It was Thursday, April 19, 1990, 10:15 a.m. In another 15 minutes representatives from the National Institutes of Health would plead their case for increasing funding of Alzheimer's research before the Subcommittee on Labor, Health, Human Services and Education, a division of the Appropriations Committee of the U.S. House of Representatives.But before that, a strange thing would occur. For perhaps only the second or third time in the past 50 years a chiropractor would address a subcommittee of the federal legislature. John J. Nugent, D.C., then director of education for the National Chiropractic Association's Council on Education, had a similar opportunity in 1943. Several chiropractic representatives had made similar appearances in the early 1970s when the fate of chiropractic inclusion in Medicare was to be decided.
The occasion this time was no less historic. As Arlan W. Fuhr, D.C., president of the National Institute of Chiropractic Research (NICR) approached the microphone, he knew he had five minutes to state his case, present his exhibits, and make his request. The cause was simple: that the United States provide the chiropractic profession with its fair share of funds for the advancement of chiropractic science and education, so as to improve the quality of care which DCs provide to citizens. The written statement (an expanded version of Dr. Fuhr's oral presentation) is reprinted below, just as it was submitted for inclusion in the Congressional Record.
It is far too early to know what effect this petition will have. It seems reasonable to suppose that this singular request will not bear fruit this year, and that we will have to repeat our request each year (until the squeaky wheel gets its grease). No doubt the FAX machines between Washington, D.C., and the AMA headquarters in Chicago, are now working overtime; and we can expect considerable opposition from organized medicine next year. But the groundwork has been laid, and the chiropractic profession can expect that perseverance in these efforts will eventually pay off. Its about time.
Here, then, is the text of Dr. Fuhr's remarks to the subcommittee:
Joseph Keating, Jr., Ph.D.
Palmer College of Chiropractic-West
Statement to the Subcommittee on Labor, Health, Human Services and Education, Committee on Appropriations, U.S. House of Representatives.
"Thank you, Mr. Chairman, for this opportunity to address the committee. My name is Arlan W. Fuhr, D.C. I am a chiropractic physician, and president of the National Institute of Chiropractic Research, a non-profit corporation which conducts and supports research in chiropractic. I have prepared a short oral statement, and respectfully request my full written statement and exhibits be included in the record.
As you are well aware, health care costs in the United States have skyrocketed, and a very major portion of these costs derive from neuromusculoskeletal disorders, such as back pain, headache, stress and lifestyle-related conditions. These disorders, which are the primary focus of doctors of chiropractic, result in considerable misery for patients, and account for an inordinate amount of the health care dollar and of days lost from work, in this country. Methods of preventing, assessing and treating these ubiquitous health problems are not well studied and, consequently, society is at risk of spending large sums for potentially ineffective, deleterious, and/or unnecessary health services. Medical scholars have recently acknowledged (Eddy, 1990) that accurate, interpretable evidence for the clinical value (i.e., efficacy, relative effectiveness, cost-effectiveness) of the patient services they provide for all health problems is currently very weak. In my own profession, I am sad to say, there is even less experimental data upon which we can base our clinical practices.
This staggering information gap persists despite the federal government's annual expenditure of at least $10,000,000,000 on medical education and research (Taskel et al., 1989; Durenberger, 1988; Medical Education, 1989) through direct funding of biomedical research and the medical schools, and by means of the symbiotic relationship between the medical schools and VA medical centers. In part, this lack of information may be attributable to the underfunding of health care outcomes research. In the case of chiropractic, however, the research gap is due to the nearly complete absence of federal funding for chiropractic education and research. Recently, the Foundation for Chiropractic Education and Research, the major funding source for chiropractic research, issued a request for proposals (RFP) to systematically evaluate federal funding policies with respect to chiropractic research, education, training, and institutional development. The RFP also calls for a comprehensive analysis of the chiropractic colleges. The foundation expects to fund a study, costing in excess of $200,000, by early summer 1990. The major outcome of the study will be the identification of factors that can increase the eligibility of chiropractic for federal funding. Despite the strenuous efforts of the chiropractic profession since the 1975 HEW conference on spinal manipulation, the federal government has made only two awards to chiropractic investigators. The sum total of these two awards is $50,800, or about 5 ten-thousandths of 1% (0.0005%) of the funds which U.S. medical schools receive every year from the federal government for training and research. Unlike students of almost all other health professions (MD, PT, RN, DPM, DO, DDS,) chiropractic students receive none of the scholarships which congress makes available through the Army, Navy, Air Force and the Veterans Administration. Chiropractic colleges receive none of the billions in federal support which other health professional schools receive. The financial brunt of the small but growing body of chiropractic scientific literature has been and continues to be borne by student tuition dollars at the chiropractic colleges and by the contributions of individual doctors of chiropractic. Consequently, the average new doctor of chiropractic graduates with an indebtedness of approximately $55,000, not counting interest on these loans.
One may legitimately ask why the chiropractic profession has not been more successful in attracting federal funding to study its methods. The answer comes in two parts: Firstly, the chiropractic colleges have traditionally viewed clinical science investigations (i.e., outcomes research) as a luxury they could not afford. Chiropractic charitable services and the patients they serve, such as Kentuckiana Children's Center, in Louisville, Kentucky, have been systematically denied access to facilities and resources which could improve patient welfare. This, in combination with the alienation of chiropractic institutions from universities and teaching hospitals, has not permitted chiropractors to develop the critical scientific skills and public funding for research and training which other health professions have enjoyed. The recently upheld conviction of the American Medical Association (AMA) and affiliated organizations for their efforts to 'contain and eliminate chiropractic' (in violation of the Sherman Anti-trust Act) provides some indication of just how extensive has been the social and political ostracism of chiropractic (see Exhibits 1, 2, and 3). In short, chiropractors have been locked out: locked out of universities, locked out of hospitals, locked out of nursing homes, locked out of HMOs and managed care systems, and locked out of federal grants and scholarships for research and training.
A second reason for the lack of federal investment in chiropractic science and education involves less intentional bias. Despite the growing interactions between MDs and DCs at the grass roots level, organized medicine has been quite successful in its efforts to tarnish chiropractic, and in so doing fosters a negative impression of all things chiropractic, including its colleges and clinical methods. Despite more than two dozen well-controlled clinical trials to support (if not substantiate) the analgesic effects of spinal manipulation (Brunarski, 1984; Curtis, 1987; Deyo, 1983; Spitzer et al., 1987), and despite the considerably greater satisfaction patients report for chiropractic vs medical care of low back pain (Cherkin et al., 1989), chiropractors and our methods are still routinely dismissed by many health investigators and policy-makers as unscientific cultism. Chiropractors' potentially valuable role as primary care gatekeepers has been ignored, and the care which 40,000 doctors of chiropractic provide to as many as 18% of adult pain sufferers in the U.S. (Harris, 1985) is not politically recognized.
Maybe, as is heard, chiropractic is all placebo, or its supposed effects are due to spontaneous remission. We think this unlikely. Perhaps chiropractors' emphasis on wellness and prevention, through sensible nutrition, regular exercise, and good hygiene will not keep people out of hospitals. Maybe chiropractors' efforts at prevention and good care for the musculoskeletal system will not help keep the elderly out of nursing homes, and will not help them maintain a higher level of functioning and a better quality of life. Perhaps the many retrospective studies (Johnson et al., 1985) which have suggested that chiropractic care can get injured workers back on the job quicker and at lower cost then medical care, are wrong. Very well, then let us work together to do the hard scientific work to make those determinations. As a society, we owe it to ourselves to find out which chiropractic methods will help which patients, with which problems, under what circumstances? As healers, the chiropractic profession has a moral duty to evaluate its technology so as to assure safety, and clinical and cost effectiveness. We are doing what we can with minimal assistance from the public treasury; we have been locked out. We ask that the congress recognize that a federal investment in chiropractic training and research is a strategic intervention, for unlike the high-tech, high-cost of modern surgery and medicine, chiropractors employ a conservative, hands-on, low technology. We emphasize keeping people out of surgery, out of hospitals, and out of bed whenever possible. A federal investment in chiropractic training and research would be an investment in cost containment in health care.
If the only concern here were equal treatment for chiropractors, these remarks would indeed be self-serving. But the issue of federal investment in the knowledge base of a profession, which has survived despite a century of persecution and has served many tens of millions of Americans, is a matter of public health. Despite the onslaught of organized medicine, my profession has survived because we have offered something of value to a suffering society. A Harris poll (Harris & Associates, 1985) indicated that as many as 18 percent of all adult pain sufferers went to chiropractors for relief. The Foundation for the Advancement of Chiropractic Tenets and Science (1989) indicates that total expenditures for chiropractic care in the U.S., amounted to $2.4 billion in 1988. Chiropractic has survived because of its grass roots support: patients have demanded chiropractic care.
On behalf of the many millions of chiropractic patients and of the many millions more who might benefit if we better understood the potential clinical value of chiropractic care, I ask that this House make a significant investment in the public's health through the appropriation of earmarked research funds for outcome trials and cost containment studies of chiropractic methods of health care, and earmarked training funds to bring the chiropractic colleges within the university system, and to provide primary care residencies for future doctors of chiropractic."
- Brunarski, D.J. "Clinical trials of spinal manipulation: a critical appraisal and review of the literature." J Manipulative Physiol Ther 1984; 7:243-9.
- Curtis, P. "Spinal manipulation: does it work?" In Deyo R.A. (Ed:) State of the art reviews. Spine. Occupational back pain. Philadelphia: Hanley & Belfus, Inc., 1987; 2(1):34-44.
- Chassin, M.; Brook, R.; Park, R., et al. "Variations in the use of medial and surgical services by the Medicare population." N Engl J Med 1986; 314:285-90.
- Cherekin, D., et al. "Patients evaluations of low back pain care from family physicians and chiropractors." Western J Med 1989; 150:351-5.
- Deyo, R.A. "Conservative therapy for low back pain: distinguishing useful from useless therapy." J Am Med Assoc 1983; 250:1057-62.
- Durenberger, D. "Perspectives: a senator." Health Affairs (Millwood) 1988; 7(2 suppl.):39-44.
- Eddy, D.M. "Clinical decision making: from theory to practice." J Am Med Assoc January 12, 1990; 263(2):287-90.
- "Foundation for the Advancement of Chiropractic Tenets and Science." Bulletin #3. ICA Review of Chiropractic November/December, 1989; 29-52.
- Louis Harris & Associates. "The Nuprin Pain Report." September, 1985, New York.
- "Medical education programs sponsored by government agencies." (Section VI). J Am Med Assoc August 25, 1989; 262(8):1068-72.
- Johnson, M.R.; Ferguson, A.C.; Swank, L.L. "Treatment and cost of back or neck injury: a literature review." Research Forum (Palmer College of Chiropractic Spring 1985; 1(3):68-78.
- Spitzer, W.O.; LeBlanc, F.E.; Dupuis, M., et al. "Scientific approaches to the assessment and management of activity-related disorders: report of the Quebec task force on spinal disorders." Spine 1987; 12(7S): supplement.
- Taskel, L.; Jolly, P.; Beran, R. "U.S. medical school finances." J Am Med Assoc August 25, 1989; 262(8):1020-8.
- United States Court of Appeals for the Seventh Circuit, February 7, 1990. Nos. 87-26-2672 and 87-2777.
- Judge Getzendanner's decision in 1987.
- American Chiropractic Association. The American Medical Association found guilty of conspiracy. ACA, March 15, 1990, Arlington, Virginia.
- Letter from George P. McAndrews (plaintiff attorney in Wilk et al.) to Arlan W. Fuhr, D.C.; April 11, 1990.
- Request for Proposals. Foundation for Chiropractic Education and Research. An evaluation of federal funding policies and programs and their relation to the chiropractic profession. November 1, 1989, The Foundation, Arlington, Virginia.
- NICR and FCER funded research projects.