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Table 1 Environmental medicine is a divided profession

From: Expert clinician’s perspectives on environmental medicine and toxicant assessment in clinical practice

Area of difference Clinician Quotes
Nature of employment OEPs I’ve never worked in the private clinical area as a fee-charging professional.
A lot of our fellows do medical-legal work and don’t do much work in the environment space.
We do more work-related than actual environmental toxins.
We reviewed the use of copper beryllium in the aviation industry.
Most court cases I do, are usually exposures to substances that are used in workplaces.
I do two days with private cases, referred to me by general practitioners which includes worker’s compensation in motor vehicle accidents assessments. It has an emphasis on musculoskeletal medicine, but from time to time, I will see some cases with Multiple Chemical Sensitivity.
There are very few people out there who can find us and see us as environment medicine specialists. I don’t get many referrals, may be one a month and people somehow they find their way to me, maybe even less.
You have to walk this very fine line where you have to tell the management to do things and you have to tell the workers to wear their hearing plugs and masks. So you’re not very popular with anybody. Most of us are more closely aligned with the management side. Our job is to really protect the workers, but I think a lot of us have moved too far to the right. I think I was a bit too critical at one stage and so I lost my job.
You’ve got to understand that the older guys have been welded to these management of the coal and gas. That’s where their money is coming from all their life, and they’re not going to start turning on their companies just yet and start advising them to close down.
  IPs The patients that I see have seen seven or eight different doctors and have been examined to death and nothing has come out of that.
The basis of my practice is chronically ill people, who do not fit into a clear medical diagnostic category.
I see more kids with, rather than an obvious diagnosis, just a splattering of all sorts of things not quite right.
Type of diseases seen OEPs Mainly chronic neck pains and chronic back pains from a work injury. So it’s much more musculoskeletal than environmental unfortunately.
A lot of our fellows are heavily involved in musculoskeletal injuries, noise, slips, trips and falls.
A lot of our doctors will be doing noise exposure history. They’ll (the worker) be deaf from being at work and just take down the history and do the audiometry and send in for their compensation.
The work I do with mining in New South Wales is a couple of cases of pneumoconiosis in coal miners.
IPs The basis of my practice is chronically ill people, who do not fit into a clear medical diagnostic category… [they] suffer [from] persistent inflammation, immunological dysregulation and neurological responses which are hyper-responses.
Chronic and complicated, ill-defined conditions like Chronic Fatigue and tiredness, chronic allergy intolerances and autoimmune dysfunction.
A mixture of the really kind of severe multiple chemical sensitivities, which I see a number of, where they come in, with a proper mask on the whole time, because they didn’t get through the waiting room to my office without being affected, to the much milder versions of that.
Kids who are affected, but not full on the spectrum… we’re just seeing a bigger cohort of those more subtly affected.
Multiple sclerosis, Motor Neuron Disease, Parkinson’s disease, those would probably be the ones I see most, and neurological dysfunctions that don’t necessarily get a name because they are somewhat atypical.
I see quite a few kids that live in a house with mold.
If a child presents with explosive behavior, or problems with focus, attention and judgement, the first thing I do is make sure it’s not a reaction to chemicals.
Toxicants of concern OEPs The environment means different things to different people. What we’re talking about is a workplace environment.
You can have significant environmental exposures, but by and large, it’s the ones we know about, you know, the lead, the mercury, the radioactive stuff. Most of these are heavy metals.
I’m doing a coal (medico-legal) case at the moment for coal dust.
I’m looking at people who were aircraft fitters and maintainers who in the course of their duly entered fuel tanks and were exposed to the various combinations of military aviation turbine fuel.
Exposures to substances that are used in workplaces like caustic or acid substances… also occupational exposures that are carcinogenic substances.
Solvents and pesticides are still one of the issues that comes up, but much less than it did in the 1990’s because of a shift to ‘softer’ chemicals, implementation of OHS regulations and changes in the method of application (moon buggies rather than aerial application).
Hormone disrupting chemicals are not a consideration in our industry.
We don’t deal with the long-term… because this is what normal life is. None of these very, molecular or unseen chemical injuries are being monitored, because that’s still really research.
If you’re talking about the millions of chemicals that are produced, not many actually have good known studies. Gold standard studies are rare as hen’s teeth on what these things actually do to people.
I have been struggling with things like electromagnetic radiation and so on. And those arguments have gone on for thirty years or more, without any definitive answers really.
  IPs It’s the very ubiquitous ones that people are routinely eating and drinking, without thinking much about it, just because of it being in the water supply and food.
I think the biggest issue with environmental toxic load, is the amount of processed food that we eat, including foods stripped of nutrition, foods stripped of fibre, foods laced with food chemicals, foods dowsed in pesticides. Foods using abnormal hydrogenated toxic oils. I think that is actually our biggest danger.
Most people expect toxins are outdoors, but most of the toxins are indoors.
Mold is very common, chemicals and some degree of heavy metal exposures are very common as well. So, it seems to be that the mix of it all, the toxic synergy creates a bad result, rather than any single substance on its own.
I see quite a few kids that live in a house with mold… you get them out of that house and they get better.
There was a period in the early 1980’s, where the organochlorine pesticides heptachlor and chlordane were required by law to be used under the slabs of homes as a termite treatment, and lots and lots of people got sick.
If I’ve got someone with really intractable hormonal issues, breast or prostate cancer, I’d be looking for exposure to plastics and pesticides and some of those xenoestrogens.
Problems with metal allergy, not just metal toxicity. So, if you take inorganic mercury from dental amalgams it can be a mitochondrial poison, it can inhibit a vast array of enzymes.
Plenty of times I’ve been looking for external toxins, there’s nothing around and then the whole process unravels and it turns out that they have a fear of spiders and they’ve had the house completely sprayed (with pesticides) in every single room.
Children eat a lot of fish, particularly Asian children, so much higher rates of mercury toxicity.
All of those children (with neurobehavioral disorders) will have a proportion of their problem due to foods and chemicals.
If you figure out that this child is reacting to a food, or a chemical and you remove that food or chemical, then, on review, you can untick all those boxes … how I regard those children, is not as having autism or ADHD, that is, really, as having food and chemical sensitivities, that express themselves with those conditions.
I see much more of the indoor air pollutants and much less of the agricultural chemicals.
Role of nutrition in toxicant exposures OEPs There’s a fringe thing called nutritional medicine... it’s not really recognised.
There is this serious discrepancy here, between Occupational and EM and this fringe group who call themselves EM practitioners.
I don’t spend my time talking about nutritional enhancement of their condition, whatever that is.
With people that don’t have a recognised problem such as an allergy, nutrition is unlikely to play a role.
I stick to the big things like fish and mercury, pesticides in fruit and lead exposures if they haven’t washed their hands this may potentially contaminate the food.
IPs Nutrition is your backbone in biochemistry; if you’ve got good nutrition, you’ve got a level of resilience against environmental insults, if you’ve got poor nutrition, you have less resilience.
When you go from healthy food to processed food, you are doing two things: you’re decreasing the nutrients and at the same time increasing the toxins, and this changes the whole balance of survival.
If a person is low in calcium and iron, they have a greater affinity to absorb lead. Likewise, if a person is deficient in Vitamin C and selenium, they have a greater affinity for absorbing mercury.
If you eat a healthy diet, high in antioxidants, you’re more likely to be able to detoxify and get rid of those toxins… if you eat an organic diet, you reduce your pesticide load; when you eat fish, you are more likely to be exposed to heavy metals and other pollutants. So nutrition has a huge amount to do with that.
If the body has optimum nutrition, then the toxic load is less likely to be problematic.
Certain toxins bind up our enzymatic pathways and create nutritional deficiencies. So nutrition is really important for protecting you against toxic exposure.
Zinc and manganese are very important for upregulating metallothionein, and in protecting you against heavy metal exposure.
If the child is iron deficient, they have increased absorption of lead and often have pica symptoms, of eating the dirt.
Food is probably the first one because I know how toxic gluten is… it is associated with inflammation.
The biggest issue with environmental toxic load, is the amount of processed food that we eat, including foods stripped of nutrition and fibre, foods laced with food chemicals, foods dowsed in pesticides. Foods using abnormal hydrogenated toxic oils. I think that is actually our biggest danger.
Attitude towards genetic testing OEPs There’s a huge reluctance in occupational and EM to do genetic testing because of the implications, discriminating against people on the basis of genetic predisposition to problems.
Are we in the position to actually do the testing and make those decisions? No, that’s very contentious.
IPs People with the HLA DRB-1 and the HLA-DQ test do put them into a category that makes perfect sense about why the person reacted (to biotoxins in a water-damaged building).
I really do think that the idea of checking the genetics and susceptibility will be a big thing, once we understand why those particular chromosomal changes predispose a person towards more toxic injury than others.
The genes that I usually look out for would be the methylation genes, the glutathione-related genes, the Phase I and Phase II hepatic detox pathway genes, the acetylation genes of glucuronidation pathways, the Metallothionein gene and PON-1 (Paraoxonase-1).
I have a sense that neurological sensitivity and methylation disorders and hypersensitivity to toxins, are different aspects of the very same thing, of the very heightened response of the central nervous system to particular inputs.