In summary Spots in California are registering, by one measurement, the most polluted air on earth. If this is the “new abnormal” of wildfires, health advocates say the state will need to step up efforts to educate and protect the public.

Large canopies of wildfire smoke continue to cover more than half of California as spots registered, by one measure, the most polluted air on the planet. If this is symptomatic of what Gov. Jerry Brown calls the “new abnormal,” health advocates say the state will need to step up efforts to educate the public and protect them from harmful exposure to hazardous air.

Air already registered as “unhealthy” grew even worse today in many parts of Northern California, hitting or maintaining “very unhealthy” or “hazardous” levels in regions well over 100 miles away from the week-old Camp Fire in Butte County. So many people have been regularly, obsessively checking the federal air quality monitoring site as a result of the state’s wildfires that the page had to be streamlined so it would load properly. Schools cancelled classes, parks were virtually deserted and pharmacies were refilling prescriptions for asthma inhalers and other remedies.

In Southern California, the Woolsey Fire that ravaged the Malibu area created its own acrid residue, but the impact on air quality was less severe—in part thanks to the Santa Ana winds blowing smoke away from populated areas.

Some advocates suggested the state could:

improve warning systems to alert people to dangerous air

require counties to distribute high-quality respiratory masks to affected areas, with a focus on at-risk populations

insist that employers require mask use for those who work outside when the Air Quality Index reaches alarming levels

more thoroughly research the long-term effects of fire smoke on those who live and work outside.

“Counties are the closest to the ground and run a lot of emergency management. But the counties are not going to prepare for it unless the state tells them to,” said Lucas Zucker, policy director for the social justice organization Central Coast Alliance United for a Sustainable Economy.

The state has to go further than just issuing notices encouraging people to stay indoors, says health scientist Ananya Roy—noting the huge number of people displaced by the fires, as well as homeless people and the poor who are still expected to work outdoors.

“They are not going to be able to be reached by health alerts,” said Roy, a scientist with the Environmental Defense Fund. “There need to be better strategies to address the most vulnerable in our populations.”

A Quartz headline making the rounds on social media this week declared that breathing in parts of California was equivalent to smoking half a pack of cigarettes a day. Drifting smoke and haze from the fires contain toxic gases and fine particles so small that, once inhaled, they can burrow into the lungs and end up in the bloodstream, triggering short- and long-term illness.

“The things you can’t see are more of a health hazard,” said Ed Avol, a professor at USC’s Keck School of Medicine who specializes in respiratory issues. “Not only is there wood burning, but also homes and buildings and other structures, and in those buildings there are all kinds of chemicals. Plastics fibers, materials from furniture, asphalt shingles, clothing, carpet and all of those things are consumed, and that is transferred into the air.”

The state’s Public Health Department issued a media advisory that encouraged people “in burned areas with ash” to “wear a tight-fitting N95 or P100 respirator mask, gloves, long-sleeved shirts, and long pants when cleaning up ash”—but that advisory did not make a similar explicit recommendation for the millions of Californians who found themselves outside of burn areas but still breathing outside air with very unhealthy or hazardous AQI numbers.

Screenshot on Nov. 15, 2018 from the website PurpleAir.com

Those federal Air Quality Index ratings score air from 0 to 500—the lower the number, the better. At 151, air is considered unhealthy. At 201, it is very unhealthy. A score above 300 is hazardous. Some parts of Northern California today soared above 400, according to both the federal site AirNow.gov and PurpleAir.com, which has monitors around the globe.

“Smoke from wildfires can cause eye and lung irritation. Breathing smoke can also make asthma symptoms worse. People with underlying lung or heart problems should limit their exposure by staying indoors,” State Public Health Officer Karen Smith said in the statement. “Heavy smoke exposure can also cause more serious disorders, including reduced lung function and bronchitis.”

The department said it has used social media to reach Californians with health cautions about fire cleanup and air quality.

Currently, it does not distribute masks or do on the ground outreach, leaving that to local agencies such as fire departments and cities, but it does provide masks to local governments that request them.

The Trump administration’s secretary of Health and Human Services, Alex Azar, declared the California wildfires a public health emergency on Tuesday, saying that would allow “greater flexibility” in assisting wildfire survivors. One example: allowing displaced Medicare and Medi-Cal patients to receive care from doctors who may not be certified as Medicare or Medi-Cal providers.

“The problem unfortunately is that these fires have become year-round,” said Avol. “Where we once thought about wildfires and smoke as extreme occasional events it’s becoming more of a common circumstance we have to deal with.”

After past fires, hospitalizations and emergency room visits for asthma, pulmonary disease and cardiovascular episodes have spiked.

“There’s not much we can do except reduce exposures,” said John Balmes, professor of medicine at UCSF and professor of environmental health sciences at UC Berkeley’s School of Public Health. “Once we have this bad air there is no magic way to clear it.”

Zucker said counties could create direct outreach because they know which census tracts have the greatest concentrations of, say, residents with asthma or those already in poor air-quality corridors.

He’s had time to think about this. His organization is based in Ventura County, where the Thomas Fire last year blazed through 300,000 acres and became the largest fire in the state’s history—only to be exceeded by the Mendocino Complex fire this year.

At that time his organization’s staff and volunteers passed out over 15,000 of the N95 respirator masks in neighborhoods and in the fields where farmworkers toiled while fires raged nearby. Zucker also met with local health and agriculture industry leaders after the fires to create a plan for the next time—although they didn’t know it would be this soon.

Those meetings did help, he said. Last week when the Woolsey Fire in Ventura and Los Angeles counties began, some farmers gave masks to their workers. But not everyone did, which is why he calls for a uniform state policy.

“When you have a population like farmworkers who are exposed to pesticides and then layer on top of that the cumulative issue of fire smoke and that they live in polluted neighborhoods to begin with, it’s a serious public health issue,” Zucker said. “And our agencies aren’t prepared to deal with it.”

He also advocates increasing health care access, which many people expect Gov.-elect Gavin Newsom to tackle in the new year. It matters here, Zucker says, because those most impacted often have little to no coverage—particularly homeless people and undocumented immigrants who spend most of their time outside in fields, on construction sites or as day laborers.

“When people are not getting preventative care and screenings, it could be difficult to catch those serious respiratory developments,” he said. “With this increase in wildfires and climate change, it requires us to start thinking and working beyond our usual silos and seeing something like health care as not just a health equity issue, but also as a climate issue and a disaster management issue.”