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Smoke Gets in Your Eyes

Sledge, George W. Jr. MD

doi: 10.1097/01.COT.0000553547.52865.80
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fire smoke; cancer
fire smoke; cancer:
fire smoke; cancer
George W. Sledge, Jr., MD
George W. Sledge, Jr., MD:
GEORGE W. SLEDGE, JR., MD, is Professor of Medicine and Chief of the Division of Oncology at Stanford University. He also is Oncology Times' Editorial Board Chair. His OT writing experience has been recognized with an APEX Award for Publication Excellence and a FOLIO: Eddie Honorable Mention Award. Comment on this article and previous postings on his OT blog at

One of my favorite oldie-but-goodie songs, written by Jerome Kern for a 1930s musical, is “Smoke Gets in Your Eyes.” I like the 1959 Platters version the best (you can Google it), but every version shares these Otto Harbach lyrics:

They said someday you'll find

All who love are blind

Oh, when your heart's on fire

You must realize

Smoke gets in your eyes

As I finish writing this issue's column, it's late in 2018 and the fires have recently been contained in Northern California. The quaintly named “Camp Fire,” though some distance from Palo Alto, turned the local air into a sooty, unbreathable, sickly mess. The local schools (including Stanford) briefly closed their doors; the air quality measures having set record highs for the Bay area. For some brief period, we had the worst air quality on the planet—worse than Beijing, worse than New Delhi, worse than just about any place but Chico, Calif., near the fire's epicenter.

No one is sure exactly how the fire began, though it's been suggested that it was caused by a sparking high-voltage power line near Camp Creek Road in Butte County (hence the “Camp Fire” name). Regardless of how it started, it spread quickly. At one point, it was growing at the rate of a football field a second. In its path was Paradise, whose 26,000 inhabitants barely had time to pack their cars and flee the oncoming firestorm. Paradise was surrounded by forest, and the forest was dry due to a prolonged lack of rain. Not everyone made it out, and we heard sickening tales of bodies found in cars and under burned-out homes. The cadaver dogs have earned their keep. Over 200 square miles of land burned. For an exceptionally well-written look at what happened in Paradise last month, I suggest Kyle Dickman's “Paradise Lost” in Outside magazine (available at

While the firefighters were still struggling against the blaze, we were blessed with a visit from the President, who informed us that the fires and the bad air quality were our fault because we had failed to sweep up all the dead trees and brush like they do in cold, wet, subarctic Finland. He admitted that maybe there was something called global warming, but he didn't think it was to blame for the prolonged drought or the millions of dead trees that litter the California landscape. Never mind that it was federal land that surrounded Paradise, and, therefore, his responsibility. Never mind that the hot, dry Diablo winds barreled through the area like a fire-spewing freight train. No, it was the state of California's mismanagement. And besides, he needed to get back to tweeting about something more important, like the Mueller investigation. And so, he left.

The dictionary defines smoke as “a visible suspension of carbon or other particles in air, typically one emitted from a burning substance.” And that is just about right: The sun's disk lacked its usual sharpness, the hills across the Bay were obscured, and my bicycling to work no longer seemed like the healthy thing to do like it had a few weeks before. The air tasted bad. You just wanted to stay indoors. The local emergency rooms saw the expected surge in asthmatics and COPD patients. My Thanksgiving vacation—out of California—came as a welcome respite. By the time I returned, the rains had come, and the firefighters finally got some well-deserved rest.

Judgements of Modern Science

An Air Quality Index of 246, the local paper told us, is the equivalent of smoking a half-pack a day or more of cigarettes. I find this comparison to cigarettes interesting. Unlike my former Indiana home, few Californians smoke (or not tobacco, anyway). It's not considered a rational or cool thing to do.

Climate denialists, of whom the leader of the free world is one, remind me ever so much of those who denied the link between cigarettes and lung cancer. The parallels abound: An industry (tobacco or energy) views the judgements of modern science as the enemy of their profits. It buys a few stooges—often aging, second-rate has-been scientists—to trumpet denialist views, casting doubt in the public sphere wherever possible. It creates shadowy “institutes” that, in turn, issue misleading policy reports masquerading as dispassionate analysis. The industry co-opts politicians (such as the representatives of the tobacco-growing states in the 1950s and 1960s or the coal-producing states of current times) who work to defeat sensible measures that might ameliorate the problem. The media, always interested in the concept of fairness in the airing of alternative viewpoints, treat the denialists as intellectually equivalent to real scientists rather than as the frauds and con artists they are.

I remember the previous denialists because they belonged to my extended family. My relatives all grew tobacco in North Carolina, and were decent, church-going folks who would not intentionally harm a soul. Unless, of course, that soul was addicted to nicotine, in which case they were fair game. They denied the linkage in part because they were basically good people, and to believe that they were willingly causing the death of others would have meant that they were, in fact, not good people. It was easier to believe that tobacco did not cause lung cancer, or at least that there was some scintilla of real doubt that one might cling to like a life preserver in stormy waters.

I also knew, during medical school and as a house officer, physicians who smoked like furnaces. Most of them are dead now, many of lung cancer or heart disease. Few of them openly derided the linkage; they read the same medical journals the rest of us did. But they had all the equivocations one could ask for: Maybe cigarettes were not causal themselves, and smoking was linked to some innate biologic trait, something genetic perhaps, that was causal. Maybe filtered cigarettes would solve the problem. Maybe there was some safe amount you could smoke. It wasn't an addiction, it was “habituation” to nicotine, because it was wrong to call good, upstanding smokers (like the head of pulmonology at one hospital where I trained) drug addicts.

One of my faculty smoked two packs a day and got a chest X-ray every 3 months, with the intent of resecting the first non-calcified mass that showed up—not a denialist per se, but a fantasist nevertheless. And, of course, not being total hypocrites, few smoking physicians told their patients to quit. Their addiction prevented them from being good doctors. But, like I said, most of them are dead now.

Cigarette smoking denialists pretty much all went radio silent years ago, though the Vice President of the United States has the wonderful distinction of having been a cigarette smoking denialist before he became a climate denialist. He doesn't talk about cigarettes anymore, presumably because that would just make him look ridiculous. It's when the ridiculous, the irrational, finally looks ridiculous and irrational to all that we move on, and perhaps we are close to reaching such a tipping point for climate change.

Human Nature

Most of us are practical climate denialists in our profligate use of energy. I cannot imagine that our descendants will thank us for this, or for our unwillingness to take meaningful steps to halt the melting of polar ice caps, the creation of vast deserts, and the evolutionarily massive extinction of wild species now occurring. “What were they thinking?” is the common refrain of every generation for preceding generations. Be it slavery, or racial or religious bigotry, or misogyny, or some unnecessary and destructive war, we all look back and see someone basically different, almost alien, wearing strange clothes and stranger beliefs, rather than realizing that we are staring into a mirror. We keep making dumb mistakes, just different ones. It is human nature. But this time we are messing with an entire planet.

And, who knows...maybe the planet is getting back at us with the conflagrations. One strange thing about the recent fires, and the ones that burned down much of the Sonoma and Napa Valley's last year, was how the sky looked. It had a yellowish-orangish hue. It never looked clean. I realize that large portions of China must be like this every day, but it was unsettling for an area accustomed to clean air for a generation or more.

This is not the first time in human history that the air has looked wrong. As reported in a recent issue of Science, in the year 536 a massive volcano erupted in Iceland, covering much of the northern hemisphere with a sickly fog. The Byzantine historian Procopius wrote that “the sun gave forth its light without brightness, like the moon, during the whole year.” Crops failed, starvation was rampant, and the weakened population then experienced the outbreak of the Bubonic plague, killing up to half of the inhabitants of the Eastern Roman Empire. The eruption left characteristic traces in ice cores from the Colle Gnifetti glacier in the Swiss Alps, which have now been analyzed, allowing for the identification of its Icelandic origin.

As bad as that was, the dinosaurs experienced something worse. Some 66.043 +/- 0.011 million years ago an asteroid struck at Chicxulub on Mexico's Yucatán Peninsula with an impact a billion times the energy released at Hiroshima and Nagasaki. Though hotly debated, one possible outcome of this was a global firestorm. Chicxulub generated an enormous amount of soot debris over a global level. I don't know if they measured an Air Quality Index in those days, but I imagine it was even worse than what we got with the Camp Fire. The amount of smoke may well have led to a sort of “nuclear winter” sufficient to causing freezing temperatures for several years, tanking food chains and ending the dinosaur's long reign. The survivors were not T. rex and its relatives, but rather low-life, also-ran, tiny scavengers called mammals. I cannot even imagine how the sky looked, but I suspect my ancestors were hiding in some underground lair, so they probably weren't looking.

Health Impact of Fire Smoke

I experienced the Camp Fire from a relatively safe distance, and 2018 was not 536 nor 66 million years ago, for which I am grateful. The long-term health effects of so-called “wildland fire smoke” is, to quote a recent review, uncertain, as “research on the health effects of this mixture is currently limited.” I can't imagine it is good for you. Firefighters got to see the Camp Fire up close, and to spend extended periods exposed to the worst of the smoke and soot. We think of firefighters as brave because they run into burning buildings, but the acute dangers might be outweighed by chronic health effects.

What happens to the firefighters over a lifetime? The largest study to date, conducted by the National Institute for Occupational Safety and Health, concluded that firefighters experience statistically higher rates of cancer (mostly digestive, oral, respiratory, and urinary cancers) than the general population. Mesotheliomas are twice as common among firefighters, for instance. Earlier this year, Congress passed a law, signed by the President, establishing a CDC-led registry that will examine the long-term links between workplace exposures and cancer for firefighters. I doubt that the exposures in an urban environment translate particularly well to a wildfire scenario.

The Camp Fire is out now, and the courage, dedication, and hard work of the firefighters have contained the residual blazes, though I do not doubt that we will see something similar once again, perhaps next year or the year following. In the meantime, let's hope no smoke gets in your eyes.

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