Friday, January 25, 2019
Hacking humans, upgrading Homo sapiens: the role of the Huntington’s disease community and the consequences for life
An influential book by best-selling historian Yuval Noah Harari, Homo Deus: A Brief History of Tomorrow, looks broadly at potential medical advances, thus providing hope for the Huntington’s disease community’s quest for a cure, but it also warns of the vast consequences for human life caused by the advance of biotechnology and the accumulation and control of data.
A professor in the History Department at the Hebrew University of Jerusalem and holder of a Ph.D. from the University of Oxford, England, Dr. Harari published the international blockbuster Sapiens: A Brief History of Humankind. Sapiens was first published in Hebrew in 2011 and was translated into nearly 50 languages, selling over 10 million copies by 2018.
In Sapiens, Dr. Harari uses macro-history (also known as “big history”) and biological evolution to explain the development of human society over the past several hundred thousand years. He focuses in particular on the “cognitive revolution” that began 70,000 years ago. During this period, the modern human species, Homo sapiens, came to dominate Earth.
“Homo sapiens” is Latin for “wise man.” “Deus” means “god.” In Homo Deus, first published in English in 2016, Dr. Harari projects current trends deep into the 21st century and speculates that humanity could double average life expectancy to 150 years. He also considers the profound changes longer lives would bring such as people in positions of authority stretching out their careers and thus cutting off opportunities for younger individuals.
Ultimately, in this century humanity may seek immortality by developing new biomedical tools and implants, fusing our bodies with high-tech machines, and perhaps also creating non-organic beings.
“You may debate whether it is good or bad,” Dr. Harari writes, “but it seems that […] the twenty-first century will […] involve re-engineering Homo sapiens so that it can enjoy everlasting pleasure. In seeking bliss and immortality humans are in fact trying to upgrade themselves into gods. Not because these are divine qualities, but because in order to overcome old age and misery humans will first have to acquire godlike control of their own biological substratum [bedrock].”
A new scientific dogma: we are algorithms
The idea of ending disease and extending life, even if by only a few years, stirred the depths of my being. The fear of death propels our psyches and civilization. In the Huntington’s community, where the disease’s devastating and fatal symptoms cut off down lives early, the fear of death is ever-present and more acute. I recalled my mother’s death from HD in 2006 at 68 and my condition as an HD gene carrier. At 59, each day without symptoms is a blessing.
Homo Deus also reminded me of my 2010 article “God, Huntington’s disease and the meaning of life,” in which I examined the Catholic Church’s little-known and little-understand acceptance of evolutionary theory and the notion that the Resurrection of Christ could be seen as a genetic mutation.
However, in Homo Deus Dr. Harari also warns that current trends in biotechnology and the gathering and control of data could also lead to the creation of a super-human elite taking control of the rest of humanity, threatening privacy, democracy, and human and civil rights.
“If indeed we succeed in hacking and engineering life, this will be not just the greatest revolution in the history of humanity,” Dr. Harari told the audience at the 2018 World Economic Forum Annual Meeting in Davos, Switzerland. “This will be the greatest revolution in biology since the very beginning of life 4 billion years ago.[…]
“Science is replacing evolution by natural selection with evolution by intelligent design. Not the intelligent design of some god above the clouds, but our intelligent design, and the intelligent design of our clouds, the IBM cloud, the Microsoft cloud. These are the new driving forces of evolution.”
Yuval Noah Harari in 2017 (photo from Wikimedia Commons)
In Homo Deus, Dr. Harari explains that “science is converging on an all-encompassing dogma, which says that organisms are algorithms” – a method or list of instructions for making calculations – “and life is data processing.”
“Humans are algorithms that produce […] copies of themselves,” he adds. The influence of computer algorithms designed by organizations such as Google has grown vastly, taking in fantastic sums of personal data for users of the Internet and personal devices. “Non-conscious but highly intelligent algorithms may soon know us better than we know ourselves.”
In their digital lives, over 2 billion Facebook members have encountered that organization’s problematic algorithm, which a company study found to be a better reader of people’s personalities than even their friends, parents, and spouses, Dr. Harari points out.
Crucial data from HD families
Homo Deus doesn’t mention HD. However, it recognizes the importance of Alzheimer’s disease and the need to prevent it and disease in general. Dr. Harari explains that upgrading humanity would include attempts to expand the abilities of the brain – which, of course, is an organ severely debilitated by HD.
The history of the search for HD treatments is key to the biotechnological revolution. HD-affected individuals and their families have both witnessed and participated in that revolution, starting with the hunt for the huntingtin gene in the 1970s, 1980s, and 1990s, and since then with a growing number of research studies and clinical trials involving thousands of individuals.
At the start of this decade, CHDI Foundation, Inc., the nonprofit virtual biotech focused on defeating HD, pioneered the use of systems biology, which includes the deciphering of vast amounts of biological data, in disease treatment (click here to read more).
CHDI has also collaborated with IBM to seek deeper understanding of the huntingtin protein’s role in the disease. In this effort, IBM has provided its immense computational power and the tools of big data analytics.
Enroll-HD, the CHDI-sponsored worldwide database of HD-affected individuals and family members, has more than 17,000 participants. Thousands of HD-affected individuals and gene carriers have also participated in the research involving the search for so-called modifier genes that affect the age of onset. The scientists have analyzed millions of small variations in these people’s genes.
Digital monitoring and algorithms
An increasing number of researchers and companies are in effect trying to hack HD’s genetic causes. The most prominent is the gene-silencing drug developed by Ionis Pharmaceuticals, Inc., in collaboration with CHDI and other researchers. On December 19, pharma giant Roche, now the drug’s license-holder, announced the first 26 planned sites for the crucial global Phase 3 trial to test the drug’s efficacy.
In that trial, participants will receive the drug via lumbar puncture (spinal tap), the first time this delivery method is being used extensively in an attempt to treat a neurological disorder.
For the study, Roche has designed an HD Digital Monitoring Platform, which will continually measure participants’ biometric data using smartphones and watches.
“The software is what’s special, and the analytics engine behind it,” Erik Lundgren, the Roche lifecycle leader of the HD team, said in an interview last March. “A tremendous amount of data comes in. The algorithms and how you make sense of that is what our team has been working hard on developing.”
A graphic illustrating the Roche HD Digital Monitoring Platform (source: Roche)
Privacy versus healthcare systems
As Dr. Harari warns, the purpose and uses of technologies and information-gathering techniques originally developed for something positive such as curing a disease could result in unintended, perhaps negative, consequences.
Companies such as Google “want to go much deeper than wearables,” he explains.
“If we give Google and its competitors free access to our biometric devices, to our DNA scans and to our medical records, we will get an all-knowing medical health service that will not only fight epidemics, but will also shield us from cancer, heart attacks and Alzheimer’s,” he writes.
However, he observes, “imagine a system that, in the words of the famous Police song, watches every breath you take, every more you make and every bond you break; a system that monitors your bank account and your heartbeat, your sugar levels and your sexual escapades. It will definitely know you much better than you know yourself.”
Google and these other algorithm-based systems could make decisions for us, from selecting which movie to watch to choosing a spouse to settling on a candidate in the voting booth.
In a world in where the stress on data takes on a religious fervor, the demand for the free and massive flow of information could trump freedom of expression and, by extension, people’s right to control their own information, Dr. Harari asserts. He cites pressure from “Dataist missionaries” for free access to all information, including copyrighted materials.
The danger is that “we will just have to give up the idea that humans are individuals, and that each human has a free will determining what’s good, what’s beautiful and what is the meaning of life.”
“The big battle over what we today call ‘privacy’ will be between privacy and health,” Dr. Harari asserted at the World Economic Forum. “Do you give access to what is happening inside your body and brain in exchange for far better health care? And my guess is that health will win, hands down.[…] Maybe in many places [people] won’t have a choice. They won’t get insurance if they are unwilling to give access to what is happening inside their body.”
What kind of world are we creating?
Because of the many critical issues it touches on regarding humanity’s future, Homo Deus is a must-read book.
For the HD community, it provides valuable context for the difficult medical, social, and ethical challenges involved in the disease and the quest for treatments.
As many in science strive, in Dr. Harari’s words, to “defeat death and grant humans eternal youth,” the complexities of HD and the close collaboration between HD scientists and families may serve as a reminder that the biotechnological and medical sectors should consult disease communities and the rest of society.
Yes, despite having back problems, to avoid HD onset I would take a drug via recurring spinal taps. I would also wear a data monitor, as do people with type 1 diabetes, for example.
However, I’m also concerned about the dystopian scenarios outlined by Dr. Harari for this century.
What kind of world are we creating for our children and grandchildren?
Monday, January 07, 2019
A friend of the Huntington’s community receives award for HD article in influential Brazilian magazine
Brazilian journalist Mônica Manir, holder of a doctorate in bioethics and a long-time friend of the Huntington’s disease community, received the Prêmio Synapsis (Synapsis Prize) for her in-depth December 2017 article on the disorder in the prestigious Brazilian magazine Piauí.
Titled “Dançando no escuro” (“Dancing in the Dark”), the article provides a detailed portrait of HD, focusing on families in Brazil and other countries affected by the condition, which causes involuntary movements, cognitive decline, and psychiatric problems. Piauí is on the level of The New Yorker magazine.
The Prêmio Synapsis is sponsored by the Brazilian Federation of Hospitals and awarded annually for the best journalistic reports on health issues in the categories of print publications, TV, online, and radio.
For her article, Manir did almost five months of reporting, traveling to the interior to visit a town with a large nucleus of affected families and also to the Vatican in May 2017 to witness Pope Francis’ special audience with the global HD community.
Upon receiving the Prêmio Synapsis in Brasília on November 27, Manir recalled the pope’s declaration that HD should be “hidden no more!”
Mônica Manir receiving the Prêmio Synapsis (photo by Federação Brasileira de Hospitais)
Manir received her degree in journalism at the Universidade de São Paulo (USP), one of Brazil’s leading universities, in 1990. She worked as both a reporter and editor for the Sunday news and cultural section of the newspaper O Estado de S. Paulo.
In 2013, she reported for the paper on the sixth World Congress on Huntington’s Disease, held in Rio de Janeiro. She also set up a talk by me on HD and bioethics in São Paulo at the Centro Universitário São Camilo’s graduate program in bioethics, where she received both her Master’s and Ph.D.
She is also doing a post-doctoral study at the USP’s Instituto Oscar Freire on the dilemmas of predictive testing for people at risk for HD.
On December 5, Manir granted the following interview via e-mail.
GV: What led you to study journalism?
MM: I was always a very curious person. I wanted to understand the “why” of everything. I always pestered my parents with questions. I also loved reading. When I was 14, my sister started studying literature at the Universidade Estadual de Campinas [in São Paulo state] and became a member of the Círculo do Livro [a bi-weekly book club]. I couldn’t wait to “inherit” from her all of those books that arrived at our house. I also loved writing and was praised for my school reports. In middle school, I discovered that the history taught in the schools had a political bias. I felt the wool had been pulled over our eyes with all of the language that permeated the school texts and that often hid the facts. I decided that, by becoming a journalist, I could try to get as close as I could to the truth to help people become more critical and aware. I wanted to be where things were happening and consider all the angles. To do that, I needed to do deeper reporting. That’s why I always preferred working for media that allowed me to do in-depth reporting.
GV: What inspired you to write an article for Piauí about Huntington’s?
MM: Although I already knew about the disease because of the article I did for O Estado de S. Paulo in 2013, I was inspired to do the piece for Piauí by the audience with the pope at the Vatican. I thought it was a theme appropriate for returning to the subject, now in a more profound way, because I would come into contact with the affected, the families, and the health professionals from different parts of the world.
GV: What did it mean for you to receive the Prêmio Synapsis for your article “Dancing in the Dark”? Why is the prize called “Synapsis”?
MM: It meant for me a big investment in an in-depth article. Just to report it took almost five months, including my trip to the Vatican and to Ervália, a small town with a large enclave of people with the disease in the state of Minas Gerais, and also the reading of articles and books, and long interviews with the affected, family members, specialists, artists. Then came the writing up of all that enormous amount of information, the organization of the text, and the fact-checking, and then the final version, which took up seven pages in the magazine. According to the sponsors, the name of the prize is intended to recognize the brilliant ideas regarding the improvement of Brazil’s health system. The term “synapsis” has to do with “link,” “connection.”
GV: What did you say as you accepted the prize?
MM: I thanked the sponsors for their initiative in stimulating discussion about the Brazilian health system, which is essential in a country with such social inequality in all areas. I also thanked Piauí magazine for having invested in a theme still little known, and for having sent me to the Vatican and Ervália to cover different angles of the subject. But I especially thanked the HD-affected, their relatives, and the health professionals, all of whom deal with prejudice, the difficulties of being diagnosed, and the hitches that have occurred in the search for treatments, all of this unfortunately also very common in other rare diseases. Lastly, I remembered the theme of the audience with Pope Francis: “Hidden no more!”
GV: After the ceremony at which you received your trophy, many people greeted you and said that they had not heard of HD but would now take an interest in it. What explains this reaction?
MM: I think the fact that a prestigious magazine like Piauí took interest in the subject is already a reason for reading the article. Another point is that this disease can be present in a family or friends without anybody knowing about it. Or, even if people know about it, they might lack detailed information. So, there’s curiosity about learning more about HD. One couple present at the ceremony said that they knew about the disease because a relative had symptoms. They called it “Huntington’s chorea,” as it is still sometimes known in Brazil, and praised the fact that the magazine had addressed the subject.
GV: It’s been a year since the publication of “Dancing in the Darkness.” Beyond your prize, what has been the article’s impact in Brazil?
MM: When it was published, it drew praise from various quarters, from apartment doormen to Brazilian celebrities, besides the subjects themselves.
GV: What was it like to cover the affected families in Rome in May 2017?
MM: It was a very rich experience! I understood much better the anguish of the families, the factors that accentuated or eased that anguish, and the determination to diminish the silence on the matter. Everybody was very kind to me, answering patiently my endless questions!
GV: What led you to study bioethics?
MM: I think bioethics combines perfectly with journalism in the sense that the guiding concept is “it depends.” Central questions of human existence can’t be viewed just from one angle. It’s necessary to turn the prism and observe the effects that has on the light. It’s necessary to understand the context of a matter, people’s wishes, the internal and external pressures, and, from that point, try to register things with sensitivity. Bioethics showed – and continues to show – me the profound dilemmas of life and death that are still far from being answered with a single response.
GV: What has most impacted you regarding Huntington’s?
MM: Huntington’s is a hereditary disease that leaves families on hold. Questions hang over them: “Do I carry the gene? Does my child? And my mother? And my nephew?” Despite the existence of a predictive test, very few undergo testing to learn their status before the actual onset of symptoms – which is completely understandable, because there is still no cure. At the same time, there are cutting-edge research projects that could block the genetic trigger and, as a result, help to treat and/or cure this and other diseases.
GV: What message would you like to transmit to the Huntington’s community in Brazil? And beyond?
Thursday, December 20, 2018
Pharmaceutical firm Roche has announced 26 planned sites in the U.S. and Canada for its historic Phase 3 clinical trial of a gene-silencing drug to slow, halt, or perhaps even reverse the progression of Huntington’s disease.
Called GENERATION HD1, the greatly anticipated trial will test the efficacy of the drug, RG6042. Roche expects to start enrolling volunteers in early 2019.
The announcement comes one year after the successful completion of the Phase 1/2a trial to measure the safety and tolerability of RG6042, developed by Ionis Pharmaceuticals, Inc.
RG6042 dramatically reduced the amount of mutant huntingtin protein in the cerebrospinal fluid (CSF) of trial participants. As a result, Roche took the unusual step of skipping a Phase 2 trial (testing efficacy for the first time) and going directly to a Phase 3 (confirming efficacy in hundreds of participants, or more).
In a statement released December 19 to the Huntington’s Disease Society of America (HDSA) and other patient groups, Roche announced the sites listed below, grouped by province/state.
Alberta, Edmonton – University of Alberta
British Columbia, Vancouver – University of British Columbia
Ontario, Ottawa – Ottawa Hospital
Ontario, Toronto – Centre for Movement Disorders
Nova Scotia, Halifax – Queen Elizabeth II Health Sciences Centre
Quebec, Montreal – Centre Hospitalier de l’Université de Montréal
Alabama, Birmingham – University of Alabama
Arizona, Phoenix – Barrow Neurological Clinic
California, Davis – University of California, Davis
California, Palo Alto – Stanford University
California, Pasadena – Arcadia Neurology Center
California, San Diego – University of California, San Diego
Colorado, Englewood – Rocky Mountain Movement Disorders Center
District of Columbia, Washington – Georgetown University
Florida, Tampa – University of South Florida
Illinois, Evanston – Northwestern University
Maryland, Baltimore – Johns Hopkins University
Massachusetts, Boston – Beth Israel Deaconess Medical Center
Missouri, St. Louis – Washington University in St. Louis
New York, Amherst – Dent Institute
New York, New York – Columbia University
Pennsylvania, Pittsburgh – University of Pittsburgh Medical Center
Tennessee, Nashville – Vanderbilt University Medical Center
Texas, Houston – University of Texas Health Science Center
Utah, Salt Lake City – University of Utah
Washington, Kirkland – Evergreen Health
Roche plans to announce sites in approximately 13 additional countries in the coming months. It hopes to enroll a global total of 660 volunteers with early HD symptoms at 80 to 90 sites. Each participant will receive the drug or placebo monthly over 25 months through a lumbar puncture (spinal tap), the way into the CSF.
The CSF bathes the brain. Because biopsies of the brain are currently not possible, measuring the effect of the drug in the CSF gives researchers a window onto the effects of the drug.
Moving as ‘quickly as possible’
“It is important to note that these sites are not fully activated nor recruiting yet,” the Roche announcement stated. “We hope to complete the final steps as quickly as possible.”
According to the statement, Roche selected sites based on a variety of factors, including prior experience with HD studies, clinic infrastructure capacity, ability to run the study as quickly and completely as possible, patient population, and geographic location.
The news follows Roche’s announcement last month of 16 sites for the HD Natural History Study, an arm of the RG6042 program to involve 100 observational study volunteers in Canada, Germany, the United Kingdom, and the United States.
The HD Natural History Study will seek to deepen understanding of the natural progression of HD, the role of the mutant huntingtin protein in the disorder, and the assessment of biomarkers (signs of the disease measured in patients) and their efficacy in predicting the effects of the drug. The volunteers will undergo four lumbar punctures to examine their CSF, but receive no drug.
Click here for the full text of Roche’s December 19 statement.
In the U.S. and Canada, HD families can contact Roche/Genentech about the trial at 888-662-6728. Information about the trial is also available at ClinicalTrials.gov.
For additional background on GENERATION HD1, click here.
If effective, RG6042 would be the first treatment to affect the progression of Huntington's.
Stay tuned to this blog for future updates on GENERATION HD1.
Sunday, December 09, 2018
Building solidarity in disease communities’ quest for better care and treatments: a conversation with a young tennis award-winner
In disease communities, it’s easy for affected individuals and their families to become insular as they struggle with the many challenges posed by their particular illness. To attract the attention and funds needed to combat a disease, sometimes they even portray their condition as more devastating than others.
In the Huntington’s disease community, we refer to HD as “the devil of all diseases,” like a combination of Alzheimer’s, Parkinson’s, and psychiatric and behavioral disorders, including a high suicide rate. There is no treatment for stopping disease progression.
However, in the quest to treat difficult chronic illnesses, disease communities need to build solidarity and learn valuable lessons from one another. Also, although the causes and symptoms of diseases vary widely, the different communities share the common cause of overcoming the limits diseases place on people’s lives.
I had a reawakening about solidarity a year ago this week. At the University of San Diego (USD), where I’m in my 26th year in the Department of History, a new advisee, 20-year-old sophomore Garrett Kurtz, sat in my office as he began to recount his own battle to live with type 1 diabetes.
Suddenly, Garrett untucked the left side of his shirt to reveal a device about the size of a small smartphone attached to his waist. He explained that it was a pump that gave him injections of insulin, which helps convert sugar in the blood so that it can enter the cells and allow them to use energy. Type 1 diabetics cannot produce this essential hormone.
I felt an immediate bond with Garrett. I shared a bit of my family’s fight against HD, including my HD-afflicted mother’s death and my condition as a gene carrier.
Remarkably, I learned, despite his potentially limiting condition, Garrett has played competitive tennis since he was seven and a half. By 12, he was ranked in the top 50 male players in the nation, and in the top ten in Southern California. He now plays for USD’s men’s team, a top 35 National Collegiate Athletic Association (NCAA) Division I team.
As Garrett explained, few prominent athletes have diabetes. Choosing the rare but ingenious combination of a history major and chemistry minor, he aims to work for a biotech or similar firm with the goal of helping physically active people, including athletes, better manage their diabetes.
For his efforts, in July Garrett was named one of two 2018 Novo Nordisk Donnelly Award national winners. The award includes a one-time $7,500 scholarship towards education, tennis development, and/or medical care. These and smaller awards go to male and female athletes ages 14-21 who are in good academic standing, manage diabetes, and play tennis competitively in tournaments or on their school team.
Garrett received the award from all-time tennis great Billie Jean King, a type 2 diabetic.
Garrett Kurtz and Billie Jean King (photo from @USDmtennis)
The inspiration of Billie Jean King
“To receive an award from someone like her was absolutely incredible, and I’m extremely honored,” Garrett said in a November 14 interview with me at USD, recalling King as a “trailblazer” in women’s sports, gender equality, and LGBTQ advocacy.
After speaking with King for an hour, Garrett was inspired by her personality and positive attitude.
“She was very direct,” he said. “She had an aura of self-confidence. She talked about how having self-confidence and a vision is something so important to people of all ages, but especially young people, wherever they may be in society.”
The awards take their name from Diane Donnelly Stone and Tracey Donnelly Maltby, two sisters who became college tennis stars and have lived successfully with type 1 diabetes since childhood. Novo Nordisk, a Denmark-based global healthcare firm with a focus on diabetes, became the award’s title sponsor in 2002.
“They want to highlight specifically tennis players who are type 1 diabetics and basically give them a voice or recognition for what they go through every day, the struggles that they have to deal with,” Garrett commented.
You can watch my interview with Garrett in the video below.
Diagnosed with type 1 diabetes
Garrett and his parents discovered that he had type 1 diabetes when he was seven, just around the same time he started playing tennis in his hometown of Newport Beach, CA.
“I was extremely thirsty and dehydrated,” he recalled. “I also had lost some weight. One of the unrelated members of my family had type 1 diabetes and we had a spare blood sugar test kit in my house. My mom took my blood sugar and I was extremely high and that was a strong indicator of what was happening. I was taken to the hospital and diagnosed pretty soon afterwards.”
Other type 1 symptoms include fatigue and weakness, frequent urination, extreme hunger, irritability and other mood changes, and blurred vision.
“I think diabetes is a very unique disease, because you cannot take a medication and just be good for the day,” Garrett said. “It’s a 24/7/365 type of disease where everything that I do – whether it be studying, exercising, eating, the anticipation of waiting for something, being happy – diabetes affects it.”
With vigilant management of the disease, today his symptoms are under control.
Understanding type 1 and type 2
In 2015, more than 30 million Americans had diabetes, 1.25 million with type 1 and the rest with type 2.
Type 1 was previously known as “juvenile diabetes” but actually affects more adults than children. It occurs in all ages and ethnic groups.
Garrett explained the differences between the two types.
“Type 1 is an autoimmune disease, which basically means your immune system attacks part of your body, whereas type 2 comes from your lifestyle, what you eat, and it’s not necessarily hereditary,” he said. “There’s a whole host of autoimmune diseases.”
His father has ankylosing spondylitis, believed by some researchers to also be an autoimmune disease. It has the same genetic marker as type 1 diabetes, but the doctors “don’t know if there’s a link between that and my diabetes,” Garrett said.
“Type 1 is something that you cannot control,” Garrett continued. “Basically what happens with a type 1 diabetic is that your immune system – and this is the great mystery with type 1 diabetes, whether it’s your environment or something you eat or it’s just how your body works – attacks all of your beta cells, which are produced by your pancreas.”
Beta cells produce insulin, Garrett explained. Insulin breaks food, especially carbohydrates, down into glucose, which is the blood sugar that diabetics measure by pricking their fingers.
“Insulin attaches itself to the sugar and allows it to get transferred to the individual cells and allows them to use the energy, for you to function and exercise,” he said.
Type 1 diabetics must “manually administer” their insulin via injection or a pump such as Garrett’s.
Type 2 diabetes generally results from an unhealthy lifestyle, including obesity, lack of exercise, and poor diet.
“A type 2 diabetic is different in the sense that they become insulin-resistant,” Garrett explained. “You become so used to consuming so much, that your body keeps producing more and more insulin. It becomes a point where it’s like taking too much of a drug. It’s like becoming addicted. You need more and more and more until the point where the insulin just doesn’t become effective.”
Unhampered on the court
From 2012 to 2015, another unexpected, painful, episodic condition hit Garrett, this time sidelining him from competitive tennis. After consulting with nearly a dozen sports orthopedic specialists and undergoing many MRI scans, he learned that he had a rare physical abnormality: a blood vessel was sitting on the nerves of his inner right elbow. In late summer 2015, he underwent a successful surgery to relieve the pain, enabling him to return to the court.
In 2016, after another tennis player recommended Garrett, USD head tennis coach Ryan Keckley recruited him for the team.
“With the understanding that he was a top ten player, and understanding his character, his family, and his love for the game, we decided to offer him an opportunity to play for USD,” Keckley told me. Since his arrival, Garrett has played in several important matches for USD. Keckley said he expects Garrett to compete in the upcoming spring 2019 season.
Receiving the Novo Nordisk Donnelly Award was “really a testament of his character and his work ethic,” added Keckley, a top player while a student at the University of Notre Dame. “There are very few athletes that have been able to manage what he manages, and are successful at it. This gives him an edge in seeking to go into the field of studying diabetes.”
Given Garrett’s small stature for tennis – 5-7, 150 lbs. – “he needs to be the little engine that could,” Keckley observed. “He has learned how to be tougher than his opponents, which is ultimately why he was one of the ten best players in the country in the 14 and unders.”
Because of Garrett’s careful management of his diabetes, the condition has not hampered his play, Keckley added.
“If you didn’t know Garrett, you wouldn’t know it was something he dealt with,” he said.
Garrett Kurtz at practice (photo courtesy USD Men's Tennis Team)
The hope of managing HD
I told Garrett that we in the HD community hope for the breakthrough that allows patients to manage the disease in a way not unlike how he controls his diabetes with his pump. HD is also a 24/7/365 disease. HD patients, I speculated, might tweak their own administration of drug the way he does.
Still, to affect HD, a drug must cross the highly protective blood-brain barrier, a monumental task for drug researchers.
HD drug developers have discussed the possibility of using pumps to deliver a drug. In 2008, in my first visit to the former Isis Pharmaceuticals, Inc., now Ionis Pharmaceuticals, Inc., the company’s senior vice president, Frank Bennett, Ph.D., explained how the company used this approach. (Click here to read my 2008 report.)
Ionis researchers inserted pumps under the skin of mice, then, for each mouse, ran a tube into the brain to deliver an experimental gene-silencing drug. At that time, researchers were considering the use of a hockey puck-sized pump placed in the abdomen of HD patients, which would pump the drug through a tube carefully inserted into the brain.
In our discussion, Dr. Bennett pointed out that people with a number of conditions such as chronic back pain or diabetes already used commercially approved pumps. Doctors could use infrared signals to program the pumps and control the flow of medication and could inject a new supply into the pump through a port just under the skin.
“It’s obviously not ideal, but considering the severity of this disease, it’s well worth the inconvenience that these pumps produce,” Dr. Bennett observed in 2008. “Once patients acclimatize to them, they’re really not that bothersome.”
A pump instead of spinal taps?
Indeed, Ionis was exploring the possibility of pumping an HD drug into the cerebrospinal fluid (CSF), which bathes the brain, via pump. It had already used one of its drugs to reduce the effects of Lou Gehrig’s disease in test rodents using this method.
So far, such pumps aren’t being used in HD clinical trial. In its historic, highly successful Phase 1/2a clinical trial, completed in December 2017, Ionis injected the drug via lumbar puncture (spinal tap) four times into the CSF of 46 volunteers, without any serious side effects.
The follow-up Phase 3 trial, to be run by Swiss-based Roche starting in early 2019, will involve 25 monthly lumbar punctures (click here to read more).
Delivering drugs via spinal fluid is a new procedure. There are no studies of the effects of long-term use of spinal taps. I expressed my own concerns about this.
With its current crucial focus on demonstrating efficacy in the Phase 3 trial, Roche is not yet ready to discuss the hypothetical use of a pump or other drug-delivery methods such as its proprietary “brain shuttle” technology (click here to read more).
Medtronic, the medical device and healthcare firm that makes Garrett’s pump, has conducted HD research but not initiated any clinical trials. It also makes a pump for delivering drugs into the CSF for treating conditions such as chronic pain.
A revolution in diabetic care
In our November 2018 conversation, Garrett spoke in great detail about his use of the Medtronic MiniMed 670G electronic insulin pump and its companion, linked device, a continuous glucose monitoring sensor.
The Medtronic MiniMed 670G electronic insulin pump (largest device in photo), continuous glucose monitoring sensor (small device on right), and blood sugar test kit (on the left)
“It’s like a temporary IV that you have to change every three days,” Garrett explained. “You put it on a region of subcutaneous fat [fat under the skin] so that it can absorb and go into your system.
“And the great thing about the insulin pump – and what makes it great for being a tennis player and being active – is you can give yourself insulin at any point in time during the day. I just have to press a few buttons, and I can configure how much insulin I’m giving myself. The great thing about the pump is that it allows you to give insulin in very small samples.”
That’s important, Garrett said, because the overall volume of insulin needed by a diabetic “is not very much.”
The system helps “cover carbs” consumed – plus glucose produced by normal bodily functions – with small, pre-programmed boluses (doses) of insulin.
“In a normal person, their pancreas is doing all this automatically,” he continued. “Every few minutes or every few seconds, your pancreas is giving you insulin. It also gives you a shot of adrenalin, which also bumps your blood sugar up.”
Garrett used to prick his finger up to a dozen times per day to measure his glucose. Now, with the continuous monitoring glucose sensor, he does it only twice. “My finger pads are in bit better shape now,” he observed, laughing.
The monitor is also attached to a small area of subcutaneous fat, generally on the stomach or the back of the arm or hips. It measures blood sugar every five minutes.
“For a diabetic, that’s extremely helpful for you to understand where you are and what you need to do,” Garrett said, noting that he can thus both anticipate and make adjustments and know whether he needs to consume sugar or insulin.
In this hybrid system, the pump and the sensor “talk to each other,” Garrett added. There are still technical difficulties, but “it’s revolutionary in terms of diabetic care, because it’s that first step in trying to get the artificial pancreas.”
He can also download data from the pump and sensor that allows him to analyze his blood glucose trends and insulin consumption for continual adjustments.
Feeling ‘on top of your disease’
The devices have not restricted his life in any way, Garrett said. On the contrary, as a tennis player, he can avoid having to take insulin shots during a match.
I asked Garrett what advice he would offer to drug companies working on neurological disease treatments and the potential of long-term drug delivery.
Garrett replied that he has recently been thinking more about the significance of his pump.
The system has allowed him to “fine-tune” his insulin intake, he observed.
“Having a pump kind of makes you feel empowered,” he said. “It makes me feel like I control my disease. I own the disease. The disease doesn’t own me.”
With drugs delivered via pump, people with HD and other neurological disorders could also feel “on top of their disease,” he said.
Disease communities learning from one another
Now a junior, Garrett turned 21 in October. As a history major and chemistry minor, he wants to research the history of diabetes and how medical care for the condition has evolved.
After graduation, he would like to work for a company such as Medtronic to focus on diabetic product design and sales. He is especially passionate about mentoring young athletes affected by diabetes. He also envisions starting a division at a healthcare or biotech firm focused on athletes and other physically active people with diabetes.
He’s also hoping for progress on the development of the artificial pancreas, the equivalent of a cure for diabetes.
Likewise, the HD community and other neurological disease communities anxiously await the first effective treatments.
“Time is of the essence in many of these diseases,” Garrett observed. “The faster you can bring cutting-edge technology to the patient, the better it is. Just 50 years ago for diabetes, you were taking your blood sugar by urinating in a cup. Now I wear a device that literally takes it every five minutes and beams it to a pump.”
These communities all can learn from one another, Garrett stressed.
I have already learned much from Garrett and his approach to life.
Wednesday, November 21, 2018
This Thanksgiving, I am especially grateful for good health – and all that it enables me to enjoy.
At my annual neurology checkup on October 31, the doctor told me that I remain asymptomatic for Huntington’s disease. My more extensive annual Enroll-HD examination earlier in the year also showed no symptoms.
I tested positive for the HD gene in 1999. Next month, I turn 59. At that age, my mother had already been diagnosed and was rapidly losing the ability to walk, talk, and care for herself. She died in 2006 at the age of 68 after a long struggle.
I never imagined that at this point I could still pursue my passion for writing, teach at the university, and support my family.
As I frequently tell students, colleagues, and my family, “health is first.” Without it, achieving goals and handling responsibilities can become very difficult, if not impossible.
Studying the history of the HD cause
I am putting the final touches on a book in my field of Brazilian history, scheduled to be published next June, From Revolution to Power in Brazil: How Radical Leftists Embraced Capitalism and Struggled with Power. I began the research more than two decades ago, not long after learning of my mother’s HD diagnosis. Seeing the project come to fruition is thrilling and profoundly fulfilling.
With the Brazil project complete, I will carry out my long-gestating plan to shift my main scholarly focus to the history of science, technology, and medicine. Last month I proposed a new, multi-year research project, titled “Racing Against the Genetic Clock: A Social, Scientific, and Personal History of the Huntington’s Disease Movement.”
I aim to study how key facets of the movement intertwined with major developments in the biotechnological and medical revolutions of the past 200 years. I believe that the HD cause can serve as a guidepost for other disease communities and inform key bioethical questions related to them.
I also want to help the HD community reflect on its path through history.
More than ever, my scholarly work and HD advocacy will meld. (Click here to read more.)
Seeing our daughter enter college
On a personal level, good health allowed me to join my wife Regina last August in helping our HD-free daughter Bianca set up for her first semester at the University of Pennsylvania, where she is studying in its College of Arts and Sciences.
I had always feared that HD would prevent me from experiencing this special moment – just as HD had stopped my mother from interacting with Bianca as a baby and young child.
I am more determined than ever to see Bianca graduate from college and find her way in life. I’m hoping that GENERATION HD1, the historic Roche Phase 3 clinical trial of a gene-silencing HD drug, will result in an effective treatment not only for patients, but as a preventive measure for presymptomatic gene carriers like me. Roche hopes to enroll the first volunteers starting in early 2019.
Looking ahead, I hope to retire on my own timeline – not because of HD.
Regina, Bianca, and Kenneth Serbin (aka Gene Veritas) during Penn Family Weekend, October 21, 2018 (family photo)
The preciousness of life
I’ve been extremely fortunate to reach this point without HD symptoms—or other significant health problems. Many HD brothers and sisters of my generation are struggling with symptoms.
Like so many in HD families and other difficult situations, I’ve learned to value each moment of life.
Others face different health issues. At this time last year, I lost two wonderful friends about my age, generous supporters of the HD cause, taken quickly and unexpectedly by other conditions. I’ve missed them dearly, and think about them daily as a reminder of the preciousness of life.
Tomorrow, I want to enjoy Thanksgiving.
God and nature willing, I’ll awake the next day ready to love my family, continue the fight to defeat HD, and dream of a day when a cure frees me to assist people less fortunate.
Happy Thanksgiving! And the best of health for you and yours.