MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

commercial interests

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The ‘College of Medicine and Integrated Health’ (CMIH) has been the subject of several previous blog posts (see for instance here, here and here). Recently, they have come up with something new that, in my view, deserves a further comment.

The new ‘SELF CARE TOOL KIT’ began, according to the CMIH, in 2009 with a national multi-centre project commissioned by the UK Department of Health, to consider the best way to integrate self care into family practice. The project involved two large family health centres and two university departments. One output was the Self Care Library (SCL).

The Self Care Library (SCL) is an online patient resource providing free evidence-based information about self-care.  The funding for the SCL did, however, not survive, and the facility was assigned to the CMIH. Thanks to funding from ‘Pukka Herbs Vitamins, Herbal Remedies & Health Supplements‘, the CMIH was able to transfer the content and to begin updating entries. Simon Mills, the coordinator of the original project who is now employed by Pukka, has led this transformation and helped the College set up the new parent portal, Our Health Directory.

The Self Care Toolkit is thus the new SCL. All concerned with this project are experienced in clinical practice and can separate the theory from real life needs. We all have academic lives as well so can be hard-nosed with the evidence base as well.

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The above text is essentially based on the information provided by the CMIH. A few critical remarks and clarifications might therefore be in order:

  • What does ‘separate the theory from real life needs’ mean? Does it mean that the scientific evidence can be interpreted liberally (see below)?
  • Is it a good idea to have a commercial sponsor for such a project?
  • Is it wise that the main person in charge is on the payroll of a manufacturer of dietary supplements?
  • Is there any oversight to minimise undue bias and prevent the public from being misled?
  • Is it really true that all people involved have academic lives? Simon Mills (who once was a member of my team) has no longer an academic appointment, as far as I know.

But, you are right, these are perhaps mere trivialities. Let’s see what the ‘Self Care Tool Kit’ actually delivers. I have chosen the entry on DEPRESSION to check its validity. Here it is:

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It isn’t likely that taking extra vitamins will make much difference to low mood or depression. It is true that many people don’t get quite enough B, C and D vitamins in their food. And it’s also true that the brain and nervous system need these vitamins. Because they don’t get stored in the body, our daily diet has to supply them. Research has shown that people with low blood levels of the B vitamin folic acid are more likely to be depressed and less likely to do well on anti-depressant medicines. So, if you are eating a very poor diet, taking extra vitamins just might help. It’s also worth remembering that alcohol, refined sugars, nicotine and caffeine all take these vitamins out of the body. Yet most people who feel depressed probably won’t benefit from taking vitamins alone. To ensure that you get a good balance of these vitamins, try to eat more whole-foods, fruits, vegetables, nuts and seeds.

Some people say that taking high doses of vitamin C (1-2 g and more a day) helps lift their mood. There is a little research to support this and none showing that high doses of vitamin C actually help clinical depression. Vitamin C levels fall after surgery or inflammatory disease. The body needs more vitamin C when coping with stress, pregnancy and breast feeding. Aspirin, tetracycline and contraceptive pills take vitamin C out of the body. Smokers also need extra vitamin C because nicotine removes it. Fresh fruit and vegetables are the best sources of vitamin C.

Doctors are increasingly concerned about low vitamin D, especially in the Asian community. A lack of vitamin D can lead to depression. Oily fish and dairy products are good sources of vitamin D, and sunlight helps the body make vitamin D. Do you get enough sunshine and eat a good diet? It is estimated that worldwide over 1 billion people get too little vitamin D.

Evidence
Taking supplements of vitamins B and D might help some people, whose diet is poor, but more research is needed.

Safety
Very high doses of vitamins and minerals can upset the body and cause side-effects. Get medical advice if you intend to take large doses. To ensure that you get a good balance of these vitamins, try to eat more whole-foods, fruits, vegetables, nuts and seeds.

Cost
If your diet is poor and you don’t get into the sun, ask your doctor about a vitamin D blood test. If it’s normal, there’s no point in taking vitamin D. If it’s low, your GP will prescribe it for you or you can buy a vitamin D supplement.

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In my view, this text begs several questions:

1) Am I right in thinking that phraseology such as the one below will encourage patients suffering from depression to try the supplements mentioned?

  • people with low blood levels of the B vitamin folic acid are more likely to be depressed and less likely to do well on anti-depressant medicines..
  • Some people say that taking high doses of vitamin C (1-2 g and more a day) helps lift their mood…
  • There is a little research to support this and none showing that high doses of vitamin C actually help clinical depression…
  • A lack of vitamin D can lead to depression.
  • Taking supplements of vitamins B and D might help some people…
  • … your GP will prescribe it for you or you can buy a vitamin D supplement.

2) How does that tally with the latest evidence? For instance:

3) The CMIH state: ‘This site gives you information NOT medical advice.’  But, in view of the actual text above, is this true?

4) Depression is a life-threatening condition. Is there a risk that patients trust the CMHI’s (non-) advice and commit suicide because of its ineffectiveness?

5) Do Pukka, the sponsor of all this, happen to supply most of the self care remedies promoted in the ‘Self Care Tool Kit’?

The answer to the last question, I am afraid, is YES!

Leprosy can be a devastating infection. But, since many years, it is treatable. The WHO developed a multidrug therapyTrusted Source in 1995 to cure all types of leprosy. It’s available free of charge worldwide. Additionally, several antibiotics are used to kill the bacteria that causes leprosy, e.g.:

  • dapsone
  • rifampin
  • clofazimine
  • minocycline
  • ofloxacin

Yes, leprosy is treatable … that is, unless you follow the advice issued in this article and treat it with homeopathy:

Homoeopathy remedies are given on the basis of similar signs and symptoms along with the miasmatic classification of diseases. Homoeopathy physicians said that leprosy is characteristics of syphilis miasm due to their mental and physical conditions. Mentally person thinks that he/she may be isolated and left alone in a corner of society due to dirty looking of the skin and tendency to spread of disease from direct contact. They feel alone and make hypothesis that the society needs outbreak from me because of physical disabilities like paralysis, and loss of controls on body functions. A well selected homoeopathy remedy helps out patient to come out from this condition and make possible to live in society from permanent restoration of health.

  • SULPHUR – ‘It is mainly known as king of anti-psoric’ in wide range of homoeopathy. Hahnemann says that sulphur has reputation as a remedy against itch perhaps as old medicine i.e., as early as 2000 years ago. Skin of sulphur indicates vesicular skin eruptions and skin may treated by medicated soaps and washes. Clinical trials says that sulphur have similar signs and symptoms as indicated by disease.
  • GRAPHITES – It is a great remedy for all sorts of skin eruptions with a tendency towards malignancy. It also indicates various symptoms of leprosy and may be used in treatment.
  • PETROLEUM – The skin of petroleum has cracks and fissures all over the body and indicates various similar symptoms as of disease condition.
  • RHUS TOXICODENDRON – Skin shows erysipelas vesicular eruptions, vesicles are yellow, from left to right with much swelling, inflammation, burning, itching and stinging that are very much similar to leprosy sign and symptoms, so it may be prescribed.
  • CICUTA VIROSA – This homoeopathic medicine used in the conditions when patients are anxious about their future and epileptic attacks with spasmodic movements of the limbs.
  • ALOE SOCOTRINA – This homoeopathy medicine works when the patients are fear of death and angry from themselves for their conditions. This medicine have tendency to acts upon the abdominal and lumbar region of the patient.
  • BLATTA ORIENTALIS – It is used when the patient is anxious about their skin and health. Patient suffers from the chronic inflammations of the chest and other lung infections that are also found in disease.

Leprosy is a non-fatal infectious disease caused by bacteria Myobacterium leprae and spread by direct contact and other mode of transmissions. It may be treated with homoeopathic medicines if well selected medicine related to mental and physical symptoms is taken by patients. Homoeopathy medicines help out patients to rearrange the vital force to fight against infectious bacteria and makes possible that the body itself fight against the disease.

To be sure, I ran a quick Medline search. You guessed the result, I suppose: not a single hint from anything resembling a clinical trial that homeopathy might be an effective therapy of leprosy.

One question, however, does remain open: how do homeopaths who claim such irresponsible nonsense sleep?

(And in case you think that the above post is a rare exception, you have not recently searched the Internet!)

… Many proponents of so-called alternative medicine (SCAM) are keen to point out that, while mainstream medicine may be good at treatment of diseases, particularly acute conditions, SCAM’s forte lies in the prevention of disease. Patients seem to have intuitively accepted this notion; a recent survey suggest that more than 50% of those Americans who use SCAM do so not to treat ailments but to remain healthy, i.e. to prevent disease and illness. If one looks closer at the evidence for or against SCAM’s role in disease prevention, one is stunned by the contrast of firmly held beliefs and the lack of reliable evidence to support them…

… Unfortunately the subject is more complex than normally appreciated within SCAM. Until we have convincing data, it is not possible to state with confidence that a given form of SCAM is effective in preventing a given condition. It follows

  1. that we now should prepare to carry out the much needed (but difficult) research related
    to preventative,
  2. that we should be cautious and abstain from overstating the largely unproven role of SCAM in the prevention of disease and illness.

These lines were written by me and published exactly 20 years ago. As far as I can see, very little has changed since.

  • SCAM providers continue to make big claims about disease prevention.
  • Many consumers continue to believe them.
  • And the evidence continues to be absent or flimsy.

It follows, I fear, that charlatans who advocate their SCAM as a means to prevent disease are dishonestly defrauding the public.

I do hope that someone disagrees with me and shows me the evidence proving me wrong!

The World Federation of Chiropractic, Strategic Plan 2019-2022 has just been published. It is an odd document that holds many surprises. Sadly, none of them are positive.

As the efficacy and safety of chiropractic spinal manipulations, the hallmark treatment that close to 100% of all chiropractic patients receive, are more than a little doubtful, one would expect that such a strategy would focus on the promotion of rigorous clinical research to create more certainty in these two important areas. If you are like me and were hoping for a firm commitment to such activities, you will be harshly disappointed.

Already in the introduction, the WFC sets an entirely different agenda:

We believe that everyone deserves access to chiropractic. We believe in chiropractors being accessible throughout the world. We believe that societies can thrive where chiropractors are available as a part of people’s health care teams.

If you are not put off by such self-serving, nauseous nonsense and read on, you find what the WFC call the ‘FOUR STRATEGIC PILLARS’

  1. SUPPORT
  2. EMPOWERMENT
  3. PROMOTION
  4. ADVANCEMENT

The text supporting the first three pillars consists of insufferable platitudes, and I will therefore not burden you with it. But the title of No4 did raise my hopes of finding something along the lines of an advancement of the evidence-base of chiropractic. Sadly, this turned out to be over-optimistic. Here is the 4th pillar in its full beauty:

Advancing the chiropractic profession together under the banner of evidence-based, people-centered, interprofessional and collaborative care.

Around the world health is delivered according to prevailing societal, cultural and political factors. These social determinants mean that chiropractors must adapt to the environment in which they practice.

As a global federation we must continuously strive to advance awareness of chiropractic under a banner of ethical, evidence-based, people-centered care.

Through consensus-building, shared understanding and respectful dialogue with partners in the health system, chiropractic should become a valued partner in contributing enhanced population health.

Throughout our 7 world regions, we must advance public utilization of chiropractors to optimize the health of nations.

Through the identification of common values and a commitment to patient-centered care, we can advance the identity of chiropractors as spinal health care experts in the health care system.

The WFC will:

– Advance awareness of chiropractic among the general public, within health systems and among health professionals.

– Advance access to chiropractors for all people and broaden the integration of chiropractic services

– Advance interprofessional collaboration and the integration of chiropractic into health systems

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END OF QUOTE

The essence of the WFC strategy for the next 3 years thus seems to be as follows:

  1. Avoid any discussion about the lack of evidence of chiropractic.
  2. Promote chiropractic to the unsuspecting public at all cost.
  3. Make sure chiropractors’ cash flow is healthy.

There are some commentators on this blog who regularly try to make us believe that chiropractic is about to reform, leave obsolete concepts behind, and become a respectable, ethical and evidence-based healthcare profession. After reading the appalling drivel the WFC call their ‘strategic plan’, I am not optimistic that they are correct.

As reported on this blog, the Spanish minister of health want to change the EU law that governs homeopathy. Now the INH has taken action in support of this idea:

THE COMMENT

… the Spanish government … no longer wants to accept the medicinal status of homeopathy, wants to ban homeopathy from pharmacies and has already “discontinued” the first batch of homoeopathics which could not present a valid proof of efficacy upon request. England is currently performing a complete “blacklisting”, i.e. a process that means the end of any registration for homeopathic medication with a drug authority.

The EU Medicines Directive does not regulate in detail how exactly the member states deal with homeopathy in health care. However, it does fix two key points: It includes homeopathy in its definition of a medical drug and obliges the states to regulate a simplified registration procedure for homeopathy instead of the usual drug approval. If one seriously wants to dispute the status of homeopathic medicinal products (and thus their privileges), one cannot completely ignore EU law.

Spain knows that. At various levels (including that of the government), there are efforts to achieve a revision of the EU directive on medicinal products in the field of homeopathy. These efforts need support. The INH has therefore addressed the following letter to German MEPs, which is initially intended to provide basic information on the facts of the case and support Spain’s position in the expected discussion. This seems all the more necessary as the European homeopathic manufacturers and associations have for a long time maintained a lobby organisation directly in Brussels, which apparently has quite good material and personnel resources and whose task is to exert direct influence “on the spot”. We do not have such resources, but we do have the facts. And who knows – perhaps one or the other national government will even join Spain and become active in the EU?

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THE LETTER TO ALL GERMAN MEPs

7 August 2019

Homeopathy in the EU Medicines Directive

Dear Madam / Sir,

The European Medicines Directive (Directive 2001/83/EC of the European Parliament and of the Council of 6 November 2001 on the Community code relating to medicinal products for human use,  Official Journal of the European Community L 311, 28.11.2001) classifies homeopathic preparations as medicinal products and requires national governments to establish a simplified registration procedure outside the otherwise prescribed rules for marketing authorisation for pharmaceutical remedies.

However, the consensus of the worldwide scientific community has long since classified homeopathy as a specifically ineffective sham therapy, the spread and “popularity” of which have completely different bases than those of medical relevance (evidence). In many countries, this insight is now gaining acceptance. It will be in the well-understood interest of the public’s health to take consequences of this. The misguiding of the public that homeopathy is a form of therapy expressly recognised by the legislator and therefore endowed with the credit of efficacy and harmlessness may not be continued.

In this respect, the Kingdom of Spain is already campaigning for an amendment to European pharmaceutical law, which not only grants homeopathic preparations the status of medicinal products by definition, but also grants them the additional privilege of registration (see also http://www.europarl.europa.eu/doceo/document/E-8-2018-004948-ASW_EN.html). This special legal framework has no objective justification, as the EASAC – as official advisor to the EU institutions – clearly stated in its statement of 20.09.2017 (https://easac.eu/publications/details/homeopathic-products-and-practices/).

In the interest of a science-based, honest and patient-oriented health policy, also on behalf of the German Consumer Association e.V. and its regional associations, we ask you to support a revision of the Medicines Directive in the sense described, in order to clear the way for appropriate national regulations under Community law.

You can inform yourself about the scientific status of homeopathy on the (multilingual) website of our association: www.network-homeopathy.info .

Yours sincerely

For the  Information Network Homeopathy

Dr. Natalie Grams – Dr. Ing. Norbert Aust – Dr. Christian Lübbers

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IF YOU FEEL LIKE SUPPORTING THIS INITIALIVE, PLEASE WRITE TO YOUR MEP.

We have looked at curcumin several (tumeric) times before (see here, here and here). It seems to have a fascinating spectrum of pharmacological activities. But do they translate into clinical usefulness? To answer this question, we obviously need clinical trials. Unfortunately, not many have become available. Here are two recent studies:

Due to the potential benefits of curcumin in the ischemic heart disease, this study was performed to evaluate whether pretreatment with curcumin may reduce myocardial injury following elective percutaneous coronary intervention (PCI). A randomized clinical trial was performed on 110 patients undergoing elective PCI. The intervention group (n = 55) received a single dose of 480 mg nanomicelle curcumin orally and the standard treatment before PCI, while the control group (n = 55) received only the standard treatment., Serum concentrations of CK-MB and troponin I was measured before, 8 and 24 h after the procedure to assess myocardial damage during PCI. The results showed that the raise of CK-MB in curcumin group was half of the control group (4 vs. 8 cases) but was not significant. There were no significant differences in CK-MB levels at 8 (P = .24) and 24 h (P = .37) after PCI between the curcumin and the control group. No significant difference was also found in troponin I levels at 8 (P = 1.0) and 24 h (P = .35) after PCI between the groups. This study did not support the potential cardioprotective benefit of curcumin against pre-procedural myocardial injury in patients undergoing elective PCI.


Ground and mashed turmeric

Inflammation along with oxidative stress has an important role in the pathophysiology of unstable angina which leads to acute myocardial infarction, arrhythmias and eventually heart failure. Curcumin has anti-inflammatory and anti-oxidant effects and thereby, it may reduce cardiovascular complications. This randomized controlled trial aimed to investigate the effects of curcumin on the prevention of atrial and ventricular arrhythmias and heart failure in patients with unstable angina.

Materials and Methods:

Forty patients with unstable angina who met the trial inclusion and exclusion criteria, participated in this double-blind randomized clinical trial. The patients were randomized into two groups: curcumin (80 mg/day for 5days) and placebo (80 mg/day for 5days). Cardiac function was evaluated by two-dimensional echocardiography devices at baseline (immediately after hospitalization) and 5 days after the onset of the trial. Atrial and ventricular arrhythmias were recorded by Holter monitors in cardiology ward, Ghaem academic hospital, Mashhad, Iran. Progression to heart failure, myocardial infarction, and pulmonary and cardiopulmonary resuscitation events as well as mortality were recorded daily throughout the study.

Results:

There were no significant differences between the two groups in atrial and ventricular arrhythmias (p=0.2), and other echocardiographic parameters (Ejection fraction, E, A, E/A ratio, Em, and pulmonary artery pressure) at baseline and five days after the start of the trial.

Conclusion:

Nanocurcumin administered at the dose of 80 mg/day for five days had no effect in the incidence of cardiovascular complications in patients with unstable angina.

Clinical trials are not a good tool for proving a negative; they rarely can prove that a therapy is totally useless. Therefore, we cannot be sure that the many fascinating pharmacological activities of curcumin do not, after all, translate into some clinical benefit. However, what we can say with a high degree of certainty is this: currently there is no good evidence to show that curcumin is effective in treating any human condition.

Perhaps there is a more general lesson here about herbal medicine. Many plants have exiting pharmacological activities such as anti-biotic or anti-cancer activity which can be shown in-vitro. These are then hyped by entrepreneurs and enthusiasts of so-called alternative medicine (SCAM). Such hype fools many consumers and is thus good for business. But in-vitro activity does not necessarily mean that the therapy is clinically useful. There are many reasons for this, e.g. toxicity, lack of absorption. The essential test is always the clinical trial.

IN-VIVO VERITAS!

It is hardly surprising that Gwyneth Paltrow’s obsession with so-called alternative medicine (SCAM) for the vagina is motivating women to try some of it. The consequences can be dramatic; not only for the wallet but also for the vagina!

Vaginal steaming made global headlines in 2015 after its promotion by celebrity Gwyneth Paltrow. One of many female genital modification practices currently on offer in Anglo-Western nations – practices both heavily promoted and critiqued – vaginal steaming is claimed to offer benefits for fertility and overall reproductive, sexual or even general health and wellbeing. We analysed a selection of online accounts of vaginal steaming to determine the sociocultural assumptions and logics within such discourse, including ideas about women, women’s bodies and women’s engagement with such ‘modificatory’ practices. Ninety items were carefully selected from the main types of website discussing vaginal steaming: news/magazines; health/lifestyle; spa/service providers; and personal blogs. Data were analysed using thematic analysis, within a constructionist framework that saw us focus on the constructions and rationalities that underpin the explicit content of the texts. Within an overarching theme of ‘the self-improving woman’ we identified four themes: (1) the naturally deteriorating, dirty female body; (2) contemporary life as harmful; (3) physical optimisation and the enhancement of health; and (4) vaginal steaming for life optimisation. Online accounts of vaginal steaming appear both to fit within historico-contemporary constructions of women’s bodies as deficient and disgusting, and contemporary neoliberal and healthist discourse around the constantly improving subject.

A recent case-report tells a cautionary tale. Here is its abstract:

BACKGROUND:

Vaginal steaming has gained increased popularity as a method to achieve empowerment by providing vaginal tightening and to “freshen” the vagina.

CASE:

A 62-year-old woman sustained second-degree burns following vaginal steaming in an attempt to reduce vaginal prolapse.

CONCLUSION:

Clinicians need to be aware of alternative treatments available to women so that counselling may mitigate any potential harm.

As the full paper is not available to me, I had to rely on another report for further information.

The woman had been suffering from a prolapsed vagina and had been led to believe the vaginal steaming could help avoid surgery. Spas advertising “v-steaming” claim it has been used throughout history in countries in Asia and Africa. They claim the practice, which is sometimes called Yoni steaming, acts to “detox” the vagina, can ease period pains, help with fertility and much more. Experts, however, warn that it can be dangerous and point out that there is no good evidence for the health claims being made.

Dr Vanessa Mackay, a consultant and spokeswoman for the Royal College of Obstetricians and Gynaecologists, says it is a “myth” that the vagina requires extensive cleaning or treatment. She recommends using plain, unperformed soaps on the external vulva area only. “The vagina contains good bacteria, which are there to protect it,” she said in a statement. “Steaming the vagina could affect this healthy balance of bacteria and pH levels and cause irritation, infection (such as bacterial vaginosis or thrush) and inflammation. It could also burn the delicate skin around the vagina (the vulva).”

Dr Magali Robert, who authored the case-report, said the injured woman attempted to steam her vagina on the advice of a traditional Chinese doctor. The woman, who gave permission for her case to be shared, sat over the boiling water for 20 minutes on two consecutive days before presenting at an emergency department with injuries. She sustained second-degree burns and had to delay reconstructive surgery while she healed.

Dr Robert, who works in pelvic medicine and reconstructive surgery in Calgary, said word of unconventional therapies like steaming can spread through channels like the internet and word-of-mouth. “Health care providers need to be aware of alternative therapies so that they can help women make informed choices and avoid potential harm,” she says in the article.

According to the European Committee of Homeopathy, the Committee on Health and Consumer Affairs of the Spanish Parliament unanimously adopted a bill in 2009 that recognises homeopathy as a medical act. It urged the government to “take the measures necessary for the exercise of homeopathy exclusively by graduates in medicine and surgery.” On 17 December 2009, the Consejo General de Colegios Oficiales de Médicos (Spanish Medical Council) adopted a resolution that recognised the practice of homeopathy as a medical act.

One decade later, the wind seems to have changed. As reported previously (see here and here), there are now several Spanish initiatives to minimise the damage bogus therapies like homeopathy do to public health. A recent article reported that the Spanish health ministry has been campaigning for a change in the EU law that classifies homeopathic products as medicines. The European Commission seems to be open to the idea.

The criticism of homeopathy in Spain was triggered at least in part by reports of people refusing or abandoning regular treatment in favour of homeopathic products to treat serious diseases like cancer. One of them was Rosa Morillo, who died of breast cancer in 2017, after she refused chemotherapy and sought homeopathic treatments instead, according to El País.

“The problem is the damage that can be done by opting for an alternative therapy that has not demonstrated scientific evidence,” Carcedo, the Sanish health minister, said. She raised the issue again in bilateral talks at the most recent EU health ministers’ meeting in Luxembourg in June. “What we can do is keep up the pressure, because the change in the directive must be done at a European level,” she told El País.

The 2001 EU directive on the code for human medicines states that “homeopathic medicinal products” are eligible for a simplified registration procedure if they are administered orally or externally, have no specific therapeutic indication on their packaging; and are sufficiently diluted to guarantee their safety. Homeopathic products with a specific therapeutic indication, meanwhile, have to get a marketing authorization following the same rules as regular medicines, including providing proof of efficacy.

The envisaged change in EU law would be most welcome, in my view. It would:

  • abolish the current double standards,
  • end the misleading messages to consumers,
  • align the law with the current best evidence,
  • abolish the unfair commercial advantage of homeopathy producers,
  • align the law with ethical imperatives,
  • make a positive contribution to public health,
  • increase trust in EU drug regulation.

But we should not be over-optimistic either. The European homeopathy lobby is powerful and is fighting with its back to the wall.

And what can we do to help? Perhaps writing to your MEP in support of the Spanish initiative might be a good idea?

In 2016, members of the World Federation of Chiropractic Disability and Rehabilitation Committee conducted an international, cross-sectional survey of all 193 United Nation member countries and seven dependencies to describe the global chiropractic workforce in terms of:
  • the availability (numbers and where they are practising),
  • quality (education and licensing),
  • accessibility (entry and reimbursement),
  • acceptability (scope of practice and legal rights).

An electronic survey was issued to contact persons of constituent member associations of the World Federation of Chiropractic (WFC). In addition, data were collected from government websites, personal communication and internet searches. Data were analysed using descriptive statistics.

Information was available from 90 countries in which at least one chiropractor was present. The total number of chiropractors worldwide was 103,469. The number of chiropractors per country ranged from 1 to 77,000. Chiropractic education was offered in 48 institutions in 19 countries. Direct access to chiropractic services was available in 81 (90%) countries, and services were partially or fully covered by government and/or private health schemes in 46 (51.1%) countries. The practice of chiropractic was legally recognized in 68 (75.6%) of the 90 countries. It was explicitly illegal in 12 (13.3%) countries. The scope of chiropractic practice was governed by legislation or regulation in 26 (28.9%) countries and the professional title protected by legislation in 39 (43.3%). In 43 (47.8%) countries, chiropractors were permitted to own, operate, or prescribe x-rays, in 22 (24.4%) countries they were lawfully permitted to prescribe advanced imaging (MRI or CT), and in 34 (38.8%) countries owning, operating or prescribing diagnostic ultrasound was permitted. Full or limited rights to the prescription of pharmaceutical medication were permitted in 9 (10%) countries, and authorization of sick leave was permitted in 20 (22.2%) countries. The care of children was subject to specific regulations and/or statutory restrictions in 57 (63.3%) countries.

The authors concluded as follows: We have provided information about the global chiropractic workforce. The profession is represented in 90 countries, but the distribution of chiropractors and chiropractic educational institutions, and governing legislations and regulations largely favour high-income countries. There is a large under-representation in low- and middle-income countries in terms of provision of services, education and legislative and regulatory frameworks, and the available data from these countries are limited.

The countries where chiropractic is explicitly illegal are the following:

  • Egypt
  • Argentina
  • Columbia
  • Austria,
  • Estonia,
  • Greece,
  • Hungary,
  • Lebanon,
  • Republic of Korea,
  • Taiwan,
  • Turkey.
  • Ukraine.

Forty-two countries (61.8%) have regulations and/or rules under the legislation to provide for registration or licensure of chiropractors. Chiropractors may be available in 90 countries, but 50% percent of these have 10 or fewer chiropractors. Importantly, the care of children is under regulation or restrictions in most countries.

In comparison to similar professions such as physiotherapy, the chiropractic total workforce is small (worldwide 103,469). The World Confederation of Physical Therapy reports an estimated number of 450,000 physical therapists worldwide with the number of physio therapists per capita per 100,000 ranging from 0.19 in Malawi to 282 in Finland.
This survey holds plenty of interesting information. Here is what I found most remarkable:
  • The World Federation of Chiropractic takes 3 years to publish data which, by then, are of course out-dated.
  • In most countries, the chiropractic care for children is restricted.
  • In many countries chiropractic is illegal.
  • In many countries, there are only very few or no chiropractors at all.
  • There are about 4 times more physiotherapists than chiropractors.
  • In 9 countries, chiropractors have the right to prescribe medicines.

Much of the data revealed in this survey suggests to me that the world can do without chiropractors.

An article in the Sydney Morning Herald might be interesting to some readers. It informs us that, after more than 25 years of running, the University of Technology Sydney (UTS) intends to stop offering its degree in Traditional Chinese Medicine (TCM). A review of the Chinese Medicine Department found it should be wound up at the end of 2021 because

  • it was no longer financially viable,
  • did not produce enough research,
  • and did not fit with the “strategic direction” of the science faculty.

The UTS’s Chinese medicine clinic, which offers acupuncture and herbal treatments, would also close. Students who don’t finish by the end of 2021 will either move to another health course, or transfer to another university (Chinese medicine is also offered by the University of Western Sydney, RMIT in Melbourne, and several private colleges).

TCM “is a historical tradition that pre-dated the scientific era,” said the president of Friends of Science, Associate Professor Ken Harvey. “There’s nothing wrong with looking at that using modern scientific techniques. The problem is people don’t, they tend to teach it like it’s an established fact. If I was a scientifically-orientated vice chancellor I would worry about having a course in my university that didn’t have much of a research profile in traditional Chinese medicine.”

But a spokesman for the University of Technology Sydney said the debate over the scientific validity of Chinese medicine had nothing to do with the decision, and was “in no way a reflection of an institutional bias against complementary health care”. Personally, I find this statement surprising. Should the scientific validity of a subject not be a prime concern of any university?

In this context, may I suggest that the UTS might also have a critical look at their ‘AUSTRALIAN RESEARCH CENTRE IN COMPLEMENTARY AND INTEGRATIVE MEDICINE‘. They call themselves ‘the first centre worldwide dedicated to public health and health services research on complementary and integrative medicine’. Judging from the centre director’s publications, this means publishing one useless survey after another.

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