Is NIH NCCAM Sailing into a Perfect Storm?

Summary: The NIH National Center for Complementary and Alternative Medicine (NCCAM), forced on the NIH by the US Congress in 1998, has always been viewed as a kind of bastard step-child by the old-line NIH establishment. Now a Congressionally-mandated re-shaping of NIH, federal budget pressures, a series of negative results and antagonistic editorials in Science, and the Journal of the Federation of American Societies for Experimental Biology, one may see, in the distance the signs of a perfect storm.

The ugly scenario, for supporters of the

Reform Plan Has Strong Congressional Support

US Rep. Joe Barton (R-TX): reforming the NIH

Barton, the chair of the House Commerce and Energy Committee appears to be close to getting what he wants. His bill, HR 6164 , the National Institutes of Health Reform Act of 2006, was approved overwhelmingly by his fellow house members, 414 to 2. It has to be approved by the Senate which may be more difficult. However, some version of it could be passed and if so, part one of the scenario will fall into place.

Christine Choate, DC, PhD, the deputy director of the Samueli Institute and a former program manager for NCCAM, clarifies that there is nothing in the bill that specifically targets NCCAM. "Congressman Barton wants to improve the way NCCAM does business," Choate explains. (Barton's statement on the legislation is available here.) Choate notes some of what she believes are exceptionally good components of the plan. These include promotion of cross-institute collaboration and the creation of a comprehensive electronic database to catalogue all NIH research activities in a standardized format. Under Barton's plan, the NIH budget would grow at 5% per year, to $29.7 billion for 2007.

Forces Putting NCCAM at Risk

Christine Choate, DC, PhD, Samueli deputy director and former NCCAM staff

So far so good. The potential for risk to NCCAM, Choate suggests, is that "the centers and institutes most likely at risk are those, like NCCAM, where other agencies are also supporting similar research." Choate points out that, all totaled, other institutes are spending roughly twice as much as NCCAM's $120-million budget on research that could be considered complementary or alternative medicine. Choate adds: "The argument would be that, look, the research is going on any way, why do we need a center devoted to CAM?"

When was the last institute or center established? In 2000, Congress funded the National Institute for Biomedical Imaging and Bioenginerering. Is anyone pushing on Congress' or NIH doors now to set up a new institute or center? Choate was not sure.

Another reason that NCCAM may be viewed as weak is the series of negative results from the Center's funded projects. These include studies of botanicals as single agent interventions and distant prayer. "Some people in NIH call NCCAM 'the center for negative results,'" Choate reflects.

Choate notes that the negative outcomes were often on studies funded before NCCAM was working as diligently as it is now to guarantee that clinicians have appropriate input on study design. "Practitioners were too often saying that the outcomes were meaningless to them because the study didn't look at what's done in clinical practice,'" Choate recalls. She commends NCCAM for its work in this area, citing the example of the partnership with the American College for the Advancement of Medicine on a chelation therapy study. But results of these newer studies are not in.

Bottom line: NCCAM has not, in the minds of many in the research community, produced a significant body of positive outcomes that would justify its existence.(1)

CAM's Long-time Opponents: Circling for a Kill?

Meantime, the anti-NCCAM editorial in the journal Science last July (see Integrator article and links) by a couple of long-time anti-CAM activists, is now "seconded" by a series of attacks this year by editor-in-chief Gerald Weissman of the

"In preventing and controlling such suffering, we must think beyond the practice of reducing everything to component parts, and this is where, I believe, modern medicine needs to accommodate a more integrated and holistic approach. (From his May 2006 speech.)

Those who know my work will know that I am not always aligned with NCCAM's priorities. I understand the criticism that NCCAM's favoritism toward reductive, single agent approaches - the Center's parent language - leads at best to CAM-grafting. At worst, these research approaches can lead to false negatives of studies examining therapies isolated from their customary use in integrated, whole person practice. The irony is that to "please Dad" by pursuing the reductive, the NCCAM may have inadvertently helped to create the very conditions which are being argued as reasons to kick it out of its home.

Despite my differences - and they can run deep - I am, at worst, deeply loyal opposition. NCCAM's value is huge. While FASEB's Weissman, polarizing the issue at every turn to make his points - some of them quite interesting - is correct that there is a belief strain of something like creationism in the "alternative medicine" world, NCCAM gives all of us in this field with left brains a way to apply ourselves. I name just a few of my favorite things NCCAM has helped create:

• There was basically no research funding available for the CAM disciplines, in particular, prior to the initiation of NIH's funding in the early 1990s. Many CAM schools are now beginning to develop research capacity - just as conventional medical schools did 60 years ago when federal dollars began to flow to them (in rather larger quantities). With no focused NIH agency - charged by Congress as NCCAM is to work with the distinct CAM disciplines - one doubts whether any of the CAM money from other NIH agencies would water these fresh starts.
  
• The magnetism of the millions in available NCCAM research funds was the deal-maker for many integratively-oriented medical doctors who had to convince their deans to allow them to develop programs in integrative medicine in their med schools. NCCAM effectively birthed, or at least god-parented, the Consortium of Academic Health Centers for Integrative Medicine.
  
• NCCAM's R-25 education grants have created most of the nation's collaborations between conventional academic centers and CAM schools and institutions, truly pioneering work in the educational integration recommended by the Institute of Medicine.
• NCCAM's health services research (HSR), while extremely limited - in the research world, exploration of the cost of care and other HSR topics is typically housed at Agency for Healthcare Research and Quality - has provided those in the field with some basic infomation about costs, and the populations using CAM services.
• The stimulation of formal and informal conversations on methodology, which can begin to help us structure whole practice/whole systems research which is suitable for measuring outcomes of health care which treats the whole person.