Architectural researcher Alexi Marmot, who headed up the study, told the society that her team's research indicates that physical building factors are not to blame for symptoms like sore throats, colds, rashes, fatigue, itchy eyes, coughs and headaches which are commonly linked to sick building syndrome. Instead, psychosocial factors like job dissatisfaction, a poor outlook on life, long commutes, second-hand smoke exposure, and poor housing show far stronger associations with the symptoms, she says.

Marmot's findings are controversial. But based on data collected through the "Whitehall II" study of 10,000 civil servants, she claims her team's is one of the more thorough studies of sick building syndrome ever done.

Marmot spoke with Industrial Safety & Hygiene News from the office of her London architectural consulting firm, Alexi Marmot Associates.

ISHN: Tell us first about your study methods.

Marmot: The Whitehall II study is a longitudinal epidemiological study of 10,000 civil servants in London's Whitehall district who agreed in 1986 to be monitored. Every few years they are invited to a medical screening and asked to fill out questionnaires about their health and lifestyle. The goal is to explore health, lifestyle, and stress, and the causes of ill health.

For our component of the study, we raised funds from the Health and Safety Executive (Britain's version of OSHA) to carry out a study from 1992 to 1995 to find out if sick building syndrome showed up in the Whitehall study. We added questions to the questionnaires people were already filling out, and we had 100 percent access to their buildings where we were able to sample things like air quality, temperature, noise, relative humidity, and drinking water, and to document workstation ergonomics, density and finishes.

That access makes our study valuable. Many other SBS studies only look at buildings where people are complaining that they're sick. And other SBS questionnaires seem to ask leading questions, like "have you suffered any of these symptoms and do they go away when you leave the building?" We didn't ask questions that way.

ISHN: What questions did you ask to assess workers' mental health? Marmot: The Whitehall study included the General Health Questionnaire which asks 30 questions about people's outlook on life and their ability to cope. It doesn't as much assess mental health as it does people's attitudes. It asks things like *have you recently lost much sleep over worry, or felt you couldn't overcome your difficulties?* Plus there are many other questions about their diet, exercise, illnesses, and about their work and how they feel about it and to what extent they feel they're in control. We asked over 100 questions, from very hard to very fuzzy questions. We also had access to their sickness absence records.

ISHN: The Royal College of Psychiatrists' press release heading, "Sick Building Syndrome is a Myth" is a very strong statement.

Marmot: I agree, it's a very strong statement. I would not choose to say something as broad as that. All I can really do is report on the population we studied. But I believe we have a good study. We found more evidence to suggest that other factors are likely to be causal than building-related factors. Our main proof is only about the strength of association.

ISHN: I agree, it's a very strong statement. I would not choose to say something as broad as that. All I can really do is report on the population we studied. But I believe we have a good study. We found more evidence to suggest that other factors are likely to be causal than building-related factors. Our main proof is only about the strength of association.

Indoor air quality experts in the U.S. say that even when they suspect psychosocial factors are the main cause of SBS symptoms, they can usually find a physical problem, like poor air quality, poor ventilation, too hot or too cold climates or low humidity. Would you say they are wrong to think any of those physical factors are partly to blame?

Marmot: We have examples of all those physical factors, and many of those also had association with symptoms. We did find, for example, that low or very high humidity appeared to elevate symptoms. However, the effect of things like general outlook on life was so much greater that one would say that humidity is not the main causal link.

As an architect I believe that buildings matter. But you have to ask "who's in them in the first place? Who's having the problems?" There's a huge number of social variables. To imply that a building alone makes people ill or unhappy is just a bit odd. However, I wouldn't want to say that you can't have desperately uncomfortable buildings. But we're not talking about comfort here. We're talking about whether or not buildings make you ill. I think we may have some cases of mass psychogenic illness. In the U.K. there have been a few buildings closed down and tens of million of pounds spent refurbishing buildings with purported "sick building syndrome" before organizations would move in.

ISHN: What are your suggestions for how employers or safety and health professionals should tactfully inform workers that their symptoms are related to their own stress, not a "sick building," without upsetting workers and thereby aggravating their conditions?

Marmot: If you don't take symptoms seriously you can be part of the cause. It's only sensible management to take any complaint seriously and see what it's all about. You must investigate them.

But you don't omit finding out things like what they think of their boss, if there have been things at work that upset them, and so on. Do they get paid well? Do they feel like their future is rosier than their past?

There's no doubt that whatever we're looking at is complex. Buildings are containers. The container can be the problem, but so can the contents. We should try to address the complex work environment rather than just the building environment.

ISHN: Were you surprised by your own findings?

Marmot: We really did our damnedest to find those associations between physical building factors and SBS symptoms. I'm always wary of those who set up a study to find what they're looking for. Methodologically, that can be said of many SBS studies. If you only look at building variables, then of course you find associations. The appeal of our study is that we knew so much more about these people. We could put multiple regression analysis of humidity together with the answers to the General Health Questionnaire. I don't think our study design was biased to find any one answer. But as far as a straight statement of what it is that causes symptoms, it's unlikely to be sick buildings.

Hunting for the syndrome source

The International Society of Indoor Air Quality and Climate hasn't ruled out the possibility that sick building syndrome can be related to physical problems in the building. But their guidelines for investigating a complaint don't ignore the chance that the cause is not building-related either. ISIAQ suggests that in cases where symptoms are found to be unrelated to IAQ, it may be possible to identify other underlying causes or contributing factors:

Thermal discomfort--(too hot or stuffy; too cold or drafty; too dry or humid). Chronic occupant concern based on thermal factors may lead some to attribute unrelated symptoms to IAQ.

Lighting, noise, ergonomics--Symptoms such as headaches, fatigue, and eye strain from such factors may be building-related but not due to indoor air quality.

Nuisance conditions--Unusual odor or visible dust may not directly cause symptoms but may concern occupants to the point where they attribute other symptoms to IAQ.

Other environmental exposures--Symptoms from water- or food-borne illness or reactions caused by direct contact with toxic materials may occur in a building population and be erroneously attributed to IAQ.

Unrelated illness--Many medical conditions may mimic IAQ-related symptoms. Such cases should be properly classified by appropriate medical evaluation. Side-effects of occupants' medication should also be considered (e.g., headaches and fatigue). Clusters of health events such as cancer and miscarriages are generally not associated with the non-industrial building environment.

Psychogenic--Individual and organizational stresses may cause occupants to experience symptoms which, in some cases, are attributed to the building.

Sociogenic--Psychogenic symptoms may be transmitted between susceptible occupants. "Mass Sociogenic Illness, although relatively rare, has been identified in some building outbreaks."

Political--An unpopular move to a new building, disagreements with management or alarming publicity on IAQ issues in general may stimulate erroneous beliefs that the building environment is harmful.

Source: "General Principles for the Investigation of IAQ Complaints," ISIAQ.

Is it all in your head?

These are the sort of questions the University College London study asked workers to determine whether their "sick building syndrome" symptoms might be caused by personal stress rather than physical building factors:

Have you recently:

lost much sleep over worry?

felt you couldn't overcome your difficulties?

been thinking of yourself as a worthless person?

been feeling reasonably happy, all things considered?