Why a fourth wave of British asbestos deaths is imminent

Over the past decade a series of alarming reports have emerged about a rising number of deaths from mesothelioma – a rare cancer of the lung lining associated with asbestos.

What is striking is that the victims have not worked with asbestos, nor have they been knowingly exposed to it. Initially dismissed as statistically insignificant or explicable by other means, this growing number of deaths now looks like the beginning of a fourth wave of asbestos mesothelioma deaths.

This article will describe the history of the asbestos epidemic, elucidate the evidence for this current wave and search for explanations. Thankfully, the overall numbers of mesothelioma and asbestos deaths may now be starting to fall, as predicted. However, this decline appears to be masking a rising trend among certain occupational groups and a number of younger ‘inexplicable’ victims.

The essential dynamics of exposure

It is useful to have a grounding in the underlying causes. There are four factors which determine the number of mesothelioma cases: (1) the number of people exposed, (2) the dose to which they are exposed, (3) the age of exposure, and (4) the toxicity of the fibre types. As we look at the waves of exposure in more detail, the interplay between these dynamics changes. Compared to the past, people are now more likely to be exposed to amosite (brown asbestos) earlier in life, albeit at a much lower dose. We know that asbestos is a zero-threshold exposure. 

A brief description of the first, second and third waves and their victims

The asbestos epidemic has unfolded in several historical waves. Each proved difficult to discern until it could no longer be ignored. Throughout this period, those with the most to gain from the continued use of asbestos have acted to obscure or deny the dangers that this material presents. In the past, companies which mined and manufactured asbestos fiercely protected their commercial interests. Yet since the use of all asbestos has been banned in the UK, we have witnessed a succession of different governments that have been unwilling to deal with the legacy of asbestos in buildings. 

The schematic below illustrates some of the prevailing dynamics at play; namely how our knowledge of asbestos has risen in line with the number of people exposed, while the dose of exposure corresponds to the fall in age of those exposed. 

First wave: The first wave comprises the handling of raw asbestos by miners and dockers, and the manufacturing of asbestos products. It lasted from roughly 1880 to 1990 in the UK. 

Nellie Kershaw died from asbestosis in 1924, having been exposed as a textile worker in Rochdale. Her death due to pulmonary asbestosis was the first such case to be described in medical literature and the first published account of disease attributed to occupational asbestos exposure. 

Second wave: In Europe and the USA, the second wave closely followed the timing of the first wave and afflicted construction workers and those installing asbestos products, such as garage mechanics and laggers, amongst others.  

Again, the number of working age people who suffered these high exposures was relatively small and the knowledge to empower prevention was relatively low, but was actively being developed. 

Third wave: Here we are describing people exposed to occasional very high doses during repair, renovation and removal of asbestos by trade and construction workers, during the period from circa 1980 to the present. By this time, our knowledge of asbestos disease and its causation had improved significantly. 

Fourth wave: Asbestos was installed liberally in the UK’s built environment throughout the last century and many of these buildings remain in use. However, some are now well past their design life, known to be in poor condition and inadequately maintained. Asbestos materials are crumbling and due to the normal disturbance of buildings they are releasing fibres into the air

Source: Charles Pickles

As a result, virtually everyone is exposed to asbestos in the UK today, albeit to much lower concentrations. 

Two scientific facts which pinpoint this are key to eradicating cases of mesothelioma from asbestos in the UK today. Firstly, the demographics of exposure. The risk of contracting mesothelioma roughly doubles for every decade exposed. So, children are more at risk. A child of five has five times the risk compared to an adult of 30, given the same level of exposure. 

Having worked in asbestos consultancy for two decades and responded to innumerable incidents of asbestos disturbance in schools, it is evident that the risks cannot be controlled. All asbestos types are highly carcinogenic, but the amphiboles much more so. The algorithm used to assess risk set out in the Health and Safety Executive’s Asbestos: The Survey Guide, (see Appendix 12, p.67), scores the risk from amosite as two on a scale of one to three, with chrysotile (white asbestos) scored one and crocidolite (blue asbestos) scored three. 

By contrast the known hazard potency for mesothelioma is one for chrysotile, 100 for amosite and 500 for crocidolite. Additionally, the algorithm omits any risk weighting for age or children. Thus, the official risk assessment massively underestimates the known risks, to give the impression that dangerous hazards can be managed in-situ. Given inevitable and concurrent exposures to amosite in schools, children are most likely to make up the future ‘fourth wave’ of mesothelioma deaths. CLASP (system built) schools, which are riddled with amosite, are arguably Britain’s public health enemy number one. 

Our knowledge of asbestos disease is now well advanced and more than sufficient to know of and act to prevent these risks. Many nations have recognised the risks of asbestos in-situ and adopted laws and strategies to mitigate the risks. In the UK, HSE, under the Health and Safety at Work Act 1974, section 11(2)(b), has a duty to commission research to answer the big questions. 

Given that asbestos accounts for circa 5,000 occupational deaths versus 138 work-related fatalities (2024 statistics), the big question is obviously how much risk is society exposed to from asbestos today and how many will die from current and future exposure?

These questions remain unacknowledged and unanswered. Academic epidemiological curiosity on the topic is met with contempt and a blind eye, with a refusal to look beyond published statistics such as the HSE SOC (Standard Occupational Classification) codes for fatal disease cases suspected to be caused by, or connected, to work-related exposures to hazardous substances. SOC codes do not include those who die over the age of 75. Currently, they record less than half of mesotheliomas and are unsuitable for capturing data for those who have suffered less exposure and are therefore likely to succumb to the disease over the cut-off age of 75 where the cause of death is not recorded. 

Thus, evidence for the fourth wave is not currently being collected by HSE, who have no plans to change. 

Moreover, Condition Data Collection 2 (CDC2), the Government document outlining the procedure used to collect school condition data to inform refurbishment and rebuilding programmes, instructs its readers ‘not to review the content’ of any asbestos surveys for schools. With the tick of a box, the asbestos risk in schools is therefore effectively ignored.

The evidence for a fourth wave of asbestos deaths

In 2018, while attending an asbestos conference, I asked an HSE official with a senior role within asbestos policy, “how do you explain the growing numbers of mesothelioma deaths amongst female school teachers?” 

His response was to imply that the numbers were statistically insignificant and that the individuals were “probably exposed while working on building sites”. The bell for the next session rang and he rapidly excused himself, leaving me and those with me to ponder in stunned silence: how many educated young women worked on building sites in the 1970s, during university holidays? Not many. 

The obvious explanation is that they had been exposed to asbestos during their many years working in CLASP schools. Against such a culture of obfuscation from those with a duty under HSWA 1974 to answer the relevant questions, it is not surprising that the evidence for a fourth wave is slow to emerge. The evidence comes from a small number of disparate sources.

In a recent presentation to a FAAM (Faculty of Asbestos Assessment and Management) conference, Emeritus Professor John Cherrie talked about the asbestos exposure risk weighting between the ‘normal’ occupants of buildings (for example, teachers) and those who occasionally work in or on such buildings (for example, maintenance contractors, such as plumbers). Due to the far greater numbers of people and much greater exposure time, the ‘normal’ occupants were seen to carry a risk 15 times greater than those who work in buildings periodically, despite significantly lower exposures. The fibre concentrations assumed were 0.00005 f/ml for normal occupation and 0.005 f/ml for maintenance workers respectively. 

The ‘Duty to Manage Asbestos’ implies all we need to do is protect maintenance workers as there is zero risk to the usual occupants. But the Duty to Manage identifies the wrong target. It is a highly ineffective policy, that emphasises the small risk to maintenance workers, while distracting attention from the real risk posed by asbestos in buildings, which is exposing society at large to this zero-threshold carcinogen. 

Professor Cherrie noted: “The main source of future mesothelioma cases and asbestos-related lung cancers is likely to arise from background exposure for people like teachers and office workers in buildings containing ACMs,” and added “the main problem with this analysis is that it doesn’t tell us how many cases of disease might occur. These weightings may represent thousands of cases or a handful.”

Seven years ago, in 2017, occupational hygienist Robin Howie presented evidence that teachers and nurses were four and two times more likely respectively to die from mesothelioma than expected.3 Howie based these calculations on Proportional Mortality Rates (PMRs) and HSE statistics. 

Later in 2023, for a BOHS (British Occupational Hygiene Society) poster presentation, Howie stripped away the masking effect of PMRs (which use the UK – the world’s most exposed population to asbestos – as the background rate), and stated that the rates of mesothelioma deaths among teachers and nurses are 84 times and 25 times higher than expected respectively. 

Similarly, a 2024 study from the Mesothelioma UK Research Centre confirmed the underestimation produced by the UK Government’s preferred source of information, stating: “ONS data records deaths per year from mesothelioma as around seven per annum (pa) for health professionals and 23 pa for education professionals. By contrast the numbers of former health and education workers claiming mesothelioma-related benefit payments are around 65 pa and 70 pa respectively.”

Writing about British schools in 2024, Dr Gill Reed estimated that hundreds of thousands would die from mesothelioma (from attending school) after the mid-1990s due to increased exposure to damaged asbestos. As school is not an occupation, these deaths will not be recorded by SOC codes and will swell the background rate, suppressing occupational statistical peaks. 

Unfortunately, the issue of ‘unexpected’ exposure is not just confined to schools, although this is clearly a heightened risk given the age profile of pupils. Most buildings built before the ban on asbestos are likely to contain the material, including hospitals and housing. 

The UK military also has a problem with asbestos and mesothelioma. In 2020, Mesothelioma UK published research showing that 340 (mesothelioma) claims were made to the AFCS (Armed Forces Compensation Scheme) between April 2016 to March 2020. 

With PMRs tracking the victims’ last occupation, military mesotheliomas are unlikely to be statistically significant using HSE’s preferred method of analysis, because veterans retire from the military and usually find another job prior to their final retirement. The truth has been revealed not by HSE, but by a charity and Professor Angela Todd’s research team at the Mesothelioma UK Research Centre. 

Recently the Daily Mail reported that mesothelioma has killed nine times more former service personnel than the conflict in Afghanistan. 

There is also anecdotal evidence of a cluster 

of mesotheliomas among BBC employees. This has yet to be properly investigated: organisations tend not to broadcast their own bad news. As the saying goes, ‘absence of evidence is not evidence of absence’.

Other clusters and cohorts exist, but there really has been insufficient national effort to collate these deaths. This is an unforgivable failure by HSE. Investigating deaths from our asbestos legacy must surely be worthy of study, rather than blithe words and a blind eye.

Conclusions

Primary legislation, such as the 1984 Asbestos Prohibition Regulations, has been remarkably effective in reducing asbestos exposure and will act to reduce the number of asbestos deaths. 

The fourth wave of deaths will thankfully be much smaller than the first, second or third waves. However, while deaths in the third wave of exposure are tragic, those from the fourth wave are inexcusable. We may expect hundreds or thousands more younger people to die from mesotheliomas as a result of exposure earlier in life. We therefore have a duty to speak out and demand action to end the UK asbestos epidemic.

Charles Pickles is the founder of Airtight on Asbestos, a campaign which aims to improve the UK’s approach to the management of asbestos. See:
airtightonasbestos.uk