The argument over whether chiropractors are equipped to care for patients with infectious diseases has thus far focused on one point: is adjustment of the spine effective in conditions of bacterial infection? This is a limited view. While there are anecdotal reports suggesting the answer is "yes," there is little controlled study on the issue. This is understandably one reason skeptics are quick to criticize. However, focusing the issue on efficacy of manipulation in infectious disease care ignores the vast complexity of infectious disease management.
Tuberculosis is a useful example. If one were to poll infectious disease experts and ask if antibiotic treatment is the sole means of managing this malady, they would likely give a resounding "no." This is because they are clearly aware that crowding, poor sanitation, poverty, malnutrition, stressful living conditions, and a host of other factors must be addressed as part of the equation. Most would admit that host resistance is the critical factor with regard to infection transmission and outcome. No one can argue about the value of antibiotics in cases of TB. Yet no one can argue that these other factors must also be addressed in order to gain control of the disease or treat a specific case. I use this analogy only to show that a medical physician treating TB would employ a spectrum of approaches to optimize the odds of success.
Likewise, one cannot view the chiropractic adjustment in a vacuum, as has been done in many of the recent articles by individuals outside the profession and those within the profession who condemn chiropractic physicians that manage cases of infectious. In my opinion, the chiropractor who treats a patient with an infectious disease by only adjusting the spine is doing his patient a disservice because he overlooks the vast biochemical, physical, psychological, and social milieu in which the patient exists. However, the chiropractor who addresses the broad spectrum of factors known to affect infectious disease outcome is in my opinion employing a more sensible and rational approach. Moreover, many chiropractic physicians with whom I associate often refer cases of infectious disease for antibiotic therapy, while continuing to care for the patient with methods that promote immune enhancement. There is no question that antibiotics are of great value. The question is, "When are they most appropriate?" Clearly from the evidence that exists today, doctors can no longer approach antibiotic prescribing with the cavalier attitude so prevalent in the past.
My issue is not to judge the action of the California Board of Chiropractic Examiners. (Editor's note: see "Calif. Board Adopts Emergency Regulations under Threat" in the Sept. 1, 1993 issue of "DC.") Each of you has probably already done this regardless of which side you choose in the debate. However, I believe it is imperative to point out that the issue of managing infectious disease is far more complex and involves many more factors than antibiotics and bacteria. We must be concerned about recent evidence regarding the role, safety, and efficacy of antibiotics in treating infectious disease, while also giving equal consideration to factors that affect host immunity. The latter is well within the scope of chiropractic practice. The evidence is substantial and this is what must be pointed out.
On August 21, 1992, a series of papers appeared in Science, sounding the alarm about the rising epidemic of antibiotic-resistant bacteria. Harold Neu, MD, professor of pharmacology at Columbia University School of Medicine, stated that in 1941, a patient could receive 40,000 units of penicillin per day for four days and be cured of a case of pneumococcal pneumonia. "Today," say Neu, " a patient could receive 24 million units of penicillin day and die of pneumococcal meningitis." Neu also noted that "...bacteria that cause infection of the respiratory tract, skin, bladder, bowel and blood ... are now resistant to virtually all of the older antibiotics. The extensive use of antibiotics in the community and hospitals has fueled this crisis."1
Richard Krause, MD, a senior scientific advisor at the National Institutes of Health, declared in 1992, "We have an epidemic of microbial resistance."2 Mitchell Cohen, MD, of the Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control, issued this warning about antibiotics in 1992: "Unless currently effective antimicrobial agents can be successfully preserved and the transmission of drug-resistent organisms curtailed, the post-antimicrobial era may be rapidly approaching in which infectious disease wards housing untreatable conditions will again be seen." Cohen also says: "The pharmaceutical industry cannot be expected to provide a limitless supply of new antimicrobial agents for resistant organisms." He continued: "Efforts should be made to decrease inappropriate antimicrobial use in humans."3
The issue of antibiotic resistance is not alone in raising our concern. In two separate studies of strep throat, one involving board-certified medical school faculty, doctors were asked to examine the patients, order a culture, estimate the probability that the patient had strep, and prescribe accordingly. Doctors in one study estimated that 81 percent had strep when only 4.9 percent were positive.4 In another study, 50.5 percent were believed to have strep while only 13.5 percent were culture positive.5 The vast majority of these patients received antibiotics needlessly.
Cantekin reported on a study of children with recurrent otitis media comparing amoxicillin to placebo. His analysis found that those on amoxicillin experienced two to six times more recurrent effusion than children in the placebo group. Cantekin also remarked on two other popular antibiotics when he stated, "...Pediazole and cefaclor also were not effective according to the methods used by the OMRC (Otitis Media Research Center at the University of Pittsburgh).6
There are also serious question about whether antibiotics are responsible for past declines in infectious disease. In extensive reviews of the literature, several prominent medical investigators have addressed this issue. According to epidemiologist R.R. Porter, nearly 90 percent of the total decline in the death rate from infectious diseases from 1860 to 1965 had occurred prior too the introduction of antibiotics.7
According to McKeown, "Examination of the (infectious) diseases which contributed to the decline (in death rate) suggested that the main influences were: (a) rising standards of living, of which the most significant feature was a better diet; (b) improvements in hygiene; and (c) a favorable tend in the relationship between some micro-organisms and the human host. Therapy [antibiotics] made no contributions, and the effect of immunization was restricted to smallpox, which accounted for only about one-twentieth of the reduction of the death rate." McKeown cites tuberculosis as one example. He writes, "By the time streptomycin was introduced, mortality from the disease had fallen to a small fraction of its level during 1848 to 1854 ... Its contribution to the decrease in the death rate since the early 19th century was only about three percent."8
In a presidential address to the Infectious Diseases Society of America in 1971, Kass argued that most of the decline in mortality for most infectious conditions occurred prior to the discovery of either "the cause" of the disease or a specific "treatment" for it.9 McKinlay et al., formerly of Boston University, have done an extensive analysis of the impact of medical treatment on infectious disease. Regarding ten common infectious diseases, their analysis suggests that "... at most, 3.5 percent of the total decline in mortality since 1900 could be ascribed to medical measures introduced for the diseases considered here." They conclude, "In general, medical measures (both chemotherapeutic and prophylactic) appear to have contributed little to the overall decline in mortality in the United States since about 1900 -- having in many instances been introduced several decades after a marked decline had already set in and having no detectable influence in most instances."10 Lappe suggests similarly that "no antibiotic can be said to have proven successful in truly eradicating any infectious disease in modern times."11
Writing in the Journal of Infectious Disease, Weinstein points out that despite the value of antibiotics, the incidence and mortality of many infectious conditions (such as subacute bacterial endocarditis, streptococcal pharyngitis, pneumococcal pneumonia, gonorrhea, and syphilis) have actually increased. He notes, somewhat paradoxically, that the incidence and mortality of other diseases such as chicken pox have decreased in the absence of any treatment.12
These studies do not imply that antibiotics have no place, nor that their use should be abandoned -- hardly. But they do show that antibiotics cannot be used with impunity, that they are not the sole means by which infectious disease can be controlled, that they are not universally effective, and that there are consequences to their overuse. These studies, and dozens of others like them, argue for more restrained application of antibiotics in medicine and a concerted effort to utilize every means possible to prevent and manage infectious disease.
Oddly, at a time when representatives of NIH, CDC, and university medical schools are calling for efforts to reduce the use of antimicrobials, some in the chiropractic profession simply bow with an obliging retort under political pressure and say, "Why yes, doctor, infections should always be treated with antibiotics," while completely overlooking the broader view of infectious and the context in which they occur. This vastly oversimplified view ignores the role that diet, nutrition, lifestyle, genetics, hygiene, environment, and psychosocial factors (all within the traditional role of chiropractic) play in resistance to infectious disease. These sentiments were offered by noted professor of social medicine and hygiene at the University of Birmingham, Thomas McKeown in 1976 when he remarked, "... the conclusion which seems inescapable is that the influences which determine man's response to infectious disease -- genetics, nutritional, environmental, behavioral, as well as medical -- are infinitely complex, and we need to be very cautious before assuming that we fully understand the infection, or that we have in our hands the certain means of their control."13
Please see part II of this article in the Dec. 3, 1993 issue.
References
- Neu HC: The crisis in antibiotic resistance. Science 1992; 257: 1064-73.
- Anonymous. Exploring new strategies to fight drug-resistant microbes. Science 1992; 257: 1036-38.
- Cohen ML: Epidemiology of drug resistance: implications for a post-antimicrobial era. Science 1992; 257: 1050-55.
- Inlander CB, Levin LS, Weiner E: Medicine on trial: the appalling story of medical ineptitude and the arrogance that overlooks it. New York: Pantheon Books, 1988; 70 (This is a study reviewed).
- Poses RM, Cebul RD, et al: The accuracy of experienced physicians' probability estimates for patients with sore throats. JAMA 1985; 254(7):927.
- Cantekin EI, McGuire TW, Griffith TL: Antimicrobial therapy for Otitis media with effusion (secretory Otitis media). JAMA 1991; 266 (23): 3309-3317.
- Lappe M: When antibiotics fail: restoring the ecology of the body. Berkeley, CA: North Atlantic Books, 1986: 17-18.
- McKeown T: The role of medicine: dream, mirage or nemesis. Oxford University Press, 1976; 391.
- Kass EH: Infectious diseases and social change. J Infect Dis 1971; 123(1): 110-114.
- McKinlay JB, McKinlay SM: The questionable contribution of medical measures to the decline of mortality in the United States in the twentieth century. Milbank Memorial Fund Quarterly Summer 1977; 405-428.
- Ibid, Lappe M.
- Weinstein L: Infectious disease: retrospect and reminiscence. J Infect Dis 1974; 129 (4): 480-92.
- Ibid, McKeown T.
Michael A. Schmidt, BS, DC, CCN
Anoka, Minnesota