Precision public health-the Emperor's new clothes.

Abstract

Recently the Centre for Disease Control suggested that ‘precision public health’ presents significant opportunities to improve the health of the population,1 but what does this concept add and does it live up to the hype? The promise is that by harnessing the power of Big Data, particularly genomic data, we may indeed see early gains in public health as a result of ‘more-accurate methods for measuring disease, pathogens, exposures, behaviors, and susceptibility’ to guide targeted prevention strategies.2 However, the term ‘precision public health’ is susceptible to misinterpretation. Long before Big Data in the form of personalized genetic and epigenetic profiling arrived, much public health screening and prevention strategy was premised on varying degrees of targeting and stratification, so this is nothing new. Nevertheless, others in the UK have used analogous terms such as ‘personalized prevention’ or ‘personalized public health’, representing them as part of an urgent agenda in which we must ‘reap the benefits of the genomic revolution’.3 The purpose of this article is therefore to highlight some of the evidentiary and philosophical challenges for the concept of ‘precision public health’ which have not been exposed to sufficient scrutiny. It is also to argue for a more considered focus beyond the genome, lest we career headlong towards a diversion of resources, away from what really matters, to the detriment of population health. To do this, we structure our critique by aligning it with the so-called population perspective on precision medicine (i.e. the ‘P4 approach’), namely that precision public health should aim to be Predictive, Preventive, Personalized and Participatory.4 The advantage of taking this approach is that whereas it focuses on the key dimensions and parameters of the decisions that could help improve care both for individuals and populations, it has gained traction among precision medicine proponents themselves. Thereafter we return to the more philosophical and ethical arguments that should remind us of a bigger picture and the trade-offs that we might be making by investing in ‘precision public health’.