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Evolutionary medicine or Darwinian medicine is the application of modern evolutionary theory to understanding health and disease. The goal of evolutionary medicine is to understand why people get sick, not simply how they get sick. Modern medical research and practice has focused on the molecular and physiological mechanisms underlying health and disease, while evolutionary medicine focuses on the question of why evolution has shaped these mechanisms in ways that may leave us susceptible to disease. The evolutionary approach has driven important advances in our understanding of antibiotic resistance, cancer, autoimmune disease, and anatomy. Medical schools have been slower to integrate evolutionary approaches because of limitations on what can be added to existing medical curricula.
Key concepts 
- Trade-offs: changes that could make an organism less vulnerable to disease can lead to a decrease in fitness due to effects on other traits.
- Pathogens evolve rapidly and respond quickly to human intervention.
- Some symptoms are useful defenses.
- Because cultural and demographic changes are more rapid than biological evolution, humans are often mismatched to modern environments.
- Human phylogenetic history leaves a legacy of biological constraint.
- Cancer is the result of somatic evolution.
- Humans have not stopped evolving.
- All phenotypes are products of gene-environment interaction and are often shaped by developmental calibration.
Important researchers in evolutionary medicine include: Randolph M. Nesse, George C. Williams, Paul W. Ewald, Stephen C. Stearns, Carlo Maley, Andrew Read, Peter Ellison, Peter Gluckman, James McKenna, Paul W. Turke and Rainer H. Straub.
A trade-off is a situation that involves losing one quality or aspect of something in return for gaining another quality or aspect. Trade-offs are pervasive in human physiology. The evolutionary perspective on trade-offs starts with the notion that changes in physiology that could reduce disease susceptibility might also lead to a decrease in fitness due to effects on other traits. This can be due limited resources or simply to constraints on physiological capacities.
For instance, take the radial bone; the bone's shape and density has been shaped by natural selection for an optimal balance between strength, function, and cost of development and maintenance. It is relatively common for humans to break their distal radius from a fall. It is called a Colles' fracture. Evolutionary medicine helps us understand why people do not have a thicker bone that would be more resistant to this type of fracture. Humans' remarkable dexterity appears to come at a cost of increased risk of this type of fracture.
As another example, the capacity to repair and regenerate enables humans to respond to damage, but leave them susceptible to developing cancer. Inflammation is critical for response to injury. Chronic inflammation arises in settings of repeated damage. Chronic inflammation of the liver, also known as chronic hepatitis, is a major risk factor for hepatocellular carcinoma.
The adaptive evolution of bacteria, viruses, other microbes and parasites plays a central role in medicine since this process is needed to understand issues such as antibiotic resistance, pathogen virulence. and pathogen subversion of the immune system.
Antibiotic resistance 
Microorganisms evolve resistance through natural selection acting upon random mutation. Once a gene conferring resistance arises to counteract an antibiotic, not only can that bacteria thrive, but it can spread that gene to other types of bacteria through horizontal gene transfer of genetic information by plasmid exchange.
For more details on this topic, see antibiotic resistance
The effect of organisms upon their host can vary from being symbiotic commensals that are beneficial, to pathogens that reduce fitness. Many pathogens produce virulence factors that directly cause disease, or manipulate their host to allow them to thrive and spread. Since a pathogen’s fitness is determined by its success in transmitting offspring to other hosts, it was thought at one time, that virulence moderated and it evolved toward commensality. However, this view is now questioned by Ewald.
Immune evasion 
The success of any pathogen depends upon its ability to evade host immunity. Therefore, pathogens evolve methods that enable them to infect a host, and then evade detection and destruction by its immune system. These include hiding within host cells, within a protective capsule (as with M. tuberculosis), secreting compounds that misdirect the host's immune response, binding its antibodies, rapidly changing surface markers, or masking them with the host’s own molecules.
Human adaptations 
Adaptation works within constraints, makes compromises and tradeoffs, and occurs in the context of different forms of competition.
Adaptations can only occur if they are evolvable. Some adaptations which would prevent ill health are therefore not possible.
- DNA cannot be totally prevented from undergoing somatic replication corruption; this means that cancer, which is caused by somatic mutations, can never be completely eliminated by natural selection.
- Humans cannot biosynthesize Vitamin C, and so risk scurvy, Vitamin C deficiency disease, if dietary intake of the vitamin is insufficient.
- Retinal neurons and their axon output have evolved to be inside the layer of retinal pigment cells. This creates a constraint on the evolution of the visual system such that the optic nerve is forced to exit the retina through a point called the optic disc. This in turn creates a blind spot. More importantly, it makes vision vulnerable to increased pressure within the eye (glaucoma) since this cups and damages the optic nerve at this point, resulting in impaired vision.
Other constraints occur as the byproduct of adaptive innovations.
Trade-offs and conflicts 
One constraint upon selection is that different adaptations can conflict, which requires a compromise between them to ensure an optimal cost-benefit tradeoff.
- Running efficiency in women, and birth canal size
- Encephalization, and gut size 
- Skin pigmentation protection from UV, and the skin synthesis of Vitamin D
- Speech and its use of a descended larynx, and increased risk of choking
Competition effects 
Different forms of competition exist and these can shape the processes of genetic change.
- genomic conflict between mother and fetus that results in pre-eclampsia
- Major histocompatibility complex mate choice
- Maternal-paternal genetic competition that by altering genetic imprinting might underlie autism and schizophrenia
Evolved defense mechanisms 
- Sickness behavior (lethargy, depression, anorexia, sleepiness, reduction in grooming, and failure to concentrate)
- Expulsions: sneezing, vomiting, coughing, diarrhea
Evolved defense mechanisms can be costly, due to increased energy use (fever increases BMR by 10-15% for each degree rise in body temperature), and due to the risk of damaging the body (vomiting can risk aspiration). A fitness advantage therefore exists in deploying defense mechanisms selectively only when the potential benefits outweigh such costs. Their deployment is controlled at several levels, including through biomolecular pathways using factors such as proinflammatory cytokines, and through higher neural top down processes in cerebral cortex areas such as the insular cortex. Neural control provides advantages in that deployment can be based on tradeoffs between costs and benefits that take into account relevant health circumstances. This evolved regulation functions as a health management system.
“Diseases of civilization” 
Humans evolved to live as simple hunter-gatherers in small tribal bands, a very different way of life and environment than that faced by contemporary humans. This change makes present humans vulnerable to a number of health problems, termed “diseases of civilization” and “diseases of affluence”.
In contrast to the diet of early hunter-gatherers, the modern one contains high quantities of fat, salt, and simple carbohydrates, which include refined sugars and flours. These create health problems.
- Trans fat health risks
- Dental caries
- High GI foods
- Modern diet based on "common wisdom" regarding diets in the paleolithic era
Life expectancy 
Contemporary humans engage in little physical exercise compared to the physically active lifestyle engaged in by ancestral hunter-gatherers. It has been proposed that since prolonged periods of inactivity would have only occurred in early humans following illness or injury that it provides a cue for the body to engage in life-preserving metabolic and stress related responses such as inflammation that are now the cause of many chronic diseases.
Contemporary humans - due to medical treatment, frequent washing of clothing and the body, and improved sanitation - are mostly free of parasites, particularly intestinal ones. This causes problems in the proper development of the immune system.
Specific explanations 
This is a partial list: all links here go to a section describing or debating its evolutionary origin.
- Arthritis and other chronic inflammatory diseases
- Cystic fibrosis
- Dental occlusion
- Diabetes Type II
- Essential hypertension
- Iron deficiency (paradoxical benefits)
- Red blood cell polymorphism disorders
- Sickle cell anemia
- Sickness behavior
- Women’s reproductive cancers
Evolutionary psychiatry / Clinical evolutionary psychology 
As noted in the table below, adaptationist hypotheses regarding the etiology of psychological disorders are often based on analogies with evolutionary perspectives on medicine and physiological dysfunctions (see in particular, Randy Nesse and George C. Williams' book Why We Get Sick). Evolutionary psychiatrists and psychologists suggest that some mental disorders likely have multiple causes.
|Possible Causes of Psychological 'Abnormalities' from an Adaptationist Perspective
|Possible cause||Physiological Dysfunction||Psychological Dysfunction|
|Functioning adaptation (adaptive defense)||Fever / Vomiting
(functional responses to infection or ingestion of toxins)
|Mild depression or anxiety
(functional responses to mild loss or stress)
|By-product of an adaptation(s)||Intestinal gas
(byproduct of digestion of fiber)
|Sexual fetishes (?)
(possible byproduct of normal sexual arousal adaptations that have 'imprinted' on unusual objects or situations)
|Adaptations with multiple effects||Gene for malaria resistance, in homozygous form, causes sickle cell anemia||Adaptation(s) for high levels of creativity may also predispose schizophrenia or bi-polar disorder
(adaptations with both positive and negative effects, perhaps dependent on alternate developmental trajectories)
(over-reactive immunological responses)
(possible malfunctioning of theory of mind module)
|Frequency-dependent morphs||The two sexes / Different blood and immune system types||Personality traits and personality disorders
(may represent alternative behavioral strategies dependent on the frequency of the strategy in the population)
|Mismatch between ancestral & current environments||Modern diet-related Type 2 Diabetes||More frequent modern interaction with strangers (compared to family and close friends) may predispose greater incidence of depression & anxiety|
|Tails of normal (bell shaped) curve||Very short or tall height||Tails of the distribution of personality traits (e.g., extremely introverted or extroverted)|
See several topic areas, and the associated references, below.
Charles Darwin did not discuss the implications of his work for medicine, though biologists quickly appreciated in the germ theory of disease its implications for understanding the evolution of pathogens, and an organism’s need to defend against them.
medicine has modelled itself after a mechanical physics, deriving from Galileo, Newton, and Descartes.... As a result of assuming this model, medicine is mechanistic, materialistic, reductionistic, linear-causal, and deterministic (capable of precise predictions) in its concepts. It seeks explanations for diseases, or their symptoms, signs, and cause in single, materialistic— i.e., anatomical or structural (e.g., in genes and their products)— changes within the body, wrought directly (linearly), for example, by infectious, toxic, or traumatic agents. p. 510
George C. Williams was the first to apply evolutionary theory to health in the context of senescence. Also in the 1950s, John Bowlby approached the problem of disturbed child development from an evolutionary perspective upon attachment.
Randolph Nesse summarizes its relevance to medicine:
all biological traits need two kinds of explanation, both proximate and evolutionary. The proximate explanation for a disease describes what is wrong in the bodily mechanism of individuals affected by it. An evolutionary explanation is completely different. Instead of explaining why people are different, it explains why we are all the same in ways that leave us vulnerable to disease. Why do we all have wisdom teeth, an appendix, and cells that can divide out of control?
The paper of Paul Ewald in 1980, “Evolutionary Biology and the Treatment of Signs and Symptoms of Infectious Disease”, and that of Williams and Nesse in 1991, “The Dawn of Darwinian Medicine” were key developments. The latter paper “draw a favorable reception”,page x and led to a book, Why We Get Sick (published as Evolution and healing in the UK). In 2008, an online journal started: Evolution and Medicine Review.
Current activity in the field 
Evolutionary medicine as a field began in the early 1990s, but has grown dramatically in recent years. These developments include the creation of the online publication The Evolution & Medicine Review which has served as a clearinghouse for important information in the field, two peer-reviewed journals (Evolution, Medicine and Public Health and Journal of Evolutionary Medicine), the founding of two evolution and cancer centers (The Center for Evolution and Cancer at UCSF and The Darwinian Evolution of Cancer Consortium in Montpellier) and The Center for Infectious Disease Dynamics at Penn State. There is now a national working group on evolutionary medicine education at the NSF sponsored National Evolutionary Synthesis Center, Infusing Medical Education with Evolutionary Thinking. Evolutionary Medicine programs have been established at a growing number of Universities, including UCLA, Arizona State University and Durham University in the UK.
See also 
- Evolutionary physiology
- Evolutionary psychology
- Evolutionary developmental psychopathology
- Evolutionary approaches to depression
- Paleolithic lifestyle
- Universal Darwinism
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- Weiner H (1 July 1998). "Notes on an evolutionary medicine". Psychosom Med 60 (4): 510–20. PMID 9710299.
- Tinbergen N (1963). "On Aims and Methods in Ethology" (PDF). Zeitschrift für Tierpsychologie 20 (4): 410–433. doi:10.1111/j.1439-0310.1963.tb01161.x.
- Nesse RM (December 2008). "Evolution: medicine's most basic science". Lancet 372 (Suppl 1): S21–7. doi:10.1016/S0140-6736(08)61877-2.
- Ewald PW (September 1980). "Evolutionary biology and the treatment of signs and symptoms of infectious disease". J. Theor. Biol. 86 (1): 169–76. doi:10.1016/0022-5193(80)90073-9. PMID 7464170.
- Williams GC, Nesse RM (March 1991). "The dawn of Darwinian medicine". Q Rev Biol 66 (1): 1–22. doi:10.1086/417048. PMID 2052670.
Further reading 
- Williams, George; Nesse, Randolph M. (1996). Why We Get Sick: the new science of Darwinian medicine. New York: Vintage Books. ISBN 0-679-74674-9 [Amazon-US | Amazon-UK].
- Stearns SC, Koella JK (2008). Evolution in health and disease (2nd ed.). Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-920745-3 [Amazon-US | Amazon-UK].
- McKenna, James J.; Trevathan, Wenda; Smith, Euclid O. (2008). Evolutionary medicine and health: new perspectives (2nd ed.). Oxford [Oxfordshire]: Oxford University Press. ISBN 0-19-530706-2 [Amazon-US | Amazon-UK].
- O'Higgins, Paul; Sarah Elton (2008). Medicine and Evolution: Current Applications, Future Prospects (Society for the Study of Human Biology Symposium Series (Sshb). Boca Raton: CRC. ISBN 1-4200-5134-2 [Amazon-US | Amazon-UK].
- Ewald, P. W. (1996). Evolution of Infectious Disease. Oxford: Oxford University Press. ISBN 0-19-511139-7 [Amazon-US | Amazon-UK].
- Moalem, S.; Prince, J. (2007). Survival of the Sickest. New York: HarperLuxe. ISBN 978-0-06-088965-4 [Amazon-US | Amazon-UK].
- Online articles
- Straub, RH.; Besedovsky, HO. (2003). "Integrated evolutionary, immunological, and neuroendocrine framework for the pathogenesis of chronic disabling inflammatory diseases". FASEB J 17 (15): 2176–2183. doi:10.1096/fj.03-0433hyp. PMID 14656978.
- LeGrand, E. K.; Brown C. C. (1 July 2002). "Darwinian medicine: Applications of evolutionary biology for veterinarians". Canadian Veterinary Journal 43 (7): 556–9. ISSN 0008-5286. PMC 341948. PMID 12125190.
- Randolph M. Nesse, Stephen C. Stearns (2008). "The great opportunity: Evolutionary applications to medicine and public health" (PDF). Evolutionary Applications 1 (1): 28–48. doi:10.1111/j.1752-4571.2007.00006.x.
- Naugler, Christopher T. (1 September 2008). "Evolutionary medicine: Update on the relevance to family practice". Canadian Family Physician 54 (9): 1265–9. PMC 2553465. PMID 18791103.
- Childs, B.; Wiener, C.; Valle, D. (2005). "A science of the individual: Implications for a medical school curriculum". Annual Review of Genomics and Human Genetics 6 (1): 313–330. doi:10.1146/annurev.genom.6.080604.162345. PMID 16124864.
- Stiehm ER (2006). "Disease versus disease: how one disease may ameliorate another". Pediatrics 117 (1): 184–91. doi:10.1542/peds.2004-2773. PMID 16396876.