Two scholars, however, recently published in The New England Journal of Medicine some cautionary words about personalized medicine, warning stakeholders that overemphasis, or exclusive emphasis, on the personalized approach by healthcare leaders could have a negative impact on public health.
According to Sandro Galea, MD, DrPH, dean of the Boston University School of Public Health, and Ronald Bayer, PhD, professor of Sociomedical Sciences and co-director of the Center for the History of Ethics of Public Health at Columbia University’s Mailman School of Public Health, it is unrealistic to think that most people will have ready access to personalized approaches even when they are more fully developed. If I read Galea and Bayer correctly, they are saying in a nutshell that this kind of therapy will be available to rich and knowledgeable patients—but will not likely be available to everyone else. And in stressing it, and funding it, to the exclusion of other approaches, the healthcare establishment may thus be doing a disservice to, well, everyone else.
Galea and Bayer frame their points in more measured language than that. They note that “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….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.” They cite a 2013 report by the National Research Council and the Institute of Medicine that indicated Americans had worse outcomes with regard to heart disease, birth outcomes, and life expectancy than people from other wealthy nations. They conclude that “decades of research have documented that health is determined by far more than health care.” They argue that policy makers must address inequities in accessibility to treatments, rather than simply develop those treatments, remarkable as they are.
In other words, the best clinical techniques and therapeutics in the world, including the tools of precision medicine, cannot help people who lack the means, either through personal wealth or insurance coverage, to avail themselves of them. Write Bayer and Galea: “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.” (Among the “trusted spokespeople” they refer to are representatives of the National Institutes of Health, who recently enthusiastically endorsed a White House initiative to devote $215 million to research in personalized medicine.)
Bayer and Galea have a point. Studies have shown (so does common sense) that people with money, and also the cultural literacy and sophistication to know about, for instance, clinical trials, tend to live longer with the same cancers that kill poorer and less aware people sooner. Similarly, it is wonderful that advances in diagnostics and therapeutics have largely transformed HIV/AIDS into a controllable condition rather than the death sentence it used to be—but that is true only for those patients who can get the superb clinical care. AIDS is killing other folks just as it used to.
“All your money won’t another minute buy,” goes the old song by Kansas, “Dust in the Wind,” but in fact the wealthy ill can often use their resources to prolong their lives. It would be a sad irony if personalized medicine serves mostly to increase the life expectancy gap between rich and poor. Policy makers must give equal attention to addressing the “social-structural factors” that underlie inequities in healthcare.