Helping People With Multiple Chemical Sensitivity
Also known as idiopathic environmental intolerance, the diagnosis is controversial — and determining house design guidelines for these clients is tricky
If you are a designer or builder specializing in green building, it’s only a matter of time before you are approached by a client who suffers from multiple chemical sensitivity. A typical request might go like this: “Many ordinary building materials can make me sick. I’m looking for someone to design (or build) me a house without any toxic chemicals.”
What’s the best way to respond to such a potential customer? To answer this question, let’s turn first to the medical experts.
Looking at the science
Medical research never rests, and our understanding of medicine is still evolving. That said, it is always valuable to look at the latest conclusions of scientific research to determine where we stand now. Although our medical knowledge may improve in the future, any conclusions we reach today can only rest on the best current data available.
For a summary of the medical community’s understanding of multiple chemical sensitivity, I recommend “Overview of Idiopathic Environmental Intolerance (Multiple Chemical Sensitivity),” by Donald Black and Scott Temple. Last updated on January 28, 2010, the paper by Black and Temple is published by UpToDate.com, a subscription-only Web site used as a reference by physicians.
Black and Temple explain that in 1996, attendees at a World Health Organization conference in Berlin proposed that the term “idiopathic environmental intolerance” (IEI) be substituted for the collection of symptoms formerly referred to as “multiple chemical sensitivity.” (“Idiopathic” means “of unknown cause.”)
Black and Temple note that idiopathic environmental intolerance “is a subjective illness marked by recurrent, nonspecific symptoms attributed to low levels of chemical, biologic, or physical agents. These symptoms occur in the absence of consistent objective diagnostic physical findings or laboratory tests that define an illness. Many experiments and observational studies consistently identify psychopathology in patients with IEI, and implicate behavioral or psychiatric causes for this illness. This indicates that the underlying illness in many cases of IEI is actually a psychiatric disorder, such as a somatoform, depressive, or anxiety disorder.”
Diagnosis by clinical ecologists
Many people claiming to have multiple chemical sensitivity have diagnosed themselves. Others, however, have visited physicians who call themselves “clinical ecologists.” Clinical ecology is not a recognized medical specialty, nor is the field part of a standard medical school curriculum. According to Black and Temple, these clinical ecologists assert that multiple chemical sensitivity “is acquired, highly prevalent in the general population, and goes unrecognized by most other clinicians.”
Most medical authorities have concluded that idiopathic environmental intolerance is not a recognizable syndrome. Black and Temple write, “Criticisms of IEI as a distinct medical entity include the lack of reliable case definitions; the lack of consistent physical abnormalities and reproducible laboratory results; the use of unorthodox diagnostic procedures; and the use of unproven and potentially harmful treatments.”
Those who suffer from multiple chemical sensitivity differ from patients exposed to toxic substances. “Toxicity due to certain chemicals such as lead and arsenic is well established, including the signs, symptoms, and pathophysiology of the disease states that occur following exposure,” write Black and Temple. “No such information exists for IEI despite many years of research. Prominent medical societies view IEI with marked skepticism. As an example, the American Medical Association concluded that, ‘Until such accurate, reproducible, and well-controlled studies are available, the American Medical Association Council on Scientific Affairs believes that multiple chemical sensitivity should not be considered a recognizable syndrome.’ ”
Severe reactions to sham provocations
Many researchers have studied these patients. “Multiple review studies have consistently failed to find a systematic connection between exposure to environmental triggers and onset of IEI symptoms,” Black and Temple point out. “Provocation studies that exposed patients with IEI to different substances found that patients could not distinguish between active and placebo substances when blinding or masking was adequate. Some patients with IEI exhibited severe reactions to sham provocations, which in one study were so extreme that the trial had to be terminated.”
Attempts to pin down IEI have been hampered by the multiplicity of symptoms exhibited by patients. “The symptoms of IEI are diffuse, nonspecific, ambiguous, and common in the general population,” write Black and Temple. “In one study, 295 patients with IEI reported 252 different symptoms. There are no essential differences in symptoms between patients who meet criteria for IEI and those who do not.”
Black and Temple conclude, “Although there is some disagreement whether IEI is a toxigenic or psychogenic illness, the evidence strongly demonstrates there is no immunologic or other biologic basis for IEI and that psychopathology causes the symptoms of IEI in at least some if not most cases. … IEI is not a distinct, valid medical entity. Symptoms lack specificity, there is no reliable case definition or set of diagnostic criteria, and there are no consistent objective diagnostic physical findings or laboratory tests.”
Professional groups are openly skeptical
The paper by Black and Temple represents the consensus conclusion of the medical community. Writing in Environmental Health and Preventive Medicine, January 2003, Mitsuyasu Watanabe, Hideki Tonori, and Yoshiharu Akizawa reached a similar conclusion. They wrote, “The Council on Scientific Affairs of the American Medical Association, the American College of Physicians, the American College of Occupational and Environmental Medicine, and other professional groups have all issued position papers that are openly skeptical of multiple chemical sensitivity/idiopathic environmental intolerance (MCS/IEI) as a distinct medical entity.”
In a 1998 paper called “A close look at ‘Multiple Chemical Sensitivity,’ ” Dr. Stephen Barrett wrote, “(1) MCS has never been clearly defined, (2) no scientifically plausible mechanism has been proposed for it, (3) no diagnostic tests have been substantiated, and (4) not a single case has been scientifically validated. For these reasons, MCS is not listed as a diagnosis in standard medical textbooks or the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM), which is the standard manual used for classifying medical conditions.”
Fortunately, diagnosis and cure is not my job
Although I have described the consensus conclusion of the mainstream medical community — one based on the best available data and research — it is not the only conclusion. A minority of physicians, including those who call themselves clinical ecologists, have reached different conclusions.
If you are a designer or builder, the disagreements in the medical community over multiple chemical sensitivity don’t really concern you; nor does it matter much whether the symptoms experienced by people with this diagnosis have a chemical or a psychiatric cause. Your issue is a narrower one: namely, will my company be able to fulfill the expectations of this potential client?
What are you getting yourself into?
Before taking on such a client, it’s useful to read as many construction case studies as possible. One such study can be found on a Web page maintained by the Healthy House Institute: “In early 2007 Kevin and Kathy Christopherson set about building a home in Hanover, Wisconsin. This was no ordinary new home construction, though. Since Kathy has an acute chemical sensitivity, special precautions were necessary — precautions that presented particularly challenging construction issues. … Since people suffering from chemical sensitivity can have negative reactions to even minute amounts of certain chemicals, Nelson instructed contractors and subcontractors to empty their work trucks of all non-approved materials and tools prior to entering the jobsite to prevent their accidental introduction to the home. Also, all sheet metal used in the home had to be scrubbed to remove any oils on it.”
Creating a “safe” home for clients with multiple chemical sensitivity is complicated by the fact that the list of possible irritants is so long. According to “Profile of Patients with Chemical Injury and Sensitivity, a paper by Grace Ziem, MD, published in Environmental Health Perspectives, 1997, “Agents whose exposures are associated with symptoms and suspected of causing onset of chemical sensitivity with chronic illness include gasoline, kerosene, natural gas, pesticides (especially chlordane and chlorpyrifos), solvents, new carpet and other renovation materials, adhesives/glues, fiberglass, carbonless copy paper, fabric softener, formaldehydeChemical found in many building products; most binders used for manufactured wood products are formaldehyde compounds. Reclassified by the United Nations International Agency for Research on Cancer (IARC) in 2004 as a “known human carcinogen." and glutaraldehyde, carpet shampoos (lauryl sulfate) and other cleaning agents, isocyanates, combustion products (poorly vented gas heaters, overheated batteries), and medications (dinitrochlorobenzene for warts, intranasally packed neosynephrine, prolonged antibiotics, and general anesthesia with petrochemicals).”
Recommendations to architects and builders
If you are tempted to take on a client with multiple chemical sensitivity, here are some guidelines:
- Don’t give health advice. Remember, you are not a doctor.
- Don’t make any health claims for a house you build.
- Don’t propose specific materials as “safe.” It’s better to say, “If you or your doctor provides a list of the substances that need to be avoided, I’ll do my best to comply with that list.”
- Manage expectations from the start. Make no promises related to your client’s symptoms.
- Be sure to include a great deal of extra time in your construction schedule for materials research and selection. A useful resource with information on the ingredients found in building materials is the Pharos database maintained by the Healthy Building Network.
Before deciding to work with a client with multiple chemical sensitivity, it's worth pondering the fact that (according to the best available data) these patients rarely improve. “The condition is highly stable and most patients remain chronically ill. A prospective study of 49 patients with IEI symptoms found that 92 percent remained ill after one year,” wrote Black and Temple. “Other studies have found that 54 to 96 percent of patients with IEI symptoms were unchanged or worse when they were reassessed several months to two years after their initial evaluation.”
What materials should be avoided?
Since some people with multiple chemical sensitivity become ill when they smell shampoo, it’s basically impossible to come up with a list of “safe” building materials. That said, here are oft-repeated recommendations noted by other writers:
- Ceramic tile is better than carpet.
- Linoleum is better than sheet vinylCommon term for polyvinyl chloride (PVC). In chemistry, vinyl refers to a carbon-and-hydrogen group (H2C=CH–) that attaches to another functional group, such as chlorine (vinyl chloride) or acetate (vinyl acetate)..
- Low-VOC paints are better than conventional paints.
- Solid-wood furniture or cabinets are better than furniture containing particleboard or plywood.
- It’s best to omit wood-burning stoves and fireplaces.
It's worth considering the advice provided by building scientist Josesph Lstiburek: “When we design buildings for ‘sensitive clients,’ we typically put material samples in a bell jar and put them outside in the sun for a couple of days and let the clients ‘sniff’ them. We repeat the process with a little bit of water in the jar. If they don’t bother the client, they go in the building. Much better than trying to get anything useful from a MSDS sheet.”
An invitation to GBA readers
Have you worked with clients with multiple chemical sensitivity? If so, please share your stories with the GBA community by posting a comment below.
It would be interesting to know, for example, if the construction project was smooth or bumpy, and whether the clients were pleased with the completed project.
For a balanced presentation of the issues discussed in this blog, see “Multiple Chemical Sensitivity (MCS): The Controversy and Relation to Interior Design,” by Linda Nussbaumer.
Last week’s blog: “How Is a Home’s HERS Index Calculated?”
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