Italian Asbestos Conference
On February 15, 2003 a conference entitled: Ban on Asbestos in Europe was held in the north-east of Italy. The location of the meeting was appropriate as Monfalcone, a town of 60,000, has been one of the most important European shipbuilding centres for nearly one hundred years. During the 1930s "Golden Age," the 5,000 strong Monfalcone workforce constructed passenger and cruise ships for international companies. Occupational, domestic and environmental exposure to asbestos used in the shipyards has produced a regional epidemic of asbestos-related disease.
Dr. Claudio Bianchi, the President of the Conference and an eminent Italian asbestos researcher, enlisted the participation of medical specialists and campaigners from Italy, Croatia, Slovenia and the UK in this well-attended event to examine local, national and international asbestos developments. The meeting was held under the auspices of the Italian League Against Cancer, the Regional Government of Friuli Venezia Giulia and the Municipality of Monfalcone. Delegates to the conference included politicians, civil servants, teachers, radiologists, surgeons, oncologists, occupational health doctors, trade unionists and lawyers; asbestos victims and their families were represented by the Association of (Those) Exposed to Asbestos (AEA), the Widows of Asbestos (Monfalcone), the Italian League Against Cancer, the Association of People Suffering from Occupational Diseases and a new Slovenian Asbestos Victims’ Group.
Gianfranco Pizzolitto, the Mayor of Monfalcone, and Alessandra Guerra, the Vice-President of the Region of Friuli Venezia Giulia, welcomed delegates to the Conference Hall, part of the recently renovated Community Gallery of Contemporary Art. Both politicians expressed their support, acknowledging the horrific impact asbestos diseases have had on local workers. Between 1980 and June, 2002, there were 215 cases of pleural mesothelioma in Monfalcone; 83% of those affected were shipyard workers. The annual incidence of pleural mesothelioma amongst male Monfalcone residents is amongst the highest in the country1. Awareness of asbestos issues has been raised by the work of local asbestos victims’ groups. Branches of the Association of (Those) Exposed to Asbestos (AEA) in Monfalcone, Trieste and Padua have thousands of members including shipyard, railway and dock workers2. For over a year, women belonging to the group: Widows of Asbestos (Monfalcone) held weekly protests in the town square. Media coverage of the conference included a television report broadcast on the evening news on February 15 and newspaper articles published on February 16.
|Mayor Gianfranco Pizzolitto (left) with Alessandra Guerra and Claudio Bianchi.|
[photograph by: Mrs. Cristina Bigolin, Studio Photo Atelier.]
The morning session was co-chaired by Laurie Kazan-Allen and Dr. Lorenzo Tomatis. The first presentation: Asbestos in the UK was made by Ms. Kazan-Allen in her capacity as the Editor of the British Asbestos Newsletter. The history of asbestos in the UK contains many landmarks:
warning bells on the hazards of occupational asbestos exposure were sounded by Factory Inspectors from the late 1890s onwards;
Dr. Montague Murray presented the first asbestos-related case to a government enquiry in 1906;
in 1927, the name of "pulmonary asbestosis" was given to the fatal, non-tubercular, diffuse pulmonary fibrosis disease which occurred in asbestos workers;
the first national asbestos regulations were enacted to protect workers by minimising the production of asbestos dust in 1931;
the link between asbestos exposure, smoking and lung cancer was made by Richard Doll in 1955;
the link between mesothelioma and environmental asbestos exposure was confirmed in 1965 by Newhouse and Thompson.
|Laurie Kazan-Allen with Lorenzo Tomatis and Stefano Bianchi.|
[photograph by: Mrs. Cristina Bigolin, Studio Photo Atelier.]
Despite the UK’s head-start in recognizing the dangers of asbestos, medical treatment of asbestos patients in the UK is inadequate and specialist medical cover is patchy. On February 4, 2003, a meeting of the Parliamentary Asbestos Sub-Committee was told:
most UK mesothelioma patients never see a mesothelioma specialist doctor;
mesothelioma patients are frequently told: "there’s nothing we can do for you;"
few patients are offered chemotherapy even though protocols pioneered at St. Barts in London, the US and in Australia have been effective at relieving symptoms and prolonging life;
although surgery to remove the affected lung can prolong life and improve the quality of life, there are only ten thoracic surgeons in the UK who can perform this operation;
these operations are further hindered by a lack of NHS surgical beds, operating time, equipment and nurses;
there is little funding for mesothelioma research in the UK.
Detailing a range of legislation minimising asbestos exposure to workers, consumers and the environment, Ms. Kazan-Allen explained that the major problem in the UK has always been the failure of the authorities to enforce regulations.
Dr. Marko Saric, formerly Director of the Institute of Medical Research and Occupational Health in Zagreb, discussed: Asbestos in Croatia. Four thousand tonnes of asbestos are still being imported to Croatia every year. Despite the lack of a national ban, there has been a shift away from the use of amphiboles: "Amphiboles are no longer an issue, except for tremolite asbestos as an impurity of chrysotile." The issue of whether to ban chrysotile in line with the EU 2005 deadline has not been resolved; Dr F. Valic3 and Dr. Saric are concerned over: "the potential harmfulness of substances being introduced as asbestos substitutes."
|Marko Saric speaking at the morning session|
[photograph by: Mrs. Cristina Bigolin, Studio Photo Atelier.]
Prior to 1960, reports of asbestosis in former Yugoslavia were limited to the extracting industry; a 1960 health survey of the workforce at a Croatian asbestos-cement plant detected asbestosis in 6 workers, all of whom had been employed for over five years. This was the first study to document asbestosis in Croatian factory workers. Subsequently, other cases of asbestosis were diagnosed in the shipbuilding and asbestos processing industry: "From 1990-2000, 317 cases of asbestosis as occupational diseases were reported in Croatia." The most recent mesothelioma study uses data from 1991-1997 supplied by the Croatian Cancer Registry. The tumour incidence was:
"higher in men than in women (1.2 vs. 0.3 per 100,000 respectively). Age-standardized incidence rates (per 100,000) by residence showed a significantly uneven geographical distribution for men: 2.66 in the coastal area, 0.69 in the continental area, and 0.75 in the city of Zagreb… more than two-thirds of patients with pleural mesothelioma were occupationally exposed to asbestos. Uneven distribution of the tumour – higher rate in men in the coastal area – may be related to shipbuilding and other industrial sources of asbestos exposure in that part of the country."
Dr. Metoda Dodic-Fikfak, Director of the Institute of Occupational Medicine in Ljubljana, spoke about: Asbestos in Slovenia. Between 1946-1996, 614,000 tons of chrysotile and 70,000 tons of crocidolite were used in Slovenia with consumption peaking in 1982. Most of the asbestos was used in the production of asbestos-cement products such as pipes and roofing tiles. One third of all Slovenian roofs are covered in asbestos-cement material much of which is coming to the end of its life. The problem of how to deal with its removal and disposal is unresolved. It is believed that 22,686 Slovenian workers could have been occupationally exposed to asbestos. Last year (2002), 1300 cases of asbestos-related disease were recognized including 18 mesotheliomas, 18 lung cancers, 350 cases of asbestosis and 900 cases of pleural plaques. The proportion of observed mesothelioma to asbestos-related lung cancer cases in Slovenia is exactly the same as the overall European rate: 1:3. It is predicted that the peak of the Slovenian mesothelioma and lung cancer epidemic will occur between 2010-2025.
|Metoda Dodic-Fikfak speaking at the morning session|
[photograph by: Mrs. Cristina Bigolin, Studio Photo Atelier.]
Carcinogenic or Not Carcinogenic: The Role of the International Organisations was the title of the presentation by Dr. Lorenzo Tomatis, formerly Director of the International Agency for Research on Cancer (IARC) in Lyon, France. Dr. Tomatis explained how IARC was set up in 1965 with donations of $150,000 from each of six participating countries. He stressed the importance of scientific independence saying that "international organisations should guarantee that the evaluation of risks are carried out freely of influence."
During the discussion segment of the morning session several interesting points were raised:
two years ago it was discovered that ships being cleaned in Slovenia were contaminated with crocidolite which was dumped near the shipyard; this has now been stopped;
the post-occupational surveillance of foreign workers is a common problem. In Slovenia, a program was established with the National Institute of Health in Bosnia to follow-up the health of Bosnian workers who had been occupationally exposed to asbestos in Croatia;
the disposal of asbestos waste is problematic; a redundant mine in the Monfalcone area had been earmarked as an official dump site but after protests by local people, this plan has been abandoned. Currently, asbestos waste generated locally must be transported to a certified dump site near Venice. This is a costly business and many asbestos removal companies follow the traditional practice of dumping the waste along roadsides.
In 1991 an Italian law stipulated that mesothelioma registries must be established in all Italian regions. The implementation of this law required government certification; unfortunately, this was not obtained until February 7, 2003. The establishment of regional mesothelioma registries will now be mandatory; they will be required to send data to the national registry. The talk by Dr. Gianni Vicario described local efforts: Malignant Mesothelioma in the Cancer Registry of Friuli Venezia Giulia, Italy. In 1998, a population-based computerized cancer registry was set up using international guidelines, to cover a region in the north-east of Italy which included 1,186,617 inhabitants, the main city being Trieste with 221,500 inhabitants. Between 1995-1998, 32,000 malignant cases were recorded; with approximately 8,300 new cancers diagnosed a year, this area has the highest incidence rate of cancer and the second highest mesothelioma rate, after Genoa, in Italy. Between 1995-1998, 158 cases of mesothelioma in males were diagnosed; 40 new cases (male) and 8 new cases (female) are diagnosed annually. Following the new national guidelines, the region of Friuli Venezia Giulia is planning the establishment of a specialized malignant mesothelioma registry.
Imaging-Based Screening in Workers with Asbestos Exposure: New Possibilities was presented by Dr. Salvatore Minniti. A recent survey of 1,000 patients revealed that:
80% of participants with more than ten years of asbestos exposure had pleural abnormalities;
computerized tomography (CT) detected twice as many pleural abnormalities as conventional radiology;
pleural thickening was the most common finding.
Based on this research, Dr. Minniti concluded that conventional radiology is no longer useful as a screening tool.
Dr. Gianpiero Fasola discussed: Low-Dose Spiral CT Screening in Asbestos-Exposed Workers: an ATOM Group Study." According to Dr. Fasola, from the University of Udine, although the early diagnosis of lung cancer by computerized tomography screening is desirable, cancer screening is a complex issue which causes anxiety, is invasive, can produce false positive findings and over-diagnoses and may not be cost-effective. Malignant Mesothelioma of the Pleura: Is an Efficacious Treatment Feasible by Dr. Vittore Pagan, of the Thoracic Surgery Unit of the Umberto General Hospital in Mestre, Italy, focused on surgical developments. Dr. Pagan said that he is cautiously optimistic after achieving some good results. Although these operations are "formidable" for patients as well as surgeons, 30% of the 30 patients Pagan has operated on have had a survival of more than 3 years. Dr. Pagan hoped that procedures which are currently difficult and time consuming will be streamlined in the future. He stressed the need for "repeatable results." His paper: Prospective Results of Trimodality Treatment for Malignant Pleural Mesothelioma will be published as part of the conference annals.
In her capacity as the Coordinator of the International Ban Asbestos Secretariat, Ms. Kazan-Allen presented: The Global Campaign to Ban Asbestos. While many developed countries have stopped using asbestos, much of the developing world is increasing consumption; in 2001, 2 million metric tonnes of white asbestos were mined. Asbestos producers developed a marketing strategy in the early 20th century which has been very effective. They have maximized their global influence through a series of asbestos associations, institutes and committees in scores of countries. From the European cartel of asbestos cement producers (1929) to the Permanent Committee on Asbestos in France, the South Pacific Asbestos Association and the Asbestos Institute in Canada (1984), asbestos producers have thrown millions of dollars at the problem in a desperate, and often successful, attempt to spread pro-asbestos propaganda. In the early 1990s, anti-asbestos campaigners in Europe took the first steps towards forming an international movement. From that beginning grew a "virtual" network of asbestos victims, health and safety campaigners, academics, doctors, scientists, lawyers, engineers, civil servants and concerned citizens from dozens of countries. The voice of this "counter-power" was heard most recently on January 25, 2003 at the World Social Forum in Porto Alegre, Brazil at the workshop: Another World Asbestos-Free is Possible". Subjects under consideration included:
the worldwide struggle to ban asbestos;
compensation for asbestos victims;
defence of health as a fundamental human right;
asbestos: a question of public health and environmental right.
Asbestos Ban in the World: The Role of the Collegium Ramazzini was the subject of a talk by Dr. Morando Soffritti, Scientific Director of the Collegium Ramazzini. The Collegium is an independent scientific academy with 200 members from 32 countries. The aim of the Collegium is to safeguard life on the planet and human health and be "a bridge between the world of scientific discovery and those social and political centres which must act on these discoveries to conserve life and prevent disease."
Since 1987, the use of asbestos has been of particular concern to the Collegium; it has been examined at a series of events:
||The International Conference on Mariners’ Health in Athens, Greece – asbestos-related problems were high on the agenda;|
||Disease Potential of Different Asbestos Fibre Varieties in Ottawa, Canada;|
||Scientific Basis for Evaluation of Asbestos-Associated Diseases, a special course held in New York, US;|
||The 3rd Wave of Asbestos Disease: Exposure to Asbestos in Place - Public Health Control in New York, US;|
|1993||Carcinogenicity of Chrysotile Asbestos in Carpi, Italy;|
|1994||Updating the Epidemiology of Asbestos Disease in Carpi, Italy.|
In May, 1999, the Collegium issued a Call for an International Ban on Asbestos, stating:
"To eliminate the burden of disease and death that is caused worldwide by exposure to asbestos, The Collegium Ramazzini calls for an immediate ban on all mining and use of asbestos. To be effective, the ban must be international in scope and must be enforced in every country in the world…
Asbestos has been responsible for over 200,000 deaths in the United States, and will cause millions more deaths worldwide. The profound tragedy of the asbestos epidemic is that all illnesses and deaths related to asbestos are entirely preventable. Safer substitutes for asbestos exist, and they have been introduced successfully in many nations…
The health risks of asbestos exposure are not acceptable in either industrially developed or newly industrializing nations. Moreover, safer substitutes for asbestos are available. An immediate worldwide ban on the production and use of asbestos is long overdue, fully justified and absolutely necessary."
Several informative publications (in Italian) were available at the conference:
Amianto Fuori Legge
Amianto un Secolo di Sperimentazione Sull’Uomo
Salute & Prevenzione, No. 61 - Dicembre 2002
The third publication listed is a magazine which contains two English language posters by Dr. C. Bianchi and colleagues. The first poster: Lung Asbestos Content in Malignant Mesothelioma of the Pleura was exhibited in Vienna at the 8th Central-European Lung Cancer Conference in September, 2002. The authors reported higher asbestos lung burdens in stevedores than in shipyard workers from the Trieste-Monfalcone area. They postulated that this is because of heavy asbestos exposure experienced during unloading of permeable sacks of asbestos fibre. Prior to 1976, when it became mandatory to transport asbestos in sealed containers, the level of asbestos exposure experienced by port workers was astronomical. Strong local winds blew asbestos from the docks to nearby residential areas. Three years ago, two women who had lived in houses near the port of Trieste died from mesothelioma; their only exposure was environmental. The scientists conclude:
"Recently, the role of factors other than asbestos (such as SV 40, and genetic factors) in the genesis of mesothelioma has been emphasized. The present findings corroborate the idea that in the Trieste-Monfalcone mesothelioma series asbestos is the main etiologic agent."
The second poster: Latency Periods in Asbestos-related Mesothelioma of the Pleura by Dr. C. Bianchi et al was presented in September, 2002 at the Epidemiological Congress of Occupational Medicine in Barcelona. An analysis of data collected between 1968-2001 of 700 mesotheliomas in the Trieste-Monfalcone area revealed:
first exposure occurred prior to 1960;
the existence of a range of latency periods from a median of 29 years for insulators, to 31.5 years for dock workers, 51.5 years for shipyard workers, 54 years for women with domestic exposure and 56 years for sailors.
The researchers wrote:
"Previous investigations conducted at the Monfalcone laboratory indicated that the above groups substantially differed in the intensity of exposure to asbestos. Insulators as well as dock workers showed markers of heavy exposure. At the other extreme, sailors and people exposed at home were characterized by signs of generally mild exposure… The present findings indicate that the effects of intense exposure (which) occurred in the 1960s and 1970s, remain to be observed. The very long latency periods seen in a majority of the cases may offer an opportunity for preventive measures in people at risk."
Data on the incidence of asbestos-related disease in Europe are notoriously difficult to obtain as there is no central collection point. Another poster made available by Dr. C. Bianchi during the conference in Monfalcone entitled: Malignant Mesothelioma In Europe and the Mediterranean Region is invaluable. This poster is based on questionnaires sent to 245 researchers in 45 countries. The authors report:
"In Europe, estimated annual crude incidence rates of malignant mesothelioma ranged between 2 cases per million in Portugal, and 29 in Belgium… In the Mediterranean region estimated annual crude incidence rates ranged from low values in Northwestern Africa (0.6 and 0.7 cases per million respectively in Tunisia and Morocco), to intermediate values in Israel and Slovenia (3 cases per million), and to high values in France and Italy (17 cases per million)."
By providing a public space for the Italian debate on asbestos to be heard, this meeting highlighted the continuing plight of Italians injured by asbestos diseases. The inclusion of international presentations on the agenda enabled useful comparisons to be made. Problems common to many countries include: follow-up surveillance of former workers, enforcement of legislation, disposal of asbestos waste, insufficient funds for medical treatment and difficulties in obtaining compensation for asbestos sufferers. The struggle continues.
February 20, 2003
1In the paper: Asbestos-related mesothelioma in Monfalcone, Italy by Dr. C. Bianchi et al (1993), the authors state: "In the time period we considered, the annual incidence rates for pleural mesothelioma were very high among male Monfalcone residents, being 189 per 100,000 among people aged 75 years or more."
2The national mobilisation of Italian asbestos sufferers began in earnest with the formation of the Associazione degli Esposti all'Amianto/Association of (Those) Exposed to Asbestos (AEA) on March 18, 1989. In a document dated July, 1991, the AEA proclaimed: "We are an Italian organisation who fight against the use of asbestos in the workplace and in the surroundings. We are mainly composed by workers and citizens who want to ban the (use of) asbestos everywhere." In April, 1993 the AEA organized a meeting in Milan: International Meeting Bastamianto. A document issued by the delegates called for an international ban on asbestos. In the mid-1990s, branches of the AEA were started by shipyard workers and railway workers in Monfalcone and Padua respectively. A few years later, a branch of the AEA was begun by port workers and stevedores from Trieste. Other branches of this organisation include those in Casale Monferrato, Milan, Bologna, Genoa and Florence.
3The controversial views on asbestos held by Professor Fedor Valic, a staff member of the World Health Organization (WHO) for more than 30 years, are well-known. In June 1999, the WHO document: Asbestos and health, for which Valic was the Scientific Advisor, had to be withdrawn from distribution two months after publication because of an avalanche of complaints from international scientists, doctors and trade unionists. The first edition of the report was misleading and, according to Dr. Richard Lemen, retired former chief of the U.S. National Institute of Occupational Safety and Health, read more like an asbestos endorsement than a critique. Ulf Asp, General Secretary of the International Federation of Building and Wood Workers, wrote to Dr. Gro Harlem Brundtland, Director General of the WHO: "the report contains a number of serious errors and has not been revised to reflect criticisms of earlier drafts by experts. The report is intended to help local authorities but in no way reaches the standards of objectivity we have come to expect from the WHO." Dr. Barry Castleman, an international asbestos expert, agreed that the report "read like it was written by the asbestos industry." In his paper: Controversies at International Organizations Over Asbestos Industry Influence [International Journal of Health Services, Vol. 31, No. 1, pages 193-202, 2001], he wrote: "In August 1998, a final draft of the Asbestos and health report surfaced. Numerous problems remained in this version, and Dr. Greenberg sent WHO-Europe a letter expressing frustration with the report's author, Dr. Fedor Valic: 'Valic has not deemed it necessary to amend his text to take into consideration certain general and specific points that the referees considered important.'"