Document X7n9BwNY40Z0ZYg5eXLMYx2Nx

PLAINTIFF'S EXHIBIT Experts cite paralysis of asbestos exposure control efforts One hears that considerable trouble is now taken to prevent the inhalation of asbestos dust, so therefore the disease is not likely to appear in the future " So proclaimed a British public health official in 1906 concerning the major health problem posed by the fledgling British asbestos industry Since that time, in the United States alone, 30 million tons of asbestos, "the wondrous mineral fiber with the strength of steel," has been nonetheless employed in many products. The result? A public health disaster of unprecedented dimensions (JAMA (medical sews] 239:2215-2216, 1978) Experts in the study of asbestos-related diseaseasbestosis, lung cancer, and mesothelioma -- now esti mate that during the next 40 years, an average of 20,000 deaths per year will result from asbestos exposure. In the period between World War II (when asbestos use first became widespread) and the end of this century, well over half a million Americans will have died of asbestos-related disease, according to Irving J. Selikoff, MD, director of the Environmental Sciences Laboratory at the Mount Sinai School of Medicine in New York What is being done to prevent slow deaths caused by asbestos inhalation? Who is examining the 10 million workers estimated to have been exposed to the substance on their jobs since WW II? Who will accept responsibility for containing the mountain of asbestos now in place? The answers are: nothing and no one Aside from meager attempts to regulate new asbestos use and to monitor occupational exposure, virtually nothing is being done to remedy the public health failure aod turn back the legacy of death from asbestos. What is worse, 700,000 tons of asbestos is still used annually in the United States to make products such as cement pipe, brake linings, asbestos paper prod ucts, and textiles. Virtually no precautions other than a maximum exposure standard for workers that some consider unacceptably high are being taken to prevent asbestos-related disease. "Unless we learn the lessons o: the past," predicts Selikoff, "we are destined to compound the deadly legacy of asbestos and start the cluck ticking :or the next 40 years " Asbestos is an extreme!) useful fibrous mineral The two commercially used varieties, serpent.-e an,: amphibole asbestos, are strong and durab.e * ir insulating qualities beyond comparison But the m.n- utely fibrous nature of asbestos that makes i: so useful also makes it deadly While asbestos fibers are visible to the naked eye. the component fihrils can be detected only with the electron microscope In the lung, cellular-mineral contact results in interaction between the fibril surfaces and intracellular, perhaps even intranuclear, components of cells Although the pathogenic mecha nism remains unclear, these interactions result in a fibrotic reaction iasbestosis), lung cancer, or both Therapy of Asbestos Diseases There is no truly effective treatment for any of the asbestos-related diseases, which include asbestosis. mesothelioma, cancer of the lung, and some cancers of the esophagus, stomach, or colon-rectum (Selikoff IJ, Hammond EC. Seuiman H Mortality experiences of insulation workers. United States and Canada, 19421977 In Health Hazards of Asbestos Exposure [inter national conference] Ann S!Y Acad Sci 330:91-116, 1979) A long latency period (25 to 30 years in most casesl, difficulty in diagnosis, and the lack of any widely applied long-term surveillance mechanism all spell a grim outcome for the asbestos-exposed popula tion. Although the malignant neoplasms result in higher mortality, asbestosis-a fibrous scarring of the lung that causes diminished pulmonary function --is the most common asbestos-related disease. Such pulmo nary fibrosis is irreversible. Current treatment con sists unly of ending further exposure and administer ing oxygen in the case of breathing difficulty. According to Anthony Robbins, MD, director of the National Institute of Occupational Safety and Health (NIOSH), asbestosis patients, because of diminished pulmonary reserves, "should be treated very aggres sively with antibiotics" if any respiratory true: infection such as bronchitis develops. Lung cancer ,s the most common asbestos-induced cancer and is male worse by the accompanying !_~g fibrosis Alvin Tierstern. MD. director of the Pulmo nary Service at Mount Sinai and an expert on treating asbestos-related Jisease, calls diagnosis of long can cer in these cases "a hell of a yob" because the fibrosis ohsr ires the rad.niogica! rinri.ngs Mesothei'.oma :s a malignant tumor of the p-e-.;::: and peritoneur Known as a "sign.a" neoplasm '.-ecause it almost nmer occurs except m cases '! asbestos exposure, mesothelioma is thought to occur o mtmtteti cm next JAMA, Jan ia, 1980 -- Vol 243, No 3 Medical News 2 1 ` O ft 000154 Medical News continued from previous page at much lower exposure levels than are known to cause asbestosia. This is evidenced by the high incidence of the disease among family members of asbestos workers. While Selikoff and Tierstein are pessimistic about treating mesothelioma. Philippe Chahinian, MD. assistant professor in the Dep:mmi'"t of v'e Hasti*ij.j.jju at Mount Sinai, says that the suuaLion is not desperate." Currently at Mount Sinai, investigators are work ing with two treatment protocols, he says. The first is a combination of doxorubicin hydrochloride and radiotherapy of the hemithorax. In 14 patients the median survival has been 12 months. The second protocol combines doxorubicin hydro chloride and azothymidine without radiotherapy. In 40 patients the median survival has been 21 months from diagnosis. Chahinian describes these results as very encouraging compared with the past "Mesothelioma is an insidious disease," he told JAMA MEDICAL sews. "There is often a delay between symptoms and diagnosis because patients have only a small amount of pain, not enough for them to seek medical care." While evidence of the disease does turn up on x-ray films, it is difficult to diagnose and has often progressed beyond the aid of surgery by the time of diagnosis. In some cases, according to Tierstein, benign dis ease, resulting in a thickening of the pleura, is detected. In these cases, a pleurectomy can sometimes be performed although this is extremely difficult. One factor that can add immensely to the risk of development of lung cancer among asbestos-exposed workers is cigarette smoking, as Selikoffs work has shown. In one Mount Sinai study cohort, asbestos /workers who smoked had a risk of lung cancer up to 90 times that of persons who neither smoked nor worked with asbestos and up to 30 times that of nonsmoking asbestos workers. "Anyone with even the slightest suspicion of asbes tos exposure should absolutely be convinced not to smoke," says Selikoff. In an extensive interview with JAMA MEDICAJL news, Selikoff, who is considered by many to be the world's foremost expert on environmental disease, stressed that the epidemic of asbestos-related disease 13 a public health failure rather than a failure of the medical profession "The medical profession is accustomed to rapidlyevaluating and treating known health problems," he said. "We take information made available to us by science and use it to correct a problem Not so with asbestos, says Selikoff, even though it is known to be a serious health hazard. We are trapped by the substance It has crept into our buildings, our schools, our homes, and our cars, and we have made an unconscious decision to accept some level of Asbestos removal Worker in New York City school seeling area where asbestos has been used in classroom ceiling He is wearing a respirator and special garments to protect him Irom possible airborne asbestos particles. Upon leaving area, he is required to dispose at garments and to shower. (Phoiograph courtesy ot Du Pont Company J mortality as the price we must pay for its usefulness. "One hundred years ago the problem was infectious disease," says Selikoff `"That was much easier to conquer. There wai .blic relations firm promot ing the tubercle bacillus and it was not deliberately woven into the fabric of our society." Another public health problem U the relatively poor understanding among most practicing physi cians regarding asbestos diseases. Unless a physician works in an area directly adjacent to an asbestos exposure site like a shipyard, he is unlikely to know much about the subject. According to Margaret Sloan, MD, of the Division of Cancer Control and Rehabilitation at the National Cancer Institute (NCD. there is a serious deficit in physician knowledge concerning asbestos disease. To correct this, the NCI is aiming educational material at four categories of physicians: radiologists, patholo gists, chest physicians, and various types of general practitioners Says Sloan, "Radiologists are unable to interpret the indications of asbestosia such as pleura: plaques or. x-rays And, due to the many different cellular patterns of asbestos disease, pathologists often have extreme difficulty in making a diagnosis. A disease 212 JAMA. Jan 18. 1980 --Vol 243. No 3 Medical News LLA 000155 Medical News like mesothelioma often looks like metastatic cancer from another site Also many chi--' ph-.-'-c: .. ' .... u/iiamniar with the manifestations of asbes tos-related disease." Perhaps most confusing of all, those concerned have not been able to agree on the most effective way of intervening in the course of asbestos disease. Will early detection have any impact on mortality-' Should all those known tu have been exposed to asbestos be subjected to periodic sputum cytological examinations and chest x-ray films'! Who will pay the massive costs of such long-term surveillance? There are no answers. "At this point screening to detect asbestos disease probably will not be effective," says the NIOSH's Robbins. "We have just begun programs to inventory all existing asbestos and to identify all the sites of human exposure, past and present. The continued use of asbestos, despite clear knowledge of its dangers, verges on the criminal." Indeed, the foolhardiness of our past use of asbestos was the subject of a lengthy seminar at the recent annual meeting of the American Public Health Asso ciation in New York. According to David P Rail, MD, director of the National Institute of Environmental Health Sciences, the peak mortality from, the firs: ' ' ' .,av;ly exposed vibe-*-, wo-'.-.-r-.- ' N joipyar'l workers --will occur in the coming decade "A second group of heavily exposed workers," noted Rail, "is an erratic but slowly increasing group of shipyard, maintenance, insulation, and construction workers whose exposure to asbestos began in the late 40s and has continued to, date. The use of asbestos has doubled during this time, and it will be the role of public health physicians to deal with the disease which we can expect to occur." The asbestos experts, mainly the staff at Selikoff's Environmental Sciences Laboratory, have been busily identifying several areas where exposure to asbestos can be expected to result in future disease. Not surprisingly, they predict continued shipyard asbestos disease While the US Navy stopped using the substance in new ship construction several years ago, there is now afloat a massive fleet of ships coated with asbestos. Over time, these ships must be repaired, refilled, and eventually broken apart as they hecome obsolete Says Selikolf, "Our latest survey of workers at a continued on page Jl'j Sudden death brings East and West together Sudden death from cardiovascular eau.ee will eiuim some 400,000 lives in this country during 1980. By definition of the World Health Organization, these are deaths occurring unexpectedly within six hours of symptom onset in apparently previously healthy persons or in patients considered to be in satisfactory condition. Such sudden deaths --some of which are being averted by increasing public use of cardiopulmonary' resuscitation techniques, improved emergency-rescue systems, and sophisticated coro nary care facilities -- probably will account for about 40% of the expected overall toll from cardio vascular diseases in the United States this year In turn, cardiovascular mortality accounts for 52% of all deaths among Americans annually. So it is clear, say cardiologists such as G. Charles Oliver, MD. Washington Univer sity School of Medicine, St Louis, that sudden death is a leading cause of mor tality in this country. Drs Vikhart ana town It also is a major prob lem in other countries, including the Soviet Union According to Anatoliy M. Vikhert, MD, DMS, National Cardiology Research Center, USSR Acade my of Medical Sciences. Moscow, up to 75% of all deaths from coronary heart disease in that country occur suddenly. In 1973, the Joint US-USSR Committee for Health Cooperation agreed to focus on sudden death in some collaborative studies. At the conclusion of the Second Joint US-USSR ----------------------------------- Symposium on Sudden Death, held at Indiana University School of Med icine, Indianapolis, in De cember, that agreement was extended through 1982. Involved are further exchanges of visits ami information ar.d a third symposium in the Soviet Union in 1982. The new agreement was signed by syrnpos.uir. chairmen Vikhert and Bernard Lown, MD. pro lessor of cardiology. Har vard University School of continued on next page JAMA. Jan 10. i960 -- Vol 243, No 3 Medical News 2 1 3 LLA 000156 Medical News continued from puije 2/J Baltimore shipyard who are engaged solely with re pair work --no new construction --showed that among workers with 20 or more years on the job, 85'A have ab normal x-ray findings." N'o precautions are now being taken, and few warnings are given to the hundreds of thousands of shipyard employees nuw at work. Another area of emerging concern is asbestos use in schools and public buildings. According to William J Nicholson, MD, of Mount Sinai, there is a "good possibility" that when the latency period of asbestos disease is up, there will be a great deal of disease related to exposure in schools. Sprayed asbestos surfacing material has apparent ly been used extensively in schools in the past, and, because of general disintegration, aided sometimes by vandalism, measured asbestos levels in some schools have been equivalent to occupational levels. As an example, according to Nicholson, 10% of all New Jersey's schools have sprayed asbestos surfaces, one third of which are crumbling. In Massachusetts, 20% of public schools have asbestos surfaces. Recently, the US House of Representatives approved a three-year program uf $30 million in grants to school districts to search for asbestos in school buildings and $300 million in loans to remove it. The measure has now gone to the Senate Perhaps the most cruel exposure to asbestos is through household contact with another family mem ber who has been occupationally exposed. More and more of these cases are being reported Because of the relatively low doses involved in household contact, it seems that some family members may be escaping asbestosis but suffering more cases of mesothelioma. This brings up the question of the dose-response ratio of asbestos, a point on which there is little disagreement. Says Rail, "While it seems that the less the exposure, the more slowly asbestos disease will develop, it remains clear that there is no dose threshold below which asbestos exposure is safe " Adds Selikoff, "There should be no asbestos expo sure at all. This is the only way to eliminate asbestos disease." The Environmental Protection Agency (EPA) con curs. "The EPA is convinced of the substantial risk with any asbestos exposure, even at very low levels," says Richard Guimond of the Office of Chcmi-a! ' L i > c EPA. Recent data to support the no-threshold contention come from Philip E Enterline, PhD, of the Depart ment of Biostatistics at the University of Pittsburgh. In his article just published in Health Hazards of Asbestos Exposure (Ann NY Acad Sci. Vol 330, 19791, Enterline estimates cumulative dust exposure of asbestos workers in millions of particles per cubicfoot A linear curve relating cumulative dust exposure of asbestos workers at the time of retirement to mortality from respiratory cancer shows that with no exposure there is no increase in mortality over standard rates, with modest exposure there is a JAMA, Jan 18, I960 --Vol 243. No 3 modest increase - mortality, ami with heavy expo sure there is a g'eat increase :r. mortality from respiratory cancer The data aiso show, according to Enterline, that the "effects of asbestos exposure continue well past termination of exposure." Several embryonic efforts are now under way to regulate future asbestos use and to revise the current exposure standard A major redm t the current standard of 2 libers per milliliter of am in the occupational environ ment is being considered by the Occupational Safety and Health Administration (OSH AI and NTOSH. The latter agency has recommended that this be reduced to 0.1 fibers per milliliter, but even this level would result in considerable exposure. `The asbestos situa tion is bad now and could get even worse," says Victor Alexander, MD, of OSH A. Ironically, the current standard is the result of a British study (since proved incorrectl that a level of 2 fibers per milliliter would substantially reduce the chance of developing early asbestosis. The cancer rink was not considered at all. At the EPA there are rumblings of a possible han on the commercial use of asbestos, a proposal that, according to Business Week, is causing concern in the asbestos industry The agency at this time appears nowhere near implementing this proposal. However, says Guimond, "There is a high probabili ty that the EPA, at some time, will implement a total ban on commercial use of asbestos." Asbestos substitutes are being explored and Used, of course These include fiberglass for fire retarda tion; ceramic fiber and polyacrylonitrile for textiles; calcium silicate, mineral wool, and expanded perlite for building insulation, and a compound of cellulose and clay wastes or a semimetallic friction material built around steel fiber and iron powder for brake linings. The latter two compounds, in particular, are said to be inferior to asbestos for such use. Perhaps Selikoff offers the most plausible explana tion for the apparent paralysis in control efforts. `This is a social problem," he told JAMA medical news. "In the United States we have made an unacknowledged decision to control asbestos rather than to ban it. Banning is easy Control is much more -r.rn I -p^ ' _ . w ha^n i lived up to our contract in this case," he continued. "We bnven't accepted the conse quences of control, I hear people rail aii the time against regulation. don't like regulation any more than the next guy. but without it no effort at control can be successful " On the subject of what lies ahead with asbestos, Selikoff is gloomy "I see exposure continuing," he said. Things de-'t always turn out ter the best. Doctors know this perhaps best of all Time doesn't soive everything 1 li just say that 1 have guarded pessimism, about the whole thing" --by Jons Eu.iorr Medical News 2 19 LLfl 000157