Air quality can affect health. Climate change is worsening both.

But this past summer was something else.

“I could not leave my apartment. I had to stay here in the air conditioning,” Rapp said. “The only time I would go out would be to go to a doctor. Other than that, I stayed inside because I couldn’t breathe.”

High heat and poor air quality were relentless for much of the summer, though there have been worse summers in Connecticut. And it was nothing like the extremes climate change has brought to the western U.S., never mind other parts of the world.

While heat is well-understood as a consequence of climate change, air quality is both cause and effect when it comes to the nexus with climate change. Emissions from motor vehicle tailpipes and burning fossil fuels cause the bad air. Those emissions also contribute to global warming, which in turn can cause or exacerbate air quality degradation.

Either way — the results manifest squarely as health issues for people like Rapp and many others in ways that may not always be obvious. And the linkage of air quality and health to climate change is only recently gaining wider traction, though David Hill, Rapp’s pulmonologist, has been aware of it for a long time.

“I think you can say that climate change, pre-COVID, was the public health issue of our lifetimes, and if we ever hit post-COVID, it is still the public health issue of our lifetime. And a lot of it is lung health,” said Hill, who is also a clinical professor at Yale and Quinnipiac Universities and a national board member of the American Lung Association.

“The vast majority of my asthma and COPD patients come in and they’ll say, ‘Oh, yeah, I can’t breathe when it’s hot and humid.’ And when I started practicing 25 years ago, if it was around one of those days, someone would complain. But now it’s in our electronic health record — triggered by heat and humidity — because so many patients come in saying they can’t breathe on those days.”

So it’s no surprise that Hill is something close to evangelical in promoting lung health by addressing climate change and barely comes up for air listing all the ways the two interconnect.

Along with many others in the medical, research and public policy fields, he starts his list of how climate change and lung health are interconnected with ground-level ozone, a precursor to smog. Connecticut is notorious for having a lot of smog — some of the worst levels in the country, in fact. Much of it derives from fossil fuel power plant emissions and other unsavory pollutants that waft in on the prevailing winds from western states, but plenty is caused by vehicle emissions and other sources, such as heavy industry right here at home. 

There are two types of ozone: stratospheric and ground-level. Stratospheric ozone is the good kind because it protects the earth from ultraviolet radiation from the sun.

Ground-level ozone, on the other hand, forms when pollution bakes in the sun and heat and can seriously harm human health. Climate change is not only making it hotter and more humid, but it’s also causing those conditions to last for longer periods of time. The hotter and more humid it becomes, the more ground-level ozone there is.

“It’s a direct lung irritant, linked to increased asthma, increased exacerbations of asthma, increased infections, increased death in elderly and the young,” Hill said. “There’s definitely cardiovascular effects. Heart attacks and strokes go up.”

There’s more.

The hotter climate can cause areas to dry out — something known as desertification — creating more dust in the air, which can lead to breathing problems, drought and wildfires. The impact of desertification is not limited to the western states, however. In the summer of 2021 the smoke, soot and pollution from western wildfires had a sharp and measurable impact on air quality right here in Connecticut.

All these factors make existing illnesses worse and cause problems for people who may not have had them before. Hill and others also point out that climate change is extending allergy season for people who are allergic to pollen.

“You just have a longer pollen season where people are being exposed to allergens. And plants actually produce more pollen when it’s hotter and sunnier. So there’s higher levels of pollen,” Hill said. “They can actually combine with the particulate pollution to form what’s called haptens where the pollen becomes more allergenic.”

The result: more asthma.

Climate change also impacts health in another way by producing more frequent and more intense storms with heavy rain and flooding, which leads to increased mold formation. Mold can make lung disease, including asthma, worse.

All these triggers also have compound effects.

“So somebody getting a viral infection when the air quality is bad, it may be more likely to trigger airway inflammation and combine to bring out asthma,” Hill said. “The combination of those pollens and somebody who’s got allergies — allergy and asthma go hand in hand when the air quality is bad — it’s another factor contributing to airway inflammation. It’s just more likely that disease is going to be more severe and lead to needing medical attention.”

Certain times of the day are most prone to high ozone readings. More often than not, it’s late afternoon and early evening when all that polluted air has had time to build up as the temperature has gone up during the day. Which is also right when outdoor activities are scheduled in the summer.

“We encourage people to make sure that they understand what the air quality index is, and use that to inform them as to whether it’s a good idea to be outdoors and play soccer that particular day,” said Marie-Christine Bournaki, a registered nurse and the asthma program supervisor at the Connecticut Department of Public Health.

Said Hill: “We’ll be telling our grandkids we used to be able to exercise outside in the summertime.”

What the research says

The state of Connecticut’s air quality is consistently bad enough that the subject figured prominently in the 2020 report Climate Change and Health in Connecticut, by researchers at the Center on Climate Change and Health at the Yale School of Public Health.

Air quality was considered critical enough among the 19 indicators the report evaluated that it warranted a separate issue brief — The Air Quality Health Benefits of Climate Action in Connecticut.

The reports pointed out that in Connecticut “some communities — predominantly communities of color and low-income communities — are inequitably exposed to higher levels of air pollution, due to highways, power plants, and other sources that are sited close by.” It also listed other risk groups: children and teens whose lungs are still developing; older adults, especially those with other medical conditions; people with heart and lung conditions; pregnant women and newborns. Again, the report said that of all groups, Black, Hispanic and low income populations suffered the most.

It also said that in the Northeast’s urban areas, on the hottest days that tend to have the most ground-level ozone and other pollutants, air quality worsens as air conditioners run more and increase the need for power that is generated from fossil fuels.

The litany of health effects from poor air quality cited by the report is long and troubling. It includes health and lung illnesses, such as heart attacks and lung cancer, harm to the brain that increases the risk of dementia, and impacts on fetal growth and childhood development. In addition, the report said, “hitchhiker” elements and compounds such as lead, cadmium, arsenic and certain hydrocarbons can push pollutants deeper into the lungs.

The New England Journal of Medicine, which this summer began a more concerted focus on climate change and health in a series of monthly articles, included air quality among its seven “exposure pathways,” noting that air quality deteriorates in conjunction with many of the other pathways, including higher temperatures, wildfires and the release of carbon dioxide from burning fossil fuels.

Caren Solomon, the series editor and a physician at the Brigham and Women’s Hospital in Boston, said air pollution has similar impacts on the human body as heat.

“The allergy thing is really interesting,” she said. “So many people are either experiencing allergies for the first time in the last few years, couple of years — or their allergies are much worse.”

Air by the numbers

Let’s be clear — we are far removed from the brown cloud days of the 1970s when air pollution was rampant and painfully visible, though back then the presence of the greenhouse gases we now know are so dangerous had not been recognized.

And it is true as the Yale report says that “since 1990, the annual number of days on which ground-level ozone exceeded safe levels decreased in all counties,” and since 1999 fine particulate matter levels exceeding safe levels also decreased in all the counties in which they’re measured. Outdoor mold concentrations are higher.

But no matter what air metrics you use, Connecticut’s air still isn’t good and still isn’t meeting some key federal standards.

“The entire state is non-attainment for ozone,” said Paul Farrell, director of air planning at the state Department of Energy and Environmental Protection.

Translation: There are federal standards for how much ozone states can have. Connecticut’s levels exceed those thresholds and have for years.

The state is split into two areas: the southwest portion — Fairfield, New Haven and Middlesex Counties, which are part of the New York City and northern New Jersey region. The rest of the state is a different region. Ozone levels are one of six pollutants measured as part of the National Ambient Air Quality Standards — NAAQS, pronounced “nax” by those who deal with them. This is mandated by the Clean Air Act.

The standards are supposed to be updated every five years, and generally they are tightened. The Trump administration ignored that process for the 2020 update, so the Biden administration is restarting it.

That said, the northern part of Connecticut still doesn’t meet the 2015 standards. And the southwest part of the state doesn’t even meet the more lax 2008 standards.

It’s not that Connecticut has been off-the-charts high like it was in 2002 when the state registered 36 days with ozone levels above the federal level during the monitoring period April through September.

Since then, March has been added to the monitoring — and there have been high ozone levels recorded in that month. 2020 and 2021 were somewhat aberrant given the effects of the pandemic with less motor vehicle traffic in particular.

This year, there were 23 ozone exceedance days. Mid-summer was marked by a steady run of ozone levels that were high, but no day hit the highest category.

“It’s been sort of flat in the number of days in which we’ve exceeded the ozone standard, which we know is a healthy standard and has immediate and acute effects on people. So those are numbers that we definitely want to see trending down, and they’ve been rather flat,” Farrell said. “It’s an intractable problem. It’s a problem we’ve had for 50 years.”

The levels, however, are quarter of what they were at times in the 1990s, nevermind the 1970s.

“So just think of how far we’ve come in protecting public health over the years, which is great news,” Farrell said. “But we’re getting to that level where we’re on the third yard line and fourth down, and it’s really, really hard to get those final two ppb (parts per billion — a common measurement for pollution) to get us into attainment.”

Asthma by the numbers

The American Lung Association has been issuing annual reports on the state of the air in the U.S. for nearly a quarter century. In the 2022 report, the metro area that includes Connecticut ranked 14th on the list of the 25 cities most polluted by ozone. And four of the state’s counties get an F for their ozone levels

“Residents from the five largest cities — Bridgeport, Hartford, New Haven, Stamford and Waterbury — account for 18 percent of the state’s population, yet more than 40 percent of the asthma acute care charges,” said Ruth Canovi, the association’s Connecticut advocacy director.

The Connecticut DPH’s asthma program also collects data. Broadly, Connecticut’s adult asthma rate in 2020 was 10.6 percent, placing it among the top 10 to 12 states with the highest adult asthma rates. The rate for children is higher — 11.8 percent.

But while there are reams of statistics on asthma that paint a dire picture, they may still underplay the problem.

With the lag time in statistics, current data reflects the first pandemic years, when air was cleaner due to fewer people out and about in cars, businesses shut down, fewer people willing or able to seek medical care, and generally people just staying at home.

In addition, DPH data mostly reflects emergency room visits and hospitalizations. It doesn’t include any data from urgent care facilities — more widely available and in use in recent years — or from doctor’s offices. It also doesn’t include separate Medicaid data, though some of that may be coming from ER visits.

“We are missing a large chunk of that information,” said Justin Peng, an epidemiology supervisor at DPH.

That said, of the numbers available, people of color have higher asthma rates, and the age-adjusted rates of emergency room visits were nearly six times higher for Black people and five times higher for Hispanic people than that of whites in 2021.

“The disparity is large and unfortunately growing,” Peng said. “We see a much bigger disparity among people who live in large cities, namely Hartford, New Haven, Waterbury and Bridgeport, people of a certain race, ethnic background, specifically the African American community, Hispanic community, where they experience about four or five times the burden of asthma hospitalization.”

The actual emergency room visits, hospitalizations and deaths are a little tough to compare due to the pandemic. They are quantified per 10,000 of the overall population. Age-adjusted emergency room visits were at 37.9 for 2021 and even lower — 30.2 in 2020. But as recently as 2019 they were 54.2. In the last decade they had reached 73. But age-adjusted ER visits for Black and Hispanic people each have gone past 150 in that time period.

“It’s multifactorial,” said DPH’s Bournaki. She also points out that these groups are often sicker with asthma. Children miss more school and that compromises their school performance. Many of the families live in substandard housing with poor ventilation, which means poor air quality.

Essentially those factors compound the climate change factors which are also getting worse.

“It’s a very complex condition,” Bournaki said. “We certainly know for sure that a certain group of the population are most affected and suffer the greatest at all levels, whether it is also with poverty, food insecurity, access to care, transportation, coordination of care, and so on.”

Bridgeport’s suffering

Bridgeport faces multiple stressors from climate change. Higher sea levels and flooding were obvious and devastating during Irene and Sandy, particularly in the south end where the streets not only flooded but the storms also inundated sewage systems, sending fecal matter into people’s homes.

The city straddles I-95 as well as Route 8 and the Merritt Parkway, all of which are perpetually loaded with motor vehicles and their tailpipe emissions. Diesel-powered ships travel in and out of the port. Along the waterfront there is still a large fossil fuel power plant — natural gas now, the coal is gone — and there is a trash-to-energy plant that burns garbage.

Asthma rates are high and have outsized impacts on the large community of those considered an environmental justice population — low-income, people of color, living in the most environmentally vulnerable parts of the city — for all of the factors above.

Yet when it became apparent the city needed to update or even rebuild Bassick High School — a school that serves a large part of that community and that in the warming climate had no air conditioning — those factors seem to have been largely ignored.

The site for the new school is in a flood zone, so while it will be somewhat elevated, the likelihood of mold from street level flooding — which is more prevalent now even on sunny days — is high. It is at the intersection of I-95 and Route 8, down the block from the power plant, a short way up the coast from the trash-to-energy plant and an even shorter way down the coast from the port.

Bridgeport school officials did not respond to multiple requests for information and comments.

Maisa Tisdale, president, CEO and founder of The Mary & Eliza Freeman Center for History and Community in Bridgeport, does not mince words when it come to the decision on Bassick, as well as the outsized representation people of color in Connecticut have as victims of climate change.

“Environment, health problems. These are all issues of equity, and just social justice, systemic racism. They all have the same roots, the same parents,” she said, pointing out that the choice for the new high school came down to a flood zone or a brownfield.

“So you’re telling me for Black and brown kids, their only choice for a school is a brownfield or a flood zone?” she said. “So does that happen to anybody else?”

She worried that the city would not have the money or capacity to deal with the care and maintenance of a school facing so many potential problems.

“The question is, why is there a difference between how the state protects the interests of residents in affluent areas and the way they protect the interests of residents in Bridgeport?” she said. “For Bridgeport, OK. I’m pretty sure it wouldn’t be OK for Greenwich.”

DEEP points out that because the project uses state money, it does need a flood management certification. But all other approvals come from Bridgeport. Air quality and other climate risks are not considered by DEEP as part of the permitting process. Legislative efforts to change this have failed in the past, though are likely again this session.

Looking for solutions

Halting the impact of poor air quality on health would require doing something about climate change at its core — stop using fossil fuels. Short of that, all we can do is address the symptoms of bad air quality and that means first figuring out where the problems are.

Even though the state has more than a dozen air pollution monitoring locations, they really don’t cover the state, and they don’t focus on individual communities that might have specific difficulties.

The state will be taking a small step toward dealing with those inequities. DPH as well as the city of Stamford were among 132 recipients in 37 states of air pollution monitoring grants recently announced by the EPA.

The state received $500,000 over three years for a project in the Naugatuck Valley specifically focused on the distressed communities in that region, which is more rural than most of the state’s pockets of pollution

Plans are for a network of sensors to monitor pollutants real-time and use that information as the basis for outreach and education, especially for at-risk groups. The effort will involve DPH, DEEP and the local health departments in the area as well as both UConn and Yale University. Stamford’s grant, which is much smaller, will help provide data to support air pollution mitigation strategies, also focused on marginalized residents.

To fix the air quality problem, DEEP’s Farrell says it’s an “all of the above” strategy for reducing fossil fuel combustion across the board: mobile sources, power plants, other large stationary sources of combustion like those in factories. The argument can be made that gas-powered vehicles are increasingly more efficient and less polluting as mileage standards and emissions are tightened, which over time will help improve air quality. But Farrell says it won’t be fast enough.

“We know what the tools are. We know what the sources are, we know what the problems are. It’s really how do we accelerate this transition to clean transportation,” he said. “I think the focus that the agency has on low to moderate income in overburdened areas in the EJ focus — as this plays out, you’re going to see that transition speed up in those areas where folks are most impacted.”

The state is also getting help from its historically activist attorney general’s office, which kicked into high gear when Trump came into office and began rolling back or otherwise neutralizing all sorts of climate change and other environmental actions and rules.

There are about two dozen lawsuits still pending related to the Clean Air Act and air quality, many of which are being held in abeyance while the Biden administration re-writes or revokes rules the Trump administration put in place. Some of the state action right now just involves commenting on proposed rules.

Among the most noteworthy are a number supporting California’s right to set stricter motor vehicle emission standards — which Connecticut follows rather than the more lax federal standard. The state also fought the Trump administration’s effort to not tighten the NAAQS standards.

Other suits involve our ongoing battle to force upwind states with polluting power plants — coal and oil in particular — to do more to control that pollution so it won’t get into Connecticut. That falls under the good neighbor provision of the Clean Air Act. The state has had some success in getting courts to agree with it, but getting the actual changes has been difficult.

In July 2021, Connecticut, New York, Delaware, Massachusetts, New Jersey and New York City reached an agreement with the Biden administration to force six upwind states to establish plans controlling their pollution, something the Trump EPA had dragged its feet on.

But lawsuits can take years to conclude, and their implementation can run even longer, even if the state wins. In the meantime, in the state’s largest cities, located along its most traveled highways and facing some of the worst air quality issues, there can still be a disconnect.

The Yale report offers a list of broad solutions, a number of which have since become law, such as mandating adoption of zero-emission trucks and school buses and committing to a zero-carbon electric grid. Other solutions include shifting to cleaner home heating and cooling such as heat pumps and addressing the barriers — such as the presence of asbestos — that keep a lot of low income housing from adding weatherization to help with efficiency. But many of these will take years to implement.

The overall message, said Bournaki, is that strategies and solutions require inter-agency and cross-sector approaches. That means more involvement from health officials, which is not always included in climate change strategizing. And it means individuals have to step up too.

“I think we need a lot more presence from the health field,” she said. “Health providers or health experts are best positioned, I think, to be able to help make the linkages between environmental changes and health.

“But you know, I think that everybody, also at the individual level, everyone has a duty, I think, to do something about making some changes to improve air quality and I guess the climate in general. That’s the future of our children. So what are we leaving behind? I think we have a responsibility for that.”

Sandra Rapp feels like she’s one of those being left behind.

“I stay inside. I’m spending my entire life inside lately,” she said. “You don’t have a social life. You can’t go out. “It’s been so long. I can’t remember what it was like not to have this anymore.”

And the idea that climate change is part of the reason is not lost on her. “I think people recognize that. I don’t see how they could miss it.”