J Chiropractic Humanities 2015 (Nov 18); 22 (1): 30–46 ~ FULL TEXT
Scott Haldeman, DC, MD, PhD
President, World Spine Care,
Department of Neurology,
University of California,
Department of Epidemiology,
School of Public Health,
University of California,
Los Angeles, CA.
The McAndrews Leadership Lecture was developed by the American Chiropractic Association to honor the legacy of Jerome F. McAndrews, DC, and George P. McAndrews, JD, and their contributions to the chiropractic profession. This article is a transcription of the presentation made by Dr Scott Haldeman on February 28, 2015, in Washington, DC, at the National Chiropractic Leadership Conference.
Chiropractic; History; Humanities; Philosophy
The Full-Text Lecture:
The McAndrews Leadership Lecture by Scott Haldeman, DC, MD, PhD
Thank you, Christine (Goertz, DC, PhD), for your kind words. I also want to thank George (P. McAndrews, JD) for his wonderful presentation and for the discussion. We all appreciate what George has done. In addition, I want to thank Lou (Sportelli, DC), one of my oldest and best friends. The profession would not be where it is if it were not for you.
This was a difficult talk to prepare. I received a request from Tony (W. Hamm, DC) to do the inaugural McAndrews Leadership Lecture. I told him that normally when I lecture, I present statistics and graphs and lots of different numbers and figures. For this lecture, I thought something different would be in order. So I am going to try something new, although I am not sure it is going to work. I am going to make it very personal, primarily because Jerry and George played a very important part in my professional life and growth. In this presentation, I want to explain how the world has evolved over the last 50 years and include how the McAndrews brothers played a part in this evolution.
I want start by having you imagine an 18-year-old kid from South Africa who arrives in Davenport, IA, on New Year’s Eve in a snowstorm. His father was a chiropractor, and his grandmother was the very first chiropractor ever to practice in Canada. And, unlike George, this young man received his first adjustment at the age of 2 days old. (I cannot beat them all.) Growing up in a chiropractic household, adjustments were the first treatment consideration for any illness. However, we primarily grew up with an understanding that the body has an innate ability to heal itself provided it is taken care of. Adjustments were not the cure for everything, but adjustments were given when needed.
I was an 18-year-old kid who arrives in a snowstorm in Davenport, but my ride does not show up. I ended up sitting at the edge of the airport, in the snowstorm, waiting until they closed and switched the lights off. Luckily, a Palmer student who was a taxi driver came by on his last rounds, picked me up, and dropped me off at a frat house for a New Year’s Eve party.
When I started chiropractic school at Palmer, I was fortunate to be taught by some the most influential people in the profession at that time. Jerry McAndrews was maybe 10 years older than I was at that time, and he was the director of clinics. He was also the chair of the division of chiropractic sciences and principles and practice. He taught clinical sciences, clinical practice and skills, as well as principles. He was one of the few faculty members who had a bachelor’s degree. I felt that he was more reasonable, was more understanding, and made more sense than many of the other faculty at the school. Besides, he also supported rugby, which meant he was important to me.
This was a fascinating time. I want to give you a feel of what it was like to be a chiropractic student and a chiropractor in the 1960s. The thing that I remember more than anything else is the unbelievable enthusiasm that the profession had—that the average chiropractic practitioner had for his or her profession. When one attended a lyceum meeting or a convention, there would be 4,000 or 5,000 chiropractors present, shaking hands, participating, and being excited. Here is another example. When I returned to South Africa, the chiropractic association would hold a meeting every month, an afternoon meeting. Chiropractors would come from all over the country just to attend that afternoon session. Every newly graduated chiropractor was asked to teach the latest skills that he or she learned just before they graduated. There was this constant enthusiasm for what everyone was doing.
Admittedly, “philosophy” dominated the discussion, but it varied somewhat. We all argued about what “innate” was. Unfortunately, the arguments were about theory. There was no science. To believe that there was no research, however, is one of those historical myths. BJ Palmer had his osteology laboratory and did some observational clinical studies; Carl Cleveland, Jr, was working with some animal models; and CO Watkins did some clinical research.  However, these were just single individuals touching upon science. At this time in our profession, there was very little research to find out the facts. Research was done to “prove the philosophy.”
Back then, almost all chiropractors had a cash-based practice. Each one practiced individually. Other events at this time included the death of BJ Palmer. Soon afterwards, the AMA Committee on Quackery was established in 1963, but nobody in the profession knew about it. There was also the formation of the American Chiropractic Association (ACA). Jerry and I became very involved in this event. He told me that the International Chiropractors Association (ICA) and the National Chiropractic Association  were going to combine and form the ACA. Jerry said he did not like that and asked if I would be willing to lead a student body against the amalgamation, which we did.
The challenges we faced in the 1960s were very interesting. Chiropractic was in complete isolation. Chiropractors practiced in a world that did not touch anybody else in the health care world. It was principles based on clinical experience. Whenever you talked to a chiropractor, all they talked about was the last patient that they saw that got better. And they talked about their belief system. Either one “believed” in chiropractic or one did not “believe” in chiropractic. The philosophy either was strongly held or was a basis of ridicule.
There was no substantial research culture. There was talk, but nobody was actively doing research; nobody was knowledgeable about research. There was no consistent educational curriculum. The profession was divided. There was no consistent professional identity. Nobody knew what a chiropractor was. Every chiropractor had his or her own identity. Going back, my father had his own identity. He was the Palmer graduate; he was the Palmer chiropractor in Pretoria and proud of it.
Let us now jump ahead 10 years to 1973. I had just completed my PhD and had entered into medical school in Vancouver, British Columbia. I was sitting in an ethics class, and the registrar of the college of physicians comes in and gives us a lecture on medical ethics. The topic that he stressed repeatedly, and which he appeared to have the strongest opinion on, was that “thou shalt not communicate with, talk with, socialize with, or in any way interact with, chiropractors.” Now there was an interesting group of people in my class. We had 5 PhDs in our class as well as a number of others professionals, including a dentist and a veterinarian. During this ethics presentation, one of my colleagues, the veterinarian, who was sitting right next to me in the class, put his hand up and he said, “What happens if you’re both a chiropractor and a medical doctor?” The registrar got red in the face and said, “You will not talk to yourself!”
It was both an interesting and the saddest time. The AMA was actively organizing to contain and eliminate chiropractic. [4, 12] Chiropractic was being attacked all over the world. Licensure was very rare outside of the United States and Canada. Chiropractic practice was not yet licensed in every state or province in North America, and chiropractors still practiced without a license in Louisiana or Quebec. Interestingly, I was asked to testify as to the role of chiropractic in both Louisiana and Quebec and had to try to give some rational explanation of chiropractic theory. There was less research being attempted in the profession at that time compared with earlier years and no formally trained scientists. I was the first chiropractic graduate to obtain a PhD in one of the biological sciences. There were still no chiropractic textbooks published by any medical publishing house. What textbooks published by members of the profession had been published personally or by a college.
The AMA considered chiropractic a menace. The AMA encouraged ethical complaints against doctors of chiropractic. They promoted opposition to chiropractic inroads in health insurance. They told their members to oppose chiropractic inroads in workers’ compensation, oppose chiropractic inroads into labor unions, and oppose chiropractic inroads into hospitals and, finally, to do everything possible to contain chiropractic schools.
The 1970s was an interesting time politically for the profession. Jerry McAndrews had gone on to become the executive vice president of the ICA. At the same time, he recognized that it was essential that chiropractors be more active in research. Jerry was active in the formation of the Foundation for the Advancement of Chiropractic Tenants and Science and became its executive vice president. He worked with the chairman of the board of ICA, Dr Joseph Mazzarelli, Sr. Together, they presented a unified vision of what everyone called the “Jerry and Joe show,” which changed what chiropractors do and how they interact with the rest of the world. Through the Foundation for the Advancement of Chiropractic Tenants and Science organization, they supported Dr Chung Ha Suh, PhD, at the University of Colorado in Boulder in 1973.
This became the very first chiropractic-sponsored research program into the theories on which chiropractic was based by scientists who were not members of the profession. After considerable dragging of their feet, the ACA joined the ICA by supporting this program as well. Jerry and Joe pushed ACA to take part in research, and together they lobbied Congress to provide funding for research. This lobbying effort eventually led to the conference organized by the National Institute of Neurological Disorders and Stroke on “The Research Status of Spinal Manipulative Therapy” in 1975 in Bethesda.  I was in medical school at the time but was asked to participate on the organizing committee of the conference and to present 2 papers at the conference.
These events led me to propose a follow-up interdisciplinary conference on “Modern Developments in the Principles and Practice of Chiropractic” to be held in February 1979. I first went to the ACA, which was not interested in interdisciplinary relations at the time. This led me to Jerry and Joe at the ICA, and they said that this would be a good idea. The ICA went so far as to sponsor the conference, and more than 500 chiropractors participated. This was one of the very first conferences where there were medical speakers sponsored by a chiropractic organization.
In 1979, I was asked to testify at the New Zealand commission upon the invitation of David Chapman-Smith. David was George’s equivalent in New Zealand. David sat on the left side of me, and there were 7 lawyers on the right side—the side attacking. I was cross-examined on the stand for 3 days. On our time off from the trial, David and I had a lot of fun though, and we have been friends ever since.
The challenges in the 1970s were very interesting. There was open hostility and containment of chiropractic through the ethical enforcement by the AMA of their rules. One milestone of the times occurred in 1975 when the National Institute of Neurological and Communicable Diseases and Stroke (NINCDS) Conference was held with the support of both the ICA and ACA. The US Congress had, through lobbying of friends of the chiropractic profession, put 2 million dollars aside to study chiropractic. Congress then went to the NINCDS (which is now called National Institute of Neurological Disorders and Stroke and is a part of the US National Institutes of Health) and asked them to study chiropractic. The authorities at NINCDS, in turn, asked, “What the heck is chiropractic?”
This led them to organize a conference on spinal manipulation. I was asked to serve on the conference organizing committee. This committee was tasked to invite all the leading authorities on diseases of the spine from around the world who might be able to shed some light on the topic. I was still in medical school at the time. It was an unreal experience. One day I would be in medical class saying “yes, sir, no, sir" to my professors and the next fly to Bethesda where I was sitting with senior National Institutes of Health people having to put ideas for an international, interprofessional conference on the table.
It was also the first time I realized that it was possible to make a difference as an individual.
The conference chairman, Murry Goldstein, led the conference committee.  After the first meeting, we were asked to go back home and think about who we wanted to invite. So I went back to Vancouver and came up with a program with such world leaders in spine research as Alf Nachemson, William H. Kirkaldy-Willis, and John Mennell. I figured no one in the room was going to listen to me. However, when I arrived at the meeting, none of the other committee members had done anything. So I put my proposal on the table. They said “Why don’t we start with what Scott has brought?” They accepted 50% of the people that I brought to the table. This showed me that participation is the single most important factor that lets you get something done.
This was a time when the chiropractic profession was starting to recognize the importance of research, but there was still minimal research culture or support. The profession was extremely divided, and there was no clear or consistent identity. One was either a straight or a mixer. One was practicing chiropractic medicine or one was a named technique person. “I am an Activator person.” Or “I am a Gonstead person.” There was no such thing as just being a “chiropractor.” The profession was led primarily by technique or practice building gurus. If you had talked about who were the prominent people at that time, they were either Parker or one of his competitors or the technique course organizers. There was nobody with any influence who had science, policy, or any other academic experience that could be named by more than 5% of the profession.
Moving ahead another 10 years to the 1980s, I was invited to Chicago, IL, to testify by George McAndrews at the first trial of the Wilk v AMA suit. I remember going into the courtroom. Instead of what happened in New Zealand with David where there were 7 opposing attorneys, now there was George McAndrews and 25 opposing attorneys on the other side. The courtroom was filled with opposing attorneys. And George is sitting there all by his lonesome. I thought, “Was this the only guy I have got helping me?” George’s passion and his skill, however, were unbelievable. He took a David and Goliath situation and made Goliath look like a fool. It took him a long time, and I will not go into the costs—the financial, personal, and professional costs —he had to sustain to do this. But this trial was a major turning point in the manner in which chiropractors looked at themselves.
The events in the 1980s, apart from the Wilk v AMA trial, included the publication of the first chiropractic textbook by a medical publishing house.  How was this possible? It was possible because the ICA guaranteed that they would purchase a sufficient number of books. The publishing house said, “Chiropractors do not read or buy books”, and they insisted on a financial commitment before publishing a textbook for chiropractors. The publishing house looked into their statistics, but there were no statistics that showed chiropractors read books. Therefore, they wondered why they would want to publish a textbook directed at a chiropractic audience.
This was also a time when David Chapman-Smith coordinated the formation of the World Federation of Chiropractic and started bringing together the world of chiropractors. David Cassidy was awarded his PhD under William H. Kirkaldy-Willis, MA, MD. Dr Cassidy was the first chiropractor who worked in an orthopedic department in a major medical school. The NASS and the American Back Society were formed at this time. Both of these societies allowed chiropractors under certain circumstances to join as members. The American Back Society allowed any chiropractor to join, but NASS would only allow chiropractors to join if they had 8 years of education; in most cases, this requires a PhD.
It was a time when the early manipulation clinical trials began to appear in the literature. I was invited to participate in the University of California, Irvine, spinal manipulation and low back pain trial.  Palmer College began considering a trial with Bill Meeker and Bob Mootz. And Nortin M. Hadler, MD, who was probably the foremost critic of chiropractic at that time, decided he wanted to do a trial that would wipe out chiropractors. Nortin and I have been friends for a long time, and Nortin would actually say this on the stage, or he did at that time. He said that he was going to wipe chiropractic off the map by proving that it did not work, but to his disgust, the manipulation group in his trial did better than the nonmanipulation group.  So all of a sudden, there was some credibility to spinal manipulation.
The challenges in the 1980s were many. One of the challenges came from the statements by Judge Susan Getzendanner who presided over the Wilk v AMA trial. She stated that chiropractors were expecting a judicial pronouncement that chiropractic was a valid, efficacious, and scientific health care service. However, she felt that she could not do that and that the answer to this question could only be provided by a well-designed controlled clinical study. She recognized that the claims that chiropractors were making were not yet validated.
The challenges at the end of the 1980s focused on engagement in the research and the medical community. The ethical issues between the AMA and the chiropractic profession had been resolved with the Wilk trial, but now the question for the profession was “How do we engage?” It was also evident that it would be necessary to start thinking about changing medical and hospital attitudes. People and institutions do not change just because a law is passed or a verdict comes down. Not everybody immediately accepts a verdict or law, especially not in the United States. Therefore, the training of chiropractic researchers became a necessity.
It was also necessary during this period to start thinking about developing standards of care for the profession. The profession remained divided with a lack of consensus about how chiropractors should practice. It was still not clear what a chiropractic doctor was. I was asked to sit on multiple identity committees, and you could not get 5 people around the table to decide what a chiropractor was. There was no clear definition of a chiropractor or what he or she did.
There was also a lack of participation in the professional spine and public health deliberation societies. There were few if any chiropractors attending meetings even though the American Back Society and NASS and other societies were beginning to open their doors—there were simply no chiropractors walking through the doors to participate.
Moving ahead another 10 years to the 1990s, I am in Washington, DC, sitting in a room at the AHCPR to look at guidelines for the management of low back pain. This is the first interdisciplinary group that looked at the science of what was reasonable for the management of low back pain. Dr Jay Triano and I were the only people in the room who had a chiropractic degree who were invited to participate. This task force concluded after reviewing the scientific literature that manipulation had some role to play in the treatment of acute low back pain but surgery had no scientific support in the management of axial back pain.  The NASS launched a major onslaught against AHCPR for these recommendations that led to the dissolution of the AHCPR, but chiropractors benefited considerably from its publication.
At this time, George McAndrews was still fighting the legal wars to remove barriers between medicine and chiropractic. He was doing the cleanup. When you fight a war, you have to bury the dead, and George was very active in reducing any further barriers in interprofessional cooperation. Jerry had now moved from the ICA to the ACA and, in my mind, revitalized the American Chiropractic Association. Jerry became the Vice President of Professional Affairs and stayed in that position for a number of years.
As the 1990s progressed, there was acceleration in the development of interprofessional cooperation and practice standards. The House of Representatives convened the subcommittee on military commissions to investigate the possibility of including chiropractors in the military. Chiropractic organizations came together for the first time to address guidelines for chiropractic practice parameters. This was an extraordinary achievement. David Chapman-Smith, Don Peterson, and numerous other leaders of the profession met to deliberate and reach a consensus on a reasonable standard of practice for chiropractic.  It is true that some chiropractors did not like it. Regardless, when this document was we presented to the AHCPR, the response was something like, “Wow, this is the only profession that has set standards for itself.” If the chiropractic profession had not developed this practice parameters document, I am not convinced that spinal manipulation and chiropractic would have gotten the positive reviews for the AHCPR.
At approximately the same time, the conclusions of the Quebec Task Force Whiplash and Associated Disorders were published on and included manipulation as one of the few treatments for whiplash that could be considered evidence based. David Cassidy as scientific secretary was the primary mover of that group. In 1992, the second edition of Principles and Practice of Chiropractic was published and had double the number of pages of the first edition. 
The challenges of the 1990s had changed from the 1980s but were a long way from ideal. Chiropractors were still not participating in hospitals or multidisciplinary health care clinics or settings. There was still a lack of engagement with the medical profession, the spine societies, and public health societies.  The number of chiropractic academic leaders who were participating could be counted on one hand. There were no reports of chiropractic research breakthroughs that were publicized within the chiropractic world and limited communication between scientists and clinicians in the profession. Scientists were working in their laboratories and clinics, and clinicians were working in their offices. There was virtually no communication between these 2 arms of the profession.
This was also a time when the philosophical purists came out of the woodwork and started becoming much more aggressive. They consumed the ICA completely. They started influencing many schools and became a dominant force. I do not want to be critical. This is just what happened at that time. The profession’s rift was even more serious than in prior years. There was still no consistent identity. A chiropractor was either a purist or a scientist. There were actually 4 different groups of chiropractors. Chiropractors and organizations were either simple straight, simple mixer, the way out straight, or the way out mixer. At the 2 fringes were the chiropractic medicine proponents and theological chiropractors.
Moving ahead 10 more years to the 2000s, I recall being in Saskatoon meeting with the Bone and Joint Decade Task Force on Neck Pain and Associated Disorders (NPTF). Lou Sportelli and Paul Carey were able to provide significant funding to allow this program to go forward and receive the additional funds from other sources. This Neck Pain Task Force would not have happened without the support of these 2 leaders of the profession.
Once funding had been guaranteed, David Cassidy and I started inviting people from around the world to sit on task force that was initially just called the Task Force on Neck Pain. The task force then was able to obtain support from the University of Toronto and the Karolinska University in Stockholm, Sweden, which is the home of the Nobel Prize. A number of other institutions of higher learning joined the task force. The World Health Organization (WHO) Collaborating Center at Karolinska then felt that this work was of sufficient value to allow the use of the WHO Collaborating Center logo. A couple of years into the Task Force, the Bone and Joint Decade Steering Committee elected to become the sponsoring organization for the NPTF. [20-26]
Eventually, a number of the world’s most prominent spine societies agreed to participate in the program. The most important aspect of the NPTF was that it was multidisciplinary. What was quite amazing for the times was that nobody who was invited objected to the fact that the 2 most prominent members of the NPTF had chiropractic degrees. None of the invitees said that they would not participate for this reason, irrespective of their training and professional degree. And this is despite the fact that about 30% of the task force had chiropractic degrees.
An example of the changes that were happening in interprofessional relations occurred during one of the larger meetings of the NPTF in Bordeaux, France. Nik Bogduk, who is an outspoken Australian physiatrist, was at the meeting. We were having a bit of a war during a discussion of the literature. The NPTF ethicist was there and had some interesting observations. She said there were intense arguments going on in the group but none of the points raised had anything to do with professional affiliation.  On the one side, there were the MD/DC/clinicians. On the other side, there were the scientists and the methodologists. At no time was there any conflict between members with chiropractic and medicine degrees within that group. As a matter of fact, Nik Bogduk at one point was asked, “What about the chiropractic influence here?” And he said that it was irrelevant, this is a scientific group, and we deal with the science.
The first decade of this century was a time when our understanding of spine and back pain was seeing rapid progress. The Duke Evidence Based Practice Center on Behavioral and Physical Treatments for Tension-type and Cervicogenic Headache  was published and stated that cervical manipulation was of benefit and the risks were minimal for treatment of cervicogenic headaches. The proceedings of the NPTF were published in 3 different peer-reviewed journals: Spine, European Spine Journal, and Journal of Manipulative and Physiological Therapeutics (JMPT). There has never been any document on spine pain published anywhere in the world by 3 peer-reviewed journals, and this fact demonstrated the stature of the conclusions from this task force.
In 2005, the third edition of the Principles and Practice text was published and was now more than 1200 pages, twice the size of the second edition.  In 2006, Simon Dagenais, DC, PhD, and I proposed to the NASS that a supplement in The Spine Journal be considered for a group of articles on “Evidence Informed Management of Chronic Low Back Pain.” [29, 30] The NASS did not flinch at the fact that 2 editors of this supplement had chiropractic degrees, and it was rapidly approved and published in 2008. The success of this supplement, which remains one of the most cited set of articles ever published in that journal, was followed by an invitation to edit a textbook on “Evidence Based Management of Low Back Pain.”  We have been told that this book has become a principal reference text in a number of orthopedic surgical residency programs. Again, it is noteworthy that both editors have a chiropractic degree and the chapters were written by authors with a wide range of professional and postgraduate degrees.
The first decade of this century was also a time when it became evident that the public was developing greater interest in alternative medicine. An article in the Annals of Internal Medicine asked why people seek the care of chiropractors, massage therapists, and others.  This article was a survey of people who had been to both a chiropractor or complementary and alternative medicine (CAM) practitioner and a medical physician. The patients were asked which was more successful. The CAM practitioner was considered more successful for back and neck pain: 46% vs 12% for low back pain and 61% vs 6% for neck pain. But if you look at all the other systemic conditions such as high blood pressure or gastrointestinal problems, the CAM practitioners were perceived by patients as irrelevant. It became very clear that the public was dissatisfied with standard medical treatment for the management of back and neck pain and some forms of headache and arthritis.
One of the major challenges for the chiropractic profession in the 2000s was finding and training chiropractors who had an interest in research. Canada took the lead in this regard. The Canadian chiropractors established a foundation that trained chiropractors to enter PhD programs, and they were placed in every major university in Canada. There is now a PhD chiropractor in virtually every university in Canada with a medical or biology faculty.
The 2000s also brought in a period of increased interest in chiropractic by the military centers in the United States including the military hospitals and the VA system. Chiropractors were invited to serve military personnel, partly through legislation and partly through increasing recognition that they contributed an important benefit in many multidisciplinary settings. Initially, it was a challenge to find chiropractors with the training and experience to serve in these settings.
There were still many challenges and shortcomings for the profession in the first decade of this century. There were still no mechanism for the distribution of chiropractic research breakthroughs to practicing chiropractors and very little communication between scientists and clinicians. Claire Johnson, DC, MSEd, and the JMPT have done more than anybody else to bridge this gap. This is especially true since the ACA made JMPT its official journal and distributed it to the profession. This was further enhanced by the publication of Health News. But you have yet to go to chiropractic association meetings in this country and see a dominance of researchers at any of the meetings. The average chiropractor still does not have access, or maybe even does not seek access, to the latest science. This is a real problem, as the research is evolving at an extraordinarily rapid pace.
Today there remains a challenge in defining the role of chiropractic in health care. The world is starting to define what chiropractors do, and because of lack of consensus in the profession, the world is ignoring what chiropractors feel that their role is. There is still a lack of participation in professional societies by practicing chiropractors. If it were not for Christine Goertz, DC, PhD, who is able to sit on committees all over the country, chiropractors would have virtually no representation in many of the most important discussions on spinal problems.
To complicate the process further, the Affordable Care Act was passed in 2010. This has been one of the most dramatic changes in health care to occur for many years in the United States. It is possible to agree or disagree with the details of this act and focus on all its flaws, but it has changed the way people seek health care. Furthermore, it has probably changed health care in the United States permanently. One of the foremost tenets of the Affordable Care Act is the inference that the only care that will be available is care that is both affordable and that works.
The Lancet published papers on the global burden of disease. [33-39]The single most important WHO document in this decade. This study concluded that low back pain was the leading cause of disability worldwide and that 10% of the world’s disability is due to low back pain. Neck pain was the fourth leading cause of disability, and low back pain is the sixth most important contributor to the global burden of disease. This includes both deaths and disability combined. The burden of spinal disorders is greater than malaria or tuberculosis, greater than preterm birth, and greater than chronic obstructive lung disease or diabetes. If you combine neck and low back pain together, spinal disorders have a greater impact on global health than HIV/AIDS, Alzheimer disease, diabetes, lower respiratory infections, depression, stroke, traffic injuries, and breast and lung cancer combined.
I would now like to ask each of you who are here today a few questions. How many people in this audience give funds to breast or lung cancer or Alzheimer disease or diabetes foundations? How many of you give to a chiropractic research foundation or charity? We need to make it a priority that chiropractors and other spine care clinicians participate in spine-related charities if we want to influence this burden. Spine pain can now be considered a major international health care crisis. The WHO and World Bank report on disability said that low back pain, arthritis, and rheumatism are the most common health conditions causing disability and that the impact of disability is greater in poorer communities, those that have lower educational achievements, and those that have fewer economic opportunities. 
In 2013, the World Federation of Chiropractic held its congress in Durban, South Africa.
This was followed by a conference in Mahalapye, Botswana. For the first time during a panel discussion on identity, one speaker after the other began to focus on the same theme: the importance and need for a primary spine care clinician. These were speakers with backgrounds in the old-time philosophical faction of the profession as well as more mainstream speakers from Europe and North America. The process of developing a consistent identity for chiropractic is starting to come together. The World Federation Identity Conference had begun the process, but it is now being debated everywhere. Suddenly, people from around the world were starting to recognize what chiropractic should be.
Recently, a study conducted through the Canadian Spine Society was published.  The authors asked questioned 101 surgeons, and 75% of them agreed that they would be comfortable not assessing patients with low back–related complaints referred to their practice if the indications for surgery were ruled out by a nonphysician, such as a chiropractor or physical therapist. It is now becoming more common at spine meetings to hear statements from surgeons who recognize that their primary role is surgery and that they need only see patients when surgery is being contemplated. They do not need to manage patients who can be managed without surgery.
There is probably no place where the change in attitude of the AMA is more evident than the statements on the Journal of the American Medical Association patient page in 2013. This information page states that “Some people benefit from chiropractic therapy.…”  Last week, Lou sent me a publication from Harvard which said that chiropractic was beneficial. This is another illustration of change in attitude in organized medicine.
The integration of chiropractic into the general spine care delivery system is changing rapidly. The co-chair of the NASS annual meeting in 2014 was Simon Dagenais, a chiropractor with a PhD who is one of the leading authorities on health economics related to the spine. This is a society that originally said chiropractors could not participate in its meetings. Simon has reached the level of respect that he has been invited to submit an application to the executive committee of NASS. The NASS, now, at its annual meeting has an entire stream of lectures and programs on non-surgical care, specifically catering to nonsurgeons including chiropractors and physiotherapists.
There is another change in the US health care system that is likely to impact practicing chiropractors. In February of 2015, at the Journal of the American Medical Association forum, Secretary Burwell proposed that 30% of Medicare payments should be non–fee for service by the end of 2016 and 50% by 2018. That is only a few years away. This was not even recorded in 2011. The intention is to have 85% of Medicare fee for service payments tied to quality of value. As Medicare goes, so goes the health insurance industry in this country. Industry often takes the lead from Medicare. Non–fee for service model, quality, and value are going to be the new rules under which we will all be permitted to practice as clinicians.
On February, 6, 2015, I was in Washington, DC, as a member of the Center for Complementary and Alternative Medicine council. It was at this meeting that the agency announced that would no longer be called the National Center for Complementary and Alternative Medicine. It had become evident that the focus of the Center was not on medicine and that it was no longer focusing on alternative treatments. It is now called the National Center for Complementary and Integrative Health.
These changes in the health environment are becoming obvious to the chiropractic institutions. On February 11th in Palm Springs, CA, I was asked to attend the Palmer College Board of Trustees. At that meeting of the board, a considerable amount of time was spent talking about the identity of chiropractic and how that is changing. The Palmer Board has recognized the necessity for change identity of chiropractic for its students and alumni and is now defining chiropractic as the “primary care professional for spinal health and well-being." The Canadian Memorial Chiropractic College mission statement now states that they are an academic institution recognized for creating leaders in spinal health.
Last night at dinner, I was talking to George and heard that on February 25, the Supreme Court ruled that state professional boards controlled by active market participants must be supervised by state government to avoid federal antitrust scrutiny. As George pointed out, this is huge. Basically, this means that the war against organized medicine may be over. But it also means that every chiropractic board can anticipate having medical physicians on its board. Chiropractic licensing boards can also anticipate the appointment of attorneys, lay people, and university professors that will likely have an impact on how chiropractors are allowed to practice.
There has been a strange reversal in thinking on the current status of chiropractic care in the accepted evidence guidelines. Spinal manipulation is now one of the few treatment options for back and neck pain that has a body of scientific research. Spinal manipulation is now included as an option in virtually all guidelines. At the same time, chiropractic theory has a solid, but incomplete, body of scientific experimental support. Chiropractic, or at least spinal manipulative therapy, is starting to be considered one of the treatment approaches that can be considered to be scientific. Chiropractors are invited to participate in most spine and public health policies, conferences, meetings, and discussions.
Chiropractors are serving in interdisciplinary clinics around the world, particularly in the United States where they are now entrenched in the VA, both military and private hospitals, and interdisciplinary clinics. It looks like a couple of US state-supported universities are considering including chiropractic teaching faculties in the next few years. There is a growing support for the concept of a primary spine care identity for the practice of chiropractic, especially among the nonchiropractic communities.
Christine Goertz at the recent National Center for Complementary and Integrative Health meeting made this statement: “I used to be asked; how could chiropractic possibly work? Then I was asked; is there evidence that chiropractic helps people? Right now I am asked; how can I find a good chiropractor?” That is how this profession is changing.
But this journey is not without challenges for the future. How do we address the continued effort by some chiropractors to redefine primary general practice physicians to include chiropractors? We still have a large body of chiropractors and some institutions who think that chiropractors should not be spine doctors but should be general practitioners of medicine as primary care physicians. There is still a significant failure by chiropractors to participate in many of the recognized programs such as the National Committee for Quality Assurance and registries. We do not have sufficient people who have the knowledge to serve on all of these committees that are seeking chiropractic involvement. It was great when I had to attend only 1 or 2 committees per year. There are now at least 100 committees that would love to have a chiropractor with the skill, knowledge, scientific background, and prestige in the profession to serve on them.
A major factor that is inhibiting the growth of chiropractic is poor participation by practicing chiropractors at national and international forums discussing spinal disorders. There is still no scientific chiropractic meeting in the United States that draws more than 600 people. When I speak at the NASS, there are 5,000 surgeons there. They are listening to us talk about nonsurgical care including chiropractic. When I speak at the national physical therapy society meetings, there are 6,000 physiotherapists in attendance. I still cannot find a forum in the United States where chiropractors will appear in large numbers to support their associations, listen to the results of the latest chiropractic research, and learn the newest and latest techniques.
Another persistent problem remains the continued claims by certain chiropractors and even institutions that chiropractic cures certain diseases without there being evidence for these claims and an unwillingness or lack of interest by chiropractic practitioners to learn about the latest changes in spine care. For example, I was invited to lecture at the Texas Chiropractic Association last year. There are 7,000 chiropractors in the state, but there were only 250 people at the convention. This showed clearly that there is inadequate participation in continuing education to prepare the profession for the new reality.
In addition, chiropractors no longer work in isolation, and there are still threats from other professions. We expect chiropractors to be challenged, especially in states with low professional participation or leadership and understanding of the new order of health care. If the leadership of the state associations does not understand what is happening, they cannot possibly fight it. George can take care of the remaining threats against interprofessional communication by the medical world blindfolded and with one hand tied behind his back. But it is up to the chiropractic profession to take care of the chiropractic world.
Chiropractic has had its knights in shining armor that appeared when a threat was evident. Jerry and George are such knights, and they have had a significant impact in scientific and legal realms. They changed the scientific, legal, and professional opportunities for chiropractors. They created an environment that allowed for unimpeded interprofessional cooperation and professional advancement. If it were not for them, chiropractic would not be where it is today.
We also need to recognize and identify the knights who are currently representing the profession. The day when the Knights of the Round Table were all men are long gone. We have to train more knights, researchers, policy authorities, and instructors from all backgrounds and sexes. And we have to support these knights. We have to give them the armor and the weapons that they need to support this profession: research support, travel, salary support, political support, publicity, encouragement, and rewards.
In conclusion, I want to share with you my current passion: the WSC program. The WSC is an example of what an interprofessional team that includes chiropractors can do. The goal of this organization is to improve the lives of people in underserved communities through a sustainable, evidence-based, spine care program. It is a nonprofit charity registered in the United States and Canada with a goal of helping people with spinal disorders in underserved communities around the world and is supported by the Bone and Joint Decade. Archbishop Tutu, Nobel peace prize laureate, is on the advisory committee. Elon Musk, who is the CEO of Tesla and SpaceX, is on the board of directors. It is supported by virtually every major national and international spine society including the World Federation of Chiropractic, the South African Chiropractic association, the European Spine Society, the NASS, the Canadian Spine Society, the International Society for the Advancement of Spine Surgery, the World Congress of Chiropractic Students, the Society of Back Pain Research in the United Kingdom, and the Canadian Chiropractic Association.
It has collaborating centers throughout the world including the University Southern Florida, CMCC (Canadian Memorial Chiropractic College), Palmer, University of Hawaii, University of Southern Denmark, University of Ontario, Oregon Health Science, and now the Mumbai Mahatma Gandhi Mission in India. It has financial supporters from both surgery and chiropractic groups. It has volunteer advisors from around the world from all major professional groups. The diagram noted in this slide is the distribution of people who are actively involved in the WSC program and various programs and societies.
According to the Bone and Joint Decade, there are more than 1.7 billion people worldwide suffering from musculoskeletal conditions such as arthritis and back pain.  Spinal disorders have a greater impact than almost any of the other major diseases. Prevalence of spinal pain is 4 times higher in developing countries. And right now, WSC is the only organization worldwide that is trying to tackle this problem. There is no other foundation that has an interprofessional, evidence-based approach. The clinical program is low cost, low tech, evidence based, and fully integrated into the local culture, and it also has long-term presence, interprofessional collaboration, and measured clinical outcomes.
The team is based on the presence of a primary spine care clinician. The primary spine care clinician screens for serious pathology, ensures timely referral when appropriate, and offers evidence-based interventions, including manual therapy, exercise, education, and occasionally mild analgesics. The team includes surgical specialists and rheumatologists who provide care when necessary and on referral from the primary spine care clinician. The care includes scoliosis screening and exercise programs including the Straighten Up project, which as you know is a chiropractic project now accepted by the WHO. This program is building capacity through patient and community education, frontline health care worker and advanced surgical training, student scholarships, professional development, and WSC spine conferences. 
For example, WSC sponsored a conference in Mahalapye in 2013 and plans to organize similar spine conferences worldwide. It arranges student tuition scholarships for clinicians who wish to assume the role of primary spine care clinician and advanced surgical group training. World Spine Care now has arranged for a Botswana student to study at Palmer and a second student at CMCC. We have had more than 15 volunteers in the Botswana clinic. The program is integrated into the local health care system. It trains local clinicians and plans to transition the clinics to local control within 5 years.
In every one of the WSC participating countries, there is a memorandum of understanding with the government Ministry of Health that the primary spine care clinician will be given the privileges of other clinicians. Geoff Outerbridge, DC, MSc, spent 2 years at the WSC clinic at the Mahalapye general hospital and the Shoshong clinic. He treated patients, but he also spent time in the operating room watching surgery done on his patients. He could order any test in the hospital. The biggest complaint we had from the hospital was about why we kept ordering blood tests and why our clinicians could not draw the blood themselves. That is the single biggest concern that I heard.
World Spine Care has recently opened a clinic in the Dominican Republic. I leave tomorrow morning to sign the memorandum of understanding with the government Ministry of Health as well as the Ministry of Education in the Dominican Republic.
Now remember, neither Botswana nor the Dominican Republic has a law licensing chiropractors. But both countries are supporting the WSC with financial support in the form of providing clinic facilities in the hospitals or community clinics, and support staff for the practice. They are also supporting students who are receiving tuition scholarships to study chiropractic. When these students graduate and return to their countries, it is likely that they will be licensed. The country has paid for their education.
In Tanzania, WSC has a memorandum of understanding with the hospital and other nongovernmental organizations for a clinic, but we do not have the funds to go there. The need for help in Tanzania is huge and deserves further help. Brian Budgell, who is on faculty at CMCC, has been very prominent in putting this program together, and there remains hope that the funds will be found to open this clinic.
The WSC also has received funds for the Global Spine Care Initiative (GSCI)
(www.globalspinecareinitiative.org). This task force has been established to develop an integrative model of care to guide the management of spinal disorders with a goal of reducing the associated global disability and burden of disease.  The GSCI is anticipated to develop and disseminate an effective low-cost spine care model which can be sustainably implemented in communities with limited resources. It is a 6-year-long project. There currently is no published model of care for the management of spinal disorders that could be implemented in any setting, not just in underdeveloped setting. If I am a hospital, clinic, government administrator, or clinician and I want to set up a spine care program, I can search the scientific literature forever and will not be able to find a model that could be implemented. There are published guidelines but not a model of spine care that could be used to implement such a program. The goal of the GSCI is to test the model in 5 carefully chosen countries and measure the impact.
Claire Johnson and Christine Goertz, who are here with us today, are members of the GSCI. There are other members from multiple countries around the world. The participants in the GSCI include orthopedic surgeons, psychologists, rheumatologists, exercise physiologists, neurosurgeons, physical medicine rehabilitation specialists, and chiropractors (Fig 4). None of the members have expressed any concerns about the participation of any member who has the qualifications and experience to contribute to the discussions.
In conclusion, I anticipate the following. The next 5 years will be the most dramatic and exciting in health care policy evolution and, in particular, spine care and the role of the chiropractic profession. The world will be different in 5 years’ time. The challenges of the present are not the challenges of the past. There is no longer any reason for chiropractors to worry about not having access or about discrimination based on its professional name. There will still be discrimination based on lack of participation. If members of a profession are not at the table, the profession is not going to be included in the discussion. There will still be discrimination based on financial issues. There always has been. One cannot be in a capitalistic society and not have competition by different providers, including physical therapists, wanting to take over what chiropractors do. This level of competition is not unique to chiropractors. There is competition by different clinical professions. Neurosurgeons often want to take over what neurologists do, and neurologists often are in competition with radiologists for the interpretation of brain magnetic resonance images. What is clear, however, is that the chiropractic profession is being asked to participate in all spine-related health care issues and has the opportunity to define its role in spine care.
I assume that chiropractors wish to define their role in the evolution of health care delivery, especially spine care. Therefore, it is essential that their organizations, educational institutions, researchers, policy experts, and clinicians understand what has happened, what is happening, and what is likely to happen; participate in the discussion; and assume leadership roles. If they do not, they cannot complain if the others define their role. Finally, and most importantly, chiropractors have to commit to helping people with spinal disorders no matter who they are. Chiropractors can no longer focus on protecting chiropractic. What is essential for the future of the profession is a clear focus on helping people with spinal problems based on the skills and knowledge inherent in the profession. At the same time, the profession has to ensure that their skills and knowledge exceed those of anybody else in this field if they hope to remain leaders in spine care.
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