The false promise of personalized medicine in the global environment

Physicians listen to the patient in front of us. We care for one patient at a time. There is inherent individualization in the patient interaction. Each story is unique. Each treatment plan is tailored.

The patient gasping for breath in the bed in front of me is not any patient; he or she is my patient. However, this patient's story and the issues that led to their difficulty breathing do not exist in isolation from broader factors. This reminds us that their story happens in a context, as no one is an island. This sets up a false dichotomy — that public health is somehow separate from individual health — and it creates a push and pull in modern medicine between ultra-personalized medicine and generalized preventive medicine.

Increasingly, the health community acknowledges the impact of the world in which patients find themselves. WHO defines social determinants of health as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.” Even more foundational are the ecological determinants of health — the global, national and local environmental factors that influence human health. This is not just the disruptions to care or the deaths caused by extreme weather events. The distribution of vector-borne illnesses is changing. Exposure to toxic chemicals can lead to neurodevelopmental and congenital defects. Pesticides, lead and mercury exposure tend to disproportionately impact children and pregnant women. Air pollution from fossil fuels has been associated with stillbirth, low birth weight, cardiovascular disease, cancer, pneumonia, asthma and increased hospitalizations. Conditions as diverse as mental health problems and dementia to heat-related illness are linked to the climate crisis. There is the emergence of new biohazards like water scarcity, crop failure, nanoparticles and microplastics.

Victor Agbafe

As clinicians, we have neglected the public arena, the environment, all that undergirds the social determinants of health, thinking we should only treat patients in the exam room. In so doing, we avoid addressing the social determinants that account for 80% of our patients’ outcomes. Instead, we convince ourselves that just addressing the remaining 20% is adequate and that we have done our jobs.

We are easily wooed when a new (and usually expensive) drug comes to market with the promise of improving LDL by 10%, extending the life of our cancer patients by 4 months, or decreasing systolic BP by 3 mmHg. We are wowed by promises of genomic screening and treatments that may work for our individual patients. However, to truly move to the next frontier of progress in alleviating human suffering, we must bring the same zeal and interest to restoring and preserving the health of the ecosystems in which our patients exist. Of course, we should continue to seek biomedical and technological advancements in medicine; however, this should be paired with interventions to address the environmental determinants that can contribute to sickness in the first place. No one would say that advancements in medicine should stall, but it is clear that an overemphasis on the individual in U.S. medicine negates the effect of the environment on everyone.

One example of how U.S. medicine has failed to address these health harms is the waste generated by the very care that we provide. U.S. health care is responsible for 8.5% of U.S. greenhouse gas emissions, and waste production from health care is second only to the food industry, with hospitals producing more than 5 million tons of waste annually.

Elizabeth A. Cerceo

It doesn’t need to be this way. We have cheaper clean energy sources, and we know how to specifically target issues in health care, such as avoiding desflurane and shifting away from single-use disposable devices. There are many resources to help health systems address this, such as the Agency for Healthcare Research and Quality’s primer for reducing health care carbon emissions, Health Care Without Harm and My Green Doctor, among others. England’s National Health Service is already on track to be net zero by 2040 by streamlining, eliminating waste, making care more patient centered and decarbonizing their supply chain. Additionally, there is often a strong return on investment, weakening the financial argument against taking action.

Small steps are being taken. In 2022, HHS put out a voluntary pledge to reduce organizational emissions by 50% by 2030 and achieve net zero by 2050, publicly accounting for progress. This followed the White House’s creation of the Office of Climate Change and Health Equity in 2021, demonstrating its understanding of the scope of the impacts. The Department of Veterans Affairs’ sustainability plan includes net-zero buildings, carbon pollution-free electricity and a zero-emission vehicle fleet. Although the health care industry successfully beat back The Joint Commission’s attempts to incorporate sustainability standards as part of their accreditation process, the writing is on the wall. We can ignore it to the peril of our patients our duty to do no harm and the global competitiveness of our health care system.

Physicians have relegated themselves to the bedside and inpatient floor while neglecting our duties and failing to speak up in the streets, in the boardroom and on the legislative floor. In doing so, e are letting the health of our patients fall to policymakers and lobbyists without a health-centric voice at the table.

A healthy environment is quite literally foundational. It is the ground beneath our feet, the air we breathe, and the water we drink. We have the tools now to prioritize public health through environmental regulation and preservation. We must tell our hospital executives that health care sustainability is important for people, the planet and profits. State hospital associations need to hear from hospitals that this matters. Physicians, residents, medical students and all who patients must raise the issues of health care sustainability and environmental health hazards with their representatives at the local, state and federal levels. Physicians must be at the forefront, advocating for policies for our patients and communities, because we cannot adequately care for the individual patient in front of us without caring for their community.

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