Joel Charles watched with surprise at his home in western Wisconsin early last summer as dark clouds – choking clouds – descended from the north and east.
It was June and distant wildfires in Ontario and Quebec were disgorging huge quantities of soot and ash into the lower atmosphere. The wind carried those microscopic particles hundreds of miles across the Great Lakes, dulling the skies above Detroit, Green Bay, Milwaukee, and Toronto – places that were largely unaccustomed to inundation by wildfire smoke.
Foul air irritated eyes and inflamed lungs. It constricted airways and triggered asthma attacks. Emergency room visits multiplied during the week-long smoke event and throughout the summer, when smoke pollution from smoldering fires intermittently spiked. People in Crawford County, a rural outpost in the hills of western Wisconsin, sought the counsel of Charles, who is a family doctor at Kickapoo Valley Medical Center. Patients arrived at his clinic not always realizing the smoke was the source of their breathing troubles. He said some people in the community viewed the hazy skies and the cold, red sun naively – as curiosities, not health threats.
“It was a point of interest,” Charles said, reflecting on the prevailing mood when the smoke arrived. “Rather than, ‘Oh, I need to be protecting myself and my kids.’”
This is the first in a series of articles and broadcasts on water, climate change, and human health in the Great Lakes region. Produced by the five partners of the Great Lakes News Collaborative – Bridge Michigan, Circle of Blue, Great Lakes Now, Michigan Public, and The Narwhal – the stories connect planetary change to personal health. At its core, the series is about unexpected outcomes and foreseeable threats to the welfare of the region’s people due to global warming and the disruption of its water. These changes – from drying forests and warming waters to rising heat and the spread of disease – will force the region’s elected officials, health professionals, engineers, researchers, and neighborhoods to rethink business as usual.
The noxious smoke last summer was certainly unusual – there were more days across the region with the worst air quality in at least a quarter century, according to U.S. Environmental Protection Agency data – but it is likely to become more common. The forests of North America, from the western United States to Canada’s eastern and boreal lands, are the trigger points in a long chain of environmental cause and public health effect. The chain begins with the increase of heat-trapping gases in the atmosphere, which is producing higher temperatures and sharper droughts. Heat and water scarcity, in turn, are drying out forests that in many cases hold too many trees per acre. Overcrowded forests in the western U.S. are a legacy of 20th century government policies that aimed to extinguish even the smallest of blazes. Aridity plus ample fuel is a recipe for calamity.
Wooded areas, in short, are primed to burn. And they are doing just that. In the 2023 wildfire season in Canada, some 18.4 million hectares (45.5 million acres) burned – an area roughly the size of Minnesota. It was by far the country’s biggest wildfire season in the last four decades, consuming two and a half times more acreage than the runner-up year. Rolling clouds of smoke and particulate matter were the byproducts. Following a warm, dry winter, the Canadian government is warning of yet another catastrophic wildfire season this summer. Depending on the wind, a repeat of 2023 is possible. As the Great Lakes region sheds its Rust Belt legacy and rids itself of industrial sources of air pollution, wildfire smoke, which is not covered by the Clean Air Act, could undo decades of air quality improvements that resulted from that law.
The measuring stick for air pollution is the Air Quality Index, a tool developed by the U.S. Environmental Protection Agency to assess the health risk from harmful gases like ozone and sulfur dioxide, as well as from particulate matter. Exposure to the tiniest particles, known as PM2.5, is most damaging because they can penetrate deep into the lungs.
An index reading between 101 and 150 is considered unhealthy for children, the elderly, pregnant women, and people with existing heart and lung conditions. Though individual health problems could appear at higher or lower levels, the general public begins to have trouble when the index is between 151 and 200.
Above 200 – a “purple” air day on the six-color coding system – is considered “very unhealthy” and a risk for all people. On June 27, 2023, an air quality station in Milwaukee registered an AQI of 220. The same day, a station in Hudsonville, Michigan, in the state’s southwest, measured a purple day of 202. It was the highest daily reading there in at least the last 25 years.
Doctors like Joel Charles are on the front lines of these environmental changes. When the air is bad, people feel it in their lungs. But even climate-aware doctors were caught off guard last year. In addition to his clinical duties, Charles is the co-founder of Healthy Climate Wisconsin, a nonprofit that works with doctors and nurses in the state to incorporate climate change considerations into healthcare. In their reports on climate change and health, members highlighted heat waves, water contamination, flooding, and the spread of tick-borne diseases. But they did not prioritize something they now view as a major omission – wildfire smoke.
“A significant wildfire event wasn't really in our bingo cards,” Charles said. “That wasn't one of the top things that we were even thinking about.”
That the 2023 smoke event blindsided the people most attuned to climate and health is an indicator, Charles said. While completing his medical residency, he lived in Santa Rosa, California. There, in Sonoma County wine country, he saw a state more accustomed to dingy air and how to respond. The Great Lakes region, where fires are not as common and smoke has not recently penetrated, does not have that muscle memory, he said. These states, provinces, and their institutions – from doctors and city officials to school principals and sports programs – are not equipped for this sort of climate risk.
“The Midwest and the Northeast are totally unprepared from a public health infrastructure perspective and cultural perspective to deal with wildfire smoke,” Charles said.
Ignorance of wildfire smoke as a health risk was evident across the region. Alexander Rabin, a clinical assistant professor of pulmonary and critical care medicine at the University of Michigan, is a lung doctor in Ann Arbor. He said he tended to more patients last summer who were having difficulty breathing and needed anti-inflammatory drugs to calm their irritated lungs. The air was bad, but they weren’t connecting it to their health.
“Some of the folks I saw didn't really understand or even realize necessarily that the reason they were having trouble was so clearly that the air quality was poor,” Rabin said. “So that was really interesting. And I think, in part, just reflective of the fact that in Michigan, we hadn't really experienced anything quite like this before.”
The health consequences of all this smoke at a continental scale are only beginning to be understood. Wildfire smoke has been linked to babies born prematurely and underweight, when their mothers are exposed while pregnant. Researchers are finding that exposure to heat and smoke at the same time is deadlier than either individually, attacking not only the lungs but also the heart. A heat-smoke combination is more likely in the coming years. The Great Lakes region is expected to experience more extreme heat as a consequence of increasing carbon emissions.
The fallout from wildfire smoke – in terms of dollars and human lives – could be gargantuan. Stanford University researchers estimated that if greenhouse gas emissions remain high, smoke-related deaths by 2050 could reach 27,800 per year in the United States, an increase of 76 percent from the 2011 to 2020 average. In the study, Michigan, Ohio, Pennsylvania, and Illinois – states within the Great Lakes basin – all rank in the top 10 for future smoke-related deaths, though the smoke is mostly generated in other regions. In 2019 dollar terms, those deaths account for $244 billion in damages in 2050. Wildfire smoke, the authors write, “could be among the most important and costly consequences of a warming climate in the U.S.”
Avoiding such a fate means reducing greenhouse gas emissions, Charles said. It also means taking action now to build out the hard and soft infrastructure to respond to smoke.
Hard infrastructure means equipment like air filters for schools and homes, and a reliable network of air quality sensors. There is an equity component, Rabin said. Wildfire smoke spreads indiscriminately, but the resources to adapt are less dispersed. Wealthy districts and households can afford high-quality HEPA filters. Poorer families? Maybe not. N95 masks, a low-cost option, also protect lungs, while makeshift box fan filters can be pieced together for a house, if one has the proper parts and instruction.
Soft infrastructure describes the social and political actions for informing and assisting a population. At-risk people – children, the elderly, pregnant women, outdoor workers – need access to health alerts. Those alerts need to be available in many languages.
Rabin watched the institutions around him struggle last summer to muster an impromptu smoke response. Schools were particularly telling, he said. Rabin’s kids are three and six, ages that are sensitive to AQIs above 100. In his district, school officials did not have any clear direction about indoor and outdoor activity during bad air days. “It was just so haphazard, and it just didn't seem like there was any kind of organized plan,” Rabin said.
Amid this information vacuum, doctors and health systems play a crucial educational role, Rabin said. In the limited time allotted for patient visits, he tries to mention air quality issues, especially to those with existing lung and heart problems. After-visit summaries could also include a list of action items, such as how to sign up for air quality alerts or where to get rebates on air filters.
Even a brief discussion can start to influence behavior, said Kindra Weid, a registered nurse and coalition coordinator of MI Air MI Health, a group of health professionals in Michigan working for cleaner air.
“It would be phenomenal to know that primary care physicians and pulmonologists are having conversations with their patients about the Air Quality Index and what to do on poor air-quality days and creating action plans,” Weid said. “That's what we're trying to educate and encourage health professionals to be aware of.”
To raise public awareness, schools and other organizations could participate in the EPA’s Air Quality Flag Program, Weid said. Similar to the color-coded fire danger signs in the western states, the program uses the AQI colors to indicate daily air quality readings via flags. Green is good, yellow moderate, orange unhealthy for sensitive groups, and red unhealthy for all. It’s a low-tech means of communicating information in the public interest. However, few organizations in the Great Lakes region participate – only 10 in Michigan and 11 in Wisconsin.
School administrators juggling a handful of rainbow-colored banners may seem unnecessary now, but the forecast for the region is for more wildfire smoke and more heat, which can worsen other air pollutants. Ground-level ozone, which swells during hot days, is an even more persistent health threat for the Great Lakes region, according to analysis by the research group First Street.
The warning signs for a smoky summer are already present. Winter hardly registered in the Great Lakes region, where temperatures were the warmest on record and ice coverage on the major lakes was the lowest ever measured. The doctors and nurses interviewed for this story all said that last year should be a wake-up call, and while they are noticing more requests for training and briefings, the region still must do better to prepare.
“There's a whole chain of things that need to happen to protect public health in these sorts of circumstances,” Rabin said. “Do we need improvement? Yeah, absolutely. And it was interesting that, well, basically that infrastructure barely exists here.”
