Exposome Perspectives Blog by Robert O. Wright, MD, MPH
Say a prayer for the cowboy
His mare’s run away
And he’ll walk till he finds her
His darling, his stray
But the river’s in flood
And the roads are awash
And the bridges break up
In the panic of loss.
And there’s nothing to follow
There’s nowhere to go
She’s gone like the summer
Gone like the snow
And the crickets are breaking
His heart with their song
As the day caves in
And the night is all wrong
Leonard Cohen, “Ballad of the Absent Mare”
The most extraordinary moments in life are often found in our most ordinary moments—when we stop our search for meaning to share a meal, walk our dog, listen to the crickets, or watch the sun set. These pauses to live in the moment matter most. “Ballad of the Absent Mare” was part of Leonard Cohen’s brief foray into country music—the perfect vehicle for metaphors on loss, heartbreak, and life. The song was inspired by the Zen Buddhist story Ten Bulls, a series of poems and drawings about the personal search for enlightenment, which requires living life: experiencing loss, mourning, feeling adrift in the world, and ultimately finding wisdom. The song mirrors the story through a man’s search for his beloved but lost mare. In the beginning, the cowboy tracks the horse, finds footprints in the mud, and glimpses of her in the distance, always seemingly beyond his reach. Eventually, he catches the horse, tames her, and returns home only to lose her again. In the end, he realizes that by releasing her, he has let go of attachment and can move on in life with wisdom and compassion. The song is meant to symbolize the spiritual journey Cohen learned over a lifetime that included studying for years in a Buddhist monastery. The wisdom he discovered is the importance of living in the moment, because all of life eventually disappears like “the smoke.”
But my darling says “Leonard, let it go by”
That old silhouette in the great western sky,
So I pick out a tune and they move right along,
And they’re gone like the smoke,
And they’re gone like this song
We seem obsessed with replacing what is real with what is artificial—like using food preservatives or genetic modifications instead of producing more natural food without thinking through whether that is wise. These are simple solutions masquerading as sophisticated approaches to solving food production. They address the problem linearly, but the world is not linear or simple. It is interconnected. Short-term, they may seem to work, but eventually simple solutions to complex problems create unintended consequences—higher pesticide exposures or obesity—because our world and our biology are interconnected. The song and the parable of “Ten Bulls” aren’t about wisdom; they are about the path to wisdom. We cannot achieve wisdom or health until we live through the stages of life and learn how to navigate human relationships. It’s easier to eat junk food or to use AI to write your paper than to cook for yourself or analyze and reflect on your own, but that is not the path to health or wisdom. We are forgetting that we are social beings and increasingly drifting apart. These societal trends have subtle implications that keep us apart even in science. We have had the tools to integrate across fields—genes and environment—for years, but we choose not to do so. Scientists work in silos because that is the simpler solution. The hard work of collaboration—which requires building relationships—is avoided.
We persist down this path even though, over the last 20 years, our approach to health is clearly not working. We are getting sicker. Anxiety and depression, heart disease, cancers, attention deficit/hyperactivity disorders, and many other illnesses are increasing. We’ve invested billions of research funding focusing on what we can quantify—nucleic sequences, proteins, chemicals, and, more recently, artificial intelligence (AI)—while neglecting the things that make us uniquely human: purpose, place, peace, prayer, and human connection. We don’t acknowledge that molecular biomarkers alone aren’t enough to find biological truth, and we avoid doing the hard work of learning something new through collaboration with other fields of science.
Magical Realism and Science
The literary genre of magical realism uses metaphor to offer a response to an increasingly empirical scientific worldview. In magical realism, the extraordinary is ordinary, and the ordinary is extraordinary. There are things about life and biology that we will never understand, and there is nothing wrong with that—in many cases, we simply need to embrace them and apply them.
In Laura Esquivel’s novel Like Water for Chocolate, food, emotions, culture, and family all intertwine to create unexplainable phenomena. The main character, Tita, is trapped by her mother into spinsterhood as family tradition dictates that the youngest daughter must care for her aging parents. Her mother has taken the meaning from her life. Tita believes she is destined to die alone, and her despair and loneliness begin to seep into her cooking. Her tears mix into a cake batter, causing everyone who consumes it to weep uncontrollably.
For Esquivel, emotions are as contagious as a virus, and she asks the reader to accept that emotional transmission can happen through cooking without scientific investigation. This metaphor for food, culture, and social connection signifies that emotions, i.e., the parts of the world we cannot quantify, are what shape our lives. We all know that food, culture, and social connection are critical to life and to health. So, when we remove the social context and culture from food to make it ultra-processed and cheap while replacing personal connection with doom-scrolling from dawn to dusk, should we be surprised that we become less healthy?
Is measurement more important than importance?
Modern science craves measurement and its associated data—like an addict needing a numbers fix. Once we find a mathematical pattern, no matter how weak, we issue press releases to tell the world that our objective discovery will either cure the incurable or predict who among us will get sick. Follow-up press releases are rare because replication is rare. The press release and a new biotech company become our destination, and they inevitably both fade from memory.
Another subtle implication of modern science is that we have no human agency—the capacity to make independent choices, act intentionally, and exert control over our lives, health, and environment. We are both predictable and replaceable. There is a soulless, “give us your blood and we’ll forecast your future health” feel to the future of medicine. We sequence the human genome even though more than 99.9% of what is measured is the same in everyone, and yet we persist in believing that the DNA sequence set at birth is all we need to predict an individual’s disease destination, ignoring the journey of the individual after birth that ultimately led them there. When it turned out that common genetic variants could not explain chronic diseases like type 2 diabetes, ADHD, or Alzheimer’s disease, rather than change direction, we doubled down—arguing that we don’t want to miss the rare variants—even though chronic diseases have become more common, not more rare. Genomic FOMO in science is the norm. Exploring interactions between the environment, our life’s journey, and our genome can wait till we’ve exhausted all the genomic possibilities. The reality is that the majority of chronic diseases are not driven by genetic mutations—yet we study them as if they are.
What are the right questions?
Our social exposome is powerful, multilevel, and deeply connected to our health—one would think that understanding how it operates would be a high priority—instead, we seem intent on minimizing it. I remember not long ago, sitting in the audience of a computational talk on AI and health. When the speaker was introduced, it was noted that he studied higher math because it was the most difficult of all subjects. I wondered to the person next to me if he’d ever written a song or a poem.
He proceeded to tell all the physicians in the room that they will soon be replaced by AI, because machines can make diagnoses faster than they can and create a more complete treatment plan. Clearly, he believed health is cognitive alone. Why this was even a good idea was never asked. There was discussion over whether AI would work, but in the end, we were told that this is inevitable. AI will definitely retrieve more information than a human and perform calculations faster, but good health care providers are not just knowledge machines. Empathy is not an add-on to health care with a billing code—it is health care. The truly hard part of medical care is not memory but trust and relationship-building. Why do we think replacing doctors and nurses is a goal worth pursuing? Why would anyone devalue the journey of the relationship that leads to provider-patient trust and think that AI is better? Profit is the answer.
Instead of improving efficiency alone, researchers should be asking—What should we be doing to get healthier? What the public needs, experiences, or deals with on a daily basis is rarely the driving factor in what we study. If it were, we’d have more research focused on reducing health care costs and improving access. We have an epidemic of chronic diseases—obesity, heart disease, cancer, dementia, ADHD, and more—yet for the last 30 years, we have concentrated our efforts on a factor that cannot explain these increases: genetics, and now we are shifting to a new idea that takes those pesky nurses and doctors out of the equation.
We didn’t arrive at this predicament because we have too much human interaction in health care or through mass mutation, but our research funding choices suggest otherwise. We also don’t need research demonstrating the benefits of promoting healthy food, social connection, exercise, and happiness; we should instead study how to promote them. We need to understand why it has become so hard in the modern world to stay or become healthy in the first place. AI can be helpful to physicians and nurses in retrieving information, or in integrating data (such as genomics and address history) to help us understand their life’s health journey, but it will never be a health care provider because it has only read about life journeys. It has never experienced one.
We keep replacing the real with the synthetic—whether it is food, social relationships, or health care workers. We are forgetting what separates us from machines. Why not study the events, activities, persons, places, and things that lead to health instead of disease? How can we even understand all this quantified genomic biomarker information without measuring the context in which it occurred and lives from conception to death? After all, we don’t just inherit our parents’ genes—we inherit their wealth (or lack of), place (home), persons (family), peace (or lack thereof), and prayer (faith). We forget that a family history will tell you as much about the shared environments your relatives lived in as it will your shared genes. Everything, even our genetics, is contextual. AI can help us integrate that information, but a machine incapable of empathy should never be in charge of health care decisions. I am not arguing that we should abandon AI; that would make me a hypocrite, as I am busy learning prompt technology so that I can understand how to use it. Instead, like Bruce Lee, I advocate being like water—rather than fight an unwinnable fight. Water flows can be redirected. Try AI if you haven’t yet, and you will be astonished at how good and bad it can be at the same time. It can absolutely make your life a little easier, but it has no life experience, which is why it is so often wrong as well. Do it, but take your time and take the journey of learning how to use it wisely.
“We must be clear that when it comes to atoms, language can only be used as poetry.” Niels Bohr
Bohr was not criticizing the limitations of poetry; he was pointing out the limitations of human thought. Our minds use language to think and, therefore, cannot describe quantum physics because the words needed to describe the concepts do not exist in any human language. Poetry takes language beyond what is literal to what is invisible (love, loss, fear), enabling these concepts to be seen and understood indirectly with language.
Math is a language as well. Like quantum physics, our ability to describe biology, health, and disease with language or math is primitive; we cannot directly capture it. The interconnections between our minds, our cells, and our tissues, and between these internal systems and the dynamic external world, operate on scales and systems that we may never fully understand.
All our attempts at understanding biology are poetry, not reality. AI is a large language model, which means it is predicting biology with the tools we gave it through language and math. Its limitations are the same as ours. The saying “there are no words” captures something emotional that is not found in the meaning of any individual word. Emotions are not quantifiable in a mathematical sense. They may correlate with hormones or proteins, but their catalysts are people, pets, relationships, situations, and even small acts of kindness. Love, sorrow, grief, happiness—these are the parts of our journey that give life meaning. The most powerful moments in our lives are emotional; they are not in our genes, and they are not captured by chemicals.
A large language model may seem to understand, but it cannot feel and has no life experience. Therefore, it will never truly understand the moments “when there are no words”—it will only make a prediction on how to respond. That prediction may be useful to us, but we need to be part of the interpretation. Quantifying and replacing what makes us human will make us less human and is doomed to failure, but it may be a very rocky path to reverse these trends if we wait too long. We still have agency—let’s choose a different path. Regulate AI so that it can be used wisely.
To pay homage to Niels Bohr, Laura Esquivel, and Leonard Cohen, here is an excerpt from a Pablo Neruda poem about how to measure one’s life.
“Ode to Age”
I don’t believe in age.
All old people
carry
in their eyes,
a child,
and children,
at times
observe us with the
eyes of wise ancients.
Shall we measure
life
in meters or kilometers
or months?
How far since you were born?
How long
must you wander
until
like all men
instead of walking on its surface
we rest below the earth?
To the man, to the woman
who utilized their
energies, goodness, strength,
anger, love, tenderness,
to those who truly
alive
flowered,
and in their sensuality matured,
let us not apply
the measure
of a time
that may be
something else