human genomics human genome program, u.s. department of energy, genomics and its impact on medicine...

52
HUMAN GENOMICS

Upload: steven-nash

Post on 29-Dec-2015

229 views

Category:

Documents


1 download

TRANSCRIPT

Page 1: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

HUMAN GENOMICS

Page 2: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 3: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

The Human Genome Project

Begun in 1990, the U.S. Human Genome Project is a 13-year effort coordinated by the U.S. Department of Energy and the National Institutes of Health. The project originally was planned to last 15 years, but effective resource and technological advances have accelerated the expected completion date to 2003. Project goals are to  ■ identify all the approximatly 35,000 genes in human DNA, ■ determine the sequences of the 3 billion base pairs that make up human DNA, ■ store this information in databases, ■ improve tools for data analysis, ■ transfer related technologies to the private sector, and ■ address the ethical, legal, and social issues (ELSI) that may arise from the project.  Recent Milestones:■ June 2000 completion of a working draft of the entire human genome ■ February 2001 analyses of the working draft are published■ April 2003 complete draft sequence available publicly

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 4: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Human Genome Data

• Derived from the Human Genome Project

• sequence freeze date in anticipation of data release: 22 July 2000

• Release of First Draft Sequence of Human Genome:

Nature 409 (6822), 15 February 2001

Science 291 (5507), 16 February 2001

Page 5: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

3.2 billion bases

28% transcribed

<1.4% encodes protein

50% repeats

Only ~35,000 genes!

FEATURESFEATURESThe

Human

Genome

Page 6: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

The

Human

GenomeLIMITATIONSLIMITATIONS

to interpreting to interpreting results of results of

projectproject

Comparative genomics

Gene Prediction

Page 7: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

GENE GENEIntragenic region

exons intronsinterspersed

repeatstandemrepeats

Gene Prediction Algorithmsbased on consensus nucleotide sequences of

•tata boxes and start codons

•stop codons

•splice junctions

•CpG islands

Page 8: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Human Genes

Page 9: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 10: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Surprising Findings = !!

• !! Only 35,000 genes• most genes in euchromatin• GC/AT patchiness• !! Gene density higher & intron

size smaller in GC-rich patches• !! 1.4% translated, 28%

transcribed• !! Origins of genes

Page 11: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Some Origins of Human Genes

• Most from distant evolutionary past(basic metabolism, transcription, translation,repli-cation fixed since appearance of bacteria and yeast)

• Only 94/1278 families vertebrate-specific• 740 are nonprotein-encoding RNA genes• many derive from partial genomes of viruses and

virus-like elements• some acquired directly from bacteria?

(rather than by evolution from bacteria)

Page 12: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 13: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Genomic Fossils

Page 14: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Genomic Fossils(also known as Molecular Fossils)

• interspersed repeats

• generated by integration of transposable elements or retrotransposable RNAs

• active contemporary modifier of some vertebrate genomes (mouse)

• formerly active modifier of human genome

• some as prevalent as 1.5 million copies

Page 15: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 16: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Reverse Transcription

• Converts primed RNAs into cDNAs

• catalyzed by RNA-dependent DNA pol

• pol encoded by retroviruses and active LINEs

Retroviral genomic RNA

Alu RNA

LINE RNA

Page 17: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Alu ElementsShort Interspersed Elements (SINEs)

• RNA polymerase III transcribed• 3’ oligo dA-rich tail• found only in primates• 1,500,000 copies • derived from 7SL RNA• dimer-like structure• most retroposition occured 40 mya

A/T-richregion and3’-UTR

direct repeats

5’ 3’

A-rich regionRNA polymerase

III Promoter

AAAnA B

31 bp

50-300 bpAlu

Page 18: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Alu Subfamily Structure (millions of years)

Oldest [J]

Intermediate [S]

Youngest [Y]

Jo Jb (65)

S (50) Sq

Sp Sx

Sc Sg

Y (25)

Yb8 Ya5 Ya8

450,000 copies

50,000 copies

Alus as Genomic Fossils

Page 19: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

ALU INSERTIONS AND DISEASE

LOCUS DISTRIBUTION SUBFAMILY DISEASE REFERENCE

BRCA2 de novo Y Breast cancer Miki et al, 1996Mlvi-2 de novo (somatic?) Ya5 Associated with

leukemiaEconomou-Pachnis andTsichlis, 1985

NF1 de novo Ya5 Neurofibromatosis Wallace et al, 1991APC Familial Yb8 Hereditary desmoid

diseaseHalling et al, 1997

PROGINS about 50% Ya5 Linked with ovariancarcinoma

Rowe et al, 1995

Btk Familial Y X-linkedagammaglobulinaemia

Lester et al, 1997

IL2RG Familial Ya5 XSCID Lester et al, 1997Cholinesterase one Japanese family Yb8 Cholinesterase

deficiencyMuratani et al, 1991

CaR familial Ya4 Hypocalciurichypercalcemia and

neonatal severehyperparathyroidism

Janicic et al, 1995

C1 inhibitor de novo Y Complement deficiency Stoppa Lyonnet et al, 1990ACE about 50% Ya5 Linked with protection

from heart diseaseCambien et al, 1992

Factor IX a grandparent Ya5 Hemophilia Vidaud et al, 19932 x FGFR2 De novo Ya5 Apert’s Syndrome Oldridge et al, 1997GK ? Sx Glycerol kinase

deficiencyMcCabe et al, (personalcomm.)

Page 20: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

What’s New About Old Fossils?In the Human Genome

• Comprise nearly 50% of genome• 50% more Alu elements than were predicted by

molecular biology• scarce in highly-regulated regions (detrimental?)• enriched in GC regions (beneficial?)• little activity, but little scouring• occur frequently within exons• contribute to formation of genes encoding novel

proteins

Page 21: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 22: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 23: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Human Proteins

Page 24: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

ProteinDomains

Page 25: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

The Human Proteome• not many modern protein families

94 / 1278 specific to vertebrates

• direct bacterial contributionsand perhaps viral (reverse trnascriptase)

• higher prevalence of alternative splicing2..6 distinct transcripts per gene from chromosome 221.3 distinct transcripts per gene in worm genome

• contains homologues of 61% of fly, 43% of worm, and 46% of yeast proteome

• domain innovation low, but protein architectural innovation substantial

new physiological capabilities

Page 26: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

New Protein Architectures from Old Domains

Yeast, Worm, Fly, and Human comparison

Page 27: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Human Complexity

Page 28: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Increased Complexity of Human Proteome may help explain Complexity of Human Organism

• greater number of genes

• greater number of domain and protein families

• greater size of protein families

• multidomain proteins with multiple functions

• novel domain architectures

How to Explain Human Complexity?How to Explain Human Complexity?

Page 29: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Segmental Evolutionof the Human Genome

Page 30: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Segmental Evolution

• 200 conserved chromosomal segments between mouse and human

diverged 100 Myr ago

• recent duplications of pericentromeric and subtelomeric segments

• duplications resulting in extension of gene families

Page 31: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 32: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Human Diversity

Page 33: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

SNPs

• Single-nucleotide polymorphisms• occur one/1000-2000 nucleotides in humans

1.6 million-3.2 million between two individuals

• reflects common evolutionary history b/w individuals

• reflects diversity of human population• may represent causes of disease and drug

susceptibilities

Page 34: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 35: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 36: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Summary

Page 37: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001
Page 38: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Summary of First Glance at Complete Human Genome

• Unexpectedly low number of genes, unexpectedly high number of different protein architectures

• significant size and gene modifying contributions of genomic fossils

• direct acquisition of bacterial genes• segmental evolution• genome-wide single nucleotide indicators of

variation

Page 39: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

What does the draft human genome sequence tell us?

By the Numbers

• The human genome contains 3164.7 million chemical nucleotide bases (A, C, T, and G). 

• The average gene consists of 3000 bases, but sizes vary greatly, with the largest known human gene being dystrophin at 2.4 million bases.

 • The total number of genes is estimated at 35,000 much lower than previous estimates of 80,000 to 140,000 that had been based on extrapolations from gene-rich areas as opposed to a composite of gene-rich and gene-poor areas.

 • Almost all (99.9%) nucleotide bases are exactly the same in all people.

 • The functions are unknown for over 50% of discovered genes.

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 40: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

What does the draft human genome sequence tell us?

How It's Arranged• The human genome's gene-dense "urban centers" are predominantly composed of the DNA building blocks G and C. • In contrast, the gene-poor "deserts" are rich in the DNA building blocks A and T. GC- and AT-rich regions usually can be seen through a microscope as light and dark bands on chromosomes. • Genes appear to be concentrated in random areas along the genome, with vast expanses of noncoding DNA between. • Stretches of up to 30,000 C and G bases repeating over and over often occur adjacent to gene-rich areas, forming a barrier between the genes and the "junk DNA." These CpG islands are believed to help regulate gene activity. • Chromosome 1 has the most genes (2968), and the Y chromosome has the fewest (231).

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 41: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

What does the draft human genome sequence tell us?

The Wheat from the Chaff

• Less than 2% of the genome codes for proteins. • Repeated sequences that do not code for proteins ("junk DNA") make up at least 50% of the human genome. • Repetitive sequences are thought to have no direct functions, but they shed light on chromosome structure and dynamics. Over time, these repeats reshape the genome by rearranging it, creating entirely new genes, and modifying and reshuffling existing genes. • During the past 50 million years, a dramatic decrease seems to have occurred in the rate of accumulation of repeats in the human genome.

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 42: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

What does the draft human genome sequence tell us?

How the Human Compares with Other Organisms

• Unlike the human's seemingly random distribution of gene-rich areas, many other organisms' genomes are more uniform, with genes evenly spaced throughout.

 • Humans have on average three times as many kinds of proteins as the fly or worm because of mRNA transcript "alternative splicing" and chemical modifications to the proteins. This process can yield different protein products from the same gene.

 • Humans share most of the same protein families with worms, flies, and plants, but the number of gene family members has expanded in humans, especially in proteins involved in development and immunity.

 • The human genome has a much greater portion (50%) of repeat sequences than the mustard weed (11%), the worm (7%), and the fly (3%).

 • Although humans appear to have stopped accumulating repeated DNA over 50 million years ago, there seems to be no such decline in rodents. This may account for some of the fundamental differences between hominids and rodents, although gene estimates are similar in these species. Scientists have proposed many theories to explain evolutionary contrasts between humans and other organisms, including those of life span, litter sizes, inbreeding, and genetic drift.

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 43: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

What does the draft human genome sequence tell us?

Variations and Mutations

• Scientists have identified about 1.4 million locations where single-base DNA differences (SNPs) occur in humans. This information promises to revolutionize the processes of finding chromosomal locations for disease-associated sequences and tracing human history. • The ratio of germline (sperm or egg cell) mutations is 2:1 in males vs females. Researchers point to several reasons for the higher mutation rate in the male germline, including the greater number of cell divisions required for sperm formation than for eggs.

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 44: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

•Gene number, exact locations, and functions • Gene regulation • DNA sequence organization• Chromosomal structure and organization • Noncoding DNA types, amount, distribution, information content, and functions • Coordination of gene expression, protein synthesis, and post-translational events • Interaction of proteins in complex molecular machines• Predicted vs experimentally determined gene function• Evolutionary conservation among organisms• Protein conservation (structure and function)• Proteomes (total protein content and function) in organisms• Correlation of SNPs with health and disease• Disease-susceptibility prediction based on gene sequence variation• Genes involved in complex traits and multigene diseases• Developmental genetics, genomics

Future Challenges: What We Still Don’t Know

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 45: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Next Step in Genomics

• Transcriptomics involves large‑scale analysis of messenger RNAs (molecules that are transcribed from active genes) to follow when, where, and under what conditions genes are expressed. • Proteomics—the study of protein expression and function—can bring researchers closer than gene expression studies to what’s actually happening in the cell. • Structural genomics initiatives are being launched worldwide to generate the 3‑D structures of one or more proteins from each protein family, thus offering clues to function and biological targets for drug design. • Knockout studies are one experimental method for understanding the function of DNA sequences and the proteins they encode. Researchers inactivate genes in living organisms and monitor any changes that could reveal the function of specific genes. • Comparative genomics—analyzing DNA sequence patterns of humans and well‑studied model organisms side‑by‑side—has become one of the most powerful strategies for identifying human genes and interpreting their function.

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 46: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Medicine and the New Genomics

• Gene Testing

• Gene Therapy

• Pharmacogenomics

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

•improved diagnosis of disease •earlier detection of genetic predispositions to disease •rational drug design •gene therapy and control systems for drugs •personalized, custom drugs

Anticipated Benefits

Page 47: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

ELSI Issues

• Privacy and confidentiality of genetic information.

• Fairness in the use of genetic information by insurers, employers, courts, schools, adoption agencies, and the military, among others.

• Psychological impact, stigmatization, and discrimination due to an individual’s genetic differences.

• Reproductive issues including adequate and informed consent and use of genetic

information in reproductive decision making.

• Clinical issues including the education of doctors and other health-service providers, people identified with genetic conditions, and the general public about capabilities, limitations, and social risks; and implementation of standards and quality‑control measures.

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 48: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

ELSI Issues (cont.)

• Uncertainties associated with gene tests for susceptibilities and complex conditions (e.g., heart disease, diabetes, and Alzheimer’s disease).

• Fairness in access to advanced genomic technologies.

• Conceptual and philosophical implications regarding human responsibility, free will vs genetic determinism, and concepts of health and disease.

• Health and environmental issues concerning genetically modified (GM) foods and microbes.

• Commercialization of products including property rights (patents, copyrights, and trade secrets) and accessibility of data and materials.

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 49: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Anticipated Benefits

Molecular Medicine

• improved diagnosis of disease• earlier detection of genetic predispositions to disease• rational drug design• gene therapy and control systems for drugs• pharmacogenomics "custom drugs"

Microbial Genomics

• rapid detection and treatment of pathogens (disease-causing microbes) in medicine• new energy sources (biofuels)• environmental monitoring to detect pollutants• protection from biological and chemical warfare• safe, efficient toxic waste cleanup

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Page 50: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Risk Assessment

• assess health damage and risks caused by radiation exposure, including low-dose exposures• assess health damage and risks caused by exposure to mutagenic chemicals and cancer-causing toxins• reduce the likelihood of heritable mutations

Bioarchaeology, Anthropology, Evolution, and Human Migration

• study evolution through germline mutations in lineages• study migration of different population groups based on maternal inheritance• study mutations on the Y chromosome to trace lineage and migration of males• compare breakpoints in the evolution of mutations with ages of populations and historical events

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Anticipated Benefits

Page 51: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

DNA Identification (Forensics)

• identify potential suspects whose DNA may match evidence left at crime scenes• exonerate persons wrongly accused of crimes• identify crime and catastrophe victims• establish paternity and other family relationships• identify endangered and protected species as an aid to wildlife officials (could be used for prosecuting poachers)• detect bacteria and other organisms that may pollute air, water, soil, and food• match organ donors with recipients in transplant programs• determine pedigree for seed or livestock breeds• authenticate consumables such as caviar and wine

 

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Anticipated Benefits

Page 52: HUMAN GENOMICS Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Agriculture, Livestock Breeding, and Bioprocessing

• disease-, insect-, and drought-resistant crops• healthier, more productive, disease-resistant farm animals• more nutritious produce• biopesticides• edible vaccines incorporated into food products

• new environmental cleanup uses for plants like tobacco

Human Genome Program, U.S. Department of Energy, Genomics and Its Impact on Medicine and Society: A 2001 Primer, 2001

Anticipated Benefits