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Rheumatic Diseases and the Environment
  1. A D DAYAN

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    Rheumatic Diseases and the Environment Editors: ld kaufman, j varga. (Pp xiv+253; £) 1999. London: Arnold. ISBN 0–412–07911–9.

    Popular belief associates “the rheumatism” with a poor environment, especially oncoming wet weather. This very readable book discusses just about every other form of environmental factor and more formally defined rheumatic diseases but has difficulty in crystallising belief into fact or even well supported possibility. The problem often is what a recent British politician unblushingly termed “economy of the actualité”.

    The editors have provided us with a very good and quite multinational set of authors, some of whom have been critical of their own and their colleagues' ideas and data, but others have been content just to reproduce popular reports, even conflicting ones, without attempting to analyse, criticise, and decide on the validity and the value of the claimed associations. If I want unrestricted and unconsidered information I can go to the Internet and be swamped. If I read a book I want learned opinion and justified criticism.

    The initial chapter is a concise but effective account of epidemiology, which explains what environmental exposures may amount to and then describes various forms of ecological and epidemiological survey that might be useful in investigating links between such exposures and rheumatic diseases. It is good in itself, but why spend six and a half pages on a general account of a subject as large as epidemiology when there are large and inevitably more effective monographs in print? Its companion chapter deals briefly and tritely with the laboratory diagnosis of selected rheumatic diseases.

    The next section covers mechanisms and the genetics of autoimmunity and environmentally associated disorders. Here you will find the ever popular lists of drugs and a few chemicals, much about HLA and MHC in human and in animal models, and the common intention of the cellular geneticists soon to have explained everything. They have yet to do so but one can learn from their travels.

    There is more meat in the accounts of proved disorders and their associations, notably, the toxic oil, eosinophilic myalgia and other fibrosing syndromes, followed by descriptions of drug induced systemic lupus erethematosus and pulmonary hypertension, the silicone catastrophes, smoking, and a duet of the peculiar chronic fatigue and multiple chemical sensitivity syndromes. Where there are physical disorders to consider, there are good accounts of what is known and a valiant attempt to note general environmental factors (diet, work, etc) possibly associated with the disorder. The uncertain conditions, such as the silicone, chronic fatigue, and multiple chemical sensitivity claims, are described but not critically assessed. They lack firm decisions about their real existence, their true nature, and possible causal factors.

    Workplace related conditions get three competent chapters covering upper limb disorders, osteoarthritis, and low back pain. The last section, also of three chapters, may hint why so much of the writing is tentative and expresses indecision in a way not normally associated with writers of such calibre. It comprises carefully written material on the surveillance of adverse reactions to food and drugs by the United States Federal Drug Administration, with almost no hint that the rest of the world can also do a good and sometimes better job, a lengthy, almost philosophical and very defensive piece on differences in causation as understood by science and medicine in general and United States legal practices in particular, and a retrospective view of some of the problems associated with attempts to survey the eosinophilia-myalgia syndrome.

    It is soon apparent that what may be regarded as association or causation in medical practice is often totally subverted by the forensic skills of fluent lawyers and prolix self professed experts. The legal system in the United States has long encouraged the growth of bizarre beliefs and only recently have attempts begun to restore the intellectual health of its expert witness system by distinguishing objective science from frank nonsense.

    There is a lot in this book and it is all very readable, but it would have benefited from greater certainty about its goal and encouragement of more of its authors to give and justify opinions rather than bland reviews of the available, often contradictory views. It could usefully have given more space to the real problems of occupationally associated rheumatic disorders and to a critical review of the claims of causal links between the diet and a wide range of chemicals encountered in everyday life and diverse common disorders. Every reader will learn something from it, especially if they have ambitions to make a career in the courts, but it is not the type of book to which you are likely to return several times for wisdom and understanding.