On January 3, 2014, just three days before the P2P Working Group meeting, a troubling series of emails was exchanged among NIH leadership. These emails show confusion at the leadership level about the ME/CFS P2P and IOM efforts, and a narrow concern from Dr. Francis Collins himself about the topics for P2P.
I obtained these emails through FOIA. I’ve posted the emails for you to read in their entirety, but the organization can be confusing. The emails are also heavily redacted, which I have appealed. In this post, I’m using a narrative format because it is critically important that every ME/CFS researcher and advocate understand this story. Bottom line? No one in charge seemed to understand what was going on, and the implications of that are frightening.
On January 3rd, Cort Johnson’s article about the dramatic decline in NIH’s commitment to ME/CFS over time appeared on ProHealth, and a note about the article appeared in the NIH internal news summary that day. This prompted Dr. David Murray (Director of the Office of Disease Prevention) to email his staff to ask for their input on a draft email to Dr. Francis Collins about the P2P meeting. The draft is redacted, as is a comment from staff member Jody Engel.
Dr. Murray then sent the following email to Dr. Collins (copying four other staff members in the Office of the Director):
I noticed the item in today’s news briefing regarding chronic fatigue syndrome. The report suggested that NIH was falling behind in this area.
Let me alert you that ODP has been planning a workshop on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) as part of its Pathways to Prevention workshop series for more than a year. Jim Anderson was involved in the initial proposal development and selection of the Working Group members. Janine Clayton and Susan Maier at ORWH have been involved from the outset. The first meeting of the Working Group is scheduled for Monday, January 6 and the target date for the workshop is Fall 2014.
We generally don’t publicize these workshops until they are further along in the planning and have HHS approval, but I wanted to share this with you so you were aware.
This is pure politics. The planned P2P Workshop in no way changes or addresses the decline in funding that Cort discussed in his article. The Workshop does nothing to avert the trajectory of NIH falling behind on ME/CFS, especially in light of everything else NIH is refusing to do. Dr. Murray saw an opportunity to put his office’s work forward, and he did.
Almost immediately, Dr. James Anderson emailed Dr. Murray and said,
Remind me- the goal of the ODP WS is to provide a research definition for ME/CSF [sic]. We are not wandering outside that box. The IOM meeting [redacted].
This is remarkable. NIH had been saying quite clearly at CFSAC meetings that the purpose of the workshop was not to come up with a research definition. Yet here is the Director of Program Coordination, Planning, and Strategic Initiatives saying the precise opposite. Before replying, Dr. Murray turned again to staffer Paris Watson and said, “I need to clarify the purpose of the workshop. It is supposed to be used to [redacted].” Is Dr. Murray asking Watson because he doesn’t know the purpose of the workshop?! This is precisely what we’ve already documented: the purpose of the P2P meeting has shifted over time and NIH has made contradictory statements about it. Apparently, this is true internally as well.
Shortly thereafter, Dr. Murray responded to Dr. Anderson, saying in part, “The goal is to address methodological issues that are holding up research in this area. So the working group will tackle the issue of what diagnostic criteria should be used in research for ME/CSF [sic].” Anderson then replied:
I think Francis needs a follow-up email explaining how the NIH and IOM goals are different. Our goal is to provide a more useful definition of ME/CSF [sic] so that our research investments produce the highest quality and valid results. [redacted]
I don’t think any ME/CFS researcher or advocate is under the illusion that the Director of NIH has our disease forefront on his mind or agenda. There’s not enough money involved for that to be the case. But I find it troubling that Dr. Collins needed an explanation of how the “NIH and IOM goals are different.” Given the controversy, and given NIH’s role as a primary funder of both initiatives, shouldn’t someone have already briefed Dr. Collins on this – or at least his senior leadership staff?
Dr. Murray turned his attention to drafting a follow-up email to Dr. Collins, again relying on Paris Watson and Dr. Susan Maier. There are some significant and troubling statements in the resulting email:
Jim Anderson suggested that I follow my earlier note to [redacted].
Our P2P workshop will review the various definitions for ME/CFS that have been used in research studies to clarify the type of patients that are captured under each definition and how those patients respond to various therapeutic options. This will inform future research by providing a better understanding of the implications of choosing one definition over another as studies are being designed. Our audience will be researchers working in ME/CFS.
The IOM effort will also review the various definitions for ME/CFS but their goal is to recommend diagnostic criteria and case definitions for clinical care. Their audience will be health providers, patients, and caregivers, not researchers.
Our planning had been underway for sometime when we learned of IOM’s interest in this topic. We have been communicating with them to avoid duplication of effort. They have invited Susan Maier from ORWH to their first meeting to discuss our P2P Workshop “in an effort to minimize overlap and maximize synergy.”
First, note the promise that P2P will clarify which patients are captured under each case definition and how that affects response to treatment. Whatever the plan was in January 2014, we now know that P2P will not do this. The evidence review made no such distinctions and lumped all the case definitions together. There is no indication that anyone is going to address the question of how case definition predicts response to treatments. Second, note the statement that IOM’s audience is not researchers. Does this signal an intention that researchers not use the IOM output? Fukuda was intended as a research definition, but it’s been used clinically for 20 years. If IOM produces an accurate and precise case definition, shouldn’t researchers be the exact audience that needs to pay attention to that? Finally, Dr. Murray admits that the P2P planning was underway for “sometime” when they learned of the IOM’s “interest” in the topic. In other words, there was NO coordination between the P2P and IOM ideas, as many of us suspected.
Finally, Dr. Francis Collins responded to the emails from Dr. Murray:
Thanks for the heads up. I hope there will be some attention to the microbiome as part of this CFS workshop.
I will admit that when I first read this email in the FOIA packet, my jaw dropped. Out of all the ME/CFS issues, including case definition (which Dr. Collins himself personally noted was a problem at the 2011 State of the Knowledge Workshop), what he asked about in January 2014 is the microbiome. Why?
I can only speculate, but perhaps the answer lies in what Dr. Ian Lipkin told Mindy Kitei in May 2014. Dr. Lipkin, whose effort to find funding for his ME/CFS microbiome study is well-known, said, “I’m on the advisory committee for Francis Collins, and I can tell you that Francis Collins, the director of the NIH, believes that chronic fatigue syndrome is a problem.” Have Drs. Lipkin and Collins discussed the microbiome study? Have they discussed the poor scores given to Dr. Lipkin’s grant proposal by a reviewer who said ME/CFS was a psychosomatic illness? Personally, I hope they have discussed it, but for this topic to be Dr. Collins’ “hope” for the workshop strikes me as myopic, at best.
As one would expect, an email from the Director of NIH received immediate attention. Dr. Murray quickly asked Dr. Maier and Paris Watson if the microbiome was in the plans for the P2P workshop. Dr. Maier responded, “I am sure that the microbiome will be discussed as part of the scientific content at the actual workshop, however, the purpose of the P2P really is to help determine the extent of evidence surrounding the case definitions . . . “ Dr. Maier also quickly told Dr. Murray and Dr. Anderson that “Microbiome is playing a larger role in ME/CFS research, with at least 2 of 16 projects following this approach as the primary objective, and others with a smaller focus on microbiome in general.”
Simultaneously, Deputy Director of NIH Dr. Lawrence Tabak emailed, “As I recall HHS was planning on sponsoring a workshop on this in FY14 that NIH is a co-sponsor of; Janine [Clayton] may know the details – if not I can find out.” And now confusion really spins out of control.
Dr. Murray, now quite flummoxed, emailed staff member Wilma Peterman Cross in part, “Francis raised the issue of the microbiome and Larry raised the specter of yet another workshop. I am trying to find out if this ‘other workshop’ is the IOM meeting. I hadn’t intended to spend most of my morning on this . . . ” Turning again to Dr. Maier and Ms. Watson, Dr. Murray asked, “Do either of you have information on this? Is this the IOM workshop that the 3 of us have been trading notes about this am? Or is there a third workshop being developed that I haven’t heard of.”
Ok, let’s pause for a minute. NIH is co-sponsoring the IOM study under their contract with the National Academy. The IOM contract had been controversial for months, and Dr. Maier was scheduled to speak at the IOM meeting in just three weeks. Yet the Deputy Director of NIH had no idea what is going on with it, Dr. Collins needed an explanation of the difference between IOM and P2P, and now Dr. Murray had to scramble to figure out if there was a third meeting he was not aware of. Am I surprised? No. Is it disheartening to see how far off the radar ME/CFS is? Absolutely.
Dr. Maier, one of the only NIH staffers who appeared to know what was going on, replied, “Yes, the 2014 workshop from HHS is the IOM workshop/study. Those are the only 2 I know about other than a potential in house one at NINDS looking at brain fog in general.” Dr. Murray then sent a final email to Dr. Collins and Dr. Tabak, repeating what he said before about the P2P vs. IOM effort and saying, “Francis…At least two currently funded projects on ME/CFS address the microbiome. That topic is very likely to come up at the P2P workshop in the fall.” Of course, we now know that the microbiome is just one of many categories of ME/CFS science that will not be discussed at the Workshop.
These emails are a telling snapshot of NIH leadership’s scramble, on the eve of the P2P Working Group planning meeting, to figure out the purpose of the P2P meeting and its difference from the IOM study. Even the Director of the ODP – the office charged with running the P2P Workshop – does not seem to understand the purpose of the Workshop and how it fit (or failed to fit) with other NIH efforts.
Furthermore, Dr. Collins’ only response to the blurb from Dr. Murray about the P2P Workshop is to say that he hopes the microbiome will be covered. Even if Dr. Collins is not tracking ME/CFS (and I doubt he is), how could the microbiome be the foremost issue in his mind? As I said, Dr. Collins attended the 2011 State of the Knowledge Workshop and acknowledged the importance of resolving the case definition issues. He sat and listened to Dr. Suzanne Vernon summarize the gaps in research and the issues that needed attention. But in January 2014, he only mentioned the microbiome – a topic that his colleague Dr. Ian Lipkin is interested in investigating.
I have no doubt that the P2P Workshop will open with statements from Dr. Anderson and Dr. Murray that this is a significant demonstration of NIH’s commitment to ME/CFS patients and research. That is how these meetings always begin. And I would love to hope that the Workshop marks a new chapter of increased attention and funding for ME/CFS at NIH. But given the confusion among leadership in January 2014, I have some trouble believing this to be a realistic hope.
This whole email exchange started because of the news item claiming that NIH was falling behind in its commitment to ME/CFS. Dr. Murray basically says Hey Dr. Collins, it’s not true because we’re planning a meeting. And then for three hours, leadership muddles around trying to figure out what exactly the meeting is about and how it differs from the IOM contract. And the only thing Dr. Collins says is, I just hope you cover the microbiome.
It’s not just the confusion that bothers me, or even the narrow focus on one researcher’s interest in the microbiome. It’s the mindset reflected in that first email from Dr. Murray to Dr. Collins. It’s the bureaucratic mindset that responds to evidence of NIH’s failure to make any progress on a costly and disabling disease with “We’re having a meeting.”
The P2P Workshop represents an opportunity to get it right. It could address the problems that are holding ME/CFS research back. That may even be the intention of staff like Dr. Susan Maier, and it is certainly the intention of the ME/CFS expert members of the Working Group. But given the deeply flawed evidence review, the closed door selection of Panelists, the exclusion of many experts and important topics, and the inclusion of speakers who believe ME/CFS is a functional somatic syndrome, is it realistic to believe that the Workshop will start a new chapter and begin to make up for the stagnation of funding? What do you think?
Illness Beliefs (or Why I Am Not an ME/CFS Activist)
Today, Joe Landson shares his thoughts on how the false illness beliefs (or even cognitive bias) among scientists is holding our field back. Joe says it is time to tear down the walls and think horizontally – to the horizon, even. Let’s look at what is actually in front of us, and not what we expect to see.
I am not an ME/CFS activist because of incorrect illness beliefs. Yes, incorrect illness beliefs – as I see it, they’re the main challenge in ME/CFS. No, no, not our beliefs as patients – the Wessely School’s notions that our beliefs make us sick are absurd, and always were. No, I mean incorrect medical ideas generally, specifically ideas of what makes an illness ‘real’ or not, or what makes an illness at all.
Let me explain. No, there is too much, let me sum up. For a very long time, doctors and researchers defined an illness as ‘organic’ by the tissue damage they could see. For example, the tumors they could see, feel and biopsy made cancer ‘real’. It was damage to an organ; hence, organic.
However this approach has had some treatment limitations. Cut the tumor out; more grow back. Eventually, medicos devised treatments to shrink the tumors and make them less likely to return: namely, chemotherapy and radiation.
For decades, treatment of cancer and other organic diseases generally improved. However treatment of those other diseases, those without detectable organic damage and called functional disorders, was decidedly mixed. It’s fair to say that treatment philosophies for those invisible functional disorders often (though not always) featured extraordinary contempt for the illness and the patient. From Dr. Lewis Yealland’s electrocution of World War One shell-shock patients to the Wessely School’s use of forced exercise for ME/CFS, it seems that contempt generally wins. Contempt is quick and seems to produce clear results… much the same way that cutting out the tumor seemed to ‘cure’ the cancer. Except it didn’t, and still doesn’t.
Meanwhile cancer treatment has evolved. As I write this, the Food and Drug Administration (FDA) is fast tracking radical new immunotherapy for cancer. Immunotherapy doesn’t affect the organic damage directly; rather, it blocks, damps or corrects the immune signals that encourage the tumors or other organic damage to occur. It’s about the signals – the signals that tell the organic damage to start or stop.
This begs the question: What about immune signals that don’t produce organic damage? What about illnesses with a chronic pattern of bad immune signals, but no apparent organic damage at all? What if the signal pattern is the damage?
This mental leap surmounts the wall medicos have built between organic diseases and functional disorders. Both types of illness can potentially be treated the same way – perhaps even with the same drugs, if the Rituximab studies are any indication. Moreover, doctors now can sometimes detect and treat disease before the organic damage ever happens.
This shift in medical beliefs is going on all around us, but not for us, because most of the official gatekeepers of ME/CFS are working so very hard to keep this illness category locked in place, endlessly describing empirical symptoms instead of genuinely investigating their underlying mechanisms. In the constant balancing act in life between control and progress, they side with control. Rather than waste time arguing with these gatekeepers, I’d like to do an end run around them, and point out that all these invisible functional disorders are ‘organic’, if we only change our minds and amend what we mean by ‘organic’. Organic can be a pattern of immune signals rather than the organ damage of yesteryear. Similarly I think our well-meaning friends who insist our bad signals must be located in our brains – organ damage all over again – are thinking too narrowly. Certainly our brains are deeply affected, but that doesn’t mean the bad signals start or end there.
When I grow up, I want to be a bomb-throwing medical anarchist. For NSA-types scanning this blog, no, I don’t mean actual bombs. I want to blow up medical ideas of what ‘organic disease’ really means. I want to explode the borders of medicine – the borders between organic disease and functional disorders; the borders between medicine and psychiatry generally. But just to keep you nervous, internet police, I can and will say that in Arabic if I have to!
This is a long way of explaining why I’m not an ME/CFS activist, per se. I think trying to maintain ME/CFS as a category is a narrow goal and a rigged game – rigged because our government seems dedicated to ‘evidence-based’ approaches to ME/CFS, rather than re-imagining the evidence we have. I think arguing over this or that definition of ME, or CFS, is a poor use of our time and energy, because none of the definitions extant define the immune signals that I suspect (but can’t prove yet) make us sick. To me, all the tiny, empirical functional categories, from bipolar disorder to Morgellon’s, are empty shells of outdated thinking. In pure immune research, someone is finding those signals as we speak – it’s just not labeled ME/CFS research, or Morgellon’s or bipolar research. At least, not yet.
We should seek this research out, celebrate and promote it. We should do as some are already doing, and point out both the sorry current state of – and the immense future possibilities for – almost all the invisible illnesses. Most of all we should see and portray the invisible illnesses as part of a continuum of immune signaling disorders, beyond their separate, and inherently unequal, empirical definitions.