Medical Tourism and Public Health By Amit Sen Gupta
Written by dsf
Sunday, 09 May 2004
THE most recent trend in privatisation of health services is medical tourism, which is gaining prominence in developing countries. Globalisation has promoted a consumerist culture, thereby promoting goods and services that can feed the aspirations arising from this culture. This has had its effect in the health sector too, with the emergence of a private sector that thrives by servicing a small percentage of the population that has the ability to “buy” medical care at the rates at which the “high end” of the private medical sector provides such care. This has changed the character of the medical care sector, with the entry of the corporate sector. Corporate run institutions are seized with the necessity to maximise profits and expand their coverage. These objectives face a constraint in the form of the relatively small size of the population in developing countries that can afford services offered by such institutions. In this background, corporate interests in the Medical Care sector are looking for opportunities that go beyond the limited domestic “market” for high cost medical care. This is the genesis of the “medical tourism” industry.
MEDICAL TOURISM AS AN INDUSTRY
Medical tourism can be broadly defined as provision of ‘cost effective’ private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialized treatment. This process is being facilitated by the corporate sector involved in medical care as well as the tourism industry - both private and public.
In many developing countries it is being actively promoted by the government’s official policy. India’s National Health policy 2002, for example, says: “To capitalise on the comparative cost advantage enjoyed by domestic health facilities in the secondary and tertiary sector, the policy will encourage the supply of services to patients of foreign origin on payment. The rendering of such services on payment in foreign exchange will be treated as ‘deemed exports’ and will be made eligible for all fiscal incentives extended to export earnings”. The formulation draws from recommendations that the corporate sector has been making in India and specifically from the “Policy Framework for Reforms in Health Care”, drafted by the prime minister’s Advisory Council on Trade and Industry, headed by Mukesh Ambani and Kumaramangalam Birla.
GROWTH OF THE MEDICAL TOURISM INDUSTRY
The countries where medical tourism is being actively promoted include Greece, South Africa, Jordan, India, Malaysia, Philippines and Singapore. India is a recent entrant into medical tourism. According to a study by McKinsey and the Confederation of Indian Industry, medical tourism in India could become a $1 billion business by 2012. The report predicts that: “By 2012, if medical tourism were to reach 25 per cent of revenues of private up-market players, up to Rs 10,000 crore will be added to the revenues of these players”. The Indian government predicts that India’s $17-billion-a-year health-care industry could grow 13 per cent in each of the next six years, boosted by medical tourism, which industry watchers say is growing at 30 per cent annually.
In India, the Apollo group alone has so far treated 95,000 international patients, many of whom are of Indian origin. Apollo has been a forerunner in medical tourism in India and attracts patients from Southeast Asia, Africa, and the Middle East. The group has tied up with hospitals in Mauritius, Tanzania, Bangladesh and Yemen besides running a hospital in Sri Lanka, and managing a hospital in Dubai.
Another corporate group running a chain of hospitals, Escorts, claims it has doubled its number of overseas patients - from 675 in 2000 to nearly 1,200 this year. Recently, the Ruby Hospital in Kolkata signed a contract with the British insurance company, BUPA. The management hopes to get British patients from the queue in the National Health Services soon. Some estimates say that foreigners account for 10 to 12 per cent of all patients in top Mumbai hospitals despite roadblocks like poor aviation connectivity, poor road infrastructure and absence of uniform quality standards.
Analysts say that as many as 150,000 medical tourists came to India last year. However, the current market for medical tourism in India is mainly limited to patients from the Middle East and South Asian economies. Some claim that the industry would flourish even without Western medical tourists. Afro-Asian people spend as much as $20 billion a year on health care outside their countries – Nigerians alone spend an estimated $1 billion a year. Most of this money would be spent in Europe and America, but it is hoped that this would now be increasingly directed to developing countries with advanced facilities.
PROMOTION OF MEDICAL TOURISM
The key “selling points” of the medical tourism industry are its “cost effectiveness” and its combination with the attractions of tourism. The latter also uses the ploy of selling the “exotica” of the countries involved as well as the packaging of health care with traditional therapies and treatment methods.
Price advantage is, of course, a major selling point. The slogan, thus is, “First World treatment’ at Third World prices”. The cost differential across the board is huge: only a tenth and sometimes even a sixteenth of the cost in the West. Open-heart surgery could cost up to $70,000 in Britain and up to $150,000 in the US; in India’s best hospitals it could cost between $3,000 and $10,000. Knee surgery (on both knees) costs 350,000 rupees ($7,700) in India; in Britain this costs £10,000 ($16,950), more than twice as much. Dental, eye and cosmetic surgeries in Western countries cost three to four times as much as in India.
The price advantage is however offset today for patients from the developed countries by concerns regarding standards, insurance coverage and other infrastructure. This is where the tourism and medical industries are trying to pool resources, and also putting pressure on the government. We shall turn to their implications later.
In India the strong tradition of traditional systems of health care in Kerala, for example, is utilised. Kerala Ayurveda centres have been established at multiple locations in various metro cities, thus highlighting the advantages of Ayurveda in health management. The health tourism focus has seen Kerala participate in various trade shows and expos wherein the advantages of this traditional form of medicine are showcased.
A generic problem with medical tourism is that it reinforces the medicalised view of health care. By promoting the notion that medical services can be bought off the shelf from the lowest priced provider anywhere in the globe, it also takes away the pressure from the government to provide comprehensive health care to all its citizens. It is a deepening of the whole notion of health care that is being pushed today which emphasises on technology and private enterprise.
The important question here is for whom is ‘cost effective’ services to be provided. Clearly the services are “cost effective” for those who can pay and in addition come from countries where medical care costs are exorbitant - because of the failure of the government to provide affordable medical care. It thus attracts only a small fraction that can pay for medical care and leaves out large sections that are denied medical care but cannot afford to pay. The demand for cost effective specialized care is coming from the developed countries where there has been a decline in public spending and rise in life expectancy and non-communicable diseases that requires specialist services.
MEDICAL TOURISM AND PUBLIC HEALTH SERVICES
Medical tourism is going to only deal with large specialist hospitals run by corporate entities. It is a myth that the revenues earned by these corporates will partly revert back to finance the public sector. There is ample evidence to show that these hospitals have not honoured the conditionalities for receiving government subsidies - in terms of treatment of a certain proportion of in patients and out patients free of cost. If anything, increased demand on private hospitals due to medical tourism may result in their expansion. If they expand then they will need more professionals, which means that they will try to woo doctors from the public sector. Even today the top specialists in corporate hospitals are senior doctors drawn the public sector. Medical tourism is likely to further devalue and divert personnel from the public sector rather than strengthen them.
Urban concentration of health care providers is a well-known fact – 59 per cent of India’s practitioners (73 per cent allopathic) are located in cities, and especially metropolitan ones. Medical tourism promotes an “internal brain drain” with more health professionals being drawn to large urban centres, and within them, to large corporate run specialty institutions.
Medical tourism is going to result in a number of demands and changes in the areas of financing and regulations. There will be a greater push for encouraging private insurance tied to systems of accreditation of private hospitals. There is a huge concern in the developed countries about the quality of care and clinical expertise in developing countries and this will push for both insurance and regulatory regimes. The potential for earning revenues through medical tourism will become an important argument for private hospitals demanding more subsidies from the government in the long run. In countries like India, the corporate private sector has already received considerable subsidies in the form of land, reduced import duties for medical equipment etc. Medical tourism will only further legitimise their demands and put pressure on the government to subsidise them even more. This is worrying because the scarce resources available for health will go into subsidising the corporate sector. It thus has serious consequences for equity and cost of services and raises a very fundamental question: why should developing countries be subsidising the health care of developed countries?
Tuesday 16 September 2008
Tobacco Industry
Tobacco Industry and its Tryst with Death By Prabir Purkayastha
Written by dsf
Tuesday, 11 April 2006
After denying for the last fifty years that tobacco is either addictive or harmful, tobacco companies are now trying to negotiate their future with the US Government. They have agreed to pay up to $300 billion over the next 20 years provided they are given total immunity against future damages in US and outside. Obviously, the US tobacco companies and the US Government both feel that US laws supersede all international laws. And if this is not enough, the cynical nature of these negotiations are that if the US government is paid off for the damage inflicted on US citizens, it should satisfy all victims -- in US or elsewhere -- and the tobacco companies can continue with business as usual. Three hundred billion may seem like big bucks, except for the huge profits king tobacco earns. After the negotiations became public, tobacco shares rose in the US stock market.
The $48 billion tobacco industry in US consisting of RJ Reynolds, Philip Morris, etc., are huge MNCs with extensive interests abroad. They have been particularly cosy with the US Government, who have threatened countries with action under 301 and Super 301 if they sought to restrain tobacco companies in any way -- even restraints that the consumers in US have been asking for. The tobacco companies have denied that their products are either harmful or addictive. James Morgan, the President of Philip Morris in a sworn statement recently has said that tobacco is no more addictive than candy. Andrew Schindler, president of R.J. Reynolds claimed, again in a sworn statement that tobacco is about as addictive as carrots. From this, to seeking future immunity against all damages while disgorging $300 billion is quite a retreat. It also lays bare the future strategy of the cigarette companies. Expand in the third world where damage suits rarely win and limit damages in US where legal losses can be heavy. Third World lives after all do not matter -- either in US or even in their own countries. Witness what our Supreme Court did to Bhopal victims -- settling for a sum that was well within Carbide’s insurance cover.
Why is the tobacco industry coming for negotiations now when they have strenuously denied that their products are anything but fun? The answer lies in the broad coalition of forces that are now coming up against tobacco. It is no longer possible to manipulate a few influential law makers in the US Senate, buy influence in Washington and stave off all dangers of either legislation or regulation. Recently released secret documents talk of calling in the tobacco backers in Senate -- Jesse Helms being one of them -- to prevent action in Washington. The Presidency has generally been accommodative of the industry, till the rising protest against tobacco makes it expedient to gain public support by attacking the tobacco industry. Both Tony Blair in UK and Clinton in US are now taking an anti tobacco stand, even though it is more token than real.
The spate of law suits in US brought by individuals, generally lost as the tobacco companies argued that they have warned the consumers of the dangers of tobacco. Even after this, if the people want to smoke it is not the problem of the companies. Though the tobacco companies did lose one case last year, where they were asked to pay $750,000 as damages, their defence has pretty much held through. Even in the Florida case recently, the Judge’s instructions to the jury made an adverse verdict against tobacco pretty much impossible.
There are two recent legal developments that have set alarm bells ringing in the tobacco industry. One is the recent ruling of a Federal Judge in New Carolina that the Federal Drug Authority can regulate tobacco as a drug. The other is that 22 State Attorney Generals have joined together to file claims against the tobacco companies on behalf of the states. Their argument is that it is finally the Medicare and Medicaid programs that are run by the state that incur huge losses due to tobacco inflicted diseases, therefore the industry should pay up these costs.
The first, may at first sight seem innocuous. If tobacco content is regulated, so what, the innocent may ask. The answer lies in the way cigarettes have been pushed world wide. Some of the more damning facts, well known in anti tobacco circles but assiduously denied by the industry, is that the nicotine content in cigarettes can be brought down to very low levels so that cigarettes are non-addictive. In such a case, leaving smoking which is so difficult, would become simple. The tobacco industry is fully aware that once nicotine content is brought down, the tobacco industry’s policy of “hook them young and keep them forever” is all but finished.
In one of the developments this year, one of the smaller tobacco companies. Ligett, agreed to co-operate with the state. Though it is one of the smaller players -- having only a mere 2% of the market in US -- its turning virtually state’s witness sent shock waves. It made available secret documents of how the tobacco industry has targeted the young, and suppressed the possibility of lower nicotine cigarettes as addiction was its key weapon for higher profits. The industry even laced cigarettes with various chemicals to enhance the nicotine “kick”. One of such enhances is ammonia, which the tobacco industry calls an "impact booster" for its ability to enhance the delivery of nicotine to the smoker. In another memo from Liggett, the company considered using synthetic ingredients to increase the addictive quality of smoking, "without the severe toxicity of nicotine itself.”
The Ligett documents also show systematic targeting of youth -- there are a large number of documents discussing "more appeal to youth" , "to appeal to young adult women" ,"16-21 -- the formative years", and so on. Obviously, tobacco has never been a habit that kids pick up under peer pressure. There is the tremendous pressure of advertising -- all sports events are sponsored by cigarette companies, the stars on screen smoke (incidentally here to documents now show that the industry used to pay movie stars to do so) and after all you feel the affect only when you are very old. For the youth, old age is out of their conceptual space. Once addicted, tobacco is life long, the cigarette companies make it so with their nicotine “cocktail”. Therefore the importance of catching them young; even a single smoke free generation will kill the tobacco companies. A convert at 16 is then a cigarette consumer for ever. As the smoker marches towards emphysema, lung cancer and heart attacks, the cash registers of the cigarette companies go on ringing.
The tobacco companies shenanigans did not stop here. After years of denying cigarettes were harmful and sponsoring research to show this, they fought a rear guard battle on the effects of second hand smoking. Recent documents brought out by Washington Post show that tobacco giant Philip Morris systematically wooed scientists who might help the company counter the growing consensus on the health risks of second-hand tobacco smoke and "keep the controversy alive". The British American Tobacco Company memo, obtained by The Washington Post, laid out in great detail Philip Morris's presentation at a February 1988 conference of its global strategy for dealing with environmental tobacco smoke. The company was "spending vast sums of money" to find scientists amenable to its cause and funding research by them, the memo said.
There is yet no world wide coalition against tobacco companies. If one looks at their record, they are responsible for deaths, disease and ill health on an unprecedented scale. Yet if we want to control them, forget banning their products, we run counter to WTO and the post GATT regime. Trade is sacrosanct and American companies even more so. People are expendable, unless of of course they are smokers. Then we can talk of smokers rights. The danger to third world is that as the West becomes more organised against tobacco, the tobacco giants will shift more to the Third World. That BAT wants to take over ITC in India is no accident. It is their long term hedge against crumbling tobacco defences in the West. Marx described capital, as dripping of blood at every pore. Their is no better example than tobacco, battening as it does on death and disease of vast numbers of people.
Written by dsf
Tuesday, 11 April 2006
After denying for the last fifty years that tobacco is either addictive or harmful, tobacco companies are now trying to negotiate their future with the US Government. They have agreed to pay up to $300 billion over the next 20 years provided they are given total immunity against future damages in US and outside. Obviously, the US tobacco companies and the US Government both feel that US laws supersede all international laws. And if this is not enough, the cynical nature of these negotiations are that if the US government is paid off for the damage inflicted on US citizens, it should satisfy all victims -- in US or elsewhere -- and the tobacco companies can continue with business as usual. Three hundred billion may seem like big bucks, except for the huge profits king tobacco earns. After the negotiations became public, tobacco shares rose in the US stock market.
The $48 billion tobacco industry in US consisting of RJ Reynolds, Philip Morris, etc., are huge MNCs with extensive interests abroad. They have been particularly cosy with the US Government, who have threatened countries with action under 301 and Super 301 if they sought to restrain tobacco companies in any way -- even restraints that the consumers in US have been asking for. The tobacco companies have denied that their products are either harmful or addictive. James Morgan, the President of Philip Morris in a sworn statement recently has said that tobacco is no more addictive than candy. Andrew Schindler, president of R.J. Reynolds claimed, again in a sworn statement that tobacco is about as addictive as carrots. From this, to seeking future immunity against all damages while disgorging $300 billion is quite a retreat. It also lays bare the future strategy of the cigarette companies. Expand in the third world where damage suits rarely win and limit damages in US where legal losses can be heavy. Third World lives after all do not matter -- either in US or even in their own countries. Witness what our Supreme Court did to Bhopal victims -- settling for a sum that was well within Carbide’s insurance cover.
Why is the tobacco industry coming for negotiations now when they have strenuously denied that their products are anything but fun? The answer lies in the broad coalition of forces that are now coming up against tobacco. It is no longer possible to manipulate a few influential law makers in the US Senate, buy influence in Washington and stave off all dangers of either legislation or regulation. Recently released secret documents talk of calling in the tobacco backers in Senate -- Jesse Helms being one of them -- to prevent action in Washington. The Presidency has generally been accommodative of the industry, till the rising protest against tobacco makes it expedient to gain public support by attacking the tobacco industry. Both Tony Blair in UK and Clinton in US are now taking an anti tobacco stand, even though it is more token than real.
The spate of law suits in US brought by individuals, generally lost as the tobacco companies argued that they have warned the consumers of the dangers of tobacco. Even after this, if the people want to smoke it is not the problem of the companies. Though the tobacco companies did lose one case last year, where they were asked to pay $750,000 as damages, their defence has pretty much held through. Even in the Florida case recently, the Judge’s instructions to the jury made an adverse verdict against tobacco pretty much impossible.
There are two recent legal developments that have set alarm bells ringing in the tobacco industry. One is the recent ruling of a Federal Judge in New Carolina that the Federal Drug Authority can regulate tobacco as a drug. The other is that 22 State Attorney Generals have joined together to file claims against the tobacco companies on behalf of the states. Their argument is that it is finally the Medicare and Medicaid programs that are run by the state that incur huge losses due to tobacco inflicted diseases, therefore the industry should pay up these costs.
The first, may at first sight seem innocuous. If tobacco content is regulated, so what, the innocent may ask. The answer lies in the way cigarettes have been pushed world wide. Some of the more damning facts, well known in anti tobacco circles but assiduously denied by the industry, is that the nicotine content in cigarettes can be brought down to very low levels so that cigarettes are non-addictive. In such a case, leaving smoking which is so difficult, would become simple. The tobacco industry is fully aware that once nicotine content is brought down, the tobacco industry’s policy of “hook them young and keep them forever” is all but finished.
In one of the developments this year, one of the smaller tobacco companies. Ligett, agreed to co-operate with the state. Though it is one of the smaller players -- having only a mere 2% of the market in US -- its turning virtually state’s witness sent shock waves. It made available secret documents of how the tobacco industry has targeted the young, and suppressed the possibility of lower nicotine cigarettes as addiction was its key weapon for higher profits. The industry even laced cigarettes with various chemicals to enhance the nicotine “kick”. One of such enhances is ammonia, which the tobacco industry calls an "impact booster" for its ability to enhance the delivery of nicotine to the smoker. In another memo from Liggett, the company considered using synthetic ingredients to increase the addictive quality of smoking, "without the severe toxicity of nicotine itself.”
The Ligett documents also show systematic targeting of youth -- there are a large number of documents discussing "more appeal to youth" , "to appeal to young adult women" ,"16-21 -- the formative years", and so on. Obviously, tobacco has never been a habit that kids pick up under peer pressure. There is the tremendous pressure of advertising -- all sports events are sponsored by cigarette companies, the stars on screen smoke (incidentally here to documents now show that the industry used to pay movie stars to do so) and after all you feel the affect only when you are very old. For the youth, old age is out of their conceptual space. Once addicted, tobacco is life long, the cigarette companies make it so with their nicotine “cocktail”. Therefore the importance of catching them young; even a single smoke free generation will kill the tobacco companies. A convert at 16 is then a cigarette consumer for ever. As the smoker marches towards emphysema, lung cancer and heart attacks, the cash registers of the cigarette companies go on ringing.
The tobacco companies shenanigans did not stop here. After years of denying cigarettes were harmful and sponsoring research to show this, they fought a rear guard battle on the effects of second hand smoking. Recent documents brought out by Washington Post show that tobacco giant Philip Morris systematically wooed scientists who might help the company counter the growing consensus on the health risks of second-hand tobacco smoke and "keep the controversy alive". The British American Tobacco Company memo, obtained by The Washington Post, laid out in great detail Philip Morris's presentation at a February 1988 conference of its global strategy for dealing with environmental tobacco smoke. The company was "spending vast sums of money" to find scientists amenable to its cause and funding research by them, the memo said.
There is yet no world wide coalition against tobacco companies. If one looks at their record, they are responsible for deaths, disease and ill health on an unprecedented scale. Yet if we want to control them, forget banning their products, we run counter to WTO and the post GATT regime. Trade is sacrosanct and American companies even more so. People are expendable, unless of of course they are smokers. Then we can talk of smokers rights. The danger to third world is that as the West becomes more organised against tobacco, the tobacco giants will shift more to the Third World. That BAT wants to take over ITC in India is no accident. It is their long term hedge against crumbling tobacco defences in the West. Marx described capital, as dripping of blood at every pore. Their is no better example than tobacco, battening as it does on death and disease of vast numbers of people.
GENETICS WORLD
The Brave New World Of Genetics
Prabir Purkayastha
25 June, 2006
AFTER the reading of the human genome, there are daily advances that research on genetics is reporting: from chimpanzee-human differences to a new world free of disabilities, superior intelligence and human happiness, all implanted into our genes. The hype of genetic technology and its promise of course is very much a marketing drive of global multi-nationals investing billions of dollars in genetic research: they are more solutions in search of problems rather problems that were awaiting a solution.
First the good news. Human beings are much closer to chimpanzees than we thought earlier. A new genetic study in Nature has shown that the pictures showing George Bush making faces and in postures very similar to chimpanzees (www.bushorchimp.com) is not merely fortuitous but a clear result of our genetic affinity to our closest cousins, the chimps. As an aside, these pictures recently appeared in a Belgian official police manual showing the importance of body language in reading of humans, much to the anger of the US administration and embarrassment of the Belgian government. The study in Nature (put on-line by Nature but not yet published) titled “Genetic evidence for complex speciation of humans and chimpanzees” by Patterson et al, shows that the split of human population from the chimpanzee one was of a longer duration than thought earlier, with the split becoming complete only about 5.4 to 6.3 million years ago. This not only reduces the time of the split from about 7 million years ago as thought earlier, but also shows that there were considerable gene flows (mating) between the two sets of populations for about a million years.
COMPLEX TREE OF EVOLUTION
Why is this so startling? Previously, it was believed that the split between two sets of populations tend to be sharp and the hybrid population generally tends to be sterile. The above study shows that this is not really the case and for quite some time, at least for the proto human and proto chimpanzee population, this did not hold true. The basis of these conclusions is also interesting. The team calculated the genetic distance of various sites on the two populations and found that the X chromosome had the smallest distance or the most similarity, consistent with the hypothesis that the two populations mated with each other even after starting to separate. Any two species that mate would be expected to have similar X chromosomes as long as hybridisation continued. A messy divorce rather than a clean break!
The other impact of this chimp human split is that it spoils the party for those that believe that there is a uni-linear model of development in which the human population evolved from the lower apes and we are at the top of the evolutionary tree. There is a hominid population which pre dates this break showing that the current branch split later from the chimpanzee family than some of the other hominid branches. The tree of evolution is considerably more complex than a simple model in which nature worked over billions of years to produce us as the apex of evolution. That we are more successful is incidental: nature had no specific plans for us as different for what it had for chimpanzees or any other species.
While the genetic research has much to say about the past, the big bucks are in the future and not in finding out about migration patterns and chimpanzee. While genetic tools are indeed powerful, laying bare the genome of humans to mice (as also plants), the promise of immediate technology is not proving as fruitful. We will not look at agriculture and genetically modified organisms in this article but look at the new genetic technology in terms of what it holds for the immediate future of the human species.
UNNECESSARY HYPE
The common fallacy in the world of science is that any great scientific advance must immediately yield substantial dividend in terms of utilisable technologies. It is this utilitarian model of science (and also technology) that governs much of the debate on funding as well as the hype regarding science. It is this same hype which convinced the world that since we know E = MC2, we must also be able to utilise this knowledge either through nuclear fission or fusion to give us inexhaustible source of energy. This was the basis of predictions of eminent scientists that by the end of 20th century, there will be no need to metre energy, as it will become virtually free. I am afraid this is the same hype that biotechnology is seeing today.
The ability to read the genetic code and being able to modify it are two different things. Genetic engineering promises to rectify defects in the genetic code by inserting a healthy gene, therefore the concept of gene therapy. While it is possible some day this might become feasible, it is clear that this cannot be done with existing technologies in the near future. All the techniques we have today, take a shotgun approach in which the healthy gene is virtually sprayed into the patient’s cell nucleus (using generally therapeutic DNA combined with a virus as a vector) and this attaches to various different sites than the gene’s actual position. In the only on-going trials for gene therapy thought to be successful, out of the original 10 children suffering from SCID (severe combined immune deficiency) of whom 9 had been cured, 4 have now developed leukaemia. SCID leads to children being born with no immune system forcing such children to live in sterile “bubbles”. While it may be argued that leukaemia and living in a normal environment is preferable to living within a sterile bubble, that leukaemia has resulted on such a large scale indicates the limited utility of current methods of gene therapy. The studies with laboratory mice also show similar high incidence of cancer in those undergoing gene “therapy”.
ISSUES OF RISK AND ETHICS
It is clear that the current gene therapies have seen limited success. But that is not the only issue in gene therapy. New issues are risk and also new ethical concerns. Risks arise in gene therapies, as we have no data from the past for such experiments and the persistence of such agents through the patient’s offsprings. Gene replacement can lead to modifications in what are called germ-line cells – sperm cells or ova – and therefore once inserted represents a long-term risk. As viruses are used as vectors, they also introduce additional risks of their own. The other issue is the ethical one whether we can make modifications for future generations who have not given their consent. Any modifications that are passed on to future generations involve this new ethical issue that we have not addressed in the past. The good thing is that we have some time here still as we have yet to find effective tools for gene transfer without the problems described above. Designer babies bred to outperform the rest and the rich growing more and more distant from such directed evolution is still the stuff of science fiction or media hype. But if we are able to bring about such gene transfers in which we can bind the healthy gene to the specific site where the defective gene lies, then we will have to address the above issues of risk and ethics.
The more immediate issue is one of genetic screening of foetuses – prenatal genetic diagnosis. This is not very dissimilar from issues that already exist: when there is prejudice against the girl child, ultrasonography leads to large-scale abortion of the girl child and sharp distortion in sex ratios. The genetic tests on foetus would not only lead to worsening of the sex ratios as genetic tests are even more conclusive than ultrasound methods, but a whole host of variations in the human gene pool may get filtered out.
The prenatal genetic tests can identify known genetic disorders, particularly if the parents are known to be carriers of such defects. Such tests can help the parents make a choice whether they would like to continue or abort the foetus. In any case, most genetic defects lead to spontaneous abortions. While there may be issues of ethical nature – by doing this are we not weeding out a possible Steven Hawkins or a Homer – the problem becomes far more serious when we look at the way genetic diagnostics is being talked of today.
Genetic diagnostics is now being offered as a solution not for known genetic abnormalities but also for what are seen as statistical risks. These statistical risks are again not related to any known cause and effect mechanisms but a view of genetics in which disease and human behaviour are seen to be largely governed by genes. This brings us back to the old debate that a genetic disposition is only one of the factors in disease and environment which determines whether the predisposition is converted to an actual disease or not. Further, disease is rarely traceable to a single gene: quite often it is a complex of genes and a combination of environmental factors that determine what actually happens. If we try and screen out genetic factors by such crude genetic theories, the result would not be very different than that of finding criminals by looking at their skull type, the favourite of phrenologists of the late 19th and early 20th centuries.
A NEW EUGENIC PROGRAMME?
The danger of all this lies in the simple fact that having invested in this sunrise area of biotechnology, capital is desperately looking for paybacks. Just addressing a small percentage of cases of infertility or genetic abnormalities will not produce large returns. If a mass market is to be developed, mass screening of the population is required. This biotech lobby is joined by the insurance lobby that believes that all statistical correlation with disease should lead to aborting the foetus so that they have to pay out a lot less for medical treatment of the persons insured. They can then use the refusal of screening as a basis for refusing insurance. All this is driving genetic testing in a direction that would fit into a eugenic framework, a framework that was never rejected intellectually by many in the west. It became illegitimate only after Hitler’s genocidal ethnic cleansing of “inferior” races.
The problem with weeding out such variations leaves out the reason why such variation exists in the first place. Quite often, the additional burden of such variation arises from some other evolutionary advantage that exists. If we weed out some of these variations, we may also take out some advantages that this variation gives us. The less the variation in the gene pool, more vulnerable is the population in case there are large-scale environmental changes.
The brave new world of genetically designed future may still be some distance away, but the threat of its insidious arrival through selective abortion and consequent reducing heterogeneity of the gene pool still remains. The heart of this is the belief that all human characteristics are genetically determined –– from disease to obesity. If we press the right buttons and take out these genes, the human population would be better off: this is the new eugenics program. It is time that society wakes up to what is on offer and takes a reasoned stand on this. With large parts of today’s scientific community getting co-opted into this new genetic wisdom and with billions of dollars in profits from their patents, the scientific community cannot be the sole arbiter of such decisions.
There is an urgent need for an informed public debate on the pros and cons of techniques that biotech companies are seeking to market. We need to separate the good from the bad in biotechnology so that good science can proceed and the bad science, like bad money, does not drive out the good from circulation. We therefore also require a strong regulatory framework to address the scope of such techniques and to address the issues of risks and ethics. In India the risks are even more. India could become the happy hunting ground of dangerous clinical trials for this new technology with its people being offered as guinea pigs.
Last Updated ( Friday, 13 July 2007 )
Prabir Purkayastha
25 June, 2006
AFTER the reading of the human genome, there are daily advances that research on genetics is reporting: from chimpanzee-human differences to a new world free of disabilities, superior intelligence and human happiness, all implanted into our genes. The hype of genetic technology and its promise of course is very much a marketing drive of global multi-nationals investing billions of dollars in genetic research: they are more solutions in search of problems rather problems that were awaiting a solution.
First the good news. Human beings are much closer to chimpanzees than we thought earlier. A new genetic study in Nature has shown that the pictures showing George Bush making faces and in postures very similar to chimpanzees (www.bushorchimp.com) is not merely fortuitous but a clear result of our genetic affinity to our closest cousins, the chimps. As an aside, these pictures recently appeared in a Belgian official police manual showing the importance of body language in reading of humans, much to the anger of the US administration and embarrassment of the Belgian government. The study in Nature (put on-line by Nature but not yet published) titled “Genetic evidence for complex speciation of humans and chimpanzees” by Patterson et al, shows that the split of human population from the chimpanzee one was of a longer duration than thought earlier, with the split becoming complete only about 5.4 to 6.3 million years ago. This not only reduces the time of the split from about 7 million years ago as thought earlier, but also shows that there were considerable gene flows (mating) between the two sets of populations for about a million years.
COMPLEX TREE OF EVOLUTION
Why is this so startling? Previously, it was believed that the split between two sets of populations tend to be sharp and the hybrid population generally tends to be sterile. The above study shows that this is not really the case and for quite some time, at least for the proto human and proto chimpanzee population, this did not hold true. The basis of these conclusions is also interesting. The team calculated the genetic distance of various sites on the two populations and found that the X chromosome had the smallest distance or the most similarity, consistent with the hypothesis that the two populations mated with each other even after starting to separate. Any two species that mate would be expected to have similar X chromosomes as long as hybridisation continued. A messy divorce rather than a clean break!
The other impact of this chimp human split is that it spoils the party for those that believe that there is a uni-linear model of development in which the human population evolved from the lower apes and we are at the top of the evolutionary tree. There is a hominid population which pre dates this break showing that the current branch split later from the chimpanzee family than some of the other hominid branches. The tree of evolution is considerably more complex than a simple model in which nature worked over billions of years to produce us as the apex of evolution. That we are more successful is incidental: nature had no specific plans for us as different for what it had for chimpanzees or any other species.
While the genetic research has much to say about the past, the big bucks are in the future and not in finding out about migration patterns and chimpanzee. While genetic tools are indeed powerful, laying bare the genome of humans to mice (as also plants), the promise of immediate technology is not proving as fruitful. We will not look at agriculture and genetically modified organisms in this article but look at the new genetic technology in terms of what it holds for the immediate future of the human species.
UNNECESSARY HYPE
The common fallacy in the world of science is that any great scientific advance must immediately yield substantial dividend in terms of utilisable technologies. It is this utilitarian model of science (and also technology) that governs much of the debate on funding as well as the hype regarding science. It is this same hype which convinced the world that since we know E = MC2, we must also be able to utilise this knowledge either through nuclear fission or fusion to give us inexhaustible source of energy. This was the basis of predictions of eminent scientists that by the end of 20th century, there will be no need to metre energy, as it will become virtually free. I am afraid this is the same hype that biotechnology is seeing today.
The ability to read the genetic code and being able to modify it are two different things. Genetic engineering promises to rectify defects in the genetic code by inserting a healthy gene, therefore the concept of gene therapy. While it is possible some day this might become feasible, it is clear that this cannot be done with existing technologies in the near future. All the techniques we have today, take a shotgun approach in which the healthy gene is virtually sprayed into the patient’s cell nucleus (using generally therapeutic DNA combined with a virus as a vector) and this attaches to various different sites than the gene’s actual position. In the only on-going trials for gene therapy thought to be successful, out of the original 10 children suffering from SCID (severe combined immune deficiency) of whom 9 had been cured, 4 have now developed leukaemia. SCID leads to children being born with no immune system forcing such children to live in sterile “bubbles”. While it may be argued that leukaemia and living in a normal environment is preferable to living within a sterile bubble, that leukaemia has resulted on such a large scale indicates the limited utility of current methods of gene therapy. The studies with laboratory mice also show similar high incidence of cancer in those undergoing gene “therapy”.
ISSUES OF RISK AND ETHICS
It is clear that the current gene therapies have seen limited success. But that is not the only issue in gene therapy. New issues are risk and also new ethical concerns. Risks arise in gene therapies, as we have no data from the past for such experiments and the persistence of such agents through the patient’s offsprings. Gene replacement can lead to modifications in what are called germ-line cells – sperm cells or ova – and therefore once inserted represents a long-term risk. As viruses are used as vectors, they also introduce additional risks of their own. The other issue is the ethical one whether we can make modifications for future generations who have not given their consent. Any modifications that are passed on to future generations involve this new ethical issue that we have not addressed in the past. The good thing is that we have some time here still as we have yet to find effective tools for gene transfer without the problems described above. Designer babies bred to outperform the rest and the rich growing more and more distant from such directed evolution is still the stuff of science fiction or media hype. But if we are able to bring about such gene transfers in which we can bind the healthy gene to the specific site where the defective gene lies, then we will have to address the above issues of risk and ethics.
The more immediate issue is one of genetic screening of foetuses – prenatal genetic diagnosis. This is not very dissimilar from issues that already exist: when there is prejudice against the girl child, ultrasonography leads to large-scale abortion of the girl child and sharp distortion in sex ratios. The genetic tests on foetus would not only lead to worsening of the sex ratios as genetic tests are even more conclusive than ultrasound methods, but a whole host of variations in the human gene pool may get filtered out.
The prenatal genetic tests can identify known genetic disorders, particularly if the parents are known to be carriers of such defects. Such tests can help the parents make a choice whether they would like to continue or abort the foetus. In any case, most genetic defects lead to spontaneous abortions. While there may be issues of ethical nature – by doing this are we not weeding out a possible Steven Hawkins or a Homer – the problem becomes far more serious when we look at the way genetic diagnostics is being talked of today.
Genetic diagnostics is now being offered as a solution not for known genetic abnormalities but also for what are seen as statistical risks. These statistical risks are again not related to any known cause and effect mechanisms but a view of genetics in which disease and human behaviour are seen to be largely governed by genes. This brings us back to the old debate that a genetic disposition is only one of the factors in disease and environment which determines whether the predisposition is converted to an actual disease or not. Further, disease is rarely traceable to a single gene: quite often it is a complex of genes and a combination of environmental factors that determine what actually happens. If we try and screen out genetic factors by such crude genetic theories, the result would not be very different than that of finding criminals by looking at their skull type, the favourite of phrenologists of the late 19th and early 20th centuries.
A NEW EUGENIC PROGRAMME?
The danger of all this lies in the simple fact that having invested in this sunrise area of biotechnology, capital is desperately looking for paybacks. Just addressing a small percentage of cases of infertility or genetic abnormalities will not produce large returns. If a mass market is to be developed, mass screening of the population is required. This biotech lobby is joined by the insurance lobby that believes that all statistical correlation with disease should lead to aborting the foetus so that they have to pay out a lot less for medical treatment of the persons insured. They can then use the refusal of screening as a basis for refusing insurance. All this is driving genetic testing in a direction that would fit into a eugenic framework, a framework that was never rejected intellectually by many in the west. It became illegitimate only after Hitler’s genocidal ethnic cleansing of “inferior” races.
The problem with weeding out such variations leaves out the reason why such variation exists in the first place. Quite often, the additional burden of such variation arises from some other evolutionary advantage that exists. If we weed out some of these variations, we may also take out some advantages that this variation gives us. The less the variation in the gene pool, more vulnerable is the population in case there are large-scale environmental changes.
The brave new world of genetically designed future may still be some distance away, but the threat of its insidious arrival through selective abortion and consequent reducing heterogeneity of the gene pool still remains. The heart of this is the belief that all human characteristics are genetically determined –– from disease to obesity. If we press the right buttons and take out these genes, the human population would be better off: this is the new eugenics program. It is time that society wakes up to what is on offer and takes a reasoned stand on this. With large parts of today’s scientific community getting co-opted into this new genetic wisdom and with billions of dollars in profits from their patents, the scientific community cannot be the sole arbiter of such decisions.
There is an urgent need for an informed public debate on the pros and cons of techniques that biotech companies are seeking to market. We need to separate the good from the bad in biotechnology so that good science can proceed and the bad science, like bad money, does not drive out the good from circulation. We therefore also require a strong regulatory framework to address the scope of such techniques and to address the issues of risks and ethics. In India the risks are even more. India could become the happy hunting ground of dangerous clinical trials for this new technology with its people being offered as guinea pigs.
Last Updated ( Friday, 13 July 2007 )
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