'A complete failure of the state': Authorities didn’t heed researchers’ calls to study health effects of burning sugar cane

This article was produced for ProPublica's Local Reporting Network in partnership with The Palm Beach Post. Sign up for Dispatches to get stories like this one as soon as they are published.

It was the eve of the 2015 harvest season in Florida's heartland. As they did every year, sugar companies prepared to torch swaths of cane, a practice that sends plumes of smoke into the skies near rural Lake Okeechobee.

This time, though, they faced mounting public criticism from residents and environmentalists, who claimed the smoke was making people sick. So on Sept. 30, industry leaders held a conference call with a special guest who tried to quell the objections: Pat Dobbins, the former head of a health department responsible for two Florida counties in the country's largest cane-sugar-producing region.

She said decades of air-quality monitoring and mountains of public-health records suggest there is no link between cane burning and poor health outcomes in the community, according to media reports.

But privately, the assessment among government researchers was anything but unanimous. Within a week of Dobbins' statement, researchers for the health department in Palm Beach County wrapped up the draft of a study that linked sugar cane burning to significant levels of toxic pollution known to cause cardiovascular disease, cancer and respiratory illness.

In fact, it was the third such air-pollution study commissioned by the department over two decades, each raising more alarms about the popular harvesting practice than the last. Its findings prompted researchers to recommend that Palm Beach County undertake a health-risk assessment, a tool the Centers for Disease Control and Prevention and state health departments use to identify environmental toxins and protect vulnerable communities. Health studies in Brazil, the world leader in sugar production, contributed to the decision there to shift away from burning cane, with officials passing laws to entirely phase out the practice by 2031 and instead use blades to remove the plant's leaves.

Although local and state health officials have assessed the health risks of pollutants in Palm Beach County at least 10 times since the 1980s, they did not follow up on this recommendation, according to the state database that lists all such reviews. While versions of the three studies were ultimately published in academic journals, the local health department did not pursue further research into the health effects of sugar cane burning, even as complaints from residents mounted and the debate moved to the legal arena.

To better understand health trends in the sugar-growing Glades region, The Palm Beach Post and ProPublica did their own analysis, using eight years of hospital and emergency room data provided by the state and focusing on patients from Belle Glade, the largest city in the area.

The review found that hospital and emergency room visits for breathing problems among Belle Glade patients spiked during cane-burning season — similar to a trend that local health officials first observed in clinics nearly 30 years ago. The seasonal difference in Belle Glade also was bigger than changes in other, similar populations where burning wasn't present, The Post and ProPublica found.

We shared the findings with three academics who specialize in air quality and health in Florida and Colorado. And while they cautioned that the analysis cannot speak to the causes of respiratory illnesses, these experts said the trends suggest that what is needed is exactly what health officials recommended six years ago: a thorough look at illnesses potentially linked to exposure to cane-burning pollution.

Officials at the Palm Beach County Health Department declined to be interviewed for this story and did not respond to detailed written questions from the news organizations about their handling of the air-quality research findings or the Post/ProPublica analysis. Dobbins did not return multiple calls for comment.

Today, Florida's multibillion-dollar sugar companies continue to burn cane, spilling ash — or "black snow," as locals call it — into mostly Black and Hispanic communities.

Glades residents are now suing sugar companies in federal court, asserting that exposure to cane burning has caused widespread respiratory illness. Sugar companies have denied that claim, in part arguing that the practice is tightly regulated by Florida's agriculture and environmental protection departments. U.S. Sugar and Florida Crystals, the region's two largest sugar producers, both declined to comment on the health department studies, but the companies did send statements saying they were committed to operating safely in the Glades.

"As a long-standing employer and responsible neighbor in the Glades community, there is no higher priority of ours than the health and wellbeing of our families, friends and neighbors," a U.S. Sugar spokesperson wrote. "That commitment is only matched by how serious[ly] we take our responsibility to be good stewards of the environment which as farmers is the foundation for the work we do each and every day."

"We are proud of our 60-year heritage in the Glades communities, where we have led and supported efforts that protect and enhance our communities," Florida Crystals said, "and we are committed to continuing to build on our legacy as a trusted partner with our neighbors."

U.S. Sugar took issue with the news organizations' analysis, saying the underlying data lacked "critical factors" needed to draw any conclusions.

Meanwhile, state lawmakers have moved to further protect the industry, pointing to the lack of conclusive data tying cane burning to health problems experienced by people living in the Glades.

In April, the state Legislature passed a bill that hinders residents' ability to sue farmers over air pollution. In fighting against its passage, Dr. Ronald Saff, an asthma specialist with nonprofit health advocacy group Florida Physicians for Social Responsibility, told lawmakers that studies have proven that exposure to pollution comparable to the particulates sent into the air by cane burning causes asthma and stunts lung development.

Rep. Spencer Roach, a Republican from Southwest Florida, pushed back, chiding Saff for referencing broad academic studies and not specific data on the Glades.

"It continues to offend me when people come before this body ... and are not ready with data," Roach said. "If you're going to propose we take action or pass a law to end someone's way of life, you better damn well have some data that you can present." The news organizations contacted Roach by email and phone for comment about the 2016 health department recommendation for further study; he did not respond.

A similar lack of data on air pollution trends in Florida's sugar region was at the center of an investigation published in July by The Post and ProPublica, which found that the state and federal framework for measuring air quality fails to capture short spikes in harmful pollution, a defining feature of Florida's cane-harvesting process.

The Post and ProPublica spoke with dozens of Glades residents over the course of a year about living amid burning cane fields. Many described widespread breathing problems during burn season and a reliance on asthma inhalers and nebulizers, as the news organizations reported in July. Activists have unsuccessfully urged state officials to pause cane burning amid the COVID-19 pandemic, saying the smoke and ash put Glades residents at further risk from the respiratory virus; Belle Glade has been a hot spot.

More than 500 pages of internal documents, released to The Palm Beach Post and ProPublica in response to a public records request, show that the county health department, which reports to the state, first began studying cane burning three decades ago, culminating with the 2016 recommendation to do a health-risk assessment. At each step, researchers pointed to concerns not unlike those that led to the Brazilian action, linking toxic pollution to sugar cane burning.

Public health experts said the health department could have taken several measures to begin to address the concerns raised in the air-quality studies, including conducting a cursory examination of health trends.

"It would be easy for a health department to look at health and hospitalization data," said Vickie Boothe, an epidemiologist and environmental engineer who worked at the Environmental Protection Agency and the CDC. "That's a complete failure of the state."

The First Pollution Studies

Signs pointed to a problem long before the Palm Beach County Health Department launched its air-pollution studies.

Field workers frequented clinics with complaints of breathing problems and parents spoke of children developing asthma as toddlers, said Dr. Jean Malecki, who ran the county health department from 1991 to 2009 and started her career as a clinician in the Glades. During that period, Palm Beach County residents regularly complained about smoke and ash reaching their homes; at one press conference in the 1990s, state officials described dozens of complaints.

"There was significant observational evidence that the burning of cane caused respiratory problems," Malecki said. "I saw firsthand the problems that the people in Belle Glade were facing."

In her first year as head of the department, she assigned a researcher to study health trends. By 1992, that researcher concluded that more people were going to local clinics for respiratory problems during cane-burning season, but he couldn't link the trend to pollution. There was too little science on cane-burning emissions. He recommended more research on the subject.

In 1997, the county health department took that step in the Glades, tapping Florida International University to study particulate matter, a mixture of tiny, hazardous particles in the air. That year, the EPA set national standards for particulate matter after research tied the pollutant to lung disease, heart disease and premature death.

The FIU team's one-year study found higher concentrations of particulate matter — specifically PM10, tiny inhalable particles smaller than the width of a cotton strand — in Belle Glade during cane-burning season than in Delray Beach, a wealthier coastal town nearly 40 miles away, where the state at the time operated an air monitor. Outside of the harvest season, the two communities had similar pollution levels.

The researchers couldn't pin down the source of the particulate pollution since it can come from an array of sources: cars, factories, even outdoor grills. Any combustion, including cane burning, could have caused the spikes, and both the 1992 and 1997 studies acknowledged there was still a lot researchers didn't know about the environmental effects of cane burning.

More than a decade passed before the health department sought to close that gap in knowledge. In 2009, James Stormer, who headed the department's air-quality division, tapped connections at his alma mater, the University of Florida, to push the research forward by looking more closely at the emissions from cane burning.

"No one else internally really seemed all that interested, to be honest," Stormer said. "It just kind of fell on me, and I was scientifically curious."

So was Chang-Yu Wu, a professor from the University of Florida who studies air pollution. Working with Stormer and a team of researchers, Wu built a combustion chamber to burn samples of cane and measure the pollutants released, and then used those measurements to predict the levels of pollutants likely suspended in the air during industry burns.

They experimented with whole stalks, as are burned in the Florida fields during the harvest, and with the outer leaves, which some harvesters elsewhere in the world remove using blades and burn off-site. Pollution emissions were consistently higher when they burned whole stalks, as farmers do in the Glades.

Of particular concern was a smaller class of particle pollution known as PAHs, or polycyclic aromatic hydrocarbons. Usually associated with burning tobacco or oil, PAHs are considered by scientists to be among the most toxic air pollutants. The Florida research team estimated that cane burning was responsible for more than half the PAHs in the air in Palm Beach County. Cane burning also produced an estimated 89% of the county's carbonyls, a category of gaseous pollutants. Among them are formaldehyde and acetaldehyde, which the EPA has linked to cancer; the higher the concentration, the higher the risk of cancer. Although federal regulators haven't adopted limits on outdoor PAHs, research shows that exposure to even low levels over a long time can contribute to illnesses, including asthma, heart disease, cancer and birth defects, a 2020 EPA report notes.

In the spring of 2010, Stormer and Wu presented their findings to health department officials in a meeting at the agency's headquarters. The event also included sugar industry representatives, according to two people present. The team said their research positioned regulators to "make better decisions about the permitting and management of this practice to better protect human health and the environment," according to the slideshow the team showed.

Wu, who spoke with The Post and ProPublica, published the findings in an academic journal two years later.

Stormer and Wu pushed forward with another study in 2013, this time collecting air samples during burn season and at other times of year.

Stormer retired in 2015, before the study was sent to an academic journal, but Wu submitted the findings the next year.

The 2016 report compared toxic pollution in Belle Glade to Araraquara City, Brazil, a cane-producing region outside Sao Paulo known for high levels of air pollution. The level of PAHs in Belle Glade were "significantly higher," at times as much as tenfold what it was in Araraquara, the study says.

Wu also pinpointed a single day, Oct. 25, 2013, when farmers burned more than 2,900 acres of sugar cane — the highest number of authorized burns during their study period. That day, researchers recorded the highest concentration of PAHs. They also noted the presence of wildland fires, which had burned through roughly 1,000 acres in the region.

Researchers recommended approving fewer sugar cane burns per day, a process regulated by the Florida Forest Service under the umbrella of the state agriculture department. They also broadly recommended more "control for sugarcane burns." State officials never adopted limits on the number of burns or acres authorized per day. (As The Post and ProPublica reported last month, state agriculture officials adopted some restrictions on cane burning in 2019, including denying permits when the air quality is poor. In the most recent burning season, however, they ultimately approved roughly the same number of burns as they had in the past five burn seasons, department data shows.)

And, finally, the 2016 study suggested the need for a health analysis aimed specifically at the illnesses linked to PAHs, including cancer.

"The health-risk assessment was the obvious next move," said Stormer, an environmental engineer. "I'm no epidemiologist. We weren't qualified to tell if there were any related health trends."

A Battle Over Clean Air

Around the time the studies were trickling out of the health department, a public battle between sugar companies and environmentalists was unfolding in the Glades. They were clashing over the facts about burning, but also competing for the attention of the health department, vying for resources to look into — or look away from — the issue.

Residents from the three sugar-producing counties in Florida — Palm Beach, Hendry and Glades — had complained dozens of times to the state or to local health departments since 2009, when health officials in Palm Beach County launched their second air-quality study.

Some complainants called state or local authorities about the nauseating scent, describing itchy eyes or chest tightness, complaint records show. Others lamented that their porches and roofs were coated in powdery soot. One complaint simply and in all caps read: "SUGARCANE SMOKE IS CAUSING HEALTH PROBLEMS."

In 2012, Donna Po, who lives in Loxahatchee, a town on the eastern edge of sugar fields in Palm Beach County, sent a detailed letter to the health department, attaching 68 pictures she'd taken of the smoke and ash. That day, she wrote, her 12-year-old son, Matthew, had coughing fits all afternoon. She gave him steroids using a nebulizer, a machine with a mask attached that turns medicine into an inhalable mist.

"I do not care about all the fancy tests that are probably being done when the wind is not blowing this way," Po wrote on Jan. 19, 2012. "I only need to look at my son and breathe the air to know that the sugar cane burning is hazardous to our health."

Po's complaint was forwarded to the Florida Forest Service. A health department official wrote her back, suggesting she direct future concerns to the Forest Service, which has no health authority but is in charge of cane burning.

"I felt very dismissed," Po told The Post and ProPublica in an interview. "It just felt like, why bother? Nothing will ever change."

The local health department routinely forwarded cane-burning complaints — including those describing health problems — to the Florida Forest Service, as the agency in charge of agricultural burns, records show. Forest rangers investigated the complaints, but regularly closed them without taking any enforcement action. They often wrote in reports that the smoke had dissipated or that the burns were authorized by the state.

In 2015, some residents who were the most vocal critics of cane burning partnered with the Sierra Club to launch a "Stop the Burn" campaign. The group held press conferences, sent emails to lawmakers and distributed glossy postcards across the region calling for the industry to adopt what activists call "green harvesting," the moniker for an alternative to burning that involves removing the leaves with blades.

Glades residents, however, soon got more mailers, this time warning that an end to burning would lead to the shutdown of a vital industry.

They came from a pro-business organization called S.A.F.E. Communities, which stands for Sustainable Agricultural Fire Education. The group's board included a U.S. Sugar executive, along with Dobbins, the former head of the joint health department in Glades and Hendry counties, according to S.A.F.E.'s website.

"Stopping Pre Harvest Burns would hurt farming, which hurts our local farm based economies and will eventually force farmers and those who depend on farmers (which is almost everyone in the Glades) - off their land and out of the area," one mailer read. The sugar industry is the largest employer in the Glades, providing more than 12,000 jobs during the six-month harvest season.

Another mailer, provided to The Post and ProPublica by residents, also warned that ending cane burning would leave "trash mounds" that would attract snakes and rats and allow for the spread of wildfire.

The organization's website went further, reassuring residents that ash often seen suspended in the air and wind during cane season wouldn't harm them.

"Ash from burnt sugarcane is not a health risk," the website once read. "The ash particles you see are large enough and heavy enough to fall to the ground. Particles of this size are not considered a health hazard."

That's not entirely true: Though research shows that smaller particles are more harmful to people's health, the CDC says that particles that are large enough to see still pose a threat, specifically those that are 10 micrometers in diameter or smaller, including smoke, soot and dust.

"Breathing in particle pollution can be harmful to your health," the CDC warns on its website. "Coarse (bigger) particles, called PM10, can irritate your eyes, nose, and throat."

S.A.F.E. Communities was launched by the Lake Okeechobee Business Alliance, a nonprofit business advocacy group. Julia Du Plooy, the alliance's president and a member of S.A.F.E.'s board, did not respond to questions about S.A.F.E.'s claims or the CDC's position on harmful particles, but instead offered a general statement. She said volunteers started the campaign to "counter the bad information" about cane burning from outside groups.

"As a mother that is raising my children in a rural farming community, I felt it was important to engage with facts about our good air quality, how farmers are good stewards and community partners that help make our communities a great place to live," Du Plooy wrote in a statement.

The mailers were just one part of the industry's counter-campaign. The Florida Sugar Cane League, a coalition of sugar farmers that lobbies for sugar interests, tapped former health department officials to speak about cane burning. Among them was Randall Miller, a supervisor with the Palm Beach County Health Department's air-quality division until 2016. Three months after retiring, he started an environmental consulting company for residential and commercial clients, including the Florida Sugar Cane League. Miller also serves on S.A.F.E.'s board.

As a consultant, he still enjoyed direct access to his former colleagues, emails obtained by The Post and ProPublica through a public records request show. Health department employees emailed Miller daily air-quality reports from his former division, according to the records. Moreover, on at least two occasions, they forwarded him complaints from a resident concerned about cane burning.

In 2018, for instance, Steve LaPorte lodged a complaint with the department about heavy smoke near his home in Moore Haven on the western edge of Lake Okeechobee. But instead of hearing back from the department, LaPorte got a response from Miller, according to a copy of the email provided by LaPorte, first reported last year by Grist and Type Investigations.

Miller wrote that he was reaching out on behalf of the Florida Sugar Cane League.

"They are interested in trying to better understand your concerns about pre-harvest burning and to see if we can determine how you and your community might have been affected yesterday," Miller wrote on April 13, 2018. "The Florida Sugar Cane League and affiliated growers work very hard at minimizing effects of agricultural activities on local (and distant) communities and are very interested in understanding how communities have been affected when concerns arise."

LaPorte said both instances shocked him. "I wondered how Big Sugar got my emails to the health department," said LaPorte, who has since joined other Glades residents as a plaintiff in the federal lawsuit against sugar companies over cane burning.

The health department declined to answer questions about this episode and how it handles complaints from the public. Neither the Florida Sugar Cane League nor Miller responded to requests for comment for this story.

In July 2019, a month after residents filed the lawsuit against sugar companies claiming cane burning was making them sick, Miller wrote a letter to the editor of The Palm Beach Post touting his public health experience and again defending cane burning. An editor's note on the letter included the fact that Miller was a consultant for the Florida Sugar Cane League.

"We do not need a trial to find facts," he wrote. "They are available today through years of publicly available data. There is overwhelming evidence that the Glades communities have very good air quality. While they may have their share of health challenges, the science shows that sugarcane burns are not a health concern."

But Stormer and Wu's studies, produced by the health department during Miller's tenure, had suggested the opposite. (Miller did not reply to questions about whether he had been aware of those studies.)

Assessing the Risks

There are clear models in place for health-risk assessments, and they've been established over the course of more than 40 years.

Congress created the Agency for Toxic Substances and Disease Registry in 1980 to investigate the health impacts of exposure to toxic chemicals in the environment. It partnered with individual states to finance researchers tasked with probing environmental health issues.

With federal assistance, Florida has acted on the recommendations of dozens of local health departments to investigate environmental pollution, like groundwater contamination or radon levels in the air. In fact, health officials have carried out such risk assessments in Palm Beach County at least 10 times since the late 1980s, to generate research into issues such as a mercury spill at a medical building; air, soil and water quality at homes built on a former landfill; and well-water safety near a former electronics plant.

And, in many cases there and across the state, the investigations yielded action that prevented harm to public health. In Tampa in 2018, the state team assessed contamination from a former chemical plant site that was slated for redevelopment. The agency recommended against building wells and called for testing pollution concentrations in the soil and groundwater before the developer could build on the site.

The state health department on its website called it "a success story," writing that, "Because of this evaluation, the Department prevented residents from being exposed to potentially toxic groundwater vapors."

The website lists another "success story" in Palm Beach County that same year. Responding to concerns about an odor coming from an oil storage tank at Saint Andrew's School, a private school in Boca Raton, state health officials collected indoor air samples to test for contaminants linked to oil. The assessment led to a recommendation to repair a ventilation system that filters out such contaminants.

After The Post and ProPublica reached out to health department employees for this story, one employee placed a call to Stormer, who had retired, to ask whether the agency had carried out a risk assessment, Stormer told the news organizations. It hadn't, he said.

A risk assessment, especially in the face of an ongoing source of pollution like cane burning, is a natural next step after finding high levels of environmental pollutants, said Boothe, the former EPA and CDC epidemiologist and environmental engineer.

In a case like this, Boothe said, a health-risk assessment would involve complicated modeling that combines pollution emissions data with health data. State and federal agencies have partnered on similar modeling for wildfires, which are more sporadic and more difficult to track, Boothe said.

"What's the excuse for not doing it in a situation where residents are exposed to smoke regularly year after year after year?" she said.

In May, The Post and ProPublica reached out to Dr. Alina Alonso, the head of the county health department. She did not return calls. So a reporter approached her at a Palm Beach Board of County Commissioners meeting to request an interview about the air-quality studies and the health impacts of cane burning. Alonso insisted she wasn't the right person to speak to about the topic and said that the department had examined health trends and determined "allergies" were the contributing factor to the health problems Glades residents had been experiencing.

But no such study on allergies in the Glades appeared in a records request for all health department studies on air quality and health in the region since 1980, and, when asked, the department did not provide any further evidence.

A mention of allergies in the Glades does appear, however, on the S.A.F.E. Communities website on a page dedicated to defending cane burning. The website claims there is "no uptick in emergency room visits for respiratory complications during the sugarcane harvest season. However, residents of the Glades and other regions do experience the normal health issues such as allergies associated with a change in the seasons."

The Post and ProPublica followed up with detailed questions by email to Alonso about the studies and the allergy trends she'd mentioned. After more than three months, the department did not answer any of them.

Looking at Hospitals

Analyzing hospital admissions and emergency room visits would have been a logical step to take in assessing health trends in the community, experts said.

"It's not a great leap for the health department to pull off that analysis, honestly," said Eric S. Coker, an environmental health professor at University of Florida and former epidemiologist for the New Mexico Department of Health.

In the absence of such an analysis, The Post and ProPublica examined health trends in the Glades using eight years of hospitalization data from Florida's Agency for Health Care Administration, which oversees hospitals throughout the state. With the guidance of academics, The Post and ProPublica compared the average rate of hospitalization and emergency room visits between burning and non-burning seasons. While the analysis cannot speak to the cause of any illnesses, experts advised that the data is useful for understanding broad trends between seasons. The news organizations focused on patients with a Belle Glade ZIP code, the largest ZIP code in the sugar-growing region.

The analysis found that for patients from Belle Glade, hospital and emergency room visits for respiratory illness rose by 35% during the burning seasons. Those months, October to March, overlap with pollen and flu seasons, so higher rates of respiratory illnesses are to be expected. But the seasonal trend was more pronounced in Belle Glade than it was elsewhere.

In fact, the Belle Glade ZIP code had the highest percentage increase among other South Florida ZIP codes of similar population size, racial makeup and median household income, including areas in Opa-Locka, Fort Myers, Fort Lauderdale and Miami, all urban or suburban areas. (Research shows that low-income minority communities are likely to experience asthma and other illnesses at a higher rate. People in low-income areas tend to have less access to adequate housing and health care, factors that can compound health problems.)

An exact geographic comparison was difficult because the Glades is unique, in that it is the only largely Black, low-income community living near agricultural fields in South Florida. So experts recommended comparing Belle Glade trends to those in a similarly rural area as well, despite differences in income and racial demographics.

In that comparison, the Belle Glade ZIP code still had a higher average percentage increase in hospitalizations and emergency room visits for respiratory illnesses. Indiantown, a rural, largely white area just north of the Palm Beach County sugar-growing region, had an average seasonal increase of 19%, compared to the 35% in Belle Glade.

Presented with the Post/ProPublica analysis, experts said the findings suggest a need to examine health trends and the potential link to cane burning more closely.

"What we do see strongly suggests the need for more intensive, robust research," said Coker, one of three academics who advised The Post and ProPublica on their analysis.

Health officials and academics, with access to additional data, could take steps to incorporate a number of factors, including pollution trends and individual medical history, Coker said.

Sheryl Magzamen, an environmental health and air-quality expert at Colorado State University who also advised The Post/ProPublica on their analysis, said the trend in Belle Glade is "a good indicator that smoke could be a strong hypothesis for why those changes are occurring." She added that though the data doesn't speak to cane burning specifically, it also doesn't rule it out as a factor. NASA recently announced a partnership with Magzamen and academics from six universities across the country to study air pollution and health in the sugar-growing Glades region, an initiative prompted by The Post and ProPublica's reporting.

Presented with the findings, the state and local health departments did not respond.

The Post and ProPublica also shared the findings with the two largest sugar growers in the region, Florida Crystals and U.S. Sugar. Florida Crystals did not comment on the findings. U.S. Sugar challenged the news organizations' analysis and said it was insufficient to draw any conclusions. The analysis, the company said, doesn't take into consideration individual factors like "age, medications and medical history, smoking history and percentage of the population on Medicaid," which are "critical factors when analyzing data."

The state declined to provide the kind of detailed patient information that would allow for such an individual-level analysis, citing federal privacy law. That data is, however, available to health departments and academics.

U.S. Sugar has also pointed to state data on the adolescent asthma rates in sugar-growing Palm Beach, Hendry and Glades counties, which are lower than the state average. A state report from 2013 — the latest "Burden of Asthma" review to be publicly posted on the state Department of Health website — shows just that. Even so, the average asthma rate in Palm Beach County lumps the small agricultural region of 31,000 people into a county with a population of 1.5 million.

The Post/ProPublica finding that there were upticks in respiratory-illness-related hospital visits during cane-burning season in Belle Glade aligns with what many residents, doctors and nurses described to the news organizations.

Dr. Seneca Harberger — a clinician at the C.L. Brumback Clinic in Belle Glade, which is owned by the Palm Beach County Health Care District — said patients often come into the clinic complaining that the smoke is aggravating their breathing problems. (The Health Care District — which also owns the only hospital in the Glades, Lakeside Medical Center — declined to comment.)

"Patients absolutely come probably on a daily basis and say their asthma, their COPD is made worse by the burning," Harberger said. (COPD, or chronic obstructive pulmonary disease, is an inflammatory disease that makes it harder to breathe.) The free clinic regularly doles out nebulizers to patients, many of whom are on government-backed health insurance, he added.

The nebulizers come shaped like cartoon animals for kids.

Peggy Cuyler, 37, owns two — a blue seal and a black-and-white panda. Her 5-year-old son Cash and 6-year-old son David both like the seal. When they have simultaneous asthma attacks, she has to choose who gets the panda.

"I have to be the bad mom that gives one the wrong nebulizer," she said from her Pahokee apartment complex, holding her third son, 6-month-old Goivanni, who was diagnosed with asthma at 2 months old.

Like others in the area, she doesn't let her kids outside during cane season. The reactions are immediate, she said. "It chokes them."

Health Data Analysis Methodology

In the absence of a formal health-risk assessment by state and local health officials, The Palm Beach Post and ProPublica examined seasonal health trends in the Glades using data on hospitalization. Reporters sought guidance from three health and air-quality academics from three universities: Amy Stuart at the University of South Florida, Sheryl Magzamen at Colorado State University, and Eric S. Coker at the University of Florida.

Through a request to the Florida Agency for Health Care Administration, we received data on all hospital inpatient admissions and emergency department visits in Florida between 2011 and 2019.

The state agreed to release data that did not include patient names, but did include information such as the patient's race, gender, age and ZIP code. The data also includes diagnoses associated with the patient admission or visit. Exact admissions and ER visit dates were not included and instead records were grouped by quarter and year.

A 2015 study carried out in Hawaii tracked negative health outcomes — hospital admissions, emergency department visits and prescription fills for acute respiratory illnesses — on days when companies burned sugar cane on the island of Maui. (Hawaii farmers used to produce sugar cane, which included a pre-harvest burning process, but phased out sugar production in 2016.)

Because the data provided for Florida lacked the exact dates of hospital visits, it was difficult to link any hospital admissions or emergency room visits directly to cane burning the way researchers had done in Hawaii. However, academics advised reporters that the available data in Florida could be used for a broader analysis, known as an ecological study. This type of study focuses on groups of people rather than individuals, and it is often the first step in carrying out a detailed health analysis.

Presented with The Post and ProPublica's findings, U.S. Sugar, one of the largest sugar producers in the region, challenged the analysis and said it was insufficient to draw any conclusions from, largely because it doesn't take into consideration factors like patients' "age, medications and medical history, smoking history and percentage of the population on Medicaid," which are "critical factors when analyzing data."

The state, however, declined to provide details like patient identifiers and medical history, which would have allowed for a thorough patient-level analysis, citing the Health Insurance Portability and Accountability Act, a federal law aimed at protecting patient medical information. That data is available to health departments and academics, who could use it to carry out a complex analysis that might link illnesses directly to a specific environmental factor. Experts said our ecological analysis suggests a need to examine the health trends in the Glades further.

Our Analysis

The reporters analyzed hospital inpatient admissions and emergency room visits during burn and non-burn seasons. Florida's sugar cane harvest season begins in October (the first month of Quarter 4) and generally lasts until March (the last month of Quarter 1). Though harvest season has been extended into April and May in the past, a majority of cane burns took place in the first six months of the harvest season in the years we examined, according to burn permit data from the Florida Department of Agriculture and Consumer Services, which oversees agricultural burns.

The analysis focused on the same diagnoses as those examined in the Hawaii study: asthma with exacerbation, acute bronchitis, acute sinusitis, acute pharyngitis including streptococcal pharyngitis, acute conjunctivitis, cough, headache, all pneumonias, and other acute airway problems.

Then, reporters organized the data by patient ZIP code, at the advice of experts. This allowed the news organizations to examine trends among residents, rather than performing an analysis by hospital, which might have included out-of-region visitors or failed to capture patients who sought medical attention outside the area.

Reporters used U.S. Census Bureau population estimates by ZIP code to calculate the crude rate of hospitalization and emergency room visits per 10,000 residents.

The data covered eight harvest years. To summarize the seasonal trends in hospitalizations in each ZIP code, reporters calculated the average visit rate during the seasons when sugar is not burned (Quarters 2 and 3) and during the sugar-burning season (Quarters 4 and 1), then calculated the percentage difference between the two.

Experts advised that there is an expected, natural increase in respiratory illnesses between the summer and winter/spring because of factors including pollen and flu seasons. The key, they said, was to examine whether the increase was more pronounced among Glades patients than patients from comparable areas.

Experts suggested comparing a ZIP code in the Glades region to similar ZIP codes outside the cane-burning Glades region. They also advised avoiding ZIP codes with too few people. The largest ZIP code in the Glades region is 33430, which captures more than 20,000 people, including all of Belle Glade, as well as some unincorporated areas outside city limits.

Ideally, the comparison ZIP codes would be similar in geography (to account for factors like rural and urban pollution) as well as race and income (to account for existing health trends linked to race or income). But the Glades is unique. Because it is the only largely Black community living among field crops in South Florida, it was difficult to find an exact match outside the cane-burning region.

To identify any areas that are similar in population size, racial makeup and income, reporters used data from the 2013-2017 five-year American Community Survey, which falls in the middle of the time period covered by the hospitalization data. In all of South Florida, reporters identified 10 ZIP codes with more than 10,000 people, Black populations larger than 35% (compared to Belle Glade's 56% Black population) and median household incomes below Florida's 2015 low-income threshold of $36,950 (compared to Belle Glade's median household income of about $26,000).

Unlike Belle Glade, these ZIP codes cover largely urban or suburban areas. The percentage increase in hospitalizations and emergency room visits for respiratory illnesses during burn seasons in the Belle Glade ZIP code was higher than the increase in these similar areas.

Percentage change in the average rate of respiratory illness visits between offseasons and burn seasons:

1. Belle Glade (33430): 35%
2. Opa-Locka (33054): 28%
3. Fort Myers (33916): 27%
4. Fort Lauderdale (33313): 23%
5. Fort Lauderdale (33311): 20%
6. Miami (33136): 19%
7. Miami (33147): 19%
8. Miami (33127): 17%
9. Miami (33150): 16%
10. Miami (33142): 16%
11. Miami (33161): 16%