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The Palmers espoused anti-vaccination opinions in the early part of the 20th century, rejecting the germ theory of disease in favor of a worldview that a subluxation-free spine, achieved by spinal adjustments, would result in an unfettered innate intelligence; this, along with other healthful lifestyle choices, would allow a person to thwart disease by marshaling the body’s natural recuperative abilities. Some chiropractors continue to staunchly champion the Palmer postulates, while others do not. At the national level, advocacy organizations publish conflicting position statements. We explore how this divisiveness has impacted chiropractic ideology, perceptions among students and practitioners, politics and issues of jurisprudence as reflected by the evolution of a standard of chiropractic practice in at least one Canadian province (Ontario). We opine that the chiropractic profession should champion a health promotion and disease prevention approach to vaccination, which would allow it to align itself with the broader healthcare community while not abandoning its traditional tenets.
Au début du 20e siècle, les Palmer ont soutenu des opinions anti-vaccination, rejetant la théorie microbienne des maladies en faveur d’une idée répandue mondialement suivant laquelle une colonne vertébrale sans subluxation, résultat d’ajustements vertébraux, se traduirait par une intelligence innée et sans contrainte. Ceci, accompagné d’autres choix sains de mode de vie, permettrait à une personne d’écarter les maladies en faisant appel aux capacités de récupération naturelles de son corps. Certains chiropraticiens continuent de défendre farouchement la thèse de Palmer, alors que d’autres s’y opposent. À l’échelle nationale, divers groupes de défense publient des opinions contradictoires. Nous examinons l’impact de cette divergence d’opinion sur l’idéologie de la chiropratique, les perceptions des étudiants et des praticiens, les politiques et les enjeux de jurisprudence, comme le reflète l’évolution de normes de pratique de la chiropratique dans au moins une province canadienne (Ontario). Nous sommes d’avis que la profession de la chiropratique devrait favoriser une approche de promotion de la santé et de prévention des maladies concernant la vaccination, ce qui lui permettra de s’harmoniser avec le reste de la communauté médicale sans pour autant abandonner ses principes traditionnels.
“It is the very height of absurdity to strive to ‘protect’ any person from smallpox and other malady by inoculating them with a filthy animal poison... No one will ever pollute the blood of any member of my family unless he cares to walk over my dead body... ”D.D. Palmer, c19101
With the possible exceptions of the term ‘subluxation’2,3 and chiropractic’s role in the health care delivery system4–7, no other issue has polarized the chiropractic profession as much as vaccination. From the time of its inception in the early part of the 20th century, both Daniel David (commonly referred to as “D.D.”) Palmer along with his son Bartlett Joshua (commonly referred to as “B.J.”) promulgated anti-vaccination stances, stances that animated much of the profession’s opposition to organized medicine.1,7,8 It was D.D. Palmer, a magnetic healer, who performed the first chiropractic adjustment in what has become the epochal event of the profession. According to chiropractic lore, D.D. restored the hearing of a deaf janitor named Harvey Lillard by adjusting a vertebrae of his mid thoracic spine that he determined to be ‘racked’ out of place.1,3,9,10 By doing so, by resolving a neurological problem (deafness) with a refined manual method of cure first employed by European bone-setters (spinal manipulation)10, D.D. and later B.J. came to believe that chiropractic care had far-reaching and more powerful effects on the human body than simply resolving back pain.1,3,5,8 Among these far reaching effects was the ability to provide defence against communicable diseases.1,3,5
But do chiropractors espouse these anti-vaccine world-views today? As the third largest primary health profession in North America this question may have serious implications to public health initiatives.11 With roughly 60,000 chiropractors in the United States11,12 and close to 8,000 in Canada13, chiropractic’s cultural authority tends to lie in the area of ‘spinal care’ with roughly 80% of a chiropractor’s patient portfolio consisting of headache, low back and neck pain conditions6,14,15, and a number of well-designed systematic reviews are investigating the effectiveness of the types of manual therapies chiropractors most often use for patient care16–19. Many chiropractors emphasize a ‘wellness’ or a health promotion and disease prevention paradigm, advising patients to exercise, not to smoke, to maintain good nutritional practices, employ proper ergonomics and to practice safe sex and safe sun20–23 – all healthful strategies around which no controversies exist. However, since chiropractors interact with a significant number of patients throughout their professional careers, it stands to reason that if a segment of chiropractors also advise their patients to eschew vaccinations, this could imperil the success of large-scale immunization programs championed by the World Health Organization (WHO)24, the Centre of Disease Control and Prevention (CDCP)25 and the Public Health Agency of Canada26.
This paper explores the issue of chiropractic and vaccination in terms of: (i) historical perspective; (ii) attitudes among chiropractic students; (iii) attitudes among chiropractors; (iv) political perspectives and; (v) issues of jurisprudence. We discuss how these issues impact the relationship between chiropractic and medicine and we recommend a path forward, one that will more firmly entrench chiropractic into the larger healthcare community, while not necessarily abandoning its core ideological tenets.
At the beginning of the previous century, the Palmers rejected the germ theory of disease, despite the fact it was gaining wide acceptance at the time.3,8 B.J, who assumed the mantle of the profession’s leadership in 1906 after purchasing the Palmer School of Cure (PSC) from his father (who was jailed for a time for practicing medicine without a license), asserted that: “chiropractors have found in every disease that is supposed to be contagious, a cause in the spine. In the spinal column we will find a subluxation that corresponds to every type of disease... If we had one hundred cases of small-pox, I can prove to you, in one, you will find a subluxation and you will find the same condition in the other ninety-nine. I adjust one and return his function to normal... There is no contagious disease... There is no infection. There is a cause internal to man that makes of his body in a certain spot, more or less a breeding ground [for microbes]”8. It was B.J.’s opinion that “the idea of poisoning healthy people with vaccine virus... is irrational. People make a great ado if exposed to a contagious disease, but they submit to being inoculated with rotten pus, which if it takes, is warranted to give them a disease”24. The curriculum at the PSC was based on the central tenet that adjusting spinal segments assessed as being subluxated [i.e. operating in an aberrant manner in terms of their structure, function or neurology, depending on the prominent model at the time10,28] would marshal the natural recuperative abilities of the body, relying on what the Palmers labelled innate intelligence29. It was reasoned that removing the nerve interference caused by subluxated spinal segments would, in the parlance of B.J., “emancipate the rivulets of entrapped life force”27. By removing subluxation and marshalling the innate intelligence of the person (removing them from a state of disease) the patient’s neurological system could function unfettered, ultimately thwarting disease. This ideology, often described as a core tenet of chiropractic philosophy, continues to be embraced by a significant portion of the profession, a portion who label themselves as ‘straight’ or ‘principled’.30 Although estimates vary, one epidemiological study conducted in Canada reported roughly 30% of chiropractors identify themselves as having this traditional or orthodox worldview.30
Busse and his colleagues31 surveyed a cohort of Canadian chiropractic students during the 1999/2000 academic year in order to ascertain their attitudes toward vaccination. Busse writes that, as a chiropractic student at the time, as the program progressed, an increasingly anti-vaccination sentiment was noted among the students32 and, since over 80% of all chiropractors practicing in Canada were educated at the Canadian Memorial Chiropractic College (CMCC), the only English-speaking chiropractic college in Canada, it was reasonable to posit that attitudes toward vaccinations identified among CMCC students may predict their attitudes upon graduation. Upon surveying his classmates, Busse et al32 found that, although 72.3% of first year students were in favour of vaccination, this number fell to 58.2% of students in their final year of study. The investigators also found that students who had a negative attitude toward vaccination were more likely to have relied on informal sources of information, such as non-peer reviewed chiropractic literature and informal social club talks.32 This study did not go unnoticed by the medical community, especially paediatricians, and a commentary appearing contemporaneously with the published Busse et al study described these results as ‘disturbing’, although it did suggest there be more inter-professional collaboration and that this may be an ideal opportunity for medical and chiropractic students to work together and learn from each other.33 Notwithstanding how it may appear, since theirs was one-time cross-sectional ‘snap-shot’ study of a cohort and not a longitudinal one, it cannot be said with certainly whether students’ attitudes became more negative as they progressed throughout the 4-year academic program or if the attitudes identified in each year were a reflection of some other unidentified factor unique to each specific class.
When Busse et al31 published their article in the Canadian Medical Assocation Journal in 2002, the lead author of this manuscript (BJG) posited that the anti-vaccine attitudes held by senior students may be a reflection of the influence of some charismatic students enrolled in the college c1999. Their advocacy of traditional chiropractic ideologies, which included a rejection of the benefits of vaccination, was spread by the student groups they organized. If correct, it would be reasonable to expect that 12 years later these results would vary greatly due to changes in the academic program, current student population, accrued scientific knowledge between the two time intervals, advances in scientific research and the adoption of the doctrines of evidence-based medicine that have been inculcated into the college milieu.
In order to learn if attitudes toward vaccination has indeed changed, we surveyed the class of 2011/12 at CMCC using the same survey instrument used in 1999/2000. In addition to using the identical 11 survey questions used by Busse et al31 (with the exception of substituting H1NI for Pertussis in one of the questions) students were also asked whether or not they had been vaccinated, if they believed they had been adequately educated on the topic of vaccination, if they believed they could discuss the topic of vaccination with their patients and if they believed they should have the legal right to be allowed to do so. Unlike the Busse et al31 study, however, we did not seek to learn what sources of information students relied upon in order to develop their attitudes toward vaccination.
As predicted, our results34 were fundamentally different than the results reported by Busse et al31. Specifically, a minimum of 83% of chiropractic students in all years in the 2011/12 acacdemic year held a favorable attitude towards vaccination. The highest favorable rate was reported by second year students (89.9%), followed by students in their final year of study (87.75). When asked ‘are you in favor of vaccination and immunization in general?’ between 80.7% and 91.9% of students in our study responded ‘yes’. We used a Welsh t-test for two samples having possible unequal variances and found a statistical difference between the two surveys, with current academic year having a more positive attitude towards vaccination. It must be noted, however, that our study did suffer from a non-response bias disproportionately affecting later years of study.see 34
There exists one large survey of the attitudes of chiropractors towards vaccination. Colley and Haas35 conducted a mail survey of randomly selected American chiropractors. Despite the fact the validity of the study suffered from a very low response rate (36%), and the sample size represented less than 1% of all chiropractors in the United States, the researchers reported roughly one-third of the 171 respondents believed there was no scientific proof that immunization prevents disease, that immunization has substantially changed the incidence of infectious diseases that immunization causes more disease than it prevents and that contacting a disease is in fact safer than being immunized against it.35
A study by Evans et al36 surveyed a random sample of chiropractors’ website that purportedly discussed ‘wellness’. Sixteen of these websites (34%) contained anti-vaccination information, and these same websites were the ones to most often mention ‘innate’, ‘subluxation’ and ‘spinal pain’ as well. This led the authors to conclude that many of these websites contained ‘useless’ information that would not help a person maintain good health.
Page and colleagues37 explored how chiropractors in Alberta brought up the topic of immunization with their patients using a set of interview questions. They reported the discussion typically was initiated after a media report of some kind, as the result of reading material left in the chiropractor’s waiting room or after a patient’s perceived adverse reaction to a vaccine. The discussion could also be initiated by chiropractors if they were seeing the children of patients. The researchers reported some chiropractors used this as an opportunity to provide anti-vaccination information and material, and that much of the waiting room material had an anti-immunization slant. The same group of researchers then asked whether these Albertan chiropractors felt prepared to discuss immunization with their patients.38 Of the 503 Albertan chiropractors surveyed, only 45% felt their chiropractic education adequately prepared them to counsel patients on the topic of immunization. Despite this, 72% of respondents indicated they felt adequately prepared to counsel their patients on immunization.
Medd and Russell39 conducted a secondary analysis of the study by Injeyan et al38 cited above. Medd and Russell39 reported that, while over 90% of the chiropractors interviewed were themselves immunized, only 35.7% of them would accept to be immunized in the future. Furthermore, only 66% of respondents had immunized their children and only 21% would refer patients for possible immunization. Russell et al40 reported that 41% of chiropractors felt immunizations were safe, that 60% felt immunization should never be given to children under the age of 1, that 30% felt they should never be provided to the elderly and 27% of them advised their patients “against having themselves/their children immunized”. Finally, a recent study by Downey et al41 reported that children were significantly less likely to receive all four recommended vaccinations if they saw a naturopathic doctor and significantly less likely to receive three of the four recommended vaccinations if they saw a chiropractor.
That all having been said, Russell et al42 subsequently reported 60% of Albertan chiropractors would be interested in participating in community immunization awareness programs. Lastly, in contrast to aforementioned studies, studies by Davis and Smith 43 and Smith and David44 reported that chiropractic patients were no less likely to be vaccinated for the seasonal influenza flu than were non-chiropractic patients, although they also reported that chiropractic users were significantly less likely than non-users to use the pneumococcal vaccine. A study by Stokley et al45 described vaccination coverage among patients according to their use of Complementary and Alternative Medicine (CAM) and found vaccination coverage levels were actually higher among recent CAM users compared to non-CAM users.
It requires minimal effort to gather position statements from prominent chiropractic organizations, newsletters and non-peer reviewed articles that assert an attitude towards vaccination that ranges from cautionary to sceptical to alarmist. Many of these documents and concerns have been catalogued by Campbell et al46, essentially advancing on an article by Nelson47 a decade earlier and expanded on by Ferrance48 a few years after that. For example, the position statement from the International Chiropractic Association (ICA) states:
The International Chiropractors Association recognizes that the use of vaccines is not without risk. The ICA supports each individual’s right to select his or her own health care and to be made aware of the possible adverse effects of vaccines upon a human body. In accordance with such principles and based upon the individual’s right to freedom of choice, the ICA is opposed to compulsory programs which infringe upon such rights. The International Chiropractors Association is supportive of a conscience clause or waiver in compulsory vaccination laws, providing an elective course of action for all regarding immunization, thereby allowing patients freedom of choice in matters affecting their bodies and health.49
Rather than debate the effectiveness of vaccines per se, the ICA position statement focuses on issue of safety and civil liberties. The policy statement on vaccination from the American Chiropractic Association50, an organization that could be characterized as the more progressive of the American chiropractic organizations (see 11), is essentially identical.
At the other end of the ideological spectrum is the position statement from the largest national chiropractic advocacy organization in Canada, the Canadian Chiropractic Associations (CCA).51 The CCA which represents upwards of 80% of all Canadian chiropractors, issued the following position statement:
Vaccination is a well-established and widely mandated public health policy and the CCA supports public health promotion and prevention strategies that encourage physical and mental health and well-being. The CCA accepts vaccination as a cost-effective and clinically efficient public health preventative procedure for certain viral and microbial diseases, as demonstrated by the scientific community. The public responsibility for vaccination and immunization is neither within the chiropractic scope of practice, nor a chiropractic specific issue. Public health programming and literature provide appropriate sources of information for patient education regarding vaccination and immunization. 51
Another topic that provides a great deal of animation to the opposition to vaccination among some chiropractors is the purported relationship between immunizations and autism.52,53 Autism is the most commonly diagnosed neurological pediatric condition among many countries (including Canada, the United States, and the United Kingdom), with current estimates that 1 in 88 children, and as many as 1 in 54 boys, are autistic.54 Although there is evidence that some of these increased diagnoses can be attributed to diagnostic substitution55, whereby children previously labeled as ‘mentally retarded’ are now classifiable as autistic, that cannot account for the exponential rise in the number of diagnosed cases. Since a definitive cause of autism has eluded modern-day science and, given the fact that autistic symptoms often appeared concurrently with vaccination schedules, a causal relationship suspected from a temporal one was understandable.
The main research evidence for this relationship was derived by a study by Wakefield et al56 published in the Lancet in 1998. In that article, Wakefield and his colleagues reported that 8 of 12 children with a disease of the digestive tract who had received the MMR vaccination subsequently developed autism.56 However, not only have no scientific studies been able to replicate Wakefield’s findings or confirm his assertion57,58, but an investigative report by journalist Brian Deer59 raises suspicions that the Wakefield study was fraudulently conducted altogether.
This led the licensing board (the Medical Council)60 in the United Kingdom to refer the matter to the Fitness to Practice Committee (FPC). The FPC found Wakefield guilty of a number of acts of professional misconduct including unethical conduct, breach of scholarship ethics, performing diagnostic procedures he was not trained to perform, not divulging conflicts of interest and abusing his power as a physician.60 At the same time, the Lancet retracted the Wakefield study from the journal.61
Concerns shifted away from the vaccines themselves and instead focused on the ethyl mercury preservative thimerosol.62 However, studies have equally failed to demonstrate any causal relationship between thimerosol and the development of autism.63,64 Despite these studies, some chiropractors continue to believe that Wakefield was the victim of a ‘witch-hunt’ and that the entire thing is a cover up by “Big Pharm”.46–48,53
The anti-vaccine opinions espoused by a small but vocal segment of the chiropractic profession has not gone unnoticed by allopathic medicine. The Canadian Paediatric Society (CPS)65 published a position statement on chiropractic in general and on the subject of chiropractic and vaccination in particular. The statement, published in 2002 and reaffirmed in 2012, referenced a survey of American chiropractors that reported one-third of respondents believed there was no scientific proof that immunization prevents disease, that immunization has not substantially changed the incidence of any major disease and that immunization causes more disease than it prevents. The CPS statement concluded:
Chiropractic treatment for children and adolescents is not uncommon. Open and honest discussions with families using or planning to use chiropractic for their children will, hopefully, bring about a rational use of this treatment in selected musculoskeletal conditions for which there is proof of efficacy, and enable parents to make informed choices about this form of therapy.65
The year 2004 was something of a watershed moment for chiropractic in Ontario, and it represented a perfect storm of challenges to the profession. In that year, the provincial government of Ontario announced that chiropractic services would be delisted from the Ontario Health Insurance Plan (OHIP), the socialized healthcare payment plan that paid for most medical services in that province.66 This followed a failed university affiliation between York University and CMCC67, as well as a decision from the Lewis Inquest that concluded the death of a patient under chiropractic care was ‘accidental’68, a decision that baffled many chiropractors based on the testimony of content experts provided at the time69. Lastly, as previously mentioned, the CPS issued its’ position statement on chiropractic65 around that time and a few years earlier the Busse et al study31 was published.
It was within this political backdrop that the licensing body of chiropractors in Ontario, the College of Chiropractors of Ontario (CCO) enacted Standard of Practice S-015: Vaccination/Immunization that essentially made it an act of professional misconduct to discuss vaccinations/immunizations with chiropractic patients. It was thought by some members of the CCO at the time (c2004) that this action would avert impending deregulation of chiropractic in Ontario. (This was no idle concern. Self-regulation is a privilege and not a right and in Ontario a Minster of Health can intervene and remove a regulatory body’s privilege of self-regulation if s/he believes it is not acting within its mandate to protect the public interest, something that recently happened to the College of Denturists).
SP-015 spawned considerable backlash from many rank and file chiropractors. Even more moderate chiropractors found the ‘gag order’ distasteful; given their education including courses on microbiology, immunology and public health and, as primary contact portal of entry healthcare providers, it was thought that a chiropractor ought to be able to render his or her own informed opinion on the issue of vaccination.
Council members of CCO change every year, and are subject to elections held throughout various districts in the province, in accordance to CCO by-laws and the Regulated Health Professions Act (RHPA)70, the omnibus regulations that governs all regulated healthcare professionals in Ontario. With a new Council constituency, the passage of time, a turnover of provincial governments (including the appointment of Ministers of Health who were seemingly much more favorably inclined towards chiropractic since 2004), and an overall change in the political milieu in the province, the CCO approved a new Standard of Practice, S-001: Scope of Practice in February 201171. This new Standard subsumed Standards of Practice S-010 (techniques, technologies, devices and procedures) and S-015, both of which were rescinded. Among other changes, the new Scope of Practice Standard permits chiropractors to discuss vaccination/immunization with their patients. Essentially, the Standard calls for a three-step process: (i) the patient must be informed that immunizations and vaccinations are outside the scope of chiropractic practice; (ii) if providing an opinion, the response provided must be ‘accurate, professional and balanced’ and; (iii) the chiropractor must then advise the patient to consult a healthcare practitioner who has vaccination/immunization within their scope of practice.
The interface between vaccination and chiropractic history, ideology, attitudes among chiropractic students, attitudes among practitioners, politics and jurisprudence has been a complex and mercurial boundary. Internecine fighting has not gone unnoticed by external stakeholders and observers.33 If the issue were one that was only of primary interest to chiropractors themselves (such as the ‘subluxation’ question) it is doubtful that outside observers would take notice. But because a significant portion of the chiropractic profession has aligned itself against one of the most successful health care initiatives of the past 100 years, the issue of chiropractic and vaccination will continue to be a source of contention, scrutiny and perhaps even animosity between chiropractic and medicine.
Perhaps recent commentaries by Lawrence11, Page see 22, and a series of ‘Best Practice’ documents by Hawk et al72–74 provide a conceptual platform that will allow the profession to move forward on this issue. Rather than focus on the issue of an individual’s rights of autonomy to opt out of immunization programs, thus framing the issue as an ethical privilege, the profession should harken to its core emphasis of health promotion and disease prevention achieved by healthful lifestyle choices. While certainly not risk-free, there does exist an over-abundance of evidence proving that vaccines are both safe and effective. By recommending their use as clinically indicated the chiropractic profession would promote the public good and, by doing so, would be in a better position to be embraced by the broader healthcare community while not abandoning its traditional tenets.