When we think about the exposome, the totality of all the environmental exposures we experience throughout our lives, we must think beyond those things that we know how to measure such as chemicals, nutrients, and air pollution. Understanding how our social environment impacts our health is key to unlocking effective interventions that promote health and well-being. Let’s think about this in the context of what gives us joy in life: love, music, and happy memories.
Exposome Perspectives Blog by Robert O. Wright, MD, MPH
“Now I’ve heard there was a secret chord That David played, and it pleased the Lord But you don’t really care for music, do ya? It goes like this, the fourth, the fifth, The minor fall, the major lift, The baffled king composing Hallelujah” (Leonard Cohen, Hallelujah, 1984, Various Positions)
Leonard Cohen started his career as a poet and closed it as a singer-songwriter. The beauty of his opening verse to “Hallelujah” can’t be denied, but its meaning can feel obscure. To whom is Mr. Cohen speaking? And why does that person dislike music? A fact made more curious by the religious analogy between composing a song and pleasing God. Perhaps most intriguingly, what is the underlying meaning of the ironic twist that God is the true composer and David is actually the instrument God is playing? In verses included in later versions of the song, Cohen shifts the mood from God and beauty and it becomes clearer that the song is about the bitterness of lost love and regret.
“Baby, I've been here before I know this room, I've walked this floor. I used to live alone before I knew ya. And I've seen your flag on the marble arch, Love is not a victory march It's a cold and it's a broken Hallelujah” (Leonard Cohen, Hallelujah, 1988, released on Cohen Live, 1994)
Measures of love
Perhaps God gave us love as he did music— both are gifts that we don’t understand. Of all of God’s gifts the most splendid, most beautiful, and most bitter is love. Given its undeniable importance, it is difficult to imagine an understanding of human health that is separate from measures of love. There are thousands of studies on intelligence—both in genetics and environmental health. But if we really think that IQ is more important to understand than love, then why has no one ever written a great poem about IQ? Even intuitively we all know that being loved and loving others is key to longevity and health. Yet there is so very little scientific literature on this topic.
So how does this relate to the exposome? Love is clearly part of the exposome, and perhaps we should think about how to include it in exposomic research. One of the hallmarks of science is that we tend to measure “things” quantitatively. If we cannot assign a number to a measure, then we assume it is subjective, and too often science ignores it. We much prefer lab tests to open-ended questions or qualitative measures. The rise of genomics may have as much to do with having assays, or tests, to quantify the genome than anything else. We think that generating a result via a machine eliminates bias and therefore its result is more likely to reflect “truth” than a questionnaire, which depends on nuanced language, hearing, comprehension, memory, pride, the desire to please the person asking the question, and a host of factors that can influence the answers away from “truth”. Because so many of our studies rely on laboratory tests, we subconsciously feel that this is the most rigorous way to conduct research. But whether studies with lab tests are more rigorous than studies using questionnaires ignores the more salient question—is what we learn from the lab test more important than what we learn from the questionnaire? With regards to love, I think the answer to that question is obvious.
You can’t capture a song in a laboratory test
A large portion of the exposome—maybe even the bulk of it —will not be captured in a blood or urine test. We may capture the cumulative impact of happiness, grief, and social networks but if all we measure is our biological response to our social environment without capturing the upstream factors that lead to our happiness, sadness or loving response, what good would that do? How will we intervene, counsel or understand how our social world shapes our health unless we measure it?
Think about your own life. What matters to you? Is it family? Friendships? Or your SAT score from 30 years ago? Perhaps you met a mentor that made a difference for you? For those of us with partners in life, aren’t there thousands of moments with them that have made you the person you are?
Who we are comes more from our memories
I recently attended my daughter’s wedding. The event was about six hours long including the dinner and reception, but the planning, the rehearsals, the phone calls to hotels, venues, family, and friends was months in the making and hundreds of hours. Most of those hours were hers and not mine. I experienced her anxiety, frustration, but most of all her joy vicariously, and it impacted me deeply. My main contribution was when about 15 years earlier, I played the “Book of Love” a Magnetic Fields song for her, when I wanted to introduce her to one of my favorite albums. Despite her teenage dislike of all things parental, she admitted that the song was beautiful. It captures peace, love, understanding, family, and partnership all at once through metaphor. She chose it for her wedding dance with the groom. As I watched her and my new son-in-law waltz to the song, I felt more joy than I had ever felt in my life, knowing she was happy and in love with someone who loved her dearly.
“The book of love is long and boring No one can lift the damn thing It's full of charts and facts, and figures And instructions for dancing But I, I love it when you read to me. And you, you can read me anything.” (The Magnetic Fields, The Book of Love, released on 69 Love Songs, 1999)
I don’t have a solution for capturing that song scientifically, but I have no doubt that it and many other songs are part of my health and well-being. I am certain that there are hormones, proteins and neurotransmitters that mark these feelings, but they are transient. Memory lasts so much longer. We will likely never draw blood during wedding receptions either, so those hormones, proteins and neurotransmitters won’t be captured in a test. But ask me about it, and you’ll get an earful- and a lingering smile to boot.
As we build the exposome, we should remember that who we are comes more from our memories, our experiences, community, travels, friends and loved ones. Even if we “misremember” some of the details, those memories are still a better reflection of our past than any lab test can be. Tests are unlikely to ever capture our past cumulative experience of peace, love and understanding. But memories and photos can. Perhaps one day, as we construct our personal exposome, it will include a video montage of our lives—hopefully happy—that tells us about the world in which we grew up. Not everything can be measured in a blood test—but that’s okay, because not everything has to be.