By Kylie Mohr for KFF Health News.
Broadcast version by Eric Tegethoff for Northern Rockies News Service reporting for the KFF Health News-Public News Service Collaboration

Every year, wildfires across the western U.S. and Canada send plumes of smoke into the sky. When that smoke blows into southwestern Idaho’s Treasure Valley, it blankets Boise-area residents in dirty air.

They include seniors living in long-term care facilities, many of whom are considered an at-risk population for smoke exposure because of respiratory or cardiac diseases.

“An astonishing amount of smoke gets inside these facilities,” said Luke Montrose, an environmental toxicologist and researcher at Colorado State University. Data from monitors Montrose installed in four Idaho long-term care facilities in 2020 showed that large amounts of smoke pollution recorded outside during wildfire season seeped into the facilities. One building let in 50% of the particulate matter outside; another, 100%. In some cases, Montrose said, “it was no better to be inside than to be outside during those smoke events.”

That’s why Montrose has spent the past few years installing more monitors in care facilities across Idaho and Montana. The study is expanding into Colorado this summer.

Understanding and addressing how wildfire smoke affects indoor air quality could help better treat the roughly 1.4 million seniors who live in more than 15,500 Medicare- and Medicaid-certified nursing homes nationwide and nearly a million more who live in assisted living facilities.

“It may be a game-changer for quality of care,” said Robert Vande Merwe, executive director of the Idaho Health Care Association. Vande Merwe helped persuade facilities to join Montrose’s study.

Although residents of the western U.S. have lived with smoky summers for decades, the fallout from wildfires is becoming a nationwide issue. Smoke from blazes in eastern Canada barreled into the densely populated Northeast and Midwest last June, making the skies above Toronto, New York, Chicago, and much of the Atlantic Coast glow an eerie orange. More than 120 million people were under air quality alerts. As wildfires increase in size, intensity, and duration, fueled by a combination of climate change and forest mismanagement, the smoke they generate will likely affect more people.

“We’re going to see more and more smoke events that reach further across the U.S. and across the world,” said Savannah D’Evelyn, a postdoctoral scholar at the University of Washington who studies wildfire smoke and its effects on health. She was not involved in Montrose’s study.

Air pollution from wildfire smoke — a brew of pollutants, water vapor, and fine debris — is a growing public health problem. Tiny particles known as PM 2.5 are small enough to embed deep into people’s lungs and, sometimes, infiltrate their bloodstream. Research has shown PM 2.5 can cause asthma and respiratory inflammation or jeopardize lung function, and the particles have been tied to some cancers. They are especially dangerous for children and people with preexisting heart or lung conditions — including seniors, the focus of Montrose’s work.

“I think honing in on this particular community that is really quite impacted by smoke exposure on the health side of things is really great,” D’Evelyn said. “It’s a gap that needs to be addressed.”

For years, public health officials have told people to go inside on bad air quality days, even though, without testing and filtration, indoor air quality often isn’t much better than what’s outside. Although skilled nursing facilities follow numerous federal regulations to participate in the Medicaid and Medicare programs — covering anything from building safety features, like fire sprinklers, to residents’ rights — indoor air quality isn’t addressed.

“There really aren’t any regulatory standards for indoor air quality, broadly, in any country that I’m aware of,” said Katherine Pruitt, national senior director for policy at the American Lung Association.

Without the few indoor air quality monitors in the study, long-term care facility managers or operators might check their local air quality index, or AQI, on their smartphone’s weather app or by watching the news. But air quality monitors don’t always provide accurate information about the air outside, let alone inside a building. Rural areas are particularly underserved by air quality monitors. According to Montrose, 25% to 30% of skilled nursing facilities in the Mountain West are more than 30 miles from a regulatory-grade monitor. Indoor air quality monitoring is rare outside of studies like Montrose’s.

That’s why Montrose is on a quest to get more air quality monitors placed inside facilities. In 2019, he contacted more than 80 Boise-area nursing and assisted living facilities to gauge interest and concern about wildfire smoke. In 2020, he collected data from indoor and outdoor air quality monitors at four nursing homes — two in the Boise area, others in northern and eastern Idaho. The monitors recorded particulate air pollution inside one facility nearly 17 times what’s considered healthy.

In 2021, data collected from six facilities from July to October — four in Idaho and two in the Missoula, Montana, area — also showed that in some buildings indoor and outdoor air quality were almost identical on smoky days. Montrose repeated the monitoring at four other southern Idaho facilities last summer. The monitors fed real-time data to a dashboard that people running the nursing homes could see and respond to.

Protecting seniors from wildfire smoke is an important piece of wildfire preparedness, yet Montrose acknowledged that conducting research in nursing homes and care facilities has challenges. Unique ethical considerations arise with dementia or Alzheimer’s patients, who can’t give informed consent. Staff turnover makes it hard for researchers like Montrose to establish relationships with facility operators, and asking overburdened nurses or employees to do extra work, like understand and check air quality monitors, can be a nonstarter. Still, Montrose said, people living in long-term care facilities are particularly vulnerable. “If we can protect them, there’s great benefit to our communities,” he said.

Some facilities in Idaho have made changes because of the research. Those include a pre-fire season facility checklist to make sure filtering systems are in good shape and that doors and windows are properly sealed. They also share the area’s AQI as part of their daily morning safety meetings.

Mark Troen, regional maintenance director for 10 Edgewood Healthcare facilities in the Boise area, four of which had monitors last summer, laid out a litany of things he does when the indoor air quality rises past healthy levels: changing air filters to a higher level that traps more particulates, turning off outdoor air intake, and alerting staff to keep doors and windows closed. “Anything I can do to keep the residents safe, I’m all for,” Troen said.

Clinical staff members also have identified which residents have respiratory problems or are immunocompromised. In an intense smoke event, those people may get portable air filtration in their rooms for extra protection.

Troen plans to install air quality monitors from his own budget once the study’s monitors need to be replaced due to age. “To actually see in real time what your indoor air quality is is huge,” he said. “It helps us mitigate some of those problems, rather than waiting until it’s bad.”

Anyone can take steps to improve the air they’re breathing during wildfire season. “It’s pretty easy to clean indoor air,” D’Evelyn said. HEPA air filters are the gold standard but can cost upward of $100; creating a box fan filter is a cheaper alternative. According to D’Evelyn, making even one room in a building a “clean air space” can make a difference during a wildfire.

The American Lung Association’s Pruitt said starting policy conversations about regulating indoor air quality faces many barriers, including perceptions of federal overreach. In the absence of federal regulations, Pruitt believes, the most effective actions would likely come from state or local building codes and ventilation standards. “Policymakers should be looking at the steps that need to be taken to protect people from exposure to hazardous levels of smoke or other outdoor pollutants,” she said.

Montrose is recruiting more nursing homes to install air quality monitors this summer, including additional facilities in Idaho, Colorado, and Montana. Vande Merwe, of the Idaho Health Care Association, said other places in the region — like his hometown, Salt Lake City, which is situated where smoke and other pollutants accumulate — should take note. Breathing in the best possible air could make a big difference for residents’ health and quality of life as they age, he said.


Kylie Mohr wrote this story for KFF Health News.


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Some sectors have made gains in Minnesota in reducing greenhouse-gas emissions. Progress has been slower for agriculture, but those pursuing solutions feel a breakthrough is near thanks to a redesign of a key farming product.

Ag experts say most fertilizers used by farmers are very carbon intensive because they're made with fossil fuels. However, Minnesota researchers have been leading the charge to phase out those elements by utilizing hydrogen from wind and solar energy in the production process.

If more farmers can take advantage of "green fertilizer", said Margaret Cherne-Hendrick, senior lead for innovation and impact at Fresh Energy, the state could be better positioned to confront troubling data.

"Agriculture accounts for about 21% of the state's greenhouse-gas emissions," she said, "and we're forecasting it's going to be one of the more difficult sectors to decarbonize."

While Minnesota government has made investments in the development of this product, including the University of Minnesota's West Central Research and Outreach Center in Morris, Cherne-Hendrick warned that the outcome of the presidential election could alter the landscape for federal incentives.

Meanwhile, a summit will be held Dec. 10 at the University of Minnesota Morris to discuss the future of this technology. The cleaner ammonia derived from this production can also be used for things such as shipping fuel.

Anne Schwagerl, vice president of the Minnesota Farmers Union, which is hosting the upcoming summit, said that having less-carbon intensive crops such as corn can open up more biofuel markets for farmers. And if more green fertilizer is made locally, it could enhance the presence of cooperatives.

"Minnesota has always been a leader in the cooperative movement," she said, "and this is just another opportunity for farmer ownership and rural community ownership of the things that we produce."

U.S. farmers have called attention to corporate consolidation among fertilizer companies, making prices out of reach for smaller independent operations. Next month's gathering is expected to include feedback about how to scale up the manufacturing of green fertilizer to help combat those market forces.

Utah's Great Salt Lake is shrinking, exposing more of its playa and lifting more potentially harmful dust particles into the air.

A new study seeks to understand the air quality and health impacts of the dust from the drying lake.

Kerry Kelly, associate professor of chemical engineering at Utah State University and the study's co-author, whose team took samples from the Great Salt Lake to assess what's known as the "oxidative potential" of dust particles, explained it gives researchers an indication of how materials within the dust could react with the lining of a person's lungs.

"That is important because more reactive materials and components can lead to inflammation," Kelly pointed out. "Inflammation is a very important process for all kinds of adverse health effects associated with particulate matter."

Kelly noted particulate pollution has been linked to health conditions and complications, from asthma to heart attack, stroke and even premature death. When the Great Salt Lake dust samples were compared to other regional playas, they were found to be more reactive, meaning they have a higher potential for serious health effects. Kelly added the study is the first of its kind and more research is needed to further understand the effects on air quality and public health.

Kelly asserted climate change is not the key driver to the shrinking of the Great Salt Lake. Instead, she explained, water diversions have led to the lake reaching historically low levels.

"We are taking the water, it's not making it to the lake," Kelly observed. "All of us -- residential, and commercial consumers -- we need to do our part but agriculture is about two-thirds of the story, so we're definitely going to have to work on agriculture."

Kelly stressed increasing dust storms are a concern in the Salt Lake Valley, located west of Utah's densely populated Wasatch Front. The research showed four to five dust storms occur in northern Utah every year, which transport metal-contaminated dust. For such situations, Kelly recommended staying inside and using a mask if you must leave the house.

With school in full swing, many Arizona students will take the bus to school.

Earlier this summer, the Environmental Protection Agency awarded $900 million of Clean School Bus Program funding to more than 500 districts across the country, some of which came to Arizona.

Currently, Arizona has secured 155 electric school buses, according to the Electric School Bus Initiative.

Hazel Chandler, Arizona State field organizer with Moms Clean Air Force, said smaller school districts in the state received enough funding to replace half their fleets.

She added that school districts are now looking to alternative avenues to continue transitioning.

"Some of them are using utility money, a lot of them are using bond money," said Chandler. "So they might have gotten a couple, or maybe three of four initially - but then they love them so much, and the families and kids love them so much they just continue to approve them."

Chandler said electric school buses, or ESB's, are game changers for students with asthma as they eliminate tailpipe emissions.

She added that the buses are also quieter, meaning a less chaotic ride for bus drivers and students. Chandler said while the federal government has done its part, more can be done.

She contended states could invest more to ensure ESB's are a top priority.

Brittany Barrett - deputy director with World Resources Institute overseeing their ESB Initiative - said older, polluting buses have disproportionately operated in school districts with more people of color, low-income households, and in rural areas.

But data from the institute show that since 2022, most ESB commitments have been allocated to serve those at higher risk of poorer air quality.

Barrett said limited funding, rebates, and grants are still available - and encourages districts to act.

"There are different ways to deploy buses within their range capacity," said Barrett, "that can ensure that the benefits of this transition happen first to those communities who need it the most."

Kevin Matthews is the head of electrification with First Student, which has committed to electrify 30,000 electric school buses by 2035 - resulting in a reduction of over 1.6 million pounds of greenhouse gases.

Matthews said while ESBs may have a costlier initial price tag, the cost savings are undeniable.

"This is primarily driven by lower cost of fuel," said Matthews. "Lower liquid changes like motor oils, engine cooling, those types of issues. Less wear and tear on brakes. So this is a significant change in that area."




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