Rand Baird, DC, MPH, FICA, FICC;
Jonathan Todd Egan, DC, MPH, PhD (cand.)
Sometimes it seems like the health care system is from some strange dystopic future where the most expensive and invasive therapies are used before the conservative; where medications are used before lifestyle change; where treatment pays better than prevention; and where evidence doesn't have the influence on practice, payment and decision-making that it should.
We often recognize the dystopic phenomenon in the treatment of low back pain, where costly injections and surgery are tried before conservative care; where opioids are prescribed, but exercise and diet changes may seem to receive lip service; and where a highly studied treatment (spinal manipulation) and its most frequent provider (chiropractors) often do not find a place at the table of mainstream practice and payment.
What is the way forward out of this dystopic scenario? I offer four suggestions, each of which is a lesson chiropractic can learn from public health.
1. Political Activity
In its landmark 1988 report, "The Future of Public Health," the Institute of Medicine (IOM) noted that public health practitioners did not do a good job at participating in the public policy realm where decisions were made and funding was provided. The IOM noted that public health practitioners tended to work in their respective fields and assumed that good policy would carry the day in a democracy. Instead, the IOM pointed out that political and managerial acumen are also critical public health skills and that public health practitioners needed to be politically active.
Chiropractors must realize that political engagement is key to successful transformation of the dystopian health care landscape. Participation in associations such as the World Federation of Chiropractic (WFC), the American Chiropractic Association (ACA), the International Chiropractors Association (ICA), and the American Public Health Association (APHA) help organize individuals nationally and internationally to accomplish what individuals otherwise cannot.
Collective effort – and the enhancement of managerial and political skill – can help chiropractors shape the debate, influence payors, and become key players in systems that desperately need a trained and conservative voice in the care of spine-related disorders.
2. Population-Level Prevention
Public health practitioners actively engage in primary, secondary and tertiary prevention at the population level to prevent conditions (such as using immunization to prevent disease and fluoridation to prevent cavities), and also resolve or manage conditions. These practitioners work with determinants of health in their communities. Dentists enjoy professional regard in part because of their support for the primary population-level prevention activity of fluoridation, though fluoridation means fewer patients need dental services for treatment of cavities. Prevention activities in the public interest can build trust and produce wellness in populations.
Chiropractors must consider how we can enhance the health of our communities through activities that will reduce the burden and severity of spine-related disorders in populations, rather than only in the individual patients we treat. These activities should increase professional regard and inclusion, as our skills will be recognized for helping to keep populations well.
Chiropractors should consider activities we can support that will help communities suffer less low back pain or neck pain in the first place. Chiropractic support of activities designed to educate populations and change behaviors cannot be overemphasized. Altruism is a virtue we can learn and re-learn.
3. Community Involvement
Public health understands that community health workers are key. These individuals are tied into the communities they serve – they know community members, they understand how to reach critical populations, and they know how to communicate in ways that connect and build.
Chiropractors should contribute expertise and generate goodwill through service in the community. Each of us has opportunities that surround us. We can take advantage of opportunities to engage the community, to know community members, to serve critical populations, and to be a member of a team of servant leaders.
Involvement in our specific communities changes the playing field. It leads to further personal invitation to participate, rather than the need to "beat down the door."
4. Scientific Expertise
The IOM pointed out that public health activities were historically based on observations and theories before the causes of specific diseases were known. For example, quarantines were known to help prevent the spread of disease without knowing why. However, as scientific understanding developed, technical expertise was required to participate and engage in a changing health care environment. What used to be sufficient was no longer sufficient – public health workers had to adapt by developing skills in biology, genetics, engineering and a host of other fields.
Chiropractors must consider how enhancing our understanding of scientific fields of study related to our work will help us to communicate, validate and enhance the benefits of the treatment we offer. Chiropractors should engage the evidence and the literature, but should also consider the role that personally obtaining further education and training could play in developing a critical mass in cultural authority to shape this dystopic health care system.
These lessons from public health (political activity, population prevention, community involvement and scientific expertise) are tools within our reach. These tools can help us adjust the current health care system and shape a future in which conservative care is valued, prevention is a lifelong habit, lifestyle change is a natural pursuit, and health is within everyone's reach. Public health can help show us how.
Author's note: If you are interested in participating in collective public health efforts with chiropractic members of the American Public Health Association, contact the Chiropractic Health Care section membership chair, Dr. Kim Khauv at drkhauv@gmail.com, or click here to join the APHA (remember to select Chiropractic Health Care as your primary section affiliation).
