Tuesday, March 17, 2009

Should the NIH Alternative Medicine Center be Defunded?

I only became aware of the controversy about the National Center for Complementary and Alternative Medicine (NCCAM) from an article in this morning's Washington Post - "Critics Object to 'Pseudoscience' Center."

In 1992 Congress allocated $2 million to establish an Office of Alternative Medicine (OAM) at the National Institutes of Health "to investigate and evaluate promising unconventional medical practices." In 1998 NIH Director Dr. Harold Varmus proposed having all alternative medicine research done through the NIH institutes, with the OAM coordinating the process. Senator Tom Harkin (Iowa), who pushed for the founding of the OAM in 1992, now pushed through legislation that elevated its status to that of a Center (NCCAM). Current funding is approximately $120 million.

The current controversy was launched on January 15 by a posting on the website the Obama administration created during the transition to solicit ideas:
Biomedical research funding is falling because of the nation's budget problems, but biomedical research itself has never been more promising, with rapid progress being made on a host of diseases. 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.

...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.
Senator Harkin's comments, intended to support NCCAM, only make the Center look worse:
"One of the purposes when we drafted that legislation in 1992 . . . was to investigate and validate alternative approaches. Quite frankly, I must say it's fallen short. I think quite frankly that in this center, and previously in the office before it, most of its focus has been on disproving things, rather than seeking out and proving things."
The idea that the Center's role is to validate faith-based health beliefs shows a deep misunderstanding of science. If the Center has a role it is to test hypotheses, not to validate faith.

But the controversy over NCCAM isn't new. In the early 20th century organized medicine was horrified by the growth of Christian Science. Wise physicians recognized that the emergence of Christian Science reflected a sense that something was missing in "conventional" medicine. That hunger is still present. More than 1/3 of U.S. adults use "alternative" medicine techniques.

This enthusiasm proves nothing about effectiveness. But it does point to phenomena that warrant serious scientific study. Otherwise the field will be ceded to quacks and hucksters, in the tradition of Mark Twain's Duke and Dauphin, selling snake oil.

I don't have a sense of how well NCCAM has carried out its mission, but some of its goals seem right on target, as exemplified by:
* Identify the common and specific features of widely used mind-body medicine practices
* Determine the extent to which patient expectations prior to treatment and satisfaction following manipulative and body-based practices are related to objectively measured biological endpoints
* Enhance understanding of the social, cultural, and economic factors relating to the use of CAM.
But there is a worrisome ambiguity in other goals:
* Establish the efficacy of selected biologically based practices to maintain health, prevent disease, and treat conditions of public health importance
* Document the benefits of some CAM whole medical system treatments for selected health conditions
Is the aim here to evaluate whether specific widely used techniques are effective and provide benefit, or to "prove" that public beliefs in these techniques are indeed true?

If it's the latter, NCCAM should be defunded. But insofar as it undertakes serious evaluations of widely used techniques, and studies just what is happening when patients derive significant subjective benefit from techniques that are not validated in controlled trials, NCCAM will be making a worthwhile effort.

In voting with its money and time the public is saying it feels healed by alternative techniques. The mechanisms of healing are worthy of scientific study, just as the mechanisms of disease are.


shawmutt said...

10 years, hundreds of millions of dollars of taxpayer money used, and not a single "alternative" modality found any more effective than placebo.

The answer's pretty clear to me.

Jim Sabin said...

Hi Michael -

Thanks for the comment!

You're right that by the criterion of finding significant cures NCCAM is a failure. There's always the possibility that a new finding will emerge tomorrow, but the track record doesn't support optimism.

But societies (not just ours) have a long history of very substantial segments (more than 1/3) using "alternative" modalities. I think that apart from the thus far elusive new cures, there are two additional kinds of important discoveries to make from this phenomenon.

First, since we know that many (millions) swear by the alternative practices, it is important to understand what the "therapeutic" impact is. "Placebo response" is the umbrella term we use. Deepening our understanding of the placebo response and how to foster it more actively, is a valuable area of research.

Second, users of "alternative" modalities are giving at least a partial vote of no confidence in our bloated allopathic medical system. Deepening our understanding of the ways in which self perceived needs and interests are not being well served is also valuable.

That said, if I were confident that the Institutes would support these research objectives I would endorse Dr. Varmus's proposal that they take responsibility for supporting the area.



Anonymous said...

Defunding NCCAM would be akin to throwing the baby out with the bathwater.

Better administration in an effort to produce better study design would be a more prudent course.

The mere fact that Glaxo would pay 3/4 of a billion for a company that hasn't conducted a single human trial on resveratrol should be a pretty good indicator that the drug indudtry believes that there are alternative modalities that are more effective than placebo. Their actions speak far louder than their words.

There's 30 years of science on functional medicine. It's efficacy is well documented.

Rik Longenecker


Jim Sabin said...

Hi Rik -

Thanks for the comment.

I agree that defunding the objectives of NCCAM would be a bad policy. I'm more flip-floppy, however, on whether those objectives are best pursued in an independent center (NCCAM) or dispersed into the existing institutes.

I've never liked the labels "alternative" or "complementary." Those terms connote separation. But in my practice (and my own life) I've seen the many things people do to promote health and well-being as unitary, in the sense that they are motivated by the same goals.

For that reason I would prefer seeing the NCCAM objectives pursued through the separate institutes, which themselves are directed at our major health priorities. But I'm dubious as to whether this would actually happen. That's why I flip-flop on how the NCCAM objectives can best be pursued.



Anonymous said...

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Jim Sabin said...

Hi Medical Assistant -

Thanks for the kind words!



Unknown said...

I support the release of funds to legitimate NIH agencies by defunding NCCAM. As an IRB chairman I have had occasion to oversee "studies" put forth by alternative sources and funded by the NCCAM. Aside from those which simply could not answer the questions posed due to poor science, I pose one example. A major institution, respected in the NCCAM world, put together a proposal which got high marks from the NCCAM. We approved the study, designed to prove/disprove the effectiveness of echinachea. The results showed strikingly no effect. Since the study sponsor teaches that this natural product is effective, they simply filed the data, did not publish, and continue to teach their students that echinacea is effective. So much for science. (Other studies from none NCCAM sources - 2 that I am aware of - also demonstrate conclusively that echinacea has no effect.)

Jim Sabin said...

Hello Richard -

Thank you for your disturbing comment. Unfortunately, simply filing negative results has happened all too often. NCCAM studies have no monopoly on this practice. You are not alone in your criticism of the scientific standards NCCAM applies. If NIH agreed that NCCAM standards were below what NIH expects NCCAM should either shape up or ship out. I would hope that the former occurred. Because there is so much public interest in "alternative" treatments, studying these treatments systematically is important. But if negative findings emerge they obviously should be made public.