A Call for Course Correction: Applying an Antiracism Lens to Precision Public Health

Precision public health (PPH) has captivated the public health field in recent years on the premise that by tailoring preventive interventions for individuals who are considered high risk, the overall health of the population will ultimately improve. In this issue of AJPH, Allen et al. (p. 1210) apply an antiracism lens to this work, highlighting evidence-based, equity-minded approaches to the development, implementation, and evaluation of PPH interventions. As such, the authors illuminate potential opportunities for researchers and practitioners to apply a critical framework to PPH mental health interventions and, in doing so, strengthen PPH’s promise of achieving greater health equity for all.

The concept of PPH emerged nearly a decade ago as an extension of precision medicine, presenting the possibility of personalized clinical approaches to population health via big data and new genomics tools to predict, detect, and treat people exhibiting the greatest risk of disease.^1,2 Elevated by President Obama in his 2016 State of the Union address, the initiative quickly captured the public’s attention, inspiring global conferences and attracting major federal funding dollars.³ However, despite the excitement surrounding it, many in the field have questioned its potential impact on population health. Bayer and Galea have argued that PPH’s individualized clinical focus distracts from the more pressing need for comprehensive social policy to address the social determinants of health that negatively affect millions of Americans across the lifespan.⁴

In recent years, focus has shifted to include greater emphasis on the structural determinants of health, with proponents arguing for more social and economic policies aimed at uprooting the social inequities that drive health disparities.^5,6 In the wake of COVID-19, the field of public health has acknowledged that greater attention is needed to comprehensively address the mental health crisis that has affected millions of Americans, especially those lacking adequate social and financial support.

THE PROBLEM WITH PRECISION PUBLIC HEALTH

The enthusiasm surrounding PPH simultaneously reflects our national appetite for shiny new things and avoidance of doing the hard work of addressing the staggering inequality that drives the majority of negative health outcomes experienced by communities that have been systematically disenfranchised by US economic and social policies. Moreover, critics have correctly highlighted that PPH fails to mitigate the real challenges these individuals face in accessing routine medical screenings and care. These include, but are not limited to, a historical mistrust of medicine (e.g., Tuskegee, Henrietta Lacks, Sara Baartman),⁷ perceived discrimination by medical providers,⁸ and limited standardization of curricula on implicit bias, antiracism, and diversity, equity, and inclusion in health professional degree programs.^9,10 People with low socioeconomic status (SES) are also more likely to be uninsured or underinsured, and consequently are less likely to opt for expensive health testing and treatment. Even for those who are insured, individuals with low SES are more often faced with the decision of paying rent or purchasing food, pushing health care further down their list of priorities.¹¹

Although PPH does offer some measure of promise to prevent disease from occurring in the first place, this premise proves tenuous at best because it fails to fundamentally address the social and structural determinants of health that disproportionately affect communities with low SES and diverse identities. When applying these challenges to mental health interventions, we must also highlight the additional stigma faced by Black, Latinx, and Indigenous communities that disincentivizes individuals from seeking professional support for themselves and loved ones.¹² This ultimately begs the question: what is the value of modernizing technologies to pinpoint the next big outbreak or genomic marker if individuals who are the most vulnerable to its potential impact are wary of getting screened—or unable to do so—because of systemic barriers to care?

NOTHING ABOUT US WITHOUT US

Coined during the 1990s disability rights movement in South Africa, “Nothing About Us Without Us” provides a common rallying call for scholars to evolve their efforts in dismantling systemic oppression.¹³ A critical first step invites us to center communities at greatest risk of disease in the research and development of interventions that they stand to directly benefit from. In doing so, researchers and community members become cocreators of knowledge, which in turn cultivates engagement and, over time, consistent opportunities to sow seeds of trust. When applying this critical framework to PPH interventions, community-based participatory research provides useful guidance, inviting the engagement of community members through community advisory boards to participate in all stages of the research, translation, and dissemination processes.¹⁴ Moreover, PPH interventions that implement a person-centered design may also mitigate another challenge posed by PPH—specifically, biases in big data created in the collection and analysis stages of research that serve to undermine equitable practices in health care delivery.¹⁵

As public health practitioners and researchers, we are called on to be more inclusive and thoughtful in our collective efforts to achieve greater health equity for all. This can only occur through thoughtful praxis, requiring vigilance and critical questioning of all new public health initiatives that claim to improve population health. In response to the fundamental challenges PPH presents, Allen et al. have effectively redirected researchers and practitioners to center people, not technology, at the heart of this work. And in doing so, they invite future PPH research and innovation to make good on its original promise.