NEWS

White House Report on Alternative Medicine Draws Criticism

Tom Reynolds

A new presidential advisory panel report calls on the federal government to boost spending for research, training, and education in complementary and alternative medicine (CAM). But critics say the report shows too much enthusiasm—and not enough skepticism—about unconventional treatments that have not been proven safe or effective.

Two years ago, President Clinton assembled the White House Commission on Complementary and Alternative Medicine Policy and directed the panel to make administrative and legislative recommendations to maximize CAM’s benefits to Americans. (See News, Dec. 20, 2000, p. 1975.) At its 10 regular meetings, the commission heard testimony from clinicians, researchers, medical educators, health insurance representatives, regulatory officials, and policy-makers. Altogether, the commission heard from 1,700 groups and individuals.

The commission, chaired by James Gordon, M.D., director of the Center for Mind-Body Medicine in Washington, D.C., and clinical professor of psychiatry and family medicine at Georgetown University, made 29 recommendations that include more than 100 action points. Most of these target two Department of Health and Human Services agencies, the National Institutes of Health and the Food and Drug Administration. (See box, p. 647.)



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Dr. James Gordon

 
The commission calls for the creation of a federal office to oversee CAM efforts at the highest possible level within DHHS. Currently, CAM research is coordinated by the National Center for Complementary and Alternative Medicine at the National Institutes of Health.

Opponents began blasting the panel for bias even before its final report came out in March. They charge that it is overloaded with practitioners and advocates of CAM and lacks balance from mainstream medical opinion. And they say the report offers no guidance on which forms of treatment under the wide CAM umbrella—covering a diverse array of interventions from diet to acupuncture to prayer to shark cartilage—deserve serious consideration and which should be dismissed as charlatanry.

Two commission members, Tieraona Low Dog, M.D., and Joseph Fins, M.D., drafted a separate statement criticizing the report’s "advocacy tone" and its failure to identify specific priorities for research. Low Dog is medical director of the Tree House Center of Integrative Medicine in Albuquerque, N.M., and chairs the United States Pharmacopoeia Dietary Supplements and Botanicals Expert Panel. Fins is an internist and director of medical ethics at Weill Cornell Medical Center of New York-Presbyterian Hospital. Their critique (appearing as Appendix G in the report) was prompted by what they see as "the Commission’s inability to appropriately acknowledge the limitations of unproven and unvalidated ‘CAM’ interventions or adequately address the minimization of risk."

"Asking for more research money to investigate an approach, practice or product simply because it is ‘CAM’ is an ideological, not evidence-based approach to science," Low Dog and Fins wrote. "While dogmatic disbelief of everything that is not currently explainable is foolish, and indeed unscientific, it seems equally foolish to ask the taxpayer to bear the enormous expense of sorting out those areas that are plausible from those that are improbable." Nevertheless, Fins and Low Dog added that "many of the Commission’s recommendations will help maximize the benefits of proven safe and effective approaches, practices and products."

Creating Bureaucracy?

Other critics, including watchdog groups such as Quackwatch and the National Council Against Health Fraud (NCAHF) were less diplomatic, charging that the commission wants to create an expensive new layer of federal bureaucracy aimed at legitimating pseudoscience. The NCAHF asserted that "Following the Commission recommendations, anyone could create a ‘new’ therapy, whether it be catching moonbeams or adding spices to coffee enemas and call it CAM. Gordon’s plan would create a perpetual motion machine for funding research on such nonsense."

In September, a group of physicians and psychologists called on Surgeon General David Satcher, M.D., to disband the commission. They expressed "profound concerns" about its membership, in particularly Gordon’s long history of involvement with "fringe" theories and practices and what they view as his "extreme absence of objectivity."

"[M]any alternative and complementary medical practices, such as homeopathy and chelation therapy, have repeatedly been shown to be ineffective in controlled studies by independent investigators," they wrote. "Still other [CAM] practices have the potential to cause physical harm, and to lead individuals to forgo treatments that have been demonstrated to be effective."

Chairman Gordon defends the commission’s integrity. He said conventional medicine was well represented, counting five of 20 panel members not affiliated with CAM. The group produced as "a very balanced, middle-of-the-road report," he said.

The critics crucially misinterpret the role of the commission, Gordon said. It is the job of the National Institutes of Health and other research agencies—not the commission—to sort the wheat from the chaff in CAM. He said the commission deliberately avoided passing judgment on specific CAM methods, instead striving to lay out guidelines for evaluation of these methods by the responsible agencies.

Gordon also said he thinks that the position of panel members Low Dog and Fins is biased and unscientific.

"To condemn something without having studied it is ridiculous," he argued. "They say don’t study psychic healing—but I don’t know about that. There is some quite good research in peer-reviewed journals ... and if somebody comes up with good data from a pilot study and applies for a grant, it should be judged exactly the same way a grant for an herb or a pharmaceutical should be judged—on its merits. Science is about going beyond what we know already."

If the report has an "advocacy tone," he added, it represents "advocacy for fairness, not for a specific therapy."

Same Scientific Standards

Gordon said the commission’s report makes clear that CAM should be held to the same standards of scientific rigor required for conventional medical treatments. But he said clinical research should also put to use the "integrative" orientation of CAM.

"It might make sense, instead of focusing so much on an individual substance or approach, to take a step back and encourage researchers to put together comprehensive and integrative programs," he said. "For example, a trial might have two arms: one with patients on conventional chemotherapy and radiation and the other arm adding a variety of mind-body approaches: guided imagery, plus group support, plus nutritional support, plus Chinese herbs."

Scott Lilienfeld, Ph.D., associate professor of psychology at Emory University in Atlanta, headed the group that wrote to Satcher criticizing the commission. He said this holistic strategy of combining diverse treatments appeals to CAM advocates but makes bad science. If several treatments are evaluated as a single entity, researchers have no way to tell which ones contributed to any observed benefit or harm, or, if no effect is seen, whether they may have somehow interacted to negate each others’ effects.

Studies of CAM

Gordon acknowledged that, as a scientific ideal, these treatments should be studied separately to tease out the risks and benefits of each. But he said this approach is too time-consuming to help patients in the near term: "If we try to do that, we may spend 200 years. People with cancer don’t have time." Instead, he said, CAM treatments that have shown preliminary evidence of efficacy should be combined to maximize potential benefit. One study estimated that 70% of cancer patients are already using some form of CAM, he said, adding to the urgency of testing these treatments in clinical trials.

Gordon noted that the cancer community is, in fact, at the forefront of the movement to integrate conventional medicine and CAM. The Center for Mind-Body Medicine holds an annual comprehensive cancer care conference, cosponsored by the NCI and NCCAM, that "brings the complementary and alternative medical world into productive dialogue with the American cancer establishment." He pointed to the Cancer Advisory Panel on Complementary and Alternative Medicine (CAPCAM)—a group that makes recommendations for CAM research to NCI and NCCAM to illustrate the kind of collaborative effort advocated by the commission.

"We see CAPCAM as a model for what should be happening throughout NIH and maybe in other areas of the government: an institute concerned with a particular disease working together with NCCAM to advance the field."



             
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