Precision medicine in low-income settings and small island developing states.

Precision medicine tailors prevention, diagnosis and treatment of cardiometabolic diseases to individual genetic, environmental and lifestyle determinants, with the potential to fundamentally change healthcare. However, low-income and middle-income countries (LMICs) and small island developing states (SIDS) experience severe implementation barriers: inadequate healthcare infrastructure, prohibitive costs, under-representation in genomic datasets and additional SIDS-specific constraints. This Perspective advances three specific contributions beyond generic equity calls. First, it delineates distinct precision medicine pathways for larger LMICs versus SIDS, highlighting SIDS opportunities for regional consortia, shared sequencing and/or biobanking hubs and technological leapfrogging via mobile health platforms and digital phenotyping. Second, it emphasizes practical and high-impact entry points that are financially sustainable. Additionally, it advocates for integrating polygenic risk-based stratification into existing non-communicable disease care pathways rather than establishing separate specialist services. Third, it delineates a staged implementation framework that prioritizes ethical oversight and robust data governance, underscoring the importance of privacy safeguards, data sovereignty, equitable benefit sharing, community consent mechanisms and alignment with the Sustainable Development Goals to minimize associated risks of exploitation. Equitable partnerships between LMICs and high-income countries, expansion of diverse genomic data and community-driven innovation will ensure that precision tools effectively target metabolic phenotypes in LMICs and SIDS while advancing global health equity.