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Cancer in firefighters

Editor’s Note: Part 1 in our series looks at the modern statistical picture before delving into the history of firefighters and the dangers they faced. In Part 2, we’ll be looking at medicine and disease in ancient firefighters. Part 3 will take us back to the present and look ahead to what needs to be done to change the increased risk of cancer that firefighters face. Dr. Kenneth Kunz is a medical oncologist who has taken action in the fight against cancer in firefighters through visiting fire departments and spreading the message of risk in various ways. Dr. Kunz has written this three-part series with the support of the Fire Chiefs’ Association of British Columbia.

Having trained professionally as a cancer researcher and a medical oncologist, I am developing an increasing interest in the health and welfare of firefighters. You see, cancer and fire are a lot alike. Both seem to strike mysteriously and when least expected. They strike incisively, often with devastating force. Both have the will and the capacity to — either quickly or leisurely — overwhelm and devour their subjects with an insensate and unquenchable thirst. Physicians and firefighters, cast in the role of onlookers or intercessors, can often do nothing, or at best are relegated to harm reduction or palliative strategies. Meanwhile the cancers — or the flames — mete out the corresponding pain, fury, and confusion that are commensurate with their power. And despite the ongoing scientific advances in each respective discipline — fire fighting and medical oncology — the physical, structural, psychological, and spiritual losses from fire and cancer remain as heartbreaking and perplexing as ever.

But there is a deeper, more personal, and tragically ironic issue that concerns cancer and fire; they share in common an even more poignant property: both are inextricably linked by their propensity to consume firefighters. And cancer, as we now know, usually claims the lion’s share of the spoils.

When I ask my friends, medical colleagues, and other members of the public, to speculate about how they think a firefighter most commonly dies as a result of work in the fire service, they often guess that it involves either being crushed, asphyxiated, or incinerated. They are often surprised when I point out what the ever-expanding scientific literature reveals: when compared with the public, firefighters are at significantly higher risk of being diagnosed with, and subsequently dying of cancer that is fundamentally related to, and caused by, the service work they do.

This poignant finding was recently highlighted by an eye-opening report published in 2018 by Rachel Ramsden and her coworkers at the Injury Research and Prevention Unit at the University of British Columbia, in collaboration with Len Garis, a retired fire chief, at the University of the Fraser Valley. Ramsden, who is currently a doctoral student at the UBC School of Population and Public Health, examined a series of workers’ compensation claims awarded to fallen Canadian firefighters or their families over a 10-year span between 2006 and 2015. Out of a total of 568 work-related firefighter deaths, 483, or 85 per cent, were attributed to occupational cancers, while only eight per cent were due to chronic illnesses like lung and heart disease, and six per cent from traumatic injury. In other words, the results of this surprising study indicate that the overwhelming majority of work-related deaths among Canadian firefighters involved cancer. This is a sobering revelation when contrasted with the more modest plight of the standard Canadian citizen, who, by comparison, has “only” a 30 per cent lifetime chance of dying of cancer. Firefighters die of this illness at significantly higher rates than the public.

The solemn relationship that exists between fire fighting, cancer, and death is continually renewed, substantiated, and updated as time moves forward and new evidence emerges. For example, in a hallowed Sept. 11, 2018 bell ringing ceremony in Calgary honouring 47 fallen firefighters, 38 of them, or 80 per cent, died of cancers that were presumed to be as a result of their jobs; and at a similar 2018 9/11 ceremony held in Colorado Springs, 249 fallen firefighters were honoured, 164 of which, or 66 per cent, succumbed to occupational cancers.

But examining the firefighter cancer mortality rates in these special, very public, and therefore sensationalized instances can have the untoward effect of magnifying or overamplifying the real numbers. A more accurate approximation of what really happens to firefighters comes from the work of epidemiologist Dr. Robert Daniels and his associates at the National Institute for Occupational Safety and Health (NIOSH), the National Cancer Institute (NCI), and the University of California at Davis. In 2015, this research team published the most thorough, ambitious, and authoritative study to date on the subject of cancer in firefighters. After examining data from nearly 30,000 urban U.S. firefighters over a span of almost 60 years, the group reported that firefighters have a nine per cent higher chance of developing cancer at some point during their lives, and a 14 per cent higher probability of subsequently dying from cancer than the general public. These may seem like modest increases; nine per cent and 14 per cent, respectively, however, they must be considered in context to the baseline cancer risk faced by the standard North American citizen. For example, if, in 2019, the average Canadian has a 44 per cent lifetime risk of developing cancer, that number jumps to 53 per cent if that Canadian happens to be, or has been, a firefighter. If the average Canadian has a 30 per cent lifetime risk of dying of cancer, that mortality rate now increases to 44 per cent if that person had a career in the fire service.

It is high time that steps be taken by society to stem this rising tide; to slow, stop and eventually reverse the number of firefighters consumed in this roiling cancer tsunami. Helping to reduce the burden of cancer, particularly as it concerns those in the fire service, falls within my special area of professional interest. To understand the entire story of cancer and firefighters, it is important and utterly fascinating to learn some of the history behind fire fighting.

On the antiquity of fire, firefighters and cancer
Curiosity has often led me to wonder: how long has the industrial association between fire, fire fighting, and cancer been going on? Probably a long time — epochs, in fact. It is now generally accepted among archeologists and anthropologists that our early ancestors began the controlled use of fire for warmth, protection, tool making, and food preparation approximately 1.5 million-years-ago. That’s about 50,000 hominid generations, perhaps longer. This allowed primitive populations to expand, disperse geographically, and evolve culturally, with the eventual introduction of agriculture some 12,000 years ago. Reliable food sources made possible the gradual expansion of smaller communities into larger cities of several hundred thousand people; cities such as Damascus, Syria, which has seen human inhabitation for 11,000 years.

In the absence of our modern synthetic construction materials, stone, mudbricks, and natural fibre were common building materials for sure, but also, indispensably and predominantly wood — and plenty of it.

Because of the scarcity of timber in the Sahara, it is recorded that in 2,600 BC, Sneferu, a powerful Egyptian pharaoh of the 4th Dynasty, ordered the construction of a fleet of 60 seaworthy cargo ships. Successive convoys of these high-capacity transport vessels sailed an ancient Mediterranean superhighway to harvest the richest source of cedar logs, found at Byblos, Lebanon. One papyrus invoice of the time catalogued the delivery of 40 such shiploads of massive cedar logs. Wood was delivered continuously and in abundance, to source the expansion of the magnificent Egyptian empire. Everywhere in the ancient world, as cities were growing, wood craftwork and construction was booming.

With so much timber used throughout these cities of antiquity, fires were ubiquitous and inevitable. Not only smaller domestic-sized blazes — but outright industrial-scale, citywide conflagrations — posed an ever-present threat to property and life. So far, we have only indirect knowledge of professional fire fighting services in ancient Egypt, but such did exist. If the Egyptians were able to design and construct ships capable of transporting 180-ton granite obelisks at a distance, they probably had a fairly sophisticated fire service as well. Knowledge regarding this comes to us from the well-kept records of imperial Rome.

A brief history of fire fighting in ancient Rome
In considering a history of fire fighting in ancient Rome, and how it leads up to the modern-day plague of cancer in firefighters, the first certain knowledge of organized attempts at urban fire control comes to us from the journalists who were there to see it. Ancient historians such as Cassius Dio (AD 155 -235), Pliny the Elder (AD 23 – 79), and Plutarch (AD 46 – 120), among others, left careful accounts of day to day life in these distant times. We learn that roughly 2,000 years ago, the city of Rome was a high-density metropolis of approximately one to two million people, a significant 30 per cent of which were slaves. We are told that the city was frequently and repeatedly ravaged by lethal and devastating fires, to the continual dismay and vexation of the empire. One estimate suggests there were as many as 100 smaller fires per day, any two of which could erupt into terrifying infernos that would threaten the city at large.

These historians tell us of a notorious, privately-owned, and commercialized fire service that emerged in Rome in the first century BC; fire fighting that amounted to little more than a swindle in the form of organized extortion. A certain Marcus Licinius Crassus (115 BC – AD 53), whose life was marked by craft, cunning, and an overpowering lust for wealth, assembled a retinue of about 500 men, indentured slaves who, before falling on hard times, were formally trained as builders and architects. The crew would rush to a blaze and then remain on standby while the brazen Crassus entered into an impassioned haggling with the distraught owner to purchase the property — as it was burning — at an insultingly low rate. If the frantic owner, in a moment of vulnerability, accepted the deal, the fire crew would jump into action and attempt to extinguish the flames. If no deal was reached, the erstwhile firefighters would stand down and watch the structure burn to the ground. In the aftermath, Crassus would often successfully acquire the damaged or burned-out ruins, which sometimes amounted to large tracts of the neighbourhood, and his skilled team of ‘contractors’ would repair or rebuild so that he could sell the properties back to their original owners, or others, at much higher rates. In this way, along with operating other nefarious schemes as well as legitimate enterprises, Crassus amassed a fortune that by today’s standards is estimated to be in the range of about $15 billion US. Dishonest intentions, however, combined with profiting from the misfortune of others, inevitably comes with a cost. We learn that Crassus, one of the first, self-stylized fire chiefs, had his head hacked off and molten gold poured down his throat (although I am not sure in what order) in a scornful public mockery of his lust for wealth.

Dr. Kenneth Kunz. PHOTO credit Dr. Kunz

Out of a total of 568 work-related firefighter deaths, 483, or 85 per cent, were attributed to occupational cancers. Photo: Getty Images

A more commendable and praiseworthy attempt at establishing a fire service took place 30 or 40 years later, somewhere around 22 BC, when a certain ambitious magistrate, Marcus Egnatius Rufus, won great distinction in Rome by establishing the next organized, privately-run, but free-of-charge fire service. Considered to be a dangerous and somewhat less than prestigious occupation, this early fire department was also necessarily staffed by slaves, to the number of about 600 men. Given the immensity of the city and the frequent number of overwhelming infernos, this poorly-resourced agency was stretched far beyond its capacity to render effective response. Historical reports suggest that the fire services were disappointingly haphazard and unreliable. The proud and confident Chief Rufus, after basking on an initial crest of popularity, was subsequently executed by reason of unrelated conspiracies combined with the sinister intricacies of Roman politics.

In exasperation after another particularly dreadful blaze around AD 6, and inspired by the lofty endeavors which won popularity for the hapless Chief Rufus, Augustus Caesar (63 BC – AD 14) resolved once and for all to implement a no-nonsense, imperially-ordained, professional fire service.

After considerable research, the following is my reasoned approximation of how Caesar was able to inaugurate his highly-effective and military-disciplined fire authority. For better administrative management, Caesar divided the expansive city into 14 distinct geographical regions. As a means of generating a fire budget, he levied a new tax of four per cent on the sale of all slaves. Caesar specified that the new fire service be modeled after the agency then operating in Alexandria, Egypt, which was renowned for its efficiency. The emperor appointed a fire commissioner, who oversaw the creation of seven municipal fire authorities, with each authority responsible for providing fire protection to two geographical regions of the city. Each of these seven main authorities were further subdivided into seven distinct fire brigades, with each brigade consisting of 70 to 80 full-time firefighters. Each brigade had its own sophisticated, expansive, and especially designed firehall complete with barracks and water cisterns, and equipped with an impressive array of fire fighting implements. Horse-drawn fire engines — rolling wagons partially filled with a reservoir of water — were fitted with a primitive form of deck-mounted deluge gun: powerful, Greek-designed, twin-suction Ctesibius piston pumps. These forerunners of our modern appartus were capable, according to some reports, of projecting a fountain of water some 20 or 30 metres high. The deck guns were manned by experienced pump operators who worked in collaboration with firefighters whose primary task was to locate and access a continuous supply of water, which they sourced from the numerous wells, basins, aqueducts, and public fountains distributed throughout the city.

With the fire monitors pumping a continuous stream of water onto the blaze, firefighters on the ground worked knockdown using buckets, ladders, grappling hooks, ropes, pickaxes, and mattocks. They were assisted in their work by heavy military engines designed to create firebreaks by demolishing burning buildings and any nearby structures also at risk of catching fire. With bravery, skill, and resource, these ancient firefighters also muffled flames by throwing large, water-soaked patchwork quilts over fires, in addition to chemically smothering flames by spraying a vinegar-based fire retardant.

Apartment blocks, some higher than five or six stories, were common in the city of Rome, thus the firefighters had a ready supply of bulky rescue mats that were designed to cushion the falls of tenants who chose to escape incineration by jumping for their lives. Motivated by fear and desperation at the thought of a fiery death, the Romans were nothing if not resourceful and daring.

Another major task was to get out and actively patrol the streets on foot, especially at night, when the fire hazards peaked due to the use of candles, oil-lamps, hearth fires, and fixed-lighting torches. Since lethal fires could spread so quickly, homeowners were expected to assist in fire suppression and prevention. Roman fire codes specified that landlords and tenants were to keep fire fighting equipment ready-to-hand, along with an abundant supply of water to assist in battling any flames that might erupt.

Archeological evidence reveals that the firefighters of ancient Rome wielded a more fearful power —even a brutal influence — over the general public than our more temperate and well-mannered firefighters of today. Tasked with serious responsibilities, and held accountable by an unforgiving imperial authority, Roman firefighters, in thought and action, were actually a hardened amalgamation of military soldier, police officer, and firefighter. This can be seen from the gravestones of Roman firefighters, which indicate that some were equipped with a lethal short sword as well as a heavy, knobby-wooded baton called a fustis, which served, essentially, as a bludgeon.

Many firefighters today would be interested to learn that, under the authority of the emperor, if a member of the public was discovered to be negligent in adhering to fire codes, or careless in managing a fire, the fire chief could order them to be summarily beaten, horsewhipped, or, at the very least, for minor infractions, given a good tongue-lashing. Many lives, then, just as now, would depend upon such responsible fire conduct.

Because of the difficulty and danger of ancient fire knockdown and overhaul, there was initially some reluctance for prospective young firefighters to enlist in the new service. Therefore, in AD 24, Tiberius Caesar (42 BC – AD 37) vowed to grant full Roman citizenship — a title with considerable privileges and benefits — in addition to a significant cash bonus, to any firefighter who survived or endured a six-year span of service.

A six-year span of service? When contrasted with the standard 25-year term expected of soldiers fighting with the imperial Roman army, this may convey significant depths of meaning regarding the anticipated survival rates of each of these disciplines. Nevertheless, the enticements offered by the government must have had some success, as a census in AD 55 recorded that the fire service in the city of Rome had grown to 3,920 full-time career firefighters. In AD 205, because of the ongoing and indispensable successes of the fire department, this number was doubled to about 7,000 firefighters. The imperial Roman government recognized that organized, professional fire brigades were an absolute necessity as the empire expanded and progressed. Therefore, similar models quickly sprung up in many, if not all, Roman cities, for example Carthage and Antioch, among others.

Look for Part 2 in our series on firefighters and cancer in the February edition of Fire Fighting in Canada.

Dr. Kenneth Kunz is a classically-trained medical internist, oncologist, chemist and cancer researcher and most recently a mental health and addictions consultant. He is a competitive track and field athlete and father of two residing in British Columbia.