Approach to patients with unexplained multimorbidity with sensitivities

Stephen J. Genuis; Marko G. Tymchak

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Re:Multimorbidity Disussion still open.
Stephen J. Genuis

Published on: 18 August 2014
Multimorbidity Disussion still open.
Sam G Campbell

Published on: 14 August 2014
Multimorbidity with Sensitivities: Hypothesis or Clinical Reality?
Stephen J. Genuis

Published on: 07 July 2014
Clinical Review or Hypothesis?
Eugene R Leduc

Published on: 30 June 2014
Environmental Medicine Realized
Jennifer M Simpson

Published on: 25 June 2014

Published on: (18 August 2014)

Re:Multimorbidity Disussion still open.
Stephen J. Genuis, Clinical Professor
Thanks to Drs. Campbell, Abbass and Zehr for their insightful response to the articles on unexplained multimorbidity with sensitivities (MWS).[1,2] Their letter highlights important issues which I would like to address.
What causes people to get sick?
There are many ways of being sick, but there are only a few factors that actually cause sickness. A detailed review of medical history will confirm tha...
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Thanks to Drs. Campbell, Abbass and Zehr for their insightful response to the articles on unexplained multimorbidity with sensitivities (MWS).[1,2] Their letter highlights important issues which I would like to address.
What causes people to get sick?
There are many ways of being sick, but there are only a few factors that actually cause sickness. A detailed review of medical history will confirm that there are only five etiological determinants of illness: i) Genetics, ii) Deficiencies, iii) Pathogens, iv) Toxic exposures, and v) Psychological factors.[3] Furthermore, the Centers for Disease Control recently concluded that virtually all illness results from the interaction of genetic susceptibility and modifiable environmental factors.[4] Integrating these two streams, it is evident that the totality of adverse modifiable environmental factors includes toxic exposures such as chemical pollutants and radiation, pathogens, deficiency states, as well as emotional and psychological adversities. When people suggest that illness is the result of autoimmune changes, chemical imbalances, hormonal dysregulation, inflammatory states, degenerative problems, and so on, it is important to realize that these processes are epiphenomena resulting from primary underlying causes and that these processes describe pathophysiological mechanisms of illness, not etiological determinants. The five factors listed above, including psychological and emotional factors, are the root source of all illness - any or all of these can contribute to multimorbidity.
To address the major tenor of the letter: each human person could be described as a unique metaphysical ecosystem configured within a biochemical machine. When considering disease etiology, a disregard of the metaphysical component of our being (the mental, social, and spiritual as discussed in the WHO definition of health[5]) would be inappropriate indeed. As the letter writers suggest, much scientific work and experience support adverse psychological states as primary determinants of morbidity. Furthermore, it is well established that measures to address adverse emotional states can have enormous potential benefit if the underlying source of the problem is fundamentally emotional and psychological. Measures to quell emotional manifestations if the underlying problem is a chemical toxicant burden (such as bioaccumulated lead, mercury, solvents, or flame retardants in the brain), however, are usually less than successful. Furthermore, as medical trainees are often not apprised of the immense role of toxic determinants of morbidity, there is often a default to attribute inexplicable multimorbidity states to pathopsychology - a reality that frustrates many patients.
What are the causes of multimorbidity?
Sensitivity related illness (SRI) resulting from toxicant exposures is definitely NOT the sole cause of multimorbidity. The papers on MWS[1,2] were never intended to be a systematic review of all causes of multimorbidity, but rather a discussion of the emerging pandemic of unexplained multimorbidity with sensitivities - i.e. unremitting MWS in patients that cannot be attributed to any other cause and that does not respond to other interventions. The above listed primary determinants of illness can all contribute to multimorbidity states. Infection with pathogens causing Lyme disease, for example, can definitely manifest as MWS. Another area not explored in the papers was widespread deficiency states, a common etiological source of multimorbidity and a subject often neglected in medical education.[6] For example, vitamin D is involved in genetic regulation and expression, with over 2700 binding sites on the human genome.[7] Insufficiency of this vital nutrient is rampant in North America[8] and is associated with assorted conditions involving most organ systems.[9] Several other prevalent deficiencies can also present as multimorbidity including inadequate levels of nutrients such as magnesium [10] and omega-3 polyunsaturated docosahexanoic acid (DHA). [11] [12]
Furthermore, primary determinants of illness can act in concert or synergistically to facilitate multimorbidity and sensitivities. While the chemical sensitivity epidemic may be primarily related to toxicant exposures, for example, it is certainly true that stress can exacerbate immune dysfunction and thus trigger sensitivities in a susceptible host. Accordingly, it is wonderful that emotional contributors to illness are addressed in Nova Scotia, as the letter writers suggest. I have not seen literature evidence, however, to suggest that stress is the predominant etiological determinant of the escalating epidemic of sensitivities.[13] There is, on the other hand, abundant evidence in the literature to support the contention that toxicant exposures are the principal etiological factor in SRI. Recent literature about young children, for example, confirms that environmental sensitivities with documented immune dysregulation are directly related to a whole variety of prenatal chemical exposures.[14,15,16,17,18,19,20] It is unlikely that intensive short-term dynamic psychotherapy will be efficacious against sensitivity related problems in this cohort.
Moving forward
Most importantly, I believe that physicians should have the training and skills to pursue ALL etiological determinants of illness in patients with MWS in order to identify which primary factors are causing the sickness. As part of a comprehensive medical workup including a psychological assessment, it is my sincere hope that a broad toxicant panel looking for bioaccumulated chemical toxicants will soon be available. I routinely incorporate this laboratory testing tool with multimorbidity patients and often find accrued chemical pollutants as a potential reason to explain the ongoing suffering and chronic illness. This metric provides objective laboratory evidence to conclusively determine if people have a toxicant burden and allows for appropriate interventions to clear the burden, if present, in order to preclude and treat illness. Elimination of toxicant burdens that are disrupting physiology on an ongoing basis can be life changing for chronically ill people.[21,22,23] Unfortunately, such testing is not yet generally available in Canada - but such analysis at a population level has been recently carried out and published by both Health Canada[24] and the Centers for Disease Control.[25] In response to the recognized problem of widespread deficiency issues, it is also my hope that in-depth training about nutritional biochemistry with appropriate laboratory testing will also be available so that clinicians can determine the nutritional status of their patients in order to address biochemical insufficiencies.
Conclusion
While considering the letter from Drs. Campbell, Abbass and Zehr, there appears to be no major difference in opinion, but rather a difference in focus. My brief articles for Canadian Family Physician were not designed to be an expansive exposition exploring all etiological determinants of morbidity, but an introduction to SRI as one of the common sequelae of chemical toxicant bioaccumulation - a prevalent determinant of multimorbidity that is increasingly being recognized and discussed in the scientific literature. Finally, it was also my objective to emphasize the importance of looking for the etiology of disease in clinical medicine whenever possible. If a persistent noise was emanating from your car engine, you would most assuredly expect the mechanic to find and correct the cause of the noise, not to dispense ear muffs. Although we can camouflage symptoms with drugs, illness commences because of a cause, illness persists because the cause persists, and illness can only truly resolve when the cause is addressed. With tools and knowledge to identify causative determinants, appropriate interventions can be undertaken to facilitate healing and restoration for many of our patients suffering with multimorbidity. Thank you.
References:
1. Genuis SJ (2014) Pandemic of idiopathic multimorbidity. Canadian family physician Medecin de famille canadien 60: 511-514, e290-513.
2. Genuis SJ, Tymchak MG (2014) Approach to patients with unexplained multimorbidity with sensitivities. Canadian family physician Medecin de famille canadien 60: 533-538.
3. Genuis SJ (2012) What's out there making us sick? Journal of Environmental and Public Health 605137.
4. Office of Genomics and Disease Prevention: Centers for Disease Control and Prevention. Department of Health and Human S (2000) Gene- Environment Interaction Fact Sheet.
5. World Health Organization Constitution: definition of health. World Health Organization, Geneva, 1948.
6. Lo C (2000) Integrating nutrition as a theme throughout the medical school curriculum. Am J Clin Nutr 72: 882S-889S.
7. Ramagopalan SV, Heger A, Berlanga AJ, Maugeri NJ, Lincoln MR, et al. (2010) A ChIP-seq defined genome-wide map of vitamin D receptor binding: associations with disease and evolution. Genome research 20: 1352 -1360.
8. Hanley DA, Davison KS (2005) Vitamin D insufficiency in North America. J Nutr 135: 332-337.
9. Schwalfenberg G (2007) Not enough vitamin D: health consequences for Canadians. Can Fam Physician 53: 841-854.
10. Nielsen FH (2014) Effects of magnesium depletion on inflammation in chronic disease. Current opinion in clinical nutrition and metabolic care.
11. Pinel A, Morio-Liondore B, Capel F (2014) n-3 Polyunsaturated fatty acids modulate metabolism of insulin-sensitive tissues: implication for the prevention of type 2 diabetes. Journal of physiology and biochemistry 70: 647-658.
12. Abeywardena MY, Patten GS (2011) Role of omega3 long-chain polyunsaturated fatty acids in reducing cardio-metabolic risk factors. Endocrine, metabolic & immune disorders drug targets 11: 232-246.
13. Genuis SJ (2010) Sensitivity-related illness: the escalating pandemic of allergy, food intolerance and chemical sensitivity. The Science of the Total Environment 408: 6047-6061.
14. Reichrtova E, Ciznar P, Prachar V, Palkovicova L, Veningerova M (1999) Cord serum immunoglobulin E related to the environmental contamination of human placentas with organochlorine compounds. Environmental health perspectives 107: 895-899.
15. Jedrychowski W, Perera F, Maugeri U, Miller RL, Rembiasz M, et al. (2011) Intrauterine exposure to lead may enhance sensitization to common inhalant allergens in early childhood: a prospective prebirth cohort study. Environmental Research 111: 119-124.
16. Jedrychowski W, Galas A, Pac A, Flak E, Camman D, et al. (2005) Prenatal ambient air exposure to polycyclic aromatic hydrocarbons and the occurrence of respiratory symptoms over the first year of life. Eur J Epidemiol 20: 775-782.
17. Grandjean P, Poulsen LK, Heilmann C, Steuerwald U, Weihe P (2010) Allergy and sensitization during childhood associated with prenatal and lactational exposure to marine pollutants. Environmental health perspectives 118: 1429-1433.
18. Okada E, Sasaki S, Saijo Y, Washino N, Miyashita C, et al. (2012) Prenatal exposure to perfluorinated chemicals and relationship with allergies and infectious diseases in infants. Environmental Research 112: 118-125.
19. Miyashita C, Sasaki S, Saijo Y, Washino N, Okada E, et al. (2011) Effects of prenatal exposure to dioxin-like compounds on allergies and infections during infancy. Environmental Research 111: 551-558.
20. Stolevik SB, Nygaard UC, Namork E, Haugen M, Kvalem HE, et al. (2011) Prenatal exposure to polychlorinated biphenyls and dioxins is associated with increased risk of wheeze and infections in infants. Food and chemical toxicology : an international journal published for the British Industrial Biological Research Association 49: 1843-1848.
21. Redgrave TG, Wallace P, Jandacek RJ, Tso P (2005) Treatment with a dietary fat substitute decreased Arochlor 1254 contamination in an obese diabetic male. J Nutr Biochem 16: 383-384.
22. Ross GH, Sternquist MC (2012) Methamphetamine exposure and chronic illness in police officers: significant improvement with sauna- based detoxification therapy. Toxicology and industrial health. 28(8):758- 68.
23. Genuis SJ (2011) Elimination of persistent toxicants from the human body. Human & experimental toxicology 30: 3-18.
24. Health Canada (2013) Canadian Helath Measures Survey. Second report on human biomonitoring of environmental chemicals in Canada. .Accessed on April 2,2014 at [http://www.hc-sc.gc.ca/ewh- semt/contaminants/human-humaine/chms-ecms-eng.php].
25. Centers for Disease Control and Prevention: Department of Health and Human Services (2013) Fourth National Report on Human Exposure to Environmental Chemicals. Atlanta: Georgia. Updated Tables.Accessed April 14/2014 at [ http://www.cdc.gov/exposurereport/pdf/FourthReport_UpdatedTables_Mar2013.pdf ]
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (14 August 2014)

Multimorbidity Disussion still open.
Sam G Campbell, Professor of Emergency medicine
Other Contributors:
The increasingly recognized issue of multimorbidity discussed by Dr Genius in his commentary in the June issue of CFP (1) and further in his narrative review with Marko Tymchak (2) is an important one, and (if indeed, it is 'one' syndrome(3)), one which is clearly not fully understood. Environmental and chemical sensitivity may well explain several of the causes of symptoms in some patients with multiple unexplained sym...
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The increasingly recognized issue of multimorbidity discussed by Dr Genius in his commentary in the June issue of CFP (1) and further in his narrative review with Marko Tymchak (2) is an important one, and (if indeed, it is 'one' syndrome(3)), one which is clearly not fully understood. Environmental and chemical sensitivity may well explain several of the causes of symptoms in some patients with multiple unexplained symptoms, but we are concerned that these articles suggest that this is the predominant cause of multiple unexplained symptoms.
Dr Genius has convincingly argued previously (4) that our tendency to 'scoff' at alternative ideas about illness, with several examples illustrating how this retards medical progress, and also that pressure from profit-based pharmaceutical companies exacerbates the problem. It appears, however, that he himself sees two approaches to this problem - his, and one involving giving patients' medication. It also appears that, as someone with a hammer sees more nails than one without, his personal interest in this particular potential cause of the 'syndrome' has strengthened and biased his search for evidence and belief in the perspective. Of course that same tendency to bias likely affects us as well, but the non-systematic nature of his review gives us cause to wonder if he relied excessively on articles that agree with his preconceptions.
Chemical sensitivity may well affect a number of organ symptoms simultaneously. One organ system, however, directly influences all others, that of the autonomic nervous system (ANS). The ANS, a relatively primitive system in comparison to that above the neck, responds in primitive ways to the stresses experienced in modern life. Inappropriate function of the ANS would be expected to produce symptoms in many different organ systems. In somatoform illness (which, although associated with anxiety and depression (5) is not synonymous with those diagnoses), a number of patterns of symptoms have been identified (3,6).
Many patients with multiple unexplained symptoms can temporarily relate the onset of symptoms to stress in their lives. Our experience using early referral for intensive short-term dynamic psychotherapy for patients with unexplained medical symptoms has resulted in a significant reduction in emergency department visits, and reported symptoms of patients (7). Response from patients is very often rapid and dramatic. We also use this treatment for patients with environmental and chemical sensitivity here in Nova Scotia (8) to address emotional contributors to these symptoms.
Chemical sensitization has been associated with autonomic arousal (9), so the physiologic mechanisms causing symptoms may share elements from both hypotheses. We do agree that we all need to keep an open mind with reference to inadequately understood conditions (3), and that includes caution to spread the net far more widely than these articles suggest.
Sam Campbell MB BCh, FCCP, CCFP(EM) Allan Abbass MD, FRCPC Centre for Emotions and Health Richard Zehr MA, Nova Scotia Integrated Chronic Care Service
1. Genuis SJ. Pandemic of idiopathic multimorbidity. Can Fam Physician. 2014;60:511-4.
2. Genuis SJ, Tymchak MG. Approach to patients with unexplained multimorbidity with sensitivities. Can Fam Physician. 2014;60:533-8.
3.Fink P, Toft T, Hansen MS, ?rnb?l E, Olesen F. Symptoms and syndromes of bodily distress: an exploratory study of 978 internal medical, neurological, and primary care patients. Psychosom Med. 2007;69:30-9.
4. Genuis SJ. Diaspora of clinical medicine: exploring the rift between conventional and alternative health care. Can Fam Physician. 2013;59:628- 32.
5. Henningsen P, Zimmermann T, Sattel H. Medically unexplained physical symptoms,anxiety, and depression: a meta-analytic review. Psychosom Med. 2003;65:528-33.
6. Abbass A. Somatization: Diagnosing it sooner through emotion-focused interviewing. J Fam Pract. 2005;54:231-9, 243.
7. Abbass A, Campbell S, Magee K, Tarzwell R. Intensive short-term dynamic psychotherapy to reduce rates of emergency department return visits for patients with medically unexplained symptoms: preliminary evidence from a pre-post intervention study. CJEM. 2009;11:529-34.
8. Fox RA, Joffres MR, Sampalli T, Casey J. The impact of a multidisciplinary, holistic approach to management of patients diagnosed with multiple chemical sensitivity on health care utilization costs: an observational study. J Altern Complement Med. 2007 Mar;13(2):223-9.
9. Fiedler N, Kipen HM. Controlled exposures to volatile organic compounds in sensitive groups. Ann N Y Acad Sci. 2001;933:24-37.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (7 July 2014)

Multimorbidity with Sensitivities: Hypothesis or Clinical Reality?
Stephen J. Genuis, Clinical Professor
Thank you to Dr. Leduc for bringing up many valid points regarding our paper on multimorbidity with sensitivities (MWS).
Limitations of Paper
We agree that the information provided in our article was not a comprehensive treatise on the issue. Rather, the paper was an introduction to the pathogenesis of, and approach to many cases of contemporary chronic illness. Because of the journal's assigned word li...
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Thank you to Dr. Leduc for bringing up many valid points regarding our paper on multimorbidity with sensitivities (MWS).
Limitations of Paper
We agree that the information provided in our article was not a comprehensive treatise on the issue. Rather, the paper was an introduction to the pathogenesis of, and approach to many cases of contemporary chronic illness. Because of the journal's assigned word limit and the inclusion of a case history, only a small portion of the expansive area of sensitivity related illness (SRI) was detailed. Because SRI is a new concept for many clinicians, much content was devoted to descriptions of terms - a necessity requested by the journal's reviewers. With the inability to expand further on this broad topic because of space restrictions, referral to relevant medical literature is provided to direct interested physicians to a more in-depth and referenced discussion.
We also agree that the paper does not focus solely on the practical. Again, because of the space limitations, the goal of the article was to provide an introductory clinical overview, not the complex details of patient management - which is not cookie-cutter and can vary considerably between patients. As a result, we received a number of requests from family physicians in Canada, who confirmed the reality of this common presentation and asked for more information on therapeutic approaches. The first note, from a rural Ontario physician, stated: "Today alone I met with two patients who meet the criteria of multimorbidity and sensitivity," while another physician from urban B.C. stated "I have MANY patients with these symptoms...and the negative labs and consults leave me feeling so helpless." With recognition of the etiology and pathogenesis of this common presentation, these physicians will now be able to explore details about the practical management of these complex cases.
Clearly, this issue is relevant to everyday primary care health providers throughout the country and requires much more discussion than can be provided in one brief paper. Just as a comprehensive and practical overview of the diagnosis and treatment of neurodevelopmental problems or respiratory complaints cannot be achieved in one case-based paper, a complete discussion of the assessment and management of patients experiencing MWS resulting from a toxicant burden cannot be achieved in a single article. This is a vast topic involving aspects from clinical toxicology, biochemistry, laboratory medicine, microbiology, and other related disciplines. However, we contend that an introduction to this emerging issue is important, and that clinical awareness of this recently recognized mechanism of illness is valuable. We are grateful for the interest of Dr. Leduc and many other physicians, and offer some thoughts to further the discussion.
Translation of Knowledge
a) It might be useful to have a more detailed written paper on this topic. If Canadian Family Physician is interested, an invitation to an environmental health physician to prepare a detailed clinical paper might be of benefit to clinicians dealing with this problem in their office.
b) There have been a number of medical conferences in other jurisdictions (for example, in the United States) where discussion of this topic has been included. A presentation and/or workshop on this health challenge at a Canadian meeting for family physicians may be helpful to clinicians.
c) Instruction on the assessment and management of multimorbidity states should be a regular component of the education and training of medical students and residents.
Quality of Evidence
Finally, Dr. Leduc's comments about 'Quality of Evidence' (QE) are also apposite. Although we agree it is important to have high quality evidence, traditional measures for QE are useful for some types of research and not for others. In other words, different kinds of medical research demand different kinds of evidence. Let me briefly mention a couple of the many issues.
a) Mechanisms of illness are not interventions that can be tested in clinical trials. All human work exploring disease pathogenesis is observational in nature and generally takes many years of surveillance. Although there is animal research that has established the generation of SRI by exposure of experimental animals to dangerous toxicants, clinical trials using humans are not possible for obvious ethical reasons.
b) Classical measures of QE are being challenged by the results from the human genome project and the expanding field of epigenetics. The recognition of individual dissimilarity in biochemistry, marked variation in the human biome, and individual differences in detoxification indices as a result of genomic variation, polymorphisms, and environmental factors, for example, has raised concerns about significant determinants and confounders not appreciated in customary research methodology.
The format of a traditional integrated review was chosen for the MWS paper as such reviews play a pivotal role in professional practice in medical issues with limited primary study and uncharted clinical territory. Accordingly, no mention of QE was provided in the paper but we confirm that observational data was the primary source of information.
Conclusion
It was the objective of both papers on the topic of Multimorbidity found in the June issue of Canadian Family Physician to introduce the topic of MWS and SRI to clinicians and to begin a discussion about how to move forward to address this expanding concern. We would like to thank Dr. Leduc for facilitating further dialogue on this health challenge.
With the detailed and referenced material in the literature on this topic as cited in our paper, and the confirmatory observations of many physicians who have observed this SRI phenomenon since it was initially described in the literature by public health physician Claudia Miller in the 1990s, we respectfully suggest that the article does not represent a hypothesis; it is a review of an emerging and important field of medicine.
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (30 June 2014)

Clinical Review or Hypothesis?
Eugene R Leduc, Family Doctor
Thank you to Dr. Genuis and colleagues for presenting their interesting "Approach to patients with unexplained multimorbidity with sensitivities". As they point out, these unfortunate patients do present us with both a diagnostic and therapeutic dilemma. However, I think this article more properly belongs in the "Hypothesis" section of the Journal rather than the "Clinical Review" section.
According to Journa...
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Thank you to Dr. Genuis and colleagues for presenting their interesting "Approach to patients with unexplained multimorbidity with sensitivities". As they point out, these unfortunate patients do present us with both a diagnostic and therapeutic dilemma. However, I think this article more properly belongs in the "Hypothesis" section of the Journal rather than the "Clinical Review" section.
According to Journal guidelines*, Clinical Review articles should give a "practical and comprehensive overview of diagnosis and treatment". I was disappointed that the only guidance to the reader for diagnosis and treatment consisted of the phrases "a diagnosis of SRI should be considered wherever a presentation of plural diagnoses or multisystem complaints exists with associated food or chemical sensitivities" and that "management strategies can be found in recent scientific literature". I find these recommendations neither comprehensive nor practical.
The Journal Guidelines for Authors* also request the inclusion of a section on "Quality of Evidence" and ask of authors, "When recommendations are based on specific evidence, provide references and give level of evidence". Despite the extensive reference list attached by the authors, there was no attempt to describe the actual evidence or even appraise or grade it. I can only assume that despite the existing research, there is not enough evidence to make recommendations, even those highlighted as "Key Points" by the editor.
* Canadian Family Physician: Guidelines for Articles: Clinical Review Articles: http://www.cfp.ca/site/Authors/Guidelines.xhtml (accessed 26 June 2014)
Conflict of Interest:
None declared
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Competing Interests: None declared.
Published on: (25 June 2014)

Environmental Medicine Realized
Jennifer M Simpson, Naturopathic Doctor
I would like to commend Dr Stephen Genius for bringing awareness to this important topic. It is becoming increasingly more common to see patients who are presenting with multimorbidity and sensitivities and unfortunately they are not receiving the care that they need. The idea that these conditions may be caused by adverse environmental exposures and toxicant bioaccumulation is not new. Naturopathic Doctors have long rec...
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I would like to commend Dr Stephen Genius for bringing awareness to this important topic. It is becoming increasingly more common to see patients who are presenting with multimorbidity and sensitivities and unfortunately they are not receiving the care that they need. The idea that these conditions may be caused by adverse environmental exposures and toxicant bioaccumulation is not new. Naturopathic Doctors have long recognized the connection between the environment and health and have long sought to help patients balance the total body burden of chemicals they are exposed to. Special training in environmental medicine is being undertaken by many health care professionals including Naturopathic Doctors and MD's. This training allows us to do a comprehensive environmental case history, order appropriate tests where necessary, and ultimately get at the root cause of the patients comorbid condition. Treatment includes counselling on the avoidance of offending chemicals, foods, and triggers; support of the bodies own detoxification pathways, chelation or other detoxification therapies to eliminate the body burden of certain offending chemicals. Treating patients with comorbid conditions is both complicated and time consuming but Naturopathic Doctors are ideally suited to collaborate with MD's and support their patients through this process. Only by working together, furthering our education and understanding of our environment and its impact on health, and listening to our patients and getting to the root of their ailments will we make a lasting impact in their health. We also must lobby government to ban many of these toxic chemicals and mandate proper labelling of products so patients can make informed choices about the products they buy. This we pledged when we took our oath to "first do no harm".
Conflict of Interest:
None declared
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Competing Interests: None declared.