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November 16, 2015

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Survival of the fittest: the evolution of firefighting

Dr Chris Ide provides an insight into the history and evolution of firefighting and how learning from the past has helped save lives in the present. 

Firefighting in the British Isles has evolved over the centuries. Medieval communities might have appointed a constable or night-watchman who would patrol and, when a fire was spotted, raise the alarm and organise firefighting efforts. The 17th and 18th centuries saw the proliferation of insurance companies who undertook to fight fires in premises whose insurance they had underwritten. This was potentially inefficient as insured buildings might be scattered all over town, leading to lengthy journeys from fire station to blaze. Also, despite premises usually carrying a plaque that identified the company insuring the property, it was not unknown for firefighters from rival companies to be involved in brawls outside burning properties.

As a result of the industrial revolution, cities and towns increased in size, which in turn saw a rise in the numbers of residential properties, as well as factories full of expensive machinery and warehouses containing valuable raw materials and finished products, all of which were vulnerable to fire damage.

Edinburgh Corporation responded to this by appointing James Braidwood as its “Master of Fire Engines” in 1824, and founding the world’s first municipal fire service. Braidwood was a surveyor, and the success of him and his crews, recruited from building tradesmen and sailors, resulted in Braidwood moving to London in 1833 to be “Master of the London Fire Engine Establishment”. He continued to develop firefighting techniques, but his style of leading from the front eventually proved his undoing when, in 1861, while fighting a fire in a warehouse, a wall collapsed and killed him.

Firefighters show the highest levels of heroism. For 11 years, I was medical advisor to Strathclyde Fire and Rescue Service, which as of April this year, is part of a single Scottish Fire and Rescue Service. There is a memorial at its headquarters in Hamilton to those firefighters who were members and died while on duty. These include 26 firefighters and salvagemen who died in two fires in 1960 and 1972. Although there have been subsequent additions to this memorial, since then all deaths have been due to natural causes.

In order for safety advisors to best direct their efforts to improve health and safety in the fire and rescue service (FRS), they need to be able to get hold of some basic information, such as why firefighters die — particularly while serving — why they prematurely retired, and why they take sickness absence.

In the first instance, the data should be available from within the particular FRS’s annual report. Although the report layouts may seem different, their content often follows a formula laid down by the Department of Communities and Local Government (DCLG), or the Scottish Government in order to make it easier for them to gather their own figures. If you are seeking further information about health matters, then contact your FRS’s occupational health service.

While they will consider themselves bound by medical confidentiality when it comes to discussing individual cases, they should be able to explain the meanings of terms on death certificates (since death certificates are in the public domain), toxicology reports, and provide information about ill-health retirements on an anonymised basis.

Next, it would be worthwhile to look at some of these compilations, such as the reports from Her Majesty’s Chief Inspector of Fire Services (there is a separate report for Scotland, published by the Scottish Government), and the Fire Statistics Monitor, published by the DCLG. These are published annually, but publications that concern themselves with events that have occurred over a longer time period are also worth studying, since they will be much better at demonstrating trends.

The Fire Brigades Union published a report which listed 122 deaths of firefighters that had occurred on duty during a 30-year period ending in 2008.1 Reports from the neighbouring FRS may also be relevant — after all, an event that occurred last year in an adjacent area may crop up in yours next year.

A newly appointed safety advisor to a FRS will probably be anticipating new challenges, of which there will be plenty. Nonetheless, there are likely to be many similarities to the organisation the advisor has just left. For example, the principal causes of ill-health retirement in firefighters are not too different from those in other occupational sectors — musculoskeletal disorders, mental health problems, and cardiovascular disease dominate, and causes of death generally tend to reflect those in the wider community.

However, firefighters generally tend to be less likely to die before their time than corresponding members of the general population. This is due to the so-called ‘healthy worker effect’, which begins on entry, since firefighters are required to pass some fairly strenuous tests as part of the selection process, which will weed out those who are less fit and who may have poorer health. The ‘healthy worker effect’ continues to apply throughout service, since those with significant health problems may prematurely retire from service or die, thus culling the ‘unhealthy’ and — in theory — leaving a fitter residual workforce.

This ‘better health’ is expressed using a figure called the standardised mortality ratio (SMR), which is calculated by expressing the observed deaths in the population under study as a proportion of the number of deaths that might be expected to occur in the general population. It can also be expressed as a percentage, by multiplying by 100. Therefore, if the SMR is 1.0 (or 100), then the number of deaths in the population under study during the relevant period of time is no different from that of the general population.

On the other hand, if the SMR is higher than 1.0 (or 100), then the members of the population under study are more likely to die, and it may be helpful to start to speculate on why this might be so. If the SMR is reduced — under 100 — then this is reassuring.

Generally, most studies of firefighters tend to show that their death rates compare favourably with the general population, and in some cases, it is very much better — for example, a number of studies cited overall SMRs for English, French and German firefighters of 63, 52 and 78 respectively.2,3,4 

Firefighters have attracted a considerable amount of occupational medicine research. A simple PubMed search reveals inputting the word ‘firefighter’ reveals 1,081 papers published since 1977.

Given their potential exposure to a variety of ‘nasties’, there has been a tendency to concentrate on research into the extent to which firefighters develop cancer; 61 papers deal with this topic. A particularly authoritative report, which drew on several of these papers, was published by the International Agency for Research on Cancer in 2007.5  This placed firefighting in category 2B: that occupational exposures were possibly carcinogenic to humans, although the evidence was limited.

Many of the studies reviewed showed evidence of increased incidence of 10 different types of cancer, but few of these increases occurred consistently across all studies, and even fewer reached statistical significance. These tumours were testicular cancer, non-Hodgkins lymphoma and prostate cancer.

As far as I am aware, there had been no general review of the wider aspects of firefighter occupational health since the ‘State of the Art’ review in 1994,6 until 2012 when Crawford and Graveling presented a review, funded by the Industrial Injuries Advisory Council, which studied non-cancerous diseases as they affected firefighters.7  They considered the broad categories of cardiovascular and respiratory disease, hip osteoarthritis, mental health, hearing loss and sarcoidosis — a disease of unknown origin that can affect the chest and other organs, such as the eye and skin.

Generally speaking, the findings are reassuring but there is not a great deal of recent research available on which to base this conclusion. Further work needs to be done in order to either confirm or refute these findings, and to dissect out the contributions made to these outcomes by lifestyle factors such as obesity and tobacco consumption.

Particular attention should be paid to the development of risk factors that may increase the likelihood of various diseases occurring, such as those affecting the cardiovascular system and diabetes.

There are some suggestions that certain activities such as fire suppression may be associated with the onset of heart attacks, and certain groups of firefighters, for example, instructors may be more vulnerable to harm because of their need to repeatedly demonstrate techniques.

The situation needs to be kept under review since firefighting techniques constantly evolve and generate new hazards leading to the need to review risk assessments. In addition, changes in the firefighters’ pension scheme, which now mean that many firefighters will have to work for between five and ten years longer in order to gain a full pension, also mean that firefighters will simply be attending training and incidents for this increased period of time, during which they will be at risk of developing ill-health.

When I look back over my time in occupational medicine, it occurs to me that success is often achieved by the deployment of managerial and organisational skills, or incorporating up-to-date research, rather than plonking a stethoscope on someone’s chest. For example, in Strathclyde FRS during the period between 1985 and 1994, of 505 ill-health retirements, 61 were due to eyesight problems but only seven had any ocular disease — the remainder were simply due to accelerated presbyopia, the changes in the eye that occur as a result of the aging process.8

At the time, firefighter regulations forbad the use of glasses on the fireground. My predecessor, along with a few other fire service medical advisors and chief fire officers persuaded the Home Office to fund a scientific study into the visual requirements of safe firefighting. This report duly appeared, its findings, which included the use of appropriate spectacles on the fireground, were implemented and in the 11 years that I was the Strathclyde FRS medical advisor, just four firefighters retired due to ocular problems.

Safety advisors should not be inhibited about becoming involved in planning matters, especially if they have experience as a firefighter. Hindsight — or, as we medics call it, the retrospectoscope — is wonderful, but, to quote Robert Burns, “the best laid plans of mice and men gang aft agley”9 sometimes because of failures to consider wider issues and the effects of technological innovation.

Over the years, I have presented a number of papers at national and international FRS conferences. At these events, I have listened to speakers describing other topics, including accounts of various spectacular incidents, such as the crash of the Concorde airliner in Paris on 25 July 2000. The aircraft came down near a populated area and was seen by large numbers of people, thousands of whom whipped out their mobile telephones to contact the emergency services. This overwhelmed the switchboard, which made mobilisation of resources difficult and impaired the response to other emergencies that occurred at the same time.

Dynamic risk assessment is an essential tool for commanders at all levels to enable them to effectively deploy personnel and equipment, bring in or scale down additional resources if required while minimising risk to those involved. However, disasters seem to take on a life of their own, and use up assets. Another aircraft crash, which killed 20 people in Luxembourg on 6 November 2002, had the effect of drawing in so many resources that there were fewer to respond to emergencies elsewhere for hours.

In the infamous attack on the World Trade Center on 11 September 2001, 32 senior officers of the New York Fire Department were among the dead, yet 26 of them had no assigned role. So, there is scope for improvement of command and control systems to ensure that only those who need to attend a particular level of incident are called upon.  However, despite the death toll, it is often forgotten that about 14,000 people were successfully evacuated from the site. In part, this was due to putting into practice lessons that had been learned as a result of the response to the World Trade Center bombing in 1993.10 

Driving is another important FRS activity in. I was surprised to recently learn that about 30 per cent of road traffic collisions resulting in death or serious injury are associated with work activities, driving to, at, or from work.11 However, the drivers will generally have specific training to maximise the chances of driving safety and arriving at the fireground without incident. There is probably far more routine travel involved, driving to and from meetings and carrying out other mundane administrative tasks, than emergency call outs.  Organising safe driver training would likely be a useful investment. In a review of car fleet performance Boorman demonstrated the benefits that arose from this sort of training — in terms of reduced insurance premiums and less ‘down time’ — which were sustained over a four-year period following the introduction of such training.12

Safety advisors have the opportunity to tackle a variety of hazards, some of which can be found in most workplaces while others may be novel, either because they are exclusive to the FRS, or because the rapid influx of technology means that new hazards are created, giving rise to new risks that need to be identified and control strategies that need to be devised in order to maximise protection to these gallant men and women.


  2. Donnan, S.P.B. (1996): Study of mortality and cancer incidence in firefighters in Britain, a third report 1965 to 1993,The Home Office
  3. Deschamps, S; Momas, I; Festy, B (1995): ‘Mortality amongst Paris fire-fighters’, Eur J Epidemiol
  4. Wagner, NL; Berger, J; Flesch-Janys, D et al. (2006): ‘Mortality and life expectancy of professional firefighters in Hamburg, Germany: a cohort study 1950 — 2000’, Environmental Health
  5. Straif, K et al (2010): IARC Monographs on the evaluation of carcinogenic risks to humans, volume 98, ‘Painting, Firefighting and Shiftwork’, International Agency for Research on Cancer
  6. Orris, P, et al (1995): Firefighters’ Safety and Health (State of the Art Reviews Occupational Medicine)
  7. Crawford, JO; Graveling, RA (2012): ‘Non-cancer occupational health risks in firefighters’, Occup Med
  8. Ide, C.W. (1998): ‘Failing Firefighters: A survey of causes of death and ill-health retirement in serving firefighters in Strathclyde, Scotland from 1985-94’, Occup Med
  9. Burns, R (1785), ‘To A Mouse’, Poems, Chiefly in the Scottish Dialect
  10. MMWR (2004): Preliminary results from the World Trade Center evacuation study — New York City, 2003
  11. Carter, T et al (2013): ‘Health and transport safety: fitness to drive’, Fitness for Work — the medical aspects
  12. Boorman, S (2009): ‘Reviewing car fleet performance after advanced driver training’, Occup Med
Dr Chris Ide is an occupational physician and regular contributor to SHP. This article was originally published in SHP magazine in October 2013.

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