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Standing Committee on Health, Aged Care and Sport
Biotoxin related illnesses in Australia

BIJLSMA, Mrs Nicole, Vice President, Australasian Society of Building Biologists

BURKE, Mr Stephen, External Advisor, Real Estate Institute of NSW

COOK, Professor Matthew, Professor of Medicine, Australian National University; and Head of Immunology, Canberra Hospital

DONOHOE, Dr Mark, Private capacity

EDWARDS, Dr Graeme, Fellow and Regional Councillor (Queensland), Faculty of Occupational and Environmental Medicine, Royal Australasian College of Physicians

GREENWAY, Ms Patricia, Consumer Board Member, Australasian Integrative Medicine Association

GUPTA, Dr Sandeep, Board Member, Australian Chronic Infectious and Inflammatory Disease Society

LARK, Mr David, Principal Mycologist, MouldLab

LAW, Dr Tim, Private capacity

PATTERSON ROSS, Mr Leo, Senior Policy Officer, Tenants' Union of NSW

PIPPEN, Ms Deborah, Executive Officer, Tenants' Union ACT

RUDD, Mr Caleb, Administrator, Toxic Mould Support Australia

STAMKOS, Mr Jeremy, Private capacity

UNGER, Ms Nicole, General Counsel, Real Estate Institute of NSW

WILLIAMS, Mrs Jeanette, Building Biologist, Building Biology Sydney

Committee met at 09:29

Evidence from Mrs Bijlsma, Mr Burke, Mr Lark, Mr Patterson Ross, Mr Rudd, Ms Unger and Mrs Williams was taken via teleconference—

CHAIR ( Mr Zimmerman ): Thank you all for joining us this morning. I declare open this public hearing in reference to the committee's inquiry into biotoxin related illness in Australia. This is the first hearing of this inquiry. We'll be holding a number of inquiries over the next couple of months. Today we've structured the hearing into three roundtables. The first roundtable, which we're about to commence, will be looking at the possible health effects of mould and dampness. The second roundtable session, which involves most of you who are here this morning but not all, will look at diagnosis and treatment of biotoxin related illness. The third roundtable, which will be this afternoon, will be one in which we hear from individuals who have put in submissions who would like to convey their own personal experiences. Before we get underway, are there any member statements?

Mrs WICKS: Yes. I'd like to disclose that I am someone who is currently recovering from biotoxin illness and that, as such, during the course of this inquiry, I may have used the professional services or indeed been treated by one of the medical practitioners who are appearing as witnesses.

CHAIR: Thank you, Mrs Wicks—that statement is noted. Because we have a large number of witnesses during the course of today, we are going to start with opening statements. I would encourage you to try and keep your opening statements to no more than two minutes, otherwise we'll do opening statements and nothing else! People always misjudge the amount of time that they speak, particularly politicians! But, as a reference point for those of you who've got a word counter on your iPad, I would calculate two minutes to be about 350 words. So it's not very long, in my experience!

Before we get underway, I need a motion from one of the committee members in relation to the media—that the media be allowed to film the proceedings today in accordance with the rules set down for committees, which includes not interfering with committee proceedings, not taking footage or still images of members', committee staff's and witness' papers or laptop screens. It's been moved by Mr Wilson and seconded by Mrs Wicks. All those in favour? I declare it carried. Do any of the witnesses I've just mentioned have any objection to being recorded by the media during today's proceedings? There is no objection.

Obviously we have a number of witnesses appearing by teleconference, which always makes it a little bit challenging, but, for those of you who are on teleconference, so that you're not forgotten in the ether of wireless space, feel free to interject if you feel like you're not getting a fair hearing. Before we start the opening statements, I need to remind you all that these are formal proceedings of parliament. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. Do you have any comments to make on the capacity in which you appear?

Dr Edwards : I'm in a private practice in Brisbane, and I've been involved in conducting investigations into sick-building syndrome, cluster investigations and multiple-unexplained-symptom disorders.

Mr Stamkos : I'm the principal consultant and indoor environmental consultant at Eronmor. I'm here today to advocate for standards and industry guidelines around this very topic.

Dr Donohoe : I'm a general practitioner and involved in integrative, environmental and lifestyle medicine.

Dr Gupta : I'm a general practitioner from Maroochydore on the Sunshine Coast, and I'm representing two organisations today: the Australian Chronic Infectious and Inflammatory Disease Society, or ACIIDS, and the Australasian College of Nutritional and Environmental Medicine, or ACNEM.

CHAIR: Hopefully they both agree on everything you say.

Dr Law : I'm an architectural scientist. I run the consultancy company Archsciences. I'm here in a personal capacity.

Ms Greenway : I'm the consumer board member of the Australasian Integrative Medicine Association. My hat is twofold today: to follow up on the submission from the board and also to talk on behalf of the community.

Mr Rudd : I'm representing the community group Toxic Mould Support Australia. I'm an administrator of the Facebook group and editor of the website.

Ms Unger : I deal with policy and legal matters. There is also Mr Stephen Burke.

Mr Burke : I am a mould inspector. I work mainly in Sydney and the Central Coast in Newcastle. My main interest is in prevention.

Ms Unger : He assisted with our submission.

Mrs Bijlsma : I'm representing the Australasian Society of Building Biologists. Our work is involved in the evaluation and control of health hazards in the built environment, like water damaged buildings. I'm also currently completing my PhD in developing clinical tools for doctors to assess and diagnose environmental sensitivities.

Mr Lark : I'm the Principal Mycologist and Director of consulting and research with MouldLab, Newcastle.

CHAIR: We'll start with opening statements. I remind you to keep them brief. I have an order here which alternates between those on the line and those physically present. We will start with Mr Rudd. I remind you that we are doing this in two sessions. This first session is focused on the possible health impacts of exposure to mould and dampness. We will do opening statements again for the second round table on the prevalence, diagnosis and treatment of biotoxin related illnesses. If you could focus on the subject matter for the first session during your opening statements, that would be fabulous.

Mr Rudd : Toxic Mould Support Australia, which I will refer to as TMSA, is a Facebook group that has, of today, 3,312 members. It also has an associated website. The aim of the group and website is to raise awareness and provide support to Australians suffering from the health effects related to mould exposure. This includes the biotoxin illness chronic inflammatory response syndrome—which I will refer to as CIRS from here on—due to the environment of water-damaged buildings. This is a condition that I also suffer from. Mould related illnesses, from mould allergy induced asthma to CIRS, create a great burden of disease in Australia. Daily, I hear the heartbreaking stories of those afflicted with chronic illnesses related to mould and see photos of terrible water damage to buildings. People write about how CIRS has devastated not only their health but their relationships, their finances and their faith in the medical, welfare and legal systems of this country.

I'm here today to give voice to the TMSA members, especially those who are not well enough to enter a submission to this inquiry. Apart from the access to affordable medical care, the issue of water-damaged buildings must also be addressed. There are fundamental issues with the design of buildings, which includes the Building Code of Australia, the construction of buildings, their ongoing care and maintenance and their remediation. Patients struggle to find and afford healthy home and a work accommodation. Landlords, real estate agents and insurance companies ignore their pleas for adequate remediation.

In summary, CIRS and other mould related conditions pose a significant public health and economic risk to Australia. I look forward to discussing these issues with the committee roundtable session today. Thank you.

CHAIR: Thank you, Mr Rudd. You've set an excellent example of the two-minute rule. Dr Gupta?

Dr Gupta : I'm representing two organisations of medical practitioners. The organisation ACNEM is a little more broad, in that it has an interest in a range of conditions and diseases related to nutrition and environmental causes. It's been operating for around 30 years, has several hundred medical practitioners as members and holds regular training in Australia and abroad. The group ACIIDS is a little bit more focused. It specifically focuses on chronic diseases of infectious or inflammatory origin. This condition related to as CIRS, or chronic inflammatory response syndrome, has been a special interest area of this organisation for the last three to four years. The majority of our medical practitioners, which is around 40 members at the moment, are seeing this condition in their practices around Australia and believe it is a growing problem that needs to be addressed. Thank you.

Dr Donohoe : I've been in general practice for 35 years and in the area of chronic fatigue syndrome for 30 years. I have research and publications in that field in relation to environmental causes and contributions to chronic fatigue syndrome. I have fellowships in the Australasian Society of Lifestyle Medicine and the society for environmental medicine. The reason I'm here is that in these past 30 years I have had a large number of patients with mould exposure and ongoing persistent unexplained illnesses. Many of the homes are in public housing. The particular reason I'm here is that three of my patients have suicided when they've been unable to leave their housing—the illness is severe enough for that to have occurred.

I'm interested mainly in the persistent illness. There are acute respiratory tract illnesses that the patients I've seen from interstate around Australia and overseas get from being in mould affected buildings. After the initial illness they get persistent ongoing inflammatory responses that result in severe illness and fatigue. That's the reason that I'm here—to sort that out and get housing, schools and workplaces straight, so that these people are not affected.

Mrs Williams : I hold an Advanced Diploma of Building Biology from the Australian College of Environmental Studies. I've been working as a building biologist in the Sydney region since 2011. I'm also a committee member of the Australian Society of Building Biologists and assist in the training of the mould testing course at the Australian College of Environmental Studies. Building biology can be described as the evaluation and control of health hazards in the built environment. As a building biologist, I diagnose buildings and not people.

In the last few years I've experienced a marked increase in the number of requests for homes and workplaces to be assessed for mould and moisture damage, and in my opinion this is due to two factors. First of all, there is a slow filtering of knowledge that symptoms of chronic inflammation and fatigue could be linked to exposure to a water damaged building, and that 24 per cent of the population are susceptible to such an illness, as per the research by Dr Ritchie Shoemaker. Also, there's an increased incidence in poor building practices, poor building design and the use of unsuitable building materials. I've observed a consistent link between damp odours, a history of water damage, visible mould and adverse health effects, although it should be noted that you don't have to see or smell mould for it to be a problem, as it often can be hidden in wall cavities, below flooring and in heating and cooling systems. In addition, whilst only around 25 per cent of mould spores are viable, dead mould can still trigger adverse symptoms.

Whilst I'm witnessing the slow awareness of the link between water damaged buildings and chronic health issues, the vast majority of people are still unaware that their chronic health symptoms may be linked to mould and other related biotoxins in their home or place of work. This lack of understanding has resulted in the continuance of poor building practices, poor building design, insufficient building maintenance and clients undertaking extensive health measures with minimal improvement of symptoms. I believe that until all parties involved are adequately educated, changes are made to the Building Code of Australia and some level of accountability is committed, we'll continue to see a large number of people suffering unnecessarily, and at great cost to society, from exposure to water damaged buildings. Thank you.

CHAIR: Thank you. Ms Pippen, are you speaking on behalf of both New South Wales and ACT?

Ms Pippen : I'm just here representing TUACT. Tenants' Union ACT is a small community legal centre in the ACT providing assistance to renters, aside from those in public housing. We've been operating for 24 years. We're the only service in the ACT specialising in this area and our client base is 28 per cent of the ACT population. In the past 12 months we have provided over 1,600 advice services, with repairs and termination being amongst the most common issues we advised on. In addition to the direct advice, we have information about mould on our website and, over the last 12 months, the mould fact sheet and information has been viewed over 3,000 times. There have only been two reported matters in the ACT Civil and Administrative Tribunal relating to mould since January this year. However, that number has to be considered in conjunction with the fact that only four per cent of applications made to the tribunal are by tenants. That illustrates the problem that we see the tenants have: they can identify an issue, but there's not much that they can do or feel that they can do about the issue. The experiences in the ACT are reflected across the jurisdictions, and this will be reported in the joint submission from the National Association of Tenant Organisations, which I believe is being submitted today.

Mr Patterson Ross : Tenants NSW is a similar organisation to that in the ACT. We act also as a resource service for a statewide network of local tenant services that collectively give advice to 25,000 people a year. Mould constitutes around four per cent of the advice that those services give, rising to over six per cent in June and July. Our interest in the inquiry is prevention and the treatment of biotoxin related illnesses through minimising exposure to mould in rented dwellings. We're particularly concerned with some of the barriers which prevent tenants from avoiding that exposure once they are aware of the mould and from accessing remedies. The particular barriers that we've identified include a poor standard of rented dwellings across the jurisdictions. We are submitting jointly with the National Association of Tenant Organisations as well as in our own right.

Every state currently has no effective minimum standard system that allows a tenant to know what is the minimum acceptable standard. We are seeing some advancements in some states, but we do need every state to improve. We also would point to the unstable and unfair renting system which allows landlords to evade their responsibilities, particularly the ongoing ability to evict a tenant without any need to give a reason, either at the end of the fixed term or outside of the contract. This works to undermine the rights that do exist in the rest of our renting laws. Our submission to the inquiry, which we got an extension on, involved collecting the experience of tenants from across Australia, and those collective experiences numbered over 400, including photos. Many people were reporting their experience of being dismissed by real estate agents and landlords and quite a large and worrying number were evicted or stayed silent because of the fear of that. That is all I can add at this point.

CHAIR: Thanks. Ms Unger, are you speaking on behalf of the Real Estate Institute of New South Wales?

Ms Unger : I'll start and then Stephen, as our expert, will continue. We encourage a scientific study on mould—its levels of toxicity and what level is dangerous. We find that, whilst mould might exist in properties, more often than not it is not dangerous. The tests used to determine the extent of toxicity are not scientifically proven. A lot of the inspectors don't have qualifications. They use a lot of common sense and the experience they've had in the industry. To sum up what I would like to say—and then I'll hand over to Stephen for more detailed information—we need to work out the problems we actually have before we start solving issues. We have a lot of leases that are broken because people see mould and have what industry believe at the moment to be unwarranted fear. While people may be susceptible to related illnesses, we're finding that they're getting a doctor's certificate from doctors who are told, 'There's mould on the property,' and that's a reason to break lease when that mould might not actually be dangerous. I will hand over to Stephen, because he's our expert on this.

Mr Burke : I inspect mainly residential properties on a daily basis. I've been doing this since 2011. Most of the properties that I go to are rentals, and I find people are very anxious and scared because of what they read on the internet. We try and eliminate that a bit by calming them down and going back to commonsense solutions to the problem. In most instances, there are a lot of lifestyle issues that contribute to this problem, and it's very, very hard because the industry really doesn't have any standards or regulations. It's very much open slather, and everybody's basing everything on internet information which, we all know, isn't that accurate.

What I've been trying to do is educate property managers in dealing with these situations a little better rather than everyone getting exasperated and wanting to break their leases and get out of their contracts. Some properties have real issues, but there are no guidelines. I think the Real Estate Institute is looking for direction just like everyone else.

Prof. Cook : I don't have a prepared statement. I think I was invited here to provide some expertise, if required, on the nature of the immune system, how it works and immune related diseases. My background is in understanding the way the immune system works and the genetic basis of immunological diseases, including autoimmunity and immune deficiency. I'd be happy to comment as required on those matters.

Dr Edwards : As a representative of the College of Physicians, the peak body of specialist medical practitioners in Australia, we recognise that there is a very broad spectrum of disorders that ranges from those that are easily identifiable, have clear associations and are materially debilitating to the individual—that's at one end of the spectrum. The other end of the spectrum is where mould or moisture can be seen as a potential potentiator of other disorders either directly or indirectly. We recognise that there is a severe lack of any useful guidelines that are consistent and accepted across the different jurisdictions of the populations of Australia, and we're looking for guidance to make some form of sense out of the quagmire.

Mrs Bijlsma : I'm representing the Australasian Society of Building Biologists. Jeanette has already alluded to what we do: the evaluation and control of health hazards in the built environment. We currently have 44 practising members that source most parts of Australia, except the Northern Territory and Tasmania. Five per cent of our work is involved in investigating water-damaged buildings, and around half of our clientele have either been diagnosed with chronic inflammatory response syndrome or are alleged to have the condition. We frequently observe serious illnesses in families from asthma, allergies, bronchitis, eczema and chronic fatiguing illnesses, including many neurodegenerative diseases in the same family as result of biotoxin exposure [inaudible] acknowledge most of the clinicians who they see, their general practitioners [inaudible] to ask about hazards in the home, let alone have an understanding of the impact of fungi and other biotoxins in a water-damaged building, despite the fact [inaudible] in the literature that dampness is strongly correlated with asthma, allergies and other lung related pathologies.

We also understand that water [inaudible] contain a chemical stew of airborne bio-aerosols like polysaccharides, bacteria, fungi and their by-products, ultrafine particles, VOCs, cell fragments and inflammogens. As a result of this, it makes it extremely difficult to determine what people in a water-damaged building react to, because of course their gene profile is also important in understanding why some people react badly and others don't. Is it the mould and its by-products, or is it the Gram-negative bacteria and endotoxins, or is it things like dust mite, which is the most common allergy in the world, or is it proteins from pests like cockroaches, rodents and termites, which are attracted to a water-damaged property?

We recognise that mould is caused by dampness, and the sources of dampness in a building can arise from internal, external and construction sources. Occupants need to be educated as to how to reduce the water vapour levels. We've noticed some cultures can exacerbate and contribute to mould-related dampness as a result of their cultural practices and bathing. We recognise the systemic failures of the Australian Building Code to protect new homeowners from condensation as a result of the push to create energy-efficient homes at the cost of the increased exposure to volatile organic compounds and condensation- and mould-related problems, and we see widespread incompetencies amongst trades industries and builders in construction and renovations, where they open up hidden mould and create secondary damage throughout the house, exposing the occupants to these biotoxins. In particular, we are concerned by the lack of duty of care by property managers and landlords to inform families and people with asthma and allergies that there have been water damage problems.

Lastly, the testing and remediation of water-damaged buildings is fraught with huge challenges, and we urgently need research [inaudible] that are consistent across the industry. We recognise fogging, spraying and gassing is completely inappropriate. It is often provided by people as a way to solve this issue, and it's not adequate.

CHAIR: Nicole, I'm not sure whether it's your line or at our end, but you do fade in and out a little bit. It wasn't enough to disrupt the narrative, but I'm not sure. If it's your phone, you might need to speak a little bit more closely into it.

Mrs Bijlsma : Okay, thank you.

Mr Lark : Thank you for this opportunity to submit a joint paper on this subject. I acknowledge the input and the 20-year research effort of my co-author, Dr Richard Shoemaker, who has given us a full picture of CIRS and how it affects those who are genetically predisposed. The submission includes more than 15 exhibits which together address the current knowledge of what CIRS in a water-damaged building is about and the community that it affects. Without limiting the relevance of the submissions made, we need further evidence from the Australian perspective, and I condone this inquiry to look at and further explore this in order to make sure of the relevance of Dr Shoemaker's work and that of others to the customer base that we serve. Thank you and good morning.

CHAIR: Thank you.

Ms Greenway : As the consumer board member of AIMA, I've probably got two hats on today. One is, as the first ever consumer board member of AIMA, to perhaps just suggest that I might table what the organisation is and to follow up with the fact that my being asked to be the consumer board member followed on from quite a few years as a policy manager of Arthritis Victoria. It gave me a wonderful opportunity to start listening to consumers, and I've done so over a very long period of time. I've followed up. I sit on several national committees—the TGA and the NHMRC—and my focus has always been: what's the patient centred care aspect of this question? I think the gathering that's here today is a terrific example. I'm a sociologist by training, by the way—nothing to do with health originally. The fact that this problem is being addressed by the widespread collaboration that's obviously here is a really good place to start. So I'm really happy to be able to talk about what I've heard from consumers about emerging issues over the years in health.

One of the big ones that I've heard is the trouble that people have with emerging issues in actually getting a diagnosis. The issue of getting that diagnosis is probably what most of the people have got to contribute today in a variety of ways. The diagnosis has often been delayed by the science not keeping up or being discouraged and disputed. Until a consensus is arrived at, there are a lot of other steps that don't take place. The Australasian group went out and did a survey of its practitioners to premise its submission on. They are mainly GPs who interact with their patients' choice of healthcare providers across the spectrum. They went out and asked that group of doctors exactly how they managed when their many patients came to them and wanted some sort of certainty. For that reason, I'm thrilled to bits that you're going to hear from real people this afternoon—but I'm not one of them. My experience is actually based on the idea of the work that needs to be done to develop some consensus so that people and the practitioners themselves can feel confident in dealing with this.

One of the other submissions that I read was really interesting in that it talked about the fact that one of the most important things that will benefit everybody is some clinical guidelines. I'll be talking in places that I talk in normally about the fact that something that might need some funding is some clinical guidelines so that patients and practitioners can get the benefit. The other thing, then, when we've got clinical guidelines, is that we can get some real patient feedback. I think that's perhaps all I need to say.

Dr Law : Thank you for including me in this inquiry and this public hearing. I have a PhD in architectural science. Architecture scientists study how to make buildings perform and also why they fail. A specialisation is in the physics of heat and moisture and in how the built environment affects health. I was previously a lecturer at the School of Architecture and Design at the University of Tasmania. As a matter of research interest, I've undertaken contract research for the Tasmanian building regulator and the Australian Building Codes Board around the matter of condensation and mould in buildings, particularly new buildings.

Within Australia the work we've been doing is pioneering. My close colleague and fellow architectural scientist Dr Mark Dewsbury and I have travelled across the state and country to alert the construction industry to the prevalence and magnitude of condensation and mould problems in buildings. There is immense interest amongst architects, building designers, builders, building surveyors, mechanical engineers and restorers. We've received numerous invitations to speak at industry events. Many of these groups are not represented here today. I can only surmise there are very few from the construction industry who make the connection between buildings and health. This is a cause for concern. I'm concerned that CIRS in WDBs is a building issue. It starts from a water damaged building, or WDB. It persists because of WDBs. But there's also a lack of awareness that WDBs and CIRS and are vitally and inseparably connected.

I'm concerned that, at a time when we have made houses more comfortable and efficient, we have unwittingly also make them less healthy. I'm concerned that, despite having such stringent building controls, we have a situation where our new buildings can no longer be assumed to be safe or healthy. The search for answers has come at a personal cost and my hope is that, by the end of today, by the witnesses telling you what you need to know, we might leave here satisfied that those sacrifices were worth making.

CHAIR: Last, but not least, Mr Stamkos.

Mr Stamkos : Thank you. My particular area of expertise relates heavily to the prevention and identification of the circumstances leading up to or causing the biotoxin related illnesses resultant from water-damaged buildings and subsequent microbial contamination. I acknowledge that further research into the health impacts resultant from biotoxin exposure in water-damaged buildings is required. However, there is already existing published research that highlights these hazards of water-damaged buildings, such as the World Health Organization's Guidelines for indoor air quality: dampness and mould.

Some of the known health impacts from exposure to water-damaged buildings and microbial contamination range from allergies, asthma, CIRS, sick building syndrome, a host of building related illnesses and even fatalities from hospital-acquired infections. Illness associated with water-damaged buildings and subsequent microbial contamination is largely avoidable through better design, construction, maintenance and proper drying and remediation following a wedding or a flooding event of a building. Unfortunately, in Australia, due to lack of standards, legislation regulation as well as education certification, many of our buildings have unchecked microbial contamination, exposing building occupants—including our most sensitive population of young children, the elderly and those in health care facilities—to unnecessary risk.

It is my position that the following issues need to be addressed to help prevent biotoxin and other water-damaged building related illnesses from occurring in Australia: research to better understand the mechanisms causing illness resultant from water-damaged buildings and how to better identify the risks; the development of Australian standards for conducting assessments of water-damaged buildings, as well as drying and remediation of water-damaged and contaminated buildings; the development of Australian training and certification for individuals conducting assessments/investigations of water-damaged buildings and microbial contamination, as well as for those conducting drying and remediation of such buildings; and compliance with the existing Australian standard—AS/NZS 3666.2: air-handling and water systems of buildings, microbial control, operation and maintenance—needs to be regulated to help prevent exposure. We also need an Australian standard for indoor air quality, which is in the process of commencing at the moment. This is greatly required to help address these sorts of subjects.

CHAIR: Thank you. We'll now move on to questions and discussion. I might kick off. I'll start with Professor Cook. I'm wondering whether, as an immunologist, you could outline your understanding of CIRS and what impact you believe that mould has on human health?

Prof. Cook : I'll go to the second part, because I don't profess any expertise in the first part of the question at all. From what we've heard, it's worthwhile framing the nature of the immune response and how it relates to the development of disease. The immune system appears to have evolved under the selective pressure of the threat of infections and pathogens. It's evolved in a very complex manner, because there are so many different sorts of pathogenic threats that we face in the diverse terrestrial environments that humans exist in.

The immune system is able to respond to components of microorganisms in their diversity. These include microorganisms that we know can cause infections and microorganisms that are otherwise innocuous, that can't cause any infections. Then we have other substances in the environment and, indeed, in our own bodies, where it would be completely inappropriate for an immune response to occur. We can think of pathology as rising from height and susceptibility to microorganisms, where individuals suffer infections due to microorganisms. These are mostly rare disorders where people who have deficiencies of their immune system get unusual infections because their immune response is somehow defective and it precludes a normal response. Amongst those with that group of rare disorders are individuals who suffer infections from moulds, yeasts and fungi. This is an extremely rare situation, and in many cases we understand the molecular basis of that—the precise abnormality that occurs in someone's immune system to develop that illness.

But we have other immunological disorders that arise not from the failure of immunity but, on the contrary, from either an excessive or an abnormal immune response. We can think about allergies as such an example—hay fever, asthma, eczema—where the immune response occurs to what is an otherwise innocuous environmental antigen, a substance, that might be derived from a microbe. That microbe doesn't really pose any immediate threat of infection to the individual, and yet they become unwell as a result of the wrong sort, or an excessive magnitude, of immune response. We call these hypersensitivity disorders.

I think this is a very important framework in which to base this discussion, because it seems to me from what I've heard already that this discussion might benefit from some clear definition of terms.

CHAIR: You wanted to add to that, Dr Edwards?

Dr Edwards : Yes. This goes to the point that there is a coupling in the wider community of exposure and disease—that exposure equals disease. What we know from the evidence base is that exposure may generate a response, and the response is always multidimensional, going from a neuro-emotional limbic system response within the biological system to the traditionally identified immunological responses that we see in the human system and the toxicological responses that we see. It's a multi-system response, and, as a consequence, we trigger both a physiological response—the ability of the human being, being a biological system, to accommodate a wide variety of stressors without causing a disease—and a pathological response, where we identify a syndrome of clinical symptoms and the potential for treatment.

Many of the biological markers that we are currently seeing in the literature are identifying evidence of a response, but we are yet to have sufficient research to distinguish between those biological markers as to whether they are representing a normal physiological response in the human being at the subcellular level or actually representing a pathological response, and it creates confusion. One of the things that we would value out of the efforts of the committee is some clarity.

CHAIR: I'm not sure that we're the people who can provide the clarity. That's why we've got all of you here! So, Professor Cook, self-evidently, some people have a response that others don't have to the introduction of, in this case, mould into their bodies. Is that a fair starting point?

Prof. Cook : Yes. To reiterate, very rare individuals might suffer an infection, an invasion of an organ system, after exposure to a mould or a yeast. But that's very rare, and we can usually identify that. A larger group of individuals can have an abnormal immune response to exposure to a substance which is derived from a mould or a yeast without that mould or yeast invading an organ system, and there are some well-defined situations where that occurs.

CHAIR: Professor Cook, are you entirely academic these days?

Prof. Cook : No, I'm a medical practitioner as well as doing research.

CHAIR: A lot of the submitters to the inquiry have spoken about their long and tortuous experience going through the medical profession because of the nature of the symptoms and a perceived lack of awareness of what's actually causing those symptoms to manifest. They have all have eventually come to the conclusion, through their own research or through seeing experts, that they have a mould related illness. What would your analysis be of why the medical profession—if I can put it this way—is failing those people? They seem to be going down a track. A lot have referred to ending up with Dr Gupta, for example, or being able to self-diagnose by reference to Dr Shoemaker's principles et cetera. What I'm struggling to understand is why, when they going through GPs and specialists and so on, they are struggling to get a diagnosis and a treatment.

Prof. Cook : I think one of the challenges of clinical practice is that many people have symptoms that can't be adequately explained, and they take many different forms. Fortunately, progress in medicine means that we're now quite good at identifying those symptoms that signify the threat of damage to an organ system or, indeed, to life. Nevertheless, many people have symptoms that don't necessarily signify that they have an illness that is a threat to normal organ function or to their survival, and they are still very debilitated by those symptoms. Obviously, they pursue various avenues to get an explanation.

Mrs Bijlsma : I published a study this year investigating and interviewing 17 of the top environmental doctors in Australia and New Zealand to see how they deal with environmental sensitivities and environmental medicine. These are experts in chronic fatigue and related illnesses, and they all indicated they did not have the knowledge or the skills to be able to diagnose many of these patients, and they did not have the exposure history. They all indicated this. One of the very few things they agreed on was that an environmental exposure history is critical. It takes—and they all agreed—90 minutes to take a proper environmental exposure history. None of them were trained in their undergraduate or postgraduate training to do this adequately. If they're not asking the right questions—and, if they do, they're flagged by the medical system for taking too long with their patients—how on earth will they ever see correlation? How will they see correlation if they've not been trained to take a proper exposure history and ask the right questions and don't have the time to be able to look at the patient's history from the beginning to the end to see the correlations when the patients move into water damaged buildings?

CHAIR: Professor Cook, do you believe there are people being diagnosed with mould related illnesses who shouldn't be diagnosed in that way.

Prof. Cook : I'm really not qualified to comment on that. It's outside my area of practice. That's all I can say.

CHAIR: Dr Edwards?

Dr Edwards : One of my roles is as a medical member of the medical assessment tribunal in Queensland, and I'm asked to work on a panel assessing the integrity of a claim. And in direct response to that question, the answer's yes. There are people who are being labelled as having a chronic inflammatory response where there are other perfectly adequate explanations if there was adequate time to take the history, delve into the dynamics and overcome some of the barriers that prevent a more structured approach to the investigation and management of the individual.

CHAIR: I want to ask a general question. It goes to how, in a regulatory way, particularly in relation to building standards and the like, regulators respond. Obviously, people are affected by different concentrations of mould, if I can put it that way. Some people won't be affected and others will. I lived in a house for 10 years where you could barely see the paint on the roof, and once a year I'd get up there with a spray can of vinegar and do my best, and, as far as I'm aware, there have been no health consequences of that. When some of these things are triggering very individual—maybe rare—responses, how do you actually set a regulatory framework that does not try to cater for 100 per cent of the population, which may be cost prohibitive and impossible to actually deliver, but rather sets a benchmark that provides reasonable protection and guidance for builders, real estate agents, property owners and the like? It strikes me that it is very difficult to do that when you are getting uncommon or individual responses to concentrations of moulds that affect different people differently.

Dr Gupta : I think one answer to that would be that there's a big importance to determining the prevalence of this illness accurately. One estimate that was given in a paper by Dr McMahon last year was that perhaps seven to 10 per cent of a general paediatrics practice actually were suffering from a disorder related to biotoxins. If that turns out to be correct, then that would seem to be a very large percentage of the population, and therefore that would need to be accounted for in the Building Code, one would think. We're not talking about a tiny proportion of the population, then. That's actually very significant.

In terms of some of the other research on genetic types that are susceptible to this disorder, for instance, the international gene registries looked at the HLA genes. HLA stands for human leukocyte antigen. Leukocyte is another word for white blood cells, and antigen is another word for foreign invaders. So these are genes in the human body which code for the ability to deal with foreign invaders, and the preliminary assessment was that there was around 24 per cent. We don't know whether or not that applies to Australia, but, in the international registries, around 24 per cent of people seem to have a susceptibility to this type of illness. So, again, that seems to be quite a large percentage of the population that we're referring to here.

Dr Donohoe : As a doctor, I only see those that fall off the edge, so I cannot come to a conclusion about the commonness of it, but I can say that there are susceptible people and much less susceptible people. Thankfully, you don't appear to have been the susceptible type.

CHAIR: That we know of yet!

Dr Donohoe : We will not know for a while, I imagine. There are susceptibilities, and, if what I've read of the literature is true and this may be around that 10 per cent range, I think that's a level where we would say that you would need to put standards to cover that 10 per cent. If it's one per cent or one in a thousand, you can't possibly regulate broadly for that kind of number. I see it only from the professional's view that, when we look back through complex illnesses, mould exposure is a very commonly reported thing in a well-taken history. And, more importantly, when people leave those environments, they recover. But I can't come to incidence yet, and I'd propose that the research actually is the most important thing to find out how many and who are affected and whether we have predictive testing that we could possibly employ to say not just 10 per cent but this 10 per cent. We can do that with allergy. We do allergy testing. We do the pinprick responses and we're pretty good at that. And when something comes up which is more generalised—it's a biotoxin; it's a different type of immune response to allergy—then we're left saying: 'We see the people. Now let's do the research.' And the starting point I'd propose is: look at the numbers, see who was affected and see what the basic research tells us.

CHAIR: There is one last question from me before I move to the other members of the committee: one of the submitters has argued that the direction of the inquiry is a little bit misplaced, and they have argued that in fact we ingest more mould through what we eat than we would get in the environment of a damp or mould-affected house. They point to, for example, some grain crops having 25 per cent mould prevalence and so on. Has anyone got a comment on that?

Dr Donohoe : I have a comment. We have a gastrointestinal tract which, as I think an immunologist or anyone will say, is an entirely different structure that is well designed to stop things that would kill us if we breathed it in, affecting us in that way. The gastrointestinal tract takes all kinds of mess. We've got the cleanest environment ever, but we ate rubbish all the way through our evolutionary history, and, had we been affected that way, we wouldn't be here today to talk about it. So the gut cannot be used to say what happens on the respiratory tract, airways or areas where the immune system responds in a far more direct way and we don't have those protective levels.

Mrs Bijlsma : Can I also add to that—asbestos is a great example. The route of exposure is absolutely critical to adverse health effects. When you inhale asbestos, of course you increase your risk for asbestosis, mesothelioma and lung cancer. When you ingest or drink asbestos fibres, which we regularly do as a result of it being present in the mains distribution system across Australia, it doesn't cause asbestosis or lung-related pathology, so the route of exposure is important.

The second thing I'd like to add is we have one of the highest rates of asthma in the western countries, affecting around 20 per cent of the Australian population, according to the Australian Society of Clinical Immunology and Allergy, and at least 80 per cent of those asthma sufferers have IgE-mediated responses to allergens, especially fungi. This isn't something that's rare. This is actually much more common. And, because clinicians don't have the skills to take an exposure history, we ask all of the clients and families we're dealing with with asthma: 'Has your GP asked about dampness in the home?' The answer is categorically, 100 per cent: never.

CHAIR: Of course, there is a theory that the French Revolution was caused by infected wheat crops—quite seriously! Mrs Wicks?

Mr TIM WILSON: Are we going to get into a discussion about what caused the French Revolution? I have many things to say on that topic. But, actually, if I may, I have one quick question for Dr Donohoe.

CHAIR: This is not Mrs Wicks for those online!

Mr TIM WILSON: No, sorry—that, or you've got a terrible cold!

Dr Donohoe : That's what moulds do!

Mr TIM WILSON: You cited a number of 10 per cent in your—

Dr Donohoe : No, what I've cited is that the work done by Shoemaker and others has suggested that the genetics proposed to be related to chronic inflammatory response may be around that 10 maybe 15 per cent mark. There is a range there. It's a hypothesis about what the possible range of people most severely affected is, not that I know that there's 10 per cent. That's the research that I think we need to do to know what happens in Australia.

Mr TIM WILSON: All right, I just needed that clarification.

Mrs WICKS: I have a million questions, so I'll try to be brief.

CHAIR: You have a two-minute limit.

Mrs WICKS: I'm not going to last that long, but I'll just ask firstly, and it may be more appropriate to those online, a question just to quantify how common indoor dampness and mould is. There's been a lot of reference to water-damaged buildings, or WDB, as we keep hearing. How common is that in Australia?

Mrs Bijlsma : If we look at the New Zealand stats, you're looking at about one in two buildings. It's one in two in the US, for example, and one in three in Canada, Norway and the Nordic countries—that's the prevalence of dampness. New Zealand, being close to home, has very similar statistics in terms of asthma and allergies to Australia. A recent study has correlated one-third of all respiratory outcomes in New Zealand were actually attributed to dampness.

Mrs WICKS: Are there any other comments by witnesses?

Dr Law : We did—when I say, 'We did,' I mean our team at the University of Tasmania—a scoping and statistical study for the Australian Building Codes Board. In late 2015, they had a survey across industry asking how prevalent condensation problems were, and condensation problems are obviously just a subset of all the damp and other moisture-ingress problems. The general consensus across Australia, across all states and across all climate zones was about one in three buildings.

Mr Rudd : One often quoted report from the World Health Organisation Europe 2009 was that 10 to 50 per cent of buildings in Australia have dampness.

CHAIR: Was that 10 to 15, or 10 to 50?

Mr Rudd : It was 10 to 50.

Mrs WICKS: It does sound like there's a wide variety of perspectives on this. Is more study, more research needed to quantify water damage in Australia, and what sort of concern is this?

Mrs Bijlsma : There is no question of that, absolutely. We definitely need to quantify the prevalence of dampness—it's been done in many countries, not in Australia—to see if there are at least correlations to things like asthma allergies, which is well documented in literature, and, potentially, to chronic fatiguing illness.

Mrs WICKS: Before I ask a couple of questions about diagnosis, there have been a lot of comments from witnesses about the need for standards and guidelines. To the question about water damaged-buildings, Nicole, you indicated that you see it in new buildings. So you see condensation arising as a result of fast building practice, I think you said. Was that you or someone else?

Mrs Bijlsma : Yes. Thirteen per cent of new builds that we see have condensation issues. In fact, there's no particular age or construction that seems to be specifically correlated with water damage to buildings because of the incredible diversity of internal sources, occupant's involvement, paving techniques, building and construction et cetera. Certainly 13 per cent of the buildings we are seeing are new builds. But, basically, it's across the entire board. It depends on the source of the dampness and moisture. Living in high humidity climates, for example, increases exposure if they don't have the air conditioning on. Air conditioning—heating and ventilation—systems are a common cause of bio toxin exposures, as are drainage issues, poor building practices, doing renovations and opening up hidden mold that then causes secondary damage throughout the house, cleaners coming in and not doing the right thing. It's just so endemic. I have documented many of the sources of moisture in the paper that I submitted as part of this inquiry.

Mrs WICKS: Just going back to a question that the chair raised, I thought it was actually a very good question in relation to diagnosis. I pick it up because so many of you have actually raised the challenge of there being no 'clinical guidelines'—I think were the words that Ms Greenaway used. Dr Edwards, I just wanted to ask the reverse of the question you were asked before, which was whether there were people who were being diagnosed with a an illness that was believed to be caused by their environment, whether they lived, worked or studied in a particular damaged building. And your response to the question of whether there were some people who were diagnosed who should not be diagnosed was yes. My second question is: are there people, potentially or otherwise, who are not diagnosed who potentially should be?

Dr Edwards : The answer to the second question is clearly yes. There are people who should be who are not. The reason why I answered definitively in response to the chair's question was that I have direct experience of more than one case, but one that comes patently to mind. Because there was not an adequate history taken, there was Aspergillus found in that particular individual's work site but the history of exposure leading to overreaction leading to disease wasn't taken. They just said there is exposure and there is disease. They didn't look at the time course of the disease. The disease that was present in that individual actually preceded the exposure. So one of the fundamentals in medicine is that you have exposure before disease. So there is a very patent example of the label being applied when it should not have been.

Mrs WICKS: In your view, would clinical guidelines—which seems to indicate, potentially, research first—go some way towards helping to address this and improve the accuracy of diagnosis?

Dr Edwards : Absolutely—because the guidelines can have embedded in them the inquiry necessary to get the temporal relationship right at the very start.

Mrs WICKS: Thank you, Dr Edwards. Does anyone have further comments?

Ms Greenway : Can I add to that. I discovered that step when I was working at Arthritis Victoria and we were looking at the mysterious condition called fibromyalgia. For people being misdiagnosed, undiagnosed or challenged when they went about that, I think your statement about the appropriate history and other conditions being examined as well—we were told at the end, when we developed a consensus statement, that the questions that are asked in the taking of the history need to be carefully drafted and they need to be based on the science of what is known and agreed. But the questions that are not asked were the ones that caused the problems with fibromyalgia. We had heaps and heaps of people who were really, really distressed at being told there was nothing there—and then eventually the science sort of caught up a bit. But it would have caught up quicker if the questions had been asked in a very, very deliberate and time factored way. On your notion that there was a pre-existing condition that had probably not been diagnosed—and the other one comes in often in that case—we got that piece of information from listening to patients' stories. They had gone and told their story but they hadn't been asked about this bit or they hadn't been asked about that bit. I think your point is really, really critical—that the history taking should be thorough and very pertinent and designed around those clinical guidelines.

Dr Donohoe : We do have the old Bradford Hill criteria for causation, of which temporality is one. The more complex problem for a general practitioner is often that there is an asthmatic who is getting sicker—not that they have got asthma, or that it was a causative factor, but for a vulnerable person their tendency towards illness in a mould affected environment may not be causative but it may be contributory. And it makes a big difference for a GP, whose job is to get them better by advising; we may not cure their asthma but we may get them out of the exacerbating circumstances. Does that sound right?

Dr Edwards : It is definitely the case. Herein lies the problem of distinguishing between causation, association and an aggravation or an exacerbation. There is relatively good consensus that there is some form of association—even though we don't know what that definition is. But association does not mean cause. There is also relatively good consensus that the causation in nearly all of the broadly termed multiple unexplained symptom disorders—until they get a label on them—is multifactorial. There is no single causative factor; it is a combination of factors. We have transitioned from an era in medicine where we can point to a thing and say that a thing causes this result. That area is bygone. We are now dealing with multisystem, multifactorial triggers—unless you have all the pieces of the puzzle lining up, you actually don't get the disease. And because we are talking about multidimensional triggers, any one individual, at any one point in time, may not have exposure to all of those triggers to get a pathological result. And therein lies the complexity.

CHAIR: You talked about the areas where there is consensus. What are the areas where there is not consensus? Where is the most conflict in views?

Dr Edwards : The most conflict is cause—that mould exposure causes all these other consequences. We know that there is consensus when there is extreme cause. But I think that, for the vast majority, there is not consensus.

CHAIR: For those who are diagnosed with, for example, CIRS, it is invariably diagnosed on the basis that it is a mould related illness. There are some in the medical sector who would argue that that is a misdiagnosis?

Dr Edwards : Yes, there are those. There is always a spectrum of practitioners. There is always—

CHAIR: Is the syndrome itself universally accepted?

Dr Edwards : No.

CHAIR: Could you elaborate on that. If I were your patient, would you at any point diagnose the syndrome as a possible descriptor for my condition?

Dr Edwards : In my practice, I don't use the term. I tend to use terms around the central sensitisation. In my clinical practice—and I am in clinical practice as a solo practitioner—I use the concept of central sensitisation and central sensitivity syndrome. That is because I am looking at a multitude of potential triggers—and mould may be one. It could be a multiple chemical sensitivity phenomenon. It could be an irritable bowel phenomenon. It could be fibromyalgia. It could be a whole host of different things—it could be electromagnetic hypersensitivity syndrome. The common unifying features in all of these conditions is related to what we do know is happening, which is neuroplasticity in the nervous system. We know that, regardless of the initiating trigger—whether it was an overwhelming infection of a mould related organism or some other viral infection—it sets up, within the biological system called the nervous system, neuroplastic changes. They can be, and have been, documented by the evidence based research. We can document that there are changes in the nervous system, and that change in the nervous system results in a change in the sensitivity and responsiveness of the human being.

CHAIR: To be clear: firstly, you are talking about triggers, as distinct from cause—and you are drawing a distinction between the two.

Dr Edwards : That's correct.

CHAIR: And you accept that, in some circumstances, there could be a sensitivity to mould which is a trigger?

Dr Edwards : Absolutely.

CHAIR: But are you saying there is an overreliance on mould as being the trigger, when there could be other factors? Is that your concern?

Dr Edwards : That is certainly the concern not only of myself but also of the college.

CHAIR: And what are the other triggers that may be overlooked in those cases?

Dr Edwards : Mould is but one of the potential triggers of the immunological system. It is also one of the potential triggers of the limbic system. The limbic system relates to the visual inputs, the other senses—whether it is smell, temperature, humidity—the environment in which we exist. We take in all these sensory inputs and it triggers a response in the individual which creates a change in the settings of the system. And once you have got the change in the settings then other triggers such as a viral infection or a mould exposure could, in the susceptible individual, trigger a consequential response and disease. One of the clear distinctions in the populations that we find informative in terms of this whole susceptibility issue is in the immuno-compromised individuals. If they have compromised systems for other reasons then they become susceptible to the mould.

CHAIR: I would like to go back to the issue I raised earlier on: what is the punter meant to do? The testimony we have received in the submissions is that people bounce around between GPs and specialists, with no diagnosis leading to an effective treatment. All the ones who have submitted to us have said—not surprisingly, because of the nature of this inquiry—that when it was finally diagnosed as a mould related illness they eventually got some relief because they were treating that trigger, if I can put it that way. We have received hundreds of submissions to that effect. What is a patient meant to do? Clearly, there are people with symptoms for which they are not getting an adequate diagnosis or treatment. And they go down this path and it seems to work.

Dr Edwards : There is no simple answer—that is the short answer. What is the patient to do? They do what they are already doing. They keep doctor-shopping. They keep exploring different options. They google. They join different organisations to get the support network and the intelligence. Eventually, some will attain the status that some in the literature call 'the adaptive coper'. They have developed a broad sense of understanding of the multidimensional nature of their disorder and, despite the medical profession, they start achieving again and having some form of gainful occupation or function. In that sense, it is the wider occupation of engaging in life and having a sense of purpose in all aspects of their human beingness. What we can do as a profession is accelerate that process of gaining the level of insight and understanding. As a profession we don't have the training or the experience, in the vast majority of practitioners, to be able to deal with this process adequately. It is not a reflection of the individual practice of the clinician, who is just trying to do the best they can for their patient under the circumstances they find themselves in.

Mrs WICKS: Would you support the research and development of clinical guidelines into such conditions?

Dr Edwards : Absolutely. As I said in my opening statement, we are looking for guidance in whatever shape or form the committee can provide.

CHAIR: Does anyone else want to comment on those issues. Dr Gupta.

Dr Gupta : One of the reasons clinical guidelines are probably so important in this condition is that it is an evolving science. Most of us have not come across this in our undergraduate training. Therefore, for instance, the importance of taking an environmental history perhaps hasn't been emphasised as much as we would like and the screening tests and the diagnostic tests for chronic inflammatory response syndrome are new and generally not covered in the training of medical practitioners. If, for instance, they are available in the form of clinical guidelines, then they can be utilised by practitioners to identify those patients who are potentially suffering from this disorder so they can get proper treatment and don't continue to doctor-shop, because that's a huge strain on the health system if they're just going from doctor to doctor without a correct diagnosis. However, if they're able to get the proper testing early and get the proper diagnosis and treatment, there is a much lower burden on the health system and there is a much higher chance of recovery.

Ms Greenway : I've just been involved with a project at Monash Uni, in Victoria, across all the health faculties. It was really interesting. It was looking at reviewing the curriculum around communication and patient issues. One of the things that kept coming up was: how do we write units for the undergraduate curriculum that help people to look at evolving issues in a really scientifically acceptable way? They were all seeing this as a challenge, because science doesn't stand still. It was about the idea of how the curriculum is updated. I think this is probably an issue that will come onto the curriculum agenda, but it doesn't seem to be there as yet. They were talking a lot about developing postgraduate units—and I think RACGP and other colleges do develop units in these things—so, if you haven't got the undergraduate curriculum ready, you might have something to start off with with practising practitioners. That was the suggestion that came out at the end of the project.

Mr ZAPPIA: I have got two questions and I don't mind who has an attempt at answering them. The first is: given Australia's climate, I would have thought that there might be other countries that are more susceptible to this kind of problem; if so, are there any countries that we can look to as to how they are managing the issue? The second question is: what would be your priority request of this committee and therefore of government?

Dr Law : Could I jump in and answer the first question? As a result of the scoping study that we did for the Australian Building Codes Board, we were comparing the Australian building codes against the international best practices. Ahead of us, I think the best practices would be in Canada and Ireland, but there are many countries ahead of us. We only looked at the codes in English, but the UK and the US are also way ahead of us, and New Zealand too. We can look to similar climates, across all the different climate zones, for example. They have encountered the very same problem of trying to make buildings more energy efficient. They have encountered the same problem of getting condensation, and a lot of their climates are even more harsh than ours in terms of them having a lot of snow and getting frost on the ground. We are not quite as bad, but we could just imitate a lot of their codes and we would be way ahead. At this point of time, we are decades behind where they were.

Mr ZAPPIA: If we were to accept their codes, or at least try to imitate them, have you estimated what additional cost that would be to our buildings?

Dr Law : Yes. Can I take the question together with the earlier point that the chairman was making, that going down this track of making mould-safe houses might be prohibitively expensive. I was just trying to pick up some statistics. Less than one per cent of people need mobility aids, yet all our commercial buildings have to be universally accessible—toilets, ramps, everything, just for that less than one per cent who require it. We have more than one per cent of people with CIRS, depending on whatever statistics you take. What is the harm in making it universally safer with all of this? We have done a cost estimate. There are a few things that are low-hanging fruit. One of them is that we should stop wrapping our buildings up in foil. Foil is vapour impermeable. You can't get the vapour out in that case. We did a cost analysis of doing a few things, and it's going to change the price. Yes, it's going to go up a bit. We reckon it will be anywhere from $3,000 to $20,000 per house. But that's the low-hanging fruit. Down the track there is much more we can do to be on track with where the other countries are. But this is really a matter of looking at current prices. As we go down the track, just like with double glazing, things get cheaper as we go en masse. When it goes into the code, then it is possible for us to get bulk discounts.

Mr ZAPPIA: Does anyone else want to add to that?

Dr Donohoe : I'd like to answer the second part, just as to outcomes. As to what you get in the submissions, I'd like to distinguish between illness, disability and disease, because we are talking about different things. Illness is the experience of a person. The disability is what they've lost in function. And disease is owned by us doctors—we give names to things when we can be pretty certain of the pathology; we have a high level of certainty. So one thing the committee can do is to enhance the ability to respond to the public's need to explore this. Do the science necessary for us doctors to be able to better make those distinctions and say what is not a mould-related illness versus what is. That requires research, at the building level, of exposure, and, at the medical level, to understand the processes that are proposed to be going on. Test them out and find out whether the science holds up.

So the movement from complaints escalating isn't just a Google issue. It has been in my practice 30 years, long before Google was around. People not having an answer is a very common thing. The medical profession doesn't have a category.

I am aware of this in chronic fatigue syndrome. We've wanted it to be called a disease for a long time, but it has never made it because it's not a single, coordinated, well-researched area. That could be a model not to replicate. Don't have 35 years of mould-related illness sitting in this middle ground. Move it from the complaints to the science. Change the buildings if necessary. And have patients not doctor-shopping but just going to a doctor and hearing: 'We have guidelines. Yes, you fall into that category. Here's the best way that we know of managing it.' If you can facilitate that process: better buildings—fewer exposures, in other words—and then better medicine—being able to say yes or no to people who come—then the patients will be satisfied. They are just dissatisfied because the next line of doctors—specialists, especially—is often: 'You don't have a disease; there is nothing I can do,' and that experience of: 'But I'm still sick,' leaves them angry. And we don't want to see that.

Mrs Bijlsma : I would add: there is already a significant amount of evidence in the literature about the correlation between dampness and various adverse health effects, and there are even documents from the National Institutes of Health on practice parameters for clinicians to diagnose allergen-related disorders, and the paper Procedures to assist healthcare providers to determine when home assessments for potential mold exposure are warranted by Chew in 2016. There is actually a lot. There are a few systematic reviews by Fisk and Mendell and Antova. The US Institute of Medicine in 2004 put out a significant document, Damp Indoor Spaces and Health. There are the WHO guidelines for indoor air quality: dampness and mould of 2009, and material from the New York State Toxic Mold Task Force, the US Department of Housing and Urban Development, the US Government Accountability Office—blah, blah, blah. There is so much on dampness and its correlation to adverse health effects.

But unfortunately the undergraduate training does not allow clinicians to take enough time with their patients to take an environmental exposure history. And then the system will flag doctors for spending too much time with their patients, and this is what I show in my research. To do this properly, they are getting flagged, because they are spending more than seven minutes with their patient, and they need 90 minutes, according to the research I did with these doctors, with environmental sensitivity. So, clearly, there is a huge problem here, even though there is already quite a lot of evidence about its correlation to asthma, allergies and respiratory outcomes.

Also, as mentioned, we do need a lot more research on its impact on biotoxin-related illnesses for other disease mechanisms like chronic fatiguing illnesses. I've just come from a talk in Chicago. I talked to a leading toxicologist from the Great Plains Laboratory. They have one of the largest labs in the world on environmental sensitivities, and they are showing very strong correlations—that water-damaged buildings are correlating with unusual biomarkers in the urine that most GPs would have no awareness of: arabinose, yeast markers and metabolites from clostridia which they are finding because of its impact on the gut microbiota.

Medicine has looked at one fungus, one disease—Cryptococcus; histoplasmosis. This is why it has failed. This is not one fungus, one disease; it's a multitude of antigens in a water-damaged environment resulting in chemical related sensitivities as a result of blocks in liver detoxification resulting in downstream effects and, ultimately, sensitivities to chemicals in their food and the environment. This is what we're consistently finding when we're talking with patients and taking histories—because I train my building biologists to take an exposure history and sit down with the patient for an hour, to go through the entire history, to see correlations and therefore identify what we need to look for in their home.

CHAIR: We've got to finish in about 10 seconds. Professor Cook and Dr Edwards wanted to comment on Mr Zappia's question, as well.

Prof. Cook : If I could just make a couple of more general comments on this question of guidelines and further work, it seems pretty obvious that there's a lot of uncertainty here. There's uncertainty about the possible causal relation. We're evoking a causal mechanism to antigens which may be ubiquitous. Even if they're necessary they're clearly not sufficient. There's considerable uncertainty at the level of what we're talking about in terms of the illness. We've heard reference to asthma and infections and other sorts of syndromes. I raise this point because if progress is going to be made—the way progress is made in science is to define as well as possible what one is dealing with so that you can then investigate causal hypotheses. So I would strongly encourage a greater definition of the terms, both the environmental exposures and the clinical syndromes.

The second point is with regard to guidelines. Of course, it's very difficult to come up with guidelines in a state of such massive uncertainty, but two things that guidelines can be useful for are to ensure that we don't miss things that we do know about. We do know about asthma, and we do know about some rare fungal induced hypersensitivity syndromes—allergic bronchopulmonary aspergillosis is an obvious one. We need to be clear that we don't miss those. The second element I would encourage in the guidelines is to avoid unnecessary and unvalidated investigations. We know an enormous amount about the immune system and it's very easy to measure lots of analytes, but, until we have an understanding of a causal mechanism, simply measuring those will not necessarily be a fruitful line of investigation. I think they're the two things to consider with regard to guidelines.

Dr Edwards : To come back to the specific questions that Mr Zappia raised, on the international marketplace, because we're dealing with this spectrum of multiple, not readily explainable symptoms at the front door when the individual presents to a clinician, whether it be a GP or a specialist. The best guide I have found in recent years is one that was developed by consensus with the US Department of Veterans Affairs, which arose out of their efforts to deal with the unexplainable-symptom disorders that arose out of the Gulf War. So there is some very good evidence based literature, which was developed by consensus, involving the sufferers as part of that process, that could be a model guideline that could be readily adopted in the Australian marketplace.

CHAIR: Dr Edwards, do you mind providing the committee with a link to those guidelines, if you have that?

Dr Edwards : Certainly. The second issue would be my preference. There is no doubt that the system of education of our doctors in Australia is deficient in this space. It has evolved over the years of developing a clinician. You come from your high school, or, now, your post-tertiary studies into a medical school and you go into a wide variety of disciplines. You are exposed to a whole lot of different body systems whether they are biochemistry, physics or gastrointestinal. Instead of maintaining that broad spectrum of multisystem analysis, we first of all have to learn all the different systems. So, during the medical schooling process, we are compartmentalised in our thinking. Once we get into the hospital situation, then our junior doctors are rotated through different specialists. It's not until we get back into a general practice setting that we start looking at a more comprehensive overview of multisystem experience again, in terms of what our patients actually suffer.

Now, we need the superspecialisation. We need the people who focus their area of research and clinical practice on immunological systems or cardiology or the gastrointestinal system or neurology. We also need those people who have that broad-church understanding of how all these different systems interplay. So, as a society, we now recognise the specialist credentials of our general practitioners. They're not just general practice; they're specialists in multisystems. We're now starting to recognise that.

So, to the specific question you asked, we can't change the system of how we educate our doctors. It's not cost effective. We can tweak it. We can make it more patient centred as we delve into the multidimensional nature of the patient's suffering, but, at the end of the day, we need to take this undifferentiated individual who has no knowledge of medicine, develop their knowledge base, develop their skills, tweak their interest in an area of interest for that particular individual and make the best use of them from a societal point of view. How we can make the best use of those people who are already out there with 30 years experience or those with one week's experience is to have clinical guidelines. Those clinical guidelines will stop excessive overinvestigation. They will stop unnecessary investigation in the vast majority of cases. If there is one thing that this committee can recommend, it is adequate resourcing of the processes necessary to get clinical guidelines that are consensus based and accepted across the different vested stakeholder interests.

CHAIR: Thanks, Doctor Edwards. We're about to adjourn now for 20 minutes. But, before we do, because I'm conscious that we will lose some people for round table 2, which I think includes the Real Estate Institute, did you want to add anything before we conclude? We haven't really thrown to you very much during the course of the questions.

Ms Unger : Our expert dropped off, but I would just like to add that, from a property management perspective, we have to fit within what's out there at the moment. Property managers need to be trained on mould prevention techniques. There needs to be a lot more education out there in the market. But, yes, we do recognise the need for guidelines to be introduced to make it easier for the industry to work with.

Mr Patterson Ross : Once the medical debate has been settled—and I'm hearing that there is still debate to be had about what the treatment and diagnosis looks like—we would encourage the committee to consider the implementation of treatments and diagnosis around mould and the effective barriers that are in place. Just going back very quickly to an older question, in Australia and in most common law systems we have a very clear legal doctrine of the eggshell rule, where you, as a person, do not get to ignore the frailties or the particular conditions of a person simply because they're not universally experienced. That is often the basis upon which we implement the regulation of different kinds of activities. A common approach to regulation is to acknowledge that there are some people who experience things differently.

CHAIR: Thank you. I thank everyone for their participation in this first round table. There has obviously been some overlap between this and the subject matter for the second, which goes to prevalence, diagnosis and treatment, but that doesn't really matter, because it is sometimes hard to neatly separate them out. We will have a 20-minute break now.

Proceedings suspended from 11:10 to 11:36