Daniela MarsiliI; and Pietro CombaII
IServizio Informatico, Documentazione, Biblioteca ed Attività Editoriali, Istituto Superiore di Sanità, Rome, Italy
IIDipartimento di Ambiente e Connessa Prevenzione Primaria, Istituto Superiore di Sanità, Rome, Italy
Notwithstanding a major body of evidence on the carcinogenicity of all asbestos fibres and a general consensus of the scientific community on the health impact of this agent, asbestos is still produced and used in a large number of countries, thus determining further harm for future generations. Prevention of asbestos-related disease requires international cooperation, transfer of know-how and dissemination of successful procedures in order to contrast asbestos exposure in the frame of a global environmental health approach.
Key words: asbestos-related disease, international cooperation, global health
The prevention of asbestos-related disease is a global public health issue and, more specifically, a matter of global environmental health. The latter is defined by the National Institute of Environmental Health Sciences (NIEHS) as "research, education, training, and research translation directed at health problems that are related to environmental exposures and transcend national boundaries, with a goal of improving health for all people by reducing the environmental exposures that lead to avoidable disease, disabilities and deaths" (www.niehs.nih.gov/research/programs/geh/index.cfm). This calls for a transnational and cross-disciplinary approach to global health [1, 2].
The global health impact of asbestos has been discussed in top scientific journals [3-5]. The total estimate of deaths each year from lung cancer, mesothelioma and asbestosis related to occupational asbestos exposure increased from 90 000 in 2006 to 107 000 in 2010 [6, 7]. In 2009, Monograph 100C of the International Agency for the Research on Cancer (IARC) provided the updated list of cancer sites causally as-sociated with exposure to asbestos adding larynx and ovary . Recently, Park et al. (2011), focusing on mesothelioma only, estimated a cumulative number of 174 000 cases during 1994-2008 in 56 countries with data on mesothelioma occurrence, and another approximately 40 000 cases in countries with no official statistics on mesothelioma, but with available data on asbestos use .
The global dimension of this issue is explained by world data on asbestos production and use. Similar to the last years, the 2012 world production of asbestos amounted to 2 000 000 tons. This considerable quantity is roughly half of the peak world production reached in 1977 (4 793 451 tons). In these 35 years, the number of asbestos-producer countries has decreased: presently, four countries concentrate nearly 90% of the world production: Russia (1 000 000 tons), China (440 000 tons), Brazil (300 000 tons) and Kazakhstan (240 000 tons) [10-12]. The current scenario of global asbestos production, use and trade is influenced by two major factors: the adoption of partial or total asbestos legislation ban by 54 countries  and the progressive reduction of asbestos production in Canada, the leading country in the last decades as producer and supplier of asbestos fibers and asbestos-containing products to numerous industrializing countries. In fact, asbestos production in Canada decreased from 1 517 360 tons in 1977 to 180 000 in 2007 and there was no asbestos chrysotile production in Canada in 2012 [10-12]. The use of asbestos is still allowed in many countries in the world, even if in 2012 its consumption was concentrated in China and India for more than 50% of the world consumption (531 000 and 493 000 tons, respectively). In that year the consumption in Brazil, Indonesia and Russia corresponded to 167 602, 161 824 and 155 746 tons, respectively (www.ibasecretariat.org). Data of asbestos production and consump-tion indicate that Russia has been taking the leading role for asbestos export previously played by Canada.
These data demonstrate that prevention of asbestos-related disease is still today a quite crucial issue in many regions of the world and that the consequences of occupational and environmental asbestos exposure are a global plague.
In this frame, United Nations agencies such as the World Health Organization (WHO) and the International Labour Organization (ILO) intervened in 2006 through specific actions particularly addressed to those countries where asbestos use was still allowed. The WHO Declaration on "Elimination of asbestos-related diseases" recognizes the carcinogenicity of all types of asbestos, including chrysotile, as well as states that the most effective way to eliminate asbestos-related diseases is to stop use of all types of asbestos, stressing the impossibility of asbestos "controlled" use. The declaration highlights the increasing global burden of asbestos-related diseases, also affecting those countries that banned asbestos, because of the long latency period of these diseases .
ILO adopted the "Resolution Concerning asbestos" in June 2006, recognizing that the elimination of the asbestos use, and the identification of the most appropriate management of asbestos currently in use, are the most effective prevention actions to protect workers from asbestos exposure. The resolution stresses that the ILO Convention on asbestos n. 162 of 1986 should not be used to provide a justification for the use of asbestos considering that all forms of asbestos, including chrysotile, are classified by IARC as known human carcinogens .
Despite the aforementioned actions promoted by WHO and ILO, an effective regulation of the international trade of chrysotile asbestos has never been reached within the Rotterdam Convention on the Prior Informed Consent (PIC) Procedure for Certain Hazardous Chemicals and Pesticides in International Trade (United Nations). In 2002, the European Union and Chile presented the first request for inclusion of chrysotile asbestos in Annex III of the Rotterdam Convention as an industrial chemical dangerous to human health and environment. The voting of the Conference of the Parties in 2004, as well as in 2006, 2008 and 2011, did not reach a unanimous consensus. The most important producers of asbestos chrysotile (Canada, Russia, Kazakhstan) and consumer countries (India) voted against the adoption of a national decision-making process on import and export of asbestos chrysotile, namely PIC Procedure. They rather claimed the "controlled" and "safe" use of chrysotile asbestos . It is important to underline that the adoption of the PIC procedure doesn't represent a global ban of a hazardous chemical, but it makes possible for importing countries to decide which are the hazardous chemicals that can be imported and to reject those that they are unable to safely handle on the basis of the advice regarding their toxicity. The most recent voting at the Conference of the Parties on the chrysotile was in May 2013 and, despite the increasing expectations for a different result, again a consensus was not reached. Consequently, the proposal to list chrysotile asbestos in the Annex III of the Rotterdam Convention will be considered in the next Conference of the Parties which will be held in 2015 . This prolonged impasse exemplifies the impact of political and economic strategies on population's health and the environment at local, national and global level.
The specific case of Italy, whose industrial development from late nineteenth century up to the asbestos ban in 1992 was characterized by asbestos mining and industrial use, has been extensively investigated [17-19]. The most recent report on the occurrence of pleural mesothelioma in Italy  shows a national mortality rate of 1.7 cases per 100 000 (corresponding to about 1000 annual deaths) with significant spatial clustering in correspondence to asbestos-cement manufacturing plants, petrochemical facilities, shipyards, other industries characterized by use or presence of asbestos and geologically contaminated areas.
Taking into account asbestos-related mortality from neoplasms other than mesothelioma and from asbestosis, a conservative estimate of the current burden of asbestos-related disease in Italy could be of about 2000 yearly deaths. Twenty-one years have elapsed since the 1992 asbestos ban, and a National Asbestos Project has been launched by the Ministry of Health in order to promote research on a number of priority issues in the domains of etiology, pathogenesis, diagnosis and treatment of asbestos-related disease (www.iss.it/amianto) .
The Italian experience has now the potential to contribute to the global prevention of asbestos-related disease. Cooperation among researchers, health and law professionals from countries that banned asbestos together with those from countries that still did not is worthwhile and urgent. Training and information dissemination can contribute to create awareness on the increasing social costs caused by delaying asbestos ban. Countries with well-established public health policies and practices for preventing asbestos-related diseases can supply their expertise and technology to those countries where asbestos is still manufactured and used, supporting their gradual transition . The above-mentioned Italian National Asbestos Project includes activities of international cooperation that are founded on previous initiatives of ISS that were de-signed for Latin American setting [23-25].
Although this brief description of the asbestos case is far from being exhaustive, it allows the identification of the key implications for global health. First, the asbestos case testifies the links between public health, environment and socio-economic development, corroborating the need for a cross-disciplinary approach. Second, national or global asbestos ban has transnational socio-economic implications related to global health. Third, the relevance of international cooperation for contributing to create awareness and preparedness to effectively address prevention action and the treatment of asbestos-related diseases. Finally, even if the global ban has not yet been achieved, the increasing number of national bans will certainly lead towards the successful epilogue of this long-lasting struggle.
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Address for correspondence:
Dipartimento di Ambiente e Connessa Prevenzione Primaria, Istituto Superiore di Sanità
Viale Regina Elena 299
00161 Rome, Italy
Accepted on 1 July 2013.