Medical Examiner

San Francisco Shouldn’t Cancel School Because of the Fires

Short-term exposure to air quality is only a problem for a small population.

Smoky skies amid power lines in California.
Power lines are seen against a smoky landscape near Pulga, California, east of Paradise on Nov. 11.
Josh Edelson/AFP/Getty Images

Many districts in the San Francisco area canceled school on Friday, citing the bad air quality caused by smoke from the Camp Fire. Smoke is expected to linger in the area until Wednesday, which likely means we’ll see some “smoke days” next week, too.

I understand the concern. My family and I delayed our trip out to California by a day due to the smoke. But, as we continue to bear witness to the absolute devastation wrought by the Camp Fire—the death toll has reached a staggering 71 with more than 1,000 people still missing, and entire communities have lost their homes—it’s exceedingly important to keep perspective on who is most at risk from the smoke and what the risk is. As an emergency physician, I would like to be extremely clear about why we made the choice to delay our trip: It was not because it would be unsafe for us and our infant daughter to be in the area; it was because it would be inconvenient. We are healthy people with healthy lungs. Being outside for short periods of time, even in these conditions, is not dangerous for us—particularly because we are fortunate to have indoor spaces to which we can retreat.

School closures are a reaction that seems sensical on its face, but it’s difficult to know if it will do more good than harm. I suspect the latter. In my view, it’s a classic case of alarmism: The smoke seems bad, being outside seems bad, so canceling school is just sort of assumed to be a good idea. But when you think about the bigger picture, it looks less and less necessary, and even possibly more harmful than protective. (The San Francisco Unified School District did not respond to a request for comment.)

“For some, closing schools just creates a hardship. It is reactionary to the situation and we should use this situation as wake-up call to be proactive,” says Dr. Kari Nadeau, a professor at Stanford University School of Medicine who studies asthma and allergies. “These particles are dangerous to people with serious lung conditions. Are they dangerous for healthy people? Probably not. They are probably more of an irritant than anything else.”

Nadeau’s message for most people is simple: stay indoors. The air quality index in almost all homes in the area remains under 30, well within the “good” range. The air outdoors does have a much higher air quality index. At 200, it crosses into the range that is considered “very unhealthy.” Official guidance states that “people with heart or lung disease, older adults, and children should avoid all physical activity outdoors. Everyone else should avoid prolonged or heavy exertion.”

But school is held indoors. Yes, schools should cancel outdoor events and sports practices. Yes, close the windows. But leaving a bunch of parents in the lurch on short notice just creates problems and solves almost none of the relevant ones. In parts of California where the fires have caused homelessness, schools actually provide a place for kids to go.

I realize that some kids walk to school and even have to be outdoors between classes in some parts of the states. In these cases, the better solution might be to arrange for more buses and public transportation than to close schools. It’s also worth noting that children with lung problems (up to 1 in 8 children suffers from some form of asthma) should be excused from school out of caution, if the short exposures to the outdoors are causing flare-ups, but this choice should be made by their parents.

More importantly, the notion that healthy people are all going to get sick from being outside for a few minutes is wrong. Unsurprisingly, a media frenzy is feeding right into that impression, leaving many unnecessarily worried. Unless you read very carefully, these stories seem to imply that many people here in California are about develop lung disease from breathing the air on a short-term basis, or that all of the children here are now on an inevitable path to asthma. These inferences rely on epidemiologic studies that are poorly understood even by most scientists and physicians, let alone laypeople and the press. For example, a study cited in the New York Times concluded that smoky days in California led to increased emergency room visits for cardiovascular problems, mainly for adults older than 65. The study is a classic example of large data leading to recommendations that are irrelevant for most people.

But the paper “seems true enough to scare people,” says Dr. Lauren Westafer, an emergency medicine physician at the University of Massachusetts–Baystate who studies how and why physicians fail to utilize modern evidence in their clinical practice. (Disclosure: Westafer and I co-host a podcast together.) But like me, Westafer feels that studies like this are designed to sound public health alarms on large-scale policies. Repackaging their takeaways to appear relevant to most individual patients is misleading and counterproductive.

Let’s take a look at the math. While their claim of a 22 percent increase in cardiovascular ER visits in elderly patients due to smoke sounds impressive, a closer look at the statistic is instructive. We have to factor in that in normal circumstances, even most of our sickest patients visit the ER for cardiovascular problems fewer than 1 out of every 100 days. Running those numbers, the math indicates that for every 500 of our most at-risk older patients, around 1 would have an extra visit to an ER for a cardiovascular problem that might (or might not) be attributable to extremely smoky days. The numbers for young and healthy people are even better.

What is more clear is that prolonged long-term outdoor exposure to heavily polluted air (for people who have no choice but to be outdoors, including the new and chronically homeless, as well as people in the workforce with outdoor jobs) certainly can increase the incidence of problems like lung disease. As fires like the Camp Fire become more common, those risks will indeed start to pile up. That is what we should be focused on.

After witnessing an event that has such profound implications for so many people’s lives, it’s worth remembering who the real victims of this catastrophe are. People in circumstances like mine may be inconvenienced, and even saddened and distressed, but we are not truly at risk. When we do things like cancel school, it gives us the misguided feeling that we are affected, and that some self-pity may even be justified. That’s a wasted opportunity, says Nadeau. “I would hope that people say instead of shutting down schools, let’s get in front of legislative bodies to address the drought conditions that caused this in the first place.”

The message that the schools ought to be sending is that kids should stay indoors as much as possible. But they should continue to hold school—and perhaps use the time to teach a lesson about what’s happened in the fire and why. Instead of literally staying home and sitting things out when things go bad, we should figure out how to inspire action, urging our leaders to take steps that will help keep California from becoming a perpetual flint.

The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.