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A Review of the P2P Systematic Review

September 29th, 2014 29 comments

IMG_3530The draft systematic evidence review on the Diagnosis and Treatment of ME/CFS was published online last week. It’s a monster – 416 pages in total. I know many ME/CFS patients may not be able to read this report, so in this post I’m going to focus on three things: the purpose of the report, the lumping of multiple case definitions, and the high quality rating given to the PACE trial. If you read nothing else about this systematic review, then these are the biggest takeaway messages.

The Purpose of the Systematic Review

NIH requested the review for the purposes of the P2P Workshop, and the Agency for Healthcare Research and Quality contracted with the Oregon Health & Sciences University to perform the review for about $350,000.

The primary purpose of the review is to serve as the cornerstone of knowledge for the P2P Panel. The Panel will be made up entirely of non-ME/CFS experts. In order to give them some knowledge base for the Workshop presentations, the Panel will receive this review and a presentation by the review authors (behind closed doors). Until the Workshop itself, this review will be the Panel’s largest source of information about ME/CFS.

But that is not the only use for this report. AHRQ systematic reviews are frequently published in summary form in peer reviewed journals, as was the 2001 CFS review. The report will be available online, and will be given great credence simply because it is an AHRQ systematic review. The conclusions of this review – including the quality rating of the PACE trial – will be entrenched for years to come.

You can expect to see this review again and again and again. In the short term, this review will be the education given to the P2P Panel of non-ME/CFS experts in advance of the Workshop. But the review will also be published, cited, and relied upon by others as a definitive summary of the state of the science on diagnosing and treating ME/CFS.

Case Definition: I Told You So

When the protocol for this systematic review was published in May 2014, I warned that the review was going to lump all case definitions together, including the Oxford definition. After analyzing the review protocol and the Workshop agenda, Mary Dimmock and I wrote that the entire P2P enterprise was based on the assumption that all the case definitions described the same single disease, albeit in different ways, and that this assumption put the entire effort at risk. Some people may have hoped that a systematic review would uncover how different Oxford and Canadian Consensus Criteria patients were, and would lead to a statement to that effect.

Unfortunately, Mary and I were correct.

The systematic review considered eight case definitions, including Oxford, Fukuda, Canadian, Reeves Empirical, and the International Consensus Criteria, and treated them as describing a single patient population. They lumped all these patient cohorts together, and then tried to determine what was effective in diagnosing and treating this diverse group. The review offers no evidence to support their assumption, beyond a focus on the unifying feature of fatigue.

What I find particularly disturbing is that the review did acknowledge that maybe Oxford didn’t belong in the group:

We elected to include trials using any pre- defined case definition but recognize that some of the earlier criteria, in particular the Oxford (Sharpe, 1991) criteria, could include patients with 6 months of unexplained fatigue and no other features of ME/CFS. This has the potential of inappropriately including patients that would not otherwise be diagnosed with ME/CFS and may provide misleading results. (p. ES-29, emphasis added)

But then they did it anyway.

Credit: ElodieUnderGlass

This is inexplicably bad science. How can they acknowledge that Oxford patients may not have ME/CFS and acknowledge that including them may provide misleading results, and then include them anyway? Is it just because Oxford papers claim to be about CFS and include people with medically unexplained fatigue? The systematic review authors clearly believed that this was a sufficient minimum standard for inclusion in analysis, despite the acknowledged risk that it could produce misleading results.

I will have a lot more to say on this topic and the problems in the review’s analysis. For now, the bottom line takeaway message is that the systematic review combined all the case definitions, including Oxford, and declared them to represent a single disease entity based on medically unexplained fatigue.

PACE is Ace

One of the dangers of the review’s inclusion of the Oxford definition and related studies was the risk that PACE would be highly regarded. And that is exactly what happened.

The PACE trial is one of seven treatment studies (out of a total of thirty-six) to receive the “Good” rating, which has a specific technical meaning in this context (Appendix E). In the systematic review, a randomized control trial is “Good” if it includes comparable groups, uses reliable and valid measurement instruments, considers important outcomes, and uses an intention-to-treat analysis. I’m certainly no expert in these issues, but I can spot a couple problems.

First of all, the PACE trial may have used comparable groups within the study, but that internal consistency is different from whether the PACE cohort was comparable to other ME/CFS patients. The systematic review already acknowledged that the Oxford cohort may include people who do not actually have ME/CFS, and in my opinion that is the comparable group that matters.

In terms of important outcomes, the systematic review focused on patient-centered outcomes related to overall function, quality of life, ability to work and measures of fatigue. Yet there is no discussion or acknowledgement that patient performance on a 6 minute walking test at the end of PACE showed that they remained severely impaired. There is also no acknowledgement that a patient could enter PACE with an SF-36 score of 65, leave the trial with a score of 60, and be counted as recovered. That is because so many changes were made to the study in post-hoc analysis, including a change to the measures of recovery. Incredibly, the paper in which the PACE authors admit to those post-hoc changes is not cited in the systematic review. It is also important to point out that much of the discussion of the PACE flaws has occurred in Letters to the Editor and other types of publications, many of which were wholly excluded from the systematic review.

Again, I will have a lot more to say about how the systematic review assessed treatment trials, particularly trials like PACE. For now, the takeaway message is that the systematic review gave PACE its highest quality rating, willfully ignoring all the evidence to the contrary.

Final Equation

Where does this leave us, at the most basic and simple level?

  • The review lumped eight case definitions together.
  • The review acknowledged that the Oxford definition could include patients without ME/CFS, but forged ahead and included those patients anyway.
  • The review included nine treatment studies based on the Oxford definition.
  • The review rated the PACE trial and two other Oxford CBT/GET/counseling studies as good.
  • The review concluded that it had moderate confidence in the finding that CBT/GET are effective for ME/CFS patients, regardless of definition.

If that does not make sense to you, join the club. I do not understand how it can be scientifically acceptable to generalize treatment trial results from patients who have fatigue but not ME/CFS to patients who do have ME/CFS. Can anyone imagine generalizing treatment results from a group of patients with one disorder to patients with another disease? For example, would the results of a high cholesterol medicine trial be generalized to patients with high blood pressure? No, even though some patients with high blood pressure may have elevated cholesterol, we would not assume the risk of generalizing results from one patient population to another.

But the systematic review’s conclusion is the predictable output of an equation that begins with treating all the case definitions as a single disease entity.

I will be submitting a detailed comment on the systematic evidence review. I encourage everyone to do the same because the report authors must publicly respond to all comments.  More detailed info will be forthcoming this week on possible points to consider in commenting.

This review is going to be with us for a long time. I think it is fair and reasonable to ask the authors to address the multitude of mistakes they have made in their analysis.

Edited to add: Erica Verillo posted a great summary of problems with the review, as well.

 

Mary Dimmock: Fight the Power

September 25th, 2014 40 comments

The draft P2P evidence review report has been issued and we have all had a chance to see just how appallingly bad it is. Now the question is what to do next.

Some have called for us to oppose P2P by boycotting it. I absolutely agree that we must oppose P2P. But where I differ is in the nature and breadth of tactics that we need to use.

What has been done to ME patients for thirty years and is being perpetuated in this P2P evidence review report is scientifically indefensible and irresponsible. Starting with the fact that the entire “CFS” enterprise as a clinical entity has been constructed on the sole basis of medically unexplained chronic fatigue. Seriously? Where is the scientific justification and evidence that all of the conditions encompassed by the common, ill-defined symptom of fatigue plus the current state of our medical knowledge are the same medical condition that should be studied and treated as one? There is none and there never can be.

And yet, for thirty years, that pseudoscience has held ME patients hostage in a living hell.

Such pseudoscience is the bread and butter of those with agendas to keep science from moving forward or to protect their own vested interests. We have seen it with cigarette smoking and acid rain and we are seeing it again with climate change. But you don’t fight climate change deniers by not exposing the flaws, bias and the hidden agendas in their “scientific” claims. You fight them by exposing where their “facts” are wrong, their “science” is unsound and their agendas are driven by self-interest. This is what ME advocates have been doing with the PACE trial and in my opinion is what we need to do with P2P.

Providing formal input to P2P allows us to expose the “science” of “CFS” for the scientific sham that it is. AHRQ (Agency for Healthcare Research and Quality, part of HHS) must respond to our comments, which become part of the public record that we can use later. Providing such input is as valid and necessary as a form of protest as boycotting or writing letters directly to HHS leaders. All forms of opposition are needed.

But given the history of this disease, we should be under no delusions that left to its own devices, HHS will listen to our P2P opposition, whether it takes the form of letters to HHS leaders, boycotting the meeting, or the submission of comments on the evidence review. Each can be dismissed by those who have chosen not to listen.

And much more fundamentally, we need to remember that P2P is just one event in a string of utter failures in HHS’ public policy toward ME that stretches back to Incline Village. You all know the issues – lack of research funding, harmful medical guidelines, abysmal medical care, lack of a strategy, the nightmare of insurance, disability and school accommodations and an agency hell-bent on acting unilaterally and with complete disregard of both disease experts and patients.

Ultimately, the real question is not what specific form our opposition to P2P should take. There is a place for all actions that shine a light on this travesty. Whatever you choose, make sure your voice is heard. Do not let your silence be construed as consent.

The real question is what else are we going to do to protest, not only about P2P but also about every other aspect of HHS’ handling of this disease for the last thirty years.

If ever there was a time for us to revolt as a community, by whatever means available, it is now.

Contact your congressional leaders and ask every one of your family and friends to do the same. Call your local and/or national media. Twitter. Sue the government. Contact the ACLU. Conduct a lie down demonstration. Protest at P2P. Whatever means of opposition that you can think of and are able to do, just do it!

 

NIH Says No, and Also No

September 23rd, 2014 18 comments

noWith no announcement or fanfare, the CFS Advisory Committee has posted a response from HHS to the June 2014 recommendations. My information is that  – inexplicably – even CFSAC members were not notified when the response was posted. I urge you to read the entire response, but I am going to focus on just a few sentences. There are very serious implications for the future of ME/CFS research, but despite NIH’s entrenched position, there are still things we can do about it.

No Data Sharing Platform For You

The first recommendation was that NIH create and maintain a data sharing platform for ME/CFS research. NIH’s response? No. But their reasoning is remarkable:

[D]eveloping and maintaining a unique ME/CFS database is cost prohibitive in light of the small number of researchers . . . the cost of developing and maintaining an ME/CFS database would significantly reduce funds available for funding research on ME/CFS . . .

Translation: There are not enough of you to make this platform idea worth the money.

But the implication of that last sentence is astounding: maintaining such a database would reduce the funds available for research. Translation: NIH will only spend a fixed amount of money on ME/CFS. Even if NIH decided to create a database, there would be no increase in funds to cover the cost – that money would simply be reallocated from grants.

The background document to the recommendation specifically states that a central data sharing platform would “greatly accelerate research discovery” and foster “opportunities for new scientists to enter the field.” The platform would lower barriers to conducting ME/CFS research. But NIH responds: No, because there aren’t enough researchers and we won’t increase our ME/CFS spending.

Put another way, ME/CFS has a problem because there are not enough researchers. CFSAC proposes a solution of a data platform that could attract the interest of new researchers. NIH says no, because you don’t have enough researchers.

Wait, what?

There Will Be No RFA

The second recommendation was that NIH fund an RFA to address the gaps in ME/CFS research. NIH’s response? No. And the reasoning on this one will make your head hurt, it is so circuitous.

Unfortunately there remains a lack of definitive evidence regarding the etiology, diagnosis, and treatment for ME/CFS. As such, issuing a Request for Applications (RFA) would not be an effective strategy as RFAs generally encourage a narrowly defined research area that addresses more specific gaps in scientific knowledge.

First of all, NIH issued an RFA for ME/CFS in 2006 and it was targeted at Neuroimmune Mechanisms and Chronic Fatigue Syndrome. So the gaps were obvious enough to issue an RFA eight years ago, and more gaps were identified at the 2011 State of the Knowledge meeting, but now we don’t know enough to target those gaps????

Second of all, why is there a “lack of definitive evidence”? Obviously, because NIH funding at $5 million a year is not likely to produce much in the way of definitive evidence on etiology, diagnosis and treatment.

It seems to me that what NIH is actually saying is: we haven’t provided enough funding to identify definitive evidence, and because you haven’t identified definitive evidence we can’t provide you with more funding. If that doesn’t qualify as circular reasoning, I don’t know what does.

What this response tells us is that if NIH persists in this approach, we will be waiting a long time for an RFA or increase in funding. We will have to wait until a) there is a miracle discovery on etiology, diagnosis and treatment or b) 10 to 15 years for the career development idea to produce more researchers who are doing ME/CFS research.

Despite the thorough background and support for the recommendation provided by CFSAC, despite letters from members of Congress in support of an RFA, despite the pleas of advocates and organizations like IACFS/ME, NIH is steadfastly refusing to provide the one thing that we know would accelerate research progress: the money. UNACCEPTABLE.

What You Can Do

The NIH response leaves the door open just a crack – and that crack could make all the difference. The response says that RFAs are “designed to build upon recommendations . . . that incorporate findings from workshops and conferences.” Remind you of anything? Think P2P.

This makes the P2P Workshop more mission critical than ever, especially now that the draft systematic review has been published. The P2P report is supposed to identify gaps in ME/CFS research. NIH has left the door open to an RFA that incorporates findings from workshops. So we need to do everything possible to make sure the P2P report identifies accurate and appropriate gaps.

The systematic review says that CBT is moderately effective. It treats all the case definitions as equivalent. Remember that this review is the single piece of evidence given to the P2P Panel in advance of the Workshop. Do you want the P2P Panel report to incorporate those findings? Do you want an RFA based on findings like that?

I don’t. So here is what you can do:

Now is not the time to lie down. NIH says No? I say push back. This is a critical moment. If we slip and fall now, the consequences will affect us for many years to come.

 

Draft Systematic Review is UP

September 22nd, 2014 7 comments

The draft systematic evidence review on the Diagnosis and Treatment of ME/CFS has been published.

This review is extraordinarily important because it is being presented to the P2P Panel in a closed door session any day now. This review will be the only evidence presented to the P2P Panel in advance of the Workshop on December 9-10, 2014. Expert presentations at the Workshop may support, refute or expand upon the review, but it is likely that the Panel will ascribe very heavy weight to this report.

I have not read the report yet, and will hold off on commenting until I do. A group of advocates is working together to review the material and prepare highlighted issues that others can use in their comments.

Public comment on the review will be accepted through October 20th. Regardless of whether you plan to submit comment, please read at least the executive summary of this report if you are able to do so. It will be one of the most important documents on ME/CFS published by the government this year.

 

P2P Participation, Part 2

September 18th, 2014 14 comments

I have new information on participation in the Pathways to Prevention ME/CFS Workshop:

The Office of Disease Prevention confirmed via telephone that the public will be able to participate in discussion at the P2P Workshop, in person and online. ODP explicitly said that people attending in person can ask questions or make comments via microphones or computers in the room. Webcast viewers can type in comments and questions in a comment box on the webpage. There is a total of 3.5 hours of “Discussion” time noted on the draft agenda, and this is when public input will be addressed. The ME/CFS meeting will follow a procedure very similar to the upcoming P2P meeting on opioid use, so we will be able to see how it works. While there is no guarantee of how much we will be included in the discussion, I am very glad that we finally got some clarity on this issue.

Dr. Susan Maier (NIH) confirmed via email that the comment period on the P2P final report will be extended. Originally, we were going to have from December 12 to December 26th to submit comment on this vital report on the direction of ME/CFS research. This is the worst possible timing for a population as disabled as ME/CFS patients, falling right at the holidays. Multiple groups and individuals requested an extension of this time as an accommodation of our disability. Dr. Maier has confirmed that the comment deadline will be extended to 30 days, meaning the new deadline should be around January 12, 2015. This is a fair and reasonable period of time, and I thank NIH for making this accommodation.

So here is where I repeat my plea for as many people as possible to attend the meeting on December 9-10th, watch it via webcast, and comment on the draft report. Register for the meeting here.

I know that some advocates believe that watching the meeting or submitting comments is some kind of endorsement of the process, and that this participation will be used against us. I strongly disagree. Silence will be interpreted as consent. This is especially true given that we now have better opportunities to participate (although it remains to be seen how many of our questions are actually addressed, of course). We have been complaining for years that NIH needs to do more about ME/CFS, and now they believe they are taking a big step to do more.

I am on record as saying that I believe the P2P Workshop is fundamentally flawed in its present form. But I will attend this meeting, I will ask questions, and I will submit comment. I am not doing so because I think I can fix the fundamental flaw by myself. I am doing so – I am doing all the P2P work I have done – because at the very least, I will make sure that this process is conducted in the light. I will make sure that people know what is being done, how and by whom.

P2P is offering us a tiny itty bitty piece of a microphone. I say hold on, and speak up.

 

Charter Changes

September 16th, 2014 No comments

Change - Blue ButtonIt came down to the wire, but HHS Secretary Sylvia Burwell has renewed the charter of the CFS Advisory Committee. While there are no sweeping changes to the charter, some of the changes may have you scratching your head.

CFSAC is a chartered advisory committee, meaning that it is created by the head of HHS and must be reauthorized every two years (by law). The charter is the operational framework for this committee, defining its purpose and the basics of its functioning. Regulations and HHS policy run in the background, but the charter sets many of the rules. I did a line by line comparison between the old and new charter to see what will be different for the next two years.

All in a Name

Throughout the charter, the word CFS has been replaced with ME/CFS. On the one hand, this reflects the overall change in how people refer to this illness. But the name of the committee is the same; it is not the ME/CFS Advisory Committee. It is still CFSAC, despite the changes in the document itself.

The other puzzler here is the fact that the IOM study includes a recommendation on the name of the disease. What will happen if IOM says the disease should be called ME or Ramsay’s Disease or something entirely new? Will we have to fight HHS all over again for them to use the appropriate terminology?

Purpose

The purpose of the CFSAC is unchanged: to provide advice and recommendations on a broad range of issues related to ME/CFS. As a side note, it is interesting to see how the areas covered by CFSAC have been stripped away by other initiatives. The CFSAC is supposed to advise on the state of knowledge and gaps in research, but that’s being done by P2P. Impact and implications of diagnostics and treatment is partly covered by IOM. Development of education programs is partly IOM and partly CDC (which has strongly resisted CFSAC’s attempts to influence here). Partnering to improve patient quality of life is about the only thing still solidly CFSAC.

Report Structure

As in previous charters, CFSAC makes its recommendations to the Secretary through the Assistant Secretary. Management and support services are provided by the Office of the Assistant Secretary, as before. The Office of Women’s Health (OWH) has never been mentioned by name in the charter, but there is little doubt that the CFSAC will remain in that office. The new DFO, Barbara James, is a staff member in OWH, and Dr. Nancy Lee has said she will remain available to assist in the transition.

Money

The most significant change in the charter is the committee budget. The annual cost for operating the committee, which includes the travel stipend but excludes the cost of staff support, has decreased 47%. This probably reflects the move to only one in-person meeting per year.

However, the cost of staff support has gone up. The estimated staff time is 1.5 full time equivalent staff for the year. This does not mean that one person only works on CFSAC, though. It’s an estimate of combined staff time, and presumably includes the contractor cost for the meetings. The cost of that staff time has increased almost 52%.

Overall, the budget for CFSAC has increased by about 12%. That sounds reasonable, but it comes at the cost of an in-person meeting. If the travel stipend was retained for two meetings per year, the increase would have been at least 33%.

The More Things Change . . .

What difference will any of these changes make? Probably not much. We already knew that we were going to lose an in-person meeting, given the trend over the last year. The CFSAC is still lodged in OWH, with a member of Dr. Lee’s staff in the role of DFO. We don’t know much about Barbara James at this point. Her public health career has focused on women’s and minority health issues, including a project to include gender focus in the Healthy People 2010 initiative. The fall meeting of the CFSAC will be our first opportunity to assess how she will approach her new role as DFO of the committee.

 

*My thanks for Denise Lopez-Majano for assisting with the research for this piece.

Why You Should P2P

September 8th, 2014 34 comments

p2p-advancing-research-banner

My concerns about the NIH’s Pathways to Prevention Workshop on ME/CFS are legion, and I’ve been quite vocal about them. But today I am asking you to participate in the P2P Workshop on December 9-10, 2014.

Registration for attending in person or by webcast is now open, and my hope is that everyone who reads this blog will sign up for one or the other.

Why would I ask you to participate in a Workshop that I have been trying to stop or delay or change? It’s simple: the P2P Panel needs to see us, hear us, and know that we are watching what they do.

I can guarantee you that the P2P Panel will not understand what this disease does. They won’t know that some of us need wheelchairs. They won’t know what a crash looks like. They will have no idea that we are held prisoner by our bodies, unable to cook, read, speak, stand in line, drive, function, live any kind of normal life. They won’t understand that scheduling this meeting right before the holidays imposes an extra and tremendous obstacle to our ability to participate.

How can I be sure that the Panel will not understand these things? Because one of the criteria for their selection is that they have no professional or personal experience of this disease. Because the evidence review is unlikely to convey the seriousness of the disease. Because the P2P Panel’s website does not even mention post-exertional malaise, let alone paint an accurate picture of this disease.

The P2P Panel needs to look around the room at the Workshop and see us. They need to see us guzzling water and electrolytes, sitting with our feet propped up on chairs. They need to see our walkers and canes and wheelchairs. They need to see our family and friends. They need to see us lying on the floor when we become too ill to sit.

The auditorium holds 1,000 people, but in the application for meeting approval (that I obtained through FOIA) NIH estimated that only 100 members of the public will attend. I don’t know if they think we aren’t interested or that we won’t bother to be present at this vital and important meeting. Prove. Them. Wrong. I cannot guarantee that you will have a chance to comment or ask a question. But I promise you that your physical presence in the room will have an impact. I promise you that making this the most watched P2P meeting will have an impact. How can it not? How can we – the people most affected by this disease and most impacted by this non-expert Panel’s recommendations – how can we possibly fail to send a message if we come together and SHOW UP.

Do not acquiesce to being made more invisible than we already are. So please, register for the meeting in-person or by webcast.

 

Burning Underground

September 3rd, 2014 11 comments

Credit: Cole Young*

Just over a year ago, advocate Leela Play noticed something odd on a federal contracting website. What she found was a notice of intent to award a sole source contract to the Institute of Medicine to create clinical diagnostic criteria for ME/CFS. And just like that, the ME/CFS landscape changed.

What followed was a month-long attempt to stop the government from issuing this contract, and when that failed more attempts were made to get the contract rescinded. The advocacy and scientific communities faced divisions over positions and tactics. Meanwhile, the IOM contract has moved towards its conclusion in March 2015.

Current activity – both IOM and advocacy – is smoldering underground. But no one should mistake this period of quiet to mean that nothing is happening.

Where Is IOM?

The process and schedule for this IOM study is set forth in the contract, and is moving pretty much on track. The committee was selected in December 2013, and held two public listening sessions (January and May 2014). The committee has met behind closed doors four times, with a fifth meeting scheduled for this week. Bare bones meeting summaries are posted on the project website after the meetings.

Committee members have reviewed a great volume of material. An extensive literature search has been conducted. In addition, the public has submitted comments and materials over the course of the contract, numbering more than 4,000 pages the last time I checked. There are also indications that the committee may have examined raw data, although details about that are not yet available.

The study seems to be running slightly ahead of the schedule laid out in the contract, at least judging from the meeting dates. If so, then it means the committee is putting the finishing touches on its recommendations and the case definition. The next step is sending the draft report out for peer review, with delivery on track for early 2015.

Where Are We?

As reflected on this and other blogs, discussion forums, and social media, ME/CFS advocacy exploded when we learned about the contract. I’ve compared it to dropping a match on a lake of gasoline. For the most part, we focused our attention outward towards the government, IOM and the media. But at various times, we’ve also focused attention inward. We’ve criticized each other for our positions on the contract, the degree to which we have participated in the process, and for the tactics we’ve used. Sometimes, the criticism has not been constructive. This is not unexpected when people feel cornered and the stakes are high.

DHHS stated at the June 2014 CFS Advisory Committee meeting that it wants to work with the advocacy community on a path forward after the IOM report. As I wrote in my meeting summary, if this “means the kind of involvement we have had to date, then there is nothing to really talk about.” HHS holds all the cards here, and it will take more than token efforts on both sides to actually move forward together. Obviously, this begs the question of whether ME/CFS advocates will even want to move forward with the IOM report. It all depends on what that report says.

What Next?

I think one possible analogy for where we are now is the Centralia mine fire. This fire has been burning in a coal seam beneath the town of Centralia, Pennsylvania for 52 years. Underground coal fires can burn for years undetected. Eventually, the ground collapses in sinkholes, allowing oxygen to rush in and fuel the fire even more.

On the surface, it may not seem like advocates are paying much attention to the IOM study right now. A number of prominent voices in our community have retired (temporarily, I hope) or taken breaks to recover from the crashes brought on by advocacy. The scientific community has not been publicly discussing IOM. And the IOM committee members themselves are bound by very strict confidentiality rules, so they’re not talking either.

Don’t let the quiet fool you. Work has continued on multiple fronts this year, and I expect we will hear developments in the near future. It won’t take much disturbance on the surface to refuel this fire. A sink hole, some oxygen, and we’ll be at it again. What I’m wondering these days is who is going to get burned.

 

*Photo credit: Cole Young, Flickr, Creative Commons license

Turnover

August 27th, 2014 6 comments

Multiple sources have confirmed that Dr. Nancy Lee is stepping down as Designated Federal Officer of the CFS Advisory Committee. Also departing is her assistant DFO, Marty Bond.

Dr. Lee was a lightning rod for criticism and controversy. During her term as DFO, we saw violations of the Federal Advisory Committee Act and heard credible allegations that Dr. Lee intimidated several members of the committee for expressing their views (an HHS investigation found no wrongdoing). Dr. Lee was also blamed for the move to hold CFSAC meetings by webinar and for contractor incompetence in managing those meetings. Perhaps the two most glaring controversies were Dr. Lee’s apparent leadership role in the creation and funding of the Institute of Medicine contract, and for publicly admonishing ME/CFS advocates for their vitriol and instructing us to call out those advocates out. As a result of all this, the relationship between the ME/CFS advocacy community and the DFO of CFSAC has deteriorated to the lowest point I have ever seen it, and there were formal requests to have Dr. Lee replaced.

In the past, CFSAC DFOs have served for approximately two years, although I can’t tell whether this is coincidence or policy. Dr. Lee replaced Dr. Wanda Jones as DFO after Dr. Jones was promoted from Director, Office of Women’s Health to Principal Deputy Assistant Secretary. I have found no announcement indicating that Dr. Lee is being promoted away from the Office of Women’s Health, although it is possible that something is in the works. It is also possible that Dr. Jones, who is now Acting Assistant Secretary for Health, decided to remove Dr. Lee from the DFO position for other reasons.

Dr. Lee’s replacement is Barbara James, currently the Acting Director, Division of Program Innovation in the Office of Women’s Health. Ms. James has been with the Office of Women’s Health since 2007, so while she has apparently never served as a DFO of an advisory committee, she is probably familiar with the CFSAC.

I’ve heard through several sources that a fall CFSAC meeting is being planned, and that it will be held via webinar. All this news strongly suggests that the CFSAC charter will be renewed, although there has been no official confirmation of that. What remains to be seen is whether the recent problems with CFSAC were rooted primarily in personality or policy.

 

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Renewal?

August 20th, 2014 13 comments

renewalWill the CFS Advisory Committee be back this fall? Not many people seem to be paying attention to the fact that it could potentially disappear.

The CFSAC is a chartered federal advisory committee, and by law it must be renewed every two years. The current charter will expire on September 5, 2014. There has not been a single peep about whether renewal is pending.

In the past, renewal has sometimes been pro forma and sometimes has required a little push from advocates. Public input has been sought on revisions to the charter as well. In 2012, you may recall, the addition of the non-voting liaison members was proposed and the public was able to provide comment on that change to the charter. This year? Nothing.

That does not automatically mean that the charter will not be renewed. After all, four new members were just appointed this summer, along with the renewal of two current members. The formation of new working groups after the June 2014 meeting also suggests that a new charter is forthcoming.

Would it be a bad thing for CFSAC to disappear? Many advocates would say no. They believe that CFSAC is an exercise in futility that drains our focus and resources away from more productive advocacy efforts. I certainly understand and share this frustration, and I’ve been a vocal critic of some aspects of the committee’s operation and recommendations.

But I think it would be a great loss for CFSAC to be dissolved. Right now, the agency representatives must give reports and answer questions. Think of all the things we have learned about only because of those reports. For example, we learned that the second phase of CDC’s multisite study will not include two-day maximal exercise testing, and CDC is relying on the advice of some ME/CFS experts in doing so. We learned about the P2P meeting more than a year before the final approval was given and the meeting officially announced.

And don’t forget that information flows the other way, as well. Through our public comment, advocates have not only conveyed the seriousness of the disease and need for urgency in the federal response. We have managed to put many issues on the public record, including sharp criticism of the CDC multisite study, the P2P meeting, and more. Do not underestimate the importance of that public record. HHS may continue to ignore what we say, but they can’t say they didn’t know and we can use that public record in other political venues.

I’ve heard it said that HHS would love to have an excuse to make CFSAC go away. For that reason alone, I hope it is renewed. I do not see a down side to requiring the agencies to report on their actions (or lack thereof), information that it would be very very difficult for us to get any other way. So let’s hope the renewal is pro forma, and that I can update this post in two weeks with a new charter.

Update August 22, 2014: The Solve ME/CFS Initiative announced via their website yesterday that they had written to Secretary Burwell in support of CFSAC renewal on August 1st. To date, they have not received a response. Read the full letter here.

Update August 24, 2014: Billie Moore, non-voting liaison for the NJCFSA, says in the comments below that there will be a fall meeting of CFSAC, and it will be via webinar. This was confirmed to me by another source, as well.