Preventive Medicine Column
Dr. David L. Katz
The May 2nd issue of JAMA includes an editorial suggesting that the budget of the National Center for Complementary and Alternative Medicine might be more productively used by other institutes at the NIH. The author runs through a litany of negative study outcomes and implausible interventions to make his case that the $130 million annual budget of NCCAM is of suspect utility.
One might think that arguments against faith-based practice are preferential arguments against CAM, but that’s not so. Much of what is done in conventional medicine is simply time-honored but not truly tested. When time-honored practices are put to exacting tests of evidence, they often fail.
I was taught- adamantly- throughout the entire expanse of my training years that drugs called beta-blockers, which reduce the force of the heart’s contraction, would be harmful in congestive heart failure. It turns out, at odds with time-honored practice and tradition, and intuition alike, these drugs reduce mortality in heart failure, and are now used routinely.
We have all heard of ‘CPR’ and many of us have learned how to do it. But unless we learned it very recently, what we learned was almost certainly wrong.
Traditional CPR included both chest compressions and breaths. This made sense. Both breathing and a pulse are truly vital to survival. It made sense, but it was wrong. Chest compressions alone are more likely to result in effective resuscitation outside the hospital than compressions and breaths.
The evidence base underlying CAM differs from that for conventional medicine by degree, not kind. I know, because colleagues and I have, literally, mapped this evidence- and found some areas to be well studied while others languish.
CAM-related funding can generate important insights about what doesn’t work. My lab has studied chromium supplementation for insulin resistance, expecting it to work. It did not, and we have abandoned the practice, and encouraged others to do likewise.
That some results are negative is not an indictment of CAM any more than of conventional medicine. Some perfectly good ideas prove to be wrong. And sometimes, what works is unexpected. The author of the editorial is correct that Echinacea does not seem to work for preventing colds. But North American ginseng does work. Studies of CAM have demonstrated both.
They are also in the process of demonstrating that massage therapy confers lasting benefits when used for osteoarthritis, absent the side effects of anti-inflammatory drugs. This is a line of inquiry my own lab, in collaboration with others, is pursuing now- with NCCAM funding.
But perhaps the critical problem with the editorial’s one-sided argument is reflected in that $130 million figure. In context, it is not a big number. It costs a drug company 5 times that sum, or more, on average to bring any given new drug to market. Just one drug.
The very modest funding of CAM is problematic. It tends to result in small studies that leave us all uncertain about what works. As an example, in 2001 a paper was published in the Lancet demonstrating the benefits of a drug called carvedilol in heart failure. The study was conducted in roughly 2000 subjects over a span of several years.
At about the same time, in 2000, the Annals of Internal Medicine published a study of coenzyme Q10 for heart failure, which both the authors, and editorialists who opined, concluded showed that the nutrient was ineffective.
But since coenzyme Q10 is a nutrient no one can patent, it lacked the deep pocket of a patent-owning drug company that carvedilol enjoyed. The study in question followed 52 men for 3 months. The simple fact is this: if carvedilol had been studied this way, it, too, would have looked utterly ineffective.
What if coenzyme Q10 had been studied in thousands of people over years? We don’t know.
And that’s a crucial distinction. Absence of evidence is not evidence of absence. If the modest support of CAM research goes away, more absence of evidence is what we’ll get.
There is baby and bathwater in both conventional medicine and CAM. If we are prepared to acknowledge the widespread bullying to which both science and sense are subject at the hands of the almighty dollar, we might commit ourselves to the systematic effort of distinguishing the two- no matter the bathtub.
Dr. David L. Katz; www.davidkatzmd.com