Archive | August 2012

Culture of Worklessness

This is an extract from a book I am writing that didn’t make it through the editing process.  The book, on disability and welfare in the UK, should be published at the beginning of December.  This extract uses quotes from Iain Duncan Smith’s speech to the US Congress as a starting point for an analysis of the government’s belief in a ‘Culture of Worklessness.’

“Not everyone is starting from the same place. There is no point assuming, for example, that everyone understands the intrinsic benefits of work, the feelings of self-worth, or the opportunity to build self-esteem. If you are dealing with someone from a family where no one has ever held work, or no one in their circle of peers has ever held work, there is no point in simply lecturing them about the moral purpose of work.  What you must tackle is the biggest demotivating factor that many people face – the fact that the complexity of the system and the way it is set up creates the clear perception that work simply does not pay. Thus, after generations in key communities, worklessness has become ingrained into everyday life. The cultural pressure to conform to this lifestyle is enormous, underscored by the easy perception that taking a job is a mug’s game. It is this factor which can stop someone’s journey back to work in its tracks…

“Take some of the figures we were confronted with when we came into office: 5 million people – some 12% of the working age population – on out of work benefits, 1 million of them stuck there for a decade or more. 1 in every 5 UK households had no one working, and almost 2 million children were growing up in workless families. This was the cultural challenge we faced – entrenched and intergenerational worklessness and welfare dependency…”

Iain Duncan Smith is misleading on several points.  The “1 in every 5 UK households [that] had no-one working” means 3.9m households at the end of 2011 compared to 3.5m before the recession.  Of adults who are out of work, and of households with no-one working, only 10% have never worked.  Over half of these 500k adults (370k households) are under-25 – that is more than 250k adults and 185k households.  73k of these are student households; of the remaining 113k some will have left education and be looking for, but not yet found, a job.  1/6th are over 25 and disabled or long-term sick.  Of the remaining third, some are seeking work but unable to find it whilst others have caring roles.  A mere 10% – that is 1% of the unemployed – have no obvious reason for not working.  “It is a serious mistake to proceed as if this 1% is somehow the essence of the problem of worklessness.”[1]

The “1 million of them stuck there for a decade or more” includes people who have worked in the past, and people who are receiving Incapacity Benefit/Employment and Support Allowance.  Given that only 500k adults have never worked, of whom 125k are under 25, it is clear that 725k of this 1 million have worked in the past.  What is not clear is how many of these have been unemployed from ‘lifestyle choice’ rather than because of caring roles or long-term disability or sickness.

The 2 million children in workless families is again going to refer to some children whose parents are not unemployed through choice.  Most of these – approximately 1.25m – are in lone parent households; it is difficult for lone parents to bring up children, particularly those still at primary school, whilst holding down a full-time job, and part-time jobs do not always fit easily with school hours.  Childcare costs are high, with the result that having a job and paying for child care may result only in the children not seeing much of their parent.  Only half of lone parents are able to hold down a job as well as raise children.  If the government wants to discuss workless families, it needs to do more to help lone parents, or simply recognise that it is valid for a lone parent to commit most of her (or his) time to raising children.

As for “entrenched and intergenerational worklessness and welfare dependency” – this is not just misleading, it is all but untrue.  Two-generational worklessness is rare – just 0.9% of households consist of workless parents with adult children.  Only 0.1% are households where neither parents nor adult children have ever worked.  That is 15 530 households, and in many of these younger generation has been out of education not even a year.  Inter-generational worklessness includes cases where the parents and children are not cohabiting, but sons with workless fathers are only 3% more likely to have never been in employment from 16-23[2].   And some of these will be households where there are good reasons for the parents or children to be out of work, such as for health reasons.  But even in these households, it is not necessarily “entrenched and intergenerational.”  These children will have extended family members who work, peers who work and peer’s parents who work.  It is fact of statistics that some people who are unemployed will also have parent’s who are unemployed; there are many reasons why two generations are unemployed other than a culture of worklessness.

“There is also nothing in these official statistics to suggest that households that have never worked deserve to be seen, or treated, differently from other workless households.”[3]

 

“They [workfare companies] are given complete freedom to deliver support, without Government dictating what they must do, through what we call the “black box”. That means trusting that these organisations are best placed to know what works.”   This trust seems to be misplaced.  Mr Hutchinson, then head of internal audit at A4e, spoke of multiple instances of fraud in A4e and in Working Links, with whom he had been previously employed.  Mr Hutchinson claims that, “Where I made recommendations to tighten controls, or strengthen policies and procedures, my advice was not heeded,” and questions whether “significant enhancements” were introduced when A4e won a government contract to provide the new Work Programme. “If this had been the case, I would have found it extremely odd that the numbers of suspected frauds and irregularities should continue to prevail and increase, as was the case at the time of my departure from A4e in 2011.”[4] A4e has since been investigated and found to have significant weaknesses in its work relating to Mandatory Work Activity in the South-East, whilst several of its employees are under police investigation for fraud.[5]   The National Audit Office also concluded that the DWP missed vital evidence in its investigation of fraud in A4e.[6]

“Work Programme service users cannot judge whether they are getting the level of service the Department intends because standards are not set out in one place… There is a risk that providers are less clear about how to abide by the terms and spirit of delivering a programme and that claimants have less clarity about the level of service they should expect to receive.”[7]

 

“We are already seeing positive signs that this cultural change is beginning to happen. Though the overall economic outlook is still poor, the jobs figures for the last 3 consecutive months in the UK showed some encouraging signs of stability, particularly stronger than expected growth in jobs from the private sector.”

However, this was all in part-time jobs, taken largely by people who want full-time but are unable to get it; the total number of full-time jobs fell.  “Virtually all employment growth is coming from part-time and temporary jobs but most of the people taking them want and need permanent, full-time work.”[8]  Much of the growth came from self-employment, but it is dangerous to consider exchanging one form of vulnerable There are reasons to be concerned that the large rise in self-employment, given the weak state of the economy, may reflect disguised under-employment rather than burst of entrepreneurial zeal.[9]  The number of people in involuntary part-time work (i.e. they want, but can’t find, full-time work) has risen to 1.41m, a record high.  There are also 607k workers in temporary positions who want permanent work.  Real wage continues to fall.  This, combined with the rise in underemployment, “suggests that the labour market is not tightening as much as the headline figures suggest.”


[1] Joseph Rowntree Foundation (JRF), Monitoring Poverty and Social Exclusion 2011

[2] Intergenerational Worklessness

[3] Joseph Rowntree Foundation (JRF), Monitoring Poverty and Social Exclusion 2011

[6] National Audit Office

[7] National Audit Office

[8] TUC, Male under-employment has doubled over the last four years. 15th May 2012 http://www.tuc.org.uk/economy/tuc-21009-f0.cfm

[9] TUC, Labour Market Report no. 27 2nd July 2012 http://www.tuc.org.uk/economy/tuc-21162-f0.cfm

Creation and evolution

Creation and evolution can be emotive topics for Christians.  Some believe, or are taught to believe, that only Young Earth Creationists are Christians; it is not possible to be a Christian and believe in evolution.

What does the Bible say?  It says God created the universe and everything in it.  It says the universe had a beginning, and has not existed forever.    It says God created all life.  It says man (humankind; men and women) was made in the image of God.  It says God sustains everything.

What does science say?  Until recently, it said the universe was eternal and had existed for ever.  It says that life did not always exist; that it started simple and unicellular, and became more complex and multicellular.  It says that as each organism reproduces, some changes are transmitted to the descendants.  These changes, if beneficial, allow the descendant to reproduce at a higher rate than co-descendants without that change.  Thus these changes become widespread in the population, by virtue of producing more organisms without that change.  This is evolution.

What does the Bible not say?  It does not – necessarily – say that the universe, earth and life were created in seven literal 24-hour days.  This is because the word ‘yom’ used for day is used in other places that do not mean ’24-hour day.’ It is used to mean daylight, 24 hour day, a season, a period of time, year, forever.[1]

It does not say how God created.  He spoke, and it was so.  Did it come gradually, or all at once?  The bible doesn’t say.

What does the Bible say about the order of creation?  It says that God created the earth.  He then separated water into sky and sea; and separated the sea to give land.  Then came plants.  After that God made the sun, moon and stars visible (the Hebrew is in the past tense, meaning they had been made before the fourth day, but were not visible at this time because of the clouds.)  The next day came animals in the oceans, and flying animals.  This is commonly translated as birds, but the term correctly refers to flying animals.  These could equally be translated as flying insects.  After that came land animals, and last of all the humans.

What does science say about the order of universe and life formation?  It says the Earth formed around 4.53 billion years ago.  It says that over time the earth cooled, and water condensed into clouds and oceans.  Life began as organisms – similar to today’s bacteria – that used solar energy and released oxygen, in the way that plants do (plants contain remnants of the earlier bacteria-type organisms as chloroplasts in their cells).  Multicellular life, similar to the plants and animals we would recognise today, began in the oceans.  Plants evolved first, then animals.  Plants were also the first to get on to land, followed by the arthropods (insects, spiders, crabs and lobsters); the insects were the first organisms to develop flight.  After this, vertebrate animals moved onto land.  Much later, humans arrived.

How does this compare to the Bible?  The story of evolution is a lot more complex; many details are included.  In contrast the Genesis account of creation is simplistic and told in poetical language.  It is structured and repeats certain phrases – and God said; it was good; morning and evening; the next day.  The Bible only ever discusses plants on land, and animals.  It therefore completely misses out the bacteria, archaebacteria, fungi and water-dwelling plants.

The Bible and history of the universe agree on two very important things: the beginning of the universe, and the order of creation/formation.  There are some important things to consider.  The Bible may be referring only to things that can be seen from land, with the unaided eye.  Most created organisms are completely ignored.  Equally, the sun, moon and stars were ignored until they would have been visible from earth.

Both agree that after the formation of the earth, water condensed into sea and sky.  Plant/plant precursors were the first things to be created/evolve; these may have been left out from the creation account as the first reference to living things is plants on land.  Then came animals in the oceans, and flying animals – these would be insects, as vertebrates made it to land some time after the arthropods (insects, spiders, crabs and such like).  Having populated the oceans, vertebrates finally moved on to land, and humans arrived much later.

The Bible and science therefore agree on how life came to be.  The only question is whether God created by speaking and causing instantaneous effect in 24-hour periods of time, or whether he created through a period of evolution.  I am inclined to trust the scientific evidence, given that the Biblical account is too simplistic and misses out too much information for us to be able to glean any reliable idea from the Bible alone of exactly how God created the universe and the life in it.

A Christian Response to Suffering

I’ve been talking a lot with my family recently about appropriate responses to suffering.

One of the most common responses I’ve come across is “You need to find out what God is trying to teach you through this.”  Sometimes it’s true.  God does discipline us, so it may be that he is encouraging us to address a specific issue in our life.  He may want us to develop perseverance through the testing of our faith.  He may want us to develop character and hope.

Sometimes it’s even helpful to be told this.  Most of the time, though, I have found it to be one of the least helpful things.  It gets a bit too close to Job’s comforters, who told him his suffering was his fault, because of unconfessed sin.  It implies I am suffering because I am ignorant, or lazy, or not listening.  Sometimes it’s true.  Sometimes there is something God specifically wants to say to me, and when I start to listen, I start to get through the suffering, or learn to rejoice in it.

A lot of the time though, I feel this isn’t the case, or isn’t all of it.  What if I’m suffering just because I live in a broken world?  What if I’m suffering because of someone else’s sin – because someone else chose to act in a way to harm me, or chose not to act in a way that would help me?

Sometimes life is just hard.  It’s stressful; it’s painful; it’s exhausting; it’s unrewarding.  At times like this I don’t need to be told to “find out what God is teaching me.”  If I haven’t learnt to trust God yet, to be confident in his love, to know that he is clever enough and powerful enough to be in control, then the time when I feel let down is not the time when I learn.  The time when I learn is the good times when I learn from the Bible how he came through for others; and the time when he comes through for me.

What I need is someone to show me what God is teaching me – that he loves me.  That no trouble, hardship, presecution, famine, nakedness, danger or sword can ever cut me off from his love, stop him feeling love towards me or stop him showing love towards me.  That death, life, angels, demons, present, future, powers, height, depth, anything ever created – none of it can separate me from God and his love.

If someone would do the housework, look after the children, meet a deadline, make a cake, write a letter; then I would learn that God cares for me and takes action to look after me.  If someone would help us over the financial hole, relieve the pressure by doing some of what needed to be done for us, and remind us every day that they love us and will help us, then I would know too that God loves me and will help me.

Sometimes suffering just is.  And sometimes the best thing we can do for someone is not to preach to them, to enter a discourse on the merits of suffering, or expound on the latest self-help book.  The world is broken; people are broken.  Sometimes we need to stop theorising and get on with practical care that allows others the time to heal, without demanding that they put themselves back together through their own strength.

CBT and GET: do they help ME/CFS?

Various media outlets have recently reported on the cost-effectiveness of receiving Cognitive Behavioural Therapy and Graded Exercise Therapy as treatment for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome.  The paper referred to is McCrone et al 2012[1] and can be found on the PLOS One website.

Amongst ME/CFS sufferers and related charities there is a lot of reticence regarding the efficacy of CBT and GET.  For those with severe symptoms, CBT at best is able to help cope with the illness and GET is often found to make it worse.  These are anecdotal conclusions, so it is important for randomised controlled trials to be conducted to find out what treatments are effective.

The trial citied above relied on the Oxford Criteria (1990) for CFS.  These are:

  • there is a definite onset (ie it is not lifelong)
  • fatigue is the main symptom
  • the fatigue is severe, disabling and affects both physical and mental functioning
  • the fatigue has been present for at least six months, during which time it has been present more than 50 per cent of the time
  • other symptoms may be present, particularly myalgia, mood and sleep disturbance.

This is markedly different from the criteria that are most widely used, from the Centre for Disease Control (1994) in the USA, which importantly includes post-exertional malaise and gives more weight to non-fatigue symptoms:

  • Fatigue of definite or new onset that is not the result of exertion, is not significantly improved by sleep or rest and which results in substantial reduction in overall performance for a consecutive period of six months or longer.

Plus at least four from the following list:

  • self-reported significant impairment of short term memory or concentration
  • sore throat
  • tender lymph glands (small swellings under the skin which are part of the immune system) in the neck region or under the armpits
  • muscle pain
  • headaches of a new type, pattern or severity
  • unrefreshing sleep
  • malaise following effort that lasts more than 24 hours
  • pains in several joints occurring without joint swelling or redness.

A previous paper[2] by the same people found that CBT and GET were more effective than ‘specialist medical advice’ or ‘adaptive pacing training’, and the size of this effect is moderate.  GET was effective in reducing post-exertional malaise and CBT was effective in improving mood.

The trial has met with significant criticism.  As the White et al 2011 paper and McCrone et al 2012 people use the same data, criticisms apply to both papers.

A report by Professor Malcolm Hooper provides information of the flaws in the above papers.[3]  These include:

  • “Significant and serious mis-reporting and non-reporting of the PACE trial results.”
    • Outcomes were measured as the distance walked in six minutes.  Completion figure for this test was 20% lower than the secondary outcome measures.  The Principal Investigators do not explain this.  If this is because participants dropped out due to poor health, then the results are biased in favour of the best-scoring participants.
    • Participants receiving GET were unable at the end of the trial to walk as far as patients with chronic obstructive pulmonary disorder, chronic heart failure or heart failure classes II or III, or those awaiting lung transplantation.  GET recipients on average improved their walking distance by 67 metres, to 379m.
    • The “clinically useful” differences used to assess improvement are “so small as to be imperceptible in daily living.”  60% of those receiving GET and 58% of those receiving CBT reported negative or minimal change.
    • Around 87% of patients did not benefit to a clinically useful degree from CBT/GET.
    • No data on recovery has been provided.
    • No data on rate of deterioration has been provided.
    • No data on return to gainful employment has been provided.  The trial was funded partly because it was hoped that it would find a therapy that brings sufficient improvement to ME/CFS sufferers to get them off benefits and into work.
    • No data relating to Investigator bias has been provided.
    • “The Investigators already knew, as did Professor Simon Wessely, that: “These interventions are not the answer to CFS”[4] and that “many CFS patients, in specialised treatment centres and the wider world, do not benefit from these interventions”[5]
  • Poor quality of research:
    • Professor White simultaneously claimed there was sufficient evidence for CBT and GET to be the recommended treatment for ME/CFS, and that there was insufficient evidence on CBT and GET efficacy such that he received a £5 million grant to study these interventions.
    • Members of this RAG ignored elementary rules of procedure that require awareness of already established knowledge of the disorder under consideration.   This is in contravention of the Declaration of Helsinki that, “Medical research involving human subjects must conform to generally accepted scientific principles (and) be based on a thorough knowledge of the scientific literature.”
    • Recruitment difficulties led to some patients feeling they were coerced into the trial, by being told they would be discharged (and thus lose consultant support for claiming State Benefits) if they did not agree to undergo CBT and GET.  This contravenes the Declaration of Helsinki.
    • It is inadvisable, misleading and unethical to advise participants that CBT is a cure.  Giving participants such a bias can create a placebo effect.
    • Patients were unable to report a deterioration.
    • The Chalder Fatigue Questionnaire cannot record post-exertional malaise.  This is unscientific when studying a disorder for which the primary symptom is post-exertional malaise.
    •  “The trial therapists were trained to provide participants with misinformation; they were also trained to advise participants to ignore symptoms arising from the interventions, a situation that may in some cases result in death.”
    • The Investigators used a six minute walking test as “an objective outcome measure of physical capacity.”  It is difficult to get reproducible results with this test and it is not truly objective.  No objective measures were obtained, because measuring post-treatment actigraphy was abandoned “on the spurious grounds that wearing such a monitor for one week would be too great a burden at the end of the trial.”  Participants’ subjective responses to questionnaires do not relate well to actual activity. “This is of particular concern when two of the interventions being tested (CBT and GET) specifically encouraged participants to re-interpret their symptoms as not resulting from disease but as normal responses to exercise in deconditioned people.”
    • The trial was not a controlled trial.
    • The MRC Research Activity Group (authored by one of the PACE trials Investigators) for ME/CFS said that it is not necessary to identify causal pathways for ME/CFS, in conflict with the duty of the Medical Research Council (MRC) to identify causal pathways.
  • Numerous changes were made to the trial after the trial began:
    • The entry criteria to the trial were diluted after the commencement of the trial. “This undermines the reliability of all conclusions to be drawn from the data, not least because the first tranche of participants met different entry criteria from those who were recruited later.”
    • Recovery statistics were redefined so that a participant could decline on both primary outcomes (fatigue and physical function) yet still fall within “normal range.” A patient could enter the trial as below normal, deteriorate and then leave the trial as “normal,” because the normal range was reset to be lower than the entry criteria.  “Normal range” thus did not mean “normal” health at the end of the trial.  Patients with Hep C, osteoarthritis of the hip or those with stable congestive heart failure would by this standard be considered “normal.” The figure of 30% of CBT and GET recipients recovering was based on this redefinition of “normal.”
    • Scoring methodology was changed, leading again to a patient deteriorating yet leaving the trial in the (new) “normal range.”  This may have been because a paper published a year previously had reported no reductions in fatigue or physical function after 70 weeks.   There was thus an incentive to change methodology in order to find a ‘significant’ effect.
    • The article cited the comparison group as the UK working age population.  In fact it was the English adult population, which includes the elderly and thus allows a lower threshold of the “normal” range.
    • The Chief Principal Investigator said, in writing, that, “The PACE trial paper …. does not purport to be studying CFS/ME but CFS defined simply as a principal complaint of fatigue that is disabling, having lasted six months, with no alternative medical explanation (Oxford criteria).” Yet ethical approval and funding were granted for studying ME/CFS, not fatigue.
  • The trial was reported in an inaccurate manner:
    • It was not correctly registered, and thus could be manipulated at a later date to appear more successful than was the case.  “Numerous changes were made between the publication of the Trial Protocol and the publication of selective results in the Lancet.”
    • It failed to comply with the Trial Protocol that primary outcome measures are reported; did not conform to Good Clinical Practice guidance, the Data Protection Act (1998), CONSORT or the ISRCTN Register for transparency and completeness; and the Chief Principal Investigator did not keep his promise to the West Midlands Multicentre Research Ethics Committee.[6]
    • Baroness Wilcox said “that the MRC does not have a position on how the outcome of MRC-funded studies are interpreted and used by regulators or policy makers.”[7]  This “essentially means that investigators can mis-report their findings and withhold their data at will because the MRC takes no responsibility for checking, and such misrepresentation of the data can then be relied upon and used with impunity by Government bodies.”[8]  Yet the MRC requires that data is presented accurately for safe use by clinicians and policy makers.
    • The data was presented in such a way that “it may be construed as their attempt to hide the fact that the PACE Trial results were disappointing. One can only conclude that Professor White endeavoured to disguise the poor results in the wealth of data presented, because the detail in the published figures serves to obscure the fact that the reported “improvements” are miniscule, and for those results to have been widely proclaimed as even “moderately successful” must border on impropriety.”
  • The researchers involved in the trial are all psychiatrists from the Wessely School, who deliberately ignore scientific consensus regarding ME/CFS:
    • They knowingly and deliberately conflate ME/CFS with chronic fatigue (burn-out).  Whilst they consider ME/CFS to be chronic fatigue, and that both are mental or behavioural disorders, current scientific consensus is leaning towards true ME/CFS as being an immunological disorder.  WHO classify ME/CFS as a neurological disease, and have done so since 1969.  The UK Read Codes, National Service Framework of long-term neurological syndromes and Department for Work and Pensions all treat ME/CFS as neurological.  It is not possible for dual classification under WHO; therefore ME/CFS cannot be classified as a mental health condition.  Chronic fatigue is a distinct condition that is separate from and unrelated to ME/CFS.  Portrayal of ME/CFS as a “dysfunctional belief” is “both scientifically invalid and also unethical.”
    • the Wessely School wrote the Oxford Criteria, which by definition excludes people with neurological conditions.  The results therefore do not apply to those with ME/CFS, contrary to the Investigator’s claims.  Regarding the Oxford Criteria, “there is no consensus about them; they are used only in Britain and only by the Wessely School; they lack diagnostic specificity, have been shown to have no predictive validity, and select a widely heterogeneous patient population.”
    • Professor Hooper lists 27 “proven and published organic abnormalities in ME/CFS”; these include cardiac failure, reduced lung function, dysfunction of energy metabolism.  There is no evidence of deconditioning or that ME/CFS is a psychiatric or behavioural disorder.
    • “From the Chief PI’s perspective, the existence of biomarkers was indeed irrelevant to the application of CBT and GET to correct what he and his colleagues assert are reversible wrong illness beliefs and deconditioning. However, they were not irrelevant to what should be the primary aim of any clinical trial, namely scientific integrity: to base research on a falsehood and to disregard the existing biomedical evidence to suit a desired outcome and personal beliefs is scientifically and morally inexcusable… The PIs portrayed their own assumptions as established facts, thereby deliberately misleading participants, which is deceitful and unethical.”
  • There were conflicts of interest:
    •  Funding for the research changed partway through, probably because of conflicts of interest.
    • The Wessely School work as consultants in the health insurance industry and thus have a vested interest in having ME/CFS classified as a mental disorder, as mental disorders are excluded from insurance benefits.
    • The Wessely School has described ME/CFS as ‘a belief’ and sufferers as ‘the underserving sick.’

Conclusion:  The trial was conducted in contravention of the Declaration of Helsinki B11.  The authors hold to a view of ME/CFS which is in conflict with the scientific consensus[9] and the World Health Organisation.   They also have numerous conflicts of interest.

The study has major methodological flaws.  It presents results that are contrary to the findings of the international scientific community and ignores knowledge and data available from previous studies.  The results it presents are “irrefutably poor.”  To present CBT and GET as effective treatments for ME/CFS will at best lead to a waste of time and resources and at worst cause a worsening in conditions of many ME/CFS sufferers.

“There is irrefutable evidence that ME/CFS is not “medically unexplained fatigue” that is perpetuated by aberrant illness beliefs, pervasive inactivity, membership of a self-help group, hypervigilance to normal bodily sensations or being in receipt of disability benefits, as claimed by the Wessely School.”


[3] Prof Malcom Hooper, June 2012, Briefing Notes re: MRC-funded PACE trial and ME/CFS http://www.investinme.org/Documents/PACE%20Trial/Notes%20for%20meeting%20with%20BIS%20officials.pdf

[4] Editorial: Simon Wessely; JAMA 19th September 2001:286:11

[5] Huibers and Wessely; Psychological Medicine 2006:36:(7):895-900

[6] “Magical Medicine: How to Make a Disease Disappear” http://www.meactionuk.org.uk/magical-medicine.htm; “Professor Malcolm Hooper’s Further Concerns about the PACE Trial, The Lancet http://www.meactionuk.org.uk/Normal-fatigue.htm; “Statistics and ME,” The Royal Statistical Society http://www.investinme.org/Article435%20Statistics%20and%20ME.htm

[7] Prof Malcom Hooper, June 2012, Briefing Notes re: MRC-funded PACE trial and ME/CFS http://www.investinme.org/Documents/PACE%20Trial/Notes%20for%20meeting%20with%20BIS%20officials.pdf

[8] ibid.

[9] Statements of Concern about CBT/GET Provided for the High Court Judicial Review of February 2009: www.meactionuk.org.uk; “at the 7th Invest in ME Conference on 1st June 2012, Professor Dan Peterson from the US said over 6,000 articles have been published.”