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Recognition and medical education

Along with consensus regarding the diagnosis being established, recognition of environmental sensitivities by decision-makers and in medical education is also necessary.

This section examines recognition of environmental sensitivities by international bodies, by levels of government and agencies, and by the health care community in Canada.

Numerous countries have recognized environmental sensitivities in a variety of manners.

Classification of Diseases

The classification of diseases plays an important role in the recognition of and research into medical conditions.

The International Statistical Classification of Diseases and Related Health Problems (ICD) is a long-standing, ongoing international effort to categorize all causes and manifestations of disease. It is compiled and regularly updated by the World Health Organization,^47,48 and it is used as a basis for the provision of health care within Canada.

The ICD-9 includes some relevant categories such as Ill-defined conditions, Injury and poisonings, Late effects of poisoning due to drug and biological substances, Poisoning by drugs and biological substances, and Late toxic effects of non-medical substances. In the most recent version, ICD-10,49 "environmental sensitivities" is not listed, but the related conditions of Chronic fatigue and Fibromyalgia have now been included. Many other possibly related conditions are also listed, such as Arthritis due to hypersensitivity. In an update of the ICD-10, wood preservatives have been recognized as causing disease.⁴⁸

The ICD is an ongoing project. Recent recognition of environmental causes of ill health, and conditions related to environmental sensitivities are good steps toward a more comprehensive system for the classification of diseases.

Table 3 highlights some initiatives taken by the Canadian federal government and national bodies.

Table 3: Recognition of environmental sensitivities by the Canadian federal government and national bodies

Recognition of environmental sensitivities at the provincial level may translate into funding and access to optimum health care. Sensitivities may also be recognized with regulation of environmental agents such as pesticides, air pollution and scents, and through public education.

Provincial bodies

Ministries of Health

Physicians bill provincial ministries of health according to services rendered, and must note conditions treated. Some provinces still use the ICD-9, while others are gradually making the transition to the ICD-10. There is now a code for chronic fatigue syndrome in the Ontario diagnostic categories list, and a time-based service code. When the complexity of the condition necessitates time-consuming consultations, this allows the physician to bill accordingly.

Provincial bodies engage in anti-smoking, pesticide-reduction and scent-free initiatives, which benefit people with environmental sensitivities. Table 4 describes a few examples of these initiatives.

In the mid 1980s, the government of Ontario appointed an Ad Hoc Committee on Environmental Hypersensitivity Disorders, chaired by Judge George Thomson ("Thomson Committee").⁶⁰ The 1985 report produced by the Committee found that environmental (hyper)sensitivity was a significant problem requiring further research, and that patients were not having their needs met within the health care system. The Thomson Committee’s recommendations and subsequent progress are summarized in Appendix D. Following the Committee’s recommendations, the Ontario Ministry of Health funded the Environmental Hypersensitivity Research Unit at the University of Toronto in 1994, and opened the Environmental Health Clinic at Women’s College Hospital in 1996.

After a six-year pilot project,⁶¹ the Nova Scotia Environmental Health Centre was established at a permanent site in 1997. This facility is associated with Dalhousie University and includes Canada’s only environmental control unit for treatment and research.

Some provincial workers’ compensation boards recognize environmental sensitivities, but eligible conditions and nomenclature vary across jurisdictions. According to the Association of Workers’ Compensation Boards of Canada, as well as a discussion paper prepared for WorkSafeBC,⁶² a national framework common to all jurisdictions with respect to environmental sensitivities does not exist. Information about the recognition of environmental sensitivities by workers’ compensation boards is presented in Table 5.

Table 5: Recognition of environmental sensitivities and possibly-related conditions on Workers’ Compensation Boards websites

Note: While various websites offer some information about environmental sensitivities, the information may not be always easily accessible.

Many public health departments provide advice regarding smoking, scents, pesticides and idling of vehicles. This advice may lead to policies and bylaws within municipalities. The following are some examples.

In Ontario, local public health departments address smoking, scents, pesticides and vehicle idling. Special consideration may be given to people with environmental sensitivities in the event that pesticides are sprayed against mosquitoes carrying West Nile virus. Ottawa Public Health instituted a voluntary registry so that people with environmental sensitivities will receive increased notice should the city consider fogging with malathion in response to West Nile virus. Ottawa also has a safe public housing project for people with environmental sensitivities. The Region of Peel is studying fragrances from laundry facilities.

Many Canadian cities,^d including most capitals, have anti-idling bylaws or policies (e.g. for vehicle fleets), idling-free zones (e.g. around schools) or educational initiatives. These are for both energy conservation and cleaner air.

Halifax was the first major Canadian city to enact a pesticide bylaw. As well, municipal employees who became sensitive to chlorine in public swimming facilities have been accommodated with changes in place of work.

Almost 130 cities in Canada now restrict the use of pesticides on private property, in part to protect people with environmental sensitivities.⁶³

Calgary Public Health has no-scent, latex and pesticides policies. A ban on smoking in public places is coming in 2007. Unlike most Canadian provinces, Alberta does not have provincial no-smoking legislation.

Since diagnostic criteria for chemical sensitivity have been accepted internationally and in Canada, the recognition of environmental sensitivities at all levels of government has been steadily increasing. Environmental sensitivities and some related conditions are also eligible for compensation by some Workers’ Compensation Boards, although there is marked inconsistency across the country. Public policy and regulations are advancing to protect people from tobacco smoke, pesticides, fragrances, vehicle exhaust and other chemicals in public places, and to minimize risks of exposures to pesticides for people with sensitivities.

The mandate of the Canadian Medical Association is "To serve and unite the physicians of Canada and be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care". The medical associations at the national and provincial levels do not formally "recognize" diseases, although they do engage in limited advocacy such as a resolution calling for banning of "weed and feed" type products.⁶⁴ A 1995 letter on behalf of the Ontario Medical Association to the Ontario Ministry of Education Special Education Advisory Council urged that "multiple sensitivities syndrome" be recognized and dealt with as a disability and that environmental improvements be made to accommodate children with this special need. As well, articles have been published in the Canadian Medical Association Journal on environmental sensitivities.^65-68

The Royal College of Physicians and Surgeons of Canada (RCPSC) is a national, private, non-profit organization th at oversees the medical education of specialists in Canada. It notes on its website, "In recognition of employees who experience allergic reactions, asthma or migraine headaches due to chemical sensitivities, the Royal College supports a scent-free environment and requests that employees refrain from using scented products such as perfumes, aftershaves, air-fresheners, etc., during working hours."

The Environmental Health Committee of the Ontario College of Family Physicians (OCFP) is taking the lead within the College of Family Physicians of Canada on environmental health, as well as in the World Organization of Family Doctors. Not only are environmental sensitivities recognized, they are carrying out education on diagnosis and treatment, as well as many other environmental health initiatives.

The Canadian Society of Environmental Medicine is a national organization for education, advocacy and research, and supports health care workers treating environmental sensitivities.

An important voice for environmental health in Canada is the Canadian Association of Physicians for the Environment. This organization is composed mostly of physicians, who bring their health expertise to environmental issues.

Environmental sensitivities have not historically been included explicitly in medical school curricula. Connections between environment and health are typically addressed under courses such as "Individual and Population Health," with a couple of hour-long lectures during the entire medical education. An "exposure history," a crucial step in diagnosing environmental sensitivities,^65,69 is covered only in the context of occupational health, rather than as a core concept.

Continuing Professional Development or Continuing Medical Education is required for fellows of the Royal College of Physicians and Surgeons, as well as for members of the College of Family Physicians of Canada. Credits are earned for courses, conferences and seminars. Diverse courses are available through numerous organizations, and individuals choose which to take. The OCFP offers Continuing Medical Education regarding environmental sensitivities and taking of a comprehensive patient history. Workshops have also been part of the Annual Scientific Assembly of the OCFP for the past four years, and been included in the annual "Family Medicine Forum" sponsored by the College of Family Physicians of Canada. As well, the Ontario Ministry of Health and Long-term Care and Health Canada helped fund an Environmental Health Peer Presenter program for physicians, whereby physicians from various regions were trained to give seminars on environmental health to other health care professionals close to home.

In 2006, an Environmental Health Scholar was designated by the OCFP in each medical school in Ontario, in part to incorporate environmental health into the undergraduate medical curriculum.

Environmental sciences are increasingly popular in university education, with courses offered through many departments such as geography, engineering or sciences; some of these courses link to health sciences.

Awareness and recognition of chronic health conditions evolves over time, and on several levels. Initial reporting by a few patients and physicians leads to awareness, research and formal agreement regarding diagnosis. Further research explores causes, mechanisms, diagnostic tests and treatment strategies, which are then formally put into practice.

International, national, provincial and municipal governments have recognized conditions related to environmental sensitivities. This has led to funding for clinical health care programs and facilities. Public and political awareness are particularly important for conditions such as environmental sensitivities, because recognition of environmental causes has diverse implications for many interests in society.

The medical community is increasingly acknowledging environmental sensitivities in medical education. Scent-free and least-toxic cleaning policies, and advocacy for smoking, vehicle idling and pesticides policies and laws are increasing.

c. ANSI/ASHRAE Addendum c to ANSI/ASHRAE Standard 62.1-2004,  American Society of Heating, Refrigeration and Air-conditioning Engineers, Inc., Atlanta, Georgia.
d. Including Ottawa, Toronto,  Montreal, Vancouver, Calgary, Edmonton, Regina, Winnipeg, Mississauga, Markham, Oshawa, London, Halifax, St. John’s and all of PEI and Quebec