|T H E N I H C A T A L Y S T||J A N U A R Y - F E B R U A R Y 1999|
JONAS MOVES ON AS CENTER MOVES IN
|by Fran Pollner|
There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy.
Hamlet, Act 1, Scene 5
With perseverance and scientific rigor, researchers have unlocked mysteries of the human condition and once-invisible mechanisms of disease-causing and healing processes.
Typically exempted from the rigors of scientific scrutiny, however, have been the "home remedies" and "unorthodox" approaches to healing collectively known as "alternative" or "complementary" medicine.
Ironically, the publics demand that alternative medicine approaches be taken seriously enough to be accorded a place at NIH has made them an accessible and funded subject for the kind of scrutiny that substantiates or disproves the value of any proffered remedy for human ailments.
That was the objective of Wayne Jonas and the concept that shaped his actions as director of the NIH Office of Alternative Medicine (OAM) from July 1995 until his departure at the close of 1998. Indeed, it was the premise upon which the OAM was launched by congressional mandate in 1992that science can throw light on areas previously thought unexplorable.
The first three years of OAMs existence were somewhat rocky, and the office had not really found its niche when Jonas came on board. The previous director had resigned in frustration, and there was tension among OAM, its advisory committee, involved congressional parties, and others.
Jonas was here for three-and-a-half years on a detail from the Army. By most accounts, he stabilized OAM operations and solidified both its place in the spectrum of NIH research and its mandate to apply scientific method and evaluation to alternative medical practicesand let the public know the state of the art.
During his watch, collaborative projects with NIH research institutes have been established, centers around the country have been funded to do complementary and alternative medicine research, and representatives of the alternative and mainstream scientific communities constructed a strategic plan for OAM activities, released last August. Two months later, Congress elevated the OAM to Center statusthe National Center for Complementary and Alternative Medicine (NCCAM)with an annual budget of $50 million (from $20 million the previous fiscal year); and the Journal of the American Medical Association and the nine AMA Archives Journals published coordinated "theme" issues with more than 80 articles and editorials on alternative medicine. The JAMA issue included an editorial by Jonas.
Jonas is returning to a faculty position at the Uniformed Services University of the Health Sciences in Bethesda, Maryland, where 40 percent of his time will be spent doing research and the rest will be divided between his family practice and teaching.
His NIH successor, Jonas believes, should be a practicing physician with a sense of the publics perspective or, if not a physician, someone who "listens very closely to that perspective." To focus the science in relevant areas, he says, "you have to both hear what the public is asking and examine where the data are leading." Jonas was interviewed by The NIH Catalyst in December, several weeks before his departure.
Q: What do the establishment of NCCAM and the appearance of the alternative medicine edition of JAMA and its affiliated journals indicate about the progress of alternative medicine?
Jonas: They reflect the increasing maturity of the field. As I said in my JAMA editorial, complementary and alternative medicine (CAM) has come of age in the scientific communityits been "of age" as far as the public is concerned for a long time, and now the mainstream community is beginning to see its importance.
Historically, this is not the first time unconventional practices have become popular. Typically, the orthodox field fights these practices for a while, then starts to examine them, and gradually adopts certain ones. Any time new ideas are brought into established areas, both sides risk changing, and both the new ideas and the old changehopefully. Both sides should change, of course, because nobody has the corner on truth, not statesmen or scientists.
The establishment of NCCAM at NIH indicates that the capacity to do research and the interest among researchers have grown. In addition, alternative practitioner groups are starting to express an interest in science. Both sides, hopefully, are coming to focus on science, and the Center at NIH reflects that social phenomenon.
Q: Do you think congressional pressure was necessary?
Jonas: Any established group, whether in medicine, science, or politics, generally doesnt like change, so theres usually some element of coercion at some point. But once people within the orthodox community begin to see where there could be value, they move toward it themselves. In the last three- and-a-half years, Ive seen a tremendous increase in interest from the mainstream community. When I started here, most people who approached me were practitioners in the CAM field who wanted a particular practice sanctioned. Now the vast majority who contact me are mainstream scientific groups who want to know how to get a grant in these areas, or what topics are of most interest, or how best they can pursue a specific research idea they have. This is progress.
Q: What do you think engendered this interestthe public or the science?
Jonas: I think its a combination of things. The public may have brought the attention of scientists to alternative medicine, but that by itself is not sufficient to move scientists into an area of research unless they can see testable hypotheses and the possibility of useful results. And, of course, theres more money available now.
Q: Which do you think are some of the testable hypotheses?
Jonas: NCCAM is involved in testing some of these right now: looking at the clinical safety and efficacy of herbal remedies; exploring the mechanisms of acupuncture analgesia; and testing the hypotheses and practices of chiropractic, which is something chiropractors themselves have gravitated toward.
As an "office," OAM did not have the authority or capacity to fund research directly. It used its funds to supplement or to co-fund projects based in other NIH institutes or to develop new initiatives with the institutes that they would then carry out. I suspect that the bulk of the new Centers projects will continue to be collaborative, even though Center status confers the capacity to execute and fund its own research. After all, $50 million will not go that far, and you wouldnt want to set up a separate infrastructure when the expertise and infrastructure required to carry out good (CAM) research already exist at the NIH. Were working very closely with NCI, for example, to help identify what look like viable projects, and we supply some of the resources, but NCI uses its existing research structurescancer research centers and regional oncology groupsto develop and test particular practices and projects.
There are other ways we collaborate with the institutes. We worked with NIAMS to put language on CAM-related research into their fibromyalgia RFAsince thats an area in which CAM is used extensivelyand about 10 percent of the applications that came in were in CAM areas. Should there be outstanding applications in those areas that NIAMS supports, well back them up with some resources. Weve done similar things with NHLBI, which is currently soliciting to re-fund their SCORStheir centers for cardiovascular disease research.
Last year, we cosponsored with 12 of the institutes a consensus development conference on acupuncture, an area ripe for both basic and clinical research. Following the conference, we had a series of meetings with the institutes to develop RFAs, and we released an RFA last year for examining acupunctures effects on pain, stroke, asthma, and neurological and immunological conditions. Theres also a trans-agency CAM committee that Dr. Varmus set up last December (1997) that includes people from the institutes and from other agencies, like the Food and Drug Administration and the Centers for Disease Control and Prevention.
Q: With which institutes have you been most active?
Jonas: Weve worked with almost all the institutes through one or another mechanism and have developed initiatives, new projects, with about half of them. Weve worked very closely with NIMH, NIAMS, NICHD, NCI, NHLBI, NIDCR, NIDA, NCRR, NINR, NIAAA, and others. We have an intramural research training program, a research support mechanism whereby intramural labs put together applications for CAM-related projects and also provide some postdoctoral research training in these areas. A board of intramural scientists reviews those applications and makes recommendations to us. Then those institutes execute those projects. For example, NIAAA was interested in examining more objective markers of the neurophysiological effects of acupuncture in alcoholics. They recruited [an intramural] fellow to set up a project using functional MRI [magnetic resonance imaging] and PET [positron-emission tomogrpahy] scanning.
Q: How many intramural projects are there?
Jonas: There are four funded now. In addition to the NIAAA acupuncture project, theres an examination of transcranial electrical stimulation and its effect on learning (NINDS); an examination of the anticancer effects of herbal folk remedies (NCI); and a series of studies on the impact of changing expectations on the clinical analgesic effects and neurophysiologic correlates of acupuncture analgesia and placebo (NIDCR).
Q: What attracted you to the OAM director position?
Jonas: Before coming here, I ran a postdoctoral research training program at the Walter Reed Army Institute of Research [in Washington]. Prior to that, I had done health promotion policy at the Army Surgeon Generals office and served on the staff of a family practice residency program in Fort Belvoir, Virginia. I got interested in CAM when I was a medical officer stationed in Germany and running a family practice clinic in the early 1980s. I speak a fair amount of German and went out to the local German medical societies to find out what was going on. What I found was that they were incorporating unconventional practices, such as acupuncture, herbs, and homeopathy, into their medical practices. This got me intrigued, and I began to study some of these selectively.
I came here, first of all, because I love science and Im very curious. My main goal was to get the office operating in a way that it could do high-quality research and be integrated into the operations of the NIH. I wanted it to grow roots into the NIH and develop collaborative relationshipswhich has happened. We have 50 projects up and running and 13 centers.
Weve also supported critical evaluation of existing CAM research: We worked with the Cochrane Collaboration, which is a group that systematically reviews randomized controlled trials in all health-care areas. We have a clearinghouse that provides the public with information on OAM activities and research. Weve worked with NLM to review over 600 CAM-related publications and journals. Weve pulled together a CAM citation index from major data sources and provided it on our home page (with over 100,000 citations), so the public can search it.
Q: What do you see as NIHs proper role in exploring or defining alternative therapeutic approaches?
Jonas: I think NIH should provide the benchmark of quality science, the gold standard for doing research in these areas. It should also do basic and other research in CAM areas that are not likely to be funded through the private sector for lack of financial incentives.Theres a strategic plan for OAM, developed over the last three years, that was released last August and outlines very clearly what the complementary and mainstream communities have agreed on are good directions for the office to go. Two months after its release, though, the Office was dissolved and the Center was created, so well see what happens.
Q: What did you most enjoy during your time here? What did you find unpleasant or frustrating?
Jonas: The most exciting thing for me is working with scientists who suddenly see something important that can be tested, an idea that suddenly crystallizes. One time, we were working with six different institutes and the Office of Behavioral and Social Sciences Research to examine the whole area of religion and spirituality. A scientist from NIAID was looking through background material when he suddenly looked up with a surprised expression and said, It looks like some of these religious practices may have effects on the immune system. Something had triggered a new perception, a way to study the neurobiology, if you will, of religion and religious practices.
And on the difficult side, as Daniel Boorstin said, and I quoted him in the JAMA editorial: The greatest obstacle to discovery is the illusion of knowledgenot difficulties in getting knowledge or even ignorance. This includes practitioners who dont feel the need to test their claimsor even claim that they cant be testedand scientists who dismiss the idea of testing what they cant explain, an unusual mysterious phenomenon they cant explain. Both are arrogance, and both are obstacles to good research.
Q: Theres a quality to the poems you submitted to the Catalyst [last year, a bit too late to be included in the May-June 1998 issue with other offerings from hidden NIH poets] that seems to express some of what you are describing, especially one called "Enlightenment in Fog."
Jonas: I was on a camping trip with my daughter in the mountains of West Virginia, looking to the east, and saw as the sun was coming up these mountains kind of emerge from the mist. I got one of those serene feelings you get in the mountains, and that poem came to me.
You could think of CAM in terms of a hazy area that we attribute to some kind of mystical thing that through good research and a little light (wisdom) gradually emerges as a normal processsomething we can explain, investigate, and control. Back in the Middle Ages when Europe was being devastated by bubonic plague epidemics, the prominent theory was that it was Gods wrath and it would be playing God to investigate it, try to interfere with the process, and reduce the death rate. We get the same attitudes today if we start to investigate so-called "mystical" or unexplained observations. As scientists, I think our attitude should be that maybe these are just normal processes that with good research we can understand and control. Surprisingly, this idea is threatening. Most people want to stick to their beliefs above all else, and good science threatens that. So, yes, "enlightenment in fog"helping something emerge from a fog of unclear ideas by throwing the light of science on itthis is what investigating complementary and alternative medicine is all about.
Enlightenment in Fog
Standing on the east side of the bald;
Waiting for the mountains to emerge
Perhaps as we grow older
Spiritual signs grow more subtle,
Until they are indistinguishable
From normal life.
Wayne B. Jonas
4 Sept. 1997
Small Talk Rock
No words can capture
the color of soft morning light
in that early time
when it illuminates
but does not strike.
No discussion can release
the deep desire I see you
have forced against the bars
of this small talk cage we make
and through which it peeks out.
There is a place I go
during times of great despair or joy
that is like a warm rock
in the sun;
and there you are.
Wayne B. Jonas
19 April 1997
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