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Public health - in need of fundamental change?
Challenges for public health in the genomic era
A new paper from PHG Foundation founder and chairman Dr Ron Zimmern has set out the challenges of genomics for public health practice.
Writing in the Journal of Public Health, Dr Zimmern contends that, whilst the current activities of public health are entirely laudable, they will not prove sufficient to meet public need in the twenty-first century, and must therefore evolve to include consideration of two key drivers. These are said to be genomic science, and the potential it offers to delivered improved clinical diagnosis, risk prediction and management; and the rise of patient autonomy within health care practice.
Dr Zimmern, an experienced public health physician, calls for ‘fundamental changes to our practice, especially across the domains of health improvement and health service organization and planning’. He notes that populations are made up of individuals, and asserts that public health needs to ‘move from an entirely collectivist to a more individually-focused framework’, implying that their stratification may have some benefit for population health.
Responses
This conceptual paper is published alongside a number of thoughtful responses from other experts.
Philosopher Professor Jonathan Wolff supports the concept of keeping an open-mind in public health, both to the idea that ‘it is certainly conceivable that what is sound public health policy for one group might be irrelevant for another group and possibly even damaging to health for a third group’ and to the possibility that genomics may offer the potential to distinguish between such groups, whilst questioning how far this potential has been realised to date. He also notes that, despite moves towards greater patient autonomy, ‘public health paternalism will not disappear easily’.
Clinical geneticist Professor Julian Sampson agrees that hitherto genomics has not had a major impact on public health, but notes that opportunities are emerging in a wide range of health settings and that ‘the potential costs of irresponsible, ineffective or inappropriate application are high’. Examples such as genetic risk stratification for screening programmes and the broader application of improved genetic diagnostics where they offer clinical and economic benefit are cited. He supports the call for public health leadership, including in the delivery of new services ‘at the interface between clinical genetics and other specialties’.
Public health expert Dr Edmund Jessop agrees that genomics is important for public health, both in terms of pathogenic genomics for control of infectious diseases, and in terms of an understanding of disease biology and therapeutics for health services planning. However, he disputes the argument that genomic data is anything like as useful as classical risk factors such as age and sex for targeting health programmes, not least because it would require major societal changes to allow easy access to such information. He concludes that for the present ‘we simply do not have enough genomic information to change our fundamental strategies in many areas’.
In their accompanying Journal of Public Health editorial, Professors Gabriel Leung and Selena Gray explore classical public health thinking about risk prediction and prevention, and query whether Dr Zimmern’s extension of Marc Lalonde’s concept of focusing disease prevention efforts on those at greatest risk by genomic stratification onto sub-populations could be employed ‘to realize public health gains through personalized medicine’. They conclude that, if so, it would require public health experts who understand and work with both social and scientific theories and drivers.
References
Genomics and individuals in public health practice: are we luddites or can we meet the challenge?
Zimmern RL. J Public Health (Oxf). 2011 Dec;33(4):477-82.
Comment: Public health, genomics and autonomy
Wolff J. J Public Health (Oxf). 2011 Dec;33(4):483-4.
Comment: Genomics, individuals and public health: a view from clinical genetics
Sampson JR. J Public Health (Oxf). 2011 Dec;33(4):485-6.
Comment: Yes, but …
Jessop EG. J Public Health (Oxf). 2011 Dec;33(4):487-8.