All For One And One For All?
Is precision medicine detrimental to increasing the health of the population?
Ronald Bayer and Sandro Galea’s article in NEJM caught the eye this week for their perspective on the value of precision medicine to the effort of improving health at a population level. They argue that the place to have the biggest positive impact on the health of the US population is outside of the clinic.
“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… Yet seemingly willfully blind to this evidence, the United States continues to spend its health dollars overwhelmingly on clinical care.”
You can find a lot out there already about the potential negative impact of precision medicine. There’s no getting around the fact that it’s likely to be expensive (although we are often told that that cost will be offset by getting to the right treatment a lot faster). The natural conclusion to draw is that the rich get healthier, the poorer don’t.
For better or for worse, there is an awful lot of hype around genomic medicine right now. It certainly has the potential to change the human experience significantly, but we’re still a very long way from that. And let’s be honest, genomics won’t fix everything. You may even have read David Dobbs’s article on BuzzFeed earlier this year that completely slammed the field. So where has that hype come from? Does the filed of genomics just talk a better talk, or is the potential value so great that it can’t be ignored?
It’s a complicated question. When you look at how funding is being allocated, you could argue that genomic research is going to offer more to the economy. It’s also a pretty sexy field to be working in. That shouldn’t discount the importance of the socioeconomic factors that Galea and Bayer are trying to draw our attention to.
“We need a careful recalibration of our public health priorities to ensure that personalized medicine is not seen as the panacea for population health,” Galea said. “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.”
In our recent poll results, I mentioned that the real watershed moment for genomics is going to be when it starts to benefit the majority of the population in a meaningful way. That’s the point at which the human experience really does start to change, and people really ‘get it’. We all know there’s a long way to go yet, so that funding is crucial for the advancement of the underlying science.
Bayer’s comments illustrate a wider point nicely, “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. 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.” Personalised/individualised/precision medicine has a lot of potential, but is still only part of the solution to a much broader goal of increasing health at a population level.
The soft answer would be to say that we should all be more aware of some of the wider issues. We certainly should be – but that’s not going to fix them. Nor will diverting funding away from translational research. With elections fast approaching, what we can do is make sure that the right questions are being addressed and putting pressure on the highest levels of government to get it on the agenda. Even then there’s still a balance to figure out. Just as precision medicine is only a slice of healthcare, healthcare isn’t the only consideration when it comes to running a country.
All doom and gloom? Not at all. If genomics is getting a load of funding right now, then great. But let’s use that as a springboard to really improve healthcare for everyone. Like I said, there’s a lot of work that goes into making personalised medicine a reality – a tonne of research, putting the right regulations in place, putting the right processes in place, putting the right infrastructure in place. Eventually, that list will extend to making sure it’s affordable for everyone.
It’s hard to disagree with the point Galea and Bayer are making. It serves as an important reality-check. I don’t necessarily agree that committing funds to the pursuit of precision medicine is damaging to healthcare. There’s a goal to be reached – improving the health of the population. Some of the most exciting work in that pursuit is taking place in this field right now. Surely that’s worth backing?