Chapter13-SystemicConditionsSYSTEMICCONDITIONS:ANINTRODUCTIONHowardM.KipenThelasteditionofthisEncyclopaediadidnotcontainarticlesoneithersickbuildingsyndrome(SBS)ormultiplechemicalsensitivities(MCS)(thelattertermwascoinedbyCullen,1987).Mostpractitionersofoccupationalmedicinearenotcomfortablewithsuchsymptomaticallydrivenandfrequentlypsychologicallyrelatedphenomena,atleastpartlyforthereasonthatpatientswiththesesyndromesdonotrespondreliablytothestandardmeansofoccupationalhealthintervention,namely,exposurereduction.Non-occupationalphysiciansingeneralmedicalpracticealsoreactsimilarly:patientswithlittleverifiablepathology,suchasthosecomplainingofchronicfatiguesyndromeorfibromyalgia,areregardedasmoredifficulttotreat(andgenerallyregardthemselvesasmoredisabled)thanpatientswithdeformingconditionssuchasrheumatoidarthritis.Thereisclearlylessregulatoryimperativeforsickbuildingsyndromeandmultiplechemicalsensitivitiesthanfortheclassicoccupationalsyndromessuchasleadintoxicationorsilicosis.Thisdiscomfortonthepartoftreatingphysiciansandthelackofappropriateregulatoryguidanceisunfortunate,howeverunderstandableitmaybe,becauseitleadstominimizationoftheimportanceoftheseincreasinglycommon,albeitlargelysubjectiveandnon-lethalcomplaints.Sincemanyworkerswiththeseconditionsclaimtotaldisability,andfewexamplesofcurescanbefound,multiplechemicalsensitivitiesandsickbuildingsyndromepresentimportantchallengestocompensationsystems.Inthedevelopedworld,sincemanyclassicoccupationaltoxinsarebettercontrolled,symptomaticsyndromes,suchasthoseunderpresentscrutinythatareassociatedwithlower-levelexposures,areassumingincreasingrecognitionassignificanteconomicandhealthconcerns.Managersarefrustratedbytheseconditionsforanumberofreasons.Astherearenoclear-cutregulatoryrequirementsinmostjurisdictionswhichcoverindoorairorhypersusceptibleindividuals(withtheimportantexceptionbeingpersonswithrecognizedallergicdisorders),itisimpossibleformanagementtobecertainwhetherornottheyareincompliance.Agent-specificcontaminantlevelsdevelopedforindustrialsettings,suchastheUSOccupationalSafetyandHealthAdministration’s(OSHA’s)permissibleexposurelevels(PELs)ortheAmericanConferenceofGovernmentalIndustrialHygienists’(ACGIH’s)thresholdlimitvalues(TLVs),areclearlynotabletopreventorpredictsymptomaticcomplaintsinofficeandschoolworkers.Finally,becauseoftheapparentimportanceofindividualsusceptibilityandpsychologicalfactorsasdeterminantsofresponsetolowlevelsofcontaminants,theimpactofenvironmentalinterventionsisnotaspredictableasmanywouldlikebeforeadecisionistakentocommitscarcebuildingormaintenanceresources.Oftenaftercomplaintsarise,apotentialculpritsuchaselevatedvolatileorganiccompoundlevelswithrespecttooutdoorairisfound,andyetfollowingremediation,complaintspersistorreoccur.Employeeswhosufferfromsymptomsofeithersickbuildingsyndromeormultiplechemicalsensitivitiesareoftenlessproductiveandfrequentlyaccusatorywhenmanagementorgovernmentisreluctanttocommitthemselvestointerventionswhichcannotbereliablypredictedtoamelioratesymptoms.Clearly,occupationalhealthprovidersareamongthefewkeyindividualswhomaybeabletofacilitatereasonablemiddlegroundoutcomestotheadvantageofallconcerned.Thisistruewhetherornotanunderlyingcauseislowlevelsofcontaminants,orevenintherarecaseoftruemasshysteria,whichmayoftenhavelow-levelenvironmentaltriggers.Usingskillandsensitivitytoaddress...
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