China’s air pollution is so bad that I can imagine doctors’ offices there are filled with sick people. And I suspect many patients have TILT, and they won’t be diagnosed correctly or get well.

China unfortunately is a perfect environment for TILT. Years of economic expansion have polluted waterways and loaded the air with contaminants.

TILT is a disorder caused by exposure to harmful chemicals. The chemical exposures can be at constant low levels, such as in China, or result from an acute event such as exposure to a pesticide.

TILT is short for “Toxicant-induced Loss of Tolerance,” and it indeed represents a breakdown in the body’s natural tolerance. People with TILT can become sick from everyday chemicals in foods, household cleaners and medications.

Sufferers may complain of fatigue, headaches, asthma-like symptoms, and cognitive disorders. But conventional treatments for their symptoms will be ineffective if they have TILT.

For this reason, I worry about the Chinese people because I suspect most health caregivers in China don’t know about TILT, or the widely used clinical screening instrument to identify it. I helped develop the instrument, called the “Quick Environmental Exposure and Sensitivity Inventory,” or QEESI, and it can lead to much better identification and treatment of TILTed patients.

It’s a free download on my website.

QEESI is a clinical assessment tool used in the United States, and it has been translated into French and Korean. Clinicians in South Korea, which also has serious pollution issues, are using the recently-translated version.

China unfortunately is a perfect environment for TILT. Years of economic expansion have polluted waterways and loaded the air with contaminants. Airlines in the past have canceled flights due to poor visibility, pedestrians in cities wear masks, household air purifiers are a status symbol, fishermen report low catches, and civil unrest has forced delay of a coal-fired power plant that residents blame for a rising number of cancer cases.

Soaring levels of pollution are driving Western business executives out of Chinese cities and dissuading others from coming, the Wall Street Journal reported in April.

What is troublesome to medical scientists is the nature of the air pollution. It’s largely unmeasured even though it blots out the sun on some days and residents have been quoted to say they can taste the air. For physicians, it’s difficult to connect an illness to pollution because the measurement of pollution is inadequate.

The Chinese government index of pollution reports only large particulate pollutants, those known as PM 10. They are 10 micrometers in diameter or larger. PM10 particulate is nowhere as dangerous as smaller particulate matter.

China’s government, acting to tighten air pollution standards, began to monitor small particles in January 2012. The state media said the government would begin to measure PM 2.5 and smaller, and publish its measurements.

Despite this, the levels of two major air pollutants rose by almost 30 percent during January-March 2013 over the same period in 2012, a Chinese news organization recently reported. The pollutants were nitrogen dioxide and particulate matter that is between 2.5 and 10 micrometers in diameter, called PM 10.

Small particles can lodge in the alveoli while large particles usually are cleared out in the nasal passages. PM 2.5 is a common byproduct of power plants and motor traffic.

China in the past has been embarrassed by discrepancies between its pollution reports and measurements published by the U.S. Embassy in Beijing. Embassy readings measure PM 2.5, and on some days the measurements have been “beyond index,” or literally off the chart, while the official reading was “light.”

The embassy publishes its measurements, taken on the office rooftop, on Twitter.

In fact, the tweets were cited as a reason the Chinese government in 2012 also recanted an earlier announcement that it would not release the newer, more precise measurements.

Until all the measurements are public, the only generally known element is that the pollution poses immediate danger to the Chinese people, and nearly everyone knows it. The New York Times has quoted a source who said more than 200 high-end air purifiers have been deployed to the office of China’s president, the Zhongnanhai compound for senior government leaders, and the Great Hall of the People.

My 85-year-old mother recently had to go to the hospital emergency room for a subdural hematoma. She’s very sensitive to fragrances. Members of her bridge club and singing group know this and respect her wish for no fragrances. Otherwise her eyes and nose water, she gets headaches and has difficulty breathing.

Hospitals need to enforce rules because fragrances can aggravate the conditions of patients. Photo: U.S. Navy.

At the ER, a nurse who was very friendly smelled so strongly that I asked him not to come close. It was the beginning of the shift. He apologized and washed it off, thankfully, but he needed to hear this from a patient’s mother who is also a doctor! I do plan to contact the director of nursing services.

People who are pregnant, get migraines or other headaches, or have asthma often need to avoid fragrances. Many hospital staff members themselves are very sensitive because they have been previously TILTed.

- Related Post: How to Thank People Who Wear No Fragrances

TILT is short for Toxicant-induced Loss of Tolerance. It affects people who have repeated low-level exposures, such as in a “sick building,” or a one-time, high-level exposure such as a chemical spill or pesticide application. TILT can cause chemical intolerances that impair a person’s health, ability to work or go to school, and other everyday activities. There’s a widely accepted screening instrument to help identify TILT, called the QEESI, or Quick Environmental Exposure and Sensitivity Inventory. It’s free to download.

Hospital staff members need to avoid wearing fragrances. This is important because patients may be unable to speak for themselves. Even worse, fragrances may precipitate vomiting in chemotherapy patients whose treatments cause nausea. And there’s certainly a need for a no-fragrance rule around newborns, babies or children, and in the intensive-care or critical-care units.

Fragrance policies for the health-care industry are emerging. Some examples:

• The Centers for Disease Control has issued a policy governing its installations.
• A Canadian organization, Bryant Community Healthcare System, for example, applies a policy for both employees and patients.
• And the Massachusetts Nursing Association published an excellent article as far back as 2006 explaining the value and way of setting up such a policy.

I don’t recall fragrances being such a problem when I was a medical student in the 1980s. Then it was tobacco smoke — first hand, second hand and third hand — and smoke retained in patients’ clothing and on their breath. We medical students would stand as far away as possible from these patients when we told them to take a deep breath and exhale. Now people come in the hospital and leave “vapor trails” of fragrances behind them — in elevators, corridors and stairwells.

Fortunately for my mother, I’m a professor and assistant dean for the dual degree MD/MPH program at the UT School of Medicine, which is directly across the street from the hospital. I’ve published many papers, books, and a screening questionnaire for assessing chemical intolerance, but not everyone knows this.

Before I left her bedside last night, she asked for a stack of my business cards so she could pass them around.

Chemically intolerant patients have for years moved from cities and other pollution sources, e.g., locations that burn wood to heat homes in winter, like parts of the Pacific Northwest, because of air pollution.

Where is the nation’s worst particulate pollution? In 2011, the American Lung Association published a list: 1. Bakersfield-Delano, Calif. 2. Fresno-Madera, Calif. 3. Pittsburgh-New Castle, Pa. 4. Los Angeles-Long Beach-Riverside, Calif. 5. Salt Lake City-Ogden-Clearfield, Utah 6. Provo-Orem, Utah 7. Visalia-Porterville, Calif. 8. Birmingham-Hoover-Cullman, Ala. 9. (tie) Hanford-Corcoran, Calif.; Logan, Utah; Sacramento-Yuba City, Calif.

Smog cloaks Salt Lake City’s skyline in 2011. (Photo: U.S. Environmental Protection Agency)

But this is new: Now couples are being advised to avoid air pollution when they try to conceive a baby. See the Salt Lake Tribune story “Docs: Wait - or get out of Utah’s bad air - to conceive.”

Cities in Utah endure days and even weeks of concentrated air pollution created by temporary atmospheric inversions. Common in winter, inversions trap air pollution close to the ground and push it to unhealthy levels. Utah is not alone. Los Angeles and Pittsburgh live with an even higher risk according to the American Lung Association.

If concentrated pollution can endanger a fetus, think about its overall threat to public health.

Exposures like those in Utah have the potential to initiate TILT, or Toxicant-induced Loss of Tolerance — the two-step disease process that is affecting growing numbers of people in the United States and abroad. Unfortunately, these people may not recognize their illness because of “masking.” Masking? Think of a frog placed in boiling water. Legend has it that the frog immediately jumps out, but if the water is slowly heated, the frog remains and boils to death. He adapts but to his detriment, even demise.

Masking is why we need doctors to screen patients with the QEESI, or Quick Environmental Exposure and Sensitivity Inventory, a medical questionnaire to detect loss of tolerance. And the rise in TILT shows the need for EMUs, or environmental medical units, to isolate the masking elements in patients. Then we can begin to “see” what these exposures are doing to us. The QEESI and EMU are important modern-day tools much like the microscope and physician Robert Koch’s 19th-century postulates, which helped “prove” the germ theory a century ago.

Salt Lake City is rightfully concerned about a new study in the journal Environmental Health Perspectives. It showed the risk of having a baby of low birth weight jumps 10 percent in areas with higher concentrations of particulate matter, including PM2.5. That’s the pollution that spikes in winter inversions and leads to Utah’s pollution. Ultrafine particles easily enter human airways and can travel through the nose to the brain’s limbic system, which regulates mood, behavior, short-term memory and a host cognitive functions.

There are no good choices to avoid the inversion threat, but inaction is the worst of them.

Are we going to become like China, where wealthier individuals equip their cars and homes with sophisticated air filtration devices? Where children wear masks in cities to filter air? What about the vast majority of families who cannot afford this?

Hundreds of Google employees were exposed for months to the toxic chemical TCE, or trichloroethylene, at the search company’s offices in Mountain View, Calif.

No employees reported becoming sick but such exposures can take months or even years to cause problems.

Repeated chemical exposures can produce the condition called TILT, or Toxicant-induced Loss of Tolerance. People with TILT suffer from chemical intolerances that can impair cognitive abilities and cause multi-symptom illnesses.

Cases like Google’s are becoming common worldwide where industrial chemicals have been buried or released underground, and slowly seep up into structures built over them, affecting occupants of buildings.

Google’s buildings are near a known underground pool of contaminants. The EPA has monitored the site since 2003 and detected the high levels of TCE in December 2012. Several companies once manufactured silicon chips near the site.
TCE is usually used as an industrial solvent.

Google says employee health was never at risk and building improvements will prevent any future episode. But nonetheless health professionals and Google employees need to understand:

• No chemical exposure is minor. Repeated low-level exposures, such as in a “sick building,” or a one-time, high-level exposure such as at a chemical spill or pesticide accident, can initiate TILT. For many individuals who have been “TILTed,” life is no longer the same. It affects their health, their ability to work or go to school, and other activities in perpetuity. Thereafter even low levels of common cleaning chemicals, fragrances, gasoline at a gas station, diesel exhaust, outgassing from new furnishings, carpet, and other products can trigger symptoms that range from mild to disabling.
• Doctors need help in diagnosing chemical illnesses. Most physicians don’t understand chemical intolerance or test patients for it. A medical study in July 2012 found that chemical intolerance contributes to the illnesses of 1 in 5 patients but their condition seldom is diagnosed. Patients and physicians need to know about and use a widely accepted screening instrument for multiple chemical intolerance that’s called “QEESI,” short for Quick Environmental Exposure and Sensitivity Inventory. Download it here.

The Japanese cedar was never known to cause allergic rhinitis in Japan until the 1960s even though the tree had been indigenous to Japan for more than a million years. Recognition of cedar-induced rhinitis and an increase in cases in Japan coincided with lenient regulation of diesel exhaust and increased numbers of diesel vehicles in that country.

What does cedar (really a juniper) allergy have to do with diesel exhaust? Exposure to petrochemicals such diesel exhaust, can lower a person’s tolerance for “natural” substances such as pollen, mold, dust mites and animal dander, leading to allergic reactions. Researchers in Japan have confirmed that exposing mice to diesel exhaust increases their IgE production, the immunoglobulin associated with allergy.

What does this have to do with TILT, or Toxicant-induced Loss of Tolerance? People who become chemically intolerant, or TILTed, frequently report amplified allergic responses. This relationship may help explain the rise in allergic rhinitis in Japan. It explains why the QEESI, or Quick Environmental Exposure and Sensitivity Inventory, asks about a person’s exposures to diesel exhaust and any associated heightened allergic responses.

I know how potent cedar pollen can be. I live in Central Texas, on the edge of the scenic Texas Hill Country. Despite its beauty, the Hill Country has hundreds of thousands of Texas Mountain Cedars that shed notoriously allergenic pollen. From December to February, the pollen causes such severe symptoms that sufferers call it “cedar fever.”

Describing preparations for Hurricane Sandy, guest blogger Laura MacCleery gives a humorous example of the old adage about how “no good deed goes unpunished.” Laura is a lawyer, mother and self-described “squeaky wheel in search of a spoke.” She writes commentary at Laura’s Rules.

By Laura MacCleery

When I recently filled out a helpful questionnaire on chemical intolerance, the Quick Environmental Exposure and Sensitivity Inventory (QEESI), or “Queasy” as I like to call it among friends, a screw-shaped light bulb went off. (Compact fluorescent, of course.)

According to the results of this scientifically validated tool for measuring sensitivities to toxins in our environment, I am on the “high” end for both exposures and symptoms, meaning that I don’t tolerate smells like gasoline and off-gassing furniture well.

The survey powerfully showed why I obsess about such things, while other people may shrug them off. Seeing how I scored was important to me because it identified some common sources for the headaches and other discomfort I often experience following exposure to an unpleasant chemical-laden odor.

Most of the things on the list on the QEESI, which is a quick inventory, as the name implies, including bleach-based cleaning supplies or a “new car” smell, can make me feel a bit off, even in small doses. I still remember being newly pregnant in a Washington, D.C., wintertime and driving with the windows way down, the cold wind in my face, because freezing was far preferable to the vinyl smell emanating from my brand-new Nissan, especially given my bionic nose from the pregnancy!

But that sensitivity hasn’t gone away since I had my daughter, either. And I’m not the only one who’s bothered by the fragrances crowding our environment. A recent article in a UK newspaper notes that: “One leading expert suggests nearly a third of people suffer adverse health effects from being exposed to scents.”

The article explains:

“Allergies are on the increase, and the amount of perfumed products is also on the rise,” says Dr. Susannah Baron, consultant dermatologist at Kent & Canterbury hospital, and BMI Chaucer Hospital. “Fragrance allergy can show up as contact dermatitis in the site a perfumed product is applied, or as a flare-up of existing eczema. It can be a real problem.” … Often it may not be immediately obvious that you’ve developed a fragrance allergy, says Dr. Baron. “You don’t react immediately; the body notes that it does not like the chemical and develops ‘memory cells,’ which cause inflammation when the body is next exposed to this chemical. Gradually, as you are exposed more and more, the body ramps up its reaction, until it becomes more noticeable to you.”

As the designer of the QEESI tool, Dr. Claudia Miller, an immunologist/allergist, explains based on her many years of research, that biological response is to the chemicals being used to produce the fragrances. Her pioneering work shows that exposures to chemicals of all kinds – not just the smelly ones – can and do trigger a loss of tolerance in some people, causing ill health.

And the simplest things can lead to new exposures, such as our recent utterly ridiculous adventures with installing a generator for our home. We often lose power, and so the prospect of Hurricane Sandy barreling down on us caused a run to the store and triggered a panicky purchase of a generator to help see us through.

Turned out we didn’t need to use it, and instead bought ourselves a world of trouble. In fact, what I didn’t know about it can be counted on all my fingers and toes in the dark, including the substantial extra costs of having an electrician hook it up properly, and the excruciating task of filling tanks up with gasoline, poised over the wafting fumes to ensure that I didn’t overfill the tanks and spill it all on my shoes.

To complete the misadventure, a small amount of gasoline did spill inside my car, rendering it nastily smelly once more. To get the odor out, I tried everything – wiping it down with baby oil, auto cleaners, and baking soda. Repeatedly.

Then I finally took it to a detail shop, and paid them a small fortune to use completely toxic cleaning supplies on the floor and seats. The smell has diminished, but it’s not gone, and it’s mingling with all the cleaners for a soupier feel. I still drive with the windows open and leave them all cracked while parked, at least when there’s no rain coming.

Contrary to what most folks think when they imagine what we are doing to “the environment,” indoor air is far more polluted than that outdoors. Given the number of people whose symptoms have been identified by the QEESI, I don’t think I’m alone in thinking that something is very wrong when the places we build – to live in, no less – are not particularly safe or comfortable for at least some living things.

So if you are like me, and these kinds of odors bother you as you go about your day-to-day, you may want to take the QEESI and see how and why they may be impacting you. And to learn what may be “masking” their effects, so that you don’t know where the headaches are coming from.

Even more pointedly, suppose you go on vacation and get a break from these exposures and feel suddenly better, which happened to a friend of mine, then you may want to start clearing your house of odoriferous chemicals and plastics to see if it makes a difference. It certainly did for her.

On the other hand, if you’re one of the lucky ones who feels just fine in this man-made world of olfactory offenders, well, then, you can snicker at us anti-chemical folk if you’d like to. But you may also want to think about whether those of us with the higher QEESI scores – and the concomitant fascination with “greening” our homes – are actually canaries in a mineshaft.

Tweet, tweet, I say, a bit sadly.

And because I’m a modern bird: Retweet? Are you a canary too?