(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.
Saying No
I’m going to out myself right now by revealing the hardest – absolute hardest – lesson that I am trying to learn from Toni: saying no as an act of self-compassion. Toni writes about this in chapter 4 of How To Live Well:
Toni shares that it is hard for her to do this because she was raised to accommodate others. I was raised to put my family first above all else, and then to put meaningful work above all else. I learned by example that my personal comfort and health do not come first. And I have also learned through hard experience that this is a recipe for disaster when coupled with a chronic disease.
The first part of Toni’s test is whether saying yes would be true to yourself. She explains:
This is so hard for me in the realm of advocacy. Over and over, I hold my work and participation to a high standard. I participate in advocacy precisely because it reflects my values. But Toni’s test doesn’t stop with that. She goes on to say:
I completely understand why so many patients take breaks from advocacy, or never get involved much in the first place. ME/CFS advocacy is like David facing Goliath without his slingshot. It is a hard uphill slog each and every day because there is so much resistance to progress. It’s not impossible, and it’s not without successes. And there are certainly many allies to collaborate with. But for ten years, I have persisted in advocacy despite the fact that it intensifies my physical suffering. I was too sick to go to the P2P meeting last year, but I did it anyway. I was too sick to give my IOM presentation, but did it anyway by phone only because I had a high fever and had spent three days in bed. I throw my body down on the train tracks more often than not. But stepping back would not be true to my values and ethics, even though it would ease my suffering. How to reconcile these conflicting impulses? I don’t know.
The second part of Toni’s test is whether saying no would be kind and helpful to yourself. She writes:
I don’t do this. I prioritize what benefits me emotionally much more than what would be kind to my body. As just one example, I attended a concert with several loved ones before Thanksgiving. I knew I would love it, and in fact, I was completely transfixed by the experience. And I used my wheelchair to minimize the strain on my body. But going out at night always induces a crash. In making the calculation to do something like this, I usually decide I don’t care how much it hurts afterwards. In fact, if I did not sacrifice my physical comfort, I would likely only leave home for doctor appointments, and would have even less of a life than I do now.
I also faced this calculation during the last two years my mother was sick with cancer. I helped my Dad take care of her, making it possible for him to keep working. I can’t drive or do housework, but I kept her company, supported her emotionally, and kept her eating. And every time I came home from staying with her, I crashed. My husband would take care of me, and then I would go back for the next treatment cycle. I was too sick to be doing this, I was too sick to be in the hospital with her as much as I was at the end, too sick to stay with her for the days of hospice care. But I did it anyway. I gladly sacrificed my physical comfort and even perhaps my long-term health in order to take care of my Mom. And I am so glad that I did. I absolutely treasure that time I had with her. Saying no would have protected my body but injured my soul.
Toni has faced this too. She writes,
I don’t see this as black and white, and I don’t think Toni does either. Sometimes we have to tip the balance toward emotional well-being over physical comfort. But what I’m trying to learn from Toni is to tip the balance a little bit more towards protecting my physical well-being. My instinct, especially where my family is concerned, is to say yes even when I know my body will suffer. I’m trying to dial it back, and be a bit more
selfishself-compassionate than I am naturally inclined to be.How To Live Well is, like Toni’s other books, very compassionate and gentle. She concludes the chapter on saying no by saying, “Think of it as a practice. That way, you won’t hold yourself to too high a standard.” This is one reason why I find Toni’s books to be so helpful: she only makes suggestions and shares what works for her. Try it, experiment, and see if it works for you. But if not, that’s ok.
For me, deep reflection on Toni’s writing reveals the wisdom behind her practical advice. Each chapter in How To Live Well is short and seems straightforward. But I find layers of meaning and lessons in each short chapter. So I’m practicing. “No” is not as comfortable a word for me as it should be, but I’m practicing.