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– The economic conditions that support the development of chiropractic, simply explained.

Occasionally someone in the world experiences a brief moment of creative genius that propels an idea into a life-changing event. That moment happened on September 19th in 1895 when D.D. Palmer made the connection between spinal misalignments and a compromised nervous system. This revelation rapidly developed into the Philosophy, Art and Science of Chiropractic and a new profession was born.

The first fifty years saw this new profession remain almost exclusively in America. Eventually there were foreign graduates and the profession began to spread throughout the world. Interestingly enough, the rate and distribution pattern of this growth occurred primarily in Western Europe like Switzerland, France, Italy, Norway, Denmark or the UK and elsewhere in English speaking countries such as Canada, Australia, New Zealand, South Africa, Hong Kong, Singapore and the Caribbean Islands. What these countries do have in common is a large economic middle class.

There are other characteristics that can be used to explain the profession’s peculiar distribution pattern of growth. The majority of these countries were formerly colonies that did well in the post-colonial industrialization era. Still others also have a geographical advantage that favors strong International trade such as major seaports or highly skilled laborers. Further studies into modern day social profiles of countries will reveal still other identifying factors that have favored the growth of chiropractic in their country but, for the purposes of this article, we will stick to the most basic element, economics. In conducting this type of analysis we find economic profiling as the common element. The string that ties it all together is the size of a country’s middle class.

I was reading an article by a young female chiropractor that opened an office with another woman chiropractor in Costa Rica. One comment in particular stuck in my mind. She said: “At first, we were surprised by the type of patients we saw. Knowing that Costa Rica is a third-world country, we assumed we would be catering mainly to the poor people. But, while poverty exists in Costa Rica as it does in any nation, mainly we’ve attracted the middle-to-upper class population (1).” The doctor does go on to say that they frequently donate their services to the poor whenever they visit outlying villages.

This story actually narrates what is and has been occurring in all developing countries where there are primarily two dominant socio-economic classes and an ever slowly increasing small middle class. In these countries, chiropractic is an imported specialty that is only financially accessible to the middle and upper classes that can afford to pay beyond basic medical care.

There is another report about a chiropractor in the Philippines that admittedly understands this two-class reality. First he has located his clinic in the city’s most exclusive mall to attract the portion of the population that can afford his regular fee. Then, on every other Sunday at his church, he donates his afternoons to hold a free clinic for the poor. Until governments can afford to provide for a larger safety net it seems to be up to the individual doctors to step in where possible. High profile foreign missions are also a part of solving this equation when designed to include the local chiropractors.

In order to truly appreciate the effect of economics on providing a fertile ground for the growth of chiropractic it follows that a review of the economic factors in the United States could well explain much of what has occurred through out the world. Yes, the USA stands heads up above the rest of the world with the highest Gross Domestic Product per Capita (GDP/c) of around $34,000. This compares to the lower GDP/c in Canada ($23,000) and Australia ($22,000) or to the much lower GDP/c in China ($3,800) and India ($1,800). Unique countries like Switzerland ($27,000) and Singapore ($28,000) are in the upper GDP/c ranges because of their small size, highly skilled laborers and globalized societies.

Looking at the United States and referring to a study by Harvard University that outlines four economic sub-groups: the very wealthy (3%), the well off (10%), the average working person (60%) and the underemployed, unemployed or unsuitable for employment (27% – which includes the children), the benefits of a country that has over 70% of the people contributing to the tax base means that there is enough money for everyone to afford healthcare. The taxes support a broad variety of welfare and unique social programs that provide an extensive “safety net” for the entire population.

Our lesson of basic-economics-in-action is like this: the very wealthy invest their money into businesses that are managed by highly qualified and well paid, now well off people. These businesses provide jobs for the average working person in the community who can now afford the services of professionals who are able to charge a high fee and join the well off group. Everyone gets to pay a fair portion in taxes which takes care of the community needs for a high quality of life and leaves enough money left over to provide for the 27% dependant and otherwise less fortunate people.

If you live in America and need or want chiropractic care, you can get it through public and private insurance, workers’ compensation and other plans. For that matter, the same can be said about Canada, England, Australia, Sweden, etc.

However, the same cannot be said about India and China where there are two chiropractors for over one billion people. There is one chiropractor for every one million people in Egypt, Kenya, Argentina, Ecuador, Guatemala, Hungary, Romania, Russia, Turkey, Brazil, etc. If one considers the proportionate economic middle class population of these countries it becomes obvious why it has been difficult to see a rapid demand for chiropractic.

Now, there is another important factor to consider… language. As we enter this new century, only 3% of all the chiropractic students in the world are being taught in the 17% of the schools (#6) that are teaching in a language other than English. This is the one single factor, other than the size of the middle class, which has severely hindered the establishment of chiropractic in most other parts of the world. The truth is that until chiropractic is taught in or near that country the profession can almost never become truly established, or enough to reach even the poor in their midst.

Here again, the issue is economics! In third-world countries only the middle class families can afford to put their children through college. The very wealthy families however can afford to send their children abroad for college and that is how chiropractic finds its way into many developing countries today; in addition to the hundreds of scholarships provided through chiropractic colleges in the modern countries. The current challenge is to create the right dynamics that will favor the establishment of new schools in all regions and all major languages like Spanish, Arabic, Russian, Cantonese, Africans, Punjabi, Hindu, etc.

In reviewing the two primary factors that are necessary for chiropractic to have a healthy growth, namely a large middle class and access to affordable chiropractic education, we can better strategize for future growth efforts. Looking at the flip side of this equation we can also see where not to waste our energy and resources and try not to allocate the majority of our focus on the establishment of the profession in countries where the conditions continue to be unfavorable for chiropractic; to do this it may be necessary to create a sliding graph that represents the conditions of each country along this scale; to be able to say in 10 or 30 years that the overall benefit to the people of the world has been good. It’s a matter of priorities.

As the chiropractic leadership begins to absorb these concepts there will be better progress because it will result from clearer intention rather than the more random-type results that are observed. It has been said: “When things don’t change… things don’t change.” It’s not that any change is a good change; but simply, that good people can promote the right kinds of change when they are given access to good information and are courageous enough to act.

(1) A Costa Rican Chiropractic Adventure by Lara Long, DC – The Chiropractic Journal, March 2000.

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.”