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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Under the federal Clean Air Act, Kentucky is required to keep haze air pollution under control in Mammoth Cave National Park.

Critics said the state's current plan falls short. Coal-fired power plants are the driving cause of air pollution impairing visibility in the Commonwealth, according to the National Parks Conservation Association.

Ashley Wilmes, executive director of the Kentucky Resources Council, said the state's current Draft Regional Haze State Implementation Plan only considers two facilities as significant pollution emitters, despite evidence there are more.

"There has to be a detailed analysis of additional major polluters in Kentucky that are contributing to this haze," Wilmes asserted. "They did not do this analysis for other major coal plants, including Ghent and Mill Creek, Trimble Station and others."

The Kentucky Energy and Environment Cabinet hears virtual public comments on the plan tomorrow at 10 a.m. ET.

Ulla Reeves, clean air program director for the National Parks Conservation Association, said several major polluters in the region are contributing to poor air quality.

"We see in Kentucky that Mammoth Cave is actually one of the most polluted national parks in the entire country," Reeves pointed out. "It is surrounded by polluting facilities."

Bryon Gary, program attorney for the council, said advocates are asking the state to include additional pollutants and facilities, and address environmental justice impacts to surrounding communities. He added residents' input will be considered by the Environmental Protection Agency.

"The public will have the opportunity to give those comments," Gary noted. "Then at some later point, the Energy Environment Cabinet will develop a written response to comments that will be submitted to EPA, along with their final state implementation plan."

Exposure to the air pollution particles triggering haze can cause breathing problems, lung cancer, heart attacks and low birth weight in newborn babies, according to the Centers for Disease Control and Prevention.

California air-quality regulators today are expected to adopt new fees for big polluters and rules to encourage large buildings to switch equipment from gas to zero-emission electric models.

Fifteen clean-air advocacy groups are rallying in front of the Southern California Air Quality Management Board in Diamond Bar today, urging passage of the new rules.

Kimberly Orbe, senior conservation program manager for the Sierra Club's Angeles chapter, said the transition would cover gas-fired water heaters, boilers and process heaters.

"Fossil fuel appliances are responsible for 10% of the emissions from stationary sources in our region," she said, "so that's really huge."

Opponents of the change include SoCalGas and industry groups representing dry cleaners and restauranteurs.

When burned, natural gas emits harmful smog-forming air pollution and greenhouse gases that fuel climate change. The So Cal Air Quality Management District's new pollution fee program would require large industrial polluters to pay to support regional clean-air efforts. The Sierra Club estimates this could raise about $25 million a year.

According to the American Lung Association, the Los Angeles/Long Beach area has the most high-ozone days of any metropolitan area in the country. Orbe said that's why advocacy groups have been pressing for stronger air-quality standards for years.

"Our region is burdened by an overwhelming amount of pollution - from oil drilling, from refineries, from the ports, from the warehouses, freeways," she said. "So, we want to make sure that we're passing strong rules to ensure that we continue to clean up our air, year after year."

The board is also expected to set a hearing date to consider new rules requiring zero-emissions technologies in the rail yards to combat diesel pollution from trains.

Leaders in Michigan are marking the historic new clean car standards, finalized by the Environmental Protection Agency.

The final rule, Multi-Pollutant Emissions Standards for Model Years 2027 and Later Light-Duty and Medium-Duty Vehicles, was announced in March.

Michigan leaders are celebrating the move as a positive step in the fight against climate change.

State Rep. Jasper Martus, D-Flushing, said many people think of climate change and creating good jobs as two separate issues, but he said he believes the two go hand-in-hand.

"When we pursue policies that combat climate change, such as investing in electric vehicles, having higher standards for the vehicles that are produced here in Michigan and the United States," said Martus, "we can do it in such a way that creates good paying jobs."

The new standards will phase in over model years 2027 through 2032.

Martus said in addition to creating new jobs, the transition to electric vehicles will also decrease pain at the pump resulting from sky high gas prices.

He added he believes it's time for companies that make EVs to make their pitch to the public.

"We're not to the point now where everything is going to be electric vehicles overnight," said Martus. "We're not even at the point where everything could be a hybrid overnight. But we're beginning that process of these companies making electric vehicles need to make the pitch."

Martus added that as EV makers pitch their product, consumers will eventually see the prices of the vehicles come down - making them just as competitive, if not more so, than traditional vehicles.




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