Jan 26 2009
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.
The first thing anyone has to realize about defunding NCCAM is that it will not be easy to develop the necessary consensus among legislators to pass the legislation that would be necessary to disband it. Actually, that’s a huge understatement. In fact, it may well be politically and bureaucratically impossible, and my discussion later in this piece of what we could do with NCCAM’s parts once it is disbanded could very well be sheer fantasy on my part and the parts of my co-bloggers. However, I still think it’s worth discussing how we might go about such a demolition.
The next thing to remember is that NCCAM was not created because of a groundswell of support among physicians and scientists who saw all this quackery out there and said, “Hey, we really ought to study homeopathy (or reiki, or therapeutic touch [or: INSERT FAVORITE WOO HERE]) to see if there’s anything to it.” Rather, NCCAM was created primarily through the effort of a single ideologue, Senator Tom Harkin (D-Iowa), a woo-friendly legislator who believed that bee pollen had somehow cured his allergies. It was Harkin who first assigned $2 million of his discretionary funds to establish the Office of Unconventional Medicine in 1992. The OUM was soon renamed the Office of Alternative Medicine (OAM). Then, as detailed in Wally’s article, the first director of OAM resigned under Senator Harkin’s pressure because he quite properly objected to nominees to the OAM Council who had been involved in Laetrile and Mexican cancer clinic scams. In 1998, then NIH Director Harold Varmus tried to bring the OAM under tighter NIH scientific control to make its studies more rigorous and was stymied when Harkin introduced legislation to elevate OAM to an independent Center. As has been discussed before, NCCAM is constituted so that even its director is hamstrung in what he (or in the case of the current Director, Josephine Briggs, she) can do because the NCCAM charter demands that a majority of its Council members be chosen from practitioners and “leaders” in the CAM field. In other words, true believers control the agenda, and it is difficult for even scientifically inclined NCCAM directors like Dr. Briggs and her predecessor Dr. Stephen Strauss to keep NCCAM from wasting precious grant money investigating the more ludicrous and implausible CAM “therapies” out there–like reiki or homeopathy. The bottom line is that by design there just isn’t that much an NCCAM director can do to change the way NCCAM operates, at least in terms of how it awards its grants and how it disburses its training grant money.
Given this history, does anyone doubt that Tom Harkin, aided by other woo-friendly legislators such as Rep. Dan Burton (R-IN) and Rep. Ron Paul (R-TX), would fight tooth and nail to protect NCCAM if they got even a whiff of news about a serious attempt to defund it? Does anyone doubt that the forces that managed to pass the DSHEA of 1994 would also join in the fight?
It’s a political battle that President Obama may not consider worth the price it would take to win, particularly given all the other problems he’s inherited and the initiatives he wishes to pursue. For defunding NCCAM to be worth his spending political capital to accomplish, there would have to be a groundswell of public support. It would require letter writing campaigns, agitation, and a lot of lobbying. It would require that advocates of science- and evidence-based medicine get down and dirty in the quagmire of politics. I’m not sure it’s even possible, given the low level of science literacy in this country that renders most voters unlikely to understand why NCCAM is such bad science and bad policy. We advocates of science- and evidence-based medicine could try to frame it as a huge waste of taxpayer money, but there are many other government programs that waste as much or even much more money. That would be a hard sell. We could try arguing that NCCAM funds colossal amounts of bad science and that it promotes quackery in medical schools, but, even if we could convince President Obama of this, it’s doubtful that we could convince enough voters to make enough of a stink to overcome the entrenched interests defending NCCAM. I like the recent suggestion to the Obama transition team to defund NCCAM as much as the next guy. But just take a look at the comments near the end, after CAM advocates had been finally warned of the initiative and started to try to vote its score down, egged on by various pro-CAM blogs. The scientific ignorance, the “what’s the problem? attitude, and the “health freedom” posturing (with a huge dollop of big pharma conspiracy mongering, naturally) are depressing to behold.
But let’s imagine for one glorious moment that somehow the political support and will were found to defund NCCAM for real. How might that look? What might be the results?
It is important to note that NCCAM is not the only source of funding for CAM/IM research in the federal government. The federal government spends close to a quarter of a billion dollars per year funding woo. In actuality, NCCAM’s budget is around $121 million a year. The other money comes from an office in the National Cancer Institute known as the Office of Complementary and Alternative Medicine (OCCAM, an acronym that, given what the Office studies, brings no end of chuckling at the irony), whose budget is also around $121 million a year. Together, that’s nearly a quarter of a billion scarce taxpayer dollars spent on CAM/IM. Both NCCAM and OCCAM would have to be defunded to realize that savings. Also, the entire NIH budget is just under $30 billion. Removing OCCAM and NCCAM would only be less than 1% of the NIH budget. The advantage, however, would be that this would represent more money that could go to studies that might actually tell us something useful or identify new treatments.
The key thing to realize is that not everything NCCAM does is worthless. One of the chief complaints we at SBM have had about CAM in general and NCCAM in particular is how they have appropriated clearly science-based modalities, such as diet, exercise, and relaxation as being somehow “alternative.” As Wally and I have argued before, this appropriation of these modalities represents the “foot in the door” or the “Trojan Horse” to allow all the other woo in, or, as Steve Novella has called it, the “bait and switch.” Diet and exercise are the bait, and the switch is made up of the reiki, homeopathy, acupuncture, and all the other prescientific placebo therapies. The problem is how to separate the woo from the potentially science-based medicine and reclaim the “bait” under the banner of science-based medicine, which is where it belongs, and discarding the pseudoscience that CAM/IM tries to “switch” for the bait. To do this, I think it’s useful to think of four divisions.
For example, let’s consider OCCAM. One huge advantage that OCCAM has is that it doesn’t require the presence of CAM “experts” in the study sections evaluating grants. By and large, study sections looking at projects funded through OCCAM are the same as study sections evaluating any other grants. This is an enormous difference and a huge plus not to be discounted. In fact, it’s the very reason why, despite the fact that the director of OCCAM is led by a legitimate scientist and physician, there is very little being done at OCCAM that couldn’t be done just as well distributed among appropriate study sections elsewhere. This is a good thing. After all, CAM is not a natural, disease- or discipline-specific area; it’s a cobbled-together, made-up wastebasket “discipline” that includes basically anything that isn’t “conventional,” hasn’t been proven, or is wildly implausible from a scientific standpoint. In other words, there is no reason for this hodge-podge of therapies and “studies” to be grouped together under a separate Office in the NCI or under a separate Center in the NIH. Its components are too disparate, too unrelated to each other, and many of its claims are actually mutually contradictory. While that may not bother CAM/IM boosters, it should well bother scientists.
On the other hand, consider this instead. If we want to study nutritional supplements and their potential interactions with chemotherapy, why not just form an Office of Nutrition and Cancer and leave out the “alternative”? If we want to do research looking for natural products that can be used to treat cancer, why not just have an Office of Pharmacognosy, instead of having the long and proud scientific discipline of natural products pharmacology “ghettoized” by its increasing association with all the pseudoscience and woo that has over the last 15 years been increasingly lumped together with the study of herbs and plant products under the CAM/IM label? Remember, pharmacognosy is not herbalism, at least not as herbalists use natural products. Think of pharmacognosy of herbalism brought into the scientific era, because herbalism is simply pharmacognosy as practiced hundreds of years ago.
In fact, CAM could be eliminated entirely if research at each Institute of the NIH were divided into four main areas:
- Drugs/pharmacology (pharmacognosy being a subdivision of this large category)
- Physical treatments (radiation therapy, medical devices, surgery, etc.)
- Nutrition (there’s where your supplements go)
- Lifestyle (exercise, relaxation, whatever)
There’s nothing “alternative” there, and close to everything could be encompassed under one or two of those four labels. In fact, to some extent, the NIH already does this, although the exact scheme of division is more complex. Indeed, one could replace “Drugs/pharmacology” with “systemic therapies” and “physical treatments” with “local therapies,” and it would match part of what NIH does fairly closely.
NCCAM, unfortunately, would be far more difficult because its very raison d’être is not just to study pseudoscience but to promote it as well. To this end, every level of the leadership is full of true believers except for the Director, making NCCAM able to resist pretty much any effort to inject any consideration of scientific prior probability or estimates of plausibility into the consideration of any CAM/IM method. Even the utter pseudoscience that is homeopathy is considered as though it were any more scientifically valid that the concepts of sympathetic magic upon which it is based. Don’t believe me? Then remember the example I discussed before, specifically the R21 grant to study homeopathic dilution and succussion and how they affect the dose-response curve of homepathic remedies. This grant was actually awarded to study whether succussion (the vigorous shaking done with each homeopathic dilution) that, claim homeopaths, is necessary to “potentize” homeopathic remedies affects the dose-response characteristics of homeopathic remedies up to a 30C dilution (30 times 100-fold, or a dilution factor of 1 x 10-60). This is a dilution factor many orders of magnitude larger than Avagaddro’s number, which is makes a 30C homeopathic remedy nothing but water. Believe it or not, the investigators are actually going to compare stirring with succussion to see whether succussion, as homepaths claim, improves the dose-response curve. This is no different than studying whether eye of newt or serpent’s tongue is more potent in casting a magic spell.
This is also yet another reason why NCCAM would have to be utterly dismantled and all of its component parts spread among the Institutes of the NIH in such a manner as to make it virtually impossible to reconstitute, at least not easily, if we are to eliminate as much as possible pseudoscience in the NIH.
NCCAM is not a scientific creation, but rather a purely a political one. Scientists did not clamor for NCCAM or even request it; rather, the OAM and then NCCAM were rammed down the throats of the NIH leadership primarily through the efforts of one powerful quackery-loving Senator. As such, NCCAM can only be dismantled through the political process, and, unfortunately, I am not at all optimistic that the necessary political consensus can be developed to the point where it is strong enough to overcome the resistance from NCCAM’s powerful patrons in Congress that any serious initiative to defund it would provoke. That is not to say that I don’t think that it’s totally worth trying to do. Indeed, there has not been a better time in years to undertake this mission, especially since President Obama has expressed a desire to “restore science to its rightful place” and to heed science when developing policy upon which science impacts. I also believe that he is serious about his pledge, and I can’t think of a better way for our new President to demonstrate a newfound respect for what science says than eliminating the worst festering sore of government-funded pseudoscience currently in existence. If President Obama were to eliminate NCCAM, that would be a far more powerful signal than appointing advisors with actual scientific backgrounds doling out a few extra billion dollars to the NIH and NSF, although those, too are powerful signals. Dismantling NCCAM would be a signal that science, not pseudoscience, guides federal government health research policy.
27 Responses to “Dismantling NCCAM: A How-To Primer”