Chemical Exposures Chemical Exposures Low Levels and High Stakes Second Edition Nicholas A. Ashford Claudia S. Miller JOHN WILEY & SONS, INC. NewYork • Chichester • Weinheim • Brisbane • Singapore • Toronto This text is printed on acid-free paper. Copyright © 1998 by John Wiley & Sons, Inc. All rights reserved. Published simultaneously in Canada. No part ofthis publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except as permitted under Sections 107 and 108 ofthe 1976 United States Copyright Act, without either the prior written permission ofthe Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 750-4744. Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 605 Third Avenue, New York, NY 10158-0012. (212) 850-6011, fax (212) 850-6008, E-mail: [email protected]. Library ofCongress Cataloging-in-Publication Data Ashford, Nicholas Askounes. Chemical exposures: low levels and high stakes / Nicholas A. Ashford & Claudia S. Miller - 2nd ed. p. em. Includes bibliographical references and indexes. ISBN 0-471-29240-0 I. Multiple chemical sensitivity. I. Miller, Claudia. II. Title. RB I52.6.A84 1997 615.9'02-dc21 97-19690 CIP 10 9 8 7 6 5 4 3 To my mother, Venette Askounes Ashford, from whom I learned to have compassion for those less fartunate than I, and who inspired me to help. -N.A.A. To my parents, Constance Lawrence Schultz. and Ernst William Schult%, who patiently read stories to me as a child, encouraged my interest in science, and taught me to keep the two separated. -C.S.M. Contents Preface w the Second Edition / xiii Preface w the First Edition / xvii Acknowledgments / xix Introduction / xxi Part I. Defining Chemical Sensitivity / 1 1. Clumlical Exposures and Sensitive Populations 3 Groups Sensitive to Low-level Chemical Exposure 3 Types ofSensitivity 5 Changes in Chemical Production and Use, and the Emergence of Chemical Sensitivity 10 Magnitude and Nature of the Problem 26 2. Key Terms and Concepts 27 Terminology 27 Adaptation 34 The Environmental Unit 54 viii Conterrts J. Origins ofMultiple Chemical Sensitivity and Effects on Health 59 Offending Substances 59 Outdoor AirPollutants 62 Indbor Air PoUutants. Domestic and Worlr.place 64 Foods. Food Additiv~. and Contaminants 70 Water Contaminants and Additives 71 Drugs and Consumer Products 72 Health Effects 74 Part ll. Mechanisms, Diagnosis, and Treatment / 85 4. Mechanisms ofMultiple Chemical Sensitivities 87 Possible Physiological Mechanisms 87 Mechanisms Involving the Limbic System 91 Immunologic Mechanisms 98 B~hem~IMechanisms 107 Vascular Mechanisms 110 Possible Psychogenic Mechanisms 113 Conclusions 124 5. Diagnosis and Treatment 125 Diagnostic Approaches 125 Therapies 128 ProvocatWn-NeutralizatWn 129 Detoxifu;atWn 135 Nutritional Approaches 138 Psychological InterventWns 140 Areas ofAgreement and Disagreement between Allergists and Clinical Ecologists 142 Part ID. Responding to the Problem / 145 6. Needs, Concerns, and Recommendations 147 Research Needs 147 Patient and Community Concerns 153 InformatWn 153 Health Care 154 Alternative Emptoynumt and Housing 155 Medical Insurance 156 Compensation 156 Social and Legal Seruices 158 The Regulation ofChemical Exposures and Other Preventive Initiatives 158 The Role of Medical Practitioners and Their Societies 159 Recommendations 163 Research 163 Information 165 Health Care 165 Alternative Employment and Housing 165 Medical Insurance 166 Compensation 166 Social and Legal Services 167 RegulJJtion ofChemicals 167 Resolution ofConflicts among Medical Practitioners and Their Societies 167 Part IV. Update since the FIrSt Edition / 169 7. Recent Developments 171 Introduction 171 A Note on Terminology 171 North American Workshops and Increased Governmental Interest in MCS 173 Developments in the United States 173 Developments in Canada 180 Government Recognition and Accommodation 181 U.S. Federal Agencies 181 U.S. Stale Agencies and Courts 187 Local Governments 190 U.S. Court Cases 190 Developments in Canada 193 European Perspectives 196 Comparison of European and North American Experiences with Low-level Chemical Sensitivity 202 Conclusion 204 8. Key Research Findings since the First Edition 207 Introduction 207 x Contents Clinical Data: Inherent Limitations and Unwarranted Extrapolations 207 Dimensions ofan mness 209 Empirical Approaches to Understanding Chemical Sensitivity 210 Characterizing the Patient Population 211 Epidemiological Studies 211 ExpoSUft Challenge Studies 218 Biomarkers 228 Overlaps with Other Illnesses 228 Magnitude of the Problem 232 Origins of Chemical Sensitivity 238 Pesticides 285 Indoor Air Pollutants 287 Ga?ets 288 Gulf War Exposum 246 Implantes 249 Childhood Abuse 251 Mechanisims 254 Olfactory-Limbic Sensitiz.ation 257 Other Hypotheses Involving the Olfactory System 261 Cholinergic and Other Receptor Supersensitivity 262 Neurogenic Inflammation 268 Metabolic Mechanisms 264 PO'ffJhyria 265 Immunowgical Mechanisms 269 9. Rn1iews, Commentaries, and Polemics 271 Published Work in ScientificJournals 272 Other Writing and Publications 281 The 1996 Berlin Workshop 282 Commentary 286 Stages ofa Paradigm Shift 287 10. Research and Medical Needs 289 Current Reflections on MCS 289 Experimental Considerations and Approaches to MCS 296 Research Needs 810 Researr:h Rtxommendations 816 Medical and Patient Needs 828 Trtatment 827 Avoidance 828 Contents xi Medications 332 Environmental Evaluation 333 Psyclwwgical Therapies 333 Help from Governmental Agencies and Other Organizations 335 Useful &ferences 338 Epilogue 341 Appendi:tc A: Health Effects Associated with Chemicals or Foods / 345 Appendi:tc B: Laboratory Diagnostic Tests Used in MCS Studies / 359 Appendi:tc C: Environmental Exposure and Sensitivity InvenWry / 371 Bibliography / 385 Index / 429 Preface to the Second Edition In 1990, the report for the New Jersey State Department of Health, which fonned the basis for the first edition of Chemical Exposures, won the presti­ gious Macedo Award of the American Association for World Health (rep­ resenting the World Health Organization) for the most outstanding con­ tribution to public health funded by a state health department. Whereas the first edition discussed in detail the clinical observations and writings of controversial clinical ecologists-physicians who first brought attention to this condition in the 19508 and who employ nontraditional therapies to treat what they see as chemically induced illness-the second edition draws from the considerable literature published since 1991, almost all from mainstream, peer-reviewed scientific publications often written by environ­ mental scientists, toxicologists, and occupational medicine physicians. Problems related to chemical sensitivity have now been reported in nearly a dozen Western European countries, and this volume captures some of the observations made by European scientists and physicians. Notably, whether such patients have been seen in North America or in Europe, by university physicians or by clinical ecologists, their patterns of symptoms and chemical intolerances have been remarkably similar. As with the first edition, our emphasis is on origins and possible mecha­ nisms for the condition. A rationale for intrusive therapies, whether physi­ ological orpsychological, is lacking. Physicians and their patients await a bet­ ter understandingofchemical sensitivity. Continuing the tone set in the first edition, we show that it is not only possible but is necessary to delve into the scientific exploration of origins and mechanisms without becoming embroiled in questions concerning therapy. Unfortunately, many of those involved in the debate that surrounds chemical sensitivity continue to con- xiv Preface found these issues. It is important to separate concerns about unproven diagnostic and treatment practices from the fundamental question of whether chemical sensitivity is toxicogenic or psychogenic. The large finan­ cial stakes and liability associated with sensitivity to chemicals in no small way drive contentious debate and action. However, itis clear that interest in chemical sensitivity has now expanded significantly beyond a few hundred controversial practitioners. We deliberatelychose to add uPdated material to, rather than rewrite, the original edition of Chemical Exposures, both because we believe that our ear­ lierobservations remain accurate and because the earlier material provides a useful "time capsule" againstwhich to evaluate progress in understanding the condition(s) known as chemical sensitivity. Since the first edition, two new patient exposure groups have emerged with features strikingly similar to those ofchemically sensitive persons: sick veterans from the Persian Gulf War and women who trace a myriad ofadverse health symptoms to silicone breast implants. Both fit what we and others believe to be a two-step model of chemical sensitivity: an identifiable initiating chemical exposure event, followed after a shortperiod by a myriad ofsymptoms triggered by low-level exposure to a large number ofchemically unrelated substances. We are increasingly convinced that low-level chemical sensitivity offers sci­ entifically testable hyPOtheses and maysignal an emerging new theoryofdis­ ease: toxicant-induced loss oftolerance (TILT). This