The clean solution

We need education, not scaremongering

Interview with Dr. Andreas Häcker, chief medical officer at the Baden-Württemberg state fire service

Dr. Andreas Häcker is chief medical officer for the Baden-Württemberg state fire service, a position he has held since 2016. In this interview, he offers insights into operational hygiene, the risk of spreading contamination ‒ and the most effective ways to keep firefighters safe. Häcker has worked full-time as a specialist in internal and emergency medicine since 1988. In addition to his day job, he heads up emergency medical services at Stuttgart Regional Council. He also spent 20 years working as the senior emergency physician for the districts of Böblingen und Ludwigsburg. He has held the role of group commander in the Ditzingen fire department since 2006.

1. What are your duties as chief medical officer for the state fire service? 

I work on a voluntary basis for the state fire service association, an advisory body that supports the state government, local authorities and state fire departments. It includes various disciplines, each of which covers different areas of expertise.

My job is to head up the specialist field of rescue services and health. The position I hold requires a medical qualification, and ideally an additional qualification or experience in emergency medicine. You also need to be an active member of a fire department, because first-hand experience is essential.

My main task is to advise the association and liaise with the president or the state's chief fire officer. I give presentations on medical topics related to the fire service at events and at fire departments.

2. You've spent many years combining your dual roles as a specialist in internal medicine and a firefighter. Have you become even more aware of operational hygiene as the years have gone by?

Yes, not just professionally, but also through personal experience. I was diagnosed with prostate cancer when I was 49. Cancer wasn't something we had seen in our family before, so it seemed likely that it was linked to my work at the fire service. I have been a firefighter since 1979, so at the time of my diagnosis I had already spent three decades coming into contact with chemical contaminants at numerous fire scenes. Back then, people didn't really talk about operational hygiene.

The situation was very different in the medical arena, where hygiene had long been recognised as a key issue and a top priority for operating theatres. That stretches back to the mid-19th century, when Semmelweis argued that doctors should wash their hands before attending a birth, because he saw that it led to lower maternal mortality rates. He wasn't taken seriously during his lifetime, and he eventually ended up in an asylum. Much later, when scientists finally obtained proof that handwashing eliminates bacteria, Semmelweis was posthumously vindicated. I see parallels between the "biological" contamination described by Semmelweis and the toxicological and chemical contamination that occurs at a fire scene.

Handwashing and decontamination are now second nature to firefighters in their 20s or 30s. Firefighters over 50 accept those things as part of the job, but they tend to be less convinced of their importance. It's hard to change people's behaviour when it's so deeply rooted!

"We need to clearly explain how exposure to harmful contaminants, soot and fire smoke occurs and help people take the necessary steps to say safe." 

3. Two years ago, firefighting was classed as carcinogenic by the IARC, an organisation belonging to the World Health Organisation. How has this international classification changed perceptions among firefighters, politicians and decision-makers in Germany?

Accident insurance companies had made that connection even before the IARC classification came into effect. In fact, insurers had already set out some initial guidelines for hygiene in firefighting operations. The IARC considers two types of cancer to be significantly carcinogenic and five to be probably carcinogenic in connection with firefighting. The most likely explanation for this phenomenon is exposure to the many different carcinogens found in soot and fire smoke. These findings are a call to action for firefighters and all those responsible for this issue – they remind us how important it is to provide the best possible protection against exposure to contaminants.

But it's equally important not to be too alarmist. Some 98 percent of firefighters are people who volunteer in their free time, and it would be disastrous if they were to suddenly believe this activity will inevitably give them cancer. It is the job of professional associations and politicians to raise awareness of this issue and to come up with practical solutions. We need to clearly explain how exposure to harmful contaminants, soot and fire smoke occurs and help people take the necessary steps to stay safe. The key is not to scaremonger, but to provide information and advice.

Since 2018, my local fire service has had a formal policy in place which is followed by everyone who works there. Whenever I mention this in my presentations, I notice how readily and enthusiastically this is accepted by younger firefighters – in stark contrast, unfortunately, to many of their older colleagues.

"If we can remove 80–90 percent of the contaminants and reduce exposure to an acceptable minimum, then that's already a big improvement."

4. Over the past 30 years, various studies have reported that members of the fire service have an elevated risk of certain cancers. How much awareness is there among firefighters in Germany? Are there any differences between paid and volunteer firefighters? 

I'm not familiar enough with the situation in professional fire departments. I know a few people who work as paid firefighters, and I get the impression that they are more reluctant to accept these findings. In Stuttgart, for example, they might attend ten incidents a day and tackle four fires. That means changing their gear four times, and many of them think, well, it doesn't make any sense if I'm going to be tackling another fire ten minutes from now. It's a pain to have to shower each time and put on clean clothes, which is why professional firefighters find it more of a hassle to stick to the hygiene rules. Of course, the cumulative risk in a professional fire department is greater than that in a volunteer service, because firefighters are exposed more frequently to soot, smoke and other fire residues, which makes the spread of these contaminants more likely.

I once did an experiment by wiping a damp cloth over the sun visor inside one of our relatively new turntable ladder vehicles. When I looked at the cloth, I saw that it was absolutely filthy. You might not see any smoke inside the vehicle at a fire scene, but the smell of burning is always there, and the contaminants are deposited in the cab as a thin, greasy brown coating. And you get those toxic coatings on every handle in the truck – not just on the windscreen sun visor. There's a useful booklet published by the DGUV – the German Social Accident Insurance Association – entitled "Hygiene und Kontaminationsvermeidung bei der Feuerwehr". It offers tips on preventing contamination and maintaining hygiene during firefighting operations. Appendix 3 of that publication contains my list of recommendations on what to take into account before, during and after a firefighting operation.

There is usually an initial trigger for cancer development, and it's particularly likely to involve contamination with asbestos-containing substances. But you also get a gradual accumulation of toxic substances inside the body. Over the years, those harmful products build up inside the body until a switch finally flips and the system collapses. According to the WHO study, this phenomenon is evident not only among members of the professional fire service, but also in all emergency personnel involved in firefighting.

The key is to use common sense and not to try and do everything absolutely perfectly. If we can remove 80–90 percent of the contaminants and reduce exposure to an acceptable minimum, then that's already a big improvement. The point is to minimise exposure to harmful contaminants – because preventing exposure altogether is both unrealistic and unnecessary. 

It's also about raising awareness. Most of the hazardous substances to which firefighters are exposed enter the body not through the respiratory tract, but through the skin. Even if you're wearing PPE at a fire scene, there is still a very real risk, particularly for your head, neck, hands and genital area. These are the parts of your body where your skin is most vulnerable. Protective clothing can repel heat, but not harmful contaminants. That's why firefighters need to proactively seek out additional ways to protect themselves.

A new skin cleaning product can help in that task: pak-ex works on the principle of adsorption, using a special mineral to bind hazardous substances before they can penetrate the natural skin barrier. This product enables users to gently remove 95 per cent of the harmful substances that adhere to the skin, such as polycyclic aromatic hydrocarbons (PAHs) and soot. That's exactly what firefighters need, especially when they have just returned from tackling a fire.