Skeptics love to hate CAM. And often, with good reason. Alternative medicines or medical treatments, as is often pointed out, become “mainstream” when the available science suggests that they work, so it is almost axiomatic that “alternative” means “unproven” and it is probably almost always true that the kinds of things that end up as “alternatives” come from sources with poor track records. For instance, one of the most common forms of alternative medicine used over the last several decades is Extra X where X is some substance we know the body uses, and that we know a deficiency of is bad. The idea is that if something is good at a certain level, loading it on by a factor of anywhere from two or three to several hundred over the usually consumed amount must be REALLY good. If a substance is used in the body for something we like … an immune system function, tissue repair, muscle energetics, etc. … then consuming vast quantities of it MUST be good. And, in some cases, this turns out to be true. There are times when consuming huge quantities of potassium is medically indicated, for instance. But this does not mean that a daily intake of seven or eight hundred bananas is a good idea. It turns out that loading huge quantities of vitamins and minerals has very little or no positive effect and it can be rather harmful in some cases. (Though there may be some exceptions.)
Another source of alternative medicine is plants or other “natural” products. Over human prehistory and history, around the world, people have adopted the practice of eating one kind of plant or another (or extracts or products from those plants) for a ritual purpose, or sometimes, health related reasons. If we believe that culture is highly adaptive and that human cultures would, over the long term and on average, mainly adopt and maintain practices that work, then we would expect a lot of “natural” cures or supplements to be effective. And, it turns out that some are. However, it is also true that some of the most effective natural substances have already been incorporated into our mainstream medicine, and in some cases, subsequently replaced by improved synthetic versions of the original “natural” product. Mostly, though, human culture turns out to be a lot like chimp culture; Both humans and chimps do things that seem at first to have a certain purpose but are by and large arbitrary and non-functional in any direct sense. (There is some interesting discussion of this here.)
So, we can probably think of “Alternative Medicine” as a proving ground or sandbox for new ideas, but one that kinda sucks as a place to actually get new ideas that lead to anything. In fact, University research departments and Big Pharm have expended a fair amount of effort in examining plants and animals as sources of medicines. I don’t think it is ever going to be productive to search around among, say, New Age Americans to see what they are doing to find new cures for diseases. Monitoring plant and animal use by cultures world wide is probably still worthwhile because it is interesting, but likely to also be low-yield in terms of real medicines. The systematic examination of life forms for interesting and useful molecules is probably the best way to go, until science has caught up somewhat with nature and can produce and test newly imagined molecules more effectively. And that day is coming; It will not be long before there is a new anti-biotic or psychotherapeutic drug invented by someone’s screen saver.
Alternative medicines might have “Placebo effects.” But I’m pretty sure I understand placebo effects and I’m pretty sure that the phrase is misused and misunderstood. Nonetheless, some people may feel better or improve more quickly from certain conditions if they carry out certain medically useless rituals. And, even if this is of only limited use, people are still going to do it. Therefore, it seems reasonable to allow for a certain amount of “Alternative Medical” research on wooish substances simply to demonstrate their safety or lack thereof. I want the NIH and the FDA to discover that this or that herbal remedy is dangerous, so people can be warned or the product regulated. But the search for effective cures among substances that we know are ineffective is a bad idea.
Having said all that, I would now like to point out that the term “CAM” has three words in it, not one. CAM does not mean what most people think it means.
Most Skeptics, when they hear the term “CAM” focus on “Alliterative” and get all skeptically thinking about that and claim that CAM is BS because acupuncture does not work, your chiropractor is a quack, and creatin does not build muscles. At the same time, people who are favorable towards CAM hear the term “CAM” and hear “Medicine” … i.e., a thing that cures you makes you feel better, etc. Neither group is hearing the first word in the phrase: Complementary!
If you like the alternative stuff, and you take your Echinacea every morning, then you may need to be reminded that CAM is not Medicine. It is Complementary. So, for instance, the process of dialysis is not CAM, it’s medicine. The practice of making a dialysis room, where someone will sit hooked up to a bunch of tubes for several hours a week, a more relaxing and less stressful place to be, is CAM. A practice that is complementary to the medicine, and maybe a good thing.
I had the opportunity a few years ago to advise a number of students in one of the country’s largest CAM programs. The CAM program was designed for medical students, but undergraduates in my program pursuing individualized degrees could sometimes hook up with CAM faculty and do projects, or even an entire undergraduate degree, related to faculty interests. I want to say that all of my CAM students but one were students that I inherited when I started working in this particular degree program (which had nothing to do with the CAM department) and it was unlikely that had the program not been cut and had I continued there, that I would personally have attracted or developed very many additional CAM students. Having said that, the students I worked with were smart, industrious, and not annoying from a skeptical perspective (mostly). I was quite impressed, in fact. And, to help my fellow skeptics understand what CAM is a bit better than they may now, I want to relate a few experiences.
At one point I was asked to sit on the oral exam committee of a student graduating from the program. My main question for the student was this: “You’ve been in the program for several years. What sorts of things that you thought were true, or likely true, in the beginning of your time in the program that you now think differently of, and why?”
The answer was essentially this: In early days, she said, she and others thought that “Alternatives Medicine” would provide specific cures for specific things. Acupuncture would be good for pain, some herbal extract would be good for a certain infection or other disease. Now, she said, we understand that most of these things either don’t work at all, or if they have a benefit, it is a more general one related to a person’s sense of well being or level of stress.
In other words, what she learned after being involved in this program for a few years was pretty much what you, as a skeptic, were probably thinking as well.
Another students worked out something I mentioned above: How to make a dialysis facility less stressful. That same student, in a different project, worked on the mind-body-art problem. When someone engages in certain kinds of activity, often involved with art, one tends to go into a trance-likes state. Is this related to some of the things shamans in various cultures do? Is it in any way beneficial? What does the brain look like when this is happenings? This was an undergraduate research project linked to a couple of classes, not a PhD, so she did not answer these questions fully. But, her approach was scientific, and she learned quite a bit, and nothing homeopathic happened.
I’m not suggesting that we build more CAM centers. Rather, I’d prefer to see those useful elements of CAM that have developed over the last couple of decades become incorporated in medical practice. Having said that, I also understand that the world of standard medicine may not be a good place for such things to exist. Perhaps CAM needs to be separate, institutionally, simply so that it won’t be eaten alive, gutted, re-purposed, or crushed.
And, having said that, I do think CAM funding should not be spent on testing things we know don’t work. Yet, having said THAT, I do not trust the medical profession to make sound judgments in that area. There are a handful of cases of medical experts writing off things prematurely that eventually became part of standard medicine, and those cases generally demonstrate that medical researchers and physicians are often not good skeptics. They receive their knowledge from their local culture the same way Vitamin-C popping New Agers do. I mentioned Creatin above. Some years back, I looked into Creatin and found that mainstream medical experts claimed it would not do what body builders thought it would do for a particular physiological reason that made sense to me at the time. But I also found out that some medical practitioners were using large quantities of Creatin effectively in certain special cases (of heart disease) in a way that violated our assumptions of why it should not work at all. And lately, I see that the Mayo Clinic web page on Creatin suggests that maybe it does work for body building after all, though with much equivocation. I no longer uncritically accept the assurances I was given ten years ago by M.D.’s that Creatin was a useless dilatory supplement. Perhaps it is, perhaps it is not (obviously I’ve got to read up on this again!). What I do remember from my first look at it is this: It was stated that a “peer reviewed study” had disproved the effectiveness of Creatin in body building. I found the study and read it, and discovered that the study’s results were ambiguous and the methodology sucked. Apparently, a study that confirms expectations is good enough to uncritically cite even if it is a bad study. This does not engender a high level of trust, does it?
Anyway, Elyse Anders asks about funding of CAM in a recent blog post which actually inspired the post you are reading now. She points out that some 120 million dollars or so are spent each year by NIH on CAM related research. That is around one half percent of the NIH budget, if my figures are correct. So, not much. Still, is it being well spent?
That funding is done through the National Center for Complimentary and Alternative Medicine (NCCAM). So, our question would be, what does NCCAM fund, and how much of it is crazy stuff vs. possibly not crazy stuff?
Well, this is what they funded in 2011. There are 15 pages of grants, so I’m not sure how to examine or summarize this for a mere blog post. How about if I tell you about the first item on every other page as a sample?
- ACUPUNCTURE PRACTITIONER RESEARCH EDUCATION ENHANCEMENT 90K
- BOTANICALS AND METABOLIC SYNDROME 540K (plus 924K from NIH)
- N-ACETYLCYSTEINE AND MILK THISTLE FOR TREATMENT OF DIABETIC NEPHROPATHY 155K
- MIDCAREER INVESTIGATOR AWARD IN PATIENT-ORIENTED RESEARCH (K24) 202K
- ELUCIDATING THE PLACEBO EFFECTS OF ACUPUNCTURE: HOT FLASHES AS A CLINICAL MODEL 132K
- AUTOMATED TECHNOLOGY FOR PURIFICATION OF ACTIVE INGREDIENTS IN NATURAL PRODUCTS 381K
- MEDICAL STUDENT BEHAVIORAL SCIENCE LEARNING/TEACHING 135K
- VITAMIN C IN POLYMICROBIAL SEPSIS 345
Before you even think about commenting on this list, please remember that a list of titles and amounts is very very hard to put a meaning to. Don’t criticize a research project until you’ve read the grant proposal or at least the summary of it (and you can find them via the link above) or you are no better than Bobby Jindal with his Earthquake Prediction Research remarks.
Having said that, I do feel a bit icky about the above randomesque sample. I was under the impression that acupuncture was total woo (am I wrong about that?). If it is, then is funding research on it merely throwing expensive bones to poorly behaved dogs? Med student behavioral science learning and teaching might be interesting. Let’s look at the description of that one:
Most medical schools recognize the growing need for future practitioners to know basic aspects of behavioral health and social science, yet pervasive challenges in teaching these topics impact the effective learning of the essential skills, knowledge, and attitudes.
1) Often behavioral and social science content is not integrated with what is traditionally viewed as the “core” curriculum, causing students, and faculty to view these topics as less important than others in the curriculum.
2) The effective teaching of behavioral health skills requires small-group instruction and practice, necessitating a large number of well-trained faculty tutors. Preparing these tutors to convey the necessary knowledge and attitudes as well as the skills presents a major challenge for medical schools.
3) Preparation for the rapidly changing world of medicine necessitates that students learn more than how to perform specific skills. Students need to learn to assess the evidence for doing something in a particular way, and the underlying theory as to why it works. At UCLA there is an established, integrated curriculum in behavioral science and extensive training available for faculty teachers. Thus the primary challenge, and the one to which this proposal is directed, is to bring in competencies in the “why” as well as the “how.” The overall goals of this proposal are to develop
1) curricular modules demonstrating the evidence base for behavioral sciences,
2) effective faculty development materials, and
3) valid and reliable assessment tools that illuminate the evidence base and attitudes behind the skills and knowledge we are teaching, and to
4) disseminate these materials to other medical schools.
This will be done by a Curricular Planning Committee, under the direction of Margaret Stuber, M.D. An Expert Consensus Panel of content experts from a variety of medical specialties, public health, health psychology, and medical anthropology, as well as students, consultants from RAND, the community, and other schools of medicine, will contribute a public health and research perspective to the content.
Basically, a good idea. The success and importance of such a program will all be in the execution. But I would say this is not woo.
Let’s look at one of the more technical and physiological oriented ones that has to do with a “plant that can cure you”: The use of Milk Thistle extract for treating Diabetic Nephropathy:
Oxidative stress and glutathione (GSH) imbalance are major contributors to the pathogenesis of diabetic nephropathy. Circulating monocytes participate to this process since these cells carry a high oxidative burden and are found in diabetic renal tissue. Current options for the treatment of oxidative stress in diabetic nephropathy are limited and only partially effective, thus interest in the development of new strategies is high. N-acetylcysteine (NAC) and the milk thistle (MTh) plant flavonolignans are nutritional supplements with complementary antioxidant properties. Both supplements are capable of neutralizing directly toxic free radicals but, more importantly, NAC is substrate for the intracellular generation of GSH and the MTh flavonolignans are inducers of many cellular enzymes participating in GSH metabolism, including GSH-reductase (GSH-R), GSH-peroxidase (GSH-Px), GSH-S-transferases (GST) and superoxide dismutase (SOD). We propose that combined oral supplementation of NAC and MTh flavonolignans will reduce proteinuria and urinary and systemic manifestations of oxidative stress and inflammation, which are characteristically observed in patients with type 2 diabetes mellitus (T2DM) and related nephropathy. We expect these effects to be achieved with minimal or no side effects, and with good patient tolerance.
To test this hypothesis, we propose a double-blind randomized, placebo-controlled, five-arm pilot study which includes a dose ranging component in patients with T2DM and established nephropathy. Intervention will consist of the individual and combined oral administration of one level of NAC and two levels of MTh flavonolignans or placebo for three months. The intervention groups are: (A) placebo; (B) NAC 600 mg BID; (C) Siliphos 480 mg BID; (D) NAC 600 mg BID + Siliphos 480 mg BID; and (E) NAC 600 mg BID + Siliphos 960 mg BID. The primary outcome measure will be urinary excretion of albumin, a marker of glomerular injury. Secondary outcome measures will be alpha-1 microglobulin, a marker of tubular injury, and urinary excretion of inflammatory cytokines and C-C chemokines, i.e. markers of renal inflammation. In plasma and in peripheral blood monocytes from the same patients, we will analyze GSH content and activity of GSH metabolizing enzymes. In addition, we will analyze the plasma and urine glycoproteome, with focus on those glycoproteins serving as inflammatory cell messengers and hormones. These variables will be monitored in relation to both treatment allocation and prevalent blood and urine levels of the active treatment. Throughout the trial, we will monitor the safety and tolerability of this combination treatment.
Cool. I wonder how it came out. This is quite possibly a good example of a CAM grant, assuming that there has not already been piles of research ruling out this thistle milk stuff. Or, it could be a case of throwing bones. I would have to do a literature review to come close to making a decision on that. In theory (and as we all know, theories are just stuff we make up but don’t believe) the whole point of having an NIH is to have trusted experts making these decisions.
The thing is, there are also politics at work when it comes to federal funding. Is the NIH funding useful research, training, and development or not? And, is it the role of the Skeptical Community to get involved in this sort of question?
The answer to the last question is a resounding yet provisional YES! I gave you the link. Pick a project, read the related literature, and figure out if funding that project is a valid use of funds, a bit of congressional pork, a wooish pet product of some bureaucrat, or a bone being thrown to someone. Write a blog post about it. Don’t extrapolate from your one careful look to the entire program, but rather, put it in proper context. If you don’t have a blog post, you can put it here as a guest post (if it is legit).
Otherwise, though, please don’t be a “relieved skeptic.” Elyse asked a valid question and raised important issues, and more are raised here. NCCAM is worth looking at … critically. We should do that.