By Ibthisam I
Ibthisam. I, MBBS 22, ESIC Medical College and Hospital, KK Nagar
It was March of 2023, and I was just a first-year student whose enthusiasm was taller than her height. I came across a flyer calling for abstract submissions for a case poster presentation competition at a reputed medical college and wanted to participate. I was rejected multiple times as I looked for mentors, with many professors undermining my abilities as a new student. Except for one professor, Dr Vignesh Dwarakanathan, who saw my curiosity and enthusiasm beyond my capabilities as a newly joined med student. He put his faith in me and connected me with a senior pulmonologist, Dr. Logamurthy Ramaswamy at my college, and that is where my journey with people surviving occupational lung disease began.
My first patient encounter was with Mr T, who used to work in hot weather conditions in a refractory brick manufacturing unit, with continuous exposure to freshly cut silica dust, for over two decades. He was diagnosed with silicosis, and despite retiring from the factory, the lung fibrosis continued to worsen, leading to severe restriction of his lungs. He was a friendly man and I was just a naive first-year who did not know how to take history properly. He mentioned everything doctors would usually ask him during his regular hospital visits. I also keenly observed my mentor taking history, trying to understand why each question was important. When I used to sit with him to take case history multiple times (I was practicing history taking with him basically), he used to be very patient with me, explaining the same symptoms numerous times, because I missed them the first time he mentioned those symptoms. Sometimes, he would read out his handwritten Tamil poetry, expressing his love for his newly born granddaughter. He now receives compensation for his disability and is under regular follow-up.
Later on, I came across a few more silicosis patients, who used to work in industries like dish soap manufacturing, and coir bricks and insulation material production. “Where is the silica exposure here?” you might ask. While manufacturing dish soap, one of the steps involves grinding soap materials manually in a huge quern-stone that contains natural silica. While manufacturing any kind of bricks, they undergo a firing process, where the bricks are put in a furnace to harden them. These furnaces are made of refractory bricks, which are mainly made of silica. Insulation materials contain silica. When exposed to freshly cut silica, lung macrophages detect it, and phagocytose it. However, silica is reactive, and it sets off a reaction that leads to apoptosis of macrophage, releasing the silica particle again. New macrophages detect it, and the cycle of phagocytosis and apoptosis continues for many years, even after silica exposure is stopped, as the silica particles remain active for years. This forms the basis of progressive massive fibrosis, where disease progression worsens even after an exposed person stops the exposure. Most of these patients were also infected with tuberculosis, and their pulmonary symptoms worsened post-TB.
I watched these patients struggle to speak clearly, as breathlessness was a constant obstacle to overcome; I saw them sitting on random sidewalks, too exhausted to walk more than a hundred meters; I witnessed a glimpse of relief as they inhaled bronchodilators, and I saw their dejected faces when they received a diagnosis of tuberculosis. Dyspnea is an unseen disability; these people do not walk around with a cast or a clutch where it is easy to identify and empathize with a person's disability. All the silicosis patients I have encountered looked normal from afar but were living with debilitating conditions.
Imagine drowning in water, feeling out of breath. Now imagine living like this your entire life. That is the life of someone living with lung fibrosis and severe restriction. Silicosis is a prevalent disease, and millions of workers are exposed to silica. Yet, it is not commonly diagnosed or reported, as it risks huge companies that do not provide workable conditions to their workers getting shut down. It is a silent epidemic, silent in the way it manifests, silent in the way it handicaps the affected person, silent in the way it goes unreported.
Silicosis is a debilitating disease, leading to lifelong breathlessness, and increased risk for TB and lung cancer. Legal statutes and policies have not been sufficient to eradicate the public health crisis of silicosis, which also poses significant human rights implications. The prevailing conditions call for a proactive screening for silicosis and an integrated medico-social framework for managing these patients.
By Ibthisam I
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