12,000 Canaries Can’t Be Wrong
by John Molot, M.D.
Hardcover 272 pages. 2014. Toronto: ECW Press. Available from Amazon or ECW Press. Learn more about the author at www.johnmolot.com.
Dr. John Molot is a Canadian physician with thirty years experience in clinical practice, expert opinion and medical advisory roles in environmental medicine. His recently published book 12,000 Canaries Can’t Be Wrong is a valuable addition for the library of anyone with a chronic illness, and of particular interest to those with chemical sensitivities. The book’s subtitle “What’s making us sick and what we can do about it” is an accurate indicator of the book’s broad content scope and practical tone.
Molot begins by writing about the history and policy of environmental medicine through personal and national lenses. Then he covers pollutants in indoor and outdoor air, food and water. The core of the book is a review of the biochemistry he feels is pertinent, both an over view for the lay person and references to the studies that demonstrate how chemical sensitivity could develop. His focus here is mainly on the limbic system, neurotransmitters, and neurons but he also gives plenty of space to detoxification, immune, and gastrointestinal systems as well as genetic variation and epigenetics. All of this leads to an oxidative stress continuum theory that pulls it all together with a follow up on how to treat the imbalanced systems.
I find this book to be complete, in the sense that it is self contained. MCS is a complicated and controversial topic so most books on the subject are understandably focused on one aspect of the issue; how to treat, one possible etiology, a criticism of policy, personal narratives, etc. So it is refreshing to read a document by someone who has worked through all the aspects of the issue and has a complete vision of the problem and a solution. That doesn’t mean I think everything he writes is correct or that the absolute truth is revealed, but within his book he is consistent and thorough. If you add in the companion reference book 12,000 Canaries Can’t be Wrong: Establishing The New Era of Environmental Medicine which cites all 2,000 articles from peer reviewed journals and will be published in 2015, it might even be comprehensive. In an attempt to cover its scope and length, my review is divided into sections that mimic the book itself.
History, Policy, and Perspective
Dr. Molot’s understanding of chronic illness is a patient driven one. His theories evolved from treating patients and his stated primary goal as a physician is to empower his patients to take care of themselves. While I cannot speak to his success as a physician, his writing certainly confirms his belief of educating the patient to make their own decisions. He manages to hit the perfect note of neither talking down to nor talking over the reader when it comes to the more technical areas of the book. His entrance into environmental medicine was a bit of an accident, as he kept seeing those kind of cases at his practice. More specifically, some curiosity lead him to review 200 of his patient charts in 1985 wherein a pattern began to merge; a pattern of common complaints that involve multiple systems. Some previous personal experiences with his brother’s and daughter’s painful health problems probably influenced that moment. You spend enough time on the other side of a doctor’s desk and that perspective stays with you. It left his mind curious enough to look for a pattern and open enough to see it.
As he tracks his personal and professional history, he also draws a parallel timeline of policy development in both the governmental and medical organization level. Sometimes the policy effected him and more recently he has effected policy. I was fascinated to follow the history of Canadian policy but glad that he included similar milestones in American organizations; some of them were familiar to me and some were news. While he is critical of most of these backward looking stances he is sympathetic to their reluctance to change, “It is not my intention to denigrate my colleagues or my profession, of which I am very proud, but doctors are no different from laypeople in being influenced by their personal and cultural characteristics during decision-making.” Molot feels that while we cannot trust the government, the market or the industry to make the policy changes we need to see, the ideal theoretical solution of trusting your doctor is not a viable option yet. As a whole, physicians are not informed about environmental illness enough and in the meantime we the patients must be the ones to make the changes. “Since you are likely going to do it on your own, gather information and make your decisions with wisdom.”
To that end, Molot works to clarify some issues for his readers; namely the difference between literature reviews, position papers, and studies. For non scientists, those can be hard to differentiate and he reminds the reader that doctors come with their own biases. He introduces one of the major themes of his book; systems medicine as the complement to reductionism. “Reductionism is invaluable, extremely beneficial, and absolutely necessary for the practice of good medicine, but it is best suited for acute diseases…It is also vital as a research tool, providing the details necessary to understand and design systems research. The problem with reductionism is the assumption that it is the only solution, the only perspective, the only manner in which doctors should think.” It is frequently stated that MCS, Fibromyalgia, ME are functional complaints with no abnormalities, and while there is disagreement on the statement, I agree with the author’s counterpoint that none of the chronic illnesses can be explained by breaking down the body into separate systems or organs. “Chronic illness is about the failure of multiple systems. We could better prevent and treat them if we took a systems medicine approach.”
Before he writes about the body’s systems, Molot reviews everything that damages them; the pollution coming from air, water, body products, food and its packaging. As a long time MCS sufferer, this was not new to me so I won’t review it much here but any new MCS patient will find this section very useful. The information is all there and well presented including the usual alarming statistics like “There are more than 3,000 high-production-volume chemicals out there. Fewer than half of them have been tested for their potential human toxicity, and less than 20 percent have been tested for their potential to cause neurodevelopmental toxicity.” One new insight that stood out for me was how indoor air quality assessments are completely inaccurate when they fail to consider the dynamic chemical reactions that are constantly occurring on surfaces, both animate and inanimate. What does it matter what an air quality test reveals in one snapshot when a few moments later, the air conditioning with mold will kick on, and the left over cleaning fluid on the table will react to something else in the air, which will then further react to one of the many undisclosed ingredients in an occupant’s perfume?
Connecting the Dots
The book’s most unique contribution towards environmental illness literature is contained in the sections where he “connects the dots” of established science, medicine, and published studies. This is the area of the book where the author’s well balanced tone worked very well for me; he goes into just the right amount of detail while still keeping the big picture in the reader’s mind. He also points out something that I, as a scientist, was embarrassed not to have realized before. My chagrin was quickly replaced by the joy of a good “a-hah” moment. So far there has not been any reliable (meaning repeatable, accurate, and precise) demonstration of sensitivity to chemicals using the ideal methodology of a double-blind study. Double blind means that neither the patients nor the observers can know if the exposure is real or placebo. Molot writes, “ However, the only way to mask the chemical is to either dilute it so there is no detectable odor or to mask it with another chemical. Either way, it doesn’t work. Patients being studied will not react to a chemical if the level is too low. Nor can they tell the difference when the chemicals being studied and the inert placebos are both masked by a separate, possibly offending chemical.”
Well, that is a conundrum. To eliminate bias and keep it blind they have to eliminate all identifying traits, including smell. Diluting or masking the smell makes this particular experiment moot. Until they figure that tricky bit of science out, we can look at separate pieces of the puzzle and mentally put them together. He explains each of the following points with published studies or established science; none of this part of the book contains his personal theory. I found this whole section fascinating but rather than detail all of his “dots”, here is his summary of the chapter:
“The limbic system of the brain contains deposits of chemical pollutants from air pollution
Chemicals sensitize the limbic system
Chemical pollutant exposure can cause oxidative stress
Oxidative stress is common among patients with MCS and SBS, as well as ME/CFS and FM, all of which are frequently co-morbid
MCS patients are more likely to have an abnormal genotype for detoxification
MCS patients have inferior detoxification systems compared to the normal population
MCS patients have oxidative stress
Once sensitization to some chemicals occurs, sensitization to other chemicals is more likely
TRPV1 receptors are found in the limbic system of the brain
Sensory neurons contain TRPV1 receptors
TRPV1 receptors are also located in the areas of the body that are dysfunctional in environmentally linked illnesses: the brain, the respiratory system, the gastrointestinal tract, the bladder, and the immune system (mast cells)
Chemicals stimulate TRPV1 receptors
Stimulation of TRPV1 receptors activates neurons
Oxidative stress sensitizes TRPV1 receptors
Chemicals sensitize TRPV1 receptors.
And, most important: MCS patients have demonstrated TRPV1 receptor sensitization in capsaicin challenge studies.”
“ What all this means is that the sciences of genetics, cell biology, and chemical toxicology, supported by animal models and proper challenge studies in humans, attest to the fact that susceptible people can become sensitized to multiple different chemicals, with resulting illness and disability. This summary of evidence provides very solid proof for the existence of MCS as a distinct biological entity. The weight of evidence is robust. To state that MCS cannot exist because it defies the traditional toxicology paradigm means that it is time for a paradigm shift. The statement “there is no science to support the existence of MCS” now borders on ignorance. The canaries are real.”
In his years as a practicing physician the author has worked with more than 12,000 patients who fit the pattern of chronic illness, thus the title of his book. Combining his knowledge of the science and studies, as listed above, and his experience in helping his canary patients, Molot has identified an underlying principle that he refers to as the oxidative stress continuum. He views it as a spectrum of health ranging from, total health to complete breakdown, that we are all progressing down. Like aging, we don’t have the power to reverse it but Molot believes that with awareness we can slow down the progression and moderate its effects.
Oxidative stress, via multiple pollutants or toxins, occurs through multiple pathways all of which Molot discusses in detail. He includes an explanation of the role of genetic variation, especially in the detoxification system. Those variations may predispose some patients towards chronic illness but he writes that it is too soon to see true genetic changes in response to environmental factors in the species as whole. However, we do see that response in epigenetics. Epigenetics is the expression or inhibition of genes and if pollution, toxins, or hormone mimickers are providing enough oxidative stress then the epigenome might be damaged. A damaged epigenome will turn it’s gene off or on at inappropriate times and then we see negative effects that might be passed down to the next generation. Molot also writes about oxidative stress to the immune system, especially in the gastrointestinal tract, and how systemic inflammation can develop through cytokines. He then discusses the oxidative stress that can damage lungs, energy production via mitochondria, and even the brain directly. He also devotes an entire section to the the oxidative damage that can lead to obesity and how that condition adds additional oxidative stress to the body.
Molot believes that the constant oxidative stress of modern living and the subsequent damage to multiple systems happens to everyone all the time, but largely goes unnoticed until the damage is too late. So why is that environment influences or causes illness in everyone, but is only noticed by people who have developed chemical sensitivities? Pollutant damage is evidenced largely in disorders of the immune, respiratory, gastrointestinal, and central nervous systems. These are all systems that interact via the limbic system, cytokines, and TRPV1 receptors, and as he demonstrated in his “connect the dots” section, those are the pathways that can be sensitized. “These are the common denominators that explain the functional disorders, and the environment influences them. If you’re a canary you can feel it. If you aren’t, you can’t.”
In the old paradigm of reductionist reasoning, where illness is attributed to a single system, MCS is frequently debated as a choice between physical or mental, and causation as a choice between chemicals and stress. Molot believes, “An alternative explanation is that the stress response is triggered by chemical exposures, that he triggering doses are not toxic but the brain reacts because it has become chemically sensitized, and that the process of sensitization is iniated by oxidative stress.” To clarify, the author is using the word stress here to include the oxidative stress of environmental exposure that he believes is the underlying agent of damage. Molot’s premise is that the same pollutants that cause oxidative stress to multiple systems in everyone’s bodies go a step further and causes central sensitization in people with the unfortunate combination of genetics and exposure. In the above quote, he refers to non toxic triggering dose in the single instance case, not as a way of declaring environmental pollutants as being safe. In fact, the toxicity of our air, food and water is the underlying assumption of his nine point treatment plan.
9 Point Grandma plan
Having reviewed the scope of environmental toxins we are exposed to, established a scientific basis for central sensitization, and traced the physical systems that oxidative stress can damage, Molot moves onto his treatment plan. He structures his advice on his grandmothers “successful nine-point program for good health and longevity — or in other words, for oxidative stress management.” I don’t like the idea of disguising a medical treatment with sentimentality, but then again, the most agreed upon MCS treatments have always been common sense based.
His plan of action includes plenty of exercise, which he breaks down with statistics on our sedentary culture and benchmarks for measuring exercise but summarizes with advice to not over think it and instead just do it. Molot and his grandmother both recommend fresh air by being aware of your community’s air quality and then working with or around that to find some good fresh air every day. MCS patients also need a clean room with adequate ventilation and minimized toxic sources. His fourth point is to ensure access to sunshine giving us enough vitamin D and stabilizing circadian rhythms. Following that, he recommends that patients get plenty of sleep. In keeping with his style, he provides plenty of statistics on how and why but ends with a simple reminder to get the right sleep at the right time. The sixth item on his grandmother’s list is cod-liver oil, or just fish oil and good fats. He also believes that not making excuses and feeling loved are essential components of healing.
Molot and his grandmother both insist we all need lots of vegetables since they are the most important source of dietary antioxidants. He spends more time discussing this point than any of the other nine, reviewing the pros and cons of mediterranean, paleo, and vegan diets while acknowledging the difficulties on making any change, “Food is where we have the most environmental control but the least self-control.” His conclusion is that we should pick which ever diet works for us, using a combination of alarming statistics and straightforward grandmother practicality to make it seem necessary and manageable. As to the question of supplements he writes, “If you are thinking of taking supplements, remember that more than a thousand antioxidants have been identified. You must emphasize antioxidant sources in your diet. Which additional antioxidants you should take is presently based on logical probabilities.”
Molot successfully covers the whys and hows of environmentally triggered chronic illnesses, with a focus on the establishment of sensitization as a proven biological mechanism and oxidative stress as the unifying link between these illnesses. There is enough exposure discussion for the new patient, enough science to appeal to the technically minded patient, and enough practical treatment options for the struggling patient. Regardless of which kind of patient you are, everyone needs to hear and believe that, “Successful chronic disease prevention and management is predicated on individualized person-centered care and empowerment.”