Global Health Watch 1 in one file
Global Health Watch 1 in one file Global Health Watch 1 in one file
Health care systems | B5 drugs based on a genomic approach to targeting molecular pathways that [have] been disrupted in disease’ (Collins 1999, Collins and McKusick, 2001). Five years on, participants at a conference on genomics and health held by the US National Academy of Sciences (Institute of Medicine) reflected on the progress made in far more modest tones. Hopes had been high of dramatic advances in cancer treatment, but the media quoted prominent scientist Dr Gilbert Omenn as saying that despite an ‘avalanche of genomic information… cancers remain a largely unsolved set of medical problems [for which] we continue to rely on highly toxic drugs’ (Boyd 2004; see also Hernandez 2005). One recent addition to the cancer armamentarium which has benefited from advances in molecular cancer biology is trastuzumab (Herceptin), used to treat HER2–positive metastatic breast cancer. It has been welcomed by clinicians but is not considered revolutionary. It extends lifetimes by a matter of months but does not avoid side-effects, is suitable for rather a small number of patients and is costly (Hedgecoe 2004). Gefitinib (Iressa), for non-small cell lung cancer, has been hailed as the next ‘genetically targeted’ treatment (Langreth 2004), but its manufacturer recently withdrew its application for European regulatory approval, following the release of clinical trial data that showed the drug did not increase lifespan (Tomlinson 2005). More generally, genomics had made little impact on clinical practice and outputs such as new treatments have failed to keep pace with increased research and development (R&D) spending (Nightingale and Martin 2004). The relatively rare Mendelian disorders such as cystic fibrosis, phenylketonuria and Huntington’s disease allow for relatively easy study of the associated molecular genetics because the risk of disease is dominated by mutations in a single gene. Prominent geneticists have pointed out that the overwhelming bulk of common chronic diseases (diabetes, coronary heart disease, cancers) have much more complex etiology that may include a familial component in addition to social, economic, psychological and biological factors. The relationship between genotype (DNA sequence at the gene locus of interest) and phenotype (manifest traits) therefore becomes correspondingly murky and contingent for those common diseases. The proportion of cases that can be attributed to susceptibility-conferring genotypes in a given population is typically small for common diseases such as breast cancer and colon cancer, making it both more difficult and less useful to identify the gene (ensembles) involved (Holtzman and Marteau 2000). Even when the molecular genetics are tractable, knowledge of the molecular basis of a disease is not easily translatable into prevention or treatment. It took 70 years for streptomycin to become available for TB treatment from the 150
11 The human genome under threat of commercialization. time Mycobacterium tuberculosis was identified as the agent involved. The molecular (genetic) basis of sickle-cell anemia was elucidated in the 1950s but palliative therapy has only recently become available. There has been little advance in the treatment of cystic fibrosis since the crucial gene was identified and cloned in 1989 and details of the molecular pathogenesis worked out. More encouragingly protease inhibitors, used in combination therapy along with reverse transcriptase inhibitors for treating HIV/AIDS patients, became available in the mid-1990s, about 10 years after the discovery of HIV-1. Given that the success of gene-based therapies has so far been modest, with few promising candidates on the horizon, commercial interest is likely to shift towards genetic testing for ‘disease susceptibility’ – in line with a paradigm shift towards ‘predictive medicine’, or individual genetic profiling to assess the risk of future illnesses. This has the added attraction of mass markets, since genetic testing for disease susceptibility may be conducted routinely as part of well-person care and screening. Corporate R&D is seeking ‘pills for the healthy ill’ or worried well (Wallace 2002), to carve out new markets not just for screening tests but also for ‘prophylactics’ for those deemed to be at risk. While busily seeking to create markets for its commodifiable biomedical outputs, market-driven R&D and its corporate sponsors will continue to ignore and bypass the diseases of the poor. This is also discussed at length in part B chapter 2 on medicines. Global spending on health research tripled from US$ 30 billion in 1990 to almost US$ 106 billion in 2001. It was split roughly between the public and private sectors, with the private nonprofit sector (including charities) playing a small but growing role. However, most R&D is still done by high-income countries in high-income countries to generate products tailored to those markets. Gene technology 151
- Page 118 and 119: B2 | Medicines Introduction Essenti
- Page 120 and 121: Health care systems | B2 of new med
- Page 122 and 123: Health care systems | B2 chapter re
- Page 124 and 125: Health care systems | B2 the fourth
- Page 126 and 127: Health care systems | B2 agenda thr
- Page 128 and 129: Health care systems | B2 nonetheles
- Page 130 and 131: Health care systems | B2 decision o
- Page 132 and 133: Health care systems | B2 for the an
- Page 134 and 135: Health care systems | B2 expenditur
- Page 136 and 137: Health care systems | B2 Medawar C
- Page 138 and 139: Health care systems | B3 between he
- Page 140 and 141: Severe shortage Low density Moderat
- Page 142 and 143: Health care systems | B3 sector and
- Page 144 and 145: Health care systems | B3 to the US,
- Page 146 and 147: Health care systems | B3 500 400 30
- Page 148 and 149: Health care systems | B3 have been
- Page 150 and 151: Health care systems | B3 to underta
- Page 152 and 153: B4 | Sexual and reproductive health
- Page 154 and 155: Health care systems | B4 10 Policy-
- Page 156 and 157: Health care systems | B4 women and
- Page 158 and 159: Health care systems | B4 of funding
- Page 160 and 161: Health care systems | B4 debate on
- Page 162 and 163: Health care systems | B4 the sexual
- Page 164 and 165: Health care systems | B4 perspectiv
- Page 166 and 167: Health care systems | B5 genome res
- Page 170 and 171: Health care systems | B5 Complete f
- Page 172 and 173: Health care systems | B5 when a tes
- Page 174 and 175: Health care systems | B5 are allowi
- Page 176 and 177: Health care systems | B5 of life sc
- Page 179: part c | Health of vulnerable group
- Page 182 and 183: Health of vulnerable groups | C1 me
- Page 184 and 185: Health of vulnerable groups | C1 pr
- Page 186 and 187: Health of vulnerable groups | C1 Th
- Page 188 and 189: Health of vulnerable groups | C1 Ca
- Page 190 and 191: Health of vulnerable groups | C1 Bo
- Page 192 and 193: Health of vulnerable groups | C1 Bo
- Page 194 and 195: Health of vulnerable groups | C1 Bo
- Page 196 and 197: Health of vulnerable groups | C1 Pa
- Page 198 and 199: Health of vulnerable groups | C2 Bo
- Page 200 and 201: Health of vulnerable groups | C2 DP
- Page 202 and 203: Health of vulnerable groups | C2 Bo
- Page 204 and 205: Health of vulnerable groups | C2 Bo
- Page 206 and 207: Health of vulnerable groups | C2 di
- Page 209 and 210: part d | The wider health context T
- Page 211 and 212: D1 | Climate change Introduction En
- Page 213 and 214: increasing quantities are now causi
- Page 215 and 216: development, local availability foo
- Page 217 and 218: 14 Droughts threaten the food secur
11 The human genome under threat of commercialization.<br />
time Mycobacterium tuberculosis was identified as the agent <strong>in</strong>volved. The<br />
molecular (genetic) basis of sickle-cell anemia was elucidated <strong>in</strong> the 1950s<br />
but palliative therapy has only recently become available. There has been little<br />
advance <strong>in</strong> the treatment of cystic fibrosis s<strong>in</strong>ce the crucial gene was identified<br />
and cl<strong>one</strong>d <strong>in</strong> 1989 and details of the molecular pathogenesis worked out.<br />
More encourag<strong>in</strong>gly protease <strong>in</strong>hibitors, used <strong>in</strong> comb<strong>in</strong>ation therapy along<br />
with reverse transcriptase <strong>in</strong>hibitors for treat<strong>in</strong>g HIV/AIDS patients, became<br />
available <strong>in</strong> the mid-1990s, about 10 years after the discovery of HIV-1.<br />
Given that the success of gene-based therapies has so far been modest, with<br />
few promis<strong>in</strong>g candidates on the horizon, commercial <strong>in</strong>terest is likely to shift<br />
towards genetic test<strong>in</strong>g for ‘disease susceptibility’ – <strong>in</strong> l<strong>in</strong>e with a paradigm<br />
shift towards ‘predictive medic<strong>in</strong>e’, or <strong>in</strong>dividual genetic profil<strong>in</strong>g to assess the<br />
risk of future illnesses. This has the added attraction of mass markets, s<strong>in</strong>ce<br />
genetic test<strong>in</strong>g for disease susceptibility may be conducted rout<strong>in</strong>ely as part of<br />
well-person care and screen<strong>in</strong>g. Corporate R&D is seek<strong>in</strong>g ‘pills for the healthy<br />
ill’ or worried well (Wallace 2002), to carve out new markets not just for screen<strong>in</strong>g<br />
tests but also for ‘prophylactics’ for those deemed to be at risk.<br />
While busily seek<strong>in</strong>g to create markets for its commodifiable biomedical<br />
outputs, market-driven R&D and its corporate sponsors will cont<strong>in</strong>ue to ignore<br />
and bypass the diseases of the poor. This is also discussed at length <strong>in</strong> part<br />
B chapter 2 on medic<strong>in</strong>es. <strong>Global</strong> spend<strong>in</strong>g on health research tripled from<br />
US$ 30 billion <strong>in</strong> 1990 to almost US$ 106 billion <strong>in</strong> 2001. It was split roughly<br />
between the public and private sectors, with the private nonprofit sector (<strong>in</strong>clud<strong>in</strong>g<br />
charities) play<strong>in</strong>g a small but grow<strong>in</strong>g role. However, most R&D is still<br />
d<strong>one</strong> by high-<strong>in</strong>come countries <strong>in</strong> high-<strong>in</strong>come countries to generate products<br />
tailored to those markets.<br />
Gene technology<br />
151
Change language