Add Your Voice to the Call to Investigate PACE

Posted on November 18, 2015 by Jennie Spotila

(reprinted with permission)

20120818_boom_volumeTwelve U.S. ME/CFS organizations have called on the Centers for Disease Control and Prevention (CDC) and Agency for Health Research & Quality (AHRQ) calling on them to investigate the PACE trial concerns outlined by David Tuller and then take the steps needed to protect patients. The letter to Director Thomas Frieden of the CDC and Director Dr. Richard Kronick of the AHRQ can be found here.

Take Action

You can add your voice by signing this accompanying petition. While the petition is directed to the CDC and AHRQ, their response will affect other countries as well, so we encourage people from all countries to sign.

Background

Recently, journalist David Tuller, DrPH, published an investigative report outlining serious concerns with the conduct, analyses, and results of U.K.’s £5 million PACE trial for chronic fatigue syndrome. PACE investigated the efficacy of cognitive behavioral therapy (CBT) and graded exercise therapy (GET)

Since then, other researchers and journalists have voiced their own concerns with the fundamental problems in the trial. Most recently, Julie Rehmeyer wrote an excellent overview of the situation in Slate Magazine and six researchers called on The Lancet to “seek an independent re-analysis of the individual-level PACE trial data.”

The PACE treatment approach is based on the theory that the debility of ME/CFS is caused by presumed deconditioning, which is the result of patients’ belief that they have an organic disease and that activity will harm them. CBT and GET is claimed to lead to improvement and even “recovery” by reversing patients’ “illness beliefs,” “fear of activity,” and deconditioning.

PACE is hugely influential in how patients are treated in the media, by society, and especially in medical practice. In the U.S., many ME/CFS clinical guidelines, including those of the Centers for Disease Control and Prevention (CDC), recommend CBT and GET, based in part on the PACE trial. This is true even in medical education and clinical guidelines published since the 2015 Institute of Medicine (IOM) report. The IOM report makes it clear that the problem is not deconditioning. It states that the hallmark of the disease is a systemic intolerance to exertion, which would be exacerbated by PACE’s treatments.

The impact of PACE is also seen in scientific evidence reviews. In 2014, the U.S. Agency for Healthcare Research and Quality (AHRQ, part of HHS) recommended CBT and GET, based in part on PACE, which it ranked as a “good” study. This is significant because the AHRQ Evidence Review can be used to support CBT and GET recommendations in future journal articles and in the clinical guidelines of any country. This evidence review already has been used for this purpose in at least one U.S. clinical guideline.

Even aside from concerns with the conduct of PACE, the AHRQ Evidence Review recommendation for CBT and GET for all ME/CFS patients is questionable since the review itself acknowledged that PACE’s Oxford definition was overly broad and could include patients who do not have ME/CFS. NIH’s 2015 Pathways to Prevention report felt this problem was so serious that it called for the Oxford definition to be retired.

Continuing to use PACE and similar Oxford definition studies to support treatment recommendations for all ME/CFS patients is an issue of grave concern because it confuses doctors on the nature of the disease and results in medical treatment that can harm patients.

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A Request That Should Not Be Ignored

Posted on November 13, 2015 by Jennie Spotila

20120818_boom_volumeSix scientists have sent a joint letter to the Editor of The Lancet asking for an independent re-analysis of the PACE trial data.

The letter, published today on Virology Blog, is signed by Dr. Ron Davis (Stanford), Dr. Jonathan Edwards (University College London), Dr. Leonard Jason (DePaul University), Dr. Bruce Levin (Columbia University), Dr. Vincent Racaniello (Columbia University), and Dr. Arthur Reingold (UC Berkeley). It states:

The PACE study was an unblinded clinical trial with subjective primary outcomes, a design that requires strict vigilance in order to prevent the possibility of bias. Yet the study suffered from major flaws that have raised serious concerns about the validity, reliability and integrity of the findings. The patient and advocacy communities have known this for years, but a recent in-depth report on this site, which included statements from five of us, has brought the extent of the problems to the attention of a broader public. The PACE investigators have replied to many of the criticisms, but their responses have not addressed or answered key concerns.

After summarizing the main flaws of the PACE trial, examined in detail in David Tuller’s series published on Virology Blog, the letter concludes:

Such flaws have no place in published research. This is of particular concern in the case of the PACE trial because of its significant impact on government policy, public health practice, clinical care, and decisions about disability insurance and other social benefits. Under the circumstances, it is incumbent upon The Lancet to address this matter as soon as possible.

We therefore urge The Lancet to seek an independent re-analysis of the individual-level PACE trial data, with appropriate sensitivity analyses, from highly respected reviewers with extensive expertise in statistics and study design. The reviewers should be from outside the U.K. and outside the domains of psychiatry and psychological medicine. They should also be completely independent of, and have no conflicts of interests involving, the PACE investigators and the funders of the trial.

That statement I placed in bold – “Such flaws have no place in published research” – is absolutely true. It is something with which no rigorous scientist can disagree. It is to the advantage of The Lancet and the PACE investigators to have such an independent re-analysis of these data. Unless of course the PACE investigators are concerned an independent re-analysis would not confirm their results. In that instance, I can understand why they would resist. But surely The Lancet would like to have independent confirmation to protect its own reputation.

I am quite certain that I am not the only advocate who, when discussing science, has been dismissed because I do not have “PhD” after my name. This is most definitely true for the advocates who have spent years gathering information, filing requests for data, and conducting their own analyses of the PACE papers based on those data they could actually get their hands on. These advocates have been writing about the PACE defects for years, and they have been ignored. Worse, they have been dismissed as “vexatious,” as a “vocal minority,” or “motivated-intruder.” Some researchers have also published critiques of the PACE trial, but their critiques have not been much more successful than that of advocates.

David Tuller’s investigation of the PACE and FINE trials took this to another level. Nearly 10,000 advocates (as of this writing) have signed the petition calling for the retraction of misleading PACE claims and release of the raw data to independent investigators. Dr. James C. Coyne, blogging for PLOS publications, has urged release of these data. Coyne quotes Dr. Jon Merz, a prominent bioethicist, as saying, “The litany of excuses – not reasons – offered by the researchers and Queen Mary University is a bald attempt to avoid transparency and accountability, hiding behind legal walls instead of meeting their critics on a level playing field.”

Today’s letter from six well-respected scientists to The Lancet turns up the volume yet again. It is time to test the PACE data on a level playing field.

This is no different than the cacophony of calls for replication of the XMRV finding, which turned into demands for retraction when it was clear that those data were deeply flawed. Good science is self-correcting, but it requires rigorous and ongoing testing for assumptions and biases.

ME/CFS has spent most of the last 30 years on very uneven ground in research funding, diagnosis and treatment, and in the quality of some science. We deserve better. The call for an independent re-analysis of the PACE data can no longer be ignored.

Posted in Commentary, Research | Tagged , , , , , , , , | 13 Comments

Someone Had To Say It

Posted on November 10, 2015 by Jennie Spotila

A long story about this moment in ME/CFS research and advocacy by journalist Virginia Gewin was published in Mosaic, a publication of the Wellcome Trust today. The article includes a great profile of Dr. Lenny Jason, coverage of the PACE trial and UK research, and includes quotes from Mary Dimmock and myself, among others. Here’s what I had to say:

Spotila thinks NIH views patients as “a pain in the ass”. “Maybe we are, but are we more of a pain in the ass than other groups waiting 30 years for improvements?” she asks. “I’ve been sick for over 20 years, my entire productive time of life is gone. I’m stuck in my house and couldn’t have kids. But that’s just me and I’m not even the sickest person.

“The pain, disillusionment, anger and frustration comes from watching the government not deal with this problem for 30 years,” she says. “If they listened to what people have been through, it would change opinions.”

I might take some heat for saying that NIH sees ME/CFS patients as a pain in the ass. But I have personally experienced that vibe from some people at NIH (not all!). And I absolutely believe that NIH (and HHS) does not understand where our anger comes from, and how they have contributed to it through their own inaction and inattention.

But this interview was conducted months ago, when I was still fighting with NIH over the misplaced P2P comments (a story which is still not over, by the way). Now we have the potential for more action and funding at NIH. And Dr. Vicky Whittemore is quoted in the story, acknowledging:

“We need to hear the concerns of the community,” she says. “At different meetings, I’ve seen these patients get cut off; people be rude to them, roll their eyes. It’s so disrespectful.”

We are a pain in the ass; I have personally been a pain in the ass to NIH and HHS on occasion. But you know what? You have to be a pain in the ass to get attention. You have to make people uncomfortable to catalyze change.

We have an opportunity now to make good on that change. If NIH is willing to listen, then let’s talk. If Dr. Collins wants to “start fresh with the patient-advocacy community,” as Brian Vastag says in Gewin’s article, then I am all in. I’ve seen the impact of having a patient representative participate in the FDA Working Group. If NIH is willing to change its orientation towards ME/CFS research and the advocacy community, then I will not let this opportunity slip.

Like I said in my post on the NIH plan: Let’s do this. We’ve waited long enough.

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FDA Progress on Measuring Outcomes

Posted on November 9, 2015 by Jennie Spotila

I have an update on the progress of the ME/CFS Outcomes Measures Working Group working with FDA.

As I reported in March 2015, the FDA helped convene a Working Group comprised of representatives from FDA, NIH, CDC, and academia in order to create and qualify a clinical outcomes assessment tool for ME/CFS. This is critically important in the drug development process. If FDA officially qualified an assessment tool, then it could encourage drug developers to get into the ME/CFS area. Such a tool does two things for drug developers: a) it saves the money of creating and qualifying the tool and b) they know that FDA will accept use of that tool in clinical trials.

I am happy to report that our effort to create the tool has officially been accepted into FDA’s Clinical Outcome Assessment Qualification Program. This means that FDA has reviewed and provided guidance on the design of a study to create the tool. The Working Group plans to test whether items from NIH’s PROMIS question bank are applicable in ME/CFS.

The Working Group understands that this is not simply a matter of measuring fatigue. In fact, figuring out how to measure post-exertional malaise is one of the puzzles we are tackling. It may turn out that PROMIS items don’t work for the ME/CFS population, but we need to test that. Starting from scratch to create a new measure takes much longer and is more expensive.

Right now, we are actively seeking funding for the study. I’ll keep you posted as things develop.

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The NIH Plan

Posted on November 4, 2015 by Jennie Spotila

Green-Start-Now-Button(updated November 9, 2015)

Unless you have been avoiding the internet for the last week, you already know that NIH has made a big announcement regarding its plans for ME/CFS research. Dr. Francis Collins has made some remarkable and welcome statements in the press:

Given the seriousness of the condition, I don’t think we have focused enough of our attention on this. (from The Atlantic)

Give us a chance to prove we’re serious, because we are. (from Science Insider)

Personally, I have waited a very long time to hear the Director of NIH make statements like this. But the details of the new plan are of primary importance, and sometimes difficult to come by.

The biggest news, in my opinion, was first mentioned in the Science Insider piece: that a new request for proposals would be issued for extramural research. In an NPR article today, Dr. Collins said that “It will be substantially greater than the current five or six million a year. We are going to ramp this up.” This is huge progress, especially if the new request is an RFA, because those have a guaranteed amount of money attached.

Researchers and advocates have been asking for an RFA for the last ten years, so the confirmation that we may finally get one is extraordinarily good news. But the real question is whether NIH and advocates define “substantially more” the same way. The last requests from the CFS Advisory Committee, the IACFS/ME, and members of Congress were for $7-10 million, and perhaps that would be a realistic expectation. But given the needs identified in the P2P report, and the thirty years ME/CFS research has spent in Siberia (as Bob Miller put it), I’m not sure we can cry victory over that kind of number. It also matters how well targeted the request for proposals is, especially in terms of case definition and types of studies. Fatigue research won’t cut it, in my opinion. Dr. Collins said the idea is to award the money in FY2016, so we should get these details soon.

The second piece of good news, confirmed on NPR today, (see update below) is that ME/CFS research will be overseen by the National Institute of Neurological Diseases and Stroke. There was initially confusion about whether this meant just the  Trans-NIH ME/CFS Working Group would move, or whether ME/CFS research itself was going to have a home at the Institute. Having an Institute home is extremely important, for three reasons:

First, being assigned to an Institute means that ME/CFS will be included in an Institute’s strategic plan. To my knowledge, that has never happened. As NIH moves increasingly towards use of strategic plans to guide funding decisions and reporting to Congress, having someone thinking about ME/CFS in that context is critical.

Second, being assigned to an Institute means that ME/CFS has a chance at getting a piece of the Institute’s budget. The Office of Research on Women’s Health, where we’ve been for many years, does not have a research budget. In 2014, funding for ME/CFS research grants was cobbled together from four Institutes (NINDS, NIAID, NIMH, NINR) and the Office of the Director. We’re not talking a lot of money, so that represents tiny investments from each of those sources. Undoubtedly other Institutes will continue to be relevant in funding ME/CFS research (especially NIAID), but having a home gives us a chance at a bigger slice.

Third, being assigned to an Institute should mean that ME/CFS will have an assigned Program Officer. The importance of this cannot be overstated. Program Officers are research portfolio managers at NIH, assigned to specific areas of focus. They write Program Announcements and Requests for Applications. They monitor grants once awarded. They must stay current on developments in their assignment areas and interact with the research community. After grant applications are reviewed (in our case by the CFS Special Emphasis Panel), Program Officers make funding recommendations to their Institute Councils. In other words, a good Program Officer is indispensable to research progress. (Here’s a great first hand account of being a Program Officer).

In 2014, seven different program officers oversaw ME/CFS grants. Seven. That does not mean we had seven people staying abreast of ME/CFS research and managing a portfolio. It means that no single program officer was responsible for doing so. And that is a huge loss. It is one of the barriers to the success of ME/CFS researchers in applying for NIH funding. The good news is that Dr. Vicky Whittemore at NINDS managed more 2014 ME/CFS grants than anyone else (five), followed by Dr. Timothy Gondre-Lewis at NIAID (three). So if Dr. Whittemore is assigned to be the ME/CFS program officer, we have a head start. The caveat is that she is already the program director for epilepsy, so it’s not likely she’ll be working on ME/CFS full time. But it’s a start.

Third, a new study at the NIH Clinical Care Center will bring the latest technology to bear on the “clinical and biological characteristics of ME/CFS following a probable infection” (that’s from the press release). We don’t know many details about the study, but the Clinical Care Center is one of the best medical facilities in the country, if not the world. Bringing in ME/CFS patients and working them up with every possible test is a great idea, and has been needed for a very long time.

We don’t know how much money will be invested, but the NPR story does say it will include 40 patients. We don’t know how patients will be selected. The Atlantic reported that the study will focus on patients left “permanently impaired” after an acute illness, but the NIH press release said that the study “plans to enroll individuals who developed fatigue following a rapid onset of symptoms suggestive of an acute infection.” (emphasis added) We don’t know if the study will focus on the newly ill, or what case definition(s) will be employed. And it’s likely that some of these decisions have not actually been made yet. We’ll have to watch how the protocol develops, and what testing is used. This study has incredible potential to yield the answers we need, if it is appropriately designed.

Here’s the bottom line of the NIH announcement: It’s a promising start. There are a lot of details we need to know. And until we actually see how much money is on the table and how it’s spent, we can’t judge the quality of the effort.

As Dr. Collins told Science Insider, “Give us a chance to prove we’re serious, because we are.”

Ok. Let’s do this. We’ve waited long enough.

Update November 7, 2015: I continue to hear conflicting reports about whether ME/CFS research will be overseen by NINDS, including having a single program officer and being included in the NINDS strategic plan. Sources who have spoken directly to NIH continue to report different answers to this question. I’m not sure if the explanation is a lack of clarity at NIH, or that advocates don’t speak NIH’s language such that people are interpreting answers differently. I think we will have to wait and see how this plays out. If we are not included in NINDS’s strategic plan or if we do not see someone step forward to truly manage an ME/CFS portfolio, then we’re quibbling about semantics instead of solving the problem.

Update November 9, 2015: Cort Johnson spoke with Dr. Vicky Whittemore and reports that she said: “To be clear, no one NIH institute, office or center has single oversight for research on ME/CFS. We will work together through the Trans-NIH ME/CFS Research Working Group to coordinate, stimulate and support research.” That sounds to me like we do not have an Institute home the way other diseases do. We are going to have to wait and see how this plays out in order to just whether this is a good development or not.

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21

Posted on October 9, 2015 by Jennie Spotila

October 6, 2015 was my 21st “sickaversary.” I know the date because the onset of ME/CFS in my case was so sudden and dramatic.

Not a single doctor told me that I could be sick for years. Not a single doctor, as the years passed, said this might be permanent. Not until I had been sick for five years. Then, and only then, was I told that where I was at five years was likely to be where I would stay. The phrase “if you are lucky” went unspoken.

But I never believed this could happen. I never imagined being in my forties, still unable to work or to live independently. In 1994, I never would have said or imagined or even feared that I could still be sick twenty-one years later.

In the past I have marked my sickaversaries with tears, testimony to the CFS Advisory Committee, and prayer. And hitting 21 years in 2015, which has been the absolute hardest year of my life, has basically sucked in almost every way. So for this year’s sickaversary?

I MADE A CAKE.

IMG_4722

My mother died in January. She was one of my best friends. But I am still here.

ME/CFS took my career, my independence, my dreams. But I am still here.

My husband had a stroke that could have killed him, and he is still out of work. But I am still here.

Two people I love had surgery this year. Others lost loved ones to cancer, disease, or old age. But I am still here.

I have spent the last twenty-one years suffering from a disease that almost no one cares about, that has no treatment, that leaves patients to suffer and die early deaths in isolation from a world that has forgotten about them and moved on. But I am still here.

In 2015, I have cried more tears than in the rest of my life combined. There have been days when I knew I could not take any more bad news or suffering, and then I did. There have been days when I breathed more out of habit than desire. But I am still here.

I have rested and found comfort in the arms of my loved ones and my faith. I have found strength deep in the marrow of my bones when I thought I was sucked dry of life and hope and endurance. I have continued. And I am still here.

So this 21st anniversary of the day my life changed irrevocably forever in ways I never would have chosen or foreseen? This day was not a sad day.

It was a fucking victory lap.

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A Miracle, and a Break

Posted on August 28, 2015 by Jennie Spotila

This year has been the most difficult of my life, starting with my Mom’s passing in January. Losing her was just the first in a cascade of bad news, and I made the decision to stop maintaining that laundry list because it just made me feel worse.

But three weeks ago, one of the worst and luckiest things happened to us. My husband had a stroke. Not only did he have a stroke, but he was misdiagnosed in the emergency room with vestibular neuritis. So he did not begin receiving treatment for the stroke until we got the accurate diagnosis last week.

As part of getting that accurate stroke diagnosis, we discovered that the stroke was in his medulla. One doctor told him that he was lucky to be alive, let alone walking around and not permanently disabled. He “dodged a bullet,” this doctor said. To have this type of stroke untreated for two weeks because of misdiagnosis, and to be walking/talking/breathing/swallowing unassisted just three weeks later is . . . . well, it’s a miracle.

My husband is my primary caregiver. Through the unwavering kindness and support of family and friends, we have been transported to every doctor appointment, had meals to eat, and all the emotional support that we need. But I had to become the primary caregiver in many ways, especially in making medical decisions and logistical arrangements. And because of that 2015 laundry list of bad news, I was crashed and depleted long before I had to summon an ambulance to our home three weeks ago, not even realizing that my husband was having a stroke.

The time has come for me to take a break. My use of social media, including this blog, will be extremely limited for a few weeks (at least). I will be monitoring email, but probably not responding to much of it. I am not “retiring” from advocacy, but I need to take care of my husband and of myself. That is my prime directive and top priority.

As I said, this is the worst and luckiest thing to ever happen to us. The only reason my husband is not dead or severely disabled is our good fortune. The stroke was extremely small, and the misdiagnosis did not kill him. Both of us will be ok, but we need some time.

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CFSAC Testimony, Jennie Spotila, August 18, 2015

Posted on August 17, 2015 by Jennie Spotila

Unfortunately, I am too sick to offer public comment by telephone for the August 18-19, 2015 meeting of the CFS Advisory Committee. I submitted these written comments for the record. Thank you to all of the advocates who are speaking by phone or in person.

Dollar-on-HookWhen I was a kid, I used to go fishing with my Dad. It was nothing sophisticated: just a borrowed boat on a small lake, live bait and a plastic bobber on the line. But there was a hitch. There was no way I was going to squish a live worm onto a hook. And even though my father is a herpetologist, he did not insist that I learn to bait the hook myself. He baited my hook and we fished. My Dad also did not ask me the obvious question: was my fishing strategy going to consist of waiting in the boat and hoping the fish would come to me on their own?

Yet this is the kind of fishing strategy that seems to be NIH policy as far as ME/CFS is concerned.

For the last ten years, advocates, scientists and this Committee have urged NIH to invest more money in ME/CFS research. Both the IOM and P2P reports reached the obvious conclusion that substantially more research is needed in this area. The IOM committee said, “Remarkably little funding has been made available” to study this disease, and “More research is essential.” (IOM, p. 225) This advisory committee has urged greater investment, and has repeatedly recommended that NIH issue an RFA with dedicated funding in order to stimulate this field.

Last year, NIH’s response to this Committee was that issuing an RFA “would not be an effective strategy”. On August 11, 2014, Dr. Francis Collins wrote to Representative Zoe Lofgren, “The lack of sufficiently trained individuals applying for NIH research funds to conduct ME/CFS research projects contributes to the low number of applications received and subsequently the annual spending on ME/CFS research.” This is in and of itself a remarkable assertion, since researchers like Dr. Ian Lipkin and Dr. Ron Davis have applied for NIH funding and been rejected. Are they not sufficiently trained?

Every time NIH has been urged to issue an RFA to stimulate research in ME/CFS, NIH’s response has been that there are not enough researchers or data to make it worthwhile. In other words, NIH is sitting in the boat and expecting that the fish will catch themselves.

This is not NIH standard operating procedure when it comes to other areas of research:

What these diverse initiatives share is an NIH investment policy designed to stimulate research in an area that needs development. But this policy is not applied to ME/CFS.

Worse, NIH’s current position on ME/CFS is not even consistent with its previous actions. In 2005, NIH issued an RFA on Neuroimmune Mechanisms and CFS. How could there have been enough known about the disease and enough qualified researchers to do the work sufficient to issue an RFA in 2005, but not now in 2015 when we have more data and more scientists than at any time in the history of the field?

Everyone – patients, advocates, researchers, members of Congress, the IACFS/ME, this Committee, the IOM and the P2P – EVERYONE has told NIH that more research is desperately needed in ME/CFS. EVERYONE has said that this is an under-researched area that needs an immediate infusion of money and personnel if patients are to have any hope at all for effective treatments. Everyone has said this, and NIH refuses to do what is necessary. Instead, NIH is sitting in the boat, waiting for the fish to come and fling themselves out of the water and into the boat on their own.

NIH knows how to encourage interest in under-researched fields. It declares an interest in the field, backed up with dedicated funding. In other words, simply bait the hook, and the fish will swarm the boat.

I say to NIH: Bait the hook. Go fishing. I know you will catch some keepers.

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CDC: Speculations and Consequences

Posted on August 12, 2015 by Jennie Spotila

cdclogoControversy continues over the Senate appropriations committee report’s recommendation that the CDC’s CFS program funding be eliminated for FY 2016. We have certainly debated the merits and faults of the program from just about every angle on this blog.

But the real question is: Why did the Senate committee recommend the elimination of funding? I can offer only speculation.

Hypothesis #1: Budget cuts were needed and ME/CFS was an easy target. This is the explanation most likely to be offered by the committee staff. It doesn’t really make sense though, at least not on a Division level. If you look at the chart on page 59 of the report, you will see that CFS was the only category in the Zoonotic Division to see a decrease from FY2015 funding. Every other category was kept stable or increased. I certainly agree that we are an easy target for cutting, given the void in our collective efforts on the Hill. But the overall Senate recommendation for CDC funding exceeds the budget for 2015, and $5 million is almost invisible when compared to the overall budget. Why were we singled out?

Hypothesis #2: Someone wanted to cut it because ME/CFS is unimportant. We are certainly well-acquainted with the misconceptions about ME/CFS. And it is entirely possible that someone on the Senate subcommittee ascribes to those misconceptions. But ME/CFS has been in the news more in 2014-2015 than at any time since the XMRV controversy. If no one working on the subcommittee (including staff) has heard of the IOM report, then we have great cause for concern, and our short-term prospects of increasing our visibility seem low.

Hypothesis #3: Someone wanted to cut it because the CDC CFS program is not producing the right results. This would be interesting. Perhaps there is a staff member who knows more about ME/CFS than we expect, and recommended cutting the funding because the program is doing more harm than good. If this is the case, this person could be a potential ally in a powerful place.

Hypothesis #4: CDC didn’t bother to fight for the program. I don’t have facts to back this up, but it seems like a foregone conclusion doesn’t it? At the highest levels, CDC has paid little attention to (and expressed little love for) the CFS program. There are two exceptions to this: when CDC got caught misappropriating funds from the program and when the early XMRV findings suggested it was a blood borne human pathogen. Other than those two occasions, CDC leadership has not been particularly interested. But even if CDC failed to fight for the funding, that doesn’t explain why it was cut.

Regardless of the reason(s) for the committee recommendation to cut the funding, the ME/CFS advocacy community is responding at full volume. There are multiple email and petition campaigns underway, as well as meetings in the works. We won’t know until September if these efforts are successful. But there would be some interesting consequences to success.

Consequence #1: Community seal of approval. To put it bluntly, the CDC’s CFS program has NEVER had the full force of the ME/CFS community on its side. Never. I am sure that CDC leadership is surprised, and Dr. Beth Unger must be gratified to be receiving such vocal support. This campaign in support of program funding opens a new chapter in CDC/community relations.

Consequence #2: Imprimatur. How will CDC interpret the ME/CFS community’s sudden turn around? I think it is unlikely that anyone at CDC will look at the complexity of the community’s discussion. Most people who are supporting the program funding are doing so because of the multi-site study, or just the basic principle of “don’t cut our funding.” Very very few advocates are endorsing the CDC’s education campaign. But this distinction will not be acknowledged by CDC.

Instead, I predict that CDC will use the advocacy support as an imprimatur on all their ME/CFS efforts. They will be able to say that the program has the vocal support of ME/CFS patients and advocates. When they roll out the latest education materials, when they discuss the multi-site study, or when they make presentations about the program as a whole, CDC will say that the ME/CFS community supports it.

Some readers may say that CDC would never twist the facts this way. But all’s fair in politics. NIH twisted the facts of the letter signed by 50 ME/CFS experts in support of using the Canadian Consensus Criteria. In his August 11, 2014 letter to Representative Zoe Lofgren, NIH Director Dr. Francis Collins said, “This is a critical, unmet need in the area since there are very few ME/CFS clinician-scientists pursuing this line of research (for example, the advocacy groups identify approximately 50 ME/CFS clinicians and scientists world-wide who are considered experts in this field).” Do you see how skillfully this was done? The fact that 50 experts signed the letter, combined with advocates touting that letter as definitive on the CCC, was twisted and fabricated into the statement that advocates identify only fifty experts worldwide. Masterful politics, and CDC excels at this too.

Consequence #3: Bargaining chip. There is a powerful and positive consequence if the program funding is continued. ME/CFS advocates will be able to claim that we got the funding restored, and that gives us power with CDC. If we can get funding restored, we can just as readily get it taken away. I hope that the leaders of the current advocacy efforts realize this.

The petitions and letter writing and meetings may be successful in securing program funding in 2016. This is being done, as far as I know, with no advance promises from CDC or Dr. Unger to make the changes we want to see (particularly in the education campaign). CDC could take the money and run, using this campaign as a shield for whatever they plan to do next. Or advocates could use the success to get CDC to come to the table and work to improve the program.

If flexing the advocacy muscle succeeds, then we must follow through to ensure the program improves. And if CDC fails to do so, then we should flex the muscle to end that funding in 2017, or at least attach so many strings of Congressional oversight that CDC has to comply.

Because one thing is for certain: if this is the beginning of a new chapter in CDC/community relations, that the chapter must benefit ME/CFS patients. Otherwise, the whole effort will have been a waste.

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No CDC Funding for CFS?

Posted on August 4, 2015 by Jennie Spotila

cdclogoME/CFS advocates focus almost exclusively on research funding from the National Institutes of Health, and with good reason. But now it appears that funding for the Centers for Disease Control’s CFS program may be at risk in the 2016 appropriations bill. This is not a done deal, and many people believe we should advocate for continued funding. I do not.

Funding or No Funding?

The first step in the federal appropriations process is at the committee level in the House and the Senate. Each committee approves the text of an appropriations bill, and submits an accompanying report for consideration by Congress.

On the House of Representatives side, the appropriations committee report recommends $5.4 million for the CDC’s CFS program (see page 39 of the report). This is the same amount of funding as in 2015. The House appropriations bill does not specify funding for CFS or any other program within the Emerging Zoonotic and Infectious Diseases branch, but only recommends aggregate funding (see page 44 of the bill).

On the Senate side, the appropriations committee report explicitly declines to include appropriations for the CFS program (see page 59 of the report). It is the only program in the Zoonotic branch that the committee declines to fund in 2016. The Senate appropriations bill, like the House bill, only recommends aggregate funding for the Zoonotic branch (see page 52 of the bill).

So the House and Senate committees have approved the appropriations bills. The House committee report recommends CDC CFS funding, and the Senate committee report does not. The next step in the process is a vote in each house of Congress on the appropriations bills. However, with Congress now in a five week recess, these votes won’t happen until September.

It is very important to understand a couple of things. First, neither of these recommendations is a done deal. The House and Senate have to vote on their versions of the appropriations bills. You can track the status of each bill as it winds through the process in the House and the Senate.

Second, even after these bills pass in the House and Senate, the differences between them have to be reconciled. The House bill allocates $460 million to the Zoonotic branch, while the Senate bill allocates $388 million. The many differences between these bills have to be reconciled in a budget conference, and then the reconciled bill has to go back to the House and Senate for a final vote. All of this has to be completed before September 30th in order to get the bill to the President and avoid a government shut down.

Third, the conference reports are not binding. Just because the Senate recommended killing the CFS funding does not mean CDC has to do it. CDC can spend money on the program even if the conference report does not recommend this. However, if CDC is looking to cut back or kill the CFS program, then the committee report certainly gives them political cover to do so.

Fourth, we don’t know why the Senate committee report declined to recommend funding. Was it because the committee didn’t hear from the public about the importance of the program? Was there a staffer who advocated this? Or was it simply a matter of looking for places to cut, and this was an easy target?

Multiple sources have expressed deep concern to me about the prospect of no funding for the CDC’s CFS program. Among other things, the CDC’s multisite study would be in jeopardy. I certainly respect these concerns, and I also respect the fact that the multisite study is an important epidemiological effort that provides revenue to the seven contracted participating sites. But there are powerful arguments on the other side too.

Why Not Support CDC Funding?

Let’s not forget that the multisite study has design flaws, although it did provide useful data to the IOM committee as they constructed the new SEID criteria. The multisite study is, of course, not the only effort in the CDC’s CFS program. The much maligned ToolKit and Medscape education units are part of the program too. CDC has resisted many recommendations by the CFS Advisory Committee, such as putting a “black box” warning on exercise recommendations. Furthermore, CDC has made no public statement about whether it will adopt the IOM’s SEID diagnostic criteria (or even just post-exertional malaise as a required symptom), and this is inexcusable given that the IOM report was published six months ago.

The potential danger that the CDC education program can pose to ME/CFS patients was underscored last week by a new posting on FedBizOpps. The post is a “Sources Sought” request from CDC for a new education effort, and the details are very troubling.

“Sources Sought” is a specific kind of request for information. Basically, the government needs to establish whether there are sources or contractors who can do the work under consideration. In this request, CDC is looking for contractors who can produce radio segments and interviews to educate the public about CFS.  The idea is expressly modeled on the Memory Loss Initiative, which has collected more than 1,800 personal stories from people living with memory loss.

On the surface, this sounds like a great idea, right? I mean, what advocate does not want the personal stories of people living with ME/CFS to be publicized? But read the posting closely. The CDC uses the name “CFS” with no mention whatsoever of ME. The description of CFS is drawn from the Fukuda definition, not IOM SEID or any other definition that requires post-exertional malaise.

Furthermore, the CDC modified the posting yesterday. The original posting acknowledged that most physicians did not know how to treat and manage the illness, but that has been deleted. Of course, who is responsible for the lack of competency among physicians? CDC and the medical associations. The original version also stated, “CDC will identify subject matter experts to serve as a steering committee or reviewers of the content.” Not surprisingly given the reaction among some advocates online, that statement has also been removed. But don’t let that fool you. This is a Sources Sought request, not the actual contracting opportunity. CDC is unlikely to pay a contractor money and not retain control over the final product in some way.

Not For Me, Thanks

This FedBizOpps posting is just the latest example of how CDC does not understand this disease. CDC refuses to admit that PEM is a distinguishing feature of the disease; refuses to acknowledge that exercise can be harmful to people with ME/CFS; refuses to use any aspect of the IOM report; and refuses to specify an appropriate diagnostic code. And many of CDC’s actions regarding this disease over the last thirty years have been harmful to patients, or just plain wrong.

Personally, I don’t want to pay CDC to persist in its approach to ME/CFS. Why should we? What’s in it for patients? I see no reason to invest my limited capacity in advocating for funding for a CDC program that is largely mistaken and misguided.

I want a CDC program that studies my disease, and that recognizes the central features including PEM. I want CDC to take the lead on educating physicians about my disease, so that all patients can be accurately diagnosed and appropriately treated. This means the end of blanket endorsements of graded exercise therapy and cognitive behavioral therapy as treatments. I want “chronic fatigue” to be excised from the CDC’s approach to ME/CFS once and for all.

Has the multisite study been a step in the right direction? Yes. Does this mean we should support funding for the CFS program? No.

The FedBizOpps notice, the silence on the IOM report, and other CDC initiatives are based on the erroneous view that Fukuda is an adequate definition for the disease and that PEM makes no difference in how one should diagnose and treat patients. If most patients are undiagnosed, it is because CDC and the public health complex have utterly failed to educate physicians about this disease, in part because of the dedication to Fukuda and Reeves’ empirical definition. Every single one of us has been told, early and often, that we need to exercise our way out of this disease. Who is responsible for the pervasiveness of that “treatment” approach? CDC.

I won’t be writing to Congress to ask that the CDC CFS program funding be cut. But I most definitely will not be writing to support the funding, either.

When I weigh the positive things about the CDC’s CFS program against the harmful and negative things, I come up short. When I think about the harm done by CDC’s persistent recommendations for exercise, I come up angry. The program is not 100% bad, and I know that many people in the ME/CFS community believe it should continue. But overall, CDC’s current approach to this disease is not worthy of my support.

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