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Genetic map may widen gap between rich, poor

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WASHINGTON — The successful mapping of the entire human genetic code is such a stupendous feat — and so full of potential for good — that it seems almost gratuitous to start worrying about downsides.

Yet I do worry — and not primarily about the baleful uses to which the new information could possibly be put: invasions of privacy, ranking of human beings by insurance risk, that sort of thing.

My big worry is that the same genetic blueprint that introduces the exciting possibility of tailor-made medications without adverse side effects and, a little farther down the road, gene-altering therapies to cure and prevent deadly diseases, will have the downside effect of broadening the gap between rich and poor.

The rich will have their lives improved and extended. The poor won't.

How can that not be the case? Medicines tailored to individuals are bound to be beyond the economic reach of the uninsured. Tinkering with genes either to cure diseases or to "correct" predispositions to them will likely be too costly even for participants in standard insurance plans.

The result could be a sort of economic Darwinism.

It's true, of course, that the rich get better everything than the non-rich. But in many cases, it is truth without a great deal of significance. Rich children may go to exclusive boarding schools, but there are still quite decent public schools in the land. The rich may have mansions and yachts and frightfully expensive clothes, but the non-rich usually don't have to sleep on steam grates, forgo leisure or dress in rags. Nobody believes poor people should have drivers, personal trainers and French-speaking nurse-nannies for their children, just because the rich do.

Medical care is a different matter — or at any rate we seem to believe it ought to be. But just the other day the World Health Organization (WHO) ranked the U.S. health care system 37th on its 191-country list — behind world-leading France but also behind Singapore, Oman, Japan and virtually all of Western Europe. (We did score close to 30th-ranked Canada and a couple of places ahead of 39th-ranked Cuba.)

Two things about that report. First, it wasn't just the quality of a country's best facilities that was examined but such other factors as disability-free life expectancy, child survival rates, responsiveness and fairness. ("Perfect fairness" is defined as every household devoting the same percentage of its non-food spending on health care — regardless of how large or small its income is, or how sick or well its members are.)

Second, it was not a matter of spending. The United States leads all countries in the amount of money spent on medical care but slides to a 54th-place tie with Fiji on fairness.

That, of course, was before Monday's DNA-mapping announcement. That breakthrough bids to increase both the overall amount of money we spend on medical care and the disparity in access to that care.

Mind you, we're not talking simply about face lifts and hair transplants — expensive items, to be sure, but not directly associated with patient health. Gene mapping will make possible vast improvements in health outcomes — for those who can pay the price.

Both the improvements and the cost will increase with each new medical discovery, each new treatment, each new device. And so will the gap between rich and non-rich.

Two factors lie behind this near-inevitability: that state-of-the-art medicine is very expensive and that we have settled on payroll-linked medical insurance as the way for most of us to pay for it.

I can't imagine what can be done about the first. As for the second, is it time to start thinking less in terms of health-care insurance and more in terms of health-care assurance? That, as I see it, is what France and others at the top of the WHO list have done. Individual ability to pay doesn't matter in those top-ranked countries because the governments pick up the tab.

And their taxes are, by American standards, outrageous.

Is there some middle ground between democracy-threatening disparities in health care and confiscatory taxation? Hadn't we better — even in the midst of our jubilation over this week's breakthrough — start looking for it?

William Raspberry's e-mail address is willrasp@washpost.com .