"Pressure Points" (CC BY-NC-ND 2.0) by Denver Aquino

The Problem with The National Center for Complementary and Integrative Health

August 2, 2019

In the course of doing background research for my last article covering alternative beliefs, it was puzzling, to say the least, to find out that there is a federal agency in the United States dedicated to alternative medicine. Perhaps more remarkably, it falls under the umbrella of the National Institutes of Health and receives in excess of $100 million in funding annually. The National Center for Complementary and Integrative Health (NCCIH) (formerly the National Center for Complementary and Alternative Medicine [NCCAM] before the negative connotations of alternative medicine became more widely known) states that its mission is “to define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health interventions and their roles in improving health and health care.” This prompted me to further consider the overall role of alternative medicine in our society. I was fairly astonished to find 893 entries for the National Center for Complementary and Integrative Health (803 while still listed as NCCAM and an additional ninety entries as NCCIH in the past four years since the attempted rebranding) on Grantome, a site tracking the awarding of public funding to individual grant applications, with information on grant topic, methodology, and study aims, and needed to do background reading first to find out why the NCCAM even existed.

It quickly became apparent that a sizeable dose of political history of the past two decades is necessary to fully understand just why this agency exists and receives almost $150 million each year in funding to distribute to these studies. Senator Tom Harkin (D-Iowa), a longtime believer in “alternative medicine” and an influential subcommittee chairman in 1991, pushed for the earmarked pork barrel spending that enacted the original Office of Alternative Medicine (OAM) in 1991–1992 with $2 million in seed money. By 1994, he had already forced out the first director of OAM for being insufficiently accommodating to his magical expectations.

In 1997, when the OAM was up to $12.5 million per year, he bemoaned that it had not “investigated and validated one darn thing” (perhaps because it was investigating things that were fundamentally invalid as treatments) and demanded that it be upgraded to a national center with its own (CAM true believer) peer reviewers and the ability to award its own grants. He called “expert” witnesses such as James Gordon, director of the Center for Mind-Body Medicine at Georgetown/first chairman of the advisory council at OAM, who called the budget “completely inadequate” and expected $100–150 million (eerily accurate with respect to the current budget). He even found it unacceptable that none of the 125 scientifically and medically qualified peer reviewers on NIH standing review committees had licenses or degrees in chiropractic and/or acupuncture. Harkin and Gordon got their way after this tantrum; in 1999, President Clinton upgraded the OAM to the NCCAM with a $50 million budget, part of which was used to establish research facilities at the naturopathic Bastyr University (Bastyr had previously been awarded almost $1 million in 1994 to search for “alternative medicine” treatments for HIV; subsequently the Bastyr dean has served as a member of the NCCAM advisory council, and the university still cultivates extremely strong ties to NCCAM today). By 2002, the NCCAM budget had ballooned to over $100 million. In 2009, as he (horrifyingly) ascended to the Chair of the Senate Health Committee, and at which point the OAM/NCCAM/NCCIH had drained over $2.5 billion in public funding, Harkin nonetheless lamented that the NCCAM had still not been sufficiently supportive of alternative medicine and had indeed focused too much on “disproving things.” He went on to aver that “it is time to end the discrimination against alternative health care practices.” Harkin’s crowning pseudoscientific achievement was shamefully pushing for the inclusion of practitioners of CAM into the Affordable Care Act.

(The Center for Inquiry has previously covered some of the impact here: https://centerforinquiry.org/campaigns/safe-secular/cover-my-ineffective-care-homeopaths-demand-insurance-coverage-of-disproven-methods/index.html; also see here for positive crowing about the ascent of CAM under the ACA: https://www.sciencedirect.com/science/article/abs/pii/S2095496414600352?via%3Dihub.)

Fortunately, while one clause can be twisted to block “discrimination” against pseudoscientific practices (what is meant by discrimination is not clarified), it did not go as far as to mandate insurance coverage of all these practices. With this overarching legacy of pseudoscience looming large, Harkin was nonetheless remembered upon his retirement as a “champion of science” in a couple of high-profile scientific journal news sections, inexplicably.

Harkin’s fanaticism in defense of pseudoscience apparently stemmed from his belief that a bee pollen supplement miraculously cured his allergies. Notably, the bee product supplement dealer was subsequently compelled to settle with the Federal Trade Commission (FTC) by paying a $200,000 fine for false advertising for such promotional tag lines as “royal jelly is the greatest rejuvenating and sex stamina food known to man, and you certainly want to have, be active sexually all the rest of your life” and “bee pollen is the answer to mankind’s quest for the Fountain of Youth,” complete with an alleged ninety-year old man who went from difficulty walking to completing a marathon with the help of bee products. (Note: I was unable to find out whether Sen. Harkin was ever confronted with the FTC settlement paid out by his miracle worker.) 

Looking over the entries for the NCCAM/NCCIH on Grantome to get an overview of what type of research is currently funded, one is met with a mixed bag of acupuncture, chiropractic, and even a bit of homeopathy. (Note: the search algorithm on Grantome seems imperfect, because terms present in funded grants, such as “distant healing,” do not always generate search results, despite being in the database. If anything, the numbers from Grantome searches cited below may be underreporting.) One awarded grant begins its application with the justification that “Over 30% of the US population reports using complementary and alternative medicine (CAM) modalities.” The relevance of this was unclear to me; 26 percent of the U.S. population also believes that the sun revolves around the earth, so appeals to widespread public support should not be a factor in funding what is supposedly “rigorous scientific investigation” (to hold the NCCIH to the standard of their own words). 

Acupuncture garners significant attention, showing up in at least fifty-nine results funded by the NCCIH. While a full discussion of acupuncture, its reported benefits (and potential negative effects), and proposed mechanisms (or rather, lack thereof) would be enough for a book, it’s worth reviewing a few points to put the funding of acupuncture research in context. Acupuncture is quite popular today and widely, though not universally, accepted among much of the medical community (half of GPs in the U.K. report prescribing it, and the National Health Service there covers it as a medical treatment).

However, acupuncture is based on a nonempirical belief system predicated upon the flow of the life force qi through the body. The needles unblock this flow. Being founded on a mistaken belief, though, does not preclude it a priori from having any benefit, so it is worth considering the evidence to date. Lack of suitable placebo is probably the greatest shadow hanging over the studies reporting positive results for acupuncture. When the needle is not merely the delivery method of drug versus placebo, but is itself the treatment, how does the clinician simulate that in a way that the patient does not recognize as false?

The relatively recent treatment of “sham” acupuncture, which involves a smaller pinprick and then retraction, without being discernible to the test subject, has ameliorated this situation somewhat. Accordingly, the inventor of this method, Edzard Ernst, MD, PhD, reports that “If we control rigorously for bias, by using proper sham needles, the trials tend to produce negative results.” An extensive meta-analysis and review in 2013, controlling for type of placebo used in the accumulated studies, concluded that “A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.”

Indeed, the more recent, better-controlled/better-designed, meta-analytical, and larger studies tend to find insufficient evidence for any efficacy of acupuncture, with conclusions such as “studies were generally of poor quality, and publication bias favoring positive studies was obvious. Therefore, rigorous evaluation standards and well-designed studies are necessary in future studies.” Furthermore, at least some of the literature purporting to show evidence for acupuncture’s efficacy also shows potential authorship conflicts-of-interest due to obvious financial incentive. In the writeup of the following putatively scientific dataset, for example, one reads: “The Acupuncture Evidence Project: A Comparative Literature Review was funded by the Australian Acupuncture and Chinese Medicine Association Ltd (AACMA).” Grants are likewise submitted involving collaboration with acupuncture practitioners demonstrating a clear financial interest in positive outcomes supporting the efficacy of acupuncture: “The Acupuncture Trialists’ Collaboration now consists of an international group of 31 physicians, clinical trialists, biostatisticians, practicing acupuncturists and other specialists including many of the most widely recognized names in acupuncture research.” Thus, the allocation of scarce funding to numerous studies that start out assuming the premise (“acupuncture works”) for which they are ostensibly intending to objectively collect data is entirely inappropriate and merits serious pushback.

It is disconcerting, to say the least, to note that some of America’s most prestigious medical institutions, from Sloan-Kettering to Massachusetts General Hospital, are grant recipients from NCCIH for acupuncture-based research programs. Equally dismaying is the insistence of some grants on referring to acupuncture within the formal terminology of “traditional Chinese medicine” as though that were a scientifically credible field of study—describing it as a traditional practice or healing art from China, or some other phrasing, would be perfectly accurate and adequate. The formal appellation “traditional Chinese medicine” brings to mind scenes of black market trades in parts from poached, critically endangered and/or cruelly farmed animals: rhinoceros horn, tiger bone, and bear bile, to say nothing of arsenic-, mercury-, and lead-containing treatments. Every type of treatment, no matter how ancient, deserves scientific consideration based on its data-driven merits, but to prop up an entire “system” already known to be riddled with utterly nonscientific concepts would be comparable to granting funding to studies based on balancing the four humors, including leech-based treatments. Sadly, and infuriatingly, there are indeed journals devoted to utterly absurd, and ecologically devastating, pseudoscience such as this: “Aqueous extracts of rhinoceros horn or water buffalo horn demonstrated significant antipyretic action at 2.5 g/ml i.p. (1 ml/animal) in rats with hyperthermia PMID: 1943172).” The NCCIH policy statement hedges by suggesting “Some mind and body practices used in traditional Chinese medicine practices, such as acupuncture and tai chi, may help improve quality of life and certain pain conditions. Studies of Chinese herbal products used in traditional Chinese medicine for a range of medical conditions have had mixed results.” Examples of positive results for herbal products are not given.

Chiropractic as a search term yields seventy-three NIH/NCCAM-funded Grantome entries (and chiropractor yields twenty-eight, with some overlap). Like acupuncture, chiropractic is based on entirely groundless (albeit somewhat more recent) theories of illness. Specifically, that spinal misalignment known as “vertebral subluxation,” undetectable by X-ray or any other mainstream method of medical imaging, is the cause of numerous ailments and that proper treatment involves manual realignment of the spine. This theory in its original scope extended even to apparently contagious conditions like smallpox and polio, which devout chiropractors insisted were nonetheless caused by spinal misalignments. Opposition to mainstream medical practice in terms of infectious disease persisted well into the second half of the twentieth century in formal chiropractic position statements circulated by the National Chiropractic Association. Subsequently, reform-minded chiropractors have conceded these grievous flaws and limited their practice to a more physical therapy-minded approach. Indeed, one of the most high-profile evidence-based chiropractors, Samuel Homola (his position statements are linked at the end of this article), concluded that given the opportunity to do it over again, he would have studied to become a physical therapist instead. This rift continues to widen among practitioners of chiropractic; just this year, a journal article within the field openly wondered whether there should be a “divorce” between evidence-based chiropractic and “traditional” (pseudoscience) chiropractic. Such a divorce would be a chance to integrate the rational chiropractors into the physical therapy field in general and would probably necessitate renaming and some re-credentialing. Defunding studies that explicitly adhere to the outdated tenets of traditional chiropractic would be a good start. There are eighty-five NCCAM grants in the past ten years in Grantome, including three in 2018, that were awarded to Palmer College of Chiropractic, established by and named for the original founder of chiropractic, D.D. Palmer. (I encourage readers to look up some of his views on health and disease and then ask whether such an institution merits public funding.) Western States Chiropractic College has likewise received twenty-six grants documented in Grantome, with titles such as “Dose-Response of Manipulation for Cervicogenic Headache” and including such wording as “The study protocol is designed to control attention and the laying on of hands” (the latter a phrase I had not ever expected to hear outside of an explicitly ecclesiastical context). The National College of Natural Medicine, which, according to their website, only grants doctoral degrees in “Naturopathic Medicine” (ND) and “Oriental Medicine” (DSOM), received at least six grants from NCCIH according to Grantome. 

There are even sixteen NCCAM/NCCIH Grantome entries involving the term homeopathy and eleven entries (some overlapping) involving homeopathic. Homeopathy takes the contrarian view that mainstream medicine (“allopathic” [allo meaning other]) is mistaken in its attempts to treat disease with an external agent that counteracts; rather, the body is capable of forming its disease response with exposure to miniscule amounts of substances that provoke the same symptoms, hence homeopathy. This gives rise to all sorts of equally daft corollaries involving substances having some kind of mystical “memory,” etc. It is regrettably funded, at least in part, by various compulsory insurance/nationalized health care systems in numerous European countries even today, though fortunately that seems to be improving somewhat. NCCIH grants on the topic include such themes as “Dilution and Succussion in Homepathic Remedy Dose-Response Patterns” and “Polysomnography in Homeopathic Remedy Effects,“ with statements such as “This study will contribute to our long-range goal of understanding the neurophysiological and biopsychosocial mechanisms of classical homeopathic remedy treatment in patients with specific clinical conditions.”

Indicating the abandonment of empiricism entirely, at least in terms of nomenclature, a search for spiritual results in twelve NCCAM/NCCIH grants with wording such as “evaluate the psychosocial mechanisms of action within the context of a larger NCI-funded study of two 10-week CAM interventions (tai chi and spiritual growth groups) on psychoneuroimmunological (PNI) outcomes with a sample of women recently diagnosed with breast cancer.” The general pattern of funding should be clear at this point. 

Just as the initial justification most of these grants offer for funding rests on shaky ground, so too do the conclusions in many of the articles published by NCCIH grant recipients. These publications include statements such as “We hypothesized that restorative yoga would achieve significant improvements in metabolic factors (fasting and 2-hour glucose, HbA1c, triglycerides, HDL cholesterol, fasting insulin, systolic blood pressure and visceral fat area) compared to the stretching group.” (On what pilot study/preliminary data, or scientific basis of any kind?) The weak conclusions were that “Restorative yoga was marginally better than stretching for improving fasting glucose but not other metabolic factors” and “There was trend to reduced blood pressure (p = 0.07), a significant increase in energy level (p < 0.009), and trends to improvement in well-being (p < 0.12) and stress (p < 0.22) in the yoga versus control group.” I cannot emphasize enough that the level of credulity involved in drawing conclusions and extrapolating meaningful trends from a p-value of ~0.2 is incompatible with objective scientific practice, but unfortunately this does not stop publication, or funding, of this type of work. The one nominally significant finding is increased energy level, which, like many outcome variables in these studies, is entirely self-assessed/self-reported. As previously noted, adequate placebos are often unavailable for techniques in which the patient can identify the nature of the method and whether it is the “real” version, and this severely impairs any kind of objectivity in measuring these outcomes. How does one convince a patient they are doing “restorative yoga” when in fact, they are merely “stretching”?

An Incomplete NCCAM/NCCIH Hall of Fame/Shame

Grant Title Topic summary Years funded Grant ID Total Funding Amount Grantee Institution Resulting Publication(s)
Distant Healing Efforts for AIDS by Nurses &’Healers’ Remote prayer to treat HIV 2000–2002 R01-AT000485 $666,035 California Pacific Medical Center Research Institute https://www.ncbi.nlm.nih.gov/pubmed/17131980
Responses to Energy & Mock Healing in Fatigued Survivors “Energy healing” reducing fatigue 2005–2007 F31-AT003021 $104,416 University of California, San Diego https://www.ncbi.nlm.nih.gov/pubmed/21823103
In Vitro Investigation of Distant Qi Gong Remote “energy” projection affecting cell growth 2002–2004 R01-AT001516 $491,805 California Pacific Medical Center Research Institute https://www.ncbi.nlm.nih.gov/pubmed/15102336
Psychoneuroimmunology and Mind-Body Medicine Lavender and lemon mood therapy 2004–2005 R21-AT002122 $373,750 Ohio State University https://www.ncbi.nlm.nih.gov/pubmed/18178322
Polysomnography in Homeopathic Remedy Effects Homeopathic “cures” affecting sleep EEGs 2005–2007 R21-AT000388 $583,974 University of Arizona https://www.ncbi.nlm.nih.gov/pubmed/20673648

https://www.ncbi.nlm.nih.gov/pubmed/20980764

https://www.ncbi.nlm.nih.gov/pubmed/22818237

Placebo effects in distant healing of wounds Whether remote healing belief and expectation affect its outcome  2003–2004 R21-AT001437 $336,275 California Pacific Medical Center Research Institute https://www.ncbi.nlm.nih.gov/pubmed/22742672
Effects of Reiki on Physiological Consequences of Acute Stress Whether Reiki affects biomarkers and stress 2005–2007 R21-AT001884 $570,299 Cleveland Clinic Lerner None found
Use of Energy Biofield Therapy for the Treatment of Cancer and GVHD Testing “Healing Touch” therapy in mice with cancer 2008 R15-AT003591 $190,688 University of Nevada, Reno https://www.ncbi.nlm.nih.gov/pubmed/27688787

 

This is not to say that all studies funded by the agency are patently and inherently unscientific; some seem to be fact-based, with measurable evidentiary outcomes to add or weaken support for a falsifiable hypothesis—studies with titles such as “Dietary impact on blood-brain barrier tight junctions.” It does raise questions of why these apparently legitimate studies could not be funded by a more mainstream branch of the NIH and why they should be lumped in with magical thinking. Notably, the grant makes the point that the proposed study addresses aims of several funding agencies beyond the NCCAM, ones with much more scientifically accepted missions (“The aims of this study address priorities of National Institutes of Health, respective to the National Institute of Neurological Disorders and Stroke (NINDS), National Institute on Aging (NIA), National Center for Complementary and Alternative Medicine (NCCAM), and the Office of Dietary Supplements (ODS)”).

Defenders of the NCCIH might try to argue that its funding for the most extreme nonscientific studies has declined in recent years, and that it is therefore on the “right path” toward scientific relevance. However, there is little hope of reforming the NCCIH as it is currently incorporated. Its charter makes clear that CAM practitioners are taken as a priori legitimate, and thus must be given major influence on the NCCIH membership council: 

Of the 18 appointed members, 12 will be selected from among the leading representatives of the health and scientific disciplines (including not less than 2 individuals who are leaders in the fields of public health and the behavioral or social sciences) relevant to the activities of the NCCIH, particularly representatives of the health and scientific disciplines in the areas of complementary and integrative health. Nine of the members will be practitioners licensed in one or more of the major systems with which the Center is involved. Six of the members will be appointed by the Secretary from the general public and will include leaders in the fields of public policy, law, health policy, economics, and management. Three of the members will represent the interests of individual consumers of complementary and integrative health.

Picking individuals whose livelihoods are dependent on positive outcomes for CAM studies is an egregious conflict of interest and one that should invalidate the legitimacy of the NCCIH in the eyes of any objective observer. Likewise, their peer review process shields them from normal scientific scrutiny and allows a carve-out niche for “CAM practitioners” to exert undue subjective influence on grant approval. Furthermore, the bogus studies funded by NCCIH continued to yield publications several years after the end of the funding, meaning they cast a long shadow over science. These publications often are linked to the institutions at which the authors are currently located, often years after they have left the institution that received the NCCIH funding. Thus, some of the absurd studies above have ended up giving press, citations, and an undeserved aura of peer-reviewed legitimacy to institutions like https://noetic.org/science/overview/ and http://www.samueliinstitute.org/research-areas/brain-mind-and-healing.html

There is no legitimate function that the NCCIH can serve that could not be better carried out by other existing organizations within the NIH umbrella. Fundamentally, a public agency, the National Institutes of Health, ostensibly committed to rigorous science-based medical research as a means of advancement in medical practice and clinical treatments, should not be considering well over $100 million per year in grants to a sub-agency whose conceptual underpinnings are on roughly the same factual level as blood group diets—especially when the NIH director goes on the record as saying the largest obstacle to an Ebola vaccine is insufficient funding.

*For interested readers, further peer-reviewed literature citations on various CAM topics are available from the author upon request.

Further Reading

https://blogs.sciencemag.org/pipeline/archives/2014/10/24/francis_collins_knows_why_we_dont_have_an_ebola_vaccine

https://www.ftc.gov/sites/default/files/documents/commission_decision_volumes/volume-116/ftc_volume_decision_116_january_-_december_1993pages_206-319.pdf


https://science.sciencemag.org/content/347/6217/news-summariesSenator Tom Harkin (D–IA) – NIH loses longtime champion”

https://www.nih.gov/news-events/news-releases/nccams-advisory-council-welcomes-five-new-members

http://grantome.com/grant/NIH/R01-AT004569-02

https://www.npr.org/sections/thetwo-way/2014/02/14/277058739/1-in-4-americans-think-the-sun-goes-around-the-earth-survey-says

https://www.realclearscience.com/articles/2013/01/31/science_says_good_riddance_sen_tom_harkin_106451.html

https://www.nytimes.com/1997/10/06/opinion/bee-pollen-bureaucracy.html

http://content.time.com/time/health/article/0,8599,237613,00.html

https://www.quackwatch.org/01QuackeryRelatedTopics/nccam.html

https://science.sciencemag.org/content/265/5181/2000.long

https://nccih.nih.gov/news/2012/020312

https://www.nature.com/articles/39409

https://www.nccamwatch.org/commentary/harkin.shtml

https://www.realclearscience.com/articles/2013/01/31/science_says_good_riddance_sen_tom_harkin_106451.html

https://sciencebasedmedicine.org/tom-harkins-war-on-science-or-meet-the-new-boss/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847521/

https://www.quackwatch.org/01QuackeryRelatedTopics/nccam.html

https://nccih.nih.gov/research/results/spotlight/061710.htm

https://slate.com/technology/2014/06/naturopaths-covered-under-medicaid-the-affordable-care-acts-nondiscrimination-language.html

https://sciencebasedmedicine.org/harkins-folly-or-how-forcing-insurers-to-cover-cam-undermines-the-aca/

https://sciencebasedmedicine.org/science-based-chiropractic-an-oxymoron/

https://www.chirobase.org/01General/risk.html