Despite the growing popularity of the One Health movement to “forge co-equal, all-inclusive collaborations between physicians, osteopaths, veterinarians, dentists, nurses, and other scientific-health and environmentally related disciplines,”1 practitioners must reckon with regulatory requirements regarding who can practice on which species, in which state and with what modality. The laws on this are confusing, continually evolving and differ between states, especially when it concerns practices such as anesthesia-free dentistry, farriery and complementary/alternative therapy (e.g., chiropractic, massage,2 etc.), unless one also has a license to practice veterinary medicine in that state.3 Thus, those joining forces in the spirit of One Health must at the same time recognize regulatory requirements instated with the goal of safeguarding the health and welfare of people, animals and public health. Or alternatively, as three massage therapists have decided to do in Arizona, sue the state board in order to gain access to animals.4 Arizona defines the practice of veterinary medicine as including veterinary surgery, obstetrics, dentistry, acupuncture, manipulation and all other branches or specialties of veterinary medicine. It exempts from this definition certified equine dental practitioners who work under the general supervision of a licensed veterinarian, animal owners or employees, and those who treat animals without compensation.5 The Institute for Justice (IJ), i.e., the litigation team representing the massage therapists fighting Arizona’s restrictions, calls itself “the national law firm for liberty and the nation’s leading legal advocate for economic liberty.” In keeping with its goal of “challenging irrational barriers to economic opportunity,” the IJ refers to its role in the case as “freeing Arizona animal massage entrepreneurs from the veterinary cartel.”6 Within a week of the lawsuit’s filing in March 2014, the blogosphere filled with statements sympathetic to the therapists’ stories.7 The IJ wrote, “According to the Vet Board, Celeste, Grace and Stacey [the plaintiffs] are criminals for practicing their craft without a veterinary license, even though their craft is just a massage. The consequences of failing to comply are severe—animal massage therapists face up to six months in jail and fines of $3,500 per violation.”8 A YouTube video paints the picture of the massage therapists’ plea, ending with a request for donations.9 The narrator of the video identifies two options offered by the state board, i.e., “become a licensed veterinarian or massage horses for free.” Celeste Kelly, the massage therapist highlighted in the video, protests, saying that she would have to move elsewhere because Arizona has no veterinary school, pay hundreds of thousands of dollars, and spend four years at an institution that does not teach massage. This is where the (in)famous phrase from former U.S. Secretary of Defense Donald Rumsfeld comes in handy. Back in 2002, in a briefing to reporters about the lack of evidence linking the Iraqi government with supplying weapons of mass destruction to terrorist groups, Rumsfeld stated, “Reports that say that something hasn’t happened are always interesting to me, because as we know, there are known knowns; there are things we know that we know. There are known unknowns; that is to say, there are things that we now know we don’t know. But there are also unknown unknowns—there are things we do not know we don’t know.”10 If one applies this statement to the “Arizona Vet Board’s war on horse massagers,”11 12 one sees “known knowns,” “known unknowns,” and “unknown unknowns.” Known Knowns Ms. Kelly’s first claim, i.e., that Arizona lacks a veterinary school, will soon drop away, because the state stands ready to open two veterinary schools.13,14 One may even allow high school graduates “to skip the undergraduate degree requirement and earn their doctorate in veterinary medicine.” 15 Advocates of each school contend their programs will counter the shortage of large animal veterinarians. To Kelly’s second point, by becoming a large animal veterinarian who offers massage, Ms. Kelly would not only help address the state’s shortage but she would also likely compete well in today’s tight job market and be better positioned to repay student debt. Her third contention, i.e., that veterinary schools do not teach massage, is also weakening as more veterinary curricula incorporate integrative approaches, sports medicine and rehabilitation therapy. And well they should, as it behooves veterinarians to learn myofascial palpation and soft tissue, manual therapy techniques. Doing so improves pain control and fosters self-healing. It may reduce the need for medications and invasive approaches such as surgery. Known Unknowns Beyond the known knowns that speak to the massage therapists’ concerns, there are known unknowns. These pertain to the need for more evidence regarding the safety, effectiveness, contraindications and possible adverse outcomes, should the practitioner step outside the veterinary setting and decide to practice solo, sans a veterinary license. Furthermore, the uneven terrain of educational “certification” programs in animal massage constitutes a known unknown; the requirements for education and certification in animal massage vary considerably from state to state and are frequently unspecified. Unknown Unknowns Those without first-hand experience of a full veterinary education have little understanding of the knowledge they lack. No matter how many years one practices massage and attends treatment workshops, courses in bodywork typically do not delve deeply into infectious disease, orthopedics, neurology and the full complement of courses a veterinary student completes.16 While it is true that human massage therapists do not need to become physicians, human patients can decide for themselves whether to pursue a medical opinion before massage and/or present for treatment to a doctor who performs manual therapy in conjunction with medicine, i.e., an osteopathic physician. Furthermore, a massage therapist could become the unwitting vector of transmission for communicable disease within a barn or from an animal to humans. Perhaps the horse that is performing poorly has more than muscle soreness. Possibilities include rabies, brucellosis, spinal instability or fracture, equine protozoal myelitis and many more. Ideally, horses should be assessed by a veterinarian who performs necessary diagnostic tests to establish a diagnosis prior to deciding on treatment. Waiting for weeks of massage therapy to work without first pursuing a definitive diagnosis risks not only the horse’s health but also puts the health of those who ride or attend to the horse at risk. What’s the Way Forward? Despite the risks outlined above, the fact remains that many veterinary patients receive regular massage and benefit greatly from it. Massage as a scientific approach to bodywork has a strong and growing body of evidence of value and safety based on studies performed mainly on humans and experimental animals. Over time, more clinical trials on massage for animals will emerge. In the spirit of One Health, the best outcome for the veterinary population as well as both professions may entail working together and exchanging information on best practices with the least invasive approaches. In Colorado, a graduate of an approved school of massage may provide care for animals if she or he does not prescribe medications, perform surgery or diagnose medical conditions.17 While not fully ideal in all circumstances, this regulatory arrangement may serve to protect consumers, animals and public health better than allowing non-veterinarians to treat animals at will as long as it’s for free.
