APPENDIX J Health Studies

APPENDIX J Health Studies

Air Quality and Human Health Assessment - i - January 2005 TABLE OF CONTENTS 1.0 INTRODUCTION... 1 2.0 STRUCTURE OF THE REVIEW... 1 3.0 CANADA GENERAL POPULATON... 2 3.1 HEALTH STATUS COMPARISONS BETWEEN BRITISH COLUMBIA AND CANADA... 2 3.2 HEALTH STATUS COMPARISONS BETWEEN THE ROBERTS BANK AREA AND BRITISH COLUMBIA... 5 4.0 CANADA FIRST NATIONS... 11 4.1 HEALTH STATUS COMPARISONS BETWEEN BRITISH COLUMBIA AND CANADA... 11 4.2 HEALTH STATUS COMPARISONS BETWEEN THE ROBERTS BANK AREA AND BRITISH COLUMBIA STATUS INDIANS... 15 5.0 UNITED STATES GENERAL POPULATION... 22 5.1 HEALTH STATUS COMPARISONS BETWEEN WHATCOM COUNTY, WASHINGTON STATE AND THE U.S... 22 6.0 CONCLUSIONS... 26 7.0 REFERENCES... 28 LIST OF TABLES Table 3-1: Health Status Comparisons Between Canada, the Provinces and the Territories (1)... 3 Table 3-2: Health Status Between the Province of British Columbia and its Health Authorities (1)... 7 Table 3-3: Health Status Comparisons between the British Columbia and the Local Health Areas for the South Fraser Valley (1)... 9 Table 3-4: Population Trends for Seniors of Fraser Health (1)... 11 Table 4-1: Health Status Comparisons between First Nations of Canada, BC Status Indians and the General Population... 12

Air Quality and Human Health Assessment - ii - January 2005 Table 4-2: Population Trends by Age and Gender for Status Indians and the General Population in the South Fraser Health Region (1)... 16 Table 4-3: Comparison of Status Indians Health Status between the Province of British Columbia and the Fraser Health Authority (1)... 17 Table 4-4: Comparison of First Nations Health Determinants between the province of British Columbia and the Fraser Health Authority (1)... 20 Table 5-1: Population Trends for Point Roberts, Whatcom County, Washington State and the United States (1)... 23 Table 5-2: Health Status Comparisons between Whatcom County, Washington State and the U.S.... 24

Air Quality and Human Health Assessment - 1 - January 2005 1.0 INTRODUCTION Health risk assessments based on chemical emission rates and air dispersion modeling have historically been employed to predict potential health problems associated with industrial emissions in the area. As proposed projects and expansions are evaluated, risk assessments will continue to be required to predict future effects; however, population-based exposure and health effects assessments can complement risk assessments by characterizing the general health status of the population of interest. In contrast to the predictive nature of risk assessment, this review seeks to determine the actual situation in the community or region of interest with respect to particular health outcomes. Knowledge gained from these studies may also help guide aspects of the methodology or interpretation of the current risk assessment. Information respecting the demographics of the Roberts Bank area, including population size, projected growth, age and gender distribution, overall health status, and disease incidence for the general population and First Nations will be compiled and evaluated. Key determinates of health recommended by Health Canada also will be included in the review. This is especially important for the aboriginal population, which traditionally has a poorer health status than the general nonaboriginal population (Health Canada, 1999a). The objective of this review is to determine whether an elevated incidence in health problems is occurring in the Roberts Bank area relative to other areas of the province/states and countries. Emphasis is placed on health studies that provide information on the health status of British Columbians; specifically, communities within the Roberts Bank area. Particular emphasis also will be placed on providing information on the health status of First Nations, with a focus on the health determinants that have the greatest relevance to the First Nations population (e.g., socioeconomic status). 2.0 STRUCTURE OF THE REVIEW For ease of reporting, the data reviewed were grouped into the following sections: Canada General Population Canada First Nations Population

Air Quality and Human Health Assessment - 2 - January 2005 United States (U.S.) General Population The Canadian sections were further assessed based on the province of British Columbia (B.C.) and its local health authorities, while the U.S. section combined the assessment of Washington State and Whatcom County. Point Roberts, which is encompassed by the Roberts Bank study area and considered to be an area of interest for the current risk assessment, is not specifically discussed in this review with respect to health outcomes as there are no health data currently available for the area. Point Roberts is located on a peninsula that is considered to be a part of Whatcom County and Washington State, for which there are health status data available. However, Point Roberts is separated from the remainder of the county and state by the Canadian border and Boundary Bay. Consequently, the significance of the health status data obtained for Whatcom County, as a whole, relative to the area of Point Roberts and the area of interest remains unclear. Thus, Whatcom County was included in this review simply for overall completeness. 3.0 CANADA GENERAL POPULATON 3.1 HEALTH STATUS COMPARISONS BETWEEN BRITISH COLUMBIA AND CANADA A Health Canada report called Toward a Healthy Future: Second Report on the Health of Canadians provides a regional and national picture of current health status and trends in Canada (Health Canada, 1999a). This report emphasizes the influence of gender and socioeconomic status on health. Health Canada provides more detailed statistics and information of their study in its Statistical Report on the Health of Canadians (Health Canada, 1999b). A summary of health status comparisons between Canada, the provinces and the territories is provided in Table 3-1. British Columbia was not appreciably different from the national average with regard to any of the health outcomes. In fact, British Columbia was lower than the national average with the exceptions of birth defects and mortality due to respiratory disease. British Columbia was among the lowest ranked provinces for cardiovascular disease deaths and respiratory disease

Air Quality and Human Health Assessment - 3 - January 2005 hospitalization rates. In general, the health status of British Columbians is comparable to that of the rest of Canada. Table 3-1: Health Status Comparisons Between Canada, the Provinces and the Territories (1) HEALTH STATUS CANADA NF PEI NS NB PQ ON MN SK AB BC YK NWT NU ASMR for all cancers (2) Males 229 262 235 264 239 263 221 230 218 198 199 241 210 366 Females 149 157 170 164 144 156 148 154 142 148 138 175 205 304 ASMR for lung cancer (2) Males 70 79 79 90 73 94 62 65 66 57 56 85 69 150 Females 35 30 33 43 37 37 33 35 36 34 35 47 49 166 Cardiovascular disease deaths 226 281 277 233 236 220 229 241 222 233 207 243 216 n/a Circulatory disease hospitalization (3) 1588 1801 1571 1976 2142 1629 1547 1605 2072 1265 1514 734 472 n/a Respiratory disease deaths 58 50 76 68 59 56 55 58 61 58 61 59 179 n/a Respiratory hospitalization rates (3) 1060 1240 1938 1270 2000 964 924 1334 2063 1137 928 983 2051 n/a Asthma prevalence(>12 yrs of age) (%) (4) Males 6.9 5.3 7.0 7.5 7.4 7.1 6.8 7.2 7.0 7.6 6.2 4.8 7.7 n/a Females 9.9 7.9 9.9 10.7 9.7 10.2 10.1 9.8 7.9 10.2 9.0 13.8 9.1 5.3 Asthma prevalence (<12 yrs of age) (%) (5) Males 12.8 n/a 23.1 n/a n/a 13.3 15.7 n/a n/a n/a n/a n/a n/a n/a Females 10.7 n/a n/a 47.3 n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Low birth weight (% of live births) 5.8 6.1 5.3 5.4 5.1 5.9 6.0 5.5 5.0 6.1 5.2 4.3 5.5 n/a Birth defects (3) 483.5 800.6 404.7 n/a 326.7 n/a 462.6 633.0 608.2 343.3 577.1 540.5 359.7 n/a Infant mortality 0.56 0.66 0.47 0.56 0.49 0.46 0.57 0.67 0.84 0.62 0.51 n/a 1.12 n/a Prevalence of current smokers (%) (6) 28 31 32 31 28 32 25 26 29 28 24 n/a n/a n/a Excellent self-rated health/wellbeing (%) 25 26 22 20 21 27 25 21 17 25 25 n/a n/a n/a 1) Data were sourced from Toward a Healthy Future: Second Report on the Health of Canadians (Health Canada, 1999a; except where otherwise noted) based on 1996 rates per 100,000, with the exception of infant mortality rates which are expressed per 1,000 live births. 2) Data were sourced from the National Cancer Institute of Canada (2003) based on 1999 rates per 100,000 that were adjusted to the age of the 1991 Canadian population.

Air Quality and Human Health Assessment - 4 - January 2005 3) Data were sourced from Statistical Report on the Health of Canadians (Health Canada, 1999b) based on 1995 to 1996 rates per 100,000 population, with the exception of birth defect rates which are expressed per 10,000 total births in 1995. 4) Data were sourced from the StatsCan CANSIM database (2004) based on 2000 to 2001 data where the population consists of individuals aged 12 and over who report that they have been diagnosed by a health professional as having asthma. 5) Data were sourced from the StatsCan CANSIM database (2004) based on 1998 to 1999 data. 6) For persons 12 and older. n/a = not available A more recent study of respiratory disease in Canada was completed in a collaborative effort by the Canadian Lung Association, Health Canada, Statistics Canada, and the Canadian Institute for Health Information (Health Canada, 2001). The study sourced data as recent as 2000 from Statistics Canada, Health Canada, the Canadian Cystic Fibrosis Foundation (CCFF), the Canadian Institute for Health Information, National Air Pollution Surveillance System (NAPS), and Human Resource Development Canada (HRDC). The purpose of the study was to provide a summary of the present state of respiratory disease in Canada to politicians, health professionals, the media, academics and students, and managers in government, industry, and other organizations. The study found that in 1998, respiratory diseases including lung cancer were the third most common main diagnosis resulting in hospitalization among men and women in Canada. In addition, respiratory diseases were the primary diagnosis for 13% of all hospitalizations of men and 11% of all hospitalizations of women. Respiratory diseases together with lung cancer contributed to 18.7% of the deaths among men and 15.5% of the deaths among women, making respiratory disease the third highest cause of death in Canada.

Air Quality and Human Health Assessment - 5 - January 2005 In British Columbia during 2000, 17% of men and 18% of women aged 15 years and older smoked cigarettes on a daily basis. No appreciable difference was found between the proportion of adults that were daily smokers in British Columbia, and the proportion that were daily smokers in Canada. The proportion of youth between the ages of 15 and 19 who reported smoking cigarettes daily in British Columbia during 2000 (13%) was lower that of the Canadian national average (18%). In addition, 15% of children under the age of 12 were exposed to environmental tobacco smoke in the home every day or almost every day in British Columbia during 2000 compared to the 25% that were exposed in the rest of Canada. According to the study, the prevalence of physician-diagnosed asthma is 8.4% overall, 7.5% among adults, and 10.7% among children and teens. Although children and teens have the highest prevalence of asthma and the highest hospitalization rates, in terms of people affected, asthma affects more adults than children in Canada with the prevalence among adults on the rise. In British Columbia, asthma hospitalization rates and mortality rates were below the national average based on a three-year average of 1996 to 1999 data. The study reported that the hospitalization rate in British Columbia for chronic obstructive pulmonary disease (COPD) among adults aged 55 years and older is lower than the national average. Typically, the highest rates were observed in the eastern provinces such as Quebec and in northern Canada. In 1998, COPD accounted for 4% of all deaths in Canada, but the actual mortality may have been higher since the primary cause of death may have been listed as pneumonia or congestive heart failure. The mortality rate due to COPD in British Columbia was lower than the national average between 1996 and 1998. 3.2 HEALTH STATUS COMPARISONS BETWEEN THE ROBERTS BANK AREA AND BRITISH COLUMBIA The Roberts Bank study region is located in the Local Health Area (LHA) of Delta within the Fraser South geographic area of the Fraser Heath Authority (FHA). The Fraser South health region encompasses a locale of approximately 840 km 2 and includes the communities of Tsawwassen, Delta, White Rock, Surrey, Cloverdale, Langley and Aldergrove. The population located in the Fraser South area has grown significantly in the last 20 years (i.e., 1981 to 2001);

Air Quality and Human Health Assessment - 6 - January 2005 experiencing one of the highest population increases in Canada (the population has doubled from 300,000 to over 600,000). An annual population growth rate of 2% is expected in this decade, which is lower than what has been experienced by this area over the last 20 years (FHA, 2003). Delta, which encompasses the Roberts Bank study area, contains 7% of the proportion of the Fraser Health population. In general, the South Fraser Valley health region was not appreciably different from the provincial averages regarding most of the health outcomes. Mortality as a result of lung cancer and all cancer in females, low birth weights, and infant deaths in the South Fraser Valley health region were marginally higher than the provincial average (BC Vital Statistics Agency, 2002). The South Fraser Valley health region health outcomes were lower in all instances compared to the other health regions located in the Fraser Health Authority (i.e., Simon Fraser and Fraser Valley), with the exceptions of low birth weights and infant deaths. A summary of health status comparisons between the province of British Columbia and its health authorities is provided in Table 3-2.

Air Quality and Human Health Assessment - 7 - January 2005 Table 3-2: Health Status Between the Province of British Columbia and its Health Authorities (1) FRASER VANCOUVER COASTAL INTERIOR NORTHERN HEALTH STATUS BC FRASER VALLEY SIMON FRASER SOUTH FRASER RICHMOND VANCOUVER VALLEY NORTH SHORE/ COAST GARIBALDI EAST KOOTENAY OKANAGAN BOUNDARY THOMPSON CARIBOO SHUSWAP NORTH WEST NORTHERN INTERIOR NORTH EAST ASMR for all cancer sites Male 20.1 20.3 21.5 18.8 18.3 20.1 19.3 20.4 19.3 20.5 22.3 22.3 21.6 Female 14.2 14.3 14.8 14.3 12.8 13.0 14.2 14.4 13.3 14.3 15.1 16.8 14.0 ASMR for lung cancer Male 5.8 5.9 6.5 5.2 5.6 5.9 5.4 5.7 5.2 6.5 6.3 7.4 7.3 Female 3.4 3.5 3.7 3.5 3.1 2.9 3.2 3.5 3.1 3.8 4.1 4.3 3.7 ASMR for circulatory system diseases Male 26.8 27.5 30.1 25.5 23.8 27.7 25.0 28.0 24.9 29.2 31.5 28.5 29.9 Female 17.9 19.5 19.5 17.3 15.4 17.8 18.0 18.7 16.0 18.4 21.9 18.4 19.3 ASMR for respiratory system diseases Male 7.7 7.1 9.2 6.6 7.0 9.2 6.6 7.8 7.1 8.7 9.9 10.0 10.3 Female 4.9 5.1 5.2 4.5 4.4 5.2 5.3 4.0 4.5 4.9 5.7 5.9 5.6

Air Quality and Human Health Assessment - 8 - January 2005 FRASER VANCOUVER COASTAL INTERIOR NORTHERN HEALTH STATUS BC FRASER VALLEY SIMON FRASER SOUTH FRASER RICHMOND VANCOUVER VALLEY NORTH SHORE/ COAST GARIBALDI EAST KOOTENAY OKANAGAN BOUNDARY THOMPSON CARIBOO SHUSWAP NORTH WEST NORTHERN INTERIOR NORTH EAST Low birth weight (2) 49.8 46.1 51.4 53.6 48.2 54.7 43.7 43.9 49.6 51.6 46.6 50.2 39.0 Infant deaths (2) 4.7 4.7 4.4 4.8 4.4 4.9 3.8 5.2 4.9 5.0 4.4 6.1 4.1 ASMR for smoking-attributable mortality Male 18.2 18.1 20.5 16.5 15.9 19.1 16.3 18.7 16.7 20.5 21.7 22.1 22.5 Female 8.2 8.6 8.7 8.0 7.0 7.6 7.9 8.0 7.3 8.9 9.7 9.9 9.0 1) South Fraser Valley Health Authority encompasses the Local Health Area (LHA) of Delta, which contains the Roberts Bank study area. Data sourced in this table were compiled from the 1991 to 2001 data presented by the British Columbia Vital Statistics Agency (2002) and reflects the health service delivery areas prior to the total boundary revision. New BC Health Regions became final in 2002 and the South Fraser Health Authority was amalgamated as part of the Fraser Health Authority. 2) Rates for birth statistics and infant deaths per 1,000 live births (BC Vital Statistics Agency, 2002). ASMR (Age Standardized Mortality Rates) per 10,000 population using the 1991 Canada Census as the standard population.

Air Quality and Human Health Assessment 9 - January 2005 The LHA of Delta, which encompasses the Roberts Bank area, was not appreciably different from the provincial averages regarding most of the health outcomes. In fact, the Delta LHA was lower than that of the provincial average in all instances except mortality as a result of respiratory system diseases (BC Vital Statistics Agency, 2001; 2002). The health outcomes for Delta were typically lower when compared to the other LHAs located in the South Fraser Health Region (i.e., Langley and Surrey), with the exceptions of female mortality due to all cancer sites, and male and female mortality from all respiratory diseases. A summary of health status comparisons between British Columbia and the Local Health Areas for the South Fraser Valley is provided in Table 3-3. Table 3-3: Health Status Comparisons between the British Columbia and the Local Health Areas for the South Fraser Valley (1) SOUTH FRASER VALLEY HEALTH REGION HEALTH STATUS BC (2) LANGLEY SURREY DELTA ASMR for all cancer sites Males 20.1 20.87 19.24 16.69 Females 14.2 12.96 13.61 13.73 ASMR for lung cancer Males 5.8 5.29 5.57 3.50 Females 3.4 2.97 3.59 3.05 ASMR for circulatory system diseases Males 26.8 26.33 25.50 24.11 Females 17.9 15.08 15.34 15.27 ASMR for all respiratory system diseases Males 7.7 7.29 6.81 9.05 Females 4.9 5.00 5.10 5.17

Air Quality and Human Health Assessment 10 - January 2005 SOUTH FRASER VALLEY HEALTH REGION HEALTH STATUS BC (2) LANGLEY SURREY DELTA ASMR smoking-attributable mortality 15.7 11.35 11.64 10.33 Low birth weight (3) 49.8 58.32 55.91 43.07 Infant deaths (3) 4.7 3.89 3.96 0.94 1) The Local Health Area (LHA) of Delta encompasses the Roberts Bank study area. Data sourced in this table were compiled from the 1999 data presented by the British Columbia Vital Statistics Agency (2001 Volume III; unless otherwise noted) and reflects the health service delivery areas prior to the total boundary revision. New BC Health Regions became final in 2002 and the South Fraser Health Authority was amalgamated as part of the Fraser Health Authority. 2) Data sourced in this column were compiled from the 1991 to 2001 data presented by the British Columbia Vital Statistics Agency (2002). 3) Rates for birth statistics and infant deaths per 1,000 live births. ASMR (Age Standardized Mortality Rate) per 10,000 population using the 1991 Canada Census as the standard population. Characteristics of age and gender are important predictors of health and health service utilization, with the young and the elderly acting as the major consumers of health care resources. The proportion of seniors (i.e., 65+ years of age) in the Delta LHA (12.5%) is slightly less than the provincial average (13.4%) (Fraser Health Authority, 2003). Additionally, the Delta LHA has the lowest number of seniors who are older than 65 years of age in the Fraser South health region (see Table 3-4).

Air Quality and Human Health Assessment 11 - January 2005 Table 3-4: Population Trends for Seniors of Fraser Health (1) HEALTH AREA ALL AGES SENIORS (65+ YRS OF AGE) PERCENT (%) Fraser South 613,736 82,534 13.4 Langley 117,749 16,241 13.8 Surrey 314,726 32,620 10.4 White Rock 78,681 20,856 26.5 Delta 102,580 12,817 12.5 Fraser North 551,489 61,026 11.1 Fraser East 251,867 35,700 14.2 Fraser Health (Total) 1,417,092 179,260 12.6 British Columbia 4,132,917 552,231 13.4 1) Data were sourced from the Fraser Health Senior s Profile (2003) based on 2002 data. 4.0 CANADA FIRST NATIONS 4.1 HEALTH STATUS COMPARISONS BETWEEN BRITISH COLUMBIA AND CANADA No significant difference between the health outcomes presented below for the Status Indian population of British Columbia and those for the First Nations of Canada was identified in the current review. However, the health outcomes identified for the Status Indians of British Columbia were typically higher than those of the First Nations of Canada. It is important to recognize the distinction between the terms First Nations referred to by Health Canada and Status Indian employed by the British Columbia Vital Statistics Agency. Health Canada defines First Nations people as Status or Non-Status Indian people in Canada and typically presents statistical information for the native people of Canada in terms of the First Nations population as a whole. The Vital Statistics Agency of British Columbia, however,

Air Quality and Human Health Assessment 12 - January 2005 indicates that although there is considerable interest in the health of the First Nations people of British Columbia, whether Status, Non-Status or Metis, in most cases, relevant data only exists for Status Indians (BC Vital Statistics Agency, 2002). Consequently, the British Columbia Vital Statistics Agency presents health data for Status Indians alone. Relative to the general population of British Columbia, Status Indians in British Columbia had higher age-standardized mortality rates for all cancers, circulatory system diseases, respiratory system diseases, and smoking-attributable mortalities. In addition, health outcomes for asthma prevalence in youth 12 years of age and older, low birth weight, infant mortality, and the prevalence of current smokers were all higher in British Columbian Status Indians compared to the general population of British Columbia. A summary of health status comparisons between Canadian First Nations, British Columbian Status Indians and the general populations of Canada and British Columbia is provided in Table 4-1. Table 4-1: Health Status Comparisons between First Nations of Canada, BC Status Indians and the General Population HEALTH STATUS CANADA GENERAL POPULATION FIRST NATIONS BRITISH COLUMBIA GENERAL POPULATION STATUS INDIAN (1) ASMR for all cancers (2) 186.5 141.5 167 186 ASMR for circulatory system diseases (2) 231.8 ASMR for respiratory system diseases (2) 63.4 213.6 219 311 63.6 61 99 Asthma prevalence(12+ yrs of age) (%) (3) Males 6.9 9.8 6.2 13.2 Females 9.9 15.7 9.0 11.9 Low birth weight (per 1,000 56 58 49.8 55.4 live births) (4)

Air Quality and Human Health Assessment 13 - January 2005 HEALTH STATUS CANADA GENERAL POPULATION FIRST NATIONS BRITISH COLUMBIA GENERAL POPULATION STATUS INDIAN (1) Infant deaths (per 1,000 live 5.5 6.4 4.7 9.3 births) (5) Diabetes (%) (3) Males 4.4 4.8 4.2 n/a Females 3.9 5.5 3.6 n/a ASMR smoking-attributable n/a n/a 12.5 15.7 mortality (6) Prevalence of current smokers 23 62 22 43 (%) (7) 1) In order to utilize information from a number of databases, British Columbia Vital Statistics (2002) defined a Status Indian based on the compilation of information available from these databases. The data reported may not match data reported by other sources and is not equivalent to the broader term of First Nations. 2) Data specific to Canada were sourced from A Statistical Profile on the Health of First Nations in Canada (Health Canada, 2003) based on 1998 data for the general population and 1999 data for the First Nations. Data specific to British Columbia were sourced from the British Columbia Vital Statistics Agency (2002) based on 1991 to 2001 data. 3) Data were sourced from the StatsCan CANSIM database (2004) based on 2000 to 2001 data where the population consists of individuals aged 12 and over who report that they have been diagnosed by a health professional as having asthma or diabetes. 4) Data specific to Canada were sourced from A Statistical Profile on the Health of First Nations in Canada (Health Canada, 2003) based on 1992 to 1996 data for the general population and 1999 data for the First Nations. Data specific to British Columbia were sourced from the British Columbia Vital Statistics Agency (2002) based on 1991 to 2001 data.

Air Quality and Human Health Assessment 14 - January 2005 5) Data specific to Canada were sourced from A Statistical Profile on the Health of First Nations in Canada (Health Canada, 2003) based on 1999 data. Data specific to British Columbia were sourced from the British Columbia Vital Statistics Agency (2002) based on 1991 to 2001 data. 6) Data specific to British Columbia were sourced from the British Columbia Vital Statistics Agency (2002) based on 1991 to 2001 data. 7) Data specific to Canada were sourced from A Statistical Profile on the Health of First Nations in Canada (Health Canada, 2003) based on 2000 data for the general population and 1997 data for the First Nations. Data specific to British Columbia were sourced from Tobacco Use in BC (Ipsos News Center, 1997) based on 1997 data. ASMR (Age-Standardized Mortality Rate) per 100,000 population using the 1991 Canada Census as the standard population. n/a = not available In addition to medical health determinants, it is worth considering the potential influence of nonmedical determinants of health such as employment, income, housing and education on the overall health of an individual and a population. In 1996, the employment rate among Canadian First Nations was reported to be 45% and the labour participation rate was 59%. Among the general population of Canada in 1996, the employment rate and the labour participation rate were 68% and 62%, respectively (Health Canada, 2003). The unemployment rate for First Nations (18%) was twice as high as the Canadian rate (9%). Among Canadian First Nations, the 1996 average income was below that of the general Canadian population at any age or level of education (Health Canada, 2003). Income levels of First Nations living on a reserve were approximately half that of the Canadian population. Homes in First Nations communities were considered adequate 56.9% of the time between 1999 and 2000. First Nations communities reported that 41.4% and 33.6% of the communities had at

Air Quality and Human Health Assessment 15 - January 2005 least 90% of their homes connected to centralized water treatment plants and to a community sewage disposal system, respectively. In Canada, the First Nations population rated lower for all educational attainment indicators such as secondary school completion rates, post-secondary education admission and completion of a university degree compared to the Canadian population during 1996. In 1997 and 1998, 74% of First Nations children in Canada remained in school until Grade 12, which was up from 37% in 1987 and 1988. Although the First Nations people of Canada typically experience poorer socio-economic status than the general Canadian population, the First Nations of Canada were not found to be appreciably different from that of the general population of Canada with respect to the health outcomes examined above, with the exception of the prevalence of current smokers. 4.2 HEALTH STATUS COMPARISONS BETWEEN THE ROBERTS BANK AREA AND BRITISH COLUMBIA STATUS INDIANS The Roberts Bank study region is located in the LHA of Delta within the Fraser South geographic area of the FHA. The Status Indian population located in the Fraser South area has grown consistently since 1991 at which time the population was estimated to be 2,445. By 2001, the Status Indian population of South Fraser had grown to 6,037 (BC Vital Statistics Agency, 2002). The South Fraser area contains 27% of the First Nations people living in the Fraser Health Authority. In addition to Delta, the South Fraser health area includes the communities of Tsawwassen, White Rock, Surrey, Cloverdale, Langley and Aldergrove. In Tsawwassen, 328 First Nations were reported to live during 2003, where approximately 60% of the population was estimated to be less than 25 years of age (Tsawwassen First Nation, 2004). Estimated population demographics for the South Fraser Health Region are listed below in Table 4-2.

Air Quality and Human Health Assessment 16 - January 2005 Table 4-2: Population Trends by Age and Gender for Status Indians and the General Population in the South Fraser Health Region (1) AGE GROUP (YRS) STATUS INDIAN (%) GENERAL POPULATION (%) MALE FEMALE MALE FEMALE <1 5.42 4.40 1.21 1.11 1 to 4 15.6 12.3 5.17 4.87 5 to 9 16.4 13.8 7.37 6.98 10 to 14 10.6 8.43 7.13 6.92 15 to 19 6.93 5.63 7.13 6.45 20 to 24 6.10 6.27 6.39 5.92 25 to 29 5.03 7.47 5.85 5.81 30 to 34 7.40 7.93 6.82 6.97 35 to 39 7.29 9.35 8.33 8.30 40 to 44 6.46 7.29 8.43 8.36 45 to 49 4.27 5.23 7.61 7.57 50 to 54 2.51 3.66 7.00 6.93 55 to 59 2.12 2.49 5.40 5.12 60 to 64 1.15 2.24 4.03 3.89 65 to 69 1.18 1.60 3.57 3.68 70 to 74 0.75 0.80 3.17 3.53 75+ 0.79 1.14 5.40 7.59 1) South Fraser Valley health region encompasses the LHA of Delta, which contains the Roberts Bank study area. Data sourced in this table were compiled from the British Columbia Vital Statistics Agency (2002) and reflects the health service delivery areas

Air Quality and Human Health Assessment 17 - January 2005 before the total boundary revision. New BC Health Regions became final in 2002 and the South Fraser Health Authority was amalgamated as part of the Fraser Health Authority. In general, the South Fraser Valley health region has higher health outcome rates than the provincial population. The only exceptions were the rates for birth statistics and infant deaths. The South Fraser Valley health region health outcomes were also typically higher than that of the Fraser Valley health region, but were generally lower than the Simon Fraser health region. A summary of health status comparisons between Status Indians in British Columbia and the Fraser Health Authority is provided in Table 4-3. Table 4-3: Comparison of Status Indians Health Status between the Province of British Columbia and the Fraser Health Authority (1) HEALTH STATUS ASMR for all cancer sites BC FRASER VALLEY FRASER HEALTH AUTHORITY SIMON FRASER SOUTH FRASER VALLEY Male 21.5 18.3 113.0 50.4 Female 5.2 13.8 61.7 42.1 ASMR for lung cancer Male 5.2 4.3 49.5 9.1 Female 3.2 2.3 10.6 10.4 ASMR for circulatory system diseases Male 35.7 39.3 162.3 103.5 Female 26.9 26.4 124.8 71.7 ASMR for respiratory system diseases Male 11.3 7.8 78.8 17.8

Air Quality and Human Health Assessment 18 - January 2005 HEALTH STATUS BC FRASER VALLEY FRASER HEALTH AUTHORITY SIMON FRASER SOUTH FRASER VALLEY Female 8.7 9.5 32.5 18.2 Low birth weight (2) 55.4 60.2 68.7 48.2 Infant deaths (2) 9.3 9.5 7.1 6.0 ASMR for smoking-attributable mortality Male 21.3 20.3 144.1 51.5 Female 10.7 10.1 43.8 28.5 1) Data sourced in this table were compiled from the 1991 to 2001 data presented by the British Columbia Vital Statistics Agency (2002) and reflects the health service delivery areas prior to the total boundary revision. 2) Rates for birth statistics and infant deaths per 1,000 live births (BC Vital Statistics Agency, 2002). ASMR (Age-Standardized Mortality Rate) per 100,000 population using the 1991 Canada Census as the standard population. Compared with the general population of the South Fraser Valley (see Table 3-2), the Status Indians of the health region were consistently higher regarding all of the health outcomes examined above, with the exception of low birth weight. In fact, the age-standardized mortality rates for the Status Indians of the South Fraser Valley were typically more than twice that of the general population. The largest disparity between the Status Indian people and the general population was the age-standardized mortality rate for circulatory diseases. Some of the non-medical determinants of health that may have an impact on the health of an individual or a population are presented below in Table 4-4. The First Nations people of the LHA of Delta, which encompasses the Roberts Bank study area, exhibit the highest average income of the First Nations people living in the Fraser South health region (i.e., higher than the

Air Quality and Human Health Assessment 19 - January 2005 Surrey/White Rock and Langley LHAs). Additionally, the First Nations people of Delta earn greater average incomes than the First Nations and the general population of the Fraser Health Authority and the province of British Columbia. However, compared to the general population of the Delta LHA, the First Nations people report lower annual incomes. The unemployment rate of the First Nations people of the Delta LHA is slightly higher than the First Nations of the LHA of Langley, but lower than that of the First Nations of the Surrey/White Rock LHA, the Fraser Health Authority, and the First Nations population of British Columbia (FHA, 2002). The unemployment rate of the general population of Delta is lower than the First Nations population of the Delta LHA. The level of education of an individual is considered, in more general terms, to be the capacity for an individual to generate income and employment opportunities, and thus it is thought to be a key determinant of health and wellbeing. Approximately 3.5% of the First Nations population of the Delta LHA have less than a grade 9 level of education and 38.1% of the population has between a grade 9 and grade 13 level of education. The First Nations of the Delta LHA have the lowest proportion of the population with less than a grade 9 education of the First Nations and the general population of the Fraser South health region, the Fraser Health Authority, and the province of British Columbia. The same trends are observed for the proportion of First Nations with an education level between grade 9 and grade 13 in the Delta LHA. With respect to secondary education, the Delta LHA includes the highest percentage of First Nations people that have received a non-university/trades certificate. Additionally, the First Nations of the Delta LHA exhibit the highest university education of the First Nations people living in the Fraser South health region (i.e., higher than the Surrey/White Rock and Langley LHAs) and the Fraser Health Authority, as a whole. A higher proportion of the First Nations population of the Delta LHA have a university level of education than the general population of the Delta LHA, but a lower proportion than that of the general population of the Fraser Health Authority and the province of British Columbia.

Air Quality and Human Health Assessment 20 - January 2005 Table 4-4: Comparison of First Nations Health Determinants between the province of British Columbia and the Fraser Health Authority (1) BC FRASER HEALTH AUTHORITY FRASER SOUTH HEALTH DETERMINANTS Average Income FIRST NATIONS GENERAL POPULATION FIRST NATIONS FIRST NATIONS GENERAL SURREY/ POPULATION DELTA WHITE LANGLEY DELTA ROCK GENERAL POPULATION SURREY/ WHITE ROCK Male 22,738 32,457 25,680 32,581 33,513 25,537 29,924 37,999 32,361 35,244 Female 15,191 20,028 16,673 20,017 19,070 16,865 17,787 21,885 19,763 20,323 LANGLEY Unemployment rates (15+ yrs of age) (%) 21 10 16 9 12 16 11 7 12 6 Level of Education (%) <Grade 9 n/a 6.6 (2) 6.3 7.0 3.5 4.4 6.3 4.9 (2) 3.5 (2) 4.7 (2) Grade 9 to 13 n/a n/a 44.1 38.2 38.1 46.6 43.4 n/a n/a n/a Non-university diploma/trades certificate n/a n/a 35.5 31.6 40.5 36.5 35.0 n/a n/a n/a

Air Quality and Human Health Assessment 21 - January 2005 BC FRASER HEALTH AUTHORITY FRASER SOUTH HEALTH DETERMINANTS FIRST NATIONS GENERAL POPULATION FIRST NATIONS FIRST NATIONS GENERAL SURREY/ POPULATION DELTA WHITE LANGLEY DELTA ROCK GENERAL POPULATION SURREY/ WHITE ROCK University n/a 17.6 (2) 14.2 23.1 17.5 12.5 15.0 17.1 (2) 20.9 (2) 11.6 (2) 1) Data sourced in this table were compiled from the 1996 data presented by the Fraser Health Authority (2002), unless otherwise noted, and reflects the health service delivery areas prior to the total boundary revision. 2) Data sourced from the 2001 data presented by the Fraser Health Authority (2003) and reflects the health service delivery areas prior to the total boundary revision. LANGLEY

Air Quality and Human Health Assessment 22 - January 2005 Overall, the non-medical health determinants for the First Nations of the Delta LHA are not appreciably different from either the First Nations or the general populations of the Fraser South LHAs, the Fraser Health Authority, and of British Columbia despite the higher health outcomes identified above for the First Nations of British Columbia. The Tsawwassen reserve is located within the Roberts Bank study area along with the Musqueam 4 reserve; however, currently there are no Musqueam First Nations residents living on the reserve. During 2003, the Tsawwassen First Nations reserve reported 168 First Nations were living on the reserve, where the average family income was described to be $20,065 (Tsawwassen First Nations Reserve, 2004). The unemployment rate on the reserve was 38% and approximately 40% of the population was on welfare or some other form of social assistance during 2003. 5.0 UNITED STATES GENERAL POPULATION 5.1 HEALTH STATUS COMPARISONS BETWEEN WHATCOM COUNTY, WASHINGTON STATE AND THE U.S. Point Roberts, located within the Roberts Bank area of interest, is considered to be a community of Whatcom County, Washington. Unfortunately, data specific to the health status of Point Roberts are unavailable. Health data for the whole of Whatcom County are available; however, Point Roberts is located on the tip of a peninsula that is separated from the rest of Whatcom County by the Canadian border and Boundary Bay. Thus, the significance of such data with respect to the health status of Point Roberts is unclear. The data for Whatcom County was included in this review simply for the sake of completeness. Despite the lack of health statistics for Point Roberts, some general demographic characteristics were available. In 2000, the total population of Point Roberts was 1,308, 14.7% of which were 65 years of age and older. The proportion of seniors (i.e., 65+ years of age) in Point Roberts was higher than that of Whatcom County, Washington State, and the United States as a whole. The population trends of Point Roberts, Whatcom County, Washington States and the U.S. as a whole are presented in Table 5-1 below.

Air Quality and Human Health Assessment 23 - January 2005 The population of Whatcom County grew 42% between 1980 and 1996, while Native Americans in Whatcom County only increased by 38% during the same time period. In 1996, Native Americans made up 3% of the Whatcom County population. The annual growth rate of Whatcom County has varied between 2% and 4% since 1989. Table 5-1: Population Trends for Point Roberts, Whatcom County, Washington State and the United States (1) AGE GROUP (YRS) POINT ROBERTS PERCENT POPULATION (%) WHATCOM COUNTY WASHINGTON STATE U.S. Under 5 6.0 6.1 6.7 6.8 5 to 9 6.8 6.8 7.2 7.3 10 to 14 5.5 7.0 7.4 7.3 15 to 19 3.8 8.4 7.3 7.2 20 to 24 2.2 10.1 6.6 6.7 25 to 34 10.7 12.8 14.3 14.2 35 to 44 18.3 14.6 16.5 16.1 45 to 54 16.1 14.4 14.4 13.3 55 to 59 9.9 4.7 4.8 4.8 60 to 64 6.0 3.5 3.6 3.8 65 to 74 9.1 5.9 5.7 6.5 75 to 84 4.4 4.2 4.1 4.4 85 and over 1.2 1.5 1.4 1.5 1) Data sourced in this table were compiled from the 2000 data presented by the U.S. Census Bureau (2000).

Air Quality and Human Health Assessment 24 - January 2005 In general, the health status of Whatcom County is not appreciably different from that of the state of Washington or the United States as a whole. In fact, of the health outcomes presented below in Table 5-2, Whatcom County was lower in all instances than Washington State. Additionally, Whatcom County s health outcomes were consistently lower than that of the United States, with the exceptions of mortality rates for all cancer sites and lung and bronchus cancer in females, and mortality due to chronic lower respiratory system diseases in both sexes. Table 5-2: Health Status Comparisons between Whatcom County, Washington State and the U.S. HEALTH STATUS WHATCOM COUNTY WASHINGTON STATE U.S. ASMR for all cancer sites (1) Male 215.1 236.5 251.1 Female 167.5 167.7 166.7 ASMR for lung and bronchus cancer (1) Male 51.6 71.0 77.9 Female 41.5 46.2 40.8 ASMR for major cardiovascular 265.9 281.5 326.5 diseases (2) ASMR for chronic lower respiratory system disease (3) Male n/a 56.8 54.0 Female n/a 43.7 37.6 Both sexes 44.3 48.5 43.7 Asthma hospitalization rate (4) 88.6 90.4 176 Low birth weight (5) 5.0 5.8 7.7 Infant deaths (5) 4.0 5.7 6.8

Air Quality and Human Health Assessment 25 - January 2005 Prevalence of current cigarette 21 21.5 22.6 smokers (%) (6) 1) Data sourced from the 1997 to 2001 data presented by the National Cancer Institute (2004). 2) Data specific to Whatcom County and Washington State were sourced from the Washington State Department of Health (2003) based on 2002 data. Data specific to the U.S. were sourced from the National Center for Health Statistics (2003) based on 1999 to 2001 data. 3) Data specific to Whatcom County and Washington State were sourced from the Washington State Department of Health (2003) based on 2002 data. Data specific to the U.S. were sourced from the National Center for Health Statistics (2004) based on 2001 data. 4) Data specific to Whatcom County and Washington State were sourced from the Washington Health Foundation (2003) based on 1999 to 2001 data. Data specific to the U.S. were sourced from the Centers for Disease Control and Prevention (2002) based on 1999 data. The asthma hospitalization rates were derived per 10,000 population and ageadjusted to the 2000 U.S. population. 5) Data specific to Whatcom County and Washington State were sourced from the Washington Health Foundation (2003) based on 1999 to 2001 data. Data specific to the U.S. were sourced from the National Center for Health Statistics (2003) based on 2001 data. Rates for birth statistics and infant deaths are presented per 1,000 live births. 6) Data specific to Whatcom County were sourced from the Washington State Department of Health (2004) based on 1999 data. Data specific to Washington State and the U.S. were sourced from the Center for Disease Control and Prevention (2004a,b) based on 2002 data and 2001 data, respectively. The prevalence of current cigarette smoker is derived from persons 18 years of age and older who reported having smoked at least 100 cigarettes during their lifetime and who currently smoke every day or some days.

Air Quality and Human Health Assessment 26 - January 2005 ASMR (Age-Standardized Mortality Rate) per 100,000 population using the 2000 United States population as the standard population. n/a = not available Non-medical health determinants of the Point Roberts area that were available include employment rates, income and education. The 2000 U.S. Census reports that in Point Roberts 3.7% of the labour force was unemployed during 2000; the average household income in 1999 was $36,146; and that 86% of the population graduated high school and 28.2% have obtained a bachelor s degree or higher. The Whatcom County Health Department recently published the results of a health survey conducted during 2002. The survey found that 26% of the population reported that they were in excellent general health and 40% indicated that they were in very good general health. Overall, 66% of the population considered their health to be better than good (i.e., the middle point of the 5 point rating system). 6.0 CONCLUSIONS In general, the findings of particular interest for the Canadian general population were that: Asthma prevalence in British Columbia was lower than that of the national average. Respiratory disease deaths were higher in British Columbia than Canada as a whole, but respiratory hospitalization rates were lower in British Columbia. Age-standardized mortality rates for respiratory system diseases were elevated in the LHA of Delta compared with the provincial average. The proportion of seniors (i.e., 65+ years of age) in the Delta LHA was less than that of British Columbia as a whole, while the number of seniors in the Delta LHA was the lowest of the LHAs in the Fraser South health region.

Air Quality and Human Health Assessment 27 - January 2005 Overall, no appreciable difference in health status was identified between the general population of the LHAs of the South Fraser Valley health region, the province of British Columbia, and Canada with respect to the health outcomes reviewed above. The findings of particular interest with respect to the Canadian First Nations were that: Age-standardized mortality rates for respiratory system disease and smokingattributable deaths among Status Indians were elevated in the South Fraser Valley health region with respect to the Fraser Valley health region and the province of British Columbia, but were appreciably lower than that of the Simon Fraser health region. Relative to the general populations of British Columbia and Canada, the Status Indians of British Columbia and the First Nations of Canada commonly reported higher health outcomes. Asthma prevalence in people 12+ years of age and the prevalence of current smokers were notably higher among the Status Indians of British Columbia and the First Nations of Canada than the general populations of British Columbia and Canada. The Status Indians of the South Fraser Valley geographical area had substantially higher health outcomes than that of the general population, where the agestandardized mortality rates for the Status Indians of the South Fraser Valley were typically on the order of twice the general population. The proportion of Status Indian seniors (i.e., 65+ years of age) in the South Fraser Health Authority was lower than that of the general population. No appreciable difference was identified between the non-medical health determinants of interest (i.e., employment, income, and education) for the First

Air Quality and Human Health Assessment 28 - January 2005 Nations and the general populations of the LHAs of the Fraser South geographical area, the Fraser Health Authority, and the province of British Columbia. Overall, the Status Indians of the Delta LHA and the South Fraser health region reported higher health outcomes than the Status Indians of British Columbia, the First Nations of Canada, and the general populations of British Columbia and Canada, with few exceptions. Lastly, the findings of particular interest with respect to the United States general population were that: No health status data specific to Point Roberts was available. Age-standardized mortality rates for chronic lower respiratory system disease were lower among citizens of Whatcom County than Washington State, but slightly higher than the national average. The asthma hospitalization rate and the prevalence of current cigarette smokers were lower in Whatcom County compared with Washington State and the United States as a whole. The proportion of seniors (i.e., 65+ years of age) in Point Roberts was higher than that of Whatcom County, Washington State, and the United States as a whole. Overall, the health status of Whatcom County was not appreciably different from that of the state of Washington or the United States as a whole, with respect to the health outcomes examined above. 7.0 REFERENCES BC Vital Statistics Agency. 2002. Regional Analysis of Health Statistics for Status Indians in British Columbia: Birth Related and Mortality Summaries for British Columbia and 16 Health Service Delivery Areas. 1991-2001. British Columbia Vital Statistics Agency and First Nations and Inuit Health Branch of Health Canada. September 2002.

Air Quality and Human Health Assessment 29 - January 2005 BC Vital Statistics Agency. 2001. Health Status Indicators in British Columbia: Birth-Related and Mortality Statistics 1995-1999. Volume III: Communities. British Columbia Vital Statistics Agency and First Nations, Ministry of Health Planning. December 2001. Center for Disease Control and Prevention. 2002. Surveillance for Asthma - United States, 1980-1999. U.S. Department of Human Health Resources, Center for Disease Control and Prevention, Morbidity and Mortality Weekly Report. March 29, 2002. 51(SS01):1-13. Center for Disease Control and Prevention. 2004a. State-Specific Prevalence of Current Cigarette Smoking Among Adults United States, 2002. U.S. Department of Human Health Resources, Center for Disease Control and Prevention, Morbidity and Mortality Weekly Report. January 9, 2004. 52(53):1277-1280. Center for Disease Control and Prevention. 2004b. Summary of Health Statistics for U.S. Adults: National Health Interview Survey, 2001. U.S. Department of Human Health Resources, Center for Disease Control and Prevention, National Center for Health Services, Vital and Health Statistics. Series 10, Number 218. January 2004. Fraser Health. 2003. A Profile of Fraser Health Seniors Population. February 2003. FHA (Fraser Health Authority). 2002. A Profile of Aboriginal People in the Fraser Health Authority. November 2002. FHA (Fraser Health Authority). 2003. Fraser Health, Health Profile. The Office of the Medical Health Officer and Integrated Analysis and Evaluation. November 2003. Health Canada. 1999a. Toward a Healthy Future: Second Report on the Health of Canadians. Prepared by the Federal, Provincial, and Territorial Advisory Committee on Population Health for the meeting of the Ministers of Health, Charlottetown, PEI, September 1999. URL http://www.hc-sc.gc.ca/hppb/phdd/report/toward/pdf/english/toward_a_healthy _english.pdf

Air Quality and Human Health Assessment 30 - January 2005 Health Canada. 1999b. Statistical report on the health of Canadians. Prepared by the Federal, Provincial, and Territorial Advisory Committee on Population Health. November. URL: http://www.hc-sc.gc.ca/hppb/phdd/report/stat/eng/report.html Health Canada. 2001. Respiratory Disease in Canada. Canadian Institute for Health Information, Canadian Lung Association, Health Canada, and Statistics Canada. September 2001. Health Canada. 2003. A Statistical Profile on the Health of First Nations in Canada. URL: http://www.hc-sc.gc.ca/fnihb-dgspni/fnihb/sppa/hia/publications/statistical_profile.htm#top Ipsos News Center. 1997. Tobacco Use in BC. Ipsos News Center: Research, Opinion and Insight. September 25, 1997. National Cancer Institute. 2003. State Cancer Profiles. Rate/Trend Comparison by State/County. URL: http://statecancerprofiles.cancer.gov/cgibin/ratetrendbycancer/rtcancer.pl?047&0&53&00&1&0&1 National Cancer Institute of Canada. 2003. Canadian Cancer Statistics 2003. Toronto, Canada. National Center for Health Statistics. 2003. Mortality Table GMWK293R. Center for Disease Control and Prevention, National Center for Health Statistics, Data Warehouse. URL: http://www.cdc.gov/nchs/datawh/statab/unpubd/mortabs.htm National Center for Health Statistics. 2004. Health, United States 2003. Updated Trend Tables. Table 41. Center for Disease Control and Prevention, National Center for Health Statistics. January 5, 2004. URL: http://www.cdc.gov/nchs/products/pubs/pubd/hus/updatedtables.htm StatsCan CANSIM database. 2004. Tsawwassen First Nation. 2004. Land Facing the Sea: Tsawwassen First Nation. A Fact Book. URL: http://www.tsawwassen-fn.org/tfn-built_feb2404.pdf U. S. Census Bureau. 2000. American Fact Finder. Profile of General Demographic Characteristics: 2000. URL: