by Charmian Proskauer
President, Massachusetts CFIDS/ME & FM Association
April 8, 2015
What's the scorecard on advocacy with federal agencies? Does it work? At this point, the review has to be mixed.
Let's take NIH's on-going Pathways to Prevention program for ME/CFS, run from the Office of Disease Prevention (ODP) as an example.
The Program, Advancing the Research on Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, was announced near the end of 2013. A Working Group was formed to consider what questions the study should consider, and met in early January, 2014. The Working Group included several prominent ME/CFS clinicians and researchers, as well as a patient representative. This group also planned the agenda and created nominated speakers for the Workshop. GOOD NEWS
In August 2014, after the Workshop Agenda was published, our Association along with 6 others sent a letter requesting a change to the Agenda to include a fuller discussion of case definitions. The final Workshop Agenda limited the case definition discussion to a single 20-minute presentation by Dr. Lenny Jason. GOOD NEWS to have this presentation by an acknowledged expert in case definition; BAD NEWS that it was still only 20 minutes.
An outside agency, Pacific Northwest Evidence-based Practice Center, under contract to the Agency for Healthcare Research and Quality (AHRQ), prepared an Evidence Report. This was first published in draft form with a 4-week period for public comments. Many advocates submitted comments. In addition, the report was reviewed by a panel of experts. GOOD NEWS
The final Evidence Report (also referred to as the "AHRQ report") was made public on December 9, 2014, the same day the Workshop took place. While the final Evidence Report mentioned the many comments submitted, it did not discount findings form the controversial PACE study, which many advocates had requested. The workshop attendees, and the Panel, would not have had time to review the final report prior to their in-person public meeting. BAD NEWS
The final Evidence Report states on p. 11 of the PDF: "The draft report was further edited in response to these [expert] reviews and [public] comments, and the specific responses were outlined in a table that will be made available after AHRQ posts the final systematic review on the public Web site." To date, this table has not been posted. BAD NEWS
The Workshop was held on Dec. 9-10, 2014. The study panel (5 non-experts) was announced just before the workshop took place. It was a public meeting, and was also videocast live. The videocast and other resources were archived and are available to the public. GOOD NEWS
The draft report was published approximately one week later. While the report contained many good points, and for the most part accurately relayed what the experts presented during the workshop, there were a number of major errors. Furthermore, the treatment recommendations, based heavily on the AHRQ Evidence Report, which explicitly outlined the limitations of the evidence and recommended that future studies not include patients selected with the Oxford case definition (which was used in the PACE trial), pointed prominently to Graded Exercise Therapy (based on the PACE trial), as well as Cognitive Behavioural Therapy and other "biopsychosocial"approaches as primary treatments. BAD NEWS
The original public comment period on the draft Workshop report was scheduled for 2 weeks from date of publication, which would have been from around Dec. 17 to Jan 1st. At the request of a number of advocates including our August letter (and perhaps an exercise of common sense) the comment period was extended to January 16, 2015. GOOD NEWS
In response to queries from advocates, ODP at first said it would not retain public comments, but simply pass them over the the panel. BAD NEWS
This stance was later changed. Advocate Jennie Spotila offered to post a copy of all public comments on her blog, if advocates sent them to her for posting. The P2P library eventually contained well over 70 entries from individuals and patient organizations, many of them lengthy and well-referenced. The themes expressed in these comments were very consistent. A strong and uniform message emerged from our community. GOOD NEWS
The publication of the Final report (from the study panel) was announced for April 14, 2015. Prior to that, advocate Jennie Spotila filed a Freedom of Information Act (FOIA) request, asking to see all comments form the public which were filed by the deadline of January 16. When the 308 p. PDF was provided, Jennie noticed that comments from several sources were not in it, including those from our own Association and those from the Chronic Fatigue Syndrome Advisory Committee. BAD NEWS!
Jennie filed a follow up FOIA request requesting the missing comments. Shortly after that, this notice was posted on the P2P ME/CFS web page:
"The ODP recently discovered that one set of public comments was not forwarded to the panel for consideration. Because the ODP is committed to ensuring that all public comments have been considered, we have paused the publication process in order to give the panel time to consider the new information and determine if changes are needed before the release of the final report. Once the panel has been able to deliberate, the publication process will resume, and the ODP will announce a new timeline on our website."
Jennie has written about this "P2P Mistrial" in her blog.
Our Board sent a letter to the Office of Disease Prevention, expressing our outrage that the panel was not given the opportunity to fully consider ALL comments submitted by the public, and strongly urging that the panel be reconvened in person to do so. You can read our letter here. We have also urged others to write to ODP. It is not clear at this point how many comments were not passed on; "one set" includes at least 3 submissions that we know about, but there could be many more. To date there has been no response from ODP. We will provide an update when we have further news to report.
So, Does Advocacy Work? It can help to keep our public agencies honest - that's the GOOD NEWS. The BAD NEWS is that this kind of work is tedious and time/energy consuming, which seems a terrible burden to place on our community.