By Michel Tetrault, DC

– A brief editorialized review of the recent WHO publication “Legal Status of Traditional Medicine and Complementary/ Alternative Medicine.”

The World Health Organization (WHO) has released its 2001 “Worldwide Review” of 124 countries and their efforts at recognizing the value of healthcare services that fall outside the recognized and highly regulated Imperial or western medicine. In this work they elected to include the current status of the chiropractic profession in each country, wherever information was available.

A notable quote from the publication can be found on page 4, where it states: “The World Health Organization encourages and supports Member States to integrate traditional and complimentary/ alternative medicine into national health care systems and to ensure their rational use.”

We are thankful for the efforts of the WHO to objectively report the representation of chiropractic in the world today in its publication. Although there may be sound arguments against including chiropractic in these other classifications, nevertheless, the WHO has elected to include the information it has received on chiropractic in its Traditional Medicine (TM) and Complementary/ Alternative Medicine (CAM) report. Chiropractic is unavailable in 160 countries and so when one looks at the lack of chiropractic presence in the majority of the world’s countries, it is understandable for the WHO to lump this emerging and growing profession at this time in history within its existing administrative capabilities. Credit is due to the major contributing organizations, in particular the World Federation of Chiropractors (WFC) and Life University for their persistent presence at the WHO over the past two decades.

The following table is a snapshot of the 189-page document outlining to what degree we find TM, CAM and Chiropractic integrated, included, tolerated or unrecognized by the respective countries in each of the 6 major regions of the globe. What does stand out is the sheer lack of exposure there really is for chiropractic in comparison to the other non-medical healthcare systems we find throughout the world and something to take serious note of.

(TM and CAM disciplines)                                         (Chiropractic Recognition)

REGION  (T#)	IG	IC	TO	UR		0	A	B	C
Africa  (44)	19	15	2	8		38	0	3	3
The Americas  (19)	9	5	3	2		12	0	3	4
E. Mediterranean  (12)	1	3	1	7		9	0	1	2
Europe  (21)	1	17	2	1		10	3	4	4
SE Asia  (9)	7	2	0	0		9	0	0	0
W. Pacific  (19)	5	14	0	0		13	1	2	3
Totals	42	56	8	18		91	4	13	16

TM & CAM:   IG = Integrated         IC = Inclusive              TO = Tolerated             UR = Unrecognized

Chiropractic:  0 = Nothing Official    A = Included in CAM      B = Partial Registration  C = Fully Protected

The majority of the non-western countries that comprise 2/3rds of the world’s population are poor and can little afford Imperial medicine and as such is where the poor see their traditional healers. In looking at the regions with the greatest utilization and acceptance of TM and CAM services such as SE Asia, W. Pacific and Africa, TM and CAM are strongly accepted by their governments and integrated in national healthcare policies. This is in direct contrast with the European and E. Mediterranean regions where laws continue to allow the monopolization of Imperial Medicine at the exclusion of all others.

One of the significant values of this report for the chiropractic profession is the specific information provided about the existing non-medical services available to the average citizen in their own country. Even though there is no duplication of chiropractic services by any other provider, we have to realize that in the absence of chiropractic services people have to go somewhere for care and when they do they frequent their TM and CAM providers. Having the knowledge of what services are already available certainly is important to know, as more and more chiropractors are willing to pioneer their profession abroad.

One difficulty faced by the pioneer chiropractors is the trend to lump chiropractic as just one more manual therapy and the challenge to educate the community about the difference offered by chiropractic care in contrast to local manual healers… i.e.: that DCs are college trained Primary Portal of Entry health care providers that utilize non-allopathic, non-drug methods of assisting their patients in regaining and maintaining their health.

The publication “Legal Status of Traditional Medicine and Complementary/ Alternative Medicine” may also serve as a useful reference text in the development of a country strategy by the chiropractic leadership. This can go a long way to understand where the prospective allies and opposition may exist in planning efforts to legitimize the chiropractic profession in a given country. There is sufficient information reported to better understand where new chiropractic patients have been accustomed to seek care and to direct further studies on these local health care providers.

An excellent example is the study of the Filipino hilots by John O’Malley, DC, PhC extending from 1992 to 1996. His thesis has meticulously detailed the folklore and techniques of these traditional healers who continue to serve their communities today. This study was distributed to the hand full of DCs now in practice in the Philippines, to aid in their understanding of the roles played by the hilots and to foster respect for them. This type of study needs to be repeated in all counties where there are traditional healers and the WHO report does an excellent job of indicating this presence.

Out of the 258 separate countries in the world, 191 have joined the United Nations and the World Health Organization. The fact that 124 countries, about half of all countries, were able to contribute to this report one can attest to the relative value of this document. In developing better ways to effectively nurture the development of chiropractic for the many pioneers that are out there it calls for the chiropractic leadership to maintain a “satelite” perspective. When there are chiropractors in 100 countries today, in comparison to just 20 or 30 just 30 years ago, it becomes important to understand the bigger picture. Thankfully, through continued involvement at the highest levels in global healthcare we are beginning to see the fruits of years of seemingly frustrating efforts.

As readers find themselves attracted to the issues in the globalization of chiropractic it is recommended to also become familiar with the “Global Strategy for Chiropractic” that has been developed by the Chiropractic Diplomatic Corps. You are invited to read this book only available online at www.ChiropracticDiplomatic.com in Adobe format. Copies of the book “Legal Status of Traditional Medicine and Complementary/ Alternative Medicine” is available from the World Health Organization, publication #WHO/EDM/TRM/2001.2.

By Michel Tetrault, DC

The Chiropractic profession has been developing a gradual and progressive relationship with the World Health Organization (WHO) since before 1985. Initially through Dr. Gary Auerbach and at his invitation, there have been dozens of chiropractors during the past two decades who have attended the WHO’s Annual Assembly, referred to as the World Health Assembly (WHA). An even smaller group has been attending regularly over all this time and these individuals have become known and trusted by the WHO in Geneva, Switzerland.

The 1988 World Chiropractic Congress in Sydney, Australia resulted in the organization of the World Federation of Chiropractors (WFC). Now, the profession could speak with one voice on behalf of the membership of the National Chiropractic Associations at International gatherings.

There are to date only a few chiropractic non-government organizations (NGOs) that have developed affiliation with the United Nations: WFC, Life International/Life University and the World Chiropractic Alliance. There are also other NGOs that serve the international communities in varying capacities but have not sought or received official sanctions of the UN. These NGOs are primarily involved in organizing humanitarian missions to developing countries or meeting some other needs of the profession as it slowly expands into non-English speaking countries. (Currently, over 95% of the world’s chiropractors practice in primarily English speaking countries.)

What is so significant about the WHO and the WHA? Every member country of the United Nations is also represented at the WHO and sends a delegation from their Ministry of Health to the annual assembly, held every spring. These assemblies bring together the representatives who are responsible for developing their country’s health care policies and programs. These are usually the same individuals who need to be contacted and informed when it is the chiropractic profession’s intention to seek legal recognition, protection and regulation. Attending the WHA is a very cost effective way to meet several Ministers of Health in a “neutral environment” to make introductions and possibly arrange for a more formal meeting back in their office with the chiropractic representatives working in their country.

The chiropractic contingency does more than simply make contacts at the WHA. As representatives of NGOs which participate in forwarding better health care for the world, these individuals are also active in developing alliances with other healthcare NGOs and bring that “unique perspective” only found in chiropractic to the healthcare discussions.

It is wonderful to see that the WHO has taken issue with the ravages caused by tobacco in our societies by establishing a Tobacco Free Initiative currently in the framework developing stages. The intention is to draft a legally binding treaty between countries to curtail the spread of tobacco usage internationally. In the year 2000, there will be 4 million deaths attributable to tobacco usage with the projections placing that number closer to 10 million by the year 2010. Tackling life style choices such as tobacco usage is an area of “common ground” where chiropractic fits in well and can more easily build relationships with other healthcare providers. The more direct contact there is between chiropractors and doctors of other disciplines, the easier it becomes to have productive face-to-face discussions about the unique role chiropractic can play in serving our respective societies.

Fifty years ago, little was known or said about computers. Today, the number of people employed and benefiting from this industry is staggering. Chiropractic has been on this planet as a separate profession for over twice that length of time. Where will chiropractic be as a profession after a second century of existence? In spite of attempts at destroying this valuable service to humanity by organized entities, chiropractic continues to grow.

Take the United States as a measuring stick for the rest of the world. Factoring in a country’s population, economy, employment and humanitarian policies, it has been estimated that the world can currently support over 360,000 chiropractors… today. The latest statistics show a total of 81,000 DCs practicing in the world, meeting only about 23% of the profession’s potential and leaving some 150 million people without access to care they need and can afford.

The profession has finally evolved beyond the survival stages and can now look forward to a century of rapid growth; but this will take leadership and support for that leadership by the entire profession and by the patients who personally benefit from the services. Vision, commitment, coordinating resources, etc. are all qualities essential to good leadership. Willing and able bodies are also needed to take their place in delivering the services to new populations and exposing entire societies to the benefits of chiropractic care: doctors who want to care for people of other cultures; teachers who can speak more than just English to build the faculty for new schools; patient advocates who can organize humanitarian efforts and keep an eye on the profession’s actions.

If you feel compelled to step forward and offer your talents in service at the international level, it is suggested that you become acquainted with the organizations which are already on the front line. The Christian Chiropractors (www.frii.com/~cca) and the Chiropractic Diplomatic Corps (www.chiropracticdiplomatic.com) are just two NGOs who have an international presence and can open some doors for prospective DCs to investigate their interest in foreign practice. Life University (www.life.edu) has several foreign programs requiring faculty and seasoned practitioners. Palmer’s successful Chiropractic Abroad Program (CAP) exposes senior student interns to servicing foreign populations (www.palmer.edu). The WFC (www.wfc.org) lists the contact information for each member association if you are looking to research a particular country as well as formal gatherings where many countries are represented. Dynamic Chiropractic (www.chiroweb.com /international) has articles that give a brief representation of chiropractic in many countries. Today’s Internet technology makes it so easy to gather quite a bit of resources and information by computer and in the privacy of your own home.

Consider this analogy. Ever notice how driving a vehicle in first gear or second gear does not allow much momentum. In fact, NOT changing gear will keep down the speed. When a person only drives on small side roads they can never get into higher gears because of all the curves and corners to negotiate. For most of the past century Chiropractic has been maneuvering the small roads. Chiropractic has now found the on-ramp to the freeway and is approaching that speed and momentum where it needs to be prepared to shift gears and really take-off! Where is this on-ramp? It is in the International arena.

Technology has made the world a lot smaller. Travel has become more affordable making it easier for people to visit foreign lands. Organizations who are paving the way for the future growth of chiropractic need your support. The Chiropractic profession is positioned to assist and support individual DCs who wish to be a part of the pioneering efforts of chiropractic’s second century. If you cannot be a player in the international scene, you can help in other ways such as donating older equipment or visiting DCs when and where ever you travel and encouraging their work. The above organizations can make good use of your gifts.

The momentum is building and pressing for the shift into the next gear. If reading this article has made you feel a little anxious and excited, it is a good indication that your heart is trying to lead you into foreign service or even to pioneer chiropractic in another country. Opportunities to serve are just a “click” away.

The Chiropractic Journal, July 2000
by Michel Tetrault, D.C.

There has been a notable increase in the number of chiropractors throughout the world in the past 10 years. In 2000, there are 81,000 chiropractors compared with 65,000 in 1989.

There has also been an increase in the number of chiropractic schools outside of the United States, from 5 in 1989 to 17 in 2000. This, in part, will account for the increase in the number of D.C.s practicing outside the USA to 12,000. (There are 69,000 D.C.s in the U.S. at present, or 85% of the world’s D.C. population.)

The past decade has also seen a significant change in the American health care industry.

Chiropractic has made some headway as a leader in alternative health care. It has also experienced the HMO squeeze and the PPO effects on the average chiropractic practice. Most D.C.s state their practices are seeing half to two-thirds of the people they were servicing 10 years ago.

It comes as no surprise that there is a growing interest for chiropractors to want to practice outside the United States. There are several reasons for this growing trend, as well as a real need to help these doctors prepare for a successful transition.

The prospects of establishing a practice in a foreign country is not as simple as moving to another city or state. Besides the similar challenges of setting up an office and moving the family, the D.C. who wants to relocate to another country will encounter several additional challenges.

There is the physical move and the local customs to establish a new business. The licensing requirements are notably different from country to country, and notably different from the USA. Plus, there are language and socio-economic realities that also present quite a challenge.

Naturally, everyone with an interest in practicing abroad needs to know the legal requirements for setting up a practice in a foreign country. This will depend on the legal status of the profession in that country. Here are the four scenarios:

1. Full legal recognition of the chiropractic profession.
2. No legislation protecting the D.C. title or defining the scope of practice but lawful to practice once a title or degree has been verified and the doctor sets up a lawful business.
3. No requirements other than setting up a lawful business.
4. Chiropractic is illegal and chiropractors are on their own.

Note: All countries require an approved resident or working visa first.

Let’s look at each of these scenarios more closely.

1) FULLY LEGAL. There are about 35 countries which have gone through the legislative process to define the scope of practice and where most protect the title “chiropractor, D.C., or its equivalent Bachelor degrees.”

These countries are: Australia, Belgium, Bolivia, Canada, Cayman Islands, Costa Rica, Cyprus, Denmark, Fiji, Finland, Hong Kong, Iceland, Iran, Jamaica, Jordan, Lebanon, Liechtenstein, Mexico, Nambia, New Zealand, Netherlands, Norway, Panama, Puerto Rico, Saint Kitts & Nevis, Saudi Arabia, South Africa, Sweden, Switzerland, Trinidad & Tobago, United Arab Emirates, United Kingdom, United States, Virgin Islands-U.S., and Zimbabwe. You can obtain a license to practice in these countries by making application, passing boards (most) and taking a practical exam. You will have to inquire as to the specific requirements of your country of interest.

2) SOMEWHAT LEGAL. The following countries have accepted the chiropractic diploma as qualification to practice chiropractic: Greece, Italy, Israel, Libya, Germany, Chile, Venezuela, Bolivia, Ecuador, Peru, Argentina, Columbia, Philippines, Singapore, Malaysia, Taiwan, Thailand, Japan, Korea, Dominican Republic, Jamaica, and the Bahamas.

However, the actual license or certificate is not necessarily for chiropractic. It is more frequently issued for a natural healer, drugless practitioner or even a physical therapist or massage therapist.

3) NOT ILLEGAL. When it is otherwise not illegal to practice chiropractic (as it is in countries with Napoleonic Laws) and there is no official recognition of the profession, there are no laws to prevent you from practicing chiropractic. In fact, the Commonwealth countries are governed by “Common Law” which makes it legal to practice your profession.

Once you meet the resident or work visa requirements, meaning that you can legally live and work in the country, all that is required is that you set up your practice by meeting all the local laws that apply to any business.

There are many countries that require citizenship in order to own a clinic, therefore you could only work in another D.C.’s office. There are disadvantages though. It is very difficult to run a regular practice. You have virtually no access to x-rays, ordering lab tests or other procedures that are under other providers’ regulations.

This tends to be handled by establishing a close working relationship with a local medical doctor. It is recommended that you visit every* chiropractor in the country to discover what he or she has learned about what is or is not permitted. (*Not everybody shares the same views.)

4) ILLEGAL (but somewhat tolerated). When it is illegal to practice chiropractic, the laws usually prevent anyone other than an M.D. to treat people. There are several countries (for example, in Eastern Europe) where M.D.s have become D.C.s and limit their practice to chiropractic.

France and Spain have seen slower growth because of this difficulty. There are only 80 D.C.s in Spain and 360 D.C.s in France (because there is a school in Paris). It is a risk, but that does not seem to deter those who are there. As Europe enters unprecedented economic cooperation, it will be interesting to see how antiquated medical dominated laws will crumble as new trade laws permit D.C.s equal access within the unified European nations.

Belgium capitalized on the growing need facing governments to acknowledge the many “complementary and alternative medical” providers in their country. This is also how Israel and the Philippines are finding their governments extending an invitation whereby chiropractors can define their profession, for regulatory purposes.

If this is done right, it can be an excellent first step. The key is to lobby for a full scope of chiropractic recognition without compromising or selling the profession short down the road. The important fact to remember here is that chiropractors are the most educated of the majority of the “alternative or traditional” providers.

This turns out to be our strength. In 1913, California was recognized under the “Drugless Practitioner’s” Act, which later became the Chiropractic Board. When we are the strongest or more educated group, we tend to dominate the “drugless” practitioners.

—–

In 1999, the Chiropractic Diplomatic Corps established a Foreign Service Registry where more than 250 D.C.s have registered from eight different countries. 95% are from the USA, 72% are graduates of subluxation-based schools, while only 20% have six or more years experience.

It’s also interesting to note that just 23% are interested in establishing a permanent practice. Everyone else is more interested in “spreading the word” and/or desires to experience different cultures. While this may be noble and a good personal growth experience, the long term benefits to these foreign communities leaves much to be desired. We don’t see the profession, nor these communities, benefiting from a working vacation type of practice.

A suitable compromise would be to urge those D.C.s who see themselves committed to only a temporary stay, to plan on remaining for five to six years, then transitioning their practice to another doctor. This way the community continues to benefit from a permanent clinic and a five-to-six year stay will make the exchange a win-win situation.

Another option is to set up a long term cooperative between a small number of D.C.s who can rotate with each other’s clinics, one of these clinics being in the United States.

We like to support and encourage D.C.s to “get right” in their hearts and minds before practicing abroad and prefer to see them moving permanently to the country of their choice. One of the main motivators for this kind of thinking is that it takes just as much time, energy and money to see a chiropractor establish a foreign practice for one year as for a lifetime (you figure out the math).

In conclusion, there are excellent opportunities for chiropractors to practice abroad. Take an honest survey of yourself. Ask friends and family to help you get a realistic view of your strengths and weaknesses:

• Do you see yourself as a pioneer?
• Do you see yourself as a solid practitioner who can adapt in a foreign culture?
• Can you learn another language?
• Can you be happy living under different physical standards?

You’ll be better able to make a decision about setting up a foreign practice the more you’re able to learn about yourself and about other cultures. There is a self- evaluation quiz on the Chiropractic Diplomatic Corps’ website (TOPIC #12) that may be of interest.

Those of you who immigrated to North America have to ask yourselves different questions. Why are you not back home, building the profession in the culture and language of your heritage? Are you going to leave it up to foreigners (albeit well meaning) to decide how chiropractic is to develop in your homeland?

The future growth of chiropractic will be in non-English speaking countries. There are six billion people on this planet. Taking into account economic and socio-cultural factors, there are an estimated 372,000 chiropractors needed to service those people who can afford the care, today.

Right now we are only caring for 21% of our potential patients. If you practice in California or Florida, you know first hand what it’s like to practice where there is a saturation of chiropractors. Think it’s getting crowded in America and harder to practice? Think again. Think differently. Think: “Do I have the right stuff to practice abroad?”

 

by Michel Tetrault, D.C.
DYNAMIC CHIROPRACTIC
September 18, 2000

While attending the May 2000 World Health Organization (WHO) Annual Assembly, as the representative for the Chiropractic Diplomatic Corps, I was given a copy of a recent WHO publication titled the Low Back Pain Initiative. (1) This is a multi-site, multi-national, multi-disciplinary research effort that took place from 1993 to 1997 by the Department of Noncommunicable Disease management.

The book’s purpose is to establish outcome assessment criteria in multiple languages and has identified the validity of four objective assessment tests that can be useful in future research: the Oswestry Disability Index, the Modified Zung Index, the Visual Analogue Scale and the Schober’s Test. All four were successfully tested for translation and back-translation. A validating aspect of the study is the inclusion of chiropractic as a significant partner and contributor, thanks to the Life University team. The document is available thru the WHO online in it’s entirety. (‘http://whqlibdoc.who.int/hq/1999/WHO_NCD_NCM_CRA_99.1.pdf‘)

The following presentation supports an opposing view of the current direction in chiropractic research and a plea for more patient involvement in the framing of future research efforts.

The study determined that Lower Back Pain (LBP) falls into one of two main categories:

1. Those with specifically identifiable causes such as protruding disk, spondylolisthesis, infections, fractures, etc.
2. The “Non-specific” LBP category representing the highest percentage of LBP.

In fact, “non-specific LBP is so common that it has been recognized as epidemic, perhaps even pandemic,” (2) according to Professor George Ehrlich. However, it is disappointing to see that the chiropractic subluxation is still not being recognized as an identifiable physical cause by the medical participants of this study. At least the chapter on chiropractic written by S.E. Williams, DC, which is the first diatribe on chiropractic present in any WHO text, defined the chiropractic profession within the subluxation based premise.

In general, the conclusions were not too surprising or revealing, but the results are only preliminary and full results will be coming in a major refereed journal. There are however notable results on the psychosocial studies regarding LBP. Dr. N. M. Hadler, well known and respected in the field, stated that “biomechanical factors matter less than workers’ perceptions about the nature of their jobs” or “about the respect workers hold for their work and position in the workplace and workforce.” (3)

In a reported 1991 study of a Boeing factory in North America, dissatisfaction with work was a major predictor of later presentation to the medical services with LBP. In another study, the likelihood of developing a new episode of back pain was significantly higher in those who were distressed.

A second area of the publication that merits particular consideration addresses the conclusions for the management of Acute LBP. If you have been objectively following the studies on Acute LBP, it has likely become apparent to you that almost anything done, or everything done or nothing done for that matter produces the same results. The greater majority of Acute LBP is self-limiting.

Perhaps the strongest message that has come out of the Low Back Pain Initiative is the significant difference between acute and chronic LBP management. “By now it should be obvious that prevention of chronic pain should be the primary goal, although the factors that convert acute to chronic pain remain elusive.” (5) What remains confusing and perplexing to providers and researchers of all disciplines are the differentiating factors that account for the high percentage of Acute LBP cases that become chronic.

A question to pose here might be: “What can be gained by stipulating that the vertebral subluxation may in fact account for the missing link in this puzzle?” Beyond the scope of the Low Back Pain Initiative studies are the unrecordable healthcare benefits of other illnesses or conditions patients feel have been prevented because of their commitment to use chiropractic as a primary health care service. In North America there could easily be millions of similar cases proclaiming healthcare benefits from the management of their spines and their general health over the past century of service by chiropractors. Although this has nothing to do with acute LBP there are scant studies that are designed to better understand these patient experiences. How can future research validate these experiences with protocols that can be scientifically supported? Relating this position relative to the Low Back Pain Initiative publication: How do we identify THAT percentage of acute LBP cases which become chronic and how to best care for these patients? The role played by chiropractic could and should be the primary and major provider.

Returning to the study, we find the participants questioning the validity of further investigations into Acute LBP because the majority of socio-economic burdens tend to result from Chronic LBP and not from Acute LBP. Research can best serve the public by shifting its focus to identifying those factors that will better identify which Acute LBP episodes are likely to become chronic. In Acute LBP management, studies have repeatedly shown that chiropractic is equally effective as conservative medical care. So what!? The fallacy of focusing so much research all these years on the neuromusculoskeletal conditions, such as acute LBP or headaches, has ultimately degraded the true strength and value of the role chiropractic plays in the delivery of healthcare in the world.

The true strength of chiropractic is and always has been in the care of chronic vertebral subluxations and that is where most future research needs to be done. Research will best serve patients when it is designed to better understand and to validate the benefits of identifying and correcting vertebral subluxations. The Life University research team is already reversing the research trends by limiting the spinal adjustments to the upper cervical subluxations during this Low Back Pain Initiative sub-acute study. Finally someone is thinking differently!

There is clearly the need for two research agendas in chiropractic at this time. The existing efforts that attempt to quantify and improve our effectiveness in specific areas and in comparison with other providers who work in similar areas. Secondly, challenge the research teams to focus more on the overall health benefits and quality of life aspects of chiropractic care globally and within specific populations.

Today, we have entire societies under national health care regimes permitting total population studies of a particular society such as the Manga Report, Province of Ontario, Canada (4). Moreover, the WHO study concludes: “Prevention of chronic back pain should be a major goal.” (5) Research studies designed to take the Ontario study to the next level should answer many questions, including viable options in prevention of chronic LBP. Based on the outcomes of such total population studies, governments would see the value of integrating chiropractic care into government programs.

In conclusion, it is fair to state that the past 15 years of research has more than adequately addressed the acute lower back issue. The lesson from this WHO publication, the Low Back Pain Initiative, is how future research programs can effectively use and improve on the objective measuring instruments/tests listed earlier. It is not this writer’s intention to denigrate what is a significant research effort which included some fine chiropractic researchers in a multi-disciplinary study. The advantage of retrospective analysis is how new and special directions can now be taken based on this knowledge.

Lastly, but not of lesser importance, it will be good to see more involvement of patients as an equal stakeholder in the structure and design of future research. This can only improve the process and produce results that are valuable to both the patient and the average chiropractor in the field. It’s time to move on. Patients influencing WHERE research can be directed for THEIR best interest instead of just the academic DC or the research institution’s best interests… What a concept!

(1) Low Back Pain Initiative, by WHO 1999/2000 – index # WHO/NCD/NCM/CRA/99.1

(2) Low Back Pain Initiative, by WHO 1999/2000 – p. 81

(3) A benefit of spinal manipulation as adjunctive therapy for acute low back pain: a stratified control trial.

– Spine 1987, 12:702-706 by Hadler NM, Curtis P, Gillims DB, Stinnett S.

(4) “Study to Examine the Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain,” Province of Ontario, Canada, by Pran Manga, Ph.D.

(5) Low Back Pain Initiative, by WHO 1999/2000 – p. 83

By Michel Tetrault, DC

– Thinking things through
PARIS 2001 – Representatives of several countries, during their Country Reports at the WFC Congress, stated that there is some preliminary work being done in their country toward the eventual establishment a chiropractic school. This indicates that the time has indeed come to prepare more resources for this growing list of countries planning on starting a new school. In order to place some relevance in this effort, it makes sense to evaluate the population and economic indicators for the possible number of schools a country can support; build a database that includes the names of the prospective universities and the mentor institution(s) affiliations within the already established schools; and, address the challenges of supplying enough teachers to meet the growing demand and growth in the number of schools. In addition, some consideration be allowed for the unique specifics of each country’s educational laws that may require modifications in the early stages of establishing a chiropractic curriculum, as seen in Brazil during the latter part of the 90’s.

Developing models that can estimate the demand and viability of chiropractic schools in new countries presents two possible directions. One is based on comparing chiropractic with the allied healthcare professions of similar levels of education, such as Dentistry or Optometry. The other relies on the population and economics within each country. In fact it may require either or both to arrive at reliable values.

To compare the number of other First Professional Degree institutions and calculate for example the ratio of Chiropractic to Dentistry schools it is best to look in countries like America, Canada and Australia, where the chiropractic profession is well established. There are 55 DDS schools to 17 DC schools in America and 9 DDS to 2 DC schools in Canada. Looking at the dental schools of both countries there are 6 times less dental schools in Canada than the US suggesting that Canada should have 3 chiropractic schools. If British Columbia ever gets its act together, the matching ratio of schools would be accurate. Now, it remains to be seen whether that ratio of 3 DDS to 1 DC school can translate into other countries with different socioeconomic realities.

In another article, this author has illustrated how the size of a country’s middle-class dictates the number of DCs that country can support. When considering this, the financial approach of estimating if a country can support a school may be more valid. This is accomplished by multiplying, for a country like the USA or Australia, the total population with the gross domestic product per individual (GDP) and dividing that number by the number of schools to come up with working denominator: POP x GDP ¸ DC school = X. This approach was taken for each of the countries where there are practicing DCs today with the results listed below. Only in the established countries were both methods required.

The number in brackets () is the estimated total of schools for that country.

Established Countries:
USA 17 Schools (18 needed) Doctor of Chiropractic Degree(First Professional Degree ratio model estimates 18 US schools while the POP x GDP ¸ DC school = X model suggests 43 possible schools. Perhaps the US population distribution supports larger sized schools?)
Australia 3 Schools (3) BSc Degree
Canada 2 Schools (3) DC Degree

Advancing Countries:
England 3 Schools (9 needed) Batchelor of Science in Chiropractic Degree
South Africa 2 Schools (2) Masters in Chiropractic Degree (?)
New Zealand 1 School (1) Doctor of Chiropractic Degree
Denmark 1 School (1) Masters in Clinical Bio-Mechanics Degree (?)

Pioneer Countries:
Brazil 2 Schools (7) DC Degree Costa Rica 1 School (1) DC Degree
France 1 School (9) DC Degree Japan 1 School (19)
Korea 1 School (4) DC Degree Mexico 1 School (5) DC Degree

Hopefuls: (11 out of 26 total)
Argentina 2 Iran 2 Italy 8 Malaysia* 1
Peru* 1 Philippines* 2 Portugal 1 Spain 4
Sweden 1 Taiwan* 2 Thailand 2 *discussions underway

Eventuals: (87 total)
Austria 1 Belgium 2 Chile 1 China 25 est.
Czech Republic 1 Egypt 1 Finland 1 Germany 12
Greece 1 Hong Kong 1 India 25 est. Israel 1
Morocco 1 Netherlands 2 Norway 1 Poland 2
Russia 4 Saudi Arabia 1 Singapore 1 Switzerland 1
Turkey 1 Venezuela 1

The current global snapshot creates the following projections:
A total of 195 possible schools in 46 countries and in 30 languages, so far that have DCs.
– 36 schools in 7 languages are established out of a possible 82 in these 13 countries.
– 11 new countries are currently at some level of negotiation.

There are of course many challenges to prepare the necessary resources for these new schools. Partnering with the right institution can have a profound influence on the success or rapid growth of the program. There are schools that have been established with little or no partnering with institutions that represent the full chiropractic product. The results were, let’s say, disastrous and there is room for concern that the lone ranger approach may not remain an obsolete practice. Problems continue to arise out of these cases in Japan, Sweden, Denmark and Italy that are very difficult to resolve.

One of the most successful mentorship models observed has been between the Sherman and New Zealand Schools. What can be learned about that example of partnership-in-action? Someday, they may elect to write about their model of cooperation. Palmer College has provided a “bridge-type” of mentorship with the first school to open in Brazil in the ’90s. Life University continues to work on a working model for “twinning” with universities of third-world countries, such as in Costa Rica, Peru and is looking at Africa. Northwestern has had their hand in consulting from a distance for several potential foreign schools in Latin America, Mexico in particular. In Asia, RMIT has an ongoing program in Korea and Japan with additional consultations with Malaysia, Philippines and Thailand. RMIT has yet to realized the same positive outcomes as seen from the American mentorship of Latin American schools. Dealing with developing countries has seen many false starts in all continents calling for a more compete resource center to reduce the barriers that have been encountered.

The lack of clear and uniform resources will continue to prevail as long as institutions struggle to just take care of their home base. Stretching abroad with thin resources of faculty and finances makes the effort particularly difficult. Palmer College, under Dr. Guy Riekeman’s leadership, is undertaking the development of a resource center that can provide specific consultative instruments for foreign schools that can take existing chiropractic college administrative roles for adaptation into a university based system. The role of a Clinic director, the Dean of Students, a Technique or Philosophy teacher for example, with specific application for chiropractic students, can be exported for use by the newer schools. There is definitely a need for this information but it is a shame that the profession has not been able to produce a single entity that can provide the whole package needed to import a chiropractic education program.

Is there a single entity that can provide the whole package to import a chiropractic education program? Palmer, Life and Sherman have pledged a continued support for the New Zealand school. Perhaps this is the beginning of an International Consortium that can extend beyond the South pacific. By adding, lets say Cleveland colleges there would be 7 schools pooling their resources to logistically support the newer schools with a “totally exportable product.”

On the subject of the philosophical focus seen at Palmer and Life, particularly as we see all new schools being developed as a department of an established University, there is the requirement for a clear International Core Curriculum that addresses these University based programs’ needs without compromising the outcome and quality of the DC graduate – subject of the following part of this series. A thoroughly structured Philosophy content can create the necessary “Chiropractic Culture” needed for the students who are educated in chiropractic within a university system. Again, another point that emphasizes the need for a cohesive and complete exportable program that would be gladly received by both the DCs in the countries attempting to see chiropractic taught there and the universities who are looking into the prospects of adding this new and exciting profession to their institution.

Curriculum Designs – Expanding the model.
Earlier, we discussed the growing need for an organized effort in planting chiropractic schools worldwide as well as the value of gathering information to better think things through. A current global snapshot was created to estimate the number of schools needed in each country that resulted with a total of 195 possible schools in 46 countries and taught in some 30 languages. There are presently 36 DC schools taught in 7 languages that are established out of a possible total of 82 in these 13 countries. In addition we see that 11 new countries are currently at some level of negotiation with a nearby university with the hopes of teaching chiropractic in their own country.

Projections suggest that during the first decades of the 21st Century there will be 1-2 new chiropractic schools starting every year and eventually 2-3 new schools annually thereafter until the foreseeable future. Will these schools graduate doctors that are equal to the current practicing DCs? What is being done to preserve the chiropractic heritage yet still allow for progressive developments that come out of technology, research and clinical experiences? Are there enough qualified teachers to fill the positions? Will there be a random implementation of independent schools or can we influence a harmonious strategic development of a global chiropractic education system? Let us discuss these seven key components: university based schools; prerequisites, core courses, preserving subculture in philosophy, Information Technology, faculty shortage and regional accreditation issues.

In the early years, chiropractic was taught by mostly small private institutions. National peer review standards evolved and accrediting bodies were formed to place chiropractic equal to other “First Degree Professional” educational institutions. Since the late 1980’s all new schools have been created within university systems and this trend is likely to continue.

Curriculum designs have mostly followed some basic standards but only recently has there been an interest in creating International Standards. In an effort to further encourage International cooperation there are several design elements that invite rational self-critique before casting the curriculum molds to stone. We will discuss some of these elements.

Private institutions have the luxury of setting their own programs and the cost of education has tripled in the last two decades. In an affluent country like the USA there will always be people who can afford to bear these costs. Economics becomes a critical factor in opening the chiropractic profession to other countries. This begins with the cost of educating DCs in these countries. At present only the children of the wealthier families can afford to go abroad for a chiropractic education. There is now the need to see new DC schools start all over the world to reach all the people.

Prerequisites in Canada and the USA have jumped from high school in the 50’s to 70’s and approaching a full BA or BS degree in the 2000’s. Three to four additional years have been added in just the past few decades. How will prerequisites be determined in countries like Egypt and Costa Rica or Hong Kong and Botswana? Certainly not a full college degree! The logical choice is to match the prerequisite standards of the existing professions of dentistry, podiatry, optometry or veterinary schools. This would range from a matriculation right out of high school in some countries to the two years required in many countries today.

In some countries, as was the case in Brazil, it may be necessary to adapt an “interim” course before the full International Standard can be provided. This would be predicated by certain country laws or the high number of non-qualified “so-called-chiropractors” who will likely attempt to be grand fathered in new laws.

Caution needs to be exercised when determining which courses are “core courses” and which are related to Western lifestyles. Competing with other healthcare professions in America has prompted our DC schools to include additional courses that meet the demands of the American stressed-based culture, often sacrificing additional classes in techniques. Some American schools have opted to focus on academic courses and offer minimal diversity in technique programs. What “core courses” need to be included that produces a proficient DC without over-minimizing and without touting one method over another? Beyond core techniques we have also seen the development of hybrid techniques over the past 25 years. There is a trend to move away from purely segmental evaluation and correction toward more neurological and meningeal methods. This may just be a North American trend but other countries are just as likely to develop culturally influenced methods that evolve out of their experiences. An exciting prospect for sure! One that should to be factored into accepted curriculum designs.

Philosophy has been a particularly interesting component of the curriculum process. When 22 out of 32 DC schools convened for the first time in Manila in 1998, to discuss International Education Standards, their first topic of concern for a detailed study was on the Philosophy of Chiropractic. So, two years later in Ft. Lauderdale, Florida the first International conference on Philosophy in Chiropractic Education was held through the WFC. The results were unexpected! It seems that we have been mandated to embrace our “vitalistic roots” as schools re-evaluate their curriculums. Philosophy experts insist that it has something to do with our “raison d’etre” and being “authentic” in our healthcare role. It has been suggested that curriculum designs include a Philosophical basis for each area of study. Not just for technique and clinical sciences but also research, physiology, pathology and other physical sciences.

Then there remains the challenge of training chiropractors in a university system not solely dedicated to the chiropractic profession. Most DCs in practice today have been privileged to receive their education in a private school that exclusively focused on chiropractic. This setting made it easy to maintain a “chiropractic culture” essential in the development of a healer in this discipline. As all new schools and many established schools are university based, DC students receive their basic science courses in a “mixed setting” with students from other health disciplines or science programs. The challenge is to integrate into the learning experience a new model that can recreate this “chiropractic culture” in a manner that maintains harmony with the shared faculty and students of the university. Realizing the value of integrating a Philosophy component in all areas of study can move things in the right direction.

The new frontiers for chiropractic are not found in Western/industrial countries but are occurring in the more recent post-colonial and third world countries. Object based educational models worked well in English speaking and post-industrial societies, even when attempting to train a vitalistic practitioner. Perhaps it is time to create curriculums that are culturally sensitive to societies that have retained a holistic based healthcare mentality as seen in China and India.

Information Technology (I.T.) developments over the past decade are contributing to the potential for expanding chiropractic education, unlike any time in our 100+ year history. Until now, only economically advanced countries could put the resources together to establish a chiropractic school. Today, I.T. systems allow Distance Learning products to be shared internationally and at reasonable costs. This relatively small profession with its limited pool of teaching staff can now share its human resources between schools. Students can be exposed to some of the best teachers in the world to supplement their local faculty through multi-media and Distance Learning technologies.

Today, it is easier to put together a quality education program for chiropractic that can be duplicated and offered worldwide. The biggest barrier to the profession’s growth is the lack of chiropractic schools. I.T. brings to classrooms uniformity in training with higher quality and lower costing tools. In establishing International Curriculum Standards we must consider the role Information Technology can play.

There still remains the problem of providing emerging schools with enough qualified teachers. There is a shortage of teachers in chiropractic yet there is no plan to prepare for the future. The availability of face-to-face teachers to staff the growing need for DC faculty is an important issue. Teachers who are experienced in the practice of chiropractic are a valuable resource.

Recruiting this “Faculty Pool” requires sensitivity to both the educational requirements of institutions and the cultural compatibility to the target country. Not all people can adapt to different standards of living but there are teachers with “ex-patriot” qualities who love to live and work in different cultures.

The true benefit that this Faculty Pool can contribute to the profession is to influence greater uniformity of education in meeting the curriculum standards. School start-ups could greatly benefit from an International Faculty Pool. If you are a qualified teacher with a tolerance or affinity for other cultures, you are invited to register with the Chiropractic Diplomatic Corps at www.ChiropracticDiplomatic.com/register.

Accrediting agencies serve an important role in contributing to the quality of education. Unfortunately, not all countries have chiropractic accrediting agencies. This has resulted in atypical school programs and a poorer quality of education. Without accountability the public remains at risk and DC students are receiving an inferior education for their tuition. Until it is practical to have an accrediting agency in each country that teaches chiropractic, there needs to be at least a regional entity that can establish an early framework to ensure that International Standards are being met by all schools. Creating an International Standard without a regulatory entity to supervise its implementation will not work. Much hope lies in the newly formed International Council on Chiropractic Education (ICCE) late in 2001 to undertake the task of building a network of regional and if needed a CCE for every country where chiropractic will be taught.

To offset a history of random implementation of chiropractic school programs there is a clear mandate to create a strategy for the development of a global chiropractic education system. The educational community has already begun the process with the assistance of the WFC and the cooperation of established chiropractic colleges. Detailed course outlines are being shared and improved through dialogue. There is still the need for financial support and creative input from additional sources such as international consultants and non-government organizations. It will be interesting to see what develops in the coming years as the Curriculum Design process continues.

As the new schools open in many different countries, prospective chiropractic students shall be accepted into a chiropractic program based on the country’s existing matriculation levels afforded other health care professions with similar exceptions to the medical practice, such as dentistry, optometry and podiatry; while the chiropractic course length shall range from 4-5 years, the pre-chiropractic education will depend on prevailing standards that are similar to the other allied health first professional degree programs in the respective countries. The educational institution that houses the chiropractic program is likely to teach the basic sciences classrooms with students combined from other healthcare disciplines with special clinical application classes that bridge the course content to the unique professional fields.

In developing countries, where the number of schools is expected to proliferate rapidly, the socio-cultural and economic reality call for an efficient, non-repetitive, traditionally based course of study that equips the new chiropractor to practice in an environment quite different than the greatest majority of today’s readers have ever experienced. Countries with a small number of practitioners, rampant poverty and usually little legal protection of the profession, require that the new DC be prepared to duplicate the practice styles and social climates that faced the earlier pioneers in Canada, Australia and the USA: lean and fit with the ability to counter guerrilla tactics of organized medicine without the benefit of a strong long-standing national association, to name one obstacle; a population that has at best 20% of the people with adequate income to afford care; and a general population that knows little to nothing about chiropractic; or worse yet – where there are hundreds or thousands of unqualified people calling themselves chiropractors.

In summarizing this article series, we discussed well-accepted educational values and ideals of the chiropractic profession and what counts as we proliferate educational programs that preserve our uniqueness. We investigated formulas that evaluated the number of institutions we could expect over time and other miscellaneous subjects on prerequisites, university based schools, Information Technology, faculty placement and regional accreditation issues. What is now needed is a universal and exportable curriculum that does the job in today’s world; one that has the flexibility to incorporate the cultural gems contributed by genuine values of other traditions in non-allopathic healthcare. It will be interesting to report on this subject after the WFC/ACC Conference on Clinical Education – São Paulo, Brazil, October 26-29, 2002. The task is at hand!

Acknowledgement: Throughout this article exerts were taken from several chapters in Dr. Sid Williams’ Collected Writings and Letters printed in his 1994 book ” Looking Back To See Ahead.”