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Dismantling NCCAM: A How-To Primer

Two of the earliest posts I wrote for Science-Based Medicine were entitled The infiltration of complementary and alternative medicine (CAM) and “integrative medicine” into academia and The National Center for Complementary and Alternative Medicine (NCCAM): Your tax dollars hard at work. Both were intended as a lament over how not only is pseudoscientific quackery, much of it based on a prescientific understanding of how the human body works and disease occurs, finding its way into some of the most prestigious academic medical centers in the U.S. (for example, Georgetown and Beth Israel) but it’s even finding its way into the heart of the U.S. military.

Worse, aiding and abetting this infiltration is the federal government itself in the form of NCCAM. As I discussed in my usual excruciating detail in my original post and as Steve Novella, Kimball Atwood, and I have subsequently discussed many times on this very blog, particularly recently (so much so that I’m thinking of giving NCCAM its very own category here on SBM), NCCAM not only funds studies of dubious “alternative” therapies, such as reiki and homeopathy, that estimates of prior probability alone would argue to be so close to impossible as to be not worth spending millions, much less thousands, of dollars upon, but it also promotes quackery by funding “fellowships” at various institutions to teach “complementary and alterantive medicine” (CAM) sometimes also called “integrative medicine” (IM). Given that it spends over $120 million a year on mostly dubious studies and CAM promotion, we all have called for NCCAM to be defunded and disbanded.

Nearly a year has passed since I wrote those two posts. Ironically enough, at the time I wrote my first post about NCCAM for this blog, I pointed out that at first I had disagreed with my co-blogger Wally Sampson and his call to “defund” the NCCAM in an article published on Quackwatch nearly five years ago. My original reason was that I thought that there was value in studying these therapies to find out once and for all whether these therapies do anything greater than placebo or not. I now admit that I was very naive, and this was how I admitted it:

Two developments over the last several years have led me to sour on NCCAM and move towards an opinion more like Dr. Sampson’s. First, after its doubling from FY 1998-2003, the NIH budget stopped growing. In fact, adjusting for inflation, the NIH budget is now contracting. NCCAM’s yearly budget remains in the range of $121 million a year, for well over $1 billion spent since its inception as the Office of Alternative Medicine in 1993. Its yearly budget contains enough money to fund around 75 to 100 new five year R01 grants, give or take. In tight budgetary times my view is that it is a grossly irresponsible use of taxpayer money not to prioritize funding for projects that have hypotheses behind them that have a reasonable chance of being true. Scarce NIH funds should not be for projects that have as their basis hypotheses that are outlandishly implausible from a scientific standpoint. Second, I’ve seen over the last few years how NCCAM is not only funding research (most of which is of the sort that wouldn’t stand a chance in a study section from other Institutes or Centers)) but it’s funding training programs. Indeed, that was the core complaint against NCCAM: that it facilitates and promotes the infiltration of nonscience- and nonevidence-based treatments falling under the rubric of so-called “complementary and alternative” or “integrative” medicine into academic medicine.

Nothing has changed since I wrote those words–except for one thing. We now have a new President who stated in his inaugural address:

We will restore science to its rightful place, and wield technology’s wonders to raise health care’s quality and lower its cost. We will harness the sun and the winds and the soil to fuel our cars and run our factories. And we will transform our schools and colleges and universities to meet the demands of a new age. All this we can do. And all this we will do.

As Kimball Atwood put it, Yes We Can! We Can Abolish the NCCAM! The big and as yet unasked (and unanswered) question is: How? Neither defunding nor dismantling NCCAM will be easy, and we have to think about how to preserve the functions of NCCAM that might be worth saving.
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Posted in: Medical Academia, Politics and Regulation, Public Health, Science and Medicine

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Yes We Can! We Can Abolish the NCCAM!

…and in so doing, President Obama, you and we would abolish the NIH’s second most prodigious squanderer of precious research funds! Surprise: The National Cancer Institute (NCI) spends slightly more on humbug than does the Center created for that purpose. All told, the NIH squanders almost 1/3 of a billion dollars per year promoting pseudoscience.

I’ve decided to add my two cents to the recent groundswell of demand to stop this sordid and embarrassing chapter in NIH history—even more sordid and embarrassing, in its way, than NIH researchers being on the take: pseudoscience is exactly antithetical to the mission of the NIH, which sponsors it repeatedly, officially, overtly, unethically, and dangerously. At least, in the case of Big Pharma greasing the palms of NIH researchers, those involved generally prefer to obscure the transactions, as good sense and traditional mores dictate.

My comments will be somewhat different from others’, not because I disagree with theirs but because it’s worthwhile to stress points that have not been stressed or even mentioned. I won’t bother to justify the assertion that “promoting pseudoscience” is an accurate description of what the NCCAM and the OCCAM do, because I’ve done that several times in the past, beginning here and here, and more recently here. I will plagiarize myself a bit, but only to introduce certain points.

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Posted in: Health Fraud, Medical Academia, Medical Ethics, Politics and Regulation, Science and Medicine

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More on the Bravewell issue

Being on the West Coast places me (and Harriet?) at disadvantage in responding to recent developments, as I find out about them later in the day, if that day. (Retirement doesn’t help.)

First I had some comments on the WSJ article on “CAM,” the NCCAM by Steve Salerno and the response by the pseudoscince leadership. The 4-author response revealed political tactics used by quacks and sectarian medicine advocates to answer with straw man points and especially to ignore what they cannot answer.

In their response to Salerno’s article they accused him of being unqualified to object to “CAM” because he was only a reporter. Fact was that most of his points were from my writings, which Slerno frankly acknowledged. The several rebutting authors never mentioned my name. Of course not. (That it was lost in the SBM analyses is understandable.)

And that is the frank dishonesty we are dealing with when we face off with these characters, who now have the ears and eyes of the Institute of Medicine, academic deans and professors, and government. They are smiling as they read this.
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Posted in: Basic Science, Health Fraud, Medical Academia, Politics and Regulation, Science and Medicine

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Guest Book Review of “Complementary and Alternative Medicine: Ethics, the Patient, and the Physician”

The following book review was written not by your poster (although I’ve added the hyperlinks), but by his friend Cees Renckens, who is a gynecologist in the Netherlands and the chairman of the Dutch Society against Quackery. A short bio of Dr. Renckens, including references to several articles in English, follows the review. Most impressive to me is that he is, as far as I know, the first and only person in the world to have earned a PhD in a field that describes much of the content here at Science-Based Medicine: the rational evaluation of anomalous and implausible medical practices.

For several years, Dr. Renckens and the Dutch Society have been embroiled in a disturbing legal case involving freedom of speech. This was previously mentioned on SBM by astute reader Dr. Peter Moran. According to Dr. Renckens, the Dutch Supreme Court will issue its final judgment of the case at the end of February.

–KA

Complementary and Alternative Medicine: Ethics, the Patient, and the Physician. Edited by Lois Snyder, 241 pp, $69.50, Totowa NJ, Humana Press (2007). ISBN 58829-584-2. 

Reviewed by Cees N. M. Renckens, MD, PhD

During the second half of the 20th century, the Moerman anti-cancer diet was very popular in the Netherlands. Moerman was a family physician with no training in oncology or nutrition. He kept carrier pigeons and believed that his birds never got cancer. Therefore he developed a diet based on food for carrier pigeons. He had no contact with oncologists, nutritionists or other physicians. The Inspector for Public Health for his area was of the opinion that Moerman had “serious medical-ethic defects.”

Add to this example the fact that “alternative” physicians appear to be successful in presenting their approach as highly ethical, with its respect for old wisdom, for the ideas and peculiarities of their patients, and for treatments borrowed from Ayurvedic, Chinese, Tibetan and other third world medical systems, all of which can be classified as backwards, and you can understand why my interest was immediately aroused when I learned that a book had been issued with the title Complementary and Alternative Medicine. Ethics, the Patient and the Physician.

Finally, I thought, a look through ethical glasses at the deceit, at the admissibility of shoddy scientific research of “alternative” treatments, and perhaps a discussion of the necessary rigor of academic medicine and about how to deal with those who reject such rigor. When, in a short review in the Mayo Clinic Proceedings, the book was judged to be “excellent,” I dispelled my dislike of the rather high price and ordered it. 

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Posted in: Book & movie reviews, Medical Academia, Medical Ethics, Science and Medicine

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Chopra and Weil and Roy, oh my! Or: The Wall Street Journal, coopted.

The quest of advocates of unscientific medicine, the so-called “complementary and alternative medicine” (CAM) movement is to convince policy makers, patients, and physicians that it does not deserve the rubric of “alternative,” that it is in fact mainstream. Indeed, that is the very reason why “alternative” medicine morphed into CAM in order to soften the “alternative” label. Increasingly, however, advocates of such highly implausible medical practices appear no longer to like CAM as term for their dubious practicies, because it still uses the word “alternative.” That is, of course, because they recognize that labeling something as “alternative” in relationship to scientific medicine automatically implies inferiority, and CAM advocates are nothing if not full of hubris. Such a term conflicts with their desire to “go mainstream,” and they most definitely do want to go mainstream, but they want to do it on their own terms, without all that pesky mucking about with science, evidence, and rigorous clinical trials. Consequently, they increasingly use a new term, a shiny term, a term free of that pesky “alternative” label. Now they want to “integrate” their unscientific placebo-based practice with real, scientific medicine. Thus was born the term “integrative” medicine (IM, an abbreviation that is the same as that for internal medicine, an identity that I don’t consider coincidence).

One of the biggest complaints we at SBM (or at least I at SBM) have about the attitude of practitioners of scientific medicine towards CAM/IM is that most of them do not see it as a major problem. Dr. Jones characterized this attitude as the “shruggie” attitude, and it’s a perfect term. Equally perfect is her analogy as to why “integrating” pseudoscience with medical science is not a good idea. I myself have lamented the infiltration of pseudoscience and outright quackery into medical academia and the role that the National Center for Complementary and Alternative Medicine (NCCAM) has played in promoting that infiltration. In addition, wealthy patrons of CAM/IM such as Donna Karan and the Bravewell Collaborative have been generous spreading their money around. In this increasingly cash-strapped health care environment, hospitals know on which side their bread is buttered and see the “integration” of woo into their service portfolio as a means of beefing up the bottom line with cash on the barrelhead transactions that require no mucking about with nasty insurance forms. In fact, services such as reiki, homeopathy, acupuncture, and others often require no forms other than credit card receipts for the patient to sign.
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Posted in: Medical Academia, Politics and Regulation, Science and Medicine, Science and the Media

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The fallacy of “balance” and “fairness” about unscientific health claims in the media: A case study

For those of us who have dedicated ourselves to promoting science-based medicine, one of the most frustrating impediments to our message is the media. Time and time again, I’ve complained about how the media takes unscientific health claims, particularly when it comes to vaccines, and gives a credulous hearing to them. Sometimes, it’s a filmmaker with a distinct ideological axe to grind who is not making even the pretense of trying to be objective. Sometimes it’s a reporter with a clear bias favoring the antivaccine movement parroting the most idiotic of unscientific lies. Other times, it’s celebrities who think their “education” from Google University trumps science, clinical trials, and epidemiology, often given aid and comfort by sympathetic physicians. Add to that others inclined to support pseudoscience against science-based medicine, such as Don Imus, Larry King, and others, and is it any wonder that the media seems like one huge cesspit of woo?

However, more often, it’s none of these things. As much as they infuriate me, I believe that most reporters in the media do really want to get it right. However, they are hobbled by three things. First, many, if not most, of them have little training in science or the scientific method and are not particularly valued by their employers. For example, witness how CNN shut down their science division. Second, the only medical or science stories that seem to be valued are one of three types. The first type is the new breakthrough, the cool new discovery that might result in a new treatment or cure. Of course, this type doesn’t distinguish between science-based and non-science-based “breakthroughs.” They are both treated equally, which is why “alternative medicine” stories are so popular. The second type is the human interest story, which is inherently interesting to readers, listeners, or viewers because, well, it’s full of human interest. This sort of story involves the child fighting against long odds to get a needed transplant, for example, especially if the insurance company is refusing to pay for it. The third type, unfortunately, often coopts the second type and, to a lesser extent, the first type. I’m referring to the “medical controversy” story. Unfortunately, the “controversy” is usually more of a manufactroversy. In other words, it’s a fake controversy. No scientific controversy exists, but ideologues desperately try to make it appear as though a real scientific controversy exists. Non-medical examples include creationism versus evolution and the “9/11 Truth” movement versus history. Medical examples include the so-called “complementary and alternative medicine” movement versus science-based medicine and, of course, the anti-vaccine movement.

But the thing that most prevents the scientifically accurate evaluation by the media of unscientific health claims has to be the “tell both sides” culture of “balance” demanded by journalists. Telling both sides is, of course, very important when one side is not obviously correct compared to the other. Examples of such a situation include virtually any political controversy, where there almost always are two (and usually more) sides to an issue. In contrast, in science and medicine, there are not always two sides to an issue. (Again, think of creationism versus evolution.) In science and medicine, there is often a side supported so overwhelmingly by evidence, experimentation, and observation that the “other side” does not warrant being told, as it has already been considered and rejected by science. An excellent example of this is homeopathy. Another excellent example of this is the antivaccine movement, and, unfortunately, a prime example of “telling both sides” of the “vaccine debate” reared its ugly head a couple of weeks ago. Worse, it reared its ugly head on a show that ostensibly claims to be medically accurate, so much so that it features four doctors as its hosts.

I’m referring to a TV show called The Doctors. If the episode segment I’m about to discuss, which aired on December 11, is any indication, these are Doctors that anyone seeking scientifically sound information about medicine should run, not walk, away from.
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Posted in: Health Fraud, Medical Academia, Science and the Media

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Battlefield acupuncture revisited: That’s it? That‘s all Col. Niemtzow’s got?

It’s like the zombie that wouldn’t die, isn’t it?

I’m referring to so-called “battlefield acupuncture,” a topic that I wrote about last week for this very blog. With a week separating my usual posts, I normally don’t write about the same topic two times right in a row, but I’m making an exception for this topic. There are three reasons. First, I remain appalled at how one ideologue, Col. (Dr.) Richard Niemtzow, a radiation oncologist and Air Force physician turned number one advocate of acupuncture use in the military, has succeeded in introducing acupuncture into not only military hospitals like Walter Reed Army Medical Center and Landstuhl Regional Medical Center (which is, by the way, the first stop outside of the Middle East for our wounded soldiers from Iraq and Afghanistan), but has even started to train U.S. Army Rangers in the technique. While before I thought the term “battlefield acupuncture” was a misnomer because it wasn’t actually being used on the battlefield, but rather for phantom limb pain and other chronic pain conditions, this latter development shows just how far Col. Niemtzow wishes to go with this “technique.” Second, Col. Niemtzow’s acupuncture technique isn’t even “real” acupuncture. He calls it “auricular acupuncture,” and it involves sticking needles a mere 1 mm into the earlobe. Worse, he justifies this technique through ignorance of anatomy, claiming that “the ear acts as a ‘monitor’ of signals passing from body sensors to the brain” and that “those signals can be intercepted and manipulated to stop pain or for other purposes.” He even made a comment about 18th century pirates wearing a lot of earrings in order to improve their night vision. I kid you not. Third, and finally, Col. Niemtzow has published another one of his “studies” to support the use of acupuncture in chronic pain syndromes among our combat wounded veterans.

Last time around, I referred to an earlier study by Col. Niemtzow published in Military Medicine in 2006. This study was clearly labeled as a “pilot study.” Although it was randomized (good), it was small (tolerable for a pilot study); it was unblinded (bad); and there was no placebo or “sham acupuncture” control group (horrible). There were multiple other serious shortcomings, but those are the main ones. In other words, Col. Niemtzow’s 2006 study was custom-designed to show a “positive” result that could be entirely explained by the placebo effect, and that’s exactly what it did. Indeed, even by that standard, its results were unimpressive. Although the pain scores in the acupuncture group were reported to have decreased by 23% initially, compared to the conventional therapy group, which did not decrease measurably, within 24 hours after treatment there was no difference between the two groups. I’ve referred to this study as “thin gruel” upon which to base the creation of a military acupuncture program, much less expanding that program into combat and training military physicians and medics being sent to combat zones in Iraq and Afghanistan to do auricular acupuncture. I still say it’s thin gruel,.

So what about this new study by Col. Niemtzow, hot off the presses in the latest issue of Medical Acupuncture?
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Posted in: Acupuncture, Medical Academia, Science and the Media

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Quackery tolerance – a learned response

Academic politeness turns to the vicious  This is more on the theme of academic and postmodern roots of sectarianism-quackery’s advance on medicine. I illustrate through the personal experience of a noted combatant – Mary Lefkowitz - in the front lines of the war with intellectual and academic buffoonery passing as scholarship. The joke is not in the buffoonery, though. The joke is turning on us.

Some of you are familiar with Prof.Lefkowitz’s academic dispute from publicity last spring. Prof. Lefkowitz is on the list of academic opponents to relativism and postmodernism. Lefkowitz’s travail began in 1993 when another Wellesley faculty member who led a department or course of Africana Studies claimed in lectures that ancient Greek and Roman intellectual advances were lifted from libraries and other sources of ancient Egypt, and that furthermore, those Egyptians were black Africans.

You recognize this as Afrocentrism, one of relativism and postmodernism’s multi-pronged attack on intellectualism and Western civilization. I attended a session on the problem in 1992 (or so) at the AAAS in San Francisco, and did not appreciate or understand what was going on, or why the raised rhetoric and voices. I do now, especially having read excerpts from Lefkowitz’s book, History Lesson, published earlier this year.
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Posted in: Basic Science, Medical Academia, Science and Medicine

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Farewell To The Medscape Journal: Profits, Losses And A Canary In A Coal Mine

On January 31, 2009 The Medscape Journal will be discontinued.* One can only assume that the journal’s parent company, WebMD, could no longer justify the cost associated with a free, open-access, peer-reviewed medical journal that receives no income from advertisers or sponsors. The Medscape Journal’s budget has been supported by revenue generated from Medscape (the website), and their robust Continuing Medical Education (CME) business.

In these challenging economic times, American companies are taking a cold, hard look at their P and L spreadsheets and nixing the least profitable parts of their businesses. The inevitable “non-profit” casualties present an ethical dilemma. What will become of the noble pursuits that are based upon “doing the right thing” rather than making a profit?

There is no such thing as completely unbiased publishing (humans all have personal agendas – whether conscious or unconscious), though The Medscape Journal came about as close to it as any medical journal ever has. The journal is free to authors and readers, and provides 24-hour online access to both professional and lay viewers from around the globe. There are no advertisements or outside sponsors, peer reviewers work without compensation or specific recognition, and editors are paid a minimal salary (full disclosure: I know this because I was an editor for The Medscape Journal several years ago). CME credit is offered for articles determined to be of special relevance, but no articles are commissioned specifically for the purpose of CME.

The Medscape Journal is a wonderful experiment in high ethics. It espouses, in my opinion, the gold standard principles of medical publishing. Tragically, market forces (or perhaps the lack of perceived value by its own parent company) killed it. So what does this mean for medical publishing? If there is no economic model for “pure science” then are medical journals doomed to go the way of health media – promoting sensational or biased science for profit?
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Posted in: Announcements, Medical Academia, Science and the Media

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How SHOULD We Discuss Quackery with Innocents and the Not-so-Innocent?

Recents posts by Drs. Albietz and Gorski have highlighted questions that are recurrent on SBM. We are convinced that medicine should be based on real knowledge, to the extent that it exists, and that physicians should be honest; these are matters of science and ethics. How do we reconcile that with heartfelt, if misguided beliefs of patients, their families, and others? When Dr. Albietz wrote that it might have been better for the chiropractor to visit in the same way that “priests, imams, prayer sessions, rabbis, etc visit children within the PICU,” it was reminiscent of Dr. Peter Moran’s hypothetical “witch doctor.” When he lamented academic medicine’s current dalliances with quackery, it brought to mind the NCCAM, David Katz, Andrew Weil, Bravewell , and their enablers.

Dr. Albietz argued that when talking to credulous patients or their families, taking a hard line against quackery is likely to be counter-productive. Most of us would agree with that. Dr. Gorski described a different scenario: after calling a quack “a quack” when talking to a friend of a friend who is a scientist, he concluded that he had been too “blunt.” Several commenters disagreed, but all would probably agree with Dr. Gorski that “you have to know when to pick one way over another; i.e., diplomacy over all out war or vice versa.”

Another Case of Foot-In-Mouth Disease

I recently had an experience strikingly similar to Dr. Gorski’s, during which I castigated myself for my rancor even as I was incapable of moderating it. Fellow blogger Dr. Val Jones was a witness!

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Posted in: Medical Academia, Medical Ethics, Science and Medicine

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