Developing a Curriculum for Evolutionary Medicine: Case Studies of Scurvy and Female Reproductive Tract Cancers

Most early evolutionary thinkers came from medicine, yet evolution has had a checkered history in medical education. It is only in the last few decades that serious efforts have begun to be made to integrate evolutionary biology into the medical curriculum. However, it is not clear when, where (independently or as part of preclinical or clinical teaching courses) and, most importantly, how should medical students learn the basic principles of evolutionary biology applied to medicine, known today as evolutionary or Darwinian medicine. Most clinicians are ill-prepared to teach evolutionary biology and most evolutionary biologists ill-equipped to formulate clinical examples. Yet, if evolutionary science is to have impact on clinical thought, then teaching material that embeds evolution within the clinical framework must be developed. In this paper, we use two clinical case studies to demonstrate how such may be used to teach evolutionary medicine to medical students in a way that is approachable as well as informative and relevant.     

Evolution and medicine in undergraduate education: a prescription for all biology students

The interface between evolutionary biology and the biomedical sciences promises to advance understanding of the origins of genetic and infectious diseases in humans, potentially leading to improved medical diagnostics, therapies, and public health practices. The biomedical sciences also provide unparalleled examples for evolutionary biologists to explore. However, gaps persist between evolution and medicine, for historical reasons and because they are often perceived as having disparate goals. Evolutionary biologists have a role in building a bridge between the disciplines by presenting evolutionary biology in the context of human health and medical practice to undergraduates, including premedical and preprofessional students. We suggest that students will find medical examples of evolution engaging. By making the connections between evolution and medicine clear at the undergraduate level, the stage is set for future health providers and biomedical scientists to work productively in this synthetic area. Here, we frame key evolutionary concepts in terms of human health, so that biomedical examples may be more easily incorporated into evolution courses or more specialized courses on evolutionary medicine. Our goal is to aid in building the scientific foundation in evolutionary biology for all students, and to encourage evolutionary biologists to join in the integration of evolution and medicine.     

The gut microbiota links disease to human genome evolution

A large number of studies have established a causal relationship between the gut microbiota and human disease. In addition, the composition of the microbiota is substantially influenced by the human genome. Modern medical research has confirmed that the pathogenesis of various diseases is closely related to evolutionary events in the human genome. Specific regions of the human genome known as human accelerated regions (HARs) have evolved rapidly over several million years since humans diverged from a common ancestor with chimpanzees, and HARs have been found to be involved in some human-specific diseases. Furthermore, the HAR-regulated gut microbiota has undergone rapid changes during human evolution. We propose that the gut microbiota may serve as an important mediator linking diseases to human genome evolution.     

Evolution in health and disease: work in progress.

This article surveys progress in Darwinian medicine since 1991. Evolutionary thinking has been providing an increasing flow of fresh ideas into medical science, ideas that would not be suggested by other perspectives. Recent contributions have shed new light on the evolution of virulence, of antibiotic resistance, of oocytic atresia, of menopause, of the timing of the expression of genetic disease, of links between mate choice and disease resistance, and of genomic conflict between mother and fetus over resource provisioning. An important consequence of changes from the environment of evolutionary adaptedness concerns reproductive cancers; the incidence of reproductive cancers may be linked to changes in the frequency of menstruation in postindustrial societies. Other intriguing developments include some unanticipated and undesirable consequences of good hygiene, hope from an unexpected quarter for progress on nerve and muscle regeneration, evolutionary interpretations of mental disease, and insights from functional genomics into the nature of tradeoffs. The application of evolutionary thinking to problems in medical research and practice has thus yielded an abundant and growing harvest of insights. Some are well founded, others remain speculative. The field is moving from an initial phase dominated by speculation and hypothesis formation into a more rigorous phase of experimental testing of explicit alternatives. Currently the most promising areas, those in which experimental rigor can be applied efficiently, include experimental evolution and functional genomics. The pioneers can be proud of what they have set in motion.     

An Alternative Approach: Teaching Evolution in a Natural History Museum Through the Topic of Vector-Borne Disease

Museums play a vitally important role in supporting both informal and formal education and are important venues for fostering public understanding of evolution. The Yale Peabody Museum has implemented significant education programs on evolution for many decades, mostly focused on the museum’s extensive collections that represent the past and present tree of life. Twelve years ago, the Peabody began a series of new programs that explored biodiversity and evolution as it relates to human health. Modern evolutionary theory contributes significantly to our understanding of health and disease, and medical topics provide many excellent and relevant examples to explore evolutionary concepts. The Peabody developed a program on vector-borne diseases, specifically Lyme disease and West Nile virus, which have become endemic in the United States. Both of these diseases have complex transmission cycles involving an intricate interplay among the pathogen, host, and vector, each of which is subject to differing evolutionary pressures. Using these stories, the museum explored evolutionary concepts of adaptation (e.g., the evolution of blood feeding), coevolution (e.g., the “arms race” between host and vector), and variation and selection (e.g., antibiotic resistance) among others. The project included a temporary exhibition and the development of curriculum materials for middle and high school teachers and students. The popularity of the exhibit and some formal evaluation of student participants suggested that this educational approach has significant potential to engage wide audiences in evolutionary issues. In addition it demonstrated how natural history museums can incorporate evolution into a broad array of programs.     

The dawn of Darwinian medicine

While evolution by natural selection has long been a foundation for biomedical science, it has recently gained new power to explain many aspects of disease. This progress results largely from the disciplined application of what has been called the adaptations program. We show that this increasingly significant research paradigm can predict otherwise unsuspected facets of human biology, and that it provides new insights into the causes of medical disorders, such as those discussed below: 1. Infection. Signs and symptoms of the host-parasite contest can be categorized according to whether they represent adaptations or costs for host or parasite. Some host adaptations may have contributed to fitness in the Stone Age but are obsolete today. Others, such as fever and iron sequestration, have been incorrectly considered harmful. Pathogens, with their large populations and many generations in a single host, can evolve very rapidly. Acquisition of resistance to antibiotics is one example. Another is the recently demonstrated tendency to change virulence levels in predictable ways in response to changed conditions imposed incidentally by human activities. 2. Injuries and toxins. Mechanical injuries or stressful wear and tear are conceptually simpler than infectious diseases because they are not contests between conflicting interests. Plant-herbivore contests may often underlie chemical injury from the defensive secondary compounds of plant tissues. Nausea in pregnancy, and allergy, may be adaptations against such toxins. 3. Genetic factors. Common genetic diseases often result from genes maintained by other beneficial effects in historically normal environments. The diseases of aging are especially likely to be associated with early benefits. 4. Abnormal environments. Human biology is designed for Stone Age conditions. Modern environments may cause many diseases-for example, deficiency syndromes such as scurvy and rickets, the effects of excess consumption of normally scarce nutrients such as fat and salt, developmental diseases such as myopia, and psychological reactions to novel environments. The substantial benefits of evolutionary studies of disease will be realized only if they become central to medical curricula, an advance that may at first require the establishment of one or more research centers dedicated to the further development of Darwinian medicine.     

Evolutionary Medicine: A Key to Introducing Evolution

Science teachers can use examples and concepts from evolutionary medicine to teach the three concepts central to evolution: common descent, the processes or mechanisms of evolution, and the patterns produced by descent with modification. To integrate medicine into common ancestry, consider how the evolutionary past of our (or any) species affects disease susceptibility. That humans are bipedal has produced substantial changes in our musculoskeletal system, as well as causing problems for childbirth. Mechanisms such as natural selection are well exemplified in evolutionary medicine, as both disease-causing organism and their targets adapt to one another. Teachers often use examples such as antibiotic resistance to teach natural selection: it takes little alteration of the lesson plan to make explicit that evolution is key to understanding the principles involved. Finally, the pattern of evolution can be illustrated through evolutionary medicine because organisms sharing closer ancestry also share greater susceptibility to the same disease-causing organisms. Teaching evolution using examples from evolutionary medicine can make evolution more interesting and relevant to students, and quite probably, more acceptable as a valid science.     

Rickettsial disease: classical and modern aspects

Rickettsial diseases have been reassessed in recent years since they represent an important field in today's medicine. New agents have been described: some are non-pathogenic agents and the others are associated with well-defined or peculiar clinical patterns. In addition, different species of rickettsiosis are found in relation to the geographic areas of the world. Some agents may be defined as variants of older diseases whereas most of the newly described forms of rickettsiosis represent distinct entities with unique epidemiologial and clinical features. Probably the main news regards the group of the spotted fevers. An additional new aspect is linked to the medicine of travellers and tourists. However, this aspect may not be significant for the rickettsial diseases in relation to other human illnesses, such as malaria. Therefore, an investigation into the geographical origin of patients has to enter our routine medical work.     

Adaptations: Using Darwin's Origin to teach biology and writing

Charles Darwin's On the Origin of Species is at once familiar and unfamiliar. Everyone knows that the Origin introduced the world to the idea of evolution by natural selection, but few of us have actually read it. We suggest that it is worth taking the time not only to read what Darwin had to say, but also to use the Origin to teach both biology and writing. It provides scientific lessons in areas beyond evolutionary biology, such as ecology and biogeography. In addition, it provides valuable rhetorical lessons—how to construct an argument, write persuasively, make use of evidence, know your audience, and anticipate counterarguments. We have been using the Origin in various classes for several years, introducing new generations to Darwin, in his own words.     

Evolutionary physiology at 30+: Has the promise been fulfilled?

Three decades ago, interactions between evolutionary biology and physiology gave rise to evolutionary physiology. This caused comparative physiologists to improve their research methods by incorporating evolutionary thinking. Simultaneously, evolutionary biologists began focusing more on physiological mechanisms that may help to explain constraints on and trade-offs during microevolutionary processes, as well as macroevolutionary patterns in physiological diversity. Here we argue that evolutionary physiology has yet to reach its full potential, and propose new avenues that may lead to unexpected advances. Viewing physiological adaptations in wild animals as potential solutions to human diseases offers enormous possibilities for biomedicine. New evidence of epigenetic modifications as mechanisms of phenotypic plasticity that regulate physiological traits may also arise in coming years, which may also represent an overlooked enhancer of adaptation via natural selection to explain physiological evolution. Synergistic interactions at these intersections and other areas will lead to a novel understanding of organismal biology.     

Evolutionary origins of the eastern North American–Mesoamerican floristic disjunction: Current status and future prospects

Biogeographic disjunction patterns, where multiple taxa are shared between isolated geographic areas, represent excellent systems for investigating the historical assembly of modern biotas and fundamental biological processes such as speciation, diversification, niche evolution, and evolutionary responses to climate change. Studies on plant genera disjunct across the northern hemisphere, particularly between eastern North America (ENA) and eastern Asia (EAS), have yielded tremendous insight on the geologic history and assembly of rich temperate floras. However, one of the most prevalent disjunction patterns involving ENA forests has been largely overlooked: that of taxa disjunct between ENA and cloud forests of Mesoamerica (MAM), with examples including Acer saccharum, Liquidambar styraciflua, Cercis canadensis, Fagus grandifolia, and Epifagus virginiana. Despite the remarkable nature of this disjunction pattern, which has been recognized for over 75 years, there have been few recent efforts to empirically examine its evolutionary and ecological origins. Here I synthesize previous systematic, paleobotanical, phylogenetic, and phylogeographic studies to establish what is known about this disjunction pattern to provide a roadmap for future research. I argue that this disjunction pattern, and the evolution and fossil record of the Mexican flora more broadly, represents a key missing piece in the broader puzzle of northern hemisphere biogeography. I also suggest that the ENA–MAM disjunction represents an excellent system for examining fundamental questions about how traits and life history strategies mediate plant evolutionary responses to climate change and for predicting how broadleaf temperate forests will respond to the ongoing climatic pressures of the Anthropocene.     

Kin selection is the key to altruism

Kin selection theory, also known as inclusive fitness theory, has been the subject of much debate and misunderstanding. Nevertheless, the idea that relatedness among individuals can drive the evolution of altruism has emerged as a central paradigm in evolutionary biology. Or has it? In two recent articles, E.O. Wilson argues that kin selection should no longer be considered the main explanation for the evolution of altruism in insect societies. Here, we discuss what these articles say about kin selection and how it relates to the theory. We conclude that kin selection remains the key explanation for the evolution of altruism in eusocial insects.     

A Clinical Perspective in Evolutionary Medicine: What We Wish We Had Learned in Medical School

Medical students have much to gain by understanding how evolutionary principles affect human health and disease. Many theoretical and experimental studies have applied lessons from evolutionary biology to issues of critical importance to medical science. A firm grasp of evolution and natural selection is required to understand why the human body remains vulnerable to many diseases. Although we often integrate evolutionary concepts when we teach medical students and residents, the vast majority of medical students never receive any instruction on evolution. As a result, many trainees lack the tools to understand key advances and miss valuable opportunities for education and research. Here, we outline some of the evolutionary principles that we wished we had learned during our medical training.     

Alternative splicing and RNA selection pressure--evolutionary consequences for eukaryotic genomes

Genome-wide analyses of alternative splicing have established its nearly ubiquitous role in gene regulation in many organisms. Genome sequencing and comparative genomics have made it possible to look in detail at the evolutionary history of specific alternative exons or splice sites, resulting in a flurry of publications in recent years. Here, we consider how alternative splicing has contributed to the evolution of modern genomes, and discuss constraints on evolution associated with alternative splicing that might have important medical implications.     

Why are proteins so robust to site mutations?

There have been repeated observations that proteins are surprisingly robust to site mutations, enduring significant numbers of substitutions with little change in structure, stability, or function. These results are almost paradoxical in light of what is known about random heteropolymers and the sensitivity of their properties to seemingly trivial mutations. To address this discrepancy, the preservation of biological protein properties in the presence of mutation has been interpreted as indicating the independence of selective pressure on such properties. Such results also lead to the prediction that de novo protein design should be relatively easy, in contrast to what is observed. Here, we use a computational model with lattice proteins to demonstrate how this robustness can result from population dynamics during the evolutionary process. As a result, sequence plasticity may be a characteristic of evolutionarily derived proteins and not necessarily a property of designed proteins. This suggests that this robustness must be re-interpreted in evolutionary terms, and has consequences for our understanding of both in vivo and in vitro protein evolution.     

The origin and evolution of the neural crest

Many of the features that distinguish the vertebrates from other chordates are derived from the neural crest, and it has long been argued that the emergence of this multipotent embryonic population was a key innovation underpinning vertebrate evolution. More recently, however, a number of studies have suggested that the evolution of the neural crest was less sudden than previously believed. This has exposed the fact that neural crest, as evidenced by its repertoire of derivative cell types, has evolved through vertebrate evolution. In this light, attempts to derive a typological definition of neural crest, in terms of molecular signatures or networks, are unfounded. We propose a less restrictive, embryological definition of this cell type that facilitates, rather than precludes, investigating the evolution of neural crest. While the evolutionary origin of neural crest has attracted much attention, its subsequent evolution has received almost no attention and yet it is more readily open to experimental investigation and has greater relevance to understanding vertebrate evolution. Finally, we provide a brief outline of how the evolutionary emergence of neural crest potentiality may have proceeded, and how it may be investigated.     

Awareness and Acceptance of Evolution and Evolutionary Medicine Among Medical Students in Pakistan

Evolutionary medicine is a perspective on medical sciences derived through application of theory of evolution to aid in therapeutics. This study sought to determine the level of knowledge and acceptance of evolutionary theory in medical students along with their attitude toward teaching evolutionary medicine as a part of their undergraduate course. Factors that are likely to cause difficulty in teaching evolutionary medicine were also identified. A cross-sectional study was carried out at Army Medical College, National University of Sciences and Technology, Pakistan in which 299 medical students were selected by nonprobability convenient sampling technique to participate in the study. Participants’ views were obtained by a structured questionnaire comprised of three sections: appreciation of evolutionary medicine, acceptance of evolutionary theory, knowledge of evolutionary theory. Medical students had a low acceptance [mean measure of acceptance of theory of evolution (MATE) = 58.32] and a low knowledge (mean score of 5.20 out of a total ten marks). Students believed that religious beliefs, lack of resources, and an existent extensive medical curriculum would cause difficulty in imparting such an education despite its potential to improve medical research and clinical practice. Only 37.2% agreed that the subject should be taught in medical schools as an individual subject.     

Evolution of genetic diversity and human diseases

The problem of development and dispersion of complex diseases in human populations requires new views, approaches, hypotheses, and paradigms. Evolutionary medicine provides one of the promising approaches to this problem, putting the disease into an evolutionary context. Unlike classic approaches oriented to proximate issues on structure and mechanisms of a disease, evolutionary considerations are broader. It provides the basis for understanding the origin, dispersion, and maintenance of the high frequencies of pathological phenotypes in modern human populations. In the current paper, we try to review the modern concepts on the evolution of human genetic diversity, to shape the outlines of evolutionary medicine, and to illustrate evolutionary medical problems using our experimental data. Data on genome-wide search for the signals of decanalization and adaptation in the human genome and on related biological processes and diseases are presented. Some hypotheses and concepts of evolutionary medicine may be productive for revealing the mechanisms of origin and dispersion of complex diseases and for pathogenetics of multifactorial diseases. One of such concepts is the hypothesis of decanalization of genome–phenome relationships under natural selection during modern human dispersion. Probably, the high frequency of alleles associated with complex diseases (and partially the high prevalence of diseases themselves) could be explained in the framework of the hypothesis.