Letters

Sensitive Reactions

In "Sick of it All" (June), Michael Fumento did not discuss the connection between multiple chemical sensitivity and airway inflammation that has been documented by a number of investigators. A controlled study of chemically sensitive patients performed by Richard Doty and his collaborators at the University of Pennsylvania's Center for Taste and Smell Research found that these patients had increased nasal resistance relative to a control group. This observation led me to carefully examine the upper airways of the patients I saw with chemical sensitivity using a fiber optic laryngoscope, and every patient had gross inflammation on examination. To further investigate this issue, a research protocol was developed to perform nasal biopsies on MCS patients to see if a reason could be found for their heightened sensitivity to chemicals. The results were astonishing, for these patients have an increase in the nerve fibers in the upper airway that are known to respond to chemical irritants by producing inflammation. We also saw chronic inflammation, as well as gaps in the protective layer of cells lining the upper airway, so that the nerves can have an increased exposure to chemicals. Rebecca Bascom and her collaborators at the University of Maryland found in a controlled study that individuals with a sensitivity to environmental tobacco smoke developed increases in nasal resistance on exposure, but there was no change for the individuals in the control group.

The question can be turned around. Do people with airway inflammation (i.e., asthma and rhinitis) have chemical sensitivity? Surveys have found that asthma and rhinitis patients report exacerbations of their symptoms by the same chemicals the MCS patients complain of, such as tobacco smoke, perfumes, and pesticides. That some of these substances do indeed trigger changes in the airway has been proven in research studies. Further, it has been documented that a single acute high-dose exposure to irritating chemicals can produce asthma and/or rhinitis that is chronic and persistent, long after the exposure is over. Fumento's conclusion that individuals with chemical sensitivity are "trapped in a hell of their own–or their doctor's–creation" may apply to some individuals with chemical sensitivity, but it certainly does not apply to those who get severe respiratory tract inflammation when exposed to substances such as cigarette smoke and perfume.

William J. Meggs, M.D.
New York, NY

I thought we'd outgrown the dark ages that dismissed health-conscious, body-aware individuals as "hypochondriacs," accused sympathetic doctors of pampering them, and gave allergies, in particular, a bum rap. People have died of things that doctors dismissed as "psychosomatic."

For about 30 years I suffered from extreme cold sensitivity and from ridicule for wearing a mask or scarf outdoors. Cold still puts some limits on my life. I can tell you from experience, a mask-wearer is not hiding from life, but showing a lot of guts, getting out there and braving the ridicule.

Maybe some MCS sufferers are exaggerating or even imagining their problems. But maybe some aren't. Maybe the woman who hangs her mail out is really that sensitive to ink. I discovered I'm sensitive to standard newsprint ink; now I find I'm not alone, and our Austin newspaper and phone book have switched to hypo-allergenic ink.

Lynn Herrick
Austin, TX

Michael Fumento's article leaves readers with the impression that only liberals get MCS. Wrong. Nor does having MCS turn people into leftist environmentalists. The only thing MCS patients have in common is a belief that not enough is known about the impact that toxic chemicals have on human health, and that what is known is scary.

In addition, Fumento's story contained several factual errors. For example, there are more articles on MCS as a physiological illness in peer-reviewed medical and scientific journals than articles concluding MCS is psychogenic.

I also think Fumento confused MCS with chronic fatigue syndrome, which is diagnosed, in part, by a lack of objective medical findings. With few exceptions, in order to get a diagnosis of MCS, patients must have at least four positive tests of objective damage in more than one of the following areas: central nervous system, immune system, porphyrin biosynthetic pathway, lungs, sinuses, and peripheral nervous systems.

The World Health Organization workshop mentioned in the article was actually sponsored by the International Programme on Chemical Safety. In its report on the workshop, IPCS stated, "These conclusions and recommendations…do not necessarily represent the decisions or the stated policy of the United National Environmental Programme, the International Labour Organization, or the World Health Organization."

While this is not a mistake, I think since Fumento flaunted the supposed liberal bias of MCS supporters, he should have mentioned, at least in passing, the industry bias of Dr. Ronald E. Gots. Dr. Gots, under oath, did not dispute the fact that 95 to 100 percent of his time is spent working on behalf of industry. It is important that people know where everyone stands on the MCS issues because the tone of the controversy was set in 1991 by the Chemical Manufacturer's Association when it stated, "There is no doubt these patients are ill….The primary impact on society would be the huge cost associated with the legitimization of environmental illness." There were many other factual distortions in Fumento's article, but I'm certain they were intentional and any attempt to set the record straight would simply fall on deaf ears.

Cynthia Wilson
Executive Director
Chemical Injury Information
White Sulphur Springs, MT

Michael Fumento makes many ill-founded remarks about the treatment of MCS by clinical ecologists and, while so doing, fails to draw attention to the parallels between the management of MCS, as he portrays it, and the diagnoses and treatment of several syndromes and diseases recognized by mainstream medicine.

Fumento insists, "The traditional definition of organic disease would lead us to expect a fairly narrow range of symptoms, of causes, and treatments. Furthermore, there should be biological tests to confirm the disease." He claims that "clinical ecologists and their supporters" sometimes arrive at an MCS diagnosis solely by a process of elimination. He finds this "unsatisfactory," as would we all. But why is Fumento talking about "organic disease"? Organic disease is defined as one producing or attended by alteration in the structure of an organ. It is functional disorders for which no biochemical or physiological explanation is known. Does Fumento mean to imply that MCS is organic, or is he just obfuscating?

This process of elimination is precisely how gastroenterologists and their supporters arrive at an irritable bowel syndrome diagnosis. Considering that IBS is the most frequent diagnosis given by gastroenterologists, one would expect Fumento to be even more outraged, but perhaps he is just too squeamish about such matters to allude to this obvious parallel.

Other common ailments for which there is no positive test or cure include excessive daytime sleepiness (EDS) and subjective tinnitus (ringing of the ear(s))–now there's one that's really all in your head, or is it? What arrogance it would take to tell someone with tinnitus that their ears weren't ringing because you couldn't test for it! Indeed, the psychological components ascribed to MCS sufferers have also been inflicted on those with IBS and EDS and IBS and EDS patients have also "bounced from doctor to doctor."

Until lactose and fructose intolerances were recognized, people with those conditions were diagnosed with IBS. This might well portend the future of MCS diagnoses.

Gerald J. Dunphy
Boulder, CO

Mr. Fumento replies: Now let me get this straight. I write a 7,000 word article packed with studies and other evidence that MCS is not an organic illness. I cite opinions to that effect from the California Medical Association Task Force, the American Academy of Allergy and Immunology, the American Medical Association Council on Scientific Affairs, The American College of Physicians, and the Ad Hoc Committee on Environmental Hypersensitivity Disorders established by the Minister of Health of Ontario, Canada. And Dr. Meggs thinks he's trumped me because of an eight-year-old study finding that subjects claiming to have MCS are more likely to have stuffed noses than control subjects. That study comprised all of 18 MCS subjects, hardly a large population. In any case, it would not be surprising to find that persons claiming to have MCS are more nasally sensitive. That would be the trigger that would begin them down the road to thinking they were allergic to everything in life, just as a single traumatic incident in childhood often triggers phobias. Further, the study also found, though Dr. Meggs neglects to tell us, that these people were more likely to suffer depression. As my article noted, many persons who believe they have MCS are probably just manifesting depression that could be readily treated with drugs, but instead they are locked into an unbreakable cycle when they go to clinical ecologists instead of a psychiatrist.

As to Professor Bascom's work, all that shows is that tobacco smoke adversely affects the nasal passages. Anybody whose ever been in a crowded bar could tell you that. But Dr. Meggs doesn't tell us how it relates to MCS.

The only other letter which so much as pretends to offer scientific evidence that MCS is anything other than a psychogenic (mentally induced) disorder is from Cynthia Wilson. It is Wilson who kindly provided me with the list showing that virtually any illness in the world is a symptom of MCS. She claims, "There are more articles on MCS as a physiological illness in peer- reviewed medical and scientific journals than articles concluding MCS is psychogenic." That's true, but only because clinical ecologists have set up journals of their own; mainstream medical journals treat them like the quacks they are.

Wilson also says that, "With few exceptions, in order to get a diagnosis of MCS, patients must have at least four positive tests of objective damage in more than one of" several specific areas. But as my article made crystal clear, there is no standard test for MCS, and diagnosis is often made simply by ruling out other illnesses, at which point a psychiatrist or psychologist would probably say the illness is psychogenic but the clinical ecologist labels it MCS. Considering the clinical ecologists I discussed who have diagnosed virtually every patient they have ever seen with MCS, it seems that probably the main "proof" that somebody has MCS is their entering the clinical ecologist's office.

Regarding Wilson's ad hominem attack on Dr. Ronald Gots, Gots says that perhaps 2 percent of his work deals with MCS–hardly the bread and butter of his occupation. On the other hand, the average clinical ecologist makes 100 percent of his or her profit from MCS.

Lynn Herrick employs the false logic that since she was wrongly labeled a hypochondriac, then labeling other illnesses as psychogenic is also wrong. Her sensitivity to standard newsprint ink is an irritation, nothing more. It's like having your eyes water when you cut an onion. Gerald Dunphy questions my use of the term organic disease, saying, "Organic disease is defined as one producing or attended by alteration in the structure of an organ" and that this isn't the issue. Actually, Dorland's Illustrated Medical Dictionary uses Dunphy's definition for "organic" but also lists "[a]rising from an organism" and "pertaining to substances derived from living organisms." In any case, "organic disease" is widely accepted as the alternative to "psychogenic disease," and thus appropriate to our discussion.

Dunphy cites irritable bowel syndrome, excessive daytime sleepiness, and subjective tinnitus, but these are all symptoms, not causes. The MCS doctor goes beyond that, saying "You have such-and-such symptoms and they're caused by such-and-such agents." That's completely different.

Second Opinions

"Cost-Conscious Care" (June) by David Jacobsen, a physician employed by Harvard Pilgrim Health Care in Boston, strikes me in the same light as a fox's affirmation of his qualification to guard the henhouse would. Dr. Jacobsen spends quite a bit of time noting how much money his HMO has saved in medical care costs. But the cost savings that he alludes to are by no means unique to managed care and, in fact, are being achieved by nearly all surgeons and physicians in the United States. In the same way that he takes umbrage that someone might accuse him of being unethical, we in the fee-for-service community take particular umbrage at the suggestion that we are absolutely insensitive to providing more care for less money.

Dr. Jacobsen then goes on to cite examples of how his HMO has economized in care and still maintained quality. He notes that he has cancer and says he would not go anywhere else for treatment. Having been a physician in an HMO, I can tell you that it is quite easy to "game" the system and that most physicians who are covered by, as well as employed by, HMOs very carefully choose to whom they would like to be referred, a privilege that does not accrue to the lay person enrolled in the same medical plan. Further, I believe that cost-cutting maneuvers such as employing a nurse to take asthma calls instead of a doctor and then stating that you have noted no decline in quality begs the question of whether one was trying to note a decline in quality in the first place.

Dr. Jacobsen then uses the recent example in Time to suggest that bone marrow transplantation is not appropriate for certain advanced diseases. I would refer Dr. Jacobsen to Tom Hazlett's article at the back of the same issue of REASON, "Risky Behavior." While it is true that bone marrow transplantation is being tried in a number of situations where it is not proven therapy, the essence of advancement in American medicine is that therapy must be tried against desperate illnesses to discover whether it will be useful. Under Dr. Jacobsen's plan for American medicine–complete managed care–I fear that innovation would stop cold in its tracks. Dr. Jacobsen is correct that medicine is not immune from the laws of economics and if no one is paid for trying anything innovative, eventually no one will try anything innovative.

Dr. Jacobsen's assertions that studies have consistently shown HMO patients are as satisfied as their fee-for-service counterparts is merely a case of picking one's favorite studies to quote. Quite a few studies show great patient dissatisfaction with HMOs, as Dr. Jacobsen knows. Furthermore, it again begs the question to obtain quotes from "HMO experts" as to whether or not patients are satisfied with HMO care.

Finally, we should return to Dr. Jacobsen's statement, "wishing that medicine could be exempt from the laws of economics does not make it so." The corollary rule in economics is that one serves he who pays. Dr. Jacobsen is paid by and is serving his HMO, whether or not he wishes to soothe his conscience by claiming to be a patient advocate. Until he looks to his customer, the patient, for payment, his caterwauling about quality, cost efficiency, and compassion will not sway me.

Readers of REASON would do well to consider the philosophic underpinnings of managed care, compare them with those of fee-for-service medicine, and decide whether a fee-for-service world will eventually give better medicine to the individual than a socialistic, monopolistic managed care world where the plan will choose what care is best for you.

Michael Schlitt, M.D.
Renton, WA

David Jacobsen defends HMOs from accusations of being "soulless" and says he "would not think of going anywhere else. I expect from my plan the same level of care as a patient that I have provided as a physician."

HMOs are no different from other forms of socialism in that the care that Dr. Jacobsen delivers and receives is centrally planned. If Dr. Jacobsen is on the HMO pharmaceutical committee and is outvoted for the drug he prefers, what does he tell his patients when they ask, "Is this the best treatment?" If he answers "no," then he could be fired for criticizing his employer. If he answers "yes," then he deserves to lose the trust of his patients.

Is there a place for HMOs in health care? I don't know, but I do know that the government should not encourage them. Our current tax code does this in two ways. First, tax subsidies encourage workers to choose job-based health insurance. Second, the income tax is anti-savings, and savings gives patients the money to pay for and thus control their own health care choices. The easiest way to level the playing field of health care is to return to the vision of our founders: Repeal the 16th Amendment and replace the anti-savings income tax with the pro-savings national sales tax. After this is done, Americans can rationally choose if they prefer corporate socialized medicine or patient-directed health care.

Bert A. Loftman, M.D.
Director of Health Care Reform
Citizens for an Alternative Tax System
Atlanta, GA

I'll bet Dr. Jacobsen is a physician I would be glad to call my own and that the utopia he describes in his HMO might occasionally be possible. I'll also bet it doesn't happen very often. Medical care abuses occur because the patient is not spending his or her own money, and the managed care organization must find a way to restrain the patient's desires. This allows the organization to retain as much as 30 percent for distribution to stockholders and executives. (Recall that the money they spend on patient care is referred to as the "loss ratio.") This encourages veterinary medicine ethics in which the patient is handled like Rover–someone besides Rover decides on the care dispensed. It should also be noted that at least Rover has a loving master making the decision, while the hapless patient has a doctor whose bottom line depends on how little he spends on the patient.

Medicine should consist of exchanges between the interested and consenting parties: patient and doctor. This can be realized when insurers sell true insurance against catastrophe and patients, in concert with their doctors, decide how much of their own money to spend. Also, the government shouldn't compound the problem by pouring fuel (money) on the flames. Finally, the medical advances Dr. Jacobsen cites came about in spite of, not because of, managed care.

Gerald E. Sullivan, M.D.
Bowling Green, KY

Dr. Jacobsen replies: I regret that some readers may have interpreted my article as a blanket endorsement of all HMOs. The intent of my article, as stated in the title, was to show that cost control and quality are not contradictory concepts in health care. I offered my HMO as an example of an organization which, in my experience, is doing a superb job of providing quality, personal health care at lower cost.

"Managed care" is an unfortunate phrase to the extent that it implies that health care choices are being made by someone other than the patient and his health care provider. I have no "plan" for health care in the United States. I believe in a market system of evolutionary development in which consumers must be the ultimate arbiters. The challenge is to determine, to the best of our imperfect ability, what constitutes optimal health care for each of us; how much of this health care we want; and finally, how much we can afford. To the extent that government regulations, licensure requirements, and tax policies thwart this challenge, they ought to be abolished. The choice is not between HMOs and fee-for-service–these may well be just way stations in the evolution of health care delivery.

The question of innovation is an important and complex one. Certainly, the innovations I outlined are not unique to HMOs. No responsible health care delivery system can simply offer its patients or its providers a blank check to foray into the unknown and unproven at whim. Science demands evidence before it can embrace innovation as a standard of care. My HMO endows a large research fund to help us define such evidence. Innovation and cost-consciousness are certainly not incompatible.

Why do medical costs increase with improved technology? Not all do. The inguinal hernia repair is much cheaper now than it was 20 years ago. Before the development of the artificial hip joint, the cost of this procedure was zero. The current cost of hip replacement is a welcome increase. In between these examples is a muddle in which new procedures and new technology have added to medical costs without always improving medical care. Getting out of this muddle will require that consumers and providers inform themselves of the costs and benefits of medical care and make their own decisions.