Perspectives in Health Magazine The Magazine of the Pan American Health Organization Special Centennial Edition Volume 7, Number 1, 2002

Genomics is creating a revolution in health and medicine. But only those countries that prepare their populations to join it will be able to fully reap its benefits.

Imagine you are sitting at an outdoor café in a European city, sipping tea and discussing the future of the world with some friends. Now imagine it is Oct. 12, 1492, the day Columbus landed in the Americas and changed the course of world history forever. Even if you had heard a news report of that event, you and your friends would have little idea of what it meant or of its enormous implications for the future. Yet if you did understand even part of it and could act on your knowledge the benefits could well be great.

Something similar is happening today at the dawn of the 21st century. Since Feb. 12, 2001, it has been possible for any one of us to go on line and browse the entire human genome, the map of the code that makes us human. Yet few of us can grasp much of what it means or what to do about it. Those who do from individuals to countries and regions will clearly be in a better position to reap the benefits.

Genomics has created a revolution in the life sciences, one that will change the way we look at and live in our world. Already, it has had a major impact on agriculture, and its influence will soon extend to everything from chemicals and energy to insurance, cosmetics and the military. But nowhere will its effects be greater than in medicine and health.

We have already begun to learn much about ourselves, even though we remain ignorant of what most of the data mean and what functions many genes play. As we learn more over the next two or three decades, what will happen? Health care will shift significantly from a reactive to a proactive endeavor. Doctors and technicians will increasingly focus on specific conditions in individual genotypes and phenotypes, and on probabilities rather than symptoms. They will know what diseases we are predisposed to and what we might do to prevent the onset of illness, as well as the reactions we are likely to have to specific drugs. We will carry genetic ID cards and consume ever more personalized medicines. We will need fewer and fewer surgeons. We will live much longer and remain much healthier throughout our lives.

We can already see some of these fundamental changes in the works. A number of biotechnology companies are successfully developing DNA- embedded silicon biochips that can test for thousands of genetic conditions. Eventually, these coin-sized chips may be able to screen for most diseases and defects known to have genetic roots.

Such diagnostic tools will lead to a shift toward highly personalized medical care. They will also turn our focus toward prevention rather than intervention. As a result, there could be a major change in the ratio of doctor bills to drug costs: from the current 9:1 to something approaching 1:1 over the next quarter century. Genomics should also spur novel ways of delivering "medicines." Consumer products such as soaps, shampoos, cosmetics, aerosols, foods and beverages may provide our daily doses of medicines. Genetically engineered health products could be purchased in supermarkets and health clubs, not just hospitals and pharmacies.

Future benefits
These developments occur mostly in, and may seem likely to benefit primarily, the world's richer countries. But developing countries should not be isolated from the life sciences revolution. By allowing us to better map out microbes and viruses, genomics will teach us more about the diseases and epidemics that plague the developing world and will help us develop more and better treatments to cure them.

Already, more than 250 million people throughout the world have been helped by more than 130 drug products and vaccines produced by biotechnology companies, according to the Biotechnology Industry Organization. And there are more than 350 biotech products and vaccines currently in the industry's pipeline. Meanwhile, supercomputing and "bioinformatics"--the use of software to facilitate drug discovery--promise to further accelerate advances in pharmaceuticals that will benefit both rich countries and poor.

The potential for genetically modified food crops to benefit poorer countries is widely acknowledged, but an equally important area of genomics for both developed and developing countries is the convergence between food and medicine. Just as crops can be genetically engineered to resist insects or to have enhanced nutritional value, they can also be genetically engineered to possess specific medicinal qualities.

For example, agribusiness firms already are trying to tap the exceptional cancer-fighting qualities of wild Italian broccoli and engineer those into commercial varieties. Others are working on bioengineered corn that can attack cancer cells, fight osteoporosis and reduce heart disease. Elsewhere, research is under way to reprogram the genes of certain fruits and vegetables to turn them into vaccines against tetanus, diphtheria, hepatitis B and cholera. To the delight of the world's children, getting a vaccine may soon mean eating an apple, a banana or a potato rather than getting a shot.

The link between agriculture and medicine will not be limited to plants. Already, some biotechnology companies are genetically engineering goats to produce milk containing antibodies and proteins that are known to fight human diseases, including cancer. Other companies are trying to produce antigens in mosquito saliva, turning pests into living vaccines for a variety of human diseases.

Of course, there is no guarantee that the benefits of the life sciences revolution will be shared equally across the globe. Indeed, the incalculable opportunities this revolution opens up are matched only by the enormous challenges entailed in sharing its benefits equitably. Political, social and economic structures along with public policy choices determine the evolution of any technology and its applications. What will the life sciences revolution mean for the future of public health in the Americas? How can we make sure that Latin America and the Caribbean will participate in this revolution and enjoy its benefits?

Equally momentous revolutions of the past have shed some light on this question. The agricultural, industrial and information revolutions all showed the importance of understanding the rules of the game and developing a working knowledge of the "dominant language." Some people, countries and regions understood the transformation of an agriculturally based global economy into an industrial one (having 12 children and a lot of land suddenly mattered much less when one had access to a thousand horsepower). Countries that prepared their citizens to understand and adapt to the industrial revolution became the dominant global players. Thus England--a little island on Europe's periphery--was able to out-produce all and run the world's largest empire, while China's and India's relative importance simply collapsed.

Today, just as then, those who understand how technology is changing the rules and the dominant language and those who prepare their populations for these changes are the ones who will reap the benefits. All the others risk getting left further behind.

A new language
The life sciences revolution is based on the single most powerful language humans have ever tried to unravel, the language of life, in which every living thing on our planet is coded. This revolution actually started 49 years ago, in 1953, when James Watson and Francis Crick deciphered the structure of DNA. Their work introduced a new alphabet based on A's, T's, C's and G's (for Adenine, Thiamine, Cytosine and Guanin), the four nucleotides that form DNA.

Today the language of genomics is increasingly merging with the language of the digital revolution, which itself transformed the global economy over the last 50 years. The ability to transmit data through ones and zeroes (or light and no light) has shifted economic activity from commodities and manufacturing toward services and knowledge. In the 1960s, one-third of the global economy was agriculture, one-third was industry and one-third was services and knowledge. Today, services and knowledge account for two-thirds of the global economy, while agriculture represents less than 4 percent.

These shifts allowed some poor countries to reeducate their own populations and reinvent their economies, and today they are much better off. Examples include Singapore, Taiwan and South Korea all of which in 1965 were much poorer than Mexico.

A region short-changed
Unfortunately, most of Latin America and the Caribbean failed to make the required adjustments, and today we see some of the results. In every country of the Region, large numbers of people live in critical conditions. In rural areas of Argentina, Brazil, Bolivia, Chile and Mexico, more than three-quarters of the population has no access to clean drinking water, much less good health care.

While life expectancy has increased during the past half-century in most parts of the world, other regions have done better than Latin America and the Caribbean. In 1960, someone living in the Region could expect to live 58 years about four years longer than someone living in South Korea. In subsequent decades, South Korea which had few natural resources invested in human capital, and by 1999 the average South Korean could expect to live 73 years, two more than someone living in Latin America.

We see a similar pattern in infant mortality. For the last 40 years, Latin American and Caribbean countries have reduced infant mortality by 70 percent, while Singapore and South Korea have seen a 90 percent decrease. In the 1960s, an Argentine baby had about a one-third higher chance of survival than the average South Korean child. Today, an Argentine baby is twice as likely to die as a South Korean baby (and South Korea is not the richest country in Asia, nor is Argentina the poorest one in Latin America).

These gaps, unfortunately, could soon widen. According to World Bank data, health expenditures in Latin America increased from 5.8 percent of GDP to 6.4 percent during the first half of the 1990s. Yet this is less per capita than in Asia: in 1995, Latin American countries spent $192 per capita on health, while Singapore spent $926 and South Korea $551.

For decades, perhaps centuries, education and health have been trumpeted as official priorities by virtually every Latin American government. Many countries' constitutions "guarantee" these as inalienable rights. We have often heard, "We will not rest until every child has access to decent doctors and good teachers." But are health and education really priorities in Latin America and the Caribbean, and are priorities in and of themselves enough?

Some have argued that the citizens of economically successful countries simply work harder. That is false. The average Mexican works longer hours than the average Japanese (the average number of hours worked annually in Mexico has increased by more than 100 since 1990). Indeed, throughout Latin America, people are working longer and harder than ever. The key difference is productivity. And productivity depends on whether a country's workers get enough to eat, whether they are healthy, and whether they understand and have the education to use the dominant economic language.

Investing in public health is essential. But it is not sustainable without parallel investments in science, technology and corporate R&D. A society has to generate wealth to be able to invest more in its human resources. And today, one rarely generates widespread wealth in a knowledge economy without developing a digitally literate population. More than 90 percent of all information produced in 1999 was in digital format, according to the University of California at Berkeley's School Information and Management Systems. Those who remain functionally illiterate in Microsoft or Linux have a much harder time making a living.

Many bureaucrats and policymakers argue that you can't have it all; either you invest in basic health care and basic education or you shift resources to R&D. This is a false dichotomy. Striving to improve basic health conditions and investing in R&D are not mutually exclusive; on the contrary, they eventually reinforce each other. While this may seem a distant objective in places like Africa or poorer parts of Latin America today, it should be remembered that South Korea had the same income per capita as Ghana in 1960.

If Latin Americans are to reap the benefits of the life sciences revolution, they must rediscover the importance of science and scientists as a key component of development. Development summits, like the recent United Nations hosted International Conference on Financing for Development in Monterrey, Mexico, will have no impact if science and technology are not at the core of any development strategy.

Patenting knowledge
One good barometer of a country's ability to produce knowledge, apply it and have it generate wealth is its ability to get patents. Unfortunately, Latin America and the Caribbean do not do well by this measure. Of the 13,566 patent applications presented in Mexico in 2001, for example, only 5 percent actually came from Mexicans. From 1997 to 2001, Argentine, Brazilian and Mexican universities failed to obtain even one patent per year, on average, in the United States. Yet over the same period, the Yissum Research Development Company at Hebrew University in Israel was granted 191 U.S. patents. The University of California was granted more than 1,800 patents between 1997 and 2000. This dismal record on patents is not surprising if you consider that Mexico has, for every 1 million people, 214 scientists engaged in R&D, and Argentina has 660 per million. By contrast, Korea has 2,235 and Singapore 2,318. Not surprisingly, the average South Korean worker today earns three times more than the average Mexican (even though as recently as 1975, Mexican workers earned five times as much as their South Korean counterparts).

Increasingly, investments, information technology, patent and licensing activities, and other commercial activities are related to advances in the life sciences. The ability to speak and work with the new language of ATCGs is changing almost every industry throughout the world: agribusiness, chemicals, pharmaceuticals, health provision, insurance, energy and military, among others. Today, most of the patents granted in the United States are related to biotechnology, not information technology or telecommunications.

The majority of Latin American countries missed the digital revolution; they cannot afford to miss the life sciences revolution by betting their future on exporting commodities and cheap labor. Neither countries nor people can continue to do what they have always done without falling further and further behind. This does not mean that every country must become a biotech cluster. But what it does mean is that at least some citizens and companies have to be literate in this new language, and the more the better. Every time Latin American countries reduce their already miniscule R&D budgets, they have less chance of participating in the new economy, and it gets harder to improve their long-term economic and social conditions. Mexico decreased its expenditures in R&D from 1985 to 1995 from 0.44 percent to 0.33 per-cent of GDP. In 2001, expenditures of the National Council for Science and Technology (CONACYT) were cut by almost one-third.

We in Latin America and the Caribbean must generate more knowledge in our own countries and patent more knowledge in the United States and Europe. Lowering inflation and further decreasing public expenditures can help stabilize the Region's economies, but these are stopgap measures that rarely generate much new wealth. Only highly trained individuals can do this rapidly and consistently.

There are three fundamental lessons of the past decades. First, investing in massive natural resource recovery projects is not a path to riches. Consider the oil-rich states of Iran, Iraq, Saudi Arabia, Nigeria, Venezuela, Mexico and the former Soviet Union. Second, countries need to invest primarily in people, particularly in public health and science-based education. Third, science-based literacy has to lead to profitable companies; otherwise incomes and investments in people tend to collapse.

As World Health Organization (WHO) Director-General Gro Harlem Brundtland wrote in the WHO report Genomics and World Health published earlier this year: "It is a reality that most genomic and biotechnology research is presently carried out in the industrialized world, and is primarily market-driven. Genomics also needs to be applied to the health problems of the developing world. It is crucial that we actively seek means to involve developing country scientists in innovative biotechnology."

For Latin America and the Caribbean, the future of public health could become much brighter, and quality of life in general much better, as a result of the life sciences revolution--but only if the Region's countries invest in their people and prepare them, not just to adapt, but to truly capitalize on change.

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