NCCAM in the news: Why does it still exist?

I’ve made no secret of my admiration for Trine Tsouderos. Whether it be her investigations into the rank quackery of prominent members of the mercury militia wing of the anti-vaccine lunatic fringe, Mark and David Geier, who seem to think that chemical castration is a perfectly fine and dandy treatment for autism because testosterone binds mercury (it doesn’t under physiological conditions) and prevents it from being removed by chelation therapy, the equally rank quackery that is the “autism biomed” movement, or the chronic Lyme disease underground, Tsouderos is one of the rare journalists who “get it” when it comes to science-based medicine. In fact, she “gets” it to the point where she’s even willing to take on “America’s doctor,” Dr. Mehmet Oz, one of my least-favorite media personalities due to his promotion of homeopathy, faith healing, Joe Mercola, reiki, and even psychic scammer (is that redundant?) John Edward. The result, not surprisingly, is that she’s found herself kicked out of autism quackfests or portrayed as a baby-eating cannibal by everybody’s favorite anti-vaccine propaganda blog Age of Autism.

We need more journalists like her.

And Trine just proved it once again by doing something that I don’t recall seeing any mainstream journalist do–ever. She just did a trilogy plus one in terms of stories. Terror if you think that medicine should have a sound basis in science. Terror if you don’t think that our taxpayer dollars should be funding research into fairy dust. Terror if you’re affiliated with the National Center for Complementary and Alternative Medicine (NCCAM). OK, maybe I exaggerate, but who cares? It’s so rare to see stories like this make it to a major media outlet. It warms the cockles of a skeptic’s heart.

Sunday and Monday, the Chicago Tribune published a series of stories on NCCAM, all penned by Tsouderos:

What’s so surprising was to read in a major newspaper something like this:

Thanks to a $374,000 taxpayer-funded grant, we now know that inhaling lemon and lavender scents doesn’t do a lot for our ability to heal a wound. With $666,000 in federal research money, scientists examined whether distant prayer could heal AIDS. It could not.

The National Center for Complementary and Alternative Medicine also helped pay scientists to study whether squirting brewed coffee into someone’s intestines can help treat pancreatic cancer (a $406,000 grant) and whether massage makes people with advanced cancer feel better ($1.25 million). The coffee enemas did not help. The massage did.

NCCAM also has invested in studies of various forms of energy healing, including one based on the ideas of a self-described “healer, clairvoyant and medicine woman” who says her children inspired her to learn to read auras. The cost for that was $104,000.

A small, little-known branch of the National Institutes of Health, NCCAM was launched a dozen years ago to study alternative treatments used by the public but not accepted by mainstream medicine. Since its birth, the center has spent $1.4 billion, most of it on research.

Every since I discovered NCCAM way back after I first started blogging, I wanted to believe that it was actually a worthwhile endeavor to study the things NCCAM studied. I came to change my mind about NCCAM over the years. The reasons are many, but much of the reason why is that I came to understand that prior probability matters. If a therapy is incredibly implausible from a scientific basis, as in so implausible that multiple laws of physics would have to be radically rewritten in order for it to work (yes, I’m talking about homeopathy or reiki), then what you’re likely to see if you do clinical trials on such a therapy is nothing more than random noise amplified by normal flaws that are present in any clinical trial. The result, as I pointed out nearly four years ago, are ridiculous studies like studies to try to determine the most effective technique of dilution and succussion of homeopathic remedies–or, as Tsouderos points out, studies of distant prayer as a cure for AIDS or studies of regimens including coffee enemas (i.e., the Gonzalez protocol), can cure pancreatic cancer. (Hint: It can’t, no matter how much Nicholas Gonzalez tries to explain away his failure.) Even worse, such studies all too often can be profoundly unethical, as the Gonzalez trial was and TACT, which Tsouderos describes well, is, given that there is no good evidence that chelation therapy does anything for coronary artery disease, certainly not enough to justify a $30 million multicenter phase III trial.

I’m not going to go over all the articles in detail, given that I’ve covered the ground in them many times before. I encourage you to read all three articles for yourself. Instead, I’ll “cherry pick” the parts that most interested me. One part that caught my interest was what NCCAM director Dr. Josephine Briggs has to say. As some readers might recall, back in the spring of 2010, Steve Novella, Kimball Atwood (featured in Tsouderos’ article on TACT), and I actually met Dr. Briggs, and that meeting is the prism through which I see Dr. Briggs’ responses in this article. For example:

Briggs, a respected NIH researcher and physician who has headed NCCAM for nearly four years, said in an interview that she is dedicated to evidence-based medicine and that the center, under her leadership, is committed to rigorous scientific studies.

The center’s recently adopted strategic plan focuses on studies of supplements and other natural products along with the effect of “mind and body” therapies like yoga, massage and acupuncture on pain and other symptoms. In fiscal years 2008-2011, NCCAM funded more than $140 million in grants involving mind and body therapies, including $33 million for pain research in fiscal 2011.

The new strategic plan “reflects real change or an evolution in our mission,” Briggs said. “We are not your grandmother’s NCCAM.”

Studies of energy healing or distant prayer likely would not get funded by NCCAM today, she said.

I’ve read NCCAM’s strategic plan. I’m not particularly impressed. It all basically boils down to a promise to do some real science for a change. And in this article, we find Briggs trying to hide from the woo:

Dr. Josephine Briggs, director of NCCAM since 2008, wrote in an email that the center has not awarded any new grants to study practices like distant prayer or other energy healing for several years.

One notes that Dr. Briggs is referring to a study on “energy chelation” that I wrote about in my very own inimitable fashion back in August that really was brain-meltingly bad, as a certain expert in the article referred to it.

Be that as it may, what Dr. Briggs says here is very much of a piece with what she said to us when we met with her. Basically, her responses to criticisms like this always seem to boil down to trying to convince people that NCCAM doesn’t look at nonsense like homeopathy or energy healing anymore. If that’s true, that’s all well and good, but it’s not enough. NCCAM still does fund a lot of studies in modalities that are almost as implausible, the most prominent example of which is acupuncture, which is based on exactly the same sort of mystical, magical ideas that underlie reiki and distance healing. The only difference is that, because acupuncture involves actually sticking a little bit of cold steel into the body, it somehow seems more plausible. Heck, it did to me several years ago. Then I started paying attention to the scientific literature and clinical trials being published about acupuncture and realized that there’s no there there. Just type acupuncture into the search box of this blog and you’ll find a number of posts by me explaining exactly why in more detail. The CliffsNotes version is that acupuncture is placebo. It doesn’t matter where you stick the needles. It doesn’t even matter if you stick the needles in. Twirling toothpicks on the skin “works” just as well as any acupuncture.

More importantly, there is nothing done at NCCAM that requires a separate institute or center within the NIH. Nothing. Supplements and herbal medicines are arguably the most plausible of all the modalities studies of which are funded by NCCAM. They are–or can be–drugs, after all. Funded through other institutes, studies of herbal remedies are nothing more than pharmacognosy, a branch of pharmacology concerned with the study of natural products in which scientists try to isolate the active ingredient or ingredients in plants and natural products. Funded through NCCAM, studies of these modalities are infused with woo, in which the herbs, supplements, and various other natural compounds are claimed, without evidence, to be synergistic when combined. In reality, far more often they are impure, adulterated drugs in which the content of natural ingredient is inconsistent. As for other modalities, there’s no reason why “mind-body” interventions can’t be studied at NIMH or NINDS. Placebo studies, which could be very useful in medicine if done rigorously and scientifically, could easily be carried out in these institutes or several others. There, they would be freed from the concept at NCCAM that placebo effects are some sort of seemingly magical effect. In this paradigm, studies of completely implausible modalities that require rewriting the laws of physics to work (again, homeopathy, reiki, and “energy healing”), wouldn’t be funded at all without evidence to demonstrate that there is an actual phenomenon to study. To do otherwise is what Harriet Hall likes to call tooth fairy science.

Moreover, as Kimball Atwood emphasizes (and I have emphasized as well), performing clinical trials on highly implausible remedies can be potentially highly unethical. The Gonzalez trial showed that patients receiving Gonzalez’s treatments survived pancreatic cancer only 1/3 as long as patients receiving state-of-the-art chemotherapy. Briggs, being understandably embarrassed by this atrocity against medical science and ethics, might try to dismiss this study as “ancient history,” but there is nothing preventing such a study from happening again. At least, if there is, Dr. Briggs doesn’t say what it is. All we seem to have is her assurance, and maybe as long as she’s director of NCCAM there won’t be another Gonzalez trial or TACT trial, from which she also tries to distance himself there won’t be another Gonzalez trial or TACT. But she won’t be NCCAM director forever. Whoever succeeds her might not be as dedicated to scientific rigor, particularly if NCCAM’s most powerful congressional patron, Senator Tom Harkin (D-IA) has anything to say about it. Also remember, that the director answers to the National Advisory Council for Complementary and Alternative Medicine, and there’s a lot of credulity on that council, whose eighteen members must include at least twelve members who are in “relevant” disciplines; i.e., “leaders” in CAM.

In other words, I don’t think NCCAM can be reformed. Under Dr. Briggs’ tenure, NCCAM is probably less noxious in its offenses against science than it was before. In fact, I honestly believe that Dr. Briggs’ heart is in the right place in terms of trying to bring more rigorous science to the study of CAM areas where rigorous science is possible. But she’s working under the delusion that she can turn tooth fairy science into real science. Meanwhile, the aspects of CAM that have some plausibility (i.e., natural products and supplement, diet, exercise) are the Trojan horse that hides woo and quackery as it is brought into academia. It’s the foot in the door, after which the quackery follows. It’s not for nothing I refer to much of academic CAM as “quackademic medicine.”

Even worse, it works. Even self-identified skeptics are taken in by it, as Greg Laden was when he was overly impressed by a study of milk thistle for treating diabetic nephropathy as evidence that NCCAM is needed and worthwhile. Here’s a hint: This study is nothing more than pharmacognosy. There’s nothing “alternative” or “complementary” about it. There is no need for a special center within the NIH to fund studies like this. NIDDK could handle such a study perfectly well. He’s also way behind the times when he emphasizes that skeptics concentrate too much on the word “alternative.” Such a statement reveals a profound ignorance of the use of language by CAM advocates as a tool to achieve the appearance of scientific legitimacy. Hasn’t he heard? CAM is dead. CAM advocates themselves killed it because “complementary” implies inferiority or subsidiary status to real medicine. The preferred term these days is “integrative” medicine, which implies more equality with medicine. Indeed, I’m surprised that Tom Harkin hasn’t stuck a line in an NIH appropriations bill to change NCCAM’s name to the National Center for Integrative Medicine.

It’s coming someday, though. Just you watch.

What contributes to this misunderstanding is that Greg seems to have a massive strawman view of the SBM position that completely misunderstands our criticism of NCCAM when he says:

So, of the studies funded in 2011, are you saying that every single one of them was of no value, or just many? Have you looked through the list, and can you point to a few examples of grants given that are clearly re-addressing old ground about some woo or another or in some way supporting foundationless science?

These are the words of someone who thoroughly misunderstands NCCAM and misunderstands what our complaint as proponents of science-based medicine about NCCAM. Our complaint isn’t that there isn’t any good science going on there. There is, although it’s nearly all in the area of natural products pharmacology (studies that are routinely criticized, by the way, as too “reductionistic” by CAM advocates, by the way). Our point is that there is no need for a separate center for these modalities. CAM is a political and ideological entity, not a scientific entity. It is a cliche, but it is true. There is no such thing as “complementary” or “alternative” medicine. When a treatment modality is demonstrated to work through science and clinical trials, it ceases to be “alternative” or “complementary” and becomes just medicine. Having a center like NCCAM in essence legitimizes modalities that are quackery (such as acupuncture) while ghettoizing modalities that are not (such as milk thistle and other examples of natural products that might have medicinal value). Such a system serves neither science nor medicine, which is why NCCAM should be abolished and its grant portfolio absorbed into the appropriate Institutes and Centers of the NIH.

Another reason that nonphysicians, or even physicians who aren’t involved in clinical trials, often fail to understand that testing highly implausible treatment modalities in human beings is inherently unethical, as they violate principles of informed consent (patients aren’t told that the remedy being tested is incredibly unlikely to have anything other than placebo effects based on basic science alone, something I like to call “misinformed consent”) and clinical equipoise (the modality tested is incredibly unlikely based on basic science alone to to benefit the subject). Sadly, Greg even uses a tired old “science has been wrong before”-style argument about Creatin (as if that says anything about CAM or anything at all other than that Greg apparently mistrusts doctors) and then claims that we should appropriate what has been found to be “useful” in CAM into medicine. The problem is, he can’t identify anything useful in CAM that is really “alternative” or “complementary.” Milk thistle or herbal remedies don’t count. Neither do placebo effects. Both are–or should be–firmly within the realm of scientific medicine. Nor is it necessary to cede to quacks the realm of building caring relationships with patients in order to enhance placebo effects. One can enhance placebo effects through care and attention to patients without resorting to woo.

In the end, NCCAM exists to promote CAM far more than anything else. That is what Harkin intended, and he was disappointed when it failed to do a good enough job at it, haranguing NCCAM for not having validated enough CAM modalities. In such an environment, science will always be secondary. Dr. Briggs might be able to swim upstream for a while, perhaps even for a few years, in her effort to bring scientific rigor to NCCAM, but sooner or later time will win out. She will retire or move on to another position. When that happens, institutional inertia and pressure from woo-friendly legislators like Sen. Harkin and Representative Dan Burton (R-IN) will build again. What has happened before will happen again. Remember, back in the late 1990s when NIH director Harold Varmus tried to rein in NCCAM’s predecessor agency and bring scientific rigor to it, Harkin responded by elevating it to a full independent center and thereby reducing the level of control any NIH director has over it. Thus was born NCCAM in its current incarnation.

Whatever good science it might be doing now, NCCAM is beyond permanent reform.