PĀHALA — Kaiwi Perkins keeps her windows closed and her door shut but still the sulfur dioxide creeps in, making it so hard for her to breathe she's now on oxygen almost every day.

Just this year the 74-year-old with a chronic lung condition has gone to the ER at Ka'u Hospital four times on high vog days. "Oh, it's bad," said Perkins, as she sat with friends at Pahala Senior Center. "I stay at home and try to do what they tell me to do. If that don't work, then 911."

For two years now, thousands of residents who live downwind of Kīlauea's Halema'uma'u Crater have been under siege by heavy volcanic emissions, which worsen many lung conditions, force people indoors and often produce vog so thick that it surpasses air quality warning levels.

For many, more difficult still than the voggy present is the uncertain future: What are the long-term health effects of the vog; how can people get relief; and when will the thick vog abate?

With no answers to those questions in sight, some are moving away.

Others are banding together to find strength — and push for more help.

"We're taking a proactive stance," said Jessie Marques, executive director of the Ka'u Rural Health Community Association. "I think the question is ... what do we do to protect our children? The children are subjected to it. They have no place to go. And we must not forget our elders."

The association, along with other community groups, is increasingly calling for more government aid to ensure that vulnerable populations have safe places to go in heavy vog. They are also trying to encourage more study of the long-term health effects of volcanic emissions, while doing their part to tackle other health issues, from smoking to obesity to diabetes.

Marques and others pointed out though the choking vog is often Ka'ū district's most talked about health threat, it is hardly the only one — and probably not the immediate danger for most.

DIFFICULT TIMES

In this southern chunk of the Big Island, sprinkled with small towns, farm land and ranches, families get by on little and pride themselves on their ability to soldier on through difficult times.

The area, with a median household income of $31,500, has the highest poverty levels in the state, according to U.S. Census estimates. About 33 percent of households are under the federal poverty level, while nearly half of households make less than twice the federal poverty level.

Figures compiled by Ka'u Hospital show the district also ranks high in preventable health problems. Nine percent of adults are diabetic and about 24 percent are obese, the statistics show.

Marques said the thick vog — and living in a place where air conditioning is hard to find — make all those health statistics much worse. She noted air purifiers and air conditioners aren't a luxury in Pāhala and other communities downwind of the volcano. "If we don't get these things, it exacerbates our conditions," said Marques, whose association offices aren't air-conditioned.

Kīlauea was the largest source of sulfur dioxide emissions in the nation even before Halema'uma'u Crater, about 18 miles from Pāhala, started spewing 1,000 to 2,000 metric tons daily in early March 2008. If Kīlauea's other active vent is any indication, then the vog isn't stopping anytime soon. The Pu'u 'O'o vent, the longest active eruption in the world, started in 1983.

Volcanologists agree there's just no way to say when Halema'uma'u emissions will let up.

"It may be part of our reality for the foreseeable future. This could do this for the next 100 years," said Donald Thomas, director of the Center for the Study of Active Volcanoes at UH-Hilo.

"That's not welcome news for anyone."

ALTERED MOODS

The prospect of the heavier vog sticking around for years more — or decades — frightens plenty of folks from Ka'ū to Kona. People say the vog doesn't just make it harder to breathe, but affects their moods. One lawmaker even wonders whether it has worsened domestic violence.

State Rep. Bob Herkes, D-5th (Ka'u, S. Kona), said the psychological impacts of the vog shouldn't be written off, especially if you consider that the emissions might be sticking around for quite some time. He says enough isn't being done to look at any of the health impacts of vog.

"We have to be cognizant of the ongoing effects," he said.

Hawai'i County Councilman Kelly Greenwell, who represents North Kona, said his district should be used to vog. It's seen grayer skies since the Pu'u 'O'o vent went off. But two years ago, when Halema'uma'u started spewing tons of emissions, Kona saw even heavier vog and more vog days. "Since then, there are periods of time where ... you can barely see," he said. "You can't see the horizon from the shore. That has a dramatic impact on how people relate to each other."

Greenwell says there's "a gloominess" in the air when the vog is thick.

On days with blue sky, "you can recognize the difference within yourself."

Greenwell, 69, a lifelong Kona resident, shudders at the thought of the thicker vog sticking around for the rest of his lifetime. Or through another generation. "I don't think you ever get used to it," he said, adding that people have also resigned themselves that the vog is there to stay.

"I don't know that there's any recovery in sight."

TASTING SULFUR

In Wood Valley, a small farming community above Pāhala, the vog is often so thick that residents taste sulfur in the air. Some have moved away because of it. Those who stay say they're doing just about the only thing they can: Getting by and hoping that conditions improve.

"You just pretty much go by nature's schedule," said Martin Wallace, 54, as he tended his garden on a voggy morning. Wallace, who moved to Wood Valley last year from Puna, said that the vog leaves him feeling under the weather, with burning eyes and a scratchy throat.

But, for now, he isn't going anywhere.

"You deal with it," he said.

Stanley Mizuno, 64, lost his entire flower business because of the vog.

But he remains at his family home in Wood Valley, living out an earlier-than-planned retirement and waiting for the vog to let up. "It has really affected us. You can't go out," he said.

"We believe it will have some effect long term."

Studies on the health effects of vog have largely proven inconclusive, though short-term impacts are apparent. They include everything from trouble breathing to getting sick more often.

Sen. Josh Green, D-3rd (Kohala, Kona, Ka'ū), who is a doctor and regularly sees patients in Ka'ū, said that since there's no turning the vog off, it's crucial people take precautions to protect themselves in heavy vog, especially since it's not stopping. That means going indoors during high vog events, knowing when to seek help and being aware of when vog levels are very high.

"I don't want people to be told to move," he said.