I have not been able to walk since February 18, 2023.
When people ask me how I'm doing, this is the first thing that comes to mind.
"Well, you know, the usual, but also I still can't walk," I think to myself.
If I dream at night, I often see myself walking or running. In conversation, if
I talk about going somewhere, I'll imagine walking there. Even though it's been
over a year, I remember walking to the bus, riding to see my friends, going out
for brunch, cooking community dinners.
But these days, I can't manage going anywhere except by car, and I can't do the
driving, and I can't dis/assemble and load my chair. When I'm resting in bed
and follow a guided meditation, I might be asked to imagine walking up a
staircase, step by step. Sometimes, I do. Other times, I imagine taking a
little elevator in my chair, or wheeling up ramps.
I feel like there is little I can say that can express the extent of what
this illness has taken from me, but it's worth trying. To an able-bodied
person, seeing me in a power wheelchair is usually "enough." One of my
acquaintances cried when they last saw me in person. But frankly, I love my
wheelchair. I am not "wheelchair-bound" I am bed-bound, and the
wheelchair gets me out of bed. My chair hasn't taken anything from me.
***
In October of 2022, I was diagnosed with myalgic encephalomyelitis.
Scientists and doctors don't really know what myalgic encephalomyelitis (ME)
is. Diseases like it have been described for over 200 years.
1
It primarily affects women between the ages of 10-39, and the primary symptom
is "post-exertional malaise" or PEM: debilitating, disproportionate fatigue
following activity, often delayed by 24-72 hours and not relieved by sleep.
That fatigue has earned the illness the misleading name of "Chronic Fatigue
Syndrome" or CFS, as though we're all just very tired all the time. But tired
people respond to exercise positively. People with ME/CFS do not.
2
Given the dearth of research and complete lack of on-label treatments, you may
think this illness is at least rare, but it is actually quite common: in the
United States, an estimated 836k-2.5m people
3 have ME/CFS. It is
frequently misdiagnosed, and it is estimated that as many as 90% of cases are
missed,
4 due to mild or moderate symptoms that mimic other
diseases. Furthermore, over half of Long COVID cases likely meet the
diagnostic criteria for ME,
5 so these numbers have increased
greatly in recent years. That is, ME is at least as common as rheumatoid
arthritis,
6 another delightful illness I have. But while any
doctor knows what rheumatoid arthritis is, not enough
7 have heard
of "myalgic encephalomylitis."
Despite a high frequency and disease burden, post-viral associated conditions
(PASCs) such as ME have been neglected for medical funding for
decades.
8 Indeed, many people, including medical care workers,
find it hard to believe that after the acute phase of illness, severe symptoms
can persist. PASCs such as ME and Long COVID defy the typical narrative around
common illnesses. I was always told that if I got sick, I should expect to rest
for a bit, maybe take some medications, and a week or two later, I'd get
better, right? But I never got better.
These are complex, multi-system diseases that do not neatly fit into the
Western medical system's specializations. I have seen nearly every specialty
because ME/CFS affects nearly every system of the body: cardiology, nephrology,
pulmonology, neurology, opthalmology, and, many, many more. You'd think they'd
hand out frequent flyer cards, or a medical passport with fun stamps, but nope.
Just hundreds of pages of medical records. And when I don't fit neatly into one
particular specialist's box, then I'm sent back to my primary care doctor to
regroup while we try to troubleshoot my latest concerning symptoms. "Sorry,
can't help you. Not my department."
With little available medical expertise, a lot of my disease management has
been self-directed in partnership with primary care. I've read hundreds of
articles, papers, publications, CME material normally reserved for doctors.
It's truly out of necessity, and I'm certain I would be much worse off if I
lacked the skills and connections to do this; there are so few ME/CFS experts
in the US that there isn't one in my state or any adjacent state.
9
So I've done a lot of my own work, much of it while barely being able to read.
(A text-to-speech service is a real lifesaver.) To facilitate managing my
illness, I've built a mental model of how my particular flavour of ME/CFS works
based on the available research I've been able to read and how I respond to
treatments. Here is my best attempt to explain it:
- After a severe (non-COVID) infection, an ongoing interaction between my
immune system and my metabolism have stopped my body from being able to do
aerobic respiration.10
- I don't know why or how, but my mitochondria don't work properly
anymore.11
- This means that if I use too much energy, my body isn't able to make enough
energy to catch up, and I have severe symptoms over the next few days as my
body tries to manage the consequences.
- Those symptoms aren't limited to fatigue: I've developed flu-like symptoms
and even fevers, limbs so heavy they felt paralyzed, tachycardia in response
to even the slightest activity.
The best way I have learned to manage this is to prevent myself from doing
activities where I will exceed that aerobic threshold by wearing a heartrate
monitor,
12 but the amount of activity that permits in my current
state of health is laughably restrictive. Most days I'm unable to spend more
than one to two hours out of bed.
Over time, this has meant worsening from a persistent feeling of tiredness all
the time and difficulty commuting into an office or sitting at a desk, to being
unable to sit at a desk for an entire workday even while working from home and
avoiding physically intense chores or exercise without really understanding
why, to being unable to leave my apartment for days at a time, and finally,
being unable to stand for more than a minute or two or walk.
But it's not merely that I can't walk. Many folks in wheelchairs are able to
live excellent lives with adaptive technology. The problem is that I am so
fatigued, any activity can destroy my remaining quality of life. In my worst
moments, I've been unable to read, move my arms or legs, or speak aloud. Every
single one of my limbs burned, as though I had caught fire. Food sat in my
stomach for hours, undigested, while my stomach seemingly lacked the energy to
do its job. I currently rely on family and friends for full-time caretaking,
plus a paid home health aide, as I am unable to prep meals, shower, or leave
the house independently. This assistance has helped me slowly improve from my
poorest levels of function.
While I am doing better than I was at my worst, I've had to give up essentially
all of my hobbies with physical components. These include singing, cooking,
baking, taking care of my houseplants, cross-stitching, painting, and so on.
Doing any of these result in post-exertional malaise so I've had to stop; this
reduction of activity to prevent worsening the illness is referred to as
"pacing." I've also had to cut back essentially all of my volunteering and
work in open source; I am only cleared by my doctor to work 15h/wk (from bed)
as of writing.
***
CW: severe illness, death, and suicide (skip this section)
The difficulty of living with a chronic illness is that there's no light at the
end of the tunnel. Some diseases have a clear treatment path: you take the
medications, you complete the procedures, you hit all the milestones, and then
you're done, perhaps with some long-term maintenance work. But with ME, there
isn't really an end in sight. The median duration of illness reported in one
1997 study was over 6 years, with some patients reporting 20 years of
symptoms.
13 While a small number of patients spontaneously recover, and many
improve, the vast majority of patients are unable to regain their baseline
function.
14
My greatest fear since losing the ability to walk is getting worse still.
Because, while I already require assistance with nearly every activity of daily
living, there is still room for decline. The prognosis for extremely ill
patients is dismal, and many require feeding tubes and daily nursing care. This
may lead to life-threatening malnutrition;
15 a number of these extremely
severe patients have died, either due to medical neglect or suicide.
16
Extremely severe patients cannot tolerate light, sound, touch, or cognitive
exertion,
17 and often spend most of their time lying flat in a darkened room
with ear muffs or an eye mask.
18
This is all to say, my prognosis is not great.
But while I recognize that the odds aren't exactly in my favour, I am also damn
stubborn. (A friend once cheerfully described me as "stubbornly optimistic!") I
only get one shot at life, and I do not want to spend the entirety of it barely
able to perceive what's going on around me. So while my prognosis is uncertain,
there's lots of evidence that I can improve somewhat,
19 and there's also lots of
evidence that I can live 20+ years with this disease. It's a bitter pill to
swallow, but it also means I might have the gift of time something that
not all my friends with severe complex illnesses have had.
I feel like I owe it to myself to do the best I can to improve;
to try to help others in a similar situation; and to enjoy the time that I
have. I already feel like my life has been moving in slow motion for the past 4
years there's no need to add more suffering. Finding joy, as much as I
can, every day, is essential to keep up my strength for this marathon. Even if
it takes 20 years to find a cure, I am convinced that the standard of care is
going to improve. All the research and advocacy that's been happening over the
past decade is plenty to feel hopeful about.
20 Hope is a
discipline,
21 and I try to remind myself of this on the hardest
days.
***
I'm not entirely sure why I decided to write this. Certainly, today is
International ME/CFS Awareness Day, and I'm hoping this post will
raise awareness in spaces that aren't often thinking about chronic illnesses.
But I think there is also a part of me that wants to share, reach out in some
way to the people I've lost contact with while I've been treading water,
managing the day to day of my illness. I experience this profound sense of
loss, especially when I think back to the life I had before. Everyone hits
limitations in what they can do and accomplish, but there is so little I can do
with the time and energy that I have. And yet, I understand even this precious
little could still be less. So I pace myself.
Perhaps I can inspire you to take action on behalf of those of us too fatigued
to do the advocacy we need and deserve. Should you donate to a charity or
advocacy organization supporting ME/CFS research? In the US, there are many
excellent organizations, such as
ME Action, the
Open Medicine
Foundation,
SolveME, the
Bateman Horne Center, and the
Workwell Foundation. I am also happy to match any donations
through the end of May 2024 if you send me your receipts. But charitable giving
only goes so far, and I think this problem deserves the backing of more
powerful organizations.
Proportionate government funding and support is desperately needed. It's
critical for us to push governments
22 to provide the funding
required for research that will make an impact on patients' lives now. Many
organizers are running campaigns around the world, advocating for this
investment. There is a natural partnership between ME advocacy and Long COVID
advocacy, for example, and we have an opportunity to make a great difference to
many people by pushing for research and resources inclusive of all PASCs. Some
examples I'm aware of include:
But outside of collective organizing, there are a lot of sick individuals out
there that need help, too. Please, don't forget about us. We need you to visit
us, care for us, be our confidantes, show up as friends. There are a lot of
people who are very sick out here and need
your care.
I'm one of them.
A new bug fix release 0.1.3 of RApiSerialize
got onto CRAN earlier today.
This is the first release in well over a year, and permits the skip the
XDR serialization format which is needed when transfering between big-
and little-endian machines. But it comes at a certain run-time cost one
can avoid on the (much more common) little-endian machines. This is a
new option, and the old behavior is the default. Those who want to can
now skip the step.
The RApiSerialize
package is used by both my RcppRedis
as well as by Travers excellent qs package. We also addressed
the recent nag by the CRAN
concerning NO_REMAP .
I am a huge fan of 
Like each month, have a look at the work funded by 
After the unfortunate and somewhat surprising 
And while we're at it: everyone using Libreoffice should give a virtual hug to rene@ for
taming that beast since 2010 and OpenOffice.org before.
In January I've removed tens of thousands of web pages on
www.debian.org. Have you noticed it?
In the past
From 1997 onwards, we had web pages for security announcements. We
had to manually prepare a .data and a .wml file which then generated a
web page for each security announcement (DSA or DLA). We have listed
the 6 most recent messages in a short list that was created from these
files. Most of the work that went into the Debian web pages was
creating these files.
Our search engine often listed the pages with security announcements instead
of a more relevant web page for a particular topic.
Preparation
At DebConf Kosovo (2022) I started with a proof of concept and wrote a
script, that generates this list without using the .data/.wml files in
the Git repository, but instead reading the primary sources of
security information