Good afternoon, one and all. I guess this is the last session for the day, so we're pleased that you're here. My name is Arthur Frank. I didn't have far to come. I'm a professor here at Drexel University and live, it was a train ride in for me, not long distance travel. But we're pleased that you're here this afternoon and I'll try to share some thoughts with you over what for me has been a bit more than 50 years of working in the area of what does asbestos do to people. And so it's a subject that people think is very much behind us, but unfortunately it is not and it's certainly still a major issue around the world. So why don't we just sort of get started with this. And I'm going to talk about what's the big deal about asbestos? Why are we still concerned? And as a proper statement, I regularly participate in medical legal activities, primarily for plaintiffs, but occasionally I get to do some even more interesting things like asbestos criminal cases for the Environmental Protection Agency. People are still being asked to rip out asbestos in very unsavory and inappropriate conditions, so I get to do that. So we're going to start with this. This is a piece of tissue that was taken at an autopsy done in the year 1899. Dr. Montague Murray, working out of the London Hospital in the UK, was examining a gentleman in his mid-30s who told him that he and nine mates, 10 young men less than 10 years earlier, had started working in an asbestos textile factory at the east end of London. And he told Dr. Murray that he was the 10th and last to die, and they all had died of respiratory insufficiency. They didn't use that term, of course, but they had trouble breathing. And this young man, I think he was 36, passed away. Dr. Montague Murray did an autopsy, and what we have here in that piece of tissue is what we now know to be an asbestos body, sometimes called a ferruginous body, but most often having an asbestos core, primarily forming on amphiboles, rarely, but occasionally on chrysotile. And so he didn't know what to make of it, and he called it a curious body. And we'll hear a little bit more about how this played into Dr. Murray's thinking in a minute. We still, these numbers are a little bit old. We're not at about 2 million tons. It's still about a million and a half tons a year of asbestos that are being used. Canada used to be the largest supplier. Russia is now the largest supplier. The other major countries, the other really major places would be Kazakhstan and China. The Canadians shut down their mine. The Finns have shut down their mine. Even the Colombians who had a chrysotile mine have shut it down, so that the world's asbestos is coming from rather unsavory places. And half of it is used between India and China alone. The rest of the world uses the other half. Brazil has sort of dropped out of that, but as you see, other countries are still making use of it. Most of it goes into asbestos cement, which is used for construction materials. It's cheap. But in some countries, they have found that there are appropriate substitutes. For example, you don't really need to make asbestos cement material. You can substitute for the asbestos weeds out of the jungle. They've done that in some of Southeast Asia, where they literally just chop up plant material and use that as a binder. And other countries have gotten it to tile making, which allows them to get away from asbestos. But having done work in both China and India, it's still a major product in both of those countries. The World Health Organization has told us that there is still about 250,000 asbestos-related deaths every year. We have about 40,000 of those deaths here in the United States. We'll talk in a little bit what the diseases are that cause those deaths. And about 70 countries in the world have now totally banned the use of asbestos. The first country that shut down its use and had a mine were the Finns. The Brazilians shut down their mine when they were still mining it. A few years ago in Colombia, where they had a mine, they first wanted to keep the mine open because there's always pressure from workers not to be out of work, but they finally saw the light when it was suggested to them that, you know, you may want to stop using it here in Colombia, but do you really want to sell a product around the world that's going to be killing other people? Unfortunately, the only advanced country in the world, the only major industrialized country that has not banned asbestos is the United States of America. It is still a legal product here. Fortunately, the peak of asbestos use was 1973, 803,000 tons. Right now, we only import three or four hundred tons a year. It's mostly used in the chloroalkali industry to make chlorine and sodium hydroxide. But other products containing asbestos, you can still buy asbestos breaks, even though we don't make them here, but they can come in from other countries. Roofing materials still have it, and then there are other issues of contaminated products, wall board from other countries, and certainly talcum powders from many parts of the world that would be contaminated with asbestos. So a very logical question is, if you stop using asbestos, do you stop disease? And clearly, the answer is yes. How do we know that? Because the first country to ban it was Iceland. There was not a lot of epidemiology going on there, but the Swedes were the next country. They banned it over 30 years ago, and if you look at the rates of mesotheliomas, which is the best disease to look at because it's most related to exposure to asbestos, you get into trouble if you're looking at things like lung cancer, which have, you know, maybe two dozen causes, even in workplaces, many of them. So the Swedes have shown that the rate of mesothelioma is coming way down. In some countries, they don't report a lot of them. There is worldwide reporting that some colleagues at the ICOH and other organizations have looked at, but we know, and we don't have a lot of data on those diseases that if you stop exposure, you stop disease. We've seen that a bit with cigarette smoking in this country, where males have given up smoking more than women, and the rates of lung cancer in males are going down. Vinyl chloride, when it was controlled at the workplace, we've stopped seeing angiosarcomas of the liver. So we do know that if you stop hazardous exposures, you can stop disease. The principle does hold. An old public health adage, of course, is that the absence of data does not mean the absence of disease. I've done work in India, and for many, many years the government agency there, the NIOH, which was responsible for collecting data on mesotheliomas, had never recorded a single case of mesothelioma. In one year alone, having talked to a surgeon from the Tata Cancer Hospital in Mumbai, he shared with me that that year alone he had taken care of 32 mesothelioma cases. So again, the absence of disease, or the absence of data doesn't mean the absence of disease. Russia, which is now the world's largest supplier of asbestos, they have stopped counting mesotheliomas. They just say, we're not counting them anymore, so if you look at their data, they don't have any mesotheliomas. But we know that it's out there. Now there are still, in this day and age, some very legitimate scientific questions and controversies about asbestos. There's still the controversy over fiber toxicity. Which of the fibers can cause more or less disease? We know that asbestos is a term that refers to six naturally occurring minerals. Nobody makes asbestos in a factory, of course. It's mined. Two amphiboles of the five are commercially important, chrysotillite and amasite. But 95 or so percent of all the world's asbestos use, including in this country, has been the chrysotillite variety or the white asbestos. And there's still arguments over the relative toxicity of the fiber. And it depends on what system you look at. Some people claim the amphiboles are more mesotheliogenic. Some people say most mesotheliomas come from chrysotillite. In cell culture systems that I've worked on, chrysotillite has actually been more toxic to certain cells than amphiboles. The other issue is fiber size. There's this argument that only fibers above five microns are hazardous. The original fiber size hypothesis scientist, which was Merle Stanton at the National Cancer Institute, he reported as he talked about fiber size that even fibers less than five microns are hazardous. Les Stainer has reported that in the scientific literature. And then there's the question of fiber synergy. Some people have written that if you mix two fiber types together and in a lot of workplaces that occurs, there's a synergy between the two fiber types, the amphiboles and chrysotile. However, there are a lot of contrived controversies. The so-called safety of chrysotile. And anybody who wants to think that chrysotile is the safe asbestos, hopefully by the end of this hour you'll have been debunked of that theory. The issue of biopersistence. This has been something cooked up by the asbestos industry saying that chrysotile doesn't last in the lung. Therefore, it's not causing disease. While they're right, it doesn't last in the lung. It has a half-life of about 90 days compared to amphiboles of two to three years. But what happens to it? Well, some of it does get dissolved in the lung. We know that. The fibers get broken down and dissolved. But it is the fiber type that is most easily moved to the pleura. And in at least four studies, one in France, two in the United States, one in Japan, they've shown that 80% of all cases had only short chrysotile fibers in the pleura. So when you're looking at this issue of biopersistence, sure, it leaves the lung, but where does it go? It goes everywhere else in the body. It can even cross the placenta. We know that because stillbirths have been shown to have asbestos in the stillborn babies, which has crossed through the mother's placenta. So the fact that it is a very movable and transportable material is clear from that. You also find it in other tissues that we're becoming more and more concerned about, GI tract cancers, kidney cancers, and such. There's also the argument about controlled use. Controlled use is a fallacy. There was a study done in Canada which has very strict limits on use of asbestos and how workplaces should be looked at. They looked at 10 workplaces. Nine of them failed any sort of controlled use idea. So when you're talking about, and I've seen conditions in places like India and like China and in other parts of the world there is no such thing as controlled use. And then there's this specious argument that I've heard in India. I've been going there multiple times a year for the last 20 years. So I've heard a lot of things there. They talk about genetic variability. The asbestos industry claims Indians don't get mesothelioma because they're genetically different than western peoples. They sort of ignore the fact that we share 99.99% of our genes and there's really no genetic variability that's going to protect you against mesothelioma. So there are these issues that one comes across and there are other issues that we could talk about, but a lot of contrived controversy. An industry that is fighting for its economic life, not because they're using it anymore, because they're still getting hit with thousands and thousands of lawsuits every year. So Dr. Murray, he did the autopsy in 1899, but in 1906 he wrote, one hears generally speaking that considerable trouble is now taken to prevent the inhalation of dust. And so the disease is not so likely to occur as heretofore. He didn't get it right. Because as we stand here today in 2023, this is the spectrum of asbestos-related disease. I break them down into two groups. The nonmalignant diseases, asbestos warts, pretty rare, not a big deal. Benign asbestotic pleural effusions, that scares the heck out of clinicians because you're dealing with a bloody effusion. You're sure there's a cancer in there, but you can't find it. I mean, I've had patients with two benign asbestotic pleural effusions who end up with a peritoneal mesothelioma thereafter, for example. And then asbestosis. We rarely see cases of truly disabling asbestosis anymore. That's because when regulations came into play starting in 1971 with OSHA, it did change the exposures for a lot of people. So we don't see many asbestotics anymore. And most of the ones we see had exposures before that. But I still see several such legal cases every year. But in some groups like asbestos insulators, 10% of them will die of asbestosis, which is thought of as a benign disease, but it's not so benign if it kills you. On the other hand, we have a whole series of these malignant changes. Lung cancer being the major one. Mesotheliomas of the pleura, peritoneum, pericardial, and in males, of course, the rare testicular mesothelioma. GI tract cancers are being seen, and the literature is growing on that. Esophageal stomach, colorectal cancers, even small bowel cancers. An extremely rare tumor. There's any number of papers now on small bowel tumors following exposure to asbestos. Laryngeal cancer is well accepted, as is ovarian cancer in women. But there's more and more data on oropharyngeal cancers and kidney cancers. I mean, even an asbestos apologist who worked for the asbestos industry back in the 60s when he did a mortality study of former asbestos workers for a company was delighted to say he only had one mesothelioma, but he also reported that he had an excess of kidney cancers. And this was back in the 60s. And Selikoff was reporting that as well. Asbestos tends to come from these open pit mines. There's some underground mining, but this is the town of Asbestos, Quebec. The big town in Russia is Asbest, Russia. You know, the town of Asbestos has gotten a bad name, so they've given it some new sort of pleasant-sounding name. I've not been to Asbestos, but I've been up and seen Thedford Mines, the other place in Quebec where they did a lot of mining. But this is how it comes out of the ground. You can identify it in the lab. This is polarized light. You can use scanning electron microscopy. Here's a chrysotile fiber with its fibrils. It's like your clothesline rope that's, you know, woven together. And this does break down to a certain extent in the lung, but it does break down and migrate. And you can do transmission and figure out what kind of asbestos you've got. And then you can fingerprint individual fibers. You'll notice here there's very little iron in this one, so it's certainly not one of the amphiboles. This, again, would be the fingerprint of chrysotile. This is a better-looking asbestos body. It's an iron and protein matrix that covers somewhat larger asbestos fibers. We think it's the way the body is trying to neutralize the fibers and their biological effect. For every one of these, there are probably hundreds, if not thousands, of smaller fibers that are uncoated in anybody's lungs. And I hate to break this to you. Everybody in this room, you've all got some asbestos in your lung. It's a ubiquitous material. It's been followed looking at the ice cores in the Arctic, so you can drill down and you can actually see asbestos started being used seriously around 1850. It really took off in the 1930s, and especially in the 1940s with shipbuilding. And you can see over the years as it rises in terms of the layers in the ice core. But it's found everywhere. You know, you walk around the streets of Philadelphia and you're going to get a little bit of asbestos. That said, if you live a whole life in an urban setting, in a lifetime, 70 years, you might take in three to four million fibers over 70 years. You can get that much in one day at work if the levels are high enough. This is what the lung tissue would look like with some fibrotic changes. It's what makes the transfer of oxygen hard from the blood vessels or into the blood vessels from the alveoli. So this is typically what it might look like microscopically. Not the best x-ray, but this is some fibrotic changes down here. Asbestos changes typically start at the base and work their way up. It's characterized, of course, by irregular opacities, whereas coal dust and silica dust start in the upper lobes and work down, and they're characterized by rounded opacities. But again, just looking at an x-ray, you can't make the diagnosis because other things will look like this. Talc without asbestos is a pneumoconiosis-producing dust. It'll still give you talcosis, but it won't give you cancer, and it would look the same as exposure to asbestos. This is not a malignancy. This is a lung section. This was a patient many years ago, a Canadian chrysotile minor. He was about 42 or 43. He'd come into the hospital for a decortication. As you see, he's got this huge, massively thickened, but benign pleura. He had one side done as a decortication. While he was recuperating before the other side was to be done, of course, it's never a good idea to have to be in the hospital. He got a hospital-acquired pneumonia, didn't have enough lung function, died, which is how he managed to get an autopsy, and this is what his lung tissue looked like, hepatocytes lung with a big, thick pleura encasing it that's not malignant. The first cases of lung cancer was suggested in this country in 1935 by Lynch and Smith. They were taking care of workers at a textile plant in South Carolina, and they just remarked that there were more lung cancers than they were used to seeing in the population. This was before smoking became a big deal, but they noted that. By 1942, Wilhelm Euper, in his book, Occupational Tumors and Allied Diseases, wrote that he considered asbestos to be a carcinogen for the lung. It was actually in 1942 that in Germany, it was the first country that, it was even during the war, compensated lung cancer cases due to asbestos, and then we had the first real epidemiology by Sir Richard Dahl published in 1955. He expected 4% of the workers to die of lung cancer. Instead, he found that 17% did over a 20-year period. Asbestos causes the same kinds of lung cancers in roughly the same proportions as cigarette smoking, your adenos, your squamous cell, and your oat cell. It does, however, migrate some of the cancers from the usual upper lobes and central location to the lower lobes and the periphery. Sometimes these cancers get hidden for a while behind asbestosis. Another point, you do not need underlying asbestosis to say that it's an asbestos-related lung cancer. That's another fallacy that's out there in the literature. And sometimes if it's very peripheral like this, and you see a growth, you're not sure you're dealing with a mesothelioma or a lung cancer. This is a field of tobacco. I'd spent a number of years in Kentucky. It was second major producing state for this product. It's a little hard to see, but there's some houses back here, and I lived in this housing development. I passed this field every day, and one day I finally got out and took a picture just to have it. And interestingly, they've stopped growing tobacco there. They built a health clinic. So first they grow the stuff to make you sick, and then they put the health clinic up. And why am I showing you tobacco? Because of this data. If you don't smoke and you don't work with asbestos, the likelihood of getting lung cancer is very small. Some people do get it. There are other things that cause it. But, you know, 11 cases per 100,000 or basic ratio of one is pretty low. If you work with asbestos but don't smoke, you get a five times increased risk of developing lung cancer. If you're a smoker, the average one-pack-a-day smoker doesn't work with asbestos, about a 10 or 11-fold increased risk. Like everything else pretty much in human health, you know, the Paracelsus statement of the dose makes the poison half a pack a day, less cancer, two packs a day, more cancer. But it's not additive five plus ten if you work with asbestos and smoke. Solikov showed this years ago that it was multiplicative. The Surgeon General's report in 1965 also documented that. Newer data shows it in some studies to be multiplicative, some to be super additive. It varies, but clearly together you get a much worse picture than if you have one or the other. So it's imperative. Anybody that works with asbestos or is around it really needs to be cautioned not to smoke. This is the typical presentation of a mesothelioma. The first mesotheliomas made it into the literature as far back as the 1930s at Mount Sinai in New York. One of the pulmonary docs there, Dr. Rabin, reported a single case in 1931, looked at the literature and he was able to find I think three other cases in the literature. A local pathologist, Dr. Otani, didn't think there was even a disease called mesothelioma. He thought it was a variant of a fibrosarcoma. So for the next 30 years they had this friendly discussion between the two of them, is there mesotheliomas? And what they did is they looked every decade, 100,000 admissions a year, every decade, a million admissions. In the 1930s, 40s and 50s they had one case of mesothelioma in each of those decades. So the background rate seemed to be about one in a million. The current background rate in the United States is about 10 per million. So that's a remarkable change in only about 50 or 60 years. And in some communities it's far higher than that. There were reports of mesotheliomas not only in 31, 38, in the 40s, in a plumber, but it was in 1960 that Dr. Wagner in South Africa reported 33 cases in a four-year period all from the Northwest Cape province of South Africa where there was an asbestos mine. So everybody said, and this was without an epidemiological study, asbestos causes mesothelioma. So the other changes you see in the pleura are calcified plaques. That's what we have here. Calcified diaphragms and, you know, that would look different on x-ray. You'd just see a thick white line there. This is what the chest of a mesothelioma patient might look like totally encasing the lung. And here's a peritoneal mesothelioma. It comes in two flavors, if you will. These little nodules are sometimes masses of tissue surrounding the bowel. But when I started in this business over 50 years ago, the average lifespan was six to 12 months. Now with the newer treatments, it's more like 18 months to three years, and some patients go a bit longer. Some of the new immunotherapies seem to work pretty well, but it's still a horrible and deadly disease. I've told you about Dr. Rabin, and then I've told you about Dr. Wagner. So Dr. Wagner, for his troubles, got kicked out of South Africa. The asbestos industry felt threatened. So he ended up moving to Great Britain and decided to do some more study on asbestos. So what he did was he gave it to some animals. And as you see here, all the different fiber types gave the animals both lung cancers and mesotheliomas. And interestingly, some people say chrysotilite is the most toxic. He got four mesotheliomas. Canadian chrysotile, he got four mesotheliomas. So others have shown that chrysotile, in all of its flavors and varieties, even some that are said to be amphibole-free, because some people claim there's some tremolite in some of these. That's another issue for another day. He got both lung cancers and mesotheliomas. So the next logical question is, well, how much asbestos does it take? And he looked at that, too. He showed that with one day of exposure, one day, he got two lung cancers and two mesotheliomas. And it's not a perfect curve, if you will, but basically a dose-response curve. The longer he gave it, and here not exactly perfect, but longer doses, greater doses gave more disease. So you say, all right, that's a bunch of animals. What about people? It's very hard to find individuals with one day of exposure to asbestos, yet there are at least five such cases that I'm aware of. One was a pair of sisters. It was during World War II. They were both college students. They came home on summer break from college, decided to go work in a shipyard, help out the war effort. They found it so dusty and dirty that they left after one day. Both of them got mesotheliomas. That sort of leads you to think, maybe there's a genetic component to this, which I clearly believe there is. There are other reported cases, one here from Pennsylvania in the 1960s of a day of exposure, one in Australia, and Morris Greenberg in England reported on somebody cutting asbestos boards outside to build sheds in his backyard, who 30 years later came down with a mesothelioma. So it's a very potent carcinogen in some people. You know, cigarettes, you know, we think of it giving us a lot of cancer, but you got to smoke a lot and for a long time, and even then, only 10% of people get lung cancer. So carcinogens sort of do vary in terms of how much it takes to give you disease. We don't have one day of smoking, or sorry, of asbestos in causing lung cancer in humans, but we have this data. This is an asbestos plant in Patterson, New Jersey that Dr. Solakov studied. And you see that working a month or less in humans doubled your risk of lung cancer. And by the time you worked at this factory for two years, you had a seven-fold increased risk of developing lung cancer. So again, very short exposures still lead to excess disease. The next logical question is what about latency? When does the disease occur? If I sprinkled you all with asbestos today, would you get sick next week, next year, next month? No. What we know is that you start to see disease at about 10 years. Some rare cases with very high exposures, I've heard of some of these cases in India, for example, three and four years of exposure, people come down with mesotheliomas. So you'll be able to read that in Solakov's book from the 1970s. It starts going up after about 20 years and it peaks for all the diseases, be it lung cancer or mesotheliomas or deaths from asbestosis at about 35, 40, 45 years. So it's got a long latency. And that tells us something we need to worry about. Even if we banned asbestos today in the United States, we'd still have cancers for 50 and 60 years down the road. I've seen cases of somebody who started working at 18, stopped and retired at 60, and got their cancers in their 90s. So very long latencies for some of these conditions. So the mechanism by which asbestos question? There was no PPE in those data. Nominally with OSHA, the military didn't even pick up on PPE after that. I mean, I still see a lot of individuals, for example, who served in the Navy who in the 70s and in other settings in the 80s, you know, you finally hear about PPE sort of in the late 80s, early 90s is when you start hearing about factories putting dust masks on people, not proper respirators. So the mechanism is unclear. But where do you get exposed? So let's talk about that. Asbestos mining and milling, making things out of asbestos, insulation installers, people in construction in general, ship building and ship repair, maintenance, power plants, railroads, but also household contacts. This has been shown at least as far back as 1960. Wagner had a case of household contact. He also had a case of environmental exposure. Molly Newhouse in 65 had a number of cases of household contact and environmental exposures living within half a mile of a facility. We've seen that in, you know, Cairo, Egypt and in Japan and here in the United States. Demolition and waste disposal, you know, we just had this major fire in Indiana at a plastics warehouse. I mean, yeah, that plastic garbage that was burning and putting out stuff had all kinds of nasty things in it. But there was also a lot of asbestos in that plant. And we know that firefighters, for example, have an excess of mesothelioma as they go in and get exposed. So every time we have a hurricane or a tornado or typhoon in other parts of the world, I've done a study in Sri Lanka where cleanup workers after the tsunami were among the highest group of individuals to develop asbestosis from cleanup work. So we have to worry about those things. This is an asbestos insulator. He and his brothers, union brothers, there were no women in those days in the union. He's putting asbestos cement on a pipe. Not surprisingly, he and others would come down with disease. They also started using sprayed mineral fiber, material called limpet. It was first used in Great Britain in 1932, brought to this country in 1935. And by 1970, it was in 71 that asbestos spraying was stopped in this country because of the next picture I'll show you. But half of all large multistory buildings were being fireproofed with sprayed on asbestos. I'm sure many of you recognize this. One of the two World Trade Center towers, the other one's still being built. Forty floors of the first tower were sprayed with asbestos. They stopped it. Other material was used above it and in the second tower. And here we have an asbestos insulator. And that's what he's doing. He's spraying asbestos onto the steel beams. And some of it even stayed on the beam. And what happened to the rest of it? This is what the laborer had to come by and sweep up. This is what the electrician got exposed to. This is what the brick mason got exposed to. So basically, all construction workers developed disease. What's going on now? We're moving the prisoners out of death row. How come? They found asbestos in the ceiling. And, you know, you think I've done at least two cases that I've helped out prisoners because they were being asked. In one case, a prison in Kentucky and a women's prison in Alaska, of all places, they were having the prisoners rip out asbestos. No protection, whatever. So you'd have to go to a federal judge and get stuff like that stopped. And prisoners don't come under OSHA. Now the prison guards do, but the prisoners don't. And so all kinds of strange things have happened with regard to that. So here's an asbestos worker dumping out a bag of asbestos cement. He's not wearing a proper respirator. That's a dust mask that really isn't going to do it. We have this gentleman in the back. He's what we might call a bystander. He could be, what, an electrician, a plumber, a carpenter. He's getting exposed as well. This was a simple engineering fix. Instead of using a paper bag, if you put the asbestos cement in a plastic bag, you could put the water right in the bag, mix it up in the bag, and dump it out wet so there wasn't all this dust. But this is what worksites looked like. Here's a fellow who belonged to the painter's union. They would go in and fill in the cracks in drywall. They would use joint compound, which at times contained up to 20% asbestos. Painters have come down with mesotheliomas from sanding joint compound. And this is what the hold of a ship looks like. You know, all this gray stuff, the blocks, the bricks here, all of this is all asbestos. A typical destroyer would have 40 tons of asbestos. An aircraft carrier might have 100 tons of asbestos on it, a serious problem. And this was shown by Peter Harries at the Devonport Dockyard in England. He looked at sprayers and laggers who were the main users of asbestos. And of the 156 cases of disabling asbestosis, not every asbestotic in a 10-year period, a third of them were in sprayers and laggers. But if you look at the 55 mesotheliomas, two of them were in the direct handling trades, and many of the others were bystanders in the same workplace. But I have to tell you, they measured up to 1,000 fibers per cc in the holds of some ships in some settings. So we're talking about enormous doses. About a million people in this country did automotive repair. That's a whole big area of controversy. Brakes, with chrysotile brakes, don't cause meso, yet I've seen hundreds of such cases in my career. Don't believe that. And you may notice he's got a testing device here. And I'm not going to tell you that every one of these fibers is an asbestos fiber, but there certainly are raw asbestos fibers in dust that would have entered his breathing zone. So we've talked about occupational exposures. Let's spend a little bit on community, consumer product, and general environmental exposure. What disease is this? I showed you a picture earlier. Typical appearance of a mesothelioma. A gentleman, 28 years old, presents with plural discomfort in November. Nobody's thinking he's got cancer, but finally by March, months later, they go in and they take some tissue, and oh my gosh, a 29-year-old has a mesothelioma. Lung biopsy showed that he had chrysotile and amicide fibers in his lungs, no crucidolite. He died just before his 30th birthday. He had no employment with asbestos. He had gone to college, had been an accounting major, had been a bookkeeper, but geographic history told us he was born on Ross Street in Brooklyn, later lived on Wilson Street. This was asbestos found in his lung. And here is Ross Street and Wilson Street, and here we have the Brooklyn Naval Shipyard. He got his exposure at birth in his neighborhood at the age of zero, and 30 years later died of his mesothelioma. Not more than about a half hour from where we are sitting right now is Ambler, Pennsylvania, the asbestos capital of the world at one point. There are 90-foot high, 30-meter high piles of asbestos that the local kids play on. So it's now covered with grass, but it's still all there. These are the waste materials that got tossed out of the factories. In the same London hospital that Montague Murray worked at, Molly Newhouse reported, and I gave you some of this data, 76 cases of mesothelioma in a 55-year period, roughly half in industrial workers, nine among relatives, 11 who lived within half a mile. The 25 no known exposures, this was a retrospective review of records, I assure you nobody in 1910 or 1920 was asking about a history of exposure to asbestos. In Finland, County A where they had an asbestos mine, 500 or so calcified plaques out of 6,300 x-rays. County B, no mine, zero, zero calcified pleural plaques in 7,100 x-rays. So environmental exposure can cause disease. Here's Washington, D.C. Here's Bethesda. I spent some years there studying asbestos at the NIH. And just cut off here is Rockville, Maryland. Why is it called Rockville? Because they mined rocks. They had a big quarry. And those veins running through the rock, those are chrysotile asbestos. Not enough to be commercially important. It was only about 3 or 4%. You need something in the teens to be commercially useful. But what did they use this material for? Well, secondary roads got sprayed with asbestos. So I'm not, you know, this isn't so bad, but I'm not sure I want to be in that vehicle. They also used it on playgrounds, parking lots. And then when they finally covered them over, before they covered them over, they sprayed them with oil. That was not a great idea. There were many products, 3 to 5,000 different products you could go out to the store and buy. Here was leak-proof asbestos liquid roof coating. You can see how old it is because there's no zip codes and they don't use the shortened abbreviations that we use today for the cities. So you could go out and buy this. This was one of our lab techs that we did put in a proper respirator. It's a little hard to read, but it's a coat that had 72% processed wool, 20% nylon, 8% asbestos. Why would anybody import that? Because pure wool carried a high tariff. Wool blends carried a low tariff. So you want to save money, you import something like asbestos-containing wool. And again, I'm not going to tell you that all of these are asbestos fibers, but there certainly are some in there if you brush the coat. School kids were not exempt. The asbestos head, they would use the waste tailings from some asbestos factories to make a papier-mache-like material and kids at schools would get their exposure. And then where else might you get exposed? Well, your Christmas decorations. You would sprinkle asbestos on your trees so you'd have a fireproof and safe Christmas. Then there was this genius of an idea, putting asbestos filter tips on cigarettes, a brand in the early 1950s. So think of it, you could get a puff of your carcinogen with every puff of your carcinogen. And then as physicians, we prescribe medications all the time, right? And until the FDA banned it, medications and a lot of other things, beer, good French wine, were all filtered through asbestos. And so there's the asbestos that you'd find at the bottom of your vials of medication that we'd be injecting IV and putting IM and putting sub-Q into our patients. This is where I trained at Mount Sinai. That's the hospital in the background. There was an old apartment building here that they were knocking down. They built a new research building on top of the parking, well first it was a parking lot, then they built a new research building. They didn't take the asbestos out first. Now you have to if it's more than 160 square feet. And so it's blowing all over the city, right? This was in the basement of the hospital. I actually would use that as a shortcut between my office and labs. And here's the asbestos piping, you know, coming off. And they finally decided they needed to remove this and replace it. So they threw it on the back of a truck, uncovered, drive down to the end of the block. That's Fifth Avenue in the heart of New York City. That's Central Park. It had to make a left turn and it was headed to the waste dump blowing asbestos out as it drove down Fifth Avenue in New York City. And of course it was a smallish truck. They couldn't get all of it on in one trip so they would store it under the main air intake for the hospital. This was in our backyard at Mount Sinai. The engineering staff didn't know and, you know, somebody got these pictures and shared that with us. So I moved on to other universities. This was when I was at the University of Kentucky. We had the same problem. We had 400 buildings with asbestos in it. I was sort of on an asbestos task force on how do we get the stuff out of buildings. And we had students, you know, tie their bikes up. Ironically, it was probably an ironing board with an asbestos pad on it. But now we're talking about the 80s. This is what the guys had to dress in to take out the asbestos, their moon suits with their proper respirators. They would have to use HEPA filters when filtering out material. They'd put it in plastic bags. They would use water to keep the dust down. Then they'd filter the water because my water supply here becomes your drinking water downstream. So you want to take the asbestos out and not give it to somebody else. You go and do air measurements in the work areas. So you want to be sure you're not making it worse than before you started. And then you throw the bags of asbestos and drums, which you bury in an appropriate hazardous waste landfill. So times have changed. And I suspect this is why we don't see as much asbestosis. Unfortunately, we still see a fair amount of cancer. What about the rest of the world? We're in a one-world marketplace. Now globe out. We have to produce to the same high standards right around the globe. What about health and safety standards? Ah, that depends on what part of the world you work in. So here's a factory in China. These are automotive brakes. I've also seen them make locomotive brakes very much bigger. The same factory. And so they've taken these shiny things that wouldn't stop your car, grinding them. So it's now got a surface that'll stop your car. Those are cotton gauze masks those ladies are wearing. Not going to keep the fibers out. This was the textile area of the plant. Same problem. There's a whole story here. The gentleman in the background was the plant physician in Shenyang in China. One of three asbestos factories they looked at. One in Shenyang, two in the city of Qingdao. The gentleman in the foreground was the dean of the School of Public Health in Beijing. My host on this trip. The lady in the middle, this was in, I can tell you, 1993. 1991, I'd been to this factory. It was a six-day work week. Until I got back two years later, it was a five-day work week. but she was coming in on a Saturday for some overtime, and she didn't have anybody to look after her three-year-old daughter. So it's bring your daughter to work day at the asbestos factory, until I educated them about that's probably not a good idea to bring your kid to this factory. So you learn all kinds of interesting things and can share some knowledge. Well it's not just places like China. This was the major asbestos factory in Israel. It's in the northern corner of Israel, not all that far from the Lebanese border. It was primarily using chrysotlite asbestos. And there you see what was ending up in the ground outside the factory, and here's the Mediterranean, and there's actually about a 200-foot swath of chrysotile going out into the Mediterranean here. This is in Nahariya. And what did they want to do? They wanted just to cover this over with a children's playground and play area, which we suggested was probably not a good idea to put kitties out there. Legal issues, I've told you I do some medical legal work. People ask why I do it. It's still one way to have some influence on this. And we know that in the world of public health, legal actions can bring about changes. We've seen that with things like COVID and lots of other things. You have to go to court to get some things done. Asbestos in the law, we've learned about workers' comp in this country. We uniquely, not uniquely, but pretty much, you don't see this in a lot of the rest of the world, and I've testified in courts in other countries on a rare occasion. Third-party suits is where most of the action's at. What did they know and when did they know it? Well, they knew as far back as 1930 when Meriwether and Price, an occupational physician and an industrial hygienist, wrote an 85-page essay on the hazards of asbestos and they said use a safer substitute. If you can't do that, put good ventilation in. If you can't do that, put the workers in a respirator. And most importantly, which we forget all the time, when you have workers working with hazardous materials, as they wrote, give the worker a sane appreciation of the risk. We don't do enough of that. We don't educate workers about the hazards of the materials. The Boral case was the first successfully litigated asbestos case. We've seen dozens and dozens of bankruptcies. 1989, Congress, the EPA tried to ban asbestos. The companies took them to court in the Fifth Circuit. The ban got overturned. There's an asbestos bill working its way through Congress. The EPA is putting out another ban. That's going to be fought. Who knows what will happen? You all know what this picture looks like. I showed you the World Trade Center going up. This is the World Trade Center coming down. A lot of the beams still had asbestos on them. What happened to most of the beams that came out of the World Trade Center? They got shipped for recycling. Where did they get shipped to? India and China. And did they ship them without the asbestos? No, they let the Indians and the Chinese take the asbestos off the steel beams. Dust was measured in lower Manhattan. Even though one tower was without asbestos, the other only had 40 floors, the dust in lower Manhattan, after the buildings came down, 4% of the dust, as measured by some people, was asbestos. Households got contaminated. Autos got contaminated. Again, the pile was a horrible place and has its own history. We've got legacies of the past. We still have projected disease and death well into the future from the continued use here and in 140 countries, potentially around the world. Engineering controls are not well developed. Regulatory feasibility just doesn't work. Bans do work. Legal uncharted complexities. We need to remember there's still 25 million tons, 25 million tons in place in buildings here in the United States. So we have to be careful that people take it out safely because they certainly didn't put it in safely. And lastly, the pneumoconiosis, all of them, but all the asbestos diseases are still best treated by prevention. So thank you and I think we've got a few minutes for questions. Or comments. Sir. Yeah. I guess they want us to use the microphones. The average age of the school buildings in the city of Philadelphia are 75 years old or greater. What's your sense of the risk of the kids that still exist and is there a true remediation process that can eliminate the risk? Well, okay. Again, let me just be up front. A number of years ago, not recently, I was hired as a consultant to the Philadelphia School District on the asbestos issue. If you go online, you'll see I've got some online materials. You're right. There's a little over 300 buildings, at least 175 of them have asbestos in them. I do know, I was told, I mean, I didn't go look through the files. I was shown they had all these files, but we keep finding that there's still many, many school buildings that they're finding asbestos in a condition that isn't appropriate for kids. I know of at least two cases of asbestos-related disease in staff. One a teacher, one a custodian. The only place where they've shown that school kids get disease that I'm aware of is out of Libby, Montana, where the whole town of Libby was contaminated by the vermiculite that was contaminated with amphibole fibers from the mine up on the hill just above town where they spread it around ball fields and the running track and people took it to their gardens and put it in their attics. That's where school kids have been shown to ultimately develop disease. Fortunately, mesotheliomas, even though they are the signal tumor for asbestos, are fairly rare, about 3,000, 3,500 a year maybe. I don't like the idea that school kids are getting exposed. I think the risk for them as a collective group is probably low. I worry more about the teachers and custodians. The custodians work with the stuff. We know that even asbestos floretile, if you buff it with a buffer, can give off fibers. In the state of Wisconsin, school teachers are the fourth highest group in terms of getting mesotheliomas. It's clearly a risk to staff. Maybe some of, it's funny, I just wrote a letter, there was an article published just the other day on seeing more and more colon cancers in younger people. I wrote a letter, which isn't going to get published by the journal, it said thank you but no thank you, that maybe somebody ought to look into the asbestos issue and that younger people are being exposed to asbestos and maybe that has something to do with it. It's not just diet and a few other issues. I worry less about the kids, it doesn't mean I don't worry, but I particularly worry about the staff. Jackie. Thank you for a great historical talk. Just a point of clarification with the World Trade Center, 40th floor of the North Tower, up to the 40th floor, but all of the elevator banks. All of the elevator shafts. Both towers. Right. Had asbestos. So there's a lot of controversy, people are saying they should have used asbestos, the towers were to fallen. That's ridiculous. But there was asbestos in both towers, it just wasn't. I didn't mean to say there was no asbestos and all the pipes, I've been in mechanical spaces, I actually got involved with some of the litigation of trying to get the asbestos out of the building. They litigated to try to get the asbestos out of the World Trade Center after they'd had a separate case for the part of authority of New York and New Jersey for other venues which were settled. They then tried to get it out of the World Trade Center, and a federal judge in Newark decided the buildings weren't contaminated, so he threw the lawsuit out. Well, A, were contaminated, and B, all of Lower Manhattan got contaminated, but that's a different story. Hello, Harold Meyer from Denmark. Thanks a lot for a very informative presentation. I was wondering, in Denmark, the occupational physicians tend to forget about the refractory ceramic fibers. Right. They're not that widespread, but they're there, and according to IAC, they have the same effects, but maybe less potent. In the States, are you talking about, are you questioning, are you asking about ceramic fibers, and what's your impression worldwide? I don't think people are taking much notice of it. We know that other fibers can do it. We know in the Anatolian plain of Turkey, fiber zeolites cause mesothelioma. The western slope of Mount Etna, where they mine fluoroetanide, there's mesothelioma, so fiber size seems to be the important thing, not the chemistry, so yes, I would worry about ceramic fibers. I think we should remember and ask about it. But many of them are quite large, and they may not get down into the lung. That's what the difference may be. Sir. Thank you for the talk, Dr. Frank. My question, I'm not sure if you know the answer, but I've had patients come and say, oh, I've scratched my popcorn ceiling a little bit, and been exposed to asbestos, it might not be a month, but it might be over a few hours. Do you know where is the, where is that threshold of saying this is enough, you know? Okay. I've dealt with those kinds of issues. First of all, they ought to have it tested. I'm living in a place now with a popcorn ceiling, okay? About 60% of popcorn ceilings had asbestos, 40% didn't. Mine does not. I mean, I sent it off to a lab I trust, I had it measured, it's sort of a cotton-like material, so I'm living in a place, because if it was asbestos, I would have done something about it. I have gotten calls from lawyers where somebody said, somebody took the floor tile out of their kitchen, and they found out it was asbestos, and they want to sue. And I said, let me do something, no cost, let me speak to them and try to put this in some perspective. And what I would say to somebody, or the situation you've got, was, first of all, let's assume that it's asbestos, but you don't really know, and you really could have it tested, and you know, probably 50 bucks would do it, a simple polarizing light microscopic examination would probably answer that. So if it's negative, it puts them completely at ease. If it's positive, what I would say to them, it's unfortunate that it happened, I wish it hadn't, but the likelihood of you getting diseased from that kind of exposure is not zero, but it's extremely small. And you know, there are many other things you do in life that are going to carry a lot more risk than a few days, or a few hours, or a day or two of ripping up some asbestos. The most recent legal case I did for the EPA, somebody was renovating, 30 guys were renovating an old railroad car, it was so old, the asbestos was mixed with horse hair in the ceiling of the old rail car, and they were just ripping it out, and it was so bad, they had to put fans in there to blow it out so they could see what they were doing, and they had to put lights in there because they couldn't see what it was doing with all the dust. And they came to me and said, do we do medical monitoring? And I said, of course you do, but then we have to sort out, you know, who deserves, because there's not going to ever be enough money to do it right, I mean, everybody should get it for the rest of their lives, but that's the ideal. So you have to make some judgment, and this is where, thank God we're still physicians, we make judgments about things. And there's no cookbook, but sometimes I think I'm doing the greater good by putting somebody at ease that the likelihood of you getting disease, while not zero, is extraordinarily small. I had a case I did for the city, a defense case, where some guy walked into a room, saw dust, left it after 15 seconds, and they don't even know if it was asbestos, but he sued. And I said, even if it was asbestos, the likelihood of him getting disease is about as close to zero as you can get without being zero. You know, he didn't get any money for that. Yes? Hi. Hi, Dr. Frank. So I would start by your comments about controlled use. And so... About what? Controlled use. Oh, okay. And in light of the issues that are going on with silica right now, it's continued to be around, but having products that are high percentage silica, can you comment on the fallacy, I guess, of controlled use of that product, or your perspectives based on your experience? There really is no such thing as controlled use. I mean, to do it properly, you ought to have a vacuum system with HEPA filters. You ought to put people in respirators. You should wet the stuff down. Nobody does... I won't say nobody, but rarely do you see the combination of things. And so, you know, most asbestos work, while there are regulations, and, you know, it's much more expensive to take the asbestos out of the building than it ever costs to put it in. When I was trying to buy a house when I was a colleague in Texas with my friends there, I found a couple of houses that I wanted to buy, and I said, I'll do the search for asbestos. I'll pay for that. You, as the homeowner, will take it out. In one case, the cost to take it out was as much as they wanted me to pay for the house. So most real estate transactions don't require even looking for asbestos, much less doing anything about it. So I don't think there really is anything like controlled use. And that's kind of where I'm going. So we have countries around the world that have now banned the use of asbestos. Do you see that at some point in the future for high silica-containing materials? For what kind of material? For high silica-containing materials. High silica? Yeah, I would hope so, because, I mean, silica, we've learned, is also a carcinogen. We didn't know that for a while. So yes, I would hope so. Again, under better use controls than we have in place now. And bans alone aren't going to do it. There's a whole controversy in the Netherlands right now. There's still a huge amount of asbestos cement roofing materials, and there's no regulations about how to take them off, particularly. So you can't put any more in, but you still may get exposed taking it out. I did a very recent IME in the state of Washington about a worker who worked in sewers repairing pipes and so forth. He was concerned about asbestos exposure. So I got him a high-resolution CT, which was totally normal. So my question is, should he have, what would you recommend for ongoing follow-up to, for further surveillance? Okay, there's two issues. The follow-up I would recommend periodic load, well, first of all, the first thing I'd recommend is to know that the cement pipe he worked on was asbestos cement pipe. I mean, if you knew that, then the answer is yes. The second part, which is not high-resolution CT, but low-resolution CT looking for lung cancer. That's the one thing that you can actually do something about. There's data now showing that if you do ongoing low-resolution CT scan, you can get about 85% of the cases early enough that they're stage one and curable. So low-dose CT every couple of years, every year maybe, depending on when he first got exposed. That's a whole other issue that, it's funny, nobody in the States wants to deal with it. I've recently been involved with some work in Canada with the UK on the issue of asbestos cement water pipe and sewer pipe. It's making it, it's putting it in, and when it breaks or repairing it, taking it out or taking it out and the people who rip it out and put it in waste sites, it's a real problem. How would I try to enforce the testing of those materials? I'm not sure you can enforce testing. What you probably need to do is have him, or if you're up for it, write to the water supply company and say, oh, those are asbestos cement pipes. Just ask. I mean, fortunately, I've asked that here in Philadelphia. I think, we still, believe it or not, in the city of Philadelphia, we still have water pipes that were put in when Benjamin Franklin was alive, which are hollowed out logs that carried water. There still are some of those pipes. We only have a very small amount of asbestos cement water pipe. Mostly we have cast iron and unfortunately some lead pipe, which is a problem, but not asbestos cement. Thank you for an interesting presentation. What would you recommend then for surveillance? You have an employer contact you and say, we want your advice on an asbestos surveillance program. Would a plain chest x-ray, low dose CT, a beavery chest x-ray, annually, or? Well, again, it depends. Since you don't really get changes until 20 years, if somebody's been exposed 20 years or more ago, get a baseline, certainly, I'd probably just start with a regular chest x-ray. If it's equivocal, if you're not sure if there's plural changes or not, then I'd go to low dose CT. If it's a smoker, I certainly would consider doing low dose CTs on an ongoing basis if they've had asbestos and cigarettes because of the lung cancer issue. You're not going to cure or stop asbestosis. Right now, you can't do much about mesos. So what you're really trying to deal with is get ahead of the curve on lung cancers. But I would also remember to do things like stool guaiacs and urinalysis just to look for the kidney cancers that show up. Right. Yes, ma'am. Thank you, Dr. Frank. You had made some comment earlier about your suspicion that there's a genetic susceptibility. Oh, absolutely. Are you aware of any, now that there's this proliferation in genomics and biobanks and all of that, but is there any research potentially looking at those issues? Oh, absolutely. We know, for example, that BAP1 is a gene you can measure, makes you more susceptible. The other thing that it makes you more susceptible to, and just in reading all the charts that I read, if you see somebody with a melanoma, melanomas and mesotheliomas seem to be more common if you have a BAP1 abnormality. So if you've got somebody with a history of melanoma, I'd be asking them, you know, have you had exposure to asbestos, and then I'd put them into some kind of surveillance program. I think as more and more genetic stuff comes online, there'll be more and more genes. And I'm not really reading that literature right now, but I have no doubt that there'll be some genes that'll make you more susceptible. Another controversy right now is there are people claiming if you have certain genetic changes that is the cause of their mesothelioma, not the asbestos. Don't believe it. All right. All right. One more, and then I got a train to catch and get home. Get the microphone, please. Thank you for the nice presentation. Thank you. And just to follow up on the other questions, which is being asked about the low-dose CT for these cases. So suppose someone did get exposed, low exposures, but we are having those employees into the surveillance. How many years later you should look for low-dose CTs? We have been getting them on the chest X-ray, maybe I think every three to five years right now, but... What I do when I write up a medical monitoring program, if it's prior to 20 years, I suggest a baseline five years, 10 years, 15 years. I mean, you can even wait to 10 years and 15 years. The odds of anything showing up at five years is remote. I once testified in a state where they wanted to have people examined every year with a chest X-ray, starting from day one of exposure, and I said, that's unnecessary and unhelpful exposure. So every year or two early on makes no sense. Disease doesn't show up that early. So certainly by 10 years, you get a baseline, 15 years, 20 years, and that's when I might start doing low-dose CT scans every three to five years and then shorten it as they get older, especially if they're both smokers and work with asbestos. This is again where judgment comes into play. I just wrote up, the EPA asked me to do a master surveillance schedule that they could use anywhere in the United States if they had a situation. That's sort of how I approached it. Does it has annual physical exam for these employees? No. No. No. Okay. I mean, again, what is an annual exam going to do for you? I mean, if you bring them in for their chest X-ray, that's a good time to do exams. It's also not bad to pick up on other things, do some routine blood work, do the urinalysis check if they're hypertensive, if they're diabetic. I mean, it's a good thing to do those things. But if you're worried just about the asbestos, annual exams aren't going to teach you anything. The only thing you're going to pick up on an annual exam is you'll hear some crackles in the lung. And by the time you hear those, you're going to see something on X-ray. What about the PFTs? PFTs are rarely, occasionally, but rarely abnormal without a positive chest X-ray. Thank you. Okay. Thank you all.

asbestos

human health

asbestos-related deaths

ban of asbestos

asbestos-related diseases

exposure

lung cancer

mesothelioma

latency period

prevention