Mixing--and separating--mold and myth: experts say it's hard to find scientific facts to support claims of some mold-related health hazards. (Mold: Property/Casualty).

Melinda Ballard became a champion of policyholder rights after a Texas jury awarded her $32 million against Farmers Insurance Group for mishandling her family's mold claims. Erin Brock-ovich, the subject of a hit movie for her legal fight against a major utility company, testified before a California state Senate committee that her mold-infested home led to family health problems. And television personality Ed McMahon sued his homeowners insurer for more than $20 million, claiming the insurance company failed to remediate a water-damage claim correctly and the subsequent exposure to mold led to his beloved dog's death.

These and other developments have helped generate public concern--and a considerable body of myths--about the health risks of exposure to mold. And dispelling these myths with the firm facts of science doesn't come as easily as experts might wish.

On one hand, researchers know that harm can come from ingesting large amounts of mold in food or by inhaling high levels of mycotoxins--the toxins produced by a fungus--at some work sites. What's not fully understood in this very complex controversy, however, is whether inhalation at far lower levels in homes, schools or offices can cause the "myriad of symptoms, such as headaches, dizziness or concentration problems, or sick-building syndrome that people have been complaining about," said Dr. Jonathan S. Rutchik, a neurologist who is also board-certified in occupational and environmental medicine.

That's why bodily injury claims based on mold exposure need to be examined on an individual basis, he said. "I can't say we know enough about any of these things to say 'yea' or 'nay.'" Rutchik said. "All we know is, we don't have enough information."

But, according to many experts, the little information gathered so far fails to support arguments that mold mycotoxins pose a health danger in homes and offices. "There is no good science today that relates any mycotoxin-related disease to indoor environmental exposures to mold," stressed Dr. Ronald E. Gots, a physician and toxicologist who is also managing principal with the International Center for Toxicology and Medicine, Rockville, Md.

"The research has simply not been done," agreed neuropsychologist Paul R. Lees-Haley. "There's no basis at all for claiming that inhalation of mold or mycotoxins or any other mold metabolites causes brain damage in an indoor residential or office environment as people have been claiming."

Seeds of the Story

He and other researchers trace one source for misinformation on mold risks to a 1994 study by the Centers for Disease Control and Prevention. In that study, researchers cited a cluster of 10 infants suffering from bleeding lungs and linked the condition to the presence of stachybotrys chartarum mold in their Cleveland homes. But when CDC scientists and those outside the agency reviewed the findings, they found that the methodology was flawed, Lees-Haley said. "It was determined the study didn't prove stachybotrys caused what was originally thought, and the CDC, for all practical purposes, withdrew it," he said.

Despite the retraction, the report began a geometrical progression of other reports linking mold with health issues, Gots said. Lees-Haley said he has seen neuropsychologists, acting as expert witnesses, refer to the original study in their reports as if the later correction never happened.

More recently, the BaHard case also fueled this fire. Some maintain that media reports after the initial verdict gave the impression that the $32 million award was for mold exposure. But on Dec. 19, 2002, when the Texas Court of Appeals reduced the award to $4 million, its decision underscored the initial court ruling that had excluded the bodily injury claim and had awarded the money to Ballard for property damage and punitive damages only.

The media has been quick to issue a flurry of stories on "toxic mold," a phrase that makes Gots, for one, bristle. "The term 'toxic mold' doesn't make any sense because almost all molds under certain growing circumstances are able to make chemicals which are known as mycotoxins," he said.

In fact, the very presence of mold does not necessarily lead to production of mycotoxins, and merely having mold somewhere in a structure doesn't mean that if mycotoxins have been produced, the people inside have been exposed to them, either, Rutchik said. "You need to establish that inhalation has occurred," he said. "Mold does not necessarily go through the building's walls, or go under the floors to get to the person inside. It needs to be actually inside a room where a patient is living or working."

Lees-Haley, who was an expert witness for the defense in the Ballard case, focuses on claims of brain injury from mold exposure. "The main way we're seeing mold complaints is really in litigation, not in clinics, especially for a neuropsychologist," he said. "I've never had a patient in my career walk in the door and say 'I'm here for psychotherapy because of injuries due to mold inhalation."'

An Allergy by Any Other Name

Medical experts tell us that some people have allergic reactions to vanous mold or fungi and "that really is a genuine, legitimate concern," LeesHaley said. Mold spores can induce allergic responses in 5% to 8% of the population, Gots said. This sensitivity can be confirmed through skin tests, Rutchik said.

Among the susceptible, mold can cause upper respiratory allergies and conditions such as hay fever, asthma and, rarely, hypersensitivity pneumonitis, or pneumonia. "There have been some cases from buildings but not many," Gots said of mold-induced pneumonia. "Mostly, these are diseases of farm workers and people with very large mold exposures."

In certain parts of the country, particularly in spring, summer and fall, mold levels can soar, he noted. For example, it's common to record 50,000 spores per cubic meter in the Ohio Valley during the summer months, Gots said.

"Usually people who are allergic to mold are also allergic to many other aeroallergens--cats and dogs, pollen, trees and grasses--so it's difficult to separate out one allergen from another," he said. "And it's certainly impossible to protect people from mold allergies because mold is everywhere."

Remediation is important for these allergy sufferers, Rutchik said. "Even for those without allergies, we know that clean-up is important because we know that ingestion of mold is a problem," he said. "You could argue that you might be more likely to ingest mold if you have a lot of it in your house."

But some remedial efforts can go too far. To Gots, it's critical in investigating mold complaints to see where water may have entered the structure and whether there is moisture and obvious mold growth. "With people who are tearing every wall apart in every facility that they come into--if you start doing that you'll find mold in probably 70% to 80% of structures, and we 11 be spending billions of dollars tearing out walls only to grow more mold after we've put the walls back," he said. "So it's a bit insane, very, very, costly and quite unnecessary."

The most serious allergic reaction to mold is hypersensitivity pneumonitis, which occurs mainly in occupational settings, often among workers in grain operations, certain farming activities, on mushroom farms, and in the timber industry where some lumbermen can be exposed to up to 100 million mold spores in their faces as they fell trees. "Those people can get hypersensitivity pneumonitis, and even then it's not all that common," Gots said.

Bird and animal handlers can be vulnerable to serious health effects from mold as well, Rutchik noted.

Beyond triggering allergic reactions, mold also is blamed for some potentially serious infectious diseases from outdoor exposure. These maladies include histoplasmosis, an infection that may occur in the lungs, liver, spleen and central nervous system, and is prevalent in the Ohio Valley, and coccidiomycosis, characterized by respiratory difficulties, fever and rarely, skin eruptions, which can be found in the San Joaquin Valley Another disorder, aspergillosis, has never been shown to have surfaced in homes, but does crop up in hospitals, affecting people whose immune systems are significantly compromised. Patients on chemotherapy or drugs for organ transplants or cancer are particularly vulnerable, Gots said.

In truth, it takes a vast amount of mold spores to supply enough myco-toxins to produce illness, Gots said. He recalled a medical report on a handful of people who worked in a grain elevator, then developed tremors and a neurological disorder that lasted several days. "That probably was related to a mycotoxin produced by the mold Fusarium, but the levels of Fusarium in a grain elevator are staggeringly high," he said.

These and other victims of occupational mold contamination don't tend to ride the wave of mold litigation, however. "That's not the kind of people we're seeing making the complaints; they're not the ones filing the lawsuits," Gots said. "It's people who are either homeowners suing the insurance companies or office workers suing the insurance companies of their employers."

Gots' recent Internet search for "toxic mold" produced 110,000 hits. "If you skim through those, a huge number are from lawyers--not from doctors who are trying to cure people of anything," Gots said. "And a huge number are posted by advocates of other kinds, who are tied to lawyers, litigation and claims."

How Much Is Too Much?

The lack of solid scientific data on mold toxicity also means that there are no generally accepted standards for mold remediation, and no state or federal agencies offering testing services for mold samples.

Rutchik also cited the lack of government-established levels stating how much mold workers can be exposed to over an eight-hour period before they can develop an illness. In that vein, he expects the Occupational Safety and Health Administration to look into this threshold-limit value in the workplace "so that industry hygienists can measure these specific species." He also predicts that the Environmental Protection Agency will apply some air standards for mold exposure in the home, namely in parts per billion over a specified period of time.

Right now, Rutchik noted, even the testing for mold contamination is a source of controversy. "This requires some pretty complicated testing for industrial hygienists, and this testing is not that well developed and that reliable," he said.

In toxicology, a standard research approach is to see how much of an agent it takes to cause illness in experimental animals, then compare that dose to the dose that would be required to produce a similar reaction in humans. As it happens, this is what the American College of Occupational and Environmental Medicine did in its October 2002 study on risk assessments for mycotoxins in the indoor environment. The ACOEM report concluded that "except for persons with severely impaired immune systems, indoor mold is not a source of fungal infections."

In fact, some researchers have shown that given even the most conservative estimates, it's nearly impossible to inhale enough mycotoxin in an office or residence to produce any meaningful effects, Lees-Haley said.

Furthermore, the kinds of studies that have purported to claim that brain damage or other diseases of significance occur from mycotoxins in the indoor environment are primarily case reports, Gots noted, "and case reports are not terribly meaningful," he said.

Lees-Haley said he has tested about 50 people--all claiming mold-induced injuries--who have been involved in litigation. But to do a good scientific study, he should weigh similar findings against data from a control group of people who have not been exposed to mold, he said. Meantime, he has been looking for any new research on this topic, but has yet to find any.

"It's very complicated to figure out how to measure exposure and dose--there are so many fungi, they're everywhere and we've always been exposed to them everywhere, all of our lives," he said. "A Harvard aerobiologist and various toxicologists have advised me there's not a house or an office in the world that doesn't have mold spores in it."

So when asked in court testimony if mold can be neurologically harmful, he can only respond that he doesn't know and his colleagues don't know, LeesHaley said.

But he is especially skeptical of the wave of claims of mold-related brain damage, a development reminiscent of the silicone breast implant lawsuits of a few years back. Similarly, mold claims are sweeping the nation, "promoted by lawyers and other advocates," he said. "If you want to believe we have this epidemic of really serious brain damage around the country caused by mold, then you have to accept the premise that neuropsychologists and physicians of all specialties throughout history have completely overlooked this dramatic epidemic. To me, this seems pretty implausible."

With breast implant litigation, hundreds of case reports were filed claiming varieties of dysfunctions associated with these implants. In the midst of the class-action lawsuits, a number of companies went bankrupt. Finally, researchers produced 17 epidemiological studies that applied proper controls and the results were all negative. "The whole breast implant litigation disappeared," Gots said. "The good science showed that there was no such disorder and breast implants did not cause what people believed."

The mold controversy is heading in the same direction, he thinks. "It's beginning to happen increasingly, but it may take a while," Gots said. "I've lived long enough to see many of these kinds of issues come and go. We had toxic carpets a few years ago; we've had dental amalgam toxicity which hangs on; then we've had silicone breast implants. These things come and go and mold is just the latest one."

But mold concerns may be one of the biggest of these recent issues to come down the pike because of the magnitude of property and personal-injury claims that could be associated with mold complaints, he said. Furthermore, fear of mold contamination has spurred growth not only in litigation, but in the remediation and testing industries, which have a significant vested financial interest in this area, Gots said. "So there's a lot of momentum to keep it going and keep it active," he said.

RELATED ARTICLE: CDC Investigates Mold

The Centers for Disease Control and Prevention is working with federal, state, local and tribal governments to investigate and respond to mold-related problems, a CDC official told Congressional subcommittees in July 2002.

Dr. Stephen C. Redd, lead CDC scientist on air pollution and respiratory health, said his agency also is assisting the Environmental Protection Agency in developing a guide for mold remediation in schools and large buildings, and in developing a brief guide to mold for homeowners.

"More than 1,000 different kinds of indoor molds have been found in U.S. homes," he said. "Molds spread and reproduce by making spores, which are very small and lightweight, able to travel through air, capable of resisting dry adverse environmental conditions, and hence capable of surviving a long time. Molds need moisture and food to grow, and their growth is stimulated by warm, damp and humid conditions."

He reported that the CDC is in the midst of a five-year initiative, begun in 1999, on work-related asthma in offices and schools, with an emphasis on moisture and mold exposures. He also pointed to a 2000 report by the Institute of Medicine which concluded that there is sufficient evidence associating exposure to mold and the worsening of asthma, a lung disease that affects more than 24 million Americans, according to the American Lung Association.

But there are a number of obstacles that must be overcome in investigating the possible effects of molds on health, Redd said. "There are no accepted standards for mold sampling in indoor environments or for analyzing and interpreting the data in terms of human health," he said. "Molds are ubiquitous in the environment, and can be found almost anywhere samples are taken. It is not known, however, what quantity of mold is acceptable in indoor environments with respect to health."

What is known is that molds can cause respiratory illnesses among workers exposed to moldy hay, straw or grain dust, and among office workers exposed to mold-contaminated humidifiers and ventilation systems. Molds also can cause infections in patients whose immune systems are compromised. And they have even been associated with some cancers--the chronic eating of foods contaminated with the mold-produced toxins, aflatoxin and ochratoxin A, has been associated with liver and kidney tumors in animals and people, Redd said.

But as yet, he added, there is no scientific proof that airborne exposure to molds is linked to other adverse health effects, such as bleeding from the lungs, memory loss or lethargy.

Allergy vs. Illness: The Burden of Proof

Based on what the scientific community currently knows about molds, it's far easier in court to establish that mold spores have caused an allergic reaction than to show they have triggered a neurological response, said William F. Stewart, a member of the law firm Cozen O'Connor, who concentrates his practice in insurance coverage, bad faith and toxic tort claims.

As Stewart sees it, if a mold that is a known allergen is found in high levels in an insured's home and the insured sees an allergist who confirms that he is allergic to this particular type of mold and is experiencing allergy-like symptoms, "it's going to be hard to keep that out of court--that's pretty much complying with science," Stewart said. "But if somebody wants to come in and establish neurological problems--loss of memory, cognitive disorders--or even bleeding lungs associated with mold, it becomes a lot more difficult to do."

Stewart primarily represents insurers in these cases, but occasionally works with defendants who are being sued. He has participated in about 30 mold cases that involved some kind of alleged bodily injury. "My guess is in 90% of them, they've got all the symptoms of hysteria and no real injury," he said. "But once in a while, you see something where there really are high levels of a particular mold that can be potentially problematic and there are symptoms that do seem to be consistent with the symptoms that some of the doctors in the initial studies have shown are consistent with exposures to particular types of toxic mold."

In the courtroom, Stewart relies on expert witnesses to present the scientific facts. In most instances, he added, plaintiffs alleging serious injuries don't have sufficient expert testimony to prove what they need to under court rules. It's not enough for a doctor to say the plaintiff has mold in his or her house, seems to be suffering from an illness that could be caused by mold and, because no other cause can be found, mold must be the culprit, Stewart said.

"The answer is that, in order to demonstrate serious mold-related illnesses like cancer and neurological problems, a plaintiff must establish the existence of a potentially toxic mold, that the mold is actually producing harmful toxins which have been ingested by the plaintiff, and that the plaintiffs illness is being caused by those toxins," he said. "This process will necessarily involve the expense of a hygienist, a chemist and a physician--and given the holes in available scientific knowledge, may still be subject to a strong admissibility challenge."

Stewart thinks homeowners insurers have to be facing far fewer lawsuits in mold disputes as time goes by. "To a large degree, many of the initial cases were first-party property insurance cases with insurers getting sued," he said. "But a number of carriers are putting mold exclusions in their policies and so a lot of those cases are going to go away."

The mold issue has caused an availability crisis for homeowners insurance in Texas, but it also has become a serious problem in other states such as California, Florida, Arizona and Nevada.

Stewart does expect to see continued mold litigation involving commercial structures such as schools and apartment buildings, however.