The RAND Corporation: Supporting the “integration” of quackery with real medicine since 2008

As regular readers of this blog and related blogs know, over the last two or three decades there has been a successful effort to legitimize quackery in the form of what is now called “integrative medicine.” Three decades ago, modalities like homeopathy, acupuncture, much of traditional Chinese medicine, reflexology, chiropractic, and many other modalities based on vitalism, prescientific mysticism, and pseudoscience were rightly referred to as quackery. Then in the 1990s came “complementary and alternative medicine” (CAM), a term that sought to sand the rough edges of quackery off of the, well, quackery.

It wasn’t enough, though. After all the word “complementary” implies a subsidiary status for the woo. It implies that science-based medicine is the real medicine and all that other stuff, such as acupuncture, naturopathy, and the like, were just “icing on the cake.” In other words, it implies that they can be discarded, that they aren’t, strictly speaking, necessary. Of course, these modalities aren’t necessary because they aren’t real medicine, but that didn’t stop CAM advocates from coining a term that implies that quackery is co-equal with real medicine. Thus was born the term “integrative medicine.”

I’ve bemoaned for years the way that academic medical centers, seemingly under thrall of an ideology that has convinced too many otherwise sensible doctors that to be more “humanistic” or “holistic,” one must embrace nonsenses. I’ve frequently criticized examples of “quackademic medicine,” such as anthroposophic medicine at my old alma mater and traditional Chinese medicine and “functional” medicine at once fully science-based institutions. Unfortunately, in some institutions this degradation of scientific medicine has paid off.

What I hadn’t realized before so much is that it’s not just medical academia, at least in the traditional sense of medical schools and their affiliated academic medical centers. Seemingly respectable other institutions, such as think tanks, have embraced “integrative medicine” as well. For example, get a load of this essay by Doug Irving published on the RAND Corporation web site, entitled Science and the Healing Arts. It’s a perfect distillation of the sorts of dubious arguments made for pseudoscience that we’ve seen in academia and elsewhere. It’s as disappointing to see them coming from the RAND Corporation as it is from medical academia.

The RAND Corporation is a nonprofit global policy think tank originally formed by Douglas Aircraft Company to offer research and analysis to the United States Armed Forces. Since then, the RAND Corporation has expanded its purview and now does research and provides policy recommendations to many other areas, including (according to Wikipedia): child policy, civil and criminal justice, education, health, international policy, labor markets, national security, infrastructure, energy, environment, corporate governance, economic development, intelligence policy, long-range planning, crisis management and disaster preparation, population and regional studies, science and technology, social welfare, terrorism, arts policy, and transportation. On its website, the mission of the RAND Corporation is described thusly:

The RAND Corporation is a nonprofit institution that helps improve policy and decisionmaking through research and analysis.

For more than six decades, RAND has used rigorous, fact-based research and analysis to help individuals, families, and communities throughout the world be safer and more secure, healthier and more prosperous. Our research spans the issues that matter most, such as energy, education, health, justice, the environment, and international and military affairs.

However, health care is one area where the RAND Corporation has distinguished itself in health care policy. Indeed, I’ve cited the RAND Corporation’s work on vaccine safety (once again showing that vaccines don’t cause autism) and critically examined one of its not-so-awesome studies before. What I hadn’t realized before is just how deep into integrative medicine the RAND Corporation has dived. I should have. After all, I’ve critiqued at least one really bad CAM paper on “energy chelation” whose co-investigators included investigators working for the RAND Corporation.

Now I realize that the RAND Corporation has in essence teamed up with the woo-promoting Samueli Institute. In fact, in 2008, the two organizations formed the RAND/Samueli Institute Chair in Policy for Integrative Medicine.. Ian D. Coulter was appointed the first chair and remains the chair today. The article that caught my attention basically summarizes the RAND Corporation’s views, approach, and “achievements” in the world of “integrative medicine.” It begins with a trope that’s become so old in the world of CAM that I really should think of a name for it. I know. It’s what I like to call the false dichotomy of the future:

Modern medicine has a problem. It can fix a damaged heart, battle cancer into remission, and operate on the deepest recesses of the human brain. Yet it continues to struggle with the everyday anguish of an aching back.

Americans now spend billions of their own dollars seeking relief from such chronic conditions in alternative schools of health, such as acupuncture or chiropractic. RAND researchers have started to examine what it would take—and what it would mean—to more fully integrate such practices into the medical mainstream.

The obstacles are forbidding; the insurance questions alone might require an actual act of Congress to solve. But the benefits could transform health care as we know it, expanding its scope from sickness and trauma to whole-body wellness.

Unconventional medicine, once dismissed as quackery by the medical establishment, might be the missing piece of modern health care.

“How do we take two parallel systems and bring them together?” asks Ian Coulter, a senior health policy researcher who holds the RAND/Samueli Institute Chair in Policy for Integrative Medicine. “That,” he added, “is the future.”

Let’s just put it this way. Even if every premise stated above were true, it would not follow that “integrative medicine” is the future. Also notice what I like to call the “they called it quackery” trope, wherein the advocate claims that all that quackery is no longer quackery because it’s being validated by science ma-an. After a quick anecdote ment to illustrate the favorite alternative medicine propaganda point that modern medicine is good at dealing with acute disease (true) but not as good at dealing with chronic disease (easily questionable), the article elaborates on the “they called it quackery” trope, complete with a historical example:

To get a sense of why those different models of medicine remain a step outside the mainstream, start with a mild October day in 1893, when medical students lined the streets of Philadelphia to jeer at a parade of homeopaths. “Sugar pill, sugar pill,” they chanted, “never cured, and never will.”

The medical establishment spent decades deriding most other practitioners as dangerous charlatans—“unconscionable quacks,” according to a pivotal paper in 1910 that set the tone for generations of doctors. The American Medical Association tried to run chiropractors out of business until 1980, dismissing their practice as an “unscientific cult”; a federal judge later ruled its boycott amounted to an illegal conspiracy.

“We’ve come a long way,” said John Scaringe, a professional chiropractor and the president of Southern California University of Health Sciences. Its students of Eastern medicine and chiropractic will soon share their classrooms with future physician assistants, a pioneering attempt to integrate even the training of health care professionals.

“We’re not looking at it as holistic versus traditional health care, but contemporary health care,” Scaringe said. “We’re hoping that in the future, we don’t have those distinctions.”

Funny to see how in 1893, medical students seem to know more than the learned scholars of the RAND Corporation do today. After all, one of the most commonly used “whole medical system” alternative medicine is naturopathy, of which homeopathy is an essential part. I also can’t help that the article complains about the derision of chiropractors and other alternative medicine practitioners as “unconscionable quacks” as though it were a bad thing. Of course, what chiropractic advocates forget to note is that although, yes, the AMA lost that lawsuit, nothing in the court decision validates chiropractic. The decision was made on a very narrow basis (restraint of trade) and said nothing that supported chiropractic as a profession. Even if it had, law is not science; indeed, it frequently gets science wrong.

More disturbing is that Irving portrays having students of Eastern medicine and chiropractic in the same classrooms with physician’s assistants as a good thing. Why on earth would anyone want to “integrate” pseudoscientific medical systems that basically posit that disease is caused by either imbalances in a mystical “life energy” (tradiational Chinese medicine) or a nonexistent anatomical alteration (subluxations) causing an alteration in the flow of a nonexistent mystical life energy (chiropractic and “innate intelligence”)?

As for “distinctions,” notice the rhetorical ploy here. It’s one that I often use, but for a different purpose. Specifically, I deny a distinction between “alternative” medicine and science-based medicine. When I use it, it generally takes the form of a statement something like, “There is no such thing as ‘alternative medicine.’ There is medicine that has been scientifically proven to be safe and effective; there is medicine that has not; and there is medicine that has been scientifically shown not to be safe and effective. Almost all of so-called ‘alternative medicine’ consists of one of the latter two categories.” Of course, that’s not what Scaringe means. He means, although he probably doesn’t realize it and would strenuously deny it if called out, that we should eliminate the distinction between quackery and medicine.

Indeed, Irving describes the barriers to the implementation of policies facilitating that “integration,” which he risibly called “fully integrated health care”:

Yet the road from here to fully integrated health care, uniting the best of modern medicine and its alternatives, remains a long one, full of barriers, RAND researchers have found.

Some states, for example, still forbid medical doctors from partnering with complementary health providers; naturopathy is entirely outlawed in South Carolina and Tennessee. Many states license CAM practitioners but limit the scope of their practice and don’t treat them as primary health care providers.

Then there’s the tangle of insurance regulations. No insurance codes even exist for some CAM specialties. Government-sponsored health plans, including Medicare, also don’t include most CAM providers, a situation that in some cases only Congress can change.

I never thought I’d approve of something about the politics of South Carolina and Tennessee. I also know that advocates of pseudoscientific medicine have been lobbying Congress to try to get it to change those laws. Fortunately, as yet this effort has not been as successful as it has been in promoting federal funding of research into quackery through the National Center for Complementary and Integrative Health.

Still, the bad analogies don’t end here:

The result has been what one RAND paper called “siloed chaos,” with mainstream and complementary medicine practicing independently of—and sometimes wholly unaware of—each other. It also has built a double standard into America’s health care system, with the full suite of treatment options available only to those who can afford to pay out of pocket for them.

Apparently to the RAND Corporation, the cure for this “double standard” is to use a double standard with respect to scientific evidence in order to facilitate the “integration” of quackery into medicine. If you don’t believe me, just go back again and look at how risibly bad one such study designed to do just that co-authored by RAND Corporation investigators. Seriously, it tested a form of faith healing called energy chelation.

Also, seemingly if someone is willing to pay for a treatment it must be good:

What those patients want to know, RAND’s Coulter says, is not so much how a specific spinal realignment performed in a clinical trial, but whether it’s safe to go to a chiropractor in the first place—and whether the visit will help that aching back.

“We know that patients appreciate CAM, we know they give it very good satisfaction scores, we know they’re willing to pay for it,” he says. “We should start paying attention to this. This is worthy of attention.”

I could say the same thing about psychics: We know people appreciate psychic readings, we know they give them very good satisfaction scores, we know they’re willing to pay for it. We should start paying attention to this. This is worthy of attention.

No, it isn’t. Just because people are willing to pay for something and like it doesn’t mean that something has value. Scientology e-meters also come to mind. It’s sad to see a think tank like the RAND Corporation use such non sequiturs to support policy positions.