In 2020, the ICPerMed (International Consortium for Personalized Medicine) published a ten-year vision for how personalized medicine, a new form of medicine, has the potential to rebuild an equitable and accessible health care system by 2030.
Precision or personalized medicines are drugs developed with genomic sequencing technologies, targeting the critical genes in specific types of cancer or genetic diseases. Thus, PMs are highly effective in treating their targeted patients, sometimes buying patients years compared to other standard treatments.
Since the Human Genome Project’s (HGP) release of the human genome sequence in 2003 and President Obama’s 216 million dollar PM initiative in 2016, more and more scientists and pharmaceutical companies are focusing on this new field.
As a pre-med student who aspires to go into the field of oncology, scientific breakthroughs that led to new medications are beyond exciting. Precision medicines seemed like the first step on a plausible path toward alleviating cancer globally. If we can stratify patients to find the most suitable treatment for all of them, wouldn’t it be a much more efficient way of dealing with global health?
However, I only needed to walk into my first medical anthropology class to know I was wrong. Drugs and medicines are not the only determinants — many more factors contribute to global health. Developing better technology and stronger medicines does not necessarily mean we are improving global health and eliminating medical disparities. We have invested hundreds of millions of dollars, hoping that precision medicine would be the new tool to improve patient care for all. Sadly, precision medicine is not for everyone. It will only widen existing health care disparities and leave people behind.
To start with, the genomic database for precision medicine research is highly unequal between races, with almost 80 percent being European and only 2 percent African. This gap is not due to discrimination but because only developed countries (mainly European countries) can afford to invest in this costly field.
Since different races have different expressions of disease, a lack of research on genetic profiles can cause uncertainty about precision medicine’s effectiveness and side effects. There are fewer diagnosis tests to determine whether black patients match for targeting genomic treatment, and even when they gain access to it, the screenings have lower accuracy. This underrepresentation in research leads to a widening of health disparities between different races.
Omitting the uncertainty caused by racial genetic profiles, the effectiveness of precision medicine still differentiates among patients.
Bevacizumab (Avastin), a powerful PM for cancer, can buy up to two extra quality-adjusted life years (QALY) for the 7 percent of breast cancer patients that have a specific target gene.
Proportional to its effectiveness is its price tag: 100,000 dollars for a one-year supply. Bevacizumab is not the most expensive precision medicine: one single treatment of precision medicine can cost up to 70,000 to 130,000 dollars. Even though genomic diagnostic tests can determine the most suitable treatment for each patient, the cost alone determines that precision medicine is not accessible or affordable for everyone.
For a two-year gain of QALY, this sky-high price might be acceptable. However, regular breast cancer patients without this target gene only gain an extra five months. Human life is priceless, but a 15-month Bevacizumab treatment, which amounts to 125,000 dollars, is much less cost-efficient for the general patient when compared to the targeted group.
To further complicate the issue, only public insurance covers the cost of precision medicines. Private health insurance, not regulated by the government, does not have to cover these treatments. In the United States, where there is no national health care coverage, over half of the people are privately insured. At least in the United States, the uninsured and privately insured population will be ‘left behind.’
Among the publicly insured patients, how should the government decide who deserves this treatment? With the limited funding for medical insurance, the government cannot afford to give this pricey drug to all patients.
Do we deny some patients treatment just because it is less cost-efficient? If so, precision medicine and health care seem like an expensive roll of dice to determine your fate.
“Health” should not be like this.
Not every health improvement is due to medical breakthroughs: medical care only accounts for 10 to 20 percent of all health determinants in a population. Socio-economic determinants and environmental factors affect populational and global health on a much greater scale.
In 2016 alone, the U.S. government invested 216 million dollars into precision medicines. Imagine if that money, or even parts of it, went into funding for public infrastructures, creating better working and living conditions, or addressing food insecurities. It would have been more cost-efficient, effective, and beneficial to everyone.
Precision medicine is still an exciting breakthrough. For a high price tag, however, it benefitted a marginal group of people while leaving behind the rest.
It is powerful, but it cannot save us all.
Yongjia Wang is an undergraduate student.
