科技如何重塑未来医疗：从基因工程、AI到肠道微生态的边界与平衡

Drew: It is really hard to kind of get credible information out there that's also compelling when you're competing in in a world where where there's so much it's so easy to generate content that is compelling that is not accurate.

Zach: Yeah. I mean there's so many ways to be wrong and there's only a few ways to be right and and so you know just if you do the math it's like if you say something it it's probably going to be wrong. Um unless you take a lot of steps to figure out if it's actually true uh true or not.

Drew: All right. You want me to go first?

Zach: Let's do it.

Zach: All right. Let's get into it. What is a health metric you wish people would focus on more?

Drew: Is it too cheeky to say no metric? Um, so I think that we are inundated with health metrics. Some of that is to the good. I'm a doctor. A lot of what I'm focused on is metrics and quantification and how do we get people's cholesterol level to the right um uh number. But um I think we're also losing the ability to feel our bodies to understand subjectively what it means to be in good health and do I have energy today? Am I feeling unsettled? Um what does it mean to thrive? And so I think that instead of layering on more metrics which have a place, um the most important metric is really this qualitative sense of do I feel healthy today?

Zach: Yeah, I love that. Uh I couldn't agree more. We try to like quantify things, put a number on it, and that makes decisions easier, right? Um but the reality is that like everybody's biology is so different and so those numbers are sort of like um indicative, but I agree with you that there's a lot of behaviors and things that I think that probably make a lot of sense like um for people to spend more time on. for myself as a microbiologist like you know my answer to this is always the microbiome right but like even there there's not like a number or a metric that you can measure everyone with and tell people to live their life based on.

Drew: totally and for some people it can be motivating to have a number So if someone says walk 10,000 steps, maybe that takes someone and gives them a real tangible goal to walk towards. But I also think there's a problem when people have to look at their sleep tracker to figure out whether they feel well rested and they're outsourcing this judgment that is actually really intuitive and subjective to a mechanical device when actually just asking yourself, "How do I feel today?" I think is the best measurement.

Drew: Yeah. What is something that seems radical in healthcare now that will seem ordinary 20 years from now?

Zach: I love this question. I think honestly it's genetic engineering. recently uh uh we the a person with cickle cell anemia we we cured that we I didn't I wasn't part of it but you know the the the medical community uh cured that uh by using genetic engineering and I think that is an amazing uh accomplishment. And I think that in 20 years we're going to see that go from curing one person to curing thousands of people and then millions of people. And as it becomes cheaper, as it becomes safer, as it becomes more accessible, it's going to totally transform healthcare. We can start eliminating things like Huntington's disease, we can eliminate all kinds of like really devastating single gene diseases. And it seems radical now, it sounds almost sci-fi, but I think that it will be completely ordinary in 20 years.

Drew: I love that and I think crisper related genetic technologies they are the future and they're going to have a um totally transformative impact and they're already having transformative impact as you're saying on certain diseases. another really powerful technology which is of course AI and machine learning. But I have a slightly different take on that, which is I think what feels radical now, but will feel totally ordinary in 20 years, is allowing AI to take over all the mechanical stuff—analyzing thousands of pathology slides, pulling patterns out of noisy medical records, doing administrative tasks—so that it actually frees up humans to do the human parts of care. In things like palliative care, or dementia, or end-of-life care, what is healing is the human presence, the empathy, the listening. If tech can get doctors away from screens and back to the bedside, that would be a radical shift that I hope becomes ordinary.

Zach: Yeah. I think that last point really sparks a thought for me which is that like a part of the care is the human interaction and like you mentioned like sort of like palative care or like dementia or things like that right where there the interacting with this trusted person right who's like looking you in the eye and really caring about you is is the therapy in a lot of ways and so technology should empower that, not replace it.

Drew: Yeah. Let's do it.

Zach: All right.

Drew: What do you think should be fair game in biology or medicine that people right now are reluctant about? I think a lot about um how poorly we do in detecting and treating cancer at an early stage and I think there's a tremendous appetite um from the public to go beyond the types of screening that we currently have. But there's a lot of reluctance in medicine around full body scans and heavy screening because of false positives and overtreatment. But on the other side, I think about using biotechnology in our food supply.

Drew: Say a little bit more about that. I mean about using biotechnology to improve the food supply. When they think about technology entering the food space, they think about ultrarocessed food.

Zach: That's such a a great call out. You're right that like a lot of what the re part of the reason why there is a lot of mistrust of technology is that the technology that is in our food system is not always to our benefit. And so I agree that that engineering or that bi technology should be being applied to improve nutritional content, to improve taste, to improve accessibility and sustainability. Historically, we bred crops for yield and shelf-life, but at the expense of flavor and nutrients. If we can use modern biotechnology to engineer plants to be drought resistant, nutrient-dense, and taste incredible without requiring tons of pesticides or creating ultra-processed junk, that's where biotechnology can do enormous good.

Drew: It's so funny. I've gotten so used to beautiful looking, tasteless fruit and vegetables. You know, the other day I was eating a tomato and it was so juicy. I told my wife like, "Why is there so much juice in this tomato?" She's like, "That's what tomatoes are supposed to be like, not these like cardboard things we buy in supermarkets."

Zach: Move on.

Drew: Let's do it.

Drew: What do people get wrong about the work you do?

Zach: Uh, you know, I'm I'm a microbiologist and I, you know, we genetically engineer uh probiotic bacteria. Uh and the goal is for for that to make that for products for people to to purchase. And I think that the the thing that everybody assumes that that is wrong is that consumers uh won't do not want anything that has the words genetic engineering on it. People assume there is this reflexive rejection. But in reality, when consumers understand the mechanism, understand the benefit, and can evaluate the risks versus benefits transparently, they are very receptive. What people reject is opacity and lack of clear benefit.

Drew: Yeah, that idea of, you know, risk and benefit resonates a lot. And I think it ties into, you know, my role. Um, you know, I work as a doctor and as a writer. And as a doctor, I think people often have the sense that you are, um, taking this huge body of scientific knowledge and just applying it to the person in front of you and coming up with a diagnosis and a treatment. And that's great when it happens. Um but more often what happens is you're operating in a type of gray zone where there isn't a perfect clinical trial and there isn't um you know uh the exact answer that you want and you're trying to walk people through the uncertainty and you're trying to weigh the risks and the benefits and the trade-offs and come up with a solution for someone that works for them. And so um so I think there's this uh kind of popular narrative of a doctor as uh having the right answer and giving it out and then things get better um or they don't. Um but a lot of what you're doing is actually managing um this whole big morass of gray area where you're you're trying to figure out what's important to someone and what types of risks are worth taking for some type of benefit. And then I think on the on the writing side um you know a lot of what I'm writing about is uh complicated scientific issues sometimes kind of controversial issues as well and particularly in the modern media environment I think people feel like you're trying to persuade or convince people or express a particular point of view and again sometimes I am trying to u you know project a particular point of view but more often than not I'm just trying to figure out what the heck's going on you know the world is so complicated things are moving so fast that I think there's a lot of value in just trying to understand reality and put it out there clearly and make let people make their own um decisions and draw their own conclusions about um what is happening and so more often than not it's an exercise in trying to see things as clearly as I can and um put them into writing so that people can um take from that set of facts what they will and and so I think um you know not everything is uh is kind of expression of a particular agenda or point of view. A lot of it is just here's the facts as clear as I can see them.

Zach: As a scientist that resonates immensely, right? I think similarly people people assume that there's like an answer, right? And especially when it comes to something as complicated as biology and human biology, right? Like as sure as you encounter as a doctor all the time that there's a vast swath of of realities and everything is in a great there's very few things that are black and white, right? because your individual biology is going to affect your outcome in a lot of ways. And it's the same with science. It's like in these conditions, in this situation, right? Um but there's so few black and whites, everything is in the middle. And I think that people want the answer and you're like, well, this is this is the heavily caveed answer based on how we set up the experiment, right? And and that's not interesting or exciting. And so you sort of get these black and whites and then people extrapolate that well beyond kind of like your own narrative.

Drew: And you know, I I think it's very similar uh uh you as a scientist, you are a writer as well. That's the challenge is that um I feel in a way science and medicine is sometimes at a rhetorical disadvantage. Yes. How the evidence that we have um is applicable in this case but not in that case and we don't want to draw broad conclusions. On the other side you have a set of people who don't care about any of some kernel of truth and just run with it. So the advantage I think we have is that often the facts are on our side and facts tend to ultimately prove out to to do well in the long run. But it's a tremendously difficult communication challenge because scientists what they're often doing is just laying out the studies and the facts as they can see it with all the relevant caveats and that's not not always the case uh for influencers on social media let's say.

Zach: right no absolutely I I think that um you're exactly right we hold ourselves to a different standard right of like saying what's accurate which is usually less provocative less interesting and so right you take like the sliver of like well in these situations this happened and then and then you kind of have a bunch of people make it more interesting by like making it a hard truth and then you go way, you know, pendulum swings, right? And then, oh, turns out that, you know, this isn't just some magical cure all for everything and then the pendulum swings all the way back to like, oh, you know, so it is really hard to kind of get credible information out there that's also compelling when you're competing in in a world where where there's so much it's so easy to generate content that is compelling that is not accurate.

Drew: Yeah. I mean, there's so many ways to be wrong and there's only a few ways to be right. And and so, you know, just if you do the math, it's like if you say something, it it's probably going to be wrong unless you're take a lot of steps to figure out if it's actually true uh true or not.

Zach: If science can change how our minds and bodies work, what should stay off limits?

Drew: That's a very good question. I think uh we were talking about gene editing before and the tremendous promise of gene editing for so many people, everything from cickle cell disease to cardiovascular disease and and beyond. And um one thing that all those therapies currently have in common is that they're somatic gene therapies. Meaning that the modification stays in the person who is receiving the treatment. It is not passed down to their children. And so I think a line that should stay off-limits right now is germline editing—editing eggs, sperm, or early embryos where changes are passed on to future generations. We simply do not understand the complex network effects, the downstream unintended consequences across generations, or the ethical consensus required to alter the human gene pool permanently.

Zach: Yeah, it's interesting. I'll push back. I'll take a a slightly a different approach to that, but I I hear where you're going with that. I think kind of what we were talking about in the last um uh question, the idea of I think it's very hard to draw black and white that everything when you zoom in enough has a little bit of gray in it, you know, and and so I think that this idea of like what you stay off limits, it's it's very hard to kind of draw a line now that that that you're sure will still make sense 20 years from now, right? And uh I think that there are things on the on the extreme ends that we could probably all agree on that are probably silly to even talk about, right? So, you know, not interesting answers. But like even like you said like you know germline mutations I not saying that I'm advocating that that we definitely should do that but I think with a germline mutation like I I think if you zoomed in enough you find the gray areas there too right like I mentioned earlier Huntington right like this idea that like what if we could we can move that right this is a mutation that that uh will shorten this person's life like totally in a very simple change could uh could could make that better and to your point like there's a lot of unknowns absolutely right that's true with any technology but ultimately all technologies come with unknowns and then as we work through them and we are comfortable with those unknowns and we make those trade-offs then at some point we sometimes decide that that that's okay and so I'm not saying for sure that that's what happen mutation I'm not I'm not not advocating passionately that we should be doing it but I think that my take on this question is it's hard to say what should stay off limits I would advocate more what should be off limits is close-mindedness like I think at the end of the day and that's not like we should we should embrace all possible technological advantages I mean I mean in all directions we should be thinking about like as the inventors and as the technologists we should be thinking about what are the impacts we should we shouldn't just do something because we can, right? We should we should think about like what are the unknowns, what's the consent, what are the ethics of what we're doing and that's not always the case. And so that needs to happen. But on the other side, I think the public and the skeptics should also maintain an open mind about like about like while something may sound scary or dangerous, like when you think about like the cost of not doing it for somebody who is bearing a lot of risk because we can't apply the technology, right? Like we can't sit in our town in in New York and tell people in Florida like what they should be doing about their environment, right? ultimately like they're the people bearing the risk of those things. And I think I think uh it's similar with genetics, right? That at the end of the day, it's it sounds scary to us, but then what about the person living without disease?

Drew: What is so special about the gut biome?

Zach: This is area of deep passion for me, of course. Uh and I think it's probably not news to anybody that it's the gut microbiome is incredibly impactful on human health. There are as many bacterial cells as human cells uh in our bodies. And while all of our human cells uh have the same DNA, um all these bacterial cells have different DNA and they're so they're performing tens of thousands more functions than our own our own cells are performing. Um we are really a walking ecosystem. And what's even more interesting is that um unlike our human cells, this bacterial community is constantly changing. It's very plastic and dynamic. And so uh it's not surprising that uh that it has this huge impact on every aspect of our health. People have probably heard a lot of kind of like the gut brain axis and this idea that like um our bacteria are kind of like communicating directly with our brain and that's true. I mean literally the chemical language that our brain uses to talk to it to between cells and neurotransmitters was taken from bacteria. Bacteria produce many of the neurotransmitters our brain do. And the challenge is that we don't right now understand much more than that than that. It's really impactful but it is such a complex system and and we're really just kind of scratching.

Drew: It seems like the gut microbiome is incredibly diverse, but also a very delicate balance. You know, in my own work, I see if too much of the bad bacteria grow and you don't have enough of the good bacteria, you can have a devastating infection. If some of the bacteria that are in your gut, the millions and billions and trillions of them uh enter the bloodstream on the heart, that could be deadly. Um so there is this really interesting balance and um uh that that's required uh inside the body in terms of the the microbiome. But it seems like we haven't quite gotten to the stage where we can intervene based on this knowledge. And so where do we need to go to get to that place?

Zach: Yeah, I think it's a it's it's a very hard question to answer because even just like kind of pick out the good bacteria versus the bad, it's actually context dependent, right? Like um we often have heard about bacteria like E.coli. It's this like you know it's a food pathogen it makes you sick. You naturally have several strains of ecoli living in your gut and they're performing really important functions all the time but then there are other strains that aren't so good. So like it's the strain level but then it's also like the context the other bacteria around that are counterbalancing it that are really important. They create this whole complex network and interplay. And so first thing we do is just learn more and learn I think more population level and network level effects of like of of a highly dynamic and highly complex system more complex than anything else we've ever examined. Basically, the more different types of bacteria you have in your gut and the more evenly they're distributed, the more functions you have at your disposal. It's basically you're building out a bigger toolbox. And so, the way you support diversity is eating more fiber and not just the absolute amount of fiber. It's eating a diversity of different kinds of fiber. Different bacteria like different types of fiber. So, eating lots of different plants every day, uh, getting from natural sources, right? It's not just like put a scoop of 20 grams of fiber in your in, you know, into your smoothie and like you're good to go. It's like really getting that that all those different types of branches and chains of fibers from all these different foods. Like for instance, I try to eat 20 different types of plant every day and and 30 different types of plant every week um as a way of supporting a diverse microbiome. You get a diverse microbiome and you do fiber fermentation in the gut creates short- chain fatty acids which we know are beneficial. So that's the lowhanging fruit. Beyond that, I think we just have a lot of work to do to figure it out.

Drew: Well, this was great, Zach. Thanks for taking the time. I really enjoyed this conversation.

Zach: Drew, this was super great. I appreciate it. Lots of thought provoking.