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Colorado is Nearer to Promoting Naturopathic Pseudomedicine—Aided by the Colorado Medical Society

This week we’ll take a break from lambasting the National Center for Complementary and Alternative Medicine, as worthy as that task is, in order to confront some of the latest events involving the pseudomedical cult that calls itself “naturopathic medicine.”* Intrepid nurse and anti-healthfraud activist Linda Rosa reports that Colorado is dangerously close to becoming the next state to endorse ”NDs” as health care practitioners, and Scott Gavura of Science-Based Pharmacy called my attention to a report that British Columbia is considering enlarging the scope of practice for NDs, who are already licensed there, and that Alberta is on the verge of licensing them. In each case, those whom the public trusts to make wise decisions have betrayed their ignorance of both pseudomedicine and the realities of governmental regulation.

To explain why, it will first be necessary to make a few assertions, which are linked to developed arguments where necessary:

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Posted in: Health Fraud, Herbs & Supplements, Medical Ethics, Nutrition, Politics and Regulation, Public Health, Science and Medicine

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Comparative Clinical Effectiveness Research: Good News In Shades Of Gray

When I first heard about the new emphasis on comparative clinical effectiveness research (CCER) in Obama’s economic stimulus bill I thought, “Thank goodness! Maybe now science will truly regain its rightful place and we’ll end the CAM, ‘me-too’ drug, and excessive-use-of-technology madness that is wasting so much money in healthcare.” In fact, I was so excited about the new administration’s apparent interest in objective analysis of medical treatment options, that I intended to write a jubilant blog post about it. However, as with most things that seem black and white at first glance, further analysis reduces them to shades of gray.

What Is Comparative Clinical Effectiveness Research?

The new economic stimulus bill, also known as The American Recovery and Reinvestment Act (ARRA) includes 1.1 billion dollars for clinical comparative effectiveness research. Interestingly, CCER is not defined in the bill though AHRQ describes it this way in their glossary:

“A type of health care research that compares the results of one approach for managing a disease to the results of other approaches. Comparative effectiveness usually compares two or more types of treatment, such as different drugs, for the same disease. Comparative effectiveness also can compare types of surgery or other kinds of medical procedures and tests. The results often are summarized in a systematic review.”

Any mention of “comparative cost effectiveness” or value-based language is notably absent.

How Does It Work?

The government’s new CCER initiative will be administered through a Federal Coordinating Council for clinical comparative effectiveness research. The FCC consists of a group of 15 federal employees, half of whom “must be physicians or other experts with clinical expertise.” [Meaning, none have to be physicians.] Some have suggested that the FCC is the first step toward an organization modeled after Britain’s National Institute of Health and Clinical Excellence (NICE). NICE is regularly tasked with helping the NHS to decide which medical treatments should be available to their beneficiaries, and which should not be covered (based on their efficacy and cost).

The budget for the CCER will be divvied up as follows:

400 million – left to the discretion of the Secretary of HHS with 1.5 million to go to the Institute of Medicine for a report regarding where to focus CCER attention initially
400 million – to the office of the director, NIH
300 million – to AHRQ

Here is a quote from the ARRA bill, discussing the mechanics of CCER:

“The funding appropriated in this paragraph shall be used to accelerate the development and dissemination of research assessing the comparative clinical effectiveness of health care treatments and strategies, including through efforts that: (1) conduct, support, or synthesize research that compares the clinical outcomes, effectiveness, and appropriateness of items, services, and procedures that are used to prevent, diagnose, or treat diseases, disorders, and other health conditions and (2) encourage the development and use of clinical registries, clinical data networks, and other forms of electronic health data that can be used to generate or obtain outcomes data: Provided further, That the Secretary shall enter into a contract with the Institute of Medicine, for which no more than $1,500,000 shall be made available from funds provided in this paragraph, to produce and submit a report to the Congress and the Secretary by not later than June 30, 2009 that includes recommendations on the national priorities for comparative clinical effectiveness research to be conducted or supported with the funds provided in this paragraph…”

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Posted in: Clinical Trials, Pharmaceuticals, Politics and Regulation, Public Health

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Research, Minus Science, Equals Gossip

“A person is smart. People are stupid.”

- Agent K (Tommy Lee Jones), Men In Black

Regular readers of my blog know how passionate I am about protecting the public from misleading health information. I have witnessed first-hand many well-meaning attempts to “empower consumers” with Web 2.0 tools. Unfortunately, they were designed without a clear understanding of the scientific method, basic statistics, or in some cases, common sense.

Let me first say that I desperately want my patients to be knowledgeable about their disease or condition. The quality of their self-care depends on that, and I regularly point each of them to trusted sources of health information so that they can be fully informed about all aspects of their health. Informed decisions are founded upon good information. But when the foundation is corrupt – consumer empowerment collapses like a house of cards.

There is growing support in the consumer-driven healthcare movement for a phenomenon known as “the wisdom of crowds.” The idea is that the collective input of a large number of consumers can be a driving force for change – and is a powerful avenue for the advancement of science. It was further suggested (in a recent lecture on Health 2.0), that websites that enable patients to “conduct their own clinical trials” are the bold new frontier of research. This assertion betrays a lack of understanding of basic scientific principles. In healthcare we often say, “the plural of anecdote is not data” and I would translate that to “research minus science equals gossip.” Let me give you some examples of Health 2.0 gone wild:

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Posted in: Public Health, Science and Medicine, Science and the Media

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More evidence that CAM/IM advocates see health care reform as an opportunity to claim legitimacy

Four weeks ago (was it really that long?), I wrote one of my usual lengthy essays for this blog in which I analyzed two editorials published by some very famous advocates of “complementary and alternative medicine” (CAM)/”integrative medicine” (IM). They included one in that credulous repository of all things antivaccine The Huffington Post (no, this isn’t about vaccines, but I can’t resist pointing out at every turn the antivaccine slant of that rather famous political blog) and in the Wall Street Journal. The first, published in HuffPo and written by Deepak Chopra, Andrew Weil, and Rustum Roy, was entitled Leaving the Sinking Ship, while the second added Dean Ornish to its team, switched from the highly liberal venue of hte previous article to the conservative WSJ, and was entitled “Alternative” Medicine Is Mainstream: The evidence is mounting that diet and lifestyle are the best cures for our worst afflictions. In doing so, advocates of unscientific and even pseudoscientific faith-based medical treatments seemingly covered the entire span of political thought, from highly liberal to highly conservative, with their message.

That message, as I have argued, along with Wally Sampson, Kimball Atwood, Val Jones, and Peter Lipson, is, to boil it down to its essence, this: The new Obama Administration has promised to make health care reform one of its top priorities, and CAM/IM advocates want to take advantage of this movement for reform as the “foot in the door” behind which they try to muscle their way in to be treated by the government as co-equal with established, science- and evidence-based medicine. How do they plan on doing this? As I have discussed before, they plan on doing this by coopting disease “prevention” strategies as being CAM/IM and using them as a Trojan horse. When the government brings the giant wooden horse into the fortress of government health care, along with the bona fide prevention strategies of diet and exercise a whole lot of woo will jump out of the belly of that horse and open the fortress doors to let in its comrades. Indeed, the same strategy can be seen in how CAM/IM advocates have coopted the Institute of Medicine with a joint conference.

In other words, because CAM/IM advocates have succeeded so well in tying the perfectly acceptable science- and evidence-based modalities of diet and exercise, as well as ghettoizing the respected pharmacology discipline of pharmacognosy by associating it with herbalism and, in essence, bringing it under the CAM umbrella, where it became unfairly and incorrectly tainted with its association with all the other woo that falls under the CAM/IM mantle, they expect that renewing an emphasis on diet and exercise by their definition and on their terms will lead to the opening of the door into the promised land of having their modalities be funded by the government. It’s a very conscious strategy, which is why Chopra et al’s articles so clearly tried to convince readers that diet and exercise are CAM/IM. Unfortunately, that they are able to do this with such success is in part because science- and evidence-based practitioners arguably underemphasize such health prevention strategies.

I learned of another salvo fired off by CAM/IM advocates through my somehow finding myself on the mailing list for The Mary Ann Liebert, Inc. family of medical journals. Unfortunately, one of the journals published by the Liebert group is the Journal of Alternative and Complementary Medicine. This particular e-mail was advertising an editorial written by a chiropractor named Daniel Redwood that spells out in the most detailed manner exactly how CAM/IM advocates plan on hijacking any health care reform that the Obama Administration might come up in order to persuade the government to fund what Wally frequently terms “sectarian medicine” and I simply like to call unscientific. The editorial is freely available to all (unlike the contents of JACM) and entitled Alternative and Complementary Medicine Should Have Role in New Era of Health Care Reform. It’s about as blatant a description of the goals of the CAM/IM movement as I have ever seen.
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Posted in: Politics and Regulation, Public Health, Science and Medicine

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Where Does Sanjay Gupta Register On The Quackometer?

Four weeks ago I wrote a blog post about Sanjay Gupta’s nomination by the Obama administration as our potential new Surgeon General. Many of you voiced concerns about Sanjay’s nomination, specifically because of his poor handling of the Raelians’ Clonaid fiasco, his inability to counter Michael Moore’s health statistics as presented in Sicko and his relationship to the pharmaceutical industry.

As I wondered about what Sanjay Gupta might be like as Surgeon General – and specifically how he might assist in “restoring science to its rightful place” – I decided to educate myself about his thought processes by purchasing his recent book “Chasing Life.” The question I sought to answer was, “is Sanjay Gupta a crank?”

The short answer is: I’m not sure.  Although I wouldn’t go so far as to say that he is a crank, I think he’s more likely to be a shruggie. For those of you who haven’t read my post on shruggies, here’s the definition:

Shruggie (noun): a person who doesn’t care about the science versus pseudoscience debate. When presented with descriptions of exaggerated or fraudulent health claims or practices, their response is to shrug. Shruggies are fairly inert, they will not argue the merits (or lack thereof) of complementary and alternative medicine (CAM) or pseudoscience in general. They simply aren’t all that interested in the discussion, and are somewhat puzzled by those who are.

The longer answer involves an exploration of Gupta’s disturbing insistence on flirting with cranks, if it gets him publicity. The back cover of Chasing Life caries an endorsement from Deepak Chopra – and the inside page a favorable review from Andrew Weil. Normally, I would assume that the author of any book endorsed by those two would contain an intolerable blend of science and pseudoscience and refuse to read it. But for the sake of the readers of Science Based Medicine, I stifled my gag reflex and purchased the book. I hope that my sacrifice will benefit you all.
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Posted in: Book & movie reviews, Public Health, Science and the Media

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Since when did an apologist for the antivaccination movement, Dr. Jay Gordon, become an “expert” in vaccine law?

I am an alumnus of the University of Michigan twice over. I completed a B.S. in Chemistry with Honors there in 1984 and then I stayed on to do obtain my M.D. in 1988. I look back very fondly on those eight years spent in Ann Arbor, as several of my longtime friendships were forged or solidified during those years. Consequently, I still care about the place. Indeed, I even once tried to see if I could get a position in the Department of Surgery there a few years back, but unfortunately the “fit” just wasn’t there at the time. That’s why it distresses me when I see my alma mater suffer from a self-inflicted wound, almost as much as the plight of the Michigan Wolverines bothers me, given that never before in my life (at least not since I was old enough to pay attention), have the Wolverines sucked so badly and so hard. Given that level of football futility, though, I consider it even more important that my alma mater not provide any more ammunition to those who would enjoy making fun of it. It doesn’t matter to me that I never went to law school at Michigan; it’s all part of the same campus to me.

This time, the embarrassment comes in the form of an article in the Michigan Law Review by a person who has previously been a subject of posts by both Dr. Novella and me. I’m referring to Dr. Jay Gordon, whom we have both–correctly, I believe–labeled as being, if not fully anti-vaccine, at least a prominent and major apologist for the anti-vaccine movement. Unfortunately, because he is the pediatrician taking care of Jenny McCarthy’s son Evan, he has gained even greater prominence in the antivaccine movement than ever, to the point where he gave a speech last summer to the antivaccine “Green Our Vaccines” march on Washington and where he is regularly called up by TV producers to give a false “balance” whenever a discussion of vaccines and/or autism comes up. He also wrote the foreword to Jenny McCarthy’s latest paean to autism quackery and attack on vaccines as the cause of autism in which he blithely repeated some of the worst distortions of the antivaccine movement. Unfortunately, Dr. Gordon lacks the intestinal fortitude to stop the piteous denials any time he is called out for his parroting of antivaccine pseudsocience and to embrace his inner antivaccinationist. Then, at least, we wouldn’t be treated to the spectacle of his simultaneously claiming he is “pro-safe vaccine, not anti-vaccine” while at the same time saying he “doesn’t give a lot of vaccines” and admitting that parents have actually had to persuade him to vaccinate “reluctantly.”

So what was the topic of the Michigan Law Review article that Dr. Gordon was apparently asked to pen? It’s actually an interesting question from a legal, political and civil rights standpoint, specifically: Whether or not parents should be held legally liable for refusing to vaccinate their children. Not surprisingly, Dr. Gordon took the “no” position. Unfortunately, as we’ve come to expect of Dr. Gordon, he uses a number of highly dubious arguments. However, more interesting to me, having had a nearly four year history sparring online with him off and on, was the seemingly “kinder and gentler” antivaccine stance that he took in this article.

But first, let’s take a look at the debate. The symposium published in First Impressions (the online companion to the Michigan Law Review) was entitled Liability for Exercising Personal Belief Exemptions from Vaccination, and it contained the following articles:

  1. Choices Should Have Consequences: Failure to Vaccinate, Harm to Others, and Civil Liability by Douglas S. Diekema.
  2. Parents Should Not be Legally Liable for Refusing to Vaccinate their Children by Dr. Jay Gordon.
  3. Unintended Consequences: The Primacy of Public Trust in Vaccination by Jason L. Schwartz.
  4. Challenging Personal Belief Immunization Exemptions: Considering Legal Responses by Alexandra Stewart.
  5. Gambling with the Health of Others by Stephen P. Teret and John S. Vernick.
  6. The Problem of Vaccination Noncompliance: Public Health Goals and the Limitations of Tort Law by Daniel B. Rubin and Sophie Kasimow

There were a number of fascinating issues raised here. Although it’s obvious that universal vaccination is a public health policy good, given that the higher percentage of vaccinated children, the greater the herd immunity, there is always the nagging question of how far the state should go to mandate vaccination in a free society; i.e., how much coercion is acceptable to bring about maximal levels of vaccination? In other words, what is the proper balance between the needs of society as a whole and the rights of the individual? The next interesting legal and moral question is whether parents who refuse to vaccinate should be held liable for injuries to other children if their unvaccinated child passes on an infectious disease. Personally, I tend to believe that it is entirely reasonable to require vaccination as a precondition for school or day care and that exemptions should be primarily medical in nature. I grudgingly allow that the freedom of religion guaranteed in the First Amendment probably requires religious exemptions (although I do not understand why religion should be given such a privileged place in society that it can endanger public health), I am far less convinced that philosophical exemptions should be mandated. I realize many may disagree with this position, but I would hope that our disagreements would be based on (1) the best science regarding the benefits and risks of vaccination and (2) honest beliefs regarding the proper balance between public health concerns and individual liberty. Clearly, this is an area of debate. I also tend to believe that if parents refuse to vaccinate their child and that child passes an infectious disease to another child, then those parents should be potentially legally liable. Indeed, Douglas Diekema argues this position very well.

Unfortunately, Dr. Gordon does not meet at least condition #1 above. He does not base his arguments on the best science.
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Posted in: Politics and Regulation, Public Health, Vaccines

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More Data on Vaccine Safety Amid New Outbreaks

The more recent issue of the Journal Pediatrics contains two article providing further evidence for the safety of vaccines and is published amid news reports of recent outbreaks of vaccine-preventable diseases in those who chose not to vaccinate over unwarranted fears. This highlights the need to continue our PR battle against the antivaccinationist movement that seeks to spread pseudoscientific fears about vaccine safety.

The Outbreaks

Haemophilus influenza type B (Hib) is a bacteria that can cause meningitis, pneumonia, and epiglotitis in young children – all serious illnesses. A Hib vaccine was introduced in 1992 followed by a significant decrease in the number of Hib infections. Last year in Minnesota, however, there were five cases of Hib meningitis, including a 7-month old infant who died. This is a significant spike above the rate we have seen since the Hib vaccine, and occuring in a cluster. Three of the five children who were affected did not have the Hib vaccine by their parent’s choice.

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Posted in: Public Health, Vaccines

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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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Let President-Elect Obama know that NCCAM should be defunded!

As you may or may not know, Change.gov is being used by Obama’s team to solicit policy ideas. Americans submit ideas, along with supporting rationale, and people “vote up” or vote down” the proposals. “Up” votes increase the score of the proposals, and “down” votes decrease the score. It is described thusly on the Change.gov website:

Share your ideas on any issue facing the new administration, then rate or comment on other ideas. The best rated ideas will rise to the top — and be gathered into a Citizen’s Briefing Book to be delivered to President Obama after he is sworn in.

A couple of days ago, P.Z. Myers let me know about an excellent proposal over at the Citizen’s Briefing Book: Defund the National Center for Complementary and Alternative Medicine:

Here’s a way to increase the available funding to NIH without increasing the NIH budget: halt funding to NCCAM, the National Center for Complementary and Alternative Medicine. This Center was created not by scientists, who never thought it was a good idea, but by Congress, and specifically by just two Congressmen in the 1990′s who believed in particular “alternative” (but scientifically dubious) treatments. Defunding NCCAM would save at least $225 million, possibly more.

Defunding NCCAM would also provide a direct societal benefit. Practitioners of so-called “alternative” medicines constantly refer to NIH’s support as a way of validating their practices and beliefs, most of which are not supported by evidence. The fact is that after >10 years, NCCAM has not yet found a single piece of positive evidence for any of these methods, which include acupuncture, “qi”, homoepathy, magnet therapy, and other treatments.

Any legitimate, promising medical treatment can be funded by one of the existing NIH Institutes. There’s no need for a separate center for “alternative” therapies – but what has happened is that NCCAM has become a last refuge for poorly designed, unscientific studies that couldn’t get funded through the normal peer-reviewed process.

He even cited our co-blogger’s (in)famous article Why the National Center for Complementary and Alternative Medicine (NCCAM) Should Be Defunded. Maybe he should take a gander at my post The National Center for Complementary and Alternative Medicine (NCCAM): Your tax dollars hard at work, as well.
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Posted in: Politics and Regulation, Public Health, Science and Medicine

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Who Should Ascend To The Office Of Surgeon General?

President-elect Obama’s nomination of CNN medical correspondent, Sanjay Gupta, for the Office of Surgeon General of the United States has ignited a firestorm of debate across the Internet. Some argue that he is not qualified for the position, others say that his charisma would be a boon to public health communications, though the lay majority appear to have mixed feelings.

It is highly irregular for a Surgeon General nominee to be announced before the Secretary of Health and Human Services is confirmed. This faux pas in itself may speak to an irresistible opportunity for self-promotion, or that the Senate confirmation hearing is not the independent review event that we assume it is.

At age 39, Gupta has long aspired to become the Surgeon General, as sources close to him report that he has been saying (since age 33) that “it’s the next logical step in his career development.”

But before we draw conclusions about who’s right for the job, we need to understand what the job entails.

I asked Dr. Richard Carmona, 17th Surgeon General of the United States, to explain the roles and responsibilities of the office. A summary of our conversation follows:
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