Chiropractic and Public Health: Current State and Future Vision☆

Cheryl Hawk 

“Chiropractic …has not come to a consensus on the implications of integration into mainstream health care… (the profession) stands at the crossroads of mainstream and alternative medicine. Its future role will probably be determined by its commitment to interdisciplinary cooperation and science-based practice.”4

Integration into the arena of public health is an appropriate means for the chiropractic profession to resolve its conflicts on identity without compromising its integrity or losing its burgeoning emphasis on evidence-based care.

The definition of chiropractic proposed by the Association of Chiropractic Colleges is “a health care discipline which emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery…(it) focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health.”5 This definition is completely compatible with the definition of public health: “a society's efforts to protect, promote and restore health.”6

The starting point for effecting this mode of integration is to refocus the profession on prevention and health promotion. This is in keeping with current trends in the wider world of health care. The national blueprint for improving the health of Americans, Healthy People 2010, places tremendous weight on disease prevention and health promotion. This initiative lays out 28 focus areas and 467 measurable objectives to guide federal, state, and local agencies; private organizations and businesses; health care providers; and private citizens to improve the health of the nation.7 Health care providers are integrally involved in meeting more than 60% of these 467 objectives,8 and chiropractors have not only an opportunity but a responsibility to participate in this effort.

The chiropractic profession can use Healthy People 2010 as a ready-made roadmap for integration into the health care mainstream. Whether chiropractors consider themselves spine specialists, primary care physicians, or wellness practitioners, they must still be aware of and contribute to the national priorities to prevent disease and promote health. These priorities are conducive to a wellness practice model. However, if chiropractic adopts a wellness model, it is essential that it be consistent with mainstream concepts and practice of health promotion and prevention.9, 10 Such a model has been proposed to include manual procedures to promote optimal function, screening for risk factors, and health behavior counseling.9

Chiropractors, chiropractic colleges, and chiropractic organizations need to be more familiar with the Healthy People 2010 objectives to identify the activities congruent with their expertise and interests. This will lead naturally to their integration into public health activities. These activities may occur on a national basis, such as through the American Public Health Association (APHA) or through collaborating with actions of the National Arthritis Foundation. Implementation may occur locally, through state or county health departments. These health departments are under Federal mandates to work toward Healthy People objectives, such as increasing physical activity or decreasing disability related to low back pain; both of which are highly relevant to chiropractic practice. Rather than functioning as the Lone Ranger of health care, it is time for the chiropractic profession to join other providers and agencies to contribute to national health objectives and demonstrate their commitment to health by integrating with the public health mainstream.11

Michael Haneline 

Public health has been defined as “The organized efforts on the part of society to reduce disease and premature death, and the disability and discomfort produced by disease and other factors, such as injury or environmental hazards.”12 It emphasizes the health of a population as a whole, in contrast with typical patient care that focuses on the treatment of individuals. Nonetheless, it is very important to most practicing doctors of chiropractic to integrate public health principles as an essential part of patient care.

Public health interventions, such as advising patients about risk factor avoidance as well as how they can integrate protective factors into their lifestyles, can significantly enhance the healing process and prevent future illness. Examples include ergonomic advice about proper keyboard usage to patients with neck and upper extremity complaints13 and advising chiropractors about the proper workstation table height to reduce loads on the lower back.14 Efforts from the chiropractic profession to educate patients about how they can reduce risk and adopt healthy lifestyles have a collective effect of improving the health of the population that is being served.

The main influence chiropractors have on public health is undoubtedly through one-on-one encounters with their patients, but in recent years, quite a few members of the profession have become involved in public health at the community level. There are an increasing number of opportunities for chiropractors to participate in various health-related activities at the local, state, national, and even international levels through membership and/or employment in various health agencies and organizations. A direct connection with the public health profession is attractive to a growing number of chiropractors because the primary purpose of these groups is to help communities achieve their health goals. As a result, the potential to positively influence the health of large numbers of people is greater through these avenues. In fact, the enormous health gains that have occurred in modern society have mostly been attributed to public health measures, whereas patient care has had much less of an impact.15

Public health is an expansive field that encompasses subjects that range from infant health to healthy aging and infectious diseases to environmental health. Although not a complete list, examples of public health topics that should be of particular interest to chiropractors include injury prevention, occupational health, prevention of chronic diseases, and physical fitness. The chiropractic profession has made significant progress integrating public health matters into college curricula as well as mainstream chiropractic practice; an amalgamation that has been of great benefit to the profession as well as the patients it serves.

Lisa Zaynab Killinger 

Although traditionally, chiropractic colleges have taught public health with a focus on microbes and infectious diseases, public health is so much more than these subjects. Public health is made up of the efforts of individuals and society to protect, promote, and restore health. This is what chiropractors do every day.

For example, when we perform a chiropractic adjustment, we are helping to relieve the public health burden of back pain on society. When we discuss the importance of physical activity with our patients, we are participating in meeting the nation's public health goals.16 When we speak to patients or corporations about how to reduce back injuries at work, we are making a major public health contribution. When we encourage patients to eat a healthy diet or to stop smoking, this also contributes to public health. Chiropractors may do more public health education than almost any other type of health professional on a day-to day basis. According to the 2005 Job Analysis of Chiropractic, 98% of chiropractors talk to patients about physical activity and nutrition, and 96% offer stress reduction recommendations.17 Multiply these efforts by the tens of millions of chiropractic patient encounters each year and it becomes clear that chiropractic and public health go hand in hand. It is important that chiropractors and other health professionals truly understand just how these 2 worlds are so intimately intertwined.

Gary Globe 

“If a man will begin with certainties, he shall end in doubts; but if he will be content to begin with doubts he shall end in certainties.” -Sir Francis Bacon

DD Palmer's pioneering work in conservative clinical methods focused on the spine as the gateway to helping patients with a wide variety of conditions. More than 100 years later, we find that evidence reviews, based on research produced over the past few decades, continue to support the use of manipulation but primarily in musculoskeletal conditions. 18, 19 In only a few areas is there nascent evidence supporting manipulation for nonmusculoskeletal conditions.20, 21 It is hoped that future studies will illuminate additional nonmusculoskeletal benefits of adjustment, manipulation, and other manual methods in carefully selected patient populations.

However, if we look within the chiropractor's scope of practice for those approaches most likely to yield the greatest good for the largest number of patients, it is clear that evidence-based preventive methods, available to doctors of all disciplines but applied far too inconsistently, are by far the most critical element. One can reasonably speculate that the example of Palmer's continued search for improved understanding and effectiveness in the conservative care of patients might lead his successors to embrace such a change in direction.

Just as the theories of other great scientists of the 20th century were ultimately updated by an ever-increasing scientific knowledge base, our present understanding of health, as conceptualized by sources such as the WHO, should now inform, update, and guide a large aspect of our professional focus in this 21st century.2 Such efforts as Healthy People 2000 and 2010 have inspired many and provided roadmaps as to how our profession can better contribute, in a myriad of ways, to improving the nation's health.16

Within our own profession, prescient leadership from both the academic and research community has enabled the profession to navigate through what were once hostile waters in achieving a mutually respectful association between the chiropractic profession and the APHA, ultimately leading to section status and the opportunity for increased respect and understanding of the chiropractic profession within the broader public health community.22, 23, 24 Furthermore, over the past 2 decades, many of these same leaders, and those they have mentored and inspired, have laid a solid foundation by updating and implementing the public health curriculum in chiropractic academic institutions. This, in turn, has led to an unmistakable increase in health promotion/disease prevention consciousness, which has formed the basis of new competency requirements and educational standards. These changes open the door to a world of opportunities for both the profession and its patients to benefit from the life-transforming impact that health-promoting/disease-preventing messages and advice can bring. However, as one may likely surmise in reading through the pages of this journal's special issue, much more work awaits us in both the academic and professional realms. This must include greater support for prevention in the form of active membership and participation in APHA throughout the profession.

Just as DD Palmer sought throughout his life to improve his theories and clinical methods, we too must focus on improving ours. This includes providing advice on health promotion and disease prevention in the form of orthodox preventive screenings and behavioral guidance, as now taught in our academic institutions.

In industrialized nations, the tremendous scourge of infectious disease has been largely contained through advancements in health sciences research and its application in public health policy. However, at the same time, chronic diseases have moved to the forefront in terms of human and financial costs. Over the past century, many within the chiropractic profession have operated under the banner of wellness, although in too many cases this was focused through the narrow lens of a static model of subluxation dogma and consequently a limited conception of what the chiropractic profession could ultimately become.

The profession must stand firmly in opposition to unprincipled practice management models that use “wellness” as a guise and whose chief motivation is economic gain. Such unethical practices are often marketed hand in hand with recommendations for unlimited numbers of visits for the correction of chiropractic subluxations. This approach, particularly prevalent in some cash practices, can lead to grotesque levels of overuse far in excess of reasonable, evidence-informed levels of care.25, 26 Practitioners who cite BJ Palmer as a respected source of inspiration would do well to remember that, in the tradition of “find it, fix it and leave it alone,” BJ was known to admonish other chiropractors for treating patients longer than 2 weeks.25

Continued breaches in the perception of our profession's ethics will further erode our public trust, which was hard earned through the honest and ethical practices of many chiropractors. What will public policy-makers think and do when they observe, once again, the soap opera–like pathos of our profession's unwillingness to stand up to the obvious abuses committed by our own in the name of chiropractic?

We must join the league of professions accessing and offering opportunities for true prevention and health promotion. To obtain any measure of broadly acknowledged cultural authority, the chiropractic profession's offer of wellness must, once and for all, move beyond the image and practice of technicians marketing an unendingly performed singular clinical procedure, to one whose practitioners are primarily engaged in holistic and evidence-based treatment of neuromusculoskeletal conditions, while integrating a focus on wellness care as exemplified and practiced by the public health community.

As consumers, health care professionals, and policy makers in the public and private sectors focus ever more intently on the costs, outcomes, and financial burdens of health care placed on individuals and society, there is increasing focus on achieving and maintaining wellness rather than solely treating disease. The goals of chiropractic, particularly DD Palmer's conservative approach to improving health and fundamental emphasis on the importance of the body's ability to heal itself, can now more than ever align with the goals of public health and other health care professionals. It is our responsibility to make it so.

Bart N. Green 

When one first thinks of the military environment, thoughts of tropical medicine, posttraumatic stress syndrome, and combat injuries often are the first to come to mind; and the relevance of chiropractic to public health in the military environment might be questioned. However, there are many opportunities for doctors of chiropractic in military treatment facilities to make a difference in the health of the military population. Musculoskeletal disorders, particularly back and neck pain, are an enormous burden on the American health care system27; and military members are no exception to this rule. More than 80% of Operation Enduring Freedom/Operation Iraqi Freedom veterans tracked in one study had diagnoses related to musculoskeletal and connective tissue problems.28

The many long days lifting ordnance onto airplanes, bending over fixing troop transport vehicles, working at cramped computer spaces on ships, and other repetitive stressors take their toll on our troops. In a recent epidemiologic study of service members treated for musculoskeletal problems during Operation Iraqi Freedom, most members experienced spinal pain often associated with regular job duties and not combat operations.29 By working with community resources, chiropractors can become involved in health promotion programs designed to decrease the morbidity associated with some of these problems in addition to providing secondary prevention during clinical care. For example, one could provide training in safe lifting techniques to a unit that has jobs requiring a great deal of lifting or education to a squadron of pilots about how to improve spinal flexibility and muscle endurance in an effort to reduce the prevalence of back or neck pain in the squadron. On-base health fairs that are designed to promote active healthy lifestyles are another opportunity for chiropractors to get out into the community and provide screening, education, and health promotion.

One growing subpopulation of our military is composed of those who have lost limbs, had other serious trauma, or polytrauma. Given that many of these members are young and expected to live for several more decades, experiencing chronic neuromusculoskeletal pain is a very real likelihood.30 In addition to participating as health care providers in amputees' rehabilitation processes, chiropractors can collaborate with other departments of their military treatment facility, such as physical therapy, primary care, comprehensive care units, and orthopedics to develop creative primary prevention strategies to reduce the incidence of new neuromusculoskeletal problems, such as back pain, as these members become accustomed to prostheses, wheelchairs, and other lifestyle changes.

Perhaps the most important opportunity for doctors of chiropractic interested in public health in these integrated health care delivery systems is that of publishing epidemiologic studies that report whether or not chiropractic care is associated with improved troop readiness, decreased costs, reduced disability, or other meaningful outcomes. There is a great need for these types of studies because no such data have been published to date. Until we investigate these relationships, we will not be able to state with any degree of confidence what benefit the inclusion of chiropractic care in military treatment facilities has provided to active duty service members. Thus, there are many public health research opportunities for chiropractic care in military treatment facilities.

Anthony J. Lisi 

Improving the health of a population is limited by one's reach. For various reasons, many individuals remain outside of a clinician's—or a profession's—sphere of influence. The reach of the chiropractic profession was extended somewhat in late 2004 when the first Veterans Heath Administration (VHA) chiropractic clinics were established. Thus, our nation's veterans, a population long purported to be in need of access to chiropractic care within VHA, began to be served.

Chiropractors are now part of the largest integrated health care system in the United States. Operating some 150 medical centers, 850 outpatient clinics and hundreds of other facilities, VHA provides care to 5.2 million individual patients per year. In 2005, approximately 4000 veterans received 19 000 chiropractic visits in VHA facilities; projections for 2008 are more than 13 000 veterans and 70 000 visits. With clinics currently in 32 VA facilities, the contribution of the nascent VHA chiropractic service in providing high-quality, safe, cost-effective care for veterans will likely continue to grow.

Yet, this increased access is only one way that the profession's reach has been extended. The inclusion of chiropractors in the VHA means more than DCs simply being able to treat veterans. In addition to providing patient care, chiropractors are now filling administrative roles, building research capacity, educating clinical trainees, and contributing to public health initiatives.

The Office of Public Health and Environmental Hazards is the national leader for VHA public health initiatives.31 VHA's Public Health Strategic Healthcare Group coordinates patient care activities, clinician and patient education, prevention activities, and research directed at continuous improvement of medical and preventive services and delivery of care to veterans.32 The Center for Quality Management in Public Health fosters innovation and improvement in clinical care through quality management techniques and clinical information systems. The Office of Public Health Surveillance and Research oversees programs associated with influenza and hospital-associated infection, surveillance, and public health research. Conditions including influenza, hepatitis C, HIV/AIDS, norovirus, tuberculosis, smoking, and tobacco use are targeted through various programs.31 Computerized clinical reminders in the VHA's electronic medical record assist this process.33

VHA chiropractic physicians are able to participate in systematic health promotion and preventive services efforts by appropriate recognition, triage, consultation, and intervention as indicated. A chiropractor may identify a patient who smokes, discuss strategies to quit, and consult a cessation clinic as needed. Some chiropractors are collaborating with programs to encourage physical activity and manage obesity. Others may be part of a pain management approach that helps keep an AIDS patient compliant with antiretroviral therapy. These are not the first instances of chiropractors providing such services; however, being part of a major integrated health care system facilitates the contributions of doctors of chiropractic to public health efforts.

Through such efforts, as well as clinical care, education, and research, the VHA chiropractic service is part of the system meeting the health care needs of America's veterans. Important public health opportunities exist for understanding and maximizing our contribution to our patient population.

Stephen Injeyan 

Since the first discovery of vaccines at the turn of the 20th century, many have been developed. They have been the subject of clinical trials, mass immunization programs, and their effectiveness and safety have been checked repeatedly in the light of bioethical and financial considerations.34, 35, 36 Throughout these events, the immunologic and epidemiologic principles underpinning immunization programs have survived. Vaccination continues to be a key strategy in the control of communicable diseases for the individual, but more important, the community. Some chiropractors still hold views that are opposed to immunization.37, 38 Rightly or wrongly, the chiropractic profession in general has gained a reputation of being antivaccinationist.39 Reversal of this trend is needed to enhance the role that chiropractors may play in the public health arena.

In the United States, the chiropractic profession has gained a presence within the APHA. This group has demonstrated initiative by contributing in various ways, including development of a resource site that contains responsible and informed content about immunization.40 Chiropractic organizations worldwide could emulate the example of their US counterparts and explore opportunities for public health involvement in this area. The mission of the Chiropractic Health Care section of the APHA is to “enhance public health through the application of chiropractic knowledge to the community by conservative care, disease prevention and health promotion.” An integral component of disease prevention and health promotion is immunization. In light of this, the Chiropractic Health Care section of the APHA offers the profession an immunization information website with links to many high-quality information sources. This site compiles annotated bibliographies of citations from the scientific literature, as well as other authoritative sources on this topic (http://www.apha-chc.org/vaccinfo/default.htm). Interestingly, a 1993 survey of US chiropractors demonstrated that only 14% of respondents supported APHA's immunization policy.37 American Public Health Association's policy on immunization has remained essentially unaltered.41 However, it is not known if the level of chiropractic support for this policy has changed since that time.

Significant proportions of US chiropractors consider themselves primary care practitioners and perceive themselves relatively well trained in clinical prevention.42 However, perception of chiropractors with respect to preparedness to counsel on immunization is not so straightforward. Those who perceive themselves prepared to counsel feel that both the benefits and drawbacks of immunization should be presented. This implies preference for providing enough information to encourage the patients' freedom of choice. However, freedom of choice in immunization may be associated with antivaccination behaviors,38 which may be counter to public health goals and practices.

It is paradoxical that the chiropractic profession has made inroads into organizations such as the APHA and the WHO,43 and yet no official chiropractic organization has provided a strong, positive statement on immunization. The leading chiropractic organizations should make supportive statements regarding immunization programs and at the same time encouraging their members to be scientifically critical. It is hoped that such a stance will discourage irresponsible behaviors on the part of chiropractors espousing antivaccinationist views and will gradually foster a paradigm shift toward contributing to public health programs from an all-inclusive global perspective.

Deborah Kopansky-Giles 

We know from the WHO that poverty increases the risk of ill health and vulnerability in the poor and that it impedes the effective delivery of health services. This leads to inequitable access and lack of use of health services.44 These inequities greatly affect the world's poorest communities and most vulnerable people. According to the WHO, there is growing evidence that health-related risk events may be the first step toward permanent poverty. Social inequities result from inequalities in the conditions in which people around the world live and work. They become determinants of health, impacting health status and our general well-being. Poor health results in incapacity to work productively, care for family and one's self, in addition to numerous other trickle-down effects on the individual and their community.

The chiropractic profession is distributed globally and is in a position to impact the negative health effects of poverty and social vulnerability. We have the ability to develop creative and innovative health delivery opportunities, specifically aimed at poor and marginalized populations.45 There are local attempts in different regions, where chiropractors have been providing services to impoverished communities. Unfortunately, up to this point in time, these efforts have had little support from our profession, both economically and in terms of human resources.

There is a wealth of information describing the health profiles of inner city and poor populations. In 2001, Wasylenki described these complex populations and the association of poverty with poor health outcomes.46 These subpopulations include homeless individuals; people with HIV infection; people with severe and persistent mental illnesses; women at risk due to social isolation, poverty, or the stresses of single parenthood; people with addictions; and inner-city aboriginal communities. In general, these populations have less access to health services, have more complex health problems, and, consequently, have higher admissions to hospitals, economically burdening health systems.

It is important to know that transference of inner-city health problems does occur to the broader community. For example, HIV, tuberculosis, and other communicable diseases transition outward over time thereby increasing the burden of disease. It is imperative, therefore, that a focus for health care reform, including chiropractic, needs to be the prioritization of access to health care by poor, diverse, and marginalized communities.

Chiropractors have the responsibility of assisting in minimizing the effects of poverty and marginalization on people's health, to become engaged with their local communities in ensuring equitable access to health services, and to help to reduce the effects of these negative social and societal determinants of health. At the practitioner level, providing chiropractic care in a nonjudgmental and safe environment with sensitivity and respect are extremely important to these populations that have specific and very complex health concerns.

At the profession level, engagement of chiropractic organizations in collaborating with others around equitable access to health care for marginalized communities is essential. In this way, our profession can greatly contribute to improving the health and well-being of our inner city and vulnerable communities worldwide.

Paul E. Dougherty 

It is projected that between 2010 and 2030, the over 65-year-old age group will increase over 70% representing approximately 20% of the United States population.47 Chiropractors may play an important role in meeting the emerging public health needs for this population. Public health is the approach to health care that is concerned with the health of populations, including health promotion and disease prevention services. Chiropractic is the most commonly used non-allopathic health care service among older adults with reported use between 11% and 18%.48, 49 This presents a significant opportunity for chiropractors to begin to address the public health needs of a very large group of individuals. Two specific areas that chiropractic may contribute to the public health needs of older adults are the areas of fall prevention and back pain treatment.

Many factors lead to falls in older adults, including balance, gait, cognition, vision, and strength issues, use of 4 or more prescription medications, postural hypotension, depressive symptoms, and painful arthritis.50 A recent study by Hawk et al51 has begun to investigate the role of chiropractors in addressing fall prevention. One practical method that could be used by chiropractors would be to recommend exercise programs that have shown some evidence to prevent falls in older adults, such as tai chi.52 Before initiating these preventative strategies, one should be familiar with the current evidence on these topics. The Canadian Chiropractic Association produces one of the best resources for information on fall prevention, this program is entitled “Best Foot Forward.”53

Back pain costs have increased 65% in the last 10 years, making it a significant public health issue.27 Back pain is the third most common reason for older adults to visit their physician.54 Unmanaged lower back pain may result in depression, functional disability, compromised quality of life, and increased analgesic medication usage.54 In 1998, the American Geriatric Society listed chiropractic management among the nonpharmacologic strategies for treating chronic pain symptoms in older adults.55 Recent published guidelines recommended spinal manipulation for chronic lower back and neck pain.56, 57 A recent practice based study suggested some evidence for the efficacy of chiropractic management for older adults.58 There is a need however for more research specifically targeted at older adults, not just for chiropractic but for all treatments of back pain. The chiropractic profession has a great opportunity to be the leader in research for this important public health problem.

As the chiropractic profession matures, it will become less concerned with protecting itself and more concerned with protecting the public. The response of the chiropractic profession to the aging society will help to define the future of chiropractic. We have an obligation to develop better prevention and treatment strategies for older adults. It is my hope that the chiropractic profession will rise to this opportunity and to a greater level of respect in the health care system.

Monica Smith 

In the early part of the 20th century, the prevalence of infectious diseases was the most important health problem of the time. This early period was characterized by a closely connected and supportive relationship between the clinical practice of medicine and public health in implementing key public health strategies of the day such as quarantine, sanitary reform, safe water systems, pasteurization, and personal hygiene. Over time, the major causes of death and disability increasingly shifted from communicable diseases to chronic diseases. The changes in the social health burden and health policy priorities, coupled with the technological evolution of biomedicine, increasingly separated the function and culture of clinical medicine from that of public health.

Today, we find ourselves in what has been termed a collaborative imperative59 to reconcile the cultural and practical divide between clinical practice and public health, and to advance successful models for synergistic collaboration These will accomplish, among other goals, improving health care by better coordinating services, improving the quality and cost-effectiveness of care, strengthening health promotion, and improving access to care by establishing frameworks to provide care for the un- and underinsured.59

Current research and education continually seek to improve the care-coordination skill set of the typical practicing chiropractor,60, 61 but much more exciting is the frontier-expanding work in integrative and collaborative care that emphasize nonpharmaceutical and nonsurgical approaches to primary care, through innovative models of care that contain costs and yield high quality and patient satisfaction.26 The chiropractic profession advances important public health initiatives by contributing to improved care coordination, improving the quality and cost-effectiveness of chiropractic care and interdisciplinary care, and strengthening provision of health promotion and preventive care.

The contribution of chiropractic college outreach clinics in caring for underserved or impoverished populations is recognized, and relatively well documented, as an integral part of the institutional and professional missions of chiropractic educational institutions.62 In addition to the safety-net care of free clinics, voluntary referral networks among clinicians in private practice also build on a long-standing tradition of providing care to the un- and underinsured.59 The charge remains, then, to better document and understand the “safety-net function” of DCs in private practice serving as a central source of accessible care for un- or underinsured populations,63 an increasingly important priority in current health policy and health system reform.64, 65

Silvano A. Mior 

Health care delivery at the turn of the last century focused on diagnosing a problem and providing the appropriate elixir, a rather reductionistic biological approach to the delivery of care. Today, as a consequence of our deeper understanding of human structure and function, the complex biopsychosocial model of health and disease requires the integration of knowledge from different disciplines and often the involvement of a multidisciplinary health care team.66 Now add the growing resource constraints and financial pressures to maintain adequate funding,67 and the importance of a health care system disposed to efficiently coordinate care delivery becomes fundamental.

Canadian commissioned government reports suggest that the health care system needs to be transformed into one in which system participants involved in the spectrum of health services work collaboratively to deliver seamless comprehensive care.68 A suggestion no doubt heard reverberating worldwide. The challenge however is that the current health care system is fragmented and composed of health care providers who in the main have not experienced collaborative or integrative care.69

Reforming the delivery of primary care has many potential advantages including a focus on disease prevention and health promotion, improving access, and having health care providers working in multidisciplinary teams. The importance of health care professionals working collaboratively has been identified as a key strategy of primary care reform70 and an answer to many complex and innovative health care solutions.71

Interprofessional collaboration has been defined as a “process by which individuals from different professions structure a collective action in order to coordinate the services they render to individual clients or groups.”72 There have been numerous reviews summarizing the key and essential concepts, barriers, and facilitators related to interprofessional collaboration, such as sharing of responsibilities and knowledge, communication strategies, nature of partnerships, the role of interdependency, trust and respect among professionals, the structure of practice, autonomy, and power. Interprofessional collaboration is seen as a process that is dynamic, interactive, and ever evolving.70 And it could potentially optimize intellectual resources, maximize the coordination of care, and recognize contributions of various professions.69

Chiropractors are one of the most frequently accessed, nonphysician provider groups for neuromusculoskeletal conditions. However, their inclusion into multidisciplinary settings has met with varied success both from the perspective of organizational structure and process of collaboration. The barriers to inclusion are not unlike those for other professions but enhanced because of philosophical differences, cultural prejudice, and the lack of knowledge, which exists among both chiropractors and other health care providers. As a consequence, care is fragmented, and interprofessional communication and understanding is limited.60

Now, more than at any other time in its history, chiropractic is positioned to increase its role through its integration into the health care delivery system. Chiropractors are being provided with increasing opportunities to practice in multidisciplinary clinics and hospitals around the world.73 Integrating into these environments provides opportunity to contribute to improving cost effectiveness and efficiencies in health services delivery by eliminating the “silo mentality,” reducing unnecessary duplication of services, creating strategies to increase accessibility, ensuring continuity of care, and sustaining the health of the population. Our experience suggests chiropractors are poised, and able, to make such a contribution in various clinical settings. To do so, it is important to be a part of the health care delivery system.

Rand Baird and Deborah Kopansky-Giles 

Although we have many chiropractors involved in graduate studies and research in public health and epidemiology, our profession may appear to have minimally endorsed the concept of the strong role that we can play in the area of public health. We know very well that physical, social, and economical factors can have an impact on a person's health. We also know that chiropractic care can significantly improve a person's quality of life.

As a profession that promotes health, one of our strongest attributes is our commitment to patient education. We do this very well when explaining the etiology, diagnosis, and treatment recommendations. However, chiropractors have the opportunity to share information about public health and get involved actively in general public health initiatives.

One example of this is the efforts to reduce the use of tobacco by the WHO that has reaffirmed the Tobacco-Free Initiative as their top priority and tobacco use as the most important, preventable health and social issue, one with a considerable cost to society.74 They have called for global action on tobacco use cessation, and the World Federation of Chiropractic (WFC) has been actively engaged for several years.

The WFC's Public Health Committee has been globally promoting tobacco use cessation. The campaign—Chiropractors Against Tobacco—has created posters and educational materials for use by chiropractors (available from the WFC website) as well as ads in chiropractic-related media.75 The uptake on these materials has been minimal, yet we know that chiropractors in general promote smoking cessation. Our committee's next priority will be to support the WHO's efforts against obesity.

Chiropractors, by the very nature of their health promotional practices, are the ideal conduit to promote healthy lifestyles and support major public health initiatives. Our involvement in these areas will serve to improve the health of our patients, the community, and the world in which we live. We will also be seen on the global stage as noteworthy contributors to public health as we should rightly be seen.

We encourage all chiropractors, chiropractic associations, and academic institutions to incorporate public health education in their practices, curricula, and policies and to become involved in sharing this information with the communities in which they practice and live. In this way, the chiropractic profession can continue to improve the quality of life for people around the world.