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hortly after the news broke last month about the death of Allya Siska Nadya and the alleged connection to chiropractic malpractice, authorities closed down several unlicensed chiropractic clinics in Jakarta.

Several foreign chiropractors from those clinics also turned out to possess neither valid health practitioner licenses, nor proper immigration and work permits. Then the authorities arrested two foreign chiropractors who reportedly had also been treating patients without proper licenses.

Allya'€™s case may be the first reported alleged chiropractic malpractice case in Indonesia since the first chiropractic clinic in Indonesia opened around 2000. Despite its increasing ubiquity over the years, it appears that the public remains largely unaware about what chiropractic really is and what the treatment entails.

First, although many chiropractors describe themselves as doctors, this does not necessarily mean that they have attended medical school; rather, the title generally indicates Doctor of Chiropractic; meaning that the practitioner has completed a chiropractic course generally lasting four years.

In a nutshell, chiropractors generally claim that many or most human ailments stem from displacement in the spine, or '€œsubluxations'€, resulting in a blockage of the body'€™s '€œinnate intelligence'€. They further claim that spinal manipulation '€” a series of adjustments in the neck, back and hips '€” will heal subluxations and in turn cure various ailments.

Many chiropractors claim that they can treat conditions as varied as headaches, migraine, period pains, infantile colic, asthma, allergies, ear infections, respiratory conditions, dermatological diseases, urinary conditions, irritable bowel syndrome and much more.

Note that to this day there has been no conclusive clinical trials-based evidence that can substantiate such claims. On the contrary, there have been numerous systematic reviews and trials concluding that there is no evidence that a misaligned spine can cause any non-musculoskeletal conditions such as the above-mentioned ailments in the first place; and there is no evidence to suggest that chiropractors can treat any of these conditions.

Chiropractic is not risk-free and chiropractic malpractice cases are not uncommon. The riskiest procedure is the '€œneck adjustment'€, in which a chiropractor twists a patient'€™s neck left and right mostly in a sudden and forceful movement accompanied by a popping or cracking sound of the surrounding joints (the procedure reportedly received by Allya).

Using the title '€œDoctor'€ in a misleading manner without proper qualifications and licenses.

Numerous reported chiropractic malpractice cases suggest that in severe cases, neck manipulation may lead to stroke, permanent brain damage, paralysis or death. Many chiropractors also acknowledge that neck manipulation particularly in the upper neck area, risks damaging neck arteries.

Now let us look at how chiropractic is governed under Indonesian laws and regulations.

Chiropractors are classified as skill-based '€œtraditional healers'€ that perform chiropractic techniques for musculoskeletal conditions (notice the specific designation in the regulation for dealing with musculoskeletal conditions only).

The national healthcare program regulation also excludes chiropractic, which is lumped in the non-proven (based on health technology assessment) complementary, alternative, traditional healing category.

In the case of foreign chiropractors and foreign chiropractic clinics, they both must meet stringent requirements and obtain permits and licenses under a diverse array of laws and regulations in various fields including health care, immigration and manpower.

Additionally, the traditional-healing regulation provides that foreign traditional healers, including chiropractors, can only work as consultants.

Further, chiropractors as traditional healers are not free from the informed-consent obligation. They must provide clear and accurate information about the traditional-healing procedure to be performed to patients, including its associated benefits and risks, and patients must consent to it after they have been properly informed.

Most importantly, the regulation requires a duly signed written informed consent for any high-risk traditional healing procedure.

Given the well-documented risks of chiropractic neck adjustment procedure, any chiropractor practicing in Indonesia must inform the patients about those risks and obtain a written consent before performing the procedure.

With regard to consumer protection, some chiropractors are indeed keen to perform the role of primary health care providers, treat pediatrics, and claim that they can heal a diverse array of non-musculoskeletal conditions despite the absence of any clinical trial-based evidence.

The traditional healing regulation explicitly forbids any cure-all type of claims. Meanwhile, under Indonesian consumer protection law, offering any service or product (e.g. chiropractic services) that does not correspond to its advertisement or promotion (e.g. promoting unsubstantiated claims of healing various non-musculoskeletal conditions) is a criminal offence punishable by up to five years imprisonment or fines of Rp 2 billion (US$147 million).

Since the traditional healing regulation limits chiropractors to treating musculoskeletal conditions only, using the title '€œDoctor'€ in a misleading manner without proper qualifications and licenses as well as claiming healing capabilities for and treating non-musculoskeletal conditions, pediatrics and other ailments falling under medical doctors'€™ scope of practice, may be tantamount to offering services to the public posing as if he/she is a licensed doctor, a criminal offence carrying a punishment of imprisonment up to five years or fines up to Rp 150 million.

Evidently foreign clinics with foreign practitioners operating inside shopping malls in major cities do not necessarily equate to quality and professionalism, not to mention legality.

Research, due diligence, and good judgment is crucial before one opts for a certain health service and procedure, especially traditional and alternatives ones, which contrary to the popular notion, are not necessarily '€œ100 percent safe'€, '€œnatural'€, or '€œrisk-free'€.

Finally, the relevant authorities need to conduct stronger supervision, especially of the increasing number of foreign clinics, to ensure that they possess valid licenses and relevant permits to prevent medical fraud and malpractice that could lead to unnecessary damage, injuries, disabilities or even fatalities.

Also, the regulation specifically provides that traditional healing may be provided in Indonesia only if it is safe, beneficial and non-life-threatening.

Given numerous chiropractic malpractice cases around the world and its well-documented risks, the relevant authorities and bodies also need to assess this alternative therapy further and closely look into Allya'€™s case to establish whether there is indeed a causal connection between chiropractic and the actual cause of her death, so the public can be properly informed of any possible risks associated with it.

In medical negligence and malpractice cases, wrongdoers can be prosecuted, offending healthcare facilities can be shut down, but nothing is worth a human life '€” preventive measures should always precede remedies. As the adage goes, an ounce of prevention is worth a pound of cure.