Genetics and Health Care: A Paradigm Shift

This article is about health care in the future—some of the things addressed are quite a few years in the future, some are here now, and others are coming very fast. I want to put my remarks in the context of my conviction that as a society we need to change our view of disease as an outside enemy—and find a new way of thinking about illness. Over the last century or so, the living conditions of human populations in developed countries have altered markedly, with resulting dramatic changes in health, largely owing to progress in nutrition and hygiene. Measures of population health such as life expectancy rose rapidly in the early decades of this century, with far fewer people dying prematurely from malnutrition or infectious diseases such as TB and cholera. A larger proportion ofthe population now lives to approach the normal biological life span of humans, which is probably in the 85-95year range [I]. The age structure of the population has changed from one that has a preponderance of young people under 30 to a distribution that includes more people in their middle years and older. The benefits of public health and good nutrition in Western societies have led to a remarkable decrease in those diseases with a primarily external cause. Perhaps because of this success, most physicians and investigators have perceived that deleterious influences on human health are of two kinds: either a deficiency of a basic resource such as food or vitamins, or exposure to hazards that may be either natural (such as parasites, bacteria, or viruses) or man-made (such as smoking, war, environmental pollutants [2]). Genetics is now showing that this view of the determinants ofhealth as being external is too simplistic. It neglects a major determinant of disease—an internal one. Far from being a rare cause of disease, genetic The author expresses gratitude for helpful comments and criticism to J. Friedman and