Recently, Washington University School of Medicine accepted a $10 million gift dedicated to precision medicine, ostensibly furthering the university’s mission to alleviate human suffering through innovative clinical research. Precision medicine aspires to tailor treatments to a patient’s unique genetic makeup using cutting-edge technology. While this future direction of medicine sounds seductive, in reality it drives the university further away from its mission to serve St. Louis.
In St. Louis, life expectancy varies by as much as 18 years by zip code. In some neighborhoods the infant mortality rate rises as high as 15 per 1,000, a ratio comparable to countries like Syria and Colombia. These gaps fall along racial lines and are driven by differential access to education, housing, employment, and healthcare. Before precision medicine can alleviate suffering in the St. Louis community, the city’s social backdrop needs to be equalized.
Thankfully, specific calls to action towards achieving equity have been outlined in detail in prominent reports such as “For the Sake of All” and “Segregation in St. Louis: Dismantling the Divide.” Moreover, Washington University does not have to abandon academic rigor to pursue social justice, as prestigious journals such as Poverty & Public Policy and The Journal of Development Studies routinely publish on such topics. Our vision is that one day WashU will dedicate $10 million gifts to research on health disparities or enacting evidence-based social justice interventions.
Many would defend Washington University’s current investment and research strategy by touting its history of laboratory successes. However, laboratory science may exacerbate existing disparities. A potent example can be found in the story of BiDil, the first medicine to be labeled for use specifically in African Americans. This labeling was based on a single study that used patients’ self-identified races, and did not include white communities, resulting in an inappropriate use of race in prescribing practices.
Indeed, precision medicine itself has already created racial disparities. In the U.S., as of 2016, less than 4 percent of all genome-wide association studies, a key instrument of precision medicine, analyzed people of African, Hispanic or Latin American ancestry, groups that comprise 31 percent of the U.S. population. It is easy to imagine how these historically marginalized groups will naturally benefit less from advances in precision medicine.
In addition to its potential for exacerbating disparities, it appears precision medicine is far from the panacea many have predicted. A 2010 study from the Journal of the American Medical Association of over 19,000 women looked at 101 genetic variants statistically linked to heart disease to see which predicted cardiovascular disease in practice. They found zero such associations. Furthermore, the benefits from the latest precision medicine treatment for prostate cancer, published in the New England Journal of Medicine, only extended survival by 2 years at a cost of $132,000 per year per patient.
While this is important progress, it is an expensive way to achieve a small fraction of the benefit that could be seen from eliminating the 18-year life expectancy gap between the low- and high-income neighborhoods in St. Louis.
To be sure, precision medicine has had some success. Engineering genes has shown promise in increasing rates of remission in leukemia and restoring normal blood clotting in hemophilia. However, even Dr. Herbert “Skip” Virgin, the head of Pathology and Immunology at Washington University School of Medicine, has emphasized that the role of genetics in disease accounts for “less than 20 percent, meaning that 80 percent of the risk is due to something else. And researchers now think that ‘something else’ is environment: where we live; what our current exposures are; what our exposures were early in life.”
A sole focus on precision medicine misses the bigger picture. Thus, a more enlightened use of Washington University’s $10 million gift would be to proportionally earmark 20 percent of the funds for genetics research and 80 percent for patients’ environments, such as investments in pre-Kindergarten education or greenlining housing to counteract historical redlining.
We believe that focusing the medical school’s vision on a “precision” paradigm violates our oath as healers who vow to “Do No Harm,” as it diverts money away from socially just, cost-effective solutions. We instead call for Washington University to look beyond genes and cells towards the research and interventions that could uplift marginalized groups across the city. This new vision would realign Washington University School of Medicine with its mission statement, which proclaims that it “will lead in advancing human health” by applying “advances in research and medicine to the betterment of the human condition.”
Such noble goals call for noble leadership. They ask us to look beyond the siren song of precision medicine and to start asking the hard questions about what bettering the human condition really means.
Michael Snavely is a student at Washington University School of Medicine (WUSM) who will graduate in May prior to starting a residency in Family Medicine at the University of California, San Francisco. Dr. Arjun Gokhale is a resident physician in Internal Medicine at Yale School of Medicine and a graduate of WUSM.
