The thalassemia syndromes: lessons from molecular medicines index case

The thalassemia syndromes were the first of human diseases to become thoroughly examined for the underlying molecular lesions by the application of molecular genetic strategies and recombinant DNA methods. Students of thalassemia have now enjoyed over two decades of experience with this research paradigm. These experiences reveal both the awesome power and the limitations of the "reductionist, deterministic" approach of gene cloning and analysis. Incredibly precise and abundant information about the exact molecular lesions responsible for various forms of thalassemia were rapidly obtained by the use of molecular genetic approaches. The mechanisms by which these mutations deranged globin gene expression could be documented with extraordinary precision and efficiency. Precise, powerful methods for detecting disease early in fetal life were rapidly developed, made practical for field use, and disseminated widely. This resulted in a dramatic reduction in the incidence of new births of patients with homozygous beta thalassemia. These experiences demonstrate the extraordinary impact that recombinant DNA technology has upon our ability to understand disease processes, to detect disease long before its phenotypic expression is apparent, and to influence the prevalence of the abnormal alleles in the population. Experience with the antenatal diagnosis of the thalassemias also demonstrates, and should alert us to, the relative ease with which genetic information can be applied to societal and governmental initiatives to alter the reproductive behavior of individuals. While the benefits of reducing the incidence of beta thalassemia are clearcut, application of the strategies that were applied in this narrow situation to broader aspects of disease or genetic manipulation does raise concerns. The thalassemia syndromes demonstrate that genetic information does have more than a theoretical potential to have a major impact upon society. The struggles of many investigators to develop effective pharmacologic agents for the treatment of hemoglobinopathies have also revealed some of the limitations of an isolated molecular approach to the understanding of disease. The tortuous course by which a class of reagents has been identified for stimulation of HbF synthesis illustrates an important point. The application of recombinant DNA methods revealed an entirely new array of pathophysiologic facts that stimulated new hypotheses about the regulation of gene expression and opportunities to manipulate that regulation therapeutically. However, practical application and proper understanding of the molecular information were achieved only when those data were placed in the context of cell biology, tissue and organ-based clinical pathophysiology, and clinical pharmacology. Progress was possible only because of the productive interaction of talented individuals with expertise in these different fields. Our two decades of experience with the thalassemias illustrate very clearly the fact that biology and disease are extraordinarily complex, non-deterministic processes. They will be understood and treated properly only if thriving centers exist within which individuals with diverse interests, expertise, and perspectives about basic science and clinical medicine can exist, interact, and have sufficient time to employ their imaginations to the fullest benefit.