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This article was originally featured on High Country News.

Editor’s note: This story contains a graphic description relating to the loss of a child.

The heat was in the triple digits when Lea Bossler and her U.S. Forest Service engine crew reached the blaze unfurling in a canyon outside Nogales, Arizona. As she trekked up a hill with her shovel-like rhino tool, flaming barrel cacti tumbled down the slope, igniting more parched fuels along the way. Despite the heat, a 45-pound pack and little sleep, Bossler felt strong and capable, mopping up the edges of the fire, extinguishing collapsed cactuses that smoldered like burnt rubber. This was her third season as a wildland firefighter, and she was well on her way to fulfilling her goal of becoming an incident commander.

After the fire was contained, Bossler and her crew drove home to Missoula, Montana, concluding a two-week roll in the Southwest. It was early July 2020, the middle of a record-breaking fire season that would burn over 10 million acres across the country, and Bossler was resting before her next assignment. There was a coronavirus outbreak at her partner’s workplace, and just a couple of days after she came home, she caught a debilitating case of COVID-19. Now, more than two years later, the 32-year-old still hasn’t recovered. Long COVID has not only damaged her health, it has also forced her to give up her career in firefighting.

Currently, over 19 million people in the United States—1 in 13 adults—are living with long COVID, though some estimates place the number as high as 23 million. Long COVID is a complex condition that affects all age groups and can involve multiple organ systems. It’s diagnosed weeks or months after a COVID-19 infection. Some of the symptoms include cognitive dysfunction, respiratory and cardiovascular problems and extreme fatigue, though roughly 200 other symptoms are recognized, and some can linger for years. Many patients meet the diagnostic criteria for other diagnoses, as well. Those include postural orthostatic tachycardia syndrome, which causes extreme dizziness, headaches and rapid heart-rate; and myalgic encephalomyelitis (ME)—sometimes called chronic fatigue syndrome—a disabling neurological disease that has been underfunded for decades.

A World Health Organization official recently warned that repeated infections may increase the risk of long COVID. A recent US Census Bureau survey analyzed by the National Center for Health Statistics showed that as many as 1 in 5 adults who were infected with COVID-19 now have symptoms of long COVID. 

While the number of US wildland firefighters affected is unknown, the workforce is considered at high risk of contracting COVID-19: In 2021, the leading cause of line-of-duty deaths in wildland firefighters was COVID-19. Firefighters are already stretched thin due to the prolonged and intensified fire seasons caused by climate change. Long COVID is not only affecting firefighters’ health and livelihoods, it could also seriously hamper their response to the escalating crisis.

Firefighters are a strikingly transient workforce, making them more vulnerable to catching and spreading COVID-19. “You have firefighters and other fire personnel who are traveling from all over the country to arrive at one common location,” said Matthew Thompson, a research forester with the Forest Service.

The lack of sanitation and privacy in the camps, combined with fatigue, heat, physically demanding work and other factors add to that vulnerability, according to the National Wildfire Coordinating Group (NWCG), which provides leadership to wildland fire operations among federal, state, local, tribal and territorial partners. One of the largest COVID outbreaks at a fire camp occurred during the 2020 Cameron Peak Fire in northern Colorado, with 79 positive cases and 273 close contacts who were quarantined. A Forest Service press officer emailed that among nearly 11,000 permanent and temporary agency firefighters, there were 1,847 reported cases of COVID-19 within the past 12 months. 

In a recent modeling study, Thompson and his co-authors found that social distancing and vaccination reduced outbreaks in fire camps, though their study did not assess long COVID or the highly contagious omicron variant. (According to a 2022 study in the journal Nature Medicine, vaccination may only slightly reduce the risk of long COVID.) Thompson’s study also found that firefighters were infected even more often outside of fire camp than within it, meaning that they are continually at risk as the US eases preventative measures, allowing for dangerous peaks that can occur in the heart of fire season. 

“It’s not only the risk of transmission or getting COVID. It’s also the severity of outcomes.” 

The NWCG recommends COVID safety prevention practices for wildland firefighters based on guidance from the Centers for Disease Control. But a widely referenced CDC document about COVID and wildland firefighters doesn’t specifically mention long COVID.

In a review published last year, Kathleen Navarro, a researcher at the National Institute for Occupational Safety and Health, noted that particulate matter—including the hazardous mixture of small particles and droplets found in wildfire smoke—could contribute to a greater likelihood of COVID-19 infection in wildland firefighters, as well as more severe illness. “It’s not only the risk of transmission or getting COVID,” said Navarro. “It’s also the severity of outcomes.” 

But firefighters face a risk of long COVID, no matter the severity of their acute case: A 2022 white paper stated that nearly 76 percent of those diagnosed with long COVID have not been hospitalized.

Bossler returned to work after her 14-day quarantine despite not feeling fully recovered. “I went back hoping I would go back to normal,” she said. “But I really didn’t. I worked through it because you just don’t pass up opportunities as a female firefighter.” She often felt like she was drowning as she continued to fight fires across Montana the rest of the summer. 

“There’s an attitude in firefighters that you don’t quit for anything,” she said. “And there’s just no education, warning, or recognition of long COVID in fire.” 

Advocates for those with chronic illness warned of the possibility of complex chronic illness following COVID-19 in the beginning of the pandemic, but the federal government’s public health apparatus did not amplify these messages and still doesn’t consistently emphasize the risk of long-term health effects following an initial case. “I can only assume that I did more damage to myself,” she said. “I gave in to this notion that because I was young and healthy, I’d be fine, when I knew, deep down, there was something really wrong with me.”

“I worked through it because you just don’t pass up opportunities as a female firefighter.”

A growing number of physicians warn that resuming activity while not yet fully recovered may increase a person’s likelihood of developing long COVID. But owing to financial hardship, inadequate sick leave and other pressures, many workers in the United States push on through their illnesses. 

Bossler continued to work on her crew through the summer, despite lingering symptoms. But then, in late August, she found out she was pregnant. She said she likely conceived around the time she first contracted COVID-19 in early July 2020.

In a joint decision with her superiors, Bossler transferred from the engine crew to a timber strike team for the rest of the season. Her due date was in May, and she planned to take a Forest Service office job that summer and resume working as a firefighter the following season—assuming she recovered from long COVID. But these plans were put on hold in January when she gave birth to her daughter, Maesyn, prematurely, at only 25 weeks. Her baby suffered fetal inflammatory response syndrome due to the maternal history of COVID, and Bossler’s placenta was filled with blood clots, which contributed to placental failure and abruption. “A COVID-affected placenta looks like you took a roadkill deer, took the liver out, and shot it with a shotgun a couple of times,” Bossler told me. 

When she first went into the hospital at 23 weeks with contractions from early labor, Bossler was told there was only a 30 percent chance of her baby surviving. Her daughter weighed just 1 pound and 6 ounces at birth when she arrived two weeks later and gained only 5 more pounds during her 115 days in the Neonatal Intensive Care Unit. She died on May 14, 2021, close to her original due date. In Maesyn’s final moments, Bossler was able to take her daughter out of the NICU to see the sky for the first time. Maesyn died outside in the spring sunlight, in the arms of Bossler and her partner, Marcus Cahoon.

Now, over two years since she first contracted COVID, Bossler continues to experience debilitating long COVID symptoms. She cannot walk more than half a mile without feeling fatigued and also struggles with headaches and memory loss, and has difficulty paying attention. She has chest pain that she says has worsened significantly since she was reinfected in June. Bossler believes her pregnancy complications made her more aware of her illness, which she might otherwise have been too stubborn to acknowledge. “I know of people that have long COVID that are still trying to be firefighters,” she said, “but I don’t think they have the same understanding or recognition of it that I might have. 

“I think all employers of wildland firefighters would be doing a huge disservice to their employees to not recognize long COVID and the mental health challenges that come from it,” Bossler said. When I reached out to the Forest Service in August about the agency’s approach to long COVID education and prevention, I was told to contact the United States Office of Personnel Management (OPM), which oversees all federal employees. The Interior Department, which employs over 5,000 temporary and permanent wildland fire personnel, wrote that it develops policy based on recommendations from the CDC and Safer Federal Workforce Task Force, which is led by the White House COVID-19 Response Team, the General Services Administration and the OPM—none of which offer publicly available guidelines on long COVID. The Office of Personnel Management sent a written statement in response to our request for comment but did not elaborate on its policies related to long COVID.

“I think all employers of wildland firefighters would be doing a huge disservice to their employees to not recognize long COVID and the mental health challenges that come from it.” 

“(First responders’) careers depend on our health and us being able to respond to a fire or an emergency at any point of time, despite how we feel,” said Karyn Bishof, the founder of the COVID-19 Longhauler Advocacy Project, a nonprofit advocating for education, research and patient welfare. She said that many first responders, including wildland firefighters, are reluctant to speak about health issues for fear of losing their livelihoods. “The flip side of that is if they’re not seeking treatment and care, they’re not only risking their own lives, but possibly the lives of their crews.”

Bishof became infected with COVID after an outbreak at her firefighter paramedic training in the city of Palm Beach Gardens in South Florida. She told me she was later let go from her job on the Fire Rescue team without explanation. In late 2020, Bishof was also denied workers’ compensation after a doctor diagnosed her symptoms as psychosomatic, a common experience for many patients with complex chronic illness. She has since filed a discrimination lawsuit against the city of Palm Beach Gardens. The city did not respond to my request for comment.

Like other infectious diseases, including Lyme, mononucleosis and SARS-1, COVID-19 can develop into complex chronic illnesses. Researchers have consistently found a range of abnormalities in long COVID patients, including micro clots, persistent viral reservoirs, reactivated viruses and autoimmune responses. The US Department of Health and Human Services has recognized that the condition can be a disability, but in the fall of 2021, Bishof—like many long COVID patients—was denied Social Security disability benefits. She reapplied but was denied a second time and is now awaiting an appeal hearing.

Because there is no cure for long COVID, Bishof said that preventing COVID-19 and increasing public awareness of its long-term consequences are paramount, especially in protecting first responders. She’s concerned that if long COVID continues to affect one of every five infected people, it will inevitably effect public safety. “If we lose that percentage of that workforce, what does that mean for emergency response times?” she asked. “What does that mean for wildfire response?”

In testimony before a Senate Subcommittee on the Coronavirus Crisis this July, Katie Bach, a senior fellow at the Brookings Institution, said that policymakers need to support improved health care, sick leave, disability and workplace accommodations for workers. Given that as many as 4 million long COVID patients are unable to work, Bach estimates a cost of as much as $230 billion in lost earnings alone, not including other costs, such as health care or reduced productivity. 

The Forest Service and Interior Department offer sick leave for employees exposed to communicable diseases, like COVID-19, as well as disability accommodations that can include teleworking and more flexible work hours. Federal firefighters who can’t work at all due to long COVID contracted on the job may be eligible for workers’ compensation, according to an Interior spokesperson. But employees infected outside of work are not eligible for any benefits, according to guidelines by the Office of Personnel Management. 

Looking back at her experience over the past two years, Bossler says the Forest Service needs to develop policies that help protect firefighters from long COVID, as well as provide support for those affected by it. She was forced to leave her job at the Forest Service when she went into early labor. “It was a medically forced resignation,” she said. After her daughter’s birth, she considered returning to the agency, but at that point, she was still grieving and unable to work full-time due to her long COVID symptoms. 

In the fall of 2021, she began working part-time as a health unit coordinator in the same neonatal intensive care unit that treated Maesyn. A number of the nurses there, like other first responders, also suffer from long COVID. “I wanted to work somewhere that would understand me,” Bossler told me. 

“I learned how to handle all these traumatic situations by relying on the lessons from fire,” Bossler said. Maesyn’s brief life and death had such a profound impact that Bossler feels an obligation to continue telling her daughter’s story while educating people about this chronic illness. “I think about other firefighters that lost their ability to do their job.

“It’s not just your job. It’s your identity. The grief that comes with that is just not discussed enough.” 

This story was supported by the journalism nonprofit the Economic Hardship Reporting Project.

Miles W. Griffis is an independent journalist based in Los Angeles, California. We welcome reader letters. Email High Country News at editor@hcn.org or submit a letter to the editor. See our letters to the editor policy.

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