Grace Ziem, M.D.,DR.P.H.

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DR. GRACE ZIEM’S ENVIRONMENTAL CONTROL PLAN
FOR CHEMICALLY INJURED PATIENTS

16926 Eylers Valley Road, Emmitsburg, MD 21727 Phone (301) 241-4346

TABLE OF CONTENTS

 

1. REQUIRED READING

2. PESTICIDE USE WARNING

3. REMODELING WARNING

4. DIETING WARNING

5. ILLNESS LOG

6. MEASURING EXPOSURE LEVELS

7. CONTROLLING EXPOSURES IN YOUR WORKPLACE

8. CONTROLLING EXPOSURES IN YOUR SCHOOL

9. CONTROLLING EXPOSURES IN YOUR BEDROOM

10. CONTROLLING OTHER EXPOSURES IN YOUR HOME

11. CONTROLLING AIR QUALITY

12. CONTROLLING WATER QUALITY

13. USING EXERCISE AND SAUNA TO ELIMINATE TOXINS FROM YOUR BODY

14. CONTROLLING EXPOSURES IN FOOD

15. CONTROLLING EXPOSURES IN YOUR MEDICAL CARE AND MEDICATIONS

16. NECESSARY MEDICAL TREATMENT

17. CONTROLLING NEIGHBORHOOD PESTICIDE EXPOSURE

18. IF YOU NEED TO MOVE TO ANOTHER DWELLING

19. PSYCHOLOGICAL COUNSELING

20. PREGNANCY AND TOXIC ILLNESS

21. SEX AND TOXIC ILLNESS

22. OXYGEN USE DURING REACTIONS

23. NUTRITION

24. LEGAL ISSUES/LEGAL ADVICE

25. REASONABLE HOUSING ACCOMMODATIONS

26. “DRY CLEANING”

27. MERCURY FILLINGS

28. IME EXAMS

29. TRAVEL

30. SPIRITUAL RESOURCES

31. GETTING MORE INFORMATION

32. REFERENCES

33. (2003) REDUCING EXPOSURES REACTION/SYMPTOMS

34. CLEANING CHEMICALS

35. SAFER PEST CONTROL

1. REQUIRED READING
Chemical injury can cause intolerance to low doses of irritants, neurotoxins, other chemicals and even many medications. There are four studies in the medical literature, which confirm that reduced exposure is a major factor in the long-term outcome of patients who developed chemical intolerance. Dr. Michael Lax, an occupational medicine physician, found that his patients who had environmental controls did much better than patients without adequate environmental controls. 305 persons who were chemically reactive were surveyed by DePaul University and found to have much greater relief from environmental controls and reducing exposure than with any form of treatment, and that the use of tranquilizing agents was actually less effective than meditation and prayer. Medication intolerance is a common occurrence in this syndrome and because of frequent impaired detoxification, symptom-masking medications should only be used when the patient feels that they are needed to improve symptoms and quality of life not as an automatic prescription. The third study was conducted by Dr. Leonard Jason who found that individuals who were chemically intolerant who had relatively nontoxic housing had a much better prognosis than those that did not have adequate environmental controls in their housing. This is because once chemical intolerance is induced, it can be exacerbated by exposures at work, at home, or elsewhere. Since this patient spends a significant amount of time at home, controlling exposures at home is critically important. A fourth study of 206 chemically hypersensitive patients by Dr. Miller and colleagues found that reducing exposure to chemicals was very helpful for 71 %, but only 17% of the 10% patients who used psychological or psychiatric services/treatment found those to also be very helpful.

Read through the article that Dr. Ziem wrote for her patients entitled “Evaluation and Treatment of Patients with and Follow-up with Chemical Injury and Sensitivity,” and then read through it again. (The article is included in your patient packet and also can be ordered separately from CIIN or other support groups). The first time, be thinking about the general approach needed to improve your health. The second time, look at specifics and make notes of things you will need to do to make your environment safer and to reduce your body burden of toxic chemicals.

Also read through the book Less Toxic Alternatives by Carolyn Gorman, which Dr. Ziem will give you when you come for your first visit (or you can order it from her office by mail). Carolyn Gorman is a health educator who has counseled thousands of chemically ill patients and this book reflects her experience and that of many patients regarding what things make such persons sick. In each category of product, think about the products you may have around the house. Which are unsafe? Any products which contain toxic chemicals described as things to avoid in this book should be removed from the house and garage whenever possible. (Toxic chemicals stored in your garage may release vapors that can attach to fabric and other surfaces of your car.) Replacing toxic products is much less expensive than being treated for the illness and chronic fatigue that often accompany ongoing exposures.

Other references, which may help you, make a healthier environment include the books Success in the Clean Bedroom by Natalie Golos and Common Sense Pest Control by Olkowski. UNTIL YOU KNOW MORE ABOUT WHAT PRODUCTS TO AVOID, do not purchase any potentially toxic consumer products without first checking in Less Toxic Alternatives (or with other chemically injured persons) for recommended alternatives.

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2. PESTICIDE USE WARNING
DO NOT USE OR ALLOW THE USE OF ANY PETROCHEMICAL PESTICIDE IN YOUR HOME OR WORKPLACE. Most commercially available pesticides contain petrochemicals and substances that are toxic to the brain and nervous system. They can cause severe effects in chemically reactive patients. YOU CANNOT AVOID PESTICIDE ILLNESS BY SIMPLY LEAVING THE ROOM AND AIRING OUT THE SPRAYED AREA. Most pesticide spraying applications leave a toxic residue that remains for weeks or months, gradually giving off toxic chemicals into your home or work environment.

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3. REMODELING WARNING
DO NOT DO ANY REMODELING IN YOUR HOME WITHOUT FIRST DISCUSSING THE PROJECT WITH DR. ZIEM OR SPECIALISTS IN NON-TOXIC BUILDING AND CONSTRUCTION MATERIALS, SUCH AS CAROLYN GORMAN (972-964-8333) OR MARY OESTEL (512-288-2369). If you notice any remodeling, construction or repair being done in your workplace, it is URGENT that you consult one of the above experts immediately, to avoid a severe increase in your illness.

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4. DIETING WARNING
Petrochemicals are stored in body fat. When the fat is “broken down” with dieting (it enters the blood before being “burned” as energy), the chemicals stored there also enter the blood. Chemically poisoned patients often have increased symptoms with dieting. If you are overweight and need to diet, you should do so in conjunction with exercise and sauna therapy (see below), to help you excrete these chemicals. DO NOT try to achieve rapid weight loss (no more than one pound per week) and avoid “diet pills.” (It is better to avoid sugars and eat more fiber-containing foods.) If your symptoms are still significant, contact Dr. Ziem to discuss the risks and benefits of dieting to your health. Unless you are overly thin, YOU SHOULD TRY TO AVOID GAINING MORE WEIGHT. Regular exercise (like daily walking in a non-toxic park) can help with weight control.

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5. ILLNESS LOG
Please keep a written record of your illness reactions, with entries in 3 separate columns as shown in the example below:

Date
1/15/94
Symptoms
Headache, Nausea, Confusion
Exposures (Prior 6-12 Hours
Pumped Gas, 2 Hours in Trafic

A sample log sheet is included in your patient packet. Keeping the information this way will make it easier for Dr. Ziem to review your exposures (to see what things in your environment still need attention) and your symptoms (to see what types of medical problems you have been having).

Under date, record the date you noticed a worsening of your symptoms. Under symptoms, list the changes you noticed in your mind or body, such as headache, sore nose, cough, chest tightness, or whatever other effects you noticed. If you have too many symptoms to record them all, record the main ones and any new ones and put “etc.” so Dr. Ziem will know you had other unlisted symptoms. Under the exposure column, list any exposures you had in the 6 hours before you first noticed symptoms or started feeling worse. List the location where you were in those 6 hours before you felt worse, such as at work, in a hardware store, in traffic. If there were several locations, list them. Bring your log to each appointment with Dr. Ziem and give it to her to review.

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6. MEASURING EXPOSURE LEVELS
Measuring exposure levels in the home or workplace is expensive and not usually very helpful in controlling chemical exposure. Since, we don't know at this time what levels of exposure cause reactions or what on-going levels of exposure might make them worse (there may be no safe detectable level in some cases). People vary widely in their genetic ability to detoxify. However, if you need to document whether a chemical exposure has occurred, Dr. Ronald Simon (703-273-9621 or 1-800-296-7053), a toxicologist and industrial hygienist may be able to help you. Please contact Dr. Ziem first to be sure the information cannot be obtained in a less expensive way. Dr. Simon should not make decisions on environmental controls for you unless discussed with Dr. Ziem.

The “threshold limit value” exposure limits used to regulate exposure to toxic chemicals (also called TLVs) were never designed to protect sensitive workers. The “TLV booklet” states that “Individuals may also be hypersusceptible ... because of ... previous exposures. Such workers may not be adequately protected from adverse effects ... at or below the threshold limit” [1, see Reference section]. The TLV exposure limits used by industrial hygienists were adopted as legal standards before it was known that there were serious scientific and other problems in the development of the TLVs. Health effects below the TLVs are commonly reported in the medical literature [2]. Research into the TLVs has documented serious problems with corporate influence during their development which was not known to the public [3]. In addition, comprehensive literature searches were not done for the development of the vast majority of the TLVs [3]. Finally, the TLVs have been shown to demonstrate no statistical correlation with the exposure levels reported to cause illness in the literature that was used by the TLV Committee [4]. They do, however, bear a strong correlation with existing exposure levels in industry at the time [4]. Many TLVs were apparently based largely on economic rather than health consideration [4]. Indoor air quality standards have been largely derived from these TLVs, and thus these standards suffer from the same scientific inadequacies as the TLVs themselves [5].

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7. CONTROLLING EXPOSURES IN YOUR WORKPLACE
The Americans with Disabilities Act (ADA) requires that employers and others make reasonable accommodations for persons with handicaps. If your chemical induced symptoms interfere significantly with your ability to breathe, work, attend school, do errands, or do housework, you have a handicap as defined under this law. Reasonable accommodation for someone needing a wheelchair includes a specially designed stall in the rest room, special water fountains at a height the person can reach, etc. Reasonable accommodation for a chemically intolerant person can include special filtering devices designed for chemically reactive persons, a no-smoking policy, a special parking area away from fumes, non-toxic pest control, non-toxic cleaning products, non-toxic construction products, the elimination of “air fresheners” (which are petrochemicals and toxic), and other environmental controls.

Dr. Ziem will ask you about your workplace and potential exposures and develop a plan for reasonable accommodation for your workplace. If you have workplace exposures you think are a problem or if you notice that you feel sicker after work than at the end of a weekend or holiday, you could have workplace exposures that need to be better controlled. Make notes about your health (use your illness log) and anything about the workplace you want to discuss with Dr. Ziem and call her for an appointment. Don't just “tough it out” with a problem workplace: Dr. Ziem has more than a few patients who did this and all went on to develop more serious and longer lasting health problems. Never sacrifice your health because you don't want to “make waves” or “cause trouble”. Even a few days of problem exposure can cause increased disability for many weeks or months, and a few weeks of toxic exposure can cause problems for many months or even years. If you are asked or required to resume working (or living) in a building which may be affecting your health, it is important that you be examined by Dr. Ziem shortly before you return on a regular basis and again, one to three months after you've returned. By comparing the results of your physical exams and laboratory tests, Dr. Ziem will be able to document whether your return has had any impact on your health and whether accommodation measures are adequate.

The ADA is civil rights legislation that forbids discrimination against the handicapped just as we have legislation forbidding discrimination against women and racial minorities. The Justice Department of the United States Government enforces this and penalties can be stiff. If your employer has been notified of your condition and refuses to make reasonable accommodation or harasses you in any way (illegal under this law), contact Dr. Ziem immediately. Keep written notes of any conversations with your employer or employer representatives and any problems you have had. Dr. Ziem will interview you about the situation and fully support your need for a safe environment, even if this requires testifying against your employer.

Obtain a copy of the ADA Handbook from your Congressperson and read it is for your protection. Also ask your state government whether your state has any additional laws to protect handicapped individuals. Public employees may be covered by a different federal law the Rehabilitation Act of 1973, which you also can obtain from your Congressperson. Remember that there are over 40 million persons in the U.S. with some handicap with accommodation, most can live normal, fulfilled lives. If you have legal questions about the law, contact the Chemical Injury Information Network (406-547-2255) and/or other support groups. If you have problems with your employer on accommodation or harassment, consult an attorney specializing in enforcement of the ADA, Bruce Bagin (412-281-1110).

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8. CONTROLLING EXPOSURES IN YOUR SCHOOL
Chemically reactive children and adults who wish to attend public or private school have a legal right to accommodation under the ADA similar to that discussed above with regard to the workplace. This protection applies to dormitories, classrooms and other areas necessary to pursue education. If you have a problem with a school environment, contact Dr. Ziem and she will evaluate the environment, develop an environmental control plan for you, and support you in any other way necessary.

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9. CONTROLLING EXPOSURES IN YOUR BEDROOM
Since most people spend 7 to 8 hours daily in bed, it is critical that your bed be non-toxic. Waterbeds made of plastic can off-gas phthalates and other chemicals, especially when they are heated, as is often the case. Even regular mattresses with synthetic covers or slipcovers can be a source of toxic off gassing. On-going exposure to chemical off gassing can cause increased illness in chemically injured persons.

The ideal non-toxic bed has a frame made of metal or untreated, solid wood and a cotton mattress or futon, preferably made from cotton grown without pesticides (sometimes called “organically grown cotton”). The mattress also should not have been treated with pesticides or other chemical additives, which are typically used for preserving commercial mattresses. Note that a doctor's prescription is required to obtain a mattress that has not been treated with fire-retardant chemicals. Since foam pillows also can off-gas chemicals, they should be replaced either with all-cotton pillows (from “organically grown cotton”) or--if you are sure you are not allergic to dander or feathers--with a down or feather pillow. If the animals have been raised without pesticides and the feathers, down, and cloth have not been chemically treated. When buying new linens (or clothing), you also should avoid permanent press fabrics and look for “organically grown cotton.” Never use a fabric softener when washing your bed linens or clothing as these products also can irritate chemically reactive individuals. For more information, read Success in the Clean Bedroom, by Natalie Golos, published by Pinnacle (Rochester NY). Organic cotton clothing and linens can be ordered from Janice Design (707-823-8834), and Heart of Vermont (800-639-4123).

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10. CONTROLLING OTHER EXPOSURES IN YOUR HOME
If your chemical intolerance is severe enough to significantly interfere with one or more major life activities (e.g. work, housework, errands, school, etc.), this qualifies as a handicap under the Fair Housing Act and you are protected by this law from discrimination in housing. Whether you live in a house, apartment, condominium or trailer, if the dwelling is managed by another party (e.g. an owner or building manager), they must make reasonable accommodations to provide you with a non-toxic environment under the anti-discrimination provisions of the Fair Housing Act. Non-toxic accommodations have been upheld by the courts as “reasonable” for hyper-reactive patients. Listed below are the accommodations that you should request in writing from the housing manager or owner. Of course, if you are the owner/manager of your own property, you should immediately implement these changes yourself.

Once you've notified your landlord or building manager about your specific needs, they have a legal responsibility to try to accommodate you. This may include providing non-toxic housing for you in a transition period until the problem can be corrected. Providing you with additional charcoal filter capacity in your living area to reduce air contamination of your living space and belongings, doubling building ventilation for interior contamination for up to a year, and switching to less toxic alternatives as recommended by Carolyn Gorman or other experts. If you notice on-going violations that cause your symptoms to worsen, you may wish to pursue your legal rights with the Justice Department in Washington, DC (202-514-4736). If you have been rendered seriously ill by violations, the responsible party should have to pay for an intensive sauna detoxification program for you if Dr. Ziem feels that it is medically necessary (see Using Exercise and Sauna, below). Fannie Mae has a mortgage program called “Home Choice” which helps low and moderate-income buyers with disabilities or persons with disabled dependents. For more information call 800-220-8770. If you need housing accommodations, contact Dr. Ziem, she will fill out a special form and support you in whatever other ways are necessary. You may be eligible for home purchase assistance under Title 8:24 CFR Parts 5, 903 and 982. Housing accommodations to request (or pursue yourself) include the following:

A. No petrochemical pesticide or herbicide use should be allowed on the building grounds, in any common-use areas of your building, or in any other building areas that share a common air supply with your living area. It is NOT safe for them to notify you first and then spray, since pesticide residue lingers for week and can contaminate the air and thus porous objects (fabrics, wood, walls, etc.) in your living space. Non-toxic alternatives are available and economical to use. For information on these alternatives, see Controlling Neighborhood Pesticide Exposure, below.

B. A no-smoking policy should be enforced in the entry, halls, stairways, elevators, and other common-use areas of your building (if you have symptoms aggravated by smoke).

C. Only non-toxic cleaning agents should be used in the common-use areas of your building (no petrochemicals, no chlorine products or other moderate to severe irritants, and no waxes or finishes containing petroleum products). For information on less toxic alternatives, consult with Carolyn Gorman (972-964-8333). Information also is available in Less Toxic Living and Non-Toxic and Natural (see required reading, above).

D. Non Toxic Air Fresheners: Most “air fresheners” are actually pleasant smelling petrochemicals that try to cover up orders by adding a stronger (chemical) order. Many are toxic to the nervous system and almost all are irritants. These are alternatives:
1. An open box of baking soda (or super washing soda or borax)
2. Bags of zeolite which absorb orders (these can be “baked out” in the sun and re-used).
3. Citrus: place a few slices of lemon, orange or other citrus and gently boil an hour or so, then leave open to air.
4. Plants which NASA has used to clean air include aloe vera, English ivy, spider plants, fig trees, chrysanthemum, and pothos.

Nearly 30,000 tons of petrochemicals are released into the air yearly in the U.S. air fresheners (EPA Study of VOC’s from Consumer and Commercial Products: Report to Congress, March 1995). Over a million tons are released from other products. Be an ANTI-POLLUTER! You can request and distribute a useful brochure on scented products: (www.epa.gov)

E. No dry cleaning should be allowed of fabrics or carpet in common-use areas, since dry cleaning uses toxic solvents which can off-gas for days. Steam cleaning should be used instead, using only non-toxic cleaners. There are now nontoxic alternatives to dry cleaning.

F. No petrochemical “air freshener” should be used in common-use areas. Any spray or solid “air freshener” is probably a petrochemical. If in doubt, ask your local Poison Control Center about the brand name. They may not have expertise on chemical intolerance but they can tell you whether or not any specific brand of product contains a petrochemical ingredient (unless the manufacturer has listed it as a trade secret or otherwise failed to disclose it). They also can usually tell you what percentage of the total product is made up of petrochemical ingredients.

G. No petrochemical-containing products should be used for repair, maintenance, and construction or remodeling in any common-use areas or areas that share an air supply with yours. These materials also should not be used in outdoor areas near your windows or other air-intake that might contaminate your air supply. Examples of products to be avoided include pressed wood and plywood – (formaldehyde and toxic glues), and fiberglass - (formaldehyde). Some other insulation - (if treated with formaldehyde, phenol or other petroleum products), many paints - (if they contain solvents or petroleum additives, fungicides, etc.), wall-to-wall carpets - (because of toxic adhesives, off-gassing from latex backing), many roofing compounds, many sealants, many coated fabrics. Alternatives are available; for more information contact Carolyn Gorman (972-964-8333) or other experts in non-toxic building materials such as Mary Oestel (512-288-2369), architect Hal Levin, the publisher of Indoor Air Bulletin (408-426-6624).

H. Minimize exposure to exhaust from heating systems and appliances that use natural gas, oil or wood. If your dwelling is heated with oil or gas or if you have appliances (washer, dryer, hot water heater, etc.) that use natural gas, you are being exposed to petrochemicals in your home even when the devices are functioning normally. A malfunction could cause even greater levels of exposure and burden you with months or years of added disability. If these appliances cannot be replaced by solar or electric devices consider relocating. Wood stoves and fireplaces should not be used since combustion products aggravate symptoms, and under no circumstances should you use kerosene or other liquid-fuel-burning portable heaters. Even portable “radiators” that use electricity may contain chemicals which can leak out and also, therefore, are not recommended. While the replacement of heating systems and major appliances can be expensive, these changes may be a necessary investment to protect your health (and future earning capacity). If your house once had gas lines entering, confirm with the Power Company that these lines have been shut off outside the house, since only closing them inside can still allow leaking. Dr. Ziem considers safer heating devices and appliances to be medically necessary expenses. Most medical insurers don't cover them, of course, but they are legitimate medical expenses in many cases for persons who become ill because of a workplace exposure, home contamination caused by another party, manufacturer negligence (toxic product, inadequate warning or labels, etc.), and certain other circumstances. Consult an attorney to discuss your legal rights.

I. Keep common areas (and your living area) well-vacuumed and free of dust as chemical contaminants can cling onto house dust for long periods, allowing them to be stirred up and re-circulated.

J. If you read a lot of newly printed papers, books or journals, consider using a reading box to control your exposure to ink and paper off-gassing (available from Carolyn Gorman 972-964-8333). Store printed materials in relatively airtight containers whenever possible metal trash cans or used “ammo” boxes from army surplus stores can be used. If working at a table or desk, place it in front of an open window, and have only the necessary printed matter for the task you are working on in front of you.

K. If you buy new cottons that bother you, a “pressure cooking” method can remove some or most of the offending chemical, mold, etc. Be certain the new clothing is one size too large for you, because it will shrink. You may want to test a button before washing; they might be damaged.
1. Fill a large pressure cooker with water, adding 3T tolerated detergent, 1/2C Borax or baking soda and clothes.
2. Heat to pressure on a range, then put it outside on a hot plate for 1-3 hours at maximum pressure (15 psi).
3. Let it cool or hose it down till the pressure is zero, crack open the lid, then pour off the horrible smelling brown soup of cotton oils and chemicals.
4. Do steps 1 and 2 again (Skip this for older clothes).
5. Do a rinse cycle, then a full wash cycle, then dry.

Clothes might require one more wash/dry cycle, but probably not. Elastic is not ruined. Colors will bleed a bit, but plaids are still plaid [6].

Garments with residues of scented products, formaldehyde and certain other contaminants can be rendered less toxic by washing with powdered milk added to wash water. This also helps residue smells in green cotton and even organic cotton.

L. Research by NASA shows that certain plants can help reduce pollution. (NASA removed polluting sources and used activated charcoal filters as well). Boston fern, pot mums, dwarf date palm, and spider plants worked well for formaldehyde and certain other pollutants. Other good pollution-fighting plants include peace lily, golden pathos, English ivy, aloe vera, philodendron and Chinese evergreen.

M. It is ideal to replace particle board or chip board furniture with solid wood, or when practical (especially beds) metal can be considered for some patients. More sensitive patients can consider lower off-gassing woods with least toxic coatings that can be evaluated in advance by samples through manufacturers such as Charles R. Bailey Cabinet Makers (870-453-5433) who specialize in least toxic/off-gassing woods, finishes, procedures and shipping. Nontoxic stuffed furniture is also available (eg. Furniture: 617-783-4343).

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11. CONTROLLING AIR QUALITY
AIR FILTERS: There are special air filter devices that can greatly assist persons with chemical injury. The best filters contain “activated charcoal” that will “soak up” (adsorb) toxic chemical vapors from pesticides and other chemical products made of petroleum or coal. You may need an additional filter in your device for formaldehyde if your original illness began with an exposure to formaldehyde (in fiberglass, particleboard, carbonless copy paper, formaldehyde treated fabrics, etc.), or if your home is located near a major highway (since traffic exhaust contains formaldehyde). If you have allergies to pollen, dust, or other airborne particles, if your home is located near a main road, or if fireplace smoke or other smoke bothers you, you also may need a “particulate” filter that can trap small particles.

All these filters are considered medical devices and, if medically necessary for your health, will be prescribed by Dr. Ziem. If your insurance carrier reimburses for other medical devices but refuses to reimburse for these, Dr. Ziem considers this a form of discrimination against chemically reactive persons (unless the policy specifically excludes all filter devices, including those for persons with asthma). If you have carefully reviewed your insurance policy, and feel your insurer is reimbursing for other medical devices, especially other filter devices, (you should ask if they cover filter devices for people with asthma). If they refuse to reimburse for your filter, you can contact an attorney specializing in “bad faith” cases against insurance companies such as Alan Casper in Philadelphia (215-546-1124). It is also possible that the vocational rehabilitation department of your state or locality may fund or advance funds for filters (and/or sauna, see below) as part of an effort to rehabilitate you for work. If Dr. Ziem has recommended the filter device for you, she will stand behind your medical need for it. Activated charcoal filter devices are considered effective in helping pollutant control by NASA [7]

Using air filters does not necessarily mean all your windows should be kept closed, unless you know you would be made sick from nearby pollution. Outdoor air is good for you if not polluted; try opening the windows in your bedroom for a few weeks to see if you feel better (but close them if the exposures bother you). Note that, in some cases of interior contamination, ozone generators may be helpful, but these CANNOT be used while you are in the building because of the irritant effect of the ozone on your respiratory system (even at levels too low to smell). The building also must be very well ventilated after the ozone generator is turned off and before you return--for 48 to 72 hours at a minimum. DO NOT use an ozone generator without first consulting Dr. Ziem.

BUYING HOUSE AND ROOM FILTERS: Air filter devices should be located at least in rooms where you spend a lot of time, such as the bedroom or other sleeping area. If you can afford it, try to install filters in each of your other major living areas. They will reduce damage to your health caused by air pollution from neighborhood pesticide treatments, fireplaces, highway traffic, industrial and commercial emissions, and so on.

The most effective approach is a filter system for your entire home, especially if you own your home. If your illness is severe enough to interfere with your ability to work, you probably need a whole house system unless you live in a relatively non-polluted area. A whole house filter system is manufactured by Allermed Company (972-442-4898).

The capacity of most portable (room-sized) filter devices is rated in cubic feet. To determine the number of cubic feet you need to filter, measure the room's length, width, and height in feet and multiple these numbers together (length x width x height) to get cubic feet. DO NOT buy a portable filter device from a hardware store, department store, mail order catalog, or other supplier that does not specialize in filters for chemically reactive people. These devices can contain toxic products. We recommend that you purchase portable filters recommended by Carolyn Gorman or our office. Call Dr. Ziem if you encounter any unresolved problems.

Sometimes persons who are quite reactive to many things notice a problem with certain types of charcoal: you should request samples to test or exchange your filter if this occurs. Some particulate filters such as HEPA filters may have glues, which bother some individuals even though filters recommended by Gorman or our office are designed for chemically injured persons. If you notice any increase in symptoms after your filter arrives that seem worse around the filter, contact Gorman or our office immediately. Remember, the usual pattern is gradually feeling better with the filter: if you are worse around it, something is wrong.

CAR FILTERS: You also may want to consider purchasing a filter for your car, especially if you have increased symptoms after being in traffic. These devices plug into the cigarette lighter attachment of your car and filter air inside the car. The windows must be closed to use this system, however, so it may be impractical in hot climates unless your car is air-conditioned. Some patients also find it helpful to have their car's engine steam cleaned, since “fresh” air drawn into the car's interior through intake ducts in the engine area may be contaminated with grease and oil from engine surfaces. The Allermed and Faust brands appear most effective.

AIR FILTERS TO AVOID-IONIZERS: Ion generators act by charging the particles in a room so that they are attracted to walls, floors, tabletops, draperies, occupants, etc. Abrasion can result in these particles being re-suspended into the air. In some cases these devices contain a collector to attract the charged particles back into the unit. While ion generators may remove small particles (e.g. those in tobacco smoke) from the indoor air, they do not remove gases or chemical vapors and may be relatively ineffective in removing large particles such as pollen and house dust allergens. Although some have suggested that these devices provide a benefit by rectifying a hypothesized ion imbalance, no controlled studies have confirmed this effect. Ion generators also create ozone, an irritant to the air passages.

AIR FILTERS TO AVOID-OZONE GENERATORS: Ozone, a lung irritant, is produced indirectly by ion generators and some other electronic air cleaners and directly by ozone generators. While indirect ozone production is of concern, there is even greater concern with direct and purposeful introduction of a lung irritant into indoor air. There is no difference, despite some marketers’ claims, between ozone in smog outdoors and ozone produced by these devices. Under certain use conditions, ion generators and other ozone generating air cleaners can produce levels thought harmful to human health. A small percentage of air cleaners, that claim a health benefit, may be regulated by the FDA as a medical device. The Food and Drug Administration has set a limit of 0.05 parts per million of ozone for medical devices. This level may not be safe for the chemically injured. Although ozone can be useful in reducing odors and pollutants in unoccupied spaces (such as removing smoke odors from homes involved in fires) the levels needed to achieve this are above those generally thought to be safe for humans.

RESPIRATORS & MASKS: It may sometimes be necessary for you to wear a simple “nose/mouth” mask or respirator in order to reduce your personal exposure in environments that are contaminated beyond your control. Sometimes these types of exposures are unavoidable, and if the unavoidable exposures make you ill, you should definitely try using a respirator to reduce your exposure. Examples of such situations are running into a store for errands and feeling sick, or getting caught in traffic and feeling sick (but don’t use a mask as a substitute for a car filter).

Cotton and silk respirators (masks) are available with a space to insert a packet of activated charcoal. These can be ordered from Sandra DenBraber, RN (817-860-9299). All masks containing activated charcoal should be kept in an airtight metal or glass container when not being used; otherwise the charcoal will continue to pick up chemicals even when you are not wearing it, greatly shortening its useful life. We do not recommend disposable “dust” masks as these do not filter out chemical vapors.

HUMIDIFIERS: Humidifying the air can reduce dryness of the mouth, nose and lungs in the winter. However, chemically reactive persons should use only water that has gone through an activated charcoal water filter (or well water that is not chemically treated) so their humidifiers do not mist solvents into the air. If you have a history of allergy to mold, try to find a humidifier in which the water constantly circulates, as mold can grow easily in those types that hold standing water. Do not clean the humidifier with chlorine-containing products (e.g., Comet, etc.), or with other cleaners containing petrochemicals: consult Less Toxic Alternatives for safer cleaning agents. If you notice any symptoms you think may be aggravated by your humidifier try turning it off for about a week and compare your symptoms. If they decrease during that week and increase when you turn it on again, contact Dr. Ziem or Carolyn Gorman (972-964-8333) for recommendations.

INDOOR PLANTS AND INDOOR AIR QUALITY: The National Aeronautics and Space Administration (NASA) has conducted research for years on which indoor plants are best for controlling air pollution so they could provide good quality, less polluted air for space projects. They found that certain plants were much better for controlling indoor air pollution, and that a sealed system (probably tighter than your home during winter) could be relatively nontoxic with a sufficient amount of the right plants, often used in conjunction with activated charcoal air filters. A NASA expert in this area, Dr. B. C. Wolverton, has summarized this experience in an easy to read paperback book: How to Grow Fresh Air (Penguin Books). You will still need to select plants according to the amount of sunlight or artificial full spectrum light you can provide them. If you are mold sensitive/allergic, select plants that can dry between watering, since this greatly reduces mold growth. Many plants do better if you let the soil become dry to the touch before watering; so mold allergy may not be significantly exacerbated. If in doubt about mold aggravation, try one or two plants first to see whether your mold allergies are affected. If you experience no problems, add further plants, as you feel able.

READING BOXES: Patients who experience illness when exposed to ink in newsprint or other printed material can obtain a “reading cabinet” from The Living Source (817-756-6341) that allows reading, writing and even typing with greatly reduced exposure. Other enclosures are available to trap emissions from computers, printers and fax machines. Contact Carolyn Gorman (972-964-8333) or Fred Nelson (517-689-6369) for more details.

COMPUTER AND TV ENCLOSURES: Some patients experience heightened symptoms with use of these items, partly due to heated plastic and electronic components. A minority of patients may have electromagnetic exacerbation, which can be improved. These may not be adequate for prolonged/frequent use such as occupational regular use. For more information call 517-689-6369. Computers have made it possible for chemically ill persons to work from home and, with net access, to obtain information. New computers can off-gas from the plastic casing and parts, as well as, other chemicals used on the electronics. When any computer is turned on, the electronics heat up, increasing release of chemicals used in and near the electronics. Lap top computers may provide less off gassing. Using an extension cord for the computer or hardware box can relocate some of the off gassing (and electromagnetic fields) farther from you, having the monitor, keyboard and mouse in front of you. Enclosures are available for computers (517-689-6369) but these need to be exhausted to the outside whenever possible, and only if outside exhaust is not possible, through an activated charcoal filter device (machine) designed for people who are chemically sensitive. At this time the enclosure with exhaust system may not provide enough protection for heavy use (eg. occupational use daily or for hours at a time). Some patients may need to combine computer use with a DenBraber Mask. If, after enclosure and exhaust is used, there are still an increase of respiratory (throat, nose, sinus, chest/lung irritation) or other symptoms, since frequent symptoms often exacerbate the underlying toxic injury and can make the person have more side effects/symptoms from other exposures. Mask, nebulized glutathione and increased antioxidants are backup protection, not a substitute for enclosure and exhaust.

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12. CONTROLLING WATER QUALITY
Chlorine used in water treatment reacts with organic (natural) material in the water to form new chemicals like chloroform and other toxic substances. These may aggravate chemically injuries when breathed in from shower vapors or ingested via drinking and cooking. Since a lot of exposure occurs during showering and bathing, you should consider installing shower-head and faucet filters or a whole-house water filtration system, which would also treat water used in clothes-washing and dish washing machines (these uses also release chemicals into your home). Some people further reduce drinking and cooking water exposures by either using bottled water (which can get expensive) or installing an extra-effective filter on their kitchen tap. If such a filter is used in addition to a whole-house system, the filters will not need to be replaced very often and the water will taste better. Whole-house water filtration systems include AMETEK Equipment, Coast Filtration, and General Ecology.

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13. USING EXERCISE AND SAUNA TO ELIMINATE TOXINS FROM YOUR BODY
As exercise breaks down body fat, it releases the petrochemicals stored in fat, which then enter the bloodstream. While these toxins are partly sweated out during exercise, more can be sweated out if the exercise is followed immediately by a sauna. Medical studies of toxic-exposed persons have shown that sweating induced by the regular use of saunas can gradually reduce the level of pesticides and other toxic petrochemicals in the body. Although filters and other environmental controls can reduce new exposures to petrochemicals, sauna and exercise are the only treatments that can reduce the total level or “body burden” of chemicals already in your body.

A small and relatively inexpensive sauna made by the Radiant Heater Company designed specifically for chemically intolerant persons can be obtained (800-774-4450). This utilizes a low temperature range (110-120 degrees F) which warms superficial fat and induces better excretion of fat-soluble petrochemicals than higher temperature saunas, which cause more water loss. A larger non-portable one is available which achieves temperatures of 130 degrees F (800-428-2343). With low temperature, sauna time is longer (30 minutes or more). Dr. Ziem's patients have improved significantly with sauna therapy and she now regards this as a medically necessary treatment for chemically injured persons. Insurers who cover medical devices should reimburse for this; it will save them money in reduced future medical costs. You will probably need a prescription from Dr. Ziem for the sauna. (Do not purchase a regular commercial sauna). Do saunas during cooler months: during warm and hot months the body will sweat without sauna. You can dress slightly more than usual when walking outdoors to slightly increase sweating: simply return home and shower.

Unfortunately, commercial saunas such as those used in gyms and health spas rarely help chemically injured persons because they are cleaned with chlorine-containing or other irritating and/or toxic chemicals. They are also often contaminated with cosmetics and other products containing petrochemicals from previous users. Also remember: a hot tub is NOT a sauna. Hot tubs contain chlorinated water and are also treated with chemicals that can react to form toxic compounds in the water.

If--after beginning sauna therapy--you experience a rash in the areas of greatest sweating, this is probably due to excreting chemicals through your skin. Unless this is minor, reduce your sauna time for a while. The rash should improve as your body burden (and thus chemical excretion) declines. Silimarin and nebulized glutathione may help detoxify better.

Another sauna designed for the chemically injured made by Fred Nelson (517-697-3989) is slightly less expensive. Its disadvantages are that it is a lying down model (easier to fall asleep), that it cannot be returned and that the unit does involve a small motor (used outside the sauna space). It has a zipper enclosure. If you use it, it MUST be used with a Dayton mechanical windup half-hour timer (part #6X763) available from 410-391-9000 for about $22. The heating unit MUST be plugged into the timer so that it automatically shuts off at 30 minutes. The zipper can be opened about 4" at the head end to allow you to look out and watch TV (TV lying on its side). This sauna achieves temperatures of 120-140 degrees F, compared to about 110-120 degrees F for the Radiant Heater sauna.

SAUNA PROCEDURE--FIRST EXERCISE: You need to exercise in a relatively non-toxic setting, because you breathe deeper and faster during exercise and your lungs will breathe in more pollutants. Non-toxic settings include your home, especially if you have filters and don't have a home contamination problem. Exercise videos and exercise machines can be used. Even with filters, however, the average indoor environment is often more contaminated than a non-toxic park. Walking in a park that is not pesticide sprayed or close to heavy traffic is great exercise; just sauna immediately after coming home. If you are unable to locate a non-toxic park or other outdoor walking exercise, please contact Dr. Ziem's office at (301-241-4346). She can request your local park(s) to stop using toxic pesticides and other lawn care products as an accommodation of your disability. NOTE THAT SPENDING TIME IN NON-TOXIC OUTDOOR SETTINGS SEEMS TO SPEED RECOVERY IN DR. ZIEM'S PATIENTS. You should begin exercising at a level comfortable for you. Don't “push” yourself; as you get in better condition, you can gradually increase the vigor or time you exercise. If you are over 35 years old and have not exercised recently, if you are over 50 years old (regardless of exercise status), or if you have a history of heart disease or high blood pressure, any exercise more vigorous than walking should be discussed first with your physician. In any case, you don't need to exercise until you “sweat” since the sauna will take care of that.

THEN SAUNA: Drink 12 oz. of water and then enter the sauna immediately after completing your exercise. If you use the Fred Nelson sauna, plug it into a 1/2-hour timer. Begin with about 10-15 minutes. If you experience any discomfort or dizziness, leave promptly. If you do fine for 2 weeks at 15 minutes, increase to 20 minutes if you wish. If you have no ill effects at all in the sauna, you can gradually increase to a maximum of 45 minutes (increasing the time by not more than 5 minutes each week). The temperature in the Radiant Heater sauna can be increased up to 130 degrees by putting a 100% cotton (or 100% wool) blanket over the cloth enclosure. Put a small towel on the bench where you sit so your sweat does not contaminate the sauna. One exercise/sauna procedure per day is usually sufficient. Try to sauna at least 5 to 6 days per week: you can do it every day if you wish. Remember that your body gradually adjusts to heat but can lose most of this adjustment in a few days. Thus, if you skip more than a day between saunas, cut back the time or temperature from your last sauna. Some saunas contain “hot rocks”; if you put water on these to create steam, the water should be charcoal filtered (or chemically untreated well water) to avoid releasing solvents in the sauna area. SET A TIMER TO AVOID THE RISK OF FALLING ASLEEP IN THE SAUNA. Drink another 12 oz. of water to avoid a headache.

THEN SHOWER: Immediately after completing your sauna, enter the shower. Soap up your scalp and entire body with a non-toxic soap and rinse off thoroughly, rubbing your skin with your hand, washcloth, or a loofa to remove the contaminated sweat and soap. (Clean the washcloth well after each shower.) Your shower water should be treated with a showerhead or whole-house filter so that you are not exposed to solvents or chlorine during your shower (see Improving Water Quality, above). Bathing is NOT recommended for women because bladder infections occur easily with women sitting in a bathtub. Showering, in any case, is probably a more effective way to remove contaminants from the skin for both men and women. If skin dryness occurs, use a non-toxic skin softener such as “organic” olive oil (grown without pesticides).

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14. CONTROLLING EXPOSURES IN FOOD
Pesticides used in agriculture are very toxic to chemically injured persons and cause increased changes in the nervous system and other organs. Unfortunately, most commercially grown foods have significant pesticide residue. This is typically spread throughout the food and cannot be effectively removed by scrubbing, peeling, etc. The Environmental Working Group (a DC non-profit agency) found significant pesticide levels on many fruits and vegetables in the U.S., and provided evidence of under-reporting this problem by the FDA. Their report is entitled: “Forbidden Fruit: Illegal Pesticides in the U.S. Food Supply.” In order to avoid adding to an already excess body level of toxic chemicals, the chemically injured person should eat foods grown without pesticides and without pesticide treatment (such as fumigation) during storage, shipping, etc. This food is usually called “organic.”

Preservatives, coloring agents, and other food additives also may be toxic to chemically sensitive persons. Additives that may aggravate symptoms include MSG, benzoic acid, parabene (methyl, propyl, butyl, etc.), TABA, BHA, BHT, BHQ, polysorbate 80, sorbitol, sorbic acid, chlorobutanol, and ethylene oxide. Foods without these agents are often called “natural,” but foods labeled natural may not be organic unless also labeled organic. Whenever possible, purchase organic foods described as without additives, preservatives, etc.

Organic foods are often more expensive than contaminated foods, partly because it takes more labor to grow them and they don't last as long on the shelf. Your regular medical insurer does not reimburse for the excess cost of organic food (just as they don't reimburse for a special diabetic diet). However, if your case is work-related or the result of a negligent manufacturer (dangerous product, product with inadequate warning labels, etc.), Dr. Ziem feels that the excess cost of organic food in these situations is a legitimate medical expense. Thus, keep track of your grocery expenses before and after you began to purchase organic foods, and consult an attorney to understand your legal rights in this area.

Meats should be from animals raised on organic pastures (without pesticide treatment) and/or fed grain that has not been grown or treated with any pesticide. This is very important for meat, since the chemicals found in non-organic grains tend to build up (or “bioaccumulate’) in the animals that eat them. Animals also should be raised without antibiotics, hormones and other synthetic chemicals. Ask for a written statement from the grower and/or supplier to ensure a safe meat supply.

Fish from the ocean are less polluted than fish from fresh water in most cases (a sad commentary on ‘freshwater’ pollution). Also, shellfish (such as scallops, shrimp, crabs, lobsters, clams, and oysters) dwell on the bottom where toxic chemicals tend to accumulate, so they are more polluted than most seafood. This also applies to flounder, which lay on the bottom. Fish that eat other fish (carnivores) tend to be more toxic than those that eat plants are, since when carnivores eat other contaminated fish the chemicals concentrate in their flesh. Most fish, however, are still healthier for your heart than red meat. For information about organic foods in Maryland, contact the Maryland Organic Farming Association (301-371-4814). For other states, contact the Beyond Pesticides (202-543-5450) or the Chemical Injury Information Network (406-547-2255). It is preferable that foods not be stored or microwaved in plastic containers or plastic wrapping (use less toxic cellophane made from wood, available from NEEDS, 1-800-462-6333).

BRAIN-DAMAGING FOODS--EXCITO-TOXINS: There are certain food substances that are similar in chemical structure to body substances that transmit nerve messages (neurotransmitters). These food substances can cause such excess stimulation of nerve cells that the nerve cells actually die from over-excitation and exhaustion. These substances are known as excito-toxins. People at greater risk include children, those with low energy levels, and persons with chemical injury (since this injury weakens the brain's protective “blood-brain barrier”). Some evidence suggests that chronic intake of excito-toxins increases risk of Parkinson, Alzheimer and other degenerative diseases of the nervous system.

Excito-toxins include aspartame (Nutra Sweet) and monosodium glutamate (MSG). Unfortunately, MSG can be in foods WITHOUT being listed on the label. Additives that contain MSG (without listing MSG on the label) include autolyzed yeast, yeast extract, calcium caseinate, sodium caseinate, hydrolyzed protein, hydrolyzed oat flour, hydrolyzed plant protein, plant protein extract, hydrolyzed vegetable protein and textured protein. MSG is usually contained in bouillon, broth, flavoring, malt flavoring, malt extract, natural beef or chicken flavoring, seasoning, stock, again without any mention on the label. MSG kills nerve cells by allowing excess calcium to enter the cell. Animals exposed to MSG become obese even with modest or lower food intake. Since Nutra Sweet can have the same effect, people consuming excito toxins may be unable to lose weight normally by dieting.

Excito toxins in liquid form (soups, beverages) are more dangerous, since they are rapidly absorbed. Glutamate from MSG remains high in human blood longer than in any animal tested. Junk foods contain the highest levels.

Other brain stimulants to avoid are caffeine, coffee, chocolate, some headache medicines, and many cold medicines, appetite suppressants and wake-up pills.

Reduce your exposure by reading all food labels, reducing consumption of pre-prepared foods, and asking the manufacturer in writing about MSG and aspartame when in doubt. Also learn more by reading the book: Excito toxins: The Taste That Kills, by Russell Blaylock, MD, a neurosurgeon.

TOXINS IN FOOD: Chemical injured patients evaluated by Dr. Ziem have shown impaired ability of the liver to detoxify toxic substances. Some food preparation methods can increase toxins in foods. More toxins are generated by:

1. Meats, fish that are grilled, blackened or smoked
2. Meats with more fat
3. Meat and fish cooked at higher temperatures (over 150-200° C)--higher temperature pan frying, broiling, hot deep fat frying, etc.
4. Meat, fish and fats/oils cooked with water allowed to evaporate (open pan-frying)
5. Beef stock, flavors, commercial sauces, vegetable stock or hydrolyzed vegetable protein
6. BHT in food.

Thus a commercial hamburger or hot dog with french fries is often a “toxic meal”.

REDUCE TOXINS BY covering food when cooking, use lower temperatures for pan-frying and use low fat meats. Milk, cheese, eggs, beans, peas, soy are protein sources that are less toxic with cooking. Best cooking methods are boiling in water, steaming without first browning, poaching or microwaving (in glass). Rotate proteins to reduce food intolerance.

Substances, which help protect your body from toxins, include quercetin, catechin, flavones and flavonols, silimarin, tocopherols and other antioxidants. Roasting and baking yield low to intermediate levels of toxins, as does low temperature pan-frying. (Source: Robbana-Barnat, S. “Heterocyclic anines: occurrence and prevention in cooked food”, Env. Health Persp 104:282-288, 1996).

FOOD INTOLERANCE: Many patients with chemical injuries feel that certain foods aggravate their illness. Such foods are often those they eat most frequently, even daily, such as milk and dairy products, wheat, corn, apples, etc. People with food-related symptoms, sometimes called “food intolerance,” may experience reactions up to 18 hours after eating, though usually sooner. If you suspect that certain foods may aggravate your illness, you should try eliminating these one by one from your diet for 4 or more days. Then you may eat the suspect food just once again, but carefully measure your pulse before and after doing so (by feeling the wrist or the artery in the neck and counting a full minute using the second hand of a watch or clock). Also compare your eyes for swelling (bags or circles) and look for any changes before and after in your mood (restless, irritable, sleepy, etc.). If you think you have identified a problem food, wait at least 4 days again to get it out of your system and then you may try eating again if you wish.

Another way to evaluate for food intolerance is a “diagnostic rotating diet” (our term). In this approach, food groups are eaten only once in 4 days, recording symptoms. Problem foods are checked for and eliminated, if any. If you feel much better eliminating certain foods, we feel you are probably intolerant to them. The procedure is complicated, since food groups must be understood, as well as interpretation of symptoms. For some patients, this can make a significant difference, especially more severely ill patients.

To track your food intolerance, you also can keep a food diary, listing what you ate at each meal, what symptoms you noticed, and when. Some patients try a “rotating diet,” not eating the same food more often than once every four days. If you stick to a regular rotation diet, you can more easily track any adverse reactions due to newly introduced foods. Remember, as discussed above, to eat only foods not grown with pesticides whenever possible, as pesticide residues also may cause serious reactions, which are sometimes confused with food allergies. Also read all labels very carefully to screen out prepared foods that contain ingredients your are trying to avoid (such as corn, wheat, and/or milk). More information on foods is in the book Success in the Clean Bedroom by Natalie Golos.

PLASTIC CONTAINERS: Food stored in plastic containers can become contaminated with the petrochemicals in the plastic (Kailin, Medical Annals of DC, October 1964). Store food in glass or metal containers whenever possible, or in cellophane bags made from wood (cellulose). This can be obtained form NEEDS (800-634-1380). Natural or wood-based cellophane tears more easily than plastic but after a few trials you will be able to use the bags multiple times. Secure bags tight by twist tie or doubling over and sealing with non-toxic tape (this seems to keep food best). They may be used for freezing also. Glass can also be used for freezing if at least one and one-half to two inches of air is left at the top.

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15. CONTROLLING EXPOSURES IN YOUR MEDICAL CARE AND MEDICATIONS
Dr. Bill Meggs, an ear, nose and throat specialist who has conducted research on reactive airways, has found typical sinus inflammation on biopsy--including swelling, redness and “cobble stone” changes--in almost all of his reactive airway patients. In Dr. Ziem's experience, it is common for doctors to misdiagnose this inflammation as a bacterial infection and prescribe treatment with antibiotics. Because chemically injured patients often develop reactions to antibiotics and other synthetic medications, and seem susceptible to yeast infection with antibiotic use, it is important that the doctor do additional tests to determine whether or not bacterial infection is in fact present. This can be done by performing a white blood count. Typically with bacterial infection, the white blood count is increased and there is an increase in the number of neutrophils, the type of white blood cells that responds to bacteria. If the neutrophils are not increased in percent or in number it is unlikely that the infection is bacterial. In this case, Dr. Ziem recommends reducing exposure first to see whether symptoms improve before using any antibiotics, especially since antibiotics may cause side effects and drug sensitivity reactions. This may also help prevent the frequent problems of yeast or candida infections that often plague chemically damaged persons after multiple doses of antibiotics.

Patients, who notice tightness of the airways, with difficulty getting enough air, chest tightness, and shortness of breath, are sometimes given inhalers by physicians to open up the airways. Unfortunately, most of these inhalers contain petrochemical propellants, which can aggravate illness in patients with respiratory reactivity. Doctors should avoid prescribing inhalers with petrochemical propellants. If your doctor feels that this is necessary, he or she should document that your lung function does actually improve with the inhaler and that you do not experience side effects from its use. This is typically done with a lung function test such as flow rate.

In Dr. Ziem's experience, irregularities of the heartbeat and/or rapid heartbeat are common in chemically injured patients after exposures. While medications for these symptoms are available, they do not seem to work as well in chemically injured patients. Unless the symptoms are potentially life threatening, therefore, Dr. Ziem recommends controlling the environment first, which is a safer and more effective preventive measure.

EMERGENCY ROOM TESTING: We are still learning about the changes that occur during reactions to better manage the patient. If you have a reaction significant enough to warrant/need emergency room evaluation, we recommend testing for blood pH (acid/alkaline balance) serum potassium, and venous oxygen level. When the latter is increased, it suggests that the oxygen is not being properly used by the tissues. Oxygen therapy (6 l/min for 2 hours daily for 18 to 36 days) has been reported to reverse this change in a way that often lasts for many months.

MEDICATIONS: Many medications can interact with other petrochemicals and/or affect the way the body is able to get rid of petrochemicals from the environment. It is important that you share this section with your physician because it has been written with your doctor in mind. Phenol often increases symptoms in chemically injured persons and is found in medications such as certain throat lozenges, calamine lotions, some antacids, and phenol-camphor petrolatum lotions. Whenever possible, phenol should be avoided. Substances such as phenacetin, acetanilid, and the disinfectant phenazopyridine are metabolized to petrochemical-like substances which injured persons may find problematic.

Medications that reduce certain liver enzymes (P450 enzymes) can cause pollutants to build up in the body. These enzymes include barbiturates, Benadryl, amantadine, and indomethacin, as well as aspirin, cimetine, and propranolol. Medications, which cause an increase in the P450 liver enzyme system, can cause a problem for certain other chemicals which are broken down faster to toxic “intermediate” chemicals. These medications include phenobarbital, phenytoin, carbamazepine, meprobamate, amobarbital, glutethimide, antipyrine, phenylbutazone, testosterone, rifampin, griseofulvin, and others. Some medications reduce blood flow to the liver, which makes it more difficult to metabolize some pollutants. These include propranolol and cimetine.

People have significantly different abilities to detoxify certain substances based on heredity. Testing can now be done of your genetic pattern, looking at common variations which can be improved by intervention. This hepatogenomics testing (Great Smokies Lab: (800-522-4762).

Medications, which increase liver blood flow, can cause a problem with certain chemicals. These include adrenergic medications such as epinephrine and also nicotine and caffeine. Medications that are tightly bound to proteins in the body can displace chemicals, which are bound to proteins and, thus, make the chemicals more available to act on the body. These medications include aspirin, sulfa drugs, and phenylbutazone. Medications that inhibit the body enzyme cholinesterase make the individual more susceptible to pesticides containing organophosphates or carbonates. Such medications include eye drops for glaucoma and medications for myasthenia gravis. The ability of the body to excrete pollutants depends upon the urine not being too alkaline or acid: thus, medications that affect the urine acidity can influence the body's ability to excrete pollutants. These medications include ammonium chloride, sodium bicarbonate, thiazide diuretics, and acetazolamide. The medications listed above are examples of medications that act by different mechanisms and are not intended to be a comprehensive listing of all medications that can affect the body's handling of all pollutants. Thus, before taking any medication, please review these mechanisms with your physician.

ANESTHESIA: Chemically damaged patients can become very ill with the use of anesthesia. Anesthesia typically involves a significant dose of synthetic chemicals to cause unconsciousness. Patients can remain ill for weeks or months following general anesthesia. For many individuals, acupuncture can provide adequate pain control for surgical procedures. The following is a list of acupuncturists in the Maryland area that you may want to contact. Note that this listing does not imply Dr. Ziem's recommendation or endorsement:

Dr. Cheng (202) 775-1108
Floyd Herdrick (703) 978-4956
David Godel (410) 657-2389
Dr. Trent (202) 659-0515
Dr. Wu (202) 363-2455 c/o Jo-Ellen Hamden

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16. NECESSARY MEDICAL TREATMENT
Two studies Lax, MB, Henneberger PK. 1995. Arch Environ Health, 50(6): 425-31 and DePaul University: Leroy, J., David, T. H., and Jason, L. A. CFIDS Chronicles, 9:52-53, 1996) show that reducing exposure of chemically intolerant patients reduces adverse health affects. This is consistent with the basic dictum of all toxicology: that reducing the exposure dose reduces adverse health effects (Casarett and Doull’s Toxicology: The Basic Science of Poisons, edited by C. D. Klassen etal. Mac Millian, New York 1986.) This is because chemically injured patients have damaged brain function, also know as toxic encephalopathy, immune abnormalities and disturbances of porphyrin metabolism (G. E. Ziem, Environmental Health Perspective) and petrochemical exposure is known to exacerbate encephalopathy and porphyrin disturbance. Chemically injured patients also have impaired detoxification usually involving reduced function of one or more Phase II steps (G. Ziem, J. McTamney, “Profile of Patients with Chemical Injury and Sensitivity”, Environ Health Persp, 105 (2): 417-436, 1997.

Many patients with chemical intolerance have chronic fatigue (85% of Ziem’s chemically injured patients have chronic fatigue, which are treatable by correcting the metabolic, nutritional gastrointestinal and impaired detoxification that occurs in these patients. More detail on medical testing and treatment is in Dr. Ziem’s August 2001 paper, “Evaluation and Treatment of Patients with Chemical Injury and Sensitivity”, available at cost (406-547-2255).

Some patients have had insurance company doctors, also called “IME” doctors, report that they needed no medical treatment and/or no reduction in exposure to neurotoxins. These doctors in our experience are virtually never treating or primary care giving physicians for chemically ill patients. Typically they have no expertise in chemical injury whatsoever, and lack basic familiarity with management approaches to illness from toxic exposure. Therefore, when these doctors lack this basic expertise, as treating clinicians, they are not qualified to render opinions as experts on the issues of treatment. And indeed, to do so probably constitutes malpractice since it is an attempt to make treatment decisions when they lack expertise to do so, and it definitely harms patients with toxic encephalopathy to remain in toxic environments. If you have had interference with your medical treatment by a physician that you believe lacks the clinical experience necessary to make treatment decisions, feel free to ask Dr. Ziem to assist you in taking action on your behalf to restore your basic right to medical care.

CONDITIONS WHICH AFFECT THE VAST MAJORITY OF CHRONICALLY ILL PATIENTS WITH CHEMICAL INJURY AND WHICH ARE TREATABLE INCLUDE: widespread nutritional deficiencies - nutrients are used to process foreign substances and repair injury and often become deficient. Impaired detoxification - our sick patients can’t detoxify for themselves without treatment, and pregnancy requires detoxifying waste for the fetus, also. Normal intestinal function - to maintain adequate nutrition, normal endocrine function (to avoid miscarriage, deformities, etc.). Adequate oxygen-supplying capacity and blood flow to vital organs - the vast majority have changes in red cell shape, due to membrane changes which impairs circulation. Many, but not all, have reduced ability of body tissues to take up the oxygen supplied through the blood stream. Both of which could cause brain or other damage to the fetus). Normal energy metabolism - disturbed in virtually all chronically tired patients by our testing. Normal pH balance - affects body chemistry of mother and fetus. These are essential for all body functions. ALL OF THESE CONDITIONS CAN BE TESTED FOR AND TREATED TO GREATLY IMPROVE BODY FUNCTION.

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17. CONTROLLING NEIGHBORHOOD PESTICIDE EXPOSURE

(Beyond Pesticides 202-543-5450 or www.beyondpesticides.org)

Many chemically damaged persons become ill from petrochemical pesticides used by their neighbors. Maryland and some other states (CO, CT, LA, MI, NJ, PA, and WV) have laws requiring that you receive advance notice for nearby commercial pesticide application if you so request: see the sample request form in your patient packet of materials for Maryland. Contact the Beyond Pesticides (202-543-5450) for information on other states. Some states only cover properties bordering yours. This is inadequate for many patients.

We recommend the brochure Drug Free Lawn by the American Cancer Society (716-698-8981). Try explaining how toxic pesticides are to your neighbors by focusing on their own health, their children, their pets, etc. Most people don't know that pesticides easily enter the body through the skin. They remain as a toxic residue for days, weeks or longer, that many can cause nervous system and/or immune damage, and that even pesticides shown to cause cancer or birth defects are still marketed and sold as “safe.” When your neighbors realize these things and learn about the non-toxic alternatives available, it is much easier to create a less toxic neighborhood safe for roaming children and pets as well as adults. Let them know that children in homes using lawn pesticides were four times more likely to develop sarcoma cancers (soft tissue cancer) and children whose parents used pest strips were twice as likely to develop leukemia [8]

PESTICIDE ALTERNATIVES: Bill Currie of the Institute of Integrated Pest Management (301-753-6930) has many years of experience assisting building managers and persons with chemical intolerant in developing non-toxic pest control programs for both grounds (lawns, etc.) and buildings. He can provide an economically feasible and low-toxic approach which can greatly reduce risk of disability and consequent legal repercussions. He has consulted for HUD and Dr. Ziem on these reasonable accommodations for the handicap of chemical injury. Other sources of information on alternatives to pesticides include: The New York Coalition for Alternatives to Pesticides (518-426-8246), Alan Cohen (202-237-7509), Entomologist Albert Green (202-708-6948), William Forbes, the non-toxic pest control expert for Montgomery County (MD) Public Schools (301-840-8122), and landscapers with expertise in non-toxic grounds maintenance, such as Nature's Tailors (410-655-7821). You also may want to consult the book Common Sense Pest Control by Olkowski.

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18. IF YOU NEED TO MOVE TO ANOTHER DWELLING
If--after pursuing all the above environmental controls--you are still severely handicapped by exposures in your home or neighborhood--you should consider moving to a less contaminated environment, even if it means breaking a lease or other housing contract. (Dr. Ziem can assist you with this, if done for medical reasons.) Of course, you also may need to move for other reasons, unrelated to your illness. Whatever the case, you are strongly urged to:

A. Avoid buying any home, condo, trailer or other dwelling until you have lived in it for at least 12 months to see whether seasonal and other exposures (pesticides, wood stoves, etc.) are going to bother you. Let Dr. Ziem know if you need medical documentation to arrange for a one-year trial lease. A lease can be broken for medical needs if you discover exposure exacerbations.

B. Avoid suburban areas in which chemical lawn treatments are used by neighbors or local government.

C. Avoid high pollution areas near highways, industrial facilities, waste dumps, etc., and congested urban areas.

D. Consider relocating to a wooded area, since plants and trees can help detoxify air. An ideal location is very close to a state, local or National Park or forest if pesticides are not used. (Dr. Ziem can help discontinue toxic pesticide use on such public land as a reasonable accommodation for you.) If you locate in such an area, keep bedroom windows open at night whenever possible. Dr. Ziem's patients who live in such areas have improved much more rapidly than average.

E. Choose a dwelling with electric or solar heat and appliances. Dr. Ziem's patients who use only electric heat and appliances also improve more quickly.

F. Ask for a written statement confirming that the dwelling has never been treated with chlordane (a toxic pesticide which persists for decades). Also ask for written records on all other dwelling/grounds pesticide use.

G. Consider a dwelling using well water, as long as the dwelling is not located near agricultural facilities that use pesticides. Patients using well water seem to do better, although most of them also live in less polluted areas. If well water is available, the water quality should be tested first, by an independent laboratory, to check for possible chemical contamination.

While pollution sources closest to you (neighbor, pesticide use, fireplaces, etc.) are critical to learn about, you can also get information on pollution in the area. This information is assembled from government--gathered data and then put in a usable form. You can select the county or city and find out how it ranks in that state for health risks, which chemicals are released (and by which companies, important in knowing the location of the source), as toxicants, neurotoxicants, etc. are released. To get the information, contact Environmental Defense, New York, NY 10010 or use a computer: Benjamin Smith@environmentaldefense.org for the Environmental Defense Scorecard.

Keep in mind that low income and disabled patients may be eligible to receive assistance (financial and otherwise) in locating low-toxic housing through their state or local housing commission. If this is available to you, be sure to ask the official(s) you are dealing with to contact Dr. Ziem about discuss the specific accommodations needed in your case to provide for a low-toxic environment. Loans may be arranged for housing the chemically injured-for more information. Call 517-689-6369.

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19. PSYCHOLOGICAL COUNSELING
Sometimes the home, work, and social adjustments needed by chemically poisoned persons can strain their (and their family's) psychological ability to cope. Fatigue and changes in the nervous system can also impair sexual function in some persons, and other problems can strain a marriage or family relation. If you have unsolved problems within your family related to your illness, please talk to Dr. Ziem, who is willing to assist you, or ask a support group to recommend a counselor.

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20. PREGNANCY AND TOXIC ILLNESS
While women with chronic illness from toxic exposure are less likely to become pregnant in our experience, perhaps due to endocrine disruption, which affects female hormones, pregnancy can occur. We recommend precautions to prevent pregnancy until you have been tested and treated adequately for the conditions that affect the vast majority of chemically ill patients in our experience. These conditions include: widespread nutritional deficiencies - nutrients are used to process foreign substances and repair injury and often become deficient. Impaired detoxification - our sick patients can’t detoxify for themselves without treatment, and pregnancy requires detoxifying wastes for the fetus also. Normal intestinal function - to maintain adequate nutrition, normal endocrine function (to avoid miscarriage, deformities, etc. Adequate oxygen-supplying capacity and blood flow to vital organs - the vast majority have changes in red cell shape. This is due to membrane changes which impairs circulation, and many but not all have reduced ability of body tissues to take up the oxygen supplied through the blood stream – both of which could cause brain or other damage to the fetus. Normal energy metabolism - disturbed in virtually all chronically tired patients by our testing. Normal pH balance - affects body chemistry of mother and fetus. These are essential for all body functions. ALL OF THESE CONDITIONS CAN BE TESTED FOR AND TREATED TO GREATLY IMPROVE BODY FUNCTION.

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21. SEX AND TOXIC ILLNESS
People who are tired and achy often experience problems with sexual function. A healthy sex life helps the immune system, however. We think you can enjoy sex more with the following suggestions. If fatigue or pains are problems, your partner should assume the positions that require the most energy, and allow you to be the less active partner. You can still give pleasure by touching and kissing areas exciting to your partner. Women can also strengthen muscles involved in orgasm in the vaginal area. This can be done by trying to interrupt your stream of urine, at least once, when emptying your bladder, which helps build these muscles. (More interruptions build them faster, but may be hard at first). (If you can only move one muscle, this is the one!) Also try sex at times of the day when you are less tired.

If vaginal yeast infections are a problem, consult section 15 in this document. Vaginal glutathione gel or suppositories can help vaginal/vulvar burning. Women can help avoid developing bladder infections following sex by always emptying the bladder shortly after sex, by asking the partner to wash hands carefully before sex, and by asking the partner to avoid touching the vaginal area with a hand that has had contact with the anal area. For lubricants, synthetics may be a problem, but you can experiment with butter or vegetable oils made from foods you are not intolerant or allergic to. Incense and perfumes should not be used to set the mood, but good music, videos or other approaches can work. All natural (organic cotton, etc.) bedding can reduce coughing and other less romantic symptoms. As you gradually improve with environmental controls and fresh air, you will gain vigor. Regular walking outdoors will help this. Sometime check out the movie, Coming Home, which shows a beautiful love scene between a war vet who is a paraplegic and a beautiful woman. The movie tastefully portrays happy sex even during this difficult situation. We encourage you to be creative, patient, and persistent.

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22. OXYGEN USE DURING REACTIONS
Some patients with chemical injury who are having a reaction to an exposure feel reduced symptoms with oxygen. This may be because blood flow to their brain can be reduced during these reactions (preliminary data from SPECT brain scans on people with toxic brain injury after exposure challenges).

When oxygen is used, it should not be used at a flow rate over 4 liters per minute (people with lung disease may stop breathing at higher flows and more flow is usually not necessary). Plastic mask and tubing often aggravate symptoms: a ceramic mask usually works well, as does the treated (non-toxic treated) Tygon 0143 nasal cannula and/or mask by Living Source (254-776-4878). A prescription is necessary for obtaining oxygen and special mask and tubing. Carefully follow ALL precautions with oxygen: NEVER use or store in a room with an open flame (cigarette lighters, cooking stove, and sterno heater, etc.).

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23. NUTRITION
Proteins are needed to properly break down chemicals in the body. Certain protein “building blocks” or amino acids-such as glycine, glutamine, taurine, and cysteine-are used in processing chemicals. Deficiencies of various protein building blocks can interfere with processing certain chemicals. Deficiencies can occur with increased exposure to certain chemicals [9], and can be aggravated by problems with absorption (common in chemically ill patients) and vegetarian diets. (Vegetarians may wish to reconsider animal and seafood protein needs, especially if fatigue is present).

Mineral, vitamin, and nutrient deficiencies-especially calcium, copper, iron, magnesium, zinc, and vitamins C, E, B complex, a natural mixture of bioflavinoids, and glutathione-also reduce the body's ability to handle foreign chemicals since these nutrients are used up in the body's processing of petrochemicals [9]. Nutritional evaluation for nutrient deficiencies is recommended for toxic injury patients with persistent chronic fatigue or with poorer absorption of food (frequent loose stools, frequent undigested food in stools). Others at increased risk of nutritional deficiencies include: persons with significant recent exposure to petrochemicals, those with a poorly balanced diet, those lacking adequate animal (or seafood) protein, and those with a long history of frequent consumption of processed or “junk” food. Animal protein such as beef, chicken, pork, mutton, etc. can accumulate antibiotics, synthetic hormones, and pesticides in the fat (often marbled in too well to effectively remove), so try to buy organically raised and range-fed (or free-range) meat whenever possible.

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24. LEGAL ISSUES/LEGAL ADVICE
If a physician has informed you, that you have a toxic-induced illness, you are likely to have a limited time interval to file a legal claim before you lose your legal rights. This differs by type of case, state, etc. It is called the “statute of limitations”. It is wise to consult an attorney with expertise. For work related cases, expertise with occupational illness is preferred. For other cases, experience with toxic cases is wise, eg. toxic torts, etc. If your case involves ADA discrimination or failure to accommodate your disability, expertise with disability law and ideally also with toxic illness.

A toxic injury group called NOLA-EI (National Organization of Legal Advocates for the Environmentally Injured) has been tracking insurance and disability discrimination cases (especially UNUM cases) and trying to organize a class action lawsuit. For more information on NOLA-EI and discrimination, contact:

Brenda Harrison
PO Box 29507
Atlanta, GA 30329
Phone: 404-264-4445,
Fax: 404-325-2569

There is legal precedent that a patient with work-related injury and chemical hypersensitivity from toxic exposure could be reimbursed through worker’s compensation for treatments. This includes nutritional evaluation and treatment of nutritional deficiencies, sauna and other measures to assist the body’s detoxification process, and environmental control measures to reduce exposure (Hanlon Vs Arizona Chemical Corp. etal, State of Florida, claim #261-62-3325, decision 12-2-86). Another legal precedent confirms that a patient with chemical injury should be entitled to ongoing medical coverage, in this case for detoxification procedures, nutritional evaluation and care, and environmental controls, even if needed in an out-of-state facility, (Perry vs. NV Inc. etal, State of Hawaii case #49200727, decision date 2-14-92).

Some patients become chemically injured as a consequence of workplace exposure, some through dangerous or improperly marketed products or services. Some develop total prolonged disability preventing them from gainful employment, and some are denied reasonable access to less toxic housing, workplace, or classrooms. All have legal rights in the United States to workers' compensation; redress under product liability precedents; Social Security and/or other disability income; and reasonable accommodation under the Americans with Disabilities Act, respectively. Furthermore, patients may find that legal recourse is necessary to secure the necessary environmental controls to reduce exposures and thus illness effects.

However, legal issues are very complex in chronic chemical injury cases. The lawyer you select must be experienced both with pursuing chemical injury cases and with the specific legal action(s) appropriate to the situation. Even then, new scientific knowledge is rapidly emerging and attorneys will need to update their technical understanding on at least a yearly basis. Dr. Ziem strongly advises that your attorney become familiar with toxic injury, preferably before filing the claim, obtain and review all medical and medical-legal information recommended, and be familiar with ever-expanding precedents in the recognition of these disorders. Cases with merit have been lost because of inadequate preparation or background of the patient's attorney. Dr. Ziem should address medical issues with your attorney to ensure they are understood and questions clarified.

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25. REASONABLE HOUSING ACCOMMODATIONS
Dr. Ziem has consulted with a civil rights specialist in the United States Government regarding the Fair Housing Act (42USC3600-23620), which applies to all housing, public and private. When you make requests for reasonable accommodation under this act, the landlord and their representatives have no legal right to know your disability diagnosis, nor to request your medical records, nor to request that you be examined by another physician (24CFR part 100). If you live in Federally assisted housing such as section 8 or 811 housing, the landlord is prohibited from requesting any money from you for costs of reasonable accommodation (section 504 of the Rehabilitation Act 29USC794). In private housing, the general legal trend and precedents have been that the owner should pay for reasonable accommodations even when there is some additional cost involved. There is no responsibility of the patient or the patient’s physician to explain why the accommodations are needed or to explain why other accommodations would not work.

There are also some provisions for requesting modifications in tenant behavior but this should be addressed by a request going through the landowner, landlord/building manager. Tenants can be requested to make reasonable accommodations if there is no real cost involved and if only minor inconvenience is involved. This can include such behaviors as requesting advance notice for repairs, pesticide applications, barbecuing, etc. It can also include requests such as not allowing their cars to idle near your apartment.

Since the patient is the only individual who is definitely legally eligible to request reasonable accommodation under the Fair Housing Act, Dr. Ziem recommends that you send a letter by Certified Mail Return Receipt Requested Addressee Only to the landlord/building manager with the following general approach:

1. I qualify as an individual with a disability as defined by the Civil Rights Laws.
2. I am asking for a reasonable accommodation of your ________________ (for example pesticide, repair, etc.) policy/procedure/practice. (Describe in detail the specific accommodations you need, eg. materials and timing).
3. Because of my disability, your current policy has an adverse affect upon my health.
4. Because of my disability, I request the following reasonable accommodations: (list the accommodations that you consider being reasonable. It is often best to consult with a knowledgeable physician or other individual to be sure that your accommodations are as specific as possible and as accurate as possible, for example if you have requested the correct brands, correct procedures, etc.).
5. Please respond to me in writing within _________ days. (Where there is an urgent situation, you may only want to ask for a few days, such as when the landlord is planning on applying pesticides/herbicides in the very near future. For other accommodations, it may be wise to allow at least a week and perhaps two to three weeks so that they have time to make the necessary arrangements and respond in writing.) We have been informed by a civil rights specialist that if they do not respond, you have reason to believe that they have denied your request. Further, it is illegal for them to deny your request unless it would cause undue financial and administrative burden. This has often been interpreted as something that would cause them to go bankrupt or cause a fundamental change in their program. For example, removing all grass and replacing it with concrete would be a fundamental change in their program. Switching from toxic to non-toxic pest control or other products is not a fundamental change in their program.

You should then sign the above statement with the five items described. Your physician can then support your request by adding the following statement:

The reasonable accommodation(s) requested above by my patient, (patient’s name), is consistent with his/her needs directly related to his/her disability and provide any further information needed, such as whether the accommodations are medically necessary, etc. If the patient’s disability qualifies as significantly interfering with major life activity, (eg. breathing) this should be noted.

Your physician should then sign this statement.

ARCHITECTURAL FEATURES (for Multi-Family Housing to Better ACCOMMODATE RESIDENTS with CHEMICAL INJURY and/or ELECTROMAGNETIC INTOLERANCE):

A. No composite, particleboard or other formaldehyde or phenol-emitting “wood product” shelving, kitchen or bathroom cupboards, or for closet doors in unit.

B. Hard surface (moppable) low-VOC (volatile organic compound) flooring in unit and path of travel.

C. Plumb and wire unit for washer and dryer for installation by resident.

D. Wire unit and path of travel for ballast-free light fixtures as an alternative to fluorescent or halogen; provide means of stopping power to stove clock.

E. Large cupboard or walk-in closet, equivalent or bigger than other residents’ storage in common area, wired for an exhaust fan or with operable window.

F. Finish walls and ceiling of unit and paths of travel with no or low-VOC-emitting durable surface or coating; provide fume and vapor barrier between the unit and neighbors’ units using Dennyfoil or equivalent product; finish exteriors with metal siding, autoclaved aerated concrete, other low-maintenance pre-colored surface.

G. Install wiring and outlets adequate for space heaters, air filters, hot water, air conditioning, cooking, medical equipment on independent circuits; no gas to unit.

H. Design landscaping and building foundations to require no chemical maintenance; use plantings that mitigate airborne mold or pollens upwind or along the paths of travel to the unit and common areas; no combustion-fueled landscape maintenance equipment i.e. leaf-blower, lawn mower, or chain saw.

I. Install wiring so the unit shares no common wall, ceiling or floor which backs an electrical panel, refrigerator, fluorescents, computer, microwave oven, re-chargers, transformers, cell or portable phone equipment of neighbors.

J. Placement of unit: protect from cell phone tower, substation, power lines; laundry exhaust, smokers’ units or gathering place; barbecue or outdoor cooking area; swimming pool chlorine fumes; landscaping with chemical maintenance, airborne mold or pollen; asphalt, traffic or parking lot fumes, combustion or gas fumes. Contact:

Susan Molloy, M. A. Accessible Housing Advocate 8657 Hansa Trail Snowflake, AZ 85937 Phone (928) 536-4625 Email: susanm@cybertrails.com

Supporters of these recommendations include the following groups, all of which invite your comments and assistance: New Horizons Independent Living Center, Inc. Nonprofit, consumer-driven 501-C3 organization that advocates and promotes independent living for persons with disabilities. Website: http://myweb.cableone.net/nhilc.

New Horizons Independent Living Center (Main Office) 8085 E. Manley Drive Prescott Valley, AZ 86314 (928) 772-1266 or (800) 406-2377 Email: nhilc@cableone.net Flagstaff Branch: (928) 214-7102

(Dr. Ziem thanks CSDA, Susan Molloy and New Horizons ILC for this information.)

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26. “DRY CLEANING”
Typical commercial “dry cleaning” of clothing actually washes them in a machine with liquid perchloroethylene or other solvents. Residues can cling to such fabrics for weeks or longer in amounts that can aggravate symptoms in persons with chemical injury. A dry cleaner in Silver Spring, Maryland has developed a special process to try to avoid chemical residues on clothing: Ed Boorstein, owner-operator of Prestige Exceptional Fabricare (301-588-0333). While, we cannot endorse or guarantee your response to his processing, consider contacting him for garments that must be “dry cleaned”, discuss your extent of chemical/solvent intolerance and his cleaning process, and decide for yourself. The wet cleaning method seems to have fewer exposures. If your garment needs spotting agents using petrochemicals, doing wet cleaning after spotting will reduce residues.

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27. MERCURY FILLINGS
For over a century, dentists have often used mercury for filling dental cavities and doing root canal procedures. These are often called “silver” fillings. Mercury has been known to be neurotoxic since before Lewis Carroll wrote about the mad hatter in Alice in Wonderland (mercury was used in preparing and shaping hats in those days).

Mercury evaporates at low levels, and evaporation from the mouth may increase with drinking hot beverages, tooth grinding, (eg. during sleep), chewing (including food or chewing gum), and drinking acidic beverages. Some studies indicate higher body levels of mercury in people with mercury fillings, greater with more fillings.

However, REMOVAL OF MERCURY FROM THE TEETH CAN ITSELF CAUSE EXCESS MERCURY EXPOSURE. This can occur because high-speed drills cause more evaporation of mercury during the procedure, since they heat the mercury and it evaporates much more quickly when heated. Also, tiny pieces can be swallowed during the procedure. This may partly explain why only 28% of 305 chemically intolerant patients found mercury amalgam removal to be a major help in a study conducted by DePaul University.

Also, CRITICAL TO RESOLVE BEFORE TOOTH REMOVAL, is the issue of the substitute material to be used in place of the mercury. Special testing may be needed to assure that the new material is not only less toxic but is tolerated well by the patient and will not induce an adverse immune response.

If you decide to have dental work involving drilling done on teeth containing mercury, consider the following precautions:

A. Ensure you have identified a less toxic well tolerated substitute before fillings are removed or root canals are disturbed/removed.
B. Select a dentist who is familiar with mercury removal precautions and willing to follow them.
C. A rubber or rubber-like dam helps prevent swallowing mercury amalgam particles.
D. An assistant holding a suction device near the tooth during all drilling and remaining removal work reduces the amount of mercury vapor breathed in.
E. Removing the filling in sections may reduce it becoming pulverized (tiny particles which more easily evaporate and/or are swallowed).
F. Copious water properly directed to reduce the heat of the drill and flush mercury particles out of the mouth, not toward the throat where swallowing may occur.
G. Using a slow speed, not high speed, drill to reduce mercury evaporation.
H. A separate air supply for you through your nose to reduce the mercury you breath from the mouth during amalgam removal.
I. Some dentists recommend the patient take chlorella for two weeks before and after the procedure. Some also recommend rinsing the mouth with chlorella right before and right after the procedure. The after rinse should be spit out. Some dentists also paint chlorella on the gums and mouth tissues as part of the procedures. Chlorella is used because it is believed it can help bind the mercury.
J. Some dentists feel that having different kinds of metals in the mouth (eg. mercury fillings and filling, braces, pins, etc. of another metal) can set up small electrical current which may stress the body over time.
K. There is some evidence that root canals may often contain low-grade infections. In these situations, this may be adverse to health.

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28. INDEPENDENT MEDICAL EXAMS
If you are required to get an independent medical evaluation by an insurer or employer physician and are concerned that spending time in a potentially toxic medical office could aggravate your illness, please contact Dr. Ziem's office for assistance. Reasonable accommodation to reduce exposure during these evaluations is important: If the IME doctor is truly an expert that is a treating doctor caring for toxic injury patients, he/she should have non-toxic measures already in place. If the IME does not serve as a treating doctor for toxic injury patients, this strongly suggests lack of clinical expertise. One would not seek an expert opinion on diabetes from a doctor who had never treated a diabetic and you should not have to risk your health for such evaluations. Dr. Ziem can assist in requesting appropriate and reasonable accommodations to which you are entitled under Federal Civil rights Laws if your condition significantly interferes with major life activities (work, house work, chores, etc.). NEVER ACCEPT ANY CHALLENGE TESTING before discussing with Dr. Ziem because some types can cause long standing exacerbation and some others have meaningless, unverified protocols and can aggravate your illness without potentially valid conclusions. This includes methacholine challenge during lung function testing. Methacholine is a respiratory irritant that can cause long lasting exacerbations (weeks to months) in toxic injury patients with reactive airway disease.

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29. TRAVEL
GETTING ANOTHER CAR: If you need to replace your car, it may be best to buy a used car that has had time to “off-gas” chemicals from carpets, plastics, treated fabrics, under-coatings, etc. Try to get a car from a nonsmoker or someone with allergies who try to avoid air fresheners and other chemicals. Used rental cars used only for nonsmokers may be a good buy. Ask whether pesticides have ever been sprayed in the car. Some chemical odors can be removed from carpeting by using a solution of half AFM Carpet Shampoo and half Mystical cleaner in a water-extraction carpet shampoo machine. An ozone generator may be used in the car for up to a few hours (longer may damage the interior). The car should then be aired for a few weeks after the ozone and before use, with windows open if possible. Never occupy any space treated with ozone before it has been thoroughly ventilated. The car dealer may allow you to leave the car on the lot with windows open after ozone treatment for several weeks.

New cars are probably a greater risk. Many leathers are treated with formaldehyde, which gives that “new leather smell.” Fabrics are coated with anti-stain treatments (“new car smell”). Undercoating treatments may aggravate symptoms for several weeks or months. Ozone and carpet shampooing can be done to reduce exposures as discussed above. Using a car filter device is even more important with a new or used car. Consider the Allermed model if you do not own one already.

TRAIN TRAVEL: If you need to take a train (Amtrak, etc.) and are unable to persuade them to provide less toxic seating for you. (A non-smoking car with no pesticide spraying in the last 1-2 months, and no odor masking, disinfectant or air freshener petrochemicals in a rest room), please contact Dr. Ziem's office for assistance.

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30. SPIRITUAL RESOURCES
Some patients wish to attend church but have not been able to do so because of scented products or other lack of accommodation. What follows is a partial list of spiritual resources focusing on chemically injured patients (your suggestions/comments welcome):

1. Share, Care and Prayer P O Box 2080 Frazier Park, CA 93225
2. Hand of Hope Counseling Ministry, Chaplain Jim and Jan Forbes RN, RR1 Box 135-B Hot Springs, SD 57747 (605)-673-5565
3. Gathering Hearts Ministry, Rev. Gulie Molekenthin 8 Camelot Court W. Canandiagua, NY 14424

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31. GETTING MORE INFORMATION
You may have questions about your environment that come up in between your appointments with Dr. Ziem. There are groups of toxic injury persons in many states that share information and support. In Maryland, contact Carol Beauregard, the hotline coordinator of the Chemical Sensitivity Disorders Association (PO Box 24061, Arbutus MD 21227, 410-792-4875). Like many support groups, CSDA publishes its own newsletter--which is available for just $10 per year. To learn about support groups in other states, contact any of the national organizations listed below. Also listed below are national organizations and hot lines that you can contact for information about particular chemicals and pesticides. For more information on reducing exposures and finding less toxic alternative products, contact Carolyn Gorman, the health educator who has counseled thousands of chemically ill persons and the author of Less Toxic Living, at 214-368-4132. For information on chemical injury in children and school issues, contact Marian Arminger at 410-247-3953.

To obtain government-held information (on workplace or other inspection results, non-trade secret chemical information, etc.) consider the booklet: A Step By Step Guide to Using The Freedom of Information Act, item #4002, $3.00 from the American Civil Liberties Union (212-549-2500 or www.aclu.org).

NATIONAL ORGANIZATIONS & PUBLICATIONS:

Chemical Injury Information Network
P O Box 301
White Sulfur Springs MT 59645
Ph # 406-547-2255
Publishes “Our Toxic Times” Membership: Free (donations requested)

Environmental Access Research Network
Route 1, Box 16G
Epping ND 58843
Ph # 701-859-6367
Publishes “Environmental Access Profiles” in Our Toxic Times (see above) and maintains extensive MCS library of over 10,000 medical references.

Environmental Health Network
P O Box 1155
Larkspur CA 94977
Ph # 415-331-9804
Publishes “The New Reactor” Membership: $10 to $35

Human Ecology Action League (HEAL)
P O Box 49126
Atlanta GA 30359
Ph # 404-248-1898
Publishes “The Human Ecologist” Membership: $15/year (national organization with local chapters)

MCS Referral & Resources
508 Westgate Rd
Baltimore MD 21229-2343
Ph # 410-462-6400
Publishes recognition issues and summaries of federal, state and local government authorities as well as court rulings and statements of independent organizations.

National Center for Environmental Health Strategies
1100 Rural Ave
Voorhees NJ 08043
Ph # 609-429-5358
Publishes “The Delicate Balance” Membership: $15/year

MCS Beacon of Hope
5427 Springwood Drive

Pinellas Park, Florida 33782

(727) 541-4390

INFORMATION ON CHEMICALS, PESTICIDES AND PRODUCT SAFETY:

EPA Sponsored National Pesticides Telecommunications Network, 800-858-7378/(806-743-3091 in TX)

Environmental Research Foundation (publishes “Rachel Carson's Hazardous Waste News”), 410-263-1584

Beyond Pesticides, 202-543-5450
Toxic Substances Control Act Hotline (U.S. EPA), 202-554-1404
Consumer Product Safety Commission, 800-638-2772

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32. REFERENCES
1. American Council of Government Industrial Hygienists. 1993-94. Threshold Limit Values for Chemical Substances, page 2.
2. Ziem, G. and B. Castleman. 1989. “Threshold Limit Values: Historical perspectives and current practice,” Journal of Occupational Medicine 31:910-918.
3. Ziem, G. and B. Castleman. 1988. “Corporate influence on the Threshold Limit Values,” American Journal of Industrial Medicine 13:531-559.
4. Roach, S.A. and Rappaport, S.M. 1990. “But they are not thresholds: a critical analysis of the documentation of threshold limit values,” American Journal of Industrial Medicine 17:727-753.
5. Castleman, B. and G. Ziem. 1989. Guest editorial: “Toxic pollutants, science and corporate influence,” Archives of Environmental Health 44: page 68.
6. Havey, B. and B. McCreary. Toxic Times Newsletter.
7. Interior Landscape Plants for Indoor Air Pollution Abatement, Sept. 1989, page 18.
8. Leiss, J. 1995 “Home Pesticide Use and Childhood Cancer”: American Journal of Public Health 85: 249-252.
9. Casarett and Doull's Toxicology: The Basic Science of Poisons, Chapter 4

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33. REDUCING EXPOSURE REACTIONS
A major mechanism causing illness symptoms at levels of chemical exposure you formerly tolerated are called NEURAL SENSITIAZATION. This is a change in brain biochemistry that until interrupted will continue to perpetuate itself. Toxic exposure and its inflammation increase the nitric oxide in the brain, which is then converted to the tissue-damaging substance peroxynitrite. That, through other chemical steps again increases nitric oxide, creating a vicious biochemical cycle. Fortunately, there is intervention that has a healing, rather than “symptom masking” effect.

To reduce the severity of exposure reactions, when you have a reaction, do the following:

A. Glutathione by nebulizer (stomach acid breaks it down): begin with dilute level NOT causing irritation, work up as tolerated to 60 mg/ml (or even 100 mg/ml later), 4 cc daily. Split doses a.m. and evening if desired, when tolerated combine to all evening (helps restful sleep, too). Glutathione is the body’s own antioxidant and major detoxifying substance.

B. B12 in the form of hydroxycobalamie goes to the brain to “scavenge” the nitric oxide (up to 5 mg twice weekly).

C. Effects of nitric oxide can be reduced by:

1. Trimethyl glycine (up to 500 mg daily).
2. Magnesium malate (125 mg daily as Magnesium, more if magnesium deficient).
3. Bioflavinoids which work best on specific organs:
a. Gingko biloba 60 mg twice daily (brain)
b. Silimarin 70 mg twice daily (liver)
c. Bilberry 60 mg twice daily
d. Cranberry extract 200 mg twice daily (urinary)
e. Carotenoid mixture: 5 mg lycopene, 5 mg beta-carotene, 5 mg lutein, and other cartenoids
D. Broad range of other antioxidants:

1. Buffered Vitamin C 250-500 mg/day. To ensure your amount is adequate, use Perque C strips to test your vitamin C levels. Perque C strips can be purchased through Needs Pharmacy (800-634-1380).
2. Mixed tocopherols (Vitamin E): Alpha, beta, gamma, and delta 200-400 IU daily
3. Selenium 200 mcg daily
4. Coenzyme Q 10 75 mg daily

E. Alpha Lipoic Acid – ESSENTIAL to convert glutathione back to active form in all tissues. Water-based and lipid (cell membranes, lymph, and brain, etc.). 600mg daily in sicker patients can be reduced after exacerbations very significantly better, to 300 mg daily.
F. Substances, which are needed to make SOD (Superoxide dismutase), essential for interrupting the vicious biochemical cycle discussed above.
1. Ample zinc, then 15mg daily. Zinc picolinate form
2. Copper 1 mg daily as copper sulfate or picolinate
3. Manganese adequate, then 1 mg daily as Manganese gluconate or picolinate (Thanks to Dr. Martin Pall, the biochemistry of neural sensitization is better understood and thus more treatable)
G. You may use Alka-Seltzer Gold or a tri-salt solution in water to reduce the acid in the body during reactions. Two parts sodium bicarbonate to one part potassium bicarbonate may also be used. Order pH strips from your pharmacy to test your urine before each dose to determine when and how much to use.
H. If you have impaired thinking or other brain or heart functions, use oxygen at 3-4 liters per minute with ceramic mask and Tygon 2075 tubing until your brain or heart function has improved. Glutathione as nasal spray can also help improve these effects.
I. If you anticipate an exposure (family event, travel, other), follow 1 and 2 above for a few days in advance at lower end of recommended doses for shorter or less intense potential problems and midrange for longer or more intense exposure. Check your pH in advance and correct using our dietary handout (or #3 above if necessary). Also take along glutathione nasal (Key Pharmacy 800-878-1322, Abrams Pharmacy 800-458-0804, or Apothecary 301-530-0800).
J. Respirator use: Remember that these precautions will not adequately protect your eyes, skin or respiratory system from irritants. If you experience burning of the skin or eyes, exposure is probably enough to cause sinus, lung or other respiratory effects-leave the area if possible. OSHA regulations allow you to leave a work area that is adversely affecting you-notify someone if you can without getting sicker. To protect your respiratory system, use a DenBraber cloth mask (look-alike masks DO NOT have adequate fit for good protection). Call 817-469-9626 or e-mail skdbrn@ticnet.com or fax 817-860-9299. Silk is easier to breathe through than cotton, lasts longer and straps are less likely to catch on hair. Order extra activated charcoal filters-they last 6-10 hours on average. Open the filter and put it in the respirator, watching the shape so it goes in correctly. Then PRACTICE PUTTING THE MASK ON QUICKLY before you need it, so when you need it, you can have it on with in seconds. Face the mask with the metal noseband up, the opening to the inside, put the bottom strap first over your head and then the top strap second, so it crosses over the bottom strap, helping hold it in place. When not in use, store mask with filter in an airtight glass or metal container (a small glass jar with a wide mouth works best), since once opened, the charcoal filter picks up vapors even when not in use. A few people don’t tolerate activated charcoal well: DenBraber (an occupational health nurse) can send samples of alternatives to use. Carry your mask when you go out and use it as needed. For less intense exposures, you may find the Air SupplyTM device to help some (less than a mask).

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34. CLEANING CHEMICALS:
A joint project between the U.S. Environmental Protection Agency and California found that 41% of standard cleaning chemicals are “dangerous”. Common dangerous ones were toilet bowl cleaners, floor strippers, degreasers, drain cleaners and oven cleaners. This is a pilot project to reduce hazardous cleaning chemicals. For more information, call 925-283-8121 or Website www.estp2net.org/janitorial/jp4.htm.

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35. SAFER PEST CONTROL:
A growing directory of companies that use nontoxic/least toxic pest control methods is being put together, thanks to Beyond Pesticides (202-543-5450), a nonprofit organization with technical and policy expertise long active in reducing toxic injury. The directory is called Safety Source for Pest management or www.beyondpesticides.org.

MB Lax, PK Henneberger, “Patients with Multiple Chemical Sensitivities in an Occupational Health Clinic: Presentation and Follow-up”, Arch Env. Health 50:425-431, 1995.
“Treatment Efficacy, a survey of 305 MCS patients,” The CFIDS Chronicle, Winter 1996, page 52-53.
T.H. Davis, L. A. Jason, and M. A. Banghart, “The Effect of Housing on Individuals With Multiple Chemical Sensitivities,” Arch Env Health, 50:425-431,1995.
C. S. Miller, “Multiple Chemical Sensitivity Syndrome”. J. Occ. Env. Med., 37:1323, 1995.