“I'm watching each one of my family members die:” Public health consequences of family dynamics in a slow-motion technological disaster

Background: Amphibole asbestos exposure in Libby, Montana constitutes what EPA called the “worst environmental disaster” in U.S. history. More than 270 people have died; hundreds have asbestos-related diseases (ARD); given ARD's lengthy latency period, thousands remain at risk. Multiple generations within families have or are at risk for ARD. Local culture values familial relationships and community identity. Purpose: Using family systems theory, this study explored how family dynamics mediate public health consequences of a “slow-motion technological disaster.” Significance: Previous research addressed rapidly-striking natural disasters' psychosocial consequences and family-level responses to disease (e.g., cancer). Little is known about responses to slow-motion disasters, less about family-level roles/consequences. Methods: Nine focus groups and five interviews (n = 71) were conducted in Libby with people with ARD, family members of people with ARD, and people without ARD in their families. Results: Family members provide informal caregiving for people with ARD (e.g., provide home care, facilitate adherence, monitor symptoms); subsidize health care costs and influence ARD-related health behavior (risk reduction, surveillance, medical care-seeking). However, complex family dynamics interfere with family-level coping and health promotion responses, including: caregiver strain, likely affecting caregivers' psychological/physical health, observing prolonged illness/death while anticipating one's own; conflict; secrecy; family-related guilt/blame; and jeopardized family structure (e.g., conflict, divorce). In addition, community conflict around the disaster sometimes creates tensions between family and community loyalty. Conclusion: Interventions and policy responding to slow-motion disasters should provide healthcare, economic, and psychosocial support to those who most often bear the burden of providing informal care and support.