Community Health Assessment Project

Pilot Study

 

 

 

 

 

Final Report to:

Nevada Agency for Nuclear Projects,

Nuclear Waste Projects Office

 


Community Health Assessment Project

Pilot Study

 

 

 

 

A Final Report to

 

Nevada Agency for Nuclear Projects,

Nuclear Waste Projects Office

 

By

 

Marie I. Boutte, Ph.D. (P.I.)

Medical Anthropologist

Department of Anthropology (096)

University of Nevada, Reno

Reno, Nevada 89512

 

And

 

Judy Conger Calder, Ed.D. (Co-P.I.)

Director, Center for Applied Research (088)

Associate Professor, Human Development and Family Studies

University of Nevada, Reno

Reno, Nevada 89557

 

 

Report Released 28 September 2000

 


PILOT STUDY: YUCCA MOUNTAIN HEALTH IMPACTS

                                                               FINAL REPORT

Purpose of Yucca Mountain Health Impacts Project

            The proposed Yucca Mountain high-level radioactive waste repository has the potential to expose citizens of Nevada to sources of ionizing radiation. Such exposures could occur as a result of routine transportation of radioactive materials through communities or because of accidents in the course of such transportation. Radiation exposures could also result from the migration of radionuclides from the repository, either through the groundwater or the air.

            An important part of the State of Nevada’s scientific oversight of the Yucca Mountain program is to establish mechanisms capable of identifying radiation exposures when and if they occur. A crucial component in this effort is the targeted monitoring of community health indicators so that health manifestations of radiation exposures can be readily identified and addressed. To do this, it is imperative that baseline health data be collected, maintained, and analyzed for potentially affected communities.

            The purpose of the overall Yucca Mountain Health Effects Study is to establish baseline health data for communities likely to be impacted by the Yucca Mountain Project, specifically the transportation and storage of spent nuclear reactor fuel and high-level nuclear waste in the state of Nevada. This will be accomplished through two stages of research: a Pilot Study of one community and then investigation of other communities after pilot study analysis. This report discusses the scope of work carried out in the Pilot Study. The principle investigator (PI) was Dr.

Marie Boutté, a medical anthropologist at the University of Nevada, Reno; co-investigator was Dr. Judy Calder, Director of the Senator Alan Bible Center for Applied Research, University of Nevada, Reno.

Purpose of Pilot Study

            The purpose of the Pilot Study was to develop and field test a household health survey questionnaire for collection of baseline health data in a community located in close proximity to Yucca Mountain or along a potential transportation route. In addition, results provided a first look at some descriptive epidemiology of the community that will be used to guide the design of future health surveys. The sample size in the pilot study was meant to be small (35 households) due to limited budget and field time and there was no attempt to use comparative control groups, nor to establish any cause and effect parameters.  The Pilot Study, titled the Community Health Assessment Project (CHAP), was carried out in three funding phases. During Phase I, the health survey questionnaire was developed and laboratory tested, and a research protocol was submitted to the Social Behavioral Human Subjects Committee at the University of Nevada, Reno. The questionnaire was field tested in Caliente, NV during Phase II; and the data were analyzed and the overall Pilot Project evaluated during Phase III.

                                                           Pilot Study: Phase One

            Step one:  item selection and construction.  The original health survey form was drawn from Legator and Strawn’s environmental health questionnaire published in Chemical Alert: A Community Action Handbook[1]. The first revision of the questionnaire focused primarily on the re-arranging of survey categories and inclusion of questions related to radiation exposure. This revision resulted from a survey conducted among students enrolled in a course in Medical Anthropology at the University of Nevada, Reno, taught by the Principle Investigator.

Step two:  questionnaire testing, revision, and construction.  The questionnaire was forwarded to the Senator Alan Bible Center for Applied Research and the list of questions was given to a team of graduate research assistants, supervisors and interviewers for cognitive lab testing.  Next, surveys were conducted by telephone with a randomly selected group of households.  The reviewers tested the instrument for flow, readability and comprehension, as well as logic with regard to the survey objectives.  Cognitive lab testing revealed the need for standardized definitions of key words that respondents might not understand during the interviewing process.  Based on this cognitive lab testing, three primary modifications were made to the instrument:  (1) questions were moved to different sections to enhance flow; (2) the wording of questions and their response codes were modified to insure that questions consisted of “neutral” (non-“leading”) stems and response categories; and (3) language was standardized to prevent respondent misinterpretation of questions.  After each lab testing process, a meeting with the Principal Investigator was held to review and make decisions on formatting changes and/or question revisions.  After three lab tests of the modified instrument, the questionnaire was finalized and an optically scannable version of the instrument was created using Teleform Software. 

The last phase of the design process included a creation of a survey codebook for individual instruments that provided a standardized list of codes used and recognized by the scannable version of the (TeleForm) survey instrument.  A final meeting with the data collection team for the Caliente pre-test was held to compare each question against its corresponding response codes.  The data collection staff made suggestions regarding coding issues, final revisions were made, and the instrument was ready for in-person interviews in the field.

            The instrument.  The pilot questionnaire was extensive and included a variety of  sections: (1) general household environment;  (2) an enumeration and description of family members, including a health profile of all adults; (3) toxic exposure history, followed by occupational history, and lifestyle profile;  (4) reproductive history of all adult women; and (5) a health profile of all children in the household.  The time required for administering the questionnaire varied, depending on the number of adults in the household, as well as the complexity of the health profile of each individual in the household.  In general, it took approximately 30 minutes to interview one adult, and up to 4 hours or more for large families or for families with multiple health problems.

Pilot Study: Phase Two

Criteria for Community Selection: Caliente, Lincoln County, NV

            In 1994, over a period of approximately one month, the Principle Investigator carried out preliminary fieldwork in nine Nevada communities proximate to Yucca Mountain or communities likely to be on transportation routes for high-level nuclear waste to Yucca Mountain. These communities were: Indian Springs, Pahrump, Amargosa Valley, Beatty, Caliente, Panaca, Pioche, Alamo, and Mesquite. A number of questions were used as an assessment framework in selecting one of these communities for the pilot study. For example, how was the community likely to be impacted by the Yucca Mountain Project? What had been the community’s past history of exposure to hazardous waste, radiation, and other forms of environmental pollution? Was there support by community leaders such as town council members and county commissioners for such a project? How homogeneous or heterogeneous was the community in terms of demographic parameters? Given the distribution of households within the community, how many households could be surveyed within a four to six week period of time? Was housing or some type of lodging available for research staff? 

            The township of Caliente seemed best suited for a pilot study because it satisfied most of the questions, which framed the assessment. Caliente is located in Lincoln County, a county designated by the federal government as one of the “affected units of government” with regard to storage of high level nuclear waste at Yucca Mountain. The town is located on potential transportation routes for high-level nuclear waste to Yucca Mountain. In fact, the town is bisected by a very busy railroad line and by U.S. Highway 93 which is a busy corridor used for movement of goods by truck and by seasonal vacationers traveling north and south. There is also the possibility that Caliente may serve as an intermodal transfer station for nuclear waste en route to Yucca Mountain. In addition, the community is located “downwind” from the Nevada Test Site and was exposed to nuclear fallout during the era of weapons testing, especially the era of atmospheric testing. Because of this exposure, selected residents over the years have been subjects in the thyroid study carried out over the years by investigators from the University of Utah. Lincoln County residents are also eligible for compensation under the Radiation Exposure Compensation Act if they meet the specified criteria. Caliente is relatively homogenous, especially with regard to ethnic groups, and the town is well laid out (for research purposes) in terms of the close proximity of its streets and dwellings.  Finally, the Caliente City Council and Lincoln County Commissioners were supportive of the Pilot Project and housing was available for the research staff. (A more general medical ethnography of Lincoln County and Caliente was carried out in 1995 and a final report was submitted to the Nuclear Waste Projects Office in December 1995.)

Field Methods

           The Pilot Study was carried out during January and May 2000 by the Principle Investigator (Dr. Marie Boutté) and a research assistant (Barbra Erickson, Doctoral Candidate in Medical Anthropology at UNR). The first step was to select the best method for random sampling, and the Caliente Utilities Customer List (dated November 9, 1999) was the chosen tool as it is the most inclusive list of Caliente resident addresses available. After obtaining approval from the Caliente City Hall staff, the Caliente Utilities Customer List was secured, each of the 792 listed addresses was numbered sequentially, and a total of 105 addresses (50 in January and 55 in May) were drawn by using a random number table[2]. The goal was to have a total research sample of 35 households, and 33 household surveys were completed within the fieldwork period. Each of the 105 addresses was thoroughly investigated to obtain the final sample size in that multiple visits were made to verify address and contact residents. When necessary, at least four contact attempts were made during day, evening, and weekends at each resident address, including speaking with neighbors, to verify household occupancy and to solicit participation in the research. From the 105 addresses drawn, the following results were obtained: 

Final results were as follows:

Methods for Soliciting Participation

            As indicated previously, the Principle Investigator had spent considerable time since 1994 in the township of Caliente before initiating the pilot project entitled the “Community Health Assessment Project.”  In 1995 for example, the PI had rented an apartment for approximately six weeks and used standard anthropological techniques of participation-observation and informal interviews to do a general medical ethnography of the community. Multiple shorter visits were made from 1995 to 2000 for research on other topics and to attend various meetings related to research topics. These contacts with the general community helped to establish rapport and trust that was deemed essential in carrying out the pilot project.

             In order to initiate the current pilot project, a formal presentation was made to the Joint City/County Nuclear Waste Impacts Alleviation Committee and letters of support were solicited and received from this Committee, as well as from the Caliente City Council and the Lincoln County Board of Commissioners. The PI and her research assistant introduced themselves during a meeting of the County Commissioners early in the fieldwork phase. It became evident early in the fieldwork that senior residents in the community were the most reluctant to participate in the survey, and thus a formal presentation was given at the Senior Center, and the field investigators had lunch at the Center several times and informally talked about the project. In addition, key seniors were asked to introduce the P.I. and her assistant to other seniors.

            The most successful strategy for soliciting participation was direct, personal solicitation by field investigators. This entailed knocking on the doors of selected households, presenting business cards with university logos, and briefly describing the purpose of our contact, as well as how their household had been selected. We asked for 5 to 10 minutes of each resident’s time, and if the resident agreed, we then sat and described the project in greater detail, using an “Introduction Script” approved by UNR’s Social Behavioral Human Subjects Committee. The majority of residents who completed the survey reported that this personal contact was a major reason for their participation.

            From the results of the fieldwork in January, it was determined that appointment cards would help facilitate success, and so in May bright yellow refrigerator magnets with appointment information were given to each household; each household was also phoned, when possible, in order to confirm appointments. We also posted fliers announcing the project in key locations throughout the community, and the PI wrote an article for the Lincoln County Record, which appeared a week before fieldwork in May describing the project. All of these strategies helped to increase our response rate.

Challenges and Problems Encountered During Fieldwork Phase

Two major challenges encountered during the fieldwork phase included:  (1) finding the actual location of the randomly selected addresses; and (2) verifying resident occupancy once these addresses were located.

            Investigators discovered early in the fieldwork phase that some streets were not identified on maps or on signposts, and several different streets had the same name.  In addition, many dwelling units did not have address numbers posted, and, in many instances, dwellings located next to one another had not been assigned addresses in any sequential order.  Therefore, the researchers were unable to determine correct address locations simply by counting, starting from a known address, a specific number of homes past the known address.   Instead, they often had to knock on several doors in the hopes of finding someone who would know the actual location of the address that had been randomly selected.

The verification of resident occupancy was also quite difficult because Caliente has more seasonal and weekend-use housing than researchers had expected, and considerable time was spent determining this status. The researchers also had to ascertain whether some homes were abandoned. In addition, particular residents were difficult to contact, including those who had dogs enclosed in yard fencing and those who had posted “No Trespassing” and “Keep Out” signs.  However, the researchers were often able to secure the cooperation of these residents by visiting their fence lines repeatedly until contact was made.

Since the investigators were very visible within the community, many residents requested to be involved in the study who were not eligible. That is, their households had not been drawn in the random sampling. Considerable time was spent with these individuals explaining the purpose of the pilot study and why they were not eligible for participation. Several of these individuals were long-term Lincoln County residents and they generally expressed concern over potential radiation exposures from past weapons testing at the Nevada Test Site and thought they should therefore be a focus of our study. Investigators felt time was well spent with these individuals as a means of increasing rapport within the community and for a higher “buy-in” factor should further studies be conducted.

On several occasions before proper identification could be made, investigators were assumed to be from Child Protective Services, or religious solicitors, or census takers. This was a valid concern since representatives from all three groups were also in the community making household calls. However, the formal presentations, fliers, and news article about the Community Health Assessment Project helped in overcoming this challenge as the fieldwork progressed. In addition, introducing the project to the managers of the subsidized apartment complex and the trailer park was beneficial as they sometimes acted as our spokesperson.  We were most often misidentified as Child Protective Services in the low-income housing complex and trailer park. 

Another major challenge in the field had to do with the political climate of the community.  Researchers encountered residents both for and against the transportation and storage of nuclear waste, a long-term political issue in the county and state.  Occasionally, people suspected us of being “minions of the government,” or as representing one side or the other in this political debate.  We were often put on the spot during our formal interviews and in the general community as to our personal ideas and beliefs concerning this issue.  We consistently maintained a neutral attitude and always attempted to refocus the discussion back to the purpose of the pilot study; political awareness was essential to the successful conduct of our fieldwork.

The project required detailed record keeping based on the necessity of maintaining the standards associated with carrying out a random sampling protocol.  This required use to seek out the locations of the houses with the randomly selected addresses as well as determining which of these addresses represented eligible households.  This protocol also required us to record the times and dates of repeated visits to each randomly selected housing unit, especially since the fieldwork phase was divided into two time periods. It was essential to have two researchers crosscheck all details in order to avoid potential errors. On several occasions it was also necessary to have two researchers available in order to reduce the length of time required for interviewing, particularly when households were composed of many adults in the same residence.  

                                                         Pilot Study: Phase Three

Descriptive Data and Results

Most simply put, the most important objective of the present pilot study was to pretest the interview instrument and, as a bi-product of this pretest/pilot study, to provide a straightforward profile of the health status of the small random sample of Caliente residents included in this study. This pilot study is designed as an initial step toward the long-range goal of establishing baseline health data for communities located near, or en route to, Yucca Mountain.  This information is essential to describing the impact of projects such as the proposed high-level nuclear waste depository on residents’ health. 

            The data in this report are based on interviews with 50 Caliente adults who resided in 33 individual households.  Due to the small sample size, none of the reported comparisons have been assessed for statistical significance.  We include prevalence rates (percentages) to simplify comparisons between groups; however, sub-categories, such as age groups, will contain even smaller sample sizes.  Values noted in parentheses reflect the actual number of respondents determining the percentage, unless otherwise noted.  Our purpose is not to provide an exhaustive epidemiological treatise. We do, however, include a basic description of the conditions found in this small randomly selected sample of Caliente households, and do so in the finest tradition of an environmental scan.

Sample Characteristics

Individual and household demographics.  A total of 50 individuals from 33 households were surveyed, including 22 males and 28 females.  The age of respondents ranged from 20 to 88, with a median age of 49.5 years. Nearly half of all adults in the sample (44% or 22) have had some college education, 4% (2) graduated from college, and 38% (19) completed their educational career with a GED or High School diploma.  Seven respondents (14%) did not finish high school.

Of the 33 heads of household surveyed, 97% (32) are White and 3% (1) are Hispanic.  Total household income for 27% (9) of households sampled is less than $10,000 per year; 24% (8) earn $10-$20,000 each year; 9% (3) receive $20-$30,000 per year; 15% (5) earn $30-$50,000 and 12% (4) earn more than $50,000.  Four respondents (12%) refused to disclose their total household income. 

Over half of the heads of household (55% or 18) were born in the area, and for 17 of these people, two or more generations of relatives have lived in the area.

Religious affiliation for the heads of household is as follows: 15% (5) are Catholic, 36% (12) are Protestant, 33% (11) are Latter Day Saints (LDS), and (2) report another religious affiliation.  One respondent is a non-practicing LDS, and 2 report no religious affiliation.

Family composition and housing.  In the Caliente sample of households, 39% (13) are families with children living at home, and of these families, 62% (8) have both parents living in the household.  Twenty-four percent (8) of families are composed of couples without children living in the home (both retired with grown children or childless couples), and 36% (12) are composed of single adults (widowed, single, or no live-in partner) without children in the household.  Finally, 67% (22) of families surveyed live in single-family dwellings, 24% (8) live in an apartment, condo or duplex housing, and 9% (3) live in a trailer or RV camper. 

Health Conditions

            Respondents were asked to indicate, from an exhaustive list of health conditions, if and when a specified condition was recognized and diagnosed (if applicable), as well as whether there a family history of particular health problems existed.  The health conditions that are most prevalent in this sample are highlighted below. Conditions that are low in prevalence, when compared to state- or nationwide rates, are also described.  Tables presenting more comprehensive health data (including family history and individual data), as well as a list of all health conditions included in the survey, can be found in the appendix.

            Lung conditions.  Twenty-six percent (13) of respondents report having been diagnosed with pneumonia at least once in their lives, and 5 of the 7 adults aged 50-64 years of age who report having had pneumonia developed the illness within the past 5 years. Only 1 respondent has a current diagnosis of lung cancer, and there are no reports of emphysema.  It should be noted that 34% (17) of respondents are current smokers, which is slightly above the statewide rate of 29%[3], and only 4 of the people in this group are over 65 years of age.  Some respondents commented that their spouses had died of lung and other cancers.  Thus, the small incidence of lung disease and other lung conditions in this sample may be due to high mortality already caused by smoking.

            Cardiovascular System.  In 1997, almost one-half of Nevadan adults over age 65 reported having high blood pressure[4].  In the Caliente survey, 40% (6) of respondents 65 and older indicate that they have been diagnosed with hypertension, and 30% (15) of the entire sample report a high blood pressure diagnosis. Of those diagnosed, 53% (8) have a family history of hypertension, 53% (8) are between the ages of 50 and 64, and 100% (6) of the women between 50 and 64 years of age report being hypertensive. 

High cholesterol and subsequent hardening of the arteries (atherosclerosis) are common causes of heart attacks, and heart disease is a leading cause of death for men and women over 45 in the United States[5]. Only 2 respondents report high cholesterol levels, only 1 reports being diagnosed with heart disease, and no respondents report being diagnosed with atherosclerosis.  The small percentage of reports of high cholesterol levels is likely due to two factors.  First, respondents were not asked about cholesterol levels specifically; the two reports of high cholesterol levels were offered in response to an open-ended item assessing “other heart condition.”  Second, it is quite probable that most respondents to this survey have never had a cholesterol screening and therefore would be unaware of the presence of high cholesterol levels. This is based on the fact that in 1997, for example, nearly 1 out of 3 Nevadans had never had a cholesterol screening[6].  The low incidence of atherosclerosis and heart disease may again be due to the high mortality associated with the development of these conditions.

Blood.  There are few reports of blood conditions.  The most common disorder in this sample is anemia, with 14% (7) of respondents reporting a diagnosis at some time in their lives.  Six females report an anemia diagnosis, and only 1 male has been diagnosed with this blood disorder.

Digestive System.  Over 60 million adults in the United States experience heartburn at least once a month, and approximately 25 million American adults report having heartburn every day[7].  It is not surprising, then, that chronic indigestion is the most frequently cited digestive condition in the Caliente sample, with 18% (7) of adults documenting its occurrence.  The majority (31%) of this group is between the ages of 35 and 49.

Frequent constipation is the next most often cited digestive problem.  Ten percent (5) of the respondents report experiencing the condition, and 4 out of the 5 in this group are female.  Only 4% (2) of respondents report ever experiencing frequent diarrhea.

Urinary Tract.  In 1996, more than 35 million Americans (13% of the total population) were inflicted with some form of bladder disease[8].  In the present survey, 18% (9) of respondents report having been diagnosed with a bladder disease sometime in their lives and twice as many females (6) as males (3) have had a bladder disease.  Two out of the 9 females (22%) age 18-34 have been diagnosed with a bladder disease. 

In addition, 14% (7) of the total sample report being diagnosed with a kidney condition, including kidney stones.  No other urinary tract conditions were cited frequently.

Endocrine/glandular.  According to the National Institutes of Health, in 1999 there were 10.6 million people (approximately 4% of the population) in the United States who had been diagnosed with diabetes.  In the Caliente sample, 6% (3) of the adult sample has a current diagnosis of diabetes and all are between the ages of 35 and 64.  It is important to note that the prevalence of diagnosed diabetes among United States adults has increased by 33 percent between 1990 and 1998[9].  It will be especially important to consider this general increase in diagnoses when assessing changes in health conditions over time for communities in the Yucca Mountain area[10].  In addition to diabetes, 6% (3) report having a thyroid condition, and 8% (4) have been diagnosed as being hypoglycemic sometime in their lives.

Skin.  Twenty-percent (10) of respondents report that they have experienced spontaneous or easy bruising of the skin, with only 2 of these respondents ever having been diagnosed with anemia. Because the prevalence of spontaneous or easy bruising in this sample appears to be exceptionally high, future surveys might address other conditions that are of increased concern when they are comorbid with spontaneous bruising, such as spontaneous nosebleeds, bleeding gums, or bleeding into joints.  Blood in the urine or stool may also accompany spontaneous bruising when clotting disorders are present, but only 1 respondent who reported spontaneous or easy bruising also indicted ever having blood in the urine.

Immune System.  Seasonal allergic rhinitis, or hay fever, is the most common allergy in the United States.  Not surprisingly, 38% (19) of Caliente respondents report experiencing the symptoms of hay fever, although only 8% (4) report actually being diagnosed with the allergy by a doctor.  Asthma has been diagnosed for 14% (7) of adult respondents, with 3 adult males and 4 adult females indicating the condition.  This is well above the nationwide rate of 5%[11].  More than a few residents in the sample have experienced one other symptom of compromised immune functioning: 10% (5) report they have had frequent colds or infections, and the majority (4), as with hay fever, are between 35 and 49 years of age.

Head and neck.  Of all adults in the sample, 20% (10) have been diagnosed with sinus troubles or infections, and most in this group are females (8).

The most frequently cited problem associated with dental conditions relates to tooth loss:  10% (5) of adults report experiencing excessive tooth loss, and 4 of these are women over 50.  With regard to eye health, 60% (30) of respondents are wearing some kind of corrective lenses, and 12% (6) report having cataracts.  It is of interest to note that although diabetes is a leading cause of cataracts (second only to age), only 1 adult in the sample of 4 with diabetes has been diagnosed with cataracts.

Nervous system.  One in 11 people  (or 9%) will experience a seizure at some point in their lives[12], and in fact, 8% (4) of respondents in Caliente, NV report experiencing a seizure.  Other conditions related to the nervous system that are more frequently cited by this sample include: frequent headaches, experienced by 16% (8) of adults; weakness or fatigue, reported by 10% (5) of respondents; tremors, cramps or spasms at some point by 8% (4); and difficulty sleeping by 14% (7).  Six of the 7 respondents who report having had trouble sleeping also report experiencing depression; however, only 3 respondents have actually been diagnosed as being clinically depressed.

Muscles and bones.  In this sample of respondents, nearly one-quarter (24% or 12) have been diagnosed with some form of arthritis in comparison to the estimated 15% prevalence rate[13] for the country. In addition, 16% (8) of respondents without arthritis report experiencing stiffness in the joints, 32% (16) have had broken bones of some sort, and 32% (16) have had some kind of limb pain or leg cramping.  These symptoms will be especially important to monitor in the future – exposure to low doses of radiation frequently results in deterioration of bone strength and muscle or bone pain[14].

Female Reproductive System.  Exactly 25% (7) of females in the Caliente sample have had a hysterectomy.  An important point to note is that the instrument does not contain a question addressing whether or not women have had this surgical procedure; women offered this information in response to other items.  Because this procedure is quite common among the Caliente sample of females, future surveys might ask about it explicitly and obtain more information regarding the reason for the hysterectomy.

Of the 28 women surveyed, 29% (8) report experiencing irregular menstrual periods sometime in their lives, 18% (5) have, or have had, disorders of the uterus, and 11% (3) have experienced disorders of the ovaries.  Only 1 respondent reports ever having a venereal disease and only 1 reports a diagnosis of infertility. No respondent reports ever being told she is sterile.  It should be noted that the terms “sterility” and “infertility” are often used synonymously; however, the precise definitions do have subtle differences.  Infertility often refers to the inability to conceive after one year of unprotected intercourse and some also use the term to refer to recurrent miscarriage, as well as the inability to conceive again after one successful conception (known as secondary infertility).  Sterility refers to the complete inability to sexually reproduce[15]. To obtain accurate population estimates of reproductive conditions, the terminology and associated definitions should be standardized and communicated to respondents in future surveys.

Male reproductive system.  Males in this sample report virtually no incidence of conditions relating to the reproductive system, including sterility, abnormal sperm count, impotence (erectile dysfunction), or any venereal disease at any time in their lives.  It is very likely that this sample has underreported the incidence of conditions associated with the male reproductive system.  For instance, the National Institutes of Health points out that an under-diagnosis of erectile dysfunction exists due to patients’ embarrassment and the reluctance of both patients and health care providers to discuss sexual matters candidly[16], and this is probably the case for other related conditions as well.  In addition, even if a respondent has been diagnosed with a disorder of the reproductive system, it is likely he may have been hesitant to discuss the condition with his female interviewer.

Cancers.  The prevalence rate for cancer or pre-cancerous states in the Caliente sample is 14% (7), with 1 respondent diagnosed with multiple cancers.  More than twice as many respondents, or 32% (16), had at least one parent or grandparent who has, or has had, some kind of cancer.  In this sample, only 1 respondent who has been diagnosed with active cancer, and 1 other respondent who had a pre-cancerous condition, have this family history of cancer.  The table below delineates the cancers developed by respondents in the Caliente sample.  These data unfortunately do not reflect the numbers of former members of the households who died as a result of cancer.  Future surveys might assess mortality rates due to cancer in the communities located near Yucca Mountain.

Type of Cancer

Number of Respondents Reporting Type

Age of Diagnosis

Gender

Pre-cancer cervix

1

23

Female

Lung

1

63

Female

Prostate

1

63

Male

Skin

3

59, 58, 74

Male, Female, Female

Stomach

1

56

Male

Throat

1

64

Male

 

Women’s reproductive history.    Twenty-five out of the 28 females interviewed have given birth to at least one child in their lives, and a total of 81 babies have been born to these females. Females in this sample reported a total of 98 pregnancies.  Women were also asked to provide information about their overall reproductive history, including each of their pregnancies, the outcome of each pregnancy, any conditions their babies experienced at birth or shortly thereafter, and whether their newborns required any extra time in the hospital after delivery.  Percentages in the remainder of this section refer either to the proportion of women responding (i.e., % of 28), the proportion of pregnancies (% of 98), or to the proportion of live births (% of 81) where specified.

In the Caliente sample of females, 25% (7) have seen a doctor at some point because they had trouble conceiving or carrying their pregnancies to term, and in the end, all of the women in this group bore children.  Of the 98 pregnancies reported, slightly more than 17% (17) resulted in miscarriage, and 1 woman experienced a tubal pregnancy.  One infant died 17 hours after delivery.

The most common condition reported for the Caliente sample of infants is jaundice, with almost 14% (11) having experienced this condition.  Nearly 9% (7) of newborns had a low birth weight, and 5% (4) had experienced lung problems (e.g. difficulty breathing or lungs not fully inflated).  These and other conditions, including one infant with extreme cleft palate complications, required 16% (13) of newborns to spend extra time in the hospital after delivery.  According to the Center for Disease Control’s 1998 estimates, the average length of stay for an infant with at least one illness or risk-related diagnosis was 5.1 days, and the average length of stay for all newborn infants was 3.2.  In 1998, the CDC reports that 12.3% of newborns had hospital stays of 4 days or longer. The infants assessed in this survey appear to have had a much greater need for lengthier hospital stays following delivery than the average US newborn.

Other conditions at birth or shortly thereafter that are reported for infants in this sample include: 1 infant having problems with extremities, 1 having an eye abnormality, 1 experiencing a lip abnormality, and 1 with a gum abnormality. A list of all conditions experienced at birth or shortly after that were included in the survey can be found in the Appendix.

Children’s health.  The Caliente survey resulted in health profiles for a total of 33 children currently living within 12 households; health data for the only child living in one household was not obtained because she was a newborn.  A child’s health profile was assessed only if he or she was currently living in the household.  Children included in the sample range in age from less than 1 year old to 20 years of age, and 64% (21) of this group are male and 36% (12) are female.

Overall, most children’s health is perceived by their parents to be “very good” or “excellent” (81% or 27 children).  Two children in two different households in the sample were given a rating of “fair” for their health status.  According to their parents, these same 2 children appear to be less healthy than other children their own age, and were characterized as being limited in terms of being able to do what they want to do because of their less than optimal health status.

Risk Behaviors:  Tobacco, Alcohol and Drug Use

            The overall objective of this and future research is to paint an accurate picture of the health effects of the proposed Yucca Mountain Project.  In this context, is important to assess the prevalence of behaviors related to health risk that could moderate or mediate relationships between radiation exposure and specific health outcomes.  These data are important because they have the potential to influence health outcomes in and of themselves, unrelated to the extent and degree of radiation exposure that has occurred.  For these reasons, respondents in the Caliente sample were asked to report on their current use of tobacco, alcohol and recreational drugs.

Tobacco use.  In 1998, 33% of males and 28% of females in Nevada were current smokers[17].  The prevalence of smoking by Caliente males is considerably higher than the statewide rate.  Of the 22 males surveyed, 41% (9) currently smoke cigarettes compared to the 1998 statewide rate of 33%.  Only one respondent reports using chewing tobacco, and no one reports being a current cigar or pipe smoker.  The smoking prevalence rate for females is almost identical to the 1998 statewide rate, with 29% (8) of Caliente females currently smoking cigarettes.  The majority of smokers in Caliente are between the ages of 18 and 49.

Alcohol use.  Among the Caliente residents surveyed, 32% report that they currently drink alcohol.  The definition of a chronic drinker according to the Centers for Disease Control (CDC) is any individual who has on average 60 or more drinks per month[18].  Based on this criterion, 6% (3) of those who consume alcohol in the Caliente sample are chronic drinkers, which is just slightly above the statewide estimate of 5.7%[19], and all are males over the age of 65.

Recreational drug use.  Overall drug use in the Caliente sample is quite low.  Only 14% (7) report ever smoking marijuana, and none do so regularly.  Only 1 female respondent uses amphetamines, and no other respondents, male or female, report having ever used this stimulant.  In addition, no respondent reports having ever used heroine, opiates, barbiturates, sedatives, cocaine, crack cocaine, hallucinogens, or inhalants.  It is fair to characterize this Caliente sample as practically a non-(recreational) drug-using group.

Environment, Radiation Exposure and Health Conditions

            There is a wealth of information regarding the health effects of radiation exposure.  This includes research data from a variety of nuclear disasters, including Chernobyl, as well as data from the on-going surveillance of the citizens of Nagasaki and Hiroshima who were exposed to the fallout from the bombs dropped on these cities at the end of WWII.  Data regarding the health effects of atmospheric testing of nuclear weapons raise important issues for policy makers to consider.  In this context, a variety of conditions associated with radiation exposure are assessed by the Caliente survey with the intent of being able to make comparisons with the outcome of future surveys designed to assess the impact on residents’ health of the proposed high level nuclear waste repository at Yucca Mountain.  This will not be possible unless baseline data are collected prior to the beginning of the operation of proposed nuclear waste repository at Yucca Mountain.

            Between the years of 1951 and 1963, the U.S. government engaged in aboveground testing of nuclear weapons.  Twenty-six percent (13) of the Caliente residents surveyed lived in the area during the atmospheric nuclear testing, and some comment that they observed this testing directly.  Some witnessed the mushroom clouds that formed after detonation of bombs, and one man commented that one day while he and other workers were riding the bus to a jobsite near the testing grounds, they had to pull to the side of the road and hide behind the bus for protection.  The workers felt the heat from the nuclear explosion. Because of the exposure that some of these residents had to radiation from this testing, data are presented addressing the prevalence of conditions among those who lived in the area during the years of aboveground testing. 

Based on a question assessing radiation exposure, 42% (21) of the Caliente sample believe they have been exposed to fallout radiation at some time during their lives, either from living in the Caliente area, living downwind from testing sites, or being in other locations where nuclear fallout occurred.  Two individuals, one male and one female from different households, who lived in Caliente between 1951 and 1963 don’t believe they have ever been exposed to radiation fallout.

            Cancers.  Of all the health effects of radiation, cancer has probably received the most attention by researchers[20].  Cancer prevalence among the Caliente residents surveyed is shown in the graph to the right.  More than half (57%) of those currently living with a cancer diagnosis (4 of 7) report having been exposed to radiation fallout.  Two of the individuals who report having a cancer diagnosis lived in Caliente during atmospheric testing of nuclear bombs between 1951 and 1963.  Both of these individuals are diagnosed with skin cancer, one of whom is a 58-year-old female, and the other is a 70-year-old male.  A third individual, a male with a diagnosis of prostate cancer, lived in Enterprise, Utah most of his life in a location downwind from the testing occurring in that state. Another male who was not in Caliente during testing, worked near the testing site in another part of the state, and is diagnosed with stomach cancer.

Thyroid.  Iodine-131, a type of radiation that Nevadans were exposed to during aboveground testing, concentrates in the thyroid gland.  Researchers studying individuals who were downwind from the nuclear testing in Nevada and Utah concluded that the radioactive iodine exposure most likely caused anywhere between 1 and 12 of the 19 cases of thyroid growths among 2,500 people sampled[21].  In the Caliente sample, 2 out of the 3 people diagnosed with a thyroid condition lived in Caliente during nuclear testing in Nevada.

Nervous system.   Even small doses of radiation can impact the nervous system and cardiovascular control may be affected due to disturbances in the peripheral nervous system, making radiation exposure a risk factor for atherosclerosis, hypertension and ischemia[22].  Although none of 13 respondents living in Caliente during nuclear testing are diagnosed with atherosclerosis, 54% (7) have a current diagnosis of hypertension, and 5 of the 8 people (or 63%) age 50 – 64 who have a diagnosis of high blood pressure lived in the area between 1951 and 1963 when aboveground testing occurred.  Two other respondents diagnosed with hypertension report being exposed to radiation fallout, although not while in the Caliente area.

Reproduction effects.  Following the Chernobyl disaster in 1986, researchers began examining the health effects of radiation exposure related to reproduction.  These effects include reduction in birth rates, increase in complications during pregnancy and birth, increase in infant mortality, and anomalies in infant development among persons living in the Ukraine and other contaminated territories[23]. These effects/conditions can occur as a consequence of genetic mutation in either the mother or father as a result of radiation exposure. 

In the present survey, 53% (9) of the 17 miscarriages were experienced by women who either themselves (7) or the father of the child (2) lived in Caliente during the aboveground nuclear testing, and 57% (4 out of 7) of infants with a low birth weight had at least one parent who lived in the area during that time; the 1 reported tubal pregnancy was experienced by a woman who lived in Caliente between 1951 and 1963 and who believes she was exposed to radiation fallout.  Of the 18 pregnancies not carried to term, either due to miscarriage (17) or tubal pregnancy (1), 94% (17) were the offspring of a mother (14) or father (3) who reported having been exposed to fallout radiation.

Of women who had lived in the area during nuclear testing, or who were trying to have a child with a man who had lived in the area during testing, less than half (36% or 4 of 11) have ever been physically unable to get pregnant at some time while trying to do so.  However, of the 7 women who have seen a doctor because they have had trouble conceiving or carrying children to term, 57% (4) of the women lived in Caliente during nuclear testing in the area and 29% (2) have a spouse who had lived in the area during that period with whom they were trying to have children.  One issue that arises when discussing infertility concerns the age of the respondent.  Because fertility decreases with age, future surveys might include questions addressing the age at which females had experienced difficulty conceiving.

Finally, A little more than 76% (10) of the 13 children requiring extra time in the hospital after birth were born to families in which one or both parents had lived in Caliente between 1951 and 1963.

Summary and Conclusions

Before making specific recommendations based upon an assessment of this pilot study, it must be noted that multiple indicators of health are needed in any one specific community for a complete health profile. That is, there is no one indicator that will stand alone as an assessment tool, no matter how well that tool is designed. A community household survey ought to be considered as only one tool among many that are needed.  However, even in this context this pilot study can be considered a success in that the field-testing of this instrument has allowed us to pinpoint questions that need to be added, modified or deleted.  It is to be expected that field tests are always required when the interview instrument being utilized is as comprehensive and complex as the one required in the current study.  This complexity is always present whenever the attempt is to measure health status comprehensively for an entire family unit.

The questionnaire form used in the pilot study was purposely long and very inclusive (see attached), because investigators wanted to capture as diverse a picture of health conditions within the community as possible. In addition, descriptive information about the general environment of the community, as well as the household, was solicited.   This included the need to describe the health status of the extended family, including those not residing in the immediate household. It is recommended that the questionnaire used in future studies be redesigned to focus exclusively on the health profiles of those family members living in the household and that it be modified so that it can be administered in approximately 30 minutes – or one hour at the most for large families. The length of the pilot questionnaire was problematic at times in that investigators had to make multiple visits to a household to complete the survey, especially in the cases of busy, working family members as well as for those households with family members who were in ill health.

During the pilot phase, all adult household members were interviewed separately; however, it was determined by both investigators that adult females were the most knowledgeable sources regarding the family’s health, including the health of the adult males and children in the household. In many cases adult men had to rely almost exclusively on their spouse or mate for their health profile information. Thus it is recommended that whenever possible, the primary “informant” or respondent in future studies be the primary adult female in
the household. The use of a primary informant would greatly expedite the interview process, without necessarily sacrificing accuracy of data.

The methodology selected in the fieldwork phase guaranteed a random sample, but given the nature of this rural community, it was exceedingly time consuming to locate and confirm eligible respondents. We would, however, recommend this method for assuring randomness and thus representativeness.  Although the number of households sampled in this pilot study was purposely kept small, the investigators specifically recommend that a significantly larger number of households be included in future surveys in order to obtain a reliable statistical sample of the community.  Larger samples would also allow stratification of the data by income, gender, and other variables of interest while maintaining sufficiently robust sample sizes in these strata to allow meaningful comparisons and conclusions to be drawn.

It is a certainty that with advanced notice in the community, a phone survey could be conducted very successfully. That is, field investigators could make initial contact with respondents and then followed-up by telephone interview to complete all or part of the questionnaire. It is, of course, essential that field and/or phone researchers be skilled interviewers and be generally knowledgeable of “rural” culture. We recommend that the interviewers be females, preferably from outside the study community, based on several respondents reporting that they would be uneasy with “people that they knew” taking their health information and being able to protect their anonymity and maintain data confidentiality.  Professional, highly experienced telephone interviewers at academically-based survey research organizations such as the Senator Alan Bible Center for Applied Research at the University of Nevada, Reno have the requisite experience and highly trained pools of professional interviewers available to conduct such research.  Their experience in conducting on-going telephone interview surveillance of high risk health behaviors for the Centers for Disease Control and Prevention and the Centers for Substance Abuse and Treatment make them ideal candidates to conduct future surveys.

Consideration could also be given to identifying “index” families within the community that could stand as surrogates for the community over an extended period of time. The health data for these families could be more closely monitored than that from a larger sample. This was a model (Research Index Family Model) used by the AEC/DOE during weapons testing at the Nevada Test Site and should be explored as to its strengths and weaknesses.

In addition to household health surveys, it is recommended that other assessment tools be used as indicators of community health. For example, it is recommended that local and county health data collections systems be strengthened. Computer equipment, software, and technical assistance should be given to:  (1) local pharmacies to track trends and patterns in pharmaceutical prescriptions; (2) local public health nurses to track trends and patterns in services and treatments given; (3) home health care agencies and respiratory therapists to track changes in care provided; and (4) local physicians and clinics to track trends in treatments. All of these data should be supplemented via funding and resources for the Nevada State Health Department for re-instituting annual and standardized “Community Health Profiles.”

We have purposely avoided attempting to compare the rates of cancer found in the Caliente sample with other rural areas in Nevada due to the small sample sizes involved.  Even without such comparisons, however, we feel that the data are sufficiently rich to warrant continued research that would involve larger sample sizes.  While it is clearly not possible to draw cause-and-effect relationships between the cancers found in those who report having been exposed to radiation fallout, this does not mean that such a relationship might not be evident given larger sample sizes.

 

 

Appendices

 

 

 

 

 

 

 

 

 

 

 


Family Health History – Frequencies of Conditions by Family Member

Medical Condition

Family Member

 

 

Father

Mother

Brother#1

Brother#2

Brother#3

Sister#1

Sister#2

Sister#3

M. 1st Cousin

F. 1st Cousin

Grand-father

Grand-mother

Nephews

Nieces

Other

allergies

6

13

5

2

2

9

2

2

1

1

1

1

1

1

3

anemia

1

6

1

0

0

1

0

0

0

0

0

1

0

0

0

arthritis/gout

6

16

3

2

0

5

1

1

0

0

3

6

0

0

1

asthma

3

4

2

2

0

2

0

0

0

0

1

1

1

1

1

bleeding/bruising

0

3

0

0

0

1

0

0

0

0

1

3

0

0

0

cancers/tumors

5

6

5

1

1

5

2

0

1

1

0

9

0

0

3

convulsions/epilepsy

0

0

2

0

0

2

0

0

1

0

0

0

1

0

1

diabetes

6

9

2

0

0

5

1

0

0

0

8

12

0

1

4

drinking/drug problems

6

2

5

3

1

2

0

0

0

0

3

1

0

0

1

eczema

1

4

0

0

0

1

0

0

0

0

0

0

0

0

1

emphysema

2

3

0

0

1

1

1

0

0

0

2

0

0

0

2

heart trouble

13

6

0

0

0

0

0

0

1

0

7

7

0

0

2

hepatitis

0

0

1

0

0

1

0

0

0

0

0

0

0

0

0

hypertension

5

11

2

0

0

5

1

1

0

0

0

4

0

0

2

frequent infections

0

0

1

0

0

0

0

0

0

0

0

0

0

0

0

kidney or bladder problems

3

1

0

0

1

0

0

0

0

0

0

1

0

0

0

mental illness

1

1

6

1

0

2

2

0

0

0

2

1

0

0

1

migraines

0

4

0

0

0

2

1

0

0

0

0

0

0

0

2

abnormal menstrual periods

 

0

 

 

 

4

0

0

 

0

 

0

 

0

0

psoriasis

2

3

0

0

0

1

0

0

0

0

0

0

0

0

0

pneumonia

4

4

1

0

0

4

1

1

0

0

0

1

0

0

0

polio

1

0

0

0

0

0

0

0

0

0

0

1

0

0

1

prostate problems

1

 

0

0

0

 

 

 

0

 

1

 

0

 

1

rheumatic fever

0

0

2

0

0

1

1

0

1

0

0

0

0

0

0

stomach/intestine disease

1

2

1

0

0

0

0

0

0

0

0

0

0

0

0

stroke

2

2

0

0

0

1

0

0

0

0

2

2

0

0

1

Family Health History – Frequencies of Conditions by Family Member (continued)

Medical Condition

Family Member

 

 

Father

Mother

Brother#1

Brother#2

Brother#3

Sister#1

Sister#2

Sister#3

M. 1st Cousin

F. 1st Cousin

Grand-father

Grand-mother

Nephews

Nieces

Other

thyroid problem

0

7

0

1

0

1

0

0

0

0

0

2

0

0

0

tuberculosis

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

ulcers

4

3

6

0

1

1

1

0

0

0

2

0

0

0

0

venereal disease

0

0

1

0

0

0

0

0

0

0

0

0

0

1

0

weight problem

0

4

0

0

1

5

0

0

1

1

0

3

0

0

1

 

 

 


Individual Health History – All Conditions Included in Questionnaire

 

*indicates no respondent reports a recognition or diagnosis of condition

 

Lung

Tuberculosis

Persistent Bronchitis

Pneumoconiosis*

Lung Disease/Cancer

Pneumonia

Emphysema*

Other Lung Condition*

Persistent Cough*

Chest Pains

Difficult or Labored Breathing

Wheezing or Asthma

Productive Cough (phlegm, sputum)

Coughing Up Blood

Other Lung Symptom*

Cardiovascular System

Heart Attack

Heart Disease

Rapid or Irregular Heart Beat

Heart Murmur

Swollen Feet or Ankles

High Blood Pressure

Stroke

Low Blood Pressure

Hardening of Arteries

Vasculitis

Thrombophlebitis*

Other Disease of Veins or Arteries

Other CV Condition

Skin

Psoriasis

Eczema

Dermatitis

Unusual Rashes*

Red, Scaly, Dry or Itching Skin

Unusual Acne*

Hives or Boils

Unusual Flushing*

Patches of Pigmentation*

Easy or Spontaneous Bruising

Small, Round, Purple or Red Spots

Other Skin Symptom

Blood

ITP (Bruising)

Anemia

Infectious Mononucleosis

Malaria*

Conditions of Spleen*

Dialysis or Pheresis*

Abnormal Blood Count

Blood Transfusion

Coagulation or Clotting Disorder *

Other Blood Condition

 

Urinary Tract

Kidney Condition

Bladder Disease

Protein in Urine*

Frequent or Painful Urination

Blood in Urine

Other Urinary Tract Symptom

Endocrine/Glandular

Diabetes

Thyroid Condition

Any Hormonal Condition

Excessive Sweating

Hypoglycemia (Low Blood Sugar)

Other Endocrine/Glandular Symptom*

 


Individual Health History – All Conditions Included in Questionnaire (continued)

 

Muscles and Bones

Arthritis/Rheumatism

Limb Pain, Hand or Foot

Stiffness in Joints

Broken Bones

Numbness, Weakness in Arms or Legs*

Leg Cramps

Muscular Dystrophy*

Multiple Sclerosis*

Other Muscle or Bone Pain

Other Muscle or Bone Symptom

Immune System

Hay Fever

Asthma

Food Allergies

Allergic Dermatitis or Skin Rashes

Frequent Colds or Infections

Chemical Intolerance

Other Immune System Symptom

 

Head and Neck

Excessively Oily or Brittle Hair

Unusual Hair Loss*

Nasal Soreness

Sinus Troubles or Infections

Excessive Salivation*

Prolonged Sore Throat

Dry Throat

Difficulty Swallowing

Unusual Taste in Mouth (garlic, metal, etc.)*

Excessive Dental Cavities

Excessive Tooth Loss (other than baby teeth)

Swollen or Sore Gums

Eyes-Red, Itchy, Watery, Sore, Dry, Inflamed

Eyes-OTHER

Blurred Vision

Constricted Pupils

Corrective Lens Needed

Cataracts

Glaucoma

Ears-Itching, Pain or Discharge*

Head Injuries - After Effects

Other Head or Neck Symptom

 

Nervous System

Epilepsy or Seizures

Frequent Headaches

Frequent Dizziness

Weakness, Fatigue

Lethargy

Decreased Sensory Perception-Smell, Taste,

etc.

Color Vision - What Color?*

Trouble Discriminating Colors in Dim Light*

Skin-Numbness, Tingling, Prickling, etc.

Tremors, Cramps, Spasms

Problems with Balance, Coordination,

Reaction Time, Clumsy*

Anxiety

Depression

Trouble Sleeping-at least once/wk for 6

months

Irritability

Hyperactivity

Restlessness or Trouble Sitting Still

Learning Disorder*

Memory or Personality Changes

Frequent Nightmares*

Meningitis*

Peripheral Neuropathy*

Other Nervous System Symptom

 


Individual Health History – All Conditions Included in Questionnaire (continued)

 

Digestive System

Gallstones

Ulcers (any site)

Hepatitis*

Jaundice

Cirrhosis of Liver

Other Conditions of Liver or Pancreas*

Esophageal Atresia*

Frequent Nausea or Vomiting

Chronic Indigestion

Colic or Abdominal Cramps*

Frequent Diarrhea

Frequent Constipation

Loss of Appetite

Loss of Weight

Alcohol or Food Intolerance

Other Digestive Symptoms

Other

Cancer (What Site?)

Leukemia*

Hodgkin's Disease*

Any Metabolic Disorder

Fever*

Chills*

Unexplained Weight Loss or Weight Gain

Twenty Pounds Overweight or Underweight

Frequently Feel Warmer or Colder Than Others

Cysts

Accidents that Required Medical Care (including Sports Injuries)

Serious Infections

Other Condition

Reproductive System - Female

Menopause

Irregular Periods

Premenstrual Syndrome

Female Replace. Therapy-Estrogen Prescribed

Disorder of Cervix

Disorder of Uterus

Disorder of Ovaries

Venereal Disease:  Type?

Infertility

Desire Response/Impotence*

Sexual Disturbances or Problems*

Other Reproductive System Condition

Reproductive System – Male

Sterility*

Abnormal Sperm Count*

Desire Response/Impotence*

Sexual Disturbances or Problems*

Venereal Disease: type?*

Other Reproductive System Condition

 

 

 

 

 

 


Infant Health History – All Conditions Included in Questionnaire

 

Q:  Did your baby have any condition at birth or shortly afterward that involved any of the following:

 

  1. Extremities (arms, legs, hands, feet)
  2. Skin rashes
  3. Moles/Birthmarks
  4. Head – Molding
  5. Eyes – Abnormalities
  6. Lips - Cleft, Other
  7. Gums - Cleft, Other
  8. Palate - Cleft, Other
  9. Other Facial Features
  10. Ears
  11. Thorax - Large, Small
  12. Lungs - Not Fully Inflated, Difficulty Breathing
  13. Heart - Abnormal Rhythm or Rate
  14. Heart Murmur
  15. Heart Valve Defect
  16. Heart – Other
  17. Liver – Jaundice
  18. Liver – Other
  19. Spleen
  20. Kidneys
  21. Skeletal Muscles
  22. Skeletal Bones
  23. Skeletal Joints
  24. Stomach
  25. Intestines
  26. Throat
  27. Genitals – Male
  28. Genitals – Female
  29. Brain - Cerebral Palsy
  30. Brain - Other Spinal Condition
  31. Brain - Other Nervous System Condition
  32. Brain - Mental Condition
  33. Reflexes – Abnormal
  34. Metabolic Disorder
  35. Chromosomal Disorder
  36. Any Other Condition


[1] Legator, Marvin S. and Sabrina F. Strawn (1993). Chemical Alert: A Community Action Handbook. University of Texas Press, Austin.

[2] Kirk, Roger E. (1990). Statistics: An Introduction. 3rd edition (pp. 650-651). Holt, Rinehart and Winston, Inc. Fort Worth.

[3] Senator Alan Bible Center for Applied Research, Report of the Nevada Behavioral Risk Factor Surveillance Survey, February 2000.

[4] Senator Alan Bible Center for Applied Research, Report of the Nevada Behavioral Risk Factor Surveillance Survey, February 2000.

[5] Office of Statistics and Programming, National Center for Injury Prevention and Control, Center for Disease Control.

[6] Senator Alan Bible Center for Applied Research, Report of the Nevada Behavioral Risk Factor Surveillance Survey, February 2000.

[7] American Gastroenterological Association

[8] Sources cited on www.bladder.org (National Bladder Foundation):  Congressional Record, Healthcare Policy Research Agency, National Cancer Society, and National Institutes of Health.

41A

[9] Mokdad, A.H., Ford, E.S., Bowman, B.A., Nelson, D.E., Engelgau, M.M, Vinicor, F., Marks, J.S. (2000). Diabetes trends in the U.S.: 1990­1998, Diabetes Care 23(9), 1278-1283.

[10] Of course, prevalence trends will have to be considered for all health conditions.

[11] Morbidity and Mortality Weekly Report (MMWR) Series, Centers for Disease Control and Prevention (CDC), April 28, 1998.

[12] Marks, W. & Garcia, P. (1998).  Management of seizures and epilepsy.  American Family Physician, 8, 1589-1610.

[13] National Institutes of Health News Release, May 5, 1998.

 

[14] Hanford Health Information Network (1996).  An overview of Hanford and radiation health effects. (SOURCE: http://www.doh.wa.gov).

[15] From “Infertility/Subfertility/Sterility:  The Impact of Language” (SOURCE: http://infertility.about.com/health/infertility/mbiopage.htm)

[16] Impotence. NIH Consent Statement Online 1992 Dec 7-9; 10(4): 1-31.

[17] Centers for Disease Control, National Center for Chronic Disease Prevention & Health Promotion, Behavioral Risk Factor Surveillance System (www.cdc.gov).

[18] Senator Alan Bible Center for Applied Research, Report of the Nevada Behavioral Risk Factor Surveillance Survey, February 2000.

[19] Senator Alan Bible Center for Applied Research, Report of the Nevada Behavioral Risk Factor Surveillance Survey, February 2000.

[20] Hanford Health Information Network (1996).  An overview of Hanford and radiation health effects. (SOURCE: http://www.doh.wa.gov).

[21] R.A. Kerber, et al. (1993). A cohort study of thyroid disease in relation to fallout from nuclear weapons testing. Journal of the American Medical Association, 270, p. 2082.

[22] US Chernobyl Immigrant Registry,  RadEFX Radiation Health Effects Research Resource, Baylor College of Medicine (SOURCE: http://radefx.bcm.tmc.edu).

[23] Krasnopolskiy, V.I., Fedorova, M.Ye., Zhilenko, M.I. et al. (1992). Pregnancy and birth in the region of the Chernobyl accident. Obstetrics and Gynecology, no. 8-12.