More people can live longer, happier, and healthier lives if as a nation we focus on our environment, socio-economic status, ethnic variations, persistent gender discrimination, and other self-induced non-medical risks—rather than personalized medicine or precision medicine.
No doubt clinical medicine has changed the way we live for the better. However, the greatest change for the better in overall life expectancy in the history of civilization has been an effective sewer system combined with a safe drinking water supply.
In fact, one of the United Nations’ major goals was to halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation. This has been accomplished ahead of schedule. Between 1990 and 2015, 2.6 billion people gained access to improved drinking water sources. Worldwide 2.1 billion people have gained access to improved sanitation.
There is great enthusiasm for precision medicine or any scientific medical research to move society forward, and this enthusiasm derives from the assumption that sophisticated and rapidly evolving science will contribute to clinical practice. The argument that research helps lower morbidity and mortality has already been proven many times. One noteworthy example in our lifetime is the prevention of polio worldwide, except for three countries that are unaccepting of modern public health measures (Afghanistan, Nigeria, and Pakistan).
However, clinical care—no matter how evidenced-based and effectively accessed—cannot make up for environmental factors affecting whole populations. “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,” according to the Center for the History and Ethics of Public Health, Mailman School of Public Health of Columbia University.
We struggle with limited resources to care for our population and the world’s population by concentrating on prevention. But healthy eating, purposeful movement, work-life balance, and many of the nine principles of the Blue Zones Project would yield greater dividends than the vast spending on precision medicine. Ideally, we would have enough resources to fund all worthwhile projects and research. Realistically we as a nation and as a world civilization may get more “bang for our buck,” by preventing illness rather than developing new technologies for repair purposes.
Nonetheless, public investments in our nation’s public health versus precision medicine will continue to be debated—much the same way that funding pure science versus applied science has been debated for decades. There probably is no “right” answer, but looking at cost benefit with the focus on how many people will be helped by adding years of quality life is a reasonable metric. This measure is called a “quality-adjusted life-year” (QALY). It is a measure of both the quality and the quantity of life lived.
The debate between precision medicine (highly specialized and very attractive) versus public health measures (well understood but more mundane) will surely continue as our nation strives to decrease the percentage of Gross Domestic Product (GNP) spent on healthcare to remain globally competitive. The United States spends about 18% on health care but ranks 37th out of developed nations for quality of healthcare according to the World Health Organization. Most other developed nations spend only high single digits of GNP, with longer and healthier life spans.
As a nation, we have opportunities we have always responded to. I’m optimistic we can both develop precision medicine and improve population health.