HEALTH IMPACTS OF
ENVIRONMENTAL POLLUTION IN
ENERGY-DEVELOPMENT
IMPACTED COMMUNITIES:
VOLUME I
COPLEY INTERNATIONAL CORPORATION
Economic Research • Corporate Planning • Marketing Research • Management Services
78 [ 7 II CKSC [ILL AV r.N ur
LA JOLLA, CALIFORNIA y 2 O ¦) 7
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HEALTH IMPACTS OF
ENVIRONMENTAL POLLUTION IN
ENERGY-DEVELOPMENT
IMPACTED COMMUNITIES:
VOLUME I
Final Report
Phase I
Prepared for the
Office of Energy Activities
ENVIRONMENTAL PROTECTION AGENCY
Region VIII
Denver, Colorado 80203
Under Contract No. 68-01-1949
N. L. Hammer, Project Officer
By
COPLEY INTERNATIONAL CORPORATION
7817 Herschel Avenue
La Jolla, California 92038
September 1976
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PREFACE
The work on which this report is based was conducted by Copley International
Corporation (CIC) under Contract Number 68-01-1949 with the Office of Energy
Activities, Environmental Protection Agency (EPA), Region VIII, Denver, Colorado.
General guidelines for this project were provided in Request for Proposal (RFP)
Number WA 75-R394, dated June 16, 1975, issued by the United States Environmen-
tal Protection Agency, Washington, DC. Approaches and proposed activities were
outlined in a Technical Proposal entitled Health Impacts of Environmental Pollution
in Energy Development Impacted Communities, dated July 14, 1975, prepared by
CIC. A detailed Work Plan, dated January 1976, submitted by CIC, outlined the
objectives, tasks, and activities involved in this study. The scheduled period of
performance for Phase I of this project was January 5, 1976 through September 5,
1976.
In order to enhance continuity and facilitate transition, chapter and section
headings in this report differ in some instances from those in the RFP and the CIC
proposal. The relationship of the tasks outlined in the RFP and proposal to chapter
headings in this report are as follows:
Task I - Environmental Quality Assessment
Chapter 4. Assessment of Health Impacts Resulting from Develop-
ment of Energy Resources
Task II - Health Impact Information
Chapter 5. Information Concerning Health Impacts Resulting from
Development of Energy Resources
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Task III - Data Analysis
A. Listing of Health Impacts from Environmental Pollution
B. Economic Aspects of Increased Public Health Services
Chapter 6. Analysis of Available Data and Information
(A) Health Impacts Attributable to Development of Energy
Resources
(B) Approaches and Economic Considerations in Providing
Health Services
Task IV - Survey Questionnaire
Chapter 7. Procedures for Evaluating Health Impacts Resulting
from Development of Energy Resources
This project was conducted under the direction of Melvin H. Goodwin, Jr.,
Ph.D., Epidemiologist, Director of Health Studies, Copley International Corporation.
Others who participated substantially included the following:
MarianO. Doscher, M.B.A., Senior Industrial Economist, CIC
R. David Flesh, B.S.E., M.S., M.B.A., Group Director, Environ-
mental Sciences, CIC
Betty Eraser, Editorial Assistant, CIC
Ellen Gore, Manuscript Developer, CIC
Alan B. Humphrey, Ph.D., Bio statistician, Consultant
Victoria Jones, Research Analyst, CIC
John W. Klock, Ph.D., Sanitary Engineer, Consultant
Catherine C. LeSeney, M.D., M.P.H., Epidemiology and Health
Services Planning, Consultant
Andrew W. Nichols, M.D., M.P.H., Health Systems Planning,
Consultant
Joyce Revlett, Project Coordinator, CIC
Thomas E. Shipman, M.S., Survey Programs, CIC
Aldona Vaitkus, M.S., Biostatistician, Consultant
Katherine W. Wilson, Ph.D., Air Quality Studies, CIC
Grateful acknowledgement is made to Mr. N.L. Hammer, Project Officer
for the Environmental Protection Agency, for his guidance and attention throughout
the course of this work. Special thanks are due to the many Federal, state, and
local officials who provided the information that comprised the basis for these
analyses. Those mentioned by name in this report are by no means all who con-
tributed time and expert assistance in this effort.
-iii-
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ibbi
TABLE OF CONTENTS
VOLUME I
PREFACE
LIST OF FIGURES
LIST OF TABLES
1. INTRODUCTION
2. SUMMARY
3. RECOMMENDATIONS
4. ASSESSMENT OF HEALTH IMPACTS RESULTING FROM
DEVELOPMENT OF ENERGY RESOURCES
5. INFORMATION CONCERNING HEALTH IMPACTS RESULTING
FROM DEVELOPMENT OF ENERGY RESOURCES
6. ANALYSIS OF AVAILABLE DATA AND INFORMATION
A. Health Impacts Attributable to Development of Energy Resources
B. Approaches and Economic Considerations in Providing Health Services
7. PROCEDURES FOR EVALUATING HEALTH IMPACTS RESULTING
FROM DEVELOPMENT OF ENERGY RESOURCES
8. BIBLIOGRAPHY
VOLUME II
APPENDICES
A. List of energy-development impacted communities, by states, planning
regions, and counties.
B. Offices, agencies, responsible officials, and other sources of data
related to health effects associated with development of energy resources.
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1111
TABLE OF CONTENTS
(cont'd)
VOLUME II
C . Summary of data from Profile Survey - Energy Resources Development
Impacted Communities conducted by Mountain Plains Federal Regional
Council.
(1) Survey form and data for 1974
(2) Survey form and data for 1975
D. Occurrence of selected adverse conditions that contribute to health
impacts in communities affected by development of energy resources
(1) Data for 1974
(2) Data for 1975
E. Intensity and relative significance of selected factors that contribute
to health impacts in communities affected by development of energy
resources.
(1) Data for 1974
(2) Data for 1975
F. Classification of communities affected by energy developments as to
extent of health impacts.
G. Examples of available demographic and vital statistics data.
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LIST OF FIGURES
Figure Page
1-1. Location of Communities Affected by Development of Energy 1-7
Resources
1-2. Number of Energy-Development Impacted Communities by 1-8
Counties
5-1. Health Service Areas 5-40
5-2. District and Regional Planning Areas 5-43
6-1. Accumulative Frequency Distribution (Population vs. 6-43
Community Size) of Potentially Energy-Development
Impacted Communities in Six States
6-2. Accumulative Frequency Distribution (No. Communities 6-44
vs. Community Size) of Potentially Energy-Development
Impacted Communities in Six States
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LIST OF TABLES
Table Page
4-1. Criteria for determining adverse conditions associated with 4-3
development of energy resources.
4-2. Weights assigned to factors for measuring extent of health 4-7
impacts resulting from development of energy resources.
4-3. Number of communities surveyed and number, by states, that 4-11
reported information on specific factors considered in evalu-
ating health impacts resulting from development of energy
resources; total number of communities surveyed in Region
VIII, number and percent of total that provided information^ 1974)
4-4. Number of communities surveyed and number, by states, that 4-12
reported information on specific factors considered in evalu-
ating health impacts resulting from development of energy
resources; total number of communities surveyed in Region
VIII, number and percent of total that provided information.(1975)
4-5. Distribution, by states, of communities according to size of 4-14
population at 1970 Census. Includes communities surveyed
in Region VIII that provided suitable data on population for
1974 and 1975.
4-6. Percent of all communities providing data that reported 4-15
adverse conditions of factors associated with health impacts
resulting from development of energy resources in Region
vni. (1974)
4-7. Percent of all communities providing data that reported 4-16
adverse conditions of factors associated with health impacts
resulting from development of energy resources in Region
Vni. (1975)
4-8. Changes in percent of adverse conditions of factors asso- 4-19
ciated with health impacts resulting from development of
energy resources in Region VHI; reported for all commu-
nities providing data, by states, for 1974 and 1975. Data
were derived from Table 4-6 and Table 4-7.
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LIST OF TABLES
(cont'd)
Table Page
4-9. Percent of all 119 communities providing data for both 1974 4-21
and 1975 that reported adverse conditions of factors asso-
ciated with health impacts resulting from development of
energy resources in Region VIII. (1974)
4-10. Percent of all 119 communities providing data for both 1974 4-22
and 1975 that reported adverse conditions of factors asso-
ciated with health impacts resulting from development of
energy resources in Region VIII. (1975)
4-11. Changes in percent of adverse conditions of factors associated 4-23
with health impacts resulting from development of energy
resources in Region VIII; reported, by states, for all 119
communities for which data were available for both 1974 and
1975. Data were derived from Table 4-9 and Table 4-10.
4-12. Number of communities and number for which data were avail- 4-25
able on factors associated with health impacts resulting from
development of energy resources in Region VIII. Data are for
119 communities involved in surveys of conditions for both
1974 and 1975.
4-13. Number of communities, by states, for which data were avail- 4-31
able for classifying the extent of health impacts resulting from
development of energy resources in Region VIII by using three
combinations of factors.
4-14. List of communities, by state, which were classified as signif- 4-33
icantly impacted by any one or more of three methods for deter-
mining the relative extent of health impacts resulting from energy
developments in Region VIII. Data include classification by
three methods using three combinations of factors.
4-15. Number of communities, by state, available for classification 4-36
and number classified as "significantly impacted" by any one
or combination of three methods for impacts resulting from
energy developments in Region VIII.
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LIST OF TABLES
(cont'd)
Table Page
4-16. Comparison of number of significantly impacted communi- 4-37
ties identified by classifications based on (1) number of
adverse conditions, and (2) intensity and significance of
factors associated with adverse health effects resulting
from energy developments in Region VH[. Data are for
three sets of factors: (1) all factors, (2) population,
water, and sewage, and (3) population. Combined data
for 1974 and 1975 for communities with data on all factors.
4-17. Comparative frequency with which significantly impacted 4-39
communities were identified by various combinations of
factors associated with adverse health effects associated
with energy development in Region VIII. Data for Colorado
and Wyoming for 1974 and 1975 were combined for all com-
munities providing data on all factors for either or both
years and evaluated by ( 1) number of adverse conditions,
and (2) relative intensity and significance of factors.
4-18. Names of communities listed, by states, in groupings of 4-41
significantly impacted, moderately impacted, and potentially
impacted as a result of adverse health effects attributable to
energy developments in Region VIII. Combinations of factors
used in classifying communities are indicated. Data for
1974, 1975, or both years were considered.
4-19. Number of communities, by state, identified as significantly 4-51
impacted, moderately impacted, or potentially impacted as-
a result of adverse effects attributable to energy developments
in Region VIII. Type of data used in evaluating extent of im-
pact is indicated. Classification is based on data for 1974,
1975, or both years.
4-20. Number of communities, by state, classified by two methods 4-52
as to relative extent of health impacts resulting from develop-
ment of energy resources in Region VIII. Data are provided
for three sets of factors. (1974)
4-21. Number of communities, by state, classified by two methods 4-53
as to relative extent of health impacts resulting from develop-
ment of energy resources in Region VIII. Data are provided
for three sets of factors. (1975)
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LIST OF TABLES
(cont'd)
Table Page
4-22. Comparative extent of health impacts, by state, resulting 4-54
from energy developments in Region VIII. Data are for all
communities available for evaluation by number of adverse
conditions and intensity and relative significance of factors
using three sets of factors.
5-1. Considerations in evaluating health status of populations 5-2
and environmental conditions.
5-2. Availability of demographic, vital statistics, and related 5-11
data for evaluating health impacts resulting from develop-
ment of energy resources, by states, in Region VIII.
5-3. Death rate, per 1, 000 population, from all causes for 5-18
individual states in Region VIII, the Mountain States, the
West North Central States, and the United States.
(1965 - 1975)
5-4. Infant death rate, per 1,000 live births, for individual 5-20
states in Region VIII, the Mountain States, die West North
Central States, and the United States. (1965 - 1975)
5-5. Death rates, per 100,000 population, from diseases of the 5-22
heart for individual states in Region VIII, the Mountain
States, the West North Central States, and the United
States. (1965 - 1975)
5-6. Death rates, per 100,000 population from accidents for 5-24
individual states in Region VIII, the Mountain States, the
West North Central States, and the United States. (1965-
1975)
5-7. Death rates, per 100,000 population, from influenza and 5-26
pneumonia for individual states in Region VIII, the Moun-
tain States, the West North Central States, and the United
States. (1965 - 1975)
5-8. Number of deaths from all causes in Colorado and selected 5-29
Colorado counties.
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LIST OF TABLES
(cont'd)
Table Page
5-9. Rate of deaths, per 100,000 population, for all causes 5-29
in Colorado and selected Colorado counties.
5-10. Number of infant deaths in Colorado and selected Colorado 5-30
counties.
5-11. Rate of infant deaths, per 1,000 live births, in Colorado 5-30
and selected Colorado counties.
5-12. Number of deaths from diseases of the heart in Colorado 5-31
and selected Colorado counties.
5-13. Death rate, per 100,000 population, from diseases of the 5-31
heart in Colorado and selected Colorado counties.
5-14. Number of deaths from influenza and pneumonia in 5-33
Colorado and selected Colorado counties.
5-15. Death rate, per 100, 000 population, from influenza and 5-33
pneumonia in Colorado and selected Colorado counties.
5-16. Status of implementing components of the Cooperative 5-38
Health Statistics System in states of Region VIII.
6-1. Types of energy developments and number of communi- 6-2
ties known to be associated with each type in Region VIII.
6-2. Prinicpal air pollutants produced by most common types 6-4
of energy development in Region VIII.
6-3. Relative amount of pollutants produced by selected 6-5
energy development processes in Region VIII.
6-4. Health effects associated with principal pollutants resulting 6-6
from primary processes of energy production in Region VIII.
6-5. Relative risk of adverse health effects in relation to length 6-7
of exposure.
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1. INTRODUCTION
Purpose of The Study
The general purpose of the project was to provide assistance to EPA in
evaluating the environmentally-related health impacts associated with developing
energy resources in Federal Region VIII, comprising the states of Colorado,
Montana, North Dakota, South Dakota, Utah, and Wyoming. The specific tasks
defined for this purpose are as follows:
Evaluate the relative extent of health impacts by assessing environmen-
tal quality in the affected communities.
Determine the scope and adequacy of pertinent health information,
available in state repositories, and summarize readily available,
relevant material.
Analyze available data to explore relationships between environmental
pollution and health impacts, and assess economic aspects of providing
needed health, .environmental, and community services.
Develop survey protocols for use in securing information related to
health impacts and remedial measures from sources in affected com-
munities .
The substance of this report is restricted to health impacts resulting from
development of energy resources. In so far as possible, general sociologic con-
siderations were not included except when necessary to preserve continuity or to
avoid omission of references to pertinent complementary work closely related to
health.
1-1
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Perspective
An articulation of the context in which this work was performed is essential
to adequate description and interpretation of the resulting observations and inferences.
The following brief statement of the investigators' perspective is drawn, in part, from
the substantial body of information and data on conditions and circumstances in
Federal Region VIII that has appeared in the few years since acceleration of energy
developments.
The rapid initiation and expansion of energy-development activities around
the early 1970's have a profound effect on the environment and lives of citizens in
the Mountain Plains Region. Many of the adverse effects have been reflected in
health-related impacts associated with community environmental services that
affect health of residents in the community and with the availability of personal
health services to the community. The intensity of the effects and inherent ability
of communities promptly to cope with potentially detrimental conditions usually
has been related inversely to the size of the community affected; the majority of
communities involved in this study have populations of less than 1, 000 persons
and more than 80 percent of them have less than 2,500 residents. Public officials
generally have dealt with problems associated with declining populations for the
past two decades and have not faced problems associated with expanding populations
and rapid industrial growth.
The communities that first experienced impacts from development of energy
resources usually had relatively little advance notice of the pending development
and little experience that provided bases for effective response. Planners and
1-2
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guidelines for anticipating potential problems, developing plans, and initiating
appropriate action generally were not available. In many communities, long en-
trenched attitudes and patterns of living were related to nonindustrial activities
and to preservation of existing environmental conditions. The prevalent value
systems generally were not compatible with the initial manifestations of activities
associated with development of energy resources. Newcomers frequently were
dissatisfied with community services and became frustrated or resigned to adjust-
ment for a temporary stay. A sense of belonging to the community generally was
not sought by them or fostered by the established residents. For these and many
other reasons, a wide spectrum of health-related problems soon emerged.
The sequential repetition or concurrence of causes and effects easily is
visualized: population influx, depletion of available housing, acquisition of mobile
and temporary housing, inadequate water supply and sewage disposal, deterioration
of environmental hygiene, increase in disease, unmet demand for medical services,
and so on. Communities, institutions, industry, individuals, and other components
of society reacted, and the resulting interventions prevented or aborted many po-
tentially untoward conditions. In fact, there is no evidence that any epidemic of
infectious disease occurred as a result of environmental pollution, although there
were instances of overt contamination because of inadequate sewage and solid
waste disposal. Substantial increases, as much as ten-fold, in the use of commu-
nity mental health services, have been documented. This most likely reflects the
reactions to stressful living conditions.
At various points in the course of events, the individual states and commun-
ties, agencies of the Federal government, industries, and other organizations
1-3
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provided initiative to develop competence for planning community services in the
areas adversely affected by development of energy resources. These efforts have
made substantial contributions toward formulating solutions for existing problems
and in preventing occurrence or worsening of others. As a result, more orderly
arrangements have been made for working relationships between industry, state
and Federal governments, communities, and other concerned organizations. Three
states have enacted legislation regulating the siting of major facilities. Among
other effects, this assures more adequate lead time for planning and promotes
regulation of other factors to reduce the extent of impact. Assistance programs
now are better defined, although much apparently still needs to be done along this
line. Guidelines for planning concerning the special aggregation of problems relating
to impacts of energy developments are being formulated and already are available
for some functional areas. An indication of the improved competence, and confi-
dence, in some communities is indicated by the optimism with which further local
energy developments are viewed. Some communities have weathered the initial
impacts and now have planning organizations staffed and operating. Community
resources have been augmented or developed to meet current and anticipated
needs, and the prevalent community attitude indicates willingness or enthusiasm
to accept further growth. (Of course, this impression depends on the source of
information.) In some instances there is local opposition to developing new
communities to serve energy developments which are within commuting distance
of established communities that have experienced and solved problems associated
with similar activities. The apparent concensus is that the established com-
munities should share the perceived advantages of the new industrial enterprise.
1-4
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The advances in coping with impacts attributable to energy developments
do not suggest that all, or even a substantial body, of such problems have been
solved. Some communities that first experienced substantial impacts are facing
worsening conditions because of additional developments in their commuting area.
"Front-end" funds for planning and physical developments often are difficult to come
by, although some states do have various forms of severance taxes, plans for pre- ¦
payment of taxes, or other means for providing such funds. Uncertainties about
plans of developers, cancellation and rescheduling of projects, judicial delays,
jurisdictional disputes, and other circumstances discourage or preclude advance
planning in some areas. For a variety of other reasons relating to traditions of
local government, some communities cannot undertake planning far enough in
advance of initiating energy developments to make the process effective in re-
ducing or preventing predictable adverse impacts. In a few situations, the preva-
lent concensus is that the development should not happen and the community should
not do anything about it.
One of the conspicuous detriments to effective planning in anticipation of
adverse impacts, especially those related to health, is the lack of applicable formats
and models for planning. This is especially significant in the energy-development
impacted communities. For example, small communities cannot be self-sufficient
to provide the extensive scope of modern medical services available today. A gen-
eration ago, or even 15 years ago, technology was much less developed and the
orientation and supportive needs of medical graduates was vastly different from now.
New planning techniques are required realistically to evaluate the health needs of
communities and to consider the alternatives available for providing the necessary
1-5
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services.
Although current methodology may be deficient, it seems that conceptual
approaches and sufficient information concerning experiences with energy devel-
opments in Region VIII, and elsewhere, are now available to enable development
of the necessary planning procedures and the requisite data base.
The Study Area
The communities identified for inclusion in this study are listed by state,
planning region, and county in Appendix A. Geographic locations of these com-
munities are approximated in Figure 1-1 and the number of communities in each
of the counties involved is indicated in Figure 1-2. All of the communities con-
sidered in this report are in Federal Region VIII which consists of the states of
Colorado, Montana, North Dakota, Soutii Dakota, Utah, and Wyoming. Other
states in the Great Plains Region and other Southwestern states also are involved
in the development of energy resources.
1-6
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\ J— FEDERAL REGION VIII
Ftg 1-2 Number of Energy-Development Impacted Communities by Counties
-------
SELECTED REFERENCES
Dempsey, John and Associates. 1975. An update of the comprehensive plan for
Rock Springs, Wyoming. City of Rock Springs. 87 pp. plus Appendix.
Gilmore, John S. 1976. Boomtowns may hinder energy resources development.
Science. 119:535-540.
Gilmore, JohnS. and Duff, MaryK. 1975. Boomtown growth management: A
case study of Rock Springs - Green River, Wyoming. Westview Press, Boulder,
Colorado. 177 pp.
Gold, Raymond L., Project Director. 1974. A comparative case study of the impact
of coal development on the way of life of people in the coal areas of eastern Montana
and northeastern Montana. Institute for Social Science Research, University of
Montana . Missoula, Montana. 185 pp.
Jackson, Richard H. and Hudman, Lloyd E. 1975. Master plan, Castle Dale,
Utah 1975. Department of Geography, Brigham Young University. B and D Enter-
prises. Provo, Utah. 73 pp.
Johnston, Malcolm F. 1975. Final report for the health impact research project.
Comprehensive Health Planning, Slate of Wyoming, Cheyenne, Wyoming. 98 pp.
Montana Energy Advisory Council. 1974. Coal development information packet.
State of Montana, Office of the Lieutenant Governor. Helena, Montana, pp. 67.
Montana Energy Advisory Council. 1975. Coal development information packet.
Supplemental. State of Montana, Office of the Lieutenant Governor. Helena,
Montana, pp. 79.
Mountain West Research, Inc. 1975. Construction worker profile. A study for
the Old West Regional Commission. Denver, Colorado.
Separate issues as follows:
Summary report
Final report
Users guide to the data
Community report - Rock Springs - Green River, Wyoming
Community report - Forsyth - Colstrip, Montana
Community report - Center, North Dakota
Community report - Langdon, North Dakota
Community report - Conrad, Montana
Community report - Killdeer, North Dakota
Community report - St. George, Utah
1-9
-------
North Dalcota State Planning- Division. 1975. Some tentative figures on the social
impacts of six coal conversion plants in the Dunn, Mercer, Oliver, and McLean
Counties area. Bismarck, North Dakota.
Northern Great Plains Resources Program. 1975. Effects of coal development
in the northern great plains. The Northern Great Plains Resource Program Staff,
Denver, Colorado, and Washington, DC. 165 pp.
Office of the State Planning Coordinator. 1975. The Utah process alternative
futures 1975-1990. Office of Governor Calvin L. Rampton. Salt Lake City, Utah.
3 volumes.
Rapp, Donald A. 1976. Western boom towns: Parti. A comparative analysis of
state actions. Western Governors'Regional Policy Office. Denver, Colorado.
58 pp.
Sixth District Council of Local Government. 1975. The impact of coal develop-
ment (a preliminary assessment). Rapid City, South Dakota. 38 pp.
Uintah Basin Association of Governments . 1976. Duchesne County Public Finance
Study. Bureau of Community Development, University of Utah. Salt Lake City,
Utah. 60 pp.
1-10
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I
11
2. SUMMARY
This Summary provides a brief overview of the project, outlines some
general observations and results, and gives some of the more significant inferences
from the work. The subheadings in the summary correspond to the titles of tasks
outlined in the RFP.
Environmental Quality Assessment
The first task concerned classification of communities, according to the
relative extent of health impacts, in three general groups: significantly impacted,
moderately impacted, and potentially impacted communities. The data used in
accomplishing this task were obtained primarily from surveys conducted by the
Mountain Plains Federal Regional Council ( FRC) in Region VIII. A summary of
pertinent data is provided in Appendix C. The variables considered in classifying
the communities included population increase, availability of housing, adequacy
of water supply and sewage disposal, accessibility of medical services, and avail-
ability of resources for planning.
Two procedures were used to classify the communities: (1) the total
number of adverse conditions m vaxiuds combinations, and (2) the aggregated
weights assigned to indicate the intensity and significance of various combinations
of adverse conditions.
Both methods proved useful in determining the relative extent of impact
among communities and are applicable for assessing the relative priority of planning
2-1
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or remedial efforts needed by the communities. Comparative assessments of
conditions were made for 120 communities for which sufficient data were avail-
able. By using one or more of three different schema, it was found that about
50 percent of the communities could be designated as severely impacted, 32 per-
cent as moderately impacted, and 18 percent as potentially impacted.
Health Impact Information
The second task concerned the scope and quality of pertinent information
about the communities that was available from public health information
repositories and other sources. It was recognized that the information needed
to evaluate the nature and extent of health impacts resulting from development
of energy resources was of three general categories:
Vital statistics and other demographic data compiled by state reposi-
tories of health information.
Information and data concerning community environmental facilities
-- e.g., water supplies, sewage disposal facilities, solid waste dispo-
sal -- usually available from local or state agencies responsible for
environmental sanitation.
Information relating to public and personal health services, including
systems for organization and delivery of services, developed by health
planning agencies, local and state departments of health services, and
organizations of providers of health services.
Specific items of data needed and availability by states are indicated in
Table 5-1 and Table 5-2. The principal sources of information obtained during
the course of this work are provided in Appendix B. From the readily accessible
data, abstracts were made from which information was developed on the antici-
pated growth of communities, public health services, environmental sanitation,
and principal causes of mortality.
2-2
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Since data generally were not available for specific communities, statistics were
compiled by counties. Examples of data are provided in Appendix G.
The data consolidated from readily available sources proved inadequate
for evaluating the extent of health impacts in the individual communities or counties.
This was due to the lack of information on the dates when energy developments were
initiated, the variation and inadequacy of population estimates, the lack of current
vital statistics and morbidity data, and other factors. These deficiencies led to
development of procedures for obtaining the needed information and to preparation
of recommendations for improving the scope and quality of data from the communities.
Examinations were made of state systems for collecting and disseminating
health information witii respect to inclusion of the seven components of die Coopera-
tive Health Statistics System (CHSS) developed and supported by the National Center
for Healdi Statistics (NCHS) . As indicated in Table 5-3, all of the states in Region
VIII are involved in developing and implementing CHSS programs. Data from each
of the CHSS modules -- vital statistics, manpower statistics, health facilities sta-
tistics, hospital care statistics, household interview statistics, ambulatory care
statistics, and long-term care statistics -- are essential to adequate evaluation
of community health needs and effective planning for providing health services.
In addition, accurate data are needed concerning short and long-term population
projections for communities and counties in order that rapid expansion and fluctu-
ating populations can be taken into account in the processes of assessment and
planning. Since the availability of data --as well as the scope and detail of sta-
tistics -- varies among the states and communities, procedures were devised for
2-3
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local development of data in communities affected by development of energy resources.
The procedures are provided separately under the title "Procedures for Evaluating
Health Impacts Resulting from Development of Energy Resources. "
Data Analysis •
The third task involved analysis of available data to evaluate the relationship
between impacts resulting from development of energy resources and to assess the
economic aspects of providing additional health services.
Health Impacts Resulting from Development of Energy Resources. Two
general groups of health effects were considered in evaluating the causa] influences
of energy developments. First, the possible etiologic significance of the processes
employed in the various industrial activities, and second, the effect attributable to
conditions resulting from rapid increases in population with consequent crowding
and needs for health and related services that exceeded the capacity of existing or-
ganizations and resources. Most effects of the first type are related to the environ-
ment of workers and are primarily in the province of industrial hygiene. Some po-
tential problems of pollution in the ambient environment obviously are created by
industrial processes; however, by far the majority of problems and the most sig-
nificant problems result from "boomtown" conditions.
Although the distinction is arbitrary, the adverse effects of rapid community
growth were considered as one of two types: those which have an impact on com-
munity environmental services such as water supplies, sewage disposal, and
solid waste disposal, and those that have a direct effect on individual persons
as evidenced by overt physical illness, mental illness, or inadequate protection
2-4
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against diseases. The available data and testimony of officials did not reflect
any epidemics or notable outbreaks of disease as a direct result of energy de-
velopment, nor was there evidence of sustained or widespread environmental
contamination resulting from inadequate sewage or solid waste disposal or from
inadequate water supplies. This is not to imply that potentially dangerous condi-
tions have not occurred, but existing laws, ordinances, and regulations were
adequate to effect preventive or remedial action by diligent public health and
other officials. Water supplies -- especially distribution systems for trailer
parks, mobile home areas, and expanding construction of permanent housing --
often could not be developed rapidly enough to keep up with demands. The ca-
pacity of existing sewage collecting and disposal systems also were exceeded
in some communities. Other community services, such as solid waste dis-
posal, lagged beyond increasing demands in some instances. Many acute situ-
ations developed that were solved or are being solved without catastrophic or
sustained detrimental effect on human health or community sanitation. There
have been, however, notable increases in use of mental health services. In
some communities the various types of stress associated with rapid community
growth allegedly have been reflected by increases in alcoholism, child abuse,
and other behavioral aberrations. Additionally, in some communities a notable
increase in work-associated accidents occurred.
The most commonly expressed concern about health impacts was the actual
or perceived inadequacy of medical services; that is, the desired accessibility of
a physician and a hospital was not possible in many communities. The reaction
has been to attempt recruitment of physicians and to undertake other measures
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in an effort to sustain the prevailing, traditional means for providing therapeutic
medical care. These efforts have not been effective in many communities and
considerable dissatisfaction is evident. It is obvious that available alternatives
for providing personal health services have not been considered in many commu-
nities. Also, in some states and sub-state areas, an adequate framework for
planning health sendees does not exist. For example, health service areas
have not been defined and guidelines for regional health services have not been
developed for many areas.
Economic Aspects of Providing Adequate Health Services. Arrangements
suggested for providing personal health services and community environmental
services took into account the incremental requirements for specific services
that are determined by the magnitude and rates of population growth and the
duration of need for services. In many of the affected communities, transitory
increases of population occurred followed by a decline that resulted in only slight
net expansion of the population in the community prior to the beginning of energy
development activities. In many instances, in the absence of adequate opportu-
nity and resources for advance planning and arrangements for needed services,
reactions seem to have resulted in costly investments in long-lived facilities.
Needs often could adequately have been met apparently at less cost and with
greater efficiency.
Because of population size, geographic location, and other factors, many
communities probably will not be able to recruit and retain physicians and op-
erate hospitals where an extensive scope of services are provided. With
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appropriate system organization, several options are available for delivering
the health services necessary to meet the needs of the communities. Such
services may be provided through local clinics, which can be organized in a
variety of ways, with established arrangements for communication and trans-
portation to secure the types of services that are not readily available. The
cost of operating such clinics in communities of Region VIII is estimated at
$100,000 - $150,000 for a one-physician facility, and between $190,000 -
$225,000 for a two-physician facility. Physicians and other professional
personnel may be provided by arrangements made with established federations
or health service corporations. Where the size of population does not warrant
the full-time services of a physician, primary care can be provided by a phy-
sicians' assistant or nurse practitioners who work under remote supervision
of a physician.
If permanent facilities are not required for a sustained population in-
crease, temporary arrangements may be made to provide less costly commu-
nity environmental services. Basic to such arrangements are accurate esti-
mates of anticipated magnitude and duration of population growth. Community
planning must also be adequate to define the needs for services and to determine
constraints of topography for storm drainage, soil types for waste disposal,
sources of water, and availability of land for disposal of solid waste.
Survey Protocols
Task 4 relates to the development of survey instruments for use in Phase II
of this project. These instruments were designed to assess the problems encoun-
tered by various communities and how the problems were handled. During the
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development of information summarized above, the need for systematic identifi-
cation, collection, consolidation, analysis, and interpretation of data pertinent
to evaluating health effects resulting from development of energy resources became
increasingly apparent. In many instances, communities and other local jurisdictions
did not have sufficient advance notice of energy developments to permit adequate
analyses of potential impacts and preparation of meliorative plans. In other
instances the resources and organization for planning were not available. Where
effective planning was possible, the financial resources often were unavailable or
inadequate for implementing preventive or corrective actions. Inview of these
and other considerations, attention was given to developing procedures that would
provide timely information for appropriate assessment and planning. As indicated
above, these procedures are provided as a separate manual.
In general, methods are proposed for characterizing physical and demo-
graphic aspects of communities pertinent to evaluating health effects attributable
to development of energy resources and for collecting and interpreting data useful
for anticipating health impacts. The protocols provided were designed to include
data, secured from industrial developers, concerning projected employment by
years during construction of projects and for subsequent operations. Procedures
are outlined for conducting health index surveys to determine preference for
securing and using health services and to evaluate health status of community
residents. Methods for acquiring and evaluating information concerning community
environmental services and for evaluating premises sanitation are provided. In
addition, procedures are outlined for evaluating the type and adequacy of personnel
2-8
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and physical resources to provide personal health services. Finally, suggestions
are made for developing recommendations concerning health and environmental
services on the basis of data obtained and information developed by procedures
outlined in the manual.
In addition to providing the bases for community evaluation, the data ob-
tained by the methods outlined are useful in developing applications for assistance
programs that require quantitative detail concerning communities. The proce-
dures provided were developed with the expectation that persons in the community
-- public employees or volunteers -- would collect and participate in analyses of
much of the data. This participation would provide opportunities for local citizens
to secure more detailed information concerning existing or potential problems and
to participate more effectively in developing solutions.
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3. RECOMMENDATIONS
In accordance with the specifications for this study the following recom -
mendations are proposed to improve data collection at the community level and to
improve public understanding of the relationships between energy developments
and health impacts .
Recommendation 1
The manual "Procedures for Evaluating Health Impacts Resulting from
Development of Energy Resources, " with appropriate revisions to conform to
EPA formats, should be distributed to energy-development impacted communities,
both those currently identified and those which later may be affected.
Recommendation 2
Hie appropriate federal agencies , the Western Governors' Regional En -
ergy Office, and the individual states should solicit the assistance of the Health
Resources Administration of DHEW in giving priority attention to developing and
supporting Health Planning and Resources Development activities and the Cooper-
ative Health Statistics System in Region VIII.
Recommendation 3
The format for periodic collection of data from energy-development im-
pacted communities by the Mountain Plains Federal Regional Council should be
expanded to obtain additional needed data identified in this report; specifically,
3-1
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annual population projections during construction phases of energy-development
projects, dates developments commenced or projected dates of initiation, dur-
ation of construction phase and total longevity of project(s) , additional informa-
tion on community environmental facilities, and more detailed information con-
cerning health services .
Recommendation 4
An appropriate Federal Office should serve as a clearinghouse for infor-
mation concerning energy development activities that affect state and local com-
munities . This office should establish channels for regular dissemination and
exchange of information to all governmental jurisdictions that potentially may be
affected .
Recommendation 5
Each state should designate an agency, preferably the state planning office,
to develop annual population projections for at least five years in advance for
counties and individual communities affected by energy developments . These
projections should take into account alternative developments of energy resources
and other recognized demographic variables .
Recommendation 1 is submitted as a means for both improving the de-
velopment of information and enhancing public understanding of health problems
associated with development of energy resources. Adapting the survey proce-
dures outlined for use in local communities and assembling available data in
the formats so devised, along with the new data developed by these procedures,
3-2
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would go far toward achieving the data required to develop plans to cope with
health impacts. Citizen participation, as envisioned in the survey procedures,
is an effective means for stimulating awareness and interest in the problems
faced by the communities. Public distribution of appropriate information ob-
tained by conducting the suggested procedures would reach a wider audience.
The intention of Recommendation 2 is to further enhance the scope,
•quality, and application of information developed for the communities. Effec-
tive encouragement for health and other funtional planning at the state level is
essential for developing efficient community programs.
Recommendations 3 and 4 are proposed to assure consolidation of perti-
nent available information from the states and communities and accessibility oJ
such information to the states and communities.
Recommendation 5 identifies a basic, essential function that should be
initiated or extended immediately.
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4. ASSESSMENT OF HEALTH IMPACTS RESULTING FROM
DEVELOPMENT OF ENERGY RESOURCES
The objectives of this aspect of the study were to evaluate the extent of health
impacts experienced or anticipated in communities affected by development of energy
resources and to classify these communities in specified categories, namely, signifi-
cantly impacted communities, moderately impacted communities, and potentially im-
pacted communities. The data used for this purpose were provided by EPA from
surveys of the communities conducted in 1975 and 1976 by the Mountain Plains Federal
Regional Council. Summaries of these data and the survey forms used are included
in Appendix C.
Indicators of Health Impacts
Adverse health effects become obvious when epidemics or overt increases in
diseases, illnesses, and deaths occur. States and many sub-state health jurisdictions
maintain systems for reporting occurrence of communicable diseases and provide
analysis of mortality reports to detect such events. Planners and health officials
attempt to identify and maintain surveillance of harbingers of these manifestations
in order that preventive measures can be undertaken in time to avoid conditions that
contribute to deterioration of health in communities. Among the factors to be watched
are rapid increases in population, over-uSe or use to near capacity of community
water supplies and facilities for sewage and solid waste disposal, inadequate housing,
and unmet needs for medical services. Data of the latter type were examined in this
analysis.
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Data Available for Determining Extent of Health Impacts . The survey con-
ducted by the FRC included provisions for collecting the following types of data:
Population from the 1970 census and estimates for 1974 and 1977.
Number of permanent and mobile dwelling units in or near the community.
Capacity of the existing water treatment and sewage treatment facilities
and percent of capacity used.
Number of medical doctors in the community or distance to the nearest
medical doctor.
Number of hospital beds in the community or distance to the nearest
hospital.
Distance to the nearest city of 25,000 population.
Availability of a planner to the community.
Availability of a plan for die community.
Development of Procedures to Evaluate the Extent of Health Impacts
Evaluation of the healdt impacts in affected communities ideally should take
into account the number of adverse conditions, the relative significance of the various
factors, and the comparative intensity of the adverse conditions.
Identification of Adverse Conditions. The first step in developing procedures
for this analysis was the formulation of criteria for determining the quantitative point
or level at which each of the factors considered could be expected to have a detrimental
effect on health of the population. The factors considered and the criteria used are
indicated in Table 4-1. Although quantitation of some variables is arbitrary, there
are reliable bases for the designations used. Some of the considerations were as
4-2
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Table 4-1. Criteria for determining adverse conditions associated with
development of energy resources.
Population
Community of
<
1,000 pop.
with
annual
rate of increase
about
6%
Community of
1,001
-2, 500 pop.
with
annual
rate of increase
about
8%
Community of
2,501'
-5, 000 pop.
with
annual
rate of increase
about
10%
Community of
>
5, 000 pop.
with
annual
rate of increase
about
12%
Housing
Ratio of population to housing > 3
Water Treatment System
Capacity used > 75 percent
Sewage Treatment System
Capacity used > 75 percent
Distance to Physician
> 15 miles
Distance to Hospital
> 50 miles
Distance to City of 25, 000 Population
> 100 miles
Availability of Planner
None available
Availability of Plan
None or adopted before 1972
4-3
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follows:
-- Population. An annual increase in population of around 5 percent is
about all that small communities can experience without disrupting
community environmental services. Communities with progressively
larger populations can tolerate larger and more rapid growth widi less
strain on community services. The specific levels assigned were those
at which adverse effects were believed to commence.
-- Housing. Three persons per dwelling unit was selected arbitrarily as
the average level of a satisfactory ratio between population and housing.
This was based upon perusal of the available data and approximated
the modal figure for communities that did not appear to have significant
impact.
-- Water Supplies and Sewage Disposal Systems. The design and construc-
tion of community sanitational facilities appropriately takes into account
the population estimated for five or ten years in the future, depending
on the type of facility planned. The use of more than 75 percent of
existing capacity is an indication of the necessity to initiate planning for
expansion or developing additional or alternative facilities.
-- Distance to Physician. Certain health services should be readily accessi-
ble to residents of a community. Such services usually are designated
as primary health services and include emergency services necessary
for saving lives or alleviation of pain, and other services that should be
4-4
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convenient for effective use. The generally recognized maximum access
time for such services is 15 minutes. Since the physician was the only
primary health service provider considered in the FRG surveys, and
since data were not available on travel time to a physician, the avail-
ability of primary services was evaluated on the basis of information
regarding distance to a physician. A travel distance of more than 15
miles was designated as an adverse condition.
-- Distance to Hospital. Other health services, usually of a more specialized
nature or those used less frequently, may effectively serve populations within
45 to 60 minutes access time. Such services may be based in community
hospitals, as well as other types of facilities. Since data were available
concerning distances to hospitals, these were used as an indication of
accessibility of services more specialized than primary services. A
distance of more than 50 miles was considered an adverse condition in
these analyses.
-- Distance to City of 25, 000 Population. More highly specialized medical
services usually are found in the centers of larger populations. Avail-
ability of these services at a distance greater than 100 miles was defined
an as adverse condition.
-- Availability of Planner. The lack of access to any planner was regarded
as an adverse condition.
4-5
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-- Availability of Plan. No community plan or one developed prior to
1972 was considered as an adverse condition.
Relative Significance of Factors. Rating the relative significance of the
various factors considered in this analysis may appear theoretically desirable as
an aid in quantitating the extent of impact. However, most of the variables eval-
uated are sequentially dependent. For example, population, housing, water supply,
sewage disposal, and medical services progressively affect the factors that follow.
Obviously, population is the determining factor and the magnitude of all the other
variables is dependent on population. Considering these relationships, assigning
relative measures of significance (weights) to the various factors is highly arbi-
trary and tests indicated that the quality of the analysis was not improved when this
was done independently from consideration of the magnitude of adverse conditions.
Some factors obviously are more significant than others in the sense of having a •
limiting effect. For example, the size of population is limited by the amount of
water available at the source of the community supply. In this analysis the relative
significance of the various factors was considered in assigning weights to reflect
intensity of the conditions, as indicated in the following section.
Comparative Intensity of Adverse Conditions. The weights assigned to
intensity of the adverse conditions attributed to the variables considered in classi-
fying the communities are shown in Table 4-2. The relative significance of the
factors is reflected in two ways: first, by the number of class intervals desig-
nated when successive intervals were increased by a weight of one unit; second,
in the case of the population factor, by increasing the successive class intervals
4-6
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Table 4-2. Weights assigned to factors for measuring extent of health impacts
resulting from development of energy resources.
Population
Housing
1. Ratio of 1974:1970 population.
2. Ratio of 1977:1974 population.
(Available population data were used for
comparison with 1970 Census)
Ratio of 1974 population to number of
dwelling units in community in 1974.
Ratio of 1977 projected population to
number of dwelling units in community
in 1974.
<
1.00
0
1.01
-1.25
2
1.00
-3.00
0
1.26
-1.50
4
3.01
- 4.00
1
1.51
- 1.75
6
4.01
-5.00
2
1.76
- 2.00
8
5.01
- 6.00
3
2.01
- 2.50
10
6.01
-7.00
4
2.51
-3.00
12
>
7.00
5
3.01
-3.50
14
3.51
- 4.00
16
4.01
- 4.50
18
4.51
-5.00
20
5.0J
-5.50
22
5.51
- 6.00
24
>
6.00
26
Water Treatment System
Percent of capacity used:
0 - 25
0
26 - 50
1
51 - 75
2
76 - 90
3
91 - 100
4
No system
5
Sewage Treatment System
Percent of capacity used:
0 - 25
0
26 - 50
1
51 - 75
2
76 - 90
3
91 - 100
4
No system
5
Distance to Physician
In community 0
< 15 miles 1
15 - 50 miles 2
> 50 miles 3
Distance to Hospital
In community 0
< 15 miles 1
15 - 50 miles 2
> 50 miles 3
4-7
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Table 4-2. (Continued)
Distance to City of 25, 000 Population
0 -
14 miles
0
15 -
49 miles
1
50 -
99 miles
2
100 -
200 miles
3
>
200 miles
4
Availability of Planner
Community, county, or regional 0
State only 1
None 2
Availability of Plan
Adopted since 1972 0
Adopted before 1972 1
No plan 2
4-8
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by increments of two units. In the analysis of all factors in combination, as
described in a subsequent section, population and housing were assigned additional
weight by using data for both periods for which population statistics were available,
i.e., 1970-1974 and 1974-1977 for most communities. Data for both periods were
added when aggregating the weights of all factors for a community. Similarly,
ratios of populalion-to-housing for two periods were added. These ratio were
calculated using the 1974 population and the number of dwelling units present in
1974, and the 1977 projected population and the number of dwelling units present
in 1974. In addition to giving additional weight to the population and housing factors,
this procedure also reflected changes in the conditions of population and housing
for the two periods. For example, if the 1974 population increased over the 1970
population and the 1977 population also was expected to increase over the 1974
population, a greater weight would result than if the population increased for only
one of the periods. A similar result occurs by considering the population-to-housing
ratio separately for the two periods.
Application of Procedures to Evaluate the Extent of Health Impacts
The data available from the FRC surveys were analyzed using the procedures
outlined above. These analyses yielded two sets of data. One of these sets indicates
by communities the occurrence of selected adverse conditions that contribute to
health impacts in communities affected by development of energy resources.
Whether or not the factors evaluated resulted, allegedly, in adverse conditions
was determined according to the criteria outlined in Table 4-1. The second set of
data indicates the relative significance and intensity of selected factors that contribute
4-9
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to health impacts in communities affected by development of energy resources.
The methods for weighing the factors considered are indicated in Table 4-2.
The two sets of data are provided in Appendix D and Appendix E respectively.
The interpretations that follow are based on these data and those in Appendix C.
General Characteristics and Indications of the Analyses
Availability of Data for Communities. The number of communities that
provided data for each factor, and for all the factors considered in the FRC sur-
vey, are shown in Table 4-3 and Table 4-4. The data for 1974 were obtained from
copies of the summary sheets provided for the individual communities. The higher
percentage of response to some items of data for 1974, compared with 1975, may
reflect efforts to augment data provided by the state when pertinent information
was available to the FRC staff, e.g., distances to hospitals and physicians. Data
in these tables suggest the lack of access to data on population, housing, and avail-
ability of community plans; the summary sheets did not provide for an entry of
"availability unknown."
Data concerning factors in 1974 were obtained from 126 communities; data
for 1975 were provided for 187 communities. Data for both 1974 and 1975 were
supplied for 119 communities. Seven communities furnished data for 1974 only
and 68 for 1975 only. No data were available for four additional communities
identified by state officials as impacted communities. In all, 198 communities
are included in the list of energy-development impacted communities provided in
Appendix A. Of the 126 communities for which data were available for 1974, only
30 (24%) provided data on all of the factors; for 1975, 43 of 187 (23%) provided
4-10
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Table 4-3. Number of communities surveyed and number, by states, that reported information on specific
factors considered in evaluating health impacts resulting from development of energy resources;
total number of communities surveyed in Region VIII, number and percent of total that provided
information. ,
Nor tli
South
State
Colorado
Montana
Dakota
Dakota
Utah
Wyoming
All States
Number of Communities
19
6
18
5
53
25
126
*
Communities
Number of Communities
Reporting
Factor*
Rei
sorting on Factors Indicated
#
%
Population: 1970 - 1974
19
4
12
5
17
24
81
64
1974 - 1977
19
4
12
5
0
10
50
40
Housing
18
4
16
5
16
21
80
63
Water System
17
1
5
4
51
19
97
77
Sewage System
17
2
14
4
52
22
111
88
Distance to Physician
19
6
18
5
51
25
124
98
Distance to Hospital
19
6
18
5
51
25
124
98
Distance to City of 25, 000
Population
19
6
17
5
52
25
124
98
I Availability of Planner
19
6
18
5
53
25
126
100
j Availability of Plan
19
6
18
5
11
25
84
67
All Factors
16
1
3
4
0
6
30
24
-------
Table 4-4. Number of communities surveyed and number, by states, that reported information on specific
factors considered in evaluating health impacts resulting from development of energy resources;
total number of communities surveyed in Region VIII, number and percent of total that provided
information.
1975
North
1 South
State
Colorado
Montana
Dakota
I Dakota
Utah
Wyoming
All States
Number of Communities
44
15
25
1 9
61
33
187
Communities
Number of Communities
Reporting
Factor*
Reporting on
Factors Indicated
#
%
Population: 1970 - 1974
38
6
25
9
53
33
164
88
1974 - 1977
33
6
6
5
9
28
87
47
Housing
24
8
25
5
54
31
146
78
Water System
40
14
20
3
59
26
162
87
Sewage System
42
14
23
I 2
60
30
171
91
Distance to Physician
42
15
25
8
3
31
124
66
Distance to Hospital
42
15
25
1 7
3
31
123
66
Availability of Planner
44
4
25
9
3
32
117
63
Availability of Plan
44
3
25
j 9
3
32
116
62
All factors
14
3
4
2
0
20
43
23
* Information not requested on distance to city of 25, 000 population.
-------
complete data.
Size of Communities. The distribution of communities, by state, accord-
ing to size of population (1970 Census) is shown in Table 4-5. As indicated from
these data, more than 65 percent of the communities had populations of 1,000 or
less in 1970; the population in more than 80 percent of the 194 communities for
which data were available had populations of less than 2, 500 in 1970.
Adverse Conditions Reported
Using the criteria indicated in Table 4-1, the frequency of occurrence of
adverse conditions was determined for each of the factors on which data were ob-
tained. The percent of communities for which adverse conditions were reported
then was calculated. These data, by states and for all states combined for the
1974 and 1975 surveys, are shown in Table 4-6 and Table 4-7 respectively. (Data
for individual communities are included in Appendix D.)
Trends in Occurrence of Adverse Conditions. The number of commu-
nities involved in Montana and South Dakota is too small to enable tenable in-
ferences from data for those states. Trends are apparent from data for the
other states, although rigorous statistical analyses are not indicated for them
because of small numbers and other characteristics of the data. Some indica-
tions from the data are useful, however, for planning further work; they also
probably are adequate indications of conditions that have occurred, are now
taking place, or are anticipated in the study area.
The factors for which unfavorable conditions were reported most fre-
quently were water supplies and sewage disposal systems. For 1974, 85 percent
of the communities reporting on water supplies indicated unfavorable conditions,
4-13
-------
Table 4-5. Distribution, by states, of communities according to size of population at 1970 Census. Includes
communities surveyed in Region VIII that provided suitable data on population for 1974 or 1975.
State
Number
of
Communities
Number of Communities
with Number of Persons Indicated
Percent of Communities
with Number of Persons Indicated
< 1000*
1001 -
2500
2501 -
5000
> 5000
< 1000
1001 -
2500
2501 -
5000
>5000
Colorado
45
34
6
4
1
76
13
9
2
Montana
15
12
1
1
1
80
7
7
7
North Dakota
25
17
5
0
3
68
20
0
12
South Dakota
9
3
1
4
1
33
11
45
11
Utah
61
40
15
3
3
66
25
5
5
Wyoming
39
22
4
6
7
56
10
15
18
All States
194
128
32
18
16
66
17
9
8
* Includes unincorporated communities for which population data were not provided.
-------
Table 4-6. Percent of all communities providing data that reported adverse conditions of factors associated
with health impacts resulting from development of energy resources in Region VIII.
1974
Factor
Percent of Communities in States Reporting Adverse
Condition of Factor Indicated
Colorado
Montana
North
Dakota
South
Dakota
Utah
Wyoming
, All States
Population: 1970 - 1974
-
63
i. , ....
75
0
40
29
63
47
1974 - 1977
79
100
8
80
*
70
68
Housing
22
75
6
20
50
33
30
Water System
88
100
0
25
100
74
85
Sewage System
47
100
50
25
71
82
66
Distance to Physician
21
50
56
60
33
48
40
Distance to Hospital
5
33
0
40
14
0
10
Distance to City of 25, 000
Population
26
100
24
40
94
40
61
Availability of Planner
89
0
89
100
7
64
46
Availability of Plan
84
100
61
100
18
80
71
* Population data not provided for individual communities.
-------
Table 4-7. Percent of all communities providing data that reported adverse conditions of factors associated with
health impacts resulting from development of energy resources in Region VIII.
1975
1
Percent of Communities
in States Reporting Adverse
Conditions of Factor Indicated
North
South
Factor*
Colorado
Montana
Dakota
Dakota
Utah
Wyoming
All States
Population: 1970 - 1974
50
0
16
0
23
55
32
1974 - 1977
79
17
o
60
78
64
63
Housing
17
25
24
20
54
39
39
Water System
53
64
15
67
80
69
62
Sewage System
64
93
48
50
78
70
70
Distance to Physician
38
40
40
0
0
35
35
Distance to Hospital
7
27
0
17
0
3
7
Availability of Planner
0
0
24
0
67
0
7
Availability of Plan
84
33
84
78
67
69
78
* Information not requested on distance to city of 25, 000 population.
-------
according to the criteria used in this study. The percent of adverse conditions
of sewage systems was 66 for 1974. Corresponding figures for 1975 were 62 and
70 respectively. These figures suggest that water supplies in some communities
were improved during this period, or that the characteristics of the communities
surveyed in 1975 but not in 1974 were different from those surveyed for both 1974
and 1975. (Evaluation of the latter possibility is considered below.) A corres-
ponding improvement was not noted for the sewage disposal systems.
An apparent decrease occurred from 1974 to 1975 in the reporting of ad-
verse conditions attributed to population for the 1970-1974 period. This may
have resulted from change or cancellation of plans for industrial development,
and consequently less population growth than was anticipated when the projections
were made in 1974. Approximately the same proportion of communities projected
adverse conditions of population for the period 1974-1977 during the surveys con-
ducted for both 1974 and 1975.
These data indicate an appreciable improvement in the availability of plan-
ners to the communities from 1974 to 1975. This difference probably reflects a
vast increase in attention to planning in the affected communities. That the in-
crease may have been recent is suggested by the data on availability of community
plans; approximately the same percent of communities reported adverse conditions
with respect to this factor in 1974 and 1975.
Adverse conditions for the remaining factors were reported in about the
same proportion for 1974 and 1975. Mention should be made of the relatively low
proportion of communities that reported adverse conditions for housing. Although
4-17
-------
housing is recognized as one of the crucial factors in boomtown situations, data
from the surveys did not reflect unfavorable conditions to the extent that they were
reported for other factors. Several circumstances contributed to this. For ex-
ample, in this analysis the ratio of the 1974 estimated population was related to
the housing inventory for 1974. This was considered as an intermediate position
in aggregating data for the communities. The data available did not indicate
whether a population increase had occurred, was in progress, or was anticipated.
Furthermore, housing is a critical limiting factor; the population increase of a
community is determined largely by the availability of housing. Data collected
during the surveys included only permanent housing units and mobile homes;
statistics on various other types of temporary housing were not obtained.
Variations in Proportion of Communities Reporting Adverse Conditions.
In ail effort to illustrate the extent of apparent change in the proportion of com-
munities that reported adverse conditions, the number of percentage-point
differences in the percent of adverse conditions reported for 1974 and 1975
was determined for each factor on which data were obtained. The direction
of change in the 1975 percent of adverse conditions from those reported for
1974 also was noted. Thus, a plus ( + ) indicates a worsening situation be-
cause a greater proportion of communities reported adverse conditions for
1975 than for 1974. The data developed in this way are shown in Table 4-8.
No special quantitative significance should be attributed to the extent of change
between the various factors as indicators of priority for corrective measures.
This is considered in the subsequent section. The direction of change and the
factors involved, and the extent of change, may be approximated from these
4-18
-------
Table 4-8. Changes in percent of adverse conditions of factors associated with health impacts resulting from
development of energy resources in Region VIII; reported for all communities providing data, by
states, for 1974 and 1975. Data were derived from Table 4-6 and Table 4-7.
Change in
Percent of Communities Reporting Adverse
Conditions for Factors Indicated
1 North
South
Factor
Colorado
Montana
j Dakota
Dakota
Utah
Wyoming
All States
Population: 1970 - 1974
-13
-75
+16
-40
- 6
- 8
-14
1974 - 1977
0
-83
- 8
-20
sis*
- 6
- 1
Housing
- 5
-37
+18
0
+ 4
+ 6
+ 9
Water System
-35
-36
+15
+25
-20
- 5
-24
Sewage System
+17
- 7
- 2
0
+ 7
-12
+ 3
Distance to Physician
+ 17
-10
-i6
-60
-33
-13
- 5
Distance to Hospital
+ 2
- 5
°
-26
-14
+ 3
- 3
Distance to city of 25, 000
Population"1
Availability of Planner
-89
0
-65
-40
+ 6
-64
-39
Availability of Plan
0
-67
+23
-22
+49
-11
+ 7
* Data on this factor were not requested for 1975.
** Population data not available for individual communities for 1970 - 1974.
-------
data. There is a general indication that water systems and availability of plan-
ners improved substantially but that other factors remained about the same.
The apparent improvement in the population variable for 1970-1974 was con-
sidered above. The small numbers available for analysis should, of course,
be kept in mind when considering these data.
Validity of Comparisons. In addition to the inherent limitations of
these data, which are considered subsequently in this chapter, the validity of
comparisons of the 1974 and 1975 data may be questioned on the basis that at
least some different communities were involved in the surveys for 1974 and
1975. The 1974 survey included 126 communities and the 1975 involved 187
communities. In an effort to refine these analyses, data were examined for
the 119 communities that were included in both the 1974 and 1975 surveys.
The percent of communities, by states, that reported adverse conditions of
the considered factors was determined, as was done for all communities as
indicated above. Data for the 119 communities are shown in Table 4-9 and
Table 4-10. The difference in percent of reported adverse conditions also was
determined for all communities. These data are shown in Table 4-11. Com-
parisons were made of the percent change in reported occurrence of adverse
conditions between 1974 and 1975 for all communities, and for the 119 that
were included in both surveys. (See Table 4-8 and Table 4-11.) Although the
magnitude of difference between the two sets of data varies in some instances,
the general direction of change is the same, except for housing. This, as well
variations in other factors, is attributable to the large changes in percentages
4-20
-------
Table 4-9. Percent of all 119 communities providing data for both 1974 and 1975 that reported adverse conditions
of factors associated with health impacts resulting from development of energy resources in Region VIII.
1974
North
South
State
Colorado
[ Montana
Dakota
Dakota
Utah
Wvomins-
All States
Number of Communities
Percent of Communities in States Reporting
Factor
Adverse Conditions of Factor Indicated
Population: 1970 - 1974
67
75
0
40
29
67
46
1974 - 1977
83
100
8
80
*
63
62
Housing
24
75
6
20
50
35
31
Water System
94
100
0
25
100
79
86
Sewage System
50
100
50
25
71
81
| 65
Distance to Physician
22
50
56
60
33
47
39
Distance to Hospital
5
33
0
40
14
0
10
Distance to City of 25, 000
Population
28
100
24
40
94
42
63
Availability of Planner
94
0
89
100
8*
63
45
Availability of Plan
83
100
61
100
18
74
69
* Data not available
-------
Table 4-10. Percent of all 119 communities providing data for both 1974 and 1975 that reported adverse conditions
of factors associated with health impacts resulting from development of energy resources in Region VIII.
1975
State
Colorado
Montana
North j South
Dakota | Dakota
Utah
Wyoming
All States
Number of Communities
.
1 6 18 | 5
53
19
119
Factor
Percent of Communities in St;
Adverse Conditions of Facte
ites Reporting
3r Indicated
Population: 1970 - 1974
1974 - 1977
Housing
Water Supply
Sewage System
Distance to Physician
Distance to Hospital
Distance to City of 25, 000
Population**
Availability of Planner
Availability of Plan
72
94
67
69
50
22
6
0
83
0
0
0
67
83
33
33
*
*
17 0
0 100
22 I 50
14 0
47 0
44 0
0 33
28 0
78 I 80
23 .
! 78
26
90
78
*
*
u.
0
74
71
37
79
94
32
0
0
58
37
73
29
72
71
31
6
8
73
* Data not available
** Data not requested for 1975
-------
Table 4-11. Changes in percent of adverse conditions of factors associated with health impacts resulting from
development of energy resources in Region VIII; reported, by states, for all 119 communities for
which data were available for both 1974 and 1975. Data were derived from Table 4-9 and Table 4-10.
Change in Percent of Communities Reporting
Adverse Conditions for Factor Indicated
Factor
Colorado
Montana
North
Dakota
South
Dakota
Utah
Wvomine
All States
Population: 1970 - 1974
+ 5
- 75
+17
- 40
- 6
+ 7
- 9
1974 - 1977
+11
-100
- 8
+ 20
*
+ 8
+11
Housing
+43
- 75
+16
+ 30
-24
+ 2
- 2
Water System
-25
- 33
+14
- 25
-10
0
-14
Sewage System
0
- 17
- 3
- 25
+ 7
+13
+ 6
Distance to Physician
0
- 17
-12
- 60
*
-15
- 8
Distance to Hospital
+ 1
0
0
- 7
0
- 4
Distance to City of 25, 000
Population
Availability of Planner
-94
*
-61
-100
*
-63
-37
Availability of Plan
0
*
+ 17
- 20 j
-18
-16
+ 4
* Data not available
** Data not requested for 1975. Presumably, there would be no change from 1974.
-------
resulting from relative small changes in actual numbers of experiences in some
states reporting for a small number of communities. It also is due to other
aberrations resulting from use of small numbers.
The extent of change for all states was determined even though some data
were not available for some of the factors. Tests indicated that the percent
change calculated for all states was not appreciably affected, either because data
on the same factor were missing for the same state in both surveys, or because
omission of small numbers did not affect the trend or significantly offset the mag-
nitude of change.
Extension of Interpretations. In attempting to extend the interpretations
of any of these data, it is essential to take into account the small number of com-
munities involved in some states, the low proportion of reporting for some factors,
the lack of reports on some factors, and the tenuous implications derived from
small samples. For these reasons, in evaluating die relative frequency of ad-
verse conditions, aggregation of data for all slates was considered, rather than
for the states individually. These limitations are illustrated by Table 4-12 which
indicates the number of communities for which data were obtained on the various
factors during the survey for 1974 and 1975.
Considering the inconsistency of reports available for the 119 communities,
the question might be raised as to why the analyses were not confined to those com-
munities for which data were available for all factors for both 1974 and 1975. Such
data were available for only seven communities -- four in Wyoming, two in Colo-
rado, and one in South Dakota. Such a small sample obviously is inadequate for
4-24
-------
Table 4-12. Number of communities and number for which data were available on factors associated with health
impacts resulting from development of energy resources in Region VIII. Data are for 119 communities
involved in sruveys of conditions for both 1974 and 1975.
North
South
State
Colorado
Montana
Dakota
Dakota
Utah
Wyoming
All States
Number of Communities
18
6
18
5
53
19
119
Numfc
>er of Communities for Which Data were
Available on Factors Indicated for 1974 and 1975
Factor
1974
1975
1974
1975
1974
1975
1974
1975
1974
1975
1974
1975
1974
1975
Population: 1970 - 1974
18
18
4
1
12
18
5
5
17
53
18
19
74
114 •
1974 - 1977
18
18
4
1
12
5
5
2
0
9
8
17
47
52
Housing
17
3
4
3
16
18
5
2
16
53
17
19
75
98
Water System
16
16
1
6
5
14
4
1
51
48
14
14
92
99
Sewage System
16
18
2
6
14
17
4
1
52
51
16
16
104
109
Distance to Physician
18
18
6
6
18
18
5
4
51
0
19
19
117
65
Distance to Hospital
18
18
6
6
18
18
5
3
51
0
19
19
117
64
Distance to City of 25, 000
Population*
18
6
17
5
52
19
117
Availability of Planner
18
18
6
0
18
18
5
5
53
0
19
19
119
60
Availability of Plan
18
18
6
0
18
18
5
5
11
0
19
19
77
60
* Data not requested for 1975.
-------
valid comparative analyses . In the next section, the analyses of selected factors,
singly and In combinations, are considered as a useful means for classifying com-
munities as to the relative extent of impact.
Approaches to Classifying Communities
In developing criteria for classifying the communities with respect to the ex-
tent of health impacts, the frequency of reporting specific adverse conditions was
taken into account. Several different combinations of factors were considered and
tested with various weighting schema . The decision was made to evaluate the com-
munities by employing three sets of factors: (1) population alone, (2) population in
combination with water and sewage, and (3) all factors together . Population was
evaluated separately because of the basic causal influence on the other factors
considered in the surveys. As shown in the previous section, water supplies
and sewage disposal, among the factors on which data were obtained, are likely
to have the greatest impacts on health in the communities involved in this study.
These factors were evaluated in combination with population to reflect the rela-
tive impact of the three factors considered to be most significant. Evaluations
were made using all factors to indicate their combined effect and for compari-
son with results obtained using the other two sets of factors.
Availability of Data. The communities classified, using these three
sets of factors, included all communities for which data were available on the
factors being considered. The numbers of communities available for types of
classification were as follows:
1974 1975
All factors 30 43
Population, water, sewage 32 68
Population 61 96
4-26
-------
As indicated previously, two sets of data were developed relating to the health
impacts in the study communities. One data set indicated the number of adverse
conditions identified in each community; the other set indicated the intensity and
relative significance of selected factors that affected health impacts in the commu-
nities. (See Appendix D and Appendix E.)
Criteria for Classifying Communities. In order to assign communities
to the specified categories -- significantly impacted, moderately impacted, po-
tentially impacted --it was necessary to develop criteria for each set of data
and for each set of factors selected for analysis. The guidelines indicated below
were devised for classifying the communities. The criteria for determining ad-
verse conditions associated, with development of energy resources are shown in
Table 4-1. The weights assigned to factors, in order to indicate the intensity
and significance of adverse conditions, are shown in Table 4-2.
Criteria for Classifying Communities According to the Number of Adverse Conditions
Combination of All Factors
Significantly impacted:
Moderately impacted:
Potentially impacted:
> 6 adverse conditions.
4 to 6 adverse conditions.
< 3 adverse conditions.
Combination of Three Factors: Population, Water, Sewage
Significantly impacted: adverse population condition
for either 1970-1974 period
or 1974-1977 period, or for
both periods, and adverse
conditions for both water and
sewage.
Moderately impacted:
adverse population condition for
either or both periods and adverse
conditions for either water or
sewage.
4-27
-------
Potentially impacted:
adverse conditions for popu-
lation only, adverse conditions
for either water or sewage, or
adverse conditions for both water
and sewage.
Single Factor: Population
The significance of population was evaluated using data for the two periods
considered in the surveys. Population ratios were calculated using the 1970 Census
data and estimates for 1974 and 1977. (In some cases, when estimates were pro-
vided for years otiier than 1974 and 1977 -- e.g. , 1973 and 1980, 1975 and 1978 --
ratios were calculated using the data supplied.) The calculations were made as
follows -- 1974 estimated population: 1970 Census; and 1977 estimated population:
1974 estimated population. 'The results provided an indication of population change
for the four-year interval between the 1970 Census and the 1974 estimate, and for
the three-year period between the 1974 and 1977 population estimates. (These
data are included in Appendix C.) The average annual percent of population change
was approximated from these ratios. Whether or not an adverse condition was
attributable to population was determined by the criteria for population indicated
in Table 4-1. The communities then were classified on the basis of the population
factor as follows:
Significantly impacted: adverse population condition
for both periods.
Moderately impacted:
adverse population condition
for only one period.
Potentially impacted:
adverse population condition
for neither period.
4-28
-------
Weighted Significance and Intensity of
Factors
Combination of All Factors
Significantly impacted: > 24 aggregated weight of
all factors.
Moderately impacted: 13-24 aggregated weight of
all factors.
Potentially impacted: 0-12 aggregated weight of
all factors.
Combination of Three Factors: Population, Water, Sewage
Significantly impacted: > 10 aggregated higher weight
for population for period 1970-
1974 or 1974-1977, water, and
sewage.
Moderately impacted: 6-10 aggregated higher weight
for population for period 1970-
1974 or 1974-1977, water, and
sewage.
Potentially impacted: < 5 aggregated higher weight
for population for period 1970-
1974 or 1974-1977, water, and
sewage.
Single Factor: Population
Significantly impacted:
Moderately impacted:
Potentially impacted:
> 12 aggregated weight for
population for periods 1970-1974
and 1974-1977.
8-10 aggregated weight for popu-
lation for periods 1970-1974 and
1974-1977.
< 7 aggregated weight for popu-
lation for periods 1970-1974 and
1974-1977.
4-29
-------
Classification of Communities
Using these guidelines, all communities were classified as significantly
impacted, moderately impacted, or potentially impacted. Classifications were
determined on the basis of the number of adverse conditions (Table 4-1) and by
the intensity and relative significance of the factors considered in the FRC sur-
veys (Table 4-2). All communities were included for which sufficient data were
available on the three combinations of factors selected for comparison, i.e.,
all factors; population, water, and sewage together; and population alone. The
results of these classifications are provided in Appendix F.
Number of Communities Available for Analysis. The number of com-
munities available for analysis using these procedures are shown, by states,
in Table 4-13. As indicated by these data, for 1974 a total of 30 communities
surveyed in Region VIII provided completed data of all factors considered.
Classification of two additional communities was possible by evaluating factors
of population, water, and sewage in combination. An additional 29 communities
were classified on the basis of population. Similar figures for 1975 were: 43
communities provided data on all factors; 25 additional ones on population,
water, and sewage; and 28 others on population that did not provide data on
water and sewage.
Thus, of the 126 communities from which data were obtained for 1974
(Table 4-3), sufficient data were available for 61. This comprised about half
of the communities, which enabled classification to be made using one of the
three methods. For the 187 communities included in the survey for 1975
(Table 4-4), about the same proportion of communities, 96, was available
4-30
-------
Table 4-13. Number of communities, by states, for which data were available for classifying the extent of health
impacts resulting from development of energy resources in Region VIII by using three combinations
of factors.
r ""
Number of Communities Available for Analysis by Three Procedures
1974
1975
|State
All Factors
1 Population
Water
Sewage
Population
All Factors |
Population
Water
Sewage
Population
Colorado
16
17
19
14
28
31
Montana
1
1
4
3
5
6
North Dakota
3
3
12
4
4
6
South Dakota
4
4
5
2
2
5
Utah
0
0
12*
0
8
20
Wyoming
6
7
9
20
21
28
All States
30
32
61
43
¦
68
96
*Data are for 12 counties; not available for individual communities.
-------
for classification.
Methods for Characterizing Communities. Using the data obtained by
classifying the communities (Appendix F) and the complete data for all commu-
nities (Appendix C), procedures were developed for preparing the specified
listing of communities in three groupings: significantly impacted, moderately
impacted, and potentially impacted.
-- Communities for Which Data were Inadequate. Those communities
were first considered for which no data were available or for which
data were insufficient to enable classification by methods developed
for this purpose. Any community identifed for inclusion in this study
may be presumed to be, at the least, potentially impacted by energy
developments. Therefore, these communities -- approximately half
the total number of communities -- are listed in the "potentially im-
pacted" group. The communities for which data were lacking or
were insufficient for classification are identified as such.in the list.
- - Communities for Which Data were Adequate for Analysis. Guidelines
then were developed for determining the extent of impact in the re-
maining communities, i.e., those for which adequate data were avail-
able for analysis. The communities determined to be significantly
impacted by any of the three methods of evaluation were first con-
sidered. The names of these communities and relevant data were
extracted from the data in Appendix F (Table 4-14). This list includes
the names of the communities determined to be significantly impacted,
4-32
-------
Table 4-14. List of communities, by state, which were classified as significantly impacted by any one tfr more of three methods for
determining the relative extent of health impacts resulting from energy developments in Region VIII. Data include
classification by three methods using three combinations of factors. (See text.)
I
CO
CO
J 974
1975
Classification by Number
Classification by Intensity
Classification by Number
Classification by Intensity
of
and Relative Significance
of
and Relative Significance
Adverse Conditions
of Factors
Adverse Conditions
of Factors
Population
Population
Population
Population
All
Water
All
Water
All
Water
All
Water
State and Community
Factors
Scwat^:
Population
Factors
Scwesw
Population
Factors
Sewage
Population
Factors
Sev/are
Population
Colorado
Bennett**
M
M
s
M
M
P
Straushurg**
—
—
s
—
—
P
Deertrall**
M
M
s
M
M
P
Cedaredge**
M
M
s
. M
S
M
Crawford**
M
S
s
M
s
P
Orchard City**
M
M
s
M
s
M
Paonia**
M
S
M
M
s
P
Carbondale
M
s
s
s
s
s
M
M
S
S
s
S
Glenwood Springs
M
p
p
M
M
P
—
S
M
—
s
M
Grand Valley
S
s
s
S
S
s
—
S
S
—
s
S
New Castle
S
s
s
M
s
p
—
M
S
—
M
P
Rifle
M
• s
M
S
s
s
—'
M
M
—
s
M
Silt
M
M
s
S
s
M
—
M
S
—
M
M
V/alden
S
S
M
s
s
M
S
M
s
M
M
P
Cokcdale**
P
P
p
M
S
P
Cnilbran
M
M
M
M
s
M
—
P
s
—
M
M
DeBeque
M
M
S
s
s
S
—
M
s
—
S
S
Fruita
M
M
M
M
s
"M
—
P
p
—
M
P
Palisade
M
M
M
M
s
M
—
P
M
—
M
M
Craig
M
P
S
M
M
S
—
M
S
—
S
S
Dinosaur
S
M
S
S
s
S
. —
M
S
—
S
M
Meeker
S
S
s
S
s
s
—
S
S
—
s
M
Rangely
—
S
M
—
M
p
—
S
s
—
s
M
Hayden
s
M
s
s
s
s
—
s
s
—
s
S
Oak Creek
—
— ^
s
—
—
M
—
—
s .
—
—
S
Yampa
—
—
M
—
—
P
—
—
s
—
—
s
Montana
Colstrip*
—
—
s
s
s
M
Forsyth*
s
S
s
s
s
M
Lame Deer*
—
—
s
—
—
M
North Dakota
None
-------
Table 4-14. (Continued)
i
co
vt^
1974
1975
Classification by Number
Classification by Intensity
Classification by Number
Classification by Intensity
of
and Relative Significance
of
and Relative Significance
Adverse Conditions
of Factors
Adverse Conditions
of Factors
Population
Population
Population
Population
All
Water
All
Water
All
Water
All
Water
State and Communltv
Factors
Scwaire
Population
Factors
Sewaco
Ponulatlon
Factors
Scwarrc
Population
Factors
Sows ere
Pooulation
South Dakota
Edgemont*
M
P
S
M
p
M
Camp Crook*
S
S
s
s
s
P
Utah
Escalante**
—
s
s
—
s
s
Panguitch**
—
S
M
—
s
" p
Tropica**
-f-
s
M
—
s
s
Cedar City**
—
p
P
¦—
s
p
Parowan
—
M
M
—
s
s
Kane County*
—
—
s
—
—
M
Enterprise**
—
s
M
—
s
p
Hurricane**
—
S
M
—
s
s
St. George**
—
M
M
—
s
M
Wyoming
Gillette
s
s
s
s
s
S
p
s
M
M
s
M
Hanna**
¦
_
s
—
—
S
Medicine Bow**
s
s
S
S
s
S
Douglas*
—
—
s
—
—
S
Glenrock
S
s
s
s
s
M
Buffalo
p
p
s
M
M
M
M
s
s
M
s
M
Diamondville*
—
—
s
—
—
P
Evansville**
M
s
s
s
s
S
Wheatland
—
M
—
—
S
P
M
M
M
s
M
Big Horn**
M
s
s
s
s
S
Ranchester*
s
s
s
s
S
M
Story**
P
p
p
M
s
P
Granger**
S
s
s
s
s
S
Green River**
M
s
s
M
s
s
Rock Springs
M
p
M
M
s
S
M
M
M
M
s
M
South Superior**
S
M
s
S
s
s
Wamsutter**
M
P
s
S
s
s
Fort Bridger*
—
s
M
—
s
P
Lyman
M
s
M
S
s
s
s
S
s
S
s
s
Mountain View*
M
p
P
s
s
P
* Data available for 1974 only
** Data, available for 1975 only
— Data not available
S - Significantly Impacted
M - Moderately Impacted
P - Potentially Impacted
-------
by any of the methods of classification used in this study, from data
for either 1974, 1975, or both years. Also included with these data
are all classifications of the extent of impact for the communities
by any of the procedures used and for all data available. Shown in
Table 4-15 are the number of communities on this list, by states,
i.e., the total number of communities available for classification
and the number classified as significantly impacted.
Analysis of Criteria for Classifying Communities. After evaluating
several alternative criteria, with a view toward selecting only the most severely
affected communities for classification as significantly impacted, it was deter-
mined that instead of reducing the list, all communities on this list should be
so designated. This decision involved several considerations: in the first place,
two different sets of criteria were used to evaluate the communities. There was,
of course, no objective means to determine which provided the more accurate
results, since standard measurements are available for evaluating the extent
of health impacts with which the classification procedures developed for this
study could be appraised. A comparison was made of the number of significantly
impacted communities revealed by the two procedures, i.e., the number of adverse
conditions and the intensity and relative significance of factors. Using the three
groups of factors -- all factors; population, water, and sewage combined; and
population alone -- data were considered only for the communities that provided
reports for all factors. Data were combined for 1974 and 1975 surveys to provide
the largest possible numbers for analysis. (See Table 4-16). The classification
4-35
-------
Table 4-15. Number of communities, by state, available for classification and number classified as
"significantly impacted" by any one or combination of three methods for impacts resulting
from energy developments in Region VIII.
| 1974
' 1975
State
Number of Communities
Available for Analysis
[ Significantly
1 Impacted
Number of Communities
Available for Analysis
Significantly
Impacted
Colorado
19
18
31
26
Montana
4
3
6
0
North Dakota
12
0
6
0
South Dakota
5
2
5
0
Utah
12 (counties)
1
20
8
Wyoming
9 l
9 .
28
16
All States
61
33
96
50
-------
Table 4-16. Comparison of number of significantly impacted communities identified by classifications based on (1) number of adverse conditions,
and (2) intensity and significance of factors associated with adverse health effects resulting from energy developments in Region VIII.
Data are for three sets of factors: (1) all factors, (2) population, water, and sewage, and (3) population. Combined data for 1974
and 1975 for communities with data on all factors.
I
CO
^0
Number of Significantly Impacted Communities by Three Combinations of Factors and Two Classification Schema
All Factors
| Population, Water, Sewage
Popula
tion
State
Number
of Adverse
Conditions
Intensity and
Significance
of
Factors
Both
Total
Number
of Adverse
Conditions
Intensity and
Significance
of
Factors
Both
Total
Number
of Adverse
Conditions
Intensity and
Significance
of
Factors
Bom
Total
Colorado
2
5
5
12
1
15
12
28
8
1
8
17
Montana
1
1
1
1
2
2
North Dakota
South Dakota
1
1
1
1
2
2
Utah
Wyoming
5
7
12
7
15
22
4
2
9
15
All States
2
10
14
26
1
22
29
52
16
3
17
V
36
-------
procedure employing weighted intensity and relative significance of factors clearly
revealed a larger number of significantly impacted communities than did the pro-
cedure using the number of adverse conditions when evaluation was based on all
factors and combinations of the factors concerning population, water, and sewage.
A greater number of significantly impacted communities were identified by
measuring the number of adverse conditions when the factor of population was
evaluated alone. This is due to the large number of class intervals used in the
weighting of the population variables.
No implication of the relative effectiveness of using the various combina-
tions of factors is intended. There were two principal reasons for using these
specific combinations. The first was to enable analysis of as many communities
as possible, although evaluation using one set of factors is not necessarily com-
parable with evaluations employing the other sets. The second reason was that
certain characteristics of the data, as discussed in the following section, raised
serious questions as to the comparability of data for various states and communi-
\
ties and the relevance of the data for determining health impacts. Both objective
and empirical information strongly suggest that the combined factors of popula-
tion, water, and sewage -- among the factors for which data are available -- are
the strongest indicators of adverse conditions. This belief is corroborated by the
data in Table 4-17. These data summarize reports for Colorado and Wyoming
communities that provided data for all factors considered in the surveys for 1974
and 1975 and which were determined to be significantly impacted by any methods
employed in this study. As shown by the data in Table 4-17, the factors of
4-38
-------
Table 4-17. Comparative frequency with which significantly impacted communities were identified by various
combinations of factors associated with adverse health effects associated with energy development
in Region VIII. Data for Colorado and Wyoming for 1974 and 1975 were combined for all communities
providing data on all factors for either or both years and evaluated by (1) number of adverse condi-
tions, and ( 2) relative intensity and significance of factors.
Number of Communities Identified as Significantly Impacted by Method and Use of Factors Indicated
State
All Factors
Population,
Water, and
Sewage
I Population
All Factors;
Population,
Water, and
Sewage; .
Population
All Factors;
Population,
Water, and
Sewage
All Factors;
Population
Population,
Water, and
Sewage ;
Population
Total
Number of Adverse Conditions
Colorado
0
2
7
3
1
4
2
19
Wyoming
0
2
°
6
0
1
4
13
Intensity and Relative Significance of Factors
Colorado
0
10
1
8
2
0
0
21
Wyoming
0
5
0
9
3
0
2
19
-------
population, water, and sewage in combination occurred more frequently than
any other set of factors as identifiers of significant impact.
The use of the population factor alone for classifying the communities is
highly tenuous. The validity of the population data for use in evaluating some
communities is questionable, as discussed subsequently. In the absence of
knowledge concerning community environmental facilities, an evaluation could
not be made as to whether or not a specific community has the potential capacity
to cope with population growth.
The above discussion relates to descriptions of procedures used in classi-
fying the extent of health impacts and to the evaluation of methods employed by ex-
amining the data for communities identified as significantly impacted. Similar
studies were made, in less detail, for the communities identified as moderately
or potentially impacted. On the basis indicated above for the significantly im-
pacted communities, it was determined that all communities identified as moder-
ately or potentially impacted by any procedure, using data for 1974, 1975, or both
years, should be listed in the respective categories.
Determined Extent of Impact. Lists of communities in the specified
groupings are provided in Table 4-18. The data used in classifying die commu-
nities also are indicated. In evaluating this list, the classification of communi-
ties using the data on the combined factors of population, water, and sewage
should be considered the most reliable. Next in order of probable reliability
are those classified using all factors. It is likely that in using data for all fac-
tors, the weights of the most significant variables -- population, water, and
4-40
-------
Table 4-18. Names of communities listed, by states, in groupings of significantly
impacted, moderately impacted, and potentially impacted as a result
of adverse health effects attributable to energy developments in
Region VIII. Combinations of factors used in classifying communities
are indicated. Data for 1974, 1975, or both years were considered.
(See text.)
Significantly Impacted Communities
State, Community
Data Used to Rate Communities
Population,
All Factors
Water, Sewage
Population
Colorado
Bennett
X
Carbondale
X
Cedaredge
X
Cokedale
X
Collbran
X
Craig
X
Crawford
X
De Beque
X
Deer trail
X
Dinosaur
X
Fruita
X
Glenwood Springs
X
Grand Valley
X
Hayden
X
Meeker
X
New Castle
X
Oak Creek
X
Orchard City
X
Palisade
X
Paonia
X
Rangely
X
Rifle
X
Silt
X
Strasburg
X
Walden
X
Yampa
X
4-41
-------
Significantly Impacted Communities
L ,
State, Community
Data Used to Rate Communities
Population,
All Factors
Water, Sewage
Population
Montana
Colstrip
X
Forsyth
X
Lame Deer
X
North Dakota
No Communities
South Dakota
Camp Crook
X
Edgemont
X
Utah
Cedar City
X
Enterprise
X
Escalante
X
Hurricane
X
Kane County
X
Panquitch
X
Parowan
X
St. George
X
Tropic
X
Wyoming
Big Horn
X
Buffalo
X
Diamondville
X
Douglas
X
Evarisville
X
Fort Bridger
X
Gillette
X
Glenrock
X
Granger
X
Green River
X
Hanna
X
4-42
-------
Significantly Impacted Communities
State, Community
Data Used to Rate Communities
Population,
All Factors
Water, Sewage
Population
Wyoming (cont'd)
Lyman
X
Medicine Bow
X
Mountain View
X
Ranchester
X
Rock Springs
X
South Superior
X
Story
X
Warns utter
X
Wheatland
X
4-43
-------
Moderately Impacted Communities
State, Community
Data Used to Rate Communities
Population,
All Factors
Water, Sewage
Population
Colorado
Aguilar
X
Delta
X
Grand Junction
X
Hotchkiss
X
Starkville
X
Montana
Circle
X
Hardin
X
Hysham
X
Lodge Grass
X
Miles City
X
Nortli Dakota
Beulah
X
Bismarck
X
Halliday
X
Killdeer
X
Stanton
X
South Dakota
Buffalo
X
Hot Springs
X
Spearfish
X
Whitewood
X
Utah
Beaver
X
Beaver County
X
Daggett County
X
Duchesne County
X
Garfield County
X
Iron County
X
Washington County
X
4-44
-------
Moderately Impacted Communities
State, Community
Data Used to Rate Communities
Population,
All Factors
Water, Sewage
Population
Wyoming
Casper
X
Chugwater
X
Dayton
X
Evanston
X
Fort Laramie
X
Lander
X
Meeteetse
X
Moorcroft
X
Newcastle
X
Rawlins
X
River ton
X
Torrington
X
4-45
-------
Potentially Impacted Communities
State, Community
Data Used to Rate Communities
Population,
Data Not Available
All Factors
Water, Sewage
Population
or Inadequate
Colorado
Bowie
X
Brush
X
Byers
X
Dove Creek
X
Egnar
X
Gateway
X
Lazear
X
May bell
X
Phippsburg
X
Redland Mesa
X
Redstone
X
Rogers Mesa
X
Slick Rock
X
Somerset
X
Montana
Ashland
X
Birney
X
Broadus
X
Crow Agency
X
Decker
X
Rosebud
X
Scobey
X
Wyola
X
North Dakota
Center
X
Coleharbor
X
Dickinson
X
Dodge
X
Dunn Center
X
Garrison
X
Glen Ullin
X
Golden Valley
X
Hazen
X
Hebron
X
Mandan
X
4-46
-------
Potentially Impacted Communities
State, Community
Data Used to Rate Communities
Population,
Data Not Available
All Factors
Water, Sewage
Population
or Inadequate
North Dakota (cont'd)
Manning
X
Mercer
X
New Salem
X
Pick City
X
Turtle Lake
X
Underwood
X
Washburn
X
Wilton
X
Zap
X
South Dakota
Belle Fourche
X
Rapid City
X
Sturgis
X
Utah
Altamont
X
Anna be 11a
X
Antimony
X
Aurora
X
Bic knell
X
Blanding
X
Boulder
X
Cannonville
X
Capital Reef
X
Carbon County
X
Castle Dale
X
Cleveland
X
Coalville
X
Duchesne
X
East Carbon City
X
Elmo
X
Elsinore
X
Emery County
X
F err on
X
Glendale
X
4-47
-------
Potentially Impacted Communities
State, Community
Data Used to Rate Communities
Population
Data Not Available
All Factors
Water, Sewage
Population
or Inadequate
Utah (cont'd)
Glenwood
X
Green River
X
Helper
X
Helt Marina
X
Hiawatha
X
Hilldale
X
Huntington
X
Kanab
X
Koorsharem
X
La Verkin
X
Loa
X
Manila
X
Milford
X
Minersville
X
Monroe
X
Monticello
X
Myton
X
Orangeville
X
Orderville
X
Paragonah
X
Price
X
Redmond
X
Richfield
X
Roosevelt
X
Salina
X
San Juan County
X
Santa Clara
X
Sevier County
X
Sigurd
X
Snow Canyon
X
Summit County
X
Sunnyside
X
Tabiona
X
Tridell
X
Uintah County
X
Vernal
X
Washington
X
Wayne County
X
Wellington
X
4-48
-------
Potentially Impacted Communities
State, Community
Data Used to Rate Communities
Population,
Data Not Available
All Factors
Water, Sewage
Population
or Inadequate
Wyoming
Elk Mountain
X
Elmo
X
Guernsey
X
Jeffrey City
X
Kaycee
X
Kemmerer
X
Mills
X
Sheridan
X
Thermopolis
X
Worland
X
4-49
-------
sewage -- are reduced by inclusion of some factors of less significance as de-
terminants of health impacts. (This is considered further in a following section.)
The use of the population factor alone is considered least reliable, as indicated
above.
Summaries of Classification. It should be noted that the data previously
presented in this chapter, for purposes of illustrating and evaluating methods
used for developing and applying classification procedures, does not involve
all of the data displayed in Table 4-18. A summary of the data in Table 4-18
is provided in Table 4-19. As shown by this summary, of the 212 communities
including 14 Utah counties available for classification, 60 were identified as
significantly impacted, 38 as moderately impacted, and 114 as potentially im-
pacted . As noted above, this evaluation was based on data available for either
or both 1974 and 1975, and each community was classified on the basis of the
data indicating the highest extent of impact.
For other possible applications, summaries of classification of commu-
nities by state are provided in Tables 4-20 and 4-21 for 1974 and 1975 data
respectively. All data available for each of the three sets of factors were used
in classifying the communities. Data available for individual communities are
provided in Appendix D and Appendix E for 1974 and 1975. The number of com-
munities for which data are available are too small for tenable comparative
analyses by states. The percent of communities, for which data were available
for analyses, that were classified as to extent of health impact is shown in Table
4-22. The percent of communities in each category is shown for both methods
4-50
-------
Table 4-19. Number of communities, by state, identified as significantly impacted, moderately impacted, or potentially impacted as
a result of adverse effects attributable to energy developments in Region VIII. Type of data used in evaluating extent of
impact is indicated. Classification is based on data for 1974, 1975, or both years.
I
State
Number of Communities Identified with Indicated Extent of Health Impact by Using Data on the Factors Noted
SigniUcantly Impacted
Moderately Impacted
Potentially Impacted
All
Factors
Population
Water
Sewatre
Pooulatlon
All
Factors
Population
Water
Sewac^;
Population
All
Factors
Population
Water
Sewage
Population
Data Inade-
quate or not
available
Colorado
9
9
8
2
3
0
1
0
0
13
Montana
1
0
2
2
2
1
0
0
1
7
North Dakota
0
0
0
3
1
1
3
0
1
7
South Dakota
1
0
1
2
1
1
0
0
. 2
1
Utah
0
8
1
0
0
7
0
0
5 j
54
Wyoming
11
6
3
4
3
5
0
0
0
10
All States
22
23
15
13
10
15
4
0
18 !
92
All Combination of
Factors
60 .
38
11
4
Total Communities*
212
* Includes 14 Utah counties.
-------
Table 4-20. Number of communities, by state, classified by two methods as to relative extent of health Impacts resulting from
development of energy resources in Region VE, Data are provided for three sets of factors. (See text.)
1974
i
cn
NJ
Classification* by
Number of Adverse Conditions
Classification* by Intensity
and Relative Significance of Factors
All
Factors
Population, Water
Sewage
Population
All Factors
Population, Water
Sewage
Population
State
S
M
P
S
M
P
S
M
P
S
M
P
S
M
P
S
M
P
Colorado
6
9
1
7
7
3
10
7
2
9
6
1
13
4
0
8
6
5
Montana
1
0
0
1
0
0
3
1
0
1
0
0
1
0
0
1
2
1
North Dakota
0
0
3
0
0
3
0
1
11
0
1
2
0
2
1
0
0
12
South Dakota
1
3
0
1
0
3
2
2
1
1
3
0
1
1
2
0
1
4
Utah**
0
0
0
0
0
0
1
5
6
0
0
0
0
0
0
0
4
8
Wyoming
2
3
1
4
0
3
4
4
1
4
2
0
6
1
0
5
2
2
All States
10
15
5
13
7
12
20
20
21
15
12
3
21
8
3
14
15
32
* S - Significantly Impacted
M - Moderately Impacted
P - Potentially Impacted
** Classification of 12 counties; data incomplete or not available for individual communities.
-------
Table 4-21. Number of communities, by state, classified by two methods as to relative extent of health impacts resulting from
development of energy resources in Region VIH. Data are provided for three sets of factors. (See text.)
1975
Classification by
Number of Adverse Conditions
Classification by Intensit
and Relative Significance of F
y
actors
All Factors
Population, Water,
Sewaffe
Population
All Factors
Population, Water,
Sewage
Po
pulatioi
l
State
S
M
P
S
M
P
S
M
P
S
M
P
S
M
P
S
M
P
Colorado
1
8
5
7
12
9
20
5
6
1
10
3
15
12
1
7
10
14
Montana
0
2
1
0
1
4
0
1
5
0
1
2
0
4
1
0
0
6
North Dakota
0
1
3
0
0
4
0
0
6
0
2
2
0
1
3
0
0
6
South Dakota
0
0
2
0
0
2
0
2
3
0
0
2
0
2
0
0
1
4
Utah
0
0
0
5
2
1
1
8
11
0
0
0
8
0
0
4
2
14
Wyoming
5
9
6
9
4
8
12
9
7
8
8
4
14
7
0
9
6
13
All States
6
20
17
21
19
28
33
25
38
9
21
13
37
26
5
20
19
57
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Table 4-22. Comparative extent of health impacts, by state, resulting from energy developments in Region VIH.
Data are for all communities available for evaluation by number of adverse conditions and intensity
and relative significance of factors using three sets of factors. (See text.)
Number of
Intensity and Relative
Method of Classification:
Adverse Conditions
Significance of Factors
Population,
Population,
"Water,
Water,
Factors Used:
All Factors
Sewage
Population
All Factors
Sewage
Population
Percent of Communities Available for Classification
Assigned to Category Indicated
1974
Number of Communities
30
32
61
30
32
61
Available for Classification
Significantly Impacted
33
41
33
50
66
23
Moderately Impacted
50
22
33
40
25
25
Potentially Impacted
17
38
34
10
9
52
1975
Number of Communities
43
68
96
43
68
96
Available for Classification
Significantly Impacted
14
31
34
21
54
21
Moderately Impacted
47
28
26
49
38
20
Potentially Impacted
40
41
40
30 |
7
59
-------
of classification using the three sets of factors. The data in Tables 4-20 through
4-22 are not applicable to comparisons between states or methods. They may
be useful in generalizations concerning extent of impact by states, with atten-
tion to the inadequacies of data previously mentioned and discussed in the fol-
lowing section.
Limitations of Data and Information
The data available for this aspect of the project were collected as an
initial, exploratory study of a problem that had not been adequately defined by
previous investigations. The available guidelines were inadequate to suggest
all of the factors that should be considered in designing more appropriate
surveys. Nor was adequate information available on the most effective proce-
dures for collecting and analyzing data. The following comments are not offered
as derogatory criticism of the highly useful, early efforts to obtain information
concerning the impacts of energy developments in Region VIII. Rather, they
are intended to point out some aspects of content, format, and procedure that
may be altered to provide more useful and definitive data from future efforts.
Some of the issues mentioned briefly here are considered more thoroughly in
the following chapter, which concerns information related to health impacts.
Specific recommendations regarding such data and information are provided
at the end of the next chapter.
A definition of "impacted community" should be developed to permit
identification of communities that should be included in future surveys. Among
factors that may be considered are: proximity to energy development; size of
4-55
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community prior to development as measured by the most recent census; and
known or anticipated data of initiating development.
Plans for reduction and analysis of data should be included in the survey
design. These plans should cover the methods by which data would be processed,
i.e., hand tabulation, punch card, or machine process, and should provide for
surveillance and follow-up to assure maximum completeness and accuracy.
General Observations. The purpose of the surveys and products expected
should clearly be articulated. Types of data required and the anticipated applica-
tion should be defined completely. Sources and users of data and information should
be determined and made available for reference during the design and conduct of
the surveys.
The probable audience for reports and other products resulting from the
surveys should be defined and considered in the survey design and in preparing
accounts of results and interpretations. The usefulness of the final output should
be evaluated on these bases.
Status of Energy Development s) . Information is needed concerning
the dates when construction commenced or is anticipated for each energy develop-
ment that may directly affect the community. The data available for this study
did not indicate whether the development was completed, in progress, or antici-
pated. This has a great influence in determining priorities of effort and, in con-
junction with other information, in defining the extent of impact. As indicated
below, the status of development is not necessarily reflected by population data.
More precise information as to geographic location of the development
in relation to the community also is desirable. This would be useful in assessing
4-56
-------
the relative extent of impacts that may occur when more than one community is,
or would be, affected.
Population Data. Population projections are needed on an annual basis
for accurate evaluation of current and potential health effects, as well as other
conditions in energy-development impacted communities.
The comparison of population data from intervals of three or four years
may omit significant changes in the intervening years. It is possible that con-
struction of a major installation requiring hundreds of workers could occur
during the interval without being reflected in the data recorded for specified
years.
The problems involved in producing annual projections are considerable
but by no means insurmountable. Ideally, in communities where rapid popula-
tion changes are occurring, a census at three- or four-year intervals is desir-
able. The data for intervening years may be estimated by projections and adjust-
ments based upon information of employment estimates, on annual or more fre-
quent bases, from industry, and from local evaluation of demographic indicators.
Although special techniques are required, the services of, or consultantions with,
a qualified demographer usually is available from the state planning agency or
a state university. Obviously, effective arrangements for prompt and accurate
advice from the industries involved are essential.
Information also should be obtained on the procedures used in preparing
the population estimates as well as the source of these data. Much of the data
used in this study appeared to be linear projections of data from the 1970 Census;
4-57
-------
others were apparently developed by local adjustment. A wide variation in re-
liability was suspected, and demonstrable, in some cases. Explanations also
should be sought for changes noted, or recorded, for significant variations in
size of populations or magnitude of projections. This will assist in determining
whether or not an estimate was altered because of cancellation of a projected
activity, a construction was completed, or some other identifiable causal effect
occurred. Without this information, a recorded change does not reveal whether
or not estimates were changed on paper or a movement of people actually took
place.
Health Facilities. Approaches to planning health services are considered
more extensively in later chapters. Information is desirable on all types of fa-
cilities where health services are provided, e.g., hospitals, nursing homes,
extended care facilities, mental health centers, diagnostic and treatment centers,
public health facilities, and others. Data should be obtained on capacity and scope
of services provided in facilities within the community as well as those at an ac-
cessible distance from the community.
Personnel to Provide Health Services. Data needed for assessing ade-
quacy of personnel are similar.to those required for facilities. These include
the number of medical specialists as well as other types of personnel who pro-
vide health services -- dentists, public health nurses, nurse practitioners,
physicians'assistants, emergency medical technicians, and many others. These
data are essential for assessing the available alternatives to providing adequate
services in communities where traditional systems are impractical.
4-58
-------
Information should be obtained on the activity status of the various per-
sonnel, i.e., active in the community, works away from the community, or
retired. Data should be developed for personnel conveniently accessible to the
residents of the community, as well as for providers that practice in the commu-
nity.
Water Supply System. Information should be obtained concerning all
components of the system including source of supply, type of treatment, method
of storage, and extent of distribution system. Information concerning the ca-
pacity and extent of use is needed for each of these components. This infor-
mation will enable evaluation of the amount of reserve capacity for each component
and for the entire system. The resulting information will permit determination
of the potential expansion of capacity or the limiting components.
Sewage Disposal System. Similar information is required for the com-
ponents of the sewage disposal system, i.e., extent of collecting system, method
of sewage treatment, and place of effluent discharge. Data should be obtained on
the capacity and extent of capacity used for each component.
The above comments were developed only for the health-related factors
included in the FRC survey. Additional factors are considered in the following
two chapters. Considering the limitation of data available for analysis, as outlined
above, questions may arise as to appropriateness of the treatment of data employed
in these efforts to classify communities. The investigators recognized that one
of the objectives of this study was to assess the requirements for data needed to
make tenable evaluations of health effects in communities impacted by develop-
ment of energy resources. Furthermore, there is an obvious need to develop a
4-59
-------
system for periodic, systematic collection and analysis of data to provide cur-
rently complete and accurate information on existing and potential health im-
pacts in individual communities, as well as for states and regions. The results
and implications of the analyses described in tills chapter are applicable to these
purposes, in addition to their immediate usefulness in characterizing the extent
of health impact in communities for which data were available for analyses.
4-60
-------
5. INFORMATION CONCERNING HEALTH IMPACTS
RESULTING FROM DEVELOPMENT OF ENERGY RESOURCES
Considerations in Developing Information
An adequate information base obviously is essential for effective assess-
ment of current and potential health problems, for developing preventive and
remedial programs, and for evaluating results. One of the objectives of this
study was to determine the scope and quality of available information pertinent
to appraisal of health-related impacts resulting from development of energy re-
sources. The first effort in this direction was to identify the specific factors to
be considered in undertaking various aspects of the projected work and then to
determine the data needed to evaluate each factor. Some of the significant
items of data required are indicated in Table 5-1. Although specific applica-
tions of these data are indicated elsewhere in this report, it is advisable to give
a brief indication here as to how some of the various types of data are used in
evaluating health problems and for developing plans for personal and community
health services. This will suggest the level of detail sought for some applica-
tions and indicate why less precise information would not serve the same purposes.
Demographic Data. Knowledge of current and anticipated population growth,
is basic to planning most community services, including health services. Adequate
planning for health services is not possible, however, without detailed informa-
tion relating to numbers of persons in specific age groups. For example, such
-------
Table 5-1. Considerations ill evaluating health status of populations and environmental conditions .
Attribute to
be Kvjluated
Factors Tliat
Should he Considered
Pain Required
Health status of
population
Causes of mortality
Crude rates of mortality
Age and cause specific rates of mortality
Comparative rates of mortality, age and cause specific, for comparable
local, county, or .state jurisdictions
Comparative rates of mortality, state and national 1
Relative significance of leading causes of death
Causes of morbidity
Same as for mortality data
Annual and seasonal rates of communicable diseases
Current health
problems
Annual trends in occurrence of deaths and disease, age and cause specific
Recent and current outbreaks of infectious diseases
Trends in use of treatment facilities by discharge diagnoses
Trends in
population
Annual rates of
population change
Rates of births
Rates of natural population change
Annual estimates of population
ftroject population: short -range annually for next five years; long-range at
five-year intervals
Age composition of
population
Age specific estimates and projections as above
Community
environ-
mental
services
Water supply
Type(s) of source(s) and capacity
Type and capacity of treatment facilities
Type and capacity of water storage facility
Geographic extent and capacity of distribution system
Proportion of dwelling units served by system
Rjrcent of system capacity used, by system components
Sewage disposal
Type and capacity of treatment facility
Geographic distribution and capacity ol collecting system
Type and capacity of effluent and solids disposal systems
Proportion of dwelling units served by system
Percent of system capacity used, by system components
Solid waste disposal
Type and capacity of disposal system
Type and capacity of collecting system
Geograpliic coverage of collecting system
Proportion of residences and businesses served by system
Ifcrcent of system capacity used, by system components
Environmental
quality
Food sanitation
Recent and current outbreaks of food-borue toxins and pathogens
Result of inspections of food processing and tood handling establishments
Environmental
sanitation
Recent and current occurrence of rodent and arthropod-borne pathogens
Condition of premises hygiene
Air quality
Air quality data
Noise
Noise intensity measurements
Health services
I\iblic health
services
Recent, current, and long range trends in occurrence of communicable
diseases
Rates of fetal and infant mortality
Rates of childhood diseases and deaths
Rates of maternal deatlis
Rates of immunization for communicable diseases
Personal health
services
Rates and trends in morbidity and mortality compared with state and
national statistics
Type, number, capacity, and accessibility of facilities for health services
Type, number, and location of personnel to provide health services
Health service area
Delineation of primary, district, and regional health service area
5-2
-------
information is needed to develop immunization programs for infants and pre-
school children, to plan adequately for maternal and child health programs, to
make appropriate provisions for the aged, and other services related to age.
The total population figures provide only part of the needed data.
Precise data on population estimates and projections also are needed on
a yearly basis. The communities involved in this study characteristically ex-
perience a rapid temporary growth in population during the construction of energy
development projects, which may extend over two to five years or longer, followed
by a precipitous decline in population. The net increase in population may be
negligible, moderate, or considerable depending on the type of activity and other
factors. Population data obtained periodically, e.g., at intervals of two, three,
or more years, are unreliable as indications of either the rate of growth or the
anticipated peaks. Population estimates usually developed for analysis of vital
statistics are mid-year estimates made from linear projections of population
trends that may take into account previous experiences of in and out migration,
births, deaths, and other factors. Accurate population projections require more
detailed knowledge of local conditions, particularly in and out migration related to
employment. Projections of maximum usefulness for the present study neces-
sitate, as a minimum, accurate information on schedules of industrial develop-
ments and the size of the work force of each activity within commuting distance
of the communities under observation.
Mortality Data. Crude death rates provide a general indication of life
expectancy and are useful in making general comparisons between populations.
5-3
-------
Such information is, however, of limited usefulness in planning for health and
other community services. In contrast, age- and cause-specific rates clearly
reveal the major cause of deaths for specific age groups. From such data,
tenable comparisons can be made of the relative significance of causes of deaths
among different populations, geographic areas, and persons of different ages.
Furthermore, experience has shown that mortality rates for specific age groups
are reliable indicators of certain attributes of the population and community for
which the rates were determined. For example, rates of infant mortality, i.e.,
deaths during the first year of life, indicate the efficiency of available public
health services. Deaths during the second year of life are a reflection of the
nutritional states of the population and the general economic level of the com-
munity.
The causes of deaths generally are predictable for specific age groups.
The occurrence of a significant number of deaths from other causes or the oc-
currence of "excess" deaths, i. e., death rates appreciably above the expected
rate from anticipated causes, signals the need for inquiry concerning the sus-
pected deviations from previous observation. It is such indications that lead to
investigation of associated factors to explore possible causes. Thus, it is im-
portant to make comparisons of age- and cause-specific death rates in areas
and between populations where energy developments are anticipated and com-
parable areas and populations where such developments are not contemplated.
Such baseline information provides a means of comparing subsequent rates if
surveillance is maintained in both types of areas and for both types of popula-
5-4
-------
tions after the initiation of energy-development activities.
Antecedent cause- and age-specific mortality data may also be used for
retrospective analyses to provide immediate suggestions of the effects of certain
activities --in this case, development of energy resources. Suppose, for example,
that data on age- and cause-specific mortality rates were available over a period of
five or more years for two comparable areas and populations. Subsequent to that
period, suppose that an energy-development activity was commenced in one of the
areas and had continued for five or more years, during which time collection of age-
and cause-specific mortality data continued. A comparison of data collected over the
entire period of ten years would indicate whether or not significant changes in mor-
tality rates occurred, coincident with the development of energy resources, and if
the trend were different in the two communities.
Morbidity Data. Data concerning the occurrence of illness are useful in many
of the same ways as mortality data, e.g., in defining trends in magnitude and seasonal
occurrence of specific diseases, comparing rates of disease between populations and
geographic areas, as harbingers of disease outbreaks and epidemics, and in evaluat-
ing the effectiveness of health services. Morbidity data are collected by a variety of
means, e.g., (1) from reports, provided by physicians and others as required by
law, on the occurrence of communicable disease, (2) from records of hospitals
and other institutions providing medical services, (3) from notification of disease
outbreaks reported to health authorities, (4) from results of surveillance of spe-
cific diseases, and (5) by special studies and surveys. The morbidity data ob-
tained through established programs for reporting communicable diseases are
5-5
-------
generally not as reliable as are mortality data, although the latter are by no
means free of errors of omission and commission. Hospital discharge records
are one of the most reliable sources of information, and these data have several
other applications in health planning, as indicated in the following discussion of
health services.
Information Related to Environmental Sanitation Facilities. Knowledge
of various attributes of water supplies, sewage disposal systems, methods of
solid waste disposal, and other municipal services related to the public health is
essential for assessing the health impacts of population growth. The two general
considerations are: the provision of essential environmental services for the new
residents, whether they are temporary or long-term residents, and the prevention
of various types of environmental pollution associated with rapid community ex-
pansion. The level of detail required for evaluation of water supply and sewage
disposal systems is indicated below.
-- Water Supplies. In order to appraise the adequacy and potential for ex-
pansion of community water systems, information is needed regarding
the type and capacity of the supply sources; method of treatment and
storage; extent and condition of the distribution system; capacity of water
mains; and constraints to increasing the capacity of any of these com-
ponents. In assessing the extent of capacity used, it is necessary to
know which elements limit the capacity of the systems. For example,
providing for additional storage or extending water mains may be fea-
sible, but if the supply source is inadequate to provide for additional
users, and other sources are not available, this is the limiting factor.
5-6
-------
In instances where the source is adequate and the capacity of the en-
tire system is limited by distribution mains, treatment plant, or
storage facilities, expansion usually is feasible. On the other hand,
unused capacity of the system may not necessarily indicate that ad-
ditional users can be accommodated. Severe constraints imposed by
terrain or climate, for example, may preclude practical extension of
the distribution mains.
-- Sewage Disposal. Similar detail is required for tenable evaluation of
the adequacy of sewage disposal systems. Information is needed con-
cerning the method of treatment, means of disposal of effluents and
solids, extent of the collection, and capacity of the various components
of the system. Analysis of the system's adequacy for current and pro-
jected users should be based upon knowledge of the feasibility of ex-
panding the current system or constructing one of a design more suit-
able for a larger population.
Information Relating to Health Services. To meet the defined needs of
a community or of residents of any other geographic area, health service planners
must take into account the resources available or obtainable and other character-
istics of the health service area, such as, personnel to provide health services,
health facilities, and resources for health planning.
-- Health Service Personnel. In order to determine the adequacy of per-
sonnel to provide health services in a specific location, information
must be obtained on the various kinds and numbers of specialists ac-
5-7
-------
cessible to the local population. Such an inventory should include all
types of personnel, since health service planning must consider the
entire needs of the population. Various mixes of personnel, depending
upon community needs, size, and other factors, also should be analyzed.
- Facilities for Health Services. An inventory of all types of health facili-
ties is essential for effective planning. This inventory should include
the number and capacity of hospitals, nursing homes, diagnostic and
treatment centers, public health clinics, ambulatory treatment centers,
and other health service facilities of any type or designation.
- Health Service Areas. The geographic relationship between populations
requiring health services and the accessibility of resources for providing
those services is necessary to determine unmet needs and to identify al-
ternative means of meeting them. A population's specific needs and the
resources available are determined from the data mentioned elsewhere
in this section. These two sets of data are related by determining the
services that should be available almost immediately, those that can be
located at a distance requiring a brief period of travel without detrimen-
tal effects or undue inconveniences, and those that can be located at a
greater distance. (This concept of regional health services is elaborated
further in this report. See page 6-23.) The resources -- personnel and
facilities -- needed to provide these sets of services then are determined.
From this information and the data obtained from the personnel and facili-
5-8
-------
ties inventories, the geographic location of the population and locations
of resources can be plotted on a map with the types and capacities of
resources appropriately coded. This diagrammatic illustration is a
convenient and effective device for determining the adequacy or de-
ficiency of the several types of health services and the resources avail-
able to meet them. The boundary of the area in which health services
are available to residents of the community defines the health service
area for that community.
This same general procedure also is used to determine the service
areas for facilities and for entire health service communities. For a
given facility and its personnel, the size and characteristics of a com-
munity that could effectively be provided specific services can be de-
termined. By plotting the location of facilities or services on maps
depicting the size and location of the population, it is possible to de-
termine the area that theoretically could be served by the resource.
There are, of course, many considerations that determine health ser-
vice areas for specific populations and specific families or individuals.
Among these considerations are convenience, individual preferences of
both providers and recipients of services, customary use of other types
of trade areas, and other factors. The idea of analyzing needs and re-
sources by service areas is not to suggest a rigid, regimented dis-
tribution of population and resources. TTiis type of planning is a means
of clearly indicating the relation between needs for health services and
5-9
-------
resources available to provide them without unnecessary duplication
or excessive expenditures and without leaving gaps of unmet needs in
the scope of services available.
Sources and General Availability of Data
After the data and information requirements for this study were defined
(Table 5-1), the possible sources were identified and contracts were made with
them by correspondence and by telephone. Efforts were made to explore the
availability of specific items from as many sources as necessary, and represen-
tations in the various states were requested to check the accuracy of the informa-
tion inventory and sources.
Table 5-2 indicates the specific data items used in this study'and their
availability from the states in Region VIII. Names of agencies and individuals
from which data and information were obtained are shown in Appendix B. Ob-
viously such a wide variety of data is collected by many specialized agencies.
The list of references at the end of this report indicates the principal published
compilations used in this study.
Specific mention should be made of certain items of data with regard to
methods of collection or development, completeness, and suitability to purposes
of this study.
Population Projections. As indicated in Appendix B, the agencies res-
ponsible for anticipating population changes and making population projections
vary from state to state. The methods of making projections and the sophisti-
cation of the process used also are widely different and depend in some cases on
5-10
-------
Table 5-2. Availability of demographic, vital statistics, and related data for evaluating health impacts resulting from
development of energy resources, by states, in Region VIE.
Type of Data
State
Colorado
Montana
North Dakota
South Dakota
Utah
Wyoming
Population
Total population
X
X
X
X
X
X
Age specific
X
X
X
X
X
X
Estimates
X
X
X
X
X
X
Projections
X
X
X
X
X
X
Mortality
X
X
X
X
X
X
Natality
X
X
X
X
X
X
Health Service Resources
Facilities plan
X
X
X
X
X
Manpower census
X
X
X
X
X
X
Facilities Utilization
Patient origin data
X
X
X
X
Patient discharge data
X
Length of stay data
X
Occupancy rates
X
X
X
X
X
-------
the needs of individual states. This function often is replicated in more than one
state agency because of the need for greater precision in projections for some pur-
poses and the requirements of various programs and agencies for specific local
projection in certain geographic areas. Such replication is, of course, desirable
and not an unnecessary duplication in the majority of instances.
In some cases, projections are simply linear extrapolations of antecedent
trends in population changes that occurred within the previous five or ten years.
Other projections consider variables such as anticipated industrial activity, changes
in patterns of land use, recreational activities, and other factors. The latter type
of projections obviously are preferable for the present study, but these are the ex-
ception. Some states have developed planning models that include alternative popu-
lation projections based upon various possibilities of industrial and other activities
that can be anticipated. These models, with indicated modifications for local con-
ditions, provide effective tools for use by local planners. In order to use these
procedures, communities must develop or have access to the basic data on indus-
trial developments and other activities that will affect local population. If local
planners do not receive these data sufficiently far in advance, they will be seriously
hampered in developing effective projections for the community.
Environmental Sanitational Facilities. Detailed information concerning
environmental sanitational facilities generally is available only from individual
communities. The state agencies responsible for community sanitational services
(see Appendix B) develop regulations, provide technical services, conduct inspec-
tions and laboratory tests, and provide other services to communities. Information
5-12
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on water supplies, sewage disposal systems, solid waste disposal, and other as-
pects of environmental sanitation generally is available in the appropriate state
agencies. These agencies are responsive to inquiries concerning specific condi-
tions or services in particular communities and geographic areas. Compilations
of data on community facilities and services are costly to assemble on a state
basis and are of limited value for local and state planning. Reports are avail-
able on the sources and quality of water supplies for some states. (See Bibli-
ography.) These are useful as sources of general information in communities.
Plans for Health Services. Health planning agencies are one of the
principal users of health statistics and information. The effectiveness of their
work depends to a large extent on the adequacy of basic health data and the effi-
ciency with which they are used. One of the principal products of health planning
agencies has been the local plan for comprehensive health services, which is one
of the milestones in achieving the objectives of health statistics systems. For
these reasons, the availability and content of plans for health services are con-
sidered in the context of health information, as well as in subsequent portions of
this report. At this point, only the available plan drafts and documents are dis-
cussed; reference to the planning agencies will be made later.
The general list of references at the end of this report indicates by state
the materials, including plans for health services, used in this study. As will
be noted, specific plans for health services are available for only a few of the
larger communities. Among the reasons for this are the short time thus far
available for preparing plans, the absence of mechanisms for health planning,
5-13
-------
the inadequate data for planning, and the lack of formats and other methodology
for planning. Examination of available drafts and plan reports revealed some
characteristics that provided the bases for subsequent recommendations. These
plans, as well as available reports pertaining to the health services included in
general plans for communities, related primarily to medical services and speci-
fically to therapeutic services. Preventive and other types of health services
were considered peripherally if at all. Considerable attention was given to dis-
cussing the need for physicians' services and the construction of hospitals. Such
real or alleged needs were determined from examination of national and state data
concerning the ratio of physician and hospital bed to population. Scant attention
was given to alternative systems for providing health services to meet identified
needs, which were inadequately defined for the majority of planning areas.
Specific health service areas have been delineated in relatively few in-
stances, and little evidence of regional planning was gained from the available ma-
terial. The realities of recruiting physicians were not reflected in the plans ex-
amined; nor, in many instances, was appropriate attention given to accessible
services outside of communities.
Consolidation of Data for Communities Affected by Development of Energy
Resources. No agencies in the states of Region VIII have been designated as
specific offices for collecting and disseminating information relating to health
issues involved in development of energy resources. Each state has an energy
office (Appendix B) responsible for developing information and policy concerning
energy activities, but these offices are not appropriate sources for the detailed,
5-14
-------
specialized data relating to health effects. The Mountain Plains Federal Regional
Council has conducted two profile surveys by soliciting responses to questionnaires.
As indicated in Chapter 4, these data have severe limitations for health planning.
Summary of Available Data
One of the activities specified for this study was to summarize for each
community all available, pertinent health data and information that could be ob-
tained from existing, easily accessible sources. As indicated in the previous
discussion, many items of essential data (Table 5-1) were not readily available,
if at all. Accordingly, this summary is concerned only with the types of data
that were published, or available in other forms, from the state repositories
(Table 5-2) . Methods were developed for consolidating, reducing, and dis-
playing the following data:
Population projections, 1976-1981
Population projections by age groups, 1965-1975
Trends in population, births, deaths, infant deaths, fetal
deaths, and maternal deaths
Trends in number and rates of deaths by principal causes
These were identified as the most significant items of available data needed for
assessment of health impacts, for planning remedial or preventive programs,
and for developing methods of surveillance that would monitor effectiveness of
connective measures and assist in modifying programs as community needs change.
Data were sought for individual communities but, as suspected, it soon
was apparent that counties were the smallest practical reporting units providing
needed material. Accordingly, efforts were made to extract data by counties.
Representative examples of the consolidated data and the forms used are provided
5-15
-------
in Appendix G. These are examples of some of the most complete data available
for the study communities.
As data were compiled, the wide variations were evident in procedures
for population estimates and projections, age groupings, combinations of causes
of deaths, completeness of data, and timeliness of reports. Nevertheless, efforts
were continued to assemble the data identified for the projected needs of this study
for each of the 66 counties involved. As indicated by the examples in Appendix G,
five forms were required to abstract data for each county. All of the data obtained
that could be adapted to the general format of the form were transcribed. (This
compilation is available but is not included with this report for reasons discussed
in the following section on limitations of data.) It was anticipated at the outset
that data readily available from repositories would be inadequate for completing
the tables for each item of data, for all times, for all states, and for every year.
Accordingly, arrangements were made in advance to secure specific items of
needed data by special requests to repositories. In many instances, data were
supplied, but in other instances the effort and expense involved in retrieval was
not considered justified in view of the dubious usefulness of available information
to this study.
Application of Available Data for Evaluating the Extent of Health Impacts.
As indicated earlier in this chapter, analyses of occurrence of vital events and of
other health indicators are useful for exploring correlations between trends of health
effects and possible causal factors. For this study, comparisons were made of rates
and trends of selected health indicators from national, state, and regional data that
5-16
-------
were readily accessible. Comparisons also were made from county data within
individual states. The principal statistics available for these analyses were mor-
tality data. Accessible statistics on morbidity were not as complete as mortality
data or as applicable to the study communities.
Indications from State, Regional, and National Mortality Data. A compi-
lation of crude death rates, i.e., deaths among persons of all ages for all causes,
is shown in Table 5-3. The regional groupings are those used by the national re-
positories and are given here to enable general comparisons for large geographic
areas. It is apparent from these data that Utah consistently has annual crude
death rates substantially below those for the United States or for other states in
Region VIII. Rates for Colorado and Wyoming were generally lower or approxi-
mated the national rates, and those for Montana, North Dakota, and South Dakota
generally were higher. Trends in annual rates of deaths have been downward for
Colorado and, less consistently, for the United States. The three with highest
rates have been essentially constant, rates have increased for North Dakota and
South Dakota in various years over the past decade, and recently have been lower
for Montana. The low rates generally have been sustained for Utah; the rates for
Montana, as well as other states, have varied considerably over the period of ex-
perience evaluated.
These data provide general indications of health conditions, as reflected by
crude rates of mortality, and are useful for initial explorations to identify adverse
health conditions. Evaluation of crude mortality rates, in relation to age compo-
sition of the population for which they were determined, often provides general
5-17
-------
Table 5-3. Death rate, per 1,000 population, from all causes for Individual sates In Region vm, the Mountain States, the West North Central States,
and the United States.
Geographic Area
Death Rate, Per 1,000 Population, From All Causes For Year Indicated
1965
1966
19 67
1968
1969
1970
1971
1972
1973
1974
1975
Colorado
8.2
8.4
8.3
8.7
8.2
7.9
7.8
7.5
7.7
6.9
Montana
9.3
9.7
9.4
9.5
9.7
9.5
9.7
9.6
9.5
8.9
North Dakota
8.5
8.9
8.5
8.9
9.1
9.1
9.0
8.9
9.0
South Dakota
9.3
9.6
9.5
10.0
10.3
9.9
10.0
10.3
9.7
Utah
6.7
6.9
6.4
6.7
6.5
6.7
6.6
6.5
6.6
Wyoming
8.3
8.1
8.8
9.4
9.2
8.8
9.0
8.9
8.7
Mountain States*
7.8
8.0
.7.9
8.2
8.1
. 8.0
8.0
7.8
7.9
West North Central States*
10.1
10.4
10.1
10.3
10.3
10.1
9.9
10.1
9.9
United States
9.4
9.5
9.4
9.7
9.5
9.4
9.3
9.4
9.4
9.2
9.0
* Mountain States: Montana, Idaho, Wyoming, Colorado, New Mexico, Arizona, Utah, and Nevada.
West North Central States: Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, and Kansas.
-------
suggestions of explanations for some variations between populations residing in
different geographic areas. For example, higher crude death rates would be ex-
pected for populations with a large proportion of persons over 65 years of age than
for a population with relatively fewer people over that age. These and many other
types of analyses require the detailed demographic data previously discussed.
Information derived from crude death rates does not indicate the specific
nature of problems, or even whether or not unusual problems exist. Precise de-
lineations can be made, at least in part, by examination of age specific and cause
specific rates of mortality. Some examples of this type of analysis are described
below.
--Rates of Infant Deaths. As indicated previously, rates of deaths that
occur during the first year of life generally are reliable indications of the effective-
ness of public health services available to the population for which the rate is deter-
mined. The rates of infant deaths, for which data are readily available, are shown
in Table 5-4 for the individual states of Region VIII and for the other areas considered
in previous analyses of crude rates of mortality. Because of the great disparity be-
tween rates for white and non-white populations, these two groups should be con-
sidered separately. As is evident from data in Table 5-4, the trend in rates of
infant deaths has been downward for all populations during the period of record
provided. This pattern suggests a progressive improvement in public health ef-
forts to reduce causes of infant deaths. Continuation of the downward trend would
indicate the desirability of maintaining, or perhaps intensifying, existing efforts.
Stability or reversal of this trend would signal the need to reexamine, programs
5-19
-------
Table 5-4. Infant death rate, per 1,000 live births, for Individual states In Region VHT, the Mountain States, the West North Central States,
and the United States.
cn
i
to
O
Geographic Area
Infant Death Rate, Per 1,000 Live Births, For Year Indicated
1965
1966
1967
1968
1969
1970
197
1
1972
1973
1974
1975
W
O
W
O
W
O
W
O
W
O
W
O
W
O
W
O
W
O
W
O
V.
O
Colorado
24.0
30.8
23.0
33.9
22.3
33.6
20.3
27.3
19. 8
30.6
19.7
23.5
18.3
17.2
17. 1
17.7
16.2
23.2
Montana
24.3
32.2
20.5
44.3
22.9
33.0
18.3
33.2
20.5
26.2
21.2
24.7
21.3
21.4
20. 9
29.5
18.7
26.0
N'orth Dakota
20.2
40.2
19.9
36.1
21.0
21.41
16.9
16.9
16.5
20.2
14.3
14.3
14.7
24.3
14.6
17.9
15.6
25.6
South Dakota
19.5
48.8
22.5
43.2
20.8
35.3
19.0
32.4
18.7
29.9
16.7
37.3
16.5
30.0
17.6
35.9
16.3
31.5
Utah
17.8
47.8
18.2
18.6
16.2
28.81
16.6
52.4
15.4
39.2
14.9
17.5
13.7
16. 1
13.9
17.2
12.4
20.5
Wyoming
21.2
42.3
23.6
36.0
23.8
8.71
19.5
55.6
26.5
43.0
19.6
27.6
24 0
36.3
24.9
33. 6
18.7
13.0
Mountain States
22.8
37.7
22.2
40.0
20.6
33.6
19.7
36.1
19.3
33.7
18.1
27.0
17.7
25.2
16.7
23.2
15.9
22.3
West North Central States
19.5
39.1
19.5
39.1
19.2
38.2
18.5
31.8
17.6
32. 9
17.3
31.4
17.5
27.9
16.6
27. 5
15.5
25.2
United States
21.5
40.3
20.6
38.8
19.7
35.9
19.2
34.5
18.4
32.9
17.8
30.9
17.1
28.5
16.4
27.7
15.8
26.2
Average
24
.7
23
.7
22
4
21.8
20.9
20.0
19.1
18
.5
17
.7
1
Based on frequency < 20
W = White
0 = Other
-------
for preventing infant mortality or to investigate causes of increase in the number
of deaths.
These data must be interpreted with some caution because of the small
number of deaths reported for some states during specific years. There are no
apparent indications from these data, however, that recent adverse conditions
potentiated the occurrence of infant deaths on a statewide, regional, or national
basis. The specific local effect of energy developments cannot definitely be deter-
mined from these data, nor do they even provide reliable indications of local ef-
fects. The relative proportion of the population affected directly by energy devel-
opments in any of the areas involved is relatively small in comparison with the
entire population for which the rate was determined. In most states, an enormous
variation between experience in the energy-impacted areas and other areas would
have to occur for changes to be reflected in state rates. (The application of data
for individual counties is considered later in this section.) Furthermore, as far
as could be determined, the period of record does not extend for a sufficiently
long period since the initiation of recent energy-development activities to provide
a tenable indication of effects.
--Rates of Deaths from Diseases of the Heart. Heart disease is the leading
cause of death in the United States and for the states and regions involved in these
analyses. For this reason, and because heart disease is exacerbated by various
types of pollution, trends in occurrence of deaths attributed to heart disease were
evaluated for the populations considered in the previous analyses. Death rates
are shown for these populations in Table 5-5. These data have the same limita-
5-21
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Table 5-5. Death rates, per 100,000 population, from diseases of the heart for Individual states In Region VE, the Mountain States, the West North Central States,
and the United States.
Ui
i
to
S3
Death Rate, Per 100,000 Population, From Diseases Of The Heart
Geographic Area
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
Colorado
295.3
299.3
291.0
300.7
289.0
272.0
271.7
266.8
274.6
Montana
327.5
344.0
326.5
319.3
329.5
323.4
331.2
319.6
319.1
North Dakota
334.8
336.8
315.0
337.0
349.4
355.5
342. 6
339.4
353.3
South Dakota
360.5
330.4
371.8
379.0
403.8
390.1
407.2
397.9
376.2
Utah
226.9
229.3
226.1
226.2
210.0
213.1
224. 8
319.0
214.2
Wyoming
278.8
281.2
312.4
332.7
300.3
294.2
313.2
308.7
306.8
Mountain States
257.8
264.5
263.1
266.2
263.7
262.7
265.8
255.5
259.5
West North Central States
397.0
403.3
390.9
¦ 395.7
393.9
384.3
381.9
392. 1
383.5
United States
367.4
371.2
364.5
372.6
366.1
362.0
360.5
363.0
360.8
-------
tions as do the data on infant mortality in that local effects, if any, may be ob-
scured and the length of record is not sufficient to reflect influence of energy de-
velopments .
There are no indications of substantial changes in directions of trends in
rates of deaths from heart disease for the various populations. Differences in
rates between the various populations may be attributable to differences in age
composition. As would be expected, the rates of heart disease correspond closely
to crude death rates.
--Rates of Deaths from Accidents. Accidents of all types are generally
the fourth leading cause of death in the states and regions involved in this study
and in the entire United States. In most years, rates of deaths from heart disease,
cancer, and stroke exceed those from accidents. For some populations, and in
some local areas, accidents are the leading cause of death. High rates of acci-
dents also are associated with specific industrial activities, with stressful situa-
tions, and with excessive use of alcohol and other drugs. For these reasons, rates
of accidents are, potentially at least, a strong indicator of some adverse health
effects associated with energy developments and boomtown conditions.
The annual rate of deaths from accidents for the populations and period
of time considered in the above examples are shown in Table 5-6. In contrast to
the health indicators previously described, deaths from accidents account for a
much larger proportion of deaths in the study areas than in the United States as a
whole. Rates vary widely among the states and generally are not declining. As
with the other possible indicators of health effects, no direct association with
5-23
-------
Tible 5-6. Death rates, per 100,000 population, from accidents for Individual states In Region VHt, the Mountain States, the West North Central States,
and the United States.
on
i
to
Geotp-aphlc Area
Death Rate, Per 100,000 Population, From Accidents
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
Colorado
62.8
63.4
63.1
62.5
63.5
58.3
58. 1
58.8
56.1
Montana
85.1
81.1
88.3
79.4
92.1
81.1
85.5
89.7
86.3
North Dakota
60.1
66.0
62.9
61.9
67.2
62.8
68.2
67.8
62.3
South Dakota
73.1
79.3
71.8
79.0
81.3
71.4
73.4
112.9
75.0
Utah
64.8
59.7
57.8
55.9
57.5 •
58.2
55.4
62.3
60.1
Wyoming
82.1
76.3
79.0
89.2
107.2
100.2
86.2
91.9
90.9
Mountain States
70.9
70.7
70.6*
72.7
75.9
72.5
70. 5
74.0
71.7
West North Central States
61.9
66.7
62.2
63.2
63.3
61.6
61.2
62.4
59.8
United States
55.7
58.0
57.2
57.5
57.6
56.4
55.0
55.4
55.2
-------
energy-development is apparent from the data available for evaluation.
--Rates of Deaths from Influenza and Pneumonia. Another probable
indicator of adverse health effects resulting from energy development is the ex-
cessive occurrence of influenza and pneumonia. These diseases prominently
affect persons highly susceptible to respiratory infections, such as those with
pre-existing pulmonary disorders and heart disease and others who are generally
debilitated. Such persons presumably are sensitive to air pollution and other con-
ditions related to energy development.
In Table 5-7 are shown the rates of deaths resulting from influenza and
pneumonia for the populations and years examined in the foregoing illustrations.
With the exception of Utah, rates for the states usually were higher than for the
entire United States. Trends in occurrence of deaths are not consistent in direc-
tion for any of the areas examined and tend to be more erratic than for the other
indicators. For the reasons mentioned in connection with the previous examples,
tenable inferences as to possible associations with energy developments cannot
be made from the data in Table 5-7. With a sufficient length of record for local
communities and adequate, frequent measurements of morbidity, the occurrence
of influenza and pneumonia would likely provide a reliable indication of adverse
health effects associated with energy developments.
- - General Obs ervations. A variety of health indicators could be examined
on the basis of current epidemiologic knowledge of the probable relation of health
effects to conditions that result from energy developments. As suggested by the
above examples, it does not appear likely that indicative information would be
5-25
-------
¦mble 5-7. Death rates, per 100,000 population, from Influenza and pneumonia for Individual states In Region VIH. the Mountain States, the West North Central States,
and the United States.
Cn
I
to
On
Death Rate, Per 100, 000 Population,
From Influenza and Pneumonia
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
Colorado
40.7
38.8
27.9
46.4
35.5
32.5
31.1
29.5
30.6
Montana
29.3
40.5
29.4
35.4
34.7
31.2
31.4
34.4
38.7
North Dakota
29.0
41.4
42.1
40.0
38.7
42.6
36 2
43.8
39.2
South Dakota
28.0
30.8
24.3
32.3
27.2
34.1
27.5
36.5
35.9
Utah
23.3
19.6
19.1
23.7
21.3
18.3
18.0
17.2
19.0
Wyoming
37.1
23.7
25.8
38.7
33.8
21.4
29.1
27.7
31.4
Mountain States
30.0
32.1
27.8
35.9
30.8
29.0
27.9
28.0
29.7
West North Central States
35.4
37.0
32.2
40.9
36.9
33.7
28.8
35.0
33.6
United States
31.9
32.5
28.8
36.8
33.9
30.9
27.7
30.1
29.8
-------
obtained by further analysis of other attributes of state data related to conditions
of health.
Indications from County Mortality Data. The same examples used to
illustrate applications of national and state data for evaluating comparative rates
and trends were extended to county data. Data from Colorado, which were repre-
sentative of the most complete material available, were employed for this purpose.
A sample of four counties, which included 25 of the 45 communities involved in
this study, was selected for purposes of illustration. These counties include com-
munities identified by state officials as being among the most severely impacted.
They also provide examples of different population sizes. The counties, the esti-
mated 1974 population, and the number of communities directly affected by energy
developments are as follows:
Estimated Number of
County 1974 Population Communities
Delta 16,637 10
Garfield 16,579 6
Mesa 58,467 6
Moffat 6,419 3
The county data, insofar as they reflect conditions in the impacted com-
munities, theoretically could be evaluated to determine the relative intensity of
indicators associated with adverse health conditions; these data could also help
determine the magnitude of these conditions in relation to "average" conditions in
the state as a whole. This comparison could suggest the priority of attention to
the various counties and to the problems disclosed by the selected indicators. In-
terpretations from such data are highly useful as general guidelines in health plan-
ning. Precise quantitative comparisons should, however, be made with caution.
5-27
-------
The data for counties have the same limitations with respect to length of
record and temporal relations to initiation of energy developments as do the state
and national data. In addition, the small number of events that occur in even the
populous counties, among those selected, may result in spurious indications of the
direction and magnitude of trends. For example, the data in Table 5-8 indicate the
number of deaths from all causes by individual counties and for the state. Because
of the relatively substantial numbers, the trends reflected by the crude death rates
derived from these data (Table 5-9) are statistically reliable. It is noted that a
difference of one death between the numbers reported for 1971 and 1972 for Moffat
County resulted in a difference of 0.1 in the crude death rates for these years.
When indicators associated with few events are compared for different years
and for different areas, the effect of small numbers is apparent. Table 5-10 shows
the number of deaths in the same counties and the state considered in the above
example. The percent of annual change that results from a difference of one infant
death is obvious. Such changes are reflected by the wide variations in rates of in-
fant deaths shown in Table 5-11. A difference between one and two events resulted
in doubling the rate. The trends developed from such data also are tenuous.
An intermediate situation is illustrated by the data on occurrence of deaths
from heart disease shown in Table 5-12 and Table 5-13. The relative large num-
ber of deaths from heart disease (Table 5-12) permits calculation of rates (Table 5-
13) that generally are statistically reliable indications of trends. Comparison of
trends between counties and with those for the state provide indications of the needs
to search for causes of the differences. For example, the rates of deaths from
5-28
-------
Table 5-8. Number of deaths from ail causes In Colorado and selected Colorado counties.
Geographic Area
Number of Deaths from All Causes for Year Indicated
1965
1966
1967
196S
1969
1970
1971
1972
1973
1974
1975
Delta County
187
190
204
197
205
220
211
224
214
188
Garfield County
155
145
130
138
143
157
158
143
142
127
Mesa County
500
474
514
561
523
587
600
561
599
566
Moffat County
50
57
66
73
64
53
56
55
61
70
Colorado
16,206
16,325
16,321
17,705
17,081
17,439
17,892
17,856
18,633
17,851
cn
N>
SO
Table 5-9. Rate of deaths, per 100,000 population, from all causes in Colorado and selected Colorado counties.
Geographic Area
Death Rate, Per 100,000 Population, for All Causes for
Year lndlcat<
;d
1965
1966
196 7
1968
1969
1970
1971
1972
1973
1974
1975
Delta County
12.3
12.6
13.4
12.8
13.2
14.4
13.8
14.2
13.1
11.3
Garfield County
10.8
9.9
8.9
9.6
9.9
10.6
10.5
8.9
8.8
7.7
Mesa County
9.3
8.9
9.6
10.4
9.7
10.8
10.9
10.0
10.4
9.7
Moffat County
7.0
8.2
9.6
10.6
9.5
8.9
8.5
8.6
9.5
10.9
Colorado
8.2
8.4
8.3
8.7
8.2
7.9
7.8
7.5
7.7
6.9
-------
Table 5-10. Number of Infant deaths In Colorado and selected Colorado counties.
cn
i
OJ
o
Geographic Area
Number of Infant Death9 for Year Indicated
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
Delta County
6
4
3
4
0
1
6
3
2
6
Garfield County
4
6
5
3
6
4
5
5
5
6
Mesa County
26
18
15
23
19
17
9
11
8
10
Moffat County
5
2
5
2
3
2
2
2
1
2
Colorado
895
820
805
762
806
829
736
678
637
612
Table 5-11. Rate of Infant deaths, per 1,000 live births, In Colorado and selected Colorado counties.
Infant Dea
te Rate, Per 1,000 Live Births, for Year Indicated
Geographic Area
1965
1966
1967
196S
1969
1970
1971
1972
1973
1974
1975
Delta County
24.8
20.1
15.5
21.2
0
4.7
27.0
14.2
9.4
25.4
Garfield County
17.0
27.9
18.9
14.0
24.9
15.1
18.3
19.0
20.5
22.8
Mesa County
30.2
23.2
20.4
28.7
23.3
20.8
9.9
13.1
10.0
11.6
Moffat County
32.3
19.0
44.6
17.7
24.6
20.0
16.8
18.9
9.9
13.2
Colorado
24.3
23.5
22.9
20.7
20.6
20.0
18,2
17.6
16.5
15.7
-------
Table 5-12. Number of deaths from diseases of the heart In Colorado and selected Colorado counties.
cn
i
CO
Geographic Area
Number of Deaths from Diseases of the Heart for Year Indicated
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
Delta County
85
71
74
62
82
75
77
104
89
62
Garfield County
54
44
31
39
40
56
52
53
50
45
Mesa County
177
161
174
180
187
197
216
204
201
200
Moffat County
13
22
19
23
17
22
16
19
26
19
Colorado
5,811
5,941
5,748
6,168
6,113
6,059
6,229
6, 292
6,497
6,129
Table 5-13. Death rate, per 100,000 population, from diseases of the heart In Colorado and selected Colorado counties.
Geocrraphlc Area
Death Rate, Per 100,000 Population, from Diseases of the Heart for Year Indicated
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
Delta County
559.2
470.2
486.8
402.6
529.0
490.6
504.1
658.2
546.0
372.7
Garfield County
375.0
301.4
212.3
270.8
277.8
377.8
347.2
329.2
309.8
271.4
Mesa County
327.8
300.9
323.4
332.1
346.9
362.3
393.9
362.3
349.9
342.1
Moffat County
182.3
317.5
275.8
334.8
252.6
337.2
243.7
296.9
403.4
296.0
Colorado
292.0
295.6
280.4
290.9
281.7
274.5
272.8
266.8
260.9
237.2
-------
heart disease in Delta County clearly are above those for the other counties in the
sample and for the state. Examination of age-specific population estimates for
1974 revealed that Delta County has a higher proportion of persons over 65 years
of age than any other county in the state. The percent of persons 65 and over is
8 percent for Colorado, 18. 5 percent for Delta County, 11.3 percent for Garfield,
12.0 percent for Mesa, and 10.2 percent for Moffat County. Although the possi-
bility of other influences is not excluded, age composition is consistent with the
rates of heart disease in the areas examined. Indications of similar relationships
could be expected from the data on deaths from influenza and pneumonia. However,
as shown by the data in Table 5-14, the number of occurrences is small and varia-
tions in rates calculated are more erratic and inconsistent (Table 5-15) than those
for death from heart disease.
Limitations of Available Data
The assessment of health effects that may result from development of
energy resources requires data on sensitive indicators of adverse health responses
of the population exposed to potentially causal conditions. As previously indicated,
comparisons may be made between retrospective and current data that are obtained
by measuring appropriate indicators. The most useful measurements are those
related to health services as listed in Table 5-1. These data generally were not
readily available for this study, and those that could be obtained were not current
to the extent that valid relationships could be established with energy developments.
Other factors that prevented adequate evaluation of health impacts in the study com-
munities were the following:
5-32
-------
Table 5-14. Number of deaths from influenza and pneumonia in Colorado and selected Colorado counties.
Geographic Area
Number of Deaths from Influenza and Pneumonia for Year Indicate
d
1965
1966
1967
196S
1969
1970
1971
1972
1973
1974
1975
Delta County
10
4
1
11
6
8
8
S
6
7
Garfield County
3
7
8
4
5
7
10
9
11
8
Mesa County
14
16
5
22
16
17
17
9
17
17
Moffat County
4
3
2
2
6
2
0
0
1
1
Colorado
797
773
673
955
749
727
706
700
754
654
cn
i
Oa
Co
Table 5-15. Death rate, per 100,000 population, from influenza and pneumonia in Colorado and selected Colorado counties.
Geographic Area
Delta County
Garfield County
Mesa County
Moffat County
Death Rate, Per 100, 000 Population, from Influenza and Pneumonia for Yeai
Indicated
1965
1966
1967
1963
1969
1970
1971
1972
1973
1974
1975
65.8
20.8
25.9
56.1
26.5
47.9
29.9
43.3
6.6
54.8
9.3
29.0
71.4
27.8
40.6
29.1
38.7
34.7
29.7
89.2
52.3
47.2
31.3
30.7
52.3
66.8
31.0
0
31.6
55.9
16.0
0
36.8
68.2
29.6
15.5
42.1
48.2
29.1
15.6
Colorado
40.1
38.5
32.8
45.0
34.5
32.9
30.9
29.7
30.7
25.3
-------
-- Date of Initiating Developments. Information was not available
on the starting date(s) of energy developments. Hence, it could
not be determined when a specific phase of activity was completed,
in progress, or anticipated. Accordingly, comparison of disease
or other rate before and after the activity commenced could not
have been made.
-- Population Estimates and Projections. Population estimates and
projections were not made consistently between states or even
among the different communities in the same state. Information
generally was not available as to how estimates were made.
Annual projections usually were not available.
-- Vital Statistics. Recent vital statistics usually were not available
because of a lag of about two years in publication. The most recent
published statistics in most areas were for 1974. Request for special
compilation, when unpublished statistics were available, was not con-
sidered justified because data were not available for specific commu-
nities .
The small population of the majority, and consequent small number of
vital events -- births, deaths, infant deaths -- precluded the comparison of rates
between communities or for the same communities in different years.
Except for the most populous states, the data generally were so incomplete
as to be unusable for analytic purposes.
5-34
-------
These observations corroborated the impression that the only usable data
for evaluating health effects in small communities are those developed locally
using procedures specifically adapted to local situations and needs. Such proce-
dures are discussed in Chapter 7.
Systems for Collecting Health Statistics and Developing Health Information
Health Statistics. In seeking health impact data and information, it is
necessary to contact respositories of the commonly available vital statistics,
morbidity data, data concerning health resources, and similar data traditionally
collected by state departments of health. Although not all of the data pertinent
to this study are available from state health agencies, as previously indicated,
this is a convenient starting place to review the procedures and extent of efforts
to gather pertinent data and to develop information for planning and operating
health programs.
Leadership for these activities is provided by the National Center for
Health Statistics (NCHS). This organization promotes the development and im-
provement of state programs for collecting and disseminating health data through
the State Center for Health Statistics (SCHS) which participates in the Coopera-
tive Health Statistics System (CHSS) developed by NCHS. The CHSS includes the
seven components briefly outlined below. The application of some of the principal
categories of data was considered earlier in this chapter.
-- Vital Statistics. These data are derived from the legally mandated
registration of births and deaths. Reporting forms provide for col-
lecting data on the cause and location of deaths and on characteristics
of individuals.
5-35
-------
-- Manpower Statistics. Data are obtained on the number, characteris-
tics, and distribution of personnel directly involved in providing health
services. Sources of information are licensing agencies and special
surveys.
-- Health Facilities Statistics. An inventory is maintained of hospitals,
nursing homes, out-patient facilities, and other types of institutions
where health services are provided.
-- Hospital Care Statistics. Data are developed from records of hos-
pital discharges to characterize how these facilities are used. Infor-
mation may be developed on the area served by the hospital, charac-
teristics of patients, length of stay according to type of illness, pro-
cedures performed, and other factors.
-- Health Interview Statistics. The NCHS has developed formats for con-
ducting health interview surveys in order to obtain data on local occur-
rence of acute and chronic diseases, accidents, disabilities, uses of
health services, and payment methods for medical care.
-- Ambulatory Care Statistics. Data are gathered concerning charac-
teristics of patients, and whether services are provided in physicians'
offices, clinics, public health centers, hospital out-patient clinics,
emergency rooms, or elsewhere.
5-36
-------
-- Long-Term Statistics. Data are obtained from nursing homes,
extended care facilities, custodial homes, mental hospitals, and other
institutions providing services of longer duration than those provided
in short-stay hospitals. Information is sought to enable definition of
service areas, characterization of patients with respect to cause and
duration of institutionalization, personal attributes, and other factors.
The NCHS has defined, or is in the process of doing so, the minimum data
sets and guidelines for operating SCHS programs. All of the states in Region VIII
are participating in this program to varying degrees. The current (July 1,1976)
involvement of the states in implementing the various components of CHSS is in-
dicated in Table 5-16. The extent of development in the individual states is in-
dicated in Table 5-2, and the titles of available materials in the lists of references.
Orderly planning has been accomplished, and procedures toward implementation
are in process to provide several data elements needed to evaluate health impacts
and develop state and local plans to provide health services. Obviously consider-
able time, years in some instances, will be required before SCHS is fully oper-
ational .
Health Planning
As indicated previously, health planning agencies are among the principal
users of health data. These agencies also are collectors and generators of such
data and have considerable influence on the kinds and scope of data collected by
other agencies. Understanding the role and relationships of health planning
5-37
-------
Table 5-16. Status of implementing components of the Cooperative Health Statistics System in states of Region VIII.*
Status of Component Development
State
Vital
Statistics
Manpower
Statistics
Health
Facilities
Statistics
Hospital
Care
Statistics
Health
Interview
Statistics
Ambulatory
Care
Statistics
Long-Term
Care
Statistics
Colorado
Operating
Approved
Operating
Montana
Operating
May be
approved 1977
North Dakota
May be
approved 1977
South Dakota
May be
approved
1977 or 1978
May be
approved
1977 or 1978
Utah
May soon be
approved
Wyoming
May soon be
approved
May soon by
approved
Operating
*Source of information: DHEW - Region VIII
-------
agencies is crucial to assessing community resources and developing comprehen-
sive plans and programs to meliorate health impacts. The present health planning
legislation (P.L. 93-641) integrates functions of Federal, state, and local organi-
zations and places responsibility of approval of certain Federal funds with desig-
nated planning organizations.
The National Health Planning and Resources Development Act of 1974
(P.L. 93-641) provides for designation of State Health Planning and Development
Agencies (HPDA). In Region VIII the HPDA designated will presumably be the
same agencies selected under previous health planning legislation (P.L. 89-749) .
Provision also is made for delineation of Health Service Areas and for appoint-
ment of Health Systems Agencies (HSAs). Not all state and sub-state agencies
have yet (July 1, 1976) been designated in Region VIII. The boundaries of pro-
posed and designated agencies are shown in Figure 5-1 and the names of these
agencies are indicated in Appendix B.
Responsibilities for the HSA include collection and analyses of data to
provide information concerning:
• the status and determinants of health of residents in the health service
area,
• the status of the health care delivery system in the area and the use
of the system by residents of the area,
• the effect the area's health care delivery system has on the residents'
health,
• the number, type, and location of the area's health resources, in-
cluding health services, manpower, and facilities,
• the pattern of utilization of the area's health resources, and
5-39
-------
NORTH DAKOTA
FOSItK i 1 l
1 ' 1 I
0I7SMAN 1 — — — — . \
I 1 \
MCllTlOSH I OICKEY jSAPCENT_1HICHLANC1'i
~CAMpT[LL| MCPERSON |BBOW* | MARSHALL I
i ; _ _ j : i 15
I ^WAIWORTH, EDMUNOS (
r I 0E*EY . , . . _
, , ( __l ! 1 ICMNJ 1
/POniR | f AULK , SPINK ^ ^"1 |
I L / I | I ^ON IDEUEL1
|ZIEBACH 'sunT~~ |HYDe[h7nd I I | hamlIn 1 !
I _ y 1 I 1 I I ^BEADU- L"' — J I—J
AHWKON !sr*KLEYT^HUGHCS [ I I |MNGS8UPtj ^ |
' 1 V I I 1 _ J -1
r v, i'VBiTFfwnT* T jiM MINER |L*W | ^ I
nurc I Nv|UFFA10 JtRAULC r$- 1 I I
[LTWAN \ L Ic5^ I I \* \
1 . BRULE \ ~
/ *uror*Id*vioi ^>' <$T|
I JACKSON
, ... '' '*URORAlDAVIO| <$>v| I
washing,J""™" |WLlITTI IlA _ J _ J _ l/J*,^-r1
w : ' \^y^r *s
IGPEGORT ^ *t .BON- ("tank 1 —1 - -)
I ] rx Ihommeton CLAy[5>
f /
x\
f-L r
I """"wo.1 ^,'uVe
\ FEDERAL REGION VIII
Fig 5-1 Health Service Areas
-------
the environmental and occupational exposure factors affecting imme-
diate and long-term health conditions.
When they become fully operational, the HPDAs and the HSAs will be effec-
tive resources to provide technical assistance in health planning for communities
impacted by energy developments. In the interim, individual communities,
counties, and planning areas must undertake health planning primarily with local
resources. This matter, including procedures for obtaining and processing
needed data, is considered further in Chapter 7.
Full-time, adequately staffed, health planning organizations have been
unavailable to the majority of communities involved in this study. The many
reasons for this situation include: lack of resources; priorities imposed at
federal and state levels that precluded adequate attention to substate areas; in-
adequate guidelines because of the newness of health planning organizations; re-
cently emerged necessity for health and other types of planning in the impacted
communities; and many other factors. The typical pattern has been for commu-
nities to acquire the services of a planner, either a generalist or a specialist
in a particular functional area, who undertook to organize planning for the com-
munity in all functional areas. As staff requirements were defined, additional
specialized personnel were secured and organizational processes developed for
categorical and comprehensive planning. The planning organization necessarily
reacted to the most urgent problems and undertook orderly, objective approaches
to establishing priorities. The organization coordinated planning in the various
functional areas only after emergencies, or most obviously urgent situations,
were handled. In some instances adequate guidelines, planning-procedures, and
5-41
-------
technical or financial assistance were not available from higher levels of govern-
ment. The health planning that was done was accomplished in this context.
Effective health planning obviously cannot be done in isolation, independent
of planning for other community services. The health problems of a population are
inextricably interwoven with considerations of other functional areas, such as edu-
cation, law enforcement, recreation, transportation, and many others. The plan-
ners in all specialities must relate to complementary efforts of others to assure
maximum benefit from use of community resources. Such coordination is poten-
tially best provided through the district or regional planning agencies for substate
areas. The boundaries of designated areas for five states in Region VIII are shown
in Figure 5-2. Substate planning areas have not been designated for Wyoming, but
city and county agencies have been organized for some jurisdictions. The planning
agencies concerned with communities involved in this study are listed in Appendix B.
Recommendations for Improving Collection and Accessibility of Data
As is evident from the foregoing account, no single agency obtains all
types or all specific items of data needed for comprehensive analyses and plan-
ning relating to health effects resulting from development of energy resources.
Nor does it seem practical that a single agency could be responsible for compiling ,
such data on a regional or state basis as a service to local communities. It is in-
cumbent upon local communities and local planning agencies to secure data of the
specific types and in the detail appropriate for local applications. For this to be
done successfully and effectively, the proper data must be available in the agencies
having responsibilities in the respective technical areas. The services that can be
5-42
-------
— - — NORTH DAKOTA
UTAH
J FEDERAL REGION VIII
Fig 5-2 District and Regional Planning Areas
-------
provided at regional and state levels include: identification of specific types of data
required; indication of the agencies responsible for collecting and disseminating
these data; assistance in the support of efforts to obtain the needed data and making
them available to users; and development of local competence for health planning.
An effort has been made in this chapter to indicate the various types of data
required and the sources, or potential sources, of information in the various states.
In addition, a set of procedures was devised to suggest how communities might use
such data in connection with other information obtained in the individual communities.
(See Chapter 7.)
The following recommendations are proposed to facilitate the processes of
data collection and planning:
1. The appropriate Federal agencies, the Western Governors' Regional
Energy Policy Office, and the individual states should urge the Health
Resources Administration of DHEW to give priority attention to fully
developing and adequately supporting Health Planning and Resources
Development activities and the Cooperative Health Statistics System
in Region VIII.
2. An appropriate Federal Office should serve as a clearinghouse for
information concerning energy development activities that affect
state and local communities. This agency should establish channels
for regular dissemination of information to all governmental juris-
diction that potentially may be affected.
5-44
-------
3. The manual, "Procedures for Evaluating Health Impacts Resulting
from Development of Energy Resources, " with appropriate revisions
to conform to EPA formats, should be distributed to energy-develop-
ment impacted communities, both those currently identified and those
which later may be affected.
4. Each state should designate an agency, preferably the state planning
agency, to develop annual population projections for five years in ad-
vance for counties and individual communities affected by energy de-
velopments. These projections should take into account alternative
development of energy resources and other recognized demographic
variables.
5. The format for periodic collection of data from energy-development
impacted communities by the Mountain Plains Federal Regional
Council should be expanded to obtain additional needed data iden-
tified in this report -- specifically, annual population projections
during construction phases of energy development projects, data
developments commenced, or projected data of initiation.
5-45
-------
SELECTED REFERENCES
Blum, Henrik L. 1974. Planning for health. Human Sciences Press, New York.
622 pp.
Health Resources Administration and National Center for Health Statistics. 1975.
Data collection and analysis under P. L. 93-641. Department of Health, Education,
and Welfare. Publication No. (HRA) 76-637. Rockville, Maryland. 11pp.
Hyman, Herbert Harvey. 1975. Health planning. Aspen Systems Corporation,
Germantown, Maryland. 460 pp.
National Center for Health Statistics. 1973. The cooperative Federal-state -
local health statistics system. Department of Health, Education, and Welfare.
Rockville, Maryland. 13 pp.
National Center for Health Statistics. 1974. Brief description of the seven com-
ponents of the cooperative health statistics system. Department of Health, Edu-
cation, and Welfare. Rockville, Maryland, mimeographed, unnumbered.
Rapp, Donald A. 1976. Western boomtowns: Parti. A comparative analysis
of state actions. Western Governors' Regional Policy Office. Denver, Colorado.
58 pp.
5-46
-------
6. ANALYSIS OF AVAILABLE DATA AND INFORMATION
A. Health Impacts Attributable to Development of Energy Resources
In exploring relationships between the adverse environmental conditions
resulting from energy developments and health impacts, two general groups of
effects were considered: (1) the effects attributable to the industrial processes
and, (2) the health effects associated with rapid growth of communities and the
consequent crowding, deficiencies in housing, over-burdened community environ-
mental facilities, inadequate health services, and other factors.
Health Effects Resulting from Industrial Process
Hie study of health effects associated with industrial processes was con-
fined to impacts in the residential environment of the community, in contrast to
the industrial environment of energy development. The latter, i.e., the working
environment, is in the province of industrial hygiene and was not considered in
this study which was concerned with factors that impinged on the community and
its residents.
Potential Toxins and Irritants. The type of energy developments and the
number of communities involved in this study are shown in Table 6-1. Coal mining
and operation of coal-fired power generating stations account for the vast majority
of industrial activities related to development of energy resources in the region.
As far as could be determined from available information, most of the other ac-
tivities are proposed, in exploratory stages, or in pilot operations. The principal
types of possible pollutants associated with the prominent existing or proposed
6-1
-------
Table 6-1. Types of energy developments and number of communities known
to be associated with each type in Region VIII.
Type of Energy Development
Number of Communities Involved
Coal Mining
146
Coal-Fired Power Station
12
Coal Gasification
24
Oil Shale Mining and/or Oil Production
20
Gas
34
Oil
47
Uranium Mining
23
Hydro-Electric Power Station
3
Thermoelectric (not specified)
17
6-2
-------
types of energy developments are indicated in Table 6-2. Under provision of the
Clean Air Act, national air quality standards have been established for all of the
pollutants listed. Table 6-3 indicates the relative amount of these pollutants pro-
duced by selected energy development processes in Region VIII.
Associated Health Effects. Table 6-4 shows the prominent health effects
associated with the principal pollutants that could be produced by the various types
of energy developments operating or proposed in Region VIII. Table 6-5 indicates,
for the specific diseases and conditions listed in Table 6-4, the relative risk of
adverse health effects depending upon relative length of exposure.
Factors Affecting Exposure to Pollutants and Intensity of Health Effects.
Air pollution resulting from energy development generally is more serious in urban
areas than in rural areas. Total air pollution is greater in urban areas where other
industries, automotive and other transportation, and other sources of pollution
contribute to the problem. In rural areas there is more dilution and adverse
effects are related to proximity of the community to the source of pollution. Other
factors such as wind, humidity, and rainfall also influence the effect. In the cur-
rent study of energy impacted communities in Region VIII, only 12 have populations
greater than 10, 000, and no community is larger than 50,000.
Among the principal types of energy development in Region VIII, coal-fired
power plants have the greatest potential for causing adverse health effects. The
stack emissions, mainly oxides of sulfur and oxides of nitrogen, cause highly
acid conditions in ambient air. These oxides occur even though ash emissions
from stacks are low, and visible smoke is minimal. Acidity is greater in winter
when humidity is high and temperatures low, both of which contribute to the
6-3
-------
Table 6-2. Principal air pollutants produced by most common types of energy
development in Region VIII.
Type of Pollutant
Hydro-
carbons
Particulates
Tvpe of Energy Development
SOx
NOx
CO
Dust1
Other ~
Coal Mining
X
Coal-Fired Power Station
X
X
X
X
X
X
Coal Gasification
X
X
X
X
X
Oil Shale
Mining: open-cut
(surface)
underground
Oil Production
X
X
X
X
X
X
Gas
X
Oil
X
X
Uranium Mining
X
Hydro-Electric Power Station
^ Includes only dry solids emitted at the source, consisting mainly of silica, carbon,
iron oxide, aluminum, and trace metals (antimony, arsenic, cadmium, cobalt,
copper, magnesium, manganese, mercury, nickel, selenium, tin, vanadium, zinc).
2
Includes aerosols emitted at source.
3 Process is still in experimental stages.
6-4
-------
Table 6-3. Relative amount of pollutants produced by selected energy-
development processes in Region VIII.
Type of Pollutant
Type of Energy Development
X
o
NOx
CO
Particulates
Hydro-
carbons
Coal-Fired Power Plant
H
H
L
L
L
Oil-Fired Power Plant
H
H
L
L
L
Natural Gas-Fired Power
Plant
L
H
L
L
L
Coal Gasification Plant
H
H
L
L
H
Shale Oil Production
L
H
L
L
L
Shale Mine (open-cut)
0
0
0
H
0
Coal Mine (strip)
0
0
0
H
0
Uranium Mine
0
0
0
H
0
Hydro-Electric Power Plant
0
0
0
0
0
H - High
L - Low
O - None or negligible
6-5
-------
Table 6-4. Health effects associated with principal pollutants resulting from
primary processes of energy production in Region VIII.
Type of Pollutant*
2
SO
X
N°x
CO3
Hydro-
Particulates
Disease or Condition
carbons
Dust
Other
Irritation of Respiratory
Tract
X
X
X
X
X
Acute Respiratory
Infections
X
X
X
X
X
Chronic Respiratory
Disease
X
X
X
X
Asthma
X
X
X
X
Allergies of the
Respiratory Tract
?
7
X
?
Heart Disease^
?
Carcinoma (lung)
?
?
X
?
Irritation of Eyes
X
X
X
* Effect on health may be due to pollutant as listed, or reaction of pollutant
with air, sunlight, or moisture.
2
Smoking increases incidence and severity of all conditions except eye irritation.
3 Concentrations in ambient air rarely reach dangerous levels.
^ Heart disease associated with air pollution is nearly always secondary
to pulmonary disease.
6-6
-------
Table 6-5. Relative risk of adverse health effects in relation to length of exposure.
Condition or Disease
Period of Exposure1
Short-
Term^
2
Long-Term
High
Exposure
Low
Exposure
Intermittant
or Repeated
High Expos.
Low
Exposure
4
Irritation of Respiratory Tract
+-H-
+ or -
+++
++
Acute Respiratory Infection^
++
+ or -
+++
-H-
Chronic Respiratory Disease^
+3
—
+++
+
Asthma
+3
+ or -
++
++
Allergies of Respiratory Tract3
+
+ or -
+++
++
Heart Disease^
+
•—
++
?
Carcinoma (lung)^
?
—
-H-t-
++
Irritation of Eyes
+-H-
+ or -
+++
+
* Assuming that exposure includes pollutant( s) implicated in
specific conditions (see Table 6-4) .
^ High or low exposure based on U.S. standard threshold limit values
and varies with each pollutant. High exposure time limit is usually to
maximum levels (or over) for 1 hour; low exposure limit is 8 hours or
annual mean.
3 Depends mainly on individual host response.
4 Smoking increases the risk factor.
6-7
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hydrolysis of sulfur and nitrogen oxides to acids.
Dust, produced by coal mining, especially strip mining and open mining of
oil shale, may cause problems if the mine is located close to communities. Goal
gasification plants, and plants producing oil from shale, vent waste gases to the
air. These gases, consisting mainly of C02, H2S, and COS (carbon oxysulfide)
could be a source of odor pollution to communities downwind from the plant.
Since H2S is rapidly converted to SO2 and then to H2SO4, problems could occur
if outputs of gas were large, if many plants were located close together, or
other sources of pollution were present.
The remaining developments --oil, gas, uranium, and hydro-electric
power stations -- pose no great risks to persons in the community.
Health effects from air pollution are manifested mainly in the respiratory
tract (Table 6-4) . Inspired air of high acidity or containing many dust particles
is irritating to lung tissue and encourages development of both acute and chronic
respiratory diseases. Concentration of pollutants and length of time of exposure
are important factors in producing disease (Table 6-5) .
The conditions occurring most commonly are infections of the upper res-
piratory tract ("colds", influenza), bronchitis, and emphysema. When pollution
is high, asthma and other allergic conditions may occur or increase. Other health
problems, which may not result directly from air pollution, but which are related
to it, are the heart diseases that develop as a result of severe respiratory disease;
tuberculosis, to which persons with respiratory disease are very susceptible; and
cancer, especially of the lung, which occurs more frequently in areas with high
6-8
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air pollution.
Persons at greatest risk are those with existing pulmonary disease; next
are smokers (Table 6-4), children, and elderly persons. Other factors that in-
fluence sensitivity to air pollution are age, sex, general state of health and
nutrition, concurrent exposures, pre-existing disease, and air temperature and
humidity at the time of exposure.
Constraints to Adverse Health Effects Resulting from Air Pollution.
Under the provisions of the Clean Air Act, as amended in 1970, the Administrator
of the EPA is required to promulgate National Ambient Air Quality Standards
(NAAQS) which are designed to protect public health. The states are required
by the administrator to measure air quality, and to present plans for achieving
the standards where they are exceeded and also to plan for prevention of "signif-
icant deterioration" in certain areas where the air is particularly clean. The
Administrator also has promulgated new source performance standards which
apply to new construction and to modifications of existing sources when the modi-
fications have the potential for increasing the emissions of pollutants. These
new source performance standards essentially mandate that all new construction
will incorporate state-of-the-art technology for controlling air pollutnats. The
standards are enforced either by EPA directly or by state or local pollution con-
trol agencies.
In summary, EPA has the following role in the protection of humans from
air pollutants that are harmful to health:
• Monitor existing air quality and take action, as required, to achieve
the NAAQS
6-9
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Prevent construction of new industrial plants if they would worsen
an existing, severe air pollution problem
Require that all new industrial plants be constructed with state-of-
the-art pollution controls
Periodically inspect industrial installations to make sure that pollu-
tion controls are functioning
Thus, there is already in operation an adequate procedure for minimizing risks
to human health from air pollution. A similar system is being implemented for
dealing with water pollution, but it will require a few more years to become fully
operational. It would appear that no additional action is necessary at the commu-
nity level except perhaps to stay informed of actions by EPA and report these to
the local citizens.
Health Consequences of Exceeding the Air Quality Standards. The NAAQS
are different from most health-related standards because they are designed to
protect the unusually sensitive segments of the population -- elderly persons who
already have heart disease or emphysema, very young children, and asthmatics.
The specific effects of various air pollutants are summarized below so that they
may be viewed in proper perspective when compared with other health effects.
Suspended particulate matter accompanied by sulfur dioxide is firmly
associated with health effects of varying severity as demonstrated primarily
by studies of populations in London and New York. Health effects associated
with suspended particulates in the absence of sulfur dioxide or sulfates rarely
have been demonstrated; however, the NAAQS were based on particulate matter
alone without regard to accompanying sulfur oxides. In Region VIII where sulfur
dioxide levels are low, there is probably much less danger from particulates than
6-10
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there would be in areas where sulfur dioxide levels are high. If the NAAQS for
particulates are exceeded by about 50 percent or more in the presence of sulfur
dioxide above the standard levels, children may experience increased incidence
of certain respiratory diseases, there may be increased absences of industrial
workers, and chronic bronchitics may suffer worsening of symptoms. The aver-
age healthy adult will probably be unaffected.
Sulfur dioxide standards were essentially based on the same studies as
those used to set the particulate standards. The effects are observed when sus-
pended particulate matter accompanies the sulfur dioxide; however, the NAAQS
were set for sulfur dioxide alone. The observed effects are the same as those
mentioned above. In Region VIII no problem is anticipated from sulfur dioxide
pollution.
Nitrogen dioxide at levels above the NAAQS may produce a greater inci-
dence of acute bronchitis among infants and school children according to the re-
sults of one study in Chattanooga, Tennessee. At 240 percent of the standard level,
the odor of NO2 is perceptible, but there are no permanent effects associated
with odor perception. At levels 1, 800 times greater than the standard, a definite
impairment of lung function occurs. It seems unlikely that the average healthy
adult would be affected by nitrogen dioxide pollution in Region VIII.
The effects of carbon monoxide are reasonably familiar to most people.
A cigarette smoker or a policeman or auto mechanic working near autos that are
producing exhaust is breathing air containing carbon monoxide in excess of the
NAAQS. The effects are comparatively subtle and are observed as impaired per-
formance on certain psychomotor tests and an impairment in visual discrimination.
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There is also evidence of physiologic stress in patients with heart disease.
Similar effects are produced when an individual, accustomed to living at low
altitudes, ascends to 7,000 - 10,000 feet. If any carbon monoxide pollution
problems should arise in Region VIII, they would probably be very localized
and caused by internal combustion engines operating in the immediate vicin-
ity of susceptible persons. No widespread effects on healthy children or
adults should occur.
Photochemical oxidant or ozone pollution at levels at or near the NAAQS
is associated with eye irritation and less-than-peak performance by student
athletes. These effects have been observed in the Los Angeles area but not
elsewhere at these levels. Oxidant levels about 50 percent above the NAAQS
have been associated with an increase in asthma attacks in about 5 percent of
a group of asthmatics. Ozone alone does not produce these effects, but at levels
about five or six times the NAAQS ozone produces chest discomfort and slightly
impaired respiratory performance in sensitive adults, especially if they are
exercising. All evidence indicates that recovery is rapid when the exposure
is terminated. Since oxidant/ozone levels in the atmosphere are almost always
below the NAAQS during the night and early morning hours, the potential for
health problems is greater in afternoon and evening in the summer months when
more sunshine occurs. The NAAQS is considered to be exceeded if the oxidant
level is above the prescribed value for more than one hour each year. Thus,
the consequences of oxidant pollution are that some individuals may experience
temporary symptoms for a few hours during an entire year.
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Existing Air Quality. As indicated above, the health consequences of
air pollution should be slight in local communities because the EPA with the
cooperation of state and county air pollution control agencies has an effec-
tive program for protecting the public. Air quality surveillance is maintained
for the following five pollutants: total suspended particulates, sulfur dioxide,
nitrogen dioxide, carbon monoxide, and photochemical oxidants/ozone. In the
judgment of EPA, control of these pollutants will protect the health of the pub-
lic from the known, harmful effects of polluted air. Other dangerous substances
• may be found in air, but they occur in such small amounts that they are not harmful,
or they are found only in the immediate vicinity of unusual industrial plants and
do not require nationwide surveillance.
Sulfur dioxide and nitrogen dioxide have been monitored in at least 18 locations
within Federal Region Yin. In all instances the measurements show that the levels
are extremely low and could increase more than seven-fold without reaching values
that are considered harmful to the most sensitive segments of the population. Infor-
mation for Colorado and Utah is very limited, but there is nothing to suggest that
the situation in these states is any different from that elsewhere in the region.
Carbon monoxide has been measured at only four locations, and the levels
were so low that they were barely detectable by the measuring instruments. A
fifty-fold increase could occur without reaching a harmful level. Carbon mon-
oxide comes almost entirely from automobiles, and the quantity per average
vehicle is expected to decrease until 1990 as the older cars without control de-
vices are removed from service. Carbon monoxide is not expected to present a
6-13
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problem even in large urban areas with high traffic densities, so there is no rea-
son to anticipate any difficulties in the sparsely populated areas with which this
report is concerned.
Photochemical oxidants and ozone have been measured for short time periods
at seven locations within Region VIII. At all locations the national air quality stan-
dard was either exceeded or approached very closely. This situation seems to be
typical for much of the United States where oxidant measurements are being made
for the first time. Some scientists believe that the oxidant arises from natural
causes and has always been present at levels near the national standard; other
scientists believe that it comes from urban centers many miles away and is trans-
ported long distances. Both groups are of the opinion that local pollution from small
communities has little effect on the oxidant levels observed in those communities.
EPA planners are actively engaged in formulating plans to achieve the national
oxidant standard, and new construction will not be authorized if an adverse effect
on oxidant air quality is predicted.
Suspended particulate matter has been more widely measured than any other
pollutant, and data are available from at least 50 locations within the region.
Generally, most of the values are low and range from 15 - 85 percent of the national
primary standard. There are some problem locations -- usually in populated areas --
where much higher values are measured. All evidence suggests that these high levels
are caused by some human activity near the monitoring site, such as travel on un-
paved or dirty streets or operation of an industrial plant that produces much dust.
Particulate emissions from new industrial plants should not be a problem because
these plants must comply with the strict national standards applicable to new sources.
6-14
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During the construction phase of any new plant, there is a possibility that dust-
producing activities could raise particulate levels above the national standards.
The problems would be entirely local and could be eliminated by a variety of
techniques -- for example, by wetting down dusty areas.
In summary, at the present time tfiere are no significant, widespread
health problems in the Region VHI area which are associated with air pollution.
The EPA has an ongoing program for monitoring air quality and controlling pol-
lution from new industrial sources, so no health programs can be anticipated
at present.
Health Effects Associated with Rapid Growth of Communities
The greatest potential impacts on health attributed to energy developments
result from boomtown conditions as a consequence of rapid population growth.
The adverse effects are of two types: (1) those that impact community envi-
ronmental services such as water supplies, sewage disposal, and solid waste
disposal and, (2) those that have direct adverse effects on people. When com-
munity environmental services become inadequate, contamination of the environ-
ment may occur. Depending on the kind of contamination, the possibility of
occurrence of various communicable diseases is enhanced. For example, over-
use of sewage disposal systems, or inadequate arrangements for sewage disposal,
may result in contamination of the ground surface or water supplies with fecal
material. This may result in dissemination of enteric pathogens capable of
producing disease such as typhoid and infant diarrhea. The latter is associated
with a high death rate among children under one year of age, and is an indication
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of the general sanitation of the environment. Inadequate disposal of solid wastes
may result in creating harborage for rodents or insect vectors of various patho-
gens capable of producing disease in humans. Inadequate water supply is detri-
mental to maintenance of personal hygiene which, in turn, is conducive to trans-
fer of pathogens between persons. Many intestinal pathogens are transmitted
in this manner.
Those impacts that have a direct effect on people include the diseases
associated with crowding and deprivation of health services. Crowding, for ex-
ample, favors the spread of air-borne pathogens such as the agents causing in-
fluenza and the common cold, as well as childhood diseases such as mumps,
measles, poliomyelitis, and others. Crowding, in common with other conditions,
has a more insidious effect in producing stress that results in mental illness, child
abuse, alcoholism, and other behavioral disorders. Another manifestation of rapid
population growth may be the inability to obtain health services because of increased
demands for a limited supply. This may result in a smaller proportion of children
being immunized against preventable diseases, a smaller proportion of screening
tests for tuberculosis and other diseases, a smaller proportion of follow-up on
active cases of tuberculosis and venereal diseases, and constraints to preventing
serious manifestation of diseases because of inability to secure early treatment.
Rapid and significant population growth also enhances the possibility of
adverse health effects of air pollution by increasing the amount of vehicular emis-
sions. The rate of automotive and other accidents also is known to increase dis-
proportionately to population growth in boomtown situations.
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Association of Health Effects with Adverse Environmental Conditions Resulting
from Rapid Growth of Communities. To develop quantitative associations between
environmental conditions and health effects, quantitative measurements are required
of both the environmental conditions and the anticipated resulting health effects. Such
data had not been developed for most of the communities involved in this study and
those that were available were not recent enough to be useful. Data from existing
county and state records also proved inadequate for reasons outlined in the previous
chapter. Development of the requisite data requires the use of specific procedures
that differ from those ordinarily employed to collect more general types of vital
statistics and environmental data.
Recognizing the necessity for determining tenable quantitative relationships
between environmental factors and health effects, guidelines and procedures were
developed for this purpose. These are summarized in Chapter 7 and presented in
detail in a separate report.
Occurrence of Adverse Environmental Conditions and Health Effects. Although
precise quantitative data are lacking, some largely subjective reports reflect the
occurrences postulated above. Overt contamination of the ground surface with
sewage was reported for several communities but there was no evidence of associated
occurrence of disease. Increases in rates of venereal diseases were reported among
temporary construction workers and among residents of a nearby Indian reservation.
Increases in attendance at mental health clinics were reported in several communi-
ties, some were on the order of ten-fold increases. Similarly, unquantitated in-
creases in alcoholism, child abuse, and crime have been observed.
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There seems to be no doubt of a causal relationship between the conditions
created as a result of boomtown development and adverse health effects. Likewise,
there is no question that effective planning for efficient remedial programs depends
upon accurate quantitation of the magnitude of the various problems and of the cause
and effect relationships. Application of the procedures described in Chapter 7
should aid in developing the required data.
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SELECTED REFERENCES
Air Pollution Control Office. 1971. Air quality criteria for nitrogen oxides.
Air Pollution Control Office Publication No. AP-S4. U.S. Environmental Pro-
tection Agency. Government Printing Office, Washington, DC._
Assembly of Life Sciences, National Academy of Sciences, and National Research
Council. 1973. Proceedings of the conference on health effects of air pollutants
Serial No. 93-15. U.S. Senate, Committee on Public Works. Government Printing
Office, Washington, DC. 709 pp.
Beeson, P.B. and McDermott, W., Editors. 1971. Cecil-Loeb Textbook of Medicine.
W.B. Saunders, Philadelphia, Pennsylvania. 1923 pp.
Comar, C.L., and Sagan, L.A. 1976. Health effects of energy production and
conversion. Annual Review of Energy. 1:581- 600.
Fenkel, A.J. and Duel, W.C. Eds. 1976. Clinical implications of air pollution
research. American Medical Association. Air pollution medical research conference.
December, 1974. Publishing Sciences Group, Inc. Acton, Massachusetts. 374 pp.
Hackney, Jack D. Physiological effects of air pollutants in humans subjected to
secondary stress. 1974. State of California, Air Resources Board. Downey,
California. 173 pp.
Hammond, Ogden H. and Robert E. Baron. 1976. Synthetic fuels: prices,
prospects, and prior art. American Scientist. 64:407-417.
KLock, JohnW. 1976. Energy development processes. Working paper prepared
for study of health effects associated with energy developments. Mimeographed . 22 pp.
National Academy of Sciences, National Academy of Engineering, and National Research
Council. 1975. Air quality and stationary source emission control: A report by
the Commission on Natural Resources. Serial No. 94-4. U.S. Senate, Committee
on Public Works. Government Printing Office, Washington, DC. 909 pp.
National Air Pollution Control Administration. 1970. Air quality criteria. U.S.
Department of Health, Education, and Welfare, Public Health Service, Environmental
Health Service.
Separate issues as follows:
Air quality criteria for particulate matter. Publication No. AP-49
Air quality criteria for carbon monoxide. Publication No. AP-62
Air quality criteria for hydrocarbons. Publication No. AP-64
Air quality criteria for sulfur oxides. Publication No. AP-50
Air quality criteria for photochemical oxidants. Publication No. AP-63
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Office of Air Quality Planning and Standards. 1975. Compilation of air pollutant
emission factors, Second edition. U.S. Environmental Protection Agency, Office
of Air and Waste Management. Publication No. AP-42. Research Triangle Park,
North Carolina.
Waldbutt, George. 1973. Health effects of environmental pollutants. C.V. Mosby,
St. Louis, Missouri. 316 pp.
World Health Organization. 1972. Health hazards of the human environment.
World Health Organization, Geneva, Switzerland. 387 pp.
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B. Approaches and Economic Considerations in Providing Health Services
The cost of providing health services depends basically upon the specific
health needs of the community, or other entity for which estimates are desired,
and the alternatives selected for meeting the defined needs. The definition and
quantitation of health needs obviously requires identification of data and infor-
mation required to characterize problems and needs; development of methods to
gather, analyze, and interpret the requisite data; and resources to perform
these tasks. Once needs are defined adequately, appropriate means for dealing
.with these needs are selected from the alternatives available. These alterna-
tives are then evaluated in terms of cost benefit, resources available, commu-
nity preference, or other factors. The ultimate selection of a course of action
may be made by objective selection of the "best" course, the least expensive
solution, preference of decision makers, popular demand, intuition, or other
considerations. Obviously, the process is not always orderly or effective.
Data are available from which estimates of costs of specific health ser-
vices for individual communities recently have been developed for some energy-
development impacted communities in Region VIII. These cannot, however, be
extrapolated to other communities because of the individual characteristics of
various locations that affect the spectrum of available options and, thus, cost.
Consequently, data are not available for realistic estimates of the cost of health
services for communities where appropriate data have not already been developed.
Nor is it possible to project state or regional cost estimates without adequate
definition of needs and current availability of resources.
6-21
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Phase II of this project will address the experiences of various communities
in identifying and solving health problems. Observations during Phase I have re-
vealed some information that should be applicable in the interim for evaluating
needs and developing remedial programs. These relate to the prevalent issues
of providing personal health services and to making arrangements for community
environmental services to accommodate temporary population during construc-
tion of projects. The reactions of some communities in dealing with these issues
obviously have incurred considerably more expense than necessary for adequate
remedial efforts. In many cases the excessive expenditures resulted from lack
of information about practical alternatives for providing services, or unwilling-
ness to consider them because of variations from current or traditional practices.
For example, many communities have spent large sums in efforts, mostly
strikingly unsuccessful, to recruit physicians when adequate medical services
could have been provided by other means. Similarly, arrangements for commu-
nity environmental services -- water supplies, sewage disposal, and solid waste
disposal -- apparently have not always been the most feasible with respect to
economic considerations. This is not necessarily to suggest that the community
always did not get what was wanted. It is possible that some of the less costly
alternatives were rejected because a majority preferred something else. There
is nothing wrong with this, provided the decision makers had access to all the
information available on each possible alternative.
As discussed in the preceding chapter, as well as elsewhere in the re-
port, the essential prerequisite to developing adequate and economical services
is the availability of appropriate expertise in planning for the various specialized
6-22
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areas of concern to communities -- these areas include health and many others
as well. This does not mean that a qualified planner necessarily must be in resi-
dence in each local community, but each jurisdiction with responsibility to pro-
vide services and authority to spend money for them should have access to appro-
priate planning expertise. It should be noted that contracting for services in
specialized areas does not necessarily replace the need for accessibility of plan-
ners to local areas. The plans and recommendations of consultants must be
subjected to impartial, expert review of appropriateness and critical examination
. to insure that alternatives were considered.
On the basis of these and other considerations, the following observations
are provided concerning personal health services and community environmental
services.
Systems for Providing Personal Health Services
As has been indicated, the problems of providing personal health services
in remote or rural areas are many and varied. These may relate to population
dispersion and particular health problems (such as high infant mortality) or,
in energy impacted areas, the related concerns of rapidly changing population
density and environmental pollution. Other problems include manpower recruit-
ment, facilities development, and system organization.
Manpower Recruitment. The problem of recruiting personnel to serve
in isolated areas has been addressed previously, as has the relationship of popu-
lation size and composition to manpower needs. In the present context it is
sufficient to state that a primary problem, which any system for providing
6-23
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personal health services must address, is the recruitment and retention of man-
power adequate to the task. Too often, communities concentrate all of their energies
on personnel recruitment and neglect the equally important task of maintenance or
retention. A report on one of the Region VIII communities noted that: "In the past
year there have been two NHSC physicians to go to (this community). However,
in both cases they acquired the misconception they were not needed." Whether
because of other physicians' resentment of the new physicians or community resis-
tance or indifference, the result is the same -- loss of needed personnel.
It is important to note that not all manpower recruitment problems relate
to physicians. The provision of personal health services requires a health team
which will support and work along with physicians. Members of this team include
nurses, dentists, pharmacists, laboratory and X-ray technologists, mental health
workers (particularly important in communities undergoing rapid change), admin-
istrators, outreach workers, new health practitioners, medical social workers,
and health educators. (Special consideration will be given certain of these per-
sonnel categories below.) Such non-physician health personnel enjoy a synergis-
tic relationship with physicians and must be considered to constitute an important
part of any system for providing personal health services.
Facilities Development. The absence of adequate facilities has long been
recognized as a barrier to providing services in many rural communities. The
Federally financed Hill-Burton program, concentrating for nearly three decades
on hospital construction, gave recognition to this fact. The results, while often
salutary, included communities which became physically and financially encumbered
6-24
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with structures they could neither staff nor operate.
A well-known example of the limitations of facility development in attracting
and retaining physicians to practice in rural areas is the Sear Foundation program.
Concentrating on the construction of modern ambulatory care facilities in needy
areas, this program failed in its basic mission -- the recruitment of physicians
to rural communities. Nonetheless, adequate facility development, appropriate
to area needs, must be considered in any program for providing personal health
services. While facilities alone wall not assure good health care, their absence
can assure inadequate care. It should be noted that the facility appropriate for
a small community usually is not a hospital.
System Organization. Perhaps the greatest problem facing the develop-
ment of personal health services in isolated areas is that of limited or absent
support systems for health providers in the field. Good physicians in good facili-
ties are limited in what they can achieve without good system supports. "System"
is here used to include the entire panoply of related services which define health
care. These include the non-physician health personnel already mentioned, com-
munication linkages, referral and consultation patterns, transportation networks,
and others. While urban practices need pay scant attention to these matters, in
isolated rural practices they are of great importance.
Referral and consultation patterns provide sufficient illustration of what
is meant. Just as it is unlikely a town of 1, 500 can (or should) support a phy-
sician, so it is unlikely that a town of 3,000 can support one obstetrician-gyne-
cologist, or a town of 5,000 support a psychiatrist. (Local conditions, e.g.,
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service area, may make any of these possible.) Yet such medical specialists
are needed. They may be provided by contract visits to the rural community on
an intermittant basis, by serving area patients in an urban setting, by salaried
retention through a federation of cooperating small clinics, by affiliation with
a university, or by other means. Whatever the method, only system organization
will assure their presence and good patient care.
The problems that must be addressed if adequate personal health services
are to be provided in remote or rural areas include manpower recruitment, facili-
ties development, and system organization. The alternative approaches noted
below for providing personal health services should be evaluated in this light.
Alternative Approaches
Various models for providing personal health services currently exist
and are viable options for health program development in remote or rural areas.
One method of categorizing these approaches to the problem is by the form of organi-
zation or control. In the Western United States today, three basic models emerge
-- those which are physician-based, those which are community-based, and those
which are institutionally-based. All three will be considered herein.
Physician-Based. The most traditional and tested model, the physician-
based practice, has undergone marked changes over the past several decades.
One of the most significant of these is the transition from solo to group practice.
This is of particular importance in rural areas.
-- Solo Practice. As recently as the end of World War n, it was not un-
usual for young physicians to go into private practice in rural areas
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by "buying" the practice of a retired or deceased physician. Unfortu-
nately, these sales were too often made by widows of men who had
burned themselves out in a lifetime of sacrifice. Whatever the rea-
son, these practices not only lost their salability; they could not be
given away. Most recently, communities have found they cannot pay
enough (including guaranteed salaries of $70,000 to $80,000) to entice
solo physicians into their areas. The reason is illustrated in the words
of a western medical student who visited solo rural physicians as part
of her assignment to a state health planning agency: "They pay for
their practices with their lives. " Fewer and fewer physicians are
willing to do so.
-- Group Practice. The physician-based alternative to solo practice is
group practice. This has become an ever increasingly significant form
of health delivery in rural areas. Typically, two or more physicians
will band together, either in a shared office or in a partnership/cor-
poration to serve an area. The most successful among these groups
tend to be the multi-physician groups which provide a limited range
of specialties among themselves and arrange for other specialists to
be brought to the area for consultation purposes.
For such a group practice approach to work, one of two things
must occur. Either the town being served must be (or be in the pro-
cess of becoming) big enough to support such an enterprise; or, sev-
eral smaller towns must both need and utilize the practice. The trend
has been for this latter development to occur, leaving certain smaller
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towns without physicians while concentrating available physician man-
power in a single community, often the commercial center for a county
or service area. Occasionally, the group extends itself to other areas
through outreach clinics, etc.
Physician-based practices are owned and operated by physicians.
Some of the larger group models can provide their patients with advan-
tages commonly associated with institutionally based clinics. They
are often efficiently manned and provide their owner-operators with
a life style more consistent with retention in the site and personal
longevity than has been the case with solo practice in similar settings.
Community-Based. Just as physician-based practices have been changing
in nature, so has the degree of community involvement in medical care. Epito-
mized by the largely urban neighborhood health center movement of the 1960's,
community involvement in rural health care has steadily increased in the 1970's.
This is true both for individual clinics and for groups of clinics working together
in federations.
-- Local Clinics. A major factor in community involvement in health
care has been the National Health Service Corps (NHSC). Promoting
the development of community non-profit corporations or sponsoring
NHSC assignees, the Corps has been influential in both establishing
and maintaining community boards in rural areas. Other programs,
most notably the Robert Wood Johnson Rural Practice Project, have
recently begun to move in the same or similar directions.
Typically, to organize itself for health care, a community will.
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go through a series of steps which may include:
• A survey of health needs and resources
• Formation of a non-profit community corporation for health
promotion
• Consideration of eligibility as "medically underserved" (based
on needs determination)
• Application for designation as a "critical manpower shortage area"
(involves professional society endorsement)
• Application to become a National Health Service Corps site
• Investigation and identification of additional resources, both
financial and professional
• Institution of a community-based health care delivery system
-- Federations. A further extension of the community-based clinic concept
is that of a federation of related clinics. Encouraged by such Federal
funding grants as Rural Health Initiative (RHI) and Health in Under-
served Rural Areas (HURA), federations serve to bring together other-
wise segregated service units for common purpose. This might include
shared professional, e.g., health education, and administrative, e.g.,
bookkeeping, resources. Increasingly, small rural clinics are dis-
covering that, while individually they may not be able to survive, to-
gether they may become economically viable, functioning entities.
Institutionally-Based. For reasons similar to those which are leading
community clinics to band together in regional federations, health institutions
are moving to bring previously unrelated health programs into single operational
entities. These institutionally-based efforts are being carried out by a number
of groups, prominent representatives of which are the health service corporations,
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the hospitals and the universities.
-- Health Service Corporations. While technically both hospitals and
universities may be classed as "health service corporations, " the
term is used to designate organizations established primarily for the
purpose of providing ambulatory health care in multiple settings .
An example of such a corporation in Region VIII is the Health
Systems Research Institute (HSRI), headquartered in Salt Lake City,
Utah. A derivative of the Intermountain Regional Medical Program,
HSRI is described more fully in a following section. The basic ap-
proach of HSRI is to negotiate a fixed price contract with a political
entry for the delivery of ambulatory care in that area.
-- Hospitals. The situation with respect to hospitals in rural areas is
complex. As noted, many small community-area hospitals have been
built in rural communities, only to fail for want of adequate staffing.
Others have been financially successful. Aside from population base,
administrative officing and degree of isolation seem to correlate posi-
tively with institutional survival. The most significant trend in rural
hospital development in recent years, however, has been the develop-
ment of hospital corporations which either own widely scattered hospitals
or operate them on contract. The Hyatt Corporation is just one example
of a commercial option (which also serves to illustrate that the hospital
is a very expensive hotel) . As part of service contracts negotiated with
physician-short communities, the corporations will often guarantee to
supply needed medical manpower.
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Non-profit hospital chains also are serving the West in growing
numbers. Some chains provide rural hospitals with everything from
janitorial supplies to an air evacuation service. Both the Lutheran
Hospital System and International Health Care, Inc. have religious
roots and serve communities that no other program would touch. The
latter program is particularly active in the state of Utah.
--Universities. Historically, universities have been thought of as some-
what insular in terms of service to outlying areas. Due to the priorities
of state legislators and the exigencies of funding, this situation is rapidly
changing. Programs aimed at assisting in rural health development,
such as the Rural Health Association in Colorado, have had their gene-
sis in the universities and maintain a close contact with them.
Generally, justifying service involvement through teaching and
research, some medical schools are nonetheless making a significant
contribution to health care delivery in their areas. Examples include
the Departments of Family, Community, and Emergency Medicine (or
its equivalent) in New Mexico, Arizona, Utah, and Colorado. Teaching
ties, where present, are often related to the training of family practice
students and residents.
In summary, then, at least three alternative approaches to organi-
zation for health care delivery in rural areas have been given. Usually
the model is not only physician-based, community-based, or institutionally-
based; rather, it is a mixture of two or more parts. In designing future
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health services, a community should be aware of the various approaches
--or combination of approaches--available and select the model best
suited for that situation.
Special Considerations. Several special considerations deserve mention
in a discussion of changing health services for rural areas. These include the need
for good administration, the potential for outreach and the availability of new health
practitioners.
Administration. Perhaps the single greatest lack in many rural practices,
particularly the community-based models, is good administration. Considered by
some to be a significant short-coming of the NHSC was their consistent inability to
support administrative personnel in NASC sites. This is now being partially cor-
rected through the institution of programs such as RHI and HURA. So convinced
is the Robert Wood Johnson program of the importance of good administration
that they are not supporting physicians in their rural practice project unless the
physicians are teamed with competent administrators.
Outreach. Outreach may take many forms. The clinic may "reach out"
to its patients through health education. Particularly useful in areas where occu-
pational health and safety risks are high, this approach is becoming increasingly
accepted by the medical community and should be considered as part of any new
rural health program. Current thinking focuses on "activating" the patient to
help prevent illness or, if sick, to assist in his own management.
A second form of outreach is the physical extension of health services
from a primary center to less densely populated service areas. This may be
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done through mobile units, satellite offices and/or use of various health practi-
tioners. Whatever the method, effective outreach is an important part of the
modern clinic.
New Health Practitioners. Extremely important in providing health ser-
vices to remote areas and changing patient populations are the new health practi-
tioners. Called nurse practitioners or physician assistants, the new health
practitioners have been trained to extend certain physician services. They op-
erate under physician supervision, require less than half the pay of a physician,
and are generally well accepted by their communities. Any area which has a
limited number of physicians should consider the option.
Means of Financing Personal Heafth Services. One factor limiting the
more adequate delivery of health services to rural areas is the financial limitation
of these areas to provide for such care. This limitation is due to the relative
dispersal of the population base in rural areas, low per capita income, and in-
adequate third party coverage for provider reimbursement, and odier factors.
Dispersed Population. It is not unusual in selected intermountain states
for the average density of populations to be one person, or less, per square mile
in some counties. Where it will support domestic animal life at all, acreage
may be sold by the cow unit, i.e., the amount of land necessary to support one
cow, which may be many acres. The land, in like manner, is not always hospit-
able to its human inhabitants, tending to large, sparsely occupied areas. One
consequence of such population dispersion is that access to medical facilities is
made more difficult. Were there to be an "adequate" number of physician pro-
viders in rural areas, this population distribution would tend to reduce per capita
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visits and, as a consequence, physician income. (In fact, per capita visits to
physicians do run less in rural than in urban areas.)
With the historic loss of physicians from rural areas, the situation has
been complicated by inflated physician-population ratios. Nationally, for example,
there are approximately twice as many physicians/100, 000 population in the five
most populous states as in the five least populous. When urban areas are com-
pared with rural areas, the ratio rises to three-to-one and higher. To some
degree this compensates, in terms of patient volume, for the relative lack of
people in many rural settings. The result, however, is not always satisfactory.
It may be a high volume practice over great distances with limited patient follow-
up. As was noted above, the combination of low patient density and a limited
physician population may be a lethal one -- first, for the physician and then,
when no replacement comes, for his practice.
Low Per Capita Incomes. A major survival barrier to health care in
rural areas is the relative poverty of most rural areas vis-a-vis their urban
counterparts. Studies have shown the per capita income in urban areas to be
one-third to one-half higher than those in rural areas. It has been said that
"nobody is poor in rural areas because everybody is poor." Clearly an over-
statement, it remains a fact that there is significantly less per capita volume
generated in rural areas than in urban. This means less disposable income to
pay for medical care. This is not true, however, for most of the new residents
of communities where energy developments are taking place.
Inadequate Third-Party Coverage. Low per capita income would not
itself constitute a problem if third-party reimbursement were adequate to
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compensate for this lack. Unfortunately, third-party coverage, both governmental
and private, is also less adequate in rural areas than in urban. Again, comparing
the five most populous states with the five least populous, some 75 percent of the
urban states population had access to more comprehensive, regular medical bene-
fits, while only 50 percent of the rural states' population was so covered.
The relatively inadequate insurance coverage of rural residents relates
not only to the lesser coverage by private carriers, but to the relatively lower
premium dollars payment for those who are covered. In addition, government
programs tend to be less beneficial for rural residents than for urban.
In summary, there are a number of problems influencing the financing of
personal health services in rural areas. These include a dispersed population
base, a low per capita income, and inadequate third-party reimbursement mech-
anisms . With greater population density, higher per capita income and improved
health benefits, communities experiencing rapid growth in the face of energy de-
velopment may avoid many of the difficulties commonly experienced by other rural
areas in financing health care.
Economics of Clinic Operation. Whatever its source of income, a com-
munity facing the sudden need for health services where none have been present
in the past, or a community that must expand its available health resources on
short notice, must ask what the cost will be. What are the elements essential for
financial liability of a small rural clinic? If potentially viable, what are the ex-
pected costs of operation and what revenues can reasonably be anticipated? These
are practical and important questions for any community considering expansion of
its health services. Too often, equally practical direct answers are difficult to
obtain or are not forthcoming.
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Guidelines for Financial Viability. In considering whether it can sustain
a personal health service delivery system, a community should consider factors
such as population density and the locally available financial support base, travel
time from alternative health resources, and the degree of external support or sub-
sidy which can be expected. The NHSC has, from its origin, required a service
population for some 4, 000 before placing any physicians in that area. An effort
is then made to assign two physicians on the assumption that approximately 2, 000
people are required to support a single family physician and that the assignment
•of solo physicians to isolated or semi-isolated areas is unwise.
The Health System Research Institute, which contracts for health services
with elected officials -- often with a view to reducing subsidies those same officials
are paying to sustain an inefficient rural hospital -- has established certain guide-
lines for entry into a new site. These include:
¦ • A physician-patient ratio of 1 - 4, 000 or worse
A one hour or greater travel time from a metropolitan area
A commercial service area with major shopping services for more
than 3, 000 people
A publically subsidized hospital losing more than $50, 000 annually
By including the last item, HSR I tacitly admits its programs may operate
at a loss, yet by reducing hospital debt claims this results in a net gain for the
community.
Expected Costs of Operation. Due to differing systems of operation,
levels of service provided and subsidies, both direct and indirect, it is extremely
difficult to obtain comparable and meaningful data concerning cost of clinic operation.
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Examples will be provided from these sources: (1) a sample NHSC clinic with
two physicians, (2) a sample HSRI clinic with a single physician, and (3) esti-
mated operating expenses for both one and two physicians' clinics in the state
of Nevada.
NHSC Clinic
Direct Health Support Personnel
Physicians (2 @ $70,000)
Nurse Practitioner
Other Office Staff
Other Support ( Lab, etc.)
*Paid by National Health Service Corps
Direct Health Professional Supplies
and Equipment - Rental and
Depreciation 10,000
Direct Health Administrative Overhead
Rent and Utilities 14,000
Office Supplies 2,000
Miscellaneous Expenses 8,000
$60,000*
15,000*
24,000
14,000
Non-Direct Health Care Disbursements
Loan Principal Payment 8,000
Capital Equipment Purchases 18,000
Rural Health Initiative System Costs 50,000
Total Cost of Operation
(Two Physician Clinic) $223,000
HSRI Clinic
Personnel
Physician $50,000
Nurse 8,000
Receptionist 6,000
Billing Clerk 6,000
Benefits 107 10,900
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Clinic Establishment
Rent - Facility $ 3, 500
Rent - Medical Suites and
Equipment 3,000
Business System Implementation 4,400
Medical Records Implementation 4, 200
Clinic Operations
Utilities 3,000
Maintenance 1,800
Telephone and Subscriptions, etc. 5,000
Taxes, Licenses and Fees 700
Personal Booking and Ins. Liability 150
General Office Supplies and Operations 1, 800
Malpractice Insurance 9, 000
MD and Staff Travel 1, 200
Medical Supplies 12,000
Laundry and Uniforms 150
Medical Support System
Physician back-up 1,400
Visiting Specialists 2, 280
Vacation, Education, and Relief 6,000
Continuing Education, MD Recruiting,
Travel, and Relocation 6,100
HSR I System Costs $25, 000
Total Cost of Operation
(One Physician Clinic) $171, 900
Nevada Estimate
Estimated 1975 Yearly Operating Expenditures for a Single-Physician Clinic
Expense Category
Medical supplies and expenses:
includes some lab work $1.20/patient
Office supplies and expenses 3, 600 + $ .40/patient
Rent, depreciation, and maintenance 5, 000
Salaries and Employee Benefits
1 full-time registered practical nurse
@ $850/month 10,200
1 Secretary clerk A $700/month 8,400
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1/2 time receptionist @ $300/month $ 3,600
Subtotal $22,200
Employee benefits and payroll taxes:
@ approximately 15% of $22, 000 3,300
Insurance
Professional liability 6, 000
Other Insurance 800
Subtotal $6,800
Total Operating Expenses $40, 900 + 1.60/patient
Net Physician Income Estimate 50, 000
Expense of Estimated 6,783 Annual Patient
Visits for one Physician 10,852
Total Cost of Operation
(One Physician Clinic) $101, 752
Estimated 1975 Yearly Expenses for a Two-Physician Clinic
Expense Category
Medical supplies and expenses:
includes some lab work $1.20/patient
Office supplies and expenses 6,600 + $ .40/patient
Rent, depreciation, and maintenance 8,000
Salaries and Employee Benefits
1 Administrative nurse secretary
@ $900/month 10,800
1 Full-time registered or licensed
practical nurse @ $850/month 10, 200
1 Secretary/clerk @ $700/month 8,400
1 Receptionist @ $600/month 7, 200
Subtotal $36,600
Employee benefits and payroll taxes:
@ approximately 15% of $36, 000 5,490
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Insurance
Professional liability
Other Insurance
$12,000
1,000
Subtotal
$13,000
Total Operating Expenses
$69, 690 + $1.60/patient
Net Physician Income Estimate $100, 000
Expense of estimated 12, 663 annual
patient visits for two physicians 20, 261
Total Cost of Operation
(Two-Physician Clinic)
$189,951
Given the non-comparability of the above figures, some generalization may
nonetheless be shown. First, we can assume that the annual cost of operating a
two-physician rural clinic in the Western United States should fall between $190,000
and $225, 000. For a one-physician clinic this may vary from $100, 000 - $155, 000
once establishment costs have been assumed. Needless to say, the more compre-
hensive the service, the greater the cost. A NHSC clinic with extensive outreach
and support services will cost more than a solo physician office with minimal sup-
port services. Also, a community in a rapid stage of development may have to
assume greater capital and personnel costs early in its history so as to accomo-
date a growing patient population.
Any such calculations should take into account potential income generation
for the community through support of other businesses in the health service area.
A second consideration which has been mentioned is the reduction of existing com-
munity subsidies to other health institutions, notably the local hospital, which
may be reduced through increased revenues - - secondary to the new or expanded
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clinic operation. Finally, the community should consider available supplemental
funds, both government or private, for assistance in clinic operation.
Expected Gross Revenues. Given the assertion that any calculation of
clinic revenues should be balanced by consideration of many related factors
(such as the effects of a particular clinic on area economy), what actual reve-
nues may be anticipated from the kinds of one- and two-physician operations
referred to above? Is it reasonable to project "self-efficiency" for small
clinics in outlying areas and, if so, what does that mean?
Potential for generation of income is normally a part of the assessment
of health needs for any given community. Factors such as population base (a
population of 1, 000 is generally felt to be required for support of one physician),
utilization of services, and patient ability to pay for services received are all
part of the equation. The same is true for institutions. The picture is com-
plicated when a medical practice which is not, in itself, self-sufficient, helps
a local hospital to raise its occupancy rate from 50 percent to 80 percent. What
does one then conclude about the financial viability of the practice?
The best general observation that can be made at the present time, with
respect to anticipated clinic revenues, is that some subsidy initially will be re-
quired in small rural settings in western states. Ignoring the salutary effect
of the clinic on area economy, an annual operational subsidy of $15, 000 - $30,000
for a one-physician office and proportionally more for a two-physician office
might be expected. This has been the experience of HSR I and the NHSC, where
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many sites manage to cover expenses other than provide salaries. Where popu-
lation density, utilization rates, and patient pay patterns are either higher or
lower than "normal", an equivalent variation in subsidy level required may be
anticipated.
Factors to Be Considered in the Design and Installation of Public Utilities and
Sanitary Facilities for Short-Term or Temporary Conditions
The installation of temporary or short-term sanitary facilities and public
utilities must offer, to a great degree, the same public health adequacy as per-
manent facilities. Although all sanitary systems do not adapt themselves equally
well to temporary forms of installation, a variety of planning and construction
factors can be employed to materially improve their effectiveness and reduce the
financial burden associated with installation, maintenance, and removal when a
community returns to the relatively stable conditions associated with post energy-
development impact. As indicated above, community planning with regard to
public health is the necessary ingredient.
Community Size. The size distribution and population of 126 communities
impacted by energy development are presented in Figure 6-1. These communities,
the first group for which data were available, range from 45 to 27,420 people with
a median value of 537. The total population analyzed amounts to 244,782 based on
the 1970 Census. Although 50 percent of the communities are smaller than 537
people, only 7 percent of the population of the 126 communities reside there, and
it is these small communities that will be most severely affected by energy develop-
ment (see Figure 6-2) . More than 50 percent live in the eleven largest cities and
almost one-quarter of the total population reside in the two largest cities.
6-42
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0
2
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Percent of Total Population in Communities of Size Equal to or Less Than Value Indicated (Probability)
99.9
Figure 6-1 . Accumulative Frequency Distribution (Population vs . Community Size) of
Potentially Energy-Development Impacted Communities in Six States
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.01 12 5 10 20 30 40 50 60 70 80 90 95 98 99
Ptercent of Communities Equal to or Smaller Than Value Indicated ( Probability)
Figure 6-2 . Accumulative Frequency Distribution (No. Communities vs . Community Size) of
Potentially Energy-Development Impacted Communities in Six States
99.9
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Population Increase. The impact, as measured by the population increase
on any given community, is calculated in the following manner:
Maximum work force per energy plant installation: 2, 500
Number of ancillary people per worker: 5
Total population influx: 5(2,500) = 12,500
Number of communities into which total population influx will be
divided: 5
Average population influx per community: 12, 500/5 = 2,500
Increase in median community population: 2, 500( 100) /537 = 465 percent
Community Planning. Community plans should reflect a synthesis of service
needs and accomodation of the physical realities of such items as topography for
storm drainage, soil types for waste disposal, ground water, and land availability
for solid waste disposal. A list of environmental factors to be considered are in-
cluded below followed by further discussion of several specific factors.
Street layout for fire protection, solid waste recovery and transport
Storm drainage
Water supply
- domestic, commercial
- fire
- future industrial
Waste water treatment and disposal
- domestic
- hazardous
Electrical utilities
Domicile Land Requirements. The most likely domiciles for the temporary
populations will include travel trailers, tents, and mobile homes. Estimated land use
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of planned communities of these living units is as follows:
Mobile Homes:
Densities: 6 to 10 units per acre
At 2.5 persons per unit, 15 to 25 people per acre
Land Requirements: 2, 500 people, 167 acres
Trailers and Tents:
Densities: 8 to 15 units per acre
At 2.5 persons per unit, 20 to 38 people per acre
Land Requirements: 2, 500 people, 125 acres
If all persons were domiciled in planned communities, the probable land
requirement would be less than 200 acres. Scattered and uncontrolled develop-
ment would probably add several hundred acres more to these needs.
Solid Waste Disposal Requirements. Additional equipment for the collection
of municipal refuse such as truck(s) and tractor(s) for the operation of a sanitary
landfill should be anticipated. Open dump and burning operations, if still existing,
should be terminated in favor of a sanitary landfill. Volume requirements for
2,500 people amounts to 7.0 acre-ft per year with moderate to light compaction
techniques. The depth of fill would be governed by the topography, soil profiles,
and depth to ground water. A minimum of four feet of soil should be maintained
above ground water elevations to minimize contamination. The weight of solid
wastes per day at five pounds per person for 2,500 people is 6.25 tons.
If hazardous wastes, as defined by EPA or other regulatory agencies, are
produced during the construction period, special collection and disposal techniques
are required. Information is available through the state agency responsible for
solid waste management. The cost to collect and transport one ton of solid waste
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to a disposal sight is about $30 per ton. The cost of disposal in a sanitary landfill
will be about $5 to $10 per ton.
Waste Water Treatment and Disposal. The volumes of waste water pro-
duced by 2,500 people will range from 150,000 to 300,000 gallons per day which
is viewed as a small quantity by sanitary engineering standards. Cost of conven-
tional waste treatment facilities would range from $100,000 to $400,000 which is
unjustifiable for a period of use of only several years. The most likely alternative
is proper soil mantle disposal in the form of septic tank installations. These can
be designed as separage units for each domicile or as common systems for groups
of trailer and mobile homes, possibly in units of ten or more. Tents require
separate sanitary facilities.
When the septic tank is to be used only for a short period, it should be
constructed in such a way that when abandoned it will not result in health, safety,
or subsequent land use problems. For short periods of three to five years, wooden
tanks and fiber pipe will serve very well. Upon abandonment of a system, the tank
should be filled with soil to prevent subsequent collapse and possible injury to
humans and livestock.
Once again, the key to the development of inexpensive temporary waste
disposal is planning. In this case a measure of the capacity of the soil to assimilate
waste should be conducted in the communities involved and suitable areas identified
and protected for such use through zoning or other administrative procedures. The
tests needed include water percolation and soil profile evaluation. In conjuction with
the soil assimilation evaluation, ground water protection must be included by properly
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locating waste fields in relation to present and future wells.
Water Supply. The development and construction of a water supply system
is probably the most expensive and least adaptable to temporary installation of the
several sanitary utilities needed by a community. Water systems normally satisfy
the needs for both domestic, commercial, and fire demands. Small communities
of this type are generally well supplied by a pumped-well system, which should be
composed of a. well or wells of adequate capacity, a storage system for domestic
and fire requirements, and a properly sized pipe supply network. Often chlorina-
tion of other treatment for bacteria and virus control is needed particularly in tem-
porary communities. Again, certain combinations of techniques and materials can
be used that will give an adequate system for a minimum investment. However,
because of the need for a constant supply of water and proper volumes, pressure
and quality, less latitude is available to the designer and some of the installation
should be considered to be permanent with a potential of supplying future commu-
nity needs for the newly developed industry and so on. Components of this type
include pumps, reservoirs, and chlorinators. During the period of construction,
particular care should be taken to assure that the piping system, even though sup-
plying only temporary housing, is adequate at all levels of water demand -- including
fire needs -- and is not subject to freezing and contamination through cross connec-
tions. Aid in the design of such systems is readily obtained through state and local
health department or the state agency responsible for environmental quality.
'Most of the difficulties associated with the development of environmental
public health requirements of a community can be avoided and the need readily met
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with a minimum cost if a proper plan is prepared in advance that complies with the
physical realities of the land on which it is situated and every effort has been made
to utilize facilities that are best suited to short-term utilization.
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SELECTED REFERENCES
Bauer, Jeffrey. 1974. An economist looks at rural health care. Rocky Mountain
Medical Journal 71: 623-627.
Hale, Frank A., Arthur R. Jacobs, and Dale Gephart. 1975. Planning a rural
community health center. Journal of the Maine Medical Association 66: 286-290.
Health Systems Research Institute. Undated. Community Health Care. Health
Systems Research Institute. Salt Lake City, Utah. 5 pp.
Kane, Robert L. and Diane Moeller. 1974. Rural service elements foil coordi-
nation. Hospitals, J.A.H.A. 48: 79-83.
Stumbo, W. Grady. 1975. Rural health centers and the development of progres-
sive patient care. Clinical Medicine. July, pp 12-17.
Swan, J. Franklin. 1975. The private, fee-for-service, community health center.
Journal of the Indiana State Medical Association 68: 644-647.
Von, Paul M. 1975. Hospital finances. Hospitals, J.A.H.A. 49:35-37.
Waller, Julian A. 1974. A rural EMS categorization system. Hospitals, J.A.H.A,
48: 111-117.
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g 11 g
7. PROCEDURES FOR EVALUATING HEALTH IMPACTS
RESULTING FROM DEVELOPMENT OF ENERGY RESOURCES
The objective of work summarized in this chapter concerned the develop-
ment of procedures for accumulating accounts of experiences in the various com-
munities relating to the identification of health problems associated with energy
developments. How these problems were approached and solved was also con-
sidered. These procedures were to be so designed that the resulting information
could be consolidated and made available for use in communities to assist in de-
veloping programs for solving local problems. The original concept was that
useful information could be obtained through a properly designed questionnaire,
addressed to selected local officials, designed to sample the general population.
The data and information compiled during the initial phases of this project strongly
indicated, however, that additional steps would be necessary to develop the spe-
cific and precise data required for the intended purposes. Such data appeared
also to be needed urgently in local communities and by state agencies to enable
characterization and quantitation of local problems. Information was needed for
dissemination to local officials and the general public to inform them adequately
of the nature and extent of current and anticipated problems that could be solved
only through concerted community action. In addition, the availability of assis-
tance from many Federal, state, and other programs was conditional upon ade-
quate definition and quantitation of categorical problems.
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Many communities in Region VIII have made substantial progress in de-
veloping programs to cope with health impacts. Accounts of the stimulus and
methods for undertaking the planning and operational efforts undoubtedly would
be valuable for other communities that anticipate problems or that have been less
successful in solving them. Not all communities, however, are prepared to apply
the knowledge gained elsewhere because of the inadequate data base available for
the community, as well as other factors. Apparently some communities simply
do not know where to begin. Between the extremes of communities that are dealing
successfully with health problems and those that have not yet begun to consider
them, are many communities in intermediate stages. Some communities are be-
ginning to think about the possibility of problems, others are collecting random
data, many are reacting to emergencies, some are instigating planning activities,
some are developing programs intuitively, and others are following or being pushed
along different courses. It is apparent that guidelines are needed: (1) to identify
data required to define and quantitate health problems, (2) to outline procedures
for collecting required data, (3) to suggest formats for recording and displaying
data, (4) to indicate methods of analysis and interpretation, and (5) to suggest
means for converting data to information that may be used for devising or modi-
fying remedial and preventive programs.
To this end, a set of procedures was devised for evaluating health impacts
resulting from development of energy resources. These procedures are provided
in a separate report. The following account is essentially a summary or, more
appropriately, an indication of content of the Procedures Manual. At the outset,
7-2
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it should be stated emphatically that the procedures outlined are suggestions and
indications of approaches. They are highly flexible and adaptable to local situa-
tions. An effort was made to indicate data requirements and how they may be met
within the constraints of local resources. The methods described are designed
to use currently available data to the fullest extent possible, and formats are pro-
vided that indicate ways of consolidating these data. In its entirety, the Proce-
dures Manual is intended to provide a means of systematically assembling exist-
ing or easily available data in a useful and readily accessible form. Means are
suggested for supplying missing data by using portions of the Manual suitable for
this purpose. Where information is desired for only a limited or specific need,
the appropriate portion of the Manual can be used. For example, if an opinion-
type survey is desired to gather information on how local officials and other resi-
dents view their problems and what has been done about them --as was envisioned
originally for this project -- a portion of the health.interview procedure may be
used for such a purpose. This procedure and others in the Procedures Manual
are outlined in the following sections, with brief annotations as to purpose and
methods of use.
General Information Concerning Energy Development
Information on the type(s) and location(s) of energy development activities
is needed to anticipate possible health effects. Especially important are accurate
data, obtained as far in advance as possible, concerning the number of employees
anticipated for each year that the activity will be in progress. It is not anticipated
that such information would be developed by a survey questionnaire or telephone
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interview. The procedures outlined anticipate that the process of gathering the
needed information would be a means of establishing or strengthening rapport
between industry and community representatives.
Physical and Demographic Profile
Information is needed concerning historical background, physical char-
acteristics, climate, land use, economy, cultural and social characteristics, popu-
lation, and health in order to develop the bases for occurrence of present and an-
ticipated health problems. Data are required for trends in population, by age,
for five or more years before the energy development commenced, and for a pro-
jection of the annual population for at least five years after the development is
initiated. Data also are needed concerning the trends in numbers and courses
of deaths and illnesses.
The information developed from these and other data are required to define
the health problems indigenous to the areas and to anticipate those that may occur
as a result of energy developments. Also, the antecedent data on disease and
deaths provide valuable indications of the general health status of the population,
the effectiveness of health services, and the economy of the community.
Community Environmental Services
Appraisal of the adequacy and future needs for water, sewage disposal,
and solid waste disposal are essential in planning to provide for temporary or
long-term increases in population. At a minimum, useful data require knowledge
of the type of systems used in the community, the capacity and extent of use of
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each component, and the constraints to expanding or extending the individual com-
ponents. For example, information on water supplies should be developed from
data on sources, treatment facility, extent of distribution system, and other fac-
tors. This enables identification of specific components to which attention should
be directed.
Current Environmental Conditions
Procedures are provided for conducting a block-by-block or area-by-area
environmental survey to identify and quantitate the various types of land use; type,
number, and condition of dwelling units; type and adequacy of water supply, sewage
disposal, and solid waste disposal; and premises sanitation. These data preferably
should be obtained before impacts occur in order to assess prevalent conditions in
the community and to anticipate where new problems may occur or where old ones
may be intensified. Surveys conducted after impacts begin are invaluable in quan-
titating adverse conditions and in precisely locating the area and determining the
relative intensity of occurrence.
Current Status of Health
The procedures for gathering subjective impressions and obtaining objec-
tive data about health status are necessarily the most extensive in the Manual. In
some ways these data are the most difficult to obtain and to interpret. Provisions
are made for obtaining data on a few hundred items, although it is unlikely that any
single community would wish to include all of these in a survey. The survey in-
struments are designed so that the factors pertinent for the community can be
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selected and used in a format to meet the needs of individual communities. Pro-
visions are made in the survey instruments for collecting data concerning the
following:
• Awareness and opinions concerning community health services
• Awareness and preferences concerning selected public health
and welfare services
• Characteristics of residency, dwelling units, and premises
" Household health profiles and patterns of health services
• Current and potential health status and sources of services
• Household income
Procedures are outlined as follows: how to select the sample of popula-
tion from which to obtain data, how to secure the items of data deemed pertinent,
how to consolidate and interpret the data, and how to display and present the infor-
mation developed.
Resources for Health Services
Gathering information concerning the personnel and physical facilities for
/
providing health services is essential for every community. Not only do expen-
ditures for health services and facilities account for a large proportion of indi-
vidual and community expenses, but planning for health services that are adequate
but not excessive for community needs is one of the most arduous and often con-
troversial tasks faced by the community. Formats for health planning, concep-
tual plans for delivering health services, and objective data are all required.
The procedures provide for inventories of all types of personnel and facilities
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concerned with providing health services, for determining the capacity and extent
of use of facilities, and for defining the various types of health service areas.
Application of Information
Methods are provided for consolidating and interpreting the information re
suiting from the various compilations and surveys, to provide a coherent, docu-
mented account of existing conditions and available resources. Means are also
suggested for identifying specific problems and defining alternative solutions.
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SELECTED REFERENCE
Copley International Corporation. 1976. Procedures for evaluating health impacts
resulting from development of energy resources. A report prepared for the Office
of Energy Activities, Environmental Protection Agency, Region VIII. Denver,
Colorado. 119 pages.
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8. BIBLIOGRAPHY
General, Regional, Multi-state
Miller, S .C . 1974 . Environmental impacts of alternative conversion processes
for Western coal development. Thomas E . Carroll Associates, Washington,
D .C . 172 pp .
Mountain West Research, Inc . 1975. An application of a procedures manual for
assessing the socioeconomic impact of the construction and operation of coal
utilization facilities in the Old West Region. Denver, Colorado. 55 pp.
Mountain West Research, Inc . 1975 . Construction worker profile . Denver,
Colorado. Separate issues as follows:
User's guide to data . 145 pp .
Summary report. 23 pp .
Final report. 129 pp .
Old West Regional Commission and U .S .D .A . Forest Service . Energy Research
Information System . Quarterly Reports . November, 1975 and May, 1976.
Billings, Montana.
Proceedings . Fort Union Coal Conference . Montana, North Dakota, South
Dakota, Wyoming. October 13-15, 1975. Bismarck, North Dakota. National
Science Foundation and North Dakota Legislative Council. 296 pp .
Rapp, D .A . 1976 Western boomtowns: Part 1: A comparative analysis of State
actions . Western Governors' Regional Energy Policy Office. Denver,
Colorado . 58 pp.
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Colorado
Colorado's Health Systems Plan Framework. Undated excerpt. Chapter IV.
The health services component of the health system . Colorado Department
of Health, Division of Comprehensive Health Planning. Denver, Colorado .
28 pp.
Colorado's Health Systems Plan Framework. 1976. Chapter VI. State annual
implementation plan . Colorado Department of Health, Division of Compre-
hensive Health Planning . Denver, Colorado. 55 pp.
Colorado Population Trends . 1976 . County population projections - 1970 to
2000. University of Colorado, Graduate School of Business Administration .
Boulder, Colorado . 6 pp .
Colorado State Plan for Construction of Hospitals and Health Facilities . 1975.
Colorado Department of Health . Denver, Colorado .
Colorado Vital Statistics . Colorado Department of Health . Denver, Colorado .
Separate issues as follows:
Summary of vital statistics for Colorado, 1960-1970. 53 pp.
Annual report of vital statistics for Colorado, 1971. 24 pp.
Annual report of vital statistics for Colorado, 1972 . 24 pp.
Annual report of vital statistics for Colorado, 1973 . 26 pp.
Annual report of vital statistics for Colorado, 1974 . 32 pp.
Demographic Profile . 1975. Colorado Planning and Management District 10 .
Colorado Department of Health . Mimeographed . 8 pp.
Demographic Profile . 1975 . Colorado Planning and Management District 11.
Colorado Department of Health . Mimeographed . 8 pp.
Demographic Profile . 1975 . Colorado Planning and Management District 12 .
Colorado Department of Health . Mimeographed . 8 pp .
Demograhic Profile . Undated. A summary of data for all districts . Mimeo-
graphed. (Most recent data included is 1975 .) 2 pp.
Environmental Study for Health Planning. 1972 . Montezuma County, Colorado,
College of Vetinary Medicine and Biomedical Sciences, Institute of Rural
Environmental Health. Colorado State University. Fort Collins, Colorado.
58 pp.
Impact. 1974 . An assessment of the impact of oil shale development -- Colorado
Planning and Management Region II. Volume I - Executive Summary;
Volume II - Personal Services — Health. State of Colorado, Office of the
Governor . Denver, Colorado .
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Colorado (Cont'd)
Jones , D . C . and D . K . Murray . 1976. Coal mines of Colorado statistical
data. Colorado Geological Survey . Department of Natural Resources,
State of Colorado. Denver, Colorado. 27 pp.
Koff, R . 1975 . An evaluation of the water supply system of Hayden, Colorado .
Colorado Department of Health . Denver, Colorado . Mimeographed.
Lyon, L.J. Undated. Administration of natural resources research . Ameri-
can Institute of Biological Sciences and State of Colorado Department of
Game and Fish . 62 pp.
Manpower Data by Planning Region . 1975. Colorado, 1972-1975.
Miller, W.T. 1976. Health system resourse assessment. West-Central
Colorado Comprehensive Health Planning Council and Colorado West-Area
Council of Governments . Colorado Region XI.
Mueller, H . F . 1971. Colorado health consumer survey, a regional analysis .
Colorado-Wyoming Regional Medical Program . Denver, Colorado .
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Montana
Community Service Program . 1975 . A study of social impact of coal develop-
ment in the Decker-Berney-Ashland area . University of Montana. Missoula,
Montana.
Eastern Montana areawide health plan . 1975 . Economic Development Associa-
tion of Eastern Montana, Areawide Comprehensive Health Planning Agency .
Sidney, Montana. 178 pp.
Institute for Social Science Research . 1974 . A comparative case study of the
impact of coal development on the way of life of people in the coal areas of
Eastern Montana and Northeastern Wyoming. University of Montana .
Missoula, Montana. 185pp.
Montana county profiles . 1973 . State Department of Health and Environmental
Sciences, Division of Comprehensive Health Planning. Helena, Montana.
163 pp.
Montana Energy Advisory Council. 1974 . Coal development information packet.
State of Montana, Office of the Lieutenant Governor . Helena, Montana .
67 pp.
Montana Energy Advisory Council. 1975 . Coal development information packet.
Supplement 1. State of Montana, Office of the Lieutenant Governor . Helena,
Montana . 79 pp .
Montana State Han . 1975 . Hospital and medical facilities construction . Mon-
tana State Department of Health and Environmental Sciences . Helena,
Montana . 299 pp.
Montana vital statistics . Montana State Department of Health and Environmental
Sciences . Helena, Montana. Separate issues as follows:
Annual statistical supplement, 1968. 41 pp.
Annual statistical supplement, 1969. 59 pp.
Montana vital statistics , 1970. 61 pp.
Montana vital statistics, 1971. 61 pp.
Montana vital statistics, 1972. 82 pp.
Montana vital statistics , 1973 . 74 pp .
Montana vital statistics, 1974. 74 pp.
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North Dakota
Cooperative Extension Service. 1974. Selected medical services by region in
North Dakota. North Dakota State University. Extension Bulletin No. 24.
Fargo, North Dakota. 13 pp.
Ludtke, R . L . and R . W . Blair . 1974 . North Dakota abridged life tables .
1960 and 1970 . North Dakota State Department of Health, Division of Health
Planning. Bismarck, North Dakota . 17 pp.
LUken, R .A. 1974 . Economic and social impacts of coal development in the
1970's for Mercer County, North Dakota . Thomas E . Carroll Associates .
Washington, D .C . 206 pp .
Manpower survey system, manpower data analysis, task analysis system . Un-
dated . North Dakota State Board for Vocational Education and the Old West
Regional Commission Special Project. Bismarck, North Dakota .
North Dakota State Planning Division . 1975 . Some tentative figures on the social
impacts of six coal conversion plants in the Dunn, Mercer, Oliver, and
McLean Counties area.
State Plan for Hospitals and Medical Facilities Construction. 1976. North Dakota
State Department of Health . Bismarck, North Dakota . 254 pp .
Vital Statistics 1970-1971. Reprint from the 42nd Biennial Report of the North
Dakota Department of Health. Bismarck, North Dakota . 66 pp .
Vital Statistics 1972-1973 . Reprint from the 43rd Report of the North Dakota
State Department of Health . Bismarck, North Dakota . 73 pp .
Vital Statistics 1973-1975 . Reprint from the 44th Report of the North Dakota
State Department of Health . Bismarck, North Dakota . 93 pp .
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South Dakota
Folland, Sherman. 1976. Health needs and resources in South Dakota: A source
book. South Dakota Department of Health. Pierre, South Dakota. 92 pp.
Health Facilities and Services in South Dakota . 1974 . Comprehensive Health
Planning Program . State Department of Health . Pierre, South Dakota .
79 pp.
Health Manpower Resources in South Dakota . 1974 . Comprehensive Health
Planning Program . State Department of Health . Pierre, South Dakota .
175 pp.
Potential methodologies for the identification of primary and secondary hospital
and physician service areas in South Dakota. 1975 . South Dakota State
Deparement of Health, Comprehensive Health Planning Program . Pierre,
South Dakota . 92 pp .
Sixth District Council of Local Governments . 1975 . The impact of coal devel-
opment. Mimeographed. Rapid City, South Dakota. 37 pp.
Sixth District Council of Local Governments . 1975 . Rapid City regional trade
area . Mimeographed . Rapid City, South Dakota . 11 pp .
South Dakota Vital Statistics, annual report for 1974 . 1975 . South Dakota
Department of Health . Pierre , South Dakota . 74 pp .
Wagner, R . T ., E . T . Butler and K . A . McComish . 1975 . Population projec-
tion models for South Dakota, 1980, 1985, and 1990. Bulletin 631, 1970
Population Series, Report No . 8 . South Dakota State University, Rural
Sociology Department. Brookings, South Dakota .
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Utah
Annual Report of Utah Vital Statistics for 1970. 1973 . Utah State Division of
Health, Salt Lake City, Utah. 177 pp.
Annual Report of Utah Vital Statistics for 1971. 1974. Utah State Division of
Health, Salt Lake City, Utah. 168 pp.
Annual Report of Utah Vital Statistics for 1972 . 1976 . Utah State Division of
Health, Salt Lake City, Utah. 132 pp.
Comprehensive Health Plan for Utah. 1974. Vol. 1. Health problems, a sum-
mary . Updated draft.
District Health Departments in Utah. 1975 . Utah State Division of Health, Salt
Lake City, Utah . 50 pp.
Jackson, R . H., and Hudman, L .E . 1975. Master Plan, Castle Dale, Utah 1975.
Department of Geography, Brigman Young University . B . and D . Enter-
prises . Provo, Utah.
Marriage and Divorce in Utah, 1972. Utah State Division of Health, Salt Lake
City, Utah. 95 pp.
Mountain West Research, Inc . 1975. Construction worker profile . Community
report. St. George, Utah . Denver, Colorado. 22 pp + appendix.
Office of the State Planning Coordinator . 1975 . The Utah process alternative
futures 1975-1990 . Office of Governor Calvin L . Rampton. Salt Lake City,
Utah. Separate issues as follows:
Introduction and Summary
Volume 1: Assumptions and projections
Volume 2: Detailed projections
Planning Survey . 1975 . Uintah and Duchesne Counties . Uintah Basin Association
of Governments and Family Services . 69 pp.
Policies, Procedures, and Recommendations for Full-Time Local Health Depart-
ments . 1975. Utah State Division of Health. Salt Lake City, Utah . 41 pp.
Uintah Basin Association of Governments . 1976. Duchesne County public finance
study . Bureau of Community Development, University of Utah. Salt Lake
City, Utah . 60 pp.
Utah Energy Resource Data. 1976. Utah Department of Natural Resources .
Salt Lake City, Utah . 27 pp .
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Utah (Cont'd)
Utah Health Manpower for 1973 . 1973 . Utah State Division of Health . Salt
Lake City, Utah . 95 pp .
Utah Health Manpower for 1974. 1975 . Utah State Division of Health . Salt
Lake City, Utah. 115 pp.
Utah Health Profile. 1973 . Utah State Division of Health . Salt Lake City,
Utah . 162 pp.
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Wyoming
Comprehensive Health Planning . 1976 . Wyoming health profiles . Wyoming
Division of Health and Medical Services . Cheyenne, Wyoming. 145 pp.
Gilmore, J.S . Boom towns may hinder energy resources development. 1976.
Science 191: 535-540.
Gilmore, J.S . and M. K. Duff. 1975 . Boom town growth management: a case
study of Rock Springs-Green River, Wyoming. Westview Press . Boulder,
Colorado. 177 pp.
John Dempsey and Associates . 1975 . An update of the comprehensive plan for
Rock Springs, Wyoming. Englewood, Colorado. 87 pp + appendix .
Johnston, Malcolm F . 1975 . Final report for the health impact research pro-
ject. Comprehensive Health Planning, State of Wyoming. Cheyenne,
Wyoming . 93 pp.
Kohrs, E .V . Social consequences of boom growth in Wyoming. 1974. Paper
given at the Rocky Mountain American Association for the Advancement of
Science Meeting. July 24-26, 1974, Laramie, Wyoming . Mimiographed.
LeBaron, Wayne. 1969. Planning guide for comprehensive community health
analysis program . Office of Comprehensive Health Planning . Wyoming
Department of Health and Social Services . Cheyenne, Wyoming .
Mountain West Research, Inc. 1975. Construction worker profile . Rock
Springs and Green River, Wyoming. Denver, Colorado. 88 pp + appendix.
Office of Comprehensive Health Planning . 1970. Community Health Analysis
for Sheridan, Wyoming. Wyoming Department of Health and Social Services .
Cheyenne, Wyoming. 88 pp.
Southwest Wyoming Industrial Association. Quarterly Reports . June 1975, Sep-
tember 1975, October 1975-March 1976. Rock Springs, Wyoming.
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