Asbestos remediation in the Netherlands: even a mouth mask is considered too expensive

Yvonne Waterman Ph.D. LL.M. MFAAM [1]

On 5 March 2019, the Dutch technological institute TNO and a number of other authors published the report 'Insights for proportional asbestos policy'.[2] On the same day, one of these authors, Professor Ira Helsloot, spoke on the eighth o’clock evening news channel (NOS) about the purport of this report: "At present, for most asbestos work, protection measures are greatly exaggerated. Yes, if you are exposed every single day to large amounts of asbestos, then you will, uh, with great certainty die from it. But incidental exposures do not pose a health hazard." The immediate consequence of this message was that broad efforts over decades to raise awareness of the health risks of asbestos exposure were seriously undermined. Suddenly there was uncertainty as to whether asbestos is dangerous at all. So what's true about this report and what should we do with it? This article will provide an answer to this question. #asbestos

1.        The commissioning parties, the authors and the general purport

The report was commissioned by the association of housing corporations Aedes and the well-known housing corporations Talis, Mitros, Vestia and Woonbron. (You will still recognize Mitros from the Kanaleneiland incident and Woonbron as the owner of the heavily contaminated ship SS Rotterdam.) They bemoan the expensiveness of removing asbestos in the media; which is, in their opinion, unnecessarily expensive. In view of their large housing stock which requires remediation, there is certainly a great financial interest involved. 

The authors of the collaborative work are Dr. Jody Schinkel (TNO), Professor Dick Heederik (University of Utrecht), Prof. Ira Helsloot (Radboud University) and Sander Kraaijenbrink and Jacco Vis, both working for Crisislab as does Prof. Helsloot. Professor Helsloot has been hired by the commissioning parties several times in recent years and, as his publication list suggests, has not published anything worth mentioning about asbestos before then. We certainly do not know him from the international circuit of asbestos experts and nobody there knows him. It is unclear to us where he gets his 'expertise' from with regard to his quoted statement, which in our opinion is totally irresponsible and has caused considerable damage to the efforts of many to raise social awareness of asbestos risks during decades. 

The report contains no mention that the commissioning parties have not been involved in the content of the report (which would suggest scientific neutrality). Evidently, the reverse is true, in view of the involvement of several dozens of people on the commissioning side who have worked before with the commissioning parties ('respondents' and 'soundboard group'). This makes the report one-sided and partial. The participation of TNO as a scientific institution is strange in this light – and does not reflect well on it, in view of the important position that TNO occupies with regard to asbestos policy and which requires neutrality towards the various stakeholders in the professional field. Have the commercial interests of TNO superseded its scientific position here? 

In brief, the purport of the report is that asbestos remediation can be done more cheaply in many scenarios and that current working methods are far too expensive – unnecessarily so. It is also indicated that in many situations it is unclear what the exposure to asbestos really is and therefore what the associated health risks are. As a result, according to TNO on its website: "It is often not possible to determine what proportional safety measures are."[3] Apparently, this reluctance in a report in which TNO cooperated does not stand in the way of determining that asbestos remediation is too expensive and that in many cases safety measures such as mouth masks and Tyvek overalls are not 'proportional' to the risks involved. 

2.       Asbestos risks: facts and emotion

The globally, scientifically accepted insight is that asbestos is a carcinogenic substance and there is no safe level of exposure; the list of scientific publications on this point is sheer endless. This position is supported by, for example, by the Dutch Health Council, the World Health Organization (WHO), International Labor Organization (ILO), World Trade Organization (WTO), International Agency for Research on Cancer (IARC), the European Union, the European Agency for Safety and Health at Work (EU-OSHA), the Environmental Protection Agency (EPA), International Commission for Occupational Health (ICOH), United Nations Environmental Program (UNEP), Collegium Ramazzini, more than fifty countries and almost every medical institution in the field of cancer worldwide. Only the Russian asbestos industry still maintains that asbestos exposure can do no harm; but it has a considerable financial interest in this viewpoint.

In societal debate, it is often thought that one asbestos fibre is fatal. That is a false, at least not realistic, interpretation in layman's terms of the lack of a safety limit. After all, we live in a country where we constantly breathe in a background value of around 30 fibres per cubic meter; and we are not going to die of that on a national scale. Blind panic about asbestos is therefore absurd and counterproductive. Wherever there is asbestos, good factual knowledge and a cool head are important. However, scientific and statistical insight are increasing that relatively small exposures can also lead to asbestos diseases. This means that the insight that this health risk only exists after long-term, heavy exposure is completely outdated.[4] In this context, Professor Arthur Frank wrote to us, with specific reference to the quoted quote from Prof. Helsloot: "[T] here is excellent animal and human data showing that as little as 1 DAY !!!!!!! is sufficient to cause a mesothelioma [...]"[5] This insight is supported by a range of scientific literature.[6] Professor Ken Takahashi, director of the Australian Asbestos Diseases Research Institute, wrote to us in the same context: "The importance of safety measures for asbestos removal work should NEVER be understated because there is no safe level to asbestos exposure, a position widely and firmly held by the scientific community." Professor Jukka Takala, chairman of ICOH, pointed out to us that the desired maximum exposure standard should be 1,000 fibres per cubic meter, with reference to a ground-breaking publication.[7] He also noted that the number of asbestos-related deaths due to occupational exposure in our country is more than 4,600 a year; and that is more realistic than the 1,000-1,300 which are mentioned as standard in Dutch literature by the official statistical institute CBS, the Institute for Asbestos Victims (IAS), the Labour Inspectorate (ISZW) etc.[8] In the context of Professor Helsloot's quote, he wrote to us: "Asbestos – any type of asbestos – is a very potent carcinogen, and there is no safe limit of exposure. We should insist on zero exposure."

It is relevant to understand that there is a cumulative risk, which means that every exposure leads to a slightly higher risk of disease. This is why it is important to prevent unnecessary exposure; and this is relevant in particular because many exposures in daily life are likely to happen unnoticed, but they all add up even so. The statistics also show more and more professions that are not traditionally associated with asbestos: doctors, nurses, school teachers, secretaries, etc., indicative that low (but proven) exposures also lead to victims. Also consider family members, through indirect exposure. I therefore dare to state with consideration that Prof. Helsloot's claim – “incidental exposures do not pose a health hazard" – is pernicious nonsense and far removed from globally recognized scientific insights. 

The cumulative risk requires good protection for employees in the remediation sector in particular, it is literally of vital importance. However, incidental and short-term exposure for private individuals should therefore not be considered harmless. After all, it is not known what the fatal limit value for any individual is; and additional causative factors such as age of exposure, higher life expectancy of a younger generation (read: more chance of completion of the incubation period), smoking behaviour, genetic predisposition, etc., can contribute to this in a relevant way. In addition, regardless of how large or small the chance of disease is, asbestos diseases are almost always incurable, are particularly unpleasant illnesses and lead to short-term death. The risk of asbestos cancer is generally (very) small, but catastrophic for the individual concerned and his loved ones. One should be respectful to this; which is different from the suggestion that breathing in asbestos during a day can do no harm. 

Asbestos diseases

What sort of asbestos diseases are there? Essentially they are all cancers, with the exception of pleural plaques and asbestosis. The present report is based on 'the big two': namely mesothelioma and asbestos-related lung cancer. These two diseases are seen on the basis of the Dutch CBS statistics as a 1:1 ratio. Taken together, the number of asbestos-related deaths amounts to about 1,000 to 1,300 a year, depending on whose statistics you choose. At foreign conferences, we are increasingly told that there is a suspicion that the ratio is much higher, which amounts to a worrying Dutch under-registration and under-valuation of the seriousness of the health risk. This is what the renowned professor Jukka Takala[9] told us: "The asbestos problem is much bigger than mesothelioma. Mesothelioma is the most obvious asbestos disease, but it's not the most common. Asbestos causes six times more cases of lung cancer than it does mesothelioma."[10] This is confirmed by the World Health Organization.[11] 

In addition, there are other globally recognized asbestos cancers, which are rarely discussed in the Netherlands, let alone registered. Think of laryngeal cancer, uterine cancer, gastrointestinal cancer and kidney cancer. There are also various cancers of which there is now a strong scientific suspicion of a causal relationship with asbestos, such as pharyngeal cancer.[12]

The present TNO report refers to an incidence of asbestos cancers of 4 per 100,000 individuals. I do not think that the above insights have been taken into account; this means that the findings and, in particular, the calculation methodology in the report are presented too optimistically.

3.        How is the report put together?

The report is based on the presumption of a maximum investment norm per life year gained, which is set at € 60,000 to calculate the proportional investment amount per exposed person; and with reference to a publication by prof. Helsloot. It is a strange presumption, because there is no question of 'gained' years of life – the people who come into contact with asbestos are healthy as a starting point, there is no question of a treatment that extends their life. 

The report states[13]: "The lost number of healthy years of life, expressed in Disability Adjusted Life Years, is calculated by multiplying the chance of developing an asbestos disease (the average number of deaths per 100,000 exposed persons) by the average number of lost healthy years. In the case of asbestos exposure, this is set at 19 years of lung cancer or mesothelioma per case. " (This is also not entirely correct, because various asbestos diseases have been disregarded and there is a considerable underestimate of the number of asbestos-related lung cancer cases.) The number of healthy years of life lost is estimated at 19 years per person, assuming that most victims fall ill and die at the age of 65, rather than at the age of 84. This does not take into account the incubation period of young persons, who now enjoy a higher life expectancy than the generation of authors and therefore have a relatively greater chance of completing the incubation period. 

"By dividing the number of lost DALYs by the number of people (i.e. 100,000), and then multiplying by the annual investment standard of € 60,000, the proportional investment amount for an entire lifetime per individual can be calculated. This amount is then divided by 40 in the case of work-related scenarios, in order to calculate the proportional investment per working year."

4.        Calculation method

On p. 16 of the report, an example is given of the calculation method for the various scenarios. Suppose: a work-related exposure of 2,000 chrysotile fibres per m3.

"At the concentration of 2,000 chrysotile fibres per m3, according to the Health Council, there is a risk of 4 10-5 when exposed during a very active life. This means that for every 100,000 exposed people, on average 65 years of age, 4 people develop mesothelioma or lung cancer. This corresponds to 4 * 19 = 76 lost years of life per 100,000 exposed people. The proportional budget to prevent this is therefore 76 * € 60,000 = 4.56 million euros for those 100,000 exposed. Calculating to what this means for an individual in each of his 40 working years, this gives a proportional investment of 4.56 million euros / 100,000 exposed people / 40 years = € 1.14 per year if all mortality can be prevented. The use of a P3 mouth cap reduces exposure and therefore mortality by 95%, so there is then available 0.95 * € 1.14 = € 1.08 per year. For this amount, P3 mouth caps cannot be purchased every day. In other words, the use of P3 mouth caps is not proportional in this situation." (Emphasis added by Waterman).

The authors seem to be aware of how thin the scientific content is and to apologize in advance. As the report on p. 6 states: "In many situations, the actual exposure to asbestos (by inhalation) is, however, unclear. Nor are the associated long-term health risks known. Therefore, it is not possible to estimate the proportionality of the measures taken." Then why do they even begin, I wonder. 

5.        Sharp criticism

There is much wrong with the report. In the first place, we think it is indecent to express the preservation of the health of an employee in euros. Secondly, it is appalling to suggest that an asbestos remediation worker is not worth the cost of a mouth mask. Does his life almost literally count for nothing? 

Thirdly: the costs of remediation do not lie in a mouth mask, which, incidentally, will be cheaper in bulk purchases than indicated. The costs are mainly determined by matters that are required by the legislator, such as a containment, a Negative Pressure Unit, professional equipment, training, extensive administration, valuable time for audits of certifying and supervisory institutions, etc. In addition, there are other unavoidable costs, such as manpower, scaffolding, an aerial work platform/crane, etc. Remediators have no choice in this. However, the report mentions little or nothing about this. It is therefore unfair to suggest that remediators increase the price of remediation for profit, because that price is mainly determined by the demands of the legislator and the aspect of personal protective equipment has only a small share in this.

In the fourth place: the Working Conditions legislation (‘arboregelgeving’) crystal-clearly prohibits exposing the employee to carcinogenic substances and orders the employer to take source based measures to prevent this. Only if this is not (fully) successful, is personal protective equipment permitted and even mandatory; which the authors of the present report consider to be 'disproportionately' superfluous in many scenarios. The EU directive 2004/37/EC is even stricter in nature, see art. 5 paragraph 3: "Where a closed system is not technically possible, the employer will ensure that the level of exposure or workers is reduced to as low as a level is technically possible." Technically – that is the requirement that Dutch legislation must implement, not proportionally. I do not see how a 'proportional approach' can be achieved within the current state of legislation. 

It is also impossible to see how and why asbestos risks in this light would be treated differently in the working conditions context than any other carcinogenic substance. The civil law aspects are mostly the same: art. 7: 658 of the Dutch Civil Code obliges the employer to take all reasonable measures to protect the health of the employee. It has already been concluded in the penultimate century that 'reasonably' covers just about everything that is possible under the sun. So also mouth masks and whatever else is needed. In relation to protection against a carcinogenic substance, the bar is very high and that is how it should be. The Parliamentary History is clear on this. 

In the light of the previous two paragraphs, the statement on p. 97 is therefore incomprehensible and misleading: "Based on the specific legislation that applies to asbestos, 'reasonable' protective measures must be taken in these cases, for which this report calculates proportional budgets." 

Let me also say something about the scenarios. In recent years, housing association Talis has often told us that remediation of window sills can be done much more cheaply in risk class 1 (least risk). Perhaps that is possible, under ideal circumstances. But is it desirable for a company to carry out work on an asbestos object without any quality control? Does it know that you should not use the household vacuum cleaner and that there will be an upscaling, official notification, additional costs, etc. in the event of a break? I read a scenario about employees who drill holes in ceilings containing asbestos – these are criminal offenses. Do the authors of the report really want to suggest that companies and individuals indulge in this, because they consider the risks involved to be low? Since when has that been a fruitful legal defence? Would they then also pay the sky-high fines imposed by the supervisory authorities in such cases? And is the Labour Inspectorate going to moderate its fines on the basis of this report, because the housing associations want to cut back on the costs of asbestos remediation and state that the risks really are not that high? I don’t think so. 

The report suggests that a day of exposure to asbestos is harmless, that it is not necessary to walk around suited up like a moon explorer. This ignores the fact that asbestos removers are not exposed to asbestos on a one-off basis but daily and they run significant health risks when performing necessary work; for which they receive far too little appreciation. The same applies to employees of installation companies and contractors who, as we understand the report, can perform such work instead of remediators. Private individuals who clean up some asbestos once in a blue moon do not need a 'moon suit' from that perspective; but what is the importance of this reasoning, since the activities of private individuals do not generally entail costs for housing associations? The reasonable explanation implies that it is apparently the asbestos remediators who are not allowed to pass on the costs of their protective clothing and face masks, because this would not be 'proportional'. However, remediators also want to reach an old age and rightly think very differently about this.

I read in the report that a single peak asbestos exposure in the event of a fire does no harm. That is debatable in view of the global medical literature; of which I have already mentioned some well-known sources in the footnotes in this document. It also ignores the possibility of (unintended) spread of asbestos during such a peak exposure and the risk of secondary contamination with a possible chronic exposure as a result. I also read nothing about other, cost-increasing circumstances in the aftermath of such a fire, such as the need to offer tenants a replacement living space, the costs of cleaning, the inconvenience, et cetera; these are difficult to blame on the remediation industry. Positively strange is the statement on p. 22: "It will be necessary to look with common sense as to what extent and how the deposited asbestos should be disposed of." It seems to us that the law and compensation law should be the guiding principle in this, and not so much what housing associations understand as 'common sense', from which we expect little objectivity. The statement, also in this context and the same page, that it is not necessary to take secondary contamination into account is surprising – then what is the NEN2991 good for? 

Above all, I am simply astonished at the main presumption: namely that a budget X determines the level of 'appropriate' health protection against carcinogens, rather than the other way around.

6.        Conclusions and some critical remarks

This report as a whole looks very purpose-driven, one-sided and biased. ‘Who pays, determines the outcome’, to quote a Dutch saying. Which has little to do with independent science. I certainly support the call for more risk-driven policy based on scientific insights – what objection can there be against that? But this report has contributed little to scientific insights and has only led to great confusion in society. 

Secondly, the author distances herself wholly from Professor Helsloot's reprehensible statement that the protective measures for most asbestos remediation work are greatly exaggerated and that incidental exposures do not pose a health hazard. This statement goes against global science and has caused serious, potentially irreparable damage to Dutch social awareness of asbestos risks. I can no longer take him seriously, except in his original field of crisis management, to which he has made valuable contributions. 

Thirdly: the report has an important shortcoming, namely the lack of verifiable substantiation. TNO does not have a large database of exposure reports; and much of what it has is also anonymous. Many of the interviews on which the report is based are also anonymous in terms of origin and content. It is surprising that the data used are predominantly the same as those used a few years ago for the classification of risk classes in the SMArt system; and that these now lead to substantially different insights. It is difficult or impossible to deduce from this report what data is involved, from when, on behalf of whom, carried out by whom, where, which circumstances, which quality of reporting, etc. etc. This is a real nuisance, because the essence of science is that it must be transparent, verifiable and reproducible. We therefore believe that this report should not be called 'scientific' – unless that should mean that we have to take everything gullibly on trust. 

This problem can be overcome: by collecting or executing more of these exposure analysis reports in all desired scenarios and sharing them mandatorily with TNO. If the asbestos policy must be risk-oriented in accordance with scientific standards, there is clearly a great need for such data. Of course the question immediately arises: who is to pay for this? The answer is obvious: Aedes and the housing associations, of course. After all, they are the ones who have the most financial interest to gain from it and are taking on the problem of expensive remediation. So Aedes and housing associations, fork it up! Put your money where your mouth is. Please note: the independence of the TNO research must be guaranteed, without any substantial or controlling involvement of the paying clients. Or have such research carried out by an independent, preferably internationally recognized research agency that remains free of interference from stakeholders. The subject is important enough for that. 

Fourthly, we note that there is still a great lack of knowledge on asbestos and that there is also a great deal of emotion. There is a wide gulf between the facts and the perception of asbestos risks. That also stands in the way of a risk-oriented policy and its implementation based on scientific insights. Professionals should know better; and fortunately they often do. But at a social level, there is still a world to be gained in raising awareness of asbestos risks. Therein lies a clear task for the Dutch asbestos remediation industry: because for her it holds just as much true to 'put your money where your mouth is'. Asbestos risks need to be taken seriously and who better to bring that message across to society than those who want to remove it under safe conditions and are most at risk? I look forward to their first tv-infomercial! 

[1]      Yvonne Waterman Ph.D. LL.M. (Waterman Legal Consultancy) specialises in asbestos liability law and is the founder of the European Asbestos Forum Foundation (EAF). She is a well-known speaker at asbestos conferences worldwide. She can be reached at [email protected].

[2]      I. Helsloot, J. Schinkel, H. Heederik, S. Kraaijenbrink & J. Vis, 'Insights into proportional asbestos policy. A study into health risks in various asbestos exposure situations and the costs of associated protection policies', Crisis Lab, Radboud University, TNO and Utrecht University, 2019. See https://repository.tudelft.nl/view/tno/uuid:61fd54e1-1f37-4df6-91f9-36c71dc626d4.

[3]      See https://repository.tudelft.nl/view/tno/uuid%3A61fd54e1-1f37-4df6-91f9-36c71dc626d4.

[4]      Health Council of the Netherlands, 'Asbestos: Risks of environmental and occupational exposure', The Hague: Health Council of the Netherlands 2010 (2010/10).

[5]      Professor Arthur Frank is a triple professor (Public Health, Medicine, Civil, Architectural and Environmental Engineering) at Drexel University in Philadelphia and recipient of the prestigious Ramazzini Award in 2016.

[6]      Cf. Soeberg et al., Malignant mesothelioma in Australia 2015: Current incidence and asbestos exposure trends, J.Tox. Environ. Health, Part B, 19: 5-6, 173-179 (2016): "The dose-response relationship between asbestos exposure and mesothelioma has no threshold, and exposures as short as 1 day were found." Or recently, Merler et al., Residual fiber lung burden among patients with pleural mesothelioma who have been occupationally exposed to asbestos, Occup. Environ. Med. doi:10:1136/oemed-2015-103382, 2016: "[M]esotheliomas may occur at relatively low exposures to asbestos, as it is highlighted in the fraction of MPMs with low fiber counts or just below the [detection limits using electron microscopy]." Even the asbestos industry(!), represented by Dr. Smyth from Union Carbide, already knew in 1956: “[N]o considerations can justify allowing inhalation of any concentration which is avoidable”. See Smyth, Improved Communication – Hygienic Standards for Daily Inhalation, Ind. Hyg. Quarterly. 17(2), 1956.

[7]      S. Furuya, O. Chimed-Ochir, K. Takahashi, A. David and J. Takala, Global Asbestos Disaster, Int. J. Environ. Res. Public Health 2018, 15 (5), 1000, see https://www.mdpi.com/1660-4601/15/5/1000/htm.

[8]      See from the previous footnote the accompanying Supplementary Table 1 'All estimated asbestos related deaths', see item 12 for the Netherlands.

[9]      Professor Takala has an illustrious career, he has been director of the European Agency for Safety and Health at Work and he is now chairman of the International Commission of Occupational Health (ICOH) and director of the ILO program SafeWork.

[10]     See the interview of Prof. Jukka Takala by Asbestos.com on July 9, 2018, https://www.asbestos.com/news/2018/07/09/asbestos-death-toll-increase. See also S. Furuya, O Chimed-Ochir, K. Takahashi, A. David and J. Takala, Global Asbestos Disaster, Int. J. Environ. Res. Public Health 2018, 15 (5), 1000; https://doi.org/10.3390/ijerph15051000.

[11]     World Health Organization. Chrysotile Asbestos. 2014. See https://www.who.int/ipcs/assessment/public_health/chrysotile_asbestos_summary.pdf. Cf. IARC, Monograph 100C: Asbestos (Chrysotile, Amosite, Crocidolite, Tremolite, Actinolite and Anthophyllite), Lyon: International Agency for Research on Cancer 2012.

[12]     Cf. IARC, Monograph 100C: Asbestos (Chrysotile, Amosite, Crocidolite, Tremolite, actinolite and Anthophyllite), Lyon: International Agency for Research on Cancer 2012.

[13]     See pages 15-16 of the report for the quotes mentioned in this section.