Genre: Information/Explanation

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: "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 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. Potential To Change Health Practices: Is it reasonably likely that the results will make a difference to consumers, providers, or policymakers? 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/natural\\... 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. Comments Julian Frost NOYDB November 1, 2012 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... Definitions of Pragmatism: "The doctrine that the meaning of an idea or a proposition lies in its observable practical consequences." "An approach that assesses the truth of meaning of theories or beliefs in terms of the success of their practical application" "A practical, matter-of-fact way of approaching or assessing situations or of solving problems." Pragmatism. Dr Killen keeps using that word. I do not think it means what he thinks it means. Eric Lund November 1, 2012 NCCAM, of course, fails on at least three out of four of these counts. Orac is being kinder than I would. I read that statement and asked myself, "Which criterion does Orac think NCCAM actually meets?" And we're spending $125M per year on this stuff? That's about a thousand grants of the size I generally propose for. I recognize that R01s are generally a bit bigger than that (I'm not a biomedical type), but we're still looking at, minimum, several hundred research grants. Or a NASA Small Explorer satellite per year, with money left over. What medical advances, or pure scientific knowledge, are we foregoing to pay for these studies of medical woo? alindrom November 1, 2012 Apparently, CAM practioners can get funded by NCCAM to learn how to do research. @Mark: That article is satire -- but it's bad that such a thing is plausible. lilady November 1, 2012 "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. OT: but is unabashed, flagrant promotion of one's self and one's business during a devastating catastrophe by a woo-meister ever TRULY OT @ RI? I should think not. Today Gary Null via his internet radio network (Progressive Radio Network) announces that he will give a lecture about surviving disaster DURING a disaster in NY. Over the past few years, he has ramped up fear about what would happen following a nuclear meltdown ( *a la* Fukushima), hurricane ( like Katrina) or a power grid failure following a solar storm, producing films and lectures on the subject as well as selling related products. In addition, he will have a price cut on various storeable goods ( beans, rice, lentils) by the 50lb bag at his health food store -- cash only. PLUS he will have his staff of nutritionists there to counsel you about what products might be useful for you, live and over the phone. Of course, his own specialised counselling is reserved for only the most serious cases. Like Mike Adams, whenever people are frightened, worrying about the future, he's there to scare you even more and then sell you nonsensial solutions. All of his recent crap is lovingly archived for posterity @ PRN Narad November 1, 2012 In addition, he will have a price cut on various storeable goods ( beans, rice, lentils) by the 50lb bag at his health food store -- cash only. These items don't store as well as one might think. Old beans cook up terribly, and 50 pounds of rice has "Meal moths: They're what's for dinner!" written all over it. (AoA also reprised their "tsunami of autism" routine over the weekend with "Hurricane Autism has made landfall," i.e., "You think you've got problems? Ha!") Krebiozen November 1, 2012 Eric Lund, And we're spending $125M per year on this stuff? It's not just NCCAM, there's also OCCAM (Office of Cancer Complementary and Alternative Medicine) with a budget of $122 million. In total, the US spends about as much on this stuff as the GDP of Finland. JBC November 1, 2012 I'd like to take Sen. Harkin and stick him so full of acupuncture needles that he'd be begging me to water board him with homeopathy solutions just to get some relief. Everything that Dr. K writes is just so much filler and really says nothing at all -- kinda like SCAM. (I'm totally for including the 's' in the CAM acronym because supplements are a HUGE part of the whole scam -- the gateway drug if you will.) Eric Lund November 1, 2012 @Denice: So Mr. Null is talking about surviving a scenario involving widespread power disruptions in a big city, and at the same time he's selling food you have to cook? I hate to break it to him, but for many people in this country (especially in big cities), there are no available safe cooking options without electricity. Fireplaces these days aren't designed for cooking, and to use a camp stove or gas grill indoors is asking for carbon monoxide poisoning. That's why you're supposed to stock up on canned goods -- so you have food on hand that you don't need to cook. LindaRosaRN ttp://www.scienceinmedicine.org November 1, 2012 Dr. Killen's use of terms, such as "pragmatic," is undoubtedly a calculated message to his funders (i.e. Congress). I wonder what Francis Collins would make of the moronic essays posted on the NCCAM blog. Who in a position of power would care? Edith Prickly November 1, 2012 re Gary Null's survival preparedness strategies, we all know reality-based advice is not his strong point -- thought I'm surprised he even bothers selling actual food. Aren't all his supplements good enough? Pass the Ultra Power Meal with extra Vitamin D, please! OTOH, the profit margin is probably much higher on beans and rice. lilady November 1, 2012 Well I posted at the NCCAM site, (still in moderation), using "palindrom's" link... "Normally the duration of the award will be for one year, but it can be extended for a second year if evidence is provided to show that the CAM practitioner is actively pursuing the next step in his/her research career. The principal investigator (PI) of the grant being supplemented can request up to $100,000 per year in direct cost for support of one CAM practitioner candidate. These funds may be used for salary and fringe benefits for the CAM practitioner, research supplies, travel, and/or tuition for courses if they enhance the research experience. Salary and fringe benefits for the candidate should be consistent with the institution's salary structure. No funds may be requested to supplement the salaries of the PI or other personnel, or to purchase equipment. This initiative is focused on providing a research experience for CAM practitioners and is not intended to support clinical residency training or other clinical practitioner training. Upon completion of the supplemental support, those CAM practitioners who chose to pursue a research career will be expected to compete for research training, career development, or research grant funds appropriate for their stage of career." This Notice encourages partnerships between institutions with demonstrated expertise in training complementary medicine practitioners and institutions with demonstrated expertise and capacity in conducting clinical and translational research. With this new FOA, NCCAM is developing a clinical research training program aimed at improving the capacity of the integrative health field to carry out rigorous research. The program will fund coherent and unified partnerships between institutions with research intensive environments (e.g., T32 and CTSA institutions) and institutions with curriculums focused on clinical training of practitioners in complementary modalities and disciplines that also have faculty with a substantial interest in rigorous clinical research. The partnership must be committed to create a comprehensive interdisciplinary complementary and integrative health clinical research training program that builds on the existing strengths, expertise and infrastructure of both institutions. The program will support mentored research-training and hands on experiences in clinical research as well as trainee-focused developmental efforts including didactic activities in clinical research methodology, integrative health, and trainee-initiated pilot clinical research projects within NCCAM's research priority areas ( http://nccam.nih.gov/grants/priorities ). The funded institutional programs are expected to generate a cadre of research clinicians who are able to participate fully in multi-disciplinary teams engaged in complementary and integrative health research." I pointed out that these proposals/grants do NOT meet any of the four objectives listed by Dr. Killen...but rather are paying tuition/training costs for CAM practitioners and for expansion of existing "Integrative Medicine"/CAM programs. err doktor bimler November 1, 2012 tMr. Null is talking about surviving a scenario involving widespread power disruptions in a big city, and at the same time he's selling food you have to cook? Good luck with water supplies, for the cooking of those beans. Does the Null range of products also include his own bottled water? Rich Woods November 1, 2012 @Eric Lund: &gt; @Mark: That article is satire -- but it's bad that such a thing is plausible. I'm going to go out on a limb and suggest that Mark already knew that. If you haven't already read it, take a look at "Good Omens" (by Terry Pratchett & Neil Gaiman) -- one of the Four Riders of the Apocalypse (Famine) does what you're describing Denice Walter November 1, 2012 @ Narad: Moth larvae in rice would be a real problem for vegans. @ Eric Lund: Actually, he also tells his followers to keep a bike so they can escape the nightmare of a city without electricity or a nuclear disaster. So I guess you'd have to cart the rice out and use a camp store. " Why didn't you move out of the city** as I told you *years* ago?" , he'd probably gloat. .-btw- canned goods are straight out. ** despite what he and Mikey say, country life might not be the best option in a world with soaring fuel costs. These guys lecture about being TOTALLY self-sufficient and living in small groups of like-minded 'back-to-nature' folks far from the madd(en)ing crowd. I'm sure those would be really jolly places. I'll make a note to never visit their new utopias. lilady November 1, 2012 I've got a long comment in moderation. I posted a comment on the NCCAM website, about the NCCAM funding of tuition and funding of expansion of existing "integrative/CAM" programs. This is a little off topic, but the New York Times has been running a series about the Civil War, and it just ran an overview of what it was like for soldiers to deal with diseases which we now prevent, like measles, but which could be epidemic back then: The correspondence between several of the vaccine-preventable diseases that are discussed in this blog, and widespread illness in the 1860s, is pretty remarkable -- smallpox, mumps, measles, influenza are given as examples. Diseases treatable with modern antibiotics were also endemic. Diseases that require control of fluids and salts were also widely debilitating. I know that there are lots of books on this subject, but the NYT blog "Disunion" puts a lot of 19th century material together in an ongoing epic story. For the non-USA readers here, the title "Brother against Microbe" is a takeoff on the description of the American Civil War as Brother against Brother. That same theme was used by an Argentinian novelist whose widely read book about the first world war was made into the Valentino film The Four Horsemen of the Apocalypse. Alain Montreal for the moment November 1, 2012 Regarding alternative methods of cooking, when we brewed our beer 2 weeks ago, we had a propane burner on the balcony and I supposed I could do likewise at home but still, there's the hassle of refilling (sp?) the bottle of propane which might be difficult in an emergency crisis. Alain Alain November 1, 2012 Thinking about it, despite Mike Adam's effort to be self sufficient, we're always gonna rely on someone else and often, there will be a network of people we have to rely on; especially in case of emergency. The philosofer. Julian Frost November 2, 2012 Did anyone else notice the contradiction in what Autismmum quoted? a non-efficacious medicine might, in some situations, be effective but... That is why we put more weight on evidence of efficacy than of effectiveness. On a side note: "Oh, we'll drink, a drink, a drink to Lily the Pink, the Pink, the Pink The saviour of, the human ra-a-ace for she invented, Medicinal Compound Most efficacious, in every case." Edith Prickly November 2, 2012 Denice: Actually, he also tells his followers to keep a bike so they can escape the nightmare of a city without electricity or a nuclear disaster... Oh, that is rich. I wonder how far he's expecting people to get with fifty-pound sacks of rice strapped to their backs? I find survivalist crank beliefs oddly fascinating -- they're essentially the secular version of the End Times mythologies that human beings are so fond of, with natural /manmade disasters taking the place of a vengeful deity who decides to wipe everyone out. That is, everyone except the intrepid few who listened to the wise oracle's warnings and prepared themselves accordingly -- and they also get the promise of a chance to remake the world in their image once all the dupes and unbelievers have been eliminated. What's truly hilarious in that scenario is the notion of preening gasbags like Null or Mike Adams lasting even 10 minutes actually doing what they advise their followers to do. Alain: Thinking about it, despite Mike Adam's effort to be self sufficient, we're always gonna rely on someone else and often, there will be a network of people we have to rely on; especially in case of emergency. Exactly. Even if you managed to survive for a while on your own in an isolated area, eventually your food and water will run out, or you'll get sick, break a limb, get attacked by a hungry animal, have a mental breakdown....and you'll either have to look for help from others or die anyway. Karl Withakay ttp://blog.cordialdeconstruction.com November 2, 2012 Somehow I missed this post yesterday. "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." Let me fix that for him: 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 are sujected to a different and lesser, substandard burden of evidence for efficacy, safety and explanation than science based medicine. This way it covers the various normally science-based modalities, such as diet, nutrition, exercise, natural products pharmacology (a.k.a. pharmacognosy), and the like, that are rebranded and practiced as "CAM" with CAM standards. By fundamental ideology and approach, CAM and science based medicine are mutually exclusive. The only way any CAM modality should ever be integrated into legitiamte medical practice is if it becomes science based through rigorous, quality scientific investigation*. So far, we're still waiting for this to happen for any CAM modality. What has actually happened is that science based modalities such as diet, nutrition, exercise, pharmacognosy, etc have beend de-scienceified/ bastardized and integrated into CAM practice, which some people then integrate back into legitimate medical practice, making the apple pie into apple-cow pie. It may make the cow pie imperceptibly more palatible, but it doesn't help the apple pie one whit. * and there really needs to be some reasonable semblance or inkling of plausibility to even warrant expending any resources on scientific investigation. Sorry Reiki and Homeopathy. Denice Walter November 2, 2012 @ Edith Prickly: Another version of apocalyptic thought amongst the woo-doers is that of personal 'end times': if you eat a typical so-called western diet, you'll get CANCER ( or an MIA or stroke) and DIE! whereas if you follow his tripe you'll live to 140! ( -btw- the number is a citation,not hyperbole- see "How to Live Forever"). They sometimes do advocate for small groups. of like-minded- or what I'd call woo-compounds ( cult-de-sacs?) There is a wealth of garbage between these two. lilady Still waiting for my post on the NCCAM site to come out of moderation November 2, 2012 @ Karl Withakay: You should really go to the NCCAM website to see other posts from Dr. Briggs ("Quirky Ideas") and Dr. Killen ("Plausibility").