Month / February 2013

by crmayes

It is not our genetics but it is your lifestyle

Gene therapy is the great promise continually reported in the media as ‘just around the corner’ and that ‘soon’ our family physician will “be able to tailor drugs to a patient’s genetic profile.”[1] While gene therapy may eventually deliver on these promises the current situation is that they have not.

The absence of effective genetic therapies is acutely evident in the areas where genetic technology has been most successful in isolating specific genes associated with particular diseases. In such cases a clear and powerful diagnosis is possible. Yet the equivalent precision and power is lacking in therapeutics. Thus a healthy woman with no symptoms can be diagnosed as carrying the BRCA1 genetic mutation, which translates as having an “80% risk of being diagnosed with breast cancer”.[2] Having been exposed to this devastating information through the precision of genetic diagnostics the therapeutic options are surprisingly limited: more frequent screening or hormonal therapy. A third option, arguably the most effective[3], is prophylactic mastectomy.[4] This is an extremely aggressive procedure first performed around 550AD. Thus through advances in genetic diagnosis we are placed in an embarrassing and tragic situation in which we can ‘know the future’ using technologies inconceivable to scientists a generation ago, yet the therapeutic response is a brutal surgical method first performed over fifteen hundred years ago.

I contend that although there is often animosity between public health and biomedicine, the (as yet) lack of effective genetic therapies for diseases arising due to a known genetic mutation has resulted in a re-emphasis on public health strategies, and particularly individual lifestyles, as both a therapeutic and preventive response. Writing in 1992 Richard Lewontin notes the difficulties in translating genetic knowledge to effective therapies, yet he argues that this difficulty “does not discourage the advocates of the Human Genome Project because their vision of therapy includes gene therapy.”[5] Here Lewontin touches on the mono-casual theory of disease stemming from Louis Pasteur, that a single gene is responsible for the manifestation of particular disease or behaviour. In questioning whether the mapping of the human genome will revolutionize medicine Holtzman and Marteau counsel that “medical and science policies in the next decade would do well to see beyond the hype” as “social structure, lifestyle, and environment account for much larger proportions of disease than genetic differences.”[7]

In the decades following the HGP a general skepticism rose around ideas of genetic determinism, being replaced with epigenetic theories and debate surrounding the efficacy of gene therapy.Not only has there been an emphasis on the interaction between genes, the environment and lifestyle in determining disease, but as Petersen and Bunton observe the therapeutic role of genetic technology is increasingly being re-framed as providing ‘empowering’ information enabling individual’s to make “the most appropriate choice about health and life-style.”[8] For example, Breastcancer.org advises women diagnosed with a genetic mutation associated with breast or ovarian cancer of “lifestyle choices you can make to keep your risk as low it can be”[9]. Such choices include maintaining a healthy weight, nutritious eating, exercise, limiting alcohol consumption and never smoking.

I am not suggesting that research into genetic therapy has been useless or that it should be abandoned. Rather the interventions into the biological life and health of individuals and populations following the HGP and development of genetic technologies have redeployed genetic knowledge to inform individual lifestyle choices. Thus rather than providing therapies to improve lived experience, these technologies further disrupt and undermine lived experience by bring a future into the present that requires a modification of the present for the sake of the future.

[1] Holtzman, N. A., & Marteau, T. M. (2000). Will Genetics Revolutionize Medicine? New England Journal of Medicine, 343(2), 141-144. doi: doi:10.1056/NEJM200007133430213. (p. 141)

[2] Breastcancer.org. (2011). Breastcancer.org  Retrieved 4/4/2011, from http://www.breastcancer.org/risk/factors/genetics.jsp

[3] Hartmann, L. C., Sellers, T. A., Schaid, D. J., Frank, T. S., Soderberg, C. L., Sitta, D. L., . . . Jenkins, R. B. (2001). Efficacy of Bilateral Prophylactic Mastectomy in BRCA1 and BRCA2 Gene Mutation Carriers. Journal of the National Cancer Institute, 93(21), 1633-1637. doi: 10.1093/jnci/93.21.1633

[4] Also prophylactic ovary removal

[5] Lewontin, R. C. (1992). Biology as Ideology: The Doctrine of DNA. New York: Harper Perennial. (p. 69)

[8] Petersen, A., & Bunton, R. (2002). The New Genetics and the Public’s Health. London: Routledge. (p. 6)

by crmayes

Lifestyle Intervention and the Aesthetics of Obesity and Smoking

The sustained concern over obesity as a threat to population and economic security has led to a proliferation of medical and non-medical experts intervening in the daily lives and practices of individuals. These interventions commonly fall under the rubric of lifestyle. Seen as both the cause and solution, the modern lifestyle is the target of modification strategies and techniques.

Of course, interventions into lifestyle are not entirely new or exclusive to obesity. Smoking, homosexuality, extreme sports or drug-use have all been described as lifestyles with associated health risks that justify outside intervention. Yet, I contend that obesity is unique in its characterization as a political, economic, aesthetic and public health problem that emanates from individual choices and practices.

The uniqueness of obesity is partly evidenced in comparison to smoking. While smokers have attracted a significant share of vitriol and harassment, much of the blame for smoking and the associated health impacts is reserved for “Big Tobacco”. If repentant, smokers can be characterized as the victims of industry deception and chemical addiction. Although there is anger directed toward “Big Food”, obesity is primarily framed as the result of individual choice and lack of control.

Furthermore, there is an aesthetic difference that distinguishes obesity from smoking. While there are active efforts to counter the “coolness”of smoking, the iconic images of Humphrey Bogart or Audrey Hepburn with cigarettes in hand continue to influence Western aesthetics. And the more recent fictional characters, Don Draper and Joan Halloway stubbornly resist the cliché that “kissing a smoker is like kissing an ashtray”. In contrast, the aesthetics and celebrity of obesity are comical, grotesque or both. Cartoon characters like Homer Simpson or Peter Griffin who eat anything within reach, from a week old sandwich to the legs of a paralytic friend, serve to confirm the message that obesity is grotesque in form and the result of lack of control.

This aesthetic also carries with it a judgement on the ability of an individual to self-govern and also to govern others. Kim Beazley, the former leader of the opposition in Australia was once told by Prime Minister Bob Hawke that the Australian people wouldn’t elect a fat prime minister. A contemporary example in the US is Chris Christie. Since at least the 2012 Republican primaries Christie’s weight has been a continual talking-point. These discussions are set to increase as speculation grows over his intentions to run for President in 2016.

Contemporary concerns about obesity and its relation to aesthetics, self-governance and the governance of others resembles regulations over sexual conduct in Ancient Greece. In examining the problematization of sexual practice in Ancient Greece, Michel Foucault outlines the link between a husband’s sexual conduct, household management and governance of the city. According to Foucault, the Greek husband’s authority and control over his home (of which his wife was a part) reflected his ability to have authority and control over himself and the life of the city.  While the husband was free to engage in sexual practice outside of the conjugal relation, “having sexual relations only with his wife was the most elegant way of exercising his control” (HSII, 151). Further, when Aristotle condemns extra-marital sexual relations as dishonourable it is not that the activity deviates from a moral law or order, rather such action demonstrates the husband’s inability to conduct himself in relation to the ethical substance of pleasure with the appropriate degree of self-control and mastery.

The example of Nicoles the ruler of Cyprus illustrates this point. According to Isocrates, Nicocles explains his conjugal fidelity in saying, “I am the king, and because as somebody who commands others, who rules others, I have to show that I am able to rule myself.” Therefore if Nicocles wishes to rule others and the city with glory and authority then he must rule himself first. Foucault argues that for the Greeks the mode of subjection was politico-aesthetic in which “political power, glory, immortality and beauty are all linked together at a certain moment.” Thus the Greek free man is at liberty to engage in sexual activity with someone other than his wife, however if he has accepted the politico-aesthetic mode of subjection, if he wishes his existence to be characterized by self-mastery and beauty, then he will recognize the particular rules of conduct that are constitutive of that subjectivity.

In a somewhat similar fashion, the American (or Australian, or any citizen of a Western liberal democracy) is free to indulge in whatever culinary and dietary activity he or she wishes, however, in return the society will discount beauty and the capacity for self-governance and the governance of others and thereby justify interventions into their daily choices, activities and practices.

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