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Environmental Medicine – Not Your Average Specialty

I recently received an announcement for a conference on “Inflammation and Autoimmunity.” The topic sounded interesting, but as I read further I saw some red flags:

A gathering of healthcare leaders with a shared vision.

This event focuses on the the [sic] true causes and effects of inflammatory and autoimmune diseases, including new treatments available for this rapidly emerging crisis.

Both of these comments sound ideology-driven. I would not expect to find language like this for, say, a conference organized by the American Academy of Pediatrics or the American Academy of Allergy, Asthma and Immunology. This conference was organized by the American Academy of Environmental Medicine. I did some checking, and it seems the AAEM is not your average academy, and environmental medicine is not your average specialty.

The AAEM is not recognized by the American Board of Medical Specialties.
It is listed as a questionable organization on Quackwatch. And the American Board of Environmental Medicine is listed as a dubious certifying board.

Note: The environmental AAEM should not be confused with the American Academy of Emergency Medicine, a reputable specialty organization that also carries the initials AAEM.

The AAEM website says:

“Autoimmune and inflammatory diseases have escalated dramatically in modern times. Most current treatments for these disorders primarily involve drugs that suppress the symptoms.”

“A quickly growing body of scientific evidence has revealed how many important inflammatory and autoimmune diseases are caused by man’s interaction with the environment, both internally and externally. At the AAEM, we understand this interaction. We can provide you with the answers you need and new insights that will open the door to newer and more effective, specific, cause-oriented, and preventive treatment for most of these conditions. [emphasis added]

Sound familiar? We’ve seen this kind of language from proponents of all kinds of alternative medicine. I’m surprised they didn’t use the word “allopathic” or attack evil Big Pharma.

When I looked up the members of the AAEM in my local area, one very disreputable name jumped out at me: Jonathan Wright. He has been in trouble with the FDA repeatedly for numerous violations and at one point he posted a notice saying that state-licensed physicians are “exempt from the restrictions and regulations of the federal Food and Drug Administration as a matter of federal law.” The notice also stated that “no employee, agent or inspector of the FDA shall be permitted on these premises.” His clinic used quack electrodiagnostic devices. The FDA raided his clinic and confiscated the machine.

Maybe we shouldn’t judge others by the company they keep. Let’s look at whether the conference offers good science.
There are two bonus electives:

One is a prolotherapy workshop. Prolotherapy is a controversial treatment not covered by insurance; a Cochrane review said there is conflicting evidence and found that prolotherapy injections were not superior to placebo injections, and that their effectiveness depended on co-interventions.

The other is on LDA Immunotherapy – Ultra Low Dose Enzyme Activated Immunotherapy (formerly known as EPD).

Learn how to treat complex inflammatory disorders, autoimmune diseases and allergies, including asthma, eczema, IBS, Crohn’s disease, rheumatoid arthritis, ankylosing spondylitis, interstitial cystitis and a multitude of others disorders with a definitive immunotherapy given only once every two months. LDA requires no testing and you can start it as soon as you get home!

While there is some preliminary evidence that seems to support enzyme activated immunotherapy, there is also evidence that doesn’t. There is certainly nowhere near enough evidence for them to make the statement they did.

Other questionable things on the agenda included sauna therapy for the management of toxicity and stool antibody testing for gluten sensitivity. None of the listings for sauna on PubMed have anything to do with toxicity. This study showed that stool testing was not suitable for screening.

Environmental medicine patients are told that the world has made them sick. They blame their symptoms on everything from cell phones to the very walls of their houses, from air pollution to food additives. The theory is that while one chemical might not be a problem, many different chemicals and substances overwhelm their ability to cope.

Environmental Medicine involves the adverse reactions experienced by an individual on exposure to an environmental excitant. Excitants to which individual susceptibility exists are found in air, food, water, and drugs, and are frequently found in the home, work, school, and play environments. Exposures to these agents may adversely affect one or more organ system and this effect is commonly not recognized by individuals and their physicians.

Their practice guidelines are explained here. Many of the diagnostic tests they recommend are questionable. Treatment includes avoidance, immunotherapy, nutritional supplements, detoxification, restricted diets, and drugs.

The poster boy for environmental medicine is Dr. William Rea, who was profiled on “Nightline” in 2008. They interviewed Rea and toured his clinic, seeing the detoxification saunas, the ceramic walls chosen because they are nonreactive, and the exercise machines that were cleaned of the lubricants that were putting fumes into the air. He claimed to have successfully treated 30,000 patients. They asked him about allegations that he had injected jet fuel into patients, and he explained that he only injected jet fuel antigens as a skin test for allergy. They asked him where his research was published and he evaded a direct answer, saying things like “The New England Journal of Medicine is a drug company journal.” (!?)

They interviewed one of his patients: a medical doctor who first thought she was depressed and saw a psychiatrist every day for a year. She had to stop because driving there exposed her to diesel fumes on the highway. Dr. Rea figured out what was “really” wrong with her: she was sensitive to practically everything in the environment. She can’t use her telephone because the magnets in it give her a headache. She injects herself daily with all kinds of unconventional allergy shots. She even injects herself with mercury. She moved to an island and created a pollutant free home. She spends 2 hours a day inhaling oxygen. Curiously, she has no sensitivities to her dogs, her horses, or the dust kicked up as she rides in a dirt arena.

They interviewed a real allergy specialist who explains that these people are reacting to stress and they have developed a conditioned response so that they have symptoms when they smell something they think they’re sensitive to. He says most of these patients have an underlying psychiatric problem. I suspect one of the reasons they improve is that they now have a mission and their attempts to avoid exposures and the effort required to detoxify and treat themselves takes up most of their time, keeps them entertained, and distracts them from dwelling on their psychological issues. But as was pointed out on Nightline, they are not cured.

As described on the Casewatch website, Rea is

facing disciplinary action that could lead to revocation of his medical license. The Medical Board of Texas has charged him with (a) using pseudoscientific test methods, (b) failing to make accurate diagnoses, (c) providing “nonsensical” treatments, (d) failing to properly inform patients that his approach is unproven; (e) practicing in areas for which he has not been trained; and (f) representing himself certified by a board that is not recognized by the American Board of Medical Specialties. Rea is best known for his promotion of the concept of multiple chemical sensitivity (MCS), a diagnosis not recognized by the scientific community.

The AAEM was so upset with ABC that it felt compelled to publish this defense.

To show how rigorous a scientist Rea is, here’s the most recent example of his published scientific studies:

Twenty-eight incapacitated individuals (average 43 years old, 7 males, 21 females, range 12-70) exposed to molds and mycotoxins were studied and treated with a protocol of cleaning up or changing their environment to be mold free. Injections of the optimum dose of antigens were given as part of the treatment protocol as was oral and intravenous (i.v.) antioxidants; heat depuration (sauna); physical therapy with massage and exercise under environmentally controlled conditions; oxygen therapy at 4-8 L/min for 2 hours with a special wood-grade cellophane reservoir and a glass oxygen container. Many patients were sensitive to plastics; therefore, exposures to these were kept to a minimum. Autogenous lymphocytic factor was given as an immune modulator. Of 28 patients, 27 did well and returned to work. One patient improved but did not return to work during the period of study.

With no controls and multiple interventions it is impossible to determine what worked or if anything actually did. Or even what was wrong with these patients in the first place. They are not trying to falsify a hypothesis or learn anything new; they are trying to justify a belief system. In my opinion, this kind of study amounts to junk science.

The underlying message of environmental medicine seems to be “The modern world is a dangerous place: technology and chemicals are bad; everything in the environment is out to get you, even your food.” The AAEM website has position statements against mercury in vaccines, GMO foods, and toxic molds. And against the FDA’s attempts to regulate bioidentical hormones. Their statement on multiple chemical sensitivity can be read here.  An excerpt:

Very sobering is the reality that certain man-made chemicals, like pesticides, were specifically designed to kill living things by poisoning their nervous systems. It should be no surprise that they wreak havoc on the brains of humans as well.

Common incitants include the following:

  • Those substances widely recognized as toxic, e.g., the aforementioned pesticides; natural gas; petroleum-based solvents like toluene and benzene; volatile organic compounds (VOCs) like formaldehyde; heavy metals like mercury and aluminum; molds and the potentially dangerous mycotoxins they release; tobacco smoke; the phthalates and other endocrine-disrupting compounds, like bisphenol A, found in plastics; flame retardants like PBDEs; and automobile exhaust fumes;
  • Those substances less often recognized as toxic, e.g., synthetic fragrances like perfumes, air fresheners, and other “pleasant-scented” products; newspaper print; personal care products; laundry detergents and fabric softeners; household cleaners; and fluoride-containing water and toothpaste; and
  • More generally, the many pollutants found in the air we breathe, the water we drink, and the food we eat.

Imagine being afraid of everything in your environment from your toothpaste to newspaper print. The lives of these people are totally disrupted. They are afraid to leave home. One woman “hung her mail on a clothesline for weeks before reading it, to allow the “toxins” in the ink to dissipate.” Quackwatch calls MCS a spurious diagnosis. MCS has not been meaningfully defined, diagnosis is based on unblinded, unvalidated tests whose findings vanish when blinding is used, and the treatment is everything but the kitchen sink.

The American Board of Medical Specialties was wise not to recognize environmental medicine as a legitimate specialty. It appears to have more in common with quackery than with science-based medicine.

Environmental medicine is not your average specialty.

Posted in: Science and Medicine

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20 thoughts on “Environmental Medicine – Not Your Average Specialty

  1. Harriet,

    Great job exposing the AAEM for the quackfest that it is. Let me humbly offer The Pseudomedical Pseudoprofessional Organization (PPO*) and Fake diseases, false compassion as useful companion pieces.

    KA

  2. micheleinmichigan says:

    Well, I guess I have a bit of a weakness for enviromental/chemical dangers. Maybe it is because as a child we used to run behind the DDT spray trucks and then I experiences the return of all sorts of beautiful birds after the common use of DDT was discontinued. (although it still has it’s place for malaria control).

    Or maybe it’s the fact that many of the people in our family have sensitive skin and that my sister’s dermatologist calls his lovely expensive house. “The house that Tide built” :)

    Maybe it’s because I deeply resent the fact I can not eat many of the fish from our local lakes as often as I’d like because of mercury contamination.

    And then there is the whole BPA debate and random chinese toy or pet food or formula (in China, not U.S.) scare. This not to mention the number of people in the world who truly suffer from health issues related to poor environmental controls in their countries.

    So my gut is that environmental health issues are very real and maybe under explored and underestimated. But I also think organizations like this that practice quackery and poor scientific method do nothing (or little) to advance more real scientific exploration of how to balance industry and human health. And they harm that real science, because they are easy targets for industry proponents to hold up and criticize.

    Just one criticism (as an aside). The examples you use (the lady with the mail) are compelling, but when I hear these extreme examples, I always think more of OCD, where even a healthy thing like hand washing can become dysfunctional, than an actual case of a practitioner advising a patient of such extreme measures. Avoiding or cleaning environmental “impurities” are one of the many OCD compulsions.

  3. Avoiding or cleaning environmental “impurities” are one of the many OCD compulsions.

    You’ve definitely hit on the perfect synergy between OCD and this manifestation of quackery. Licensed health care practitioners shouldn’t egg on obsessive-compulsives.

  4. micheleinmichigan says:

    # Kimball Atwoodon 17 Nov 2009 at 7:06 am

    “You’ve definitely hit on the perfect synergy between OCD and this manifestation of quackery. Licensed health care practitioners shouldn’t egg on obsessive-compulsives.”

    Yes, I agree and synergy is a good word, because they feed each other. And unlike a typical patient, I think someone with OCD or OCPD will have more of a tendency to seek out such a practitioner and maintain a regime that most typical people would find unlivable.

    And I really shouldn’t have said that was a criticism. I think I was trying to take Dr. Hall article farther than her point that AAEM is not good SBM.

  5. Sivi Volk says:

    Looking at that abstract – how do these people even get degrees? I’m in the first year of my master’s, and I would never be allowed to submit something like that as an abstract even for a poster, let alone for a paper.

  6. Kausik Datta says:

    So the peddlers of pseudoscientific woo-woo fakery in the United States have gone one step further. After getting themselves fake medical degrees (like doctor of naturopathy), promoting fake treatments (like faith healing, homeopathy and chiropractic), publishing their ‘studies’ in fake medical journals (like the Journal of American Physicians and Surgeons; more here and here) and organizing fake conferences (like Autism One in Canada), they have now tried to up their ante by creating fake certification agencies in the form of the AAEM. Oy vey! Will this insanity ever cease?

  7. edgar says:

    Very interesting post and something to consider. However, the study of environmental intoxicants is incredibly hard, and animal studies that extrapolate threshold limits are lacking. I would like see SBM ask an expert in toxicology or ecology speak to this issue. Sandra Steingraber comes to mind.

  8. edgar says:

    As for the Sauna therapy, I do not know much about it, but as I have stated before, I work in Indian county and have heard of diabetes patients with kidney disease not having to undergo dialysis because they sweat regularly.

    Just anecdotal, I know.

  9. I feel for these people, really I do.

    I was one of those poor sad OCD folks who grew up fearing toxins in everything I touched– mainly because I had OCD tendencies as a child, and my parents were into every form of woo imaginable and raised me on it. Once I was out of the house, my natural laziness kept me from taking handfuls of supplements every day, but I felt guilty about it! Learning to evaluate claims rationally was the best thing that ever happened to me. It literally gave me a life.

    It makes me unspeakably sad to see people wasting their precious time worrying about such teeny, tiny increments of risk like the level of ink-toxins in their mail.

  10. tariqata says:

    edgar: I’m not an expert in toxicology or ecology, but I’m in an “environmental studies” program and I took a course last year in “environment and health”, the point of which was to try to tease out some of the *possible* connections between acute or chronic exposure to a variety of human-made environments and health outcomes. (One or two of my classmates were promoters of some pretty outrageous woo (including a vocal anti-vaxer), so I was extremely glad that one of the first readings we had was entirely concerned with explaining that correlation is not causation.)

    What I got out of the course – which included reading some of Sandra Steingraber’s work, not surprisingly – was that although there is evidence that some of the chemicals that we put out into our environment *may* be harmful when we’re chronically exposed to small amounts, it’s probably never going to be possible to conclusively show that particular diseases are caused by chronic low-dose exposure to them. We discussed Multiple Chemical Sensitivity, but it was noted that there was no real evidence to support the diagnosis.

    To me, the fact that we don’t always know the potential long-term health impacts of our materials means that we should look for alternatives to known toxic/carcinogenic chemicals wherever possible, carefully control how and where we use chemicals such as pesticides, and have strict regulation and enforcement of industrial chemical use/manufacture, because we don’t know. However, if we environmentalists argue that we do know the long-term impacts based on testimonials and unfalsifiable claims, we undermine our own case for caution.

  11. micheleinmichigan says:

    edgar, on the sauna issue.

    Just an idea but if there were a correlation between sauna use in a native american population and better diabetes control, there could be other factors that the “sauna” group have in common, such as a more traditional diet or exercise habits or support system, etc that could have a positive effect on diabetes outcomes. Just throwing out the idea.

  12. Harriet Hall says:

    Sauna in place of dialysis? Hardly seems likely, unless those people have sweat glands that have mutated into nephrons.

  13. MCS sufferer says:

    I’m surprised that someone who likes to think they are being scientific promotes the belief that MCS is psychological with just television interviews as evidence.

    If you are genuinely interested in the science of MCS you could look it up on PubMed (looking at all the research objectively, not just the reasearch that fits with your preconceived ideas). You could also read Martin L. Pall’s chapter in General and Applied Toxicology, 3rd edition http://au.wiley.com/WileyCDA/WileyTitle/productCd-0470723270,descCd-tableOfContents.html or his ‘Multiple Chemical Sensitivity: Toxicological and Sensitivity Mechanisms’ here: http://www.thetenthparadigm.org/mcs09.htm

  14. Scott says:

    MCS wasn’t the point of the post, so there wasn’t any cause to go into depth on it here. The Quackwatch link goes into more depth, with references, but suffice it to say that the weight of the evidence does not support such the existence of such a condition.

    That doesn’t, however, stop unscrupulous quacks from taking advantage of people who are genuinely suffering for some other reason.

  15. edgar says:

    Harriet,
    it was a case report, and then man in question was doing 3 hour sweats daily.

  16. edgar says:

    OK, I am going to retract my statement. I cannot find confirmation where I heard that (I think it was pretty soon postpartum, so mommy brain is kicking in), but I could have sworn I heard that at a provider conference I went to, but I checked with some people from work, and non of them remember it.

    If I get more info I will post. Sorry for that.

  17. edgar says:

    Tari,
    fascinating, I think the Precautionary Principle is something worth considering, and the fact of the matter is that that EPA has approved exponentially substances that are known or suspected carcinogens in the last 10-15 years or so.

  18. Grinch says:

    MCS sufferer:
    “If you are genuinely interested in the science of MCS you could look it up on PubMed (looking at all the research objectively, not just the reasearch that fits with your preconceived ideas). You could also read Martin L. Pall’s chapter in General and Applied Toxicology, 3rd edition http://au.wiley.com/WileyCDA/WileyTitle/productCd-0470723270,descCd-tableOfContents.html or his ‘Multiple Chemical Sensitivity: Toxicological and Sensitivity Mechanisms’ here: http://www.thetenthparadigm.org/mcs09.htm

    MCS sufferer, you do realize that this is just a hypothesis? The NO/ONOO- cycle which he, himself, says they are “proposed mechanism.” In fact, he loves to cite himself as a reference (which would destroy his credibility in any other setting). I once read a ‘theory’ called the “spontaneous generation.” The problem with that one was that it wasn’t supported by science. It’s one thing to propose a mechanism or a theory, it’s a another to prove it. I guess that’s why the evil scientists insist on a theory be able to be proven, over and over and over and over (well, you see where I’m going with this). Please let me know if you need any further explanation.

  19. MCS sufferer says:

    Grinch, you sound just like a creationist saying, “the theory of evolution is just a theory”. Of course I realise that it’s just a hypothesis. I suggested Pall’s article because it includes a recent overview of MCS research, including genetic polymorphisms influencing susceptibility to MCS, evidence for biomarkers and a critique of psychogenic claims.

    Scott, the Quackwatch article doesn’t go into any depth and it is misleading. The references are biased and the most recent dates from 2000. If you looked at the research into MCS on PubMed you would see that the weight of evidence does support the existence of MCS and that it has a physical basis.

  20. weing says:

    “If you are genuinely interested in the science of MCS you could look it up on PubMed (looking at all the research objectively, not just the reasearch that fits with your preconceived ideas).”

    Are you certain that this is not what you are doing?

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