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Microscopic genes affected by macroeconomic events

From the March ACP Internist, copyright 2012 by the American College of Physicians

By W. Gregory Feero, MD, PhD

Available evidence suggests we live in an era of widening gaps between those with and those without. From the Occupy Wall Street movement railing against the concentration of wealth into smaller segments of the population, to the recently published observation of a 47-fold net worth differential between households headed by those over 65 years versus those under 30 years, the nation's wealth gap is a major topic of conversation.

The differential in wealth across the population is also evident in the health care arena. One in seven is uninsured, despite our nation spending an estimated 17% of its gross domestic product on health care. Inequity and high cost in our health care system are likely to be major topics of discussion in the 2012 election year, especially with the Supreme Court's recent decision to hear the case against certain provisions of the 2010 Affordable Care Act. Underlying these conversations remains the fundamental question: Is access to high-quality health care a right or a privilege in the United States?

Microscopic genes affected by macroeconomic events

Our genomics may seem independent of macroeconomics. One is a physical aspect of our cells and the other is a construct of society. But genes express themselves differently depending on their environment, and upon further consideration, how people access health care (if at all) could determine how their genes affect their health.

The consequences of inequities in access to emerging genomic health care technologies are potentially profound. Differential uptake of new technologies could increase the relative health care burden on populations with the least financial resources and access to medical care. The ripple effect of differential access to genomic technologies might extend beyond the individual and family to affect community systems, perpetuating health and socioeconomic disparities.

Recently, I had the pleasure to participate in the annual Personalized Medicine Conference (PMC) at Harvard Medical School. This two-day event explored the landscape of health care applications informed by genomic technologies and was run in conjunction with Harvard Business School.

As one might expect, the attendees were derived largely from the business side of the genomics community, and little attention was paid to the looming issue of genomic technologies' effects on health disparities. In the emerging landscape of personalized cancer care, remarkable advances in diagnosis and treatment due to genomic discovery are now a reality for some tumor types. If patients are savvy, early adopters and can travel to U.S. institutions at the cutting edge of genomic technology development, then maybe sequencing of their tumor genomes could provide profound insights into highly effective targeted treatment options.

The costs of both the diagnostics and the targeted therapies are high, and indications are that they may remain so. How and when such advances will move to underserved and underresourced populations in the United States' complex and cost-constrained health care system remain to be seen.

The standout presentation at the PMC meeting from a health disparities perspective was given by Fabien Calvo, MD, PhD. In egalitarian French fashion, the French National Cancer Institute and Ministry of Health have teamed up to make a major commitment to provide state-of-the-art molecular diagnostics and targeted therapies for all French citizens diagnosed with non-small cell lung cancer (NSCLC). This has required substantial attention to the distribution of laboratory services and clinical expertise across the country, as well as a willingness of the national health care system to commit resources to pay for very new technologies. The project is ongoing, with impressive patient accrual, and will lead to a better understanding of the effectiveness of targeted treatments in a wide diversity of patient populations.

Could a project like this be duplicated for every NSCLC patient in the U.S.? In our balkanized health care and research system, it seems unlikely that such a grand scale could be achieved. However, the foundational principle of equitable access could be explicitly incorporated into all clinical trials and state-of-the-art cancer treatment programs. Developing the resources needed to provide access for all new technologies will often require creative solutions developed in the context of local environments.

Will this be easy? No. But the stakes are high, literally life and death, for the most vulnerable in our population. The genomics community and each part of the health care system responsible for the U.S. population have a moral responsibility to get the issue of equitable access to new technologies right.

W. Gregory Feero, MD, PhD, a family physician with a doctorate in human genetics, is Special Advisor to the Director of the National Human Genome Research Institute (NHGRI) and faculty at the Maine-Dartmouth Family Medicine Residency Program (MDFPR). The opinions expressed in the column are his own and not necessarily those of either organization.

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