CFSAC testimony - Dr. Joan Grobstein on Responsibility

The CFSAC committee met again on October 3-4, 2012. Public testimony can be seen in the above youtube clip and an accompanying one. As usual the testimonies of patients and advocates were varied, heartfelt and stirring. Over the years these presentation have done a great deal to publicly give a face to ME/CFS and to elaborate, in the most personal and often harrowing terms, the toll that it takes on patients. Collectively these testimonies are the strongest evidence of the case against the government for   their weak response to this medical emergency. This year there is some slight evidence that the CFSAC committee and the federal government itself, principally the FDA, is waking up from their long slumber and beginning to take ME/CFS seriously.

Many years ago I came to realize that the testimonies of Dr. Joan Grobstein are particularly articulate and insightful. Dr. Grobstein has the capacity to distill various problems down to their essential matter - and to cut out the crap. Dr. Grobstein has repeatedly clarified the central issues and constructed a path that will lead us out of the quagmire impeding research and treatment into this illness. It has always been my opinion that this woman should be given a position where she could "make things happen". Certainly her background as a physician gives her a unique and important perspective. When concerned people are gathered to design a plan of how to attack this illness, Dr. Grobstein's name should be first on the list.

Dr. Joan Grobstein's oral presentation at the October CFSAC meeting begins at 38:50 on the youtube video . Previous testimonies of Dr. Grobstein are available elsewhere on this blog or on youtube. Each of them is noteworthy.

In no way should this focus on Dr. Grobstein be seen as diminishing the myriad fine efforts of all the participants in the public testimony. Their testimonies do us all a very great service and I thank these individuals for the special time and effort that it takes to give testimony.

• Two important items of Dr. Grobstein follow: The first is a transcript of Dr. Grobstein's oral statement delivered at the CFSAC meeting. The second is Dr. Grobsteins' five-page written submission.

"Hello.  I’m Dr. Joan Grobstein.  I’m a physician.

My topic is responsibility.

Recently we’ve seen accomplished scientists honestly and courageously admit that their original findings about XMRV were mistaken.  They took responsibility for an error.  At its best, this is how science works:  form a hypothesis, test the hypothesis, revise the hypothesis.  We would like to see the same honesty and courage from scientists at CDC about the empiric definition.  The hypothesis that the empiric definition defines the same disease as either Fukuda or the Canadian definitions has been tested and found to be wrong.  Scientists at CDC must take responsibility for this error.  The original paper on XMRV in ME/CFS patients has been retracted. CDC should retract all papers using the empiric definition or, at least, rename them to indicate that they are studies of Idiopathic Chronic Fatigue and major depression, not ME or CFS.

NIH must also take responsibility:  fund studies that will clarify the definition controversy, as it did with XMRV.  Because we saw money appear quickly to study XMRV, we know that funds are available.  It’s clear that CDC’s new study about the definition is unlikely to be impartial.  They are vigorously defending their position.  During a recent phone contact with patients Dr. Unger said CDC could be “lumpers one day and splitters the next”.  This is a remarkably unscientific statement.  The scientific method demands that we rigorously define the conditions of our investigations.  Without understanding this, how can Dr. Unger be trusted to undo the harm to ME and CFS patients that the definitional conflict has caused?  Leaders at CDC must take responsibility and ensure that science done at CDC is impeccable.  There are biomarkers for Canadian-defined ME/CFS patients.  Does CDC wish to conceal that these biomarkers are not found in empiric-defined CFS patients?

Turning now to the responsibilities of the voting members of CFSAC, its staff, and its ex officio members, we’re all aware that very few recommendations made by this Committee have been implemented.

For example, CFSAC made three specific revenue-neutral recommendations  which have been ignored.  The first, from 2009, condemned the use of the empiric definition.  Despite this recommendation, CDC continues to publish studies using the empiric.  The second recommended removing the Toolkit from the CDC website.   The third recommended making IACFS/ME’s Primer widely available.  These last two recommendation were made 4 months ago.  Today, the Toolkit remains on the CDC website.  Meanwhile, CFSAC’s own website has a new link to the Toolkit and no link to the Primer.

Who’s responsible for the lack of action?  Committee members have fulfilled their responsibilities.  It says on the website they “asked” that these three things be done.  On the contrary, they are experts, and, as such, they made recommendations to the Secretary.  Yet neither the ex officio members nor the staff have apparently worked on implementation.  Dr. Koh’s comments gave no indication that he is aware of the importance of these recommendations.  In a letter to advocates explaining his refusal to meet, Dr. Koh said, “CFSAC provides a mechanism to ensure stakeholders are engaged and have the

opportunities to offer input.”  Instead, it appears that CFSAC provides a mechanism to ensure stakeholders are contained and have opportunities to offer input that will be ignored.  So what is the point of CFSAC?  If it cannot accomplish these small, high impact tasks how can it accomplish what we really need:  significantly increased funding for research, better education and improved clinical care?  CFSAC costs $235,000 annually.  That sum could fund a study of natural killer cell function in Canadian-defined patients, or create a mechanism to identify an undiagnosed low-income patient, or educate a few more physicians.  I’m a taxpayer.  I’m concerned that we’re spending almost a quarter of a million dollars each year on a committee whose recommendations are routinely ignored by DHHS.

Here’s a suggestion.  Ask ex officio members to take responsibility.  Ask staff members to assign each recommendation to the agency or agencies with responsibility for implementing that recommendation.  Ask each ex officio member to report on activities to implement each recommendation at every meeting.  If nothing is happening ask for explanations from higher levels within the agencies.

We need to see progress. 

[Please read my written testimony which contains other suggestions for progress.]

If you fund it they will come.

Progress in our understanding of ME and CFS has been hampered by a lack of funding for good research.  We have been told by the NIH that funding levels are low because very few high quality applications are received addressing these diseases.  Yet we are told by researchers who have had repeated success in obtaining NIH funding for research in other areas that their applications for funding for projects concerning CFS have been repeatedly rejected.  Funding for clinical trials has been rare.  This has resulted in a vicious cycle:  few people enter the field out of fear that they will not be able to obtain funding, and thus there is a smaller pool of high quality applicants and applications.  It is time to break that cycle with dedicated funding for ME and CFS research.

Following the model that resulted in Requests for Applications issued on September 21, 2012, by the National Cancer Institute, I suggest that several Institutes at the NIH develop a list of provocative questions (PQs) about ME and CFS that then lead to Funding Opportunity Announcements, using RO1 and R21 mechanisms.  The total funding available in the NCI announcements was $64-84 million.  In addition, $21 million was made available for a Clinical Trials Network, something that is also desperately needed to further our knowledge of ME and CFS.   The relevant institutes that should be involved in developing the PQs are:  National Cancer Institute (increased incidence of early malignancy),  National Eye Institute (multiple ophthalmologic problems), National Heart, Lung, and Blood Institute (orthostasis, post-exertional malaise and altered blood volume), National Human Genome Research Institute (increased incidence in family members), National Institute of Allergy and Infectious Diseases (multiple co-infections, possible infectious etiology, immunological abnormalities), National Institute of Arthritis and Musculoskeletal and Skin Diseases (joint and muscle involvement), National Institute of Child Health and Human Development (pediatric ME and CFS), National Institute on Deafness and Other Communication Disorders (hyperacusis), National Institute of Diabetes and Digestive and Kidney Disorders (associated irritable bowel syndrome), Nation Institute of Environmental Science (associated chemical sensitivity), National Institute of General Medical Science (basic processes of cellular energy allocation), National Institute of Mental Health (adjustment of patient, family and community to chronic disease), National Institute on Minority Health and Health Disparities (no access to diagnosis or treatment for minorities and low-income individuals), National Institute of Neurology Diseases and Stroke (cognitive dysfunction, sleep disorders, autonomic nervous system dysfunction, possible disorders of glymphatic system), National Institute of Nursing Research (need for nursing care for homebound and bedbound patients, quality of life in a chronic illness), National Center for Complementary and Alternative Medicine (patients forced to use alternative medicine because no mainstream treatments available), NIH Clinical Center (clinical studies of bedbound patients), and National Center for Advancing Translational Sciences (need for rapid implementation of bench science in these diseases).

Many of these divisions are already represented on the Trans-NIH ME/CFS Research Working Group.  This group should be tasked with formulating the Provocative Questions with the input of both expert clinicians, who have been working with affected patients for years, and also expert patients.  Because patients have been largely abandoned by the scientific and medical communities, many have developed considerable expertise in pathophysiology and available therapeutics. We know which Questions are the most Provocative, because we live with these questions every day.

The Working Group is currently reported to be meeting monthly.  An accelerated schedule will be necessary to develop and prioritize the Provocative Questions, so that RFAs can be issued as soon as possible.  A high priority should be given to studies of potential therapeutic agents, because there are no therapeutic agents currently approved for the treatment of ME or CFS.  Similarly, there are no validated biomarkers to use for diagnosis or to follow responses to therapies.  This is also a very high priority.  Of note, expert clinicians are using therapies that they believe to be effective and also use biomarkers to evaluate those therapies.

Unlike cancer, which has been well-funded and extensively studied for decades, ME and CFS have largely been ignored.  Although there are over 5000 published studies, most are small and many have not used rigorous criteria for inclusion of subjects.  The required funding for this first initiative is therefore larger than in the cancer initiative described above.  It is, of course, impossible to know how much funding is needed to advance our knowledge of ME and CFS to the point where patients’ lives will be measurably improved.  However, it is possible to make an educated guess based on current NIH funding for Multiple Sclerosis, a disease which causes a similar level of disability and may well be a related or overlapping condition.  MS is estimated to affect approximately 400,000 Americans and receives $121 million per year from NIH for research.  ME and CFS are estimated to affect at least 1,000,000 Americans.  It therefore seems reasonable to allocate $302 million annually to ME and CFS research.

A Barrier to Productive Research Besides Funding

The biggest problem for ME and CFS research has been a somewhat esoteric one:  there have been multiple definitions of the disease, some of which have been overly broad, have not focussed on the most important and unique features of the diseases, and have been shown to include large numbers of patients with other disorders as their primary diagnosis.  This has resulted in wildly varying results  and has made it appear that there are no consistent biomarkers or responses to therapeutic agents.  It has also given an erroneous picture of the diseases.  For example, because large numbers of patients with major depressive disorder were included in cohorts defined by a definition developed by the CDC (the empiric definition) and probably also by another definition developed by physicians in the UK (the Oxford criteria), it has appeared that ME and CFS could be psychological disorders which may respond to cognitive behavioral therapy and a program of increasing exercise intensity (called graded exercise therapy or GET).  However, even in this diluted population the benefits of these therapies are quite minimal.  There is evidence that GET is actually harmful to patients with ME and CFS defined by more stringent criteria preferred by expert clinicians.  It is therefore extremely important that research funded by the NIH use an appropriate definition during patient selection.

The International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME), an organizations of clinical and research experts, has recommended using the Canadian Consensus Criteria (CCC) to define ME/CFS in its CFS/ME Primer for Clinical Practitioners.  Patient groups also support this definition.  Thus, it seems reasonable to use this definition in NIH research.

Most (but not all, as noted above) research in the past has used the Fukuda definition, developed at the CDC in 1994.  The problem with Fukuda is that it does not insist on post-exertional malaise, which is probably the cardinal symptom of ME.  It also does not give a higher priority to the presence of other very important features of ME:  orthostasis (not even mentioned in Fukuda), cognitive dysfunction and sleep disorders.  Until the issues in the definition are clarified, it will be necessary for every study funded by the NIH to also classify patients using Fukuda and, in addition to standard data analysis, to separately analyze the data for patients who meet Fukuda criteria and those who meet Canadian criteria (many will meet both).  Thus, over time it will get clearer if there are distinctions between groups defined by these two criteria.  It seems likely that CCC defines ME and Fukuda defines a less-specific group that has been called CFS.  However, only consistent data analysis will provide this clarification.

There was recently an effort among researchers, including the CDC, to establish a minimal data set for ME and CFS research in order to begin to answer some of the questions about differences between definitions and also basic information about the diseases.  However, I have recently heard that this effort has stalled, for unclear reasons.  This is unfortunate.  This could be one of the Provocative Questions:  what data should be collected in every study in order to make patient cohorts uniform (or at least clarify when they are not) and enhance our understanding of these diseases?  An NIH-funded review of the 5000 studies already done to see whether the definition used correlates in any way with the results would be very helpful.

The only study that is currently being done about the definition is a study by the CDC.  This is problematic, because the CDC is the originator of both the Fukuda and the empiric definitions.  They have continued to publish research using the empiric definition as recently as this year, although it has been condemned by CFSAC (see below), and most researchers now agree that it is overly broad and that research using the empiric definition is biased toward demonstrating psychopathology in CFS.  Although it is possible that the next CDC definition will be an improvement, this seems unlikely.  In a recent question-and-answer session with patients, the head of the CDC’s CFS program, Dr. Elizabeth Unger said that she thought the CDC could be “lumpers one day and splitters another” (lumpers referring to more inclusive definitions and splitters to more precise ones).  She also said that she thought that heterogeneity has been the barrier [to moving forward in our understanding of ME and CFS].  It is unnerving that she thinks that heterogeneity is the barrier, and yet she is unwilling to improve consistency by promoting a splitter-definition over a lumper.  She may feel more of an allegiance to past failed efforts of the CDC to appropriately define the diseases than she does to rapidly advancing research that will help to alleviate the suffering of patients.

It is obvious that more research must be done to specifically address the problems that the multiple definitions have created.  NIH should be actively promoting this effort.  A possible solution is an NIH-funded symposium whose task would be to address the definition problem and the resulting methodological challenges with the goal of creating standards for research within a year.   

It is important that outside groups either validate or challenge CDC’s efforts.  However, this should not delay other research, especially in the areas of biomarkers and therapeutics.  Patients should not have to wait for therapies because researchers are squabbling over the small details of definitions.  We have two serviceable definitions:  Canadian and Fukuda.  For now, the best solution is probably to recruit only patients who meet both sets of criteria, but it may also be possible to use a study design that incorporates patients who meet one and/or the other.  It is also possible to improve Fukuda by requiring post-exertional malaise.  In any case, it must be very clear what definition is used, and it will be important to analyze data collected in such a way that it can be leveraged to clarify the definition problem.  It is vital that the definition used be stated in the abstract to the article, so that clinicians and researchers can rapidly ascertain the study’s relevance to their patient population.  Continuation of the effort to delineate minimal data sets is also very important. 

Yet another barrier:  will

To members of the patient community it does not appear that HHS is really interested in promoting research or other solutions to the problems and challenges that American citizens with ME and CFS face.  We have asked to meet with high level officials in the Department and have been told that our only avenue of communication with the Department is the Chronic Fatigue Syndrome Advisory Committee (CFSAC).  Patients have attended meetings of the Committee with great difficulty and at great personal cost.  The Committee has made some excellent recommendations to the Secretary, but these recommendations have mostly not been implemented.  Most recently, three revenue-neutral recommendations have been ignored:  a condemnation of the empiric definition (2009), a recommendation to remove the CDC’s clinical guidelines from their website (2012--see Mary Dimmock’s testimony about the Toolkit), and a recommendation to post the IACFS/ME Primer instead (2012).  There have also been multiple recommendations to increase funding for research and for centers of excellence for research and clinical care.  NIH research funding for CFS is currently $6 million per year.  This level of funding is 220th out of 232 diseases.  There is no funding for ME, i.e., no funding that requires using the Canadian definition.  There are no centers of excellence.

No HHS official has given an explanation as to why the three important, revenue-neutral recommendations (empiric definition, toolkit and primer) have been ignored.  To date, Dr. Koh’s comments have given no indication that he is aware of those recommendations or of their importance.  At this point, many patients are asking, what is the point of this committee?  If it cannot accomplish small tasks that probably only require a single bureaucrat’s signature how can it ever accomplish something more substantive like significantly increased funding for research, education and clinical care?  What, then, is the purpose of this committee?  CFSAC costs $234,532 annually. This money could fund a study of natural killer cell function in Canadian Consensus Criteria-defined ME/CFS patients and/or a study to determine appropriate dosing of rituximab for ME.  As a taxpayer, I am extremely concerned that we are spending nearly a quarter of a million dollars each year on a committee whose recommendations are routinely ignored by HHS.  We have begun discussions about this problem with our legislators.

We feel that CFSAC, as it is currently functioning, is not meeting our need for an urgent, coordinated and fully funded federal response to ME and CFS.  Here is a link to the reply we received from Dr. Koh, Assistant Secretary for Health, when we asked to meet with him and key deputies to discuss our concerns:  http://bit.ly/TnoClG .  The full text of the letter can also be read in testimony submitted to CFSAC by Denise Lopez-Majano.  Of note, in response to a request for patients to have direct input on the Ad Hoc workgroup Dr. Koh stated, “While the [Ad hoc] workgroup and its charge are inherently internal to HHS, some of the members are also ex officio members of the CFSAC where they hear the stakeholder perspective. CFSAC provides a mechanism to ensure stakeholders are engaged and have the opportunities to offer input.”  I would suggest that CFSAC keeps stakeholders engaged in activity that consistently leads to no results and gives the opportunity to offer input that is consistently ignored.  This has to change.

If CFSAC is to become a more effective avenue for cooperation between the patient, clinical and research communities and the federal government that produces substantive action to rapidly improve the lives of citizens with ME and CFS, we need to see some changes in how it functions.  We need to be able to question the ex officio members and Dr. Koh directly.  We need frequent updates on the activities of the Ad hoc workgroup (we have had none to date).  We need to see the promised report from the NIH the State of the Knowledge conference 18 months ago.  We need to discuss many other important issues.  We need to see substantive recommendations implemented.  We need to see progress.  If CFSAC continues to be ineffective and its recommendations are ignored, it should be disbanded.  A more productive process must be implemented.  We need to meet with Dr. Koh and key deputies from HHS to discuss these issues.

We look forward to a better future.

"All there, all the time." - Rich van Konynenburg

It was with great sadness that I learned of the death of Rich van Konynenburg. Rich did a tremendous amount of good for patients with neuro-immune illness. He was a beloved figure.

Rich's background was in engineering. He was retired from a job at Lawrence Livermore Laboratories when he got hooked, through chance, into applying his intellect and fine mind to the complexities of ME/CFS. He stumbled into the field as many do - through having a friend with ME/CFS. What a wonder and a delight this chance happening was for the rest of us!

Rich van Konynenburg - an independent, non-medical, unaffiliated researcher - has done a tremendous amount to "get at" this illness. The operative words here are independent and unaffiliated. Bringing betterment to this patient population became his life. He connected to the patients and felt their isolation and frustration.

It was said about the painter Georges Braque that he was "all there, all the time". Well Rich too was "all there, all the time".

About ten years ago Rich formed an idea about this illness - the essentials borrowed from an Autism treatment of Jill St. James and Amy Yasko. Rich transferred this Autism treatment, with adjustments, to ME/CFS, developing, through analysis, the idea that glutathione depletion was a critical problem in this illness. Applied to ME/CFS, the idea was a good one, it had legs, and the theory put into practice has brought a great deal of betterment to many ME/CFS patients. Over the years, Rich elaborated, researched and promoted his concept of a methylation block/glutathione depletion as a central, perhaps the central, feature with these neuro-immune illnesses. Once in, he displayed perseverance, love, support, empathy, resolve, intelligence and an astonishing array of other wonderful human qualities. As far as I could see, this fellow had no downside.

Rich van Konynenburg will not be replaced. He is truly irreplaceable.

For a number of years, Rich was a member of the Ratna Ligne group, a privately financed alliance of clinicians and researchers. It was here that he was able to present his big picture concepts of the working of this illness. It was here that he forged long-term relationships with other thinkers.

I first heard of Rich van Konynenburg from Dr. Karen Vrchota of Winona, MN. Dr. Vrchota was an early believer in Rich's ideas of methylation blockage, with accompanying glutathione depletion. Dr. Vrchota introduced my daughter to the protocol and over time, it has benefited her. A number of years ago, Rich wrote an analysis on my daughter. He was interested in her case as it was so well documented. What did I learn from reading this analysis? I learned that this is a complex multi-faceted illness that has to be taken apart and attacked in pieces. I learned that there are existing therapies that can help with this illness. I learned that certain things need to be done for other things to be added.

In time, Rich built a relationship with Dr. Tapan Audhya at Vitamin Diagnostics and asked Dr. Audhya to construct a test or series of tests that accurately measures reduced glutathione and various components in the methylation cycle. With these tests patients were able to identify the problem - and more importantly were able to track progress. These few simple supplements supporting the therapy remains one of the essential actionable treatments for this illness. A great many people have experienced positive benefit with the methylation protocol and testing.

In 2009, Rich did a privately funded treatment study with Dr. Neil Nathan. The study can be found here. The positive study results warranted further controlled study, which has not been done.

I first encountered Rich van Konynenburg in January 2007 in Fort Lauderdale at the IACFSME conference. Rich presented a "poster paper" on the methylation blockage concept. This meant that he  "posted" a visual display of his research ideas (for selected hours).

At this conference, after each series of lectures, there was an "open microphone" question period. Rich was quick on his feet, always first to the microphone, waiting to ask his question. At the end of his question time, he would move to the end of the line, hoping to ask another question. His questions were always articulate, specific, challenging, thoughtful and respectful. Always they connected his theory to the existing, mostly abstract, dogma being presented at the conference. One looked at this situation and wondered, what is wrong with this picture?

Why is this fellow Rich asking the questions? Why is he not up front, on the lectern, giving a lecture and presenting his ideas? It made no sense to the perceptive viewer. After all, Rich had a thoroughly constructed theory, a practical and researched idea, an idea that was actionable, and one that could be studied and tested. All this was too much for the powers that be.

The response from the dias to his politely framed clarifications were always the same - a lackluster indifference. What did they ultimately think of Rich voicing his ideas publicly? At the next conference it became clear. At the 2009 Reno conference they canceled the open microphone and took questions through writing, enforcing a situation where they could control the flow.

In Reno, I asked Rich about this change of format. He just looked at me and smiled that wonderful wry smile of his - and said nothing. My conclusion was that he "had seen it before". Rich's response was to move on, to give renewed effort to the avenues afforded to him - the poster paper presentations.

I saw Rich in Reno in 2009, in Ottawa in 2011, in Bethesda at the NIH and in NY at the Mt. Sinai ME/CFS Center conference in 2011. Rich was always the same, engaging anyone who would listen to his ideas. At conferences he could be seen standing from the beginning of the day to the end conversing with anyone from Dr. Cheney to the newest patient or advocate. Rich had a passion for the subject and no bias. One never got the sense that he was talking down to you. He was fascinating.

More recently, and to our collective good fortune, Rich van Konynenburg reached a broader audience in the presentations of his work. He gave a comprehensive three-hour lecture on his theories in Sweden a year ago, which can be viewed here. He also made a shorter version of this lecture at the Mt. Sinai ME/CFS conference in New York in November 2011. This conference was organized by Dr. Derek Enlander. Video footage was made of this lecture and will be available online. There is a blog post on his presentation at this conference here.

Rich was scheduled to speak at the November 2-4 ILADS Lyme conference in Boston. This lecture will now be given by his friend and research colleague Dr. Neil Nathan. Rich was also scheduled to talk in Belfast on Novermber 11, again at the invitation of Dr. Enlander.

Perhaps now the NIH will pick up on his research idea and run studies to conclude what the rest of us already know: Rich's protocol brings benefit to a large number of patients.

The death of Rich van Konynenburg is a devastating loss to the ME/CFS community. Patients all across the world are crying because of this very sad news.

Dr. Denise Faustman, researcher

Since 1990, for unspecified reasons, I have been reading every day about diabetes. Over that time, I have followed diabetes research and treatment closely. I have learned a great deal about the illness, but I know very little about the actual science of the research.

Since about 2002 I have been reading extensively about ME/CFS and other immune dysfunction illnesses. Again, I have no scientific knowledge upon which to draw.

While I have no scientific or medical background, I believe that it is possible to gain a "feel" for these illnesses- diabetes and ME/CFS -  in spite of being scientifically ignorant. In both situations I have no built-in prejudices and have no vested economic or career interest in either field that might interfere with my judgements. In other words, I have no connection to the "Industry" of these illnesses. Most importantly I have always tried to connect to gifted people who can flesh out my own "insufficiencies".

Years ago I was privileged to meet Al Mann, the founder of Minimed. With his small, flexible and innovative company, Minimed, Al Mann greatly improved the maintenance possibilities of diabetic patients. Al Mann was an amazing man who cared deeply about patients - and it was a sad day when Minimed was sucked up by the large Minnesota company, Medtronic.

Early on, in learning about diabetes. I stumbled upon the work of Dr. Richard Bernstein. At the time Dr. Bernstein and his ideas about diet and diabetes were highly discredited by mainstream endocrinologists. Since that time, Dr. Bernstein's ideas have gained great currency. His book can be purchased here. There are intimations of Dr. Bernstein's ideas in Dr. Joseph Burrascano's imploring Lyme patients to ditch the carbs.

Diabetes, at the moment, is a maintenance illness. With slightly more information, perhaps ME/CFS can reach this status? More needs to be known about the etiology of ME/CFS.

In this post I am unable to list all the diabetes researchers that I admire and follow. Instead I would like to focus on one of them: Dr. Denise Faustman of Massachusetts General Hospital. I have written a previous blog post on Dr. Faustman here.

Dr. Faustman is back in the news this week with a very small, early stage paper publication in PLoS ONE.  The proposed treatment, a relatively safe tuberculosis vaccine in use for eighty years, is apt to yield no profits for the pharmaceutical industry.

The hope is that this vaccine can shut down the autoimmune reaction in type 1 diabetes (and perhaps other autoimmune illnesses). Perhaps ME/CFS researchers Mella, Fluge, Peterson, and Kolgenik are reading about Dr. Faustman's work? I certainly hope so.

Several articles on Dr. Faustman's paper can be found here and here.

From the Bloomberg article:

"Faustman and her colleagues at Massachusetts General in Boston are working to get the vaccine to market. After their early findings in studies with mice, she said they tried to interest every major drug maker in developing the vaccine as a possible cure for diabetes. All told her there wasn't enough money to be made in a cure that used an inexpensive, generically available vaccine, Faustman said."

This publication is very exciting news for those interested in a solution for type 1 diabetes. However major questions rear their ugly heads. Why is there so much resistance to this research? Why is Dr. Faustman so isolated with this research after so many years? Who is going to finance further research? In the big picture, these questions are disturbing - and yet they are so familiar, familiar also to those who know the history of research into ME/CFS.

Dr. Faustman outlines her research and answers some pressing questions in several youtube videos, the first from 2012, the second from the year before.






Dr. Faustman is a very impressive researcher. She does not look like she is going to be dislodged from pursuing her interests. She gives me hope that there are other individuals out there looking for unique solutions to complicated medical questions - and specifically that there will be some spill-over into ME/CFS/lyme diseases.

"The Garden"

In the course of my job as patient advocate for my daughter, I travel to various places - CA, London, New York City, Ottawa, Brussels. Most of the time I am mired down in patient advocate work, which is only partially rewarding. One positive reality is that I do get to meet many extraordinary people - and this could certainly be the subject of another and longer post. In these travels there are moments of relief -  ducking into the National Gallery to view my favorite painting (Titian's The Death of Acteon), a hot dog with mustard and sauerkraut on the corner of 69th and Lexington on a sweltering day, checking out the Gauguin painting at the Indianapolis Museum of Art, or going to an Orchestra concert in Minneapolis.

Gauguin, 1889

Throughout the mid-West there are these extraordinary museums reflecting broad and deep collecting interests of past inhabitants of these towns - Minneapolis, Detroit, Cleveland, Cincinnati, and St. Louis.

This summer I had the privilege of visiting with Dr. Dale Guyer at his Institute of Molecular Medicine in Indianapolis. I really admire this clinician. I have learned fundamental approaches to ME/CFS from him. At the end of my time with him, I asked if I could have a picture taken with him. Dr. Guyer suggested that we go out into "The Garden" for the picture.

I stepped out back of his clinic and encountered an astonishing world.

Chris Cairns and Dr. Dale Guyer

In the approximately 1/2 acre behind his clinic, Dr. Guyer has planted a vast array of conifers and Japanese Maples. Dr. Guyer explained to me that the two plants directly behind us in the above photo were recently added and are of a species that is quite rare, yet can exist in the environment of Indianapolis.

I can only assume that Dr. Guyer has made every single decision in regards to the plantings and combinations of this rare and beautiful garden. One can discern from the photos the care taken regarding color, variety, size and placement of each and every plant, stone and path. The reality is very powerful. Everything is calculated to deliver the greatest visual and emotional impact. Nothing is haphazard and the entirety has a sense of oneness, of great unity. It is like a gigantic three dimensional painting.

It occurs to me also that this garden is an extension of Dr. Guyer's skill and experience as a physician. Certainly the garden gives a clear insight into the complexity of his personality. His staff jokes that when he gets really refined in his medical practice, he will just send his patients out back to sit, resonate and heal in the environment.

I spent some time walking around "The Garden" and took a few pictures. My only regret was that I did not stay longer, and I have thought about this space and its effect on me a great deal since then. It is very seldom that I am swept away by a spot and enter into a suspended space where I am lost or do not know where I am. This is the profound effect of this garden as you walk into its midst. Suddenly you are transported to - who knows where? It is another world, a world suspended from the raucous existence of modern life.

Dr. Guyer's garden reminded me of another favorite destination of mine, a place that I have not been for many years, but to which I yearn to return: Bok Gardens and Tower in Lake Wales, FL. Although Bok Tower is much different than Dr. Guyer's garden, it has the same powerful effect on the visitor. Much of the impact comes from not expecting it. Bok Garden takes you into a suspended world where you are suddenly and completely detached from yourself. I suppose many people, like me, return there for solace and removal from life's travails - and to reacquire a bit of peace or peace of mind.

I asked Dr. Guyer what he does in his Garden? He says that he sits there in the evening with a glass of wine.

It is not possible this morning to leave this appreciation of Dr. Dale Guyer and his garden without mentioning a recent article that appeared this morning. The article is found here and concerns gut ecology. Both Dr. Guyer and Dr. Kenny De Meirleir  have emphasized the need to heal the gut. It is a central issue in ME/CFS to both of them. Recent research into the gut environment begins to confirm what a number of ME/CFS physicians and researchers believe - that gut ecology might very well be at the center of this illness. If one wonders - as I do - why MAF 314 brings improvement to the patients who have access to it, this article suggests an answer.

Myalgic Encephalomyelitis - an impact video

It is important to be clear about this disease Myalgic Encephalomyelitis, ME. Clarity is something that has been sadly lacking over the years. This short video, under five minutes, brings certain things about ME into sharp focus. It is an "impact video". The first half has Dr. David Bell articulating, in his excellent manner, some of the main symptoms of this illness. The second half focuses on a severely ill ME patient, a young man of 19 years of age.

It is my belief that we, collectively, have to look more closely at the most severely ill ME patients. It is my belief that they harbor, in their severity, the keys to this illness. Most doctors do not see the most severely ill. Kenny De Meirleir, in his trips into Norwegian homes, treats the very ill. Paul Cheney and David Bell also have occasionally seen the severely ill. Perhaps others have - and hats off to them. But by and large, this patient population is isolated from everyone. The severely ill ME patients cannot get to a doctor's office. They languish in darkened rooms, cut off from reality, isolated and often abandoned, without medical care. It seems that no one cares a whit about them. It is these patients on whom we have to focus our attention, both for their sake and for ours. More effort has to be made to "get close to them", although this, in itself, is difficult, under even the best of circumstances.

I know of a number of these patients. I am interested in identifying more of them. Mostly they have the willingness to participate, through testing, in their own betterment - provided that the severity of their situation is taken into consideration. Many already have had testing for immune function, NK cell activity, cytokine disregulation, gut dysbiosis, brain scans and so forth. Consistent testing needs to be applied to these patients using existing parameters - if only to set the stage for future possibilities that will soon arise.

Peter Cairns, whose own sister is ill, has made this film. Peter has both the skill and the ability, born of experience and empathy, to approach these patients, to get close to them without disturbing them too much - for these patients live in a very fragile and vulnerable world.

Most people do not want to take a look in this direction. Most people turn away, including doctors. It is time to toughen up - and to consider these patients, and what they are going through, especially since they might hold the key. Testing of the half-sick (no disrespect here) has not brought clarity. We need to brace up, take a good look and then move in close. While it is difficult it is the only decent and humane thing to do.

This video interview of Dr. David Bell was made in August 2010 at the opening of the Whittemore Peterson Institute building on the Reno, NV campus. The video was a private project.

It occurs to me to add this fine, very moving testimony of Laurel from 2009.

CFSAC Testimony of Anonymous #3

The testimonies of the recent CFSAC meeting are now online. They can be found here. Why these meeting cannot be streamed live and put immediately on the internet, I do not know. Much of a person's testimony is attached to his or her physical self, gestures and voice. To get the true feeling one needs to see the person presenting the testimony (when possible). It is so easy, it is done everywhere now. It is part of modern life.

The fact that these meetings were not streamed and made available immediately speaks to an "intention" - and that intention is "not good". The decision goes beyond stupidity and it is very worrisome - very worrisome. Things have meaning, actions have meaning.

The testimonies are worth reading in their entirety as they give a tremendous collective overview of ME/CFS.

If I were to pick one testimony that everyone interested in learning about ME should read, it is the testimony of Anonymous #3 - a person of a great courage. What this woman writes is like the very most precious gold. To mine more, read the CFSAC Spring testimony of Anonymous #3 here.

To the Members of the Chronic Fatigue Syndrome Advisory Committee:

Thank you for your service and for the recommendations you made at your meeting last May. In particular, I thank you for recommending that “chronic fatigue syndrome” be moved out of the wastebasket R codes of the United States’ next version of the International Classification of Diseases, the ICD- 10-CM.

In my testimony in May, I described my daily life as a severely ill ME patient. I got sick at age 20 and have been ill for more than 17 years; seven of them spent essentially bedbound. I’m sorry to report that I have lost more function since your May meeting. Now I often can’t lift a pillow from the floor to my bed, and I can no longer swing my laptop computer from my bedside table onto my bed. In order for me to lie on my back and type this testimony, one of my parents, who are my caregivers, had to lift and position my computer for each writing session.

Today I would like to tell you about my last doctor’s appointment--the only time I have been able to go downstairs, outside, and leave my home in the past year.

For severe ME patients, leaving one’s home is an extraordinary undertaking that requires weeks of preparation and months of recovery. A week before the appointment, my parents began to fill our van, which they have converted into an improvised ambulance, with items I would need for the trip. The day before the appointment, I struggled through my monthly bath in the tub and my mother washed my hair. Ordinarily, I bathe in my bed and change my nightgown twice a week, with help. Due to my extreme orthostatic intolerance, I can’t sit long enough to shower, even with the aid of a shower chair.

The morning of my appointment I put on street clothes for the first time in several months. This activity so exhausted me that I could not carry a lightweight purse. I tackled the stairs, which are next to my bedroom, by slowly walking down three steps on rubbery legs, then sitting and resting for a couple minutes, then wobbling down three more with support from the railing. From the foot of the stairs I was pushed in my wheelchair out to our porch, where my father had backed up our van to a loading platform he had constructed.

The bright colors of the outdoors dazzled me. After six months mainly spent lying on this mattress in my small bedroom with one window, I wanted to linger on the porch and take in the vast, arching sky, the touch of breeze against my skin, the hum of insects in the sunlit fir trees. But I had to lower my body onto the bed in the back of our van and rest with eyes closed, wearing earplugs to block the noise of traffic, so that I would have enough energy to get through my appointment.

At the hospital, I had to transfer five times. I heaved my leaden body from the van to my wheelchair, then to a bench in the waiting room where I lay motionless as 85-year-olds hurried past me, then back to my wheelchair, and finally to the table in the exam room.

All of this extra movement and sitting upright took so much of my energy that by the time I reached the paper-covered table, I could barely lift my arms. I lay there blinking at the harsh fluorescent light and wincing at the hospital noises: distant machines beeping, conversations, doors opening. I was glad my doctor was 20 minutes late, because the effort of changing from my street clothes into the hospital gown weakened me so much that it was a while before I could speak again.

And what was the result of my enormous effort in getting myself to the doctor? Essentially, nothing. My doctor renewed my prescriptions for thyroid medication and B12 shots, ordered a few routine blood tests--which came back normal--and did a cursory physical exam. Then she told me to come back in a year and walked out. She had no treatment whatsoever to offer for the sickness that has destroyed my life. Can you imagine HIV or MS patients getting minimal medical care only once a year?

At least she didn’t mock me like past doctors who have said such things as, “It must be nice to get so much attention” and “You’ll have a lot more opportunities in your life if you leave your home.” And in fairness, my doctor has been very good about completing paperwork related to my illness.

Back at home, my parents called a young woman from our local emergency squad and asked her to bring a special carry chair with handles so I could be carried up our stairs. While we waited for her, I lay on the futon in my mother’s office downstairs, a room I had not even seen for more than a year.

Many of my old college textbooks were on her shelves, and I stared at their spines, remembering my active life before I got sick. I took a full course- load, worked part-time, jogged daily, volunteered, and happily partied with my friends.

Now I can no longer read books. Now I spend up to ten hours per day resting with eyes closed, about six hours sleeping, and only short periods here and there listening to audiobooks or checking my email.

It took three people to carry me up the stairs in the chair, though my weight is normal. A few times, as they strained and sweated, I thought we would all go tumbling down the stairs. I clung to the banister, remembering how I used to run up and down those stairs all day as a teenager. Even when my ME was more moderate, I could walk up and down them whenever I wanted to.

Finally, I was back in my room, so depleted I could barely turn my head. And here I have remained for the past six months. A few times a day I walk to the bathroom, but mainly I just lie here, listening to the whoosh of my air cleaner. On my computer I see photos of my old friends, who have gone on to careers, marriage, children and beautiful homes. Outside my window, another year goes by.

Members of CFSAC, my doctor can do nothing for me, but you can. You can influence the Secretary of Health and Human Services, and in turn, the government and public at large. I ask you to please pass strong recommendations on the following issues:

1. Promote the study and awareness of severely ill ME patients--those who score below 10 on the Bell Disability Scale.

A. Count them. No one knows how many American ME patients function at my level or below because no one--including the CDC and the CFIDS Association of America--has ever studied us. The CAA, which promotes psychotherapy and exercise as treatments, has chastised severely ill patients for supposed “kinesiophobia” (fear of movement) and advocates mainly for people with mild fatigue or “unwellness.”

B. Study them. Encourage several research studies composed entirely of severe patients, those who function below 10 on the Bell Disability Scale or who require a nursing home level of care, like me. I’m not a scientist, but it’s logical that the underlying pathology(-ies) of ME should be more pronounced in severe patients and therefore easier to detect

in their bodies. Testing severe patients will have “trickle up” benefits for mild and moderate patients.

C. Include them. Severe patients should comprise half the cohort of all research studies to avoid skewing results toward mild patients. In order to include the severely ill, researchers will have to make accommodations such as sending phlebotomists into patients’ homes. I was able to participate in a Whittemore Peterson Institute study, in which I tested positive for HGRVs, because the WPI--under the leadership of Dr. Judy Mikovits--hired a phlebotomist to come into my bedroom and draw my blood. We may not be able to undergo invasive procedures such as spinal taps in our homes, but there’s no reason why we can’t provide blood, stool, saliva and urine samples to researchers. Stop excluding from your studies the very people whose bodies are most likely to yield answers for all ME patients!

D. Publicize them. Making severe patients the public face of ME is an efficient way to get medical professionals, lay people, and government agencies to take this disease seriously. Rather than being seen as an asterisk, afterthought, or anomaly, severe patients should be the focus of newspaper articles, advocacy materials, and the CDC website. As long as high-energy patients--those who can care for themselves and their families and even hold jobs--are seen as typical, the government will continue to starve ME research of funds. This is a disabling disease, and the severely afflicted are the most capable of showing that!

E. Make teachers of them. Medical school students should be required to make house calls to severe ME patients. Most doctors and researchers have no idea how disabling ME can be because virtually all the patients they see have mild/moderate ME. Why? Because severe patients have extreme difficulty traveling to doctors, or can’t travel at all. Even many ME experts have never met a severe patient in person. After seeing us up close, perhaps future doctors won’t dismiss us with “I’m tired too.”

F. Form a CFSAC task force devoted to severe patients. The Secretary of Health and Human Services has repeatedly ignored your resolutions, but there’s no reason why the CFSAC itself can’t create a committee to actualize the above recommendations for these most overlooked and underserved of patients.

2. Ask for a vast increase in funding. As I wrote in May, if our government believes in equal rights for equal disabilities, it must increase funding for ME research by twenty-fold. Even a private endeavor, the poorly named Chronic Fatigue Initiative, is spending $10 million on research--twice what our government outlays for ME or CFS each year. Ask Secretary Sebelius how she can justify spending on Multiple Sclerosis 100 times, per capita, what she spends on ME or CFS, when I am more disabled than anyone I know with MS. Why has our government left us to decompose in our beds?

3. Adopt and promote the new International Consensus Criteria (ICC) for ME, which were published recently in the Journal of Internal Medicine by a panel of 26 respected clinicians and scientists from 13 countries. Researchers must closely adhere to these strict guidelines to create homogeneous cohorts. Note that to receive an ME diagnosis defined by the ICC, a person must function below 50% of normal activity. While this requirement may be too restrictive for diagnosis, it should be observed for research. Doing so will keep the focus on more disabled patients and facilitate the search for biomarkers and treatments.

4. The term “chronic fatigue syndrome” should be phased out. In particular, research using the Empirical Definition--which was co-authored by Bill Reeves, Beth Unger and Suzanne Vernon--should not receive government funding. Research based on this definition is virtually meaningless because it does not correspond to any disease entity but to a hodgepodge of psychiatric conditions, simple tiredness and unwellness. Any research on “chronic fatigue syndrome” must be based on the Canadian Consensus Criteria, which, like the ICC, defines a distinct neuro-immune disease and requires patients to function below 50% of normal activity.

Patients who don’t fulfill the ICC or CCC should not be admitted to studies of either ME or CFS because they confound research results.

Thank you for reading my testimony, which took me five weeks to write because I can concentrate for only short periods.

Mt. Sinai ME/CFS conference - Dr. Enlander lecture

Dr. Derek Enlander, who practices medicine in NYC, was instrumental in arranging a one-day ME/CFS conference at Mt. Sinai Hospital on Sunday, November 20, 2011. Dr. Enlander is well known in the ME/CFS community for his devoted work with patients with this illness. Dr. Enlander has provided support and care for thousands of patients in NYC and indeed worldwide. He travels regularly to Ireland and England and attends most ME/CFS conferences, playing a very important role down in the "trenches".

With a recent generous gift to Mt. Sinai Hospital by one of Dr. Enlander's patients, Dwight Merriman, Dr. Enlander wasted no time in getting this research and treatment center at Mt. Sinai underway. In the process he has enlisted three top researchers, two of them previously unknown to ME/CFS research. These researchers are Dr. Eric Schadt, Dr. Miriam Merad, and Dr. Ila Singh. On the clinical side, two well-known ME/CFS researcher/clinicians will be collaborating with Dr. Enlander at Mt. Sinai - Dr Kenny De Meirleir and Dr. David Bell. They will be undertaking various treatment paths, some of which are outlined in Dr. Enlander's lecture. See also Dr. Kenny De Meirleir's lecture on the latest with GcMAF.

Dr. Enlander, ever the gentleman, gave the last lecture of the day on that Sunday. In many ways his lecture functioned as a summation of the day's presentations and pulled various threads together.

Collectively these six lectures at this conference gave those in attendance great hope for the future of ME/CFS research at Mt. Sinai Hospital. The Mt. Sinai ME/CFS Center gives every indication of wanting to work collaboratively to get at this disease. This entire enterprise is exciting news indeed and we have Dr. Derek Enlander and his fine colleagues to thank for it. Let us hope that this small scale, hard-hitting conference idea becomes a regular practice.

The audio and videos of these lectures were done by Peter Cairns and Nicholas Cairns.