When Bill Toepper was doing his Wednesday rounds for Portland Street Medicine, a group that provides care and advice to people without housing in the Oregon city, he looked up at the sky with concern: the clouds were thick and dark enough that it reminded him of tornado weather in the Midwest, where he once lived. But those clouds were actually smoke from the dangerously un-contained wildfires that are swarming all over the American West.
By Thursday, that smoke would settle over the city in a post-apocalyptic haze.
Though it’s still early in the 2020 wildfire season, the sheer volume of fires and acres burned—over 2 million—has already set records. Sickly orange-red skies and showers of ash have become common sights from Washington State to Southern California, and air quality advisories have been issued from Seattle to Colorado.
But the real danger for those living under the smoke isn’t something you can capture on Instagram. It’s the microscopic PM2.5 particles, tiny bits of carbon 30 times smaller than the width of a hair that can cause asthma-like symptoms in healthy people and much worse consequences—up to and including death—for particularly vulnerable populations. And doctors on the frontline, like Toepper, worry this unprecedented fire season is now dovetailing with the pandemic to unleash a fresh health nightmare.
“In this day and age, It’s hard to know if your coughing is related to the smoke or your asthma or if it’s a new COVID infection,” Toepper told The Daily Beast.
Sharon Chinthrajah, a pulmonologist at Stanford Health Care in Palo Alto, California, said that some of her patients were coming in with symptoms like wheezing, shortness of breath, and runny noses—which could be a result of breathing in the bad air. It could also be a sign of coronavirus.
“It’s really hard to distinguish whether or not somebody’s symptoms are due to COVID versus the poor air quality,” Chinthrajah told The Daily Beast. “There’s also the exacerbation of underlying conditions versus allergic symptoms from what’s being released from the wildfires and into the air.”
Doctors aren’t sure whether wildfire smoke can make someone more susceptible to COVID-19, though some studies have found that “it does look like in the places where air pollution is bad, you are also seeing worse COVID-19 outcomes,” according to Stephanie Christenson, an assistant professor of medicine at the University of California–San Francisco (UCSF).
The way PM2.5 particles cause harm is by lodging in the lungs, causing an inflammation that can lead to coughing or mucus. “When they get down to the lowest part of the lung, they actually cross into the blood through the capillaries in the lungs,” said Jahan Fahimi, a professor of Emergency Medicine at UCSF. “If someone who’s predisposed to having a heart attack or predisposed to having a stroke—that added bit of inflammation from exposure to PM2.5 might be the risk factor that pushes them over the edge.”
Fahimi added that it’s not possible to know whether any individual patient’s heart attack or stroke was caused by PM2.5, just as it’s difficult to know whether a bad case of COVID-19 may have been impacted by smoke exposure. But concern is skyrocketing among medical professionals that the smoke could cause a host of health problem, both short- and long-term.
“Intuitively, if your lungs are already damaged, [and] you get COVID, you’re gonna get sicker,” said Toepper. “That’s pretty much common sense.”
Basic cloth masks of the sort that many are wearing to guard against the pandemic are virtually useless against PM2.5, so experts are advising those in smoke-filled areas—which is practically a quarter of the country—to stay indoors when possible. But when you couple that with the pandemic directives to avoid indoor gatherings, and the growing body of evidence that COVID-19 may be less likely to spread widely in outdoor venues like parks, residents could get exasperated, to say the least.
“We’re telling people, don’t go out in public in the outdoors because of wildfire smoke. And we’re telling people, don’t go out in public into indoor spaces because of COVID,” said Fahimi. “Really the only recourse for people is to stay indoors in your own home, and that’s not totally feasible in the long run.”
The people most in danger right now are those who can’t go inside, like farm workers and the unhoused people Toepper works with. On Thursday, he said, most of them were staying inside their tents to remain clear of the smoke, but they have no effective shelter from the lung-damaging air—and are also more likely than the average person to have the kind of chronic lung conditions that put them at risk.
“We know that this smoke is going to affect our population in a much more profound way than the entire population,” Toepper said. “There really is no escape from it. Everything’s closed. You can’t go to McDonald’s. You can’t go to the library. There haven’t been shelter beds or housing in Portland for 20 years.”
A spokesperson for Multnomah County, which provides services to unhoused people in Portland, said authorities were opening additional 24-hour shelter spaces to get people out of the smoke and had just received a shipment of 40,000 KN95 masks that they planned to distribute through outreach teams to people living on the street. (Those masks, unlike cloth masks, can filter out particles when properly fitted.)
But one additional problem Toepper pointed to is that there aren’t enough accessible COVID-19 tests in Oregon—as in so many states across America. And if there’s a fresh surge in people with respiratory symptoms looking for tests amid the wildfires, it could create a new backlog.
“Even on a good day, you might get a test back in seven days,” said Toepper. “So it doesn’t really do a whole lot of good in the moment. But yeah, I’ve got to say that people are going to suffer because they can’t breathe.”