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Asbestos is a disaster.1 It has been responsible for over 200 000 deaths in the USA, for 400 000 deaths in Europe and continues today to cause an estimated 180 000 deaths each year worldwide.2 Asbestos is a known cause of cancer, and the International Agency for Research on Cancer considers all forms of asbestos—including chrysotile, the form in major use today—to be proven human carcinogens.3 Asbestos causes cancer of the lung, larynx and ovary as well as malignant mesothelioma. It is associated with stomach, pharyngeal and colorectal cancer. It causes asbestos-related non-malignant respiratory disease. No form of asbestos is safe and no level of exposure is safe. The WHO,4 the International Labour Organisation5 and the Collegium Ramazzini6 have called for a global ban on all production and use of asbestos.
Despite widespread knowledge of asbestos’ dangers, global production and sales remain strong. Two million tons were produced worldwide in 2013, down from a peak of 5 million tons per year in the 1980s, but similar to levels in each of the three preceding years. Russia (1 million tons annually), China (420 000 tons), Brazil (300 000 tons) and Kazakhstan (240 000 tons) are the top producer nations.7 Canada was previously a major producer but has now ceased all production. The leading consumers are China, India, Russia, Brazil and Indonesia.6 Vast quantities of asbestos are exported each year to low-income and middle-income countries across Asia, Africa and Latin America where environmental and occupational health protections are weak and public health infrastructure poorly developed.8 Over 125 million people are exposed occupationally to asbestos and millions more, including women and children, are exposed in the environment.4 5
Asbestos is not an essential material. Safer substitutes exist and have been successfully introduced in many countries.6 The grave hazards of asbestos and the availability of safer substitutes have led 55 countries to eliminate all import and use of asbestos and many more have restricted use. In the USA, asbestos use has been sharply curtailed, but not legally banned. Bans and restrictions on the use of asbestos produce significant decreases in asbestos-related mortality that typically become evident after 20–30 years, a lag consistent with the typical latency of asbestos-related cancer.9
Opposition to further reductions in use and production of asbestos is fierce. The tactics of the asbestos industry and the asbestos-producing countries are similar to those of the tobacco and lead industries and consist of lies, attacks on scientists who speak truth and the manufacture of doubt.10 11 A particularly egregious example is seen in the success of the asbestos-producing nations in blocking the inclusion of asbestos among the hazardous chemicals restricted in international trade under the Rotterdam Convention.12
Public health data provide powerful tools for preventing disease and overcoming vested opposition. From John Snow’s use of mortality maps to contain cholera in 19th century London,13 to William Foege’s use of incidence charts to eradicate smallpox in India,14 to Herbert Needleman’s documentation of the toxicity of lead at low dose,15 data have proven critically important time and again in mobilising public opinion and in persuading governments to take action to end disease and save lives. Locally relevant data showing that disease and death are striking home in a city, state or country have an immediate reality and are particularly powerful.
The report by Odgerel et al 16 provides important and locally relevant public health data that will contribute to the global elimination of asbestos-related disease in countries around the world. The goal of this study was to calculate the annual global burden of death from malignant mesothelioma. The investigators developed this global estimate by painstakingly combining national data on mesothelioma mortality with data on past and current levels of asbestos consumption in each of the world’s 230 countries. The study focused on mesothelioma because this malignancy has no cause except asbestos and therefore provides a unique and unmistakable marker of asbestos exposure.
To develop their country-by-country estimates, the authors used the WHO’s Mortality Database and divided countries into those that do and do not report mesothelioma mortality. To assess country-specific asbestos consumption, they used data from the US Geological Survey7 and divided countries into four categories ranging from no consumption to high consumption, cross-tabulated by level of cumulative and per capita consumption. To estimate age-specific and gender-specific mesothelioma mortality in countries not reporting mesothelioma deaths, the investigators extrapolated from countries with high-quality reported data and adjusted their estimates to reflect level of cumulative and per capita asbestos consumption in each country. The 59 countries that report mesothelioma mortality recorded 15 011 mesothelioma deaths annually in each of the past 3 years. Extrapolating from these data, the authors calculated that 38 400 mesothelioma deaths occur each year globally. The authors note that this estimate is within the range of previously reported estimates, but is higher than the estimate produced by the Global Burden of Disease study.2
A particularly important aspect of this study lies in its development of robust estimates of mesothelioma mortality for virtually every country in the world. These estimates are highly credible. They are based on data from two impeccable sources—the WHO Mortality Database and data from the US Geological Survey on asbestos consumption—and they are derived using a highly transparent and replicable methodology. These estimates provide a benchmark that will enable researchers to update calculations of mesothelioma deaths in future years and assess trends and emerging patterns in mortality from asbestos-related disease.
Even more importantly, the powerful country-by-country calculations of mesothelioma mortality presented in this report demonstrate clearly that no country is immune from asbestos-related disease. Ministers of Health and Heads of State in every country have a responsibility to protect their people against asbestos. Because no form of asbestos is safe, no level of exposure to asbestos is safe and there is no way to work safely with asbestos, a complete ban on all production importation, processing and use of all forms of asbestos in every city, state and country around the world is the only effective way to prevent asbestos-related disease and end the asbestos pandemic.4–6
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
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