By 2010, therapeutic and preventive practices will be dramatically different from today’s. In this section we review five of the most significant advances in therapeutics and prevention: genomics, nanotechnology, the information revolution in health care, the customization or personalization of health care and, finally, where chiropractic and other CAAs merge most visibly with conventional therapiesin integrated therapeutics. As with the other trends discussed in this report, technological advances carry both threats and opportunities for chiropractors. See Table 3-1.
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Table 3-1: Implications of Selected Technological Advances for Chiropractic
Threat Opportunity
Genomics Health care becomes even more high-technology focused and reinforces the dominance of allopathic care
Musculoskeletal uniqueness can be proven, with
implications for customizing manipulation; chiropractors are involved in identifying this and integrate its information into their practice
Information Revolution Consumers have greater self-care capacity; this may reinforce CAAs that
compete with manipulation; non-chiropractors (and DCs) can use virtual reality to learn manipulation more quickly; expert systems become effective “back health” coaches for consumers
Chiropractors can spend more time and cost- effectively expand their offerings beyond
manipulation using expert systems; DCs use info technology to collect and to improve their outcomes; expert systems may be designed to alert patients to when they have a
subluxation or other problem that would benefit from a visit to a chiropractor Automated spinal
manipulation Technology evolves to the point where machines can accomplish spinal
manipulation more cheaply than visiting the chiropractor
Spinal manipulation, including the value of the DC’s touch, cannot be done by a machine
Integrated Therapeutics, such as Dean Ornish’s program
Manipulation is less favored in the integrated packages; or it is co-opted by other, non-DC, providers
Manipulation is proven an important component, and DCs can prove they provide higher outcomes from their manipulation
Source: IAF, 1997
Genomics
Just as evolving health care markets and the expanding definition of health will present certain threats and opportunities to all health care providers, so innovations in
biomedical knowledge, technology and telecommunications will change therapeutics and prevention.
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The mapping of the human genome by 2005 or sooner will profoundly affect health care. Genomics—the study of genetics and its application to health care—has crucial implications for both conventional health care and CAAs. It will allow us to understand the genetic proclivities to many diseases, as well as how various genetic proclivities interact with a person’s current condition and environment.
Simultaneously, technology will make these advances far more accessible to individuals and their health care providers. For example, “gene chips”—computer chips that
instantly analyze the distinctive pattern of genes active in a given disease or condition based on a small sample of blood or saliva—will come into play.
The related learning process will sweep aside traditional disease categories, replacing the old taxonomy with a far more powerful, complex one consisting of families of genetically defined subtypes of disease.
The first gene chips, designed to analyze certain cancers, will become available over the next several years. Soon individuals will be able to put a few of their cells on a gene chip scanner and quickly test for scores of different diseases. Looking ahead 20 or 30 years, it may be possible to build a “human model on a chip”—that is, a chip with DNA representing all of the approximately 100,000 human genes, allowing characterization of a broad spectrum of diseases.1 This analysis will be complicated by our deeper
understanding of the relationship between the “coding regions” which have been determined to carry the genetic instructions, the “control regions” which affect the expression of the coding regions and the “silent regions” of the gene, whose role has not yet been determined.
Gene chips will make individual genetic profiling, or genotyping, possible at reasonable cost. This will allow individuals to know, with some level of statistical precision, if they are predisposed to certain diseases. Several predispositional tests for individual diseases will become available over the next few years and our “DNA profile” or “genetic profile” will become an integral part of medical records within a decade.2 Between now and 2020, health care will evolve to a higher stage of customized care in which therapeutic selection will be precisely tailored to individual biochemistry. Today, for example, many physicians advise all patients with hypertension to go onto low-salt diets, even though this helps only a minority of patients. Myriad Genetics is currently evaluating a test for mutants of the AGT gene, which codes for a protein that regulates salt retention. If hypertension patients with AGT mutants are helped by a low-salt diet, physicians will be able to use Myriad’s AGT test to identify people who will actually benefit from salt restriction.3
The drug discovery and development process also will be accelerated and
fundamentally redesigned over the decade ahead in response to progress in genomics (see Chapter 2 on Clinical Development). There will be a dramatic increase in the number of effective therapeutic agents.4 In fact, genomics will produce new generations
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of antibiotics, potentially stemming a global health crisis caused by the proliferation of bacteria resistant to conventional antibiotics.5
Genomics will open up a new field of immunotherapy, based on novel methods for fighting diseases by enlisting the cells of the body’s own immune system. For example, in February 1997 Professor David Wallack and his colleagues at the Membrane Research and Biophysics Department of the Weizmann Institute in Israel reported in
Nature the discovery of a gene, called NIK, that helps remove a “molecular brake” that
keeps the immune response in check. Wallack’s team believes the discovery will lead to drugs that enhance and regulate the immune response.6
DNA vaccines will begin to be available over the next five to ten years and are likely to be universally adopted before 2020. They will be far superior to traditional vaccines: safer; more effective at conferring both humoral and cellular immunity; effective against a broader spectrum of pathogens and able to confer long-term immunity with a single dose. It will be possible to inject genes from multiple pathogens at the same time, creating new kinds of broad-spectrum vaccines.7 Some chiropractors and other critics charge that vaccines are already overused and effectively require people to put
themselves and their children at risk, against their will. As with other therapies each will increasingly be forced to show cost-effective outcomes in order to be used. Assuming these vaccines are cost-effective, the side-effects question may also be able to be dealt with. Genomics will enable us to identify, for many drugs and procedures, who is most susceptible to particular side effects of medications.
Another emerging therapy that will be useful in the treatment and prevention of
infectious disease is called “antisense.” Essentially, antisense therapies are compounds designed to block selected gene functions by genetically engineering proteins that are opposite to the proteins needed for cell division. Antisense is anticipated to come into common use to attack bacterial, viral, cancer and other diseases driven by cells that replicate.8
Gene therapy will emerge between now and 2020 as one of the truly revolutionary developments in the history of medicine, comparable in its impacts to the introduction of microscopy, anesthesia, vaccination or antibiotics. The first concrete results are likely within the next few years, in the area of gene-based cancer immunotherapies.9 In all cases, these biotech-related advances will have to stand the tests of efficacy and cost- effectiveness.
Advances in genetics will create new interactions between chiropractors and
conventional medicine. For example, chiropractors will need to discover how to utilize the information that a patient is predisposed to certain diseases, and how to work with other health care providers as well as their patients to maximize the new opportunities. Research on how herbs, biologicals and dietary supplements affect gene function and vice versa has already begun and is being used by some practitioners. The
“Customization” section below considers some of these implications, including those areas where conventional health care will learn from CAAs.
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