mardi 11 août 2015

Personalized Medicine Distracts From Public Health, 2 Scholars Argue

Personalized Medicine Distracts From Public Health, 2 Scholars Argue

Personalized medicine is all the rage. President Obama mentioned it in his State of The Union address this year and launched a multimillion-dollar initiative to push a personalized medicine agenda forward. The head of the National Institutes of Health has made it a priority. And really, what’s not to like about the general concept of medicine that’s personalized (it’s also called “precision medicine”) —  an approach that analyzes an individual’s genetics to make medical decisions about diagnosing and treating disease.

Well, two public health scholars argue in the New England Journal of Medicine that the current high-profile fawning over personalized medicine may be a “mistake” that diverts resources away from other public health efforts that could benefit far more people.

Ronald Bayer, Ph.D., a professor at Columbia University’s Mailman School of Public Health, and Dr. Sandro Galea, dean of the Boston University School of Public Health, write in the journal that the great enthusiasm around personalized medicine “derives from the assumption that precision medicine will contribute to clinical practice and thereby advance the health of the public.” But, they note, that may not be the case:

We suggest, however, that this enthusiasm is premature. “What is needed now” is quite different if one views the world from the perspective of the broad pattern of morbidity and mortality, if one is concerned about why the United States has sunk to the bottom of the list of comparable countries in terms of disease experience and life expectancy, or if one is troubled by the steep social gradient that characterizes who becomes sick and who dies. The burgeoning precision-medicine agenda is largely silent on these issues, focusing instead on detecting and curing disease at the individual level…

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.

I spoke with Dr. Galea about why he and Bayer targeted personalized medicine, in particular. Here, lightly edited, is what he said:

Personalized medicine has become this rallying cry around resource allocation in the health sciences. The president mentioned in the State of the Union. There is a White House precision medicine initiative, and it has dominated much of the NIH agenda…so it seems important to address it directly…

Nobody is arguing that precision medicine does’t have potential, but the number of people who you could point to who have actually benefited from it are very small. And so we are investing in potential — which is fine — but it’s a matter of calibrating our investment. Instead of investing in a untried, untested approach, we should be investing in things that we know make a difference…

We know that macroeconomic taxation on unhealthy substances, on alcohol, for example, can save thousands of lives, early childhood education can make an enormous difference, efforts to increase and improve vaccination rates, efforts to mitigate cycles of violence, one could go on and on….these could improve the lives of hundreds and thousands of people…

Our commentary was a call for a recalibration…I think there’s a feeling in the scientific community that the precision medicine agenda is becoming the overwhelming direction in which we are headed and that we would benefit from discussion and debate and a more careful calibration of the questions we ask and where we invest our resources.

Here’s more from the BU website:

Arguing that clinical intervention will not remedy pressing health problems that arise from environmental conditions and inequities in income and resources, they cite a 2013 report by the National Research Council and the Institute of Medicine that found Americans fared worse in terms of heart disease, birth outcomes, life expectancy and other indicators than their counterparts in other high-income countries. The report concluded that “decades of research have documented that health is determined by far more than health care.”
They call for greater public investments in “broad, cross-sectional efforts” to minimize the socioeconomic and racial disparities in the U.S. that contribute to poor health.

Bayer and Galea say the NIH’s most recent Estimates of Funding for Various Research, Condition and Disease Categories report shows that total support for research areas including the words ‘gene,’ ‘genome’ or ‘genetic’ was about 50 percent higher than funding for areas including the word ‘prevention.’ And investment in public health infrastructure, including local health departments, lags substantially behind that of other high-income countries.

In explaining why they felt compelled to speak out, Galea and Bayer said they are wary that that specialized medicine will push larger public health initiatives aside.

“We need a careful recalibration of our public health priorities to ensure that personalized medicine is not seen as the panacea for population health,” Galea said. “We would love to see the same enthusiasm directed to research initiatives that would affect the health of millions of people, such as treatments of chronic diseases, and policy changes to address poverty, substance use and access to education.”

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