I Want To Believe Dr. Collins, But I Don’t

Dr. Francis Collins, Director of the National Institutes of Health, spoke to the ME community earlier this month at the meeting on Accelerating Research on ME/CFS. For the ten minutes he was present, Dr. Collins said a lot of nice things. I sincerely want to believe it all.

But I don’t.

I want to believe that the meeting is “a real milestone.” I want to believe that the Trans-NIH ME/CFS Working Group will “bring forward ideas about new projects, new kinds of funding,” and that those ideas will have Dr. Collins’s “strong personal support” and thus become reality.

Except Dr. Collins’s remarks this month were strikingly similar, in many ways, to what he said exactly eight years ago at NIH’s State of the Knowledge Workshop on ME/CFS Research. In 2011, Dr. Collins pointed out that “we really need to understand a lot more about what subsets might exist.” He said there had been “hopeful presentations” about approaches coming out of new technologies. He expected “new ideas” to come out of that workshop and that “those new ideas might suggest new research.” Subsets, the promise of new technologies, and new ideas. Dr. Collins hit all these same notes in his 2019 remarks.

Even so, I want to believe him. Dr. Collins said, “we are part of a family now.” He said he is impatient for progress, just like we are. He acknowledged that NIH has often not seemed to be as responsive as our community wanted, and he regrets that. Dr. Collins was correct when he said that NIH had ratcheted up funding; there was a 75% increase from 2016 to 2017. I want to believe him when he said, “we don’t want to wait a minute if we can see a way to accelerate that progress.”

Except . . . In 2018, NIH funding dropped 17%. Back in 2015, Dr. Collins promised to ramp up funding, but ramps don’t go up and down like a roller coaster. In 2015, Dr. Collins also said, “Give us a chance to prove we’re serious, because we are.” Yet we already know that NIH’s plan is to plant the seeds of the Collaborative Research Centers and then wait. We are halfway through FY 2019 and NIH has made only two new ME/CFS grants, so we are on pace for another decrease in funding.

Dr. Collins said, “We want to be [the National Institutes of Hope] for ME/CFS.” He said, “We want to provide the kind of hope for ME/CFS that is attached to action . . What follows after this meeting is going to be actions as well.”

I want, with all my heart, to believe him. But I can’t.

It’s not that I think Dr. Collins is insincere.

I don’t believe him because we have heard all this before, over and over for many years.

I don’t believe him because the losses are mounting: The money. The scientists. The years. The people.

I don’t believe Dr. Collins because—in this same speech—he signaled to us that we couldn’t. He said, “We have done what we can in terms of the resources, both intramurally and extramurally.”

NIH has done what it can.

Dr. Collins was, I think, trying to give our community hope. He was saying that NIH has gotten the ball rolling with the Collaborative Research Centers and the young investigators meeting. At the same time, he was telling us to be patient. NIH has done what it can, and he wants us to wait for the Working Group to come up with new ideas. As if these new ideas will be a magical substitute for the solution we all know is needed: large scale research funding. He was asking us to hope that actions would follow this meeting, instead of delivering those actions.

I am long past the stage in my life where I will find hope in promises, especially promises from people in positions of power. To believe such promises requires trust, and I have been disappointed too many times.

When actions prove that a person can be trusted, then I will trust. When I see sufficient actions, then I will have hope. To me, hope looks like that 75% increase in funding, but repeated many years in a row. Hope looks like a dozen more Collaborative Research Centers funded by NIH in the next five years. Hope looks like one hundred NIH-supported postdoctoral fellowships.

There are so many people affected by ME who need hope in order to keep going. They believe that research money and treatments and public acceptance are on the way, and soon. They believe that they can trust our government to do the right thing, if we just provide the right information, if we ask in the right way. Reasonable people, when presented with the facts, will do the right thing. I would like to believe that too.

Yet hope is not a plan. Hope, without action, is just a wish. Dr. Collins quoted Peter Levi, and said, “No action, no hope.” I would like to see every #MillionsMissing event blanketed in signs that say: “No Action, No Hope.”

With all my heart, I want to believe the good things Dr. Collins said. But given everything I have witnessed in the last 25 years, I need a lot more than words.

I will believe in the National Institutes of Hope for ME/CFS when NIH starts acting like it.

 

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Return on Investment II: David Tuller

Last year, I fully endorsed Dr. David Tuller’s crowdfunding appeal in support of his investigative reporting on ME.

This year, I am happy to endorse Tuller’s fundraising once again.

The progress report that accompanies Dr. Tuller’s fundraising request (and also posted on Virology blog) details his research, writing and publications during the last year. A number of those accomplishments were part of the plan he shared in last year’s fundraising, and it’s good to measure his progress over time.

Tuller also summarizes the scrutiny and attacks he has sustained in the last year. The authors of PACE and their like-minded colleagues have made complaints against him publicly and privately. Yet the walls of PACE are crumbling away. It reminds me of this famous quote:

First they ignore you. Then they ridicule you. And then they attack you and want to burn you. And then they build monuments to you. – Nicholas Klein

The true believers in the psychosocial explanation for ME (and make no mistake, it is a belief) ignored, then laughed, and then attacked the many people with ME who criticized PACE. Now they are attacking Dr. Tuller as well. But the data are clear, and more scientists have publicly criticized the flawed science of PACE. Neither Tuller nor people with ME want monuments. We want good science, and treatments based upon it.

Last year, my endorsement of Tuller’s work ruffled some feathers, namely those of Dr. Michael Sharpe, one of the PACE co-authors. Dr. Sharpe recently told a reporter that he was leaving the ME field, so perhaps he won’t notice my comments this year.

But I hope you will notice Tuller’s work. He cannot bring down PACE single handed. We need excellent science, and critical reviews of all the science. We need NIH and CDC to step up and fix the situation they have helped perpetuate. Tuller’s work brings scrutiny and visibility to the scientific malpractice in PACE, and this is a tool we can use to bring about necessary change.

As an individual, I cannot make all these things happen. But I can help, and so can David Tuller, and so can you. Please join me in supporting David Tuller’s work.

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Dr. Collins: Transcript of Remarks on April 5, 2019

Dr. Francis Collins addressed the Accelerating Research in ME/CFS meeting for ten minutes this morning. This is my best effort at a transcript of those comments.

Thank you, Walter. I’m really glad to be able to be here for at least a few minutes to address this distinguished group at what I think is a real milestone in our efforts to understand the cause and ultimately define preventions and cures for ME/CFS. I hope you have heard in that brief introduction from Walter, but I’ll tell you myself, how deeply committed I am to trying to find answers in this circumstance.

I get lots of emails from people who are suffering from this condition. They are heart wrenching, oftentimes, in terms of the stories of what people are going through and their sense of frustration at the lack of progress. I was involved in a very significant way ten years ago when it looked as if we might have for the first time a really exciting clue—and even a clue that would lead to treatment—namely, the suggestion that a retrovirus XMRV might in fact be the pathogen involved in many cases. And it was intensely disappointing for everyone involved when that hypothesis ultimately fell apart and left us once again with no answers to understanding why these hundreds of thousands or maybe millions of people are affected with a condition that we understand so poorly and have relatively little to offer in the way of real hopes for cure.

We supported, then, the National Academy of Sciences to conduct that study which reported in February of 2015 a number of really important recommendations about what needed to be done to try to organize a more effective research focus, a clinical care focus. In responding to that, in October of 2015 we did pull together a much more aggressive plan at NIH, convening this Trans-NIH ME/CFS working group, which has been involved lots of scientists from around the 27 Institutes and Centers to work together to try to identify the most effective path we might take. And it did allow us then to ratchet up our funding—not enough I will agree with you—but certainly in a way that has provided the opportunity to fund the centers that we are now seeing at this meeting, producing a lot of very interesting findings in metabolomics, in immunology, in neuroscience. All of these giving us ideas of what may be going on in the circumstance, but probably also underlining that there are different kinds of ME/CFS and if we really want to understand this disorder, just like any other condition we need to understand the subsets that may have different pathogenesis and therefore be susceptible to different interventions.

We are doing that with virtually every other disease right now. I’m on the way to a meeting in New York to talk about how we might do this for schizophrenia and Parkinson’s Disease: identify subsets that have different kinds of molecular basis. We’re doing that with Alzheimer’s Disease. We do that with diabetes. We do that with heart disease. We need to do that here as well to really understand what is going on with a large number of individuals who have somewhat different presentations and it seems also potentially different causes, once we begin to get that data.

So I’m excited about what I see being presented at this meeting. It does seem to me like this really is a milestone where some very bright, capable groups have turned some of the latest technologies to work on this: the single cell biology efforts to look at the immune system; new and more specific ways to understand metabolomics—which are yielding all kinds of clues that suggest things such as maybe this really is a mitochondrial disorder which we need to understand even better.

I was particularly delighted that as part of this meeting on Wednesday there was a meeting of early-stage investigators and mid-career investigators who are just getting into this field. Because clearly if we want to make progress, we need to see that kind of recruitment of new people with new perspectives, new ideas, bring their talents to this circumstance. If history is any guide it will often be the person who didn’t know a lot about the condition, but brought a particular insight to it, that results in some kind of a new breakthrough that everybody else can then jump on and move forward. And so getting that new talent into this space is a critical part of NIH’s agenda.

We have done what we can in terms of the resources, both intramurally and extramurally. Right after I finish speaking, you will hear about the intramural program right here in this building that is aiming to try to understand in a very detailed characterization way—admittedly with a small number of patients because the program is so intense—to see what we could learn by looking at every possible feature of individuals with ME/CFS. And that will add, I think, also to our body of knowledge.

But I come to you today basically to say that we are listening closely to all of this scientific advance, and certainly to the cries of help from the community. We do want to see coming out of this some new ideas that could result in further NIH investments. We don’t know what they’re going to be, but one of the reasons to hold this gathering was to have all in one place the kind of presentations that would help our Working Group identify what those next opportunities might be, that they can then bring forward ideas about new projects, new kinds of funding, present those to all of the Institute directors to see what we can do in this space. And that will have my strong personal support, because I think we are starting to see now the kind of moment that has been needed in ME/CFS and we don’t want to wait a minute if we can see a way to accelerate that progress.

This is a very tough problem. You all know that better than I do. And it has obviously not been one where the answers come easily or we would have them already. But with the talent of the scientists now engaged in this, and all of you in this room are part of that community, I am more optimistic than I could have been a couple of years ago: that we may ultimately sort this out, find out what the causes are, and figure out the interventions that are so desperately needed.

I know that we have in this particularly community at NIH often not seemed to be as responsive as you would like, and I regret that. But we are a part of a family now. We don’t always agree with each other, but it does feel to me like we’ve come together in a fashion that was needed to address these issues collectively. You should keep pushing us—and I know you will—and we will keep doing what we can to try to find the resources and the talents and the capabilities to move this forward. And you know when we pull this kind of a gathering together again, and we will aim to do that on a regular basis, every time I will hope I will see new faces and new ideas and ultimately very exciting kinds of things that will end up in the front pages of the newspapers: that we finally have come to a place where we understand this condition and we have specific interventions that we know can help people who have waited far too long for that. I know you are impatient. I want to tell you I’m impatient, too.

I wear on my lapel here this little button, which is actually something that got designed back in the dark days of 2013 when we had the government closure for sixteen days. Where this very building had to be emptied out of anybody who was not essential for patient care, and I had to send all the scientists back in the laboratories on this campus home under threat of being criminally prosecuted if they showed up to do experiments. A very dark sixteen days indeed. And I wanted to do something to try to explain to the world why this was a wrong kind of way to try to produce the kind of next insights into medical research that we all needed. I was thinking of black armbands; my wife talked me out of that and said that might be a little extreme. So instead, we decided there had to be some kind of insignia for what NIH is all about. Being a guitar player, I started with a guitar pick. And then it had to have some kind of statement on there, which has now I think caught on a lot of places, basically the statement here is: Hope at NIH. Because we think of the National Institutes of Health also as the National Institutes of Hope. This building you’re in—the Clinical Center—where people come from all over the country, all over the world, because all other options have kind of run out for them is often called the house of hope. We want to be that for ME/CFS.

And yet hope is not something you just sort of throw out there and then walk out of the room. Hope is something that has expectations for actions. Peter Levi wrote this wonderful description of hope which I think of every time I talk about that word: “Hope in every sphere of life is a privilege that attaches to action. No action, no hope.” We want to provide the kind of hope for ME/CFS that is attached to action. That’s what this meeting is about. What follows after this meeting is going to be actions as well. Watch us. Encourage us. Hold us accountable. We want to be part of your family in the best way. Thank you all very much for the chance to say a few words.

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NIH Deadlines

In the next two weeks, there are three important opportunities for the ME community to engage with NIH.

April 4th and 5th: NIH is hosting the Accelerating Research on ME/CFS Meeting. Take a look at the agenda and invited speakers. The organizing committee of this meeting is comprised mainly of ME scientists and advocates, and as far as I can recall this is the largest ever ME community representation on an NIH meeting committee. You can watch the meeting online, and the link should be posted to the meeting information page.

April 9th, 2pm (Eastern time): NIH will host another advocacy call. To participate, call 866-844-9416, and use passcode: 7178985. No agenda has been posted, and it comes right on the heels of the research meeting.

April 15, 2019 Deadline EXTENDED to May 1, 2019: The National Advisory Neurological Disorders and Stroke (NANDS) Council Working Group for ME/CFS has issued a Request for Information to inform its work. The Working Group has asked for input on ten questions. You can view the questions and respond on this webpage, but note the deadline of April 15th! You have two weeks for your response.

There is one odd thing about this Request for Information. Some readers will recall that NIH issued a similar RFI in 2016. NIH received over 460 pages of responses, which you can still read online. There is substantial overlap in the questions from 2016 and this year. Hopefully the answers will add enough new information to be worth our time in responding and the Working Group’s time in reading.

 

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Drinking From A Fire Hose

News is coming at the ME community at a crazy pace right now. Each time I go online, there is another controversial article that requires a response. First there was the NPR chronic pain piece and ensuing debacle. Then came the infamous Reuters article, and this week we’ve seen media coverage in the UK that is shockingly bad. On the happier side of the spectrum, we have the Emerge Australia Conference and the upcoming NIH meeting on accelerating ME/CFS research.

And it’s only Tuesday.

After the NPR story, I started mentally drafting an article about misogyny, ableism, and NPR’s shocking ignorance of the landscape into which they dropped that stink bomb. The Reuters article deserves to be demolished with a factual wrecking ball. I haven’t had the capacity to give the UK stories and critical responses more than a glance.

Meanwhile, I’ve been working on my analysis of NIH’s grant review panels and application approvals. As I collate the data from multiple FOIA requests, I am finding inconsistencies. NIH gave me data that differs from the data they gave another advocate. There are even inconsistencies among the responses NIH has given me. For example, in one response NIH told me no meeting was held on a particular date. But in another response, NIH told me how many grant applications were reviewed at a meeting corresponding with that date. Catching these errors takes a lot of time, and careful cross-checking instead of accepting NIH responses at face value. And when I find errors like this, I have to file additional FOIA requests to get clarification.

Amidst all of this, I am writing a book.

It’s all too much. I do not have the capacity to write thousands of words a day, or push forward multiple projects. My ME brain cannot multi-task or focus on more than one thing. Small interruptions, like a short phone call or text from a friend, derail my concentration and short circuit what I’m trying to do.

I am constantly asking myself, “What’s the most important thing I need to do?” Trade-offs are familiar to everyone with ME. Take a shower or answer an email? Pay a bill or cook some food? Read to your kid or do some stretches? Read a news article or research a treatment? You can only pick one thing at a time, and hope there will be capacity left for something after that.

Self-care is a necessity, not a luxury, for people with ME. The more I pay attention to my choices, the more I realize that I suck at self-care. Since I first got sick, I have consistently chosen to sacrifice what my body needs in favor of what my family needs, what advocacy needs. It’s a vicious cycle that leaves me wondering if these choices have made me sicker. How well might I be if I had put my own body first?

I am trying to do better. Now I ask myself, “If I can only write one thing, what is the highest priority?” I have chosen to write words for the book, rather than write words about all the controversies this week. I will watch the NIH meeting from home to save the energy of attending in person. I am asking the people I love for help and understanding.

We all have limits, regardless of health or circumstances. Everyone, at some point, has to choose to do one thing and sacrifice another. No one can have it all. People with ME, and other chronic diseases, have to make choices about activities others take for granted, but the principle is the same: what is next most important thing I need to do, and what other thing do I have to give up?

We need to rely on each other. I am learning to trust that even if I cannot participate in an advocacy issue, there are others who can. I am changing my focus from “What needs to be done?” to “What can I do?” It might sound like a distinction without a difference, but for me it is a tectonic shift.

So if you are struggling or overwhelmed, I see you. If you need to take a break from something, I support you. Do what you must to turn down the fire hose and drink from a water fountain instead. I’ll be standing right next to you.

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Who Reviews ME/CFS Applications for NIH?

Note: After publishing this post, I discovered that I had inadvertently missed one meeting in 2017. This post was updated on February 12, 2019 to reflect all new calculations. The changes are not significant enough to alter any conclusions.

There is no question that NIH’s funding of ME/CFS research has been minuscule relative to the size of the public health crisis. Review of ME/CFS grant applications at NIH has drawn scrutiny from the public as one contributing factor. The public perception is that the grant review panelists have not been ME/CFS experts, and that this has led to the unfair denial of qualified applications.

That first point—that grant reviewers are not ME/CFS experts—has a factual answer. The second allegation—that the lack of experts has negatively impacted funding decisions—is harder to answer with publicly available information. Nevertheless, in 2013 I embarked on a project to gather the evidence and answer these questions.

This article will focus on the first issue: who is reviewing the applications. My analysis of the data points to two main conclusions:

  1. A small subset of reviewers (experts and non-experts) wield disproportionate influence because they serve so many times.
  2. NIH changed its approach to ME/CFS application reviews in November 2010. Since that date, NIH has primarily appointed ME/CFS experts to evaluate the applications.

Let’s begin by reviewing the basics of NIH’s grant review process.

How NIH Reviews Grant Applications

When a grant application is submitted to NIH, a multi-level review process begins. In the first stage, a review panel of non-federal scientists with relevant expertise evaluates and scores the application on a variety of criteria.

The Center for Scientific Review (CSR) at NIH is responsible for selecting reviewers for the panels. CSR manages hundreds of these panels, which fall into two general categories: standing study sections and special emphasis panels. Special emphasis panels (or SEPs) are comprised of temporary members, selected specifically for the applications under review at a single meeting. Most SEPs are used once and then dissolved, but there are a dozen or so recurring SEPs for areas with an ongoing need for review. ME/CFS is one of those topic areas, and its recurring SEP has a new roster for each meeting.

Each study section and SEP is managed by a Scientific Review Officer (SRO). This is not a desk jockey job; the SRO has a substantive impact on the peer review process. The SRO is responsible for selecting scientists for the panel, monitoring potential conflicts of interest, and preparing summaries of the peer review scores and critiques.

Review panel members must have substantial relevant scientific expertise and knowledge of the most current science. SROs look for reviewers who have themselves received major peer-reviewed grants, and who understand the peer review process. The quality of grant application reviews is largely dependent on selecting the right scientists to review them.

The Methods of This Project

The obvious first step for my analysis was to gather all the SEP rosters and look at who served. Study sections and SEPs are federal advisory committees, and as such their membership must be made public. You might think that getting the rosters would be easy. You would be wrong.

In 2013, I looked for the rosters online, and found very few. When I asked NIH about it, I was told that the rosters were not posted publicly “due to threats some previous panel reviewers have received.” (this is an interesting story for another time) I was instructed to file a FOIA request for the rosters. NIH then denied that request, and to make a long story short, it took me two years of appeals to finally obtain the rosters. For several more years, NIH absurdly required me to file a FOIA request for each roster. It took intervention by Dr. Joe Breen in 2016 to finally change CSR’s policy on publishing the ME/CFS SEP roster.

Since one of my main objectives was to identify how many ME/CFS experts participated, I had to define who qualified as an expert. I did not assume that I knew all the experts and could simply rely on name recognition. For purposes of this analysis, I set the expertise bar very low. I defined an ME/CFS expert as anyone who—at the time they served on the SEP—had at least one publication on ME/CFS or had an NIH grant for ME/CFS research.

I compiled all the roster names for the SEP meetings from 2000 through 2018. I searched PubMed for each person’s ME/CFS publications at the time he or she served on a SEP. I also did my best to identify the scientific specialization of all the members by reviewing their institutional profile pages and CVs. Then I looked for the trends and patterns.

Representation As A Whole

Between January 2000 and December 2018, the ME/CFS SEP met 62 times.* A total of 327 people served as reviewers. Of those 327 panelists, 58 (or 17.7%) qualified as ME/CFS experts under my liberal definition.

Half of all reviewers served more than once, and each roster varied between 5 and 36 members. To calculate the average number of times individuals served, I counted the combined roster seats across all the meetings: 836 seats. Of the total 327 panelists, each person served an average of 2.6 meetings. However, the 58 ME/CFS experts served a combined 207 seats, or 24.7% of the total seats. Those 58 experts served an average of 3.6 meetings each.

First finding: Between 2000 and 2018, 17.7% of the reviewers were ME/CFS experts, and they served 24.7% of the total roster seats.

The percentage of ME/CFS experts at each meeting varied between 0 and 100%. Eight meetings included no ME/CFS experts whatsoever, while four meetings were 100% experts. Over the entire time period, ME/CFS experts made up 20% or less of the rosters of 32 meetings.

Second finding: Just over half of the meetings included 20% or less ME/CFS experts, and eight of those meetings included no experts at all.

Of the 327 total individuals who served on the SEP, I identified 65 (20%) that have psychology or psychiatry degrees. Note that this includes researchers who are ME/CFS experts, such as Drs. Jarred Younger and Lenny Jason. Twenty-four people (7.3%) specialize in craniofacial diseases such as Temporomandibular Disorders. Fourteen (4.2%) are sleep researchers. There are six people who appear in more than one of these categories (such as a psychologist specializing in insomnia).

To measure the influence of these specialties, I looked at how many times these individuals served on the SEP. The 65 psychologists served a total of 214 times, or 25.6% of the total seats. Adding in the sleep and craniofacial specialists (and taking the overlaps into account), these three categories combined represent 29% of the total individuals, but 36.7% of the meeting seats.

Third finding: One-third of all reviewers specialize in psychology/psychiatry, sleep, and/or craniofacial areas, and occupied 36.7% of the meeting seats between 2000 and 2018.

As mentioned above, each reviewer served an average of 2.6 times. However, this is a bit misleading because 71% (233 people) served only once or twice, and the remaining 29% served three or more times. The reviewers who only served once or twice occupied just 36% of the review seats. That means 29% of the reviewers (experts and non-experts) occupied 64% of the seats. To be clear, this means just 94 people filled 534 seats between 2000 and 2018 because they served so many times.

Fourth finding: A minority of reviewers (29%) had a disproportional influence on the review process because they served so many times (64% of seats overall).

The ME/CFS Experts

As I stated in the Methods description above, I used a very liberal definition of ME/CFS “expert.” I classified an individual as an expert if he or she had at least one ME/CFS publication or at least one NIH grant for ME/CFS research at the time of service on the SEP. It turned out that there are a few reviewers who served on the SEP prior to having a publication or grant in ME/CFS, and then served again afterward. I adjusted my analysis to take this into account. You can read the entire list of ME/CFS expert reviewers here.

A total of 58 out of 327 reviewers (17.7%) met the expert definition for at least one meeting served. Many of the names will be immediately recognizable as experts, but others may be a surprise. For example, Dr. Ila Singh published on XMRV and then left the ME/CFS field. Dr. Jordan Dimitrakoff co-authored a paper with his colleagues from the CFS Advisory Committee, but he is a pelvic pain specialist and has done no ME/CFS research. Yet under my liberal definition, both are counted as ME/CFS experts. I was also surprised to find five people who were CDC employees when they served on the SEP: Dr. Jim Jones, Dr. Elizabeth Unger, Dr. Alison Mawle, Dr. Mangalathu Rajeevan, and Dr. Alicia Smith. I do not know if it is unusual for CDC employees to serve on NIH grant review panels.

Fifth finding: Using the most liberal definition of ME/CFS expert, only 17.7% of the reviewers qualified. Multiple people on the list were never involved in much ME/CFS research and/or left the field. Five individuals were CDC employees at the time they served on the SEP.

ME/CFS experts served an average of 3.6 meetings each, but this is misleading because 40% of the group served only once. When I removed the one-timers from the calculation, the remaining 35 reviewers served 184 times, which is 89% of the total number of expert seats. Concentrating grant review assignments to such a small number of scientists is risky. One person’s bias, expectations, preferences, and professional experience can shape the direction of NIH funded research, for better or worse. This is especially true for the reviewers who serve most frequently. At the very top of that list are:

These four reviewers served a combined 49 times, which is 23.6% of the total expert seats. The heavy influence of Dr. Friedberg is an example of the inherent risk of this approach. While he has worked in this field for more than fifteen years, and has received $3.9 million in NIH grants, he is a psychologist. Proposals that rely on computational biology, cutting edge imaging, or immunology could be challenging for a behavioral psychologist to properly evaluate. There are other ME/CFS experts, including other psychologists like Dr. Jarred Younger, who may be better positioned to review these applications.

Sixth finding: Just 35 ME/CFS experts have served a combined 184 times (89% of expert seats). Just four experts (Friedberg, Baraniuk, Biaggioni, Hanson) have occupied 23.6% of those seats. They have likely wielded great influence on application scores and critiques.

Before and After November 2010

So far, I have presented my findings based on all the rosters from January 2000 to December 2018 combined. That is not the whole story, however. NIH changed its approach to reviewing ME/CFS grant applications in November 2010.

Prior to November 2010, the SEP reviewed grant applications related to Chronic Fatigue Syndrome, Fibromyalgia, and sometimes Temporomandibular Disorders (TMD). The rosters had titles like “CFS/FM SEP” and “CFS/FMS/TMD.” Beginning with the SEP meeting on November 2, 2010, NIH narrowed the focus of the panel to CFS only. The meeting titles changed to “Chronic Fatigue Syndrome” and “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.”

The name of the SEP was not the only difference. The types of reviewers appointed to the panels changed significantly. Pain researchers and dentists were out, and ME/CFS experts were in.

Before Nov 2010 After Nov 2010
Number of Meetings 36 26
Number of Seats 605 231
Meetings with No Experts 8 (22%) 0
Meetings with 1-20% Experts 23 (64%) 1 (4%)
Meetings with 21-50% Experts 5 (14%) 7 (27%)
Meetings with 51-99% Experts 0 14 (54%)
Meetings with 100% Experts 0 4 (15%)
Non-expert seats 538 of 605 (89%) 91 of 231 (39%)
Expert seats 67 of 605 (11%) 140 of 231 (61%)
Psych/sleep/craniofacial 275 of 605 (45.5%) 34 of 231 (14.7%)

As you can see, beginning with the November 2010 meeting the SEP rosters are almost directly opposite to the earlier rosters. The expert representation went from 11% to 61%, while non-expert representation dropped from 89% to 39%. I do not know why the shift was made at that particular time, but there is no doubt that it was. It seems unlikely that this was the sole decision of the SRO at the time, but I have no documentary evidence that points to how the decision was made.

Seventh finding: Beginning in November 2010, the focus and composition of the SEP shifted dramatically and included substantially more ME/CFS experts than any meetings prior to that date.

As good as things look after November 2010, there is one troubling trend. Eight of the 25 meetings had 50% or less ME/CFS experts. Seven of those meetings were held since April 2017, including the panel that reviewed the RFA proposals in July 2017.

The roster for the RFA review went through multiple iterations. The final version included 37% ME/CFS experts. This roster must have been difficult to put together because there were so many experts participating in one or more of the fifteen proposals reviewed at that meeting. The conflict of interest policy would have excluded many of them from service on the panel.

The panels for the meetings since July 2017 may signal a dangerous shift in approach. All four had less than 50% ME/CFS experts, with the April 2018 meeting including only one expert and seven non-ME/CFS experts. All four rosters were overseen by Dr. Jana Drgonova. What her approach will be going forward remains to be seen.

Eighth finding: The SEP that reviewed the RFA proposals included only 37% ME/CFS experts, possibly due to the conflict of interest policy excluding many reviewers. The use of experts on the normal SEP panels declined to less than 50% after July 2017, for reasons unknown.

Summary

Rather than repeat the legend that ME/CFS grant applications are reviewed by dentists and psychologists, I set out to examine the data on who reviews these applications. My analysis points to two main conclusions.

First, there is an inside/outside club of reviewers. For ME/CFS experts and non-experts alike, a small subset wields great influence through service at multiple meetings. Among ME/CFS experts, 60% of the experts occupied 89% of the expert seats. The top four individuals occupied 23.6% of the seats. Among non-ME/CFS experts, 48% of the reviewers occupied 78% of the non-expert seats. Given how these subsets wield out-sized influence through repeated appearances, one hopes that this is favoring high-quality reviews and not unreasonably negative ones.

Second, these data show that NIH adjusted its approach in November 2010. The reliance on ME/CFS experts jumped overnight, and the SEP was refocused on ME/CFS applications alone. However, the negative trend to use fewer experts in 2018  bears careful watching.

The real question is how these rosters impacted grant funding decisions. My next article will present that analysis.

Recap of Findings:

  1. Between 2000 and 2018, 17.7% of the reviewers were ME/CFS experts, and they served 24.7% of the total roster seats.
  2. Just over half of the meetings included 20% or less ME/CFS experts, and eight of those meetings included no experts at all.
  3. One-third of all reviewers specialize in psychology/psychiatry, sleep, and/or craniofacial areas, and occupied 36.7% of the meeting seats between 2000 and 2018.
  4. A minority of reviewers (29%) had a disproportional influence on the review process because they served so many times (64% of seats overall).
  5. Using the most liberal definition of ME/CFS expert, only 17.7% of the reviewers qualified. Multiple people on the list were never involved in much ME/CFS research and/or left the field. Five individuals were CDC employees at the time they served on the SEP.
  6. Just 35 ME/CFS experts have served a combined 184 times (89% of expert seats). Just four experts (Friedberg, Baraniuk, Biaggioni, Hanson) have occupied 23.6% of those seats. They have likely wielded great influence on application scores and critiques.
  7. Beginning in November 2010, the focus and composition of the SEP shifted dramatically and included substantially more ME/CFS experts than any meetings prior to that date.
  8. The SEP that reviewed the RFA proposals included only 37% ME/CFS experts, possibly due to the conflict of interest policy excluding many reviewers. The use of experts on the normal SEP panels declined to less than 50% after July 2017, for reasons unknown.

 

*There was a meeting scheduled for February 22, 2011 but it was canceled. A meeting was eventually held on March 24, 2011 with a different roster. I have excluded the February meeting from this analysis.

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NIH Obstacles Thwart ME Research

After I published my post on the NIH Obstacle Course (November 2018), readers’ reactions made clear that a shorter version of the article could be useful.

Today, STAT published that shorter article in the First Opinion section. You can read it here: The NIH is thwarting research on a poorly understood but serious condition.

Please read and share widely! Given the ongoing work of the Working Group advising the Council of the National Institute of Neurological Diseases and Stroke, I think the article in highly relevant in our field.

My thanks to STAT for giving this article a home, and to Julie Rehmeyer for pointing me in the right direction.

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NIH’s Obstacle Course to Success for ME/CFS Researchers

A shorter version of this article was published on STATNews on January 10, 2019.

One message dominates NIH’s talk about ME/CFS research: submit more high quality grant applications. Funding would increase if there were more high quality grant applications. Give us a chance to prove we’re serious, but send more high quality grant applications. Thank you for your petition with 50,000 signatures, but send more high quality grant applications.

In a field desperate for research funding, one might think that ME/CFS researchers would be flooding NIH with grant applications. Yet that does not seem to be happening. One significant reason why is that NIH’s business-as-usual approach actually increases the barriers to success for ME/CFS grant applications.

A researcher who wants NIH funding for ME/CFS research has to navigate an obstacle course that begins long before the grant application gets in front of reviewers, an obstacle course which arises from NIH’s own broken response to ME. There are at least six questions a researcher must consider in deciding whether to apply for funding:

  1. Does NIH want my grant? A researcher may decide the answer is no, especially if she wants to generate hypotheses or has been discouraged by NIH’s lack of interest.
  2. Is there NIH funding for my grant? Given that NIH currently has no Funding Opportunity Announcements targeted at ME/CFS, researchers could very well conclude the answer is no.
  3. Can I write this grant? On top of the time pressure and institutional challenges that all researchers face, ME/CFS researchers may face additional barriers such as lack of support from institutions, lack of mentors, and the general stigma associated with this disease.
  4. Who will review my grant? Based on the SEP rosters for the last eighteen years, researchers should expect that some reviewers will be ME/CFS experts but they may not make up the majority.
  5. Will the SEP members review my grant fairly? Given the unique challenges of the field that are not recognized by non-experts, applicants may conclude the answer is no.
  6. Who is my competition? There is no set answer to this question. Depending on timing, the competition could be fellow ME/CFS researchers or a much larger and harder to define pool.

Let’s follow a hypothetical researcher as she runs this gauntlet to submit her ME/CFS proposal to NIH.

Does NIH want my grant?

Before the first word is typed on a grant application page, a researcher asks herself whether NIH will be interested in her project. There are multiple reasons why she may conclude that the answer is no.

First, NIH does not fund hypothesis-generating research. A proposal that boils down to “I’m going to look and see what I can see” is not going to succeed. Yet ME/CFS research needs these projects at this stage. This field has not just been ignored; it has been suppressed by decades of stigma and the false narrative that it is caused by deconditioning and depression. Ironically, NIH has tacitly admitted that hypothesis-generating research is needed. The Clinical Care Center study run by Dr. Avindra Nath is designed to collect reams of data that will then generate hypotheses for further research.

Second, a researcher may be deterred by NIH’s demonstrable lack of interest as evidenced by low ME/CFS funding. NIH currently has no Funding Opportunity Announcements targeted at ME/CFS (see below). In addition, NIH funding has been appalling over time–including the 17% decrease in funding last year–so a researcher may conclude that NIH simply isn’t interested in ME/CFS projects.

Third, if the researcher wants to conduct a clinical trial of a drug treatment, she will have trouble at NIH. Dr. Nancy Klimas has tried, but she said, “There is no door to walk through at the NIH” for clinical trial funding in ME/CFS. Klimas attributed this to the fact that the ME/CFS Special Emphasis Panel (see below) does not review clinical trial applications.

Finally, a researcher may be individually discouraged from applying. I have heard multiple stories along these lines, although people are understandably reluctant to go on the record. Dr. Ron Davis went public with the rejection of two of his pre-proposals in 2015. One of the reasons given by the National Institute of Neurological Diseases and Stroke was that, “It was not clear if the proposal falls within the mission of NINDS.”

Is there NIH funding for my grant?

A researcher might decide NIH is interested in her project, but she also has to ask if there is funding available for it. To answer that question, she will look at two general types of Funding Opportunity Announcements.

First, she will look for a Program Announcements, or PA. The PAs are like open house invitations. NIH says, We’re interested in seeing grant proposals in such-and-such area of research. The invitation is really important, because it tells a researcher where the open house is and what time it is happening. There is no guarantee that there will be enough food and booze to go around, but the researcher knows that if she shows up at the specific place and time then she can try to fight her way to the buffet. However, NIH’s last open house invitation for ME/CFS research was issued in 2012 and it expired in 2015. There is nothing whatsoever targeted for ME/CFS at this time.

Incidentally, on the last NIH telebriefing, Dr. Vicky Whittemore said that NIH would no longer be issuing Program Announcements. However, when I followed up with her after the call she said that her comments were premature. Apparently NIH is contemplating moving away from PAs but no announcement has been made yet.

The second type of Funding Opportunity Announcement is the Request for Applications, or RFA. Unlike a general invitation, an RFA is a specific type of funding competition. NIH says, We have X dollars set aside and we want to spend that on this specific type of research. This is more like a competitive swim meet than an open house. You have to qualify for the swim meet in order to compete, but someone is definitely going home with a gold medal. If an ME/CFS researcher is doing the kind of research the RFA wants, then she knows her application has a shot at the set aside funding.

This is why ME/CFS advocates and researchers are constantly asking for RFAs instead of PAs: someone is going to get money out of an RFA competition. This is also why NIH is very reluctant to issue RFAs: it requires NIH to decide in advance how much money it will invest and then set that money aside for the competition.

Just to be clear, NIH issues plenty of RFAs across its full research portfolio, including forty-three RFAs in October 2018 alone. NIH can do this. But NIH has been clear that it has no intention of issuing an RFA in ME/CFS research any time soon.

It’s easy to understand why a researcher might give up on applying to NIH, given the picture I’ve painted thus far. However, let’s assume that our hypothetical researcher has concluded that NIH wants her grant. And despite the fact that there is no funding opportunity targeted at ME/CFS, our researcher has concluded that there is a chance that NIH might fund her grant. Next she has to ask:

Can I write this grant?

Generally speaking, scientific researchers at academic institutions are responsible for obtaining their own funding. Universities do not fund much research themselves. Researchers know they have to write successful grant applications to get funding, and it is essential to their careers to do so.

Yet it is not that simple. An NIH grant application can take several months to write, and that is after months of planning time. The typical NIH application might be 30 pages long, but the applications for the Collaborative Research Center RFA were hundreds of pages long. The more complex the project and the more collaborators involved, the more difficult and time consuming it is to write the application. Submitting successful applications is part of the job description, but so is conducting current research, teaching a full course load, supervising graduate students, and successfully publishing study results. Oh, and there are committee meetings and other administrative duties. The average professor works sixty hours per week.

And our hypothetical researcher does not just need time. She needs support from her institution in the form of equipment, space, and staff. She needs her department head to support her ideas (or at least not actively squash them), and her application must include letters from her institution and collaborators to prove she has that support.

Obviously, this can go wrong in multiple ways, and many of these issues are not limited to ME/CFS research. However, the decades of stigma and misinformation have a unique impact in ME/CFS. Support from institutions and colleagues is harder to come by. Mentors are few and far between. All of the well-known challenges of writing successful grant proposals are multiplied in this field, increasing the difficulty of our hypothetical researcher’s obstacle course. NIH has done nothing to alleviate the challenges that have arisen from its own history with ME/CFS.

Who will review my grant?

NIH’s peer review system is at the core of its funding decisions. The Center for Scientific Review appoints reviewers with relevant expertise to Study Sections and Special Emphasis Panels. The reviewers score applications on a variety of criteria, and come up with an overall impact score. This peer review is not the final decision on an application, but it is critically important. A bad score in peer review is fatal for the application.

Given the importance of the peer review scores, it’s obvious that reviewers must have the appropriate knowledge and expertise. Yet this has not always been the case when it comes to ME/CFS research.

I have been tracking the rosters of the various incarnations of the CFS Special Emphasis Panel, or SEP since 2000, and I’ve seen definite trends. In earlier years, the SEP covered the areas of CFS, Fibromyalgia, and Temperomandibular Joint Dysfunction. As a result, the SEP reviewers were predominantly dentists, psychologists, and pain experts. Between 2000 and 2010, the average representation of CFS experts on the SEP was 15%.

In November 2010, the SEP was assigned a more narrow scope of just CFS (changed to ME/CFS in 2012). The new scope had an immediate effect on the representation of experts on the rosters. Between November 2010 and the end of 2017, ME/CFS experts made up 72% of the rosters on average.

There is one exception, and that is the roster of the SEP that evaluated the applications for the Collaborative Research Centers and Data Management Center in 2017. ME/CFS experts made up only 26% of that roster. There are several possible reasons for this. First, NIH’s conflict of interest policy meant that anyone applying for RFA funding would have been excluded from the roster, along with many of their colleagues. (Read more about the COI policy here ). Second, the nature of the applications required peer review by experts in population studies, computational biology, and other areas outside of ME/CFS research.

Then, the SEP rosters took a puzzling turn in 2018. ME/CFS experts made up 25-44% of the rosters at the three review meetings. I have no explanation as to why the rosters have shifted to include fewer ME/CFS experts. Since the SEP panel is reconstituted for every review cycle, there is also no way to predict representation on future meeting rosters.

Will the SEP members review my grant fairly?

Our hypothetical researcher should be prepared for her application to be reviewed by a variable mix of ME/CFS experts and non-experts, and so she has to wonder if she will get a fair and accurate review score. I am not assuming that non-experts will automatically trash ME/CFS grant applications, but I also do not assume that all SEP members will use the right standards.

First, it is possible that ME/CFS experts on the SEP are not able to assess all aspects of all ME/CFS grant applications. For example, a POTS researcher on the panel may not be familiar with design of genome-wide association studies or computational biology. A psychologist may not be able to critique a study with newer technology like QEEG. Expertise in ME/CFS does not automatically convey expertise in every possible study of the disease.

Second, reviewers bring their own biases with them. Sleep researchers have a different understanding of fatigue than ME/CFS experts. Reviewers may be unfamiliar with post-exertional malaise, including how it differs from fatigue and how to assess it. The worst case scenario is a reviewer who believes the lie that ME/CFS is depression and deconditioning. Dr. Ian Lipkin said that this is exactly what happened with one of his applications in 2014:

I have been in competition now twice to get funded, and the people there who reviewed me gave me abysmal scores.  And the critiques of my work were unfair, and one of the people who critiqued my work said, in fact, that this is a psychosomatic illness.  I was floored.  I protested, and for reasons that are obscure to me this same individual wound up back on the study section, and I got a similar unfundable score.

Third, ME/CFS research has unique challenges that are well-known inside the field, but potentially not understood by scientists outside the field. Case definition is an obvious example of this. The field has used multiple case definitions over the years, some of which have fatal flaws. NIH has refused to select a single gold standard case definition, arguing that researchers should justify their chosen definition in the applications. But how is a non-expert supposed to evaluate that choice and justification? Someone outside the field is probably unfamiliar with the differences between the Oxford, Fukuda, Reeves, Canadian Consensus, and National Academy of Medicine criteria. Outside reviewers will have difficulty assessing the impact of chosen criteria on a study, and they are unlikely to appreciate the challenges of recruiting appropriately diagnosed subjects.

Fourth, peer reviewers will bring expectations from their own fields of study. A cancer or heart disease researcher is used to multi-center studies, with sample sizes in the thousands. That kind of study has been and remains impossible in ME/CFS. Reviewers may have unrealistic expectations about data quality and study design. Non-ME/CFS experts will also be unable to assess whether an area of study is a strategic priority in the field.

The peer review process is a cornerstone of funding decisions at NIH, but it is far from the only factor in play. Our hypothetical researcher faces additional barriers, including her competition.

Who is my competition?

Competition for NIH funding is fierce, not matter what the area of study. NIH’s overall application success rate was 18.7% in 2017. However, an ME/CFS grant application has to compete in ways that put our hypothetical researcher at a disadvantage.

First, an ME/CFS grant application is naturally competing against all the other applications reviewed at a specific SEP meeting. This can actually happen more than once. NIH allows researchers to revise and resubmit applications based on reviewer comments. On the second submission, an ME/CFS application will compete against an entirely new group of applications in front of a different group of reviewers. That means that an application for a proteomic study could have been scored in comparison to other -omics studies in one round, but then compared to POTS or infection studies in the next round. Given that each review meeting has a new roster, new reviewers may have different criticisms of the application than the first group. So our hypothetical researcher could revise her application based on comments from Group 1, and then get entirely new and different criticisms from Group 2.

Second, the competition pool is heavily influenced by the Funding Opportunity Announcement. Recall the open house vs. swim meet analogies I discussed earlier. Those are very different sets of competitors. With a Program Announcement, our hypothetical researcher is competing against everyone else headed for the buffet at the open house. With an RFA, our researcher is competing against just the swimmers in the pool—and someone is guaranteed to win. This will influence the peer review scores. Reviewers for an RFA know that a good score will basically guarantee funding, and select from among the applications in front of them. Normal Program Announcement review is a more diffuse competition, in part because no one is guaranteed funding and the full group of applicants might not be reviewed by the same group of reviewers.

Third, applications that score well at the SEP stage are then sent to the relevant Institute’s Council for consideration. At this level, the application is now competing against all the other applications reviewed at the Council meeting, regardless of the field. For example, an ME/CFS infection study will compete against every other grant coming before the Council of the National Institute of Allergy and Infectious Diseases. The infection study might be fabulous compared to other ME/CFS applications, but not as strong compared to hepatitis and influenza studies that have huge sample sizes, etc. In addition, ME/CFS is not a named priority at any Institute. The ME/CFS immune study might be critical in our field, but the Council (which has no ME/CFS experts on it) might see it as a much lower priority given the Institute goals.

As I pointed out before, ME/CFS has neither an active RFA nor PA. New applications are currently being submitted under very general parent announcements like this one. It invites applications (to any of twenty-three participating Institutes) for defined projects “in scientific areas that represent the investigators’ specific interests and competencies”. This is an incredibly broad net, and the competition is basically all grants being considered in a funding cycle by a particular Institute. There is no target our hypothetical researcher can aim for, other than get the best score she can and cross her fingers.

Should I stay or should I go?

NIH’s proposed fix for the dismal state of ME/CFS research funding is simply “submit more high quality grant applications.” In order to do that, our hypothetical researcher has to climb over a series of barriers created and maintained by NIH’s actions in ME/CFS research.

Should our hypothetical researcher submit another ME/CFS grant application? NIH sees no reason why she shouldn’t. As a person with ME, I desperately want her to submit one. But will she decide to invest the time and effort, roll the dice, and apply? How many times will she try? Can anyone blame her if she decides to move to another field?

NIH is responsible for erecting and maintaining this obstacle course. Yet they wash their hands of the problem and repeat the refrain, “Send more high quality grant applications.” NIH’s normal approach to encouraging more proposals will not work in ME/CFS.

There is no single silver bullet that can fix NIH’s broken response to ME. However, there are many actions NIH could take to lower the barriers and truly encourage more applications. Difficult problems require complicated solutions. It is time for NIH to tackle this problem with more than just words.

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The Best Holiday Ever

Getting a puppy was not in the plan. My husband and I already had a dog (Fargo) and a cat (Lucas). The plan was for my parents to pick out a dog, and I just went along to help since they were seeing the same breeder from whom we had purchased Fargo.

Is there anything better than a litter of puppies? Goofy little furballs gamboling about, until they fall asleep right where they are? My parents fell in love with Sasha, and made arrangements with the breeder.

But there was a little guy, off by himself. He was smaller than his littermates, and didn’t engage in play exactly the same way. He was perfectly healthy and normal, but just a little . . . different. I heard myself saying, “If no one has spoken for this one, I would be interested.”

My husband had been asking for a second dog for months, and I always said it was more than I could handle. He was at work all day, and traveled for work sometimes. I could not walk Fargo, and he was still a high energy Labrador Retriever. Now I had fallen in love with another Lab. I rationalized it by saying it was a surprise for my husband.

A few weeks later, when my husband came home from work, I met him at the door with the puppy in my arms. Thinking it was my parents’ dog, he started to ask why she was at our house. I held the puppy out to him and said, “This is your new puppy.” Fourteen years later, I can still get out of trouble by reminding him, “I got you a puppy.”

Grif was our special boy. When my husband would bring him upstairs at night, I would exclaim, “Puppy!” from bed and Grif would galumph right over. And when we lost Fargo, and then Lucas, Grif poured on extra love. If I cried, Grif would bring me his toys.

I don’t think Grif ever met a person he didn’t love, and he always assumed they would love him back. He liked to offer his toys to visitors, usually while snorting and wiggling. He wagged his tail with his entire body. Grif didn’t give kisses the way Fargo did, but he loved to snuffle and snort, preferably in your armpit or ear.

Grif was more of a chaser than retriever. He waited for us to kick or throw a ball, and then he would race to it and chew on it, occasionally looking up to wonder why we hadn’t followed to repeat the game. And he wasn’t necessarily the brightest dog. When I sent him into the backyard to chase deer away from the fence, he always ran to the same corner of the yard regardless of where the deer were actually standing. While Fargo knew his toys and the rooms of the house by name, Grif was more focused on where “Daddy” was, and his favorite phrase was: “Daddy’s home.”

Labs are notoriously food focused, and Grif was no exception. His eyes bugged out with joy when he was given a little vanilla ice cream. We are just the kind of crazy dog people who will order a cup of foam from a coffee shop and give it to the dog. He loved french fries and, inexplicably, green beans. One night, on a whim, I sprinkled a little parmesan cheese on his nose, and it was like doggy Christmas had come.

When I was stuck in bed, Grif was my buddy. If I was asleep, he curled up behind my knees. If I was sitting up in bed, he wedged himself in my lap and served as a computer desk. But when my husband was home, Grif curled up on that side of the bed and slept on my husband’s pillow. There is no love like doggo love.

Which brings me to the best holiday ever. You might think I am referring to Thanksgiving, which was yesterday here in the US, and we did have a lovely time with our family. But I am talking about Wolfenoot.

Have you heard of Wolfenoot? Here is the amazing origin story:

The love and light of this child’s imagination went viral. Thousands of people have gotten on board, and Jax Goss turned the attention into a way to raise money for Wolf Park. There will even be a story book, illustrated by a thirteen year old artist, which will tell the story of The Great Wolf.

People all over the world are celebrating wolves (and canines) today, simply because a seven year old imagined that we should. For that reason alone, this is a happy thing to do. I was all in as soon as I heard about it, because we need more imagination and creativity and love and light in this dark world.

And because earlier this year, Grif died.

Shortly before my husband had his stroke in 2015, Grif tore one of his ACLs. We thought we could avoid surgery, until he tore the other one about six months later. After two separate surgeries, and severe activity restrictions during recovery, Grif and my husband did rehab together. My husband was in vision and vestibular therapy, and he and Grif would take slow walks down the street, doing their exercises together.

We had gone from a family of one disabled homebound person plus healthy human and dog, to two disabled homebound people and a disabled dog. The three of us spent a lot of time together. Grif was most content when we were watching tv, giving him lots of pats and scruffles. He couldn’t run or play or climb stairs, but he was still our Grif.

By this past summer, three years of pain and limitations had taken their toll. Grif was having more trouble walking, and then standing on his own. My husband knew the end was coming, but continued to insist it was weeks or months away because he could not imagine life without Grif. After a few days in which we had to pull Grif up to a standing position multiple times a day, I told my husband that we could not ask anything more of Grif. He had taken care of us for so long, and it was time to let him go.

For the first time in twenty years, we have no pets in the house. We will get another dog, but we have to figure out the timing and logistics. It’s very different to contemplate training a puppy when we are both disabled. For now, the house feels empty. There is less dog hair about, true, but it doesn’t really feel like home. Not the way it did before.

Wolfenoot was invented when we needed it most. Today, I will slow-roast some lamb. We will pretend the leftover pie we brought home from Thanksgiving is in the shape of the moon. And we will remember our beloved and sorely missed Grif. If he was watching over us now, he would not want us to be sad. He would bring us his toys, and snort and wiggle to make us laugh. Grif was the best doggo. Howly Wolfenoot, everyone.

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Educating Doctors

The Philadelphia Inquirer recently published an article I wrote about educating doctors about ME. The article can be read here. This week, the Philadelphia County Medical Society is hosting a screening of the film Unrest, followed by a panel discussion about ME. The event is open to the public, and medical professionals can obtain CME credit for attending. More info and the registration link are found here.

If you are new to the topic of ME, here are a few links for more information:

If you have questions or need more resources, pop it in the comments and we’ll crowdsource the answer as best we can.

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