PĀHALA — Ka'ū Hospital, which sits at the gateway to this rural community in the state's voggiest corridor, is the only option for acute care in a district the size of O'ahu. But with no central air and few air purifiers, it's hardly a refuge in a place where sulfur dioxide concentrations in vog often get dangerously high.

Hospital staff have improvised to improve conditions: In places, plastic sheeting has been taped over jalousie windows to keep bad air out. Small fans are positioned near entrances to push out the vog. And on the worst vog days, all the hospital's patients and workers move to an activity room — the only place in the facility, other than the emergency room, with wall air-conditioning units and multiple air purifiers.

It's a system that falls far short of providing a haven from the at-times choking volcanic smog in Pāhala and neighboring Ka'ū communities. And it's a case in point of why residents and lawmakers in the towns downwind from Kīlauea, which two years ago doubled its emissions, are increasingly raising their voices.

They're frustrated, they say, with the pace of government aid to affected communities. And some are questioning why more isn't being done to help. "We're just not getting answers," said state Rep. Bob Herkes, D-5th (Ka'ū, S. Kona). "It is a natural disaster — no question about it. Yet, we don't seem to be paying attention to the health, safety and welfare of the people who have to live here and who have no option to leave."

It's been two years since a new vent opened at Kīlauea's Halema'uma'u Crater, spewing out 1,000 to 2,000 metric tons or more of volcanic emissions — mostly sulfur dioxide and fine particulates — daily on top of the average 1,000 to 2,000 metric tons a day emitted at the Pu'u 'Ō'ō vent that opened in 1983.

The Halema'uma'u event has changed life in the Ka'ū district, an economically disadvantaged area of small communities and ranch and farm land. Even before the new vent started, Kīlauea — the longest actively erupting volcano in the world — was the nation's largest producer of sulfur dioxide.

Today, the volcano spews out thousands of times the sulfur dioxide of a major industrial polluter, and that gas and the fine particulates routinely make the air in areas of the Big Island some of the worst in the United States.

Emissions from the vent have decimated crops and spurred worrisome health effects in cattle and other farm animals. What the vog — which regularly raises sulfur dioxide concentrations in the air above federal warning levels — is doing to the estimated 20,000 people who live downwind of the vent is harder to say.

HEALTH UNCERTAINTY

Short-term exposure to the heavy vog can be very detrimental to people with asthma and other lung diseases, triggering asthma attacks, making breathing difficult and increasing the likelihood of developing bronchitis and other illnesses. But the long-term health effects of being exposed to vog are largely unknown.

That uncertainty weighs heavily on residents.

It doesn't help that they have so few places to get relief from the bad air.

In the Ka'ū district, which often sees vog so thick residents can smell sulfur in the air, there is no emergency shelter or safe room for people to get a reprieve. And Ka'ū Hospital isn't the only place struggling to keep out the volcanic emissions: Air conditioning is something of a rarity in Ka'ū, and most people don't have it.

Even the Pāhala Senior Center, Ka'ū community center and Pāhala preschool are open-air.

"There are no safe places to go," said Bob Martin, 40, who lives in Nā'ālehu.

The lack of a vog shelter is one of a list of complaints among residents. They also say the state isn't monitoring the vog well enough, has done little to better equip Ka'ū Hospital and other community centers and hasn't sufficiently explored the possibility of issuing a disaster declaration — which could open the door to millions in federal aid dollars. Many residents say that they understand there's no way to decrease the volcano's emissions, but they say something should be done — soon — to give people some fresh air.

"It doesn't take a rocket scientist to figure it out. If the government has already acknowledged the vegetation (is affected by vog) ... it certainly is impacting humans," said Jessie Marques, executive director of the Ka'ū Rural Health Community Association. "What kind of solutions does the government have?"

Marques said there are a host of out-of-the-box strategies the state could consider, from tax credits for air purifiers or purchasing air conditioners for people in voggy zones to putting up more monitors to track vog.

'CHEMICAL ATTACK'

State and county officials, meanwhile, say they're responding the best they can to a natural event that is unprecedented in the modern history of the Islands, shows no signs of stopping and has no rule book. This is not an earthquake or a flood or a hurricane, they say, where the devastation is immediately apparent and easily quantifiable. Determining the effects of the vog on health is next to impossible, not least because the emissions are still going. And calculating the vog's effects on farms and ranches is equally hard, they say.

"The vog is a chemical attack by Mother Nature," said Maj. Gen. Robert Lee, the director of state Civil Defense. "We have an open-ended disaster. Our concern is ... the nature of the long-term impact on people."

Lee cautioned, though, against panic and jumping to a state declaration of disaster, to trigger federal disaster aid dollars. He said a federal disaster declaration is a one-time deal — and can't be reissued for an event, even if the situation worsens. He also said such a declaration requires a certain threshold of loss — equal to the value of 100 homes in a given area — and the state isn't certain it has reached that point yet.

"Is this the right time to do it?" Lee asked.

He thinks not.

"With the vog, we know when it started," he said. "How do you say when it's the end?"

SOME PLANS TO HELP

Lee and others in state and county government also say that, despite the budget crisis, there have been major moves to help people in Ka'ū and that there are plans to do more. Among the improvements they point to:

• The state plans to transfer $18 million from the state Department of Education budget, set aside for a gymnasium at Ka'ū High School that was on hold, to Hawai'i County to build a combination vog shelter, gym and community center on the school grounds. The funds are in a draft state budget for fiscal year 2011.

• About $719,000 in state funds has been spent for air-conditioning improvements at Ka'ū Hospital, including to air-condition its emergency room with wall units. The state Legislature approved $4.5 million for the hospital last year to kick off a project to install central air, but those funds have not been released. They also aren't expected to be enough to complete the work.

• Public schools in the Ka'ū district have been equipped with sulfur dioxide monitors, and Pāhala Elementary School and Ka'ū High School have air conditioning, fans and air filters in classrooms. During high vog events, "students and staff remain in these rooms until conditions improve," said principal Sharon Beck.

• In 2008, the state formed an interagency task force on vog, which brings different state departments together with other entities to discuss the impact of vog and consider remedies. That task force met just once, though, in 2008 and once in 2009, and hasn't met this year. The group plans to meet later this year.

• The state Health Department installed an air monitor in Pāhala in August 2007 — coincidentally just months before the Halema'uma'u vent opened — and plans to install a new air monitor in Ocean View (also downwind from the vog) this year. The monitors, which are housed in small shelters and continously collect air quality data, cost about $100,000 each. Lisa Young, an environmental health specialist with the Health Department's Clean Air Branch, said the state has four other air monitors on the Big Island.

Prior to the March 2008 event, she added, the vog rarely reached federal air quality warning levels.

Since then, the levels have been exceeded nearly 200 times.

• State Civil Defense estimates that the state, excluding the DOE, has spent about $1.3 million on a variety of other "services, products, material" and travel for personnel to help people affected by the vog and to respond to the disaster. That money has gone to a host of projects, including to set up the state's vog help line.

It has also gone to air-monitoring equipment and for a public website so people can track vog levels.

• Hawai'i County Civil Defense set up a system that allows people in vog-affected areas to sign up for telephone calls warning them when vog levels are high. The agency also issues radio and TV warnings when the vog gets particularly thick. Quince Mento, the county's civil defense administrator, estimated that about a dozen phone alerts and countless other public warnings have been issued over the past two years.

'LONG-TERM ISSUE'

Hawai'i County spokes-man Kevin Dayton, who responded to Advertiser questions for Big Island Mayor Billy Kenoi, said there have also been other ideas thrown around that are still in the planning stages, including buying air conditioners for people in the voggiest areas.

Dayton said the county is doing all it can to help residents, and added that its response to vog has changed dramatically since the vent went off. Initially, the first response was to evacuate people. Now, residents are told to shelter in place and officials try to get as much information to them on vog levels as possible.

Dayton said officials are looking for other improvements, but he also said that residents have to figure out for themselves if they can live in vog-affected areas.

"We're asking people to really assess where they're at," Dayton said. "Obviously, the March 2008 impact with the opening of the new vent was really significant. It became pretty clear pretty quickly this was going to be a long-term issue. It isn't what you'd call a normal disaster."

The thousands of people who live downwind of Kīlauea, by far the largest source of sulfur dioxide emissions in the nation, would probably agree with that. And while most acknowledge there has been state work to improve conditions since the vent went off, several say there needs to be more planning — and action.

Herkes, the state representative, said he wants to see a more coordinated effort to get help to residents, and is also pushing for more monetary relief for farms that have lost crops.

Several farms did get small farm loans from the state. And the U.S. Department of Agriculture has issued about $110,000 in cash payments for lost crops to six producers, which represents a fraction of what was lost. Other applications for growers are being processed.

"We need more grants. We don't need loans," Herkes said.

BREATHING VOG

This legislative session, Herkes is pushing for a series of measures to help vog-affected communities, including a bill that would develop rules for workers' compensation claims for vog-related medical conditions and another that would push the state to better monitor highway signs and guardrails badly corroded by vog.

Most of the vog bills have stalled, but one appears likely to pass. It would divert federal Homeland Security funds to purchase a mobile medical van for the Kona and Ka'ū districts. It's unclear, though, whether the federal funding would be enough to buy the van and hire workers to staff it.

Herkes said the key is making sure vog is at the top of the state's priority list — and he doesn't believe it is.

"You take for example what precautions are we doing for state highway workers in heavy vog?" he said. "We need to look into all of the health aspects. It is impacting humans. We need to find out how."

Guy Enriques, Hawai'i County councilman for Ka'ū, said he also feels the state isn't paying enough attention to people in Ka'ū — and the health and other problems they're grappling with.

He's pushing for more meetings between a variety of agencies to understand all the effects of the vog.

"We've got to start somewhere," he said.

Residents, meanwhile, say they're not asking for much in the way of assistance. Most said they'd like a little help buying an air conditioner or an air purifier. Several said they want to see central air installed soon at the 21-bed Ka'ū Hospital.

Debbie Wong Yuen, a longtime Pāhala resident, saw her asthma go from manageable before the 2008 vent opened to nearly fatal after it went off. Living in vog is a daily struggle, she said.

Now, her 6-year-old granddaughter is developing symptoms.

She said there are ways to get more help to residents, even during tough economic times. One option, she said, might be working more closely with insurance companies to help people buy air purifiers.

Yuen added that despite her severe asthma, she had to buy air purifiers and air conditioners out of pocket.

She also said she's increasingly concerned about the elderly and children in her community. "It would be nice to have a safe place that these people could go to in case it gets really bad," she said. "I think of the children and the elderly, if they're breathing it in."

'YOU CAN FEEL IT'

But John Roddy, of Nā'ālehu, isn't sure there's much more that can be done to help people. The vog, he said, isn't stopping — and everybody has to go outside eventually.

"There's nothing you can do about it," said Roddy, who has lived in Nā'ālehu for 25 years. On a recent day, he was taking a slow stroll through the community with his grandsons, 9 months and 5, who were born there and both have asthma. He said sometimes living in vog isn't easy, but he doesn't plan on moving.

"Sometimes," he said, "you can't hardly see it, but you can feel it."

Particularly frustrated by the situation are the people who work at Ka'ū Hospital.

On a voggy day last month, Dr. Brian Panik sat in his emergency room and remembered the day before — another voggy day, when he had several patients severely affected by the vog, one so badly that she nearly had to be put on a ventilator. "Those people ... would have been much better served if they had had a place where they could retreat to, a place of safety next to the volcano where their lungs wouldn't be exposed" to vog.

Ka'ū Hospital serves about 6,000 patients a year.

Several times since the Halema'uma'u vent went off, its clinic has closed because of the vog.

Its ER has never closed, but staff members working in the vog have suffered and, Panik and others said, patients are harder to treat in a facility where the air is sometimes as bad or worse than the air outside. "When the vog is bad, we have no way of keeping it out," said Merilyn Harris, the hospital's administrator.

"When people are having trouble breathing, where are you going to go? They are going to go to the hospital," said Harris. "Well, if the air quality inside the hospital is sometimes worse than it is outside, because the air has come in and now it's trapped, then obviously that's a very bad thing."

On a tour of the facility, Harris demonstrated just how difficult it is to keep the voggy air from creeping in: When closed, the hospital's doors still have spaces for air to seep in; when Harris tried to shut a jalousie window, one of many in a corridor where long-term patient rooms are, the handle wouldn't budge.