Precision Medicine and Individual Health

In “Will Precision Medicine Lead to a Healthier Population?” (Issues, Winter 2020), Richard Cooper and Nigel Paneth write that “mass diseases are the products of the societies in which we live” and that “we do not believe genomics and precision medicine will transform biomedicine and population health.” These statements summarize the authors’ views on the role (or lack thereof) of precision medicine in improving population health. Cooper and Paneth provide an overview of the societal changes and scientific and technological advances that have helped achieve a remarkable increase in life expectancy over the past 60 years. They review the history and premise of genomics, and how precision medicine will most likely not result in an improvement in population health, with a few exceptions.

The authors’ ideas and language resonate with the eminent epidemiologist Geoffrey Rose’s insights decades ago. Sick societies, he said, require society-level solutions for their epidemics. Furthermore, addressing powerful upstream determinants of health is crucial to reducing the burden of specific diseases in entire populations and for truly improving population health. For example, a population-wide salt substitution trial in Peru reported a 50% drop in hypertension incidence through the replacement of regular salt with potassium-enriched salt. In an even more impactful example, a recent trial conducted in rural South Asia reported a 30% reduction in mortality from all causes through a community-based intervention providing enhanced access to public health care. These recent population-wide randomized trials support Cooper and Paneth’s premise that population health improvements come from population-level interventions.

But it is also essential to acknowledge that population-wide interventions can be challenging. Gaining an understanding of mass influences requires either a comparison between populations that are exposed to varying mass influences or analysis of changes within populations in these mass influences. For example, finding a gene responsible for health disparities may seem like a much lower hanging fruit than finding a society with no racism to act as a control group, regardless of how fruitless the search for the “disparities gene” has been. For this reason, and though there is evidence for these population-level interventions, Geoffrey Rose did not state that individual-level (high risk) interventions were useless, but rather that these interventions were intended to improve individual health, not population health.

Usama Bilal

Richard Cooper and Nigel Paneth provide a detailed and coherent account of the research and intervention strategies that have worked in the past to dramatically improve population health in developed countries. They then contrast this success with the relatively less fruitful record for the molecular techniques that have dominated for the past several decades. But they only obliquely discuss the explanation for this sudden enfeebling of biomedical progress.

Scientists and physicians ought to be the most evidenced-based of all segments of society, able to quickly discern what works from what does not work. How is it conceivable, then, for such a smart and creative segment of society to collectively make a wrong turn and not even notice? What could possibly explain such massive dysfunction in the prioritization of approaches that are efficient and effective from those that are perpetual disappointments and voracious money pits?

Cooper and Paneth allude vaguely to some systemic forces that might begin to explain this mass delusion. Steady progress in population disease prevention, they note, has been replaced by “a reductionist, technology- and theory- (and career- and profit-) driven approach to health and medicine that [is] … wildly expensive.” Is the explanation for the failure of the collective scientific orientation therefore an economic order that increasingly commodifies the biomedical research process and the provision of care?

Indeed, universities increasingly seek patentable technologies, while medicine is ever more corporate and consolidated in the hands of large hospital and insurance conglomerates. Perhaps it is simply more lucrative, for universities organizing research efforts, for scientists conducting them, and for clinicians delivering care to patients, to delve into the high-technology world of genomics than into the less remunerative tasks of behavior modification and old-fashioned screening. Not to mention that molecular medicine requires endless varieties of expensive equipment for use in both the laboratory and the clinic, for which manufacturers and suppliers form an aggressive lobby.

Communism was ridiculed for producing the scientific catastrophe of Lysenkoism, but perhaps capitalism has fallen into its own perverse ideological dysfunction, so intent in generating huge profits that it can no longer be bothered to prioritize promising results over useless ones for actual human health and well-being. When the utility of selling something becomes more important than the utility of preventing a disease or extending a life, then the system has indeed failed us.

Jay S. Kaufman