untitled The Finnish disease heritage REIJO NORIO AND MARKKU LÖYTÖNEN Norio, Reijo & Markku Löytönen (2002). The Finnish disease heritage. Fennia 180: 1–2, pp. 177–182. Helsinki. ISSN 0015-0010. The Finnish disease heritage (FDH) is the concept for nearly forty rare heredi- tary diseases which are overrepresented in Finland compared to the size of the population. They are rare diseases in Finland as well, because their inci- dence varies from 1: 10,000 to 1: 100,000. Thus, in a population of about 5 million inhabitants and 60,000 newborns per year, the annual number of new patients in one disease is perhaps ten, perhaps not even one. Excluded from the FDH are rare hereditary diseases that are as frequent in Finland as else- where and those common diseases in which genes act as predisposing factors in addition to environmental factors. This article provides an overview of the FDH and examines the connections between hereditary diseases and popula- tion history as well as geographic circumstances in Finland. Reijo Norio, The Family Federation of Finland, P. O. Box 849, FIN-00101 Hel- sinki, Finland. Markku Löytönen, Department of Geography, P. O. Box 64, FIN-00014 Uni- versity of Helsinki, Finland. E-mail: markku.loytonen@helsinki.fi Characteristics of the Finnish disease heritage All branches of medicine are represented among the disorders of the Finnish disease heritage (FDH). Most diseases are severe, many even le- thal. Some of them can be treated successfully if correctly diagnosed. They may appear as mental retardation, visual handicap, hearing disorders, congenital anomalies, skeletal or metabolic dis- turbances, neurological or renal diseases, or as many other kinds of symptoms and signs. On the other hand, some diseases, such as cyst- ic fibrosis or phenylketonuria, that can be called common among rare disorders elsewhere, are ex- tremely rare or absent in Finland. The Finns can- not therefore be regarded as abnormally sick, but the assortment of their diseases is exceptional. Most of the Finnish diseases show autosomal recessive inheritance. In other words, the affect- ed individual must possess two disease genes, one from both unaffected parents who possess only one gene for the disease. The close relatives of the patients are usually healthy, because both par- ents in several couples of the kindred very rarely have the same rare gene. On the other hand, all individuals in all populations carry some rare sin- gle recessive genes. Fortunately, they seldom are the same genes as their spouses have. However, this situation may be more probable than in gen- eral if the parents are consanguineous, i.e., they share genes derived from a common ancestor. The vast majority of all recessive disease genes in the population belong to healthy carriers of a single gene, the heterozygotes. The proportion of disease genes transmitted forward through the ho- mozygous patients and their near relatives is min- imal. That is why all preventive measures direct- ed towards such individuals would be doomed to fail. The background of the Finnish disease heritage Two presuppositions are needed for the fact that one population has its own assortment of rare re- cessive diseases and an overrepresentation of those diseases. Firstly, the genes for those disor- ders must exist in this population. Yet bare genes cannot produce diseases. Affected individuals will not be born until two similar genes meet each oth- er, first in the parents of one family and then in their child. Secondly, an overrepresentation of 178 FENNIA 180: 1–2 (2002)Reijo Norio and Markku Löytönen rare recessive diseases in a population presuppos- es the existence of some factor that easily brings two carriers of the same rare gene into the same union. In Finland, the above-defined two presupposi- tions materialize as the national and regional iso- lation of the Finnish population. The national iso- lation is due to Finland’s geopolitical status. Fin- land is a small country near the northern edge of the inhabited world and between two different linguistic and cultural entities, Sweden and Rus- sia. The small group of ancestors of the contem- porary Finns has not brought to Finland all possi- ble disease genes but a random assortment of genes. This assortment has remained quite un- changed at least during the historical era. Great migrations of peoples have not taken place in the north of Europe, contrary to the situation in cen- tral or southern Europe. The primary conditions for the regional isola- tion have been Finland’s large area and sparse population as well as the character of the terrain: vast forests and almost 190,000 lakes (Raatikai- nen & Kuusisto 1990). The most important factor is a strong wave of internal migration in the 1500s, supported and even pushed by the Swed- ish Crown. At that time, many individual families from the southern Savo region in the southeast moved to central, eastern and northern parts of today’s Finland. This changed the way of living in these areas from hunting and fishing to stationary agricultural settlement. The settlers brought their genes from the area of early settlement (Fig. 1) to their new domiciles. Because of the limited need for continuous migrations some of these genes have remained clustered through generations. It is therefore not unusual in this area of late settle- ment that both parents, related to each other be- yond six, ten, or twenty generations, happen to have the same disease gene and produce affect- ed children (Norio 1981, 2000, 2002). Genetic phenomena behind the FDH The genetic phenomena that have influenced the development of the Finnish disease heritage are the founder effect, genetic drift and bottleneck phenomenon. The founder effect means that when a new pop- ulation originates from few individuals only, this new population gets no more than a small ran- dom sample from the genes of the primary popu- lation. The genes of different subpopulations orig- inating from the same primary population thus differ greatly from each other. The genetic drift influences the genetic pools of small subpopulations by chance. The children and grandchildren of a settler do not inherit from him or her the disease gene or its normal coun- terpart in similar proportions. One disease gene may have better luck in Nature’s gamble than the chance one in two and may be transmitted to dis- proportionally many descendants of an individu- al settler. Another gene, correspondingly, may dis- appear more or less totally from the new popula- tion. This is how chance affects the genetic pool of a new population. Fig. 1. The boundary of the stationary settlement in the be- ginning of the 1500s divides today’s Finland into areas of early and late settlement (according to Jutikkala 1933). FENNIA 180: 1–2 (2002) 179The Finnish disease heritage The bottleneck phenomenon is a special case of the founder effect and the genetic drift. A large population may diminish into a small fraction due to a war or an epidemic. In the remaining part of the population that has passed through this bottle- neck, founder effect and genetic drift may act as in a freshly-formed small subpopulation. The bot- tlenecks may have been regional but sometimes more or less ‘national’, at least in the past times. Where have the disease genes come from? An- cient immigrants have probably brought some of them. Perhaps a greater part has originated from new gene mutations in individuals within the Finnish population. Both alternatives have been greatly dependent on chance, so they do not re- veal much about the roots of the Finns nor their genetic relationships to other populations (Norio 2000, 2002). The geography of Finnish diseases According to both the outlined pattern and em- pirical experience, the Finnish diseases are not evenly distributed in Finland. Investigations into these phenomena have created a geography of Finnish disorders. The birthplaces of the patients do not reveal any core areas of the disease genes because of the lively internal migration from the countryside to the cities after World War II. In- stead, the birthplaces of the grandparents indicate the origins of the disease genes. The vast majority of the grandparents have been born in the coun- tryside and nearly 80 percent of them in the de- scribed area of late settlement. In half of the fam- ilies, both parents have been born in the same lo- cality. In one-fourth of the families, all four grand- parents have been born in the same or neighbour- ing community (Norio 2000, 2002). The disease maps in this article show some dis- tributions of the disease genes (Fig. 2). Over one half of the maps of 30 investigated recessive dis- eases (Norio 2000, 2002) show a pattern inverse to the population density in Finland, whereas the disease genes are few in the densely and early populated southern and southwestern parts of the country. The majority of these disease genes are thus clustered in the area of late settlement since the 1500s. In this area, each map shows a distri- bution of its own. The distribution patterns of some diseases dif- fer from those described above. In six diseases, the genes are distributed almost everywhere in the country, although local clusters may appear in the area of late settlement. The genes of those diseas- es must be distinctly older than 500 years. Two diseases have maps congruent with Finland’s pop- ulation density. Strictly speaking, these diseases should perhaps not be called ‘Finnish’, because later on they have been found to be relatively fre- quent also in some other populations. These genes may descend from ‘Indo-European’ immigrants beyond several thousands of years. Two diseases, in turn, appear only in a very small area restrict- ed to one historical province. These two are prob- ably caused by a very recent gene mutation in an isolated subpopulation. Investigations into particular diseases How have the Finnish diseases become known, how have they been studied, and what are the benefits drawn from such investigations? The sto- ry of the first detected disease, the congenital ne- phrosis, may serve as an example (Jalanko et al. 2002). In the 1950s, at the University of Helsinki Children’s Hospital, several newborn babies were admitted with an often familial and always fatal renal disease manifesting with edema and pro- teinuria (Hallman et al. 1956). The information on this condition provided in international textbooks was nonexistent. As data of more than 30 patients were sampled, extensive studies on the disease’s clinical features and its Finnishness were started. Through Finnish church records, genealogical and genetic studies revealed recessive transmission of the disease, whereas several extrinsic factors could be excluded (Norio 1966). While the con- ventional treatment of nephrosis remained unsuc- cessful, renal transplantation – as soon as suffi- cient preoperative techniques were learnt – saved normal life and development for the patients (Holmberg et al. 1995). In the DNA-era of the 1990s, the gene of congenital nephrosis was first mapped to chromosome 19 (q13.1) and, subse- quently, its structure was characterized (Kestilä 1995; Lenkkeri 1998). This led to the detection of the protein nephrin, which is encoded by the gene in question and is defective in the patients’ kidneys. Nephrin, in turn, is probably a central component in the general filtration properties of the kidney and its faults may explain even many other mechanisms of renal diseases (Patrakka 2001). The detection and studies of ‘new’ Finnish dis- eases usually start from observations of alert cli- 180 FENNIA 180: 1–2 (2002)Reijo Norio and Markku Löytönen FENNIA 180: 1–2 (2002) 181The Finnish disease heritage nicians. The nationwide sampling of patients and centralization of the studies into few hands has warranted an effective accumulation of knowl- edge for the physicians and the best possible aid for the patients and their families in the entire country. These investigations also help physicians elsewhere may they confront patients suffering from a ‘Finnish’ disease. Studying the pathogene- sis of rare diseases also helps in understanding the normal mechanisms of the human body that are disturbed in genetic diseases. Due to excellent study conditions and some internationally acknowledged research groups, the DNA structure of the majority of the Finnish disease genes is already known. This has given quick and reliable possibilities for diagnosing these disorders in children and adults as well as in fetuses. Population screening of the carriers, i.e., healthy possessors of one disease gene, is technically possible as well, but the practical and ethical problems of these procedures have not been solved yet. The maps of diseases benefit not only genetic and epidemiological research but practicing phy- sicians as well. The maps guide them to be aware of rare disorders that appear in their working areas – no physician can recognize forty rare disorders by heart. Only some 60 newborns each year are, or will be, suffering from one of Finnish disorders. Thus the FDH is just one unique contribution in the whole of the medical genetic task, from the per- spective of both the patients and the physicians. In this context it should not be forgotten that the bulk of medical genetics in Finland is of interna- tional character, i.e., the same conditions are found all over the world. Future developments In average one ‘new’ Finnish disease has been re- vealed annually up to these days. Now the fre- quency of new detections seems to be decreas- ing gradually. All Finnish diseases are not yet known, however. The internal migration into cities reduces the size of the isolates although this movement does not intermingle the isolates. As an increasing number of couples will be formed in cities, this should diminish the probability that two similar rare genes meet. Due to this migratory shuffling of the rare genes, the incidence of Finnish diseas- es should decrease, although the amount of dis- ease genes remains the same. Such a decrease has not yet been detected, not least because of the observation time has been too short so far. What is the effect of today’s foreign immigrants? Different migrant groups bring to Finland their own rare genes. Also some cases of rare reces- sive diseases not seen heretofore will be found if the immigrants intermarry frequently. Theoretical- ly, the newcomers ‘dilute’ the Finnish gene pool. The practical diminishing effect of this on the in- cidence of ‘Finnish’ diseases may be imaginary, however, and at least very slow, if the number of foreign immigrants does not increase unexpect- edly indeed. ACKNOWLEDGEMENTS We are indebted to Doctors Christer Holmberg, Kari Launiala, Seppo Similä, Olli Laakso, Riitta Salonen, and Aune Hirvasniemi for the data needed for Fig- ure 2, and the Finnish Cultural Foundation for a grant to the first author of this article. Fig. 2. Four maps of Finnish autosomal recessive diseases depicted by the birthplaces of the patients’ grandparents (one patient/family). (A) Congenital chloride diarrhea: a congenital watery diarrhea due to an intestinal resorption defect of chloride. The disease is lethal if not treated properly, but allows nor- mal life when diagnosed and treated with peroral mineral supplementation. The grandparents are concentrated in the area of late settlement populated in the 1500s and thereaf- ter. (B) Congenital nephrosis of Finnish type: a congenital renal disorder causing severe failure to thrive due to protein leak- age in the urine. This otherwise lethal disorder can be suc- cessfully treated by renal transplantation. The grandparents spread over most parts of Finland forming clusters in the area of late settlement. (C) Meckel syndrome: a perinatally lethal multiple malfor- mation syndrome with severe brain anomaly, extra fingers and toes, and large cystic kidneys and liver. The western predomination of grandparents is congruent with Finland’s population density. (D) Northern epilepsy: An epileptic disorder beginning in childhood with later appearing psychic deterioration. The grandparents originate from a restricted area of one histori- cal province. 182 FENNIA 180: 1–2 (2002)Reijo Norio and Markku Löytönen REFERENCES Hallman N, L Hjelt & EK Ahvenainen (1956). Neph- rotic syndrome in newborn and young infants. Annales Paediatriae Fenniae 2, 227–241. Holmberg C, M Antikainen, K Rönnholm, M Ala- Houhala & H Jalanko (1995). Management of the congenital nephrotic syndrome of the Finnish type. Pediatric Nephrology 9, 87–93. Jalanko H, H Kääriäinen & R Norio (2002). Neph- rotic disorders. 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