BOSTON/NEW YORK – US President Barack Obama’s administration recently issued an appeal for ideas to advance its “precision medicine initiative,” which will channel millions of federal research dollars toward efforts to tailor clinical treatment to individual patients. The idea of personalized medicine, which builds on dramatic advances in genetics and molecular biology, certainly sounds appealing – and not only in the United States, but also in Britain and elsewhere. Unfortunately, the assumption that precision medicine will benefit public health by improving clinical practice does not hold up.
Much of the scientific leadership in the US, particularly at the National Institutes of Health, has thrown their enthusiastic support behind Obama’s initiative. According to Harold Varmus, director of the National Cancer Institute, and Francis Collins, director of the NIH, such “a broad research program […] to build the evidence base needed to guide clinical practice” is precisely “what is needed now.”
But in focusing on the detection and treatment of diseases at the individual level, precision medicine neglects broader health patterns. When one takes a closer look at the health of populations – in particular, the poorer segments of society – “what is needed now” looks quite different.
Though the US outspends every other country in the world for health care, the health of its population is relatively poor. In 2013, the National Research Council and the Institute of Medicine issued a bleak report documenting the extent to which Americans lag behind their counterparts in other high-income countries in terms of birth outcomes, heart disease, sexually transmitted diseases, chronic lung disease, motor-vehicle accidents, and violence. Americans fare better only when they reach the age of 75.
Precision medicine is unlikely to change that. The reason is simple: Clinical medicine in general, though far from perfect, is not the problem. On the contrary, great advances have been made in the field in recent decades, resulting in a strong capacity to treat and cure sick people.
But not everyone benefits equally from that capacity. What really determines public health, as many studies have confirmed, are factors like income, housing conditions, social policy, and the distribution of money, power, and resources. When one considers that large swaths of society still struggle daily with the forces of institutionalized racism, the persistence of large health disparities would seem to be a foregone conclusion.
Indeed, a broad range of empirical studies has demonstrated that clinical intervention, however important, cannot remedy health inequalities. Perhaps most convincingly, the Whitehall Studies of the British Civil Service in the United Kingdom revealed that even when health-care services were provided as a matter of right, and the cost of care was no longer a barrier to treatment, inequalities persisted; a substantial proportion of the population continued to fare poorly on health indicators.
Moreover, the inequity wasn’t simply a gap between the rich and the poor: People at every income level did better than those at the level just below them. Advocates for the precision-medicine agenda are largely silent on these factors influencing the health of populations.
None of this is to say that precision medicine should be abandoned altogether. But it should not absorb such large sums of scarce public money – funds that could be channeled toward efforts to improve the health of the many, not the few. Initiatives like free universal pre-kindergarten, higher taxes on health-damaging substances, and broader vaccination coverage would probably do much more than precision medicine to enhance public health over the coming decades.
Research undertaken in the name of precision medicine may well open new vistas of science and improve the treatment of a narrow set of genetically determined conditions. But the challenge of improving public health will not be tackled on the frontiers of science and molecular biology. Rather, it will be met with social and economic policies that address deep-rooted societal pathologies and promote the wellbeing of all.
Sandro Galea is Dean of the Boston University School of Public Health. Ronald Bayer is Professor at the Columbia University Mailman School of Public Health.
By Sandro Galea and Ronald Bayer