Precision Public Health: Reconciling Biological and Social Determinants of Health

June 15, 2016 by Muin J Khoury, Director, Office of Public Health Genomics, Centers for Disease Control and Prevention

a mother and child surrounded by DNA and several images of environmental factors

a mother and child surrounded by DNA and several images of environmental factors

On June 6-7, 2016, I had the honor of participating in the “Precision Public Health” summit hosted by the Gates Foundation and the White House Office of Science and Technology at the University of California in San Francisco. The summit focused on developing a global “precision” agenda to improve health and prevent death and disease in the first 1000 days of life, but many of the concepts discussed apply throughout the life span. Experts from around the country explored how “big data” can be used to ensure that all children have the best opportunity to survive and thrive.

The meeting featured leaders from public health, healthcare, academia, industry, community organizations, philanthropic organizations, as well as patients. The meeting included presentations on several aspects of child health and development as well as focus of infant and child diseases of public health significance. Topics discussed included sudden death, prematurity, asthma, lead poisoning, infectious diseases, newborn screening, and others.

The concept of “precision public health” is relatively new. Of course, the “precision medicine” movement has taken off in the past few years, especially with the implementation of the precision medicine initiative in the US. If the goal of precision medicine is to deliver the right health intervention to the right person at the right time, the ultimate goal of precision public health is to develop and implement health interventions that can benefit the right populations at the right time. While implicit in the precision medicine concept is the use of genomic, behavioral, and environmental data in developing new and targeted interventions, more often than not, the discourse is about developing new drugs for treating cancer and other diseases. There is much less emphasis on joining biological with social/environmental determinants of health to develop and implement precision approaches to keep individuals and communities healthy.

For two days, participants heard about examples of increased precision in public health approaches with a clear focus on social and environmental determinants of health. The passion and commitments exhibited by participants were quite impressive. Breakout groups tackled many topics including, among others, building a definition and success criteria for the field of precision public health, engaging communities in precision public health, integrating various sources of environmental data for policy and decision support, and creating a Precision Social Justice Toolkit.

As we eagerly await the summary write-up of this event, I reflect briefly on the three essential elements of precision public health.

Data: As the data deluge continues, we have a unique opportunity to use information from multiple levels both “below the skin” (genomics, omics, molecules) and “above the skin” (behavior, environment, place, policies) to have a more coherent picture of determinants of health and disease in each population. As discussed at the meeting, there are ongoing studies (e.g. asthma) and near term opportunities for linking existing data and applying new tools of measurement to get a more complete picture of health and disease in relation to time, place and persons. Better and more precise measurements of environmental and social determinants of health and their interactions with our biology could lead to more focused interventions that are not “just drugs, genes and diseases.”

Action: One important take home message is that data are not enough! New and more precise population health data should be used to develop and implement actions that can improve health and prevent disease. Actions can include treatments, prevention strategies, policies, and programs. The “precision” in action will be based on evidence that ties population data to measurable outcomes in subpopulations stratified by persons, place, and time. Action is also multilevel (e.g., individual, family, community, societal) and multisectorial (healthcare, education, housing, etc.) Solving health problems of children (and adults) will involve both the private and public sector using decision support tools and community data to impact health and policy and program decisions.

A focus on equity: A fundamental concern for public health is promoting health equity by reducing health disparities among groups of people. Throughout the summit, there was a focus on addressing health equities in populations both in the US and globally. If precision medicine is to succeed as a movement, its’ benefits need to reach all segments of society. Starting with equity in mind, population data collected should not only document that inequities exist, but influence actions and solutions to address them. Dr. Sue Desmond-Hellman articulated this emphasis on equity, in her recent TED talk and reiterated again at the summit. For example, on the topic of precision surveillance she said:

“…let’s say, for example, we find out in certain areas of Africa that babies are dying because of a bacterial infection transferred from the mother to the baby,known as Group B streptococcus. In the absence of treatment, mom has a seven times higher chance that her next baby will die. Once we define the problem, we can prevent that death with something as cheap and safe as penicillin. We can do that because then we’ll know. And that’s the point: once we know, we can bring the right interventions to the right population in the right places to save lives.”

Precision approaches can also be applied to other global health problems, such as malaria, HIV, cervical cancer, and more.

In closing, I believe that precision public health is not a “me, too” movement that is attempting to divert attention from the important work of precision medicine, but an essential public health partner that can leverage new tools and technologies to measure health in populations and to develop the right interventions that will benefit all segments of society. The work is just getting started to establish collaborative processes, networks, governance and tools to build a strong evidentiary foundation for precision public health.

June 15, 2016 by Muin J Khoury, Director, Office of Public Health Genomics, Centers for Disease Control and Prevention