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PETITIONER: CONSUMER EDUCATION & RESEARCH CENTRE AND OTHERS

       Vs.

RESPONDENT: UNION OF INDIA & OTHERS

DATE OF JUDGMENT27/01/1995

BENCH: RAMASWAMY, K. BENCH: RAMASWAMY, K. AHMADI A.M. (CJ) PUNCHHI, M.M.

CITATION:  1995 AIR  922            1995 SCC  (3)  42  JT 1995 (1)   636        1995 SCALE  (1)354

ACT:

HEADNOTE:

JUDGMENT: 1.  Occupational  accidents  and diseases  remain  the  most appalling  human  tragedy of modem industry and one  of  its most  serious forms of economic waste.  Occupational  health hazards  and  diseases to the workmen employed  in  asbestos industries are of our concern in this writ 640 petition  filed under Article 32 of the Constitution by  way of   public  interest  litigation  at  the  behest  of   the petitioner, an accredited Organisation.  At the inception of filing  the  writ  petition  in the  year  1986,  though  it highlighted   the  lacuna  in  diverse  provisions  of   law applicable  to the asbestos industry, due to orders  of-this Court  passed from time to time, though wide gaps have  been bridged by subordinate legislation, yet lot more need to  be done.  So the petitioner seeks to fill in the yearning  gaps and  remedial measures for the protection of the  health  of the  workers engaged in mines and asbestos  industries  with adequate  mechanism  for and diagnosis and  control  of  the silent killer disease " asbestosis", with amended prayers as under-               (a)   Directions to all the industries and the               official-respondents to maintain  compulsorily               and  keep  preserved health  records  of  each               workman for a period of 40 years from the date               of  beginning  of the employment or  10  years               after   the  cessation  of   the   employment,               whichever is later;               (b)   To  direct  all the factories  to  adopt               "THE MEMBRANE FILTER TEST";               (c)   To direct all industries to compulsorily               insure   the   employees  working   in   their               respective industries, excluding those already               covered  by the Employees State Insurance  Act               and  the  Workmen Compensation Act  so  as  to

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             entitle   the   workmen   to   get    adequate               compensation   for  occupational  hazards   or               diseases or death;               (d)   To  direct the authorities to appoint  a                             committee of experts to determine the standard               of  permissible  exposure  limit  value  of  2               fibre/cc  and  to  reduce  to  1-fibre/cc  for               Chrystolite type of asbestos, 0.5-fibre/cc for               Amosite  type  of asbestos and  for  the  time               being  0.2-fibre/cc  for Crocidolite  type  of               asbestos   at  par  with   the   international               standards;               (e)   To direct the appropriate Govenunents to               cover the workmen and to extend them Factories               Act  or  by  suitable  regulatory   provisions               contained  therein to all small scale  sectors               which arc not covered under the Factories Act;               (f)   To  direct  re-examination  of  such  of               those  persons  who are found  suffering  from               Asbestosis    by   National    Institute    of               Occupational   Health  but  not   the   E.S.I.               hospitals; and in particular the Inspector  of               factories,  Gujarat, be directed to  have  re-               examined all those workmen, examined by ESI by               N.G.D.H. and to award compensation; and               (g)   To  direct  the  Central  Goverment   to               appoint  a committee to recommend whether  dry               process  can  be completely  replaced  by  wet               process. 2.   It  would  appear from the record  that  in  Karnataka, Andhra  Pradesh  and Rajasthan, there  exists  about  thirty mines  and  the workmen employed therein are  about  106  1. There  are  about  74 asbestos industries  in  nine  States, namely,   Haryana,   Delhi,   Andhra   Pradesh,   Karnataka, Rajasthan, Maharashtra, Kerala, Gujarat and Madhya  Pradesh. It would also appear that as on August 1986 there are  about 11,000  workmen  employed in those  industries.   Basing  on Biswas  Committee  report,  the petitioner  filed  the  writ petition.   The  Central Govt. accepting  the  said  report, framed  modal  Rule 123A of Factories Act and on  its  model relevant  laws  and Rules were amended and are  now  brought into  force.   We  are not referring  to  the  findings  and recommendations  of Biswas Committee as the  "Asbestos  Con- vention, 1986" covered the whole ground. 3.   In Convention 162 of the Interna- 641 tional  Labour Conference (ILC) held in June, 1986,  it  had adopted on 24th June, 1986 the Convention called "the Asbes- tos  Convention, 1986".  India is one of the signatories  to the  Convention and it played a commendable role  suggesting suitable amendments in the preparatory conferences.  It  has come  into force from June 16, 1989, after its  ratification by  the Member-States.  Article 2(a) defines  "asbestos"  to mean  the  fibrous form of mineral  silicates  belonging  to rock-forming   minerals  of  the  serpentine   group,   i.e. chrysotile  (white  asbestos), and of the  amphibole  group, i.e. actinolite, amosite (brown    asbestos,  cummingtonite- grunerite),anthophyllite, crocidolite (blue asbestos), tremolite, or  any mixture containing one or more of these."  "Asbestos dust"  is  defined  as "airborne particles  of  asbestos  or settled particles of asbestos" which may become airborne  in the  working  environment  "Respirable  asbestos  fibre"  is defined  as a particle of asbestos with a diameter  of  less than sum and of which the length is at least three times the diameter;  "Workers" coverall employed persons;  "Workplace"

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covers all places where workers need to be or need to go  by reason  of  their  work and which are under  the  direct  or indirect control of the employer; 4.   Article   5(2)   provides  that   "National   laws   or regulations  shall  provide  for  the  necessary   measures, including   appropriate  penalties,  to   ensure   effective enforcement  of  and compliance with the provisions  of  the Convention.". Article 8 provides that "employers and workers or  their  representatives shall co-operate  as  closely  as possible at all levels in the undertaking in the application of  the  measures prescribed pursuant to  this  Convention". Article  9 in Part III prescribes Protective and  Preventive Measures,  regulating that the national laws or  regulations shall  provide that exposure to asbestos shall be  prevented or controlled by one or more of the following measures   (a) making work in which exposure to asbestos may occur  subject to regulations prescribing adequate engineering controls and work practices, including workplace hygiene; (b) prescribing special  rules and procedures including  authorisation,  for the  use  of  asbestos or of certain types  of  asbestos  or products containing asbestos or for certain work  processes. "  Article 15 postulates that (1) "the  competent  authority shall  prescribe limits for the exposure of workers  to  as- bestos  or other exposure criteria for the evaluation of  me working  environment  (2)  the  exposure  limits  or   other exposure  criteria shall be fixed and periodically  reviewed and  updated  in  the light of  technological  progress  and advances in technological and scientific knowledge,  (empha- sis  supplied),  (3)  in all workplaces  where  workers  are exposed to asbestos, the employer shall take all appropriate measures to prevent or control the release of asbestos  dust into  the air, to ensure that the exposure limits  or  other exposure  criteria are complied with and also to reduce  ex- posure  to  as low a level as  is  reasonably  practicable." Clause  (4)  provides that on its failure to carry  out  the above direction to the industry to maintain and replace,  as necessary,  at no cost to the workers, adequate  respiratory protective  equipment  and special  protective  clothing  as appropriate.  Respiratory protective equipment should comply with  standards set by the competent authority and  be  used only as a supplementary, temporary, emergency or exceptional measure and not as an alternative to technical control. 642 5.Article  16 mandates, that  ’each employer shall  be  made responsible  for  the establishment  and  implementation  of practical  measures  for the prevention and control  of  the exposure of the workers he employs to asbestos and for their protection  against the hazards due to asbestos "  (emphasis supplied).   Article  17 provides demolition  of  plants  or structures containing friable asbestos insulation etc.,  the details whereof are not necessary.  Article 18 obligates the employer  to provide clothing to the  workers,  maintenance, handling  and cleaning thereof etc. etc.  Article  19  deals with the disposal of the waste containing asbestos.  Part IV consisting of Articles 20 and 21, deals with surveillance of the working environment and workers’ health.  Article 20 (1) provides  that "where it is necessary for the protection  of the  health  of  workers, the  employer  shall  measure  the concentrations of airborne asbestos dust in workplaces,  and shall  monitor  the  exposure  of  workers  to  asbestos  at intervals  and  using  methods specified  by  the  competent authority."   Sub-Article  (2)  of  Article   20   envisages maintenance of the records:- "the records of the  monitoring of the working environment and of the exposure of workers to asbestos  shall  be  kept for a  period  prescribed  by  the

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competent authority " (emphasis supplied).  Clause (3)  "the workers concerned, their representatives and the  inspection services  shall  have access to these records."  Clause  (4) "the  workers or their representatives shall have the  right to request the monitoring of the working environment and  to appeal to the competent authority concerning the results  of the  monitoring.  ". Article 21(1) envisages  That  "workers who are or have been exposed to asbestos shall be  provided, in  accordance  with national law and  practice,  with  such medical  examinations  as are necessary to  supervise  their health  in  relation  to the  occupational  hazard,  and  to diagnose   occupational  diseases  caused  by  exposure   to asbestos ". Clause (2) adumbrates that such monitoring shall be free of the charge of the workers and shall take place as far  as  possible  during the  working  hours.   Clause  (3) accords to the workers of the right to information, in  that behalf,   of  the  results  of  their  medical   examination (emphasis  supplied) "shall be informed in an  adequate  and appropriate  manner  of  the results of  their  medical  ex- aminations  and receive individual advice  concerning  their health  in  relation  to  their work.   Clause  (4)  is  not material  for  the  purpose of  this  case,  hence  omitted. Clause  (5)  postulates that the competent  authority  shall develop  a system of notification of  occupational  diseases caused by asbestos. 6.Article  22,  in  Part  V,  relating  to  information  and education  is  not relevant for the purpose  of  this  case, hence  omitted.  In Part VI-Final Provisions, Article 24  is relevant for the purpose of this case and Clause (1) thereof states  that  "this Convention shall be  binding  only  upon those Members of the International Labour Organisation whose ratifications  have  been  registered  with  the   Director- General".  The other Articles 23, 25 to 30 are not relevant. 7.International  Labour  Office, Geneva,  has  provided  the Rules  regarding " safety in the use of asbestos".  In  Rule 1. 1.2 (Possible health consequences of exposure to asbestos dust),  it  is  stated  that there  are  three  main  health consequences  associated with exposure to airborne  asbestos (a)  asbestosis: fibrosis (thickening and scarring)  of  the lung tissue; (b) lung 643 cancer:   cancer    of    the    bronchial    tubes;     (c) mesothelioma:cancer   of  the  pleura  or  peritoneum.    In asbestos  workers, other consequences of  asbestos  exposure can  be  the development of diffuse pleural  thickening  and circumscribed  pleural plaques which may  become  calcified. These  are regarded as no more than evidence of exposure  to asbestos   dust.   Other  types  of  cancer  (e.g.  of   the gastrointestinal  tract)  have been attributed  to  asbestos exposure though the evidence at present is inconclusive.  In Rule 1.3, definitions of asbestos, asbestos dust, respirable asbestos fibre have been defined thus :-               (a)   cubestas is defined as the bibrous  form               of  mineral  silicates belonging to  the  ser-               pentine  and amphibole groups  of  rockforming               minerals,   including:  actinolite,   arnosite               (brown asbestos, cumming to nite, grunnerite),               anthophyllite,  chrysotile  (white  asbestos),               crocidolite (blue asbestos), tremolite, or any               mixture containing one or more of these;               (b)   asbestos  dust  is defined  as  airborne               particles of asbestos or settled particles  of               asbestos  which  may become  airborne  in  the               working environment;               (c)   respirable asbestos fibre is defined  as

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             a particle of asbestos with a diameter of less               than. 3 um and of which the length is at least               three times the diameter; 8.In Chapter 3, Exposure limits have been defined thus :-               3.1.1.     -  The concentrations  of  airborne               asbestos in the working environment should not               exceed  the exposure limits ap.proved  by  the               competent  authority after  consultation  with               recognised scientific bodies and with the most               representative organisations of the  employers               and workers concerned.               3.1.2.     -  The aim of such exposure  limits               should be to eliminate or to reduce, as far as               practicable, hazards to the health of  workers               exposed to airborne asbestos fibres.               3.1.3.     -  The exposure level  of  airborne               asbestos in the working environment should  be               established by: (a) by legislation; or (b)  by               collective   agreement   or   by   any   other               agreements  drawn  up  between  employers  and               workers; or (c) by any other channel  approved               by the competent authority after  consultation               with  the most representative  employers’  and               workers’ organisations.               3.1.4 -  it provides periodical review in  the               fight  of technological progress and  advances               in technical and medical knowledge  concerning               the health hazards associated with exposure to               asbestos dust and particularly in the light of               results of workplace monitoring. 9.    In Chapter 4, under Monitoring in the workplace,  Rule 4.4.4  is  relevant  for  the purpose  of  this  case  which adumbrates  that  the measures of airborne  asbestos  fibres concentrations in fibres per millilitre in the workplace air should  be  made by the membrane filter method  using  phase contrast light microscopy as described in Appendix B of  the Rules.  All respirable fibres over 5 um in length should  be counted  by  this  method.  Rule  4.4.5  provides  that  the measurement  of airborne dust concentrations (mg/m3) in  the workplace  air  should  be made  by  gravimetric  method  as described  in  Appendix  C to the Rules.  The  mass  of  the collected total dust should be determined and, by  analysis, the of asbestos and its mass percentage. 10.Rule 4.5 Monitoring Strategy and Rule 4.6-Record keeping, have been adumbrated as under:- 644               4.6.1.  Record should be kept by the  employer               on  aspects of asbestos dust  exposure.   Such               records should be clearly marked by date, work               area and plant location etc.  etc. 11.In General preventive methods, in Chapter V. Rule 5.2. 1. -  All appropriate and practicable measures of  engineering, work practice and administrative control should be taken  to eliminate  or to reduce the exposure of workers to  asbestos dust  in  the  working environment to  the  lowest  possible level.   Rule 5.2.2. provides that "    engineering controls should include mechanical handling, ventilation and redesign of  the  process to eliminate, contain or  collect  asbestos dust  emissions  by such means as  (a)  process  separation, automation  or enclosure; (b) bonding asbestos  fibres  with other materials to prevent dust generation; (c)   general ventilation of the working areas   with clean air, etc. etc. 12.  Chapter  VI  deals  with  personal  protection  of  the respiratory  equipment  etc., the details  whereof  are  not necessary.   Chapter  VII  deals with the  cleaning  of  the

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premises  of  the plant.  Detailed instructions  as  to  the manner  in  which work premises are maintained  in  a  clean state, free of asbestos waste, have been provided and it  is not  necessary to enumerate all the details.  Suffice it  to say  that  every industry shall scrupulously adhere  to  the instructions  contained  in Chapter VII and Ix.   Chapter  X deals with the supervision of the health of workers. 13.  Part  B  deals  with control of  asbestos  exposure  in specific  activities, mining and milling,  asbestos  cement, Textiles.   In  Chapter  15,  Encapsulation  or  removal  of friable   thermal  and  acoustic  insulation  provides   the procedure  for repairs or removal of  asbestos  insulations. In Rule 15.10, dry stripping and Rule 15.10.1. provides that dry  stripping  is  associated  with  very  high  levels  of asbestos  dust  which should, therefore, be, used  only  (a) where wet methods cannot be used; (b) where live  electrical apparatus might be made dangerous by contact with water; (c) where  hot metal is to be stripped and the use of water  may be damaging.  Rule 15.10.2 provides that where dry stripping is  employed,  as  effective a  standard  of  separation  as possible  should be preserved between the work site and  the adjacent areas to prevent the escape of asbestos dust.  Rule 15.10.3 envisages that all workers within the separated area should   be   provided  with,  and  should   use,   suitable respiratory  equipment and protective clothing.   All  other guidelines  are not necessary, hence omitted.  In Rule  15.1 1, wet stripping provides procedure thus:-               "  15.1 1. 1. Areas in which wet stripping  is               being  carried  out should be  separated  from               other work areas.               15.11.2.   All  workers within  the  separated               area    should   use   suitable    respiratory               protective equipment and protective clothing.               15.11.3    Electrical  equipment in  the  area               should be isolated from the entry of water.               15.11.4.   At the end of the work a  competent               person  should ensure that it is safe for  the               electrical supply to be restored.               15.11.5.   Before  removal  is  started,  care               should  be taken did do: asbestos material  is               saturated with water.  This may be made easier               by the addition of a waterwetting agent.               15.11.6    (1) Where cladding has to be               645               removed,  it should first, where  practicable,               be  punctured  and  the  asbestos   containing               material   within  the  cladding   should   be               thoroughly wetted.               (2)   The  cladding  should  then  be  removed               carefully  within the enclosure and  all  sur-               faces  should  be  vacuumed  or  sprayed  with               water.               15.11.7.The water-saturated material should be               removed   in   small   sections   and   placed               immediately   in  labelled  containers   which               should then be sealed.               15.11.8.Any   slurry   produced   should    be               contained  and  not  discharged  into   drains               without adequate filtration. etc. etc. 14.  Rule  15.12 provides stripping by  high-pressure  water jets  the details whereof are not material but suffice it to emphasise that specialised method should be carried out only by  trained  personnel and all precautions relevant  to  the operation  should  be taken.   Special  safety  precautions, including those given in this section of Code, are required,

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since  they  arc very high-pressure spraying  or  dangerous, displaying  at  the  proper  place  in  addition  to   other stripping   warning  notices.   Other  guidelines  are   not relevant  for the purpose of this case but suffice to  state that  every  industry should adopt, adhere to  and  strictly follow  the  Rules  provided for the safety in  the  use  of asbestos. 15.  In  the  "Encyclopaedia  of  Occupational  Health   and Safety",  Vol-1, published by International  Labour  Office, Geneva, the latest 4th Edition, 1991, provides definition of asbestos as has been found hereinbefore and therefore, it is not  necessary to its reiteration.  Its Pathology  has  been stated at page 188 in Vol-1, which is as follows:- "The retained fibres in the alveolar region are 3 um or less in  diameter but may be up to 200 um long.   Animal  experi- ments strongly point to the longer fibres, 5 um and over, as being  much more fibrogenic than shorter fibres.  A  propor- tion  of  the longer fibres, especially  amphiboles,  become coated with an iron Protein complex producing the  drumstick appearance of asbestos bodies.  All types of asbestos  cause similar  fibrosis.  The fibrosis starts in  the  respiratory bronchioles  with  collections  of  macrophages   containing fibres,  and  others lying free.  These  deposits  organise, collagen  replacing  the initial reticulin  web.   Initially only  a  few respiratory bronchioles are affected,  but  the fibrosis  spreads centrally to the terminal bronchioles  and peripherally to the acinus.  The areas increase in size  and coalesce   causing   diffuse  interstitial   fibrosis   with shrinkage.   The  process  starts  in  the  bases  spreading upwards  as the disease progresses; in advanced disease  the whole  lung  structure is distorted and  replaced  by  dense fibrosis, cysts, and some areas of emphysema. The  pleura,  both  visceral  and  parietal  surfaces,   are affected  by  the  fibrosis and to a degree  which  is  much greater than in other types of pneumoconiosis.  The visceral surface may be sclerosed up to 1 cm thick.  In the  parietal pleura  thickening  starts  as  a  basket-weave  pattern  of fibroblasts, the sheets of fibrosis lying along the line  of the  ribs  especially in the lower thorax  and  posteriorly. The edges become rolled and crenated and, after many  years, calcified. The  parietal  thickening may be extensive  and  thick  with little or no parenchymal fibrosis.  The reasons for this are not  fully understood but indicate the need to separate,  if possible, parietal and visceral pleural thickening in life. Diagnosis and types : 646 Table  1 lists the types of fibrosis in the lung  caused  by asbestos that can be Partially or well separated clinically. Recent  epidemiological research indicates  that  asbestosis and  pleural plaque may have differing actiologies,  natural histories,  and  significance  in  terms  of  morbidity  and mortality. Table 1. Types of lung fibrosis caused by asbestos ------------------------------------------------------ Parenchynml Pleural:             Visceral: Acute            Asbestosis                       Chronic             Parietal: Hyaline             Calcified                 Pleuralplaques ------------------------------------------------------ 16.  The Asbestosis has been signified at page 188 which  is as follows: Asbestosis  The signs and symptoms of asbestosis are similar

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to  those caused by other diffuse interstitial  fibroses  of the  lung.  Increased breathlessness on exertion is  usually the  first  symptom,  sometimes associated  with  aching  or transient sharp pains ;in the chest.  A cough is not usually present except in the late stages when distressing paroxysms occur.   Increased  sputum is not. present unless  there  is bronchitis,  the result of smoking.  The onset  of  symptoms (except  following very heavy exposure) is usually slow  and the  subject  may  have forgotten having  any  contact  with asbestos.   Persistent  dull  chest  pain  and   haemoptysis indicate  the need to investigate further the  diagnosis  of bronchial or mesothelial cancer. The  most important physical sign is the presence  of  high- pitched fine crepitations (crackles) at full inspiration and persisting  after  coughing.  They occur  initially  in  the lower  axillae  and  extend more  widely  later.   Agreement between skilled observers on detecting this sign is good but it  may  vary from day to day in the early stages.   It  may also  be  present as an isolated sign in 2-3%  of  otherwise normal  individuals.  There are now means of recording  this sign on tape.  Other sounds  wheezes and rhonchi  are of  no help  in  diagnosis,  but  indicate  associated  bronchitis. Clubbing of the fingers and toes was formerly regarded as an important physical sign.  There is an impression that it  is now less frequently seen.  Its seventy does not relate  well to other aspects of the diagnosis.  There is poor  agreement between   observers  except  when  the  clubbing   is   very pronounced.  It is possible that its presence relates to the rapidity of progression of the disease. The chest radiograph remains the most important single piece of  evidence,  even though the appearances  are  similar  to other types of interstitial fibrosis.  When the  radiography is classified by three or more skilled readers using the ILO 1971  scheme independently, it is found that  virtually  all cases  of  asbestosis are picked up by one or  more  of  the readers   as  Category  1/0  or  above.   The   radiographic appearances  are  well illustrated in the  set  of  standard films  of  the ILO 1980 Classification of  the  radiographic appearances  of  the  pneumoconioses  (see   PHEUMOCONIOSES, INTERNATIONAL   CLASSIFICATION  OF).    The   classification provides  a means of recording the continuum from  normality to the most advanced stages on a 12-point scale of  severity (profusion)  and of extent (zones) affected.   The  earliest changes  usually occur at the bases with the  appearance  of small  irregular  (linear)  opacities  superimposed  on  the normal  branching architecture of the lung.  As the  disease advances the extent increases and the profusion of irregular opacities  progressively  obscures  the  normal  structures. Shrinkage  of  the  lung  occurs,  with  elevation  of   the diaphragm. in advanced cases 647 distortion  of  the  lung with cysts  (honeycomb  lung)  and bullae  occur.   The  hilar  glands  are  not  enlarged   or calcified unless exposure has been to mixtures of  silicious dusts.   This  may occur, for example,  in  making  asbestos roofing  shingles  or pressure pipes, and  in  mining.   The small opacities may then be rounded rather than irregular. The  pattern of lung function provides the  important  third component  in  diagnosis.  The functional  changes  are  the result  of  a  shrunken and  non-homogeneous  lung,  without obstruction  of the larger airways  (restrictive  syndrome). The  total lung volume is reduced and especially the  forced vital capacity (FVC), but the ventilatory capacity  (FEV1.0) is  only reduced in proportion to the FVC, so the ratio  FEV 1.0/ FVC is normal or even raised.  The transfer factor  for

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carbon monoxide is reduced in later stages, but in the early stage an increase of ventilation on a standard exercise test may  be  the only alteration indicating  impairment  of  gas exchange.   Although  the restrictive syndrome is  the  com- monest  pattern  (about 40%) in about 10%  of  cases  airway obstruction is the main feature and in the remainder a mixed pattern  is seen.  This is though to be largely due  to  the confounding effects of cigarette smoking. Visceral  pleurisy:  chronic and acute This  occurs  in  two forms  chronic and acute.  The former is the commoner and is a  usual  accompaniment  of  parenchymal  disease,  but  its severity does not run parallel with the parenchymal disease. The diagnosis is radiographic.  In some cases one or both of the costophrenic angles are filled in but the more  specific feature  is  the appearance of well defined  shadow  running parallel to the line of the lateral chest wall and separated from  it by a narrow (1-2 nun) clear zone.  This is  due  to the  thickened pleura seen "edge on".  It is illustrated  in the ILO 1980 standard set of films.  The thickening is  best seen  in  the middle and lower third of  the  lateral  chest wall, the apices are usually spared.  It is common in  those only lightly exposed to find this pleural thickening as  the only  radiographic  feature.   It  is  readily  missed  when present  only  over a short length of the wall  and  if  the radiographic technique does not give a clear picture of  the periphery of the lung.  When the visceral pleura is  greatly thickened  it  causes veiling of the lung  field,  obscuring both  the  normal structure and parenchymal  changes.   This probably  the  basis of the "shaggy heart" and  the  "ground glass"  appearance  described  in  the  carly  accounts   of asbestosis.   The  wide  recognition  that  small  areas  of pleural thickening may be the only sign of past exposure  to asbestos  is  recent, and it seems to be a  feature  of  the effects of low exposure to the dust.  It is likely to remain an important observation for monitoring exposure to improved conditions in the future. Acute pleurisy affecting the bases, and costophrenic angles, with effusions, sometimes blood-stained, is now a recognised sequel  to  asbestos dust exposure.  It is  associated  with pain,  fever, leucocytosis and a raised blood  sedimentation rate.  It settles in a few weeks but leaves the costophrenic angles obscured.  No precipitating factors have been identi- fied.  Its recognition is important.  Firstly, the cause may be missed unless and adequate occupational history is taken; secondly  not all effusions in asbestos workers signify  the onset  of  an  asbestos-related  cancer.   A  few  weeks  of observation may be necessary to confirm the aetiology. Summary of diagnosis  The diagnosis of asbestosis  therefore depends upon (a)a history of significant exposure to asbestos dust rarely starting less than 10 years before examination: 648 (b)  radiological  features consistent with  basel  fibrosis (Category 1/0 and over, ILO 1980); (c)  characteristic bilateral crepitations; (d)  lung  function  changes consistent with at  least  some features of the restrictive syndrome. Not all the criteria need to be met in all cases but (a)  is essential,  (b) should be given greater weight than  (c)  or (d);  however,  occasionally  (c) may be  sole  sign,  Other investigations are not of much help.  Asbestos bodies in the sputum  indicate past exposure to asbestos but are  not  di- agnostic  of asbestosis.  Their absence when there  is  much sputum  and marked radiological changes of fibrosis  suggest an alternative cause for the fibrosis.

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Immunological  tests  may  be positive but do  not  help  in consistent  separation  of asbestosis from  other  types  of fibrosis.   Lung  function  results  must  be  assessed   in relation  to appropriate standards allowing for ethnic,  sex and age differences and for cigarette smoking. Asbestos  corns  on  the fingers  area  of  thickening  skin surrounding  implanted fibres  are now much less common  be- cause much of the asbestos fibre is packed mechanically  and gloves  are  worn.   Corns do not lead to  skin  tumors  and disappear on removal of the fibres. 17.Pleural plaques and sources of exposure to asbestos  have been stated at page 189-191, thus :- Pleural plaques  Parietal pleural plaques alone rarely cause symptoms.   They  may occur alone or with  asbestosis.   The diagnosis  in  life is radiological and the  appearance  are more specific than in the case of parenchymal fibrosis.   PA films   will  detect  most  cases,  but  because  they   are frequently  thickest posteriorly their full extent  is  best seen  using oblique views.  The ILO 1980 standard film  show their  appearance  and the scheme provides,  for  the  first time, a separation of parietal (circumscribed) and  visceral (diffuse)  pleural  thickening.  The plaques lie  along  the line of the ribs, and when thick cast a well defined  shadow over  the  lung field extending in from  the  lateral  chest wall, where they may also be seen "edge on". Separation  from  visceral thickening depends largely  on  a defined edge to the shadow.  Both types may occur  together. Dependent mostly on the length of time since first exposure, and  age,  patchy Calcification occurs in the  edges.   This produces  a  bizarre  pattern of dense  shadows  likened  to "gluttering  candle  wax" or a "holly leaf".  The  onset  of calcification  reveals  many small  plaques  not  previously visible.   When  calcification  occurs  in  a  crater-shaped plaque  on  the dome of the diaphragm a  diagnosis  of  past exposure  to asbestos or related minerals can be  made  with confidence. Sources of exposure to asbestos  Formerly it was though easy to establish past exposure to asbestos by inquiry about work in manufacturing plants, or the application of the fibre for insulation.  Now it is realised that only the most  detailed history  of  all  jobs, residences and  occupations  of  the family  will  reveal possible exposures  to  asbestos.   The reasons for this change are (a)  the much wider use of asbestos in thousands of products especially since the Second World War (see ASBESTOS): (b)  the  recognition that significant exposure to  asbestos occurred around mines and manufacturing plants in the past; (c)  the  discovery of family exposure to the  dust  brought home on clothing, and 649 also  that  those  working in an area where  lagging  is  in progress  may be affected, even though they are  engaged  in lagging; (d)  the    finding   that   calcified   pleural    plaques, indistinguishable  from those occupationally  exposed,  also occur  in  the  general population  in  localised  areas  in several countries (Finland, Czechoslovakia, Bulgaria, Turkey and others). With the discovery of such diversity of sources of  possible exposure,  but virtually no quantitative  information  about its  severity, and few long term follow up studies of  those exposed, it is not surprised that there is controversy about the health hazards.  However, some conclusions emerge  which must be subject to revision in the future. (1)Asbestosis  is  primarily  occupational  in  origin,  the

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result of mining , milling,   manufacturing,       applying, removing  or transporting asbestos fibre.  Exposure is  much less when the fibre is bound in the product (asbestos cement and  asbestos plastic and paper product).  Also exposure  in the  past was much greater than it is today with the use  of the best working practices. (2)Asbestosis  may  have been caused by home  exposure  from dusty  clothing at a time when there was no dust or  hygiene control in the factories. (3)Asbestosis does not result from the very limited exposure to  which  the general public is or has been  subject,  even though asbestos fibers are detectable in the lungs of a high proportion  of adults in industrialized areas.   The  median numbers  of fibres so detectable are two to three  order  of magnitude  less than that found in those occupationally  ex- posed. (4)  There  are and have been important differences  between countries  in the use of asbestos,so that exposure  for  the same  occupation  varies  widely.   For  example,  dry  wall fillers  (sparkling) contain asbestos in the  United  States but  not the United Kingdom; thus sanding of internal  walls during construction and maintenance is a source of  exposure in  the  former  but  not  in  the  latter.   On  the  other hand,spraying of crocidolite was much more widespread in the 1940s in the United Kingdom that elsewhere. (5)  Pleural  plaques  can  arise  at  levels  of   exposure probably much lower that required to produce asbestosis.  In addition  it  is  probable that  other  minerals  can  cause plaques.   For example, among chryosotile miners  in  Quebec calcified  plaques are limited to those who have  worked  in two out of the eight mines.The minerals causing the  plaques in  general  population  have not  been  fully  established. Tremolite,  an  amphibole  often  present  in  deposits   of asbestos, may be important. (6)  Whether   chrysotile  and  the  amphiboles  differ   in fibrogenicity  in  man  is  uncertain,  but  some   evidence indicates  that the amphiboles may be more  fibrogenic.   In animals there is little difference but the amphiboles remain in the lung much longer than the chrysotile. The  relation of asbestosis to dose of dust  In only  a  few instances are there records of past dust sampling to  relate to  the  prevalence  or incidence of  asbestosis.   But  the information  has been exhaustively analysed for  miners  and millers in Quebec, a group of asbestos cement workers in the United  States  and asbestos textile workers in  the  United Kingdom,  because of its relevance to setting hygiene  stan- dards.   In North America the dust was measured in  millions of  particles/ft3, in the United Kingdom in fibres/cm3   the measurement now international used. 650 All the data show a clear relation between estimated dose of dust (concentration x time of exposure) and the incidence or severity  of  disease,  but are  insufficiently  precise  to determine  whether  there is a threshold level  below  which asbestosis  will not occur.  A cautious conclusion from  the North  American  studies  is  that  at  about  100   million particles/ft3/yr there might be a threshold or that the risk of developing asbestosis would be as low as 1% of men  after 40 years’ exposure could be as WWI as 1.1 fibres/cm3 or  may have  to  be  as  low  as  0.3  fibres/cm3".   More  precise information  will  only  become  available  when  the   dust sampling introduced widely after the mid-1960s is related to the incidence of disease in the future. The  relation of asbestosis to lung cancer -  The  important questions  here  are: firstly, is there an  excess  risk  of

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bronchial cancer only in those who also have some degree  of asbestosis?  Secondly, if the dust exposures are low  enough to  eliminate asbestosis, will the excess lung  cancer  risk also  be  reduced  to  an  acceptably  low  level?   Neither question can be answered at present, and so disagreement  is likely.   It  is  known that there is  a  close  association between asbestosis and lung cancer, about 50% of those dying from  or with asbestosis have a lung cancer at post  mortem. Among those knowledgeable about details of the dose-response data  there would probably be agreement that dust  exposures low enough to eliminate asbestosis will also reduce the  ex- cess  bronchial cancer risk to a very low value.  This  does not extend to the risk to a very low value.  This nearly  so closely   related  to  that  of  asbestosis  (see   ASBESTOS (MESOTHELIMO AND LUNG CANCER). PREVENTION - This  depends  on successful control of  dust  exposure  and medical surveillance to protect the individual, as far as is possible,  and  for  the detection of health  trends  in  be group. Engineering  control  -  Replacement of  asbestos  by  other material believed to be safer has been widespread since  the mid1970s.   Man-made  mineral fibres  and  other  insulating materials   are   rapidly  replacing   asbestos   for   heat insulation.   But for other uses, for example, asbestos  ce- ment,   friction  material  and  some  felts  and   gaskets, substitution is not at present practicable. Dust  control  has  been gradually improved  by  partial  or complete  enclosure of plants and the wide use of  well  de- signed local exhaust ventilation.  In the textile section  a completely new wet process of forming the thread has greatly reduced dust level, previously difficult to control.  During maintenance work on old insulation much stricter control  of exposures is possible by isolation of the working areas, and by  training in the use of good working practices to  reduce the  dust,  for  example damping of  the  insulation  before removal and the use of vacuum cleaning in place of sweeping. But  removal of old insulation is likely to remain for  many years  a major potential source of high exposure  (see  also DUST CONTROL INDUSTRIAL. Medical surveillance  The insidious onset of asbestosis  and the  lack of highly specific features indicate the need  for well   recorded  and  systematic,  initial,   and   periodic examinations  of  asbestos workers.  This ensures  the  best chance   of   detecting  the   earliest   signs.    Physical examination of the chest, full-sized, high technical quality chest radiographs and test of FVC and FEV1-0 are the minimum required.   The interval will vary from annually up to  four times  yearly,  with  more frequent visits  when  there  are clinical  reasons.   There is increasing evidence  that  the radiological 651 features   of  asbestosis  are  in  part   cigarette-smoking dependent which requires the recording of smoking histories. This  and  the multiplicative effects of asbestos  dust  and cigarette  smoking on the risk of bronchial  cancer  provide the strongest possible grounds for stopping cigarette  smok- ing  in  those potentially exposed  to  asbestos.   Personal advice  on  the  special dangers  of  smoking  and  limiting opportunities  for  smoking at work are essential  steps  in prevention.   Full  personal protective  equipment  will  be required where dust levels cannot be lowered to the  hygiene standard.    The  system  of  periodic   examinations   also provides, if properly analysed, essential information  about the  effectiveness or failure of the engineering control  of

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the dust.  Tabulation, by age and years of exposure, of  the results  of  classifying  the chest films on  the  ILO  1980 scheme  preferably  by  independent  readers   gives   early evidence  of trends in the prevalence of  asbestosis.   This valuable  information will be missed if the  group  findings are not examined in detail. Treatment:- There  is no specific treatment for asbestosis.   Where  the rate of progression appears unusually rapid further  special investigations,  including lung biopsy, may be justified  if it  is likely to assist in the differential  diagnosis,  and influence  treatment  for example the use of  steroids,  but these  are  not  of  proved value.   The  severity  of  past exposure  is the only factor known to influence  progression rate.   Thus,  those with some evidence  of  asbestosis,  if young   or  middle-aged  should  be  removed  from   further exposure.   In cases where exposure has not been  heavy  and asbestosis  is only detected late in life,, progression  may be very slow and the grounds for removal from work with  as- bestos,  under  good  conditions,  are  less  compelling.The widespread  and  often  misleading publicity  given  to  the hazards  of exposure to asbestos may cause much  anxiety  to those  with  asbestosis, both for their own health  and  for that  of their family.  Reassurance, and the putting of  the likely prognosis in true perspective, are an important  Part of   good  treatment.   The  special  risks  of   continuing cigarette  smoking need emphasis.  Mesotheliomas are a  rare complication in those exposed only to chrysotile. Compensation: - The   conventions  on  the  awarding  of  compensation   for asbestosis    vary   in   different   countries.     Unusual breathlessness on exertion, as a cause of disability, may be required,  even though it is not essential for  a  confident diagnosis  of  asbestosis.  Compensation May be  limited  to those with evidence of parenchymal disease; pleural fibrosis parietal or visceral alone may not be accepted.  Lung (bron- chial)  cancer  is usually accepted as part of  the  disease provided  there  is at least some  evidence  of  parenchymal fibrosis,  but may be rejected if there is  no  radiological evidence  of  pleural  or parenchymal  fibrosis.   There  is plenty  of opportunity for disagreement, especially  when  a factor for uncertainty of prognosis is included.  It is  now established  did asbestos dust alone may cause  lung  cancer although the absolute risk is very small comPared with  that from the combined effects of cigarette smoking and  asbestos dust.   It  has not been established  that  pleural  plaques alone   result  in  an  increased  risk  of   bronchial   or mesothelial  tumours,  above that for similar  exposures  to asbestos  dust  without  these pleural  changes.   The  con- siderable  uncertainty about the likely rate of  Progression of   the  fibrosis  makes  assessment  on  first   diagnosis especially difficult.  Lung biopsy is not justifiable solely for compensation assessment. 652 ASBESTOS (mesothelioma and lung cancer) While  pulmonary  fibrosis  due  to  exposure  to   asbestos (asbestosis)  has been known for decades, the first  reports of  individual cases of asbestosis combined  with  pulmonary cancer which appeared from time to time in various countries were accepted more as a curiosity.  They Id not attract much attention  untill  in  1947 a  British  Chief  Inspector  of Factories, E.R.A. Merewether, reported that lung cancer  was found to be the cause of death in 13.2% of persons known  to have asbestosis who had died and been autopsied between 1923 and  1946.   A similar high proportion of cancer  deaths  in

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asbestosis   was  found  by  other  pathologists   and   the probability   of   a   role   of   asbestos   in   pulmonary carcinogenesis    was   definitely   established    by    an epidemiological  study  by Doll in 1955,  and  confirmed  by further studies. Soon afterwards a new surprising discovery was made in South Africa.  An accumulation of cases of an otherwise very  rare tumour   of  the  pleura  and  peritoneum,   the   malignant mesothelioma, was reported by Wagner in 1959 and related  to exposure to the locally mined type of asbestos, crocidolite. Soon  afterwards cases were identified in  non-mining  occu- pational  exposures  to asbestos in England, in  the  United States and elsewhere. In  contrast with asbestosis, and in contrast    with    asbestos-related    pulmonary    cancer, mesothelioma  was found  also in persons whose exposure  was not necessarily occupational. Bronchogenic carcinoma related to asbestos: - Bronchogenic  carcinoma of the lung.There is a disease  very in  the  general population.  While in  many  countries  the total mortality from cancer slowely declines, the  incidence and  mortality from lung cancer increases and stands as  the most  frequent cause of death from cancer,  particularly  in cigarette  smokers.   It begins with transformation  of  the mucous membrane lining the inside of the bronchus at various level  and such foci of transformation may remain  at  their initial  spot  for some time shedding at times  atypical  or metaplastic  cells  into the sputum  without  causing  other symptoms.   This  is the period in which  we  sometimes  may succeed in discovering these pre-cancerous, or the  earliest cancerous,  changes by sputum cytology sooner than by  other diagnostic methods.  Some of such early alterations of cells is  reversible  and may spontaneously heal  when  the  cause disappears,  e.g. when the person stops smoking.   When  the original  focus  develops definite cancer cells,  the  focus begins  to grow, to bleed and slowly to obstruct the way,  a growing  malignant tumour becomes visible on  the  radiogram and  unless  it  can  be  surgically  removed  as  soon   as confirmed,  it  tends to spread through growth  and  through dissemination  by blood and by lymph and to lead  eventually to   death.   Supporting  treatment  by   chemotherapy   and radiation successfully prolongs life and radical surgery can provide complete healing. The  various components of the bronchial lining may  undergo malignant transformation and consequently the carcinoma  may be  composed of various cells and have various  histological appearances such as adenocar-cinoma or squamous, or oat-cell carcinoma. There  are  no histological or  other  characterstics  winch would specify the individual lung cancer as cancer caused by asbestos. In many cases of asbestos-linked pulmonary cancers the lungs also show pulmonary fibrosis-asbestosis 653 microscopically,  and often macroscopically, and  on  x-ray. examination.    Some  scientists  believe   that   so-called "asbestos lung cancer" can only develop on a  pathologically changed  terrain of asbestotic fibrosis.  There is  evidence of  such a possibility in human pathology:  the  scar-carci- noma.   Others  believe that exposure  to.  asbestos  alone, particularly  in  a  smoker, may  provoke  cancerous  growth without  also causing asbestosis.  The decision between  the two  opinions  is difficult to reach because  in  individual clinical  cases  of bronchogenic carcinoma  we  cannot  dis- tinguish  what is an "asbestos cancer", a "ciprette  cancer" or lung cancer from yet another cause.  Thus, in most  coun-

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tries  bronchogenic carcinoma is considered an  occupational disease  due to asbestos, e.g. for  workmen’s  compensation, only in the presence of coexisting asbestosis.  If pulmonary fibrosis  were a prerequisite for development  of  asbestos- linked lung cancer, it would follow that lowering  exposures to  asbestos to levels which effectively prevent  asbestosis would automatically eliminate "asbestos lung cancer". Epidemiological data In man the link of lung cancer with asbestos has been mainly epidemiological.  while asbestosis cannot occur without  ex- posure to asbestos mad consequenty every case of asbbestoses must  be linked with such exposure, with  pulmonary   cancer the  situation  is quite different.  It is a  rather  common disease  in the general population.  The link with  exposure to asbestos is based on finding whether in those exposed  to asbestos  is  based on finding whether in those  exposed  to asbestos  bang cancer occurs more frequently than  in  those unexposed, i.e. whether in those exposed there is an  excess incidence of lung cancers. Since Doll’s study a number of other epidemilogical studies, of various levels of excellence, have been carried out which confirm  that  indeed  there is an  excess  of  bronchogenic carcinoma  in  persons exposed to  asbestos,  under  certain circumstances, and thus that asbestos must be considered one of a number of carcinogenic substance. What  are the circumstances of a manifest risk of cancer  in asbestos  exposure?   It has been established  that  smoking cigarettes  greatly increases this risk.  In fact the  large majority  of  lung cancers attributed to  asbestos  exposure have  occurred  in smokers.  A lung cancer in  an  asbestos- exposed  non-smoker  has been a rarity.  Table 1  shows  the effect  of  both exposures together while each  of  the  two exposures  also  carries  a risk by  itself.   A  particular exposure  to  asbestos  in the  reported  group  of  workers increased the basis risk of pulmonary cancer in  nonsmokers. However,  since the risk in nonsmokers was very  small,  its further increase still meant only very few cases, if any  at all.  On the other hand, when the basic risk of exposure  to asbestos  was combined with the 11. 8 time higher risk of  a smoker, this combination necessarily produced a serious risk leading to an excess of incidence of pulmonary cancer.  This experience  has  an important  practical  implication:  most "asbestos  cancers of the lungs" could be prevented  if  the workers  did not smoke.  In fact it was found that the  risk for  the asbestos workers who had stopped  smoking  declined after 10 years to the low level existing for non-smokers. The bronchogenic carcinoma has a long latent period, usually 20 years or more.  Consequently, what excesses of  incidence of pulmonary carcinoma linked with asbestos have been  found to  date  must  be linked with exposures 20  years  or  more development  of the tumour.  It is known that  exposures  in those days 654 were  generally very high.  But we usually do not  have  any precise measurements.  Thus in most existing epidemiological studies  it has not been easy, and in some not possible,  to establish  a relation between the incidence of cancer and  a certain quantitative level of exposure, other than that  the exposure had been high. Table 1 -----------------------------------------------------------                     Asbestos  exposure                     Little          Moderate        Heavy Non-smokers          1.0               2.0           6.9 Moderate smokers     6.3               7.5           12.9

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Heavy smokers        11.8             13.3           25.0 From   :   McDonald,J.C.  "Asbestos-related   diseases:   an epidemiological  review" (587-601).  Biological  effects  of mineral   fibres.   Wagner,  J.C.  (ed).   IARC   scientific publications No.30 (Lyons, International Agency for Research on Cancer, 1980) Vol.2. ----------------------------------------------------------- One  quantitative measure commonly used is the  duration  of exposure in years.  In other studies the period since  first exposure   and  the  duration  of  exposure.   Only  a   few investigations  love had the additional benefit of  actually measured data on past levels of exposure.  An example of the latter  is the series of epidemiological studies of  workers of  the  chrysotile  mines of quebec  carried  out  by  J.C. McDonald and his collaborators.  This and some other studies showed a dose-response relationship, i.e. the higher was the dose,  in  terms  of level of exposure,  or  of  periods  of exposure,  or of both of them combined, the higher  was  the excess incidence of bronchogenic cancer.  In fact the excess incidence  of  lung cancer and  statistically  significantly increased relative risk was usually found only in groups  of persons most severely exposed (see Table 2) Table  2.  Relative  risks of lung  cancer  in  relation  to accumulated  dust  or  fibre  exposure,  before  and   after correction  of  work  histories with  controls  matched  for smoking -----------------------------------------------------------                        Accumulated dust exposure                        (millions of particles per                        cubic foot x years)                        ------------------------------------                       <30      30    300      >1000     All                               <300   <1000 ----------------------------------------------------------- Before correction Cases                 89       73    56        27       245 Controls              108      87    42        8        245 655 Relative risk          1       1.02    1.62     4.10    - After correction Cases                  85       73      59        27    244 Controls               101      89      44        10    244 Relative risk          1        0.97    1.59      3.21   -                        Accumulated fibre exposure                        (fibres per ml x years)                        ---------------------------------------                       <100     100    1000 >     3000   All                       <1000   <3000                        --------------------------------------- After correction Cases                   86      76      56        26     244 Control                 110     87      35        12     244 Relative risk           1       1.12    2.05      2.77    - From:     McDonald   J.C.:  Gibbs,  G.W.,  Liddell,   F.D.K. "Chrysotile fibre concentration and lung cancer mortality: a preliminary   report"  (811-817).   Biological  effects   of mineral   fibres.   Wagner,  J.C.  (ed).   LARC   scientific publication No.30 (Lyons, International Agency for  Research on Cancer, 1980), Vol.2. ----------------------------------------------------------- 18.In  Asbestos  Medical  and  Legal  Aspects  by  Barry  1. Castleman at p. 10 had stated that Dr. Merewether  following the  diagnosis by Homburter in his co-incidence  of  Primary Carcinoma  at  EC Lungs and Pulmonary Asbestos  1943  stated that  fibrosis  of  the lungs as it  occurs  among  asbestos

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workers  as the slow growth of fibrous tissue (scar  tissue) between the air cells of the lungs wherever the inhaled dust comes to rest.  While new fibrous tissue is being laid  down like  a  spider’s  web,  that  deposited  earlier  gradually contracts.   This  fibrous tissue is not only useless  as  a substitute for the air cells, but with continued  inhalation of the causative dust, by its invasion of new territory  and consolidation  of  that already occupied it  gradually,  and literally strangles the essential tissues of the lungs.   In Malignant  Mesothelioma in Norway by Gunnar Mowe, 1986  Ed., he stated at p.8 on Aetiology of malignant mesothelioma that in  1943, Dr. Wedler reviewed malignancies in 30  asbestosis cases  in  Germany,  and suggested  a    casual  association between   asbestosis  and  both  bronchial   and   malignant mesothelioma.   At p.9, he stated that in 1969,  Wagner  and Berry reported that 656 all  the  main  types of asbestos  fibres  were  capable  of producing  mesotheliomas  in  rats  after  intrapleural   or intraperitoneal installation.  In the same page in para 2.2, he  stated  that the importance of asbestos  fibre  size  in explaining  the  biological effects of  asbestos  was  first emphasized  by  Timbrell  in 1965.  At p. 14  in  para  3.2, caption   lung  fibre  burden, he  stated  that  lung  fibre burden,  which  is defined as the total content  of  mineral fibres in the lungs, depends on external asbestos  exposure. At  pA 5 in Table 5, Biological effects of  natural  mineral fibres  (asbestos  related diseases), he  stated  that  long latency time from first exposure until onset of disease is a typical feature of all the asbestos related diseases.  At p. 16  in  para  3.4, he stated that among  948  patients  with malignant mesothelioma, 65% were pleural, 24% peritoneal and 11%  pericardial.   At p.21, lung fibre analysis  under  the caption  material  and methods, para 3, he stated  that  the lung  tissue samples- for fibre analysis were obtained  from twelve,  pathology departments the analysis samples from  85 men  and 13 women disclosed the malignant mesothelioma.   At p.25, summary of his results in Paper V, he stated that  the median  latency time from the first year of  exposure  until death was 35 years (range-18-53), and the median time inter- val  from  last year of exposure until death  was  14  years (range:  upto  40  years).   At p.32,  he  stated  that  the estimated  proportion of-men with at least possible  occupa- tional asbestos exposure were 82%.  At p.40, he stated  that strict  regulations and effective control of such  work  are vital  in order to prevent asbestos related cancers  in  the future.   At p. 41 in para 4, he stated that high  amphibole concentration in lung tissue increases the risk of malignant mesothelioma considerably.  Asbestos exposure  corresponding to  only one million fibres per g. of dried lung  tissue  is also  associated with increased risk.  In Blannie S.  Wilson v.  Johns  Manville Sales Corpn Ltd., 684  Federal  2nd  III (1982),  the  United  States Court of  Appeal,  District  of Columbia  Circuit, Ginsburg, J., as a Judge in the Court  of Appeal  deciding the question of limitation of 3 years  from the date of diagnosis of mild asbestos held that the  period of 3 years should be computed from the date of discovery and that  asbestos,  which  is not a cancerous  process,  has  a latent period of 10 to 25 years between initial exposure and apparent  effect.   Even  longer periods of  time  may  pass before mesotheliorna manifests itself In William T. Urie  v. Guy  A. Thompson, 93 L. Ed. = 337 US 163, the Supreme  Court of the United States of America laid that the limitation  of three  years prescribed by the statute of limitation  starts from  the time when the employee discoveres the disease  and

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the  cause  of  action accrues only when  diagnosis  of  the disease   is  accomplished,  and  not  when   the   employee unwittingly,  contracts it nor is each inhalation of  silica dust a separate torn giving rise to a fresh cause of action. 19.It  would thus be clew that disease occurs  wherever  the exposure   to  the  toxic  or  carcinogenic  agent   occurs, regardless  of the country the type of industry, job  title, job  assignment, or location of exposure.  The disease  will follow  the trail of the exposure, and extend the  chain  of carcinogenic risk beyond the workplace.  It is the  exposure and the nature of that exposure to asbestos that  determines the  risk and the diseases which subsequently  result.   The development of the carcinogenic risk due to asbestos or  any other carcinogenic agent, does not require a continu- 657 ous  exposure.   The  cancer risk does not  cease  when  the exposure  to the carcinogenic agent ceases, but  rather  the individual  carries  the increased risk  for  the  remaining years  of life.  The exposure to asbestos and the  resultant long  tragic  chain of adverse medical, legal  and  societal consequences, reminds the legal and social responsibility of the employer or the producer not to endanger the workmen  or the  community of the society.  He or it is not absolved  of the  inherent responsibility to the exposed workmen  or  the society at large.  They have the responsibility legal, moral and social to provide protective measures to the workmen and to  the public or all those who are exposed to  the  harmful consequences   of   their  products.    Mere   adoption   of regulations  for  the enforcement has no  real  meaning  and efficacy without die professional, industrial and governmen- tal resources and legal and moral determination to implement such regulations. 20.  The preamble and Article 38 of the Constitution   of India  the supreme law, envisions social justice as its arch to  ensure  life to be meaningful and  liveable  with  human dignity.  Jurisprudence is the eye of law giving an  insight into the environment of which it is the expression.  It  re- lates the law to the spirit of the time and makes it richer. Law is the ultimate aim of every civilised society as a  key system in a given era, to meet the needs and demands of  its time.   Justice, according to law, comprehends  social  urge and commitment.  The Constitution commands justice, liberty, equality  and fraternity as supreme values to usher  in  the egalitarian   social,  economic  and  political   democracy. Social  justice, equality and dignity of person  are  corner stones  of social democracy.  The concept  ’social  justice’ which  the  Constitution  of India  engrafted,  consists  of diverse  principles  essential for the  orderly  growth  and development  of  personality  of  every  citizen.    "Social justice"  is thus an integral part of "justice"  in  generic sense.  Justice is the genus, of which social justice is one of  its  species.   Social justice is a  dynamic  device  to mitigate  the sufferings of the poor, weak, Dalits,  Tribals and deprived sections of the society and to elevate them  to the level of equality to live a life with dignity of person. Social  justice is not a simple or single idea of a  society but  is  an essential part of complex of  social  change  to relieve  the  poor etc. from handicaps, penury to  ward  off distress, and to make their life liveable, for greater  good of the society at large.  In other words, the aim of  social justice is to attain substantial degree of social,  economic and   political   equality,   which   is   the    legitimate expectations.   Social security, just and humane  conditions of  work and leisure to workman are part of  his  meaningful right  to  life  and  to  achieve  self-expression  of   his

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personality  and to enjoy the life with dignity,  the  State should provide facilities and opportunities to them to reach at  least minimum standard of health, economic security  and civilised  living while sharing according to  the  capacity, social and cultural heritage. 21.  In  a  developing  society  like.  ours  steeped   with unbridgeable and ever widening gaps of inequality in  status and  of  opportunity, law is calalist. rubican to  the  poor etc. to reach the ladder of social justice, Justice K. Subba Rao, the former Chief Justice of this Court, in his  "Social Justice and Law’ at page 2, had stated that "Social  Justice is  one of the disciplines of justice and the discipline  of justice relates to the society." What is due 658 cannot  be  ascertained  by absolute  standard  which  keeps changing  depending upon the time, place  and  circumstance. The  constitutional concern of social justice as an  elastic continuous  process is to accord justice to all sections  of the  society  by providing facilities and  opportunities  to remove  handicaps and disabilities with which the poor  etc. are  languishing  to secure dignity of  their  person.   The Constitution,  therefore,  Mandates  the  State  to   accord justice to all members of the society in all facets of human activity.  The concept of social justice embeds equality  to flavour  and  enliven practical content of  ’life’.   Social justice and equality are complementary to each other so that both   should  maintain  their  vitality.   Rule   of   law, therefore, is a potent instrument of social justice to bring about equality in results. 22.  Article 1 of the Universal Declaration of Human  Rights asserts human sensitivity and moral responsibility of  every State  that  "all human beings are born free  and  equal  in dignity  and  rights.   They are  endowed  with  reason  and conscience and should act towards one another in a spirit of brotherhood."  The  Charter  of  the  United  Nations   thus reinforces the faith in fundamental human rights and in  the dignity  and  worth  of the human person  envisaged  in  the directive  principles  of  State  policy  as  part  of   the constitution.  The jurisprudence of personhood or  philosopy of  the right to life envisaged under Article  21,  enlarges its sweep to encompass human personality in its full blossom with invigorated health which is a wealth to the workman  to can  his livelihood to sustain the dignity of person and  to live a life with dignity and equality. 23.  Article 38(1) lays down the foundation for human rights and  enjoins the State to promote the welfare of the  people by  securing  and protecting, as effectively as  it  may,  a social   order  in  which  justice,  social,  economic   and political, shall inform all the institutions of the national life.   Art.46  directs the State to protect the  poor  from social  injustice  and all forms of  exploitation.   Article 39(e)  charges  that  the policy of the State  shall  be  to secure "the health and strength of the workers".  Article 42 mandates that the States shall make provision, statutory  or executive  "to secure just and humane conditions  of  work". Article 43 directs that the State shall "endeavour to secure to   all  workers,  by  suitable  legislation  or   economic organisation  or any other way to ensure decent standard  of life  and full enjoyment of leisure and social and  cultural opportunities  to  the workers".  Article 48-A  enjoins  the State  to  protect and improve the  environment.   As  human resources are valuable national assets for peace, industrial or  material production, national wealth,  progress,  social stability,  descent standard of life of worker is an  input. Art.  25(2)  of the universal declaration  of  human  rights

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ensures right to standard of adequate living for health  and well-being   of  the  individual  including  medical   care, sickness  and disability, Article 2(b) of the  International Convention on Political, Social and Cultural Rights protects the right of worker to enjoy just and favourable  conditions of work ensuring safe and healthy working conditions. 24.  The   expression  ’life’  assured  in  Art.21  of   the Constitution  does  not  connote mere  animal  existence  or continued  drudgery  through  life.  It  has  a  much  wider meaning which includes right to livelihood, better  standard of life, hygienic conditions 659 in  work  place  and  leisure.  In  Olga  Tellis  v.  Bombay Municipal Corporation, 1985(3) SCC 545, this Court held that no person can live without the means of living i.e. means of livelihood.  If the right to livelihood is not treated as  a part of the constitutional right to life, the easiest way of depriving a person of his right to life would be to  deprive him  of his means of livelihood to the point of  abrogation. Such  deprivation  would  not only denude the  life  of  its effective  content of meaningfulness but it would make  life impossible  to live, leave aside what makes  life  liveable. The right to life with human dignity encompasses within  its fold,  some of the finer facets of human civilisation  which makes  life worth living.  The expanded connotation of  life would  mean  the  tradition and  cultural  heritage  of  the persons  concerned.   In State of H.P. v. Umed  Ram  Sharma, (1986)2  SCC  68,  this Court held that the  right  to  life includes  the quality of life as understood in its  richness and  fullness by the ambit of the constitution.   Access  to road was held to be an access to life itself in that state. 25.In Sunil Batra v. Delhi Administration, (1978) 4 SCC 494, considering the effect of solitary confinement of a prisoner sentenced  to  death  and the meaning  of  the  word  ’life’ enshrined under Article 21, the Constitution Bench held that the quality of-life covered by Article 21 is something  more than the dynamic meaning attached to life and liberty.   The same view was reiterated in Board of Trustees of the port of Bombay v. D.R. Nadkarni, (1983) 1 SCC 124, Vikrant Deo Singh Tomar   v.  State  of  Bihar,  (1988)  Suppl.SCC   734,   R. Autyanuprasi v. Union of India, (1989)1 Suppl.  SCC 251.  In Charles  Sobraj v. Supdt.  Central Jail, Tihar, AIR 1978  SC 1514, this Court held that the right to life includes  right to  human  dignity.   The right against  torture,  cruel  or unusual punishment or degraded treatment was held to violate the right to life.  In Bandhua Mukti Morcha v. Union of  In- dia,  (1984) 3 SCC 161 at 183-84, this Court held  that  the right  to live with human dignity, enshrined in Article  21, derives its life-breath from the directive principles of the State policy and particularly Clauses (e) and (f) of Article 39  and  Articles  41 and 42.  In C.E.S.C. Ltd.  &  Ors.  v. Subhash Chandra Bose, 1992(1) SCC 441, considered the  gamut of   operational   efficacy   of  Human   Rights   and   the constitutional  rights, the right to medical aid and  health and  held that the right to social justice  are  fundamental rights.   Right to free legal aid to the poor  and  indigent worker was held to be a fundamental right in Khatri (11)  v. State  of  Bihar, (1981)1 SCC 627.  Right to  education  was held to be a fundmental right vide Maharashtra State  B.O.S. &  H.S. Education v. K.S. Gandhi, 1991(2) SCC 716. and  Unni Krishnan v. State of A.P., (1993)1 SCC 645. 26.  The right to health to a worker is an integral facet of meaningful  right  to  life to have not  only  a  meaningful existence  but also robust health and vigour  without  which worker  would lead life of misery.  Lack of  health  denudes

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his livelihood.  Compelling economic necessity to work in an industry  exposed  to  health hazards due  to  indigence  to bread-winning  to himself and his dependents, should not  be at  the  cost  of  the health and  vigour  of  the  workman. Facilities  and  opportunities, as enjoined in  Article  38, should  be  provided to protect the health of  the  workman. Provision  for  medical test and treatment  invigorates  the health of the worker for 660 higher   production   or   efficient   service.    Continued treatment, while in service or after retirement is a  moral, legal  and constitutional concomitant duty of  the  employer and the State.  Therefore, it must be held that the right to health and medical care is a fundamental right under Article 21  read with Articles 39(c), 41 and 43 of the  Constitution and  make the life of the workman meaningful and  purposeful with  dignity of person.  Right to life includes  protection of  the  health  and strength of the  worker  is  a  minimum requirement  to enable a person to live with human  dignity. The  State, be it Union or State government or an  industry, public or private, is enjoined to take all such action which will  promote  health, strength and vigour  of  the  workman during the period of employment and leisure and health  even after  retirement as basic essentials to live the life  with health and happiness.  The health and strength of the worker is  an  integral  facet of right to  life.   Denial  thereof denudes  the  workman  the finer facets  of  life  violating Art.21.   The  right  to  human  dignity,   development   of personality,  social protection, right to rest  and  leisure are  fundamental  human rights to a workman assured  by  the Charter of Human Rights, in the Preamble and Arts.38 and  39 of the Constitution.  Facilities for medical care and health against  sickness  ensures  stable  manpower  for   economic development   and  would  generate  devotion  to  duty   and dedication  to give the workers’ best physically as well  as mentally in production of goods or services.  Health of  the worker enables him to enjoy the fruit of his labour, keeping him  physically  fit  and  mentally  alert  for  leading   a successful  life,  economically,  socially  and  culturally. Medical facilities to protect the health of the workers are, therefore, the fundamental and human rights to the workmen. 27.  Therefore, we hold that right to health, medical aid to protect  the health and vigour to a worker while in  service or post retirement is a fundamental right under Article  21, read  with  Articles  39(e), 41, 43,  48A  and  all  related Articles  and fundamental human rights to make the  life  of the  workman  meaningful  and  purposeful  with  dignity  of person. 28.  In  M.  C. Mehta v. Union of India, (1987) 4  SCC  463, when  tanneries  were discharging effluents into  the  river Ganges,  this Court, in a public interest litigation,  while directing  to  implement Water (Prevention  and  Control  of Pollution)  Act or Environment (Protection)  Act,  prevented the   tanneries   etc.  by   appropriate   directions   from discharging   effluents  into  the  river  Ganga,   directed establishment  of primary treatment plants etc. and such  of these  industries  that did not comply with  the  directions were  ordered  to  be closed. when  ecological  balance  was getting upset by destroying forest due to working the mines, this  Court directed closer of the mines.  In  Pt  Parmanand Katara  v.  Union  of  India, (1989)4  SCC  286,  Ohs  court directed  even private doctors or hospitals to  extend  ser- vices to protect the life of the patient, be an innocent  or a  criminal  liable for punishment in accordance  with  law. In  National  Textile Workers’ Union v.  P.R.  Ramakrishnan,

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1983(1) SCR 922, the Constitution Bench, per majority,  held that  the  role  of a company in  modem  economy  and  their increasing  impact  of individuals and  groups  through  the ramifications of their activities, began to be  increasingly recognised.   The socio-economic objectives set out in  Part IV  of  the constitution guide and shape the  new  corporate phi- 661 losophy.  "Today  social scientists and  thinkers  regard  a company  as a living vital and dynamic social organism  with firm  and  deep  rooted affiliations with the  rest  of  the community in which it functions.  It would be wrong to  look upon it as something belonging to the shareholders." It  was further held that "it is not only the shareholders who  have supplied capital who are interested in the enterprise  which is being run by a company but the workers who supply  labour are  also equally, if not, more interested because  what  is produced  by the enterprise is the result of labour as  well as  capital.   In  fact, the owners  of  capital  bear  only limited  financial risk and otherwise contribute nothing  to production  while  labour contributes a major share  of  the product.   While  the  former invest only a  part  of  their moneys,  the  latter invest their sweat and  toil,  in  fact their  life itself.  The workers, therefore, have a  special place in a socialist pattern of society.  They are not  mere vendors  of toil, they are not a marketable commodity to  be purchased  by the owners of capital.  They are producers  of wealth as much as capital  nay very much more.  They  supply labour without which capital would be impotent and they,  at the  least, equal partners with capital in  the  enterprise. Our constitution has shown profound concern for the  workers and  given  them a pride of place in the  new  socioeconomic order envisaged in the Preamble and the Directive Principles of  State  Policy.   The  Preamble  contains  the   profound declaration  pregnant with meaning and hope for millions  of peasants  and workers that India shall be a socialist  demo- cratic  republic  where  social and  economic  justice  will inform all the institutions of national life and there  will be  equality  of status and opportunity for  all  and  every endeavour  shall be made to promote fraternity ensuring  the dignity of the individual.  " In that case, the question was whether the labour is entitled to be heard before a  company is closed and liquidator is appointed.  In considering  that question  vis-a-vis Article 43-A of the  constitution,  this Court, per majority, held that they are entitled to be heard before  appointing a liquidator in a winding up  proceedings of the company. 29.  In Workmen of Meenakshi Mills Lid v.    Meenakshi Mills Ltd. (1992) 3 SC(: 3 36, a Bench of three Judges  considered the vires of Section 25-N of the Industrial Disputes Act  on the  anvil of Article 19(1)(f) of the Constituion.   It  was held that the right of the Management under Article 19(1)(f) is  subject to the mandates contained in Articles 38,  39-A, 41  and  43.   Accordingly,  the  fundamental  right,  under Article  19(1)(g)  was held to be subject to  the  directive principles  and  s.25-N  does not suffer from  the  vice  of unconstitutionality. 30.  It would thus be clear that in an appropriate case, the Court would give appropriate directions to the employer,  be it the State or its undertaking or-private employer to  make the  right to life meaningful; to prevent pollution of  work place;  protection  of the environment;  protection  of  the health  of  the workman or to preserve free  and  unpolluted water  for  the  safety  and  health  of  the  people.   The authorities or even private persons or industry are bound by

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the  directions  issued by this Court under Article  32  and Article 142 of the Constitution. 31.  Yet another contentions of the petitioners is that  the workman  affected  by  asbestosis are  suffering  from  lung cancer 662 and  related ailments and they were not properly  diagnosed. They  be sent to national institute and such of those  found suffering  from diseases developed due to  asbestos,  proper compensation  paid.  It is needless to reiterate  that  they need  to  be re-examined and cause for the disease  and  the nature  of the disease diagnosed.  Thereon each one of  them whether  entitled to damages?  The employer  is  vicariously liable  to  pay  damages is unquestionable.   The  award  of compensation  in  proceedings under Article 32 or 226  is  a remedy  available in public law.  In Rudul Sah v.  State  of Bihar,  1983(3) SCR 508, it was held that this  Court  under Article  32  can grant compensation for the  deprivation  of personal  liberty, though ordinary process of court, may  be available  to  enforce the right and money  claim  could  be granted   by  this  Court.   Accordingly  compensation   was awarded.   This  view was reiterated in Nilabati  Behera  v. State of Orissa, (1993) 2 SCC 746 and awarded monetary  com- pensation  for  custodial death lifting the  State  immunity from  the purview of public law.  It is, therefore,  settled law  that in public law claim for compensation is  a  remedy available  under Article 32 or 226 for the  enforcement  and protection of fundamental and human rights.  The defence  of sovereign immunity is inapplicable and alien to the  concept of guarantee of fundamental rights.  Them is no question  of de fence being available for constitutional remedy.  It is a practical and inexpensive mode of redress available for  the contravention   made   by  the  State,  its   servants,   it instrumentalities,  a company or a person in  the  purported exercise  of  their  powers and enforcement  of  the  rights claimed  either under the statutes or licence  issued  under the  statute  or for the enforcement of any  right  or  duty under the constitution or the law. 32.  The  Government of India issued model Rule 123-A  under the Factories Act for adoption.  Under the directions issued by  this Court from time to time, all the State  governments have  by now amended their respective rules and adopted  the same  as  part of it but still there are  yearning  gaps  in their  effective  implementation  in that  behalf.   It  is, therefore,  necessary to issue appropriate  directions.   In the  light of the rules "All Safety in the Use of  Asbestos" issued  by the I.L.O., the same shall be binding on all  the industries.   As  a  fact, the  13th  respondent-Ferodo  Ltd admitted  in  its  written submissions that  all  the  major industries  in India have formed an association  called  the "Asbestos  Information Centre" (AIC) affiliated to  the  As- bestos International Association(AIA), London.  The AIA  has been publishing a code of conduct for its members in  accor- dance with the international practice and all the members of AIC  have  been  following  the  same.   In  view  of   that admission,  they are bound by the directions issued  by  the ILO referred to in the body of the judgment.  In that  view, it is not necessary to issue any direction to Union or State Governments  to  constitute a committee to convert  the  dry process of manufacturing into wet process but they are bound by the rules not only specifically referred to in the  judg- ment  but all the rules in that behalf in the  above  I.L.O. rules.  The Employees State Insurance Act and the  Workmen’s Compensation   Act   provide  for   payment   of   mandatory compensation  for the injury or death caused to the  workman

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while  in  employment.  Since the Act does not  provide  for payment  of compensation after cessation of  employment,  it becomes   necessary  to  protect  such  persons   from   the respective dates of cessation of their employment till date. Liquidated  damages  by  way of  compensation  are  accepted principles of 663 compensation.   In the light of the law above laid down  and also  on the doctrine of tortuous liability, the  respective factories  or  companies shall be bound  to  compensate  the workmen  for the health hazards which is the cause  for  the disease  with  which the workmen are suffering from  or  had suffered pending the writ petitions.  Therefore, the factory or  establishment  shall be responsible  to  pay  liquidated damages to the concerned workmen. 33.  The  writ  petition is, therefore,  allowed.   All  the industries are directed (1) To maintain and keep maintaining the health record of every worker up to a minimum period  of 40  years from the beginning of the employment or  15  years after retirement or cessation of the employment whichever is later;  (2)  The Membrane Filter test,  to  detect  asbestos fibre  should be adopted by all the factories or  establish- ments  at  par with the  Metalliferrous  Mines  Regulations, 1961; and Vienna Convention and Rules issued thereunder; (3) All  the  factories whether covered by the  Employees  State Insurance Act or Workmen’s Compensation Act or otherwise are directed  to  compulsorily insure health coverage  to  every worker; (4) The Union and the State Governments are directed to review the standards of permissible exposure limit  value of  fibre/cc  in  tune  with  the  international   standards reducing  the  permissible  content as prayed  in  the  writ petition referred to at the beginning.  The review shall  be continued after every 10 yews and also as an when the I.L.O. gives   directions  in  this  behalf  consistent  with   its recommendations  or any Conventions; (5) The Union  and  all the State Governments are directed to consider inclusion  of such of those small scale factory or factories or industries to  protect  health  hazards of the worker  engaged  in  the manufacture  of asbestos or its ancillary produce;  (6)  The appropriate  Inspector  of Factories in  particular  of  the State  of  Gujarat,  is directed to send  all  the  workers, examined  by the concerned ESI hospital, for  re-examination by  the National Institute of Occupational Health to  detect whether  all or any of them are suffering  from  asbestosis. In  case of the positive Ending that all or any of them  ant suffering  from the occupational health hazards,  each  such worker shall be entitled to compensation in a sum of  rupees one  lakh  payable by the concerned factory or  industry  or establishment within a period of three months from the  date of  certification by the National Institute of  Occupational Health. 34.  The writ petitions are accordingly allowed.  No costs. 665