Hispanic environmental health: Ambient and indoor air pollution

Hispanic environmental health: Ambient and indoor air pollution

Hispanic environmental health: Ambient and indoor air pollution NATIONAL COALITIONOF HISPANIC HEALTHAND HUMAN SERVICES ORGANIZATIONS(COSSMHO),Washingt...

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Hispanic environmental health: Ambient and indoor air pollution NATIONAL COALITIONOF HISPANIC HEALTHAND HUMAN SERVICES ORGANIZATIONS(COSSMHO),Washington, D.C.

Air pollution has sedous deleterious effects on health and is a public health matter of the utmost importance. The National Coalition of Hispanic Health and Human Services Organizations (COSSMHO) believes that reducing exposure to air pollution is a priority issue for the Hispanic community because 80% at Hispanics (compared with 65% of non-Hispanic blacks and 57% of non-Hispanic whites) live in nonattainment a r e a s - areas that tail to meet the Environmental Protection Agency ambient air quality standard. Although Hispanics in general live as long as or longer than non-Hispanic whites, what morbidity data are available reveal that the quality of that life is severely impaired by a variety of chronic conditions, such as asthma. This makes environmental health a pressing matter for Hispanic communities, particularly in the area of air pollution. Action items are included. [OTOLARYNGOI.HEAD NECK SURG "/996; 114:256-64.}

]n 1987 and again in 1990 the U.S. Environmental Protection Agency (EPA) convened its Science Advisory Board (SAB) to identify the top environmental threats to human health. In 1987 the EPA SAB considered four major types of risk-cancer risks, noncancer health risks, ecologic effects, and welfare effects-in an evaluation of 31 environmental problems based on both quantitative data and expert judgment2 (p14)The results of the evaluation included an EPA ranking of environmental hazards on the basis of cancer risk, as follows: (1) radon/worker exposure to chemicals; (2) pesticide residue on food; (3) indoor air pollutants other than radon/consumer exposure to chemicals; (4) hazardous/toxic air pollutants; (5) depletion of stratospheric ozone; (6) hazardous waste sites-inactive; (7) drinking water; and (8) application of pesticides. ~(pp2s9~ More recently, in 1990 the EPA SAB's Relative Risk Reduction Strategies Committee released a report which, while not ranking risk from highest to lowest, identified more generally the highest risk environmental exposures for human beings. This listing

Presented at the conference "Air Pollution Impacts on Body Organs and Systems" of the National Association of Physicians for the Environment, the National Press Club, Washington, D.C., Nov. 18, 1994. Received for publication July 6, 1995; revision received Sept. 29, 1995; accepted Sept. 29, 1995. Reprint requests: COSSMHO, 1501 Sixteenth St., NW, Washington, DC 20036. Copyright © 1996 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/96/$5.00 + 0

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substantially overlapped with the ranking of risk developed by the EPA in 1987 (Table 1). Such assessments of threats to health assist in evaluating the EPA's environmental policy-making priorities to protect the public health, including the health and well-being of Hispanic communities. Examination of each of the high-risk exposure areas reveals that, in terms of risk, Hispanics either fare the worst or face significant threats to their health for every area identified by the EPA as a top threat to human health, including the area of air pollution. HISPANIC DEMOGRAPHICS

Hispanics constitute a significant portion of the American population-about 22.4 million persons in the United States 3(pp23-1~3~and an additional 3.5 million persons in Puerto Rico. 3(p3~ Hispanics are also a youthful population, with a median age of only 26.1 years, compared with 27.7 for blacks and 33.6 for whites. 4High birth and fertility rates characterize U.S. Hispanics, who in 1989 had a birth rate of 26.2 per 1000 persons, compared with an overall birth rate of 16.3 per 1000 for the United States in general. 5 Additionally, the "estimated fertility rate for U.S. Hispanic women aged 15-44 years was 104.960% above the rate of 65.7 for non-Hispanic women. '5(p7~ These high birth and fertility rates, together with the relative youth of the Hispanic population, have led to projections that by the year 2010 Hispanics will number 31 million persons and constitute a significant segment of the working age population2 Geographically, nearly 90% of the U.S. Hispanic population is concentrated in 10 states: Arizona, California, Colorado, Florida, Illinois,

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Massachusetts, New Jersey, New Mexico, New York, a n d T e x a s . 3(p4) Further, approximately 90% of Hispanics live in metropolitan areas, compared with about 76% of the non-Hispanic population, 3~p6) an important consideration in discussions of exposure to air pollution.

Table '1, EPA SAB's top four high-risk h u m a n exposures2 Ambient air pollution Worker exposure to chemicals in industry and agriculture Pollution indoors Pollutants in drinking water

EPA HIGH-RISK HUMAN EXPOSURE: AMBIENT AIR POLLUTIONS

Air pollution can have both chronic and acute health effects. Acute effects of air pollution on the respiratory system include "triggering or aggravating of asthmatic attacks, exacerbation of symptoms of chronic obstructive disease, increased upper or lower respiratory infections, transient changes in pulmonary function, increased respiratory symptom reporting, increased respiratory hospital admissions or doctor visits, and increased daily mortality. ''7 Chronic effects of air pollution on the respiratory system include "promotion of the development of asthma, increase in non-specific airway responsiveness, reduced level of lung function, increased rate of lung-function decline, decreased rate of lung growth, development of chronic obstructive pulmonary diseases, increased reporting of persistent respiratory symptoms, lung cancer, and increased mortality. ''7 T h e chronic and acute health effects of exposure to air pollution are in large part responsible for introduction of air pollution control laws in the United States} The Clean Air Act (CAA), ~ which "establishes comprehensive sets of measures to control outdoor air pollution throughout the nation, ''s(vT(,°) is the E P A modern mechanism for national regulation of air quality. To control the amount of pollution in the air, the E P A sets National Ambient Air Quality Standards ( N A A Q S ) - u n i f o r m national air quality standards that restrict ambient levels of certain pollutants to protect the public health3 ~p~29°)According to section 108(a)(2) of the CAA, NAAQS must "accurately reflect the latest scientific knowledge useful in indicating the kind and extent of all identifiable effects on public health or welfare which may be expected from the presence of such pollutant in the ambient air. ''~ NAAQS exist for particulate matter, which includes emissions from sources such as incinerators, lead, ozone, carbon monoxide, nitrogen oxide, and sulfur dioxide. ~(~772~ Unfortunately, Hispanics appear to face elevated risk for developing acute and chronic responses to exposure to air pollution because a disproportionate number of Hispanics live in areas failing to meet one

or more NAAQS. A recent study by Wernette and Nieves of the Argonne National Laboratory revealed that 80% of Hispanics live in areas failing to meet one or more E P A air quality standards, compared with 65% of blacks and 57% of whites. ~°(~7~ Additionally, in areas failing to meet two or more NAAQS, three or more NAAQS, and four or more NAAQS, Hispanics are consistently significantly worse off as measured by percentage of the population living in these nonattainment areas. Sixty percent of Hispanics. 50% of blacks, and 33% of whites live in areas failing to meet two or more NAAQS; 31% of Hispanics, 20% of blacks, and 12% of whites live in areas failing to meet three or more NAAQS; and finally, 15% of Hispanics. 10% of blacks, and 5% of whites live in areas failing to meet four or more NAAWS ''~°(~71 (Fig. 1). There are some specific data on health outcomes related to air pollution that are consistent with the acute and chronic health effects from exposure to air pollution. The American Lung Association reports that "63% of pre-adolescent children residc in counties classified as non-attainment for one or more NAAQS."11 Further. "61% of pediatric asthma cases less than 18 years of age among children living in non-attainment areas for one or more N A A Q S . " " With the exception of regional data on asthma among Puerto Rican children, who are more than three times as likely as non-Hispanic white children to have active asthma. ~zspecific quantitative knowledge on the environmental health status of Hispanics is not available. This is in large part because of the failure to collect Hispamc-specific data m national data systems.* Nevertheless. on a pollutantby-pollutant basis, data that show disproportionate risk for Hispanics provide an indication of the type of health effects to which Hispanic communities are exposed. Particulate Matter P a r t i c u l a t e m a t t e r ( P M - 1 0 ) is essentially dust or

soot less than or equal to 10 ~m in size, suspended in the air. PM-10 comes from a variety of industrial s o u r c e s - w o o d - b u r n i n g stoves, urban dust, and

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8070-

KNO/_

6050E 40-

e~ 302010OOne Standard Unmet []

Hispanics

Two Standards Three Standards Four or More Unmet Unmet StandardsUnmet ~

Non-HispanicBlacks

~

Non-HispanicWhites

Fig. t. Percentage of persons living in areas failing to meet EPA ambient air quality standards, by race/ethnicity. [Data from Wernette DR, Nieves LA. Environmental Protection Agency Journal 1992; March/April: t 7.]

open burning for forest management and agricub tural purposes. ~31p4) Hispanics are more than two times as likely as either blacks or whites to live in areas with elevated levels of particulate matter. Thirty-four percent of Hispanics, 16.5% of blacks, and 14.7% of whites live in EPA nonattainment' areas for particulate matter j" (Fig. 2). Research into the effect of exposure to particulate matter on lung function reveals that both forced vital capacity and forced expiratory volume are consistently lower in urban children than in suburban children, ~4strongly suggesting that urban ambient air pollution exposure (particulate matter, N O 2 , SO2, etc.) is responsible for the retardation in growth of lung function in children. Research conducted by Joel Schwartz of the Harvard School of Public Health ~5 reports an association between elevated levels of PM and death rates for various conditions that have respiratory factors contributing to the underlying causes of death. Lead

Lead (Pb) emissions to the atmosphere come primarily from nonferrous smelters and battery plants ~3(p2)and to some extent from lead additives in gasoline, although this has all but been eliminated as a source of atmospheric lead in the United States. Nevertheless, Hispanics are more than two times as likely as either blacks or whites to live in areas with high levels of lead in the air: 18.5% of Hispanics, 9.2% of blacks, and 6% of whites live in EPA nonattainment areas for lead ~ (Fig. 3). The effects

of lead on child development are well documented and well known. Indeed, "chronic low-level exposure to lead has been linked to damage to the central and peripheral nervous system, low birth weight, learning disabilities, chronic anemia, shorter stature, impaired hearing, and impaired formation and function of blood cells in young Children, infants, and fetuses. ''~' Ozone

Tropospheric ozone, the primary, component in smog, is created when sunlight acts on two other criteria pollutants, nitrogen oxide and volatile organic compounds. These two pollutants come from a variety of sources, including gasoline vapors, chemical solvents, and fuel combustion products, j~Ip3)Hispanics are most likely to live in an EPA nonattainment area for ozone. Seventy-one percent of Hispanics, 62% of blacks, and 52% of whites live in areas with high levels of ozone '° (Fig. 4). " T h e r e are some provocative indications that there may be substantial adverse effects [to ozone exposure]. The indications include: greater rate of loss of lung function in nonsmoking men and women . . . . reduced baseline lung function when annual average 03 concentration is greater than 40 ppb [parts per billion], based on a national population sample, and an unexpectedly high incidence of centriacinar region disease in the lungs of adolescents and young adults examined post-mortem in Los Angeles County. ''~7 Additionally, "acute reduction of pulmonary function performance following ozone exposure has

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55-

2520-

I050-

Hispanic

Non-Hispanic Black

Non-Hispanic White

Fig. 2. Percentage of persons living in EPA nonattainment areas for particulate matter, by race/ethnicity. (Data from Wemette DR, Nieves LA. Environmental Protection Agency Journal 1992;March/Aprih 17.1

2

Hispanic

Non-Hispanic Black

Non-Hispanic White

Fig, 3. Percentage of persons living in EPAnonaflainment areas for lead, by race/ethnicity, (Data from Wernette DR, Nieves LA. Environmental Protection Agency Journal 1992;March/April:l 7.]

been documented in epidemiological studies in which small groups were followed over a short period. ''s Carbon Monoxide

Carbon m o n o x i d e - a colorless, odorless, poisonous gas produced by incomplete fuel combustioncomes mainly from motor vehicle exhaust, as well as from incinerators and various industrial processes. 13~p2t Eighty-eight percent of Hispanics and 85% of n0n-Hispanic blacks live in nonattainment areas for carbon monoxide, compared with 50% of non-Hispanic whitesY~ "Carbon monoxide binds with hemoglobin in the blood to form carboxyhe-

moglobin (COHb), reducing oxygen transport to the tissues. The most common symptoms of carbon monoxide poisoning are headache, dizziness, drowsiness, nausea, and vomiting. In addition, it can also lead to confusion, neurological damage, cardiac arrhythmias, coma, and death. Retinal hemorrhages are standard signs of CO poisoning '~°~p~5~ (Fig. 5). EPA HIGH-RISK HUMAN EXPOSURE: INDOOR POLLUTION

At first glance, indoor pollution appears to be an inconsequential threat to health, compared with other exposures, but it can be just as deadly. Among the most serious indoor air quality issues are envi-

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00.J 70-

50. 50. 40, ~. 2;0. 2010-

0/

Hispanic.

Non-Hispanic Black

Non-Hispanic White

Fig. 4. Percentage of persons living in EPA nonattainment areas for ozone, by race/ethnicity. [From

Wemette DR, Nieves LA. Environmental Protection Agency Journal 1992;March/April:17.)

R!:lo/~

Hispanic

Non-Hispanic 13lack

Non-Hispanic Wh ite

Fig. 5. Percentage of persons living in EPA nonattainment areas for c a r b o n monoxide, b y race/ethnicity. (From Wernette DR, Nieves LA. Environmental Protection A g e n c y Journal 1992; March/April: 17.)

ronmental tobacco smoke (ETS) and radon. T h e dangers to health posed by these two indoor air pollutants are distinct from many other environmental threats to health in that they are most directly caused by preventable consumer behavior, as in the case of ETS, or by a randomly occurring natural phenomenon, as in the case of radon. ET$

It is well established that cigarette smoking is a major cause of death and disease. According to the U.S. Department of Health and Human Services, "[t]obacco use is responsible for more than one of every six deaths in the United States and is the most important single preventable cause of death and

disease in our society. Cigarette smoking accounts for about 434,000 deaths yearly, including 21% of all coronary heart disease deaths, 87% of all lung cancer deaths, and 82% of all deaths from chronic obstructive pulmonary disease. ''r~ The threat to health from tobacco use is not limited to the user of the tobacco product. Others who are near a smoker can be exposed to passive smoke, otherwise known as ETS. a~(~p~-2~ETS is "composed of exhaled mainstream smoke (MS) from the smoker, sidestream smoke (SS) emitted from the smoldering tobacco between puffs, contaminants emitted into the air during the puff, and contaminants that diffuse through the cigarette paper and mouth between puffs. ''2~ Although ETS is dilute

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compared with MS, it is similar in composition, containing more than 4000 chemicals and at least 40 known carcinogens. 2°(pp~'2)2~ Compounds present in ETS include 1,3-butadiene, acetic acid, acetone, ammonia, benzene, carbon monoxide, carbon dioxide, formaldehyde, formic acid, hydrogen cyanide, toluene, and various types of particulate matter, including dicyclic and polycyclic aromatic hydrocarbons. 2° ETS contains "many of the same carcinogenic and toxic agents ''2° present in MS, and as such, ETS poses a significant threat to the health of nonsmokers occupying the same environment. Consistent with this threat to health, the U.S. E P A in 1992 designated ETS as a known human lung carcinogen, or "group A" carcinogen, under EPA's carcinogen classification system. 2~The group A designation is used "when there is sufficient evidence from epidemiological studies to support a causal association between exposure to the agents and cancer. ''2° The application of stringent criteria led to conservative estimates by the EPA that ETS causes approximately 53,000 deaths annually among nonsmokers in the United States, including 3000 lung cancer deaths. = The EPA's designation of ETS as a group A carcinogen is amplified by the noncancer health effects of exposure to ETS. A positive link has been established between ETS and respiratory illness in children, -~°(pmwith numerous epidemiologic studies demonstrating a causal association between ETS and bronchial hyperresponsiveness; "additional episodes and increased severity of asthma in children who already have the disease"; reduced lung function as measured by various airflow parameters such as forced expiratory volume; and cough, phlegm, and wheezing? ° Other studies on the noncancer health effects of ETS on children show evidence of an association between ETS and acute lower respiratory tract illnesses such as bronchitis and pneumonia occurring up to twice as often during the first 2 years of life in the children of smokers; acute upper respiratory tract illnesses, acute middle ear infections, and acute middle ear effusion, "the most common reason for hospitalization of young children for an operation"; and sudden infant death syndromeY ~ Hispanic children are regularly exposed to ETS. According to the National Center for Health Statistics, 44.3% of Hispanic preschool children have been exposed to tobacco smoke, compared with 50.8% of non-Hispanic white children. ~2~t Of this substantial number, Hispanic children are more likely to be exposed to tobacco smoke postnatally

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rather than prenatally. Of all Hispanic children exposed to tobacco smoke, 23.5% have been exposed postnatally, compared with 20.9% of nonHispanics22(p~°~ This distinction is important because it indicates a significant deterioration in the quality of Hispanic children's environment once they are born and points to a need for postnatal health education and intervention in Hispanic households with children. Radon

Radon gas is derived from the radioactive decay of radium, a ubiquitous element found in rock and soil. The decay series begins with uranium-238 and goes through four intermediates to form radium-226... Radium-226 then decays to form radon-222 gas. Radon's half-life, 3.8 days, provides sufficient time for it to diffuse through soil and into homes, where further disintegration produces more chemically and radiologically active radon progeny "radon daughters." These radon progeny, which include four isotopes with half-lives of less than 30 minutes, are the major source of human exposure to alpha radiation. This alpha radiation is responsible for cellular transformation in the respiratory tract, which results in radon-induced lung cancer. 23 Although the probability that radon will be a problem is essentially random, public awareness is largely the result of purposive public health education campaigns. Difficulties in raising public awareness about the seriousness of the threat to health posed by radon are centered largely on the fact that radon is colorless, odorless, tasteless, and causes no immediate symptoms. Further, whereas federal efforts at public education have succeeded for nonHispanic whites, this is far less true for Hispanics. The Department of Health and H u m a n Services' National Center for Health Statistics reports that 61.2% of Hispanics have never heard of radon, compared with 21.5% of whites 24 (Figs. 6 and 7). Public education materials and programs targeting Hispanic communities are critical to reducing this knowledge gap. CONCLUSIONS

Mortality data for Hispanics reveal rates that are competitive with rates for the non-Hispanic white population.t Looking only at mortality, Hispanics are doing as well as their non-Hispanic white counterparts, who have the most access to health care, the highest incomes, and the highest educational attainment levels. However, even though Hispanics in general live as long as or longer than non-His-

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7o-/" 60-,

i I

50-

40-

50-

20-

IO-

Hispanic

Aslan/Pacific islander

Black

American indian

White

Fig. 6. Percentage of persons who have never heard of radon. (Data from the National Center for Health Statistics, National health interview survey, 1990. Washington, D.C.: U,S. Department of Health and Human Services, 1990,)

10% I

INon-Nrspan~c White

Natrve American

mon-t-f~span/c Black

~lspanlc

As~an American

Fig. 7. Radon testing rates, by race/ethnic group. (Data from the U.S. Environmental Protection Agency, Office of Radiation Programs, Radon Division, 1993.)

panic whites, what morbidity data are available* reveal that the quality of that life is severely impaired by a variety of chronic conditions, such as asthma, as noted above. This makes environmental health a pressing matter for Hispanic communities, particularly in areas with high levels of air pollution. Accordingly, COSSMHO makes the following recommendations in this area. Ambient Air Pollutions

1. As the EPA collects exposure and other population data, it should require methods that include ethnic identifiers, conduct oversam-

piing, and collect samples that are of a size sufficient to allow breakout by Hispanic subgroup and that require linguistic competence for interviewers. At minimum both the EPA and the Department of Health and Human Services should adhere to Office of Management and Budget directive no. 15. . The EPA should conduct an internal audit of its enforcement activities to determine the extent to which non-Hispanic white communities benefit from more punitive enforcement, as compared with Hispanic and black communities.

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3. Existing N A A Q S should be reviewed and modified as needed in light of new research indicating m o r e serious health effects from exposure to ozone and other criteria pollutants. Existing N A A Q S may be too lax. 4. The U.S. E P A should require adherence to state implementation plans under the C A A with renewed vigor. Noncompliance with N A A Q S results in unacceptable health costs for affected communities and places a particularly onerous burden on children and their development. 5. Programs targeting Hispanic community-based organizations and individuals for training on how to use the toxic release inventory should be a priority to e m p o w e r Hispanic communities in the monitoring and influencing of local industry. Although the toxic release inventory has b e e n a particularly effective tool for nonHispanic white communities, it remains largely inaccessible to Hispanic communities. 6. T h e E P A should fully and completely assess the extent to which particular racial and ethnic groups are m o r e likely to live in proximity to chemical plants, refineries, and other facilities that contribute to the degradation of air quality. For noncriteria pollutants this should be done without determining risk or causation. This assessment is critical to developing appropriate community-based interventions designed to reduce exposures. Indoor Air Pollutions

1. A tobacco tax of at least $2 per pack should be instituted to reduce smoking behavior while at the same time raising revenue for critical national efforts. 2. Increase public education targeting Hispanic communities with health promotion messages on radon, ETS, and other indoor air pollutants. It is well established that simple translation of materials intended for mainstream, non-Hispanic white audiences or other communities is not effective. 3. Encourage development of creative programming targeted to Hispanics that not only focuses on raising awareness and eliciting testing for radon but also seeks to provide tow-cost options for mitigation. ENDNOTES

*The lack of data that would be useful in assessing with specificity the environmental health status of Hispanics remains an important issue. To date, Hispanics continue to be regularly excluded from important federal research

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and data collection activities through methods that fail to require ethnic identifiers, do not oversample, do not collect samples of a size, sufficient to allow breakout by Hispanic subgroup, or rely on interviews conducted by field researchers without the appropriate cultural and linguistic competence. These data collection issues are well documented. The most recent General Accounting Office study on Hispanic access to health care reports that, although there are "sources of data that do provide some useful information on the health status of the Hispanic population," "no existing database currently provides accurate, complete, and available data on the entire Hispanic population, including subgroups, residing in the United States. ''25 Delgado and Estrada state the problem more specifically, noting that the U.S. Department of Health and Human Services has 21 national health data collection systems that "largely form the basis of our quantitative knowledge of public health in the United States... Of the 21 systems, 6 do not collect Hispanic population data, including the Medicare statistical system. Furthermore, of these data systems, only the National Vital Statistics System collects data for all Hispanic subpopulation groups. Seventeen of the 21 data systems do not collect samples of a size adequate for analysis for any of the four major Hispanic subpopulation g r o u p s . ''26 Although the Office of Management and Budget has provided the minimal standards for federal data collection efforts encompassing race and ethnicity in its directive no. 15, the exclusion of Hispanics from critical national data systems has persisted, Of examples too numerous to mention, the most recent is a proposal by the U.S. EPA's Office of Research and Development to conduct phase I of a national health exposure assessment survey with no methodologic consideration to cultural and linguistic competence of surveyors or oversampling for Hispanics. 27 Changes need to occur in federal data collection and reporting. Until these changes take place, the information that is needed to determine the environmental health status of Hispanics with specificity will continue to elude policy makers, and federal, state, and local entities will be unable to protect the health and well-being of all people in the United States in a comprehensive manner. tThe rate of low birth weight among Hispanics is 6.2% compared with 5.6% for non-Hispanic whites and 13.1% for non-Hispanic b l a c k s 4(p3°) (note: data are for 30 states reporting and the District of Columbia). The infant mortality rate for Puerto Ricans is 9.6%; for Mexican Americans it is 7.9%, and for Cuban Americans it is 7.4%, compared with 7.9% for whites and 18.5% for blacks4(p32~ (note: death rates per 1000 live births; data are for 19831985 birth cohorts). In 1990, for every 100,000 persons aged 45 to 64 years, 166 Hispanics died of heart disease compared with 244 whites and 426 blacks4(psv) (data on Hispanic origin are from 26 states and the District of Columbia), In 1990, for every 100,000 persons aged 45 to 64 years, 152 Hispanics died of malignant neoplasms compared with 289 whites and 401 blacks. 4

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REFERENCES

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14. Hricko A. Environmental problems behind the Great Wall. Environ Health Perspect 1994;102:127-244. 15. Schwartz J. What are people dying of on high air pollution days? Environ Res 1994;64:26-35. 16. Environmental issues in primary care. Minnesota Department of Health. 1991:4. 17. Lippmann M. Use of human lung tissue for studies of structural changes associated with chronic ozone exposure: opportunities and critical issues. Environ Health Perspect 1993; 101(suppl 4):209-12. 18. Devlin RB. Identification of subpopulations that are sensitive to ozone exposure: use of end points currently available and potential use of laboratory-based end points under development. Environ Health Perspect 1993;101(suppl 4):225-30. 19. Health United States. Washington, D.C.: U.S. Department of Health and Human Services, 1992:260. 20. Respiratory health effects of passive smoking: lung cancer and other disorders. Washington, D.C.: U.S. Environmental Protection Agency, December 1992:1-2 (EPA/600/6-90/006F). 21. Heart and stroke facts: 1994 statistical supplements. Dallas: American Heart Association, January 1993:147. 22. Tobacco use: an American crisis, final conference report and recommendations from America's health community. Chicago, !11.: American Medical Association, Jan. 9-12, 1993. 23. Case studies in environmental medicine: radon toxicity. Atlanta, Ga.: Agency for Toxic Substances and Disease Registry, 1992:3. 24. National Center for Health Statistics. National Health interview survey, 1990. Washington, D.C.: U.S. Department of Health and Human Services, 1990. 25. Hispanic access to health care. Washington, D.C.: General Accounting Office, 1992;GAO/PEMD-92-6:20. 26. Delgado JL, Estrada L. Improving data collection strategies. Public Health Rep 1993;108:540-1. 27. Information Collection Request to the Office of Management and Budget. Washington, D.C.: U.S. Environmental Protection Agency, 1994; no. 1701.01, 59; Fed. reg. no. 41758.