Genomics 2030 (EN)

“I predict that, by the year 2030, gene-based therapy will have revolutionised the practice of medicine.” This remark (and similar statements) of W. French Anderson [French Anderson, 1999] in the late 1990s led to many speculations about the possibilities of this new technology. In the meantime, six years have gone by. Speculations are only slowly replaced by insights and expectations based on facts.

This book concerns such a new technology. Facts will be presented aiming to feed the debate on genomics. This is necessary, for discussions are, and were, often much too abstract; many people lacked the essential basic facts. That nevertheless a discussion was started, was frequently caused by a wide spectrum of expectations ranging from all sorts of gloomy scenarios to ideas about radical changes in health care, where they were caused by expectations about unprecedented predicting possibilities attributed to genomics. For that matter, such discussions occur quite regularly in health care. Often, their outcome is similar. Therefore it is wise to first put into perspective an essay on new technologies in health care. First, a brief history.

From our current point of view, the 1960s and 1970s gave rise to many unrestrained fantasies. They were fed by the big successes in medical science that were quite often world news. In 1966, several possibilities were described to substantially influence the brain and accordingly the behaviour of people with medication, and this before the year 2000 [Krech, 1966]. The futurologists Kahn and Wiener examined this seriously a year later. They saw big possibilities to influence the brain as a result of the knowledge acquired by analysing the secrets of RNA and DNA structures [Kahn and Wiener, 1967]. Not only did these ideas live in the United States, in the Netherlands similar insights were passed on: direct stimulation of the brain, pharmacological improvement of the memory, and the like, were expected before the year 2000 [Hattinga Verschuere, 1971]. These fantasies could perhaps still be ascribed to the belief in the success of technology during the Cold War, but the ideas about the transplantation of organs or replacing them by all sorts of substitutes were different. These were considered as real developments in the 1960s, maybe even before the year 2000. The belief in technological progress was very much alive, sceptics were hardly believed.

Manipulation of hereditary material was discussed very seriously [Hattinga Verschuere, 1971]. The results were considered to be very clear. The result, influencing the quality of offspring, was seen as a reality in the near future. These speculations rapidly changed into wild fantasies. Often, they were taken very seriously, as shown by a quote from 1966, for instance, that caused a great deal of controversy in the Washington Post. The text reads more or less as follows: “Within 10-15 years, a housewife will be able to visit a new type of institution and examine a row of packages as if she were looking for flower seeds. Then, she will choose her baby on the basis of the label. Each package contains a frozen one-day-old embryo. The label states the expected colours of hair and eyes and the child’s IQ (…)” [Washington Post, 1966; Kaiser Aluminum News, 1966].

The above ideas are ascribed much too easily to the fanciful 1960s. In the years around the turn of the century, similar insights existed that have been described excellently in Francis Fukuyama’s book ‘The New Man’ [Fukuyama, 2002]. He describes three scenarios that might unfold within one or two generations.

The first scenario also concerns the influencing of behaviour. Many have heard of Prozac and Ritalin, medication that is effective in respect to characteristics such as self-respect and ability to concentrate. A drawback is that they can have undesirable side-effects. It is probable that by adapting them specifically to the user’s genetic make-up, these side-effects can be almost entirely prevented. Unhappy people can become happy, introvert ones extravert, and so on. The second scenario concerns replacing tissues and organs. Not by all sorts of transplantations but by application of the results of stem cell research. This appears to make it possible in the future to regenerate almost all body tissues. In the last scenario, the line of Kahn and Wiener is further extended into the future. Fukuyama also considers influencing the quality of offspring as a realistic option. In his opinion, rich people can afford to have embryos checked on a regular basis before they are implanted. As a consequence, the social background of young people can be told to an increasing extent from their looks and intelligence [De Vries, 2005].

These three scenarios of Fukuyama’s have a surprisingly large similarity with the perceptions of forty years ago. There is an ever increasing technological imperative in health care on our way towards the horizon — without ever reaching it.

Whoever thinks that this optimism is widely shared, however, will be disappointed. Little by little, doubts are being expressed about the possibilities of technology in medical science and in connected sciences. For instance, in the year 1979, the biologist Glass came with an argument that was confronting at that time about the progress of science. He stated that the development of science had more or less reached its apex and that the pace of new findings would only decrease. He acknowledged that much could still be learned, but that in his opinion real breakthroughs would only decrease [Glass, 1979]. Glass is not alone in his pessimism. Le Fanu, a physician, presumes that we are confronted with a decline in the number of developments [Le Fanu, 1999]. This point of view is extremely interesting, because he draws our attention to a number of inhibiting factors that appear to be becoming more and more manifest in medicine. Le Fanu, but he is not alone in this, thus provides a necessary counterbalance — necessary in order to keep both feet on the ground. For that matter, Le Fanu acknowledges the successes achieved in medical science in the past century. He cites developments such as penicillin, cortisone, open-heart surgery, MRI, liver transplantations, and so on. In his opinion, all these developments are hardly the result of systematic scientific research but more likely of seizing opportunities, of perceptivity, of doggedness and perseverance. After the 1970s, says Le Fanu, these have been increasingly lacking, and the abundance of ideas is decreasing. New developments become more and more scientifically-oriented, also as a consequence of the thalidomide affair, resulting in delays in the production of new concepts. And indeed, we see a worldwide decrease of, for instance, new pharmaceutical products — in ten years a decrease of more than 20% [Efpia, 2003]. At the same time, the R&D costs have doubled in this industry over the same period, in spite of the recession affecting a large number of economies.

The paradox mentioned lets us presume that there is more going on. Traditional R&D techniques are being abandoned, a trend of computer-related research techniques is emerging, which is making ‘wet chemistry’ partially redundant. But this is not all. New knowledge is emerging by way of alliances with all kinds of genomics and ‘baby biotech’ companies; convergence of disciplines (nanotech, biotech and infotech) is more and more common. This appears to be giving rise to new research cultures both within and outside the pharmaceutical industry. There is every indication that in the near future the downward movement of the number of medical innovations will stop. Reorientation of scientific research is the decisive factor in this context.

It is no longer unthinkable that researchers have almost solved the mystery of how cancer develops. Findings of the Human Genome Project played an important role in this. It is clear that much progress has been made and that it is probable that in approximately ten years various forms of cancer will be reduced to chronic diseases, like diabetes [Workman, 2004].

The importance of nanotechnology for medical scientific research is rapidly increasing. In the meantime, nanotechnology has become a (political) spear-head. In 2004, the United States government alone spent twice as much on research as in the most expensive years of the Human Genome Project. Apart from direct economic importance (new materials and products), acquired conceptions will be very useful in research into medicines, in medical diagnoses and in important analyses. For instance, sensors on a nanoscale will be useful in tracing infections within the next three to five years [Economist, 2004].

All new developments point to a type of health care increasingly centred on the patient. Treatment will increasingly take place outside hospitals. The trend to more and more treatments in outpatients’ departments or in the patient’s private environment has begun: cyber-medicine and ‘hospital at home’. ICT will be of crucial importance in this instance. This trend will not be over for a long time.

The influence new technologies will ultimately have on the patient and on the health care system is far from clear. However, it does appear to be probable that developments will lead to ‘personalised medicine’. This development appears to respond to the individualism and increasing consumerism in health care. The latter only seems to be the case, because it can be assumed that at the same time the egalitarian aspect of health care — an important aspect of consumerism — will be considerably eroded by new developments. The following is a construed example [De Vries, 2005]:

New developments indicate that future pharmaceutical products will become more and more specific. The number of cancerous disorders the patients are confronted with will increase, because diversity at a molecular level is very extensive: for each type of cancer a separate approach will have to be selected. This means that the markets for medication will become considerably smaller. The consequence will be that the industry will only focus on subtypes of frequently occurring disorders. Less frequently occurring disorders can be dealt with but will often not be developed for market technical reasons. Prices will considerably increase, not only because of the smaller markets but initially also because of the necessary research that has to be done with smaller populations.

The consequence will be that very effective but also very expensive drugs will be created. The most attractive markets for the industry are the elderly — as for numbers and effectively anticipated demand. Then it is the question whether the health care system can produce the solidarity to finance qualitatively superior drugs (including expensive maintenance doses). It must be feared that in this field important social issues will occur. The solidarity will not only be limited to the price but also to the question whether the available knowledge must or can be applied for less frequently occurring disorders. To maintain an egalitarian system as in the Netherlands, it is essential that new technologies are always tested for their consequences for the health care system — it is hardly possible to exclude the technologies, but a careful introduction process can prevent many problems.

The Dutch population is growing old. Growing old means an increasing consumption of health care, which is a reason for a number of organisations

to study the consequences of this phenomenon. In the meantime, several views have been published, many of them ending in negative scenarios. For instance, it has been calculated that there will be shortages in particular with regard to family doctors, nurses and attendants — shortages to the extent of 23% in 2020 are probable [SCP, 2004].² In many scenarios, the influence of technology hardly plays a role, many confine themselves to continue the existing demand for health care, taking into account the expected developments of a number of important diseases, another and maybe better use of the labour factor. Up to now, the latter has not been the case, except for some exceptions. The Dutch Central Planning Office (CPB) considers the technology factor as one of the causes of the future increase of the health care demand [Folmer, 2001]. It is debatable whether this also applies to new technologies — there are reasons to make subtle distinctions in this context. Genomics, nanotechnology and information technology can in principle be used to ensure access to health care for all, but it is questionable whether market realities will cor-respond with this. A continuous assessment of this issue will remain relevant in future.

• Economist (2004). A Survey of Nanotechnology. The Economist. January 1. pp 1-15
• Efpia (2003). The Pharmaceutical Industry in Figures — 2003. Update p 4
• Fanu, J Le (1999). The Rise and Fall of Modern Medicine. Little, Brown and Company
• Folmer, K et al (2001). Een scenario voor zorguitgaven 2003-2006. CPB-Document, No 7
• French Anderson, W (1999). Gene Therapies. In: E Griffith (ed.). Predictions, 30 Great Minds on the Future. Oxford University Press. pp 12-21
• Fukuyama, F (2002). De nieuwe mens. Onze wereld na de biotechnolo-gische revolutie. Olympus. p 23 et seq.
• Glass, B (1979). Milestones and Rates of Growth in the Development of Biology. Quarterly of Biology. March. pp 31-53
• Hattinga Verschuere, JCM (1971). Patiënt, ziekenhuis, gezondheidszorg op weg naar 2000. Agon Elsevier. pp 36-52
• Hattinga Verschuere, JCM (1971). Patiënt, ziekenhuis, gezondheidszorg op weg naar 2000. Agon Elsevier. pp 36-37
• Kahn, H, AJ Wiener (1967). The Year 2000. Macmillan Company. p 111
• Kaiser Aluminum News (1966). Forseeing the Unforseeable, No 6. p 22. In: H Kahn, AJ Wiener (1967). The Year 2000. Macmillan Company
• Krech, D (1966). Controlling the Mind Controllers. Think. July-August. pp 3-7
• SCP (2004). In zicht van de toekomst. Sociaal Cultureel Planbureau. p 436
• Vries, T de (2005). Technologie en zorg: Wie wordt er beter van? Farewell Speech. University Utrecht, The Netherlands
• Washington Post (1966). October 31. In: H Kahn, AJ Wiener (1967). The Year 2000. Macmillan Company
• Workman, P (2004). Inhibiting the Phosphoinositide 3-Kinase Pathway for Cancer Treatment. Biochem. Soc. Trans, No 32. pp 393–396