What is the role of NCCAM at the NIH? Dr. Killen tries to explain.

I’d like to publicly thank Dr. John Killen, Jr. I was looking for something to write about yesterday evening, and, just when I was beginning to despair that I might have to do another post on the lunacy that is antivaccine nonsense (even I get tired of taking on antivaccine idiocy, as regular readers know), he generously provided me with a perfect non-vaccine-related topic. Truly, to a skeptical blogger and supporter of science-based medicine like myself, the National Center for Complementary and Alternative Medicine (NCCAM) blog is the gift that keeps on giving. I’ve written a lot of critical things over the years about NCCAM, from pointing out how it has a track record of funding bad science and promoting quackademic medicine to the point that it can never be truly scientific, to pointing out how its most recent “conversion” in its strategic plan boils down to a promise to do good science for a change, to making a bit of fun of its recent attempts to justify its existence by arguing that it’s now taking scientific plausibility into account. It’s all been enough for me to half-jokingly suggest that we should take off and nuke NCCAM from orbit. It’s the only way to be sure.

This time around, Dr. Killen is trying once again to justify NCCAM’s existence by describing what he thinks to be “our center’s niche at NIH.” One thing that’s clear right up front in this post is that your comments are having an effect. Several of you have become regular commenters over at the NCCAM blog. No, no, don’t deny it, I know you have, and I’m proud of you for putting a bit of heat on the NCCAM leadership to try to explain themselves. It’s a thankless task, in some ways more difficult than taking my approach, which is to blog away about NCCAM. We each do what we’re good at, and I’m good at blogging. I’m also good at wading into comment threads, but I can’t do both. I just don’t have the time. So this division of labor has been most beneficial.

But back to Dr. Killen’s lament. In his post, he attempts to answer two criticisms/questions that frequently come up, and guess what? They’re criticisms and comments that I (and other skeptical bloggers have been hammering NCCAM about for years now. Those issues, according to Dr. Killen, include:

1. “questions about what makes something “specifically complementary and alternative medicine (CAM),” or why other NIH Institutes or Centers (ICs) can’t do what NCCAM does, since the scientific methods and approaches are the same”; and
2. a perspective that CAM borrows from other science-based fields “to lend false legitimacy to pre-scientific magical thinking.”

See what I mean? You and I have been having an effect, skeptical bloggers like myself hammering NCCAM for its failure to consider scientific plausibility in decisions regarding which grants and educational programs to fund and for its doing nothing that other institutes at the NIH could do better. So what is Dr. Killen’s response to these criticisms? Let’s take a look. First, he sets things up by trying (and failing) to produce a good definition of CAM:

As it is generally defined, the term CAM encompasses an extremely large and eclectic assortment of substances, interventions, practitioners, approaches, theories, and dogmas that share only one common denominator: they once were or still are—by virtue of origin or use in the real world—somehow “out of the box” of modern, scientific biomedicine. While generally useful in describing attributes of health care, such definitions by exclusion pose challenges for NCCAM and the field of research we support. Among them are the plethora of potential research topics, vagaries about when or whether something is in or out of “the box,” and issues highlighted in my previous post on “Plausibility”.

Of course, Dr. Killen’s prior post on “plausibility” certainly cracked me up. One reason was because Dr. Killen basically admitted that many CAM modalities are, from a scientific viewpoint, utter nonsense, referring to them as “ensconced in belief systems” that “lack foundations in modern science,” but argued that we should study them anyway. In essence, Dr. Killen admitted that, yes, a lot of CAM is unscientific and a lot of CAM practitioners and advocates of CAM research can’t defend their quackery based on science but that, instead of accepting that most of it is pseudoscientific nonsense, we should spend $125 million a year (the approximate budget of NCCAM) to study it anyway.

Amazingly, Dr. Killen has an admission that I find very disturbing but not very surprising. Given the problem with plausibility that underlies so much CAM research funded and promoted by NCCAM, one would think that the issue of what is and is not “CAM” would be a big deal around NCCAM. You’d think that the leadership of NCCAM would be very much interested in such questions. Apparently, to hear Dr. Killen tell it, you’d be wrong:

Frankly, we do not spend much time wrestling with questions about whether something is “specifically CAM.” Instead we look at the wide range of things that fall more or less under the CAM umbrella from a much more pragmatic perspective on real-world health practices, and see four things. First, the public is using many of these interventions on a large scale, very often “off the shelf” or otherwise without professional guidance. Second, health care providers of all sorts are integrating some of these interventions into their health care practices on a substantial scale. There are many reasons, some good and others less so, but the fact that this is happening more and more is clear. Third, consumers and providers are, in some instances, perceiving benefits; in other instances, consumers are experiencing harms. Finally, everyone is confronted, routinely, with a paucity of reliable scientific evidence concerning safety and usefulness. NCCAM’s congressional mandate and our strategic approach rest squarely in the highly pragmatic need to bring more, objective, reliable scientific evidence to the most important of these evidence gaps.

Ah, pragmatism! CAM proponents do love their pragmatism, don’t they? When it comes to studies, they much prefer “pragmatic” unblinded studies to rigorous randomized clinical trials. When it comes to even defining what CAM is, they prefer the “pragmatic” approach that Dr. Killen has just described. There is a problem with this, and it’s a big one. First, such a “pragmatic approach” completely ignores the history of quackery/alternative medicine/CAM/”integrative” medicine. That history, as I’ve pointed out before many times, involves taking science-gased modalities, such as nutrition, exercise, natural products pharmacology (a.k.a. pharmacognosy), and the like, and then “rebranding” them as “CAM.” These sorts of science-based treatments then are lumped in with the real quackery, like “energy healing,” “homeopathy,” and the like. This is not an accident. The known plausibility of nutrition and exercise and the know efficaciousness of such modalities for many health problems “rub off” on the woo, as they’re all lumped together as CAM. This “pragmatic” approach advocated by Dr. Killen facilitates this “rebranding” and “bundling” of certain plausible science-based modalities with CAM. In essence, Dr. Killen is unconcerned with actually defining CAM. All he cares about is that it’s outside the scientific mainstream and that people use it.

On one level, this is not an entirely unreasonable position to take, or wouldn’t be if NCCAM weren’t so deeply involved in not just studying the quackery that is so much of CAM but in actually promoting it through educational R25 grants, such as the one that funded Georgetown’s CAM program. You might recall that that program involved the “seamless weaving” of CAM into the medical school curriculum from day one, an example being having an acupuncturist teach “acupuncture anatomy” in first year anatomy class. It might be a defensible position if NCCAM didn’t have to placate quacks on its advisory board. I truly don’t envy NCCAM’s director, Dr. Josephine Briggs. Trying to be science-based directly conflicts with her need to keep these people happy and, above all, to keep her main Congressional patron, Senator Tom Harkin, happy. Senator Harkin, you may remember, becomes quite testy when NCCAM doesn’t validate his beloved quackery.

That leads to NCCAM’s four factors for priority setting:

1. Scientific Promise: How strong is the body of evidence supporting the concept?
2. Amenability to Rigorous Scientific Inquiry: Are there reliable and reproducible methods—e.g., diagnostics, outcome measures, biological effects, quality control, etc.?
3. Potential To Change Health Practices: Is it reasonably likely that the results will make a difference to consumers, providers, or policymakers?
4. Relationship to Use and Practice: Do the methods and approaches actually address the most important questions about use or practice in the real world?

NCCAM, of course, fails on at least three out of four of these counts. I’m hard pressed to think of anything that NCCAM has investigated over the last 14 years that shows much in the way of scientific promise, has much potential to change health practices, or actually address the most important questions about use and practice in the real world. To me, what that means is that it doesn’t really matter if these modalities are amenable to rigorous scientific inquiry. What’s the point, after all, of investigating modalities that show no scientific promise, aren’t likely to change health practices for the better? The only area where NCCAM has arguably funded research that might change health practices is in the study of placebos, and the changes suggested are not a good thing. With more and more CAM having failed to meet even the most minimal standards of efficacy (or to show any efficacy at all above placebo), increasingly CAM practitioners and NCCAM are rebranding CAM yet again, this time as “harnessing the power of placebo.” This is not a good thing. Think of it this way: What would the reaction of most CAM practitioners be if a pharmaceutical company said that it should be given permission to market a drug that fails to do any better than placebo control? They’d be outraged. Yet that is exactly what CAM practitioners do with their treatments. They’re no better than placebo, but CAMsters want to sell them as real treatments.

All of which brings us to what Dr. Killen thinks to be NCCAM’s niche at the NIH:

There are two points to make about NCCAM’s ecological niche within NIH at large. First, we consult and collaborate all the time with our colleagues in other ICs. For example, we routinely seek advice on proposed intervention trials to ensure that the study is clinically relevant and employs state-of-the-art methods and measures. Second, NCCAM’s primary scientific identity, now honed by more than a decade of actual experience, lies in understanding how best to address the specific scientific challenges of studying interventions that fall under the CAM umbrella. For example, NCCAM has evolved a set of policies and practices for applying the tools and methods of pharmacology and pharmacognosy to investigation of herbal medicines, dietary supplements, and probiotics (nccam.nih.gov/research/policies/naturalproduct.htm). These set the pace at NIH for research on these products because they specifically address a variety of issues related to the often unusual regulatory status of these products.

See what I mean? “Apply the tools of pharmacology and pharmacognosy to the investigation of herbal medicines, dietary products, and probiotics”? Why is a special center in the NIH needed for that? It isn’t. it’s all pharmacognosy and pharmacology. That’s all that’s needed. There’s nothing special about herbal medicines, dietary products, and probiotics, but CAM proponents want you to think that there is because it justifies separating them from the rest of pharmacognosy and putting them under the rubric of NCCAM.

Finally, Dr. Killen pulls a gambit that I like to call, “What have you got against science?” Basically, he castigates NCCAM’s critics for focusing on how NCCAM lends legitimacy, the imprimatur of the federal government, to quackery:

It may be unavoidable that some choose to see the existence of Government investment by NIH in this research as lending false legitimacy to interventions before it is due. We see things differently, believing very strongly that the net benefits of more, reliable, objective scientific evidence—whether or not it favors use—far exceed any risks of “false legitimacy.” NCCAM is simply not about legitimizing anything unless that is where the evidence points. As the track record of NCCAM-funded research demonstrates clearly, it sometimes does and often does not.

“It sometimes does”? That’s news to me. After 20 years and a close to a couple of billion dollars, NCCAM has yet to “legitimize” (or, more properly) scientifically validate a single CAM therapy as unequivocally efficacious and useful. Yes, it’s produced a number of negative studies, but even those are spun as somehow indicating that there is promise enough to justify further research. In particular, NCCAM has been pushing “mind-body” medicine lately, a particularly silly and useless term because it is rooted in Cartesian mind-body dualism, as though the mind were separate from the body. It’s not. The mind is a manifestation of brain function, and therefore is the body. It’s not this magic force that’s separate from the brain, but such is the implication of the very term “mind-body medicine.”

And you skeptics, you! You’re not real scientists! Real scientists (like those at NCCAM) are so dedicated to science that they don’t care if they inadvertently lend false legitimacy to quackery by funding bad studies that equate placebos with CAM in such a way that CAM is rebranded as “harnessing the power of placebo.” But that’s a small price to pay for expanding the frontiers of knowledge and they’re willing to take that risk because they’re just that dedicated! They go where the evidence shows, no matter what!

Perhaps that lack of concern for legitimizing quackery is the reason why NCCAM funds so many training programs to teach “integrative medicine.” That would certainly explain a lot.