CHAPTER OUTLINE Deﬁnitions and Descriptions …samples.jbpub.com/9780763758226/58226_CH01_FINAL.pdf · Public Health, Public Health Agencies, and the APHA Rand Baird, ... Still

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Introduction to Public Health,

Public Health Agencies,and the APHA

Rand Baird, DC, MPH, FICA, FICC, and Mitchell Haas, DC, MA*

DEFINITIONS AND DESCRIPTIONS OF PUBLIC HEALTH

This book is designed to be used as a textbook forteaching public health courses to chiropractic studentsand as a professional reference for doctors of chiroprac-tic during their careers, whether in private practice set-tings, in teaching and educational administration, orrelated employment. For these purposes, a commonlanguage or lexicon, nomenclature, and terminology tofacilitate communication with all the various disciplinesinvolved in public health is essential. And a commondefinition of “public health” might be ideal.

Public health, however, is a broad and diverse multi-dimensional field that includes many health-related

CHAPTER OUTLINE

Definitions and Descriptions of Public Health

Chiropractic and Public HealthPrimary, Secondary, and Tertiary

Levels of Care and PreventionThe Three Levels of CareThe Three Levels of Prevention

Agencies:How Public Health ServicesAre Organized and Delivered

Quasi-governmental GovernmentalNongovernmentalChiropractic Within Public Health

The Special Case of the AmericanPublic Health Association

StructureGoverning CouncilExecutive BoardSectionsState AffiliatesIntersectional Council and

Committee on Affiliates

Boards and CommitteesAPHA StaffHistory of Chiropractic in

the APHA

Chiropractors in the APHA and Public Health

disciplines. One universally accepted standard definitionof public health does not exist. Instead there are many ac-ceptable definitions of public health available from variousauthoritative sources. And all of the definitions of publichealth have a precursor in the definition of “health,”which according to the World Health Organization (WHO)is: “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”1

Some years ago, the American Public Health Association(APHA) emphasized the following definition of publichealth: the application of medical, social and allied disci-plines in an organized community activity designed prima-rily to protect and advance the health of the people (italicsadded. The word application is used because public health ispractical, not just theoretical; community is used because

*Contributor to The Special Case of the American Public Health Association on pages 13–17.

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© Jones and Bartlett Publishers, LLC. NOT FOR SALE OR DISTRIBUTION

will ensure to every individual in the community a stan-dard of living adequate for the maintenance of health.5

Mary-Jane Schneider, PhD, in her 2000 book Introductionto Public Health claims that public health is “. . . an abstractconcept, hard to pin down . . .”6 and states further that,“Public Health is not easy to define.”7 Likewise, BernardTurnock, MD, MPH, former director of both the Illinois andChicago Departments of Public Health, in his 1997 bookPublic Health: What It Is and How It Works, says, “What hasbecome clear to me is that the story of public health is notsimple to tell.”8 These comments by noted authorities whowork and teach in the public health field are an understate-ment, and if they cannot define public health, who can? Ifthe definition is, “It is what it is,” in the vernacular, “what itis,” equates to “what it’s all about.” And public health isabout many, many diverse things. Besides everything elseunder this broad umbrella called public health, the publichealth field, the public health profession, and a public healtheducation course are “all about” the following:

• Politics and political questions; public health isboth political per se and in its context.

• Primary care, and all the multidisciplinarypractitioners who provide it.

• The environment, and the lifestyle choices/components of health.

• Hygiene and sanitation.• Government’s roles in protecting the health of

the people (e.g., the U.S. Surgeon General andhis or her recommendations).

• The contagious, communicable diseases, thereportables, the sexually transmitted diseases(STDs), acquired immune deficiency syndrome(AIDS), and safe sex.

• Wellness, and healthy people in healthycommunities.

• Prevention, and prevention, and prevention.

This list illustrates one more reason there are somany acceptable definitions for the term public health. Anoperational definition of public health is what publichealth does. This definition has the added advantage ofbeing able to change as public health needs change overtime and place, but also has both the strength and theweakness of being rather all-encompassing.

Whether concerned with learning or teaching publichealth, unlike certain other medical sciences such asanatomy, which are relatively static, it becomes obviousthat public health, like personal health status, is dy-namic and ever changing, almost like a study of inter-national and global current events as well as domesticones.

the unit of concern and the intervention target is thegroup or larger community as a whole rather than justthe individual patient; and protect is included becausethe focus is on prevention rather than treatment or cur-ative care. More recently, APHA publications seem toprefer the 1988 Institute of Medicine definition for pub-lic health: “Public health is what we, as a society, do col-lectively to assure the conditions in which people can behealthy.”2 The APHA website in 2008 stated: “Publichealth is a series of individuals, communities, activitiesand programs working to promote health, to preventdisease, injury and premature death and to ensure con-ditions in which we all can be safe and healthy.”3

Some experts have pointed out that public health is a fu-sion or amalgam of two other disciplines, clinical medicineand epidemiology. There are many other good defini-tions of public health; each has a somewhat different em-phasis, perhaps depending on the background of thedefiner because public health is so multidisciplinary andincludes so many experts from so many diverse areas ofexpertise. Some emphasize the target for interventionand define public health as community medicine or com-munity health; others emphasize the methodologies andsimply define public health as “preventive medicine.”Some emphasize the social justice aspect of publichealth: “what we do as a society to provide an environ-ment for health and to protect those that cannot protectthemselves.”4 Many experts define public health as anyand all aspects of government’s involvement in health,whereas others stress the importance of collaboration, ofpartnerships formed between government and the pri-vate sector. Public health is primary care integrated withcommunity actions. Many public health terms, includingthe term public health itself, are better explained by lists ofwhat is included under the definition rather than by apure dictionary definition alone, and the categories thathelp characterize a term are not always completely mu-tually exclusive. Public health is like a diamond withmany facets, and no one facet defines the entirety. Amore recent modern trend is to emphasize the healthpromotion and wellness aspect of public health, withwellness being the buzzword of the day.

Still in wide use today, C. E. A. Winslow’s classic defini-tion of public health from the 1920s is:

the science and the art of preventing disease, prolonginglife, and promoting physical health and efficiencythrough organized community efforts for the sanitationof the environment, the control of community infections,the education of the individual in principles of personalhygiene, the organization of medical and nursing servicesfor the early diagnosis and preventive treatment of dis-ease, and the development of the social machinery which

2 | INTRODUCTION TO PUBLIC HEALTH FOR CHIROPRACTORS



There are valid general indicators or indices of thehealth status of a community. Defined in this book’sGlossary, incidence, prevalence, morbidity, mortality, andlife expectancy are the most commonly used indices fordetermining the health status of a community as awhole, and for comparisons among communities oreven entire nations. Statistical rates (various proportionsexpressed per a base, most commonly a base of 1000people) are calculated, and discussions should includeboth gross rates and the specific rates that are the piecesof the pie described by the overall gross rates. The failureto include both gross rates and the specific rates that intoto compose the gross rates, and a lack of homogeneityamong communities or nations being compared, oftenleads to flawed conclusions, but nonetheless the ratesand indices are useful descriptive tools.

The so-called triad or triangle, which in normal bal-ance is called health and when out of balance is calleddisease, consists of agent-host-environment. To oversim-plify, allopathic medicine concentrates on the agent fac-tors, chiropractic care concentrates on host factors, andpublic health concentrates on environmental factors.Although the general public often associates health withprovision of medical care, public health professionals areequally concerned with the other-than-medical-care de-terminants of health (overall living conditions, nutrition,degree of environmental sanitation, educational levels,war and peace, lifestyle choices, socioeconomic status,racial and ethnic categories, gender, and other dispari-ties and inequities). Health is typically discussed as anentity, but in reality health is less of an entity and moreof a status, an ever-changing, moving target, not staticbut dynamically changing on a continuum or slidingscale from before birth to death. The level of health careintervention is geared to the level of health need, rangingfrom prenatal care to postmortem care. Public health de-cision makers must be cognizant of this continuum andits ranges when formulating health policy.

The scope of public health goes through an ongoing evo-lution over time and is still changing. Among other things, itincludes the traditional contagious communicable diseases;health problems, projects, or programs that affect largepopulation groups having some characteristic in common toform a community of patients; programs funded by gov-ernment or tax dollars or public funds; noncommunicablehealth threats having high frequency with resultant high so-cietal costs of morbidity and mortality; the catch-all cate-gory of any health need that is being unmet or not evenaddressed by the private sector, such as medically under-served populations or geographic areas, so that govern-ment must step in, almost by default; and any disease orsituation that is defined as preventable, or any disease

or health situation that by its very nature is preventable orhaving high potential for preventability, and any and all effortsthat focus on prevention rather than treatment. Publichealth is both theoretical and practical, based on strong sci-ence and balanced by pragmatic realities.

Hygiene is a term currently more commonly used torefer to personal cleanliness; however, it formerly wasused to describe the science of preserving and promotinghealth in general. The term was often joined or used inconjunction with public health (e.g., public health and hy-giene classes). The term hygiene can also mean anythingthat a person or patient does to alleviate their own healthissue or prevent its recurrence. In clinical practice, includ-ing chiropractic clinical practice, there is a long tradition ofrecommending individual patient hygiene and simplycalling it “patient dos and don’ts.” A variation of hygiene,social hygiene, is used to describe the hygiene and preven-tion of disease for groups rather than individual patients.

On a broader level, the term sanitation is used to describecontrol of the environmental risks to health. Although origi-nally used to refer to garbage, filth, or unclean or dirty con-ditions (i.e., unsanitary), sanitation risks now also includemicrobial hazards, pathogens, toxins, and over time havecome to include physical hazards as health threats in thephysical environment. Sanitization refers to the process of ef-forts to perform sanitation on inanimate objects and sur-faces. The phrase environmental hygiene and sanitation isstill in common use in public health.

Within public health, whether discussing the field ofpublic health, the practice of public health, or formal ed-ucation programs in public health, it is customary torefer to the various branches, tracks, or areas it encom-passes. There are various ways to group or classify thesebranches. One common list of the branches is:

• Epidemiology• Biometry and biostatistics• Environmental health sciences• Health care services• Health resources management• Occupational or industrial medicine• Population sciences and international health

Other equally good classifications combine healthcare services with health resources management, orcombine epidemiology and biometry, or separate popu-lation sciences from international health. But all areways to group various areas of specialized expertise andknowledge into logical components and a structuredconceptual framework.

It is said that public health has a philosophy and a goal(or goals). Its philosophy is to prevent disease by treatingthe community to provide an environment for health, to

Chapter 1 | Introduction to Public Health, Public Health Agencies, and the APHA | 3



simply to identify the risk factors and the high risk pop-ulation groups, and then somehow devise barriers orways to keep them apart.

Public health originally had four so-called classicalfunctions: (1) control of communicable diseases, (2)provision of health care services including clinics andlabs, (3) environmental sanitation, and (4) health educa-tion and research. These four have now been condensedand summarized into the three modern core functions of public health: (1) assessment, (2) policy development, and (3) assurance.

In 1990, the Public Health Practice Program Office ofthe Centers for Disease Control and Prevention pub-lished a list of what it termed “The 10 Essential PublicHealth Services,” which are listed in Table 1-1.

As a body of knowledge, public health includes some im-portant concepts and many important facts. This book’sGlossary lists some key terms and their definitions. Tomake further reading more comprehensible, the reader isadvised to become familiar now with at least the follow-ing terms: high risk group(s), and both generic andhealth hazard–specific subgroups; rates; incidence andprevalence; morbidity and mortality; primary, secondary,and tertiary care; sanitation and sanitization; environ-ment and ecology; hygiene and social hygiene; prophy-laxis; gatekeeper; triage; and health promotion.

Chiropractic and Public Health

There is a unique aspect to chiropractic students andchiropractic doctors learning about public health. Every

care for the community at large as a whole, to empha-size lifestyle and environmental factors in health, and totake a multidisciplinary team approach to care. And itsgoal is simply to prevent—to prevent by having the great-est possible positive impact on morbidity and mortalitywithin a community, to prevent by doing the most goodfor the most people while spending the least amount ofmoney, to prevent by providing some basic health care forall people as opposed to a higher level of health care forthe select few, to prevent by protecting the health andproviding the social justice of care for those who can nei-ther protect themselves or obtain their own, to prevent byproviding an environment in which health can occur,and simply to prevent whatever can be prevented.

Public health also has a vision (Healthy People inHealthy Communities) and a mission (To promote healthand prevent disease). As mentioned earlier, a unique fea-ture of the public health philosophical approach is that it at-tempts to prevent disease by treating the community toprovide an environment for health. To a public healthpractitioner, the community is the patient. The unit ofstudy and of concern is not the individual, but ratherlarger population groups. And the community is increasinglyinternational (i.e., the global community concept).

The public health methodology has several characteristics:

• Recognition of group responsibility• Reliance on teamwork, interdependence, and

multidisciplinary referrals• Acknowledgment of prevention itself as a major

program objective• Recognition of disease as a multifactorial

problem requiring multidisciplinary solutions• Declaration that health care leading to maximally

attainable health is a right of every citizen ofevery country and of every person on the planet

• Utilization of epidemiology to determine a hostof factors and their interrelationships

• Dependence on biostatistical methods• Education of the public• Adaptation of programs to local community culture• Recognition of the agent-host-environment triad,

but with emphasis on environment

The public health approach, reiterated by former U.S.Surgeon General David Satcher, MD, PhD, from an earlierCenters for Disease Control and Prevention (CDC) re-port, involves “. . . defining and measuring the problem,determining the cause or the risk factors for the prob-lem, determining how to prevent or ameliorate theproblem, implementing effective intervention strategieson a large scale, and subsequently evaluating the impact.”9

An oversimplification of the public health approach is


Table 1-1 The 10 Essential Public Health Services

1. Monitor health status to identify community healthproblems.

2. Diagnose and investigate health problems and healthhazards in the community.

3. Inform, educate, and empower people about health issues.4. Mobilize community partnerships to identify and solve

health problems.5. Develop policies and plans that support individual and

community health efforts.6. Enforce laws and regulations that protect health and

ensure safety.7. Link people with needed personal health services and ensure

the provision of health care when otherwise unavailable.8. Ensure a competent public health and personal health

care workforce.9. Evaluate effectiveness, accessibility, and quality of personal

and population-based health services.10. Research for new insights and innovative solutions to

health problems.



other course in their chiropractic curriculum or postgradseminars has the goal of preparing them for the one-on-one encounter with each of their respective patients.Only their public health courses or extra training have adifferent and unique focus: preparing them for theirbroader role as primary health care providers within thehealth care delivery system. Although in one sense theyare “limited” primary care providers, nonetheless allcaregivers have limitations, including those with less re-stricted licensed scopes of practice.

Likewise, the challenge of teaching public health to chi-ropractors or chiropractic college students is to take ma-terial that is not necessarily intrinsically interesting, andperhaps not even of obvious current or future profes-sional relevance, and to present it in such a way thatlearning occurs, learning objectives are met, learning isenhanced, and the student becomes motivated and ex-cited about future participation and the integration of chi-ropractic into mainstream public health activities. Apublic health class in a chiropractic college is like that inany other institution of higher learning, and the nature ofthe material is such that many of the topics presented arecontemporary international current events. Recognizingthe importance and the need for high quality standardeducation in public health concepts for chiropractic stu-dents, Michael Perillo, DC, MPH, and his project partici-pants and collaborators obtained a Health Resources andServices Administration (HRSA) grant for 2000–2002 toresearch this topic, and constructed A Model Course forPublic Health Education in Chiropractic Colleges.10 TheChiropractic Health Care section of the American PublicHealth Association assembled a task force that providedsome suggestions for the content and syllabus for theproposed model course. Several trends in the chiropracticprofession in the various areas of public health werenoted in this model, including the following:

• Chiropractors already utilize some public healthskills in practice, particularly in the area ofclinical preventive services.

• There is room for improvement. Enhancedpublic health training should represent animportant tool for the chiropractic healthprofessional to meet 21st-century challenges.

• There is an indication of a small population impact,primarily as complementary to conventionalmedical care. Impact may be a function of practicefunctions as well as geographic location. Furtherassessment of this impact is warranted.

• There appears to be a need and desire for moretraining in the public health area on the part ofstudents and field chiropractors.

• To help achieve inclusion as a practice characteri-stic, public health knowledge and skills inchiropractic education should emphasize clinicallearning over classroom learning, and beincluded in various examinations, including theNational Board Exam.

• Public health training may have direct implica-tions for the profession’s wellness model.10

Doctors, including doctors of chiropractic, have cer-tain legal, ethical, and moral responsibilities to publichealth. These include registering themselves and theirpractice locations with their local health department(often not done as commonly now as in the past); re-porting communicable diseases encountered, whethersuspected, known, or diagnosed, even if not treated; ed-ucating their patients in hygiene and sanitation as it re-lates to their condition; observing good personal andenvironmental hygiene and sanitation in the practicesetting; and counseling or teaching patients how to pre-vent or ameliorate health problems.

PRIMARY, SECONDARY, AND TERTIARYLEVELS OF CARE AND PREVENTION

The Three Levels of Care

Public health is concerned with primary care, secondarycare, and tertiary care, and in particular with primary pre-vention, secondary prevention, and tertiary prevention,whether for acute or chronic conditions. See the Glossaryfor more comprehensive definitions for the relative termsprimary care, secondary care, and tertiary care. In 1976the National Academy of Sciences reviewed 38 differentbut acceptable definitions or variations on the theme of pri-mary care. For the sake of introduction, these variations,and those for secondary and tertiary care, can be para-phrased to the following working definitions:

• Primary care is office setting–based; is concernedwith outpatients who are ambulatory (or in theircustomary state of ambulation); emphasizespreventions, health promotion, and healthmaintenance; has a pattern of care that is moregeneral than specialized; is rendered by aphysician or provider of first diagnostic ortherapeutic encounter or first contact who isconsidered a portal of entry and referral; dealswith more minor health issues or more serioushealth problems in their earlier stages; andincludes basic public health screenings and adegree of comprehensiveness of services eitherdirectly or by referral.




Both proponents and opponents of considering chiro-practors as deliverers of primary care might arguablyagree that it is not necessary to meet all aspects and com-ponents in order to qualify under a definition; rather, mostcriteria should be met in full or in part to achieve substan-tial compliance and achieve the objectives of defining acategory. An obvious but salient point is that no provider ofprimary care can be all things to all ill, injured, and needypeople. Only a degree of comprehensiveness in caregivingis required by most definitions for primary care, with re-ferral to a specialist when indicated being one of the keyparts of the primary care definition. Chiropractors alreadyfunction as gatekeepers and triage points for sorting andacting as portals of referral into the health care system.There is even an old chiropractic adage: “Chiropractic first,medicine second, surgery last,” which somewhat parallelsprimary, secondary, and tertiary care, at least in its consid-eration of three levels based on severity of illness and intensity of services. There are both traditional andnontraditional primary care providers; in fact, if somegroups of nontraditional primary care providers, particu-larly chiropractors, were offered additional training andformal recognition with defined roles within primary care,then some of the shortage of primary care providers wouldlikely be alleviated.

Chiropractic care is a form of conservative, noninvasive,nondrug, nonsurgical primary care. Chiropractors are pri-mary care providers who use adjustment or manipulationof the spine and other articulations as their preferredtreatment of choice, and utilize other forms of manualtherapies or so-called “body work” for diagnosis, analysis,treatment, and prevention. Without arguing semantics,specific adjustments to reduce or correct subluxations,general and specific manipulation to improve joint func-tion or relieve nerve pressure, and the other natural andholistic interventions performed by chiropractors havegained widespread public support and ever-increasing sci-entific community and medical world acceptance as well.

Of course the terms primary care, secondary care, andtertiary care are relative one to another, and not com-pletely mutually exclusive; rather, they are comparativeand without sharp demarcations between them, eachblending and overlapping into the others. In a morenearly perfect world there would be less need for sec-ondary or tertiary care because primary care would be somuch more effective.

For several years one of the biggest compound prob-lems in health care delivery in the United States wasphysician overspecialization, a shortage of primary careproviders, and a geographic maldistribution of providers.Chiropractic doctors had always been a source of primary

• Secondary care is hospital setting–based; isconcerned with inpatients who have been ren-dered at least partially nonambulatory by theirhealth problem(s) and are hospital bed-ridden forat least a portion of the day; includes so-calledroutine surgeries; and is more specialized,intensive, and costly than primary care.

• Tertiary care is also hospital setting–based, but isrendered in specially designated areas of generalhospitals or at specialty hospitals or majormedical centers; uses more advancedtechniques, technology, equipment, personnel,staff, and other resources; includes morecomplicated surgical operations; and isqualitatively and quantitatively more specialized,intensive, and expensive than either primary orsecondary care.

Note, however, that an equally good paradigm ofdefining these levels of care reserves the term tertiarycare for care rendered in tertiary care facilities such asnursing homes and skilled nursing facilities. Its empha-sis is on rehabilitation and restoration, or simply ongoingcare, even if in the ambulatory setting, that is continuedafter a patient is discharged from a hospital or other facility(i.e., tertiary care equals postdischarge care).

Although the focus of this chapter is public health in theUnited States, mention should be made that other coun-tries have different nomenclature for the divisions oftheir health care. Using just one example, in Englandmost physicians are either exclusively office-based orexclusively hospital-based, so that becomes the duality ofits primary and secondary care.

Chiropractic care is clearly a type of primary care ormay even be called limited primary care. In a society thathas come to recognize great value in pluralistic and multi-disciplinary team approaches, chiropractic adds anotherdimension of freedom of choice, alternative and comple-mentary methods, and wide applicability. It is likely thespecific treatment of choice for many ailments and pro-vides a measure of general palliative relief to many otherswhere it is not the preferred treatment of choice. Chiropracticis most known and recognized for treatment of nonsur-gical spinal disorders and neuro-musculo-skeletal condi-tions, but there is also considerable anecdotal evidence forits usefulness in many visceral or somatic conditions.

Depending on which of the many definitions and howstringent the criteria, chiropractic care would appear tosatisfy most of the components of the primary care defini-tion, or at least be in substantial compliance with it—stronger on some elements while weaker on others.




care for certain populations, making them a natural com-ponent of a solution to this compound problem. In somegeographic areas and in some medically underservedareas, chiropractors historically have been the only pri-mary care providers serving a given community. Themultidecade shortage of primary care doctors in theUnited States continues to the current day.11 This short-age is detrimental and may cause harm to the health of anation. It is postulated that chiropractic doctors can serveas primary care doctors or even be designated as limitedprimary care doctors. Certainly it is reasonable that thestrengths of any given profession can help alleviate theweaknesses in another area of the overall health care de-livery system. It is a very fair contention then when oneprofession provides a logical and rational, reasonable an-swer or partial answer to questions, issues, and problemsraised by another profession, by government, or by soci-ety, it behooves all to collaborate on joint solutions. And al-though chiropractors are trained as limited primary careproviders, much of their training also easily translatesinto those settings where secondary and tertiary care is rendered. In its WFC Consultation on the Identity of the Chiropractic Profession, the World Federation ofChiropractic (WFC) called for a profession-wide em-bracing of a patient-centered and biopsychosocial approach, emphasizing the mind/body relationship inhealth, the self-healing powers of the individual, and indi-vidual responsibility for health, and encouraging patient

independence.12 Certainly this identity is highly compati-ble with rendering primary care.

It is clear that the chiropractic profession, chiropracticorganizations and institutions, and individual or groupsof chiropractic doctors have important roles to fulfill in so-cial and community health. The relationship of chiro-practic and chiropractors to public and communityhealth should be no different than that of other healthcare providers in the community. Chiropractic studentsand doctors of chiropractic (DCs) need an understand-ing of public health in order to enhance their communi-cation and credibility with the mainstream public healthsystem so as to maximize their participation for thecommon good of all.

A few selected examples of health care system prob-lems to which chiropractors offer partial solutions areprovided in Table 1-2.

The Three Levels of Prevention

The best way to define the three levels of prevention inpublic health is to describe what is prevented in each.Primary prevention is the prevention of the occurrence orthe incidence of illness or injury, prevented by risk re-duction in susceptible populations; this is literally pre-vention of the initial onset of injury or illness. If primaryprevention were perfect, society would need no otherlevels of intervention. But this is an imperfect world,


Table 1-2 Examples of Health Care System Problems to Which Chiropractors Offer Partial Solutions

Problem Solution

Shortage of primary care providers Designate doctors of chiropractic (DCs) as primary care providers, who after obtainingadditional training can work in areas with plenary physician networks for backup.

Geographic maldistribution of DCs are more likely to respond to incentives to relocate to underserved areas.primary care providers

High-tech but also often impersonal Chiropractic care and manual therapies are more personal, more hands-on, allopathic care less mechanized.

Medical care that has become Chiropractic adds another dimension, and works well in partnership with other healingpaternalistic and monopolistic, arts such as acupuncture and other Eastern traditionsrepresenting only one school of having similar philosophies or approaches.thought (i.e., “Western medicine”)

Overreliance on and overutilization Nondrug, nonsurgical approach to health care.of drugs and surgical procedures

Nonspecialist MDs are reported as The training of DCs is geared toward neuro-musculo-skeletal and spinal conditionsundertrained for diagnosis and and focuses on conservative methods.treatment of neuro-musculo-skeletal and low back conditions, and especially for nondrug, nonsurgical conservative care alternatives for them.



AGENCIES: HOW PUBLIC HEALTH SERVICESARE ORGANIZED AND DELIVERED

A variety of types of agencies are involved in publichealth. The contributions of each are well-documentedin the public health literature, and important for thereader to review. Their classifications are reiteratedhere and some important examples given, but thereader is referred to more comprehensive sources formore information about the literally hundreds of agen-cies involved in protecting the public and promotingits health. Remember that many entities that do notconsider themselves to be health agencies and are notlegally classified as such, nonetheless carry out someroles and functions that can be considered healthagency tasks or as an extension or complement ofthem.

Agencies are how public health services are organizedand delivered, an organizational resource. They are amajor component of the health care system’s infrastruc-ture. The term infrastructure is commonly heard in pub-lic health discussions. The public health infrastructure isthe underlying resources for public health, the supportsystem. Like other public health terms, it is best definedby the components it includes:

• People: The human resources, key individualsand teams

• Agencies: The organizational resources andstructures

• Data: The informational technology resources• Funding: The financial resources and money to

pay for what is needed

Public health agencies can be classified on a few dif-ferent bases and characteristics: by levels of function,by sources of funding, by responsibilities, by organiza-tional structure, and by defining characteristics. The majortypes of public health agencies are:

• Quasi-governmental (a hybrid category)• Governmental, also known as public• Nongovernmental, also known as private and

abbreviated as NGO (nongovernmentalorganization)

Each of these will be discussed in the following sec-tions. Although there are private agencies in existence,the term agency in the name of an organization mostcommonly indicates that it is a public sector govern-ment agency. On the other hand, the term associationmost frequently indicates a voluntary, private sector,nongovernmental organization.

and primary prevention efforts can do only so much.For those cases too late or too severe by the time theyare appropriately noticed, there is secondary preven-tion. Secondary prevention is prevention of disease orinjury progression (prevention of severity or prevalenceof disease or injury) by early detection and diagnosisand prompt intervention in exposed populations to re-duce the extent of the burden on health. Likewise, sec-ondary prevention efforts are imperfect, so a thirdlevel termed tertiary prevention is necessary. Tertiaryprevention is prevention of permanent disability ordeath due to illness or injury, by ongoing care and re-habilitation for affected populations, treatment ofcomplications, and restoration of functions. All threelevels of prevention—primary, secondary, and tertiary—aim to prevent mortality and varying degrees of morbidity.

The public health care system includes all three levelsof prevention but puts the most emphasis on primaryprevention. Public health itself can be considered as thefoundation or infrastructure base for primary, second-ary, and tertiary care. Public health as an industry hashad major accomplishments in prevention throughouthistory. The 20th-century accomplishments were partic-ularly notable in the United States because organizedpublic health initiatives were responsible for great re-ductions in morbidity and mortality rates and an esti-mated 25-year increase in life expectancy. Table 1-3lists, in random order, the 10 great achievements of the20th century in American public health according tothe CDC, and publicized in Morbidity and MortalityWeekly Reports throughout 1999.13 Selections werebased on opportunities for prevention. Directly or indi-rectly, these achievements greatly benefited the healthof every community during the last century and con-tinue on into the new millennium.


Table 1-3 Ten Great Public Health Achievements in theUnited States, 1900–1999

1. Identifying tobacco as a health hazard2. Declines in deaths from heart disease and stroke3. Family planning4. Fluoridation of drinking water5. Healthier mothers and babies6. Immunizations7. Motor-vehicle safety8. Control of infectious diseases9. Safer and healthier foods

10. Workplace safety



Quasi-governmental

Although quasi-governmental agencies have some re-sponsibilities assigned by government, they operatemore like voluntary agencies. They are funded by com-binations of grants, tax dollars, and private sources.They operate relatively independently of governmentsupervision, but have been delegated, or contracted, orjust assumed some functions by custom and defaultthat over time became tradition. Perhaps the best ex-ample of a quasi-governmental agency at the interna-tional level is the International Red Cross, also called theRed Crescent or the Red Crystal in certain countries. Itperforms various services across borders during emer-gencies and war. Likewise, the American Red Cross per-forms duties ranging from war and disaster relief andservices to armed forces, to safety-first campaigns, nurs-ing services, blood drives, swimming classes, cardiopul-monary resuscitation (CPR) classes, and AIDS educationwhile coordinating with both the civilian branches ofgovernment and the military structure.

Governmental

Government agencies are of course operated and man-aged by government officials, whether elected or ap-pointed, and by salaried bureaucrats who are theiremployees. They are funded primarily by tax dollars or as-sessments and fees imposed on industries that are beinginspected and regulated. They have authority for some ge-ographic catchment area or jurisdiction. Whether fairly ornot, like other government agencies, health agencies havebeen criticized as too bureaucratic, too political, poorly co-ordinated, wasteful, and duplicative.

One parameter on which to classify agencies is by thelevels at which they function and the level of govern-ment that is responsible for their administration.

• International-level agencies function in two ormore different sovereign nations, often in oracross several.

• National/federal-level agencies function primarilywithin one country, although they may havesatellite stations in other countries.

• State or multistate regional-level agenciesfunction within one of the U.S. states or in a fewadjacent states.

• Local-level agencies function within one city,county, district, or parish, or sometimes incombinations across a few adjacent jurisdictions.

At the international government level is the WorldHealth Organization (WHO) with headquarters in Geneva,

Switzerland. The WHO is a branch of the United Nationsand has carried out its work since 1948 in six designatedregions throughout the world. It is the world’s overall di-recting and coordinating authority on questions involvinghuman health. Historically, the first real international publichealth agency was called the International SanitaryBureau, which formed in 1851 to stop an epidemic ofAsian cholera that was threatening to become a pan-demic; as an ad hoc agency it disbanded after formulatingits plan and recommendations. Another internationalagency is the Pan American Health Organization (PAHO),which is the international public health agency cov-ering the region of the north and south Americas.Originally a free-standing agency, it existed before WHO,making it the oldest international public health agency in continuous existence; however, it now maintainssome independence while operating as a branch of the larger WHO.

At the level of national government, all countries havea primary department, agency, bureau, or ministry re-sponsible for the health of their citizens. It may be acabinet-level agency and either part of some other agencyor free-standing within government. The national-orfederal-level health agency in the United States is theDepartment of Health and Human Services (DHHS). It in-cludes the United States Public Health Service (USPHS),which is the principal federal agency concerned withpublic health in America, and the Centers for DiseaseControl and Prevention (CDC), which is the USPHSagency responsible for monitoring infectious diseasein the United States and around the world in order toprevent disease and promote health. There are manyother major and minor governmental agencies carry-ing out their tasks at the federal level under the over-all organizational structure of the Department ofHealth and Human Services; their roles and func-tions are thoroughly described in other texts. A listof the various agencies included under the Depart-ment of Health and Human Services is maintainedat its website, which can be accessed at http://www.hhs.gov.

At the state government–level in the United States,every state has a state health department or board ofhealth that, similar to the national level, may be a free-standing agency or may be a branch or part of somebroader agency. The state level in the United States isconsidered to be the level of sovereign power in healthprograms and is under the direction of a state health of-ficer appointed by each state’s governor. Each has thestated purpose to promote, protect, and maintain thehealth and welfare of their citizens.




• Usually categorical in purpose• Have basic stated objectives such as research,

education, services, or advocacy• Funded or self-funded by donations, including

from such sources as fundraising events andtelethons

• Operated most commonly as nonprofit;occasionally as for profit

• Under their own jurisdiction rather than underdirect government control

• Sometimes criticized for a lack of public healthexpertise and failure to coordinate withgovernment agencies

• Often have high overhead and administrative costs• Often able to energize a community response by

an emotional appeal for their issue of interestrather than the more standard public healthapproach of starting with a survey of communityneeds and then prioritizing them for action steps

• Especially effective for start-up programs

Voluntary agencies usually cooperate with governmentagencies, but sometimes conflict when self-interests orspecial interests diverge from government plans. Thestandard public health approach of conducting commu-nity needs surveys and inventories; gathering and pro-cessing data; identifying trends, patterns, and clusters;ranking priorities; and balancing these against budgetconstraint realities is sometimes seen by private agenciesas too bureaucratic, too much “red tape,” too slow moving,and too confining for their liking.

Examples of larger voluntary NGOs include theAmerican Cancer Society, American Heart Association,American Lung Association, Braille Institute, DiabetesAssociation, and many other fine agencies. NGOs can havevarious subcategories or classifications as well. Service or-ganizations and social clubs such as the Shriners with theirstring of children’s hospitals, the Elks, the Lions, RotaryInternational, and many others include health servicesamong the other worthy and charitable causes they support.

Likewise, religious organizations and churches, some-times referred to as the faith community, can fulfillhealth roles. Faith-based ministries, notably the Catholic,Protestant, and Jewish congregations, have often in-cluded a health care component within their congrega-tions as well as extending into outreach programs.Pastoral care and chaplaincies in hospitals, missionarymedicine, and relief programs have operated in both do-mestic and foreign sectors and incorporate a spiritual orholistic component in their approaches.

State-level public health agencies are considered re-sponsible for:

• Financing care for the poor and chronicallydisabled

• Regulating health care costs, including regulatinghealth and other insurances

• Ensuring provider quality, including the licensingand regulation of health care facilities andprofessionals

• Providing training and setting standards for healthprofessionals and for their training programs

• Authorizing local government health services asneeded

Most counties and cities also have a health depart-ment or board of health, which is considered at thelocal level; like those at the state-wide level these maybe a free-standing agency or a branch or part of somebroader agency. (In Louisiana, the local level of designa-tion is called a parish rather than a county.) Some areashave combined resources and have an agency spanninga wider region, which may consist of several smallercities or even a few counties. The local level in theUnited States is the level at which regulation and provi-sion of direct personal health services occurs. This is the“hands-on” level where many public health needs in thevarious communities are coordinated and regulated.

No matter what the level, each government healthagency bears some responsibility for ensuring some as-pect of the so-called three core functions of publichealth (enumerated earlier) to the people of their re-spective jurisdictions.

Nongovernmental

In addition to agencies operated by government entities,there are also voluntary organizations, also called non-governmental organizations (NGOs), civil societies, orsimply private sector agencies. By virtue of a formalizedrelationship and official designation, an NGO can be apart of or formally affiliated with a government agencyand carry out specific government obligations, often as acondition of the status it holds. These NGOs may operateat any level: international, national, state, or local. Theyare of many types, including voluntary, professional, social,philanthropic, service, religious, and corporate. They havecommon defining characteristics, including:

• Created to meet a specific health need or even asingle health issue, but can also cover an entireprofession




Corporate America also has created certain healthcare facilities that act somewhat as agencies for specialtarget groups of workers. Workplace health and safetypromotion; occupational medicine; provision of healthinsurance; on-site company doctors, nurses, or medical di-rectors; Occupational Safety and Health Administration(OSHA) regulation compliance efforts; and even laborunion–negotiated health benefits may qualify as an ex-tension of public health endeavors, despite being carriedout by the private sector.

Educational settings play a role in community healthas well. The potential of coordinated school health pro-grams for students, teachers, and employees to positivelyimpact community health has been amply described in atext by McKenzie and colleagues.14 They refer to health ed-ucation, on-site health services, a healthy school environ-ment, school nutrition, and physical education as keyelements that contribute to healthy students. At least inpublic schools supported by taxes, this appears to be anatural role opportunity. Other aspects of the educationalsystem as part of healthy communities would includecampus clinics, infirmaries, and university hospitals andmedical centers.

Hospitals, even private hospitals, in a very real senseare a community resource and component of the healthcare system. In that sense, hospitals also can be consid-ered health agencies, and hospitals work collaborativelywith many other health agencies in their common com-munities. Many hospitals also reach people outside theirwalls through community outreach programs.

Some communities have a variety of smaller inde-pendent clinics or dispensaries, often with services tothe surrounding neighborhood provided either free oron an ability-to-pay basis. “Free” clinics may be foundin many inner-city areas throughout the United States.Some of these community clinics aim their services atspecific target groups, such as women, ethnic minori-ties, or immigrants. Many have affiliations with full-service hospitals for referral and back-up purposes.

Philanthropic foundations are entities that are formedby wealthy individuals or their corporations to rechan-nel some of their profits back to community causes; examples include the Bill and Melinda Gates Foundation;Ted Turner’s United Nations Foundation; the CarnegieFoundation, which funded and commissioned the famous Flexner Report on early medical education in America; the W.K. Kellogg Foundation; the FordFoundation; and the Rockefeller Foundation. TheRockefeller Foundation is historically considered themost important for public health in the United Statesand has been credited with resolving endemic hookworm

infestation in the southern states, as well as for fundingthe implementation of the recommendations of theFlexner Report.

Professional health organizations and associationsexist principally to serve the needs of their collectivemembers. They generally have a primary purpose ofpromoting high standards of professional practice fortheir specific profession, a concept similar to historicalguilds or early trade unions. Most also express some-where in their charters or mission statements a commit-ment to improving or safeguarding the people’s health.Examples of professional health organizations includethe American Medical Association (AMA), the AmericanNurses Association (ANA), the American Hospital Association (AHA), the American Chiropractic Association(ACA), and the International Chiropractors Association (ICA).The special case of the American Public HealthAssociation (APHA) is treated separately later in thischapter.

The World Federation of Chiropractic (WFC), founded in1988, is an international federation headquartered inToronto, Canada. The WFC is an association of nationalchiropractic associations, an umbrella organization overmany independent associations, and has status with theWHO as a formally affiliated NGO. The World Federationof Public Health Associations (WFPHA) provided an offi-cial letter of support for the WFC’s original applicationfor official relations to the WHO, partly in recognition forchiropractors working within the American Public HealthAssociation for the previous several years. The WFC appli-cation was accepted by the WHO in January 1997. Aspart of its overall mission, the WFC fulfills a public healthrole by promoting international standardization of chiro-practic education, research, practice, legalization, licens-ing, and codified scope of practice. This commitment toprotect the public as well as to further its own professionhas demonstrated that the leadership of the professionhas concerns broader than their identity and role as thespinal health care experts in the health care system,even while specializing in that role.

Each May the WFC sends a delegation to join the otheraffiliated organizations and participate in the WHO WorldHealth Assembly meetings in Geneva, Switzerland. Afterworking cooperatively with the WFC over a few years, theWHO published its first WHO Guidelines on Basic Trainingand Safety in Chiropractic in November 2005. The WHOhas had a chiropractic researcher from Life ChiropracticCollege on its staff, and in 2008 it had its first chiroprac-tor serving as a WHO intern.

The WFC established an international Public HealthCommittee (formerly its “Health for All Committee,” so




interagency multidisciplinary cooperation are the currentand most exciting development in public health.

Chiropractic Within Public Health

Roles for the chiropractic profession and individual chi-ropractors’ involvement in these agencies are an evolvingand fairly recent development. In the past few decades,chiropractic has moved from a profession that tradition-ally practiced outside the mainstream and in relative isola-tion, to one that actively seeks integration and participation.A sentiment of “me-too-ism” has prevailed as integrationincreases. Doctors of chiropractic having extra interest,training, expertise, qualifications, dual credentials, andadvanced degrees (MPH, DrPH, etc.) have led the way torecognition in various mainstream public health agen-cies and even in gaining greater visibility in the privatesector in nontraditional roles for chiropractors, which inturn has led to greater acceptance in the public sector.Chiropractors have served well in decision making andadvisory roles on councils, commissions, and commit-tees, and for the Department of Veterans Affairs,Department of Defense, Department of Health andHuman Services, and other health departments andagencies at the international, federal, state, and localgovernment levels.15 Chiropractors have provided clini-cal services in projects at Veterans Administration hospi-tals, and been proposed for commissions in the U.S.Armed Forces and in the uniformed U.S. Public HealthService Corps.

A new cohort of chiropractors holding the combinedDC, MPH degrees developed around the new millen-nium, and some crossovers changed careers or pursueddual careers in public health and chiropractic. Chiropractichad long had some tradition of being a change-of-careerprofession, and those with a foot in each were naturallypositioned to bridge gaps between professions. Evenholders of the MD, DC degree combination found thatthe professional credibility and respect earned in oneprofession would generalize and carry over to another;the minority phenomenon of chiropractors obtaininghospital privileges, medical staff appointments, and vari-ous other affiliations further helped this evolution. Theseoften successful efforts started with volunteerism, andobserved track records of performance brought moreand higher levels of opportunity to participate in thepublic health arena.

It is easy to conceptualize and envision DCs servingin salaried posts, as consultants, as members of multi-disciplinary teams, and as volunteers within practicallyall the agencies listed earlier in every category. More

named to mirror the former WHO objective) underchairman Dr. Rand Baird and charged it with coordinat-ing chiropractic public health programs with WHO ini-tiatives, cabinet-level programs, projects, and priorities.This committee, with its international membershipfrom the seven world regions of the WFC, coordinates ano-smoking and no usage of tobacco products cam-paign called CAT (Chiropractors Against Tobacco) in sup-port of the WHO Framework Convention on TobaccoControl (FCTC) and its Tobacco Free Initiative. ThePublic Health Committee carries out charges from thepolicy level of the WFC Council and Assembly, passingstatements on international health issues down to thegrassroots level of producing action steps including cre-ating and distributing materials for individual DCs touse in their own offices. Given the importance of tobacco-related morbidity and mortality, and its ranking as thenumber one preventable health problem in the world,the chiropractic involvement is more than symbolic.The WFC Public Health Committee also promotes ef-forts in support of the WHO Global Strategy on Diet,Physical Activity, and Health (GSDPAH), with emphasis onreducing the worldwide pandemic of obesity, encourag-ing exercise, and using postural and movement routinessuch as the very successful Straighten Up and Move pro-gram pioneered by Dr. Ron Kirk of Life ChiropracticCollege, which has been featured during the annualWorld Spine Day in October. Because tobacco use, nutri-tion choices, and physical activity all involve behaviorand lifestyle modification, and all can be addressedwithout the use of drugs or surgery, the natural methodsof chiropractic and the position of the chiropractor as arole model, health counselor, and health expert author-ity figure are clear. Besides World Spine Day, other in-ternational public health designated days such as WorldHealth Day, World Environment Day, and World NoTobacco Day each May 31 are observed and promotedthrough the WFC and other chiropractic organizations.

Besides their actual health endeavors, all of these civilsocieties and NGOs, public and private alike, publishuseful information both for professional audiences andthe lay public. The critical significance of all of thesecivil societies in contributing to the overall public healthmission of preventing disease and promoting health is in-estimable. Around the world, the importance of coordi-nation, cooperation, partnerships, joint ventures, andcombinations of efforts among agencies of all typesworks to the common benefit, and as a practical issue isthe only way to move forward. In fact, partnerships,joint endeavors, alliances, and other cooperative combi-nations between the public and private sectors and




important to the various communities served, there isa need for chiropractic participation and a void with-out it. Chiropractors bring a unique perspective andapproach to complete the health care team. As agenciesbecome more attuned to complementary and alterna-tive medicine (CAM) and concepts of multidisciplinary, in-tegrated care teams, roles for chiropractors will evolvefurther. Public health has always had a team-care ap-proach, and positions have opened that were originallyreserved for so-called “plenary” physicians (MDs andDOs) but eventually also were filled by dentists andveterinarians who developed interests in public health,obtained public health degrees, and assumed theirrightful places in public health. So too should DCsmove into various roles and positions throughout thepublic health industry. It is not difficult to project andimagine DCs as federal, state, and local health officersin the United States, and DCs as heads or staffers in in-ternational, national, regional, and local health agencieswhether governmental, NGO, or quasi-governmental.And in thinking a bit futuristically and out of the prover-bial box, it’s not out of the question to envision a DC asU.S. Surgeon General. Current developments are open-ing new opportunities, making for a most exciting fu-ture ahead for chiropractic roles and functions withinpublic health.

THE SPECIAL CASE OF THE AMERICANPUBLIC HEALTH ASSOCIATION

The APHA can best be summarized by Article II of itsBylaws (April 2008):

The Object of this Association is to protect and promotepersonal and environmental health. It shall exerciseleadership with health professionals and the generalpublic in health policy development and action, withparticular focus on the interrelationship between healthand the quality of life, on developing a national policyfor health care and services and on solving technicalproblems related to health.16

Detailed information about the organization, its manyunits, and its functions may be found at http://www.apha.org.

Founded in 1872, the APHA is the oldest, largest, mostinfluential, and most diverse organization of publichealth professionals in the world. It aims to protect allAmericans and their communities from preventable, seri-ous health threats. It strives to ensure that community-based health promotion and disease prevention activities,and comprehensive, quality health services are universally

accessible in the United States. The APHA represents abroad array of health providers, educators, environmen-talists, policy makers, and health officials at all levelsworking both within and outside governmental organiza-tions and educational institutions. As the oldest (servingthe public’s health since 1872), largest (55,000+ APHAand state public health association affiliate members),most influential (among the top 15 most effective lobbieson Capitol Hill every year), and most diverse (representing25 sections of approximately 76 professions in variousaspects of public health), there is no other organizationcomparable to the APHA.

The APHA’s multifaceted mission is to improve the pub-lic’s health, promote the scientific and professional foun-dation of public health practice and policy, advocate theconditions for a healthy society (particularly advocating inCongress and mobilizing its expertise for federal agen-cies), emphasize prevention, enhance the ability of itsmembers to promote and protect environmental andcommunity health, and support its affiliate state associationmembers. The APHA paraphrases this mission as to pre-vent illness and injury, to promote good health practices, tokeep the environment clean, healthy, and safe. An APHAslogan is, “APHA: Protect, Prevent, Live Well,” and some ofits leaders have stated that the abbreviation APHA canalso stand for “Advocates for a Public Health Agenda.”

Chiropractic participation in the APHA and other publichealth organizations is essential for true multidisciplinaryrepresentation, and is a professional responsibility aswell. It affords the profession another opportunity to par-ticipate in and help shape the nation’s health careagenda. It provides visibility and creates an atmosphere fordeveloping interprofessional collaborations. The APHA isa strong advocate for universal health care, and is thus anavenue for chiropractic to advocate for an “any qualifiedprovider” clause in the U.S. health care insurance system.Many chiropractic colleges have clinics that serve indi-gent and other underserved populations. Participation instate public health associations and involvement withlocal health departments can raise awareness of our clin-ics and ensure that they are included in public healthsafety networks. The APHA is also an avenue for explor-ing opportunities by chiropractic for inclusion in integra-tive care clinics and provider networks.

Structure

The APHA is a complex organization that emphasizes in-clusion and diversity. Broadly speaking, members repre-sent two main constituencies: 25 professional sections, ofwhich chiropractic health care is one, and 53 state affiliate




boards and the Intersectional Council, Committee onAffiliates, and Student Assembly. The Executive Boardcarries out the policy of the Governing Council, hires theexecutive director, oversees the administration of theassociation, appoints committee and board member-ships, and serves as trustee of the association’s assets.

Sections

Currently there are 25 sections with diverse professionalmissions. These range from Chiropractic Health Care,Vision Care, and Podiatric Health to Medical Care, OralHealth, and Public Health Nursing, to Statistics andEpidemiology, to Health Administration, and a variety ofothers. Each section has a chair, chair-elect, immediatepast chair, and secretary. Each elects a section council andat least two governing councilors. The section appoints anAction Board representative and representation to theMembership and Program committees. Section budgetsare allocated based on membership. The three chairs sit onthe Intersectional Council. As an example of the structureof one of the sections, the Chiropractic Health Care sec-tion has the following internal committees: Awards,Communications, Membership, Nominations, Program,Resolutions, and Section Manual. The section conducts ascientific program of paper sessions and has had anaward-winning exhibit booth at the APHA annual meeting.It also has several business meetings at this time, as well asa midyear meeting held during the annual Association ofChiropractic Colleges conference.

State Affiliates

The 52 state public health associations and the Washington,DC, association fall under the category of state affiliates.These are independent incorporated organizations hav-ing a contractual relationship with the APHA. Each has arepresentative to the Governing Council, called the AffiliateRepresentative to the Governing Council (ARGC). The rela-tionship between the states and the APHA is importantbecause it allows a coordinated effort to be made onhealth policy issues of both national and local signifi-cance.

Intersectional Council and Committee on Affiliates

The Intersectional Council is composed of all sectionchairs, chairs-elect, immediate past chairs, and a steeringcommittee. The Chiropractic Health Care section leader-ship thus has the opportunity to formally interact with the

organizations. In addition, the APHA has special interestgroups, forums, caucuses, and a student assembly. TheAPHA is governed by the Governing Council, its legislativebranch, and the Executive Board, its executive branch.The organization is supported by a dedicated professionalstaff led by the executive director. There is a broad rangeof leadership and service opportunities in the organiza-tion. These include association-wide boards and standingcommittees, as well as task forces and working groups.Each section has its own officers, council, and commit-tees. In addition, section and affiliate leaders have the op-portunity to be elected/appointed to the IntersectionalCouncil Steering Committee and to the Committee ofAffiliates that represents the association’s principal con-stituencies. The APHA has its own newspaper, The Nation’sHealth; the prestigious Journal of the American PublicHealth Association; and an extensive website that includessubstantial public health information, as well as theChiropractic Health Care section newsletters. The APHAholds an annual convention and is an active supporter ofNational Public Health Week every April.

The highlight of the year is the 5-day annual meetingand convention every fall attended by as many as 15,000members and leaders in health and government. Hereone can attend thousands of scientific and educationalsessions, and national public health and political figuresspeak at the opening and closing sessions. The GoverningCouncil, Executive Board, sections, boards, councils, andcommittees all have business meetings at this time.There are endless social events and the exhibit hall is aslarge as some city shopping malls. The venue provides agolden opportunity to meet public health leaders fromnumerous universities, all levels of government, and pri-vate institutions, all dedicated to improving the health ofthe public.

Governing Council

The Governing Council consists of about 200 voting rep-resentatives from the 25 sections, elected or appointedmembers from the affiliate state public health associa-tions, and ex officio members from the Executive Board.The Governing Council debates and establishes organi-zation policies and resolutions, elects officers, guidesthe Executive Board, and receives reports from the association leadership.

Executive Board

The Executive Board consists of the association officers,elected members, and ex officio members from APHA




leadership of all professional sections. The function ofthe Intersectional Council is to represent the commoninterests of the 25 sections. The Committee on Affiliates(CoA) is composed of an affiliate governing councilorfrom each of the 10 DHHS regions, officers, Action Boardmembers, and Executive Board appointees. Its functionis to help strengthen APHA/affiliate relationships andoperations.

Boards and Committees

The APHA has an Action, Education, Science, Editorial,and Publications Board. Of particular importance, allsections have a representative on the Action Board andare thus involved in planning and organizing APHA pol-icy implementation; this includes APHA’s legislative pro-gram. Standing committees include Bylaws, Equal HealthOpportunity, Membership, Women’s Rights, and Policy.There is also a program committee that includes a mem-ber of each section.

APHA Staff

The APHA provides extensive services to its membersand organizational units. Staff is also responsible for or-ganizational operations and policy implementation. The executive director oversees the following depart-ments: Convention Services, Government Relations andAffiliate Affairs, Membership Services, Publication Services,Media Relations, Scientific and Professional Affairs, Learningand Professional Development, and Section Affairs.

What is the purpose of DCs’ public health involve-ment through APHA participation? Simply stated, it isthe right thing to do! Chiropractic is a holistic healthcare discipline. As such, it has an obligation to address thepatient’s social and physical environments, both on thepersonal level and in the community domain. Communityhealth is the domain and purview of public health and ishence a natural fit for chiropractic participation. TheAPHA is the public health organization for chiropracticparticipation.

History of Chiropractic in the APHA

Public health has a long and glorious history, probablydating from prerecorded times; its written history goesback thousands of years from perhaps before 2000B.C., all the way forward to modern days. This history isimportant to study but well-documented in other texts,and need not be repeated here. However, the history ofchiropractic in public health in the United States, and in

particular the history of chiropractic involvement in theAPHA as part of its integration into mainstream publichealth activities, began in the late 1970s. Just as thechiropractic profession and individual chiropractorshave had a history and roles in public health, so does chi-ropractic and chiropractors have an important historyand roles within the APHA. The APHA has been andcontinues to be an important vehicle for integrationinto mainstream public health activities. Over the yearsboth the ACA and ICA have passed various policies andresolutions dealing with public health, not the least ofwhich is the public’s right to choose chiropractic care aspart of its quest for health. Professional involvement inpublic health has served the public interest by enhanc-ing chiropractic communication and credibility. In1983 the Governing Council of the APHA passed itsPolicy #8331, The Appropriate Role of Chiropractic inPatient Care, recognizing “. . . spinal manipulation bychiropractors [as] safe and effective [for] certain disor-ders of the neuro-musculo-skeletal system, particularlylow back pain.”17

In 1995 the Chiropractic Health Care section was es-tablished within the APHA, giving chiropractic the eq-uity and parity with all other health care professionsthat it had sought. The section’s name was very deliber-ately chosen by its leadership in order to be the onlyone of APHAs many sections to have both the termsHealth and Care in its official name. The formal sectionapplication document of the former Chiropractic Forumspecial interest group within the APHA was written by ateam consisting of six of the most highly regarded and ac-knowledged experts in the area of chiropractic and pub-lic health. The application document showed a depth ofknowledge and a commitment to public health.18

Chiropractor members of the APHA have served onvarious APHA committees and held various officer postswithin the APHA. Articles by chiropractor authors andabout chiropractic care have been published in theAmerican Journal of Public Health and The Nation’sHealth. Every year the chiropractic national associationsand chiropractic colleges fund paper presenters, re-searchers, teachers, and exhibits at APHA annualmeetings. Chiropractic students are encouraged to jointhe APHA as student members during their publichealth classes. The world’s largest chiropractic tradepaper, Dynamic Chiropractic, has for many years carrieda regular column titled “Chiropractic in the APHA,” editedby Dr. Rand Baird with contributions from various chiro-practic authors.

The ACA and the Association of Chiropractic Colleges(ACC) maintain agency membership within the APHA.




Standard public health publications, including theAmerican Journal of Public Health and Morbidity andMortality Weekly Report (MMWR) from the CDC, arefound in chiropractic college libraries. To varying degreesthe chiropractic colleges also include teaching about theDHHS’s Healthy People National Health Objectives as aframework for identifying the most significant preventa-ble threats to health and establishing national goals to re-duce these threats.21

Chiropractors in the APHAand Public Health

Opportunities for leadership and participation aboundwithin the APHA structure, and the expanded knowl-edge base, plus the contacts and collegiality of being inthe APHA fraternity, also stimulate interest and open ex-tramural opportunities in other mainstream publichealth sectors. Many chiropractors and other profes-sionals working at chiropractic institutions have madecontributions to the efforts of the Chiropractic HealthCare section and its predecessor, the ChiropracticForum. These are unfortunately too many to discuss indetail, but the entire profession appreciates all thechairs, secretaries, elected and appointed officers, gov-erning councilors, Action Board representatives, pro-gram planners, and committee chairs, some of whomserved multiple terms in these positions. Many havealso made presentations at APHA scientific sessions.

Several members of note have served in leadershiproles on APHA-wide boards and committees. Somehave also served outside the APHA. Hopefully their ac-complishments will serve as models and inspiration forfuture chiropractors. Dr. Rand Baird is credited with pio-neering modern chiropractic involvement in publichealth, using the APHA as the vehicle for participation.His efforts in leading the battles for chiropractic recog-nition within the APHA, establishing a ChiropracticForum special interest group within the APHA, andcoauthoring and successfully championing a new APHApolicy regarding chiropractic are thoroughly describedin the two articles reprinted at the end of this chapter.

At the 1995 APHA annual meeting, Dr. Mitch Haas in-troduced a motion on the floor of the Governing Councilto establish the Chiropractic Health Care section to re-place the Chiropractic Forum. After the motion passed,Dr. Haas then became the first chair of the new section.The following year, Dr. Haas was elected by theIntersectional Council to its Steering Committee. Heserved two terms on the Steering Committee, was sec-retary of the Council in 1997, and became chair in 2000.

Several chiropractic colleges have also done so for anumber of years, and so did the Council on ChiropracticEducation (CCE). The ICA did for over 20 years. The ACAand ICA have at one time or another passed official reso-lutions urging their own respective members, but also allchiropractors, to join the APHA and support publichealth. The ACA House of Delegates re-affirmed this po-sition in 2008. The ACA has appointed a standingCommittee on APHA for many years. National PublicHealth Week (NPHW) is an annual APHA activity in Apriland various chiropractic institutions have participated,with the ACA signing on as an official APHA partner, pro-moting the events in its publications and encouraging allits members to participate. ACA publications often fea-ture public health topics and include a message that allchiropractors should be involved in public health and inthe APHA. Notably the June 2002 issue of JACA: Journal ofthe American Chiropractic Association had a public healththeme and a cover article titled “Public Health andChiropractic—Meeting Somewhere in the Middle,”which extolled chiropractic involvement in public healthand quoted several chiropractic leaders who were APHAmembers.19 An earlier article in the same publication ex-plored the importance of chiropractic activism in theAPHA to the chiropractic profession as a whole and to in-dividual DCs, while detailing what chiropractic offered tothe APHA, and ending with emphasis on gaining inputto APHA policy making, which has far-reaching impacton health care decisions.20

An interesting side note is that throughout chiroprac-tic history some individual chiropractors and some chi-ropractic groups have expressed opposition to certainstandard public health practices, such as vaccination,immunization, fluoridation of public drinking watersupplies, and pasteurization of milk and dairy products,and entered the political arena to debate or oppose,often successfully, those measures in their communities.With a philosophy of preferring natural, nondrug in-terventions and freedom of individual choice, their op-position is perhaps understandable in that context, but itwould be a myth to assume that such opposition isprofession-wide or even very widespread. The necessityand utility of vaccination, immunization, fluoridation,and pasteurization are in most respects a non-issue forthe leadership and the majority of chiropractors today. Allof these topics are presented in chiropractic collegeclasses, and chiropractic colleges have always had re-quired, not merely elective, courses in public health intheir curriculum, prompting advocates to point out thatsome DC programs have more required public healthclasses than found in some MD training programs.




Because of a vote in the Governing Council that yeargiving a new position to the Intersectional CouncilChair, the Chiropractic Health Care section had its firstmember on the APHA Executive Board within 5 years ofit charter. Dr. Haas was appointed by two president-electsto serve on the Annual Meeting Planning Committee and the APHA Bylaws Committee. As a member of thePlanning Committee he was able to organize a specialsession where he had the honor of introducing theSurgeon General, Dr. David Satcher, and APHA past-president Dr. Barry Levy. Dr. Haas also served on the adhoc Development Task Force and the Work Group onUniversal Health Care. Finally, he served on the Committeeof Affiliates from 2005 to 2006 and received a citationfrom the chair for his contributions.

Other chiropractors who have been appointed toAPHA-wide service include Dr. Lisa Killinger, whoserved on the Task Force for Aging; Dr. Andrew Isaac,the CHC’s first African American section chair, whoserved on the Diversity Task Force; and Dr. ChristineChoate, who served as the Action Board’s OperationsSubcommittee co-chair.

Chiropractors have made contributions to other or-ganizations and public health institutions as well.Between 1999 and 2002, Dr. Cheryl Hawk was a mem-ber of the Iowa Board of Health, Iowa State PreventiveHealth Advisory Committee, and the Director’s Council ofScientific and Health Advisors of the Iowa Department ofPublic Health. Dr. Michael Perillo is currently the PublicHealth Emergency Preparedness Representative IV forthe New York State Department of Health. His primaryfocus is development and evaluation of emergency pre-paredness initiatives for health care facilities, including145 hospitals, 325 long-term care facilities, and 25 com-munity health centers. In 2006, Karen Konarski-Hart,

DC, was appointed to a multiyear term on the ArkansasState Board of Health by Governor Mike Huckabee andserved a term as the organization’s elected president.Dr. Konarski-Hart is believed to be the first chiropractorto serve as a president of a state board of health. Otherchiropractic doctors have served as board members oftheir local health departments. Because of his experi-ence with the APHA, Dr. Haas was elected Oregon’sAffiliate Representative to the Governing Council. Hewas a member of the Oregon Public Health Association(OPHA) Executive Board and Executive Committee be-tween 2002 and 2008, and served as OPHA presidentin 2007. Dr. Andrew Cohen became president-elect ofthe Hawaii Public Health Association before leaving thestate to practice elsewhere. Other chiropractor mem-bers of the APHA have served in other capacities in var-ious health agencies, public and private.

Two articles detailing the history of the chiropracticprofession’s involvement have been published inChiropractic History—The Archives and Journal of theAssociation for the History of Chiropractic. Dr. HerbertVear authored the first, which appeared in 1987. Thesecond article, by Dr. Jonathon Egan with coauthors Dr.Rand Baird and Dr. Lisa Zaynab-Killinger, appeared in 2006and was designated by the journal as its “best article of theyear.” Together these two articles provide an excellentchronology for the reader, but perhaps more importantlycan serve to illustrate what can be accomplished withdedication and perseverance by chiropractors workingtogether for public health. Much has been done andmuch more remains to be done by chiropractic in pub-lic health through the APHA. Role models, precedents,and examples for the future participation abound inthese articles, and they are reprinted here with permis-sion (tables and photos omitted).


THE ANATOMY OF A POLICY REVERSAL: THE A.P.H.A. AND CHIROPRACTIC, 1969 TO 1983Herbert J. Vear, DC22

Although all CCE accredited colleges provide core cur-riculum education in public health to meet state andprovincial statute requirements, there is little historic evi-dence to suggest that the chiropractic profession hasbeen active or supportive in matters of public health withthe possible exception of that for orthostatic posture eval-uation. There are several valid reasons for this isolationfrom mainstream public health, all of which parallel the ex-planations for the historic isolation of chiropractic practiceand education from the scientific health community.

This paper traces the process of involving the professionwith the American Public Health Association, and the14-year campaign that turned around the policy of thisorganization toward chiropractic.

State and provincial chiropractic statutes in NorthAmerica require examination of candidates for licen-sure in one or more of the following public health sub-jects: hygiene and sanitation, public health, toxicologyand microbiology; however, there is little evidence tosuggest that the chiropractic profession has been active



in light of our policy on the issue of chiropractic andnaturopathy.8

Baird concluded that there was no occupational cat-egory for chiropractors because of Policy No. 6903.This resulted in an exchange of correspondence withthe Director of Membership Services, Harold Cary, be-tween July 1980 and October 1981.9 Baird made the fol-lowing points in his letters: “I chose #14, ‘DruglessPractitioners,’ because I could not find a category for‘chiropractor’ nor ‘chiropractic physician’ . . . this is aserious flaw, and as a concerned member, feel it maybe discriminatory as well . . . you [should] remedy thesituation by either establishing a new category for ‘chi-ropractor’ or ‘chiropractic physician’.”

Cary acknowledged that when the occupational cat-egories were revised several years ago no one hadever expressed concern for the omission of a chiro-practic category. Cary stated further, “yours is the thirdletter indicating a change should be made. This isgood timing since we are planning to purchase a newcomputer soon which will necessitate the rewriting ofevery one of our membership programs.” The last let-ter in the exchange is dated October 13, 1961, andconfirms that the new Codes Pamphlet lists “chiro-practic physician” under Code 14. In the meantimeBaird had recruited over 200 new chiropractic mem-bers, mostly students from Cleveland ChiropracticCollege of Los Angeles. The preceding events encour-aged him to study the APHA Constitution, bylaws andpolicy making procedures with a goal of reversing thenegative APHA chiropractic policy.

Baird contacted the American Chiropractic Association(ACA), the International Chiropractic Association (ICA)and the California Chiropractic Association for assis-tance. The ICA responded favorably by sending a representative to attend the APHA meeting in LosAngeles, November 1–4, 1981. The California ChiropracticAssociation agreed to sponsor a chiropractic exhibitbooth. The booth was a first for chiropractic and wasstaffed by chiropractic physicians and students fromCleveland College.

Although the APHA has a procedure for introducingchanges or amendments to existing policies, it is possi-ble to submit a “late breaking” resolution to the JointPolicy Committee (JPC) for their consideration duringthe annual meeting. Baird prepared a chiropractic “latebreaking” resolution for the annual meeting in LosAngeles.” The JPC decided not to consider the resolutionsince the arguments in the resolution did not qualify itas a true “late breaker.” This meeting hardened the

or supportive in matters of public health. The labeling ofchiropractic as a “marginal profession” by Wardwell1

in 1951 and later as “deviant” and “unorthodox” byothers2 did little within the chiropractic profession toencourage support of public health issues. Since its ori-gins, survival of chiropractic as an independent healthcare profession was more important than support ofmedically dominated public health measures.3

Chartered in 1872 the American Public HealthAssociation (APHA) is the largest, oldest and most pres-tigious, multidisciplinary public health organization inthe world. In November 1969, the APHA passed a policyresolution, No. 6903: Chiropractors and Naturopathy,4

which was based almost entirely upon the biasedDepartment of Health Education and Welfare (DHEW)Independent Practitioners Under Medicare Report,mandated by the U.S. Congress.4 The Congress, in plan-ning the Social Security Amendments of 1967, PL 90-248, decided it needed more information about healthcare disciplines not included in Medicare legislation, be-fore enacting amendments to Title 17 of the SocialSecurity Act. The DHEW Report was refuted by a uni-fied chiropractic profession response which encouragedthe Congress to ignore DHEW recommendations. TheAPHA action in adopting a strong anti-chiropractic policy(No. 6903) appears to have gone unnoticed by the chi-ropractic profession in 1969.

The first record of any communication to the APHAinformation on the status of chiropractors is creditedto Rand Baird, D.C., M.P.H., who wrote to John H.Romani, APHA president, on May 16, 1979. At thattime, Baird was a student at the Cleveland College ofChiropractic in Los Angeles and also an instructor inPublic Health. He asked the following questions:

1. Does the APHA have a policy statement regardingthe role of Doctors of Chiropractic? 2. Does the APHArecognize chiropractors as primary physicians? 3. Arechiropractors eligible for APHA membership? 4. Havethere been any articles in the Journal, either for orabout Doctors of Chiropractic and their function in thehealth care delivery system?

Baird received a response on June 25, 1979 fromKatherine S. McCarter, MHS, Director of GovernmentRelations for the APHA:

Enclosed is a copy of a resolution, adopted by theAssociation, which states that APHA considers thepractice of chiropractic and naturopathy hazard tothe health and safety of our citizens.

While chiropractors are not specifically excludedfrom membership, very few have joined (less than 10)




determination of the chiropractic participants tochange the APHA chiropractic policy at the next annualmeeting in November 1982. There was an obviousneed for an improved chiropractic identity within theAPHA, which would be served best by forming a chiro-practic special primary interest group (SPIG).

Following the 1981 Annual Meeting Baird madeformal application to APHA to form a “Forum onChiropractic Health Care.”12 A response to this requestwas not forthcoming until April 21, 1982. The applica-tion “was disapproved by the Executive Board,” Theletter went on to say that:

the Board felt that chiropractors should be welcomeas individual members of APHA; however, in view ofthe current policy of the Association regarding chiro-practors, the Board did not feel chiropractors should bea special group of the association at this time. Thedoor was left open with this statement; The Boardnoted that this policy could be changed, but it is up tothe group to change it.13

On June 4, 1982, Baird received his first formal en-couragement from the APHA Joint Policy Committee(JPC) to pursue his objective in having 6903 repealedand replaced with a new policy.14 They had reviewed,thoroughly, the resolution “Chiropractic Health Care,” ofNovember 1981 and also a revised version submittedearly in 1982. The letter explained in some detail whatwas expected in order to supersede 6903. Bairdrewrote his chiropractic resolution and the new ver-sion was submitted for publication in The Nation’sHealth, September 1982.15 News of this appeared in anICA news release, along with a review of Baird’s ac-complishments in advancing the chiropractic causewith the APHA.16 This article prompted the author towrite Baird and pledge the support of Western StatesChiropractic College17 and to write to ErnestNapolitano, President of the Council on ChiropracticEducation (CCE) requesting that he join the APHA onbehalf of the CCE. The author was appointed as the of-ficial CCE spokesperson at the public meetings.

Baird’s acknowledgement of WSCC support was ac-companied by a request for letters of support to bewritten to the Co-Chairpersons of the JPC of APHA.18

WSCC, along with other chiropractic institutions andassociations, responded to this request.19–22 Baird wasnow receiving strong support from the ACA and theICA. G. M. Brassard, Executive Vice-President of theACA, had joined the APHA as an individual memberand planned to attend the hearings in Montreal onNovember 22, 1982. Arrangements were made for all

chiropractors attending the meeting to meet before-hand and plan a strategy for the public meeting.

Eight people met beforehand to plan a strategy for thepublic meeting, With a maximum of thirty minutes topresent and defend the resolution, it was decided thatBaird would present the position paper, “Testimony on aChiropractic Policy Proposal.”23 Fred Colley, Ph.D., a mi-crobiologist at Western States College of Chiropractic,would speak to his experience as a public health teacherat both a medical and a chiropractic school. WalterWardwell, Ph.D. from the University of Connecticutwould present a sociological viewpoint of chiropractic.Gerald Brassard, D.C., the Executive Vice President ofthe ACA, would reinforce the gains made by the profes-sion since 1969 and Herbert J. Vear, D.C., F.C.C.S., thePresident of Western States, would speak to the accredi-tation process in chiropractic education. Also present atthat meeting were Karl Kranz, D.C., representing theICA, James Watkins, D.C. of the Canadian ChiropracticAssociation and Robert Wakamatsu, a student at ClevelandChiropractic College, Los Angeles.24

The Resolution went uncontested at the public meet-ing. The absence of public opposition to the resolutionfrom the Medical Section of APHA suggested that oppo-sition would surface either at the JPC or GoverningCouncil meetings. The Policy Committee-C decisionwas to present the chiropractic resolution to the JPC thenext day as being uncontested. On November 23, thechiropractic contingent lobbied for support andplanned strategies while the JPC met in closed session.

It was learned during the day that opposition to theresolution would occur the following day during theGoverning Council meeting. As predicted, the MedicalCare Section (MCS), the largest section within theAPHA, spoke against the resolution and used a delayingtactic to avoid having it come to a vote. Their strategy wasto have the chiropractic resolution studied by an un-named committee.25 Interestingly, the APHA ExecutiveBoard Minutes, November 12–18, 1982, “reported thata resolution was coming before the Governing Councilwhich seeks an endorsement of chiropractic and whichwould supersede the 1969 resolution.”26

On November 24, the chiropractic resolution sur-faced for discussion by the Governing Council. Theoriginal resolution had been altered in content by theJPC but not beyond acceptance.27 The main objectivewas to have the 1969 resolution rescinded even if anew resolution could not be passed. During the dis-cussion, attempts were made to further alter thewording of the revised resolution, particularly changing




cover two important documents to support the find-ings of his letter of protest.35,36 He attached an intro-ductory note which emphasized an importantobservation, “one additional salient issue is the factthat APHA based its policy #6903 on the DHEW study;there is no internal APHA committee study of chiro-practic art and science.”

In anticipation of the January 13–14, 1983 meetingof the APHA Executive Board, Baird, Brassard andKranz prepared a statement on the “ChiropracticHealth Care proposal (1982).”37 No chiropractic repre-sentative appeared at this meeting. The following areextracts from the minutes:

Dr. Robbins stated that the first order of business is toexamine the scientific basis of chiropractic, and heurged that an individual be selected to review the stateof the art and report back to the Board on the currentstatus of chiropractic. He felt that the important thinghere was to conduct the study, not establishing yetanother committee.

Dr. Walker believed that the Governing Council hadassigned the Board a fact-finding task, not a judgmen-tal one, but the Executive Director commented thatthere were those on the Governing Council who feltthat to consider this as purely a scientific issue wouldoverlook such matters as choice of care, or inequities inholding chiropractors to a scientific standard that isnot applied to, for instance, health administrators, Dr.Robbins, however, felt that it was important to sepa-rate these points from the scientific questions becauseotherwise they become blurred together. Dr. Johnson,agreeing with the approach suggested by Dr. Robbinsmoved, and it was seconded, that an individual be engaged to conduct a literature search and prepare adocument for the Board’s review on the scientificbasis of chiropractic. The motion passed but notunanimously.38

The APHA commissioned Sylvia Simpson, M.D.,M.P.H., to prepare a background paper on chiropracticas directed by the Executive Board. The paper, titled“Background Paper on Chiropractic”39 was submitted tothe APHA on April 6, 1983.40 This 21 page paper with34 references was generally favorable to chiropractic.

The weakness in the Simpson paper is its relianceon very dated chiropractic concepts, discredited early studies (e.g., DHEW, 1968) by adversaries, andno reference to legislative, educational and researchachievements since 1968. The objective for the“Background Paper” was to examine the scientific sup-port for chiropractic, it is unfortunate that a more seri-ous effort was not made to accomplish that goal.41,42

However, the Baird response43 was charitable with thefollowing comment: “for a background study on

the phrase “primary care” to “limited care” and thephrase “licensed primary providers” to “licensed lim-ited providers.” The Governing Council, after twoamendments to the resolution, voted to table the res-olution until a committee selected by the Board ofthe APHA could discuss the resolution. The chiro-practic representatives were disappointed but real-ized, without a spokesperson on the GoverningCouncil, the resolution had no other route to follow.The major concern was the attempt to use the word“limited” to replace the word “primary.” The chiro-practic representatives met to examine the day’sevents and plan. Two actions were agreed to; first,the contingent would continue as an Ad HocCommittee to plan for 1983 and, second, to encouragemembership in the APHA—Radiological HealthSection, by chiropractic physicians and students. Itwas the committee’s opinion that the RadiologicalHealth Section with only 250 members offered thebest opportunity for the profession to have a chiro-practic member of that section elected to theGoverning Council to speak on behalf of chiropracticat Governing Council meetings.

Shortly after returning from the APHA meeting,Brassard contacted Wardwell and former ACA presi-dent S. Owens, both of Connecticut and closefriends of the newly elected APHA President-Elect,Susan Addis. He asked for their help in having Bairdeither appointed to the special committee to studythe chiropractic resolution or to be, at least, thesenior chiropractic consultant to the committee.30 Onthe same date, Brassard wrote to the APHA ExecutiveDirector and requested a chiropractic presence onthe committee.31 These actions prompted the authorto write to the APHA president on behalf of CCE and offer the CCE’s cooperation with theExecutive Board.32 Brassard continued with his con-tacts “on the APHA chiropractic resolution,” and onDecember 1, 1982 recommended seven actions toBaird.33

In the meantime, Baird was planning his responseto the Governing Council’s action of November 24,1982. He wrote a letter to the new APHA president,“to protest the actions of the Governing Council andExecutive Board in allowing the MCS to defer votingon the ‘Chiropractic Health Care’ proposed resolu-tion.”34 As Baird noted, correctly, the “only specificissue raised by the MCS was on the current relevancyof the 1968 DHEW findings on chiropractic educationand practices.” Baird enclosed and sent under separate




chiropractic, Dr. Simpson’s paper was fairly accurate;however, it is only a brief and very general overview ofthe profession.” The ACA response was less charitablewith the following comment:

Unfortunately, it suffers from two major research flaws;hopelessly outdated statistics and data, and omission ofinformation essential to the subject matter. The out-come is a report which leads its readers to numerous in-accurate impressions about chiropractic health careand its providers.4

Not one of Simpson’s thirty-four references is datedafter 1952. Only three chiropractic references arenoted and two of these were cited in the DHEW re-port. There is no evidence that Simpson interviewedany chiropractic educators or requested current infor-mation from any chiropractic source. The importance of Council on Chiropractic Education publications,particularly “Educational Standards for ChiropracticColleges Manual,” were ignored. Equally ignored werecollege catalogs, which list all faculty educationalqualifications.44

Acknowledged to be out of context, the following are examples of statements made by Simpson:“Chiropractors do not recognize other causes of disease,such as micro-organisms.45 Chiropractic places muchless emphasis on diagnosis than does orthodox medi-cine.46 Chiropractors reject surgery, drugs and immu-nizations as violating the sanctity of the human body.47

Now most schools require two years of college. Nowmany schools require that their basic science facultyhave graduate degrees.48 Users tend to be older, reportmore chronic health problems, have used physiciansrelatively frequently, but report difficulty getting doc-tors (M.D.) appointments.”49

The two chiropractic responses not only correctedthe above misconceptions, but went on to detail thehigher education gains made by the profession since1968. Both reports quoted from the Council onChiropractic Education Standards50 with emphasis onadmission requirements, standard chiropractic degreeprogram, diagnosis, scope of practice, cause of dis-ease, academic educational standards required by allfaculty, and practice standards.

The Baird response51 is noteworthy in response tothe statement by Simpson, that “chiropractic sees it-self as an integrated healing system, separate and dis-tinct from orthodox medicine,”:

In our view only part of the above statement is cor-rect. Chiropractic is indeed a separate and distinct

healing art, philosophy, and science in contrast to tra-ditional orthodox medicine. We hesitate to suggesthowever that it “is a complete integrated healingsystem.” In the words of the New Zealand RoyalCommission, “Chiropractors do not provide an alter-native comprehensive system of health care, andshould not hold themselves out as doing so.”Chiropractic has been forced to practice isolated mostof the time as a result of the ostracism it has beenfaced with. In any case, we generally see chiropractorsas being practitioners of “limited primary healthcare.” Chiropractors are primary care practitioners to adegree by virtue of the fact that patients may consultthem directly and as such may gain entry to the gen-eral health care system. At the same time, chiropractorsare “limited” in that they do not offer the comprehen-sive services often required in acute crisis care situation.In contrast, however, most medical physicians are“limited,” type practitioners considering that theydon’t generally provide all the services necessary tocompletely serve their patients.

This reference to chiropractic as a “limited primaryhealth care provider” is one of the first times that thisdescription has been used by the profession to clarifythe role of chiropractic in the health delivery system.

At the April 14–15, 1983 APHA Executive BoardMeeting four actions were taken.52 First, theExecutive Board designated itself as the referral groupfor further study of chiropractic policy issues and wasto report its conclusions and recommendations tothe Governing Council after considering the staff-commissioned background materials on chiropracticand a discussion with the chiropractic at its July meet-ing. Second, the question of a Chiropractic SpecialInterest Group was examined with the following ac-tion, “that the issue would be considered at the nextmeeting.” Third, by motion the Board favored propos-ing a new resolution to replace 6903, based on the“Background Paper” and other materials. Fourth, ap-plication by chiropractic organizations to becomeagency members was deferred until the Board arrivedat a final decision. Under the continuing leadership,of Baird, Brassard and Kranz, plans were made toattend the July 14–15, 1983 meeting. The AmericanChiropractic Association and the InternationalChiropractors Association actively encouraged theirmembers to join the APHA to strengthen the chiro-practic presence. Both ACA and ICA passed resolu-tions in support of participation in a national publichealth forum.

At the APHA Executive Board Meeting on July14–15, 1983, lengthy discussion took place on the“complex” question of chiropractic policy issues.53




1984, the council suspended its rules and allowed himto speak on behalf of the resolution. The text of Baird’sremarks are short, but of sufficient importance to berestated.

Thank you for suspending your rules and allowing me to speak. I have been asked to represent the chiropractic profession, and its organizations knownas the American Chiropractic Association, theInternational Chiropractors Association, the Council onChiropractic Education, and the Canadian ChiropracticAssociation, altogether totaling over 30,000 people, aswell as several hundred chiropractor members of theAPHA.

I am here now to represent our interests, and to an-swer your questions.

In response to the issue on the floor, the chiro-practor members of the APHA do not agree witheverything in the background paper by Dr. Simpson.But we are willing to accept it for what it is. It is an at-tempt to be objective, and to encompass many differ-ent viewpoints into a single summary document.Likewise, we do not fully agree with the alternativeresolution proposed by your Executive Board. But as acompromise to which we had some input, we arewilling to accept and support it.

A three year process, including a year long consid-eration by your Executive Board, led to this carefullyworded compromise resolution. This is a free choiceissue, this is a membership rights issue, this is a fairplay issue.

APHA is a multi-disciplinary organization.

Following Baird’s presentation and the endorsementof the Governing Council, resolution #8331 passed.60

On November 14, 1983 the Dental Section and theMedical Care Section attempted to have the chiroprac-tic resolution overturned but they were overwhelm-ingly defeated by the Governing Council and ExecutiveBoard majority.

The Chiropractic Special Interest Group has spon-sored in 1985 and 1986 the presentation of educa-tional, technical and scientific papers on chiropracticwhich have been well attended and applauded by themultidisciplinary audiences. Regardless of the com-fort the profession may take from adoption of a newpolicy on chiropractic by the APHA, there is still agreat deal of concern within the hierarchy of theAPHA for chiropractic patient care.61 It is this author’sopinion that the positive manner in which the presti-gious APHA was encouraged to reverse its harsh policyon chiropractic health care should serve as a modelfor others seeking to change policy or opinion of likeorganizations.

The chiropractic profession was represented byBaird, Brassard. Kranz, and Wardwell. As spokesmanfor the chiropractors, Baird acknowledged that “theyfound the proposed substitute resolution almostcompletely acceptable, with a few revisions.” Boardmember Sheps raised his concern for the “scientificvalidity” of the larger group of practitioners called“mixers,” who supplement their spinal manipula-tions with “more questionable” therapies. He alsoexpressed concern for the “sharp differences” intherapy used by the liberal and conservative practi-tioners. Baird provided an excellent answer in stating“the philosophical approaches to problems of healthand disease are different for the two professions, butthe bio-scientific basis for any health profession isgrounded in two sciences, anatomy and physiology.”He defended the chiropractic use of, for example, ul-trasonics, by explaining that chiropractors utilizesuch modalities in exactly the same way as physicaltherapists and medical doctors.

Following the chiropractors’ presentation, the Boardmet in private and “debated the chiropractic issues ex-haustively.” Typical of these issues, as recorded in theminutes,55 was that

many chiropractors do not limit themselves to thoseprofessional services which have been demonstratedto be safe and effective, and in fact some patientsturn to them for complete care. The Board felt thatthere is a potential for harm and; they may treat con-ditions for which they are not properly trained, theymay misdiagnose, and appropriate treatment may bedelayed.

The Executive Board went on to approve a resolu-tion for submission to the Governing Council inNovember, and approved formation of a ChiropracticSpecial Interest Group, however they denied agencymembership until the fate of the resolution was de-cided.56 The SPIG was established in September 1983,with Kranz as interim chairman. The APHA ExecutiveBoard announced its chiropractic decision in the asso-ciation’s publication, The Nation’s Health.57 OnSeptember 23, l983, Baird was mailed a “draft” copyof the chiropractic resolution proposed by the ExecutiveBoard.58

At the long-awaited meeting of the APHA GoverningCouncil on November 11, 1983, the proposed compro-mise chiropractic resolution finally surfaced for discus-sion. Since Baird had been elected a GoverningCouncil delegate for the Radiological Health Section in




References for “The Anatomy of a Policy Reversal”

1Wardwell, W.I., Social Strain and Social Adjustment in theMarginal Role of the Chiropractor. (Ph.D. Dissertation,Harvard University, 1951)

2Kranz, Karl C., Chiropractic in The Health Care System, 113thAnnual APHA Convention, Washington, DC, November18, 1985

3Evans, G. D., “A Sociology of Chiropractic,” Journal CanadianChiropractic Association, October 1973, pp. 6–18

4American Public Health Association Resolution 6903,“Chiropractic and Naturapathy,” Nov. 1969

5Cohen, W. J.: “Independent Practitioners Under Medicare: AReport to Congress,” (Dept. Health Education and WelfareWashington, D.C., 1968), pp. 146–207

6American Chiropractic Association, International ChiropracticAssociation, Council of State Chiropractic Examining Boards,“Chiropractic’s White Paper on the Health Education andWelfare Secretary’s Report ‘Independent Practitioners UnderMedicare,’ Washington, D.C., 1968” May 1969

7Correspondence of Rand Baird with John Romani, May 16,1979

8Correspondence of K.S. McCarter with Rand Baird, June 25,1979

9Correspondence between R. Baird and H. Cary, July, 1980-October, 1981

10Correspondence of B. Nordstrum with R. Baird, June 18,1981

11Baird, R., “Chiropractic Health Care,” late breaking APHAresolution, November 3, 1981

12Correspondence of R. Baird with S. V. Showell, November25, 1981

13Correspondence of S. V. Showell with R. Baird, April 21, 198214Correspondence of D. Anderson with R. Baird, June 4, 198215Baird, R., “Chiropractic Heath Care,” Section C, Personnel

and Training. The Nation’s Health, September 1982, p. 916News Release, International Chiropractors Association, July

26, 198217Correspondence of H. J. Vear with R. Baird, August 3, 1982.18Correspondence of R. Baird with H. J. Vear, August 16,

198219Correspondence of H. J. Vear with K. Davis and C. Johnson,

September 9, 198220Correspondence of W. Wardwell with K. Davis and C. Johnson,

October 18, 198221American Chiropractic Association, “Special Washington

Report, October 28, 1982,” Arlington, Virginia22“D.C. Members Seek Change in APHA Chiropractic Policy,”

California Chiropractic Association Journal, October 198223Baird, R., Kranz, K., “Testimony on a Chiropractic Policy

Proposal: Chiropractic Health Care,” Behalf of the ChiropracticProfession, ACA, ICA, CCE, CCA, before the APHA PolicyCommittee, November 22, 1982

24Vear, H. J., A Report to Dr. E. Napolitano, President, Councilon Chiropractic Education re: The American Public HealthAssociation Convention November 22–25, 1982, MontrealCanada, (unpublished document), p. 1–2

25Ibid., p. 2–326Minutes of Executive Board Meeting, American Public Health

Association, Item 3.43, p. 72, November 12–18, 1982

27Joint Policy Committee, American Public Health Association,revised “Chiropractic Health Care Resolution,” November23, 1982

28Minutes of Governing Council Meeting, American PublicHealth Association, November 24, 1982

29Vear, H. J., Rep. Napolitano, p. 3–430Correspondence of G. Brassard to R. Baird, November 30, 198231Correspondence of G. Brassard to W. McBeath, November

30, 198232Correspondence of H. Vear to T. Robbins, December 15, 198233Correspondence of G. Brassard to R. Baird, December 6,

198234Correspondence of R. Baird to A. Robbins, December 6,

198235Baird, R., Kranz, K., Testimony-APHA36McAndrews, G., Speeh-Palmer37Baird, R., Brassard, G., Kranz, K., “Statement Regarding The

Chiropractic Health Care Proposal (1982),” January 198338Minutes of Executive Board Meeting, APHA, January 13–14,

198339Simpson, S., “Background Paper on Chiropractic, April 6,

1983,” for the American Public Health Association40Minutes of Executive Board Meeting, APHA, April 14–15,

198341Baird, R., Brassard, G., Kranz, K., “Response to the

American Public Health Association ‘Background Paper onChiropractic,’” July 1983

42American Chiropractic Association, “A Response to theAmerican Public Health Association ‘Background Paper onChiropractic,’” ACA, Washington, DC, July 1983

43Baird, R., Brassard, G., Kranz, K., Response44American Chiropractic Association, A Response45Simpson, S., Background Paper, p. 146Ibid., p. 247Ibid., p. 348Ibid., p. 549Ibid50Council on Chiropractic Education, Standards51Baird, R., Brassard, G., Kranz, K., Response52Minutes of Executive Board Meeting, APHA, April 14–15,

198353International Chiropractors Association, “American Public

Health Association Resolution, April 1983” adopted at1983 convention in Seattle, WA

54Minutes of Executive Board Meeting, APHA, July 14–15,1983

55Ibid56Ibid57American Public Health Association, The Nation’s Health,

August, 1983, p. 858Correspondence of S. B. Brodbeck to R. Baird, September

23, 198359Baird, R., “Comments to APHA Governing Council, November

11, 1983,” Houston, TX60American Public Health Association Policy Resolution,

8331, “Appropriate Role of Chiropractic In Patient HealthCare” November 11, 1983

61Correspondence of W. McBeath to R. Miller, January 9, 1985




made the APHA a powerful ally. Indeed, when the pro-fession in the form of the World Federation ofChiropractic (WFC) sought official relations with theWorld Health Organization (WHO) in 1996, the WorldFederation of Public Health Associations (WFPHA) offi-cially endorsed the application to WHO. This supportcame about specifically because of chiropractic in-volvement with the APHA, a significant member of theWFPHA.

This full parity as health professionals within theAPHA did not always exist. As late as 1983, the APHAhad an official policy against chiropractic. Chiropractorswere considered a threat to the public health per APHApolicy #6903. Through this policy, the APHA called onfriends of public health throughout the United States topursue the revocation of licensure of chiropractors ineach state. That policy stood from 1969 to 1983—14years!

In 1987, Herbert J. Vear, DC, outlined the overturning ofthat policy in “The Anatomy of a Policy Reversal: TheA.P.H.A. and Chiropractic, 1969 to 1983” in ChiropracticHistory. In that paper, Vear described how chiropracticstudent Rand Baird, MPH approached the APHA in 1979to determine their openness to chiropractic. It was thenthat the profession became aware of the anti-chiropracticpolicy. Vear described Baird’s efforts to get chiropractic a“profession code” within the APHA, so chiropractorscould join the APHA as chiropractors despite the anti-chiropractic policy. Vear outlined the efforts of chiroprac-tors, chiropractic colleges and chiropractic associations topush for policy change from within the APHA after join-ing it. In 1983, chiropractors were permitted to form aSpecial Primary Interest Group (SPIG), called theChiropractic Forum, though chiropractic organizationsand colleges did not yet achieve status as APHA affiliatedagencies. Late in 1983, policy #6903 was reversed with#8331, a compromise policy that supported chiropracticon a limited basis.

Some groups, such as the Dental Care Section, hadopposed passage of policy #8331 and also tried toblock agency membership for chiropractic organiza-tions. They did so by noting what they described asthe historic opposition of some chiropractors to well-established public health measures such as drinkingwater fluoridation. As that opposition was raised,

Chiropractors were granted the right to form a groupidentity within the American Public Health Association(APHA) at the conclusion of 1983 after an officialanti-chiropractic policy was reversed. Beginning in1984, chiropractors began serving alongside otherpublic health professionals within this prestigious as-sociation, the world’s oldest and largest public healthorganization. Although permitted a group identitywithin the APHA, chiropractors still had to overcomemany obstacles to full participation, including profes-sional bias, misunderstanding, and struggle withinthe ranks. By 1995, chiropractic succeeded in achiev-ing full APHA section status, or full equivalence toother health professions within the APHA. Theyear 2005 marked the tenth anniversary of thisachievement. This article traces the history of chi-ropractic within the APHA from the early years of acceptance to the eventual celebration of a decadeof full parity.

The year 2005 marked the tenth anniversary of theChiropractic Health Care (CHC) Section within theAmerican Public Health Association (APHA). In thatyear, two elected chiropractors and the section chair ofthe CHC section served on the Governing Council, theofficial policy making body of the APHA. There were17 scientific and technical papers authored by 37 chi-ropractic co-authors presented in 4 sessions at the133rd annual meeting of the APHA in Philadelphia, PAin December 2005.

In this and other recent years, chiropractors havebeen found at all levels of the APHA, having served onthe Executive Board, published in the prestigiousAmerican Journal of Public Health (AJPH), functioned invarious leadership positions, and coordinated the ac-tivities of the CHC section. Chiropractors have re-ceived several significant honors within the APHA,including awards of distinguished service, the opportu-nity to personally introduce the United States SurgeonGeneral at the Annual Meeting, and recognition for in-dividually recruiting more members than any othermember in the history of the association.

Chiropractic has full parity within the APHA, servingalongside over 50,000 other professionals who advo-cate for health promotion, disease prevention, andhealthy individuals and communities. This parity has


CHIROPRACTIC WITHIN THE AMERICAN PUBLIC HEALTH ASSOCIATION, 1984–2005: PARIAH, TO PARTICIPANT, TO PARITY

Jonathon Todd Egan, DC, MPH, Rand Baird, DC, MPH, and Lisa Zaynab-Killinger, DC23



Rand Baird, DC, MPH said to the assembly, “We’lltoast the Dental Care Section by drinking a glass ofAnaheim fluoridated drinking water right here.” ThoughDr. Baird was ruled out of order, the wry humor suc-ceeded and the new chiropractic agency memberswere allowed.

For full details on reversal of policy #6901 and thepassage of policy #8331 see the Vear paper.Chiropractic involvement in the APHA since the rever-sal of that policy from 1984 forward will be furtheroutlined here.

The Council on Chiropractic Education (CCE)formed a Panel on APHA in 1984. The first chair andmembers were Dr. Rand Baird and Drs. John Barfoot,Karl Kranz, and Herbert Vear. A significant first for chi-ropractic occurred this year, as Dr. Baird was elected tothe Governing Council of the APHA by the RadiologicalHealth (RH) section, the section most chiropractorsjoined to allow professional representation within APHAthrough aggregated numbers. The path was becomingclear for increased chiropractic participation, andshortly thereafter both the American ChiropracticAssociation (ACA) and the International ChiropractorsAssociation (ICA) passed resolutions encouraging alltheir chiropractor members to join the APHA as a non-sectarian profession-wide venture.

Because chiropractors were now welcome as a pro-fession within the APHA and had achieved a group sta-tus and identity, 1985 became a year of many morefirsts for chiropractic. Chiropractors had previously op-erated booths in the exhibit hall at the annual meeting.1985 was the first year that chiropractors presentedscientific and technical papers within the APHA at theannual meeting. Those annual presentation sessionscomprise the educational program, and have been aprestigious venue for researchers, educators, and clini-cians to present their work to multidisciplinary audi-ences in the years since. Dr. Rand Baird became thefirst chiropractor to serve on any APHA committee,serving on the Election Tellers committee. (The ap-pointment of Dr. Baird to this committee by Dr. VictorSidell, MD, APHA President, was a real show of sup-port. Dr. Sidell had already played a key role in helpingchiropractic gain acceptance within APHA.)

Chiropractors were invited to participate in theGoverning Council elections for unaffiliated members(from the chiropractic SPIG, as chiropractic still lackedits own official full section). They further continuedservice as members of the Governing Council from theRH section. Another significant first showed the power

of membership in a membership-driven professionalorganization: When contacted during the electionprocess, each candidate for the President-elect andExecutive Board within the APHA this year expressedsupport for the role of chiropractic within the APHA.

Despite these gains, a problem that would hauntchiropractors organizing within the APHA became evi-dent, even at this early stage. Many chiropractors—and especially chiropractic students—were joining theAPHA, yet few were renewing membership. In 1986,despite 101 new chiropractic members in the RH sec-tion, there was no net gain in membership because176 chiropractic members failed to renew. Similarly,the Chiropractic Forum SPIG had 113 new membersbut 134 did not renew their membership. Though theChiropractic Forum remained the largest SPIG withinthe APHA, it was observed that it would have been25% larger if chiropractic members would renew theirmembership. As will become clear, chiropractic en-franchisement within the APHA would be threatenedbecause of high non-renewal rates. However, chiro-practic yet remained enfranchised, which continuedto provide unique opportunities for chiropractors toengage their fellow health professionals.

In late 1985, another difficulty that would follow chi-ropractors within the APHA was the failure of electedmembers to fill their leadership roles. A true leadership cri-sis appeared this year, when the Vice-Chair and Secretary-Treasurer did not fulfill their duties, the Program chair/Unaffiliated Governing Councilor resigned, and theelected Chair resigned due to health problems. Dr. KarenLarson took the helm for 1986–1987 and did a remarkablejob leading the SPIG through a leadership crisis. In 1986,Dr. Vear announced his intention to transfer from theRH section to the Chiropractic Forum to help provideleadership there.

In 1986, Dr. Baird questioned the candidates for theAPHA Executive Board. He queried: “Although APHAhas a SPIG Chiropractic Forum and several hundredchiropractic doctors, chiropractic educators, and chiro-practic students, as well as four agency members,there still seems to be some controversy about chiro-practic participation in APHA; what is your opinion ofchiropractic participation in APHA?” He received uni-formly favorable responses from all candidates.

At the 1987 annual meeting, all of the chiropracticpresentation sessions were attended by Ruth E. Parry,M.A., M.A.S., a representative of the Veterans’ Adminis-tration (VA). She explained that she was attending to learn about the chiropractic profession, including





education and scope and standards of practice. She didnot share her specific opinions of what she heard thatday beyond being generally pleased with the presenta-tions. However, chiropractic was clearly “on the radar”within the APHA. Organizations were taking notice andtaking the opportunity to learn about the professionfrom chiropractors at their educational program paperpresentations.

Relationships between APHA and chiropractic or-ganizations were developed and strengthenedthroughout the decade. In 1987, the ACA establishedits Committee on the APHA. Dr. Vear served as thefirst chair of this committee, whose inaugural mem-bers included Drs. Baird and Lee Selby. (Dr. Baird hadalso served as the ICA representative to the APHA an-nual meeting each year from 1983–2003, and othersoccasionally served the ICA in this role.) The ACApanel in essence filled the role the CCE panel servedfor the prior 4 years, and so in 1988 the CCE panelwas dissolved, though the CCE retained affiliatedagency status with APHA. As chiropractors affiliatedwith the APHA continued to refine these professional re-lationships, it became clear that increased coordina-tion was needed with other chiropractic groupsinterested in public health. In 1989, officers of the chi-ropractic SPIG, RH section, ACA APHA panel mem-bers, the ICA representative, and ACA executive boardliaison enhanced inter-organizational communicationand coordination in an attempt to eliminate the dupli-cation of effort. Common purposes forged stronger re-lationships. Despite this, at year’s end there was noformal contact between chiropractors in the APHAand chiropractic college public health instructors, theAssociation of Chiropractic Colleges (ACC), and nowthe CCE.

By 1989, chiropractors represented a majority ofthe membership within the RH section for the firsttime (189 out of 341 members). As chiropractic repre-sentation grew, so did the number of chiropractorsserving as officers within the section. In 1989, chiro-practors served in every leadership position within theRH section except the Section Chair—a deliberatestrategy to prevent alienating the non-chiropracticmembership of that section. However, many chiro-practors were again elected that did not or could notfulfill their responsibilities.

Despite the aforementioned difficulties in retentionand in the failure of some elected to leadership toserve, the dedication of several determined individualsand the support of several professional organizations

and schools made the difference. Chiropractic sur-vived and continues within the APHA due to the ef-forts of a core group of active members and leaderswho diligently championed the role of chiropracticwithin public health. Many volunteered, some eventaking unpaid leave from private practices to serve thegreater good of the chiropractic profession. Collegesand associations sponsored many others. These individuals eventually helped achieve parity for chi-ropractic within this prestigious multidisciplinaryassociation.

In 1990, a national health program appeared likely tosucceed under the direction of the ClintonAdministration. The Chiropractic Forum SPIG fre-quently pondered the role chiropractic might fill insuch a system. Members of the group felt concernedthat there did not appear to be a national chiropracticstrategy at any level to help shape the national healthcare policy from chiropractic’s point of view. Membersof the SPIG were concerned that it was unclear if man-dated coverage would be determined at the state ornational level and that chiropractors were not engag-ing this policy debate.

Another concern in 1990 was that the ICA had cre-ated new policies against immunization and drink-ing water fluoridation. Immunization and fluoridationare widely accepted public health practices and itwas feared that these ICA policies would not be wellreceived within APHA. Further, the ICA was anagency member of the APHA, and these policies ap-peared to contradict other verbal statements by theICA made when it applied to be an APHA agencymember. A related concern raised in 1990 was thatchiropractors lacked interest in the overall publichealth effort because the public health educationgiven chiropractic students may have overly focusedon fluoridation and immunization. This strong focuson these “hot-button” issues appeared to be made atthe expense of broader public health issues—andpotentially at the expense of the role chiropracticcould play in public health. To address this concern,Drs. Baird and William Meeker were asked to pre-pare a sample syllabus for a chiropractic publichealth course. At the same time, they were asked toconsider and make recommendations for the appor-tionment of questions for national board exams inpublic health and microbiology that would reflectthe enlightened curriculum.

Old problems persisted in 1990. Several electedmembers did not serve or show up for meetings and



retention remained unacceptably low, preventing theSPIG and the RH section from reaching their poten-tial. Compounding the problem this year was that thecall for abstracts for the annual meeting of the APHAwas not appropriately published within the profes-sion. A relatively poor response ensued. Further, thoughchiropractors had been formally admitted to theAPHA for 5 years, no chiropractic-authored paper hadyet appeared in the prestigious AJPH. Dr. Baird hadtwo letters published in The Nation’s Health, the peri-odical of the APHA, and two letters to the editor inAJPH, but no article authored by chiropractors had yetappeared in AJPH.

Chiropractors within the APHA attempted to addressmany of these problems in 1991. To address member-ship, Dynamic Chiropractic offered to donate advertisingspace, run a recruiting article, and include membershipapplications to the APHA. Leadership service improved,with only one member not attending the annual meet-ing this year, yet still submitting a report. To address thepublic health issues of immunization and fluoridation,chiropractic members of the APHA recommended thatthe ACA take an official stand in support of these publichealth measures. To improve attendance at chiropracticpresentations at the annual meeting, the SPIG and theRH section determined to have copies of each other’sprograms within their booths. In spite of errors in thepublication of the “Call for Abstracts” for the annualmeeting educational program in many chiropractic ven-ues that year, chiropractors were making progresswithin APHA.

Positive events in 1992 included Dr. Baird’s ap-pointment from the RH section to the APHACommittee on Membership, only the second time achiropractor was appointed to a national committeewithin APHA. In 1992, a pro-chiropractic APHApresident (Helen Rodriguez-Trias, MD) was electedwho would begin service in 1993. Dr. Rodriguez-Trias would prove an important ally now and yearslater when official section status was sought. Also in1992, Dr. Vear presented the proposed draft of apro-vaccination policy for the ACA to consider en-dorsement. Fluoridation was discussed as well.Most Chiropractic Forum members present at theannual meeting voted to support these policies.They felt, as do almost all in the public health field,that immunization and fluoridation are proven pub-lic health tools. The group again recommended thatthe ACA adopt positive official stands on vaccinationand immunization as an agency member, especially

in light of the ICA’s perceived opposition to thesemeasures.

Dynamic Chiropractic and other publications againhelped publicize the need for chiropractors to join theAPHA. This year, the “Call for Abstracts” receivedmuch better attention. At the 1992 annual meetingwhen the presentations were given, four medical epi-demiologists from the Centers for Disease Control andPrevention attended the chiropractic session on im-munization. These epidemiologists appeared genuinelyinterested in the presentations.

Despite gains in recruitment, 1992 was a criticalyear for membership. The chiropractic SPIG had the4th best recruitment rate but the absolute worst reten-tion rate of all APHA SPIGs. The RH section had the 8thbest recruitment rate of all 24 sections within APHA,but ranked a dismal 23rd in retention. Because of this,there was another net loss in membership in both theSPIG and the RH section. Membership is critical for the re-tention of section status—and the voting seats on theGoverning Council and APHA budget allocation thatcome with such status. As long as chiropractors wererepresented in an official section (in this case, the RHsection) and had members on the Governing Council,they were able to help shape APHA policy. Otherwise,they effectively stood to lose representation and identitywithin the APHA. If chiropractic did not have 250members in the RH section by September 1993, thesection could be disbanded. All that had been accom-plished over the last 13 years in the struggle for recog-nition of chiropractic within APHA would be lost.

Chiropractors worked hard at recruitment, and in1993, chiropractors within the APHA reaped the re-wards of their labors. Many chiropractic publications—especially Dynamic Chiropractic and those of theFoundation for Chiropractic Education and Research(FCER) and the ACA—had discussed the possible loss ofenfranchisement and voting seats if more chiroprac-tors did not join the APHA. Dr. Baird authored severalarticles within Dynamic Chiropractic about theSeptember deadline. As a result, 1993 was a huge yearfor recruitment. The RH section reached 614 mem-bers, with the best recruitment rate of all sections andthe largest membership in the 28-year history of thesection. However, the renewal rate remained theworst. The Chiropractic Forum SPIG grew to 352members, reflecting the best recruitment rate amongSPIGs. It also had its highest membership ever; its sizeeven exceeded that of 2 official sections. However, its re-newal rate was the very worst of all sections and SPIGs.




about a broad range of health issues, many of whichtranscend their own discipline.” As the professioncontinued to integrate and enter the mainstream, itwas felt that Dr. Coulter succinctly expressed theneed for chiropractors to become “literate” abouthealth care issues larger than themselves. A third sig-nificant event was that an educational session at theannual meeting called “Alternative Care—Fad orMedical Failure” was held that was not co-sponsoredby chiropractors and had 6 speakers, none of whichwere chiropractors.

Networking with other healthcare professionals iscritical, and this represented a missed opportunity, asdid the fact that chiropractors mostly had been pre-senting research to other chiropractors at these annualmeetings. One example of the power and importanceof networking with other professionals became evi-dent at the 1993 annual meeting. Just as Dr. Sidell andDr. Rodriguez-Trias were powerful allies who had beenand would yet be tremendously helpful to the profes-sion achieving parity, others with increasing familiar-ity with chiropractic would become friendly andhelpful. The new incoming President for 1994 (whobegan service at the 1993 annual meeting) wasEugene Feingold, PhD, JD. He had formerly vigorouslyopposed formal chiropractic participation within theAPHA. However, he later took part in the reaccreditationprocess for Palmer College of Chiropractic and wasnow satisfied with chiropractic’s scientific base. Hestated that he welcomed chiropractic within theAPHA. Here, and in so many other occasions, famil-iarity with chiropractic brought new respect for theprofession. Working in the APHA, which allowed chi-ropractors to work closely with thousands of simi-larly public health-minded practitioners, affordedmany opportunities for building these new bridges ofunderstanding.

1994 was another critical year. Echoing the failureof the Clinton health plan was a leadership crisis in thechiropractic SPIG. The elected chair of the SPIG, a non-DC, was removed from office after 11 months of failureto perform duties. Dr. Mitchell Haas took up the reins asacting chair after special election by the other SPIGleaders. This was a portentous time. There was a criti-cal mass of chiropractors in the RH section and in theSPIG. The RH section had determined to change itsname to “Radiological Health and Chiropractic CareSection,” but the request to change the name was de-nied by the Executive Board of the APHA in July 1994.The Board suggested that rather than change the

This growth did not escape the attention of the APHA,where it was noted that this August was one of thebest single recruiting months in APHA history, largelydue to the chiropractic response.

Subsequent to this tremendous growth and the factthat over 500 of the members of the RH section werechiropractors, consideration was given to changingthe name of the RH section to reflect chiropracticparticipation. Chiropractors were satisfied with theirrelationship to the section; they simply wanted thename to reflect the interests of the group. Severalnames were discussed, including “Chiropractic Careand Radiological Health Section” and “ChiropracticCare and Radiation Protection Section.” A committeewas formed to prepare a 5-year plan for the section.The committee members were Bill Kirk, PhD, DennisMurphy, PhD, Martin Meltz, PhD, and Rand Baird,DC. The plan would include the mission, vision, andgoals for the section, which would help direct thenaming process.

Because of the number of chiropractors now pres-ent in the APHA in both the Chiropractic Forum SPIGand the RH section, consideration was also given tohaving members of the SPIG transfer to the RH sec-tion if a name for the section was chosen that re-flected professional identity. If this happened, thecombined section would have strength exceeding1,000 members, and would be the 11th largest sec-tion. Voting seats and budget would accompany size,and would afford great privileges to chiropracticwithin the APHA. As will be noted, the name changenever happened, and events unfolded that wouldlead to chiropractic forming its own official sectionin the near future.

In recognition of service and recruitment, the RHsection presented a Distinguished Service Award in1992 to Dr. Rand Baird, the first time a chiropractorreceived such distinction in the history of the APHA.Dr. Baird also continued in his role on the APHACommittee on Membership, only the second time thata chiropractor served at the national committee level.

Several noteworthy events occurred at the 1993annual meeting of APHA. First, Hillary Clinton spokewith APHA leaders about national health care reform.Second, Ian Coulter, PhD, gave a presentation at thechiropractic research sessions on how to think abouthealth care policy issues. According to his abstract,“education as a health professional will not necessar-ily result in the ability to do policy analysis. Its purposeis to enable health professionals to become ‘literate’




name of a section organized around an interest, thatchiropractors seek their own independent section.Strong leadership was essential here.

Six chiropractors accepted the substantial responsi-bility to complete the application for Section statuswithin the APHA. Drs. Mitchell Haas (serving as chair),Rand Baird, William Meeker, Robert Mootz, MichaelPerillo, and Fred Colley, PhD, agreed to do the consid-erable work assembling the materials required by theAPHA. It took several months, but the opportunity rep-resented the culmination of sixteen years of effortwithin the APHA.

As part of the strategy to become a full section, Dr.Baird suggested that 200 chiropractic members of theRH section switch their membership to the chiroprac-tic SPIG. When this was done, there were over 500members in the SPIG. At this size, the chiropracticSPIG was larger than all the other SPIGs combined andlarger than 7 sections. It was also the largest SPIGever—which placed chiropractic in a great position toachieve full section status with voting privileges on theGoverning Council and full parity. These authors haduntil April 1995 to prepare the APHA section applicationfor the chiropractic profession.

Despite the excitement among chiropractic mem-bers about the potential opportunity to become a full-fledged section, chiropractic continued to be plagued bynon-attendance at the year-end APHA annual meet-ing. Three of the sixteen papers scheduled for presen-tation during the chiropractic sessions were simplynot presented, because their authors did not attendthe conference. One of the chiropractors scheduled topreside over a session failed to attend without provid-ing notice. Dr. Craig Nelson substituted at the lastminute for this individual, but credibility was still af-fected every time someone failed to fill the responsi-bilities they had accepted.

Three exciting developments from 1994 deservefinal mention. First, the APHA officially supportedCalifornia’s Health Security Proposition 186. Thoughthe proposition ultimately did not pass, this was a wa-tershed moment, as the APHA gave as one reason forits support the fact that this proposition had chiroprac-tic coverage as one of its benefits. In this and later po-litical battles, it was clear that participation in thishighly regarded organization was important for chiro-practic and for public health. The APHA was a perennialstrong voice on Capitol Hill—and now included chiro-practic interests in its agenda. Another developmentwas that the RAND Corporation, a scientific “think-tank,”

published studies on chiropractic that helped to fur-ther the chiropractic cause. A last development of notefrom 1994 was that a new SPIG formed: “AlternativeMedicine.” This SPIG had few members to start with,but had substantial interest. One of their sessions,“Alternative Methods of Medical Care,” had an audi-ence of 250.

April 1995—the deadline for the chiropractic sec-tion application—arrived. This excerpt from the 1995ACA Committee on American Public Health Associationannual report summarizes the events leading to fullsection status for chiropractic in APHA [original gram-mar, spelling, and punctuation retained except asnoted]:

The application and supporting documents were firstsubmitted to APHAs Executive Board in March for theBoard’s April 17–18 meeting, deferred until May 9,1985. After lengthy discussion and evaluation of theapplication according to the 1975 “APHA Criteria forEstablishment of New Sections,” the Board returnedthe application to the authors requesting additional in-formation and more specific answers to some of thequestions that accompanied the criteria. These wereaddressed and the application revised again, andresubmitted to the Executive Board which then re-viewed it July 18, and determined its completeness,and scheduled it on the subsequent agenda of theGoverning Council. . . .

Throughout the Summer and Fall, the team mem-bers, especially Drs. Haas and Baird, continued corre-spondence and conversation with APHA leaders,Governing Councilors, and Executive Board members,answering questions and concerns and lobbying forthe application. Varying degrees of support wereelicited from Board Members. . . . Lively debate wasencountered from [some].

The Governing Council began the discussion of theChiropractic section application on Wednesday,November 1, 1995 shortly after 9:00 am. Dr. MitchellHaas as a Governing Councilor from the SPIGs, and Dr.Rand Baird holding a proxy from the RadiologicalHealth chairman, were seated.

When the Governing Council began the debate, sev-eral other well-known leaders in the scientific commu-nity spoke out for chiropractic! William Kirk, PhD,radiation physicist, spoke on chiropractors’ expertise inradiation protection of the public. Victor W. Sidell, MD,a highly regarded former president of APHA and inter-nationally acclaimed physician spoke about our dedica-tion and our contributions. Letters of support werereceived by the Governing Council from DennisMurphy, PhD, Chair of the Radiological Health Section,and from Helen Rodriguez-Trias, MD, another recentAPHA past president. Professor Jon Lemke, PhD, fromthe Statistics Section, spoke about chiropractic researchand praised Palmer College’s research department.




the time of the application. Dr. Rodriguez-Trias voicedher support with these words:

Over the years that the Chiropractic Forum has been ac-tively involved in APHA activities, I have met with manyof its leading members. I have been struck by their un-derstanding and commitment to APHA’s mission andgoals. The Chiropractic Forum would make an excellentaddition to the community of APHA sections. I hope thatthe Executive Board will add its support to the Forum’s ap-plication when it comes before the Governing Council.

Dr. Haas became the first chairman of the newChiropractic Health Care (CHC) section. He immediatelyappointed the other five chiropractors that had helpedcomplete the application for section status to a commit-tee to prepare a mission statement for the new section.Drs. Rand Baird, William Meeker, Robert Mootz, MichaelPerillo, and Fred Colley, PhD went to work.

Because the new section had been created, chiro-practic members continued to shift from the RH sectionto the CHC section. It was assumed that some chiro-practors with DACBR (Diplomate, American ChiropracticBoard of Radiology) credentials would remain in theRH section, but most chiropractors transferred. Thiswas a blessing to the new CHC section, but did harmthe RH section. RH section members and officers—many of whom were not chiropractors—deservethanks for their support of the chiropractic section ap-plication. The RH section faced downgrading to SPIGstatus before chiropractors began joining the sectionin the early 1980s, and now did again as the chiro-practors left. Chiropractic membership had temporar-ily breathed new life into the RH section, but theradiation protection members never revitalized re-cruitment from their own primary profession. Many ofthe RH leadership roles had been expertly filled byDrs. Rand Baird, John Pammer, Jr., Sharon Jaeger,Michael Loader, and Robin Canterbury, but an unfilledgap was created when they eventually left to join thenew CHC section. In 1998, three years after chiroprac-tic achieved its own section, the RH section wouldfinally revert back to a SPIG after 34 years as a section.The low renewal rate of chiropractic members contin-ued to plague the new CHC section. It was clear that toretain section status, the CHC section should strive tohave 500 members in September 1998 when the offi-cial membership tally was taken by APHA. If therewere not 500 members, section status would beendangered.

At the moment, though, chiropractors in APHA cele-brated the fact that many years of hard work had paid off.

Ted Miller, PhD, from the Injury Control & EmergencyHealth Services Section, eloquently described the highquality of chiropractic care for low back pain and otherinjuries, for valid data documenting our efficacy, quotedthe [Agency for Health Care Policy and Research] guide-lines and other studies, and praised chiropractic col-leges and ACA and ICA for their track record inmaintaining agency membership in APHA.

Minimal opposition was raised to the chiroprac-tic section application, mostly in the form of con-cerns about chiropractic support of proven publichealth practices such as immunization and waterfluoridation. Concern was also raised that aChiropractic section should focus on rallying chi-ropractors’ support for public health preventativeprograms; the need to monitor fringe practitionersand unscientific procedures was also mentioned.Opposition was voiced by John Muth, MD, MPH,from the Colorado affiliate, and from APHA President-elect E. Richard Brown, PhD. Mention was made fre-quently of an anti-vaccination letter filled withquestionable references that had been published afew weeks prior in The Nation’s Health by a self billed“DC-MPH homeopathic physician-public health edu-cator” (who fortunately was determined not to be a member of ACA or ICA or APHA!). Dr. VictorSidell spoke again in our defense, as did Alan I.Trachtenburg, MD MPH, chairman of Alternativeand Complementary Health Practices SPIG [the re-named “Alternative Medicine” SPIG], and acting di-rector of the Office of Alternative Medicine at [theNational Institutes of Health].

Dr. Haas expertly answered several concerns, andDr. Baird ended the debate by calling for fair play,equal membership rights, and non-discriminationagainst a profession, pointing out to the GoverningCouncil that the section application was in good orderand that the chiropractic members were stronger insome areas than others but nevertheless in substan-tial compliance with the required criteria for beinggranted full section status.

The application was voted upon and by an over-whelming majority the CHIROPRACTIC HEALTH CARESECTION was established, becoming the first new sec-tion in three years, joining APHAs 24 other sections asa full-fledged partner with equity and parity with allother disciplines. It was noted that in its Centennialyear, the Chiropractic profession had joined the otherprofessions for public health.

Indeed, in the year chiropractic celebrated its hun-dredth birthday, it achieved equality in this setting.

The section’s name was chosen by Dr. Rand Baird,and was—and remains—the only section with boththe words “health” and “care” in it. As noted previ-ously, connections made in years past had proven for-tuitous. Both Dr. Sidell and Dr. Rodriguez-Trias asformer APHA presidents provided critical support at




The CHC section was excited to work with the PodiatricHealth, Vision Care, and RH sections, as well as with theAlternative and Complementary Health Practices(ACHP) SPIG on collaborative projects as a full APHApartner at last. The ACHP SPIG was growing rapidly andwas very public with their support of the chiropracticsection. Last, another important contact came into a po-sition to help the profession: Fernando Trevino, PhD,MPH, Executive Director of APHA was elected presidentof WFPHA. The WFC would make its application toWHO in the next year, and WFPHA would offer its sup-port with these words:

The purpose of this letter is to offer the support of theWorld Federation of Public Health Associations(WFPHA) for the application of the World Federation ofChiropractic (WFC) for official relations with WHO. Weare familiar with the WFC . . .

Members of the chiropractic profession have beenincreasingly active in national public health associa-tions. In 1995, after approximately ten years [sic] of col-laborative work, the American Public Health Associationcreated a separate chapter for chiropractic in recogni-tion of the contribution of members of the profession tothe activities of APHA. WFPHA is of the view that theWFC can be a significant resource in assisting the goalsand activities of WHO.

For these reasons, WFPHA gives its warm supportto the present application.

Those “years of collaborative work” were beginning tobear fruit in 1995 and 1996 and the future seemedbright for chiropractic and public health. In 1996, chiro-practors were serving in multiple roles at the nationalAPHA level. The CHC section staffed its first booth at theAPHA annual meeting under Dr. Michael Perillo’s coordi-nating efforts. The section produced its mission state-ment, section information sheet, and booth descriptionunder the direction of Drs. Haas and Baird. The CHCsection co-sponsored presentation sessions with at leastfive other groups at the annual meeting. For the firsttime, the CHC section presented its own awards forDistinguished Service and Accomplishments. Thesewere given to Drs. Rand Baird, Karl Kranz, and HerbertVear. The RH section gave awards of DistinguishedService to two chiropractors: Drs. Beverly Harger andMichael Loader. The new President-elect of APHA—Dr.Quentin Young, MPH—was an old hospital acquain-tance of Dr. Baird and “pro-chiropractic.” Despite con-tinued poor renewal resulting in only 362 membersremaining in the CHC section, these positive eventsdemonstrated that chiropractic was fully engaged in APHA.

In 1997, Dr. Cheryl Hawk of Palmer College ofChiropractic facilitated another first for chiropracticin the APHA. Dr. Hawk arranged for ContinuingEducation credit for the chiropractic-sponsored education sessions, generating positive visibility.Additionally, the CHC section continued to coordi-nate presentation sessions with other groups. TheCHC section was involved in many APHA projects, in-cluding work on the Strategic Plan and various taskforces and initiatives. APHAs Executive Director, Dr.Mohammed Akhter, recognized Dr. Baird for his tremen-dous success in recruiting members to the APHA. Dr.Baird has recruited more members to the APHA thanany other member in the history of the association.Chiropractic membership in the CHC section didmildly increase in 1997 to 430. However, by 1998,500 total members were needed or the section couldbe threatened with dissolution.

In 1998, the section discussed several topics, includ-ing the ideal chiropractic public health curriculum thatwould be presented at the next ACC meeting and policystatements on immunization and fluoridation by APHAagency members ICA and ACA that seemed to contradictofficial APHA positions. The CHC section discussedsubmitting input to the “Healthy People 2010” goals,but found that FCER was already working on this. Thegroup further noted a significant trend was emergingin that an increasing number of chiropractors werepursuing formal public health degrees. Section mem-bers hoped that this would help further unite chiro-practic practitioners with public health practice. Despitethe section’s efforts, membership dropped below 300in August 1995. Though recruitment of new memberswas exceptional, low renewal rates continued to plaguethe section.

Several significant events occurred in 1998. First,Dr. Mitchell Haas was elected to serve the APHAIntersectional Council as Chair-elect (and would serveas Chair in 2000–2001). This remains the highestelected position any chiropractor has held in the APHA.Due to a rule change, he would also receive an auto-matic seat on the Executive Board in 2000, which be-came the highest position ever filled by a chiropractorwithin the APHA. Second, a chiropractic-authoredpaper appeared in AJPH for the first time. Eric Hurwitz,DC, PhD, Ian Coulter, PhD, Alan H. Adams, DC, BarbaraGenovese, MA, and Paul Shekelle, MD, PhD published“Use of Chiropractic Services from 1985 through 1991 inthe United States and Canada” in the May 1998 issue.Other chiropractors served on APHA-level committees.





Last, as noted, the RH section was downgraded to aSPIG in 1998. By then all chiropractors had transferredto the CHC section.

In 1999, the ideal public health curriculum for teach-ing public health in chiropractic colleges was continued,and even received some attention in The Nation’sHealth. For the first time, other health care disciplinesoffered continuing education credit to their memberswho attended chiropractic sessions, a practice thatwould continue. Despite these accomplishments, mem-bership in the section continued to struggle and wasabout 300 that year.

Dr. Michael Perillo received a Health Resources andServices Administration (HRSA) grant in 2000 to furtherthe development of the ideal chiropractic public healthcurriculum. In 2001, that progress would be noted in afull article in The Nation’s Health. Unfortunately, CHCsection membership slipped under 300 in 2000, con-tinuing the difficulty persistently faced by chiropracticwithin this venerable institution.

In 2001, because of his service as the Chair of theIntersectional Council, Dr. Haas sat on the APHAExecutive Board. As such, he had the opportunity to pre-side at a session featuring U.S. Surgeon General DavidSatcher. That year, Dr. Haas was also elected by theOregon Public Health Association to its seat on theGoverning Council and its Executive Board, a historicfirst. The APHA officially recognized Dr. Baird for“Commitment, Dedication, & Outstanding Leadership.”Significantly, Dr. Lisa Killinger, at the request of theAPHA Executive Director, presided at a special sessioncalled “Faith, Terror, Hope, and Public Health: Exploringthe Common Ground” at this post 9/11 annual meeting.Dr. Monica Smith co-authored an article to appear inAJPH this year, only the second article with chiropracticauthorship in that journal. The APHA also announcedthat it would produce a special issue of AJPH in October2002 on “Complementary and Alternative Medicine.”Chiropractic was making amazing gains in the APHAand within public health.

Furthering those gains, the ACA declared its inten-tion to develop a wellness model and increase involve-ment with APHA. Dynamic Chiropractic began aregular feature called “Chiropractic in the AmericanPublic Health Association” edited by Dr. Rand Bairdthat would ultimately feature articles by Drs. RandBaird, Joseph Brimhall, Cheryl Hawk, John Hyland,Lisa Killinger, John Pammer, Jr., Monica Smith, andmany others. Ironically, at this time of great achieve-ment, chiropractic membership dipped to an all-time

low of about 240. The CHC had now become thesmallest section within APHA.

Membership fell to 215 in 2002. Somewhat shock-ingly, one member who had failed to perform dutieson the Section Council for three years showed up atthe annual meeting exhibit hall where he rented hisown booth and promoted his own commercial ven-ture! Several other members failed to attend or fulfillsection duties. A rather biased article was published inthe “Complementary and Alternative Medicine Issue(CAM)” of AJPH about chiropractic. In spite of these lowmoments, there were many bright spots for the CHCsection in 2002. Dr. Michael Perillo presented the“Model Public Health Curriculum” for chiropractic col-leges to the ACC Annual Meeting in New Orleans. Dr.Lisa Killinger successfully authored and obtained anAPHA grant to sponsor activities promoting inter-sectional collaboration, including a multi-disciplinaryhealth promotion booth at the annual meeting. Thiscollaborative booth won second prize for exhibits atthe annual APHA conference, the first time chiro-practic received an award for APHA exhibition.Chiropractic members continued to serve on officialAPHA committees and Dr. Haas continued as a mem-ber of the Oregon Public Health Association’s ExecutiveBoard. AJPH did publish two chiropractic-authoredarticles in the October CAM issue. A total of fourchiropractic-authored articles had now appeared inthat prestigious journal.

In 2003, several positive developments continued.The CHC section collaborated for the second time withthe Vision Care, Podiatry, and Oral Health Sections toproduce a mega-booth in the exhibit at the AnnualMeeting, which was awarded a tie for first place forfinest exhibit. Several thousand people saw the booth,including a U.S. Navy flight surgeon “seeking DCs inHawaii to whom Navy patients could be referred.” Dr.Haas continued in his positions on the GoverningCouncil and on the Executive Board of the OregonPublic Health Association, and chiropractors contin-ued to serve on committees of the APHA. Dr. Haasalso was the co-author on an article published in AJPHin December, only the fifth chiropractic-authored articleto appear in this prestigious journal. This year, be-cause of changes within APHA regarding the decliningvalue and status of Agency membership, most col-leges let their agency status lapse and instead weresupported under the Association of ChiropracticColleges (ACC), which had established agency affilia-tion with the APHA. Dr. Baird and a delegation from



the WFC had an opportunity to attend the WHO WorldHealth Assembly in Geneva, Switzerland. There hemet with Drs. Georges Benjamin and Allen Jones, bothof whom hold significant positions within both theAPHA and WFPHA. Surprisingly, chiropractic mem-bership in APHA remained small, despite thesetremendous gains made by and on behalf of the pro-fession through affiliation with this organization. TheCHC section continued to be the smallest in APHA,with membership of about 270 in 2003.

In 2004, the ACA expressed interest in a publichealth column appearing in their new online publicationscheduled to launch in 2005. This would signif-icantly complement the ongoing efforts of DynamicChiropractic, which has provided column space for ar-ticles on any aspect of “Chiropractic in the AmericanPublic Health Association” since 2001. More chiro-practors presented papers in multidisciplinary set-tings at the annual meeting, an encouraging trend.The CHC section cosponsored another mega-booththis year in the exhibit hall. Despite these opportuni-ties to function as equals in a multidisciplinary setting,membership in the CHC section remained low,below 235 in 2004. The section membership chairhad not been fulfilling duties, and a new one was ap-pointed for 2005.

There were positive developments in this activesection. The Public Health Committee of the WFCdeveloped two anti-tobacco public health postersthat were distributed to all chiropractors through theefforts of Dynamic Chiropractic and many chiroprac-tic organization cosponsors. Dr. Cheryl Hawk workedwith many of these sponsoring agencies to co-authora published field study on WFCs anti-tobacco cam-paign. It was noted that increased emphasis wasbeing given to Healthy People 2010 and related cur-rent public health information by the CCE and onNational Board exams. It was proposed that chiro-practic colleges should consider subsidizing APHAmembership dues at least for lead public health in-structors on their faculty. The section also an-nounced plans in 2005 to create a national registry ofchiropractic public health instructors. The sectionhonored Dr. Baird for 25 years of work (1979–2004)within the APHA and for promoting chiropractic andpublic health. The CHC section was moving activelyinto the future.

The year 2005 marked the tenth anniversary of theCHC section and over 20 years of chiropractic withinthe APHA. Achievements this year included cosponsoring

a session at the APHA annual meeting with theVision Care Section and cosponsoring a mega-boothfor the fourth time with Vision Care, Podiatry, and theOral Health sections. The CHC section reviewed the“Straighten Up and Move” program presented by Dr.Ron Kirk of Life Chiropractic College. The ACA beganpublishing a public health article in its online publica-tion. In 2005, the sixth chiropractic-authored articleappeared in the AJPH, this one with Eric Hurwitz, DC,PhD as lead author. Dr. Paul Dougherty of New YorkChiropractic College introduced Dr. Baird to publichealth and chiropractic student Jonathon Egan at theconclusion of the CHC section business meeting.There, Dr. Baird extended the invitation to Dr. Eganto commemorate the 10th anniversary of the CHCsection by chronicling the history of chiropracticwithin the APHA over the last two decades—the in-spiration for this article. Also at this annual meeting,the APHA Executive Director and MembershipCommittee recognized Dr. Baird for his efforts overmany years. Further, CHC section chair Dr. JohnHyland and Drs. Mitchell Haas and Rand Baird werehonored at the APHA awards ceremony in recogni-tion of chiropractic’s ten year anniversary as an officialsection.

Again, in spite of all these positive events, sectionmembership remained an obstacle and concern. TheCHC section was the second smallest section in theAPHA in 2005, exhibiting no real growth over the pastseveral years and retaining membership just above200. A new membership chair in 2005 provided hopethat the section would again grow. Dynamic Chiropracticagain showed willingness to support chiropractic andpublic health by generously donating column spacefor a membership drive in 2006.

To help enhance membership and connections withchiropractic campuses, the CHC section sought tocomplete a registry of all public health instructors atchiropractic colleges. While this was not completed in2005, the CHC section recommitted to its completionin 2006. It was again noted that chiropractic collegePresidents should subsidize APHA membership duesfor all lead public health instructors on chiropracticcampuses.

Chiropractic efforts within APHA will continue. In2006, several leaders of the CHC section met again atthe Association of Chiropractic Colleges-ResearchAgenda Conference (ACC-RAC) in Washington, DC andwill continue to explore ways to enhance the role ofchiropractic in public health, including the promotion of




to those self-sacrificing volunteers who demonstrateddetermination, perseverance, and persistence whilestriving for the greater good of their profession overmany years, creating a role for chiropractic within theAPHA. Their work opened the way for chiropractic inmany venues, including state agencies and as affiliatemembers of WHO. The past has been bright. Thepresent is full of potential. Chiropractors can now takean active role in the local, national, and global publichealth effort, fully embracing a future with chiroprac-tic and public health together.

membership in APHA. Meanwhile, the accomplish-ments of the past two decades should be recognizedand celebrated. Chiropractic went from pariah, to par-ticipant, to full parity over 25 years of contact and cooperation within APHA.

This example could serve as a model for chiroprac-tic engagement within other political and professionalorganizations. By collaborating with other profession-als and developing relationships of trust, chiropractichas become a respected partner on both the nationaland global stages. All chiropractors owe a debt of gratitude


1. Constitution of the World Health Organization—BasicDocuments, 45th ed., Supplement, October 2006.

2. Institute of Medicine, Committee for the Study of theFuture of Public Health. The Future of Public Health.Washington, DC: National Academy Press; 1988.

3. American Public Health Association. Membership Information:You Are Public Health, We Are Public Health. 2008. Washington,DC. http://dev.apha.susqtech.com/about/membership/

4. Institute of Medicine, National Academy of Sciences. TheFuture of Public Health. Washington, DC: NationalAcademy Press; 1988, p. 40.

5. Winslow CEA, Williams Memorial Publication Fund. The Evolution and Significance of the Modern Public HealthCampaign. New Haven, CT: Yale University Press; 1923:1.

6. Schneider M-J. Introduction to Public Health. Gaithersburg,MD: Aspen; 2000:xix.

7. Ibid.:4.8. Turnock BJ. Public Health: What It Is and How It Works.

Gaithersburg, MD: Aspen; 1997:xi.9. Satcher D, Higginbotham EJ. The public health approach

to eliminating disparities in health. Am J Public Health.2008;98(3):400–403.

10. Perillo M. A Model Course for Public Health Education inChiropractic Colleges: A User’s Guide. ASPH Project #H092-04/04; 2002:16–17.

11. Krisberg K. Shortage of doctors in primary care may harmhealth of nation: more U.S. physicians educated overseas.Nations Health. 2008;16:1, 16.

12. World Federation of Chiropractic. WFC Consultation on the Identity of the Chiropractic Profession. 2005. Toronto.

http://www.wfc.org/website/WFC/Website.nsf/WebPage/IdentityConsultation?OpenDocument&ppos=2&spos=5&rsn=y

13. CDC. Ten Great Public Health Achievements—United States,1900–1999. MMWR. 1999; 48(12):241–243.

14. McKenzie JF, Pinger RR, Kotecki JE. An Introduction toCommunity Health. 4th ed. Boston: Jones and Bartlett;2002:42–43.

15. American Chiropractic Association. Annual Report. Arlington,VA: American Chiropractic Association; 2007:14.

16. American Public Health Association. Bylaws of theAmerican Public Health Association. 2008. Washington, DC.

17. American Public Health Association. APHA Policy #8331,passed by Governing Council in November 1983.

18. Haas M, Baird R. Proposal to establish an APHA section onchiropractic health care. J Am Chiropr Assoc. 1996;33(2):41–47.

19. American Chiropractic Association. Focus—public healthand chiropractic: meeting somewhere in the middle. J AmChiropr Assoc. 2002;39(6):9–16.

20. Mootz R, Vear H, Baird R. Public health and chiropractic: theimportance of professional activism in the American PublicHealth Association. J Am Chiropr Assoc. 1990;27(5):31–36.

21. U.S. Department of Health and Human Services. HealthyPeople 2010. Vol. 2. 2nd ed. Washington, DC: U.S.Government Printing Office; 2000.

22. Vear HJ. The anatomy of a policy reversal: the A.P.H.A. andchiropractic, 1969 to 1983. Chiropr Hist. 1987;7(2):17–22.

23. Egan JT, Baird R, Zaynab-Killinger L. Chiropractic within theAmerican Public Health Association, 1984–2005: pariah, toparticipant, to parity. Chiropr Hist. 2006;26(1):97–117.

REFERENCES

