ATS Bias:

Origins of Anti-Science in the 2004 Official Statement on Asbestos Diagnosis

In 2003 Dr. Thomas Martin (no relation) wrote the American Bar Association after the ABA adopted a policy that would recognize asbestos claims only if they met specific medical criteria (click here for complete ABA proposal). Dr. Thomas Martin (I will use his first name, to distinguish him from this author) wrote a response to Dennis Archer, JD, ABA President-elect. In this letter he makes statements that have no medical foundation. He wrote "The medical criteria used in the [ABA] document do not reflect the current state of screening and diagnosis for asbestos-related diseases." He did not acknowledge the "current state," as if he was unaware of the asbestos scam being run by plaintiff-attorney-hired B-readers.

Dr. Thomas Martin's letter to the ABA suggests that people making the screening diagnoses adhere to some objective criteria, which was (and is) far from the truth. (Read Section A: Litigation Screenings, in the ABA document.) He wrote: "significant asbestosis can be present with an x-ray profusion less than 1/0 or even with a normal chest x-ray." What does this mean? That if an attorney-hired B-reader reads a normal chest x-ray as "significant asbestosis," that's acceptable? That because some autopsies have shown changes of asbestosis when the chest x-ray did not, that anything goes in diagnosis? This has to be one of the most inane comments ever to appear from the ATS. It is anti-science. His letter can only be interpreted as supportive of the asbestos screening status quo -- an attorney-run program that has been described as a "scam," "swindle," and "fraud". There's more evidence of bias in his letter, discussed by Dr. Renn in a letter-to-the-editor of AJRCCM.

Dr. Joseph J. Renn wrote a strong letter to AJRCCM, which their editor at the time published. Dr. Thomas Martin's reply, which follow's Dr. Renn letter, is defensive and bureaucratic in tone. It really does not answer Dr. Renn's criticisms, but does convey an attitude: 'We are the experts. If ATS states something, it must be so. Don't challenge us.'

In 2003 Dr. Boushey wrote a letter to Senators Orrin Hatch and Patrick Leahey, as the U.S. Senate was preparing to debate asbestos legislation. Dr. Boushey's letter is crafted so as not to hinder the process of compensating claimants without provable disease. He wrote:

"The ATS does not have a position on the need for, merits of, or construction of asbestos litigation reform legislation."

Why not? The diagnosis of asbestosis is being made by a completely unscientific screening process, a process that has created a phony epidemic of asbestosis and along the way disrupted major portions of our legal and business fabric. At the same time, ATS has taken on the task of authoring an Official Statement on Diagnosis of nonmalignant asbestos disease. And Dr. Boushey says the ATS has no position? For ATS to not have a position on this diagnostic process is tantamount to endorsing it.

In his letter Dr. Boushey also wrote: "Evidence supporting the link between asbestos exposure and colon cancer is at least as strong or stronger than evidence linking asbestos exposure and stomach cancer." In fact there is no hard evidence to support this statement, and even the final Official Statement did not come out this strong; it states (p. 711, 4th para.): "Studies suggest that there may be an elevation in the risk of colon cancer, although this remains controversial." Why didn't Dr. Boushey tell Senators Hatch and Lahey that a link was "controversial"?

Finally, Dr. Boushey wrote: "The effect of asbestos is to more than double the risk of lung cancer among smokers, even though these are people who are already at risk for lung cancer from their smoking." Dr. Boushey doesn't acknowledge the debate over whether asbestosis has to be present to implicate a role in lung cancer, or explain just what he means by "effect of asbestos." If a plaintiff's lawyer says his client with a 50-pack-year smoking history and lung cancer worked around asbestos, is that sufficient? If a plaintiff B-reader mis-interprets chest wall fat as asbestos pleural thickening, is that sufficient? How does one compensate a heavy smoker with lung cancer when there is no objective evidence for an asbestos condition (objective defined as not coming from people paid for their diagnosis). Like others quoted in this web site, Dr. Boushey seems to abandon rationality and science when it comes to asbestos diagnosis.

Of all the physicians discussed in this web site, Dr. Harbut has perhaps been the most vocal in his socio-polical beliefs regarding asbestos. In 2000 the American College of Chest Physicians endorsed the The Fairness in Asbestos Compensation Act, an industry-backed bill designed "to streamline the compensation process for asbestos victims." The bill was approved by the House Judiciary Committee and headed to the full house for consideration. Dr. Harbut, an ACCP chairman of its environmental committee, wasn't consulted prior to the endorsement, and publicly quit the ACCP. In a statement of ultimate irony (considering his co-authorship of the un-scientific ATS Official Statement), Dr. Harbut wrote ACCP:

"The staff and leadership of the ACCP has constructed a fire wall built of asbestos to protect whatever it is they are protecting. There is no interest in ethical behavior. There is no interest in organizational responsibility. There is no interest in medical science. There is no interest in helping patients with asbestos-related disease beyond the proposed law written by an asbestos company attorney."

In a statement from Dr. Harbut promoting a total asbestos ban, he wrote:

"Over the past 12 years I have treated thousands of persons with diseases associated with asbestos."

For anyone who practices pulmonary medicine, this is an astounding statement. I have been in practice almost 30 years, which includes training dozens of pulmonary fellow, working in teaching and non-teaching hospitals, and inner city and suburban clinics. I've also reviewed hundreds of asbestos claims in detail. I don't see how any physician, pulmonary or otherwise, can claim to "have treated" thousands with asbestos disease, when the patients just aren't there. Furthermore, almost none of the asbestos claimants has been under treatment for asbestos disease by their primary care physician, simply because they have no true disease, or documented impairment from asbestos. True asbestosis, a serious condition, is rarely diagnosed today by practicing pulmonologists. And pleural thickening and/or plaques almost never require "treatment" of any sort. If Dr. Harbut alone has treated "thousands of cases," his experience is unique: why doesn't he report it? Assuming his experience was replicated by other pulmonologists, we would have an epidemic. Why isn't it in the medical literature? Because no such epidemic exists. Dr. Harbut has simply invoked obvious (and unjustified) hyperbole to make his case for banning asbestos.

In a January 2000 letter to the American Medical Association Dr. Harbut displayed more bias regarding asbestos diagnosis and compensation. For example:

• He wrote: "Although most informed persons feel the existing legal approach is in desperate need of reform, this letter does not speak to the legal matters raised." This is a disingenuous comment, to say the least. THE CAUSE OF THE ENTIRE PROBLEM REGARDING DIAGNOSIS is "the existing legal approach," yet he won't speak to it. He didn't in 2000 and still did not in the 2004 ATS Statement. By ignoring the root cause of the problem Dr. Harbut sets up a straw man, the strict and "arbitrary" criteria in the proposed legislation.
• He wrote: "[The proposed bill] defines asbestosis, cancer etiologies in relationship to asbestosis, and sets forth specific criteria to reach these diagnoses....What are patients and physicians to do if the law is in conflict with the science? Or if the science advances more quickly than the legislative process?" This is another disingenuous statement. The plain fact that he chooses to ignore the crucial "legal issues", and has never come out against the anti-science methodology of plaintiff-attorney-driven diagnoses, belies his complaint.
• He wrote: "That leaves payment up to everyone except those who caused the illness." Here his bias is most obvious: the assumptions that a) all claims are legitimate and b) those sued "caused the illness." He evidently doesn't know or care about the dysfunctional legal system that generates thousands of bogus claims against companies that never were in the asbestos business.

Dr. Harbut was also co-author of a 2004 letter to Academic Radiology criticizing the Gitlin, et al study of plaintiff B-readers (Acad Radiol 2004;11:1397-9); this letter is discussed in the section on Dr. Guidotti.

Overall, it is apparent that Dr. Harbut has strong biases on asbestos issues, and that they have infused the ATS Official Statement on diagnosis.

Dr. Albert Miller was a colleague of Dr. Selikoff's at Mt. Sinai Hospital in NYC. Dr. Selikoff, of course, alerted the nation to the medical hazards of asbestos, by finding real disease in pipe fitters, asbestos miners and other workers who had suffered close contact with the fiber. Dr. Miller has continued with this research, and has extensive experience in evaluating insulators and other workers heavily exposed to asbestos. Unfortunately (for ATS) he appears to have no experience evaluating claims manufactured by attorneys in mass asbestos screenings (if I'm wrong, it doesn't reflect in his publications). His experience with legitimate cases has led him to a major error of logic:

DR. MILLER'S ERROR OF LOGIC

(a) Radiologic asbestosis can be defined with profusion scores starting at 1/0 (Miller A. Chest. 1998 Jun;113(6):1439-42).

(b) All 1/0 profusion readings by plaintiff attorney hired physicians are accurate (implied throughout ATS Official statement, and specifically by relying on conclusions [page 710, Official Statement] from the junk science study published in Chest by Ohar, et al).

(c) Therefore, any 1/0 profusion reading is presumptively diagnostic of asbestosis (ATS Official Statement; page 696).

Dr. Miller no doubt would object to my parsing his logic this way, but the facts (or quotations) speak for themselves. In my opinion this error of logic is inexcusable, since he clearly knows the literature, the articles that show 1/0 can come from smoking or non-asbestos exposures (see his Response letter in Chest. 1999;115:303-305 - "On Perception, Perspicuity, and Precision."). I am sure Dr. Miller is also aware of the literature showing that plaintiff-attorney-hired B-Readers over-interpret chest x-rays a majority of the time. In July 2003 Drs. Linton and Gitlin wrote, in a letter to Senator Orrin Hatch, results of a study they were to publish the following year:

"...the initial readers [B-readers hired by plaintiff attorneys] interpreted the study radiographs as positive for parenchymal abnormalities with a small profusion category of 1/0 or higher 91.7% of their 551 reports. The consultants [blinded to the origin of the films] interpreted the same set of cases as category 1/0 or higher in only 4.5% of their 3306 reports [6 consultants per x-ray]... we surveyed the world literature on x-ray studies of asbestos-related changes and could find no studies anywhere that reflected the 91.7% percent positivity reported... by the initial readers."

The findings of Drs. Linton and Gitlin were published in early 2004, and could have been included in the 2004 ATS Official Statement (but were left out). Either way (open letter to Senator Hatch, or actual publication), this information had to be known to Dr. Miller. By ignoring it and other relevant studies, Dr. Miller could make his error of logic. He erroneously extrapolated from asbestos disease that he knows and has diagnosed, to the hundreds of thousands of subjective x-ray interpretations made by plaintiff-attorney-hired B-readers who routinely over-interpret films. This simple (and, for a scientist, inexcusable) error of logic led him to co-author the anti-science statements on chest x-ray interpretation in the ATS article.

Dr. Hillerdal, from Sweden, is an international authority on asbestos, and has been very influential in setting policy in his own country. Like Dr. Miller, he has seen the ravages of asbestos, and has become biased in such a way as to affect his pronouncements on asbestos. In an article on asbestos disease in Sweden, Dr. Hillerdal wrote:

"We can already see how asbestos-related diseases in people exposed to environmental "background levels" of asbestos are increasing, but the risk is much less for these people than for those with heavier exposures."

Like many of his colleagues who resort to hyperbole and unfounded generalization on asbestos diagnoses, Dr. Hillerdal provides no reference for this assertion. Is it based on a scientific study, done by impartial physicians? Or does it come from diagnoses made by plaintiff-attorney-hired B-readers?

Dr. Wagner is Director, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health (NIOSH). He testified before the Congressional Subcommittee on Superfund, Toxics, June 20, 2002, regarding health hazards of asbestos. In his testimony (available on the internet) he stated:

"Exposure to asbestos significantly increases the risk of contracting several diseases. These include:
1) Asbestosis...
2) Lung cancer - for which asbestos is one of the leading causes among non-smokers, and which occurs at dramatically high rates among asbestos-exposed smokers:
3) Malignant mesothelioma...
4) Nonmalignant pleural disease...
In addition, asbestos exposure is associated with excess mortality due to cancer of the larynx and cancer of the GI tract.."

Dr. Wagner's main point was to draw attention to the horrible consequences in Libby, Montana, where vermiculite caused a high rate of true asbestos-related diseases (from tremolite asbestos, which makes up about 10 to 20% of the fibrous materials in vermiculite). Nonetheless, by using gross exaggeration and generalization, he shows his bias on asbestos disease. Specifically:

Lung cancer DOES NOT occur at dramatically higher rates among asbestos exposed workers, if one defines "asbestos exposed" as anyone who ever worked in a location where asbestos was simply in the vicinity (i.e., in the pipes, walls, stacked in the shipping department, etc.). It is actually controversial about whether the lung cancer risk is increased with any asbestos exposure in the absence of true asbestosis. Medical journal articles can be found on both sides of this issue. The real problem is that the phrase "asbestos-exposed" has been cheapened by the asbestos screening claims to the point of meaninglessness, and should not be used without qualification - especially by scientists or authors writing for the ATS.

Dr. Gregory knows the importance of qualifying the phrase "asbestos-exposed." He was quoted in a Montana newspaper regarding asbestos hazards:

"The most obvious and serious contributing factor is smoking...combination of smoking and asbestos exposure creates a muliplicative chance for lung cancer. That number [of lung cancer cases] is going to depend on the intensity of exposure."

In other words, there are varying degrees of exposure, and without qualification (and, in a legal claim, documentation) "asbestos exposure" conveys no useful information. Nonetheless, the unqualified phrase "asbestos-exposure" appears in the ATS article in the context of cancer risk. The faulty reasoning is by now familiar -- extrapolation from real and deadly disease (e.g., Dr. Selikoff's original cohort of insulation workers; the Libby, Montana workers) to hundreds of thousands of cases manufactured solely for the purpose of filing claims. Intuitively, even without firsthand experience in evaluating bogus claims, the ATS authors must know that not all the claims made by PAHP can be legitimate, that not all the 1/0 readings can be substantiated, that not all the hundreds of thousands of workers had significant exposure to friable asbestos. If that is the case, then the only reasonable explanation for allowing unwarranted generalizations and misstatements into the article is bias.

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William Beckett, M.D., M.P.H., University of Rochester, assisted the 11 authors in preparing the ATS Statement, and was acknowledged in the credits on page 712. Dr. Beckett is well known in academic asbestos circles for his expertise. Unfortunately, he shares the same biases as the other physicians quoted above, and so contributed to the anti-science, plaintiff-oriented slant of the Official Statement. An example of this bias showed up in a 1997 editorial he wrote for Chest. Chest published back to back editorials regarding the diagnosis of asbestosis. David Rosenberg, M.D., M.P.H., a practicing pulmonary specialist in Cleveland, wrote in favor of uniform criteria for the diagnosis, specifically:

1) "asbestos exposure of significant intensity of duration and latency must have occurred."
2) "it is imperative to confirm that fibrosis exists."
3) "the exclusion of confounders for the presence of pulmonary fibrosis."

As part of his argument, Dr. Rosenberg quoted a 1991 paper (Gaensler EA, Jederlinic PJ, Churg A. Idiopathic pulmonary fibrosis in asbestos-exposed workers. Am Rev Respir Dis. 1991;144:689-96) which showed open lung biopsies did not confirm 5.1% of clinically and radiologically-diagnosed asbestosis. Dr. Rosenberg wrote:

"As Gaensler pointed out, while the prevalence of nonasbestos-induced interstitial lung disease in this select study population was low (5.1%), the future occurrence of such cases will be increasing because asbestosis is a disappearing disease."

After further discussion of his recommendations, Dr. Rosenberg observed:

"...due to inaccurate diagnoses, far fewer individuals probably have asbestos-related diseases than are implied by the number of personal injury claims that have been made. Consequently greater specificity should be utilized in the clinical diagnosis of asbestos-related disorders....Arguments of legal attributability, which focus only on a few "selected" asbestosis criteria while negating or failing to consider others, lowers the predictability below acceptable standards for diagnosing asbestosis. Under such circumstances, the likelihood of an individual having asbestosis is too uncertain for sound legal or policy judgments."

The opposing editorial by Dr. Beckett exemplifies the same error of logic made by Dr. Miller and others on the committee. He extrapolates from real disease, diagnosed by treating (and usually academic) physicians, to the population of bogus claims created by the plaintiff-attorney-machine. The real disease in the Gaensler study was profusion of 1/1 or greater, i.e., disease that met the 1986 ATS criteria for asbestosis. Thus Dr. Beckett wrote:

"These clinical criteria [referring to the 1986 ATS criteria, profusion at least 1/1 for asbestosis] were tested against the gold standard of lung biopsy [Gaensler, et al]. The study found an approximately 95% false-positive rate for the clinical criteria, i.e., that 95% of the clinically diagnosed cases did indeed have asbestosis, and 5% had other disease."

From this comment he argues there is no sound reason to do open lung biopsies, and then states [italics added]:

"The problem of overdiagnosis, if it exists, is not any failure of these criteria, but only failure to apply them."

The irony of this comment should not be lost on the reader. It shows a logical inconsistency for Dr. Beckett, and raises some important questions. I will pose these questions on the internet, and wait for Dr. Beckett's response.

1) Dr. Beckett, you promulgated profusion of 1/1 as the entry level for diagnosing asbestosis in 1986, and again in the 1997 editorial. What happened that caused you to change to a profusion of 1/0 in 2004? (No explanation was provided in the 2004 Official Statement.)

2) Were you really, honestly not aware in 1997 that there was a major problem in over-diagnosis of asbestosis by plaintiff-attorney hired B-readers? What made you express doubt in 1997 ("if it exists")? Along the same line, how do you reconcile Dr. Gaensler's comment in 1991 ("...because asbestosis is a disappearing disease, such cases [clinical asbestosis found to be something else when the lung is biopsied] will become more frequent") with the explosion of asbestosis claims since then?

3) What percentage of positive biopsies do you estimate would be found today if EVERY ASBESTOS CLAIMANT solicited and diagosed by the plaintiff-attorney-screening process was to have an open lung biopsy? More than 5%? How much more? Would you ever put your name to the figure? (This is another way of asking you what percentage of these asbestosis diagnoses do you believe are real.)

4) Finally, why have you never written or acknowledged the basis for which Dr. Rosenberg wrote that 1997 editorial in the first place: The anti-science method of diagnosis employed by the plaintiff-attorney-screening process?

There is scientific disagreement in the medical literature over whether the evidence supports asbestos as a cause of lung cancer when there is no asbestosis (i.e., no pulmonary fibrosis, or definite lung scarring from asbestos). In 1994 Dr. Abraham entered the debate with "Asbestos inhalation, not asbestosis, causes lung cancer," (Abraham JL, Amer J Ind Med 1994;26:839-42), and he has presumably held this view ever since.

In 1999 Dr. William Weiss published a review of the relevant literature, and wrote: "Much debate has resulted over the hypothesis that excess lung cancer risk occurs only among those workers who develop asbestosis, some favoring the hypothesis [Churg, A (1993) Asbestos, asbestosis, and lung cancer. Mod Pathol 6,509-511; Jones, RN, Hughes, JM, Weill, H (1996) Asbestos exposure, asbestosis, and asbestos-attributable lung cancer. Thorax 51(suppl 2),S9-S15; Browne, K. Is asbestos or asbestosis the cause of the increased risk of lung cancer in asbestos workers? Br J Ind Med 1996: 43,145-149] and some opposing it [3 articles cited, including Dr. Abraham's 1994 paper]."

From his review Dr. Weiss concluded: "the evidence indicates that asbestosis is a much better predictor of excess lung cancer risk than measures of exposure and serves as a marker for attributable cases." In essence, Dr. Weiss's review disagreed with the conclusions of Dr. Abraham and others. Neither Dr. Weiss's paper nor references 21-23 were listed among the articles were listed among the articles cited in the Official Statement when it discussed asbestos exposure and lung cancer. Several news accounts also document Dr. Abraham's strong environmental views and criticism of government inaction on asbestos issues (Seattle news artlcle; News&action article; Mesothelioma Research article). I am not critical of his positions, but only point out that they are in concert with the other architects of the ATS article, and confirm lack of any balance on the ATS author committee.

A second issue related to Dr. Welch's Expert Report is that experts in asbestos (Dr. Guidotti and his committee, for sure) were well aware of the work of Drs. Friedman and Gitlin, and Mr. Brickman, but chose to omit any mention of them in the ATS Official Statement. Dr. Welch at least thought it important to try to counter their conclusions (conclusions which undermine the very foundation of the asbestos scam, not to mention much of ATS's Official Statement). Surely their work at least merited a mention by ATS. Was it omitted because of lack of space in a 26-page article with 160 references? Or bias?