Is Genomics Widening the Schism Between Medicine and Public Health?

In 2007, we published a paper entitled: “Will genomics heal or widen the schism between medicine and public health?” We explored the long standing split between medicine and public health and how the emergence of genomics and other technologies can affect it. The “schism” was identified by Kerr White in his 1991 book in which he described a growing gap between individual- and population-based approaches to improving health in the 20th century. Kerr stated “today, the two cultures “medicine and “public health” seem to live in different, often unfriendly worlds”. Advances in genomics are fueled by the investigation of biological mechanisms of disease, leading to personalized treatment. On the other hand, public health emphasizes the study of environmental and social influences on health and disease, focusing on health promotion and disease prevention.

Since 2007, while medicine continues to enhance its capacity in genomics and emerging technologies, public health has, by and large, steered away from this new field. Breathtaking advances in genomics continue to be touted by scientists and medical academic institutions as a revolution in personalized healthcare, with cancer providing the leading edge of precision medicine. In this new “omic” world, the focus is usually on individual health as new approaches to personalize treatments and prevention are pursued. The role of the public health sector is rarely, if ever, mentioned (except in traditional public health run newborn screening programs). The 2014 4^th edition report of the Personalized Medicine Coalition “The Case for Personalized Medicine” provides an overview of the progress in genomics and personalized medicine, and the gradual shift towards prevention, but makes no specific mention of a role for the public health functions of assessment, policy development and implementation.

On the other hand, recent public health reviews and commentaries have focused on the importance of population approaches in improving health in the United States. In 2011, the National Prevention Council released the first-ever National Prevention Strategy to focus on prevention and wellness. The 2014 Report features achievements of public health and its partners. In general, public health approaches emphasize policy and environmental changes including development of international policies to promote adoption of measures to prevent disease. Public health does not emphasize personalized and genomic approaches in improving health, although genetic factors play a role in almost all diseases of public health significance, and there is an increasing number of genomic applications that have strong evidentiary basis for action.

These recent reports make us wonder whether or not genomics is widening the gap between medicine and public health. They illustrate how the two worlds approach health issues. While medicine is increasingly focusing on genomically-based personalized strategies, public health increasingly focuses on population level interventions such as policy and environmental changes. While both approaches are needed to improve health, I continue to believe that genomic sciences represent an important and perhaps unique opportunity for increasing medicine-public health collaboration, given the volume of new scientific discoveries and their potential applications in all areas of health and disease. The issues and potential solutions identified in the 2007 paper are still as timely in 2014, and they are worth repeating here. Briefly, the applications of genomics and new technologies to improve health require a strong medicine–public health partnership in at least 4 overlapping areas.

1. A population perspective, which requires a large amount of population-level data and epidemiologic studies to validate genome discoveries for clinical applications. In the words of Craig Venter at the 2014 Scripps meeting on the Future of Genomic Medicine, in order to make sense of one genome, we need thousands of genomes. We are seeing this population perspective increasingly in large scale collaborative epidemiologic studies to study genetic and nongenetic factors in many diseases.
2. A commitment to evidence-based principles in integrating new knowledge into practice. Sometimes, individualized genomic medicine has been viewed as exempt from principles of evidence-based medicine. We have explored this false dichotomy in a recent blog entitled “is evidence-based medicine the enemy of genomic medicine?”
3. A focus on prevention—a traditional public health concern but now a promise of genomics in the realm of individualized prevention and early detection. The tools of omics are providing endless possibilities of new biomarkers that, if validated, could be helpful in risk assessment and screening. The challenges of using such biomarkers in prevention are numerous. We have explored this topic in the recent blog entitled: “nobody is average but what to do about it? the challenges of individualized prevention based on genomics“
4. An emphasis on “translational sciences” covering the full spectrum of inquiries from basic discoveries to population health impact, and including multiple scientific fields such as clinical research, epidemiology, health services research, ethical, legal, psychological and social sciences, economics and others to evaluate benefits and harms of new technologies in populations. Readers can find additional information on the continuum of translational research in genomics in previous publications.

These overlapping areas of collaboration are essential in the appropriate translation and implementation of genomic research to improve population health. The recent efforts by public health departments in a few states illustrate the trail blazing public health-health care collaboration in accelerating the implementation and health impact of evidence-based cancer genomic applications (such as hereditary breast, ovarian and colorectal cancer).

In 2006, Dr. Mike McGinnis, a public health leader said “the dominant issues for health and health care today can be effectively engaged only if public health and medicine work together as better partners”. To improve health of individuals and populations, genomics should lead to greater collaboration between medicine and public health for decades to come.