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.
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.
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.
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 asbestos1,2,3,4
) 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 countries5
).
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 ARDs6
) 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
asbestosis6, 7
). When the global burden of each type of ARD was considered
separately, the estimated number of deaths per year was 41,000 for ARLC9
) 43,00010
)−59,0007, 9, 11
)
for mesothelioma, and 7,00012
)−24,00013
) 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 exposure7
). 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 bans14
). 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 pipes15, 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 use17
).
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 countries18
) 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 licensing19
).
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 surveillance19
). 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 prevention20
) 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 Statement21
) 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
valuable22
).
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.