was about 30%. Post-wildfire, we’re seeing more like 52%, so more than one in two participants in the study were showing depression symptoms. Low self-esteem was another issue. Something that was really worrisome was suicidal ideation: Pre-wildfire, it was less than 1%; post-wildfire, at least for the people in the cohort, it was about 4% of the population. That’s more than a four-time increase.

The second issue is physical health: Nearly half of the participants reported worse health since the fires. We saw respiratory issues, such as coughing, wheezing, difficulty breathing, and also skin and eye irritation, fatigue, and weakness. We’re seeing that about 74% of the participants are facing a heightened risk of cardiovascular disease. We also performed a lung check using spirometry and oscillometry breathing. Based on the spirometry measure, 60% of participants may have poor lung health, and 40% may have mild to severe lung obstruction. We believe this is associated with the exposure to ash and the personal protective equipment individuals wore when they returned to the fire site.

We’ve written a lot about the dangers of wildfire smoke at Heatmap, but I think people are less aware of the risks of wildfire ash. Could you say more?

It’s really toxic. People need to take care of themselves. There are the harmful substances you’d expect in ash: lead, arsenic, asbestos — those are poisons.

Why was our population in Lahaina affected by this? Because they went back to the burned homes and did not wear any PPE. To me, that was crazy. The county said that wearing PPE was a voluntary decision, and that was a mistake. And PPE is not just a mask: you really need eye protection, gloves, footwear, and long clothing, because the ash is really toxic.

Even in small amounts, the poisons in ash can harm the lungs and the heart, and there are long-term effects, including cancer, which is one of the things we’re trying to prevent. In the case of Hawaii, for the initial batch of 767 individuals in the study, we did a heavy metal analysis — a comprehensive panel of 32 of the most expected heavy metals. We already knew that five of the most common heavy metals were found in ash present in Hawaii: arsenic, lead, antimony, copper, and cobalt. We learned that 20% of participants affected by the fires in our cohort were showing an elevated level of at least one of these heavy metals, which is not something that you would expect. We don’t want these things in our bodies at any level. People must know that these things are harmful and they need to take care of their health.

And that’s all just from people returning to their homes and sifting through the ash? Or can ash blow into an area that didn’t burn and affect people that way, as well?

Many participants were uneducated about the harmful effects ash has, especially when it has contact with your skin. But you should also avoid breathing or swallowing soot and ash at any cost. The effects were seen in individuals who had direct contact at a site or were indirectly exposed through smoke or blowing winds — but the majority was direct contact.

That’s so scary.

Not everything was bad news. We found some exciting ways to potentially address some of these issues. For instance, resiliency was at the top of the minds of many participants in the study: “How can I be resilient? How can I survive this catastrophe?”

We also found that lower-income individuals trust and use community organizations more than government services, like federal, state, and county agencies. This information could potentially help us intervene, especially when considering underserved populations like immigrant populations. They just don’t trust the government. Addressing issues through community organizations on the ground was extremely helpful because it allowed people to access the services they needed.

Another thing that we noticed that was super helpful was that people who maintain strong relationships with family and friends experience better health outcomes. Social isolation after a wildfire was really bad, especially for mental health problems. Individuals who are more connected with their friends, family, or are doing something in their community volunteering tend to have better health outcomes, particularly in terms of depression.

How close do you need to have been to a wildfire to experience these effects?

Individuals whose homes were on the perimeter of the burn area experienced more physical symptoms, worse quality of life, and worse mental health. But that doesn’t mean that if your house doesn’t burn, you will not experience any of the symptoms. Even if you didn’t go to a contaminated site, there was all the smoke over the city, and you’re exposed to that. Individuals who are not directly affected can be indirectly affected — at a lower rate, of course, as you’d expect.

Many of the mental health impacts you described were related to things like housing, job, or food insecurity, as well as the lack of access to healthcare resources following a fire. Would you expect mental health impacts to not be as bad in L.A., since it was a more affluent area that burned?

Yes. In fact, coincidentally, one of our scientific advisory board members is a resident of L.A., and he’s been saying that he doesn’t expect the health effects to be as bad in L.A. as they were in Maui because the shortage of doctors is not as big. Also, the type of demographic that is being affected is more affluent.

Having said that, in Hawaii, we had the advantage of winds that blew smoke and soot away. I was reading reports that in L.A., there were no winds, and the smoke was just staying there. In that case, the effects in terms of pulmonary health won’t just be the people directly affected, but the whole city.

What would you want emergency managers and medical professionals in Los Angeles to know about your study as they address the impacts of these fires?

First, we must emphasize to people that this is not a forest fire; houses are burning, full of toxic substances. People need to know that if they return to the burn zone, they need to take care of their health and ensure they are wearing PPE. We need to conduct many communication campaigns around this.

The second thing is, don’t underestimate the power of community and community organizations, especially in L.A., where there are many immigrant populations. Community organizations should be used to provide information because people don’t trust the government or FEMA officials.

The third thing I would emphasize is that after a disaster, when people struggle with housing, job, and food insecurity, their health becomes a lower priority. This is understandable, but unfortunately, neglecting your health at this time can worsen the long-term effects. It’s really important that we emphasize to individuals that even if you don’t have a house or a job right now, you need to take care of your health.

An example of this is in the aftermath of 9/11; years later, more lives have been lost due to exposure to environmental hazards than the disaster itself. If we don’t intervene early on, things can get really bad. That’s what we are trying to do: prevent those long-term effects from happening.