Appeal to fear in public awareness campaigns for hypertension (high blood pressure) – The silent killer
Up to this point I have considered public awareness campaigns aimed at modifying behaviours such as tobacco smoking and drunk driving. It is worth considering a campaign designed to raise awareness about a medical condition (hypertension) and motivate the target audience to take action (have their blood pressure checked).
Reports by the American Heart Association (AHA) and the Centers for Disease Control and Prevention [63, 64] paint a clear picture why hypertension is a primary public health concern.
About 1 in 3 American adults or 75 million (29%) have high blood pressure.
Only about half (54%) of people with high blood pressure have their condition under control.
Nearly 1 of 3 American adults has prehypertension—blood pressure numbers that are higher than normal, but not yet in the high blood pressure range.
More than 360,000 American deaths in 2013 (almost 1000 deaths per day) included high blood pressure as a primary or contributing cause .
High blood pressure increases risk for dangerous health conditions:
First heart attack: About 7 of every 10 people having their first heart attack have high blood pressure.
First stroke: About 8 of every 10 people having their first stroke have high blood pressure.
Chronic (long lasting) heart failure: About 7 of every 10 people with chronic heart failure have high blood pressure.
High blood pressure is a major risk factor for kidney disease .
Hypertension is a lifestyle modifiable, preventable, and controllable risk described by the World Health Organisation as The Silent Killer . As detailed in the AHA report, hypertension is the primary and most common risk factor for heart disease, stroke and renal diseases. It is labeled the silent killer because hypertension has no symptoms therefore the only way to determine the presence of hypertension is by measuring one’s blood pressure.
Hypertension is not confined to the developed world. Indeed, it is considered to be a worldwide epidemic and is the leading risk factor for death and disability globally. It is estimated that nearly one billion people are affected by hypertension worldwide, and this figure is predicted to increase to 1.5 billion by 2025. Nearly one-half of this population is unaware of their condition . Thus, public awareness campaigns are designed to alert the target audience to the importance of
Having their blood pressure checked
Modifying lifestyle factors (diet, exercise, alcohol consumption)
Receiving medical attention and
Adhering to medical advice, including taking prescribed medication.
The World Hypertension League (WHL) is an international, nonprofit organization with membership from 85 countries; it works through its member countries to promote hypertension awareness, early detection, and the prevention and control of this modern epidemic. In 2005, in an attempt to improve the awareness of high blood pressure, the WHL initiated World Hypertension Day (WHD). The aim of WHD is raising public awareness about hypertension, its life-threatening complications and measures to prevent it. Appeal to fear plays a role in raising awareness by alerting the target audience (all adults) to the complications of hypertension: heart attack, stroke, kidney disease, and death. WHD is considered to be highly successful and is being expanded on a yearly basis [65,66,67].
Subluxation: The other silent killer – Appeal to fear in chiropractic subluxation advertising
Thus far I have reviewed appeal to fear used in anti-smoking campaigns, driver safety and hypertension awareness campaigns. As discussed, to use appeal to fear in this manner is considered appropriate but its use may need to be reconsidered in terms of effectiveness and ethicality and collateral damage.
It is now appropriate to examine fallacious use of appeal to fear using chiropractic advertising as an example.
The putative lesion that chiropractors ‘treat’ is commonly referred to as chiropractic subluxation, vertebral subluxation complex (VSC) or simply ‘subluxation’ [differentiating the chiropractic lesion from orthopaedic subluxation]. Broadly speaking within chiropractic today the term ‘subluxation’ has two meanings: the Traditional Palmerian Subluxation (TPS), whereby the presence of subluxations leads to ill health and the second: The Modern Subluxation, whereby subluxations have a local biomechanical effect.
The TPS is the focus of this discussion. DD Palmer, who ‘discovered’ chiropractic in 1895 proposed that 95% of all disease (dis-ease) was due to subluxations of the spine and that the remaining 5% was caused by subluxations of the extremities, particularly the joints of the feet . DD and his son BJ Palmer hypothesized that the chiropractic vertebral subluxation differed from the medical “subluxation” in that it interfered with the transmission of Innate Intelligence (a fraction of Universal Intelligence) , independent of what has come to be recognized as the action potential. However, Innate Intelligence remains a metaphysical construct .
The more contemporary position is that Palmerian subluxations cause interference within the nervous system, which leads to suboptimal health and symptomatic dis-ease, and that chiropractic health care is primarily involved in the detection and removal of subluxations . Chiropractors who still adhere to the founder’s paradigm – and there are many such practitioners – depict and market subluxation as an enemy that needs to be contained and eliminated.
Before examining examples of subluxation marketing, it is cogent to briefly discuss the history of chiropractic and its embracing of marketing to attract clientele. Chiropractic emerged in the late nineteenth century and, in spite of fierce opposition, grew rapidly in practitioner numbers and patient numbers during the first half of the twentieth century . This is in part attributable to chiropractic adopting a unique professionalism. Unlike traditional professionalism wherein altruism is a central tenet , chiropractic professionalism favoured entrepreneurialism with recognition of financial success as a strong indicator for accomplishment . While medical professionalism witnessed an ethical ban on advertising as early as 1847 , the emerging chiropractic profession embraced marketing. In fact, even chiropractic students were encouraged to advertise heavily [74, 76]. The Developer of Chiropractic, BJ Palmer advised his many readers:
What you want to keep out of a news- paper is news.
What you want to get into a newspaper is an advertisement  p. 44.
Whether or not current chiropractic advertising is a legacy from the early days of chiropractic is moot. It is evident however that advertising claims made by some chiropractors and indeed by some chiropractic colleges are suspect [77, 78]. A few examples of subluxation marketing are in order.
WH Koch, a chiropractic author makes the danger posed by subluxation abundantly clear:
We must now look at this condition of 'disease’, Vertebral Subluxation Complex, which is so disturbing to the flow of life force and innate expression in your body that it causes pain and the progressive breakdown of the body tissue known as pathology. The V.S.C. is the silent killer, one of the most serious health threats known to man  p. 34.
The World Chiropractic Alliance (WCA), is a worldwide organisation promoting subluxation based care. The WCA represents the interests of more than 70,000 doctors of chiropractic and chiropractic students, In 2006 the WCA issued a position paper stating that “chiropractic care to detect and correct vertebral subluxations offers benefits for all people, including those who do not demonstrate symptoms of a disease or health condition”.
‘Patient education’ materials prepared by Chiropracticis aims to educate patients to “believe choosing to be checked for the presence of vertebral subluxation throughout a lifetime is the only logical choice”. Once patients understand 5 facts about their health, they are well on their way to being chiropractic patients for life. The five facts are:
Your Spinal Cord is located in the spine and is your Nervous System’s information highway.
Your Nervous System controls and coordinates every part of your body.
Misalignments of your spine can DISTORT nerve messages and contribute to a wide range of health problems.
Misalignments of the spine are known as vertebral subluxations and negatively affect your nervous system, health and well-being.
Maintaining the health of your spine and nervous system should be a regular part of a health lifestyle and can dramatically improve your quality of life.
Koren Publication’s What is a Subluxation? brochure tells readers that chiropractic has become so popular because “chiropractors are the only professionals trained to locate and remove subluxations. If subluxations are in your body, you cannot be truly healthy”.
JC Smith, a prolific chiropractic author and subluxation advocate advises in his paper “Killer Subluxation”.
“The idea of sudden cardiac arrest from a vertebral subluxation is just too far outside the consciousness of most people … [however] "killer subluxations” actually may not be that far from the truth.
The subluxation brochure produced by Patient Media, Inc., is perhaps the most alarmist publication. Its Subluxation pamphlet provides a succinct description of how vertebral subluxations operate as well as the importance of their detection and removal.
Maybe you’ve never heard of subluxations. That’s OK. There probably was a time when you’d never heard of AIDS or Alzheimer’s.
There are three basic causes of subluxations. Physical causes include slips and falls, accidents, repetitive motions and improper lifting. Stress, anger and fear are examples of emotional causes of subluxations. Alcohol, drugs, pollution and poor diet can be chemical causes of subluxations. The result is the vertebral subluxation complex, or more simply, a subluxation.
Subluxations are serious!
However, the most important aspect of a subluxation is its effect on your nervous system. Compromising the way your nervous system controls and regulates your body can have grave consequences. Distorted communications between your brain and your body can cause all kinds of health problems beyond just headaches and backaches.
You can have subluxations and not even know it. Like tooth decay or cancer, subluxations can be present before any warning signs appear. The results of a thorough examination can show the location and severity of any subluxations you may have.
In an essay entitled ‘If You Don’t Know Subluxation, You Don’t Know Chiropractic’ Dr. Carey N. Pabouet-Sigafoose alerts readers to the dangers of subluxations:
There’s loss of motion in the body causing death because of a subluxation. It’s a major problem, a major killer, a major cause of disease in man and we’ve got to understand that. We’ve got to take ourselves in and give it the time and the space and the effort to get these things cleared up, not in just you, but your friends and your family. It’s imperative.
These are but a select but indicative sampling of the 176,000 results obtained by conducting a Google search using ‘subluxations kill’.
Chiropractors adhering to the TPS theory or its contemporary interpretation believe that subluxations have an effect on the overall health of the individual while those adopting the modern subluxation theory hold that the subluxation has a more local biomechanical affect. It is often reported that TPS practitioners represent only a small portion of the overall profession . This is not the case. A survey of North American chiropractors found amongst respondents, in excess of 75% of those adhering to the modern subluxation construct believe that the adjustment of the vertebral subluxation complex usually elicits improvements in select visceral ailments . Compounding the problem is the commonly relayed message that subluxations are only detectable by the skilled hands of a qualified chiropractor. Given this, one must ask: what is the evidence supporting the TPS ideology that minor vertebral displacements cause visceral disease?
Nansel and Szlazak  carefully examined this very question and concluded scientific consensus does not support the theory that nerve interference caused by vertebral misalignment or subluxation is a cause of visceral disease. Further, Nansel and Szlazak clearly state “there have been no appropriately controlled studies that establish that spinal manipulation or any other form of somatic therapy [manual therapy] represents a valid curative strategy for the treatment of any internal organ disease”. It is noteworthy that Nansel and Szlazak’s findings have never been challenged.
Worse yet, from an epidemiological perspective (strength of association, specificity, temporality, dose response, experimental evidence, biological plausibility, coherence and analogy), the subluxation is found to be wanting  as is adherence to subluxation theory as a mode of practice [70, 84,85,86,87,88,89].
Many chiropractors argue for the ‘neurological effects’ of the adjustment. While it is safe to say that the high velocity low amplitude thrust employed by chiropractors has a neurological effect, as does stubbing one’s toe, it is a stretch to suggest that the adjustment’s effect is predictable, lasting and always positive. Haldeman, a qualified chiropractor, medical neurologist and holder of a PhD in neurology, wrote on the subject of the purported neurologic effects of the chiropractic adjustment.
A significant leap of faith is required to accept and present a convincing argument about the various theories on the neurologic effects of the adjustment. …
What must be avoided at this stage of understanding of the neurologic effects of the adjustment is the unreasonable extrapolation of current knowledge into speculation and presentation of theory as fac .
Thus we have a large portion of the chiropractic profession, a group recognized as being the third largest primary-contact health care profession in the Western world , telling health care consumers that undetected subluxations, if not removed, will result in adverse health consequences and an untimely death. This is a position unsupported by evidence. In short, it is an unsubstantiated claim the purpose of which is to drive asymptomatic members of the public into chiropractor’s offices to receive examinations to locate subluxations and treatment to remove killer subluxations before they cause unimaginable harm to the individual. Undeniably, it is the appeal to fear fallacy exemplified.
Not only is it unethical  it is totally inappropriate. Some chiropractors have even gone so far as to suggest that subluxation based practice is a threat to the public health . Given the best available evidence I suspect chiropractors marketing their care in this fashion could be faced with the unenviable task of defending against an allegation of unconscionable conduct under Australian Consumer Law.