Mr. Chairman, as you may recall, our presentation to this committee in 1990 (Fuhr, 1990) noted the rapid rise in health care costs in the United States, and the significant contributions to these costs which are derived from neuromusculoskeletal disorders such as back pain, headache, stress, and lifestyle related conditions. We also noted the dearth of outcome information about effective means of preventing, diagnosing, and treating health care problems in general. As a consequence of this information gap (e.g., Cotton, 1991; Eddy, 1990), the American people risk spending phenomenal sums of money for potentially harmful and/or unnecessary health care services. Unfortunately, little has changed since we spoke with you last years.
Mr. Chairman, some 45,000 licensed doctors of chiropractic in all 50 states provide care for millions of patients every year, but in many respects (if you'll allow the pun), our hands are tied. No one doubts that chiropractors are the most extensively trained practitioners of manipulative methods, but little serious research attention has been given to the less hazardous and less expensive health services we can provide to patients. Moreover, we have been stymied in our efforts to systematically study the effectiveness and cost-effectiveness of chiropractic vs. the alternatives in medicine and surgery. We need to better understand the potential value of chiropractic methods for routine musculoskeletal problems and in special populations and conditions, such as the elderly, patients with severely debilitating disorders, expectant mothers, and the under served. Clinical outcome data, the kind of research that chiropractic scientists are best able to provide, are needed both to improve our methods and to guide health care policy makers. But we cannot do this work alone.
Mr. Chairman, it is unreasonable to expect that the chiropractic profession will be able to raise the millions of dollars needed to thoroughly explore these issues. Despite the billions of dollars invested in fundamental research every year by the National Institutes of Health (NIH), almost nothing is being spent to study the results of conservative (non-surgical) chiropractic care. Yet, if chiropractic institutions had access to just one-tenth of one percent of the ten billion dollars available every year to U.S. medical schools for biomedical research and education, we might be in a position to significantly reduce health care cost in this country and improve the quality of patients' lives.
Is this false bravado? We don't think so. Funding from within the chiropractic profession (e.g., from the Foundation for Chiropractic Education and Research) has allowed chiropractic colleges to demonstrate their ability to conduct the sophisticated clinical outcomes studies that doctors, patients, and health policy makers need (such as Northwestern College in Minneapolis; the Los Angeles College of Chiropractic; Palmer College in Davenport, Iowa; Palmer College/West in Sunnyvale, California; and the National College of Chiropractic in Lombard, Illinois). Overhead (indirect) costs for research at the largest university-based medical research centers average about 40 percent, and can run up as high as 70 percent. In contrast, the indirect costs for clinical trials conducted are as low as 10 percent.
Additionally, there is good reason to expect that scientific studies of clinical outcomes and cost-effectiveness of chiropractic will yield positive and very useful results. The findings in a recent outcome study reported in the prestigious British Medical Journal bears this out. In a recent clinical trial of spinal manipulation (Meade et al., 1990), conducted by medical epidemiologists in cooperation with chiropractors at the Anglo-European College of Chiropractic, more than 700 patients with low backpain were studied. Patients were randomly assigned to either hospital-based physical therapy or spinal manipulation at several chiropractors' private offices, and were followed for several years after treatment. The results were rather clear: "chiropractic treatment was more effective than hospital outpatient management, mainly for patients with chronic or severe back pain... the benefit of chiropractic treatment became more evident throughout the follow-up period. Secondary outcome measures also showed that chiropractic was more beneficial." Moreover, Dr. Meade and co-workers found that the advantage chiropractic care provided starts "soon after treatment begins," and that the longer the patients were followed (up to three years), the greater advantage chiropractic offered, particularly in the most chronic and difficult cases. Dr. Meade concluded that chiropractic care should be considered for inclusion in Britain's National Health Service. A brief commentary in the prestigious journal, Science, estimated that for every dollar spent on chiropractic care, four dollars would be saved (British study, 1990).
We recognize that this study is not without flaws, and surely no single study can settle any question. Nevertheless, the possibilities for meaningful scientific advances, improved patient services, and significant cost-containment are obvious. Why are we in American doing so much less to explore these possibilities? Mr. Chairman, the Flexner report of 1910 prompted private philanthropy and the federal government to invest ever greater sums of public dollars into the biomedical research and training enterprise in this country. These investments in health education research were not prompted by the success of the health care enterprise at the turn of the century, but because of the great need to improve the quality and quantity of medical scholarship. No similar commitment has ever been made to chiropractic health care. Despite the obvious potential of chiropractic care to significantly improve the quality and reduce the costs of health care in the U.S., federal funds are not reaching chiropractic colleges. We do not have access to the educational and scientific resources available to most other health care provider professions, and it is unlikely that we will be able to compete successfully at the National Institutes of Health for more than token research monies. Nevertheless, several large-scale, randomized controlled clinical trials of chiropractic methods have been or are underway at a number of U.S. chiropractic colleges. These investigations, representing many hundreds of thousands of dollars, have been supported exclusively from within my profession, that is, from students' tuition dollars and gifts from doctors of chiropractic. And, although we are gratified that the Agency for Health Care Policy Research has elected to include chiropractic care in a three year clinical trial of treatments for low back pain, this effort will barely scratch the surface in terms of the investigations which need to be done.
Mr. Chairman, it is unreasonable and unwise for the federal government to leave the exploration of the probable benefits of chiropractic science solely in the hands of the NIH. Although the scientific expertise of chiropractic college investigators has been implicitly acknowledged by the appointment of several chiropractors to NIH study sections, and by respectable scientific scores in grant applications submitted to the NIH, none of the studies our colleges have proposed have been funded. Although chiropractic investigators are publishing in refereed medical journals (e.g., Frymoyer et al., 1986; Kirkaldy-Willis and Cassidy, 1985; Triano and Schultz, 1987; Waagen et al., 1986) and participating in scientific meetings (e.g., American Back Society, American Society of Biomechanics, American Public Health Association, International Society for the Study of the Lumbar Spine, North American Spine Society), we have been locked out (de facto) from the scientific resources which Congress makes available to all other health disciplines. A preliminary report from the Corporate Health Policy Group (Hanft, 1991), which was commissioned to study the lack of federal funding for chiropractic studies and training, notes and "inherent bias" encountered when attempting to compete for federal research dollars with "established researchers and research teams." This inherent bias is above and beyond whatever specific bias derives from years of defamation by organized medicine.
Dr. Mead, principal investigators in the British study noted earlier understands the problem here. In an interview aired by the Canadian Broadcasting Corporation last October 20, Dr. Meade explained why it has taken so long to conduct the first extended, large-scale clinical trial of chiropractic care: "It's partly ... due to some extent, perhaps unconscious protection of vested interests. I mean, people don't like to be shown up as being perhaps less effective than other groups, and so there's been a certain amount of resistance to stimulating the sort of research that I think is now going to happen ..." (Meade, 1990).
The flavor or discrimination against chiropractic among federal purse string holders (intentional or not) was also captured in the New Zealand government's 1979 investigation into science and education in chiropractic. Among the main reasons they cited to explain the dearth of university based chiropractic research was: "... the prejudiced attitude of organized medicine toward chiropractic and the effect of this attitude on medically dominated federal funding agencies in the health area. This is obvious and needs no futher comment ..." (New Zealand report, 1979, p. 225).
The recently decide Wilk et al. case (Chapman-Smith, 11989; Getzendanner, 1987), in which the AMA was found to have violated the Sherman Anti-Trust act in its effort to "contain and eliminate" the chiropractic profession, is only the most recent episode in a centuries-long anti-scientific struggle against manipulative surgery and its practitioners (e.g., Cooper, 1985), a struggle which is easily traced to 19th century Europe (e.g., Barker, 1927; Hood, 1871). This Hatfield-McCoy feud between professions, and the information gap it has produced, must end. The American people deserve to find out, at long last, whether the dollars they spend on chiropractic vs. medical care for comparable health problems are well spent or wasted.
Mr. Chairman, we recognize that it is not the habit of this subcommittee to recommend earmarked funding; but we ask you to consider that there are situations in which such may be necessary. Earmarked funds are available (or proposed) by the federal government for research development in minority institutions, for family medicine education, nursing research, and for the recently proposed women's health institute. Surely, a similar strategy for chiropractic colleges is reasonable, desirable, and cost effective. The sorts of research our colleges and research organizations wish to conduct (e.g., Exhibits 1-4) closely parallel many of the priority topics which NIH has recognized (e.g., Frymoyer and Gordon, 1989). In fact, the clinical importance of one of their priorities (the flexion/extension phenomenon) was first reported by a chiropractic investigator (Triano and Schultz, 1987). Help us to contribute more fully to the health and welfare of the nation through improved science and education.
Arlan W. Fuhr, D.C.
Editor's Note: Exhibits mentioned in the last paragraph of Dr. Fuhr's address were papers provided for the committee's edification on the following subjects: exhibit 1, National Institute of Chiropractic Research; exhibit 2, Consortium for Chiropractic Research; exhibit 3, Foundation for Chiropractic Education and Research; and exhibit 4, Center for Clinical Studies.