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by David Tuller, DrPH

[June 25, 2017: The last section of this post, about the PLoS One study, has been revised and corrected.]

I have tip-toed around the question of research misconduct since I started my PACE investigation. In my long Virology Blog series in October 2015, I decided to document the trial’s extensive list of flaws—or as many as I could fit into 15,000 words, which wasn’t all of them—without arguing that this constituted research misconduct. My goal was simply to make the strongest possible case that this was very bad science and that the evidence did not support the claims that cognitive behavior therapy and graded exercise therapy were effective treatments for the illness.

Since then, I have referred to PACE as “utter nonsense,” “complete bullshit,” “a piece of crap,” and “this f**king trial.” My colleague and the host of Virology Blog, Professor Racaniello, has called it a “sham.” Indeed, subsequent events have only strengthened the argument against PACE, despite the unconvincing attempts of the investigators and Sir Simon Wessely to counter what they most likely view as my disrespectful and “vexatious” behavior.

Virology Blog’s open letters to The Lancet and Psychological Medicine have demonstrated that well-regarded experts from the U.S, U.K. and many other countries find the methodological lapses in PACE to be such egregious violations of standard scientific practice that the reported results cannot be taken seriously. In the last few months, more than a dozen peer-reviewed commentaries in the Journal of Health Psychology, a respected U.K.-based academic publication, have further highlighted the international dismay at the study’s self-evident and indisputable lapses in judgement, logic and common sense.

And here’s a key piece of evidence that the trial has lost all credibility among those outside the CBT/GET ideological brigades: The U.S. Centers for Disease Control still recommends the therapies but now insists that they are only “generic” management strategies for the disease. In fact, the agency explicitly denies that the recommendations are related to PACE. As far as I can tell, since last year the agency no longer cites the PACE trial as evidence anywhere on its current pages devoted to the illness. (If there is a reference tucked away in there somewhere, I’m sure a sharp-eyed sleuth will soon let me know.)

It must be said that the CDC’s history with this illness is awful—another “bad science” saga that I documented on Virology Blog in 2011. In past years, the agency cited PACE prominently and has collaborated closely with British members of the biopsychosocial school of thought. So it is ridiculous and—let’s be frank—blatantly dishonest for U.S. public health officials to now insist that the PACE-branded treatments they recommend have nothing to do with PACE and are simply “generic” management strategies. Nevertheless, it is significant that the agency has decided to “disappear” PACE from its site, presumably in response to the widespread condemnation of the trial.

Many of the PACE study’s myriad flaws represent bad science but clearly do not rise to the level of research misconduct. Other fields of medicine, for example, have abandoned the use of open-label trials with subjective outcomes because they invite biased results; Jonathan Edwards, an emeritus professor of medicine from University College London, has made this point repeatedly. But clearly large segments of the psychological and psychiatric fields do not share this perspective and believe such trials can provide reliable and authoritative evidence.

Moreover, the decision to use the very broad Oxford criteria to identify patients is bad science because it conflates the symptom of “chronic fatigue” with the specific disease entity known often as “chronic fatigue syndrome” but more appropriately called “myalgic encephalomyelitis.” This case definition generates heterogeneous samples that render it virtually impossible for such studies to identify accurate information about causes, diagnostic tests and treatments. Although a 2015 report from the National Institutes of Health recommended that it should be “retired” from use, the Oxford definition remains in the published literature. Studies relying on it should be discredited and their findings ignored or dismissed. But that’s probably as far as it goes.

Many definitions of “research misconduct” exist, but they generally share common elements. In Britain, the Medical Research Council, the main funder of PACE, endorses the definition from Research Councils U.K., an organization which outlines its principles in a statement called “Policy and Guidelines on Governance of Good Research Conduct.” In exploring this question, I will focus here on just two of the planks of the definition cited by the MRC: “misrepresentation of interests” and “misrepresentation of data.”

Let me be clear: I am not trained as a bioethicist. I have never been involved in determining if any particular study involves research misconduct. And I am not making any such claim here. However, when a clinical trial includes so many documented flaws that more than 100 experts from around the world are willing and even eager to sign a letter demanding immediate retraction of key findings, the question of whether there has been research misconduct will inevitably arise. Although people with different perspectives could clearly disagree on the answer, the final and authoritative determination will likely not emerge until the PACE study and the details involved in its conduct and the publication of the results are subjected to a fully independent investigation.

In the meantime, let’s look at how research misconduct is defined and examine some of the possible evidence that might be reviewed. For starters, the cited definition of “misrepresentation of interests” includes “the failure to declare material interests either of the researcher or of the funders of the research.”

I have repeatedly pointed out that the investigators have misled participants about their “material interests” in whether the trial reached certain conclusions—namely, that CBT and GET are effective treatments. The three main investigators have had longstanding links with insurance companies, advising them that rehabilitative approaches such as the interventions under study could get ME/CFS claimants off benefits and back to work. No reliable evidence actually supports this claim—certainly the PACE results failed to confirm it. And yet the investigators did not disclose these consulting and/or financial ties in the information leaflets and consent forms provided to participants.

Why is that a problem? Well, the investigators promised in their protocol to adhere to the Declaration of Helsinki, among other ethical guidelines. The declaration, an international human rights document enacted after WWII to protect human research subjects, is very specific about what researchers must do in order to obtain informed consent: They must tell prospective participants of “any possible conflicts of interest” and “institutional affiliations.”

Without such disclosures, in fact, any consent obtained is not informed but, per Helsinki’s guidelines, uninformed. Investigators cannot simply pick and choose from among their protocol promises and decide which ones they will implement and which ones they won’t. They cannot decide not to disclose “any possible conflicts of interest,” once they have promised to do so, even if it is inconvenient or uncomfortable or might make people reluctant to enter a trial. I have interviewed four PACE participants. Two said they would likely or definitely not have agreed to be in the study had they been told of these conflicts of interest; in fact, one withdrew her consent for her data to be used after she had already completed all the trial assessments because she found out about these insurance affiliations later on and was outraged at not having been told from the start.

The PACE investigators have responded to this concern, but their answers do not actually address the criticism, as I have previously pointed out. It is irrelevant that they made the appropriate disclosures in the journals that published their work; the Declaration of Helsinki does not concern itself with protecting journal editors and journal readers but with protecting human research subjects. The investigators have also argued that insurance companies were not directly involved in the study, thereby implying that no conflict of interest in fact existed. This is also a specious argument, relying as it does on an extremely narrow interpretation of what constitutes a conflict of interest.

Shockingly, the PACE trial’s ethical review board approved the consent forms, even without the disclosures clearly mandated by the Declaration of Helsinki. The Lancet and Psychological Medicine have been made aware of the issue but have no apparent problem with this breach of research ethics. Notwithstanding such moral obtuseness, the fact remains that the PACE investigators made a promise to disclose “any possible conflicts of interest” to trial participants, and failed to honor it. Case closed. In the absence of legitimate informed consent, they should not have been allowed to publish any of the data they collected from their 641 participants.

Does this constitute “misrepresentation of material interests” within the context of the applicable definition of research misconduct? I will leave it to others to make that determination. Certainly the PACE authors and their cheerleaders—including Sir Simon, Esther Crawley, Lancet editor Richard Horton and Psychological Medicine editors Robin Murray and Kenneth Kendler—would reject any such interpretation.

Turning to the category of “misrepresentation of data,” the MRC/RCUK definition cites the “suppression of relevant findings and/or data, or knowingly, recklessly or by gross negligence, presenting a flawed interpretation of data.” One of the PACE trial’s most glaring problems, of course, is the odd fact that 13% of participants met the physical function outcome threshold at baseline. (A smaller number, slightly more than one percent, met the fatigue outcome threshold at baseline.) In the Lancet study, participants who met these very poor outcome thresholds were referred to as being “within normal ranges” for these indicators. In the Psychological Medicine paper, these same participants were referred to as being “recovered” for these indicators.

Of course, it was obvious from the papers themselves that some participants could have met these thresholds at baseline. But the number of participants who actually did meet these thresholds at baseline became public only after the information was released pursuant to a freedom-of-information request. (This was an earlier data request than the one that eventually led to the release of all the raw trial data for some of the main results.)

The decision-making behind this earlier release remains a mystery to me, since the data make clear that the study is bogus. While the bizarre nature of the overlap in entry and outcome thresholds already raised serious questions about the trial’s credibility, the fact that a significant minority of participants actually met both the “disability” and “normal range”/”recovery” thresholds for physical function at baseline certainly adds salient and critical information. Any interpretation of the study made without that benefit of that key information is by definition incomplete and deficient.

Given the logical impossibility of meeting an outcome threshold at baseline, it is understandable why the authors made no mention of the fact that so many participants were simultaneously found to be “disabled” and “within normal range”/“recovered” for physical function. Any paper on breast cancer or multiple sclerosis or any other illness recognized as a medical disease would clearly have been rejected if it featured such an anomaly.

The PACE team compounded this error by highlighting these findings as evidence of the study’s success. At the press conference promoting the Lancet paper, Trudie Chalder, one of the three principal investigators, touted these “normal range” results by declaring that twice as many people in the CBT and GET groups as in the other groups “got back to normal”—even though some of these “back-to-normal” participants still qualified as “disabled” under the study’s entry criteria. Moreover, the PACE authors themselves were allowed a pre-publication review of an accompanying Lancet commentary about the PACE trial by two Dutch colleagues. The commentary argued that the “normal range” analyses represented a “strict criterion” for recovery and declared that 30 percent of the participants had met this recovery standard.

Yet this statement is clearly preposterous, given that participants who met this “strict criterion” could have had scores indicating worse health than the scores required to demonstrate disability at trial entry. The ensuing headlines and news stories highlighted both Professor Chalder’s statement that CBT and GET were effective in getting people “back to normal” and that 30 percent had “recovered” according to a “strict definition.” This misinformation has since impacted treatment guidelines around the world.

I have previously criticized the authors’ attempts to explain away this problem. They have essentially stated that it makes no difference if some participants were “recovered” on one “recovery” threshold at baseline because the study included other “recovery” criteria as well. Moreover, they point out that the “normal range” analyses in The Lancet were not the main findings—instead, they have argued, the comparison of averages between the groups, the revised primary outcome of the study, was the definitive evidence that the treatments work.

Sorry. Those excuses simply do not wash. The inclusion of these overlapping entry and outcome thresholds, and the failure to mention or explain in the papers themselves how anyone could be “within normal range” or “recovered” while simultaneously being sick enough to enter the study, casts doubt on the entire enterprise. No study including such a bogus analysis should ever have passed peer review and been published, much less in journals presumed to subject papers to rigorous scientific scrutiny. That The Lancet and Psychological Medicine have rejected the calls of international experts to address the issue is a disgrace.

But does this constitute “misrepresentation of data” within the context of the applicable definition of research misconduct? Again, I leave it to others to make that determination. I know some people—in particular, the powerful cohort of PACE supporters—have reviewed the same set of facts and have expressed little or no concern about this unusual aspect of the trial.

[This section about the PLoS One study has been revised and corrected. At the end of the post, I have explained the changes. For full transparency, I have also re-posted the original paragraphs for anyone who wants to track the changes.]

Now let’s turn to the PLoS One paper published in 2012, which has been the subject of much dispute over data access. And yet that dispute is a distraction. We don’t need the data to determine that the paper included an apparently false statement that has allowed the investigators to claim that CBT and GET are the most “cost-effective” treatments from the societal perspective—a concept that factors in other costs along with direct health-care costs. PLoS One, like the other journals, has failed to address this concern. (The journal did post an “expression of concern” recently over the authors’ refusal to share data from the trial in accordance with the journal’s policies.)

The PACE statistical analysis plan included three separate assumptions for how to measure the costs of what they called “informal care”–the care provided by family and friends—in assessing cost-effectiveness from the societal perspective. The investigators promised to analyze the data based on valuing this informal care at: 1) the cost of a home-care worker; 2) the minimum wage; and 3) zero cost. The latter, of course, is what happens in the real world—families care for loved ones without getting paid anything by anyone.

In PLoS One, the main analysis for assessing informal care presented only the results under a fourth assumption not mentioned in the statistical analysis plan—valuing this care at the mean national wage. The paper did not explain the reasons for this switch. Under this new assumption, the authors reported, CBT and GET proved more cost-effective than the two other PACE treatment arms. The paper did not include the results based on any of the three ways of measuring informal care promised in the statistical analysis plan. But the authors noted that sensitivity analyses using alternative approaches “did not make a substantial difference to the results” and that the findings were “robust” under other assumptions for informal care.

Sensitivity analyses are statistical tests used to determine whether, and to what extent, different assumptions lead to changes in results. The “alternative approaches” mentioned in the study as being included in the sensitivity analyses were the first two approaches cited in the statistical analysis plan—valuing informal care at the cost of a home-care worker and at minimum wage. The paper did not explain why it had dropped any mention of the third promised method of valuing informal care—the zero-cost assumption.

In the comments, a patient-researcher, Simon McGrath, pointed out that this claim of “robust” results under other assumptions could not possibly be accurate, given that the minimum wage was much lower than the mean national wage and would therefore alter the results and the sensitivity analyses. In response, Paul McCrone, the King’s College London expert in health economics who served as the study’s lead author, conceded the point.

“You are quite correct that valuing informal care at a lower rate will reduce the savings quite substantially, and could even result in higher societal costs for CBT and GET,” wrote Professor McCrone. So much for the paper’s claim that sensitivity analyses showed that alternative assumptions “did not make a substantial difference to the results” and were “robust” no matter how informal care was valued.

Surprisingly, given this acknowledgement, Professor McCrone did not explain why the paper included a contradictory statement about the sensitivity analyses under alternative assumptions. Nor did he offer to correct the paper to conform to this revised interpretation he presented in his comments. Instead, he presented a new rationale for highlighting the results based on the assumption that unpaid informal care was being valued at the mean national wage, rather than using the other assumptions outlined in the protocol.

“In our opinion, the time spent by families caring for people with CFS/ME has a real value and so to give it a zero cost is controversial,” Professor McCrone wrote. “Likewise, to assume it only has the value of the minimum wage is also very restrictive. In other studies we have costed informal care at the high rate of a home care worker. If we do this then this would show increased savings shown [sic] for CBT and GET.”

This concern for patients’ families is certainly touching and, in a general sense, laudable. But it must be pointed out that what they did in earlier studies is irrelevant to PACE, given that they had included the assumptions they planned to use in their statistical analysis plan. Moreover, it does not explain why Professor McCrone and his colleagues then decided to include an apparently false statement about the sensitivity analyses in the paper.

Another patient-researcher, Tom Kindlon, pointed out in a subsequent comment that the investigators themselves chose the alternative assumptions, which they were now dismissing as unfair to caregivers. “If it’s ‘controversial’ now to value informal care at zero value, it was similarly ‘controversial’ when they decided before the data was looked at, to analyse the data in this way,” wrote Kindlon. “There is not much point in publishing a statistical plan if inconvenient results are not reported on and/or findings for them misrepresented.”

Whatever their reasons, the PACE investigators’ inclusion in the paper of the apparently false statement about the sensitivity analyses represents a serious lapse in professional ethics and judgement. So does the unwillingness to correct the paper itself, given the exchanges in the comments. Does this constitute “misrepresentation of data” within the context of the MRC/RCUK definition of research misconduct?

As I have said, I will leave it to others to make that determination. I look forward to the day when an international group of experts finally pursues a thorough investigation of how and why everything went so terribly wrong with this highly influential five-million-pound trial.

A post-script: I did not contact the PACE authors prior to posting this blog. After my initial series ran in October 2015, Virology Blog posted their full response to my concerns. Since then, I have repeatedly tried to solicit their comments for subsequent blog posts, and they have repeatedly declined to respond. I saw no point in repeating that exercise this time around. I also did not try to solicit a response from Professor McCrone, since he has not responded to multiple earlier requests seeking an explanation for why the PLoS One paper contains the apparently false statement about sensitivity analyses.

However, I would be happy to post on Virology Blog a response of any length from any of the investigators, should they decide to send one. I would of course also correct any documented factual errors in what I have written, which is something I have done whenever necessary throughout my journalism career. (June 25, 2017: Of course, I have now made such corrections, per my professional obligations.)

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Next post: The Lancet’s awful new GET trial

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*Explanation for the changes: In the original version, I should have made clear that my concerns involved an analysis of what the investigators called cost-effectiveness from the societal perspective, which included not only the direct health-care costs but other considerations as well, including the informal costs. I also mistakenly wrote that the paper only presented the results under the assumption that informal care was valued at the cost of a home-care worker. In fact, for unexplained reasons, the paper’s main analysis was based on none of the three assumptions mentioned in the statistical analysis plan but on a fourth assumption based on the national mean wage.

In addition, I mistakenly assumed, based on the statistical analysis plan, that the sensitivity analyses conducted for assessing the impact of different approaches included both the minimum wage and zero-cost assumptions. In fact, the sensitivity analyses cited in the paper focused on the assumptions that informal care was valued at the cost of a home-care worker and at the minimum wage. The zero-cost assumption also promised in the protocol was not included at all. I apologize to Professor McCrone and his colleagues for the errors and am happy to correct them.

However, this does not change the fact that Professor McCrone’s subsequent comments contradicted the paper’s claim that, per the sensitivity analyses, changes in how informal care was valued “did not make a substantial difference to the results” and that the findings were “robust” for the alternative assumptions. This apparently false claim in the paper itself still needs to be explained or corrected. The paper also does not explain why the investigators included the zero-cost assumption in the detailed statistical analysis plan and then decided to drop it entirely in the paper itself.

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Here is the original version of the section on the PLoS One paper, for anyone who wants to compare the two and track the changes:

Now let’s turn to the PLoS One paper published in 2012, which has been the subject of much dispute over data access. And yet that dispute is a distraction—we don’t need the data to determine that the paper included an apparently false statement that has allowed the investigators to claim that CBT and GET are the most “cost-effective” treatments. PLoS One, like the other journals, has failed to address this concern, despite an open letter about it posted on Virology Blog last year. (The journal did post an “expression of concern” recently over the authors’ refusal to share data from the trial in accordance with the journal’s policies.)

The PACE statistical analysis plan included three separate assumptions for how to measure the costs of “informal care”–the care provided by family and friends. The investigators promised to provide results based on valuing this informal care at: 1) the average wage paid to health-care workers; 2) the minimum wage; and 3) at zero pay. The latter, of course, is what happens in the real world—families care for loved ones without getting paid anything by anyone.

In PLoS One, the main analysis only presented the results under the first assumption—costing the informal care at the average wage of a health-care worker. Under that assumption, the authors reported, CBT and GET proved more cost-effective than the two other PACE treatment arms. The paper did not include the results based on the other two ways of measuring “informal care” but declared that “alternative approaches were used in the sensitivity analyses and these did not make a substantial difference to the results.” (Sensitivity analyses are statistical tests used to determine whether, and to what extent, different assumptions lead to changes in results.)

Yet in the comments, two patient researchers contradicted this statement, pointing out that the claim that all three assumptions would essentially yield the same results could not possibly be accurate. In response, Paul McCrone, the King’s College London expert in health economics who served as the study’s lead author, conceded the point. Let me repeat that: Professor McCrone agreed that the cost savings would indeed be lower under the minimum wage assumption, and that under the third assumption any cost advantages for CBT and GET would disappear.

“If a smaller unit cost for informal care is used, such as the minimum wage rate, then there would remain a saving in informal care costs in favour of CBT and GET but this would clearly be less than in the base case used in the paper,” wrote Professor McCrone. “If a zero value for informal care is used then the costs are based entirely on health/social care (which were highest for CBT, GET and APT) and lost employment which was not much different between arms.” So much for the paper’s claim that sensitivity analyses showed that alternative assumptions “did not make a substantial difference to the results.”

Surprisingly, given these acknowledged facts, Professor McCrone did not explain why the paper included a completely contradictory statement. Nor did he offer to correct the paper itself to conform to his revised interpretation of the results of the sensitivity analyses. Instead, he presented a new rationale for highlighting only the results based on the assumption that unpaid informal care was being reimbursed at the average salary of a health-care worker.

“In our opinion, the time spent by families caring for people with CFS/ME has a real value and so to give it a zero cost is controversial,” Professor McCrone wrote. “Likewise, to assume it only has the value of the minimum wage is also very restrictive. In other studies we have costed informal care at the high rate of a home care worker. If we do this then this would show increased savings shown [sic] for CBT and GET.”

This concern for patients’ families is certainly touching and, in a general sense, laudable. But it must be pointed out that what they did in earlier studies is irrelevant to PACE, given that they had included the alternative assumptions in their own statistical analysis plan. Moreover, it does not explain why Professor McCrone and his colleagues then decided to include an apparently false statement about the sensitivity analyses in the paper.

One of the commenters, patient-researcher Tom Kindlon from Dublin, pointed out in a subsequent comment that the investigators themselves chose the alternative assumptions that they were now dismissing as unfair to caregivers. “If it’s ‘controversial’ now to value informal care at zero value, it was similarly ‘controversial’ when they decided before the data was looked at, to analyse the data in this way,” he wrote. “There is not much point in publishing a statistical plan if inconvenient results are not reported on and/or findings for them misrepresented.”

Whatever their reasons, the PACE investigators’ inclusion in the paper of the apparently false statement about the sensitivity analyses represents a serious lapse in professional ethics and judgement. So does the unwillingness to correct the paper itself to reflect Professor McCrone’s belated acknowledgement of the actual results from the sensitivity analyses, rather than the inaccurate results reported in the paper. Does this constitute “misrepresentation of data” within the context of the MRC/RCUK definition of research misconduct?

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By David Tuller, DrPH

Last week, I e-mailed a letter to Sue Paterson, director of legal services at the University of Bristol, to express my concerns about Professor Esther Crawley’s false claim that I had libeled her in reporting on her research for Virology Blog. On Friday, I received a two-sentence response from Ms. Paterson. She addressed it to “Mr. Tuller” and wrote this:

“Thank you for your email of 14 June. Your comments have been noted.”

I wasn’t sure what to make of this terse reply. Was that all that Bristol’s director of legal services had to say about the fact that a well-known faculty member issued an absurd allegation during a high-profile event sponsored by this august institution? Had she simply noted my concerns herself, or had she actually conveyed them to Professor Crawley, as I’d requested? Did the university feel any sense of responsibility for what had occurred? Would Ms. Paterson’s “noting” of my comments be followed by any further missive or perhaps even an apology after the university investigated the event? Who knows?

I responded at somewhat greater length but prefer for the moment to keep the exact phrasing private. My tone was what I would describe as very pointed but within bounds, although I have come to realize that the British tend to interpret “within bounds” somewhat more narrowly than Americans.

Here’s the first paragraph:

“Thank you for your response. (For the record, it should Dr. Tuller, not Mr. Tuller. I have a doctorate in public health, as I indicated in the sign-off to my letter. However, please feel free to call me David.)” 

I have a feeling the pro-PACE camp might have difficulty with the “Dr” thing because my behavior—like tearing up Lancet papers at public events—does not fit their preconceived notions of how people with advanced academic degrees should act. However, this group apparently thinks it’s fine to accuse patients of being “vexatious” just because they want to know the actual answers that the PACE investigators promised to provide in exchange for five million pounds of public funds.

Anyway, my letter went on from there. To paraphrase: I noted that the prolonged silence from Professor Crawley indicated to any reasonable observer that she could not defend her allegation, and that I took this as her tacit acknowledgment of error. I also noted that Ms. Paterson’s own minimalist, content-free response included no documentation or evidence that anything I wrote about Professor Crawley’s research was inaccurate. I stated that, as far as I was concerned, no further communication about the matter was necessary, since at this point it was obvious to all that I had not written “libellous blogs” about Professor Crawley.

I also wrote that I hoped someone would explain to Professor Crawley the distinction between opinions she dislikes and libel. And I expressed the expectation that the offending slide would be retired for good and that Professor Crawley would no longer repeat her false libel accusation in public. I explained as well that whatever she said about me in private was obviously her own business.

I have no idea if I will hear back again from Ms. Paterson or anyone else in Bristol’s legal department, but I will provide an update if I do.

The TWiV hosts review an analysis of gender parity trends at virology conferences, and the origin and unusual pathogenesis of the 1918 pandemic H1N1 influenza virus.

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PlaqueOn the wall of a Columbia University Medical Center building just across the street from my laboratory is a plaque commemorating two participants in the discovery of a mosquito vector for yellow fever virus.

The plaque reads:

Aristides Agramonte, Jesse William Lazear, Graduates of the Columbia University College of Physicians and Surgeons, class of 1892. Acting Assistant Surgeons, U.S. Army. Members of the USA Yellow Fever Commission with Drs. Walter Reed and James Carroll. Through devotion and self-sacrifice they helped to eradicate a pestilence of man.

Yellow fever, known in tropical countries since the 15th century, was responsible for devastating epidemics associated with high rates of mortality. The disease can be mild, with symptoms that include fever and nausea, but more severe cases are accompanied by major organ failure. The name of the illness is derived from yellowing of the skin (jaundice) caused by destruction of the liver. For most of its history, little was known about how yellow fever was spread, although it was clear that the disease was not transferred directly from person to person.

Cuban physician Carlos Juan Finlay proposed in 1880 that a bloodsucking insect, probably a mosquito, was involved in yellow fever transmission. The United States Army Yellow Fever Commission was formed in 1899 to study the disease, in part because of its high incidence among soldiers occupying Cuba. Also known as the Reed Commission, it comprised four infectious disease specialists: U.S. Army Colonel Walter Reed (who was the chair); Columbia graduates Lazear and Agramonte, and James Carroll. Lazear confirmed Finlay’s hypothesis in 1900 when he acquired yellow fever after being experimentally  bitten by mosquitos who had fed on sick patients. Days later, he died of the disease.

The results of the Reed Commission’s study proved conclusively that mosquitoes are the vectors for this disease. Aggressive mosquito control in Cuba led to a drastic decline in cases by 1902.

The nature of the yellow fever agent was established in 1901, when Reed and Carroll injected filtered serum from the blood of a yellow fever patient into three healthy individuals. Two of the volunteers developed yellow fever, causing Reed and Carroll to conclude that a “filterable agent,” which we now know as yellow fever virus, was the cause of the disease.

Sometimes you don’t have to wander far to find some virology history.

Update 6/16/17: The statement on the plaque that Agramonte and Lazear “helped to eradicate a pestilence of man” is of course incorrect, as yellow fever has never been eradicated. Recent large outbreaks of yellow fever in Brazil and Angola are examples of the continuing threat the virus poses, despite the availability of a vaccine since 1938.

By David Tuller, DrPH

This morning I e-mailed the following letter to Sue Paterson, the University of Bristol’s Director of Legal Services and Deputy University Secretary, to protest Professor Esther Crawley’s accusation that I libeled her in blogging about her work. I cc’d the office of the university’s vice-chancellor, Professor Hugh Brady.

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Dear Ms. Paterson:

I have recently learned that Professor Esther Crawley of the University of Bristol’s Centre for Child and Adolescent Health, in her inaugural lecture on February 24th of this year, accused me of libel. During her talk, she showed a slide with the phrase “libellous blogs,” accompanied by a screen shot of one of my blog posts on Virology Blog. While that slide was on the screen, she also mentioned “libellous blogs,” obviously referring to the Virology Blog post, among others.

This libel accusation is false. Given that Professor Crawley made this unsupported charge in such a high-profile academic setting, I felt that it was important to bring the matter to your attention and express my surprise and displeasure. (I have also cc’d the office of the university’s vice-chancellor, Professor Hugh Brady.)

Virology Blog is a well-regarded science site hosted by Professor Vincent Racaniello, a prominent virologist at Columbia University. (I have also cc’d Professor Racaniello.) For the last year and a half, I have been writing an investigative series for Virology Blog called “Trial by Error,” about the many flaws of the PACE trial and related research, including Professor Crawley’s work. In accusing me of libel, she was also accusing my colleague, Professor Racaniello, of publishing libellous material. Professor Crawley used this slide again during a talk in April to the British Renal Society. I have written several subsequent posts about the libel accusation itself.

It is certainly true that the post highlighted in the slide, titled “The New FITNET Trial for Kids,” is harsh on Professor Crawley’s recent work. It is my opinion, as a public health expert from the University of California, Berkeley, that her research and the FITNET-NHS protocol are highly problematic in their presentation of the illness variously called chronic fatigue syndrome, myalgic encephalomyelitis, ME/CFS, or CFS/ME. In the post in question, I outlined these issues and carefully documented the facts on which I based my arguments. My concerns are shared by many leading scientists and experts in study design and research methodology.

In my post, I explained how Professor Crawley has misstated the NICE guidelines in both her research and her FITNET-NHS proposal, in ways that appear to eliminate post-exertional malaise as a required symptom. I also noted that she has conflated the symptom of “chronic fatigue,” a hallmark of many illnesses, with the specific disease entity she prefers to call “chronic fatigue syndrome.” As many have previously noted, this conflation generates samples that are far too heterogeneous to yield reliable and valid conclusions about prevalence, causes and treatments.

I acknowledge that I have expressed myself in sharp, colorful and–some would say–offensive terms. That just makes me sharp, colorful and possibly offensive. It does not make me libellous. Professor Crawley has a right to disagree with my interpretation of the facts and explain why I am wrong. And she is free to make her points in hard-hitting language, as I have chosen to do. But without providing evidence or documentation that what I wrote was inaccurate, she has no legitimate grounds to accuse Professor Racaniello and me of libel.

I have e-mailed Professor Crawley several times asking her to explain her charge of libel, or to apologize. In my e-mails, I have let her know that I would be happy to post her full statement on Virology Blog. In other words, I have offered her the opportunity to make her case, at whatever length she wants, in the same forum in which I purportedly libeled her. Moreover, should she document any factual errors in my work, I am of course happy to correct the public record, as I have done throughout my career as a journalist. Even though she has not so far responded with evidence to back up her accusation, the offer to post her full statement on Virology Blog and correct any documented factual errors still stands.

My main goal in sending this letter is to let you know that Professor Crawley’s  accusation will not deter me from my work. Nor will it impact Professor Racaniello’s support for this project, which involves accurate reporting and opinionated commentary on PACE and other issues involving ME/CFS. In the meantime, I suggest that someone should explain to Professor Crawley that  accusing other academics or anyone of libel without providing evidence—and then refusing to respond to reasonable requests for clarification–is unacceptable, unjustified and reckless on many levels. Professor Crawley should not make public accusations that she cannot or will not defend when challenged.

I have not cc’d Professor Crawley on this letter. Because she has declined to respond to my recent requests for an explanation and my offers to publish her full statement on Virology Blog, I see no point in further efforts to communicate with her. I therefore trust you will convey to Professor Crawley the concerns I have expressed here on behalf of Professor Racaniello and myself, as well as our determination to keep pursuing this investigation.

Sincerely—

David Tuller, DrPH

 

**********

If you appreciate my PACE-busting efforts, I urge you to help me continue with this project by supporting my crowdfunding campaign:

https://www.crowdrise.com/virology-blogs-trial-by-error-more-reporting-on-pace-mecfs-and-related-issues1

From Nido2017 in Kansas City, Vincent  meets up with three virologists to talk about their careers and their work on nidoviruses.

Show notes at microbe.tv/twiv

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Carl SaganAt the ASM Microbe 2017 meeting last week in New Orleans, Ed Yong interviewed astronaut Kate Rubins for the keynote address. The large theatre was packed, and overflow crowds watched the event on monitors throughout the New Orleans Convention Center. But I think that a scientist should have interviewed Dr. Rubins.

Rich Condit and I had the good fortune to interview astronaut Astro Kate for TWiV 444 at ASM Microbe 2017. Several hours later, she was on stage with Ed Yong. It’s clear why ASM wanted Yong speaking with Rubins: he would draw the biggest possible audience. His science writing is outstanding, and his first book, I Contain Multitudes, sold very well. In fact, Ed was at ASM Microbe to autograph copies of his book.

In 2016 the keynote speaker at ASM Microbe was Bill Gates, for the same reason: to draw a crowd. He was interviewed by Dr. Richard Besser, formerly of ABC News.

I have nothing against Ed Yong; I think he’s doing a great job communicating science. But I think that a scientist should have interviewed Kate Rubins. Why? Because the public views scientists as the most trustworthy spokepersons for science (source: ResearchAmerica). Not bloggers, or journalists, or elected officials, but scientists. And I want scientists to showcase their field, especially in front of other scientists.

What living scientist would have been as popular as Ed Yong at ASM 2017? Surely Steven Hawking, or Neil deGrasse Tyson, who are widely known. But they are not microbiologists. The only life scientist who is as well known as Ed Yong and would draw a big crowd might be Richard Dawkins. Bill Nye is not on this list because he’s an engineer, not a scientist, but he would be a huge draw, bigger than Yong. I would not be surprised to see him at a future ASM Microbe meeting.

We need more celebrity life scientists who are loved by millions, who can explain the nuts and bolts of biology, microbiology, biotechnology, cell biology, and more, and who draw huge crowds. I’m not one of them – my blog and podcasts have many followers, but I would not draw like Ed Yong did at ASM Microbe (our TWiV with astronaut Kate Rubins attracted 50 people). But I believe that my work in science communication shows young scientists that they can appeal to a broad range of science minded people, and perhaps become very popular themselves.

Let the Yong-Rubins keynote be a call to early career life scientists to communicate their science, build their visibility, and become the next Carl Sagan, who reached millions with his television shows and books. It’s not easy, especially combined with a career in research and teaching. But Sagan and others have shown that it can be done. And hopefully you will one day be a big draw at a keynote address!

By David Tuller, DrPH

In February, 2011, I wrote a bad article about the PACE trial. At that time, I was reporting on the XMRV situation and had never heard about this piece of crap. As happens at news organizations, my editor at The New York Times sent me the Lancet paper and asked me to write it up for publication later that day. I did the best I could. Not knowing any of the background, I took the study at face value and reported the bogus findings—that cognitive behavior therapy and graded exercise therapy appeared to be effective treatments. I did include a few caveats—that the authors had links to disability insurers, that they used a broad definition for the illness, and that patients had reported that exercise made them worse.

I got immediate push-back from patients, which was what persuaded me to examine the concerns they were raising—and that ultimately led to my 15,000-word investigation of this disastrous piece of research. Little did I know at the time that my article had triggered a crisis for someone who would later become a valued friend and colleague—journalist and ME/CFS patient Julie Rehmeyer, who has been instrumental in the ongoing efforts to discredit and debunk the PACE paradigm. As this campaign has progressed since Virology Blog posted my initial investigation in October 2015, we have strategized together and have reviewed and supported each other’s work, culminating in the opinion piece we co-wrote for The New York Times this spring.

Last month, her terrific book—Through the Shadowlands: A Science Writer’s Odyssey into an Illness Science Doesn’t Understand—was finally published. It deserves to be widely read. It is an engrossing and deeply moving account of an intelligent, curious, open-minded person forced to engage with this devastating illness. It is a meditation on the strengths and weaknesses of science and scientific institutions. And it is a cautionary tale about the importance of questioning widely accepted but unfounded assumptions and the flawed scientific findings that result. Finally, it advances the push to get rid of the PACE “treatments” once and for all and to find legitimate answers to this medical mystery. Julie and I recently spoke and e-mailed about her book, her initial encounter with my work, and other issues.

 

Why did you write the book?

The book had to be written. It wasn’t really a choice!

At the time my chronic fatigue syndrome got really bad, I was making my living writing about math research for science magazines. That’s pretty cognitively demanding, so when I was really sick, it was a struggle.

On the other hand, I was of course hugely motivated to figure out what was going on with me health-wise, and I started writing long e-mails to friends just about what was happening and how I was thinking about it. One of my friends wrote back and responded and basically laid it out for me, saying, ‘You have to write a book about this.’ I read his email and immediately thought, ‘That’s my book.’

And this is when you were in the middle of it?

Very much in the middle of it—I was at my sickest, often too weak to turn over in bed. I was too ill to work on it in a concerted way, but that was the point that I knew I’d be writing a book about this and had a fairly clear sense what it would be. It wasn’t a decision — it was more an expectation about what was going to happen.

This was in 2011, right at the time the PACE trial came out. At that time, there was very little good information about ME/CFS. So on a practical level, I felt like the book was needed. But on another level, I had this bigger sense that I was in the middle of this huge experience, and while I didn’t know where it was going to take me, it felt so much bigger than me. A million other Americans were going through something similar, and society had pushed all of us into the shadows—our experience was almost completely invisible. To the extent it was seen at all, it was seen negatively, because there was so much prejudice about chronic fatigue syndrome, and there still is.

So I sort of felt like Jonah in the belly of the whale, in a dark place being carried to who-knows-where. Even then, it had a mythic quality, and as the events I recount in the book unfolded, it became even more mythic.

Is the book just about this illness, or is there a larger issue?  

It’s about a lot more than illness.

Chronic fatigue syndrome has attracted so much prejudice in part, I think, because it’s so scary. The idea of getting sick in such a formless way and becoming so powerless is frightening. We like to imagine that our energy is ours, that it can’t be taken away from us. But of course, that’s not true.

In a more general way, ME/CFS forces you to realize how little control you have really have over your life. Of course, none of us has perfect control over lives—we could get hit by a car any moment. But most people are able to construct lives where they feel enough control in a day-to-day way that they can push the ways they don’t have control out of their minds. That’s not a luxury you have with this illness. You never know from day to day what you’ll be capable of.

So the deepest question the book asks is, how can we live with the immediate knowledge of our own powerlessness? How can we construct meaningful lives in face of that fact?

The book has many other layers as well. On one level, it’s just a really entertaining story, one that, I hope, will suck you in, even if you’re lying on a beach digging your toes into the sand. It’s also a meditation on the nature of science, a mystery, a story of personal transformation, and a love story. I hope that people will pick it up, get sucked in, and emerge at the end with a greater feeling of spaciousness and curiosity and hope in their lives.

So you were first aware of my work when you read the first New York Times article I wrote about the PACE trial, when it was published in early 2011. What happened?

It’s a funny story in retrospect, though it didn’t feel funny at the time. That first story of yours was a fairly straightforward news article about the trial. It expressed some criticism, but not in a prominent way. And I was at my very sickest then, often too ill to turn over in bed. So I was lying in bed one morning reading The New York Times on my cellphone, and I saw the headline, ‘Psychotherapy eases chronic fatigue syndrome.’ I thought, ‘Therapy? They’re saying it’s all in my head?’

The fundamental premise of the trial was an offensive one: It was that patients like me were simply out of shape and obsessed about our symptoms, and all we needed was to stop worrying, build up our exercise and we’d be fine. I had this horrifying image of my editors reading this and thinking, “Ah, so that’s why Julie hasn’t gotten me that story! She’s just screwed up in the head!”

Your story was a shocking awakening for me. Until then, I knew that there was a prejudice about chronic fatigue syndrome, so that came as no surprise. But I’d been able to push it out of my consciousness. My friends certainly never expressed that.  But this was in the New York Times. The study had been published in The Lancet. It really made me feel that science and journalism were not on my side.

It sharpened a feeling I’d been struggling with already, and that I think pretty much all patients deal with: I felt abandoned by the world. And with the PACE trial, it was not only the world at large abandoning me, but the specific communities I had made my life in, science and journalism.

Of course, at the time, I didn’t know what the scientific problems with the trial were—I just knew that it didn’t fit with my experience. And I did hold out the possibility that I had either misinterpreted the trial or misinterpreted my own experience, and they were more compatible than I realized. But bit by bit, I realized the true explanation was that they had distorted their results, and I learned from many of the same sources you drew on for your huge expose.

On the one hand, it was comforting to understand what the heck was going on. On the other hand, it was enraging. It was enraging to see science so abused, but it was also enraging because I couldn’t figure out how to expose the problems myself. I describe the situation this way in the book:

I contemplated pitching a story about the PACE trial myself: “Dear Editor, I want to write a story about the biggest treatment trial in the history of chronic fatigue syndrome, published in the Lancet, led by some of the most reputable psychiatrists in Britain, which has influenced public health recommendations around the world and has received nearly no public criticism by the scientific establishment. But I, Julie Rehmeyer, can tell you it’s a crock of shit. Oh, and by the way, I’m a patient, I’m personally offended by this work, and I might be too sick to finish the story.” Hmm. Not a very compelling pitch.

Nor could I get other journalists interested in writing about the problems with the trial. I wrote a chapter of my book about PACE, but of course that was years after this.

I was working on that chapter when I heard from you about your expose about the trial, and I thought, “Hallelujah!” I was thrilled both because it meant that the PACE trial would be taken down sooner than when my book came out — and also because my book didn’t have to do the very hard work you did, making a scientifically bulletproof argument against it. Instead, I could give a readable, emotionally powerful summation of the “low lights,” as it were. Which is a lot better for my book, because I tried to write it to be a compulsively good read for anyone, even those who aren’t especially interested in science.

So did your experiences with this illness change your relationship to science?

Absolutely. I’d always known, of course, that science can go wrong, but I’d never seen the kind of breakdown that happened with the PACE trial. The problems there were on all levels: with the trial itself, with peer review, with the way it was marketed, with the journalism about it, with the response of the scientific community and the public health agencies, on and on and on. In that case, science — at least as practiced in this case — was not my friend.

But it wasn’t just the PACE trial that affected me. When I first got sick, I expected that science would save me, whatever was wrong with me. But I came to realize that the existing science about the illness was terribly weak, lots of small, unreplicated studies that might or might not mean anything. And the NIH had been spending only around $5 million a year on ME/CFS research for the previous couple of decades — five bucks a patient, since there about a million American ME/CFS patients — that wasn’t likely to change anytime soon. So I was forced to accept that I was on my own.

And my situation got pretty desperate: I had pretty much run out of medical options, I was living by myself but not really able to care for myself, I was running out of money, I had no family to turn to. So I, uh, relaxed my standards as I considered treatments that didn’t have a lot of scientific backing. In particular, I heard from other patients who said they’d improved enormously by taking extreme measures to avoid toxic mold. I thought the idea was almost certainly hooey — as far as I knew, mold might exacerbate allergies or asthma, but it couldn’t paralyze you. But these patients were smart and impressive, and their stories were mind-blowing. One patient wrote about how after two months living in a cargo trailer in the desert, he could run and lift weights again. I read his post over and over again, and cried.

The very short story is that I tried it, and it worked spectacularly well for me.

I was thrilled, but also puzzled. Why did so many scientists say that people like me, who said that mold had neurological effects, were wacko? What did we know scientifically about the health effects of mold? And what could explain my experiences? I found answers to these questions, ones I found pretty compelling, and it increased my sense that our scientific institutions often don’t function well in the face of complex and confusing illnesses.

At the same time, science was an enormous tool for me personally in navigating all of this. I absolutely relied on scientific thinking in evaluating, and sometimes rejecting, my theories. And even with no research budget, as individuals, we can apply science to our lives to great effect.

Here’s one example of that: I wanted to make sure that I was correct in my belief that mold was indeed an enormous factor in my illness, that I wasn’t somehow fooling myself. In particular, I was concerned that I could be experiencing what scientists call a “nocebo effect,” the evil twin of the placebo effect: being convinced that something will hurt you can itself bring on physical symptoms. So I performed a placebo-controlled, double-blind experiment on myself, by sending a half-dozen washcloths to a moldy building and keeping a half-dozen washcloths clean, and then seeing if I could distinguish them. I ended up doing so well enough that I would have had only a two percent chance of doing as well if I were just guessing (that is, I had a p-value of .019).

The PACE trial came out in 2011. Do you think things have changed in the ME/CFS world since then?

Things have changed hugely over the last six years, on a lot of different fronts. Your work has made an enormous difference. I’ve called you a hero and I really think that’s true. Having the flaws of the PACE trial finally brought to light in a really serious way has been transformative, as has your work galvanizing the previously-quiescent research community against it.

Things have changed on other fronts, too: A few other journalists, like Miriam Tucker, have gotten very interested in the illness. And other journalists have gotten interested too — folks who may not know much about it initially but they are taking it seriously and writing good stories.

The scientific world is finally taking the illness seriously, too. The attitude at the NIH has really changed in the last six years. We’ve got a long way to go, but nevertheless it’s a really different world than it was. As much as anything, we’ve got their attention, they’re thinking about it and they care about it. Plus, some really good researchers are now seriously interested in the disease.

And on top of all that, the patient community has become far more organized and active, for example organizing the Millions Missing marches around the world (for the millions of patients missing from their lives and the millions of dollars missing from ME/CFS research budgets).

What about in the UK?

There’s no question that the UK has a lot further to go. And I don’t mean to be at all ignoring them in expressing optimism. We’re not done until things have changed over there too. But as research comes out in the U.S. and elsewhere it changes attitudes more broadly. And also, your work has made taking PACE seriously less tenable. The U.K. is slower to pay attention, but these developments are still having an impact and making their way through.

I also hope that my book will have an impact in the U.K. as well. Rational arguments reach people on one level, and emotionally powerful stories reach them on another. Part of the book’s work in the world is to reach people without any particular interest in ME/CFS, keep them fascinated and invested for 300 pages, and in the process, to shift their attitudes a bit. And hopefully, that will help to make life less miserable and difficult for my patient friends in the rest of the world as well.

 

By David Tuller, DrPH

First, since I’m in London at the moment, I need to say that it feels weird and even wrong to be posting about PACE-related issues right after Saturday night’s terrible events. But in our f**ked-up world, life goes on for everyone else, including ME/CFS patients, and my job is to report this stuff, and so that’s what I’m going to do.

On Thursday, wearing a beautiful and beautifully ironed shirt, I gave a talk at the dinner before this year’s annual Invest in ME conference, at a hotel right next to the Tower of London. About 100 or so scientists, advocates, patients, caregivers, and others attended the event and had little choice but to listen to my presentation: “The PACE Trial: ‘Thing of Beauty’ or Pile of Trash?” It was Sir Simon Wessely who coined the “thing of beauty” line. I guess he thinks PACE is the Mona Lisa of clinical trials. Of course, “pile of trash” was my own counter-formulation. I assume no one wonders what side of that equation I’m on.

In addition to outlining the unacceptable flaws of the trial, I discussed whether the ethical and methodological lapses could be defined as “research misconduct.” And then, as foretold in the title slapped onto my presentation by Invest in ME (“Tear It Up!”), I engaged in a bit of performance art. I tore up not just one but three papers. First was the 2011 Lancet paper. Next, the 2013 Psychological Medicine “recovery” paper.  Finally, by special request from interested parties, I ripped up an Esther Crawley paper—specifically, her 2016 prevalence study in Pediatrics, which featured her inflated claim that almost two percent of kids in the U.K. suffer from chronic fatigue syndrome when all she documented was that they suffered from chronic fatigue.

(The front desk at the hotel had printed out the three papers on single-sided sheets rather than on both sides. So these were three thick stacks. I have to confess that I slightly pre-tore all three, so I wouldn’t be struggling on the podium to initiate the rip.)

After I finished, with shredded scraps of bad studies scattered on the floor around me, it was time for a few questions. A U.K. doctor stood up and asked me what I thought about some apparently authoritative hearsay: Dr. Crawley’s reported intention to have Bristol University slap me with a cease-and-desist letter (see correction below) to stop “harassing” her. After my initial surprise, I laughed. What a boon to my crowdfunding campaign that would be! Let’s be clear: Dr. Crawley publicly accused me of libel several weeks ago and has since refused to provide either an explanation of her charge or an apology. But, if this hearsay is true, she apparently thinks I’m the one doing the harassing.

Now it’s certainly true that I have e-mailed Dr. Crawley multiple times. I have sent my purportedly  libelous blog posts in which I have outlined what I view as egregious flaws in her research. I have also sent her the various posts I wrote about her accusation of libel, which she made during a recent talk to the British Renal Society. I have assured her in each of my recent e-mails that I would be happy to post a statement of any length from her on Virology Blog, so she can explain why she considers my work libelous. It didn’t occur to me that making such an offer or being persistent in seeking details about her defamatory accusation could be construed as “harassment.” (That being said, I’m perfectly happy to refrain from sending her any more of my blog posts, if she’d prefer. However, that means I will not be able to fulfill my journalistic responsibility to seek comment from her on anything I write involving her actions or her research.)

In fact, as I’ve noted before, Dr. Crawley appears to be unable to distinguish between criticism she dislikes and serious misconduct, like libel and harassment. I’ve written very negative things about her work, and that makes her mad. I get that. But I have based all my statements on documented facts. Any attempt to pull a stunt like sending me a “cease-and-desist” letter (see correction below) in an effort to suppress my accurate reporting and opinionated commentary would further damage her reputation and trigger an uproar from patients. If she is actually considering this, I hope those close to her—Stephen Holgate? Sonya Chowdbury?—have the wherewithal to tell her that such a move would not only be stupid but futile.

Dr. Crawley doesn’t scare me. I know a lot of lawyers, and I have the science on my side; she has her “dysfunctional cognitions” about the effectiveness of CBT and GET, along with her belief that PACE was a “great, great” trial, as she said months ago in a radio interview. But as the open letters to The Lancet and Psychological Medicine have demonstrated, dozens of top scientists and academics from around the world share my poor assessment of PACE and recognize that the reported results cannot be taken seriously.

I don’t know if the hearsay about Dr. Crawley’s intentions is correct. But if it is, and she chooses to pursue this ill-advised strategy, she will have a fight on her hands, and she will lose.

 

*Correction: In two places, I referred to a “cease-and-desist order.” I have changed “order” to “letter.” My guess is I would first get a letter from Bristol University demanding that I “cease and desist” whatever it is they want me to stop doing. If I refused, they could presumably seek a “cease-and-desist order” from a judge or court or other relevant authority to force me to stop whatever it is they want me to stop doing.