by Al Gore
In 2011, Japanese fertility scientists at Kyoto University caused a stir when they announced that they had successfully used embryonic mouse stem cells to produce sperm when transplanted into the testicles of mice that were infertile. When the sperm was then extracted and put into mouse eggs, the fertilized eggs were transferred to the uteri of female mice, and resulted in normal offspring that could then reproduce naturally. Their work builds on an English science breakthrough in 2006 in which biologists at the University of Newcastle upon Tyne first produced functioning sperm cells that had been converted from stem cells and produced live offspring, though the offspring had genetic defects.
One reason why these studies drew such attention was that the same basic technique, as it is developed and perfected, may soon make it possible for infertile men to have biological children—and opens the possibility for gay and lesbian couples to have children that are genetically and biologically their own. Some headline writers also savored the speculation that since there is no reason why women cannot, in theory, produce their own sperm cells using this technique: “Will Men Become Obsolete?” On the lengthening list of potentially disquieting outcomes from genetic research, this possibility appears destined to linger near the bottom, though I am certainly biased in making that prediction.
LIFESPANS AND “HEALTHSPANS”
Just as scientists working on fertility have focused on the beginning of life, others have been focused on the end of life—and have been making dramatic progress in understanding the factors affecting longevity. They are developing new strategies, which they hope will achieve not only significant extensions in the average human lifespan, but also the extension of what many refer to as the “healthspan”—the number of years we live a healthy life without debilitating conditions or diseases.
Although a few scientific outliers have argued that genetic engineering could increase human lifespans by multiple centuries, the consensus among many aging specialists is that an increase of up to 25 percent is more likely to be the range of what is possible. According to most experts, evolutionary theory and numerous studies in human and animal genetics lead them to the conclusion that environmental and lifestyle factors contribute roughly three quarters to the aging process and that genetics makes a more modest contribution—somewhere between 20 and 30 percent.
One of the most famous studies of the relationship between lifestyle and longevity showed that extreme caloric restriction extends the lives of rodents dramatically, although there is debate about whether this lifestyle adjustment has the same effect on longevity in humans. More recent studies have shown that rhesus monkeys do not live longer with severe caloric restrictions. There is a subtle but important distinction, experts on all sides point out, between longevity and aging. Although they are obviously related, longevity measures the length of life, whereas aging is the process by which cell damage contributes over time to conditions that bring the end of life.
Some highly questionable therapies, such as the use of human growth hormone in an effort to slow or reverse unwanted manifestations of the aging process, may well have side effects that shorten longevity, such as triggering the onset of diabetes and the growth of tumors. Other hormones that have been used to combat symptoms of aging—most prominently, testosterone and estrogen—have also led to controversies about side effects that can shorten longevity for certain patients.
However, excitement was also stirred by a Harvard study in 2010 that showed that the aging process in mice could be halted and even reversed by the use of enzymes known as telomerases, which serve to protect the telomeres—or protective caps—on the ends of chromosomes in order to prevent them from damage. Scientists have long known that these telomeres get shorter with the aging of cells and that this shortening process can ultimately halt the renewal of the cells through replication. As a result of the Harvard study, scientists are exploring strategies for protecting the telomeres in order to retard the aging process.
Some researchers are optimistic that extensive whole genome studies of humans with very long lifespans may yet lead to the discovery of genetic factors that can be used to extend longevity in others. However, most of the dramatic extensions in the average human lifespan over the last century have come from improvements in sanitation and nutrition, and from medical breakthroughs such as the discovery of antibiotics and the development of vaccines. Further improvements in these highly successful strategies are likely to further improve average lifespans—probably, scientists speculate, at the rate of improvement we have become used to—about one extra year per decade.
In addition, the continued global efforts to fight infectious disease threats are also extending average lifespans by reducing the number of premature deaths. Much of this work is now focused on malaria, tuberculosis, HIV/AIDS, influenza, viral pneumonia, and multiple so-called “neglected tropical diseases” that are barely known in the industrialized world but afflict more than a billion people in developing tropical and subtropical countries.
THE DISEASE FRONT
There has been heartening progress in reducing the number of people who die of AIDS each year. In 2012, the number fell to 1.7 million, significantly down from its 2005 peak of 2.3 million. The principal reason for this progress is greater access to pharmaceuticals—particularly antiretroviral drugs—that extend the lifespan and improve the health of people who have the disease. Efforts to reduce the infection rate continue to be focused on preventive education, the distribution of condoms in high-risk areas, and accelerated efforts to develop a vaccine.
Malaria has also been reduced significantly over the past decade with a carefully chosen combination of strategies. Although the largest absolute declines were in Africa, according to the U.N., 90 percent of all malaria deaths still take place in Sub-Saharan Africa—most of them involving children under five. Although an ambitious effort in the 1950s to eradicate malaria did not succeed, a few of those working hard to eradicate malaria, including Bill Gates, now believe that their goal may actually be realistic within the next few decades.
The world did succeed in eliminating the terrible scourge of smallpox in 1980. And in 2011 the U.N. Food and Agriculture Organization succeeded in eliminating a second disease, rinderpest, a relative of measles that killed cattle and other animals with cloven hooves. Because it was an animal disease, rinderpest never garnered the global attention that smallpox commanded, but it was one of the deadliest and most feared threats to those whose families and communities depend on livestock.
For all of the appropriate attention being paid to infectious diseases, the leading causes of death in the world today, according to the World Health Organization, are chronic diseases that are not communicable. In the last year for which statistics are available, 2008, approximately 57 million people died in the world, and almost 60 percent of those deaths were caused by chronic diseases, principally cardiovascular disease, diabetes, cancer, and chronic respiratory diseases.
Cancer is a special challenge, in part because it is not one disease, but many. The U.S. National Cancer Institute and the National Human Genome Research Institute have been spending $100 million per year on a massive effort to create a “Cancer Genome Atlas,” and in 2012 one of the first fruits of this project was published in Nature by more than 200 scientists who detailed genetic peculiarities in colon cancer tumors. Their study of more than 224 tumors has been regarded as a potential turning point in the development of new drugs that will take advantage of vulnerabilities they found in the tumor cells.
In addition to focusing on genomic analyses of cancer, scientists are exploring virtually every conceivable strategy for curing cancers. They are investigating new possibilities for shutting off the blood supply to cancerous cells, dismantling their defense mechanisms, and boosting the ability of natural immune cells to identify and attack the cancer cells. Many are particularly excited about new strategies that involve proteomics—the decoding of all of the proteins translated by cancer genes in the various forms of cancer and targeting epige
netic abnormalities.
Scientists explain that while the human genome is often characterized as a blueprint, it is actually more akin to a list of parts or ingredients. The actual work of controlling cellular functions is done by proteins that carry out a “conversation” within and between cells. These conversations are crucial in understanding “systems diseases” like cancer.
One of the promising strategies for dealing with systemic disorders like cancer and chronic heart diseases is to strengthen the effectiveness of the body’s natural defenses. And in some cases, new genetic therapies are showing promise in doing so. A team of scientists at the University of California San Francisco Gladstone Institutes of Cardiovascular Disease has dramatically improved cardiac function in adult mice by reprogramming cells to restore the health of heart muscles.
IN MANY IF not most cases, though, the most effective strategy for combating chronic diseases is to make changes in lifestyles: reduce tobacco use, reduce exposure to carcinogens and other harmful chemicals in the environment, reduce obesity through better diet and more exercise, and—at least for salt-sensitive individuals—reduce sodium consumption in order to reduce hypertension (or high blood pressure).
Obesity—which is a major causal factor in multiple chronic diseases—was the subject of discouraging news in 2012 when the British medical journal The Lancet published a series of studies indicating that one of the principal factors leading to obesity, physical inactivity and sedentary lifestyles, is now spreading from North America and Western Europe to the rest of the world. Researchers analyzed statistics from the World Health Organization to demonstrate that more people now die every year from conditions linked with physical inactivity than die from smoking. The statistics indicate that one in ten deaths worldwide is now due to diseases caused by persistent inactivity.
Nevertheless, there are good reasons to hope that new strategies combining knowledge from the Life Sciences Revolution with new digital tools for monitoring disease states, health, and wellness may spread from advanced countries as cheaper smartphones are sold more widely throughout the globe. The use of intelligent digital assistants for the management of chronic diseases (and as wellness coaches) may have an extremely positive impact.
In developed nations, there are already numerous smartphone apps that assist those who wish to keep track of how many calories they consume, what kinds of food they are eating, how much exercise they are getting, how much sleep they are getting (some new headbands also keep track of how much deep sleep, or REM sleep, they are getting), and even how much progress they are making in dealing with addictions to substances such as alcohol, tobacco, and prescription drugs. Mood disorders and other psychological maladies are also addressed by self-tracking programs. During the 2012 summer Olympic Games in London, a number of athletes were persuaded by biotech companies attempting to improve their health-tracking devices to use glucose monitors and sleep monitors, and to receive genetic analyses designed to improve their individual nutritional needs.
Such monitoring is not limited to Olympians. Personal digital monitors of patients’ heart rates, blood glucose, blood oxygenation, blood pressure, body temperature, respiratory rate, body fat levels, sleep patterns, medication use, exercise, and more are growing more common. Emerging developments in nanotechnology and synthetic biology also hold out the prospect of more sophisticated continuous monitoring from sensors inside the body. Nanobots are being designed to monitor changes in the bloodstream and vital organs, reporting information on a constant basis.
Some experts, including Dr. H. Gilbert Welch of Dartmouth, the author of Overdiagnosed: Making People Sick in the Pursuit of Health, believe that we are in danger of going too far in monitoring and data analysis of individuals who track their vital signs and more: “Constant monitoring is a recipe for all of us to be judged ‘sick.’ Judging ourselves sick, we seek intervention.” Welch and some others believe that many of these interventions turn out to be costly and unnecessary. In 2011, for example, medical experts advised doctors to stop routinely using a new and sophisticated antigen test for prostate cancer precisely because the resulting interventions were apparently doing more harm than good.
The digitizing of human beings, with the creation of large files containing detailed information about their genetic and biochemical makeup and their behavior, will also require attention to the same privacy and information security issues discussed in Chapter 2. For the same reasons that this rich data is potentially so useful in improving the efficacy of health care and reducing medical costs, it is also seen as highly valuable to insurance companies and employers who are often eager to sever their relationships with customers and employees who represent high risks for big medical bills. Already, a high percentage of those who could benefit from genetic testing are refusing to have the information gathered for fear that they will lose their jobs and/or their health insurance.
A few years ago, the United States passed a federal law known as the Genetic Information Nondiscrimination Act, which prohibits the disclosure or improper use of genetic information. But enforcement is difficult and trust in the law’s protection is low. The fact that insurance companies and employers usually pay for the majority of health care expenditures—including genetic testing—further reinforces the fear by patients and employees that their genetic information will not remain confidential. Many believe that flows of information on the Internet are vulnerable to disclosure in any case. The U.S. law governing health records, the Health Insurance Portability and Accountability Act, fails to guarantee patient access to records gathered from their own medical implants while companies seek to profit from personalized medical information.
Nevertheless, these self-tracking techniques—part of the so-called self-quantification movement—offer the possibility that behavior modification strategies that have traditionally been associated with clinics can be individualized and executed outside of an institutional setting. Expenditures for genetic testing are rising rapidly as prices for these tests continue to fall rapidly and as the wave of personalized medicine continues to move forward with increasing speed.
The United States may have the most difficulty in making the transition to precision medicine because of the imbalance of power and unhealthy corporate control of the public policy decision-making process, as described in Chapter 3. This chapter is not about the U.S. health care system, but it is interesting to note that the glaring inefficiencies, inequalities, and absurd expense of the U.S. system are illuminated by the developing trends in the life sciences. For example, many health care systems do not cover disease prevention and wellness promotion expenditures, because they are principally compensated for expensive interventions after a patient’s health is already in jeopardy. The new health care reform bill enacted by President Obama required coverage of preventive care under U.S. health care plans for the first time.
As everyone knows, the U.S. spends far more per person on health care than any other country while achieving worse outcomes than many other countries that pay far less, and still, tens of millions do not have reasonable access to health care. Lacking any other option, they wait, often until their condition is so dire that they have to go to the emergency room, where the cost of intervention is highest and the chance of success is lowest. The recently enacted reforms will significantly improve some of these defects, but the underlying problems are likely to grow worse—primarily because insurance companies, pharmaceutical companies, and other health care providers retain almost complete control over the design of health care policy.
THE STORY OF INSURANCE
The business of insurance began as far back as ancient Rome and Greece, where life insurance policies were similar to what we now know as burial insurance. The first modern life insurance policies were not offered until the seventeenth century in England. The development of extensive railroad networks in the United States in the 1860s led to limited policies protecting against accidents on railroads and steamboats, and that led, in turn, to
the first insurance policies protecting against sickness in the 1890s.
Then, in the early 1930s, when advances in medical care began to drive costs above what many patients could pay on their own, the first significant group health insurance policies were offered by nonprofits: Blue Cross for hospital charges and Blue Shield for doctors’ fees. All patients paid the same premiums regardless of age or preexisting conditions. The success of the Blues led to the entry into the marketplace of private, for-profit health insurance companies, who began to charge different premiums to people based on their calculation of the risk involved—and refused to offer policies at all to those who represented an unacceptably high risk. Soon, Blue Cross and Blue Shield were forced by the new for-profit competition to also link premiums to risk.
When President Franklin Roosevelt was preparing his package of reforms in the New Deal, he twice took preliminary steps—in 1935 and again in 1938—to include a national health insurance plan as part of his legislative agenda. On both occasions, however, he feared the political opposition of the American Medical Association and removed the proposal from his plans lest it interfere with what he regarded as more pressing priorities in the depths of the Great Depression: unemployment compensation and Social Security. The introduction of legislation in 1939 by New York Democratic senator Robert Wagner offered a quixotic third opportunity to proceed but Roosevelt chose not to support the legislation.
During World War II, with wages (and prices) controlled by the government, private employers began to compete for employees, who were scarce due to the war, by offering health insurance coverage. Then after the war, unions began to include demands for more extensive health insurance as part of their negotiated contracts with employers.
Roosevelt’s successor, Harry Truman, sought to revive the idea for national health insurance, but the opposition in Congress—once again fueled by the AMA—ensured that it died with a whimper. As a result, the hybrid system of employer-based health insurance became the primary model in the United States. Because older Americans and those with disabilities had a difficult time obtaining affordable health insurance within this system, new government programs were implemented to help both groups.
