|Year : 2012 | Volume
| Issue : 3 | Page : 131-136
Asbestosis: Past voices from the Mumbai factory floor
Abhijeet V Jadhav, Nobhojit Roy
Department of Public Health, Jamsetji Tata Centre for Disaster Management, School of Habitat, Tata Institute of Social Sciences, Mumbai, Maharashtra, India
|Date of Web Publication||13-May-2013|
Abhijeet V Jadhav
Saraswati Colony, Old Ausa Road, Latur - 413 512, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Asbestos's production, processing, and consumption is on very high scale in India and it is increasing, and so do the related diseases. Asbestosis is such a disease which causes progressive respiratory disability. Aim: To find out perceptions and thinking about this disease and its risk among the patients which will help in constructing an effective community-based prevention and rehabilitation program. Materials and Methods: It was a community-based, qualitative study using a semi-structured interview schedule with 17 asbestosis patients from Mumbai, disgnosed by specialist with pulmonary function test and X-rays as per International Labour Organisation's recommandations. Results: The risk percived by the patients is very less and attitude toward the illness is bengine as there is no clear understanding about the causation. The prolong latent period appears to be the main cause. It suggests a need of very strong program for prevention of asbestosis with the incorporation of worker awareness and eduaction for safety. The socio-economical status and educational levels of the workers make this floating population more vulnarable for manipulation by the corporates. Conclusion: Apart from the radical step of ban on asbestos, there is a need of community-based sustainable, affordable, and accessible rehabilitation program with a component of palliative care which will consider the different needs of this marginalized group. The need for such a program is intense as the number of asbestisis patients will keep on increasing till 30 to 40 years of asbestos ban.
Keywords: Asbestosis, community-based rehabilitation, palliative care, pneumoconiosis
|How to cite this article:|
Jadhav AV, Roy N. Asbestosis: Past voices from the Mumbai factory floor. Indian J Occup Environ Med 2012;16:131-6
| Introduction|| |
According to the extrapolations of international labor organization (ILO), a million people will die due to asbestos-related cancers by 2020.  The number of suspected people who were exposed to asbestos in India was 10 million till 2002.  In the developed countries, where asbestos use was banned, the peak of asbestos-related illness occurred after 25 to 30 years of implementation of ban. In India, there is no such ban on the use of asbestos. Quite on the contrary, there is an increasing consumption rate of asbestos in India. , Coupled with a weak occupational health system and no law in place, we can expect a rise of such cancers in the coming years. This health system is neither fully capable of diagnosing, treating, and rehabilitating these cases nor law implementing system is too strong to prevent the exposure to workers.  In recent decades, life expectancy of poor working class has increased (from 43.2 years for males-1960 to 65.5 years for males-2010)  and due to long lives, the asbestos-related diseases got expressed fully. It is now that we understand the actual magnitude of the burden of asbestos-related diseases. The push for reforms will have to be from the Worker Unions. 
Asbestosis is a debilitating lung disease which occurs in 20% to 60% of exposed, , manifesting after 20 to 37 years of initial exposure  with the chief complaints of severe shortness of breath and dry cough, mainly because of interstitial lung fibrosis with decreased diffusing capacity. ,, Knowing the exact prevalence is a very challenging task as it is very difficult to follow-up a floating population for around 40 years. Asbestos exposure is clearly related to serious morbidity and early mortality.  If we just look at the parenchymal changes among asbestos-exposed people, it is up to 82%. , It is very well proven that through rehabilitative programs patients can be benefited to a significant extent. ,, In order to construct an effective strategy or program for prevention as well as for better rehabilitation of these victims, we need to understand the patients' perspectives, perceptions, attitude, and knowledge about this disease and its causes in this setup.  This study is an effort to facilitate this process and to better understand the special needs of this unorganized and vulnerable group.
| Materials and Methods|| |
This was a qualitative study of 17 asbestosis patients, conducted in Mumbai (Maharashtra). Data was collected using open-ended semi-structured interviews. It was a purposive sample. The workers were formerly working in an asbestos sheet and cement making factory which was closed in 1983. These patients were selected conveniently from a screening program of exposed workers, which was initiated by the local workers' union and few activists. Subjects were identified with the help of a key contact-union leader and other union activists.
The subjects were approached personally by the researcher and the purpose and method of the study was explained to each individual. Those who were willing to participate were required to give their written consent. Interviews were conducted at informal places like their houses or a meeting place of the workers, near their residence. Core questions were grouped into themes like workers' knowledge and attitude toward risks and illness, their working conditions, effect of illness on their family, etc., Responses were simultaneously noted down in the interview schedule form. Anonymity was assured, names of participants or key contacts were not disclosed but they were coded and the codes were known to the principle investigator only, and the details were kept in a locked secure location.
| Results|| |
All the 17 participants were male and retired from the same factory. The mean age of the participants in years was 65 with range of 59 to 71. The average family income per month was $100 USD (range: $ 8 to 268). Mean years of experience was 31 years (range: 22 to 38). Only three workers had completed their graduation or equivalent education.
Their risks and knowledge
Their knowledge about their occupational hazards was minimal. Most of the workers did not know about asbestos or names of other chemicals. They referred to asbestos as "fiber" and to all other chemicals as "powder." For most of the people, there was no training after being recruited for the job. Some of them did not know about work-flow operations in other sections of the factory, where asbestos was processed. They were able to see clouds of dust but they did not know where it was coming from. "I used to prepare those (mixture of chemicals) as per the written guidelines. In this process various types of dust and vapors used to form." "My work was to pack various compounds in a drum which used to go to the furnace. This place was like cloud of dust."
Workers were appointed as contract workers for initial few years and then they were converted into permanent workers. There was no fixed work, minimum wages, or other facilities during the contract-work period.
Knowledge about their illness
None of the participants knew the name of the disease with which they were suffering. Only two subjects knew that they had a respiratory illness induced by their previous working conditions. For both of them, it was an incidental finding by their physicians when they were investigated for other illnesses. "I came to know about it 15 years back, when I was being treated for chest pain (angina?). The doctor was aware of this factory and exposure to fiber (asbestos). He mentioned that it may be the cause of my respiratory problems. At that time only I suspected the dangers of this fiber." The rest of sufferers (n = 15) did not know about their illness, till their union initiated a screening program. It was evident by the narration of a worker- "around 1995, when they gave us masks and all, people thought that there is some problem. They can't be so generous to us, without any reason. Then someone said it is because of the dust which is harmful to us. But I got a clear idea two years back when I came here." All these people suffered from gradually increasing breathlessness.
Working conditions and behavior
The working conditions varied depending upon the process a worker was involved in. Conditions common to all were the hot climate and dust from small fibers. Management reportedly took some steps to make conditions better but it is difficult to guess about their efficiency as most of the workers kept complaining about their working environment. ,"There was a dust collection system but it was not foolproof. A ventilation duct system was also there, but still there were pockets where these systems were inefficient." As per the norms they installed the vacuum cleaners and ventilators but it seems it was not helping much. "There was an over-head ventilator but still considerable amount of dust used to cover our body."
It is evident that workers were not given proper information about the health hazards in the factory; neither were they trained to use personal protection equipment. Occasionally, workers were provided with basic accessories like gloves, shoes, masks, and a small towel.
Personal protective equipment was not universally given to all. In some specific sections, they distributed gloves where the workers needed to use their hands directly in contact with the raw material, and the dusty section workers were distributed masks. "I was in other section so I never needed to wear mask. I wore them only when I had to go to the processing unit." Also they were not taught how and why to use these protective masks. In last two decades of the factory, the supply of masks and gloves was highly irregular. "Stock of the facemasks used to be consumed in short span and next would arrive a few months later. We used to get masks and other personal protective equipment only when some guests were visiting factory." Some of the workers suggested corruption in the management. "When I was on contract, I got nothing. After becoming permanent they gave me a set of two dresses. Sometimes we used to get masks but we had to reuse those after washing. I used to get gloves once in a month or so, which used to get shriveled in three to four days." The overall practice and attitude toward the use of personal protection equipment was very poor and the newly joined, on contract workers were very much vulnerable for exposure. The actual protection afforded by these secondary protective gear are largely uncertain but even these were not used efficiently. Only 3 out of 17 workers said that they used masks regularly for all the years and for all hours a day. Some workers said that it was not possible to use masks as it used to bother their breathing and communication, also it was very irritating. For some it was difficult to work with gloves on. "I used to wear mask when I was working but I used to remove when there used to be no work. Also while sweating, taking rest or talking I used to remove it." Some participants said that the management was not much cautious about their health. "In case of inspection or when important people visit, they used to stop the machines for one hour or so to make everything presentable. They used to distribute all the accessories beforehand like- gloves, towels etc., They used to even bear one hour's production loss."
Apart from exposure to asbestos dust, there were many other health-related risk exposures "Since 1981 I started getting black colored expectoration. Mostly I used to work near a big furnace. It used to be always smoky there."
During health check-ups, factory management used to get x-rays of the workers, probably twice a year but workers did not get any reports in return. "It wasn't a meaningful thing. It was a wasteful circus. Sitting in a bus in batches and going to the hospital for x-ray, coming back, and no reports in return. We couldn't even ask for it because we didn't pay for it." Some workers tried to get the reports of their x-rays out of curiosity, "When we used to ask about our reports they used to avoid the answer or used to say that it is sent to your factory, go and ask there. Some people went and ask to manager also but they refused it by saying these are company's orders not to disclose the reports."
To the question " Given chance to go back to the past, will you take this job again? Why?", only five participants said that they would not take the same job again. One person said that he could not tell what he would have done and rest of the 11 people said that they would have gone for the same job. "It is difficult to say. How can I possibly know what is hidden in future? I think I would have continued there because I was helpless. I had no other options." There were not many jobs in the market at that time. "For people like us it was very difficult to get job and this was a very reputed company at that time. I think I would have neglected the advice and continued to work there." "So many people were working there and all of them were fine. Everything was good. It was 'A' grade company. The salaries were more than other reputed companies." Workers really felt that they were helpless and there was no hope to find another job with fairly good salary. "I still would have done the same job. My immediate need was to feed the mouths of my family. From where would I have got another nice job?"
Two patients were with some neurological problems. Their doctors failed to find any specific etiology. "Yes there is huge limitation. I took voluntary retirement. It was due to this problem as well as my balancing problem. I can't walk properly. I lose my balance like this (leans to one side), on the top of it there was this problem of breathlessness. So I left my job much early. Now I can't speak properly, my speech has become slurred. I have a young son and I'm worried about his future."
Effect of the illness on family life
This disease has also affected their quality of life and independence, "I just can't climb stairs. I get breathless while walking for some distance. I don't think I would have gone for a job at this age anyways but life would have been much better without this disease." "I don't want to do a job now but I have to do a bit of work at home like shopping, cleaning etc., but it is really problematic for me to do all those things." Another worker said, "I stay at my farm but can't work there properly. Other family member think that I'm am not only vestigial but a burden." Many of them avoid doing outside work like small shopping or taking care of grandchildren. Some of them wanted to go for walk or jogging but they were not able to.
A worker with nearly Rs. 3000 monthly income said, "I eat 10 tablets every day. And my total expenditure is around Rs. 1500 per month." The same person said "I can't work and one of my sons has TB. I even can't help him with his work."
For this untreatable disease, patients kept on buying ineffective drugs. "I visited many doctors and got many pills and injections for my weakness. But no one suggested specialist or x-ray. Even now also I feel weak."
After asking 'how did you feel after knowing the cause of your illness', the reaction was mixed; "Then I got angry. They (factory owners) suppressed everything knowingly. It is betrayal. They used to check us only for this reason and didn't show us the results. They should be taught a lesson." But most of the people were quite forgiving, "What to say. It's my fate, what else? There were many other people as well but they didn't get the disease." And recent teaching about the causation of their illness didn't seem to change this attitude much.
| Discussion|| |
As per government of India (1997 data), Indian mines produce 2800 tons of asbestos per month which is just a quarter of total asbestos turnover in India. , In asbestos mining alone, there were 100000 workers involved till 2000  and if we include other asbestos-related industry this number will increase many folds. The asbestos usage rate is increasing at the rate of more than 7% annually in India with 673 small- and 33 large-scale asbestos processing factories currently active. , So in coming decades we are likely to face a huge burden of asbestosis and other asbestos-related diseases.
Problems in diagnosis, treatment, rehabilitation, and reporting
As per WHO report, less than 10% of workers in developing countries, and 20-25% of workers in industrialized countries have access to occupational health facility.  Asbestosis is mainly a diagnosis by exclusion with a positive occupational history. High latency period, the time period between exposure and disease manifestation, is posing unusual hurdles in diagnosis and prevention of this serious occupational disease.  If a case is diagnosed today, its exposure has had occurred about 25 years back and there is no way we can prevent the diseases among other colleagues of that patient.
Ban on asbestos is the ideal step to prevent this disease, , but even after a ban there will be huge burden of this disease for about 30 years. As this is not a curable condition, the best available option is the palliative and rehabilitative care, specifically designed for this illness. Unfortunately, most of the patients belong to lower socio-economic class who cannot afford specialist care, and avail local general practitioners or quacks who give them some symptomatic and non-specific treatment with no cure or prolong betterment. But expense for a disabled and a non-earning member leads to further financial burden on the family, often pushing them below the poverty line.  This contributes to guilt and makes the patient depressive. 
The doctors are not specifically trained to diagnose these respiratory diseases through the lens of occupational diseases. Even when diagnosed, there is lack of referral facilities which can take care of specific health problems of these patients and advise them about the legislative matters for compensation. In India, there is not even a registry for occupational diseases.
Occupational physicians and therapists who are likely to diagnose these patients are employed by factory owners. It is expected that these doctors should willingly or unwillingly perform the role of the gatekeeper, by preventing losses of the firm from the compensation or production loss.  While there is little doubt that doctors have their primary responsibility towards their patients this dual loyalty puts the employer interests ahead of the patient care.
For private practitioners, there is no standard protocol of referring the worker to any specific body which will take care of worker's health as well as rights. 
Out of 17, at least 11 patients had problem in walking for more than 10 min, fast walking, or climbing on slope. As per the modified medical research council- MRC grading of breathlessness (having incremental grades from 0 to IV, indicating higher the grade greater is the breathlessness), two patients had grade IV, four had grade III, seven had grade II and rest had grade I breathlessness; seven patients had accompanied palpitation and four complained about cough.
From the narrations of these workers, it is clear that apart from asbestos exposure, there were many other health hazards from various chemicals, heat and dust in the working environment. The combined effect of all these hazards is difficult to predict. But it is suggested that there is added risk due to combined effects of these factors on lung diseases and cancers.
This problem affects other co-morbidities especially non-communicable diseases such as other pulmonary diseases and cardio-vascular diseases like hypertension, stroke, and dyslipidemia. Due to disability, patients do not move around much and their physical activity reduces significantly reducing the overall quality of life. 
It is seen that quality of life decreases among asbestosis patients. , There are many factors which might have affected quality of life in these patients like old age, poverty, chronic illness, disability and mobility restriction, dependability, and no efficient medical care. Depression is highly prevalent in these patients leading to lack of self-care causing further degradation of health.
There is added risk of deaths due to pneumonia among asbestosis patients due to compromised functioning of the respiratory system. Studies have shown that in these patients, it is beneficial to use Pneumococcal and influenza vaccine. 
Apart from that, studies have shown that there is a significantly high incidence of mesothelioma among asbestosis patients. ,
Construct of workers' attitude
The selective distribution of protective instruments, no precise training and lack of health awareness diluted the conceived importance of use of the protective equipment among the workers and this practice seems to be quite common in India.
In the sixties and seventies, there was a shortage of good employment and this factory was recruiting. The Indian economy was closed and people were crowding in the economical capital of India of Mumbai, with the hope of employment. Asbestos sheets are cheap and reasonably good material for low cost houses and shelters. So there was a good demand of asbestos sheets and at that time this industry was booming because of overcrowding in cities. There were not many jobs in the market, making this a much sought-after job.
When the ill health effects of a risk are directly visible, workers are more likely to become aware. But in the case of asbestos, the gradual deleterious effects are evident after 20 to 30 years. Further, it is difficult to diagnose with conventional investigations. There seemed no apparent risk or threat to their health.
All the people were above the age of 59 years and were retired from their work. So primarily, most of them perceived that their respiratory problems and disability were manifestations of old age. Due to the gradual increasing disability, it got accepted by the patients. India is a society where the concept of karma and fate is an explanation for symptoms, in the absence of any direct/visible causative agent. Most of the times worker continued to suffer without the knowledge that his past work was responsible for his existing condition even after diagnosis, compounded with a lack of explanation by the specialist doctor to old and poor patient. 
It seemed through informal talks that subjects had hardly any feeling of violation of their rights and it did not occur to them that this illness was an injustice to them. This suggests the need for a very intense program to make workers aware about their health and rights. These training program need to be individualized depending upon the type of industry and it should be regulated by an independent government body.
A report on health status of asbestos worker by Government of India itself conclude that there are no precautionary measures for prevention, health status is very bad with 34.6% of the examined workers had compromised pulmonary function.  It is a vital responsibility of state to protect the workers who have no other option than to work in risky environment by proper implementation of the acts related to workers health and rights.  Workers are in such a predicament that they are ready to do anything to earn their bread. The risk perception is at very minimal level especially for diseases with long latent period.  It is not practical to ask job for everyone but state has to at least make sure that working environment should be safe for all. In India, more focus is on infectious diseases and recently non-communicable diseases have also been given importance in public health. The neglect toward occupational diseases remains, even though these diseases have promising control and prevention possibilities. These workers are the backbone of India's industrial development but unfortunately they are the only people who are paying for this development through their disabilities and low quality of life.
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