Is Precision Medicine The Wrong Use of Federal Health Research Funds?
Interview with Ronald Bayer, Professor of Social Science at Columbia University’s Mailman School of Public Health
Precision medicine has a lot of important people in government excited. It’s a relatively new model of healthcare in which physicians use information about a patient’s particular genetic makeup to help prevent, diagnose or treat a disease.
In January 2015, President Obama asked Congress for $215 million to fund the Precision Medicine Initiative, which aims to collect the DNA of 1 million Americans. The head of the National Institutes of Health has made precision medicine a priority and the state of California announced its own initiative this spring.
But two scholars are worried that precision medicine is diverting funds and attention from health problems that affect the least advantaged in American society – problems, they argue, that cannot be solved through genetic research. Ronald Bayer, a political scientist and professor at Columbia University’s Mailman School of Public Health and epidemiologist Sandro Galea, dean of the Boston University School of Public Health made their case in a recent issue of the New England Journal of Medicine in an opinion piece: “Public Health in the Precision-Medicine Era.”
We spoke with Bayer to learn more.
Andrea Muraskin: When the President announced the Precision Medicine Initiative in January he said "Ultimately this has the possibility of not only helping us find new cures, but it also helps us create a genuine health care system as opposed to just a disease-care system. Part of what we want to do is to allow each of us to have sufficient information about our particular quirks, so that we can make better life decisions." This sounds like it's going to be great for public health. But you're saying, not really.
Ronald Bayer: I would have to say that the President's characterization of this effort was not his finest intellectual moment. But there are many people — including the head of the NIH — who have shaped a science agenda that supports this kind of work [precision medicine].
Between 400,000 and 500,000 people die every year as a result of smoking cigarettes.* If you were to say to me "The real question that confronts us is 'Why are there people who smoke cigarettes who never get sick?’ " I would say to you that from a public health point of view I don't really care why there are some people who don't get sick. The issue is that 500,000 people die from smoking, and our goal in public health is to prevent or reduce those deaths. And that means by restricting access to tobacco, everything that public health has tried to do over the last century in terms of tobacco control.
Sandro Galea and I mention in our article that when Americans' health is compared to that of other advanced nations, we're at the bottom of the heap. That's not because the nations that share our economic status have a better understanding of the genome of their population. It's because they have structured their healthcare systems, and perhaps more importantly their societies, so that their people live longer, and live healthier lives.
Social inequality in America now is greater than it has been in a century. And it's that deep social inequality that has a huge impact on our health and wellbeing. And it’s those social forces that are ignored when people talk about the importance of knowing what our particular genomic composition is so that we as individuals can make the appropriate choices.
Obesity, cancers that are environmentally [caused]...roadside accidents, violence — these are not issues that we're going to resolve by focusing on the genome. I say hats off to those who want to do this science, but it seems to me they owe the American people a candid assessment of what ails America, and what we need to do to correct those things. And then we can discuss the very individualized focus of precision medicine.
AM: Why do you think that despite the evidence that health disparities are driven by social factors and environmental factors, we as a country continue spend the bulk of our healthcare dollars on clinical care?
RB: This is the $64,000 question. It's a paradigm. It's the dominant paradigm at the NIH.
This is a longstanding theme, and I don't have a good answer for why. I think part of it is to really confront the question of how social inequalities impact patterns of health and disease really would force you to ask questions about "Is it fair? Is it just?"
I read something in the August 11 Issue of JAMA. The title of the article is “Racial Bias in Healthcare and Health: Challenges and Opportunities.” It says explicitly "although racial and ethnic disparities in access to care as well as in the quality and intensity of care contribute to racial and ethnic disparities in the severity and course of disease, most racial disparities in the onset of illness occur prior to the presentation of patients to receive healthcare."
The point is that it's the circumstances within which African Americans live that shape patters of disease and life expectancy.
So I think what we really need is to open up the conversation again. This is not a question of being anti-science. It's a question of "How do we look at the evidence before us?"
AM: It seems that doctors and hospitals have a lot more clout than nonprofits that care about public health and country health departments. There’s a lot more money and prestige in medicine than there is in social science in this country.
RB: That's true. But I think part of it is, when you're sick, you want to get the best medical care you can get. The problem of public health is that public health is concerned about numbers and statistics, and clinical care is about real human beings. We desperately spend to save the lives of people who are very ill, because something in us tugs at us. In a way, that's the positive side of why we spend so much money on clinical care.
There's one more piece of it: I think that it's overwhelming to look at the issue of social inequality and health outcomes. It means having to think about how we deal with this vast challenge that's been getting more acute over the last 40 years. It feels overwhelming and it makes you feel powerless. And in clinical medicine you can actually do something about it: you can help a sick person -- and that makes you feel good.
AM: If you could take the money that's being spent on precision medicine and redirect it, what sort of research do you think would benefit public health?
RB: There are huge questions to ask about public health and environmental issues. Questions like how does a bad environment get into the body of someone and make them sick? We don’t really understand it. We have correlations. We know that poor people are sicker. We know that inequality in and of itself seems to produce terrible health outcomes. How does that happen? There are many explanations. Is it stress? Is it cultural, social norms that are bred by poverty and inequality? We don’t really have straight answers.
AM: Are there policies in other countries that you think if the US implemented, we'd start seeing better public health outcomes?
RB: From the end of World War Two until 1970 America was becoming less and less unequal. And then beginning in 1970 the path was reversed. And I think America at this point probably has the worst Gini coefficient [a measure of inequality] of any of our comparable nations.
We would have a huge impact on the health of Americans, not only children and adolescents but later in life, if the number of children living in poverty was drastically reduced. Something like 25 percent of American children are living in poverty.** That's a recipe for public health disaster.
My first two priorities would be eliminating childhood poverty or radically reducing it, and eliminating gun violence. I do believe in raising the minimum wage so that people who work a full week make a living wage. All the issues I'm mentioning have to do with social policy. They don't have to do with better hospitals; they don't have to do with better clinics. They have to do with the way people live. And what we've known since the 19th century is the way people live has a profound impact on whether people get sick and when they die.
*Over 480,000 US deaths annually are attributed to cigarette smoking, including exposure to second-hand smoke, according to the Centers for Disease Control.
**Twenty-two percent of US children live in poverty according to the National Center for Children in Poverty.