The Medicalization of Public Health: “Precision Medicine” vs. “Precision Health”?

Posted on | August 5, 2016 | 6 Comments

NIH Director Francis Collins

Mike Magee

Last week I was at a small, invitation only dinner in New York City, and left a bit downcast and feeling “odd man out”. I saw the failure as mine alone – an inability to articulate succinctly, and in few enough words, my concerns about the evening’s topic: Precision Health (that’s “precision health”, as I was repeatedly reminded throughout the dinner, most definitely not “precision medicine”).

The emphasis on the word “health” over the word “medicine” was apparently viewed by my sponsors as a free pass into the world of prevention where disease was avoided rather than treated. And yet, it was unclear whether the nomenclature change was accompanied by any significant change in medical organizational structure, career ladder incentives, research tools or tactics that would desegregate the academic medical center. There was no sign of a focus on public health social determinants or a desire to integrate the medical school into the broader liberal arts university community – not unless a strategic partnership with Google now qualifies as such.

“Precision Health” is in many ways the latest contribution to a war of words between “public health” and “precision medicine”.  Public Health, at least when it comes to NIH-funded projects, has been losing that battle. Funding for NIH projects with the word “public” or “population” in the title have declined by 90% in the past decade. In contrast, $15 billion of the total $26 billion of extramural NIH funding in 2016 has been awarded to projects that included one of the following four index terms – gene, genome, stem cells, or regenerative medicine.

Critics of the biomedical research community trace the problem back to NIH director Francis Collins who envisioned a genetic revolution in 1999, one which would unravel the genetic mysteries behind common chronic diseases, improve early diagnosis, drive preventive medicine efforts, result in new precise therapeutics, and result in a range of pharmaco-genetic treatments and stem cell therapy.

This focus, in concert with a massive effort to expand the use of electronic health records and harness the power of ever growing health databases, received a presidential endorsement in President Obama’s 2015 State of the Union address with the words, “Tonight, I’m launching a new Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes — and to give all of us access to the personalized information we need to keep ourselves and our families healthier.”

With the President’s support, the NIH has now embraced the call for $215 million in 2016 to support “precision medicine” – $130 million to enroll 1 million US volunteers in a long term interactive health database, and $70 million to study cancer genomics in yet another “war on cancer”. 

Now, a decade and a half since his initial pronouncements, Francis Collins is more convinced then ever that he’s on the right track, having stated “the 21st century is the century of biology”. He says, “the prospect of applying this concept broadly has been dramatically improved by the recent development of large-scale biologic databases (such as the human genome sequence), powerful methods for characterizing patients (such as proteomics, metabolomics, genomics, diverse cellular assays, and even mobile health technology), and computational tools for analyzing large sets of data. What is needed now is a broad research program to encourage creative approaches to precision medicine, test them rigorously, and ultimately use them to build the evidence base needed to guide clinical practice.”

To say his critics don’t see it that way would be something of an understatement. They say, “None of these popular topics has had any measurable effect on population mortality, morbidity, or life expectancy in the United States. The improvements of the past decades in these outcomes, which have been substantial but are now stalling, have largely reflected improvement in non medical aspects of everyday life and the operation of broad-based public health and classic prevention efforts, such as curtailing smoking, that are undervalued as outmoded and old-fashioned by the narrative.”

Those same critics, this week, went one step further, suggesting that rosy predictions and advertised results may be ethically compromised and require independent review. In their own words, “Assessors must be objective, independent of the funding source, and have no professional stake in whether a particular line of research is deemphasized. The deliverable criterion should include public health benefit achieved by these initiatives (ie, measurable reductions in mortality and morbidity). Criteria such as number of publications, citations, prizes, and recognition are irrelevant as these are simply self-rewarding artifacts of the system. After several decades of substantial investment, the fundamental question is whether these big ideas have improved quality of life and life expectancy, by how much, for how many, and for whom. These are public dollars that should benefit the many, not the few.”

Stalwarts of the Public Health community say, “Research undertaken in the name of precision medicine may well open new vistas of science, and precision medicine itself may ultimately make critical contributions to a narrow set of conditions that are primarily genetically determined. But the challenge we face to improve population health does not involve the frontiers of science and molecular biology. It entails development of the vision and willingness to address certain persistent social realities, and it requires an unstinting focus on the factors that matter most to the production of population health.”

In this week’s JAMA critique of “precision medicine”, titled “What Happens When Underperforming Big Ideas In Research Become Entrenched?”, the authors challenge both the results of “precision medicine” and the motives – including profit and career advancement. One of the three authors is the Director of the Stanford Prevention Research Center, the very same Stanford that today champions the term “precision health” over “precision medicine”. He is also the author of  “Why most Published Research Findings are False”, the most-accessed article in the history of Public Library of Science (exceeding 1.5 million hits), according to his Stanford professional bio.

Stanford Dean Lloyd Minor is the leader of their Precision Health movement. He wrote an article that appeared in the January 13, 2016 issue of Forbes titled “We Don’t Just Need Precision Medicine, We Need Precision Health”. In the article he states that since President Obama’s 2015 address, “we have seen many breakthroughs in the development of therapies tailored to individual patients to treat the deadliest of diseases”, citing President Carter’s recovery from brain cancer as an example. He believes those efforts are worthy of continued support, but should be broadened. As he writes, “instead of a frantic race to cure disease after the fact, we can increasingly focus on preventing disease before it strikes… we call this idea Precision Health, where we focus on helping individuals thrive based on all the factors that are unique to their lives, from their genetics to their environment.”

Changing or broadening terms is unlikely to settle the dispute, and Stanford isn’t the only university that lacks consensus on the issue. Columbia’s Mailman School of Public Health internal publication says, “Precision medicine or population health? On the face of it, the two couldn’t be further apart: one aims to tailor treatments to the few while the other works to confront disease for millions on a global scale.” As with Stanford, Columbia finds its leaders on both sides of the fence. Their president, Lee Bollinger, announced a institution wide precision medicine effort in 2014. But Sociomedical Sciences professor Ronald Bayer calls the promise of precision medicine a “stretch”. “People haven’t become obese because of a genetic transformation. They’re fat because they get the wrong foods. It’s not going to solve poverty or hunger.”

What I wanted to say the other night, but failed to effectively, is what I said in a speech to the Library of Congress on March 23, 2005. I said, “Health is profoundly political. Why is this the case? For multiple reasons: Health is a collection of resources unequally distributed in society. Health’s ‘social determinants’ such as housing, income, and employment, are critical to the accomplishment of individual, family, and community wellbeing and are themselves politically determined. Health is recognized by many throughout the world as a fundamental right, yet it is irreparably intertwined with our economic, social, and political systems. And growth in health, health care, and health systems requires political debate and political consensus.”

So if an academic medical center can integrate with its’ public health community, and with university sociologists, political scientists, economists, philosophers and theologians – as well as its basic scientists and computer scientists – to advance individual and population wide human potential in a sustained manner – and call it “Precision Health” – I’m all in. Otherwise, it’s just an empty branding exercise.

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