Document v1YdzNnRZe7NZJMrN4MBgkeR8

MUSC LIBRARY a 34 0 159159c Hill 1111 1 H<M_ ( --^a | C5^0> | *-H O' <TOC <n t DOU< (\l f Ifl ct -ih in~*00 <r E CD CO*--* 1 * CO _J * <\JLL s*-0</)UJO * <A OCXS* .* >h-t< * m-i< * * zuL>Z * TDU-lUO * C_lt~ * O--J IM * g.<Xcouj * NU(*<J 00 f-l_J oc HIQCH< foo.ujujr-x o<IIhu "4. Cr- I itv. - *1 i4 :*v '. 4 >/j*-7'/'f f ?:v,s .: f-fV f / r a* ? 1 X-.. June 1991, Vol. 81, No. 6 Editorials 685 Childhood Lead Poisonin I``ET-n09 687 Can Stress Cause Cancer? D. T. Janerich Commentary 689 Drake Chemical Workers' Health Registry: Coping with Community Tension over Toxic Exposures 1-- C. Levitan, G. M. Marsh, E Talbott, D. Pavlock, and C Callahan Featuring Environmental and Occupational Health 694 Asthmatic Responses to Airborne Acid Aerosols B. D. Ostro, M. J. Lipsett, M. B. Wiener, andJ. C Seiner Jr 703 A Randomized Trial to Evaluate the Risk of Gastrointestinal Disease due to Consumption of Drinking Water Meeting Current Microbiological Standards P. Payment, L, Richardson, J. Siemiatyda, R Dewar, M. Edwardes, and E Franco 709 Risk Assessment and Control of Waterborne Giardiasis J. B. Rose, C. N. Haas, and S. Regii 719 Cancer Rates after the Three Mile Island Nuclear Accident and Proximity of Residence to the Plant M. C Hatch, S. Wallenstein, J. Beyea, J. W. Nieves, and M. Susser 725 Effectiveness of Source Documents for Identifying Fatal Occupational Injuries: A Synthesis of Studies N. Stout and C Bell ^ 729 Female Homicides in United States Workplaces, 1980-1985 C. A. Bell 733 Occupation, Industry, and Fatal Motor Vehicle Crashes in 20 States, 1986-1987 D. P. Loomis 736 An Analysis of Occupational Blood Lead Trends in Manitoba, 1979 Through 1987 A. Yassi, M. Cheang M. Tenenbein, G. Bawden, J. Spiegel, and T. Redekop 741 Occupational Carpal Tunnel Syndrome in Washington State, 1984-1988 G. M. Franklin, J. Haug, N. Heyer, H. Checkoway, and N. Peck 775 Public Health and the Law. OSHA's Four Inconsistent Carcinogen Policies George J. Annas Public Health Then and Now 781 Understanding History to Shape the Future--The New Editors' Vision E Fee and R R Korstad 782 The United Mine Workers of America and the Recognition of Occupational Respiratory Diseases, 1902-1968 A. Derickson 791 The Silence: The Asbestos Industry and Early Occupational Cancer Research--A Case Study D. E Lilienfeld ?M rjrmrm . JV. . (continued page 675) The Silence: The Asbestos Industry and Early Occupational Cancer Research--A Case Study David E. Lilienfeld, MD, MPH, MS Engin If in ax gores someone that they die, then the ax shall be lolled, and his flesh shall not be eaten; but the owner of the ax will not be liable. But if the ax has given indications ofgoring persoas, and his owner was so informed, and the ox was not kept in and he killed someone; the ox shaU be killed and his owner also shall be killed. Exodus 22:28-29 The Industrial Revolution brought with it widespread occupational exposures to pathogenic agents, such as silica and lead. Recent legislative initiatives in the United States have greatly reduced such expo sures. However, in the absence of major enforcement efforts, the effectiveness of this legislation depends on corporate cooperation and compliance. Many of the . corporations whose products cause occu pational diseases sponsored the initial de velopment of that etiologic knowledge.1** Recent legal actions by some members of the asbestos industry have disclosed doc uments describing the development and subsequent suppression of data concern ing the hazards of asbestos. Members of both the insurance industiy and the aca demic medical community participated in such activities which permeated the as bestos industiy. This paper describes the develop ment ofthese actions and how the concern with asbestosis which had developed first, was extended to cancer. It discusses the industry's growth, the development of concerns about asbestosis, and the forma tion of a research program to counter them. When these studies found that as bestos was a carcinogen, this information was suppressed. The ensuing cover-up, effected through industiy associations and research compacts, resulted in thousands of deaths.7,8 The Asbestos Industry, 1850-1927 The attributes of asbestos, a silicate, that fostered its widespread use have been known for at least two millenia.9 Yet it was the unique confluence of the Indus trial Revolution, innovations in building construction, and the economic growth in the United States that led to its wide spread use during the past century. Insu lation was needed for efficient energy use to maximize engine power.10 Resistance to both heat degradation and combustion was desirable. Asbestos was such a ma terial. The asbestos industiy developed as a response to this need for insulation. It grew in tandem with the post-Civil War development of heavy industiy. During the late 1800s, many in the industry thought that if asbestos felts could limit engine heat Joss, then asbestos roofing felts might similarly limit building heat * loss. Asbestos became a construction ma terial. Rapid growth of the industiy was not without serious consequences.11 In the 1920s, for example, the medical com munity recognized a fibrotic lung condi tion, similar to silicosis, that resulted horn asbestos exposure.9,12 The Hazard Suggested In the late 1800s and early 1900s, the hazards of occupational silica exposure were recognized, and the widespread na ture of such exposures became appar ent. 13 They were made clear in a landmark 1917 report by a young Public Health Ser vice (PHS) physician, Anthony Joseph Lanza.14 After entering the PHS in 1907, Lanza was detailed to the Fort Stanton, New Mexico, Marine Hospital Tubercu losis Sanatorium. He left that assignment with an interest in pulmonary medicine and the clinical skills to pursue it. In 1914, Lanza was appointed as the Chief Surgeon to the Bureau of Mines. He was assigned to the Joplin, Missouri, lead and zinc mining areas "to investigate and report on the prevalence, causes, and methods of control of pulmonary diseases among miners."15 A series of investiga tions followed that quickly established him as an expert in the pneumoconioses.14 Reprint requests should be addressed to David E. Lilienfeld, Mount Sinai School of Medicine, Division of Environmental and Occupational Medicine, Department of Community Medi cine, Box 1057,1 Gustave L. Levy Place, New York NY 10029. American Journal of Public I leallh 791 Public Health Then nd Now Further assignments in occupational med icine followed. In 1920, Lanza left the PHS to practice and consult in the private sector. Six years later, he was hired by the Metropolitan Life Insurance Company to "provide industrial medicine and indus trial hygiene services to companies whose group life insurance policies were held by the Metropolitan."14 The Metropolitan also provided these services to companies whose disability or workmen's compen sation policies it carried. The recognition of silicosis and its as sociation with employment-practices, coupled with a high injury rate in many industries (particularly in mining), led to the enactment of workmen's compensa tion statutes in the United States between 1910 and 1930.16,17 Corporations bore this system's cost as a business expense. It was therefore only in the 1920s that the Metropolitan's services were needed by industry. At the same time, asbestosis was identified as a distinct entity caused by asbestos.6 No direct evidence exists that these reports were alarming to the indus try. However, subsequent events suggest that the companies did not immediately acknowledge (or desire to do so) the haz ard created by asbestos exposure. One response was a 1929 request by several asbestos companies to the Metro politan for an industrial hygiene survey of several of their plants. The survey also was to determine if asbestosis even exist ed.6,16 If the disease did not exist, then there could be no liabilities from it. An additional concern was whether asbesto sis led to tuberculosis in a manner akin to silicosis, since asbestos was a silicate. If asbestosis did so, the compensation costs would be much greater. Lanza, an expert in the pneumoconioses, was to direct the study. Lanza was well aware of the legal implications of such work. For example, s in November 1929, he had sent to Mr. Allan Wardwell (of Davis and Polk, a Wall Street law finn and Johns-Manvillc's out side corporate counsel) a bibliography on asbestosis.19 A year later, Lanza wrote to Wardwell concerning the definition of as bestosis to be used in the workmen's com pensation schedule for New Jersey, then being codified.70 The surveys found that asbestosis, present in large segments of the industry's workforce, did not predispose to tuberculosis.21-23 In 1931, Lanza sent the American plants survey findings to Wardwell, noting: "It is, of course, understood that this report is confidential and it will be given no publicity by us except with the consent of the firms concerned.'*24 A sim ilar report for the Canadian plants (written by Lanza's superior, E. McConnell, MD) was also sent to Wardwell.23 Three months later, at a meeting with JohnsManville officials, Lanza recommended the inclusion of asbestosis under work men's compensation: "(HeJ is very' strongly of the opinion that asbestosis* should be made compensable.... He feels that this is the only protection which the industry has.. .permitting the disease to remain outside the compensable class lends encouragement to unethical lawyers and physicians to work up claims.*'26 By 1932, Johns-Manville had several suits against it from workers with asbes tosis.27 In contesting these suits, the cor poration sought to question the diagnosis of pulmonarydisease. In February, Lanza wrote to F.V. Meriwether, MD, ofthe US Bureau of Mines, requesting his assist ance in reviewing some x-rays from the Manville, New Jersey, plant.26 In a fol low-up letter from S.A. Williams (JohnsManville Vice President for Mines and, Production), Meriwether was told "you will readily appreciate that we desire thej results ofyour readings to be held in strict- ' est confidence and that no unnecessary publicity be given to the fact that you are making these readings for us... we wish, if possible, to prevent the results of our efforts being used against us either in the pending suits or in any suits which may be brought against us.''27 Meriwether subse quently agreed.29 Vandiver Brown, Johns-Manville's genera1 counsel, coordi nated the logistics.30 In 1933, Williams wrote to A. R. Fisher (manager of the Manville, New Jer sey, plant) concerning Lanza's reply to questions from a physician at Johns-Man ville's Waukegan, Illinois, plant.31 The Waukegan physician had reportedly asked Lanza, "Do you agree with my rec ommendation that employees definitely be made aware of the fact that asbestos dust is hazardous to their health?" Lanza replied: "I doubt if the hazard is sufficient to justify warning posters.... This is es pecially true in view of the extraordinary legal situation." The legal aspects of the situation had had an impact on a physi cian's (i.e., Lanza's) approach to a med ical problem, i.e., they led him to ignore it. Later in the exchange, the plant physician noted: "I have made a diagnosis of asbes tosis. ... In my judgment the best dispo sition ofsuch a case is to remove him from the dust and give him a job in some other part of the plant." Lanza replied: "It is difficult.... One of the difficulties and vexations ... of pneumoconiosis is that economics as well as production factors, must be balanced against the medical fac tors." In November 1933, Lanza met with Johns-Manville executives to discuss the completion of the Metropolitan surveys.32 Attendees included W. R. Seigle (chair- 792 American Journal of Public Health June 1991, Vol. 81, No. 6 Public Health Then and Now Asbestos being sprayed during con struction. Courtesy of Mitchell Cohen. nun of the board), E. M. Voorhees (sec retary and treasurer). Brown, and Wil liams. Lanza thought that resurveys of both the plants and the employees would be necessary. He stated that it would be advantageous if Wardwell spoke with the Metropolitan's president to stress the im portance of the project's completion. Voorhees asked about obtaining annual dust counts in the plants "in the event we should ever be involved in litigation." I an?a suggested that the Saranac Labo ratory, a tuberculosis sanatorium and re search facility, would be better positioned for such a task. A follow-up meeting, again in Seigle's office, was held in late December, 1933.33 Joining the meeting were S. Simp son (president of Raybestos-Manhattan) and M. F. Judd (another Raybestos-Man hattan official). Among the topics of dis cussion was pending litigation: "It was de cided that this committee ... would ... obtain Dr. Lanza's recommendation with respect to locating or developing an expert whose services might be utilized from the standpoint of court work." At the same time, L. U. Gardner, MD (medical director at the Saranac Lab oratory) wrote to Lanza concerning the disposition of some mine workers at the Philip Carey Company (in Canada) who had developed silicosis.34 When any of these workers filed a compensation claim, the Saranac Laboratory would review the x-rays for the Metropolitan. Gardner noted that the closing of the Carey mine would precipitate the filing of many such claims for silicosis and silico-tuberculosis. Carey had dealt with this situation by transferring these men to its operations across the border in Michigan, where there was no compensation law. By the end of 1933, it was clear that the industry and at least one of its insurers were concerned with asbestosis-related litigation and wanted to minimize the as sociated economic impact. A key figure in these activities was an employee of Met ropolitan Life, Lanza. It was through his association with the asbestos industry that the foundation was laid for future formal oonoerted action to conceal research find ings relating asbestos exposure to both as bestosis and cancer. The Codification At an early 1934 meeting, officials of Johns-Manville, Raybestos-Manhattan, and Metropolitan Life were "advised... as to the relatively better position in which the companies would be placed in the event of litigation if... an outside expert of recognized reputation ... would state that he had made certain recommenda tions ... and that these recommendations had been followed."35 Lanza stated that he would discuss this role with Dr. P. Drinker of Harvard University. Until late 1934, the efforts of the in dustry, of the Saranac Laboratoiy, and of the Metropolitan had been directed at keeping research findings confidential. For instance, in 1933, the Saranac Labo ratory had released confidential data on silicosis.34,37 As a result, the Wisconsin Industrial Commission was able to publish a report on silicosis and tuberculosis that was none-too-favorable to the industry. Lanza scolded the Saranac Laboratory for this unauthorized release.38 Outright de ception began in December 1934.39 Lanza was publishing the results of the 1931 sur vey. Brown, concerned about, the article (then in galley proofs), discussed some changes with one ofJohns-Manviile's out side counsels (G. Hobart). Within a week, Hobart sent Brown a marked-up version of the paper, noting that "one of our prin cipal defenses ... has been that the sci entific and medical knowledge has been insufficient until a very recent period to place upon the owners of plants or facto ries the burden or duty of taking special precautions against the possible onset of the disease to their employees."40 A week later. Brown forwarded these comments to Lanza, noting that "I trust that you will give his comments and suggestions, as well as those mentioned in my letter, your most serious consideration. I apt sure that you understand fully that no one in our organization is suggesting for a moment that you alter by one jot or tittle any sci entific facts or inevitable conclusions re vealed orjustified byyour preliminary sur vey. All we ask is that all of the favorable aspects of the survey be included and that none of the unfavorable be unintentionally pictured in darker tones than the circum stances justify-"41 The desired changes were made prior to publication.42,0 In early 193S, Lanza sent a reprint of the published article to WardwcU, noting: "the Public Health Reports publication gives this piece of work authoritative and dignified presentation."44 Subsequently, S. E. Whiting (Assistant Chief Engineer of the Liberty Mutual Casualty Insurance Company), requesting a reprint from Lanza, referred to the continued funding of the Saranac Laboratory by Liberty Mu tual and the Metropolitan.45 He also sug gested that the Saranac Laboratoiy re lease the Lanza survey results to these insurance companies, who would in turn convey the findings to the industry. The data were subsequently so released.44 In late 1936, the asbestos industry again found itself in legal troubles as it had compensation cases to settle. Simpson de scribed the problem in a letter to H. D. LaMont of the Asbestos Manufacturing Company: "They claim it [asbestosis] leads to Tuberculosis, but we do not find this to be the case. Still, we cannot go into court and state definitely and specifically that it will not do so."47 Simpson went on to describe the Saranac Laboratory's ca pability to address the tuberculosis-asbestosis issue. He also suggested that mem bers of the industry (Johns-Manville, Thermoid Rubber, Keasbey and Mattison. Asbestos Manufacturing, Russell Manufacturing, and Raybestos-Manhat tan) contract with the Saranac Laboratory to conduct these experiments: "to have four or five (or even more if we could get them) Asbestos manufacturers take over this study . . . and then we could deter mine from time to time after the findings are made, whether we wish any publica tion or not. . . it would be a good thing to distribute the information among the med ical fraternity, providing it is of the right type and would not injure our compa nies." On November 9,1936, Simpson met with Lanza, McConnell, Brown, and Gardner to discuss the possibility of con ducting such studies.48 Nine days later, these companies (Appendix A) so con tracted with the Saranac Laboratory, with the provision that "the results obtained will be considered the property of those I(V)I Cl Mrt A American Journal of Public Health 793 Public Haiti) Tben tod Now i. who arc advancing the required funds, who will determine whether, to what ex tent, and in what manner they shall be made public. In the event that it is deemed desirable.. .themanuscriptofyourstudy will be submitted to us for approval prior to publication.'*49,50 There matters rested for three years. Gardner was unable to complete his ex periments. The medical literature contin ued to accumulate on the noxious effects of asbestos.6,9 In the winter of 1940, Brown advised Gardner that the funding would be extended by a year and that the terms of the original agreement continued to apply.31 Presumably, this last comment referred to the provision concerning in dustry approval prior to publication. In 1942, Ivan Sabourin (chiefcounsel for Canadian Johns-Manville) joined in these endeavors. On May 6, he sent a medical report to Gardner that he (Sab ourin) had ''taken the liberty of drafting for you___ for the benefit of my cli ents."32 The report was to be sent by Gardner to various state workmen's com pensation boards. Soon afterwards, Sab ourin became the general counsel for the Quebec Asbestos Producers Association (a Canadian asbestos industry associa tion), which would undertake much of the asbestos-cancer research conducted dur ing the coming decade. Cancer Gardner's asbestos work continued. An interim report noted that 81.8 percent of animals exposed to asbestos had devel oped lung tumors, an overly high rate.33 Gardner thought the result to be impor tant: ''The question of cancer susceptibil ity now seems more significant than I had previously imagined." A copy of the re port was sent by one sponsor, Keasbcy and Mattison, to its parent, Turner and Newall (a major asbestos manufacturer) in England, with the comment "we feel that reference to the question of cancer sus ceptibility should be omitted from the re port since it is inconclusive."54 Concurrently, the asbestos industry and the Metropolitan turned their atten tions to Canada. This change in focus be gan with a Metropolitan actuary's report to G. W. Wheatley, MD (assistant direc tor of the Metropolitan's Medical Divi sion) of a high tuberculosis rate at the Johnson Company in Thetford, Que bec.55,56 This finding again raised the issue of asbestosis and tuberculosis. The Met ropolitan decided that a survey of the Johnson Company was needed.37 During a trip to Quebec in October, 1944, Wheatley met with Sabourin, among others.50 Sabourin's clients had been deal ing with asbestosis compensation claims and were in the process of establishing an asbestosis clinic at Thetford, Quebec. The Quebec view was that asbestosis in creased the riskoftuberculosis. At a meet ing ofSabourin, O. C Smith (president of Bell Mines), A. Penhale (manager of the Asbestos Corporation mines), A. Johnson (president of the Johnson Company), and the Metropolitan staff, the logistics of es tablishing the clinic (the Thetford Clinic) were discussed. Dr. P. Cartier, of the Montreal Anti-Tuberculosis Society, was to direct the clinic. In the United States, meanwhile, the concerns about Gardner's findings contin ued. One sponsor wrote to Brown in April 1946, indignant that the draft mentioned cancer.39 After Gardner's death in Octo ber 1946, Brown wrote the other sponsors to suggest that someone else at the Sa ranac Laboratory complete the report. As work proceeded accordingly, the spon sors reiterated (heir right of approval of all public releases of the findings.60,61 In the interim, Lanza sent Gardner's last draft to Professor Kenneth Lynch, MD, of the Medical School of South Carolina for re view. Lynch recommended the publica tion of the report without revision.62 As the drafting ofa final report neared completion in late 1947, Fisher wrote to J. P. Woodard (a Johns-Manville senior executive) that the final report should be reviewed by "the top man of the Quebec Asbestos Producers Association."63 By late November 1947, Sabourin was veiy anxious to have the report completed to counter local Quebec groups upset about the health effects of asbestos exposure. Yet there was still no final report. In March 1948, a frantic Woodard noted to Lanza that labor problems in Quebec were related to asbestos.64 Two months later. Brown wrote to Muehleck (president of Keasbey and Mat tison) suggesting that the Asbestos Textile Institute (ATI) review the report. (The ATI, an industiy trade association, had been founded in 1944 to promote asbestos textiles. Its membership (Appendix B) had considerable (but not total) overlap with the sponsors.6) Muehleck thought that the sponsors should review the work.65 Brown noted that although some sponsors were not ATI members, the ATI members had provided most of the funding.66 Therefore, Brown argued, the ATI, not the sponsors, should conduct the review. Muehleck finally agreed.67,68 By this time, A. J. Vorwald, MD, had been appointed as Gardner's succes sor.6 With much urging from Woodard, he completed a draft of the Gardner re port (including a cancer section) that was ready for review.69,70 One sponsor had already indicated that the cancer section should be removed; now, other sponsors concurred.39,69"76 Brown agreed; Lanza was told to handle the matter.76"78 In the process ofthis review, all ofthe sponsors (except Keasbey and Mattison, and Raybestos-Manhattan) received cop ies ofthe draft that had been numbered by Brown. The reason was simple: "It is ob viously undesirable that the report in its present form receive any distribution or publicity outside a limited number of peo ple in our respective organizations."76 The next month. Dr. Hamlin, medical di rector for American Brake Block, reas sured his superiors that the report was not controversial "since most of the basic facts with the exceptions of the more de tailed studies mentioned in the report are already known ... no unfavorable reac tion need be anticipated."76,79 About two weeks after the review committee decided to remove the cancer section. Brown communicated this conclusion to W. T. Kelly (Hamlin's boss at American Brake Block). Brown noted that all of (he copies of the report had been "retrieved ... ex cept the one we sent you, which ... Dr. Hamlin would like to keep. I wish, how ever, you would prevail upon him to re turn it.... Everyone felt that it would be most unwise to have any copies of the draft report outstanding."76 Kelly subse quently asked Dr. Hamlin to return the draft.80 The January 31, 1949, draft of the re port had the section entitled "Neoplasm" marked through with the word "out."81 The revised report was published in 1951.82 One member of the investigative team has stated that this act was unrelated to sponsor pressure.83 On March 8, 1949, Brown wrote Sa bourin that "because of our close associ ation in Canada with others interested in the solution of the asbestosis problem, the results of these experiments should be made available to them in advance of pub lication. ... I am providing you ... as counsel to Quebec Asbestos Mining As sociation [the successor to the QAPA]-- with two copies of the report. "w By June, 1949, the report had begun to be promoted in the United States. For instance, Gatke noted that the Massachusetts Industrial Board "would likely be more lenient in 794 American Journal of Public Health June 1991, Vol. 81, No. 6 Public Ileallb Then and Now their decisions if they had the advantage of the information disclosed in this re port."45 As K. Smith, MD (the medical direc tor of Canadian Johns-ManviUe) noted, the report left many questions unan swered, including the importance of fiber size, and specific aspects of the asbestoscancer issue.4447 Vorwaid wrote to Smith in October, 1949, suggesting that the x-rays of the Quebecworkers be reviewed for lung cancer.44 A study protocol was quickly formulated.49 Smith wrote to Lindell (president of Canadian Johns-Man viUe) that "there has been a tremendous increase in the number of articles in med ical journals during the past year which deal with the subject of occupational can cer. Very high on the list of causes... is asbestos. There seems to be increasing proof that asbestos fibers do cause lung cancer. This conclusion is drawn only from articles reported in the journals.... 1 have been unable to find any x-ray evi dence of lung cancer among our employ ees ... but this whole subject could cause our companies unlimited embarrassment and untold expense if labor leaders made use ... of the subject.... If we are to defend ourselves in the compensation courts, we must have proof. I believe that we should discuss this matter at a QAMA Meeting and___ask____[the Saranac Laboratoryf to outline a sug gested plan of study."90 (Smith had al ready reviewed the Saranac Laboratory report at the QAMA meeting in 1949.91) He noted: "As far as J-M is concerned, I know of two hazards in our operations which may lead to pulmonary malignancy, namely asbestos and silica. There is ever increasing evidence in the medical litera ture today that these materials lead to lung cancer." A study was needed. By March, 19S0, the, issue had be come whether further study should be un dertaken by William Smith, MD (a toxi cologist at Lanza's unit) or by the Saranac Laboratory.92,93 (Following Lanza's re tirement from the Metropolitan in 1948, he founded the Institute of Industrial Medi cine at New York University.94) Site visits suggested that both facilities could com plete the work.93,95-97 Lanza drew up a contract which left "little choice to the donor if the results of the study are unfa vorable to company interest and are sub mitted for publication. However, I [K. Smith] fail to see how they can find any thing more unfavorable than that which already has been published.. ."94 In Sep tember, Vorwaid submitted a competing contract for the Saranac Laboratory, which stated that "the Saranac Labora or without asbestosis." (Ironically, Johns- tory reserves the right to publish the re Manville would argue two decades later sults of its investigations in the recognized that mesothelioma was not a distinct can manner.. .whereby the manuscript prior cer.5) to its publication is submitted to the spon In October, Vorwaid presented his soring company for its review and approv al."99 Later that month, the QAMA noted that "a relationship between the inhala tion of asbestos dust and pulmonary can cer has been stated publicly by certain health authorities.... It is necessary for us to .*.. prove that this statement is not correct or to accept it and the conse quences that gowith it. Ourposition in this matter is the same as the Association and Industry found itself in 1937 as regards to asbestO6is."l00The proposed studywould use "the same methods as our antago nist" Animal studieswere also suggested. Another activity "would consist of more publicity coming from our association... rather than taking the defensive attitude that we have... .That we arrange to have our doctors lecture at medical schools yearly. That we attempt to affiliate our doctors in some manner with research centers such as Saranac and in such orga nizations as the Industrial Hygiene Asso ciation and the Institute of Industrial Med icine [Lanza's New York University group]" Despite the long association between Lanza and his industry colleagues, the lack of sponsor control of publications in initial findings to the QAMA: "Although only six months had elapsed... animals which were killed during this time pre sented no greater incidence of pulmonary cancer in the dusty group than in the nondusty group... he is certain that there is no association between the cancer and as bestos, but... cannot state this scientif ically, for at least twenty months must elapse before conclusive evidence can be produced and in the meantime, this statis tical survey [the epidemiologic study] should be carried on."105 In February, 1952, A. L. Fisk, Jr. (Johns-Manville's Legal Department) wrote to Lanza: "As you are aware, the Industrial Commission of Illinois has pro mulgated rules as to the labeling of sub- stances harmful to the health and safety of employees___ in our opinion asbestos fiber comes within the preview of the reg ulations. ... It is our intention to label our bags containing asbestos fiber, using the foUowing: " `CAUTION--ASBESTOS FIBER' Inhalation of asbestos fiber over long peri ods MAY BE harmful. The material should be used as not to create dust or, if this is not possible, employees should be equipped with adequate protective devices."'06 the New York University proposal led to For unknown reasons, a warning label the Saranac Laboratory's being awarded was not added to the bags for another 13 the contract.99-101 In November, Lanza, years.6 Sabourin, and Woodard met with Vor The QAMA-sponsored Saranac Lab waid to review the project.101 The studies oratory animal study continued. At 14 began and were soon almost complete.102 months, the animals exposed to asbestos Smith (now medical officer for Johns- had a higher incidence of cancer than Manvilk) thought that an epidemiologic those not exposed.107 The study was not approach was needed. He wrote Johns- published. The industry was well aware of ManviUe officials that "we would be wise the stakes involved. For example, in 1953, to wait [for a news release] until we have the Indiana State Division of Industrial proof of no causal relationship between Hygiene contacted National Gypsum con asbestosis and pulmonary cancer... we cerning the safety of asbestos spray prod might not wish to bring attention to the ucts.108 The National Gypsum safety di asbestos industry if the cancer research is rector wanted to reply that the applicators not entirely favorable."103 should wear respirators. A National Gyp In July, 1951, Cartier reviewed can sum executive characterized the sugges cers among eight asbestos workers.104 He tion as "full of dynamite," stating that "I observed: "some causal factor will pro am much concerned that National Gyp duce the samevariety of tumors and there sum is on record . . . that Thermacoustic fore why do we observe such a variety of is hazardous business. If this snowballs, [cancers]... [if] we may assume that the we are out of the Thermacoustic busi asbestos factors might produce a bron ness." chogenic carcinoma ... then only two Vorwald's tenure at the Saranac Lab cases of the series would serve as evi oratory was ended in 1953, after he at dence because the other cases are me tempted to investigate further the asbes sothelioma or lymphosarcoma or second tos-cancer relation.6 He sought ary malignancy in cases without exposure employment as a professor at a California lime 1991. Vol 81. No. 6 American Journal of Public Health 795 Public Health Then and Now "LIMPET" prayed asbestos application. UMPET was a product of tha Keasbey and Mattison Company. Note the two men at the far right feeding the machines. Courtesy of Mitchell Cohen. institution. Lanza flew to California to which I must give at present. Its tone must prevent that Vorwald would be offered the have given you quite a jolt. When your position (personal communication, W. ' letter came in February, Doll and I had not Smitb).10*-1** The trip is alleged to have finalized our paper. On completion we been paid for by the Metropolitan. A sim sought permission to publish and, to my ilar fate befell W. Smith (a toxicologist in great surprise, were refused by the Lanza's unit) after he had indicated an in company--at present. Up until a few days terest similar to Vorwald's (personal com ago, I had hopes of a more favorable tum munication, W. Smith). of events but the ban remains. The head At the Seventh Saranac Symposium line news about lung cancer has scared in 1952, the asbestos-cancer relation was people over here and it was thought we discussed and the carcinogenic potential might attract undesirable publicity in our of each ofthe fiber types noted.112 Attend area.... I am sending you personally a ing this meeting, in addition to industry copy of our paper. Perhaps the people to physicians, were representatives of the whom it would be most unwise to mention Liberty Mutual, the Travelers, the Amer it would be those associated in any way ican Mutual, and other insurance compa with our industry."114 When Doll learned nies. Turner and Newail (in Rochdale, En of the ban, he wrote Knox: "For my own gland) sent a physician, J. Knox, to attend part, I feel that any positive findings with this meeting. At the Seventh Saranac regard to the cause of cancer must be Symposium, he met W. Smith. Stimulated made available to all research workers on by the reports at the symposium, Knox the subject. . .it is by free publication that decided to examine the Rochdale asbestos the work can be tested and utilized (or workers' lung cancer experience. He be disproved) by others."113 In 1955, the gan to trace the Rochdale workforce, col manuscript was published; Knox was ac laborating with Sir Richard Doll (then an knowledged anonymously.116 That indus epidemiologist at the London School of try-supported investigators in North Hygiene) on the data analysis. By Decem America had previously gleaned the ber 1953, both men had realized that lung causal association could not have been cancer mortality was much above what it known by Doll. should have been.113 A paper was drafted Discussions of the cancer-asbestos with Knox as the senior author.114 link within the asbestos industry ensued. In June, 1954, Knox wrote W. Smith, The QAMA and the Asbestos Textile In describing Turner and Newall's response stitute, for example, communicated with to the research findings: "This letter is ad each other about the subject.117 Yet an dressed to you in your private capacity. industry manual compiled by the Magne The letter of 31/5/54 is the official answer sia Insulation Manufacturers Association (another industry trade association) stated that asbestos "offers no hazard to the worker."11* Also, it is apparent that, at a National Cancer Institute (NCI) discus sion in 1955 on asbestos and cancer, at tended by Vorwald and K. Smith, no dis closure of either Gardner's or Vorwald's findings was made.119 The meeting con cluded that "there have been no asbestoscancer animal experiments." It noted that given the widespread use of asbestos, if it were carcinogenic, the public health im plications would be great. Also in atten dance was an NCI staff member, W. Hueper, PhD. Hueper was very much convinced of the causal relationship be tween asbestos and lung cancer.130 In February 1956, K. Smith wrote to Daniel Braun, MD, [the medical director at the Industrial Hygiene Foundation (IHF)], concerning Hueper's statements that asbestos caused cancer.131 (The IHF [Appendix C] was established in 1936 to provide dust control information to its membership, which included many mem bers of the asbestos industiy.3,6) K. Smith noted that "we have too much at stake to allow . . . such indiscriminate state ments." In response, Braun prepared a report on asbestos and lung cancer for the QAMA (under die auspices of the IHF).*23"124 (The Asbestos Textile Insti tute had rejected an IHF proposal for fur ther work on asbestos and cancer because it would "stir up a hornet's nest and put the entire industry under suspi cion."133,136) A final report was soon com pleted.137 The copies were numbered. Braun stated that "a comparison of rela tive frequency of lung cancer and asbes tosis is less reassuring... this is because of an underreporting of asbestosis cases. The incidence of asbestosis indicated by the medical records is far below that which would be expected. . . . However, this may be 12.5% of the recorded cases of asbestosis in this state of development of lung cancer, a figure slightly lower than those quoted by authors who confine themselves to this type of comparison." The consequences of the industry's pre vious underreporting of asbestosis now became clear. The concluding sentence of the report was less equivocal: "The re sults suggest (hat a miner who develops the disease asbestosis does have a greater likelihood of developing cancer of the lung than a person without this disease." Once the QAMA had received the report, Sabourin met with Braun to pro duce a "condensation" for publication.138 Concurrently, K. Smithwrote to Sabourin that "[we] have noted deletion of all ref- 796 American Journal of Public Health June 1991, Vol. 81, No. 6 Public Health Then and Now erenets to the association of asbestosis and lung cancer. ... While we believe that this information is of great scientific value, we understand the desire of the QAMA to emphasize exposure of the as bestos miner and not the cases of asbes tosis."129 K. Smith noted that the pub lished condensation would be criticized "because all ofthe authors todaycorrelate lung cancer to cases of asbestosis/' In 1958, the Archives of Industrial Health published the "condensed" Braun report (without the quoted concluding sentence).00 In his letter of acceptance, Stoldnger, the editor (a major figure in the development of threshold limit values) noted his pleasure that "the main conclu sion of the paper was against the associ ation of lung cancer with asbestosis, for I had come to a similar conclusion on ob viously far less information.... I am en closing a review which contains a few statements that I have marked in this con nection that appears in theAnnualReview of Medicine, Volume 7, 1956. You will recall at this time evidence greatly favored the positive correlation of lung cancer and exposure to asbestos."131,132 At a 1958 symposium, the "condensed" report was presented. Sabourin reported to the QAMA that the news of this symposium provided "wonderful public relations val ue."133 By the early 1960s/lhe industry and its associates had succeeded in suppress ing much of the knowledge gleaned over the prior two decades concerning asbestos and cancer. During the 1960s, academic scientists and physicians, such as Selikoff and Wagner, discerned the relationship between asbestos with cancer.134 These findings were quickly appreciated by the general medical community.133 The indus try was in a compromised position. In 1963, K. Smith suggested the purchase of a shredding machine to "destroy com pletely all copies of correspondence which you do not wish to retain. ... I believe that this is highly essential but all copies of correspondence of such confidential na ture should be thoroughly destroyed so that our position in Workmen's Compen sation claims cannot be doubted."136 In the mid-1960s, the industry began to place warnings either on the bags of asbestos or on the sides of the wooden crates used to ship the products containing asbestos. In 1965, a series of Johns-Manville memos clearly state that for products exported from the United States, the warning on the bags should be covered and those on the crates, sanded off.137,130 Similar memos exist for other members of the industry. For instance, a 1964 EaglePicher memo concerning such warning la bels stated the following: "This is large enough type face [1/B inch height] to be completely legible, yet does not `shout CAUTION from the roof tops/"139 In 1970, an Owens-Coming memo succinctly stated the reluctance to use such labels: "Reference is made ... regarding the warning label.... Are you saying that we have to do this now? I naturally would like to delay this requirement as long as pos sible."140 A little more than a decade ago (in 1977), the following exchange took place within the Phillip Carey Company: "I got very strong reactions in Japan to our re quirement to translate the ... [warning] Label into Japanese.... Confidentially, the Kakiuchi staff told me that they delib erately left out the word cancer from the text because this must not even be men tioned in Japan in connection with asbes tos. Altogether they are against a warning label because they do not wish to raise problems with the workers. They are al ready attaching a label on each bag ac cording to Japanese law. Kakiuchi would prefer to sign a certificate holding us blameless from harm.... Asbestos Cor poration and Bell have both gone this route per attached blank forms. Kakiuchi are of the opinion that we cannot impose American law on foreign counties and on Japan in particular. ... I do not believe that we should raise problems with people who are more primitive than we are, or less educated."141 The reply: "As far as the caution label is concerned ... we must be sure to cover ourselves only where the law of the land requires. I sug gest we go ahead with the new caution label in English and French only. What do you think the Japanese, Finns, Swedes and Dutch will have to say about that?"142 By the late 1970s, the industry was under attack in the courts and in the press. One Johns-Manville memo, labeled "Confidential", dated January 12, 1979, addressed to John A. McKinney, presi dent of the company, assessed events: The situation confronting Johns-Manville and asbestos has changed dramatically in recent days___now the integrity ofpre sent-day management is being severely challenged. The shift in the thrust of public opinion is crucial in that favorable legisla tion on compensation will not be possible if the credibility of the corporation ... is questioned by Congressmen and, more im portantly, their constituents. I believe the seriousness of the situation has now gone beyond the implementation of a communication effort, though that should be done ... here arc a few examples: 1. JM position: Prior to 1964, we lacked scientific knowledge about cancer haz ards of asbestos. FACT: In the tnid-50s, JM officials knew of scientific studies showing a relation ship between cancer and asbestos. 2. JM statement to North Carolina judge: So-called "cover-up letteis" not avail able. FACT; Letters had been used in a New Jersey trial several weeks before ... 3. JM position: though sprayed asbestos in appropriate for use in schools, we see no evidence of danger. FACT: If no problem, then why an in appropriate use? 4. JM position: There will be no future problems with workers. FACT: Workers in Mexico are not being protected. 5. JM position: Knoxville trial shows there was no conspiracy. FACT: Knoxville judge tells the Asso ciated Press "off the record" that his rul ing on punitive damages does not dear the company of a "cover-up" charge. 6. JM position: Sinoe 1964, JM has "come dean" with employees about asbestos * hazards. FACT: A current 41 year employee of JM has called me to say that he has a spot on his lung... but no one at JM has ever communicated with him about it. 7. JM position: There was no cover up. FACT: A current employee. .. says his father worked for JM for 35 years at Manville and was never told about dan gers. Father was dismissed because of `miners' asthma'... he had to take JM to court to get compensation for an as bestos-related disease. 8. JM position: We have communicated openly with employees about illnesses. FACT:... it was company pradice into the early 70s not to tell a person about his illness. 9. JM position: JM has taken precautions to prevent excessive exposure to fiberglass workers. FACT: Plant manager... is reluctant to post HS Sc E bulletin because precau tions not taken at his plant . . . I can easily see why we have members of Congress calling us `liars'.141 Conclusions This case study illustrates how a se ries of concerted actions was planned and carried out during half a century, in which data were generated and then suppressed. Some of the principals in these activities were also leaders in occupational medi cine. The societal response to the ambiv alence and inaction by these leaders with respect to industrial carcinogens was the Occupational Safety and Health Act of 1970. The Occupational Safety and Health Administration removed some of these leaders from the dominating positions they had held in the development of na- June 1991, Vol. 81, No. 6 American Journal of Public 1 lealth 797 i.. Public Health Then and Now tionaJ policy on industrial carcinogens. The success of this approach remains un dear. Another interesting aspect of this ep isode is how the information became pub lic. It was by legal actions that these doc uments were produced (through "discovery," the legal process of infor mation disclosure). None of the compa nies involved provided these papers freely to the general public. Indeed, to have done so would have greatly compromised SO years of corporate safety and health poli ties. If major legal reform had been en acted prior to this litigation, it is possible that these documents would not have be come public knowledge. It is equally dis turbing that none of these data were ob tained through the existing occupational safety and health enterprise erected dur ing the past two decades. The effective ness of the current framework for devel oping and enforcing occupational safety and health considerations must therefore be questioned. However, a complete dis cussion of this issue is beyond the scope of the present work and should be consid ered by the occupational health policy community. The degree to which scientific fraud permeated published reports is also of concern. The activities described suggest that fraud in non-govemmentally sup ported research occurs, and that it has po tentially great impact on health policy. However, unemployment or withdrawal of research support may be the ultimate "reward" for those who do not participate in such activities. The implementation of mechanisms to prevent such fraud should not await yet another public health trag edy. Despite the disclosures of suppres sion and fraud, no mechanisms have been implemented to prevent future such oc currences. It was not only in the asbestos indus try that voluntary corporate compliance with societal norms of conduct in worker health and safety were violated. Michaels has shown that similar problems existed in the aniline dye industry.3 As the recent A. H. Robins-Dalkon Shield episode illus trates, in the 1970s, some corporations (outside the asbestos industry) thought lit tle about suppressing detrimental medical knowledge. Until such activities cease, the potential for future similar public health disasters to occur continues. Acknowledgments The author would like lo thank Drs. M. Gordon Wolman, Abel Wotman, and I. J. Selikoff, and Ms. M. Burger for their many comments and the Industrial Arts, Manufacturers and suggestions concerning this manuscript and Commercial Products. New York: E. and Messrs. R. Motley, D. Austern, T. Crumpier, J. F. N. Spoo, 1879. Rion, C Patrick, J. Gelman, and S. Hoffman, 11. [Anonymous]. Management by Morgan. and Drs. D. Ozanoff, I. J. Selikoff, and B. Cas- Fortune. 1934 March: 82-89, 128, 130. tleman for their assistance in obtaining access 132, 135-6, 141-2, 144, 146. to many of the documents referred to in this 12. Weill H, Jones RN. Occupational pulmo manuscript. All comments and conclusions are nary diseases. In: Fischman AP (ed.). Pul the author's. monary Diseases and Disorders. 2nd ed. This work was supported in pari by NIH New York: McGraw Hill, 1988. grant K08-ES00161. 13. Forbes JJ, Davenport SJ, Morgis GG. Re viewofliterature on dusts. U.S. Bureau of References Mines Bulletin 978. Washington, DC: Note: The references for this paper include ex hibits used as evidence in several legal proceed ings. All of the correspondence, reports, etc., for which no other identification information is provided were used as exhibits at the JohnsManville v. United States. CV 465-83 (Federal Circuit Claims Court, DC) 1983. All such ex hibits are available from the Claims Court in the District of Columbia. Other ,cases in which these exhibits were used are also tiled. If no case citation appears for a given letter, memo, or nonpublished article, then'the reader may assume that the reference may be found as part of the evidence introduced in the Johns-Manvflle v. United States litigation. The other pro ceedings (with corresponding abbreviations used in the reference list) are as follows: Laura Bialy, Administratrix of the estate of Theodore Bialy v. Johns Manville Corp. et al. Civ. Act. C/AN 79-1336 (D.NJ.) (1986). (Cited as "Bialy"). Govt Printing Office, 1950. 14. Goldstein DH. Anthony J. Lanza, MD, 1884-1964. Arch Environ Health 1964; 9:271-4. 15. Derickson A. Federal intervention in the Joplin epidemic. Bull Hist Med 1988; 62:236-51. 16. [Anonymous]. Workmen's Compensa tion for silicosis. Safety Eng 1934; 57:71-4. 17. Gelman JL. New Jersey Workmen's Compensation Law? St. Paul, MN: West Publishing, 1988. 18. [Anonymous]. Report on a Dust Study of the Manville Plant of the Johns-Manvflle Company, 1930 (Bialy Exhibit 2). 19. Letter from Lanza to Wardwell, Novem ber 25, 1929 (Bialy Exhibit 3). 20. Letter from Lanza to Wardwell, Novem ber 11,1930 (Bialy Exhibit 7). 21. [Anonymous]. Report of a Dust Study of the Charleston, SC Plant of the General Paulene Kulzer as Executrix of the Estate Asbestos &^Rubber Division of Raybes- of Richard Kulzer v. Pittsburgh Coming tos-Manhattan, Inc., 1930 (Bialy Exhibit Corporation et al. Civ. Act. 87-03867 Fed eral District Court, Western Dist. New 4). 22. [Anonymous]. A Study of Dust Condi York (1990). (Cited as "Kulzer"). tions in the Mannheim Plant of the United 1. Markowitz G, Rosner D. The illusion of medical certainty, silicosis and the poli cies of industrial disability, 1930-1960. Milbank Quarterly 1989; 67 (Suppl. 2, Part I):l-26. 2. Ozanoff D. Failed warnings: asbestosrelated disease and industrial medicine. In: Bayer R. (ed.). The Health and Safety of Workers. New York: Oxford Univer sity Press, 1988:139-220. 3. Michaels D. Waiting for the body count: corporate decision-making and bladder cancer in the U.S. dye industry. Medical Anthropology Quarterly 1988; 2:215-32. 4. Rosner D, Markowitz G. A "Gift of States Asbestos and Rubber Division of Raybestos-Manhattan, Inc., 1930 (Bialy Exhibit 5). 23. Pedley F. Report of the Physical Exami nations of Asbestos Workers in Asbestos and Thetford Mines, Quebec. November, 1930 (Bialy Exhibit 8). 24. Letter from Lanza to Wardwell, March 20, 1931 (Bialy Exhibit 11). 25. Letter from McConnell to Wardeli, July 9, 1931 (Bialy Exhibit 13). 26. MinutesofJulyl5,1931tmectingbetween Lanza, McConnell, and various JohnsManvflle officials (Bialy Exhibit 14). 27. Letter from Williams to Meriwether, Feb ruary 26, 1932 (Bialy Exhibit 16). God": the public health controversy over 28. Letter from Sayers to Surgeon General, leaded gasoline in the 1920s. AJPH February 20, 1932 (Bialy Exhibit 15). 1985;75:344-51. 29. Letter from Sayers lo Meriwether, April 5. Brodcur P. Outrageous Misconduct: The 11, 1932 (Bialy Exhibit 20). Asbestos Industry on Trial. New York: 30. Letter from Lanza to Meriwether, March Pantheon Books, 1985. 24, 1932 (Bialy Exhibit 17). 6. Castleman BT. Asbestos: Medical and 31. Letter from Williams to Fisher, August Legal Aspects. New York: Harcourl 29, 1933 (Bialy Exhibit 25). Brace Jovanovich, 1984. 32. Minutes of November 28, 1933, meeting 7. Nicholson WJ, Perkei G, and Selikoff U. ofLanza, Seigle, Voorhees, Williams, and Occupational exposure to asbestos, pop Brown (Bialy Exhibit 29). ulation at risk and projected mortality, 4*L33- Minutes of December 29,1933, meeting of 1980-2030. AJTM 1982; 3:259-311. Seigle, Voorhees, Williams, Brown, 8. Lilienfeld DE, Mandcl JS, Coin P, Schu- Simpson, and Judd (Bialy Exhibit 31). man LM. Projection of asbestos related 34. Letter from Gardner to Lanza, December disease in the United States, 1985-2009:1. 12, 1933 (Bialy Exhibit 30). Cancer. BUM 1988; 45:283-91. 35. Minutes ofJanuary 4,1934, meetingofthe 9. Selikoff U, Lee DHK. Asbestos and Dis *5 Raybestos-Manhattan-Johns-Manville ease. New York: Academic Press, 1978. Committee for Coordinating and Stan 10. Andre GG (ed.). Spon's Encyclopedia of dardizing the Ways and Means of Elim- 798 American Journal of Public Health June 1991, Vol. 81, No. 6 Public Health Then and Now inadng Dust and Protecting tbe Health of Employees Engaged in Manufacturing Operations (Bialy Exhibit 33). 36. Letter from Gardner to Knight, April 14, 1933 (Bialy Exhibit 23). 37. Letter bom Gardner to Lanza, April, 1933 (Bialy Exhibit 22). 38. Letter bom Lanza to Cummings, April 11, 1933 (Bialy Exhibit 24). 39. Letter bom Brawn to Lanza, December g 10,1934 (Bialy Exhibit 52). 40. Letter bom Hobart to Brown, December 15, 1934 (Bialy Exhibit 53). Z7.Z 41. Letter from Brown to Lanza, December ^ 21, 1934 (Bialy Exhibit 55). 42. Lanza AJ, McConnell WJ, Fehnel JW. 2,7-b The effects of the inhalation of asbestos dust on the lungs of asbestos workers. Public Health Reports 1935; 50:1-12. 4^2>43. Letter from Judd to Brown, December 24, ' 1934 (Bialy Exhibit 56). 44. Letter bom Lanza to Wardwell, January 16, 1935 (Bialy Exhibit 60). 45. Letter from Whiting to Lanza, February 19, 1936 (Bialy Exhibit'64). p 46. Memo to Lanza, February 25,1935 (Bialy { Exhibit 66). 47. Letter from Simpson to LaMont, Novem ber 10, 1936 (Bialy Exhibit 84). 48. Letter bom Brown to Gardner, January 17,1940 (Bialy Exhibit 113). 49. Memorandum of Agreement between the . . / Saranac Laboratory and American Brake " Block Corporation, Asbestos Manufac turing Company, Gatke Corporation, Johns-Martville Corporation, Keasbey Sc Mattison, Raybestos-Manhattan, Incor porated, Russell Manufacturing Com pany, United States Gypsum Company, Thermoid Company/-and Southern As bestos Company, November 20,1936 (Bi aly Exhibit 85). 50. letter from Brown to Simpson, Novem ber 23, 1936 (Exhibit D at Deposition of David E. Lilienfeld, March 28, 1989, United States District Court, Eastern Dis trict of Texas, Beaumont Division). 51. Letter from Brown to Gardner, January 17, 1940 ((Bialy Exhibit 115). 52. Letter bom Sabourin to Gardner, May 6, 1942 (Exhibit 15 at Deposition of David E. Lilienfeld, March 28, 1989, United States District Court, Eastern District of Texas, Beaumont Division). 53. Letter from Gardner to Brown, February 24,1943 (Exhibit 7 at Deposition of David E. Lilienfeld, March 28, 1989, United States District Court, Eastern District of Texas, Beaumont Division). 54. Letter from Muehleck to Shephard, March 8, 1943. 55. Lener from Wheatley to Burnette, July 26, 1944 (Bialy Exhibit 140). 56. Lener from Morecroft to Wheatley, June 13, 1944 (Bialy Exhibit 135). 57. Memorandum from Wheatley to Arm strong, July 3, 1944 (Bialy Exhibit 137). 58. [Anonymous]. Notes on a Trip to Canada, October 16-21, 1944 (Bialy Exhibit 142). 59. Letter from Gatke to Brown, April 18, 1946. 60. Minutes of meeting of Lanza, Jackson, Woodard, Fisher, Lee, Eisenhart, Brown, Hite, and Hamilton, January 21, 1947 (Bialy Exhibit 177). 61. Letter bom Woodard to Lanza, August 4, 1947 (Bialy Exhibit 181). 62. Minutes of meeting of Lanza, Hite, Jack- son, and Hamilton, August 6,1947 (Bialy Exhibit 182). 63. Letter from Fisher to Woodard, October 29.1947. 64. Letter bom Woodard to Lanza, March 25.1948. 65. Letter bora Muehleck to Brown, April 27, 1948. 66. Letter from Brown to Muehleck, April 30, 1948. 67. Letter from Brown to Muehleck, May 3, 1948. 68. Letter from Rohrbach to Brown, May 5, 1948. 69. Letter bom Woodard to Vorwald, June 1, 1948 (Bialy Exhibit 190). 70. Letter bom Brown to American Brake Block, Gatke Corporation, Keasbey and Mattison, Raybestos-Manhattan, Russell Manufacturing, Thermoid (Southern As bestos), Union Asbestos and Rubber, and United Slates Gypsum, March 3, 1949. 71. Letter from Gatke to Brown, September 14. 1948. 72. Letter from Brown to Muehleck and Ro hrbach, October 22, 1948. 73. Letter bom Muehleck to Brown, October 28, 1948. 74. Letter from Welles to Brown, November 8, 1948. 75. Letter from Brown to Butler, November 12, 1948. 76. Letter from Brown to Kelly, November 12, 1948 (Exhibit 12, at Deposition of David E. Lilienfeld, March 28, 1989, United States District Court, Eastern Dis trict of Texas, Beaumont Division). 77. Letter from Woodard to Gatke, Novem. ber 30, 1948. 78. Letter from Lanza to Vorwald, December 14, 1948 (Bialy Exhibit 195). 79. Memo from Hamlin to Kelly, November 3. 1948. 80. Letter from Kelley to Brown, November 16, 1948. 81. Saranac Laboratory. Asbestosis. January 31, 1949 (Bialy Exhibit 199). 82 Vorwald AJ, Durham TM, Pratt PC. Ex perimental studies of asbestosis. Arch Ind Hyg 1951; 3:1^43. 83. Pratt PC. Deposition. July 12, 1988. U.S. District Court, North Georgia District, Atlanta Division. 84. Letter from Brown to Sabourin, March 8, 1949. 85. Letter from Gatke to Brown, June 14, 1949. 86. Memo from Woodard to Foster, April 15, 1949. 87. Memo from Smith to McCaw, February 7, 1950. 88. Letter from Vorwald to Smith, October 15, 1949 (Bialy Exhibit 3017). 89. Letter from Vorwald to Smith, January 3, 1950 Paly Exhibit 3019). 90. Letter from Smith to Lindcll, January 28, 1950 (Bialy Exhibit 3020). 91. Memo from Smith to Foster, February 1, 1950 Paly Exhibit 3024). 92. Letter from Sabourin to Cartier, February 8, 1950 (Bialy Exhibit 3027). 93. Letter from Woodard to Smith, March 16, 1950 (Bialy Exhibit 3032). 94. [Anonymous|. Annual Report. The In dustrial Health Section, 1948 (Bialy Ex hibit 184). 95. Letter from Smith to Cartier, June 3,1950 (Bialy Exhibit 3041). 96. Letter from McCaw to Woodard, June 7, 1950 Paly Exhibit 3042). 97. Letter from Smith to McCaw, June 19, 1950 (Bialy Exhibit 3043). 98. Vorwald AJ. Proposal on Asbestosis and Pulmonary Cancer, September 21, 1950 (Bialy Exhibit 3057). 99. (Anonymous]. Report to the Quebec As bestos Mining Association re: Pulmonary Cancer. September 25, 1950 (Bialy Ex hibit 3058). 100. Letter from Woodard to Fisher, October 20, 1950 (Bialy Exhibit 3064). 101. Minutes of meeting between Lanza, Sab ourin, Vorwald, and Woodard, Novem ber 7. 1950 (Bialy Exhibit 3070). 102. letter from Smith to Grainger, March 30, 1951 (Bialy Exhibit 3100). 103. Letter from Smith to McCaw, June 11, 1951. 104. Letter from Cartier to Smith, July 3,1951 (Bialy Exhibit 3111). 105. Letter from Smith to McCaw, October 11, * 1951 (Bialy Exhibit 3114). 106. Letter from Fisk to Lanza, February 20, 1952. 107. Saranac Laboratory. Asbestosis and Pul monary Cancer. Unpublished report to the Quebec Asbestos Mining Association, May 7, 1952. 108. Letter from National Gypsum Safety Di rector to Indiana Division of Industrial I lygiene, March 12, 1953. 109. letter from Smith to Lanza, June 28,1954 (Personal Correspondence- W. E. Smith, MD, Bangor, ME). 110. Irwin T. On-the-job cancer--the killer theywon't track down. Cavalier !962Jan. 12(103):52-5, 82-5. 111. Letter from Smith to Armstrong, June 12, 1956 (Personal Correspondence, W. E. Smith, MD, Bangor, ME). 112. Seventh Saranac Symposium. Unpub lished proceedings, September 1952 (Ex hibit 13 at Deposition of David E. Lilienfdd, March 28, 1989, United States District Court, Eastern District of Texas, neaumont Division). 113. letter from Knox to Smith, December 3, 1953 (Personal Correspondence, W. E. Smith, MD, (Bangor, ME). 114. letter from Knox to Smith, June 2, 1954 (Personal Correspondence, W. E. Smith, MD, Bangor, ME). 115. letter from Doll to Knox, June 8, 1954 (Kulzer Exhibit 1485). 116. Doll R. Mortality from lung cancer in as bestos workers. BJ1M 1955; 12:81-6. 117. letter from Penhalc to Widmayer, Au gust 2, 1954 (Bialy Exhibit 3129). 118. MIMA Insulation Manual, January 1, 1955. 119. [Anonymous], Conference on Environ mental Carcinogens, National Institutes of Health: Bethesda, MD. May 7-8, 1955. 120. UCLA School of Public Health. Cancer Control in the United States. 1946-71. DHEW Pub. No. NIH 79-1517. Washing ton DC: Govt. Printing Office, 1979. 121. letter from K. Smith to Braun, February 19, 1956. ' June 1991, Vol. 81, No. 6 American Journal of Public I Icalth 799 f\ibUc Health Then and Now 121 Letter from Braun to Soutar, March 16, 1956 (Bialy Exhibit 3145). 123. Memo from the Industrial Hygiene Founda tion to the Quebec Asbestos Mining Associ ation, March 16,1956 (Bialy Exhibit 3146).. 124. Letter from Braun to Sabourin, Februaty 4, 1957 (Bialy Exhibit 3176). 125. Letter from Holmes to Braun, April 26, 1957 (Bialy Exhibit 3180). 126. Minutes of Asbestos Textile Institute meeting, March 7,1957. 127. Braun DC An epidemiological study of lung cancer in asbestos in miners. Sep tember 1957 (Bialy Exhibit 3188). 128. Letter from Sabourin to Grainger, De cember 18,1957 (Exhibit 23 at Deposition of David E. LSicnfeld, Match 28, 1989, United States District Court, Eastern Dis trict of Texas, Beaumont Division). 129. Letter from Sabourin to Braun, Decem ber 30, 1957 (Bialy Exhibit 3194). 130. Braun D, Truan T. An epidemiological study of lung cancer in asbestos miners. Arch Ind Health 1958; 17:634-51 131. Letter from Stokinger to Braun, January 20, 1958 (Bialy Exhibit 3198). 132. Caistleman BI, Ziem GE. Corporate influ ence on threshold limit values. AJIM 1988; 13^31-^559. .133. Letter from Sabourin to the QAMA, June 22, 1958 (Bialy Exhibit 3200). 134. SelikoffU, Hammond EC, ChurgJ. Asbes tos exposure and neoplasia. JAMA 1964; 188:22-6. 135. Barclay WR. Asbestos. An industrial as set with a health cost. JAMA 1984; 252:96. 136. Memo from Smith to Grot, Februaty 26, 1963 (Kulzer Exhibit 4594). 137. Memo from Pocius to Hodson, January 29, 1965 (Kulzer Exhibit 4584). 138. Letter from Lindstrom to Jensen, January 29, 1965 (Kulzer Exhibit 4585). 139. Memo from McCarthy to Jones, June 19, 1964 (Kulzer Exhibit 1436). 140. Memo from Kern to Konzen, September 21,1970 (Kulzer Exhibit 3929). 141. Memo from Reiser to Pros, April 14,1977 (Kulzer Exhibit 1445). 142. Memo from Bagenstose to Reiser, July 8, 1977 (Kulzer Exhibit 1447). 143. Memo from Linke to McKinney, January 12, 1979 (Kulzer Exhibit 4296). -itiri Ifaf nKttfaHr-V Vu\usorni1c la?;': W'! f$Kcjspef end Mattisoh,* Uworpbrated Russell ' *`y Southem'Asbestos Company ` Themvoid Rubber Company :K Union Asbestos and Rubber Company United States Gypsum Company ; APPENDIXC--Some Asb&tfe* ............. GAF-Ruberoid*, 'y Ea^e-Pidier ^fOweiilfCoadag^ ' ' ! : Owens-Illinois ' : ' ' 4: Pittsburgh-Coming Raybestos-Manhattan ' Johns-Manville > 600 American Journal of Public Health June 1991, Vol. 81, No. 6