Precision Medicine a Threat to Population Health

The problem with precision medicine is "the paradox of prevention… some very significant achievements at the individual level can be achieved without having much of an impact at a population level," says a public health researcher.

So far, precision medicine has been long on potential but short on delivery and some health policy experts question whether this focus on this novel and cutting edge medical discipline may distract from proven but more mundane population health strategies.

In a recent essay in the New England Journal of Medicine, Ronald Bayer, and Sandro Galea, MD, write that the movement toward precision medicine comes even as consensus solidifies around the idea that health differences between and within groups have more to do with social factors than with clinical care.

Bayer shared his concerns about the potential drawbacks of precision medicine in an interview with HealthLeaders Media. The following is an edited transcript.

HLM: What do you mean by "precision medicine?"

Bayer: "There is a view that the goal of public policy and science should be to make diagnoses and focus treatments that are specific to the individual, so that rather than thinking about how we should treat large numbers of people, we should be concerned with which people will be most likely to respond to a given intervention or therapy because of their biological or genetic background.

We believe that precision or personalized medicine takes our focus off the question of 'what do we do to improve the health of vast numbers of people living globally' and asks a different question, which is 'how can we target medicine most effectively to treat those who are sick?' We think this is a huge mistake.

HLM: Why?

Bayer: It is focusing on the wrong problem because we have just begun to provide decent and adequate healthcare for all of our citizens under the Accountable Care Act and we have a long way to go to just provide decent medical care to people.

The issue goes even beyond that. Americans don't know it, but they are at the bottom of the heap when we talk about life expectancy and every other stage of the life cycle when compared with other people in other countries similarly situated. The question is why and the answer can't be that they know better what the genome of their citizens is, or that they know better how to target medical care.

Population Health? Slash Health Disparities First

The reason clearly is that the US has become over the last 40 years increasingly and strikingly vastly socially unequal. Everything we know about who gets sick, how they fare when they get sick, who dies, when they die, at a population level, is that social inequality is bad for health.

HLM: How is a focus on precision medicine detrimental to population health?

Bayer: For example, the question we want to ask about tobacco is 'why do some people smoke for a lifetime and never get cancer or emphysema?' My question is why 'do so many people who smoke get sick?' The answer from a public health point of view is to severely regulate tobacco consumption, not to figure out the genomic bases for figuring out lung cancer or heart disease.

In public health it is call the 'paradox of prevention.' Very small reductions in risk at the individual level can produce huge consequences at a population level. The problem with precision medicine is that some very significant achievements at the individual level can be achieved without having much of an impact at a population level. That is what we have to be concerned about."

HLM: Do you see any value in precision medicine?

Bayer: Yes. I believe we should push the frontiers of science and there is much we may learn in the future. My sense as I read the literature is that there is a lot of hype involved. While a lot of serious scientists may understand the limits of what they are doing, the way it is presented to the public is that this is going to transform our world not in the next century but within our experience. I just think that is baloney.

Advancing the frontiers of science is a great idea. It's a question of priorities and a question of the public discourse about health. Every time I read a statement that advances the agenda of personalized medicine, it has the aura of religious fervor and that is misleading. And from the point of view of public health, we know that there are these vast disparities within our own nation.

Americans like to boast that we have the most technologically sophisticated healthcare system in the world and they go from that to say which of course means we must be the healthiest people.

There is no connection between the two, and at some level the question is, 'what is the metric you use to define the best healthcare system in the world?' Is it the one that can take care of a rare disease most exquisitely or is it the one that has an impact on life expectancy?

HLM: Why do you think precision medicine is getting so much attention?

Bayer: Being at the leading edge of science and exploring new frontiers accounts for it. My concern is that what we've written might be seen as 'anti science.' People at the center of precision medicine have said we are cranking out the same old story, but I think there is a need for a serious conversation, where people take a step back, take a deep breath, stop hyper-ventilating and ask 'what are our needs?' How do we prioritize our resources and our attention. It is pretty clear that the precision medicine crowd is diverting our attention from where it needs to be.

HLM: Do you get a sense that precision medicine is somehow designed with more affluent patients in mind?

Bayer: More money is spent on the treatment for male pattern baldness globally than on research on tuberculosis. There are hardly any new drugs in the pipeline for TB, which kills about 2 million people a year. The drug companies aren't interested because it doesn't look like these drugs will have huge profit margins. The use of the words 'personalized' and 'precision' is strategically very interesting.

Of course we want clinical intervention to be as precisely targeted to the problem as possible and certainly we want our doctors to treat us as people and not statistics. But it sometimes seems to be something darker that is involved, and that is, a kind of mismatch between what public and population health tells us we need to be doing and this huge intellectual and resource investment in the world that is not going to make an impact on those issues.

HLM: You cite $215 million that NIH has earmarked for precision medicine research. That's not a lot of money when you consider that the U.S. spends close to $3 trillion on healthcare.

Bayer: The goal and mission of the NIH is to advance the frontiers of medicine and science. The absolute spending at this point may look small, but when NIH says the 21st century is the century of biology, I'm concerned about the sharpness of the challenge.

It's time for those who've been proclaiming the vast implications for wellbeing from precision medicine to give an explanation for why a focus on precision medicine is not a diversion from meeting the health needs of Americans at a global level, the vast numbers of people who suffer and die too early from preventable diseases.

HLM: How can we strike a balance?

Bayer: There is much we might learn delving deeper into the biological and genetic foundations of disease. At the same time we must recognize that major achievements in our lifetime will not come from those investments, but will come from changing the conditions under which people live and the conditions under which they receive care.

There we will see returns on investment within our lifetime. The investments we are making in precision medicine and genomics are for the future.