The Future (46 page)

The digitizing of human beings, with the creation of large files containing detailed information about their genetic and biochemical makeup and their behavior, will also require attention to the same privacy and information security issues discussed in
Chapter 2
. For the same reasons that this rich data is potentially so useful in improving the efficacy of health care and reducing medical costs, it is also
seen as highly valuable to insurance companies
and employers who are often eager to sever their relationships with customers and employees who represent high risks for big medical bills. Already, a high percentage of those who could benefit
from genetic testing are refusing to have the information gathered for
fear that they will lose their jobs and/or their health insurance.

A few years ago, the United States passed a federal law known as the Genetic Information Nondiscrimination Act, which
prohibits the disclosure or improper use of genetic information.
But enforcement is difficult and
trust in the law’s protection is low. The fact that insurance companies and
employers usually pay for the majority of health care expenditures—including genetic testing—further reinforces the fear by patients and employees that their genetic information will not remain confidential. Many believe that flows of information on the Internet are vulnerable to disclosure in any case. The U.S. law governing health records, the Health Insurance Portability and Accountability Act,
fails to guarantee patient access to records gathered from their own medical implants while companies seek to profit from personalized medical information.

Nevertheless, these self-tracking techniques—part of the so-called self-quantification movement—offer the possibility that behavior modification strategies that have traditionally been associated with clinics can be individualized and executed
outside of an institutional setting. Expenditures for genetic testing are rising rapidly as prices for these tests continue to fall rapidly and as the wave of
personalized medicine continues to move forward with increasing speed.

The United States may have the most difficulty in making the transition to precision medicine because of the imbalance of power and unhealthy corporate control of the public policy decision-making process, as described in
Chapter 3
. This chapter is not about the U.S. health care system, but it is interesting to note that the glaring inefficiencies, inequalities, and absurd expense of the U.S. system are illuminated by the developing trends in the life sciences.
For example, many health care systems do not cover disease prevention and wellness promotion expenditures, because they are principally compensated for expensive interventions after a patient’s health is already in jeopardy. The new health care reform bill enacted by President Obama
required coverage of preventive care under U.S. health care plans for the first time.

As everyone knows, the U.S. spends far more per person on health care than any other country while achieving worse outcomes than
many other countries that pay far less, and
still, tens of millions do not have reasonable access to health care. Lacking any other option, they wait,
often until their condition is so dire that they have to go to the emergency room,
where the cost of intervention is highest and the
chance of success is lowest. The recently enacted
reforms will significantly improve some of these defects,
but the underlying problems are likely to grow worse—primarily because insurance companies, pharmaceutical companies, and other health care providers retain almost complete control over the design of health care policy.

The business of insurance began as far back as ancient Rome
and Greece, where life insurance policies
were similar to what we now know as burial insurance. The first modern life insurance policies were
not offered until the seventeenth century in England. The
development of extensive railroad networks in the United States in the 1860s led to limited policies protecting against accidents on railroads and steamboats, and that led, in turn, to the first insurance policies protecting against sickness in the 1890s.

Then, in the early 1930s, when advances in medical care began to
drive costs above what many patients could pay on their own, the first significant group health insurance policies were offered by nonprofits:
Blue Cross for hospital charges and Blue Shield for doctors’ fees. All patients paid the same premiums regardless of age or
preexisting conditions. The success of the Blues led to the entry into the marketplace of private, for-profit health insurance companies, who began to charge different premiums to people based on their calculation of the risk involved—and refused to offer policies at all to those who represented an unacceptably high risk. Soon, Blue Cross and Blue Shield were forced by the new for-profit competition to also link premiums to risk.

When President Franklin Roosevelt was preparing his package of reforms in the New Deal, he
twice took preliminary steps—in 1935 and again in 1938—to include a national health insurance plan as part of his legislative agenda. On both occasions, however, he
feared the political opposition of the American Medical Association and removed the proposal from his plans lest it interfere with what he
regarded as more pressing priorities in the depths of the Great Depression: unemployment compensation and Social Security. The introduction of legislation in 1939 by New York Democratic senator Robert Wagner
offered a quixotic
third opportunity to proceed but Roosevelt chose not to support the legislation.

During World War II, with wages (and prices) controlled by the government, private employers began to compete for employees, who were scarce due to the war, by offering health insurance coverage. Then after the war, unions began to include demands for more
extensive health insurance as part of their negotiated contracts with employers.

Roosevelt’s successor, Harry Truman, sought to
revive the idea for national health insurance, but the opposition in Congress—once again fueled by the AMA—ensured that it died with a whimper. As a result, the hybrid system of
employer-based health insurance became the primary model in the United States. Because older Americans and those with disabilities had a difficult time obtaining affordable health insurance within this system,
new government programs were implemented to help both groups.

For the rest of the country, those who
needed health insurance the most had a difficult time obtaining it, or paying for it when they could find it. By the time the inherent flaws and contradictions of this model were obvious, the American political system had degraded to the point that the companies with an interest in seeing this system continued had so much power that nothing could be done to change its basic structure.

With rare exceptions, the majority of legislators are no longer capable of serving the public interest because they are so dependent on campaign contributions from these corporate interests and so vulnerable to their nonstop lobbying. The general public is effectively disengaged from the debate, except to the extent that they absorb constant messaging from the same corporate interests—messages designed to condition their audience to support what the business lobbies want done.

The same sclerosis of democracy is now hampering sensible adaptations to the wave of changes flowing out of the Life Sciences Revolution. For example, even though polls consistently show that approximately 90 percent of American citizens
believe that genetically engineered food should be labeled, the U.S. Congress has
adopted the point of view advocated by large agribusiness companies—that labeling is unnecessary and would be harmful to “confidence in the food supply.”

However, most European countries already require such labeling. The recent approval of
genetically engineered alfalfa in the U.S. provoked a larger outcry than many expected and the “Just Label It” campaign has become the centerpiece of a new grassroots push for labeling genetically modified (GM) food products in the United States,
which plants twice as many acres in GM crops as any other country. Voters in
California defeated a referendum in 2012 to require such labeling, after corporate interests spent $46 million on negative commercials, five times as much as proponents. Nevertheless, since
approximately 70 percent of the processed foods in the U.S. contain at least some GM crops, this controversy will not go away.

By way of background, the genetic modification of plants and animals is,
as enthusiastic advocates often emphasize, hardly new. Most of the food crops that humanity has depended upon since before the dawn of the Agricultural Revolution were
genetically modified during the Stone Age by careful selective breeding—which, over many generations, modified the genetic structure of the plants and animals in question to manifest traits of value to humans. As Norman Borlaug put it, “Neolithic women accelerated genetic modifications in
plants in the process of domesticating our food crop species.”

By using the new technologies of gene splicing and other forms of genetic engineering, we are—according to this view—
merely accelerating and making more efficient a long-established practice that has proven benefits and few if any detrimental side effects. And outside of Europe (and India) there is a consensus among most farmers, agribusinesses, and policymakers that GM crops are safe and must be an essential part of the world’s strategy for coping with anticipated food shortages.

However, as the debate over genetically modified organisms (GMOs) has evolved, opponents of the practice point out that none of the genetic engineering
has ever produced any increase in the intrinsic yields of the crops, and they have raised at least some
ecosystem concerns that are not so easily dismissed. The opponents argue that the insertion of foreign genes into another genome is, in fact, different from selective breeding because it disrupts the
normal pattern of the organism’s genetic code and can cause unpredictable mutations.

The first genetically engineered crop to be commercialized was a new form of tomato known as the
FLAVR SAVR, which was modified to
remain firm for a longer period of time after it ripened. However, the
tomato did not succeed due to high costs. And
consumer resistance to tomato paste made from these tomatoes (it was clearly labeled as a GM product) caused the paste to be a failure.

Selective breeding was used to make an earlier change in the traits of commercial tomatoes in order to produce a flatter,
less rounded bottom to accommodate the introduction of automation in the harvesting process. The new variety stayed on the conveyor belts without rolling off, was easier to pack into crates, and its tougher skin prevented the machines from crushing the tomatoes. They are sometimes called “square tomatoes,” though they are not really square.

An even earlier modification of tomatoes, in 1930, also using selective breeding, was the one that resulted in what most tomato lovers regard as a
catastrophic loss of flavor in modern tomatoes. The change was intended to enhance the mass marketing and distribution of tomatoes by ensuring that they were “all red” and ripened uniformly, without the green “shoulders” that consumers sometimes viewed as a sign that they were not yet ripe. Researchers working with the newly sequenced tomato genome discovered in 2012 that the elimination of the gene associated with green shoulders also eliminated the plant’s ability to produce most of the sugars that used to give most tomatoes a delicious taste.

In spite of experiences such as these, which illustrate how changes made for the convenience and profitability of large corporations sometimes end up triggering other genetic changes that most people hate, farmers around the world—other than in the European Union—have adopted GM crops at an accelerating rate.
Almost 11 percent of all the world’s farmland was planted in GM crops in 2011, according to an international organization that promotes GMOs, the International Service for the Acquisition of Agri-biotech Applications. Over the last seven years, the
number of acres planted in GM crops has increased almost 100-fold, and the almost 400 million acres planted in 2011 represented an increase of 8 percent from one year earlier.

Although the United States is by far the largest grower of GM crops, Brazil and Argentina are also heavily committed to the technology. Brazil, in particular, has adopted a fast-track approval system for GMOs and is pursuing a highly focused strategy for maximizing the use of biotechnology in agriculture. In developing countries overall, the adoption of modified crops is growing twice as fast as in mature
economies. An estimated 90 percent of the 16.7 million farmers growing genetically engineered crops in almost thirty countries were small farmers in developing markets.

Genetically modified soybeans, engineered to tolerate
Monsanto’s Roundup herbicide, are the largest GM crop globally.
Corn is the second most widely planted GM crop, although it is the most planted in the U.S. (“Maize” is the term used for what is called corn in the U.S.; the word “corn” is often used outside the U.S. to refer to any cereal crop.)
In the U.S., 95 percent of soybeans planted and 80 percent of corn are grown from patented seeds that farmers
must purchase from Monsanto or one of their licensees. Cotton is the third most planted GM crop globally, and canola (
known as “rapeseed” outside the United States) is the other large GM crop in the world.

Although the science of genetically engineered plants is advancing quickly, the vast majority of GM crops grown today are still from the first of
three generations, or waves, of the technology. This first wave, in turn, includes GM crops that fall into three different categories: