Environmental Medicine

The practice of environmental medicine involves the understanding and treatment of health problems that arise from or are affected adversely by the interaction between people and the environment. Consider the following facts.

Since the Second World War, 80,000 chemicals have been produced in North America alone. Almost 3000 are in high production, i.e. 1 million pounds or more are produced per year. According to the U.S. Environmental Protection Agency, basic toxicity information is available for less than 50% of these chemicals, and information on developmental toxicity is available for less than 20%.

Note that 82% of Canadians live in urban and suburban neighbourhoods, which are more polluted with ozone and particulate matter than rural areas. We spend 90% of our time indoors, which can provide more chemical pollutant exposure than the outdoor environment. Some man-made chemicals do not break down easily or quickly and tend to accumulate in the environment. They are known as persistent organic pollutants and accumulate in water, the ground and subsequently, up the food chain. Humans are at the top of the food chain, drinking and cooking with polluted water, while breathing polluted air.

Although the significance of these exposures is not fully understood, it is clear that there is a measurable burden of man-made chemicals in all humans in the industrialized world.  Every child and adult has accumulated numerous toxicants in their bodies, which include chemical solvents from industry, pesticides, plastics and fire retardants. Cumulative exposure from various sources has resulted in the US Centers for Disease Control finding that the average child and adult have accumulated up to 200 toxicants in their bodies. The older we are, the more we have accumulated. These chemicals can be found in fat, serum, bone, sperm, ovaries and breast milk and women tend to have higher levels than men. While these chronic exposures may seem small, insignificant and harmless, there is increasing evidence that these chemicals are contributing to the development of clinical illness in susceptible individuals. Groups most at risk are children, middle-aged women and the elderly.

Starting in the 1970’s, observed negative effects from chemical exposures, including cognitive complaints, were being published in the medical literature. The World Health Organization described and categorized these patients, according to the severity of symptoms in the central nervous system. Because of the energy crisis, new and existing buildings were insulated more and ventilated mechanically, while using cheaper materials, which tend to off-gas chemical pollutants, to build, renovate and furnish. This resulted in the development of Sick Building Syndrome, first described by the World Health Organization in 1984.

At the same time, many people began to complain of a variety of other new problems, which they attributed to chemicals in their environment. As a result, the government of Ontario appointed an ad hoc committee on Environmental Hypersensitivity Disorders, chaired by Judge George Thomson, to investigate whether research and clinical efforts were needed in Canada regarding these conditions. That 1985 report stated that environmental hypersensitivity (a.k.a. Multiple Chemical Sensitivity) was a significant problem requiring further research. It was also noted that patients were not getting their needs met in the health care system. With all this in mind, it was recommended that patients be treated with compassion, and that a special clinic be initiated as a bridge between patients, health professionals, and researchers.

Thus, in 1994, the Ontario Ministry of Health established the Environmental Health Unit in the Department of Public Health, Faculty of Medicine, at the University of Toronto. In 1996, the Environmental Health Clinic at Women’s College Hospital was subsequently established to be a provincial resource in promoting environmental health, and to improve health care for people with environment-linked conditions such as Chronic Fatigue Syndrome, Fibromyalgia and Multiple Chemical Sensitivity. These patients frequently have problems from exposures to common contaminants of indoor air, at levels which are usually tolerated by the general population. This clinic has been affiliated with the Environmental Health Unit at the University of Toronto. There is a second provincially funded unit situated in Nova Scotia.

The Environmental Health Clinic at Women’s College Hospital now also provides an opportunity for students (medical, nursing, dietetic, environmental studies) to learn about Multiple Chemical Sensitivity, Fibromyalgia, Chronic Fatigue Syndrome and other environment and health issues by doing a practicum. It also offers a one-year academic or clinical fellowship to family physicians as a third year residency program in collaboration with the Department of Family and Community Medicine at the University of Toronto.

Back in 1992, the Board of the Ontario College of Family Physicians (OCFP) established a standing Committee for Environmental Health, to develop the tools to assess, diagnose and effectively treat individuals who had been harmed by environmental exposures. Members of the committee fulfill the mandate by researching the impacts on health of various environmental contaminants and by sharing their findings with OCFP members as well as publishing review papers. For example, the pesticides literature review entitled Systematic Review of Pesticide Human Health Effects has played a significant role in the legislated reduction of cosmetic pesticide use in many municipalities across the country. The   committee members are also actively involved in education for medical students, family medicine residents and practicing family physicians.

In addition, the College of Family Physicians of Canada and the World Organization of Family Doctors recognize the academic strength of the Environmental Health Committee members and rely on its guidance and advice on environmental health issues. Furthermore, in 1999-2000, the Continuing Medical Education Committee of the Ontario College of Family Physicians partnered with the Environmental Health Committee to develop and promote a Peer Presenter Program on Environment and Health. Faculty provided training to two to three family physicians from each of the six provincial regions of Ontario to disseminate information to other physicians and the general public in their home regions. This program evolved to include an Environmental Scholar to mentor faculty in the Departments of Family Medicine in each medical school in Ontario.

Unfortunately, medical problems associated with environmental factors, such as Chronic Fatigue Syndrome, Fibromyalgia, Sick Building Syndrome and Multiple Chemical Sensitivities do not as yet have biological markers. That is, there are no known specific, objective laboratory tests available clinically to aid in making the diagnosis. As a result, people with these diagnoses have non-evident disabilities which are not well understood by society, and this can lead to reluctance to acknowledge the existence of the problem, stereotyping, stigma and prejudice.

On the other hand, these same entities are now recognized by the Ontario and Canadian Human Rights Commissions, so that people diagnosed with these ailments now have the right to be accommodated. Furthermore, the Ontario Hospital Insurance Plan (OHIP) has now provided a special fee code (K007) to encourage and allow physicians to spend the time required to care for and support patients with these chronic, complex conditions.