number of years ago, five families in Brooklyn who had had babies with a
devastating disease decided to try what was then nearly unthinkable: to
eliminate a terrible genetic disease from the planet.
The disease is Tay-Sachs, a progressive, relentless neurological disorder
that afflicts mostly babies, leaving them mentally impaired, blind, deaf and
unable to swallow. There is no treatment, and most children with the disease
die by 5.
The families raised money and, working with geneticists, began a program
that focused on a specific population, Ashkenazi Jews, who are most at risk
of harboring the Tay-Sachs gene. The geneticists offered screening to see
whether family members carried the gene.
It became an international effort, fueled by passion and involving
volunteers who went to synagogues, Jewish community centers, college Hillel
houses, anywhere they might reach people of Ashkenazic ancestry and enroll
them in the screening and counsel them about the risks of having babies with
the disease. If two people who carried the gene married, they were advised
about the option of aborting affected fetuses. Some matchmakers advised
their clients to be screened for the gene, and made sure carriers did not
marry.
Thirty years later, Tay-Sachs is virtually gone, its incidence slashed
more than 95 percent. The disease is now so rare that most doctors have
never seen a case.
Emboldened by that success and with new technical tools that make genetic
screening cheap and simple, a group is aiming even higher. It wants to
eliminate nine other genetic diseases from the Ashkenazic population, which
has been estimated at 10 million, in a worldwide screening.
The groundwork is laid, the group says. Its members — genetic counselors,
geneticists and pediatricians at the New York University School of Medicine,
the Montefiore Medical Center and the Albert Einstein College of Medicine —
point out that the genes for the major recessive diseases that afflict
Ashkenazim have been isolated. New technology allows screening for all those
diseases, plus Tay-Sachs, at once.
That, some geneticists say, is what the Human Genome Project has
promised, an ability to scan a person's genes and find those that can cause
disease.
Critics say such projects are just what worry them about the genome
project. People will receive a flood of genetic information that may be
difficult to understand and interpret about diseases, unlike Tay-Sachs, that
can have courses that are impossible to predict.
Some see the project as a test case.
"It is a model for delivering these genetic services," said Dr. Michael
M. Kaback, a geneticist at the University of California at San Diego. "That
is why it is important."
Dr. Kaback, an architect of the Tay-Sachs screening, emphasized that
worldwide screening for 10 diseases would be difficult, requiring careful
attention to detail and to assessing the project as it starts. But, he said,
"It could work."
The project ethicist, Nancy Neveloff Dubler, who directs the bioethics
program at Montefiore, said the effort could show the positive side of
screening. "These are largely diseases that take a terrible toll early in
life," Ms. Dubler said. "We could save families from sorrow and children
from suffering. That's a tremendously important goal."
Some experts, however, worry about stigmatizing Jews. "It's a dilemma,"
said Jayne C. Gershkowitz, director of the National Tay-Sachs and Allied
Diseases Association.
Ms. Gershkowitz fears that Jews will be seen as a people uniquely
afflicted with 10 genetic diseases. In fact, most diseases occur in the
general population, too, although the genes are much less prevalent.
Other ethnic groups have their own genetic diseases. For example, people
of Mediterranean ancestry may have genes for an iron storage disease, beta-thalassemia,
and blacks and Mediterraneans may have genes for sickle cell disease.
Others worry about how people will use the screening information and
whether or not they should.
Lori B. Andrews, a professor of law and an ethicist at the Chicago-Kent
College of Law, said the screening might be the start of a troubling era, as
people receive information they may not be prepared to handle about diseases
that may or may not prove deadly.
"How much information do we want, and what do you do with it?" Professor
Andrews asked. "This is not like other medical areas, where there is a clear
treatment. This has an impact on self-concept and on relationships with
others. It is not a simple blood test."
As many as one in three Ashkenazim has one of the genes, but those
carriers are fine. The disease occurs just when a child inherits a gene from
each parent. If two carriers of a mutated gene have children, each baby has
one chance in four of inheriting the mutation from each parent, giving rise
to the disease.
Not every disease is like Tay-Sachs. Others affect some people who
inherit two copies of the mutated gene and spare others, with no way of
knowing who will be ill.
Yet, the Tay-Sachs history has shown what is possible, said Dr. Harry
Ostrer, a project leader. Dr. Ostrer, also the director of the Human
Genetics Program at N.Y.U., said that before the Tay-Sachs screening began
in the 1970's couples had no idea that they might have a child with the
disease until it was diagnosed. The experience of watching babies suffer and
slowly die was so sad that many of the parents never had other children.
The screening changed that. Now, Dr. Ostrer said, the number of babies in
the United States with Tay-Sachs has dropped, from 50 a year to 5, and most
of those are born to couples who are not Jewish and but happen to have the
mutated gene.
Many scientists assumed that the next steps would be straightforward.
Just find the genes for the other major recessive diseases in the
Ashkenazim, and those diseases, too, would die with screening.
The genes were found. In some cases, parents of affected children raised
the research money themselves.
But, said Dr. Susan J. Gross, a geneticist at Montefiore and Albert
Einstein, which began a Tay-Sachs program in the 70's, nothing happened. Dr.
Gross and others watched with dismay as babies continued to be born to
couples who had no idea that they carried aberrant genes. Doctors were
either unaware of the tests or were not offering them to their patients.
Jews were unaware that they were at risk or did not ask for or receive
testing.
"The current medical model is not working," Dr. Gross said.
She decided that the solution was to offer testing to the world's Jews
rather than wait for people to ask for it. "I can't see any other way to get
this fixed," Dr. Gross said.
The group worked with the Trust for Jewish Philanthropy, which convened
experts on genetic disease research and testing and asked them for advice.
"The opinion I had was, `Why not?' " said Dr. Charles R. Scriver, a
geneticist at McGill University in Montreal. In previous decades, Dr.
Scriver directed screening in Montreal to identify carriers of Tay-Sachs and
beta-thalassemia, a genetic disease that causes severe anemia.
High school students were told about the diseases and offered an
opportunity to be tested and given information about the results. Although
those who chose to be tested learned about their genes, no one else could
see their results.
"The Tay-Sachs and thalassemia carrier screening programs over their
30-year existence in Montreal have resulted in an almost complete absence of
new cases of these two diseases," Dr. Scriver said.
Some critics ask about ensuring that people understand more complicated
Jewish diseases, which may be more typical of genetic diseases in general.
In Gaucher's disease, people can have a serious illness starting in infancy
with anemia, bone pain and enlarged livers and spleens. While there is an
effective treatment, it has cost as much as $150,000 a year. Half the people
who inherit two copies of the mutated gene have no symptoms at all until
their mid-40's, and some may never develop symptoms at all.
"You cannot predict who will have the severe disease," said Dr. Arno G.
Motulsky, a geneticist at the University of Washington and a member of the
advisory board to the group that wants to screen for the 10 disease genes.
"This becomes a very tricky issue. How should you counsel?"
A similar problem occurs with cystic fibrosis, another of the 10
diseases, Dr. Kaback said. One child will be severely ill, and his brother,
who inherited exactly the same disease-causing genes, may have nothing wrong
except, perhaps, the absence of the vas deferens, which carries sperm from
the testes.
Ms. Dubler, not overly concerned, said: "It's not that complicated. We
have taught people about health issues that are much more difficult. It's a
matter of finding the messages that people listen to most easily and the
metaphors. We can do that."