April 13th, 2004
Dear Dr. Bell,
I have just read your special report on Multiple Chemical Sensitivity (MCS) in the January, 2003 issue of the Psychiatric Times. It led me to question the attempt being made in many such articles, to summarize theoretical aspects of this diagnostic construct and report on a limited number of clinical observations made regarding some affected systems. The statistically defined population parameters involving CI (chemically injured) and/or MCS patients in such investigations are automatically biased due to legal issues which skew data and prevent accurate conclusions from being drawn. This problem is perpetuated by our health care systems unless one attempts to study the broader population of persons who self-report sensitization to toxic chemicals (cited as 12 to 16% of the population). Among the legal issues limiting the collection of a representative sample of patients under the categories of CI or MCS are:
1. MCS does not have an ICD code in this country and so is unlikely to be used by physicians who require the listing of conditions more likely to result in financial reimbursement for medical visits and tests from third party insurers. Therefore the number of person who may qualify for this diagnostic construct will rarely receive it.
2. The use of toxic chemicals in residential and employment settings is ubiquitous and does not legally require the advance notification of exposed parties. Unless an individual has reason to suspect past exposure to a toxicant and subsequently petitions the responsible parties in writing for the details (post-exposure), individuals are unlikely to uncover their exposure history. This leaves the performance of toxicological testing on the environment to reveal exposures but few patients will be aware of this option. Therefore, any statistic referring to the percentage of persons who can trace onset of chemical injury to a specific exposure (approximately 60% of patients), is largely a function of access to confirmatory information. It does not reveal the percentage of actual patients who had specific pre-morbid exposures. Similarly, since CI can accrue from chronic versus acute exposures, the patient will often overlook a source of toxic exposure that is part of their daily lives such as gas stoves, air fresheners, office machinery or monthly visits by exterminators to homes and offices. This makes CI another infrequently diagnosed condition although ICD codes do exist for it (Toxic Effects…).
3. Most physicians receive only six hours of toxicology instruction during their educations according to Dr. Phillip Landrigan of Mt. Sinai’s division of Occupational and Environmental Medicine in N.Y. Many do not even ask about exposure histories. Therefore, they are most unlikely to do more than diagnose and treat presenting symptoms while ruling out structural anomalies in affected systems (e.g. prescribing antacids for reflux while ordering a GI series; prescribing broncho-dilators for asthma while ordering PFTs and a chest X-ray). They may note inflammation markers commonly seen post-exposure but rarely explain sudden appearance of an aggravated ANA or elevated homocystein levels etc.
4. Generally the most available information concerning exposures comes from the workplace. This entails a patient seeking medical attention to visit a doctor to address an occupational injury/illness in a field where relatively few professionals take worker’s compensation cases. It is illegal to charge patients for occupationally related injuries which can prevent a rigorous and thorough documentation of related factors in the presenting illness by the most qualified specialists. Furthermore, many doctors fear the financially unrewarding tasks of documenting illness and injury where patients may file for disability and/or become involved in litigation. This reluctance further skews population variables. Specific biomarkers of chemical exposure such as residues in bodily fluids are rarely sought and tests of this nature may even be illegal to perform in some states. For example, no labs in NYS are permitted to test for pesticides in fatty tissue biopsies or the pyrethroids used in municipal spraying for west nile virus.
5. Patients who are inadequately informed about their exposure histories and who are seen by physicians unable to adequately compensate for the lack of such specific information, are more likely to receive a ‘default’ diagnosis of psychiatric origin based upon negative, rather than positive, medical evidence. The literature is full of citations where illnesses of a multi-systemic nature and unclear etiologies lead patients to seek out many diagnostic tests and opinions, gathering a chart of increasing “thickness” in the process. Such patients are open to a somatization diagnosis which ends further diagnostic inquiry in mainstream medicine. It also raises the number of CI patients with diagnosed psychiatric conditions without regard for the accuracy of such findings.
Similarly, counting the number of doctor visits annually for persons disabled by MCS is also misleading. Disabled individuals must, by law, visit a physician every thirty to forty-five days to continue qualifying for disability payments, regardless of need for examination. This economically driven, pre-determined schedule of visits cannot reveal any useful medical information about disabling conditions regardless of etiology.
6. We are learning more about the detoxification processes which influence the body’s efficiency to perform as a toxic waste treatment plants in a polluted environments rich in untested mixtures of chemicals which are incompatible with our biochemistry. There is a real need for acquiring pre-exposure baseline information concerning protective enzymes that may later become depleted (e.g. paroxonase, acetylcholinesterase). An understanding of the relative efficiency of various detoxification pathways required to clear certain drugs and foods such as those containing caffein or alcohol is also useful. Preventative medicine must recognize the constant onslaught of the environment upon systems designed to fight endogenously produced toxins rather than petrochemicals and flame retardants. The MSDS sheets on these common products such as formaldehyde and permethrin specify their properties as sensitizers and the numerous adverse outcomes of exposure. It should not surprise physicians when such symptoms are reported.
Lastly, many physicians who address these forms of illness from a perspective of organicity, may pay heavy professional penalties for doing so within their medical societies, hospital affiliations, third party payment sources and licensing boards. Psychiatric conclusions (often reached by underqualified practitioners of internal medicine or other specialities) do not appear to suffer such consequences. This also skews available data in the study of chemically induced injuries. Until such inequities are addressed, studies will be unable to secure uniform groups of experimental subjects and so be biased in terms of outcome.
Only when the science of toxicology, usually comprised of PhD credentialed individuals, is permitted to attain partnerships with physicians for objective patient evaluation, will we see positive steps towards a serious approach to the chemically injured patient. This will require the extension of a definition for preventive medicine beyond patient preferences in nutrition and lifestyle. This will require the extension of patient treatment beyond the artificial barriers imposed by worker’s compensation laws and insurance reimbursement.
Definitely a challenge in medicine within a society where profitable applications of technology precede an understanding of the sciences that should be guiding it.
Thank you for your attention.