The National Center for Complementary and Integrative Health (NCCIH), formerly the National Center for Complementary and Alternative Medicine, and prior to that the Office of Alternative Medicine, is developing their strategic plan for 2016-2021. They are seeking public comment, and my colleagues and I at science-based medicine (SBM) will be sending it to them.

The NCCIH is a center at the National Institutes for Health (NIH), which uses federal money to fund biomedical research. The center is largely the child of senator Tom Harkin, who is enamored of alternative medicine (I will use the term CAM for convenience) and wanted a separate office (then center) at the NIH specifically to fund research into CAM therapies.

About his center and its purpose, Harkin has famously said:

One of the purposes of this center was to investigate and validate alternative approaches. Quite frankly, I must say publicly that it has fallen short. It think quite frankly that in this center and in the office previously before it, most of its focus has been on disproving things rather than seeking out and approving.

If anything science should be tilted toward demonstrating that any new claim is false, and only ideas and claims that survive dedicated attempts to do so should gain tentative approval. Harkin gives away the game in this statement – that the purpose of NCCIH is to put a huge ideological thumb on the scale of medical science, to give special preference to exactly those claims in medicine which are least plausible, and then flip science on its head by seeking to approve them, rather than critically testing them.

We at SBM have been critical of the NCCIH for this and other reasons. Those criticisms include:

• After diverting billions of dollars away from more deserving medical research, the NCCIH has essentially nothing to show for it (as Harkin’s statement above admits).
• It is a waste of scarce research money to research highly implausible methods. Worse, those that use those methods show no inclination to follow the results of research.
• Much of the research is not designed to test the core question of whether or not methods work, but nibble around the edges with useless and premature research into how they are used and “integrated,” how people feel about them, pragmatic studies that are not designed to test efficacy, or explorations into possible mechanisms of unproven interventions.
• Where it does test more legitimate claims it is redundant to other centers at the NIH.
• The net result of the center is to prop up dubious methods and practitioners and support them with funding of endless research that will never settle anything.

With all this in mind, let’s take a look at he proposed strategic plan for the next five years.

Draft NCCIH Strategic Plan

Here is the outline of the draft, with my comments below each item. The draft includes a longer description of each item, which you can read here. 

Objective 1: Advance Fundamental Science and Methods Development

• Advance understanding of basic biological mechanisms of action of natural products, including probiotics.

“Natural” is not defined in the statement, which lends itself to a false dichotomy. But that aside, this is a perfectly reasonable area of research. It’s called “pharmacognosy” and is the study of plant-derived compounds, identification of active ingredients, and studying their pharmacology. This is how many drugs are developed. Probiotics are also a perfectly legitimate area of research, although as is true of many immature areas the hype and products are outpacing the science.

I therefore have no objection to funding research into pharmacognosy itself, but doing do under the banner of CAM is misleading and provides false legitimacy to this vague umbrella term.

• Advance understanding of the mechanisms through which mind and body approaches affect health, resiliency, and well-being.

“Mind-body” approaches is another vague category, and one that contains a lot of pseudoscience. The draft statement lists examples: “Meditation, spinal manipulation, massage, yoga, tai chi, hypnosis, and acupuncture.”

Meditation is relaxation. I have yet to see research which demonstrates a specific effect that cannot be explained as simple relaxation (partly because most studies are not designed to make that distinction). Yoga and tai chi are stretching and exercise (I guess that’s the body part). Spinal manipulation is a largely unproven and unnecessarily aggressive form of physical therapy. Massages are massages, they are pleasant and relaxing, and can also help to relax muscles and relieve tension. Hypnosis is genuinely interesting, and may be of some use in diverting people away from pain. Acupuncture is complete nonsense that has already been adequately demonstrated to not work. Further research into acupuncture, in my opinion, is a complete waste.

These interventions have nothing to do with each other, except for some vague hand-waving reference to “mind-body.”

Further, why are these non-pharmacological methods being studied at the same NIH center as pharmacognosy? Generally NIH centers organize around a specific area of expertise. There is no overlap in expertise in any of these areas, except for the underlying false dichotomy that they are somehow “alternative.”

This statement also puts the cart before the horse – researching “how” treatments work before proving that they do work.

• Develop new and improved research methods and tools for conducting rigorous studies of complementary health approaches and their integration into health care.

This section is all over the place. While the individual goals are mostly reasonable, again one wonders why one center at the NIH is focusing on such far-reaching methods. They specifically want to develop mobile care and diagnostic methods, methods for testing herbal products, imaging techniques, and the development of biomarkers for things such as pain.

Again, these are all superficially legitimate, the real question is how will they focus their research? You can see how each of these items can be distorted as an end-run around normal clinical research as a way of “proving” (as Harkin requested that they do) that CAM methods work.

This section also includes mention of studying new ways to track subjective (patient-reported) symptoms. I think the reason for this objective is obvious.

To reiterate my point above – why bring such disparate areas into one NIH center? This matters, because having specific expertise matters. Centers generally have a focus on one scientific area of expertise (like cardiology, for example) so that the proper experts can assess applications for funding. No real area of expertise ties the NCCIH together. They say they collaborate with other centers to acquire this expertise, which only raises again what the purpose of the NCCIH is.

Objective 2: Improve Care for Hard-to-Manage Symptoms

• Develop and improve complementary health approaches and integrative treatment strategies for managing symptoms such as pain, anxiety, and depression.

This section mostly restates the above goals but with specific focus on pain, anxiety, and depression. There is nothing really new here, but it does bring home my above criticisms – the only thread that ties everything together is the vague category of “alternative.”

• Conduct studies in “real world” clinical settings to test the safety and efficacy of complementary health approaches, including their integration into health care.

This is perhaps the worst entry – this states most directly the diverting of biomedical funding for wasted research. “Real world” studies is code for  – not rigorously controlled. CAM proponents like these real world or pragmatic studies because they are almost guaranteed to be positive, because they are not controlled or blinded.

Studying how to integrate non-scientific treatments into scientific medicine is inherently counterproductive. Just prove that a treatment works, and it will be integrated. You only need to study how to integrate treatments that are not supported by adequate science.

Objective 3: Foster Health Promotion and Disease Prevention

• Investigate mechanisms of action of complementary and integrative health approaches in health resilience and practices that improve health and prevent disease.

Prove they work first, then you can worry about mechanisms. Otherwise you are just doing “Tooth Fairy science.”

• Study complementary health approaches to promote health and wellness across the lifespan in diverse populations.
• Explore research opportunities to study and assess the safety and efficacy of complementary health approaches in non-clinical settings such as community- and employer-based wellness programs.

Nothing too specific here, just a statement of ordinary goals of research as applied to the false category of CAM.

Objective 4: Enhance the Complementary and Integrative Health Research Workforce

• Support research training and career development opportunities to increase the number and quality of scientists trained to conduct rigorous, cutting-edge research on complementary and integrative health practices.
• Foster interdisciplinary collaborations and partnerships.

This just amounts to diverting funding to supporting CAM centers and practitioners, which is the worse practical outcome of the NCCIH.

Objective 5: Disseminate Objective Evidence-based Information on Complementary and Integrative Health Interventions

• Disseminate evidence-based information on complementary and integrative health approaches to health care providers, researchers, policymakers, and the public.
• Develop methods and approaches to enhance public understanding of basic scientific concepts and biomedical research.

These are worthwhile goals, but an assessment of how the NCCIH is doing in this regard is beyond the scope of this post. I will say that in general they do a fair job of presenting the scientific evidence on specific topics. They don’t always put that evidence into proper focus, however, and generally fail to consider scientific plausibility.

Of course, if they addressed scientific plausibility of the methods they study, they would “disappear in a puff of logic,” (to quote Douglas Adams).

Conclusion

The draft strategic goals reinforces the criticisms that I and my colleagues at SBM have made about the NCCIH over the years. Ideally I would like to see the NCCIH be dissolved and its budget folded back into the NIH and distributed to other centers.

I think centers at the NIH should be organized around specific areas of scientific expertise. Further, the mere existence of the NCCIH lends legitimacy to CAM, which is a vague and often false category containing a large variety of medical methods and interventions.

Exactly what CAM contains is a matter of dispute. Proponents include methods that are not CAM, such as pharmacognosy, probiotics, exercise, physical therapy, and nutrition. They do this in order to lend legitimacy to the category.

The category also includes an eclectic mix of methods (often mutually exclusive in philosophy) that are highly implausible, unproven, or already disproved. Within the space of CAM are many practitioners who are, in my opinion, highly misguided at best, charlatans and con-artists at worst.

For this reason the existence of NCCIH is a net negative on the health (and finances) of Americans.

If the NCCIH is not going to be dissolved, then what should the strategic plan include? First, I think they need to focus. They should acknowledge that certain methods have already been adequately studied, like acupuncture, and don’t require further research. Other methods are essentially magic and don’t deserve scientific study.

They should forget pragmatic studies, studying how CAM is integrated, and trying to devise new research methods to bypass real scientific rigor. They should only fund highly rigorous efficacy studies  – ones that are designed to show if a treatment works or not. In this regard they could serve an actual purpose. They could also develop a genuine area of expertise – expertise in folk and unscientific medicine.

In that regard SBM would be happy to collaborate with them. That is our expertise.