The Silence: The Asbestos Industryand Early Occupational CancerResearch-A Case StudyDavid E. Lilienfeld, MD, MPH, MS Engin

If an ox gores someone that they die,then the ox shall be killed, and his fleshshall not be eaten; but the owner of theox will not be liable. But if the ox hasgiven indications of goring persons, andhis owner was so informed, and the oxwas not kept in and he killed someone;the ox shall be killed and his owner alsoshall be killed. Exodus 22: 28-29

The Industrial Revolution brought with itwidespread occupational exposures topathogenic agents, such as silica and lead.Recent legislative initiatives in the UnitedStates have greatly reduced such expo-sures. However, in the absence of majorenforcement efforts, the effectiveness ofthis legislation depends on corporatecooperation and compliance. Many of thecorporations whose products cause occu-pational diseases sponsored the initial de-velopment of that etiologic knowledge."4Recent legal actions by some members ofthe asbestos industry have disclosed doc-uments describing the development andsubsequent suppression of data concern-ing the hazards of asbestos. Members ofboth the insurance industry and the aca-demic medical community participated insuch activities which permeated the as-bestos industry.

This paper describes the develop-ment ofthese actions and how the concemwith asbestosis which had developed first,was extended to cancer. It discusses theindustry's growth, the development ofconcems about asbestosis, and the forma-tion of a research program to counterthem. When these studies found that as-bestos was a carcinogen, this informationwas suppressed. The ensuing cover-up,effected through industry associations andresearch compacts, resulted in thousandsof deaths.7'8

The Asbests Idiy,1850-1927

The attributes of asbestos, a silicate,that fostered its widespread use have beenknown for at least two millenia.9 Yet itwas the unique confluence of the Indus-trial Revolution, innovations in buildingconstruction, and the economic growth inthe United States that led to its wide-

spread use during the past centuzy. Insu-lation was needed for efficient energy useto maximize engine power.10 Resistanceto both heat degradation and combustionwas desirable. Asbestos was such a ma-terial.

The asbestos industry developed as aresponse to this need for insulation. Itgrew in tandem with the post-Civil Wardevelopment of heavy industry. Duringthe late 1800s, many in the industrythought that if asbestos felts could limitengine heat loss, then asbestos roofingfelts might similarly limit building heatloss. Asbestos became a construction ma-terial. Rapid growth of the industry wasnot without serious consequences." Inthe 1920s, for example, the medical com-munity recognized a fibrotic lung condi-tion, similar to silicosis, that resulted fromasbestos exposure.9'12

T7e Hazard SuggestedIn the late 1800s and early 1900s, the

hazards of occupational silica exposurewere recognized, and the widespread na-ture of such exposures became appar-ent.13 Theywere made clear in a landmark1917 report by a young Public Health Ser-vice (PHS) physician, Anthony JosephLanza."4 After entering the PHS in 1907,Lanza was detailed to the Fort Stanton,New Mexico, Marine Hospital Tubercu-losis Sanatorium. He left that assignmentwith an interest in pulmonary medicineand the clinical skills to pursue it.

In 1914, Lanza was appointed as theChief Surgeon to the Bureau ofMines. Hewas assigned to the Joplin, Missouri, leadand zinc mining areas "to investigate andreport on the prevalence, causes, andmethods of control ofpulmonary diseasesamong miners."'15 A series of investiga-tions followed that quickly establishedhim as an expert in the pneumoconioses.14

Reprint requests should be addressed to DavidE. Lilienfeld, Mount Sinai School of Medicine,Division of Environmental and OccupationalMedicine, Department of Community Medi-cine, Box 1057, 1 Gustave L. Levy Place, NewYork NY 10029.

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Further assignments in occupational med-icine followed. In 1920, Lanza left thePHS to practice and consult in the privatesector. Sixyears later, hewas hired by theMetropolitan Life Insurance Company to"provide industrial medicine and indus-trial hygiene services to companies whosegroup life insurance policies were held bythe Metropolitan."'"4 The Metropolitanalso provided these services to companieswhose disability or workmen's compen-sation policies it carried.

The recognition of silicosis and its as-sociation with employment practices,coupled with a high injury rate in manyindustries (particularly in mining), led tothe enactment of workmen's compensa-tion statutes in the United States between1910 and 1930.16,17 Corporations bore thissystem's cost as a business expense. Itwas therefore only in the 1920s that theMetropolitan's services were needed byindustry. At the same time, asbestosiswasidentified as a distinct entity caused byasbestos.6 No direct evidence exists thatthese reports were alarming to the indus-try. However, subsequent events suggestthat the companies did not immediatelyacknowledge (or desire to do so) the haz-ard created by asbestos exposure.

One response was a 1929 request byseveral asbestos companies to the Metro-politan for an industrial hygiene survey ofseveral of their plants. The survey alsowas to determine if asbestosis even exist-

ed.6"8 If the disease did not exist, thenthere could be no liabilities from it. Anadditional concern was whether asbesto-sis led to tuberculosis in a manner akin tosilicosis, since asbestos was a silicate. Ifasbestosis did so, the compensation costswould be much greater. Lanza, an expertin the pneumoconioses, was to direct thestudy.

Lanza was well aware of the legalimplications of such work. For example,in November 1929, he had sent to Mr.Allan Wardwell (ofDavis and Polk, a WallStreet law firm and Johns-Manville's out-side corporate counsel) a bibliography onasbestosis.'9A year later, Lanza wrote toWardwell concerning the definition of as-bestosis to be used in the workmen's com-pensation schedule for New Jersey, thenbeing codified.20

The surveys found that asbestosis,present in large segments of the industry'sworkforce, did not predispose totuberculosis.21-23 In 1931, Lanza sent theAmerican plants survey findings to Ward-well, noting: "It is, of course, understoodthat this report is confidential and it will begiven no publicity by us except with theconsent of the firms concemed."24A sim-ilar report for the Canadian plants (writtenby Lanza's superior, E. McConnell, MD)was also sent to Wardwell.25 Threemonths later, at a meeting with Johns-Manville officials, Lanza recommendedthe inclusion of asbestosis under work-

men's compensation: " [He] is verystrongly of the opinion that asbestosisshould be made compensable.... Hefeels that this is the only protection whichthe industry has ... permitting the diseaseto remain outside the compensable classlends encouragement to unethical lawyersand physicians to work up claims."2

By 1932, Johns-Manville had severalsuits against it from workers with asbes-tosis.27 In contesting these suits, the cor-poration sought to question the diagnosisofpulmonary disease. In February, Lanzawrote to F.V. Meriwether, MD, ofthe USBureau of Mines, requesting his assist-ance in reviewing some x-rays from theManville, New Jersey, plant.28 In a fol-low-up letter from S.A. Williams (Johns-Manville Vice President for Mines andProduction), Meriwether was told "youwill readily appreciate that we desire theresults ofyour readings tobe held in strict-est confidence and that no unnecessarypublicity be given to the fact that you aremaking these readings for us ... we wish,if possible, to prevent the results of ourefforts being used against us either in thepending suits or in any suits which maybebrought against us."27 Meriwether subse-quently agreed.29 Vandiver Brown,Johns-Manville's general counsel, coordi-nated the logistics.'

In 1933, Williams wrote to A. R.Fisher (manager ofthe Manville, New Jer-sey, plant) concerning Lanza's reply toquestions from a physician at Johns-Man-ville's Waukegan, Illinois, plant.31 TheWaukegan physician had reportedlyasked Lanza, "Do you agree withmy rec-ommendation that employees definitelybe made aware of the fact that asbestosdust is hazardous to their health?" Lanzareplied: "I doubt if the hazard is sufficientto justify warning posters.... This is es-pecially true in view of the extraordinarylegal situation." The legal aspects of thesituation had had an impact on a physi-cian's (i.e., Lanza's) approach to a med-ical problem, i.e., they led him to ignore it.Later in the exchange, the plant physiciannoted: "I have made a diagnosis of asbes-tosis.... In myjudgment the best dispo-sition ofsuch a case is to remove him fromthe dust and give him a job in some otherpart of the plant." Lanza replied: "It isdifficult.... One of the difficulties andvexations ... of pneumoconiosis is thateconomics as well as production factors,must be balanced against the medical fac-tors." In November 1933, LanzametwithJohns-Manville executives to disALss thecompletion ofthe Metropolitan surveys.32Attendees included W. R. Seigle (chair-

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An electron micrograph of chiysotile asbestos fibers, magnfied 6,500 x. Chrysoileasbestos was the most common type of asbestos used In the United States. Courtesyof Irving Weisman, Sr.

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man of the board), E. M. Voorhees (sec-retary and treasurer), Brown, and Wil-liams. Lanza thought that resurveys ofboth the plants and the employees wouldbe necessary. He stated that it would beadvantageous if Wardwell spoke with theMetropolitan's president to stress the im-portance of the project's completion.Voorhees asked about obtaining annualdust counts in the plants "in the event weshould ever be involved in litigation."Lanza suggested that the Saranac Labo-ratory, a tuberculosis sanatorium and re-search facility, would be better positionedfor such a task.

A follow-up meeting, again in Sei-gle's office, was held in late December,1933.33 Joining the meeting were S. Simp-son (president of Raybestos-Manhattan)and M. F. Judd (another Raybestos-Man-hattan official). Among the topics of dis-cussionwas pending litigation: "Itwas de-cided that this committee ... would ...obtain Dr. Lanza's recommendation withrespect to locating or developing an expertwhose services might be utilized from thestandpoint of court work."

At the same time, L. U. Gardner,MD (medical director at the Saranac Lab-oratory) wrote to Lanza concerning thedisposition of some mine workers at thePhilip Carey Company (in Canada) whohad developed silicosis.4 When any ofthese workers filed a compensation claim,the Saranac Laboratory would review thex-rays for the Metropolitan. Gardnernoted that the closing of the Carey minewould precipitate the filing of many suchclaims for silicosis and silico-tuberculosis.Carey had dealt with this situation by

transferring these men to its operationsacross the border in Michigan, wherethere was no compensation law.

By the end of 1933, it was clear thatthe industry and at least one of its insurerswere concerned with asbestosis-relatedlitigation and wanted to minimize the as-sociated economic impact. A key figure inthese activities was an employee of Met-ropolitan Life, Lanza. It was through hisassociation with the asbestos industry thatthe foundation was laid for future formalconcerted action to conceal research find-ings relating asbestos exposure to both as-bestosis and cancer.

The CodificationAt an early 1934 meeting, officials of

Johns-Manville, Raybestos-Manhattan,and Metropolitan Life were "advised ...as to the relatively better position in whichthe companies would be placed in theevent of litigation if ... an outside expertof recognized reputation ... would statethat he had made certain recommenda-tions ... and that these recommendationshad been followed."35 Lanza stated thathe would discuss this role with Dr. P.Drinker of Harvard University.

Until late 1934, the efforts of the in-dustry, of the Saranac Laboratory, and ofthe Metropolitan had been directed atkeeping research findings confidential.For instance, in 1933, the Saranac Labo-ratory had released confidential data onsilicosis.36'37 As a result, the WisconsinIndustrial Commission was able to publisha report on silicosis and tuberculosis thatwas none-too-favorable to the industry.Lanza scolded the Saranac Laboratory forthis unauthorized release.38 Outright de-ception began in December 1934.39 Lanzawas publishing the results of the 1931 sur-vey. Brown, concerned about the article(then in galley proofs), discussed somechanges with one ofJohns-Manville's out-side counsels (G. Hobart). Within a week,Hobart sent Brown a marked-up versionof the paper, noting that "one of our prin-cipal defenses ... has been that the sci-entific and medical knowledge has beeninsufficient until a very recent period toplace upon the owners of plants or facto-ries the burden or duty of taking specialprecautions against the possible onset ofthe disease to their employees."' Aweeklater, Brown forwarded these commentsto Lanza, noting that "I trust that you willgive his comments and suggestions, aswell as those mentioned in my letter, yourmost serious consideration. I am sure thatyou understand fully that no one in our

organization is suggesting for a momentthat you alter by one jot or tittle any sci-entific facts or inevitable conclusions re-vealed orjustifiedbyyour preliminary sur-vey. All we ask is that all of the favorableaspects of the survey be included and thatnone ofthe unfavorable be unintentionallypictured in darker tones than the circum-stances justify."41 The desired changeswere made prior to publication.42'43

In early 1935, Lanza sent a reprint ofthe published article to Wardwell, noting:"the Public Health Reports publicationgives this piece ofwork authoritative anddignified presentation.""4 Subsequently,S. E. Whiting (Assistant Chief Engineerof the Liberty Mutual Casualty InsuranceCompany), requesting a reprint fromLanza, referred to the continued fundingofthe Saranac Laboratoryby LibertyMu-tual and the Metropolitan.4' He also sug-gested that the Saranac Laboratory re-lease the Lanza survey results to theseinsurance companies, who would in turnconvey the findings to the industry. Thedata were subsequently so released.'

In late 1936, the asbestos industryagain found itself in legal troubles as it hadcompensation cases to settle. Simpson de-scribed the problem in a letter to H. D.LaMont of the Asbestos ManufacturingCompany: "They claim it [asbestosis]leads to Tuberculosis, but we do not findthis to be the case. Still, we cannot go intocourt and state definitely and specificallythat it will not do so."47 Simpson went onto describe the Saranac Laboratory's ca-pability to address the tuberculosis-asbes-tosis issue. He also suggested that mem-bers of the industry (Johns-Manville,Thermoid Rubber, Keasbey and Matti-son, Asbestos Manufacturing, RussellManufacturing, and Raybestos-Manhat-tan) contract with the Saranac Laboratoryto conduct these experiments: "to havefour or five (or even more ifwe could getthem) Asbestos manufacturers take overthis study ... and then we could deter-mine from time to time after the findingsare made, whether we wish any publica-tion or not . . . it would be a good thing todistribute the information among the med-ical fraternity, providing it is of the righttype and would not injure our compa-nies."

On November 9, 1936, Simpson metwith Lanza, McConnell, Brown, andGardner to discuss the possibility of con-ducting such studies.' Nine days later,these companies (Appendix A) so con-tracted with the Saranac Laboratory, withthe provision that "the results obtainedwill be considered the property of those

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who are advancing the required funds,who will determine whether, to what ex-tent, and in what manner they shall bemade public. In the event that it is deemeddesirable ... the manuscript ofyour studywill be submitted to us for approval priorto publication."49'50

There matters rested for three years.Gardner was unable to complete his ex-periments. The medical literature contin-ued to accumulate on the noxious effectsof asbestos.6'9 In the winter of 1940,Brown advised Gardner that the fundingwould be extended by a year and that theterms of the original agreement continuedto apply.51 Presumably, this last commentreferred to the provision concerning in-dustry approval prior to publication.

In 1942, Ivan Sabourin (chief counselfor Canadian Johns-Manville) joined inthese endeavors. On May 6, he sent amedical report to Gardner that he (Sab-ourin) had "taken the liberty of draftingfor you ... for the benefit of my cli-ents."52 The report was to be sent byGardner to various state workmen's com-pensation boards. Soon afterwards, Sab-ourin became the general counsel for theQuebec Asbestos Producers Association(a Canadian asbestos industry associa-tion), which would undertake much of theasbestos-cancer research conducted dur-ing the coming decade.

CacerGardner's asbestos work continued.

An interim report noted that 81.8 percentof animals exposed to asbestos had devel-oped lung tumors, an overly high rate.53Gardner thought the result to be impor-tant: "The question of cancer susceptibil-ity now seems more significant than I hadpreviously imagined." A copy of the re-port was sent by one sponsor, Keasbeyand Mattison, to its parent, Turner andNewall (a major asbestos manufacturer) inEngland, with the comment "we feel thatreference to the question of cancer sus-ceptibility should be omitted from the re-port since it is inconclusive."54

Concurrently, the asbestos industryand the Metropolitan turned their atten-tions to Canada. This change in focus be-gan with a Metropolitan actuary's reportto G. W. Wheatley, MD (assistant direc-tor of the Metropolitan's Medical Divi-sion) of a high tuberculosis rate at theJohnson Company in Thetford, Que-bec.55'56 This finding again raised the issueof asbestosis and tuberculosis. The Met-ropolitan decided that a survey of theJohnson Company was needed.57

During a trip to Quebec in October,1944, Wheatleymetwith Sabourin, amongothers.58 Sabourin's clients had been deal-ing with asbestosis compensation claimsand were in the process of establishing anasbestosis clinic at Thetford, Quebec. TheQuebec view was that asbestosis in-creased the riskoftuberculosis. At a meet-ing of Sabourin, 0. C. Smith (president ofBell Mines), A. Penhale (manager of theAsbestos Corporation mines), A. Johnson(president of the Johnson Company), andthe Metropolitan staff, the logistics of es-tablishing the clinic (the Thetford Clinic)were discussed. Dr. P. Cartier, of theMontreal Anti-Tuberculosis Society, wasto direct the clinic.

In the United States, meanwhile, theconcerns about Gardner's findings contin-ued. One sponsor wrote to Brown in April1946, indignant that the draft mentionedcancer.59 After Gardner's death in Octo-ber 1946, Brown wrote the other sponsorsto suggest that someone else at the Sa-ranac Laboratory complete the report. Aswork proceeded accordingly, the spon-sors reiterated their right of approval of allpublic releases of the findings.80'61 In theinterim, Lanza sent Gardner's last draft toProfessor Kenneth Lynch, MD, of theMedical School of South Carolina for re-view. Lynch recommended the publica-tion of the report without revision.62

As the draftingofa final report nearedcompletion in late 1947, Fisher wrote toJ. P. Woodard (a Johns-Manville seniorexecutive) that the final report should bereviewed by "the top man of the QuebecAsbestos Producers Association."63 Bylate November 1947, Sabourin was veryanxious to have the report completed tocounter local Quebec groups upset aboutthe health effects of asbestos exposure.Yet there was still no final report. InMarch 1948, a frantic Woodard noted toLanza that laborproblems in Quebecwererelated to asbestos.'

Two months later, Brown wrote toMuehleck (president ofKeasbey and Mat-tison) suggesting that the Asbestos TextileInstitute (ATI) review the report. (TheATI, an industry trade association, hadbeen founded in 1944 to promote asbestostextiles. Its membership (Appendix B) hadconsiderable (but not total) overlap withthe sponsors.6) Muehleck thought that thesponsors should review the work.65Brown noted that although some sponsorswere not ATl members, the ATI membershad provided most of the funding.66Therefore, Brown argued, the ATI, notthe sponsors, should conduct the review.Muehleck finally agreed.67'8

By this time, A. J. Vorwald, MD,had been appointed as Gardner's succes-sor.6 With much urging from Woodard,he completed a draft of the Gardner re-port (including a cancer section) that wasready for review.69 70 One sponsor hadalready indicated that the cancer sectionshould be removed; now, other sponsorsconcurred.59'6976 Brown agreed; Lanzawas told to handle the matter.7-78

In the process ofthis review, all ofthesponsors (except Keasbey and Mattison,and Raybestos-Manhattan) received cop-ies of the draft that had been numbered byBrown. The reason was simple: "It is ob-viously undesirable that the report in itspresent form receive any distnbution orpublicity outside a limited number of peo-ple in our respective organizations."76The next month, Dr. Hamlin, medical di-rector for American Brake Block, reas-sured his superiors that the report was notcontroversial "since most of the basicfacts with the exceptions of the more de-tailed studies mentioned in the report arealready known ... no unfavorable reac-tion need be anticipated."76'79 About twoweeks after the review committee decidedto remove the cancer section, Browncommunicated this conclusion to W. T.Kelly (Hamlin's boss at American BrakeBlock). Brown noted that all of the copiesof the report had been "retrieved ... ex-cept the one we sent you, which . . . Dr.Hamlin would like to keep. I wish, how-ever, you would prevail upon him to re-turn it.... Everyone felt that it would bemost unwise to have any copies of thedraft report outstanding."76 Kelly subse-quently asked Dr. Hamlin to return thedraft.80

The January 31, 1949, draft of the re-port had the section entitled "Neoplasm"marked through with the word "out."81The revised report was published in1951.82 One member of the investigativeteam has stated that this act was unrelatedto sponsor pressure.83

On March 8, 1949, Brown wrote Sa-bourin that "because of our close associ-ation in Canada with others interested inthe solution ofthe asbestosis problem, theresults of these experiments should bemade available to them in advance ofpub-lication.... I am providing you ... ascounsel to Quebec Asbestos Mining As-sociation [the successor to the QAPA}-with two copies of the report."' By June,1949, the report had begun to be promotedin the United States. For instance, Gatkenoted that the Massachusetts IndustrialBoard "would likely be more lenient in

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their decisions iftheyhad the advantage ofthe information disclosed in this re-port."85

As K. Smith, MD (the medical direc-tor of Canadian Johns-Manville) noted,the report left many questions unan-swered, including the importance of fibersize, and specific aspects of the asbestos-cancer issue.8'-87 Vorwald wrote to Smithin October, 1949, suggesting that thex-rays ofthe Quebecworkers be reviewedfor lung cancer.88 A study protocol wasquickly formulated.89 Smith wrote to Lin-dell (president of Canadian Johns-Man-ville) that "there has been a tremendousincrease in the number of articles in med-ical journals during the past year whichdeal with the subject of occupational can-cer. Very high on the list of causes ... isasbestos. There seems to be increasingproof that asbestos fibers do cause lungcancer. This conclusion is drawn onlyfrom articles reported in the journals....I have been unable to find any x-ray evi-dence of lung cancer among our employ-ees ... but this whole subject could causeour companies unlimited embarrassmentand untold expense if labor leaders madeuse ... of the subject.... If we are todefend ourselves in the compensationcourts, we must have proof. I believe thatwe should discuss this matter at aQ.A.M.A. Meeting and . . . ask ... [theSaranac Laboratory] to outline a sug-gested plan of study."90 (Smith had al-ready reviewed the Saranac Laboratoryreport at the QAMA meeting in 1949.91)He noted: "As far as J-M is concerned, Iknow of two hazards in our operationswhichmaylead to pulmonarymalignancy,namely asbestos and silica. There is everincreasing evidence in the medical litera-ture today that these materials lead to lungcancer." A study was needed.

By March, 1950, the issue had be-come whether further study should be un-dertaken by William Smith, MD (a toxi-cologist at Ianza's unit) orby the SaranacLaboratory.9?'- (Following Lanza's re-tirement from the Metropolitan in 1948, hefounded the Institute of Industrial Medi-cine atNewYork University.94) Site visitssuggested that both facilities could com-plete the work.93 L997anza drew up acontract which left "little choice to thedonor if the results of the study are unfa-vorable to company interest and are sub-mitted for publication. However, I [KSmith] fail to see how they can find any-thing more unfavorable than that whichalready has been published ... ",,98 In Sep-tember, Vorwald submitted a competingcontract for the Saranac Laboratory,

which stated that "the Saranac Labora-tory reserves the right to publish the re-sults of its investigations in the recognizedmanner ... whereby the manuscript priorto its publication is submitted to the spon-soring company for its review and approv-al."5599

Later that month, the QAMA notedthat "a relationship between the inhala-tion of asbestos dust and pulmonary can-cer has been stated publicly by certainhealth authorities.... It is necessary forus to ... prove that this statement is notcorrect or to accept it and the conse-quences thatgowith it. Ourposition in thismatter is the same as the Association andIndustry found itself in 1937 as regards toasbestosis."'°10 The proposed studywoulduse "the same methods as our antago-nist." Animnal studieswere also suggested.Another activity "would consist of morepublicity coming from our association ...rather than taldng the defensive attitudethatwe have.... Thatwe arrange to haveour doctors lecture at medical schoolsyearly. That we attempt to affiliate ourdoctors in some manner with researchcenters such as Saranac and in such orga-nizations as the Industrial Hygiene Asso-ciation and the Lnstitute of Industrial Med-icine [Lanza's New York Universitygroup]"

Despite the long association betweenLanza and his industry colleagues, thelack of sponsor control of publications inthe New York University proposal led tothe Saranac Laboratory's being awardedthe contract.9'01 In November, Lanza,Sabourin, and Woodard met with Vor-wald to review the project.101 The studiesbegan and were soon almost complete."0Smith (now medical officer for Johns-Manville) thought that an epidemiologicapproach was needed. He wrote Johns-Manville officials that "we would be wiseto wait [for a news release] until we haveproof of no causal relationship betweenasbestosis and pulmonary cancer ... wemight not wish to bring attention to theasbestos industry if the cancer research isnot entirely favorable."o103

In July, 1951, Cartier reviewed can-cers among eight asbestos workers."04 Heobserved: "some causal factor will pro-duce the samevariety oftumors and there-fore why do we observe such a variety of[cancers] ... [ifl we may assume that theasbestos factors might produce a bron-chogenic carcinoma . . . then only twocases of the series would serve as evi-dence because the other cases are me-sothelioma or lymphosarcoma or second-ary malignancy in cases without exposure

orwithout asbestosis." (Ironically, Johns-Manville would argue two decades laterthat mesothelioma was not a distinct can-cer.5)

In October, Vorwald presented hisinitial findings to the QAMA: "Althoughonly six months had elapsed ... animalswhich were killed during this time pre-sented no greater incidence of pulmonarycancer in the dusty group than in the non-dusty group ... he is certain that there isno association between the cancer and as-bestos, but . . . cannot state this scientif-ically, for at least twenty months mustelapse before conclusive evidence can beproduced and in the meantime, this statis-tical survey [the epidemiologic study]should be carried on."105

In February, 1952, A. L. Fisk, Jr.(Johns-Manville's Legal Department)wrote to Lanza: "As you are aware, theIndustrial Commission of Illinois has pro-mulgated rules as to the labeling of sub-stances harmful to the health and safety ofemployees ... in our opinion asbestosfiber comes within the preview of the reg-ulations.... It is our intention to label ourbags containing asbestos fiber, using thefollowing:

" 'CAUTION-ASBESTOS FIBER'Inhalation of asbestos fiber over long pen-ods MAYBE harmful. The material shouldbe used as not to create dust or, if this is notpossible, employees should be equippedwith adequate protective devices." 06

For unknown reasons, a warning labelwas not added to the bags for another 13years.6

The QAMA-sponsored Saranac Lab-oratory animal study continued. At 14months, the animals exposed to asbestoshad a higher incidence of cancer thanthose not exposed."0 The study was notpublished. The industrywaswell aware ofthe stakes involved. For example, in 1953,the Indiana State Division of IndustrialHygiene contacted National Gypsum con-cerning the safety of asbestos spray prod-ucts.108 The National Gypsum safety di-rectorwanted to reply that the applicatorsshould wear respirators. A National Gyp-sum executive characterized the sugges-tion as "full of dynamite," stating that "Iam much concerned that National Gyp-sum is on record ... that Thermacousticis hazardous business. If this snowballs,we are out of the Thermacoustic busi-ness."

Vorwald's tenure at the Saranac Lab-oratory was ended in 1953, after he at-tempted to investigate further the asbes-tos-cancer relation.6 He soughtemployment as a professor at a California

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institution. Lanza flew to California toprevent that Vorwaldwould be offered theposition (personal communication, W.Smith).'09" The trip is alleged to havebeen paid for by the Metropolitan. A sim-ilar fate befell W. Smith (a toxicologist inLanza's unit) after he had indicated an in-terest similar to Vorwald's (personal com-munication, W. Smith).

At the Seventh Saranac Symposiumin 1952, the asbestos-cancer relation wasdiscussed and the carcinogenic potentialofeach ofthe fiber types noted."12 Attend-ing this meeting, in addition to industryphysicians, were representatives of theLiberty Mutual, the Travelers, the Amer-ican Mutual, and other insurance compa-nies. Turner and Newall (in Rochdale, En-gland) sent a physician, J. Knox, to attendthis meeting. At the Seventh SaranacSymposium, he metW. Smith. Stimulatedby the reports at the symposium, Knoxdecided to examine the Rochdale asbestosworkers' lung cancer experience. He be-gan to trace the Rochdale workforce, col-laborating with Sir Richard Doll (then an

epidemiologist at the London School ofHygiene) on the data analysis. By Decem-ber 1953, both men had realized that lungcancer mortality was much above what itshould have been."13A paper was draftedwith Knox as the senior author."14

In June, 1954, Knoxwrote W. Smith,describing Turner and Newall's responseto the research findings: "This letter is ad-dressed to you in your private capacity.The letter of 31/5/54 is the official answer

which I must give at present. Its tone musthave given you quite a jolt. When your

lettercame in February, Doll and I had notfinalized our paper. On completion we

sought permission to publish and, to mygreat surprise, were refused by thecompany-at present. Up until a few daysago, I had hopes of a more favorable turnof events but the ban remains. The head-line news about lung cancer has scaredpeople over here and it was thought wemight attract undesirable publicity in our

area.... I am sending you personally a

copy of our paper. Perhaps the people towhom it would be most unwise to mentionit would be those associated in any waywith our industry.""14 When Doll learnedof the ban, he wrote Knox: "For my ownpart, I feel that any positive findings withregard to the cause of cancer must bemade available to all research workers onthe subject ... it isby free publication thatthe work can be tested and utilized (ordisproved) by others.""15 In 1955, themanuscript was published; Knox was ac-

knowledged anonymously."6 That indus-try-supported investigators in NorthAmerica had previously gleaned thecausal association could not have beenknown by Doll.

Discussions of the cancer-asbestoslink within the asbestos industry ensued.The QAMA and the Asbestos Textile In-stitute, for example, communicated witheach other about the subject."17 Yet an

industry manual compiled by the Magne-sia Insulation Manufacturers Association

(another industry trade association) statedthat asbestos "offers no hazard to theworker."'18 Also, it is apparent that, at aNational Cancer Institute (NCI) discus-sion in 1955 on asbestos and cancer, at-tended by Vorwald and K. Smith, no dis-closure of either Gardner's or Vorwald'sfindings was made.119 The meeting con-cluded that "there have been no asbestos-cancer animal experiments." It noted thatgiven the widespread use of asbestos, if itwere carcinogenic, the public health im-plications would be great. Also in atten-dance was an NCI staff member, W.Hueper, PhD. Hueper was very muchconvinced of the causal relationship be-tween asbestos and lung cancer."2

In February 1956, K. Smith wrote toDaniel Braun, MD, [the medical directorat the Industrial Hygiene Foundation(IHF)], concerning Hueper's statementsthat asbestos caused cancer.121 (The IHF[Appendix C] was established in 1936 toprovide dust control information to itsmembership, which included many mem-bers of the asbestos industry.5'6) K. Smithnoted that "we have too much at stake toallow ... such indiscriminate state-ments." In response, Braun prepared areport on asbestos and lung cancer for theQAMA (under the auspices of theIF)122-124 (The Asbestos Textile Insti-

tute had rejected an IHF proposal for fur-therworkon asbestos and cancer becauseit would "stir up a hornet's nest and putthe entire industry under suspi-cion."'125 26)Afinal reportwas soon com-pleted.'27 The copies were numbered.Braun stated that "a comparison of rela-tive frequency of lung cancer and asbes-tosis is less reassuring ... this is becauseof an underreporting of asbestosis cases.The incidence of asbestosis indicated bythe medical records is farbelow thatwhichwould be expected. ... However, thismay be 12.5% of the recorded cases ofasbestosis in this state of development oflung cancer, a figure slightly lower thanthose quoted by authors who confinethemselves to this type of comparison."The consequences of the industry's pre-vious underreporting of asbestosis nowbecame clear. The concluding sentence ofthe report was less equivocal: "The re-sults suggest that a miner who developsthe disease asbestosis does have a greaterlikelihood ofdeveloping cancer ofthe lungthan a person without this disease."

Once the QAMA had received thereport, Sabourin met with Braun to pro-duce a "condensation" for1publication.28Concurrently, K. Smithwrote to Sabourinthat "[we] have noted deletion of all ref-

796 American Journal of Public Health

"UMPEr' sprayed asbestos application. UMPET was a product of the Keasbey andMattison Company. Note the two men at the far right feeding the machines. Courtesy ofMitchell Cohen.

June 1991, Vol. 81, No. 6

Public Health Then and Now

erences to the association of asbestosisand lung cancer.... While we believethat this information is of great scientificvalue, we understand the desire of theQAMA to emphasize exposure of the as-bestos miner and not the cases of asbes-tosis."129 K. Smith noted that the pub-lished condensation would be criticized"because all ofthe authors today correlatelung cancer to cases of asbestosis."

In 1958, the Archives of IndustraHealth published the "condensed" Braunreport (without the quoted concludingsentence).-" In his letter of acceptance,Stokinger, the editor (a major figure in thedevelopment of threshold limit values)noted his pleasure that "the main conclu-sion of the paper was against the associ-ation of lung cancer with asbestosis, for Ihad come to a similar conclusion on ob-viously far less information.... I am en-closing a review which contains a fewstatements that I have marked in this con-nection that appears in theAnnualReviewof Medicine, Voiwne 7, 1956. You willrecall at this time evidence greatly favoredthe positive correlation of lung cancer andexposure to asbestos."'131'132 At a 1958symposium, the "condensed" report waspresented. Sabourin reported to theQAMA that the news of this symposiumprovided "wonderful public relations val-ue. ,133

By the early 1960s, the industry andits associates had succeeded in suppress-ing much of the knowledge gleaned overthe prior two decades concerning asbestosand cancer. During the 1960s, academicscientists and physicians, such as Selikoffand Wagner, discerned the relationshipbetween asbestos with cancer."3 Thesefindings were quickly appreciated by thegeneral medical community.135 The indus-try was in a compromised position. In1963, K. Smith suggested the purchase ofa shredding machine to "destroy com-pletely all copies ofcorrespondencewhichyou do not wish to retain... . I believethat this is highly essential but all copies ofcorrespondence of such confidential na-ture should be thoroughly destroyed sothat our position in Workmen's Compen-sation claims cannot be doubted."'l3

In the mid-1960s, the industry beganto place warnings either on the bags ofasbestos or on the sides of the woodencrates used to ship the products containingasbestos. In 1965, a series of Johns-Man-ville memos clearly state that for productsexported from the United States, thewarning on the bags should be coveredand those on the crates, sanded off.137'138Similar memos exist for other members of

the industry. For instance, a 1964 Eagle-Picher memo concerning such warning la-bels stated the following: "This is largeenough type face [1/8 inch height] to becompletely legible, yet does not 'shoutCAUTION from the roof tops.""'39 In1970, an Owens-Corningmemo succinctlystated the reluctance to use such labels:"Reference is made . . . regarding thewarning label.... Are you saying that wehave to do this now? I naturallywould liketo delay this requirement as long as pos-sible."140

A little more than a decade ago (in1977), the following exchange took placewithin the Phillip Carey Company: "I gotvery strong reactions in Japan to our re-quirement to translate the ... [warning]Label into Japanese.... Confidentially,the Kakiuchi staff told me that they delib-erately left out the word cancer from thetext because this must not even be men-tioned in Japan in connection with asbes-tos. Altogether they are against a warninglabel because they do not wish to raiseproblems with the workers. They are al-ready attaching a label on each bag ac-cording to Japanese law. Kakiuchi wouldprefer to sign a certificate holding usblameless from harm.... Asbestos Cor-poration and Bell have both gone thisroute per attached blank forms. Kakiuchiare of the opinion that we cannot imposeAmerican law on foreign counties and onJapan in particular.... . I do not believethatwe should raise problems with peoplewho are more primitive than we are, orless educated.""14 The reply: "As far asthe caution label is concerned . .. wemust be sure to cover ourselves onlywhere the law of the land requires. I sug-gest we go ahead with the new cautionlabel in English and French only. What doyou think the Japanese, Finns, Swedesand Dutch will have to say about that?""42

By the late 1970s, the industry wasunder attack in the courts and in the press.One Johns-Manville memo, labeled"Confidential", dated January 12, 1979,addressed to John A. McKinney, presi-dent of the company, assessed events:

The situation confronting Johns-Manvilleand asbestos has changed dramatically inrecent days . . . now the in y ofpre-sent-day management is being severelychallenged. The shift in the thrust of publicopinion is crucial in that favorable legisla-tion on compensation will not be possible ifthe credibility of the corporation ... isquestioned by Congressmen and, more im-portantly, their constituents.

I believe the seriousness of the situationhasnowgonebeyond the implementation ofa communication effort, though that shouldbe done ... here are a few examples:

1. JM position: Prior to 1964, we lackedscientific knowledge about cancer haz-ards of asbestos.FACT: In the mid-50s, JM officials knewof scientific studies showing a relation-ship between cancer and asbestos.

2. JM statement to North Carolina judge:So-called "cover-up letters" not avail-able.FACT: Letters had been used in a NewJersey trial several weeks before ...

3. JM position: though sprayed asbestos in-appropriate for use in schools, we see noevidence of danger.FACT: If no problem, then why an in-appropriate use?

4. JM position: There will be no futureproblems with workers.FACT: Workers in Mexico are not beingprotected.

5. JM position: Knoxville trial shows therewas no conspiracy.FACT: Knoxville judge tells the Asso-ciated Press "offthe record" that his rul-ing on punitive damages does not clearthe company of a "cover-up" charge.

6. JM position: Since 1964, JM has "comeclean" with employees about asbestoshazards.FACT: A current 41 year employee ofJMhas calledme to say that he has a spoton his lung. . . but no one atJM has evercommunicated with him about it.

7. JM position: There was no cover up.FACT: A current employee ... says hisfather worked for JM for 35 years atManville and was never told about dan-gers. Father was dismissed because of'miners' asthma'. . . he had to take JMto court to get compensation for an as-bestos-related disease.

8. JM position: We have communicatedopenly with employees about illnesses.FACT: ... itwas company practice intothe early 70s not to tell a person about hisillness.

9. JM position:JM has taken precautions toprevent excessive exposure to fiber glassworkers.FACT: Plant manager... is reluctant topost HS & E bulletin because precau-tions not taken at his plant ...

I can easily see why we have members ofCongress calling us 'liars'.143

ConcuionsThis case study illustrates how a se-

ries of concerted actions was planned andcarried out during half a century, in whichdata were generated and then suppressed.Some of the principals in these activitieswere also leaders in occupational medi-cine. The societal response to the ambiv-alence and inaction by these leaders withrespect to industrial carcinogens was theOccupational Safety and Health Act of1970. The Occupational Safety and HealthAdministration removed some of theseleaders from the dominating positionsthey had held in the development of na-

American Journal of Public Health 797June 1991, Vol. 81, No. 6

Public Health Then and Now

tional policy on industrial carcinogens.The success of this approach remains un-clear.

Another interesting aspect of this ep-isode is how the information became pub-lic. It was by legal actions that these doc-uments were produced (through"discovery," the legal process of infor-mation disclosure). None of the compa-nies involved provided these papers freelyto the general public. Indeed, to have doneso would have greatly compromised 50years of corporate safety and health poli-cies. If major legal reform had been en-acted prior to this litigation, it is possiblethat these documents would not have be-come public knowledge. It is equally dis-turbing that none of these data were ob-tained through the existing occupationalsafety and health enterprise erected dur-ing the past two decades. The effective-ness of the current framework for devel-oping and enforcing occupational safetyand health considerations must thereforebe questioned. However, a complete dis-cussion ofthis issue is beyond the scope ofthe present work and should be consid-ered by the occupational health policycommunity.

The degree to which scientific fraudpermeated published reports is also ofconcern. The activities described suggestthat fraud in non-governmentally sup-ported research occurs, and that it has po-tentially great impact on health policy.However, unemployment or withdrawalof research support may be the ultimate"reward" for thosewho do not participatein such activities. The implementation ofmechanisms to prevent such fraud shouldnot await yet another public health trag-edy. Despite the disclosures of suppres-sion and fraud, no mechanisms have beenimplemented to prevent future such oc-currences.

It was not only in the asbestos indus-try that voluntary corporate compliancewith societal norms of conduct in workerhealth and safety were violated. Michaelshas shown that similar problems existed inthe aniline dye industry.3 As the recentA. H. Robins-Dalkon Shield episode illus-trates, in the 1970s, some corporations(outside the asbestos industry) thought lit-tle about suppressing detrimental medicalknowledge. Until such activities cease,the potential for future similar publichealth disasters to occur continues. U

AcknowledgentsThe authorwould like to thank Drs. M. GordonWolman, Abel Wolman, and I. J. Selikoff, and

Ms. M. Burger for their many comments andsuggestions concerning this manuscript andMessrs. R. Modley, D. Austern, T. Crumpler, J.Rion, C. Patrick, J. Gelman, and S. Hoffman,and Drs. D. Ozanoff, I. J. Selikoff, and B. Cas-tleman for their assistance in obtaining accessto many of the documents referred to in thismanuscript. All comments and conclusions arethe author's.

This work was supported in part by NIHgrant K08-ES00161.

ReferencesNote: The references for this paper include ex-hibits used as evidence in several legal proceed-ings. All of the correspondence, reports, etc.,for which no other identification information isprovided were used as exhibits at the Johns-Manville v. United States. CV 465-83 (FederalCircuit Claims Court, DC) 1983. All such ex-hibits are available from the Claims Court in theDistrict of Columbia. Other cases in whichthese exhibits were used are also cited. If nocase citation appears for a given letter, memo,or nonpublished article, then the reader mayassume that the reference maybe found as partof the evidence introduced in the Johns-Man-ville v. United States litigation. The other pro-ceedings (with corresponding abbreviationsused in the reference list) are as follows:

Laura Bialy, Administratrix of the estateof Theodore Bialy v. Johns ManvilleCorp. et al. Civ. Act. C/AN 79-1336(D.N.J.) (1986). (Cited as "Bialy").Paulene Kulzer as Executrix of the Estateof Richard Kulzer v. Pittsburgh CorningCorporation et al. Civ. Act. 87-03867 Fed-eral District Court, Western Dist. NewYork (1990). (Cited as "Kulzer").

1. Markowitz G, Rosner D. The illusion ofmedical certainty. silicosis and the poli-cies of industrial disability, 1930-1960.Milbank Quarterly 1989; 67 (Suppl. 2, PartI):1-26.

2. Ozanoff D. Failed warnings: asbestos-related disease and industrial medicine.In: Bayer R. (ed.). The Health and Safetyof Workers. New York: Oxford Univer-sity Press, 1988:139-220.

3. Michaels D. Waiting for the body count:corporate decision-making and bladdercancer in the U.S. dye industiy. MedicalAnthropology Quarterly 1988; 2:215-32.

4. Rosner D, Markowitz G. A "Gift ofGod": the public health controversy overleaded gasoline in the 1920s. AJPH1985;75:344-51.

5. Brodeur P. Outrageous Misconduct: TheAsbestos Industry on Trial. New York:Pantheon Books, 1985.

6. Castleman BT. Asbestos: Medical andLegal Aspects. New York: HarcourtBrace Jovanovich, 1984.

7. Nicholson WJ, Perkel G, and Selikoff U.Occupational exposure to asbestos, pop-ulation at risk and projected mortality,1980-2030. AJIM 1982; 3:259-311.

8. Lilienfeld DE, Mandel JS, Coin P, Schu-man LM. Projection of asbestos relateddisease in the United States, 1985-2009: .Cancer. BJIM 1988; 45:283-91.

9. Selikoff IJ, Lee DHK. Asbestos and Dis-ease. New York: Academic Press, 1978.

10. Andre GG (ed.). Spon's Encyclopedia of

the Industrial Arts, Manufacturers andCommercial Products. New York: E. andF. N. Spon, 1879.

11. [Anonymous]. Management by Morgan.Fortune. 1934 March: 82-89, 128, 130,132, 135-6, 141-2, 144, 146.

12. Weill H, Jones RN. Occupational pulmo-nary diseases. In: FischmanAP (ed.). Pul-monary Diseases and Disorders. 2nd ed.New York: McGraw Hill, 1988.

13. Forbes JJ, Davenport SJ, Morgis GG. Re-view of literature on dusts. U.S. Bureau ofMines Bulletin 978. Washington, DC:Govt Printing Office, 1950.

14. Goldstein DH. Anthony J. Lanza, MD,1884-1964. Arch Environ Health 1964;9:271-4.

15. Derickson A. Federal intervention in theJoplin epidemic. Bull Hist Med 1988;62:236-51.

16. [Anonymous]. Workmen's Compensa-tion for silicosis. Safety Eng 1934;57:71-4.

17. Gelman JL. New Jersey Workmen'sCompensation Law. St. Paul, MN: WestPublishing, 1988.

18. [Anonymous]. Report on a Dust Study ofthe Manville Plant of the Johns-ManvilleCompany, 1930 (Bialy Exhibit 2).

19. Letter from Lanza to Wardwell, Novem-ber 25, 1929 (Bialy Exhibit 3).

20. Letter from Lanza to Wardwell, Novem-ber 11, 1930 (Bialy Exhibit 7).

21. [Anonymous]. Report of a Dust Study ofthe Charleston, SC Plant of the GeneralAsbestos & Rubber Division of Raybes-tos-Manhattan, Inc., 1930 (Bialy Exhibit4).

22. [Anonymous]. A Study of Dust Condi-tions in the Mannheim Plant of the UnitedStates Asbestos and Rubber Division ofRaybestos-Manhattan, Inc., 1930 (BialyExhibit 5).

23. Pedley F. Report of the Physical Exami-nations of Asbestos Workers in Asbestosand Thetford Mines, Quebec. November,1930 (Bialy Exhibit 8).

24. Letter from Lanza to Wardwell, March20, 1931 (Bialy Exhibit 11).

25. Letter from McConnell to Wardell, July 9,1931 (Bialy Exhibit 13).

26. Minutes ofJuly 15,1931, meetingbetweenLanza, McConnell, and various Johns-Manville officials (Bialy Exhibit 14).

27. Letter from Williams to Meriwether, Feb-ruary 26, 1932 (Bialy Exhibit 16).

28. Letter from Sayers to Surgeon General,February 20, 1932 (Bialy Exhibit 15).

29. Letter from Sayers to Meriwether, April11, 1932 (Bialy Exhibit 20).

30. Letter from Lanza to Meriwether, March24, 1932 (Bialy Exhibit 17).

31. Letter from Williams to Fisher, August29, 1933 (Bialy Exhibit 25).

32. Minutes of November 28, 1933, meetingofLanza, Seigle, Voorhees, Williams, andBrown (Bialy Exhibit 29).

33. Minutes ofDecember 29, 1933, meeting ofSeigle, Voorhees, Williams, Brown,Simpson, and Judd (Bialy Exhibit 31).

34. Letter from Gardner to Lanza, December12, 1933 (Bialy Exhibit 30).

35. Minutes ofJanuary4, 1934, meetingof theRaybestos-Manhattan-Johns-ManvilleCommittee for Coordinating and Stan-dardizing the Ways and Means of Elim-

798 American Journal of Public Health June 1991, Vol. 81, No. 6

Public Health Then and Now

inating Dust and Protecting the Health ofEmployees Engaged in ManufacturingOperations (Bialy Exhibit 33).

36. Letter from Gardner to Knight, April 14,1933 (Bialy Exhibit 23).

37. LetterfromGardnertoLanza, April, 1933(Bialy Exhibit 22).

38. Letter from Lanza to Cummings, April11, 1933 (Bialy Exhibit 24).

39. Letter from Brown to Lanza, December10, 1934 (Bialy Exhibit 52).

40. Letter from Hobart to Brown, December15, 1934 (Bialy Exhibit 53).

41. Letter from Brown to Lanza, December21, 1934 (Bialy Exhibit 55).

42. Lanza AJ, McConnell WJ, Fehnel JW.The effects of the inhalation of asbestosdust on the lungs of asbestos workers.Public Health Reports 1935; 50:1-12.

43. LetterfromJudd to Brown, December24,1934 (Bialy Exhibit 56).

44. Letter from Lanza to Wardwell, Januaiy16, 1935 (Bialy Exlibit 60).

45. Letter from Whiting to Lanza, February19, 1936 (Bialy Exhibit 64).

46. Memo to Lanza, February 25, 1935 (BialyExhibit 66).

47. Letter from Simpson to LaMont, Novem-ber 10, 1936 (Bialy Exhibit 84).

48. Letter from Brown to Gardner, January17, 1940 (Bialy Exhibit 113).

49. Memorandum of Agreement between theSaranac Laboratory and American BrakeBlock Corporation, Asbestos Manufac-turing Company, Gatke Corporation,Johns-Manville Corporation, Keasbey &Mattison, Raybestos-Manhattan, Incor-porated, Russell Manufacturing Com-pany, United States Gypsum Company,Thermoid Company, and Southern As-bestos Company, November 20,1936 (Bi-aly Exhibit 85).

50. Letter from Brown to Simpson, Novem-ber 23, 1936 (Exhibit D at Deposition ofDavid E. Lilienfeld, March 28, 1989,United States District Court, Eastern Dis-trict of Texas, Beaumont Division).

51. Letter from Brown to Gardner, January17, 1940 ((Bialy Exhibit 115).

52. Letter from Sabourin to Gardner, May 6,1942 (Exhibit 15 at Deposition ofDavid E.Lilienfeld, March 28, 1989, United StatesDistrict Court, Eastern District of Texas,Beaumont Division).

53. Letter from Gardner to Brown, February24, 1943 (Exhibit 7 at Deposition of DavidE. Lilienfeld, March 28, 1989, UnitedStates District Court, Eastern District ofTexas, Beaumont Division).

54. Letter from Muehleck to Shephard,March 8, 1943.

55. Letter from Wheatley to Burnette, July26, 1944 (Bialy Exhibit 140).

56. Letter from Morecroft to Wheatley, June13, 1944 (Bialy Exhibit 135).

57. Memorandum from Wheatley to Arm-strong, July 3, 1944 (Bialy Exhibit 137).

58. [Anonymous]. Notes on a Trip to Canada,October 16-21, 1944 (Bialy Exhibit 142).

59. Letter from Gatke to Brown, April 18,1946.

60. Minutes of meeting of Lanza, Jackson,Woodard, Fisher, Lee, Eisenhart,Brown, Hite, and Hamilton, January 21,1947 (Bialy Exhibit 177).

61. Letter from Woodard to Lanza, August 4,1947 (Bialy Exlibit 181).

62. Minutes of meeting of Lanza, Hite, Jack-son, and Hamilton, August 6, 1947 (BialyExhibit 182).

63. Letter from Fisher to Woodard, October29, 1947.

64. Letter from Woodard to Lanza, March25, 1948.

65. Letter from Muehleck to Brown, April 27,1948.

66. Letter from Brown to Muehleck, April 30,1948.

67. Letter from Brown to Muehleck, May 3,1948.

68. Letter from Rohrbach to Brown, May 5,1948.

69. Letter from Woodard to Vorwald, June 1,1948 (Bialy Exhibit 190).

70. Letter from Brown to American BrakeBlock, Gatke Corporation, Keasbey andMattison, Raybestos-Manhattan, RussellManufacturing, Thermoid (Southern As-bestos), Union Asbestos and Rubber, andUnited States Gypsum, March 3, 1949.

71. Letter from Gatke to Brown, September14, 1948.

72. Letter from Brown to Muehleck and Ro-hrbach, October 22, 1948.

73. Letter from Muehleck to Brown, October28, 1948.

74. Letter from Welles to Brown, November8, 1948.

75. Letter from Brown to Butler, November12, 1948.

76. Letter from Brown to Kelly, November12, 1948 (Exhibit 12, at Deposition ofDavid E. Lilienfeld, March 28, 1989,United States District Court, Eastern Dis-trict of Texas, Beaumont Division).

77. Letter from Woodard to Gatke, Novem-ber 30, 1948.

78. Letterfrom Lanza to Vorwald, December14, 1948 (Bialy Exhibit 195).

79. Memo from Hamlin to Kelly, November3, 1948.

80. Letter from Kelley to Brown, November16, 1948.

81. Saranac Laboratory. Asbestosis. January31, 1949 (Bialy Exhibit 199).

82. Vorwald AJ, Durham TM, Pratt PC. Ex-perimental studies of asbestosis. Arch IndHyg 1951; 3:1-43.

83. Pratt PC. Deposition. July 12, 1988. U.S.District Court, North Georgia District,Atlanta Division.

84. Letter from Brown to Sabourin, March 8,1949.

85. Letter from Gatke to Brown, June 14,1949.

86. Memo from Woodard to Foster, April 15,1949.

87. Memo from Smith to McCaw, February7, 1950.

88. Letter from Vorwald to Smith, October15, 1949 (Bialy Exhibit 3017).

89. Letter from Vorwald to Smith, January 3,1950 (Bialy Exhibit 3019).

90. Letter from Smith to Lindell, January 28,1950 (Bialy Exhibit 3020).

91. Memo from Smith to Foster, February 1,1950 (Bialy Exhibit 3024).

92. Letter from Sabourin to Cartier, February8, 1950 (Bialy Exhibit 3027).

93. LetterfromWoodardto Smith, March 16,1950 (Bialy Exhibit 3032).

94. [Anonymous]. Annual Report. The In-dustrial Health Section, 1948 (Bialy Ex-hibit 184).

95. Letter from Smith to Cartier, June 3, 1950(Bialy Exhibit 3041).

96. Letter from McCaw to Woodard, June 7,1950 (Bialy Exhibit 3042).

97. Letter from Smith to McCaw, June 19,1950 (Bialy Exhibit 3043).

98. Vorwald AJ. Proposal on Asbestosis andPulmonary Cancer, September 21, 1950(Bialy Exhlbit 3057).

99. [Anonymous]. Report to the Quebec As-bestos Mining Association re: PulmonaryCancer. September 25, 1950 (Bialy Ex-hibit 3058).

100. Letter from Woodard to Fisher, October20, 1950 (Bialy Exhibit 3064).

101. Minutes of meeting between Lanza, Sab-ourin, Vorwald, and Woodard, Novem-ber 7, 1950 (Bialy Exhibit 3070).

102. Letter from Smith to Grainger, March 30,1951 (Bialy Exhibit 3100).

103. Letter from Smith to McCaw, June 11,1951.

104. Letter from Cartier to Smith, July 3, 1951(Bialy Exhibit 3111).

105. Letterfrom Smith to McCaw, October 11,1951 (Bialy Exhibit 3114).

106. Letter from Fisk to Lanza, February 20,1952.

107. Saranac Laboratory. Asbestosis and Pul-monary Cancer. Unpublished report tothe Quebec Asbestos Mining Association,May 7, 1952.

108. Letter from National Gypsum Safety Di-rector to Indiana Division of IndustrialHygiene, March 12, 1953.

109. Letter from Smith to Lanza, June 28,1954(Personal Correspondence- W. E. Smith,MD, Bangor, ME).

110. Irwin T. On-the-job cancer-the killertheywon't track down. Cavalier 1962Jan.12(103):52-5, 82-5.

111. Letter from Smith to Armstrong, June 12,1956 (Personal Correspondence, W. E.Smith, MD, Bangor, ME).

112. Seventh Saranac Symposium. Unpub-lished proceedings, September 1952 (Ex-hibit 13 at Deposition of David E. Lilien-feld, March 28, 1989, United StatesDistrict Court, Eastern District of Texas,Beaumont Division).

113. Letter from Knox to Smith, December 3,1953 (Personal Correspondence, W. E.Smith, MD, (Bangor, ME).

114. Letter from Knox to Smith, June 2, 1954(Personal Correspondence, W. E. Smith,MD, Bangor, ME).

115. Letter from Doll to Knox, June 8, 1954(Kulzer Exhibit 1485).

116. Doll R. Mortality from lung cancer in as-bestos workers. BJIM 1955; 12:81-6.

117. Letter from Penhale to Widmayer, Au-gust 2, 1954 (Bialy Exhibit 3129).

118. MIMA Insulation Manual, January 1,1955.

119. [Anonymous]. Conference on Environ-mental Carcinogens, National Institutesof Health: Bethesda, MD, May 7-8, 1955.

120. UCLA School of Public Health. CancerControl in the United States. 1946-71.DHEW Pub. No. NIH 79-1517. Washing-ton DC: Govt. Printing Office, 1979.

121. Letter from K. Smith to Braun, February19, 1956.

June 1991, Vol. 81, No. 6 American Journal of Public Health 799

Public Health Then and Now

122. Letter from Braun to Soutar, March 16,1956 (Bialy Exhibit 3145).

123. Memo from the Industrial Hygiene Founda-tion to the Quebec Asbestos Mining Associ-ation, March 16, 1956 (Bialy Exhibit 3146).

124. Letter from Braun to Sabourin, February4, 1957 (Bialy Exhibit 3176).

125. Letter from Holmes to Braun, April 26,1957 (Bialy Exhibit 3180).

126. Minutes of Asbestos Textile Institutemeeting, March 7, 1957.

127. Braun DC. An epidemiological study oflung cancer in asbestos in miners. Sep-tember 1957 (Bialy Exhibit 3188).

128. Letter from Sabourin to Grainger, De-cember 18, 1957 (Exhibit 23 at Depositionof David E. Lilienfeld, March 28, 1989,United States District Court, Eastern Dis-trict of Texas, Beaumont Division).

129. Letter from Sabourin to Braun, Decem-ber 30, 1957 (Bialy Exhibit 3194).

130. Braun D, Truan T. An epidemiologicalstudy of lung cancer in asbestos miners.Arch Ind Health 1958; 17:634-52.

131. Letter from Stokinger to Braun, January20, 1958 (Bialy Exhibit 3198).

132. Castleman BI, Ziem GE. Corporate influ-ence on threshold limit values. AJIM1988; 13:531-559.

133. Letter from Sabourin to the QAMA, June22, 1958 (Bialy Exhibit 3200).

134. Selikoff U, Hammond EC, ChurgJ. Asbes-tos exposure and neoplasia. JAMA 1964;188:22-6.

135. Barclay WR. Asbestos. An industrial as-setwith a health cost. JAMA 1984; 252:96.

136. Memo from Smith to Grot, February 26,1963 (Kulzer Exhibit 4594).

137. Memo from Pocius to Hodson, Januaxy29, 1965 (Kulzer Exhibit 4584).

138. Letterfrom Lindstrom to Jensen, January29, 1965 (Kulzer Exiibit 4585).

139. Memo from McCarthy to Jones, June 19,1964 (Kulzer Exhibit 1436).

140. Memo from Kern to Konzen, September21, 1970 (Kulzer Exhibit 3929).

141. Memo from Reiser to Prus, April 14, 1977(Kulzer Exhibit 1445).

142. Memo from Bagenstose to Reiser, July 8,1977 (Kulzer Exhibit 1447).

143. Memo from Linke to McKinney, January12, 1979 (Kulzer Exhibit 4296).

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800 American Journal of Public Health June 1991, Vol. 81, No. 6