Dr. Raja Flores, head of thoracic surgery at Mount Sinai Medical Center in New York City, is recognized for pioneering efforts in the treatment of mesothelioma, a rare form of cancer caused primarily by asbestos exposure. But it's what he didn't know about the cause of the disease that recently astonished him.
"I've been doing asbestos-related cancer surgery for most of my career," Flores said, who established the VATS lobectomy procedure, considered the gold standard in the surgical treatment of lung cancer. "It wasn't until recently that I realized that asbestos isn't banned. I was shocked – this is my area of expertise.”
In addition to advancements in surgical procedure, Flores' research into mesothelioma has led him to investigate the consequences of asbestos exposure, including work on a $4.8 million study funded by the Agency for Toxic Substances and Disease Registry. Yet for years, Flores was unaware that hundreds of tons of asbestos continue to be imported annually into the United States. The toxic substance can be found in items ranging from automotive parts to some children's crayons.
"Many people think there is a ban," he said. "Almost everyone in the United States know asbestos is bad and causes cancer, and they know to avoid it. They assume it's banned, but it's not."
Asbestos has been banned in 55 countries, including the UK, Australia, German, France, Israel, Qatar and Saudi Arabia, but not China, Russia or the United States. While the first federal restrictions placed on asbestos were approved in the 1970s, many asbestos-containing products are still manufactured and sold today.
Found in various floor and ceiling tiles, roofing materials, older fiberboard and insulations, and dozens of other home products, asbestos is commonly found in buildings and homes constructed prior to 1990. However, there is little risk of exposure to asbestos fibers if it’s left alone. It's when those products are disturbed or broken that tiny asbestos fibers are released into the air.
Efforts by the Environmental Protection Agency (EPA) in 1989 to ban most asbestos products were thwarted by a federal court of appeals ruling stemming from a lawsuit filed by manufacturers. The agency is now preparing to conduct a risk evaluation to determine whether asbestos presents an unreasonable risk of injury to public health or the environment, an undertaking called for under the Obama administration that some say is being watered down by the current EPA director, Scott Pruitt.
"It's outrageous that in the year 2017, asbestos is still allowed in the United States," said Sen. Jeff Merkley (D-Oregon), who introduced the Alan Reinstein Ban Asbestos Now Act of 2017 in November. "It's time for us to catch up to the rest of the developed world, and ban this dangerous public health threat once and for all."
The bill aims to require the EPA to identify and assess known uses of and exposure to all forms of asbestos, and to impose restrictions on the use of asbestos within 18 months of enactment. The bill also bans manufacturing, processing or distribution of asbestos other than prescribed by the EPA's rule.
In Michigan, monitoring and enforcement of federal asbestos regulations are conducted by the Michigan Department of Environmental Quality (DEQ), which handles outdoor air issues, and the Michigan Occupational Safety and Health Administration (MIOSHA), which handles indoor air and workers' health issues. Under the regulations, property owners and contractors conducting renovations or demolitions of asbestos-containing materials must file notices with the agencies.
Discovered in ancient times as a magical mineral capable of being woven into fireproof fabrics, asbestos applications developed during the Industrial Revolution transformed the material from a novelty item into a valuable commodity responsible for spawning a multi-billion dollar industry.
Asbestos refers to a group of six naturally occurring silicate minerals that grow as thin, microscopic crystals, which combine to form bundles. When handled or crushed, asbestos bundles separate into individual mineral fibers. While soft and flexible to the touch, asbestos fibers are resistant to heat, electricity and chemical corrosion, making it an effective insulator and strengthener when mixed with cloth, paper, cement or other materials.
The most common form of asbestos is chrysotile, or white asbestos, found in roofs, ceilings, walls and floors, as well as automotive brake linings, gaskets, boiler seals, insulation for pipes, ducts and appliances. Chrysotile has accounted for more than 90 percent of the world's asbestos production, according to the U.S. Geological Survey.
Amosite, or brown asbestos, was used most frequently in cement sheets and pipe insulation. It can also be found in insulating board, ceiling tiles and thermal insulation products.
Crocidolite, or blue asbestos, was used to insulate steam engines, as well as some spray-on coatings, pipe insulation, plastics and cement products.
The first restrictions on asbestos came in 1973, when the EPA banned spray-applied asbestos-containing material for fireproofing and insulation purposes. Two years later, the EPA banned asbestos pipe and block insulation, with some minor exceptions. The Consumer Product Safety Commission in 1977 banned the use of asbestos in artificial fireplace embers and wall patching compounds. In 1978, the EPA banned all other spray-applied materials for purposes not already banned in 1973.
In 1989, the EPA set out to ban the majority of remaining asbestos-containing products through the Toxic Substance Control Act's final rule. However, a lawsuit filed by manufacturers upended the rule in 1991.
The EPA had proposed phasing out products over seven years, eliminating about 84 percent of asbestos-containing materials in domestic products. A federal appeals court struck down the ban, ruling that the agency didn't consider alternative regulations other than banning. The ruling upheld some restrictions that went into place in 1989, but struck down those that would have been phased in 1993 and 1996.
Today, the manufacture, importation, processing and distribution of certain asbestos-containing products is banned. Those products include items such as corrugated paper, rollboard, commercial paper, specialty paper and flooring felt. "New uses" of asbestos, or its use in products that haven't historically contained asbestos, are also banned. The federal Clean Air Act also bans the manufacture or sale of asbestos pipe insulation that is either pre-formed or friable. Spray-applied asbestos-containing materials with content of more than one percent of asbestos for buildings, structures, pipes, and conduits are also banned, unless certain conditions are met. Still, there are hundreds of asbestos-containing products that aren't banned, including cement corrugated sheet, some clothing, pipeline wrap, roofing felt, vinyl floor tile, cement shingles, millboard, automatic transmission components, clutch facings, disk brake pads, gaskets and some coatings.
The vast majority of raw asbestos imported to the United States today is used by the chlor-alkali industry to make semipermeable asbestos diaphragms.
Overall, asbestos use in the United States has decreased since 1973, when the domestic manufacturers used 803,000 tons of asbestos. The last U.S. producer of asbestos ceased operations in 2002, making the country wholly dependent on imported asbestos to meet manufacturing needs.
Today, global production of asbestos is about two million metric tons per year, with Brazil currently supplying more than 90 percent of asbestos imported to the United States. Russia produces about 1.1 million metric tons of asbestos annually, while China produces about 400,000; followed by Kazakhstan (200,000 metric tons), and India (200 metric tons).
In 2016, U.S. consumption of asbestos was estimated to be about 340 tons, down about three tons from the previous year, according to the U.S. Geological Survey. However, some environmental groups claim the amount of imported asbestos in 2016 was more than double that amount.
A study by the Environmental Working Group and the Asbestos Disease Awareness Organization that analyzed data from the U.S. Department of Commerce and the U.S. International Trade Commission estimates about 705 metric tons of raw asbestos were imported in 2016. Most of the surge, the groups said, came in the fourth quarter of the year following the passage of the revamped Toxic Substances Control Act (TSCA), which was amended the same year to give the Environmental Protection Agency (EPA) broader authority to ban toxic chemicals. Asbestos is one of 10 such substances being evaluated for regulation.
However, the DEQ's Air Quality Division is struggling with financial restrictions limiting its effectiveness, according to a recent Michigan Auditor General's report.
The program is responsible for reviewing notifications of intent to demolish or renovate a building containing asbestos or asbestos-containing materials, as well as inspecting demolitions and asbestos removals. With more than 17,000 such notices filed in 2016, the program was unable to inspect even 15 percent of notices and complaints it received, according to a recent audit.
"The DEQ should work with the legislature to establish a fee structure to assist in funding the asbestos program," the Michigan Auditor General's office said in the audit, which found the DEQ spent $635,000 on the program in 2016, employing four full-time and one part-time employee dedicated to performing inspections across the state. "Increased funding could be used to hire additional staff to assist the DEQ in meeting its scorecard goal of inspecting 15 percent of notifications received."
Meanwhile, the number of asbestos-related diseases being diagnosed each year isn’t expected to drop off anytime soon.
"I think a big spike is coming down the line," said Dr. Flores, who was a principal investigator of asbestos exposure following the 9/11 terrorist attacks that brought down untold amounts of asbestos on the city. "I think we will see a general spike in New York City as time goes by."
While exposure can be deadly, it usually takes years for symptoms to appear.
"Asbestos-related diseases, which include mesothelioma, lung cancer and asbestosis are rare, they are deadly. When you have it, it's hard to take care of, and it's hard for doctors to diagnose, even when it's staring them in the face. It takes someone with a high degree of suspicion of asbestos-related diseases, and persistence," Flores said. "There are things that can set off a red flag, like if someone has a history of asbestos exposure in a job, like construction, or now a lot of firefighters."
Three major diseases are caused by inhalation of asbestos fibers: mesothelioma, which is a rare and always fatal cancer that attacks the thin membrane lining of the lungs, heart, chest cavity, gastrointestinal system and reproductive organs that is primarily caused by exposure to asbestos; asbestosis, which is caused by inhaled asbestos fibers that lodge deep in the lungs, scarring the organs or triggering a growth of excess tissue, a condition known as fibrosis; and lung cancer, which can be caused by inhaling asbestos fibers. Researchers also believe some cancers of the larynx, ovaries, stomach and colorectal area are triggered by asbestos exposure.
Nationally, asbestos-related diseases kill between 12,000 and 15,000 people each year, according to a study conducted by the Environmental Working Group's (EWG) Action Fund, which estimates there have been between 189,000 and 221,000 deaths between 1999 and 2013 caused by asbestos exposure. The study based those estimates on a review of federal records kept by the Centers for Disease Control and Prevention (CDC).
The study found annual deaths from mesothelioma remained between 2,481 and 2,832 between 1999 and 2013, while deaths from asbestosis remained between 1,208 and 1,486 – evidence that death rates from asbestos-related diseases aren't dropping, despite existing federal restrictions on some products.
Overall, the study found the death rate from asbestos-related diseases in Michigan to be 5.2 per 100,000 people. The national average was calculated at 4.9 deaths per 100,000 people.
The EWG said about 7,878 Michigan residents died from asbestos-related diseases between 1999 and 2013. That includes 517 deaths from asbestosis; 1,479 from mesothelioma; and 5,916 to non-mesothelioma lung cancer. Locally, Oakland County saw the third highest number of asbestos-related deaths in the state, with approximately 688 deaths between 1999 and 2013; while Wayne County had about 1,061 deaths and Macomb County had approximately 688 deaths.
Because asbestos-related deaths aren't precisely recorded or reported by public health authorities, EWG researchers said an exact number of deaths can't be pinned down.
"Our estimates are still conservative because some unknown number of deaths may have been attributed to pneumonia, other respiratory disease or lung fibrosis of unknown origin," the researchers said in the study. "If doctors failed to ask patients about asbestos exposure, or if patients were unaware they had been exposed to asbestos, the death certificate would not mention asbestos as a cause."
Dr. Michael Harbut, founder of the Center for Occupational and Environmental Medicine at Providence/St. John's Hospital and former director of the Environmental Cancer Program at the Karmanos Cancer Institute, said asbestos-related diseases are often misdiagnosed because the illnesses may not show themselves for decades.
"Asbestos causes scarring of the lungs, which can be fatal, and thickening of the covering of the lungs, which can become mesothelioma, which is quite horrible and deadly in months," he said. "It causes lung cancer and the same kind of tumors you see in smokers, but most people don't think of (asbestos) right away. People with asbestos-related diseases die of pneumonia more often, and often they aren't diagnosed because of the latency period, which can be 15 to 45 years. It doesn't have to be continuous exposure.”
He said even low-level exposure to asbestos can cause problems and take years to develop. Some patients may be told initially that they have bronchitis or COPD, while mesothelioma may first present itself as back pain.
Harbut, who co-authored the American Thoracic Society's criteria for diagnosis and treatment of asbestos-related diseases, said Providence/St. John's medical program is the only one in the metro area that requires a specific number of hours for medical residents to learn about asbestos. He said projections in the 1990s showed asbestos-related diseases would spike about 2017 or 2018.
"What we are seeing now is a lot of homeowner exposure who did remodeling and tore out walls or insulation," he said. "In the early 1990s and late 1980s, we used to say asbestos would take care of itself and go away, but it looks like there is a second spike or wave of asbestos diseases.
"There's still a lot of asbestos out there, and it doesn't stop killing."
Even if all current uses of asbestos were banned in the United States, there are still enough asbestos-related products in use to continue to pose significant harm to the public.
A review of the Michigan DEQ's asbestos program revealed the department received 17,188 notifications of intent to demolish or remove asbestos-containing materials, and conducted 1,404 inspections, with the majority of notices (10,565) coming from Wayne County and the city of Detroit's blight removal project. Genessee County had the second highest number of notices, with 1,531, while Oakland County had the third most notifications, with 554, in 2016.
Under the federal Clean Air Act's National Emissions Standards for Hazardous Air Pollutants (NESHAP), the DEQ is required to review notifications from property owners and contractors who will be demolishing or renovating a location with asbestos-containing materials. Those notifications are intended to minimize the release of asbestos fibers into the air. Such projects ensure that asbestos is wet and contained to reduce the release of fibers, and that waste is transported correctly to an authorized landfill. The DEQ is also responsible for inspecting Type II landfills that are permitted to receive asbestos.
A state audit of the DEQ's asbestos program released in August 2017 found the department's Air Quality Division didn't ensure timely and complete input of all required inspections, complaints and violations into the state's database, or Michigan Air Compliance Enforcement System.
In total, the program received 17,188 notifications in 2016 and completed 1,404 inspections. The audit found the Air Quality Division acted upon 98 percent of complaints within seven days of receiving them. The majority of issues listed related to the timeliness and completeness of input into the state's database, and timely responses to violation notices by liable parties.
The audit also found the DEQ couldn't demonstrate it inspected 87 percent of Type II landfills to ensure proper disposal of asbestos-containing materials. The audit listed two landfills in Oakland County qualified to receive asbestos – Oakland Heights Development in Auburn Hills and Eagle Valley Recycle and Disposal Facility in Lake Orion.
Oakland Heights Development was last inspected in February 2017, according to DEQ records. The inspection report stated the landfill doesn't currently accept asbestos waste, and hasn’t since 1998.
Eagle Valley Recycle and Disposal Facility is licensed to accept asbestos materials, but doesn't currently do so; however, it may have in the past, according to a June 2016 inspection report by the DEQ.
In total, Michigan landfills received 10,655 notifications in 2016 of intent to demolish or renovate from contractors or property owners.
Contractors and property owners may also be required to file notifications with MIOSHA, which is responsible for enforcing federal labor laws regarding asbestos.
"If they are doing the work themselves, they don't have to notify us," DEQ Asbestos Program Supervisor Karen Kajija-Mills said. "On a single-family home, if they have a contractor, they are required to notify MIOSHA. They handle a smaller amount than we do. It's a complex program."
While Kajija-Mills said the two programs worked together in the past, they are now separate. Overall, the DEQ's program has four full-time and one part-time staff, while MIOSHA has six full-time employees for its asbestos program.
The DEQ places complaints at the top of the list.
"Complaints range from a neighbor that might tell on someone to a contractor tattling on another contractor. We get lot of good cases that way," Kajija-Mills said. "A demolition may not be listed on our website. Non-notifiers are typical because they don't know about the program. We do a lot of outreach. Most demolitions usually get a permit from a local entity, and they aren't the greatest at dispensing information."
Oakland County Environmental Health Director Anthony Drautz said the department doesn't have an asbestos program, instead referring to the state programs, with MIOSHA handling workplace and indoor air issues, and the DEQ, outdoor air issues.
In terms of staffing, Kajija-Mills said the state's audit of the DEQ's program confirmed what the department already knows.
"It's a well-known fact that we aren't staffed properly to do the program justice," she said.
Among the most common places for asbestos to be found are schools, universities and hospitals. To protect students, staff and visitors, all school districts are required to conduct a full asbestos survey and maintain an updated log of where asbestos-containing materials are located.
Locally, there have been 1,188 project since 2014 involving asbestos removal that have filed notices with MIOSHA. That includes 61 projects in Birmingham; five in Bloomfield Township; 61 in Bloomfield Hills; 14 in Rochester Hills; and 47 in Rochester.
The database provides the location, amount of asbestos material being removed, who is conducting the work and when it is to be done and completed. Locations include residential, commercial and public buildings. For instance, of the 14 projects listed in Rochester Hills, multiple notices were listed for Munson Elementary School, Hamlin Elementary School, Baldwin Elementary School and Meadow Brook Amphitheater. In Rochester, multiple notices were listed for Oakland University facilities. Likewise, multiple projects in Bloomfield Hills were undertaken at schools, including Cranbrook Education Community, Fox Hills, Hickory Grove, Andover, Lahser, Marian and other schools.
Bloomfield Hills School District’s Bruce Coltman said all buildings in the district have their own asbestos inventory.
"When work is done at each site, we will hire a company to remove any and all substances that are asbestos containing before any renovation is done," he said. "Another contractor will also monitor air and clear the area for renovation to be completed.
"The district's updated manuals are now on three discs and are updated every six months. I am working on getting these on our web page for easy access by all."
Lori Grein, director of community relations for Rochester Community Schools, said while districts are required to maintain an asbestos inventory, they aren't required to be posted online. This, she said, is likely because the law was promulgated in 1987, prior to widespread internet use.
Rochester Community Schools first conducted extensive asbestos inspections in 1988, leading to a comprehensive asbestos management plan. That plan is evaluated and updated regularly and is available at request to the public.
Birmingham Public Schools spokeswoman Marcia Wilkinson said the district is required by law to maintain an asbestos inventory, and does so. The documents are available to the public upon request.
Despite the risk of asbestos exposure in schools, the majority of states do not conduct regular inspections of school buildings, with the total hazard in schools widespread but difficult to ascertain, according to a 2015 report, Asbestos in America's Schools, written by the staff of Senator Edward Markey (D-MA) using responses to an investigation launched by him and Senator Barbara Boxer (D-CA).
The two senators sent letters to governors of all 50 states to inquire about the implementation and enforcement of the Asbestos Hazard Emergency Response Act (AHERA), which was passed in 1986 and requires schools to keep an inventory of asbestos in their buildings. Of the 50 requests, just 20 responded. Michigan did not respond to the request.
Markey's report included mention of student and staff exposures to asbestos at the Dearborn Heights Schools District. That case resulted in a federal suit filed against the district by Theresa Ely, a custodian working at the district, involved the sanding of asbestos-containing floor tiles.
According to court records, Ely filed suit against the district after they disciplined her for speaking out about the possibility of asbestos contamination at the school. An investigation by MIOSHA later revealed that the tiles did contain some asbestos, despite claims from the district that dust had been tested and came back negative for asbestos contamination.
Attorney Robert Fetter, who represented Ely in a whistleblower case and a First Amendment case from the incidents, said the cases are troublesome not only because of the exposure to asbestos, but because it appears the district tried to cover up its mistakes. Specifically, he said the district appeared to have filed a fraudulent report regarding the testing of the asbestos dust generated by the sanding of floor tiles.
"We thought there were suspicious things," he said. "There was asbestos found on the sanding pads, but they issued a statement to the parents and school community that the report didn't find any asbestos, so we thought in regard to those concerns, the district was lying."
He said the First Amendment case has been settled, while the whistleblower case is being conducted through the MIOSHA administrative process. Still, he said such problems aren't uncommon.
"I have handled some of these cases across the country, and it's a big problem that a lot of school districts aren't training staff on how to handle asbestos," he said. "There should be reports that are regularly updated, so anyone working in a school knows where it is. Those are routinely ignored, if they have them at all. It's a big problem. The agencies that are tasked to enforce the law to handle asbestos in schools are way understaffed. The chance of you having an inspection is nil to none.”
A review of violation notices and inspection reports found no violations regarding asbestos at any of the public school districts in the Birmingham/Bloomfield or Rochester/Rochester Hills area. Oakland University did enter a consent order with the DEQ in 1991 involving a $19,000 settlement for violating work-practice and notification standards of federal air quality laws. Cranbrook Academy of Art had three consent orders relating to asbestos removal in the late 1990s.
Violations regarding asbestos removal typically involve residential properties, including one in Rochester Hills. That violation, issued to MJC Woodland Crossings on October 6, 2017, involved the removal of asbestos at a property at 1171 E. Auburn Road, without notifying the DEQ within 10 days of the work.
"According to our investigation, MJC Woodland Crossing, LLC owns the facility and Quality Environment Demolition LLC performed the renovation activities at the facility," the DEQ said in an inspection report. "During the inspection, staff observed ongoing asbestos abatement activities at 1171 E. Auburn. 1171 and 1183 E. Auburn will be demolished as part of a project to build a subdivision in the area; as such, renovation and demolition activities at these properties are subject to the Asbestos NESHAP."
An EPA spokesman told Downtown that risk evaluation for asbestos "must include hazards, exposures, conditions of use, and potentially exposed or susceptible subpopulations the administrator expects to consider."
As the EPA considers further asbestos bans, some environmental and health organizations believe any evaluations will be watered down by excluding major points of exposure risk. That includes excluding exposure from legacy uses, or uses no longer permitted but still posing a risk of exposure to asbestos, said Linda Reinstein, co-founder of the Asbestos Disease Awareness Organization.
Rather than relying on the EPA to restrict asbestos, Reinstein and some other groups are pushing for a full-out ban on asbestos, as outlined in the federal legislation named for her late husband, Alan Reinstein, who died in 2006 from mesothelioma.
"Like most Americans, my husband and I thought our air, soil and water were free from contaminants. Alan was diagnosed in 2003, and I had never heard of mesothelioma before that," Reinstein said. "One day it appears your life is fine, and the next you're thrown into a sea of chaos."
Alan had worked in naval shipyards in the past – now considered a high-risk occupation for asbestos exposure.
She said the EPA's evaluation could exclude past uses of asbestos, while legislation would not. "The bill takes the evaluation out of the equation," she said.
Such a ban is opposed by the American Chemistry Council, which represents chlorine manufacturers in the chlor-alkali industry, which uses asbestos to construct filters used in the production of chlorine. The council is also pushing for an exemption to the EPA's upcoming risk evaluation. The industry produces about $129 billion in economic output in the United States each year.
Pressure from the industry, as well as other manufacturers of asbestos-containing products, could make further restrictions on asbestos difficult for those seeking to ban it or restrict its use further.
"I think the biggest hinderance to banning asbestos in the United States is that there are a lot of people that have other financial interests," said Dr. Flores. "When you have millions of dollars that are going to be lost, some people aren't going to want to see asbestos completely banned.
"It's like Upton Sinclair said, 'It's difficult to get a man to understand something when his salary depends on his not understanding it."
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