The Collegium Ramazzini is an international scientific society that examines critical
issues in occupational and environmental medicine with a view towards action to prevent
disease and promote health. The Collegium derives its name from Bernardino Ramazzini,
the father of occupational medicine, a professor of medicine of the Universities of
Modena and Padua in the late 1600s and the early 1700s. The Collegium is comprised
of 180 physicians and scientists from 35 countries, each of whom is elected to membership.
The Collegium is independent of commercial interests.
Summary
The Collegium Ramazzini (CR) reaffirms its long-standing position that responsible
public health action is to ban all extraction and use of asbestos, including chrysotile.
This current statement updates earlier statements by the CR with a focus on global
health dimensions of asbestos and asbestos-related diseases (ARDs). The ARD epidemic
will likely not peak for at least a decade in most industrialized countries and for
several decades in industrializing countries. Asbestos and ARDs will continue to present
challenges in the arena of occupational medicine and public health as well as in clinical
research and practice, and have thus emerged as a global health issue. Industrialized
countries that have already gone through the transition to an asbestos ban have learned
lessons and acquired know-how and capacity that could be of great value if deployed
in industrializing countries embarking on the transition. The accumulated wealth of
experience and technologies in industrialized countries should thus be shared internationally
through global campaigns to eliminate ARDs.
Background
Every asbestos fiber that is mined is indestructible which repeatedly exposes many
individuals during its life-cycle from mining and extraction of asbestos-containing
rocks to manufacturing of asbestos-containing products (ACP), and further during use,
repair, demolition and abatement of ACP. Since 1993, the Collegium Ramazzini has repeatedly
called for a global ban on all mining, manufacture and use of asbestos
1
-
4)
. The Collegium has taken this position based on well-validated scientific evidence
showing that all types of asbestos, including chrysotile, the most widely used form,
cause cancers such as mesothelioma and lung cancer, and showing additionally that
there is no safe level of exposure. The Collegium has continued to criticize as fallacious
and unachievable the so-called "controlled use" of chrysotile advocated by the asbestos
industry. Unfortunately, despite these concerns and abundant scientific evidence,
global usage of chrysotile has remained at around two million metric tons per year
in recent years. Most of this current use is concentrated in low- and middle-income
countries
5)
.
The Collegium reaffirms its position that, given the well-documented availability
of safer, cost-effective alternative materials, the responsible public health action
is to ban all extraction and use of asbestos. State of the art technologies must be
employed in asbestos removal and disposal. This current statement updates earlier
statements with a focus on the global health dimensions of asbestos and asbestos-related
diseases (ARDs).
UN Organizations
In 2006, the World Health Organization (WHO) called for the elimination of ARDs
6)
taking the position that the most efficient way to eliminate ARDs is to cease using
all types of asbestos. The 2014 update of this statement, which was attached to the
WHO document "Chrysotile Asbestos"
7)
published in response to the continuing widespread production and use of chrysotile,
emphasized that all forms of asbestos, including chrysotile, are causally associated
with an increased risk of cancer of the lung, larynx and ovary, mesothelioma and asbestosis;
these observations are in line with the recent evaluation by the International Agency
for Research on Cancer (IARC)
8)
. In its 2014 update, the WHO reiterated the call for global campaigns to eliminate
ARDs. These efforts have been joined by other United Nations agencies including the
International Labour Organization (ILO) and the United Nations Environment Programme
(UNEP). The Chemical Review Committee of the Rotterdam Convention has repeatedly recommended
that chrysotile asbestos be put on the Convention's list of hazardous substances,
thus requiring exporting countries to obtain prior informed consent (PIC) from the
importing countries. A handful of countries have opposed that recommendation, thus
preventing this basic safety protection from coming into effect. The Collegium calls
on all Parties to the Rotterdam Convention to support the listing of chrysotile asbestos.
Global Burden of ARDs
Occupational exposure to asbestos causes an estimated 107,000 deaths each year worldwide.
These deaths result from asbestos-related lung cancer (ARLC), mesothelioma and asbestosis
6
,
7)
. When the global burden of each type of ARD was considered separately, the estimated
number of deaths per year was 41,000 for ARLC
9)
43,000
10)
- 59,000
7
,
9
,
11)
for mesothelioma, and 7,000
12)
- 24,000
13)
for asbestosis. No estimate is available for the annual numbers of deaths due to asbestos-related
cancers of the larynx or ovary. Because asbestos is more likely to cause lung cancer
than mesothelioma, the total burden of ARDs will differ substantially with the estimated
magnitude of ARLC. The WHO recently advanced a risk ratio of 6:1 for contracting lung
cancer versus mesothelioma following chrysotile exposure
7)
. As these estimates are derived by different methods, inconsistencies might be eliminated
through a cross-verification of the various estimation methods used. Regardless, the
ARD burden is more likely to be underestimated than overestimated because ARDs are
well known to be under diagnosed and underreported.
National Bans
Since Iceland first introduced a ban on all types of asbestos in 1983, more than 50
countries have implemented similar bans
14)
. However, the pace of countries adopting bans has slowed in the past decade. Indeed,
the governments of several industrializing countries have withdrawn bans while others
have prescribed long periods over which to move towards a ban. Such actions are likely
a consequence of the corrupting influence of pro-chrysotile lobbies, whether foreign
or domestic. Asbestos industry lobbyists employ "product defense" science to foment
uncertainty to sway the opinions of industrializing countries, a delaying tactic which,
unfortunately, has often succeeded. Nine of the ten most populous countries in the
world, all of which use or have used substantial amounts of asbestos, have yet to
adopt bans. Coverage of the world population by bans thus remains low and is biased
towards industrialized countries.
Alternatives to Asbestos
In countries where asbestos has been banned, safer, cost-effective substitute materials
have been successfully introduced. Polyvinyl alcohol fibers and cellulose fibers can
be used instead of asbestos in building products such as flat and corrugated fiber-cement
sheets, which are used in roofing, interior walls, and ceilings. Polypropylene and
cellulose fibers have been used instead of asbestos to make fiber-cement products
in Brazil. Virtually all of the polymeric and cellulose fibers used instead of asbestos
in fiber-cement sheets are greater than 10 microns in diameter and hence are non-respirable.
For roofing in remote locations, lightweight concrete tiles can be fabricated using
cement, sand and gravel; and optionally, locally available plant fibers such as jute,
hemp, sisal, palm nut, coconut coir, kenaf, and wood pulp. Galvanized iron roofing
and clay tiles are other alternative materials. Substitutes for asbestos-cement pipe
include ductile iron pipe, high-density polyethylene pipe, and metal-wire-reinforced
concrete pipes
15
,
16)
. While these materials are considered safer than asbestos, good work practices should
be observed for the protection of those working with these materials.
Patterns of the ARD Epidemic
Countries continuing to use asbestos will shoulder the burden of ARDs in proportion
to their prior levels of asbestos use
17)
. Countries where asbestos has been banned or greatly limited invariably exhibit a
sustained epidemic of ARDs. Age-adjusted mortality rates of mesothelioma are increasing
in most industrialized countries
18)
. But the rate of increase has slowed in only the few industrialized countries, which
started to reduce asbestos use decades ago. With the known synergy of asbestos and
smoking, it can be expected that the many industrializing countries with high smoking
prevalence and continued use of asbestos will shoulder a substantial burden of asbestos-related
lung cancer. The ARD epidemic will likely not peak for at least a decade in most industrialized
countries and for several decades in industrializing countries. Asbestos and ARDs
will therefore continue to present challenges in the arena of occupational medicine
and public health as well as in clinical research and practice. Hence, asbestos and
ARDs are global health issues.
Industrializing Countries
Many industrializing countries have been slow to reduce, let alone ban, the use of
asbestos. The multiple factors at play include the low price and easy accessibility
of asbestos, demand from the construction sector in emerging economies, scarcity of
medico-social resources, and fierce propaganda by the asbestos industry and other
parties with conflicting interests. These factors are interrelated and converge uniquely
in each country, presenting significant challenges to concerned parties. For example,
a number of rapidly growing industrializing countries in Asia and former Soviet Union
countries currently sustain a high level of asbestos use and/or production and they
fail to provide even minimal protection to workers; they have a serious lack of expertise
and resources required to diagnose and report ARDs. Furthermore, several industrializing
countries that were importers (but not exporters) of asbestos were among the countries
that opposed the inclusion of chrysotile into the aforementioned PIC procedure of
the Rotterdam Convention. This is a blatant reflection of the corrupt influence of
the asbestos industry and crude trade pressures of asbestos-exporting countries. Advocates
for banning asbestos must continue to strive to overcome the reluctance, denial and
antagonism of their opponents.
Industrialized Countries
The highest priority in reducing ARDs is primary prevention; that is, banning asbestos
use in countries where it remains legal and preventing exposure to in situ sources
in all countries with historical asbestos use. In industrialized countries, large
quantities of asbestos remain as a legacy from past construction practices in many
thousands of schools, homes, and commercial buildings. Significant quantities of asbestos
also remain in various industrial applications. It is of importance to document and
mark existing asbestos in buildings and industrial applications to avoid exposure
during maintenance, repair and demolition. As the materials weather, erode, break
or are cut by power tools, asbestos fibers are released into the air, soil and water,
where they become a source of community-wide exposure. Policies, regulations and practices
should safeguard workers engaged in the removal of asbestos-containing structures
and the handling of the resulting waste material, via schemes for specialized training
and licensing
19)
.
Secondary and tertiary prevention are also assuming vital importance in industrialized
countries. In particular, workers exposed to asbestos in current or past occupations
should be identified; registered and followed-up for health monitoring and surveillance
19)
. The unfolding ARD epidemic in these countries poses costly challenges in the arenas
of basic and clinical medicine. In medical practice, such challenges include the development
of biomarkers for the early detection of mesothelioma, as well as effective modalities
for its treatment. It is imperative to design and implement just compensation schemes
for people with ARDs and their families. Industrialized countries should provide assistance
to industrializing countries on issues related to asbestos and ARDs.
In countries having banned asbestos, as well as in countries still using asbestos,
a large number of workers remain at high risk of developing ARDs from past exposure,
in particular lung cancers and mesotheliomas. Most of these previously exposed people
remain in the general population without any ongoing health monitoring. The Collegium
recommends that countries develop strategies for identifying their previously and
currently asbestos-exposed workers, to quantify their exposure, and register them,
subsequently developing methods for continuous health surveillance and secondary prevention
20)
In addition to workers there should be monitoring of household members of workers
if they bring asbestos into their homes.
International Co-operation
The accumulated wealth of experience and technologies in industrialized countries
should be shared internationally through global campaigns to eliminate ARDs. Industrialized
countries have experience in primary, secondary and tertiary prevention, with the
strengths of any given country depending on its particular stage in their epidemic
of ARDs. The knowledge and technological developments that have emerged from these
experiences could be of great benefit to countries in which asbestos continues to
be used. The Statement
21)
on asbestos by the International Commission on Occupational Health (ICOH) describes
a broad range of activities at each of the three levels of prevention. For optimum
effect, the resources of industrialized countries should be combined and distributed
in a manner tailored to the needs of the beneficiaries. Scientific expertise is an
important resource to be shared, including capacity building and surveillance of ARDs.
Given the wide range of problems encountered at the global level, the development
of regional initiatives should be particularly valuable
22)
.
Industrialized countries that have already gone through the transition to an asbestos
ban have learned lessons and acquired know-how and capacity (i.e., "soft" technology)
that could be of great value if deployed in industrializing countries embarking on
the transition. Collaboration between industrialized and industrializing countries
can be led by international organizations, the scientific community and/or grass roots
NGOs, and should involve practitioners, researchers, administrators and civil society.
For example, through fora such as international workshops or conferences, countries
with bans in place can outline how they implemented a ban and provide practical guidance
on how countries currently using asbestos can move towards a ban.
Conclusion-The Need for a Global Health Approach
Asbestos and ARDs have emerged as global health issues. All countries with a history
of asbestos use are experiencing an epidemic of ARDs, with the stage of the epidemic
being a function of a country's past asbestos use, whether and when it implemented
a ban, and, if no ban is in place, at what levels it continues to use the material.
Gaps in human capital and technology available to countries warrant international
cooperation. The expansion of national bans in industrializing countries and reducing
the burden of ARDs in industrialized countries are the short-term targets. Given that
ARDs are 100% preventable, zero new cases of ARDs should be the ultimate goal for
both industrializing and industrialized countries. The pandemic of ARDs is an urgent
international priority for action by public health workers.