Closing Geographic Health Gaps Will Take a Local and Systemic Response

The US has some of the world’s most advanced medical research institutions, spends more on healthcare than any other country, and routinely delivers remarkable cures. However, where an individual lives can still profoundly influence their risk of disease, access to effective care, and likelihood of surviving an illness.

That contradiction was at the center of a special lecture delivered yesterday by Monica M. Bertagnolli, MD, FACS, president of the National Academy of Medicine (NAM).

“We map the human genome, engineer vaccines in record time, and routinely perform surgical miracles that would have seemed like science fiction a generation ago,” Dr. Bertagnolli said. “And yet, for all of that, our health system fails us—repeatedly and predictably—in ways that should not be acceptable to any of us.”

Dr. Bertagnolli, a surgical oncologist and physician-scientist who previously served as director of the National Institutes of Health and National Cancer Institute, argued that improving health nationally requires a better understanding of the conditions affecting patients where they live.

Geographic Health Gaps Persist Despite National Progress

Drawing from her area of expertise in cancer care, Dr. Bertagnolli noted that geographic differences in cancer mortality illustrate the problem. The overall US cancer death rate has fallen substantially during Dr. Bertagnolli’s career, with millions of lives saved through advances in treatment, earlier detection, and reductions in smoking. But those benefits have not reached everyone equally.

She contrasted Summit County, Colorado, which had one of the nation’s lowest age-adjusted cancer mortality rates, with rural Union County, Florida, where the rate was more than four times higher.

These differences cannot be explained primarily by inherited genetic risk, she said. Physical environmental factors, including pollution and chemical exposures, as well as social conditions, lifestyle, social support, and access to affordable healthcare can all influence disease incidence and outcomes.

“Where you are born in America shapes your health in ways that are as profound as your genes,” she said.

Genetic and Environmental Factors Must Be Addressed

The growing capabilities of precision medicine make understanding those influences increasingly important.

Dr. Bertagnolli pointed to the case of an infant who received personalized gene-editing therapy using CRISPR, customized specifically for his genetic variant. It is a remarkable demonstration of what modern biomedical science can accomplish, but delivering that treatment required extraordinary scientific, regulatory, healthcare, and industry resources.

That achievement therefore raises a larger question about whether medical advances can reach everyone who could benefit.

“In the richest nation in the world, we haven’t found a way for all people—forget CRISPR-based gene therapy—to receive the care we already know will save their lives,” she said.

Precision medicine consequently must encompass more than matching genetic or molecular characteristics with treatments.

“Today, the focus needs to be about so much more,” Dr. Bertagnolli said. “This approach calls for new ways of classifying disease by deeply integrating basic research data and clinical data, not just identifying which gene or protein variants should be used, but integrating all relevant data, including the cultural and societal factors that drive health disparities.”

Central to that vision is a learning health system that continuously collects evidence, measures outcomes that matter to patients, and uses feedback to improve care, a longtime priority of the NAM.

Such a system also could better connect biomedical information with environmental and social data relevant to individual patients and communities.

Getting AI Right Must Benefit All

Artificial intelligence (AI) could accelerate that process, but Dr. Bertagnolli cautioned that its value will depend on the quality and representativeness of the data underpinning it.

Excluding populations from datasets risks perpetuating or worsening existing disparities, an issue the NAM is working to address by calling for health data to be treated as a public utility and used for the benefit of all.

Along those lines, an important goal of the NAM is to ensure policymakers are guided by evidence when creating coordinated laws, regulations, and government actions that improve public health and foster progress in biomedical research and healthcare delivery.

She also emphasized that healthcare should approach AI with the same rigor used for other potentially transformative medical interventions.

“Not so different from powerful new drugs, the way we develop and deploy new AI methods carries risks that must be minimized by very careful product development to achieve patients’ needs, comprehensive pre-implementation testing, and ongoing monitoring to maintain performance as medical practice evolves,” she said.

Technology, however, cannot substitute for one of medicine’s most important assets: the relationship between clinicians and patients.

“Medicine is founded on a sacred concept: trust that is earned by human-to-human interactions,” Dr. Bertagnolli said. “I don’t see us trusting AI for our care. Using its amazing capabilities? Absolutely, I can’t wait. But we will never, ever eliminate a caring human being from the loop.”

The talk is available on demand on the conference Meeting Platform for all registrants.