EDITORIAL

Progress lies in precision

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Science  19 Aug 2016:
Vol. 353, Issue 6301, pp. 731
DOI: 10.1126/science.aai7598
PHOTO: ©BILL & MELINDA GATES FOUNDATION/STEVEN DEWALL

Too often, I feel as though I live in two worlds. One is populated by scientists working on advanced tools, such as big data, sequencing, and data-based disease surveillance. The other is populated by public health professionals working on the demanding challenges of combating infectious diseases, empowering women and girls, and ensuring that more children survive and thrive. If we want to achieve the ambitions set out by the United Nations for global health and development by 2030, we need to bring these two worlds closer together through a new concept—precision public health.

PHOTO: ©BILL & MELINDA GATES FOUNDATION/RICCARDO GANGALE

“Precision public health is already happening…”

The idea of precision public health has its roots in the precision medicine revolution, particularly in cancer treatment. By harnessing more effective tools—from big data to predictive analytics—oncologists are making more informed therapy decisions, applying specific agents to subtypes of tumors in ways that minimize side effects and maximize optimal clinical outcomes. This approach is starting to transform the way physicians think about treating other diseases, enabling different strategies, for different patients, at different times. Can we take the principles of precision medicine a step further, from individuals to populations?

Today, public health strategies involve epidemiologists examining geography, medical histories, biomarkers, and physical and demographic characteristics; and measuring exposures, behaviors, and susceptibility. General policies and programs are then developed. But a one-size-fits-all process does not always bring desired results. By more accurately detecting, identifying, and tracking unique traits in subpopulations, subgroups, or even communities, we can respond with greater precision.

Precision public health is already happening in a limited way, with big impact. Worldwide, around 17 million women are living with HIV. If an infected individual gets pregnant, she can pass the virus to her baby. Half those babies will die before their second birthday. Antiretroviral therapy almost guarantees that mothers will not pass on the virus. However, it has not been possible to test every pregnant woman everywhere for HIV, and then treat those who test positive. Instead, testing and treatment are focused on the areas of sub-Saharan Africa where enhanced data collection and analysis have revealed that HIV among women is most prevalent. This more exact approach to a public health problem has cut HIV transmission to babies by almost half in 5 years.

Although technological and scientific advances are changing the way some diseases and conditions are tracked and treated, there has been too little focus on how scientific tools used in high-resource areas can help people in low-resource areas. Take, for example, the lack of specificity around the 2.6 million neonatal deaths every year, most of which occur in the world's poorest countries. Much of what we know about them relies on “verbal autopsies” and model data. The Bill & Melinda Gates Foundation is now working with partners on a program that takes tissue samples from the newborn to determine causes of death more definitively. The goal is to identify trends in a particular region, and then deliver specific interventions to help reduce infant mortality. Ultimately, I believe this approach could help save 1 million babies every year.

Imagine what more could be achieved. More children will survive and thrive if we know more about the causes of malnutrition in different populations with different diets and cultural practices. More women will avoid cervical cancer, the leading cause of cancer deaths in low-resource countries, if we know more about different risks in different populations. Fewer people will contract malaria if we know more about how it spreads differently among populations, and how the parasite and mosquito become resistant to remedies.

We have the tools to bring the right interventions, to the right people, in the right places to save lives. Now, we just need the will.

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