Abstract
Inequality. The word had all but vanished from public discussion of economic policy. Then Occupy Wall Street happened, and suddenly “inequality” was on everyone's lips, as though people were waiting for an opportunity to recognize, however belatedly, an uncomfortable truth—individual virtue doesn't guarantee security, let alone prosperity. And, finally, people felt free to admit that there might be, after all, such a thing as society.
A comparable shift in discourse may be in store for precision medicine, if two public health scholars have anything to say about it. These scholars—Sandro Galea, M.D., Dr.P.H., and Ronald Bayer, Ph.D.—are adamant that differences in public health outcomes are less a matter of access to medical care than they are a matter of sheer socioeconomic differences. Moreover, they suggest that if access to medical care matters relatively little, the availability of precision medicine matters even less.
In other words, individual factors are not everything. Collective factors are important, too. This straightforward assertion, expressed in a Perspective article that appeared August 6 in the New England Journal of Medicine, directly challenges the individual focus that prevails in “personalized” medicine.
“There is now broad consensus that health differences between groups and within groups are not driven by clinical care, but by social-structural factors that shape our lives,” wrote Dr. Galea, Dean of the Boston University School of Public Health, and Dr. Bayer, co-director of the Center for the History and Ethics of Public Health at Columbia University's Mailman School of Public Health. “Yet seemingly willfully blind to this evidence, the United States continues to spend its health dollars overwhelmingly on clinical care.
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“It is therefore not surprising that even as we far outpace all other countries in spending on health, we have poorer health indicators than many countries, some of them far less wealthy than ours.”
The authors hasten to add that precision medicine may eventually “open new vistas of science” and make contributions to “a narrow set of conditions that are primarily genetically determined.” Nonetheless, the authors insist that the burgeoning precision medicine agenda is largely silent on a more immediate issue: the “steep social gradient that characterizes who becomes sick and who dies.”
Arguing that clinical intervention will not remedy pressing health problems that arise from environmental conditions and inequities in income and resources, the authors cited a 2013 report by the National Research Council and the Institute of Medicine that found Americans fared worse in terms of heart disease, birth outcomes, life expectancy, and other indicators than their counterparts in other high-income countries. The report concluded that “decades of research have documented that health is determined by far more than healthcare.
“Without minimizing the possible gains to clinical care from greater realization of precision medicine's promise, we worry that an unstinting focus on precision medicine by trusted spokespeople for health is a mistake—and a distraction from the goal of producing a healthier population,” the authors continued.
To substantiate this concern, the authors noted that according to the NIH Reporter, the proportion of NIH-funded projects with the words “public” or “population” in their titles had dropped by 90% over the past 10 years. The authors also pointed out that our investment in public health infrastructure, including local health departments, lags substantially behind that of other high-income countries, and the CDC's annual budget is dwarfed (by a factor of about five) by investment in the NIH, even as the latter pursues an approach increasingly focused on science and treatments that aim to promote individual health.
Both Dr. Galea and Dr. Bayer warned that specialized medicine could push larger public health initiatives aside. “We need a careful recalibration of our public health priorities to ensure that personalized medicine is not seen as the panacea for population health,” said Dr. Galea. “We would love to see the same enthusiasm directed to research initiatives that would affect the health of millions of people, such as treatments of chronic diseases, and policy changes to address poverty, substance use and access to education.”
“We face increasing challenges to improve health at the population level which entail addressing certain persistent social realities and have little to do with the frontiers of science,” added Dr. Bayer. “We must not let the current focus on individualized medicine sidetrack us in advancing a broad agenda that reduces health inequities both domestically and across the globe.”