Chapter 9

Exposures Unnecessary: Time Does Not Heal All Wounds

Much is mysterious about the functioning of the lungs, and nothing more so than the reactions initiated after an inhalation. The lungs have a dual purpose, and the purposes unfortunately are in direct opposition to each other—bringing oxygen in while keeping everything else out. The latter objective is almost impossible, especially since we take more than fifteen thousand breaths a day.

The lungs have an advanced system for both keeping noxious particles out and rejecting unwanted particles if they do get in. The system of defense begins in our nose, where hairs help filter the air. The airways, including the bronchi and bronchioles, also have tiny hairs, termed cilia, which beat constantly to expel unwanted particles that make it past the initial defenses. The other lines of protection we have are coughing, sneezing, and clearing our throats, which all serve to manually force noxious material out.

The defenses of our lungs are not foolproof, and dust regularly gets down into our airways. Proportion matters here, and the smaller the particles are, the farther down they can penetrate, with those measuring five microns or less able to get to our alveoli. In an average room, every cubic foot may contain twenty thousand to thirty thousand particles of respirable dust in this size range. Construction sites may contain eight hundred thousand particles of respirable dust per cubic foot. It is impossible to keep all of these particles out.

Typical home dust is made up of a mixture of tracked-in soil, soot, ash, particulate matter from cooking, dust mite debris, flakes of human skin, and lint from clothing and bedding. The makeup of the outside air is determined by where you live, but is usually a mix of soil particles, pollen, particles from exhaust, and perhaps salt flecks if you live near the ocean, or sand particles if you live near a desert. The composition of air at workplaces very much depends on the type of worksite and its location.

We have evolved to live with dust, and most of it is harmless. Dust also does a lot of good in nature, like absorbing water vapor, which otherwise would make the biosphere extremely muggy. Fungal spores travel as dust, landing to perform the all-important function of breaking down dead matter. Pollen has the critical task of fertilizing flowers and plants, a job done with the help of bees but also by pollen in the form of free-floating dust.187 Farm dust is thought to help protect children from developing asthma and allergies later in life, a salutary interaction between our immune system and dust.

In addition to all this beneficial dust, however, there is also a lot of bad dust, especially at our worksites, where we often have little control over it. And since our worksites have changed so radically in the past two centuries—even in the past twenty years—keeping up with potential airborne threats is hard. Of all the organs in the body, the lungs, on the forefront of our interaction with the environment, are the most affected by toxins in the workplace.

Police officer Cesar Borja was one of the forty thousand American heroes who selflessly went to Ground Zero in New York City to aid in the cleanup effort after 9/11. He worked there sixteen hours a day, coming home sweaty and grimy and tired. He stayed at home only long enough to eat, shower, and sleep a few hours, and then returned to help with the massive effort.

The damage was vast, with four hundred million pounds of steel and six hundred thousand square feet of broken glass spread over sixteen acres in a toxic pile of burning rubble. On the job, masks were optional. Some workers wore them, but many—including Cesar—did not. Little did he and many other workers know that the air they were breathing was poisoned with toxic dust particles such as asbestos, mercury, lead, and cadmium. The fires that burned on the site for months added dioxins and polycyclic aromatic hydrocarbons, both known carcinogens. Particles of gold from melted jewelry were also in the air.188

Cesar worked at Ground Zero for three months. Five years later he died in a hospital bed from idiopathic pulmonary fibrosis, the devastating illness that causes scarring in the lungs. His family then asked the questions that came to everybody’s mind: Did his working at Ground Zero without a mask cause his illness? If Cesar Borja didn’t know he was inhaling a toxic mixture of carcinogens, were there people who did?

The use of respiratory masks at the 9/11 site is a complicated matter, not surprisingly, given the uniqueness of the massive cleanup effort. The first firefighters who arrived at the cleanup site used their own full-face masks and breathing apparatus, but the cartridges lasted only a day. Firefighter Palmer Doyle from Brooklyn was at the site on the first day, and then arrived back at the scene on September 15 with fifty other firefighters. He remembers being handed one respirator for the group. It was given to the youngest member, and they started their work. An order was placed by the fire department to the city on September 28 for five thousand masks, which cost about fifty dollars each, and ten thousand replacement cartridges. The order went unfilled for two months.189

Some 150,000 masks were distributed during the cleanup effort, but their use was sporadic, and they often didn’t fit well. Those working for the Pentagon at the Ground Zero site were escorted off if they weren’t wearing a mask, while New York’s city and state workers were allowed to work without them. Some wore paper masks or surgical masks, but these were later deemed to be useless. The effective P100 masks, outfitted with cartridges that block almost all particulate matter, were uncomfortably hot and made communication among workers difficult. Many reasoned they could do without masks.

This sentiment was reinforced by Christine Todd Whitman, head of the EPA at the time. Three days after the attacks, she stated, “The good news continues to be that air samples we have taken have all been at levels that cause us no concern.”190 She did state that those working directly on the pile should take precautions, but raised no further alarm. This line was echoed many times by the mayor of New York City, Rudolph Giuliani.191

The issue at the time was complicated. The World Trade Center area was not just a cleanup site, it was at first a massive rescue site, a fire that needed controlling, and also a crime scene. Many firefighters and EMT workers naturally felt that by donning a mask they were selfishly putting their own health above those who needed rescuing. Workers also wanted to show the world that America would not be deterred.

But the story of the World Trade Center cleanup now reads like an uncontrolled science experiment. Tens of thousands of people were exposed to all manner of toxic dust, costing billions of dollars in lawsuits and future medical treatment, to say nothing of the diseases incurred and the suffering they caused. Environmental health expert Dr. Paul J. Lioy, a scientist at New Jersey’s Environmental and Occupational Health Sciences Institute, watched the buildings come down on his television at home and immediately knew it could be a health disaster. Similarly, occupational physicians at Mount Sinai School of Medicine, among the most knowledgeable experts in the world on the subject of dust-induced illness, instantly recognized the tremendous potential for health issues.

At Fresh Kills, the Staten Island dump where 9/11 waste was deposited, there was a strict mask policy, with a more than 90 percent compliance rate. At Ground Zero, by contrast, on any given day as few as 30 percent of workers wore masks. Later, with plenty of toxic dust still inside local residences and businesses, on bookcases and coffee tables, and under beds and desks, families came back to their homes, and workers went back to their offices. The different types and manifestations of lung disease we are seeing today because of this exposure are tragic.

Cesar Borja finished his work on the 9/11 cleanup site and went back to his job at the New York Police Department tow pound. Initially, things seemed fine, and he retired in 2003, But the quiet didn’t last long. In early 2005, he started noticing a cough, dry and incessant. He went to see a doctor, and a chest X-ray and CT scan followed. He was diagnosed with pulmonary fibrosis of the lungs, an irreversible condition in which fibrous tissue is produced in the lungs at an increasing rate, turning them from a soft sponge to dense rock, usually over the course of months to a few years.

Cesar held his own for a few months, until he woke up one morning unable to breathe. His wife called an ambulance, and at Mount Sinai Hospital in New York City, Cesar was put on a ventilator and given medicines, without positive results. During this time, Cesar Borja Jr. wrote to the local papers about his father’s condition, hoping to start a groundswell push for a lung transplant. Normally, patients on ventilators cannot get lung transplants, but Cesar Jr. argued this was a special case.

Cesar’s powerful story landed on the front page of the New York Daily News.192 As Cesar languished on a ventilator at Mount Sinai, his family’s phone rang off the hook with calls from local and national newspapers and television outlets. Hillary Clinton, then a senator from New York, took notice, and Cesar Jr. found himself at Ground Zero speaking alongside her and others regarding the health problems afflicting first responders. He was then flown to Washington, DC, to be Clinton’s guest at the State of the Union address, and later met with President George W. Bush to promote the cause of his father and other injured workers. Sadly, no lung transplant materialized, and Cesar Sr. passed away two hours before the State of the Union address his son attended.

Cesar Borja was one of many afflicted with disease caused by the cleanup efforts after the 9/11 attacks. Dr. Robin Herbert of Mount Sinai Hospital describes three distinct waves that frequently occur after a massive dust exposure. The first is characterized by the acute effects of the inhalant, a burn-like effect. The second wave occurs in the following months, characterized by ongoing inflammation, with diseases such as asthma, or lung conditions that lead to scarring. The third wave, which can happen years and even decades after the exposure, involves cancers and other life-threatening conditions.193

The first wave of patients began showing up soon after 9/11, their airways burned by the very caustic Drano-like dust, with a severe dry cough, eye irritation, and cherry-red nasal passages from the burn. The cough from the burn was so harsh, so distinctive, that Dr. Herbert could walk into the waiting room at her clinic and instantly know which patients were from 9/11. Palmer Doyle, the firefighter from Brooklyn who had started work at Ground Zero in the early days, developed a serious case of bronchitis, so severe that his parents didn’t recognize his voice when he talked to them on the phone.194

Many of these coughs did not resolve easily. Firefighters who showed up on the first day the building collapsed had the highest incidence of this cough syndrome, at 8 percent (128 of 1636), while those who got there on day two had a somewhat lower incidence of 3 percent (187 of 6958). Of those with this cough, 63 percent had evidence of lung function abnormalities.195 Symptoms of shortness of breath, acid reflux, wheezing, and sinus issues were also higher in these patients.

The second wave of illness began to rise in the following years. Prior to 9/11, the incidence of asthma among those who would work at the World Trade Center (WTC) site was 2.9 percent. By 2002, it was 12.8 percent, and by 2007 it was 19.4 percent.196 A study published in 2011 looked at nine years of data and showed an asthma rate of 27.6 percent, as well as strikingly elevated rates of sinus inflammation and acid reflux disease.197 Over the years, unusual diseases such as sarcoid and eosinophilic pneumonia, both inflammatory lung diseases that can cause scarring and respiratory failure, became unusually prevalent. A 2015 review of the data stated that, given the consistency of findings in multiple studies, a causal link between WTC dust and diseases such as asthma, COPD, acid reflux, and scarring diseases of the lung could be made with scientific certainty.198 High rates of depression and panic disorders among first responders have also been documented.

In 2007, Dr. Herbert gave an interview to the New England Journal of Medicine, outlining the diseases she was seeing, but also sounding an alarm about the third wave of even more deadly diseases to follow, namely cancers.199 Unfortunately for those affected, more than a decade after this interview, higher-than-normal rates of skin cancers, thyroid cancer, and certain blood cancers such as multiple myeloma are indeed occurring. A chilling review published in the Journal of the American Medical Association Oncology in October 2018 predicted higher-than-normal levels of prostate, thyroid, and melanoma cases among WTC workers going forward to 2031, with an overall elevated incidence of the total cancer rate.200 The third wave of illnesses also includes persistent PTSD, as well as greater risk of heart disease and stroke. The dust, it appears, didn’t just go into the lungs, but also triggered inflammation throughout the body. Overall, as of September 2019, the CDC estimated that 15,543 cancer cases are related to 9/11 exposure.201

The names are etched on three granite walls, honored as 9/11 heroes. However, these walls are not in the shadow of the Freedom Tower in downtown New York, but rather in a park fifty miles west, in Nesconset, Long Island. In the park, known as the “9/11 Responders Remembered Park,” the three walls, named Courage, Honor, and Sacrifice, stand serenely, paying homage to those who died not on 9/11, but after that event, and because of it.

The park’s caretaker and planner, John Feal, got the land donated, raised money, and added $130,000 of his own to get the fundraising over the line. He spends ten hours a day, without any salary, vetting people to determine whether their names should go on the wall and whether they should receive benefits from his foundation. To make the difficult decisions about who gets on the wall and who gets benefits, Feal reads obituaries, and talks to families, and sometimes asks tough questions. He always stresses that his goal is to be inclusive and to make sure the people who continue to die because of that day are remembered and honored.

John was at the World Trade Center on the days after the towers came down, working long hours, until September 17, when an eight-thousand-pound steel beam fell and mangled his left foot, causing injuries to his spine and knees as well. He lives with chronic pain today. Ironically, he considers himself lucky, because he knows that if he had worked at the site longer, he might be one of the names on the wall he helped build.

John’s FealGood Foundation advocates for all the needs of those suffering with 9/11 illness—medications and prescriptions, transportation to chemotherapy sessions and other medical treatments, help with nutrition support and utility costs. The foundation also puts people in touch with specialized doctors and lawyers, and considers other requests on a case-by-case basis. Feal is both honoring those who have fallen and trying to prevent more from ending up on the wall. He has inspired legislation at the state and federal level, making sure the nation lives up to its duty to take care of the countless people who rushed to help in a time of great need.

The topic of occupational diseases rarely attracts attention either in the medical field or the press, except after major disasters or lawsuits. Most of us take for granted that the places where we work are safe, healthy environments with clean air and water. Diseases are something we pick up from viruses, or our genetics, or our lifestyles. Illness does not come from our workplaces.

As a group, occupational lung diseases are less recognized than other types of occupational hazards. The inhalation of toxic dusts can be subtle, frequently going unnoticed because the particles don’t always cause a cough or other immediate respiratory symptoms. A worker who was exposed for only a few months might come to his doctor thirty years later with a cancer that has spread throughout the body. Establishing cause and effect can be very difficult.

Once toxic dusts are inhaled, the inflammatory reaction to the particulate matter can also be unpredictable, with some heavily exposed workers developing no disease, while others with limited exposure develop a devastating illness. The same inhaled particle may also cause completely different diseases in different people. Some patients may react by developing asthma, while others end up with pulmonary fibrosis, lung cancer, or other inflammatory conditions. Why the same particle causes different diseases in different people is largely unknown, although it likely goes back to how much is inhaled, how our lungs handle the particle, and our unique genetics.

Occupational lung diseases have been with us for millennia. The lungs of fifteen ancient Egyptian mummies were recently examined and, surprisingly, they show a degree of particulate matter not so different from what is found in the lungs of somebody living in a modern-day city. Ancient Egypt did have dangerous industries, such as metalworking and mining, and citizens were regularly exposed to dust storms. One mummy examined in the early 1970s, a thirty-eight-hundred-year-old named Nekht-ankh, lived to almost sixty, and his lungs contained a remarkable amount of particulate matter, along with fibrosis.202

With the Renaissance and modernization in Europe came new occupational lung diseases. As early as 1473, German doctor Ulrich Ellenbog recognized the emergence of these diseases in a book entitled On the Poisonous Wicked Fumes and Smokes of Metals. In 1700, the father of occupational medicine, Bernardino Ramazzini, published De Morbis Artificum Diatriba (A Treatise on the Diseases of Workers). Ramazzini described some two hundred occupational diseases, many of them affecting the lung. Today, the list of workers at risk for occupational lung diseases is surprisingly long. From those who work with seemingly innocuous plants like strawberries, to bakers who work with flour, to the more obvious cement workers, rubber workers, chrome platers, coal miners, and firefighters, workers face real risks from inhalational disease.

Ventilation efforts and personal protective equipment have reduced the incidence of these occupational inhalation diseases. The one exception to this trend, and the inhalational disease with the strangest, most numerous, and most deadly manifestations, is asbestos. There has not been a more deadly inhalation disease in American history than the one caused by this tiny fibrous mineral.

Asbestos is a beautiful fiber, found in soil and rock, that occurs naturally as a long, thin crystal. It is extremely strong, fire resistant, and is found in nature in stunning colors of bright white, emerald green, iridescent blue, and light brown. Although typically thought of as a modern material, asbestos has a long history of use in civilizations going back thousands of years. Twenty-five hundred years ago, the ancient Egyptians used asbestos-reinforced cloth to wrap the bodies of pharaohs for preservation.

Asbestos was also used in ancient Greece and Rome, where it was mined from local quarries. Asbestos was regarded as a miracle fiber and recognized for its flame-resistant properties. The Greek historian Herodotus, in 456 BCE, wrote about bodies wrapped in asbestos shrouds before burning to prevent the ashes mixing with the fire. Romans also wove the fiber into napkins, reportedly throwing them into fires for cleaning, then retrieving them, white and unharmed.203

If the Greeks and Romans recognized the unique resiliency of asbestos, they also recognized its potential for harm. The Greek historian Strabo, writing in the first century CE, described a “sickness of the lungs” in those slaves who manufactured asbestos-containing cloths. Pliny the Elder, writing around the same time, also described lung disease in slaves who worked in asbestos mines, noting that they wore masks crafted from the bladder of goats or lambs.204

The mining of asbestos declined in Europe over the next thousand years, although its use did not cease entirely. King Charlemagne, as a parlor trick for his guests, would throw an asbestos cloth into a fire and demonstrate his powers by removing it unscathed. Stories abound of traveling hucksters selling asbestos crosses said to be made from the original cross of Jesus, their flame-resistant properties ostensibly proving their divine origin. With the rise of the industrial revolution in the nineteenth century, however, widespread asbestos mining and use began.

Asbestos fiber made its way into a surprising number of products, from building-insulation materials to brake liners of cars to fire blankets, caulking material, vinyl floor tiles, thermal pipe insulation, and cigarette filters; it was even in the snow in the film The Wizard of Oz. The use of asbestos continued unabated through the 1970s, despite a loud warning about its danger some fifty years earlier.

Nellie Kershaw worked in the textile industry as a rover at Turner Brothers Asbestos Company in Rochdale, England, taking the raw material of asbestos and spinning it into yarn. She started working there in 1917, at the age of twenty-seven, and began exhibiting respiratory symptoms at twenty-nine. She worked another two years at the mill, until she was unable to carry on. At home, and struggling with her breathing, she wrote a letter to Turner Brothers, trying to obtain some compensation from the company: “What are you going to do about my case? I have been home nine weeks now and have not received a penny—I think it’s time that there was something from you as the National Health refuses to pay me anything. I am needing nourishment and the money, and I should have had 9 weeks wages now through no fault of my own.”205

Nellie died in 1924, at the age of thirty-three, from respiratory failure. Her family brought a lawsuit against Turner Brothers Asbestos Company. At trial, Dr. William Cooke, a local pathologist, testified that Nellie’s lungs had evidence of extensive fibrosis, and within this fibrosis he clearly saw “particles of mineral matter . . . of various shapes, but the large majority have sharp angles.”206 Comparing these particles to a sample of asbestos, Dr. Cooke made the obvious conclusion that the jagged fibers “originated from asbestos and were, beyond a reasonable doubt, the primary cause of the fibrosis of the lungs and therefore of death.”207

Written up and published in the British Medical Journal in 1927, Nellie’s case spurred an inquiry from the British parliament in 1930. The inquiry culminated in the paper “Occurrence of Pulmonary Fibrosis and Other Pulmonary Affections in Asbestos Workers,” which was published in The Journal of Industrial Hygiene. The authors definitively identified a link between asbestos and pulmonary fibrosis, demonstrating that 66 percent of workers at the Rochdale factory where Nellie Kershaw worked were afflicted with pulmonary fibrosis.

In 1931, in response to this paper, the government of the United Kingdom established regulations to control dust exposure and provide compensation for those afflicted with pulmonary fibrosis from asbestos. This reaction prompted Thomas Legge, the former Chief Medical Inspector of Factories, to state in 1934: “Looking back in the light of present knowledge, it is impossible not to feel that opportunities for discovery and prevention of asbestos disease were badly missed.”208

Despite Nellie’s case and Legge’s expression of regret, the mining and use of asbestos continued unabated worldwide for the next four decades, with few attempts at controlling dust exposure. A mining town sprang up in Western Australia, where beautiful but deadly blue asbestos was pulled out of the ground. Quebec, Canada, became the world’s leader in asbestos production, from the appropriately named town of Asbestos. The United States, Russia, and Europe also dug large mines to harvest this miracle fiber.

The strength and resilience of asbestos are the same properties that make it so deadly. When inhaled, very little protective cough reflex occurs, and the fibers lodge themselves into the tissue of the lung. The body normally deploys cellular scavengers, like macrophages, to eat and digest foreign material and microbes, but the fibers of asbestos are too big and strong for the body’s scavengers to digest. So they sit there, in the lung, forever.

With increased asbestos use, the prevalence of diseases such as lung cancer and pulmonary fibrosis increased, and a strange new cancer began appearing—mesothelioma. A cancer of the lining of the cavities of the body, typically either the lung or the abdomen, mesothelioma is one of the most lethal cancers, with a life expectancy measured in months. Unlike lung cancer, mesothelioma is not related to smoking, and with very few exceptions, its only known cause is asbestos. It grows like a python in the body, slowly encasing and suffocating organs. Chemotherapy is generally useless, with side effects worse than any benefit. Surgery may extend life a few months, but rarely more.

Studies have now shown that mesothelioma typically takes up to thirty or forty years after the exposure to manifest. It is mostly a workingman’s disease, but it can also be a workingman’s wife’s disease, as women have been exposed from washing their husband’s clothes. A handful of celebrities have died from mesothelioma, including the musician Warren Zevon, at age fifty-six, and the actor Steve McQueen, at age fifty. Another famous victim was Merlin Olsen, a fourteen-time Pro Bowl defensive player in the NFL, and later an actor on Little House on the Prairie. He grew up in rural Utah, and his exposure to asbestos was traced back to when he was a teenager in the 1950s working summer jobs at construction sites.209 The use of asbestos has been drastically reduced in the United States. However, because of the long lag time from exposure to potential outcome, and the widespread use of asbestos in the 1970s, the incidence of mesothelioma has not yet declined, with on average about three thousand new cases per year.210

With gathering evidence of harm, bans on asbestos began in the early 1970s, and today the use of asbestos is banned completely in all twenty-eight European Union nations. The United States initially instituted a complete ban in 1989, which was overturned in 1991 by a circuit court, and the importation, processing, and distribution of products containing trace amounts of asbestos is still permitted. This includes goods such as disc brake pads and linings, gaskets, and roofing and fireproofing materials. Domestic production of asbestos ceased in 2002, but all told the United States imported on average about five hundred tons of asbestos per year between 2014 and 2018, mostly from Russia and Brazil.211

Russia still mines and uses asbestos on a large scale. The town Asbest, at the foot of the Ural Mountains, is home to the largest of the mines, and the dust there is insidious. As Tamar Biserova, a resident, commented in a July 2013 New York Times article, “When I work in the garden, I notice asbestos dust on my raspberries.” So much dust blows against her windows, she said, that “before I leave in the morning, I have to sweep it out.” In true Russian fashion, Nina Zubkova, another resident, wryly commented, “Of course asbestos dust covers our city. Why do you think the city is named Asbest?”212

Russia still mines about a million tons of asbestos every year, with hundreds of thousands of workers dependent on the asbestos industry for their livelihood.213 Worldwide, some two million tons are mined every year. We are just a few years away from the hundred-year anniversary of Nellie Kershaw’s death, and our lungs have still not learned how to digest this deadly fiber.

187. Hannah Holmes, The Secret Life of Dust: From the Cosmos to the Kitchen Counter, the Big Consequences of Little Things (Hoboken, NJ: Wiley, 2003), 8.

188. Anthony DePalma, City of Dust: Illness, Arrogance, and 9/11 (Upper Saddle River, NJ: FT Press Science, 2010), 253.

189. Anthony DePalma, “Air Masks at Issue in Claims of 9/11 Illnesses,” New York Times, June 5, 2006, https://www.nytimes.com/2006/06/05/nyregion/05masks.html.

190. Caroline Bankoff, “What We Know About How 9/11 Has Affected New Yorkers’ Health, 15 Years Later,” New York Magazine, September 10, 2016, http://nymag.com/intelligencer/2016/09/15-years-later-how-has-9-11-affected-new-yorkers-health.html.

191. DePalma, City of Dust, 30–31.

192. Adam Lisberg, “New Lung or WTC Cop Dies,” New York Daily News, January 16, 2007, https://www.nydailynews.com/news/new-lung-wtc-dies-officer-stricken-months-ground-zero-article-1.263583.

193. Jonathan M. Samet, Allison S. Geyh, and Mark J. Utell, “The Legacy of World Trade Center Dust,” New England Journal of Medicine 356, no. 22 (May 31, 2007): 2233–2236.

194. John Lehmann, “9/11 Ills Forcing Firemen off Job,” New York Post, December 21, 2001, https://nypost.com/2001/12/21/911-ills-forcing-firemen-off-job/.

195. David J. Prezant, Michael Weiden, Gisela I. Banauch, et al., “Cough and Bronchial Responsiveness in Firefighters at the World Trade Center Site,” New England Journal of Medicine 347, no. 11 (September 12, 2002): 806–815.

196. Hyun Kim, Robert Herbert, Philip Landrigan, et al., “Increased Rates of Asthma Among World Trade Center Disaster Responders,” American Journal of Industrial Medicine 55, no. 1 (January 2012): 44–53.

197. Juan P. Wisnivesky, Susan L. Teitelbaum, Andrew C. Todd, et al., “Persistence of Multiple Illnesses in World Trade Center Rescue and Recovery Workers: A Cohort Study,” Lancet 378, no. 9794 (September 3–9, 2011): 888–897.

198. Morton Lippmann, Mitchell D. Cohen, and Lung-Chi Chen, “Health Effects of World Trade Center (WTC) Dust: An Unprecedented Disaster with Inadequate Risk Management,” Critical Reviews in Toxicology 45, no. 6 (2015): 492–530.

199. Samet et al., “The Legacy of World Trade Center Dust,” 2233–2236.

200. Ankura Singh, Rachel Zeig-Owens, William Moir, et al., “Estimation of Future Cancer Burden Among Rescue and Recovery Workers Exposed to the World Trade Center Disaster,” JAMA Oncology 4, no. 6 (2018): 828–831.

201. Centers for Disease Control and Prevention, “Program Statistics,” World Trade Center Health Program website, February 7, 2020, https://www.cdc.gov/wtc/ataglance.html.

202. Rosalie David, The Manchester Mummy Project (Manchester, UK: Manchester University Press, 1979), 97.

203. Irving J. Selikoff and Douglas H. K. Lee, Asbestos and Disease (London: Academic Press, 1978), 4.

204. United Nations of Roma Victrix, “Asbestos in the Roman Empire,” UNRV.com, https://www.unrv.com/economy/asbestos.php.

205. Irving J. Selikoff and Morris Greenberg, “A Landmark Case in Asbestosis,” JAMA 265, no. 7 (1991): 898–901.

206. W. E. Cooke, “Fibrosis of the Lungs Due to the Inhalation of Asbestos Dust,” British Medical Journal 147, no. 2 (1924): 147.

207. Peter Bartrip, The Way from Dusty Death (London: The Athlone Press, 2001), 12.

208. Miriam Haritz, An Inconvenient Deliberation (Alphen aan den Rijn, NL: Kluwer Law International, 2011), 78.

209. Alex Strauss, “Mesothelioma Takes Life of Merlin Olsen,” Surviving Mesothelioma website, March 12, 2010, https://survivingmesothelioma.com/mesothelioma-takes-life-of-merlin-olsen/.

210. Jasek M. Mazurek, Girija Syamlal, John M. Wood, et al., “Malignant Mesothelioma Mortality—United States, 1999–2015,” Morbidity and Mortality Weekly Report 66, no. 8 (March 3, 2017): 214–218.

211. Tim Povtak, “US Geological Survey: 750 Metric Tons of Asbestos Imported in 2018,” Mesothelioma Center, asbestos.com website, https://www.asbestos.com/news/2019/03/26/asbestos-imports-2018-chloralkali/.

212. Andrew E. Kramer, “City in Russia Unable to Kick Asbestos Habit,” New York Times, July 13, 2013, https://www.nytimes.com/2013/07/14/business/global/city-in-russia-unable-to-kick-asbestos-habit.html.

213. Tim Povtak, “Asbestos Mining in Russia Still Fuels the Economy in Some Cities,” Mesothelioma Center, asbestos.com website, https://www.asbestos.com/news/2013/07/16/asbestos-mining-russia-fuels-economy/