Wildfire survivors suffer mental, physical health effects long after flames are extinguished
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* Mark Barna

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Val Casco, whose home in Lahaina, Hawaii, was devastated by the Maui wildfires, hugs her grandson, Hawea Casco, 9, in August 2023. Over 2,200 structures were destroyed in the fires.

Photo by Tamir Kalifa, courtesy The Washington Post/Getty Images

> “Mental health and physical health must be priorities. The trauma from wildfires does not end when the flames die out.”
> 
> *— Ruben Juarez*

Erin Rhatigan was trapped in traffic on a road surrounded by swaying pine trees on fire. Bright embers swirled through the darkened sky, pelting her car. Then the truck caught fire behind her.

Rhatigan grabbed her cellphone, called her stepdaughter and said goodbye: “I thought, this is it, I am not getting out of here,” she told *The Nation’s Health.*

On the morning of Nov. 8, 2018, Rhatigan was one of thousands of people trying to escape a wildfire rampaging through Paradise, California, a foothill township in Butte County in northern California with a population of 26,000. Within hours, Paradise was devastated.

The wildfire was not contained for 17 days, during which 85 people died, over 50,000 people were displaced and 18,800 structures destroyed. A faulty electricity line ignited brush that burned through 153,000 acres of rolling land, which years of extreme heat had turned to kindling. It remains the deadliest wildfire in California on record.

Wildfires in the U.S. typically happen in western states. Homes in California are the most vulnerable, with 1.2 million properties at risk, followed by Colorado with 321,000 properties.

Since 2018, 10 wildfires have burned across the Golden State, each blackening more acres than the Paradise blaze. Climate-related extreme heat and drought create the conditions for the fires.

From a public health perspective, wildfires can do more harm to communities than floods, extreme heat and other climate-related disasters, said Nicole Lambrou, PhD, MArch, assistant professor of urban and regional planning at California State Polytechnic University-Pomona. Floods, for example, generally do not lead to broad home displacement, and when waters recede, cleanup begins, she said. But wildfires cause vast destruction and leave behind a chemical mess that can take years to clean up.

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A survivor of the Maui fires provides a blood sample in 2024. The University of Hawaii in Lahaina is tracking the health of people who were exposed to the fires in a long-term study.

Photo courtesy Ruben Juarez

“Wildfires are really unique because of the level of toxicity that gets released,” Lambrou told *The Nation’s Health.*

The burning of buildings, infrastructure and cars releases a cocktail of pollutants into the air and soil that science is only beginning to unravel. The toxins have been linked to cancer, respiratory ailments and other chronic diseases.

At the same time, numerous studies have shown that wildfire smoke exposure places survivors at risk for chronic respiratory problems, with some research linking it to skin diseases, eye ailments and cancer.

Allan Stellar lost his home in Paradise on the first day of the fire. For weeks, he couch-surfed at friends’ homes and stayed in hotels in nearby towns. Eventually authorities allowed him to visit his former address, now a blackened patch of twisted metal and foundation stone.

Stellar breathed the lingering smoky air for months without an N95 mask. Today, over six years later, he still has shortness of breath, something he did not experience before the wildfire.

“I can’t tell you how smoky it was and how stupid I was” for not wearing a mask, Stellar, 64, told *The Nation’s Health.*

Most homeowners generally do not rebuild or remain in an area after a wildfire. Three-quarters of Paradise’s residents never returned, as average home prices rose from $236,000 to $440,000, gentrifying the town, said Lambrou, lead author of a study published this year on the wildfire’s impact on Paradise’s housing market. Many survivors were priced out as outsiders swooped in and bought up real estate.

## Mental health needs high for survivors

Not having permanent living space creates anxiety and stress. And when combined with the trauma of a living through a disaster, survivors are likely to have behavioral and mental health needs. But the needs often go unmet, especially for vulnerable populations, according to Ruben Juarez, PhD, a professor of health economics at the University of Hawaii.

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A charred vehicle is left in the road in 2018 after the Camp Fire in Paradise, California.

Photo by Ray Chavez, courtesy Digital First Media/The Mercury News/Getty Images

Juarez is co-leader of a long-term study measuring community health following the August 2023 wildfires in Maui, an island in the Hawaiian archipelago. Serval wildfires erupted, the most devastating in Lahaina, a coastal community in northwest Maui. Over 2,200 structures were destroyed and more than 100 people died. Officials say strong winds knocked down power lines that ignited bone-dry land and spread across 4,500 acres.

In January 2024, Juarez and his team of a dozen health workers from the University of Hawaii arrived in Lahaina to set up clinics and support social services. Fourteen months later, 2,000 people from Lahaina and central Maui were enrolled in the university’s biomedical study. The health, environmental exposures and economic and social struggles of survivors are being tracked, which can inform state policy decisions, Juarez said.

Preliminary findings show nearly half of survivors reported a health decline months after the fires, and three-quarters had a heightened risk for cardiovascular disease due to hypertension. Respiratory complaints, such as coughing and difficulty breathing, are common.

Moderate to severe anxiety impacts about 30% of survivors, Juarez said.

Maui is a melting pot of races and ethnicities, with a large Hispanic community that is isolated and tends to work low-wage jobs. Some Hispanic people were also undocumented. When interviewed at the university’s clinic, about half of them said it was the first time a care professional had asked about their well-being after the fires, Juarez said.

One patient shared how she often wakes up at night and roams the Lahaina streets to make sure everything is OK — that no fire is sweeping the landscape, Juarez said. Showing signature signs of PTSD, she was referred to a therapist at Lahaina Comprehensive Health Center.

Juarez lamented that less than 5% of the $1.6 billion federal relief funding allocated by the Biden administration for the Maui fires is for social services.

“Mental health and physical health must be priorities,” Juarez said. “The trauma from wildfires does not end when the flames die out.”

## Leaving Paradise proves challenging

As Rhatigan sat in traffic on Pearson Road in Paradise in 2018, the California Department of Forestry and Fire Protection told her she could not get out. She drove back to the shuttered local hospital, where she worked as a registered nurse. After hours stranded, she joined a carpool and escaped.

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Michael John Ramirez hugs his wife Charlie Ramirez while combing through the rubble of their home, which was destroyed during the 2018 Camp Fire in Paradise, California.

Photo by Marcus Yam, courtesy The Los Angeles Times/Getty Images

That night, she tried to sleep in a hotel in Dixon, California, 106 miles west of Paradise. She woke up in the early hours and panicked because she smelled smoke and believed the wildfire was outside her door, but she was smelling her smoke-drenched clothing. It was her first experience of post-fire PTSD. Two months after the incident, she started PTSD treatment.

Rhatigan and her husband’s 2,400-square-foot Paradise home was destroyed. The couple could not afford to rebuild and moved out of state.

Rhatigan tried to work as a hospital case manager but could not handle the stress and opted for early retirement. Six years on, Rhatigan, 63, still has PTSD symptoms, she said. She becomes irritable easily and struggles to focus.

“When I talk about disaster case management and disasters in general, I always go back to Maslow’s hierarchy,” Rhatigan said. “You have to take care of the physical needs first, because that’s the security part that you need. But then you have to go to the psychological part. Wildfire survivors cannot manage all the things they have to do physically, to get back on their feet, if they can’t function mentally.”

In January of this year, numerous wildfires broke out across the Los Angeles basin, driven by aggressive winds. The Palisades Fire in Pacific Palisades and the Eaton Fire in Altadena were largest. The fires burned 57,000 acres, destroyed over 18,000 structures and took 29 lives.

Experts are trying to avoid the public health mistakes made after past fires. Trauma response teams have parachuted into ravaged communities to address physical, mental and behavioral health needs.

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In January, Emilee and Natalee De Santiago sit near the ruins of their Altadena, California, home, which was destroyed by fire.

Photo by Brandon Bell, courtesy Getty Images

The L.A. fire regions are surrounded by hospitals and care providers, which could help survivors receive timely long-term care, Juarez said. By contrast, the Paradise and Maui fires were in rural areas, creating a greater challenge to providing care.

Meanwhile, a team of public health experts from Harvard University, the University of Texas-Austin and several California institutions have come together to work on a 10-year study on the L.A. fires. A primary focus is tracking long-term health effects of wildfire toxins. The team released its first update in February on indoor air toxins in surviving homes.

“We’re locking elbows so that we can all help each other with our expertise to address long-term public health issues,” Kari Nadeau, MD, PhD, a professor at Harvard’s T.H. Chan School of Public Health, told *The Nation’s Health.*

For more information, visit [www.lafirehealth.org](http://www.lafirehealth.org) and [www.mauiwes.info](http://www.mauiwes.info).

*   Copyright The Nation’s Health, American Public Health Association