A resurgence of the preventable disease known as “black lung” has exposed a screening shambles
The resurgence in Queensland of the preventable, but untreatable, disease known as “black lung” has exposed a shambles in the medical-screening system set up to protect the state’s coal miners.
After decades without a single occurrence in Australia, at least nine cases of coal workers’ pneumoconiosis (CWP) have been confirmed or feared in Queensland since last year, according to miners’ union the CFMEU. However, the union says the number may be just the tip of the iceberg.
Dr Ewen McPhee, a GP based in Emerald in Queensland’s coal-rich Bowen Basin, said the failure to detect the slow-developing condition lay with a dysfunctional state-run medical surveillance program, not the GPs who performed health assessments for coal mines.
“I really fear it leaves GPs open to being the patsies here,” he told The Medical Republic.
“What concerns me is the complete failure of governance around the follow-up and management of chronic lung disease and what happens to the chest X-rays, right from who reads them,” said Dr McPhee, who is also president of the Rural Doctors Association of Australia.
Programs to give GP assessors guidance on identifying issues, appropriate management follow-up, and what restrictions should be placed on mine workers, had fallen away as a result of funding cuts, he said.
Moreover, doctors were unable to refer to patients’ earlier assessments because they had no access. Miners’ medical reports and radiographs disappeared off to the department, “never to be seen again”.
“When you consider the money that is spent on the medicals, and how we do the medicals in good faith … the governance behind it is lacking. The guidance and support to GPs have been withdrawn. I think you can lay it at the feet of government, to be honest.”
GPs such as Dr McPhee make up 62% of the 237 Nominated Medical Advisers appointed by Queensland mining companies to conduct the required pre-employment and five-yearly medical checks on coal workers. Another 12% are occupational physicians.
An interim report commissioned by Queensland’s resources minister, Dr Anthony Lynham, has called for formal training of NMAs including stricter protocols for early detection of dust diseases such as pneumoconiosis. It also said NMAs should be appointed by the government rather than mining companies.
The report, prepared by a team led by Monash University Professor Malcolm Sim, found a long list of failings in six early CWP cases, including poor documentation regarding follow-up or referrals after abnormal spirometry and chest x-rays, and an absence of recommendations to mitigate further dust exposure.
In some cases, medical reviews had been performed less frequently than required and lacked requisite tests. Obstructive abnormalities on spirometry were wrongly attributed to tobacco use, and chest X-ray reports were not based on the International Labour Organisation (ILO) classification for pneumoconiosis.
The report also revealed that an enormous backlog of 100,000 coal miners’ medical assessments had not even been loaded into a database kept by the mines department’s Health Surveillance Unit.
“Resources to enter data into the database did not increase when the number of health assessments increased during the mining boom,” the report said.
The respiratory component of the assessment includes spirometry to test lung function, but a chest X-ray is required only for workers deemed by employers to be “at risk of dust exposure”.
Professor Peter Gibson, president of the Thoracic Society of Australia and New Zealand, said CWP was entirely preventable with control of dust levels and monitoring of workers to permit early detection.
“You need to detect very subtle changes and you therefore need to compare things at the moment to what was collected in the past,” he said. “Doctors doing the assessments do not appear to have had access to previous documentation. So it would be impossible for them to detect subtle changes.”
Professor Gibson said the onus to explain the detection failures was on the coal industry.
“The message to the coal industry is they need to get to the bottom of why these people were not detected in the first place. It’s their responsibility, they are running the mines, they are in control of the exposure to the workers, and they need to satisfy themselves, their workers and the community that the exposure is safe,” he said.
Experts say NSW, which has a single agency overseeing health and safety at all coal mines, appears to have a recently clean record for CWP. But it’s impossible to tell whether, and to what degree CWP, and similar diseases are occurring across Australia.
Dr Deborah Yates, a thoracic medicine specialist at Sydney’s St Vincent’s Hospital who has had experience of black lung cases in the UK, said Australia needed to adopt federal legislation for mandatory reporting of CWP and dust controls.
“There’s no centralised reporting. There’s no way that we, as respiratory physicians, can tell exactly what’s going on. And because we were so successful in stopping the disease earlier, the awareness of it has gone down and people won’t recognise it because they don’t see enough of it,” she told The Medical Republic.
“Medically, there’s no question about what we should do. We need to implement appropriate regulations, have a valid screening program with more up-to-date techniques and people who have expertise in the radiology and lung function interpretation. And you need to have workers who want to be screened,” Dr Yates said.
Unlike asbestos, for which there is no safe exposure, some amount of coal dust can be inhaled without serious health impacts. But early detection is crucial to avoid simple CWP turning into progressive massive fibrosis, which brings disability and can be fatal.
“The cases diagnosed in Queensland on the whole were ones who had had higher exposure early on,” Dr Yates said. “Pneumoconiosis happens with cumulative dust exposure, so you need to pick out the (miners) who have had heavy dust exposure and make sure they have no more exposure.”
While a resurgence in CWP in the US since the 1990s had been linked to smaller mines with less advanced ventilation systems, there was no such correlation in Australia, she said.
Calls are also being made for Australia’s coal industry, which is worth $56 billion a year in exports, to adopt unified coal dust exposure limits matching international best practice. Current limits are 3mg/m3 in Queensland and 2.5 mg/m3 in NSW, compared with 1mg/m3 in the US.
At the Queensland limit, exposure over 30 years would result in a 15% to 25% prevalence of CWP, according to Professor Sim’s interim report.
