Diagnosis Environmental medicine
Medical Misdiagnoses and Their Consequences
by Harold E Buttram, MD
September 11, 2001 (REVISED)
As a matter of personal opinion and observation, there is at present a dichotomy of almost schizophrenic proportions between ongoing American scientific research in the medical field, most of which takes place in academic institutions and medical centers, and the genuine needs of the American public.
The scope and direction of this research, most of which is funded by the National Institute of Health (NIH), is of tremendous importance in that it forms a source of guidelines and a scientific foundation for the clinical practice of medicine. In other words, the clinical practice of medicine as it exists today has been largely shaped by decisions made in the NIH and other government health agencies in the granting of research money. This is a system which has existed since the 1930s, but there may be serious misdirections which are proving to be very costly in terms of the health and welfare of the American public, especially as applies to its children.
There are two medical conditions from which it is predictable that American society and economy will be strained to the breaking points in coming years by overwhelming numbers of medical indigents unless these conditions are addressed effectively and decisively in the very near future. The two conditions to which I refer are childhood autism and environmental illness with chemical sensitivity, neither of which are being recognized for their true nature by mainstream medicine because of a misdirection of research funding in certain key areas, as will be reviewed in the following:
Childhood Autism, Predominantly an Environmental Illness
In regards to childhood autism, a condition characterized by severe mental regression, fifty or so years ago autism was so rare that many pediatricians had never heard about it. At least this was the experience of Dr. Bernard Rimland, founding director of Autism Research Institute. In 1956 Dr. Rimland, whose Ph.D. is in research psychology, had a son who was later found to be autistic. In his annual DAN (Defeat Autism Now) conferences Dr. Rimland is fond of telling the story about the early days with his son during which he had great difficulty in finding a pediatrician who knew anything about or who had ever seen a case of autism. How different it is now. Childhood autism has become so prevalent that there are very few who do not know of a family with an autistic child. Families with two autistic children are not uncommon, and I personally have seen a family in which all three of the family's children were autistic. Latest statistics estimate that over one half million American children are autistic, (1) and with numbers steadily growing, there is no end in sight. It can be expected that treatments will improve the outlook of these children, but as far as is known at present, many or most of these will require custodial care for life, at an average cost to society as much as three million dollars per child. (2)
In the opinion of this observer, the misdiagnoses in childhood autism come not in the diagnosis of the condition itself, something that is unmistakable once one has seen a few children with the condition, but from a failure to recognize autism as predominantly an environmental illness. (In this instance the term, "environmental illness," is used to include illnesses brought about by exposures to commercial chemicals and medical interventions as well infectious microorganisms and other exposures from the natural environment). This statement is based on a recent seminar on childhood autism held in the Washington D.C. area as sponsored by the National Institute of Health and other health agencies September 6th and 7th, 2001, at which the largest portion of the meeting was devoted to areas of genetics and neuropathology of autism. (3)
As related to childhood autism, it should be stressed that the field of genetics involves a susceptibility to autism but, except in rare instances, has nothing to do with its causes. The same could be said about virtually all epidemic-type diseases, in which there will be variability in genetic susceptibility. By their very nature, epidemics always arise from environmental sources of one type or another and not from genetic causes. Genetic changes take place very slowly in an evolutionary scale over a period of millennia and never with the rapid increases as seen today with autism.
Major areas now under suspicion as being causally related to childhood autism include childhood immunizations, (4) toxic environmental chemicals, (5) commercial food processing, (6) and the overuse of antibiotics. (7) The only possible way of salvaging the situation is to find and modify the causes while at the same time doing the very best we can to develop effective treatments for those already afflicted with this condition.
Childhood Immunizations - Deficiencies in Basic Science and Safety Guidelines
As reflected in a series of U.S. Congressional Hearings concerning issues of vaccine safety which have taken place annually since 1999, (4) there is now growing awareness of major deficiencies in safety testing for current childhood immunizations. A few examples will be given here:
(a) Safety studies on vaccinations are limited to short time periods only:
several days to several weeks. There are no (none) long-term (months or years)
safety studies on any vaccination or immunization.
(b) In 1994 a special committee of the National Academy of Sciences (Institute of Medicine) published a comprehensive review of the safety of the hepatitis B vaccine. When the committee, which carries the responsibility for determining the safety of vaccines by Congressional mandate, investigated five possible and plausible adverse effects, they were unable to come to conclusion for four of them because they found that relevant safety research had not been done. Furthermore, they found that serious "gaps and limitations" exist in both the knowledge and infrastructure needed to study vaccine adverse events. Among the 76 types of vaccine adverse events reviewed by the IOM, the basic scientific evidence was inadequate to assess definitive vaccine causality for 50 (66%). The IOM also noted that "if research (is) not improved, future reviews of vaccine safety will be similarly handicapped. (8)
(c) In an article published in Adverse Drug Reaction & Toxicology Review, (9) researchers Andrew Wakefield and Scott Montgomery, who have been investigating a possible causal relationship between the MMR vaccine (measles-mumps-rubella) and the autism enterocolitis syndrome, carefully reviewed inadequacies of the early pre-licensing trials of the MMR vaccine with a maximum follow up of 28 days and even shorter periods in some of the studies. They stressed that such short periods of observation following the vaccine were totally inadequate to detect delayed reactions, including pervasive developmental delay (autism), immune deficiencies, and inflammatory bowel disease, which are known from earlier published reports to occur following both the natural measles infection and the measles vaccine.
The most interesting feature of the Wakefield/Montgomery article was that it was reviewed by four leading British authorities, all of whom had previously held positions in the regulation and licensing of medicines in the United Kingdom. (10) Taken as a whole, the reviewers were supportive of the article, three highly so. Peter Fletcher, formerly a senior professional medical officer for the Department of Health wrote, "being extremely generous, evidence on safety (of the MMR vaccine) was very thin." Noting that single vaccines for measles, mumps, and rubella already existed, he argued, "caution should have ruled the day the granting of a product license was definitely premature." Professor Duncan Vere, former member of the Committee on the Safety of Medicines, agreed that the periods for tests were too short. "In almost every case," he wrote, "observation periods were too short to include the onset of delayed neurological or other adverse events."
(d) In 1984 an intriguing study was reported in a little noted letter-to-the-editor in the New England Journal of Medicine in which a significant though temporary drop in T-helper lymphocytes was found in 11 healthy adults following routine tetanus booster immunizations. (11) Special concern rests in the fact that, in 4 of the subjects, the T-helper lymphocytes fell to levels seen in active AIDS patients. If this was the result of a single vaccine in healthy adults, it is sobering to think of the possible consequences of multiple vaccines (19 within the first 6 or so months of life at latest count) given to infants with their immature and vulnerable immune systems. Unfortunately, other than clinical observation, we can only speculate at these consequences, as the test has never been repeated.
Environmental Illness - Deficiencies in Basic Science and Safety Measures
In my opinion, the second area of misdiagnosis is the common approach of mainstream medicine in dealing with environmental illness and its related condition of multiple chemical sensitivity (MCS). In contrast to the American Medical Association, which denies the existence of MCS as a valid diagnosis, there is a group of physicians in the field of environmental medicine who believe that millions of Americans are being made ill and sensitized in various degrees to toxic airborne chemicals from a class of chemicals known as volatile organic compounds (VOCs). (12) Illnesses brought about by breathing these chemicals inside buildings are referred to as "The Sick Building Syndrome." A number of official government and health agency publications have been issued on this subject. (13-18) However, the major thrust of most of these publications is to stress how little we actually know about the effects of these chemicals and emphasize the over-riding need for further safety research in this area. As pointed out in the text, Multiple Chemical Sensitivity, (National Research Counsel, 1989), "about 70,000 chemicals are used in commerce, of which several hundred are known to be neurotoxic. However, except for pharmaceuticals, only 10% have had any testing at all for neurotoxicity, and only a handful of these have been evaluated thoroughly." (19)
Since the publication of Multiple Chemical Sensitivity, the situation has changed in one respect: There is now a substantial body of literature dealing with occupational exposures to solvent-type chemicals or VOCs, prominent among which are publications by Lisa Morrow and coworkers at the University of Pittsburgh, several of which are sited here. (20-23)
For the issue of multiple chemical sensitivity, on the other hand, it is far different. Once again we are faced with major deficiencies in safety-oriented studies on the effects of potentially toxic environmental chemicals on the human system and of safety measures that would have followed, had these studies been done. Basic science in this area, at very best, has been fragmentary. For this reason and this reason alone, evidence for support of the diagnosis of MCS has not yet reached standards of scientific proof. However, the fact that adequate research has not yet been done to prove its existence, it does not follow that MCS has been disproved or that it does not exist. Yet, this is the practical conclusion one generally finds in mainstream medicine.
Based on my own experiences in many workman's compensation cases involving airborne chemical exposures, the near universal response of mainstream medicine has been to deny its existence.
As a result, many patients with more advanced forms of chemical sensitivity are becoming like the lepers of ancient times, disabled outcasts of society, and their numbers are growing larger by the day. (24)
However, we are not entirely barren in this area. Though small in number and preliminary in nature, there are a number of publications tending to confirm a widespread presence of MCS in our population, publications which can form a nucleus for further study. A few of these are enumerated below:
(a) Two publications involving studies with SPECT brain scans have shown impairments in brain functions resulting from chemical exposures. (20,25)
(b) In a recent study of a group of veterans with the Persian Gulf War Illness, an activated coagulation system was found with platelet activation and fibrin deposits on the endothelial surfaces of blood vessels, which resulted in a constriction of blood flow. The authors concluded that heavy exposures to toxic chemicals during the Gulf War in all probability were the underlying cause of the pro-coagulant state, although other possible causes were also mentioned in the article. (26)
(c) Studies of patients with chronic fatigue and fibromyalgia at the Electron Microscopy Unit at the Adelaide Institute of Medical and Veterinary Science, Australia demonstrated deformities in the red blood cells (RBCs) of these patients described as dimpled spherocytes (rather than the normal oval shapes of RBCs) along with increased rigidity of the RBC membranes, these changes resulting in reduced flow of the RBCs as a result of their deformities. The article went on to point out that a great majority of these patients had been exposed to environmental chemicals, some working in chemical factories, others in wheat fields or orchards subject to periodic pesticide/herbicide sprayings, many patients noting deterioration following these exposures. (27)
(d) In an article by P Beaune and coworkers, the term "suicide inactivation" was used to describe the mechanism whereby foreign toxic chemicals may damage and cripple the enzyme systems necessary for detoxification and elimination of toxic chemicals. (28) This now thought or suspected of being a major factor in the pathogenesis of MCS.
(e) Among those working in the field of environmental medicine, (12) The Environmental Health Center in Dallas, Texas has always been considered a major center of research in this field. Authored by William J. Rea, M.D., much of the work of this center has been recorded in a four-volume set of books with the simple title, Chemical Sensitivity. (29) Many of those familiar with this center believe it will in time be accredited with being one of the earliest centers to fully recognize the increasing impact of foreign chemicals on human health and to do meaningful, systematic study in this area.
With reports such as these now in the scientific literature, further documentation and confirmation of environmental illness and MCS as valid diagnoses cannot be long in following, along with a more realistic appraisal of their prevalence.
Finally, no treatment of environmental illness would be complete without mention of possible ongoing damage being done to the reproductive systems of both men and women when exposed to toxic airborne chemicals during their reproductive years, (30) or of fetal damage when women work in such conditions during their pregnancies. (5) Although as yet largely theoretical, sooner or later these are issues which must be addressed.
In the late 1800s and early 1900s there was a time now referred to as the golden age of medical diagnosis. Those were the times of Sir William Osler of Johns Hopkins University, remembered as the father of internal medicine, and of other stellar names of the times. In those days doctors took time to listen to their patients, and equally important, took very seriously the information given by the patient. It was a time of clinical observation, when doctors believed what their eyes told them and deduced diagnoses based on these observations. It is no small coincidence that the mythical master of observation and deduction, Sherlock Holmes, the creation of Sir A Conan Doyle, was based on a physician that Doyle had known in his student days.
How does this compare with today? Based on personal experience, very few doctors listen to parents of autistic children, or if they listen to them, very few believe what they are told by the parents. (31) This is even truer for patients with environmental illness who, in a majority of cases in my experience, are commonly referred to psychiatrists or psychologists by their physicians, their physicians telling them that their symptoms are psychosomatic or imagined.
However, in defense of doctors directly involved in care of the public, it is doubtful that there has ever been a time with greater demands on their time combined with greater economic/political pressures intervening in the care of their patients than at present. Most of them are doing the best they can under the circumstances.
I take great pride in being a medical doctor. I would not change places with anyone in the world. But I also fear for the future of my profession. Whether in the realm of nature or human affairs, all things must remain relevant to survive. In the natural world all life forms must adjust to their environment or perish. In the healing professions, these professions must both recognize and address the genuine needs of the public or stand in danger of passing into the limbo of forgotten things. Actually I believe the medical profession will survive, but to do so will require a higher level of vision with issues surrounding childhood autism and environmental illness than has been the norm until now.
For practicing physicians to recognize the nature of their patients' problems and treat them properly, the physicians must be provided with valid science by those engaged in research, science realistically directed at the genuine health needs of the public.
(1) On April 25, 2001 James J Bradstreet, M.D., F.A.A.F.P gave testimony before the U.S. House of Representatives, Committee on Government Reform recalling his own experiences with an autistic son as well as providing a broad review of issues surrounding childhood autism. In a written supplement to the oral presentation, which can be accessed on the website: http://www.gnd.org/Testimony/Congressional.htm , Dr. Bradstreet provided current statistics on autism, pages 3-7.
(3) NIH/ACC 2001 Conference: Potential Cellular and Molecular mechanisms in autism and Related disorders Sponsored by NICHD and NIEHS, Co-Sponsored by NIMH, NINDS, and NIDCD, September 6-7, 2001, Bethesda, Maryland. (Having personally had the privilege of attending the meeting, there were very excellent presentations having to do with neuro-anatomical findings as well as genetics of autism, areas constituting basic science for the field. A portion of the meeting was also devoted to the possible roles of pesticides and other neurotoxicants in causing autism, but even these were of an academic nature. Clinical studies of potential value in either the prevention or treatment of autism were notable by their absence.)
(4) Annual hearings specifically dealing with questions about vaccine safety have been taking place in the U.S, House of Representatives since 1999. This is only one of many indications of growing public and professional concern on this issue.
(5) Edelson SB & DS Cantor, Autism: xenobiotic influences, Toxicology and Industrial Health, 1998; 14(4):553-563. (This study, which appears to be the first of its kind, points out that the breathing of toxic, chemical-laden air in sick buildings by women during their pregnancies may be a contributing cause of brain damage to the fetus and a common factor in the rising incidence of childhood autism).
(6) Among the many works dealing with the adverse health consequences of "fast foods," which form an increasing pattern in the diets of American children, two books are recommended here: Nourishing Traditions, by Sally Fallon with Pat Connolly and Mary G Enig, Ph.D., ProMotion Publishing, San Diego, 1995 and Special Diets for Special Kids, by Lisa Lewis, Ph.D., Future Horizons, Arlington, Texas, 1998.
(7) No reference is needed here - the overuse of antibiotics in medicine and the food industry is now universally recognized and is being taught at leading medical centers.
(8) Stratton KR, CJ Howe and RB Johnston, Jr., Editors, Adverse Events Associated with Childhood Vaccines; Evidence Bearing on Causality, Institute of Medicine, National Academy Press, Washington D.C., 1994, pp 211-236.
(9) Wakefield AJ & S Montgomery, Measles, mumps, rubella vaccine: through a glass darkly, Adv Drug React Toxicol Rev, January, 2001; 19(3):1-19.
(10) Hurley DR, DW Vere, A P Fletcher, Referee 1, 2, 3, & 4, Adverse Drug React Toxicol Rev, 2001; 19(4):1-2.
(11) Eibl M et al, Abnormal T-lymphocyte subpopulations in healthy subjects after tetanus booster immunization, (letter), NEJM, 1984; 310(3):198-199.
(12) American Academy of Environmental Medicine, with headquarters at American Financial Center, 7701 East Kellogg, Suite 625, Wichita, Kansas 67207-1705, phone (316) 684-5500, Fax (316) 684-5709.
(13) Pesticides in the Diets of Infants and Children, National Research Counsel, National Academy Press, Washington D.C., 1993. (Although this book deals with foods rather than air, it provides further evidence of concern in leading scientific circles about the potential impact of toxic chemicals on human health).
(14) Neurotoxicity, Identifying and Controlling Poisons of the Nervous System, Superintendent of Documents, Government Printing Office, Washington D.C., GPO Stock # 052-003-01184-1, April, 1990.
(15) Environmental Hazards in Your School, A Resource Handbook, US Environmental Protection Agency, Washington D.C., Publication # 201-2001, October, 1990.
(16) The Healthy School Handbook, Norma L Miller, Ed.D., Editor, a National Education Association professional Library Publication, National Education Association, Washington D.C., 1995.
(17) Multiple Chemical Sensitivities at Work, Produced by The Labor Institute, NYC, 853 Broadway, Room 2014, New York, NY 10003, 1993 (funded by a grant from the New York State Department of labor, Occupational Safety and Health Training and Education Program).
(18) Multiple Chemical Sensitivities, National Research Counsel, National Academy Press, Washington D.C., 1989.
(19) Ibid, page 2.
(20) Callender TJ, L Morrow, & K Subramanian, Evaluation of chronic neurological sequelae after acute pesticide exposure using SPECT brain scans, J Toxicol Environm Health, 1994; 41:275-284.
(21) Morrow LA, CM Ryan, & M Hodgson, Cacosmia and neurobehavioral dysfunction associated with occupational exposure to mixtures of organic solvents, Am J Psychiatry, 1988; 145:1442-1445.
(22) Morrow LA, MJ Hodgson, & N Robin, Assessment of attention and memory efficiency in persons with solvent neurotoxicity, Neuropsychologia, 1992; 30(10):911-922.
(23) Morrow LA, CM Ryan, MJ Hodgson, & N Robin, Risk factors associated with persistence of neuropsychological deficits in persons with organic solvent exposure, J Nervous & Mental Dis, 1991; 179:540-545.
(24) Michelle Conlin, Is your office killing you?, Business Week, June 5, 2000, pages 114-125. (In this article the authoress stated, "Experts predict that the 5% to 10% of the population that is allergic to chemicals will grow to 60% by 2020." She did not state where she obtained these figures, but a general observation of the American scene tends to support their validity.)
(25) Simon TR, DC Hickey, CE Fincher et al, Single photon emission computed tomography of the brain in patients with chemical sensitivity, Toxicol Industr Health, 1994, 10(4/5):573-577.
(26) Hannan KL, DE Berg, W Baumzweiger, HH Harrison et al, Activation of the coagulation system in Gulf War Illness: a potential pathophysiologic link with chronic fatigue syndrome - a laboratory approach to diagnosis, Blood Coagulation and Fibrinolysis, 2000; 11:673-678.
(27) Buist RA, Chronic fatigue and chemical overload, Intern Clin Nutrition Rev, Oct., 1988, 8(4):173-175.
(28) Beaune P et al, Autoantibodies against cytochrome P-450; role in human disease, Adv Pharmacol, 1994; 30:199-245. (Note: detoxification in the body is centered around two enzyme systems. The first is the P-450 system which, by a process of oxidization, converts the lipid-soluble state of volatile organic compounds into a more water soluble form, in which form they are more readily excreted by the kidneys. There is a price to pay, in that the water-soluble forms of VOCs may be more toxic than their parent compounds. In health the second phase of detoxification, that of conjugation, takes place immediately to neutralize the toxicity in which process the toxic product is combined with various natural substances in the body, predominantly glutathione. In many instances in chemical sensitivity there appears to be a relative deficiency of the conjugation enzyme activity which results in an accumulation of the more toxic products of phase I oxidation.
(29) Chemical Sensitivity, Volumes I - IV, William J. Rea, M.D., Lewis Publishers, Boca Raton, FL , Vol I, 1992, Vol II, 1994, Vol III, 1995, Vol IV, 1997.
(30) The Case for Preconception Care of Men and Women, Margaret and Arthur Wynn, AB Academic Publishers, PO Box 42, Bicester, Oxon, 0X6 7NW England 1991.
(31) Among the parents with autistic children, a significant portion of these parents believe that their children have been damaged by vaccines. A common story in such instances is that the child was developing normally into his or her second year, was beginning to speak a few words, was affectionate with parents and playful with siblings until a vaccination took place, after which the child lost all speech and regressed into a world of its own, no longer responding to parents or playmates.
As further evidence of such a pattern, during October, 1999 an autism conference was held in Cherry Hill, New Jersey sponsored by the Autism Research Institute, referred to as a DAN conference. Over 1,000 people were in attendance, the great majority of whom were parents of autistic children. At one point in the meeting, when the chairman asked those in the audience who believed that their child's autism was caused by vaccines to stand, a large majority of the audience rose to their feet. Reportedly there was much the same response when the same question was asked at the DAN conference in San Diego during October, 2000.
And yet, this writer has read many evaluations of autistic children from major medical centers without finding a single instance where vaccines were mentioned or considered as a possible cause. In those instances in which parents mentioned their suspicions about the vaccines, apparently they were ignored.