Firefighter health research: Who's next?

In mid-November, nearly 100 fire service personnel, researchers, industry partners and representatives of national fire service organizations convened in Washington, D.C. to develop the National Fire Service Research Agenda. The meeting, hosted by the National Fallen Firefighters Foundation, was the third of its type to convene over the past 10 years.

Attendees were divided into categories ranging from health/wellness and occupational disease to wildland firefighting. The sessions included broad overviews of research occurring over the past decade, review of past research agenda items and consensus among each group about what to propose as agenda items.

Each item was presented to the whole group and a jury of key personnel who then voted on what to classify as critical, important or emerging items.

The research agenda is used to set research priorities for funders such as the Assistance to Firefighters Grant's Research & Development projects. Researchers also can use the agenda items and priorities as justification for needing funding from other organizations such as the National Institutes of Health or private research foundations.

Two groups — the health and wellness group and the occupational disease group — proposed agenda items related to further research on under-researched populations. Specifically, the groups identified both women and racial/ethnic minorities as needing additional study.

One participant asked if, given the low rates of women and minorities in the fire service, is it worth making research on them a high priority given the limited research funds.

Not-so-simple answer
I was happy to hear the question, not because I agreed with the sentiment, but because I realize the question is likely one several people in the room had in their mind and it was important to address it.

The answer to the question is a simple yes but the explanation for why is not quite as simple. A decade ago when FEMA started funding firefighter health research, there was limited research available on the health status of firefighters.

The CDC's report on the leading cause of line-of-duty deaths being cardiovascular was the foundation of most research questions. Of the "firefighter" hits on PubMed (a site that catalogues peer-reviewed health research), 66 percent of the studies have been published in the past 10 years.

Ten years ago, what we knew about firefighter health was limited — Dr. LeMasters had not yet published her meta-analysis identifying the probable and possible cancers related to firefighting, NIOSH had not conducted its cohort study examining the relationship between exposures and cancers, and the New England Journal of Medicine had not yet published Dr. Kale's work on the cardiac risk of responding to a fire.

Ten years ago, there was limited research on health behaviors, health risks, obesity and fitness among firefighters. We know more than ever before about how firefighting affects physiology and what the impact is on overall health.

Statistically insignificant
The limitation to the research to date is this: It is primarily based on white males. To be fair, white males make up the vast majority of the fire service, so it make sense that the foundation of the research was based on the largest group.

However, what is now being funded and the questions being asked are becoming increasingly complex and specific. Now that there is a strong foundation of research, specific questions need to focus on difficult-to-access and -study populations within the fire service.

As an example of the challenges, peer-reviewed scientific journals are hesitant to publish studies with small sample sizes in any specific sub-group. In a previous cohort study of more than 1,000 firefighters, only about 50 of our participants were women.

When the team tried to publish results stratified by gender, editors suggested removing females from the sample given statistical comparisons between groups could not be made.

In firefighter cancer research, the odds ratios (a measure of risk) are relatively large for some gender specific cancers like breast cancer. However, because the sample sizes are so small, the findings are not statistically significant.

Serving those who serve
If you are one of the women whose breast cancer is not being covered by presumptive laws due to lack of scientific evidence, the time for research on female firefighters is yesterday.

Now that there are several well-designed studies exploring cancer risk for the fire service in general, there is a need to study specific sub-groups. For example, it is important to know if African American firefighters are at a higher risk of certain types of cancers or cardiovascular disease.

And the notion that all people are created equal doesn't pass muster. We've long known that different genders and races are more susceptible to different illnesses. For example, black males are 50 percent more likely to contract lung cancer than white males, despite less tobacco use — they also have greater incidents of high blood pressure and death from cancer.

Lack of data on these under-researched groups also has been suggested to play a role in the recruitment and retention challenges facing the fire service in increasing diversity.

Reproductive health issues were identified as an agenda item in the first research agenda, but were not voted a high priority by the attendees. Preliminary evidence from the past has suggested reproductive health issues — conceiving, birth outcomes, and birth defects — might be a concern for firefighters.

While not a popular topic, if reproductive health issues exist for women in the fire service, it is possible that similar challenges might exist for men. Now that general research is available on several health issues, looking more in depth at topics such as reproductive health is necessary for moving the field forward.

If people still want to argue that the research should be remained focused on white males, I would challenge them that if numbers should drive funding decisions, 800,000 of the 1.1 million firefighters are volunteers. Yet, limited data is available specific to volunteer firefighters.