Health
Asbestos continues to cloud the present and the future
■ A recent report warns that the long latency period for asbestos-related diseases may mean that illness rates have yet to peak.
By Victoria Stagg Elliott — Posted May 10, 2004
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Brad Black, MD, a physician in Libby, Mont., is one of the lucky ones. He's breathing just fine. But he can't say the same for many of his patients.
About a quarter of the people in the area, the former home of a vermiculite mine contaminated with asbestos, now show the ill effects of exposure. Miners come to him barely able to inhale. Their spouses who washed the work clothes laden with asbestos dust and their children who played in the slag heaps are experiencing problems, too.
Dr. Black, a pediatrician who came to Libby in the 1970s, is aware that he also faces risk. He used the vermiculite in his garden. And, like everyone else in Libby, he has been breathing asbestos-contaminated air for decades. Still, he has not experienced any symptoms.
"If I was going to have any lung problems, they probably would have developed by now, but there's still the possibility of mesothelioma," said Dr. Black, currently the medical director of Libby's Center for Asbestos Related Disease.
Libby is an extreme example of the health havoc wrought by asbestos. But this hamlet, with a population of 2,000 and another 8,000 people in the surrounding areas, is not the only place in the United States touched by the contaminant. Doctors around the country report an increase in the diagnosis of people with lung diseases linked to it.
"I'm seeing a flood of them," said Alan Whitehouse, MD, a pulmonologist in Spokane, Wash. "I'm seeing more now than I ever saw in the 1970s and 1980s."
Watchdog organizations also are paying attention. The Environmental Working Group, a Washington, D.C.-based nonprofit organization, published a report, "Asbestos: Think Again," in March. The document predicts 100,000 asbestos-related deaths, and many more people developing lung impairment related to exposure, over the next decade, a significant increase from the more than 43,000 deaths recorded from 1979 until 2003.
"Asbestos is not an economic issue but a public health crisis -- one that has yet to reach its peak," said Richard Wiles, lead author and EWG senior vice president.
An unclear forecast
Public health officials and those who regularly deal with asbestos-related diseases say, however, that the situation is extremely complicated. Some feel related diseases may have already peaked and that those who will be affected already have been.
"I think the tidal wave is probably under way or may have already crested," said Howard Frumkin, MD, DrPH, professor and chair of environmental and occupational health at Emory University, Atlanta. "Most of the intensive asbestos exposure is long past, and the use started to fall off in the 1970s and 1980s. Lots of people have had low asbestos exposure since, but the incremental risk is also quite low."
Others aren't so sure.
The latency period for asbestos-related disease is considered to be about 20 years, though there is speculation that it could be longer. And even though asbestos use has declined in the past 30 years, it is not completely gone.
"There's still asbestos being imported. It's still being used," said Harvey Pass, MD, co-director of the National Center for Vermiculite and Asbestos-Related Cancers and professor of surgery and oncology at the Karmanos Cancer Institute at Wayne State University, Detroit. "There are going to be a lot more people having problems related to asbestos exposure than you think."
Because exposure is so common, many experts suggest that physicians take note of occupational and environmental histories.
"Primary care physicians have a very important role because there is increasing concern about asbestos exposure and asbestos-related disease," said Vikas Kapil, DO, MPH, senior medical officer at the government's Agency for Toxic Substances and Disease Registry. "It's very important for physicians to ask about current or past exposure and refer as appropriate for further evaluation."
But pinpointing asbestos exposure can be tricky. Many patients may not be aware that they've had any exposure at all, particularly if it was outside the workplace. The exposure could have been for a very short time at a very young age and could be little more than a hard-to-reach memory.
"It can be very difficult," said Eric Gottesman, MD, a pulmonologist at Long Island Jewish Medical Center in New York.
"They may not recall re-doing a house. If they were in the service, they may not realize they were exposed. Auto mechanics might know but might not realize that it could cause problems," Dr. Gottesman said.
And even if the exposure has been nailed, it may not be relevant. Some patients have worked with asbestos their whole lives, and it has had little effect.
Three-quarters of the residents of Libby have yet to be affected and may never be. Others have had much shorter exposures and haven't been quite as lucky.
"We see a lot of mesotheliomas arising in people in their 30s from when they may have had exposures in their homes," said Jacqueline Moline, MD, vice chair of community and preventive medicine at Mount Sinai School of Medicine in New York. "They may have assisted their parents when they were remodeling the basement, and their job was to sweep up every day after the contractors were there. Some of these are scary."
There are also significant limits on treatment options for the most common asbestos-related diseases -- mesothelioma, asbestosis, lung cancer and gastrointestinal cancer.
"That's the unfortunate thing," said Dr. Gottesman.
"If you diagnose lung cancer early you can treat it, but you can't really do anything for asbestosis. A lot of the times when you make the diagnosis [of asbestos exposure], you make it at an autopsy."