Scientist Stories: Kiran Musunuru, Meaning of CRISPR Gene Editing

Friends, I am so excited for the conclusion of this event, and I am so glad that you have stuck around today through this whole time. I have saved the most heady and mind-blowing for the end. So now you're all warmed up, and all of you who are joining us from home or from your car or your backyard or wherever it is that you're joining us from, welcome back as well. And it is now my great pleasure to announce our keynote speaker for today. Dr. Kiran Musunuru is an associate professor of cardiovascular medicine and genetics at the Perelman School of Medicine at the University of Pennsylvania. His research focuses on the genetics of heart disease, which runs in my family, so thank you for your work. And seeks to identify genetic factors that protect against disease and use them to develop therapies to protect the entire population. In his recent work, he has been using gene editing to create a one-shot vaccination against heart attacks. I know. Dr. Musonuru is an actively practicing cardiologist as well as a committed teacher. He is the recipient of, and this might take a second, the Presidential Early Career Award for Scientists and Engineers from President Barack Obama at the White House, the American Heart Association's Award of Meritous Achievement, the American Philosophical Society's Judson Dallin Prize for Outstanding Achievement in Clinical Investigation, the American Federation for Medical Research's Outstanding Investigator Award, and Harvard University's Fannie Fox Prize for Excellence in Science Teaching. He recently served as editor-in-chief of the scientific journal Circulation: Genomic and Precision Medicine and is the author of The CRISPR Generation: The Story of the World's First Gene-Edited Babies. Would you please join me in welcoming Dr. Kiran Musunuru.

Well, thanks so much. It's a real pleasure to be here. I'm deeply honored that Reverend Jackson invited me to speak to a non-scientific audience. I get to speak to many scientific audiences, and my talks always have to devolve into scientific minutia, and it really gets deep, and it's like, it's fine, it's what I do for a living. But to actually talk about the big picture and big ideas before an audience like this is actually a treat for me. I also commend Reverend Jackson for the extraordinary care he put into putting this program together. I think the panel discussion we just saw by Drs. Green, Lawton, and, and Fakhra, I think it just so beautifully highlighted a lot of the same issues that you were asking about during the panel discussion and that I'll be talking about in the context of real-life events in my presentation today. And I'm very grateful for all of you who are here in the room who stuck it out to the end. Grateful to those of you who are those of you who are looking back at this from the future, watching this on YouTube or whatnot, thank you for listening. And so let's get started. I'm mindful what President Matthews mentioned this morning, that today is a day for questions, but it's also a day for storytelling. And rather than get bogged down in exactly how CRISPR works and DNA bases and this and that, I want to tell some stories, and I hope you'll find some of them inspiring. Inspiring. And I also expect you'll find one of the stories to be horrifying, because being at the center of it myself, I found it incredibly horrifying and one of the signal events of my life, but not in a good way. And you'll see exactly what I'm talking about and understand where I'm coming from. But let's start with the good, and then we'll get to the not so good, bad, ugly, and then we'll come back to the good. So that's sort of our, uh, our game plan here. But let's start with a patient. So, this is Avery Watts, who was featured a few years ago in our hometown paper here, the Philadelphia Inquirer. She has a condition that causes her to have extremely high cholesterol levels, a condition called familial hypercholesterolemia. And you can kind of tell from the roots there, familial means that it's inherited. It's a genetic disorder. She got two bad copies of a particular gene, one from mom, one from dad. That's how a lot of genetic diseases work. You have the two bad copies, and you end up with a genetic disease. She has sky-high cholesterol levels. Normally, it's on the order of 100 in the average person in the United States. Hers, as you can see here, over 800. So high that it puts her at extreme risk of having heart disease. And it is so bad that medical treatments, they'll help her a little bit, but they won't do the job. So she has to take a day out of every week, travel 3 hours to the nearest facility that has a dialysis-like machine. You can see her hooked up to it there, sit hooked up to it for several hours to have the cholesterol cleaned out of her blood. And she has to do this week in, week out. Despite this very aggressive treatment, at the age of 11, so about a year after this picture was taken, during her 11th year of age, she had to undergo 3 open-heart surgeries because she had already developed such bad heart disease. And she's doing fine now, but that just tells you how devastating some of these genetic disorders can be. And this is what she's facing for the rest of her life, having to be hooked up to this machine week after week, at risk for having more heart disease in the future. So then the question becomes, and as this newspaper article posed, can CRISPR fix the problem? And I believe the answer is yes. And in fact, I'm increasingly sure the answer is yes. And part of it has to do with this woman who is not actually a patient. I mean, I'm sure she's a patient in the sense that we're all patients. We all have things that go wrong at some point or the other, but she's actually extremely healthy and she actually came to our attention because, in a sense, she has the opposite condition as Avery Watts. This is Anna Fuhrer. She has extremely low cholesterol levels. She has a condition that we call familial combined hypolipidemia. Forget the medical jargon. It just means she has extremely low cholesterol levels, eye-poppingly low. So I told you 100 or so is the average in the population. Her cholesterol is in the teens. And it turns out 3 of her brothers have the same condition. She's part of a large family, 9 siblings total. 4 of them, 4 of the siblings have the same condition, have extremely low cholesterol. And about 12 years ago, we did a genetic study to try to understand why these individuals had these low cholesterol levels. And we found the responsible gene. It turns out that these 4 siblings have a cholesterol-regulating gene entirely turned off. So they actually have inherited 2 bad copies, if you want to call it bad, of a certain gene, one from mom, one from dad. But in this case, it's not bad. It's actually good because by turning this cholesterol gene off, you end up with very low cholesterol levels. And the siblings are in the best of health. They have no negative consequences whatsoever of having these mutations. They're extremely healthy. Their hearts are great. We've actually looked at the arteries that feed the heart muscle, and they're totally clean. They've lived to ripe old ages, have children who are healthy, probably grandchildren by now. You can kind of think of them as genetic superheroes, if you want to think of it that way. This gene being turned off is important because not only does it give us a clue how to reduce cholesterol levels in someone like Avery Watts, but also tells us that it's going to be safe because we have people who are walking around miraculously who have this gene turned off, have very low LDL cholesterol levels, and they are totally healthy. So we can reproduce that effect in patients like Avery with CRISPR gene editing, we might be able to definitively treat the condition. So we've talked a lot about CRISPR this afternoon. I'm not gonna dive into the details of exactly how it works, because to be honest, some of the details are even beyond what we understand. But the first thing I should note is that CRISPR is not an invention in any real sense. It naturally exists. In a vast variety of bacterial and archibacterial species. It's a naturally occurring component of an adaptive immune system that bacteria use to fight off viruses and other invaders in the microscopic world. The big innovation is that humankind has figured out how to take this naturally occurring mechanism, this defense mechanism of bacteria, and turn it into a tool that allows us to modify our own genes, for better or for worse. And just to give you a sense of how it works, what it looks like, it's basically a little molecular machine, and it has two components. It has a protein component, and that's what you see there in white, and that protein is what actually does the editing. And then it has a second component that you can kind of think of as a GPS. It's an RNA molecule. It's about 100 letters in length, and the first 20 letters of that RNA molecule give the address where to go in the genome. The protein, the RNA, in this case the RNA is in purple, so it's that one strand that's kind of winding in the middle of the white. Those two components come together to form this molecular machine, and when they come into contact with double-strand DNA, and you can kind of see that here with the blue and green strands that are interwoven, looks like a double helix, which of course is the shape of DNA. If it hits a double-strand DNA molecule, it will scan across the whole thing looking for the address specified by the RNA, by that GPS. And if you put this in the middle of a human cell, in the nucleus, which is where all the DNA is, the 3 billion letters that make up the human genome, it will scan the entire genome very quickly. And look for the address. And if it finds the address, it stops there, and then the protein does the editing. And that's the magic of CRISPR gene editing. And so what we can do now is, to me as a scientist, is actually miraculous. We can do things I wouldn't have dreamed of even 10 years ago. We can find a single letter in a single gene in the entirety of the genome, one letter out of 3 billion letters, and make a precise switch of just that one letter. And that's what we're doing now. Just to give you a sense of what's possible, before we do anything in human beings, we're obligated to do it in animal models. That's just how we do things. That's what we feel as a community, as a society, is ethically right. You don't want to start experimenting in humans until you have some surety that it's working and, for lack of a better term, lower orders of life, if you will. And so a lot of experimental science biology is done in mouse models. And here's an example where we treated a mouse with CRISPR with the intent of turning off a gene, change a single letter in such a way that it turns off a gene, and the protein that's normally coded for and produced by that gene would be gone. And we weren't sure how well this was gonna work the first time we did this, not even 10 years ago. But here you can see on the left a mouse that was not treated. We were targeting a protein made in the liver, and you can see the brown color across the slice of liver. That's the protein. It's in basically every liver cell, as you can see there. When we used CRISPR, delivered it into the liver with the intent of turning off this gene in a very precise way, what you can see is that the protein, the brown staining, is almost entirely gone. As on the right. That's what we're able to do. We can get almost 100% efficiency. And so what can we do with that? Well, we used a mouse model that has familial hypercholesterolemia. It was engineered to have the same mutations, essentially, that Avery Watts has. And it has very high cholesterol levels. And just to give you a sense of that, if you take some blood out of that mouse and you remove the red cells, the red blood cells, so you don't have the red color, On the left, that's what the blood looks like. And you don't need to be a scientist or a physician. You can immediately tell, wow, there is a lot of cholesterol and a lot of fat in that blood sample. That is what Avery's blood looks like every week before she starts that dialysis-like procedure. What we were able to do is put CRISPR into the liver of these mice. And what we found is that within days, the blood cleared up and looks like that on the right. Got rid of all the excess cholesterol, or a lot of the excess cholesterol. And the hope is if we can do something similar in patients like Avery, we can permanently convert her blood from looking like that on the left to that on the right. She would no longer need that dialysis procedure. She might not even need a lot of medications. And I think unambiguously it would be an improvement in her life and hopefully prevent her from having to undergo heart surgeries again. So how are we doing this? Well, we're all very, very familiar with what I'm showing you here— lipid nanoparticles. 3 years ago, none of us had heard of it. Well, I'd have heard of it, but none of the rest of you had heard of it, I'm assuming. But now we're all intimately familiar with it because we've either received or multiple doses of these lipid nanoparticle COVID-19 mRNA vaccines. And here you see a schematic. It's basically these lipid components, basically fat molecules that form the shell, the sphere. And within this fatty sphere is contained the cargo, which is an RNA molecule. Now, with the COVID-19 vaccines, you know, we're talking about a component of the SARS-CoV-2 virus, the spike protein.. And the goal is you inject it into the arm, as many, if not all of us have received multiple times, and the immune cells are right around the site of injection, pick up the mRNA, and then they start producing the spike protein. And by doing that, instigate an immune response against the protein. And then the idea is that you get immunity. It doesn't last forever, clearly, but you get some degree of immunity. To the virus. So if you get exposed to the virus, you're more likely to fight it off, or even if you do get infected, you have a much less severe infection. And again, one of those things that seems to me as a scientist to be almost miraculous, that at the moment we needed in the face of this devastating pandemic, somehow all the different threads of technology that we needed— and there's so many different things that had to go into making this— all of them just happened to be available and ready to go. That in less than a year, the scientific community was able to make these vaccines and then start distributing them to literally billions of people around the world. So we're taking a page out of this book. We're going to use the same technology. We are using the same technology, lipid nanoparticles. But that RNA molecule in the middle, it's not making the spike protein of the virus. It's making CRISPR. So both the protein as well as the second component, the GPS, the guide RNA. So it's actually two RNAs, as you kind of see schematized here. And the goal is, okay, now we can inject this into the bloodstream. Why inject it into the bloodstream instead of the arm? Well, if you put LNPs, as we abbreviate this, if you put LNPs into the bloodstream, they go straight to the liver. Now, if you want to send it to some other organ that you needed to treat, like the brain or the kidneys or the heart, we haven't gotten there yet.. But what we do know how to do is go to liver because these LNPs naturally just happen to go to liver. That's kind of liver's job in the body is to clean things out of the blood. So a lot of things, a lot of therapies we put into the blood invariably go to the liver. So that's the point. We can take essentially the COVID-19 vaccines and repurpose them to deliver CRISPR into the liver and treat entirely different diseases. So we've made these LNP particles that have CRISPR. And here are studies we did in monkeys to see whether this would work to reduce cholesterol levels. And we were targeting a particular protein. The name is not important. You see the letters and numbers there, the gobbledygook, PCSK9. It does mean something, but I'm not going to torture you with that. But it's a cholesterol gene. Its role in the body is actually to push cholesterol levels up. If you turn it off, we know that it can safely reduce cholesterol levels. And there are other medications that work on this, but they're temporary medications. They're injections you take every few weeks and you got to take them every few weeks for the rest of your life. Our goal here is to use the treatment to deliver CRISPR into the liver, change one letter, out of the 3 billion letters, the letter being in this gene that makes this protein, and permanently turn it off, permanently inactivate it. And we know this is working because we can look at the protein levels that are in the blood. The protein's made in the liver, but then it's put out in the bloodstream. And what you can see here is within a week or two after the monkey's receiving this treatment, the amount of protein in the blood is down 90%, so almost entirely cleared from the blood in the body. And then the exciting part is if you follow these monkeys over time, it's down forever. Now, this goes out to about 8 months, but now we have data out to 2 to 3 years, and there's no reason to think it's not going to last for the lifetime. So this is monkeys, not human beings yet, but we're getting there. Now, here's what we care about. This is cholesterol, in particular, the bad form of cholesterol that drives heart disease, LDL cholesterol. I'm hoping most of you know what your LDL cholesterol levels are, because if you don't and it turns out you have very high cholesterol, it means you're at high risk for a heart attack, and there are things we can do to treat that. But what you can see here, these same monkeys, within a couple of weeks, the LDL cholesterol level is down 60 to 70%, and once it's down, it's down forever. So imagine if you could apply something like this to Avery Watts and permanently reduce her cholesterol levels. It would be a one-time thing, we think, for what ordinarily we think of as a chronic disease, something you would take pills every day for the rest of your life, like a statin medication, or injections every few weeks, or having to be hooked up to a machine every week and have cholesterol cleaned out of your blood. All right, so we're on the verge of being able to potentially try this out in human beings in clinical trials. But even before we get to that point, let's think about who would this actually benefit. Well, you know, unquestionably this would help patients with familial hypercholesterolemia, patients like Avery. They have a genetic condition through no fault of their own. They were born with a genetic condition. And so using a genetic therapy to redress the balance is the way I view it, makes a lot of sense. And I think we can all get on board with that. But I think we can do a lot more because it turns out that if I take the average person and reduce their cholesterol levels by a substantial amount, it'll reduce their risk of a heart attack. Now, let me ask you this question. Over the past 2.5 years, what has been the biggest global health threat? What has killed more people than anything else? Good. OK, so you didn't fall for the trick. It's not COVID-19, although that is what has dominated our attention. COVID-19, depending on the estimates, anywhere from 5 million to as many as 20 million people worldwide over the extent of the pandemic. During the same time period, at least 50, probably more, 50 million people died of heart disease. It is by far the number one killer worldwide. And even in this challenging time of a global pandemic, it is still the preeminent health threat. More people are dying of this than anything else, even cancer. Heart disease, even in the poorest countries on Earth, believe it or not, we become good enough— still not great, but good enough— at tackling infectious diseases like malaria tuberculosis, and other killers that we typically associate with developed countries. We've become good enough at keeping people healthy and alive long enough for them to get heart disease. And so even in the poorest countries on Earth, heart disease has become the leading killer. It's indiscriminate. It doesn't matter who you are. Just to put in context, just looking at this room, in the United States, how many— If you're a man, what is your chance of getting a heart attack in your lifetime? It's 1 in 2. Yeah. And if you're a woman, you're somewhat protected, at least before menopause. And so it's 1 in 3. So to put this— just to put the right perspective on this, look to your left and then look to your right. One of you is in trouble. So this is important because this is something that affects all of us. It affects all of our families. And we're all at risk. Now, here's what we know. We know that if a patient has a heart attack and comes into the hospital and we fix them up as best as we can— we use balloons and stents to open up the arteries that feed the heart muscle— it is standard of care. It would be malpractice if we did not send them out of the hospital without a prescription for a really high dose of a statin drug to reduce their cholesterol levels. Because unequivocally, we know from clinical trials that that will reduce their risk of the next heart attack, and it might be the next heart attack that kills them. Here's the problem. We give out the prescriptions, but how many people out of all those people who are having heart attacks and coming to the hospital and then going home, what percentage do you think are still taking the statin a year later? Wow, that's really pessimistic, 30%. It's not quite that bad. But depending on the study, if you average it out, it ends up being about 50%. People don't like taking pills, especially if they don't make you feel any different. People can't get access to them for cost reasons because they don't have good access to healthcare. They can't get the prescriptions renewed. There are all sorts of reasons. There's structural inequities built into the healthcare system. That's a whole separate issue and a whole other lecture. But it's a problem. Medications don't work if you don't take them. So my dream as a cardiologist who takes care of these patients in the hospital when they have heart attacks, some of them very bad heart attacks, some who almost die or some who do die and they don't make it out of the hospital. But those who do make it, for me, it just makes so much sense before they leave the hospital, give this, give them this once and done therapy to permanently reduce their cholesterol levels. Protect them for the rest of their lives, reduce the risk of their getting the next heart attack, and you take the burden away from them of having to take the pills every day for the rest of their life, right? To me, it would be transformative. But then you might very well reasonably be asking, why are you waiting for a heart attack to happen? Why not stop the heart attack from happening in the first place, right? We know cholesterol is a big driver of heart attacks. Don't let anyone try to convince you otherwise. If there's anything I'm sure of in life as a cardiologist, it is that thing, that cholesterol is a big driver of heart disease. And if you reduce cholesterol, you will reduce the risk of heart disease. So you could extend this further and say, if you are sure this treatment was exquisitely safe— and it'll take some time to prove that beyond reasonable doubt— if you're sure that this is safe, why not offer it to any young adult? And I say young adult because I do feel that people have to be old enough to make medical decisions of this type on their own. And so I'm thinking about 20 years of age, and heart attacks aren't really starting to become an issue, or heart disease isn't really starting to become an issue until after that point. So you're 20 years old, you'd have the chance to take this therapy, reduce your cholesterol levels for the rest of your life, and be protected from heart disease. It's not a vaccination per se, but It's kind of like that COVID-19 vaccine, right? It's the LNPs and the mRNA. So that's one parallel. The other parallel is this would be a once and done type of thing. You take it once and then you're protected for a very long time, the rest of your life. This would push off on average across a population, it would push off heart attacks by decades. It could mean the difference of a person dying of a heart attack at age 60 versus dying of a heart attack at age 90. Which is a very different proposition. And if you were able to successfully deploy this across an entire population, heart disease, as I've said a few times now, it is the leading cause of death worldwide. It would be transformative. It would increase life expectancy in a meaningful way. That is the potential we are looking at here. Now, whether it's a good idea or not to do this, that's some of what we've been discussing today. And we can certainly address it. A bit later. But that's the potential we have in our hands. And then we really have to decide as a society and as individuals whether we want to partake in this. But the potential is there for lifelong protection with a single shot. Now, before we actually do anything in human beings, we have to be very, very mindful of the potential risks. We have to be very, very, very rigorous. We can't just start doing things in human beings. And so to quote the late Donald Rumsfeld, and of course, he was talking about military strategy, but I think there is actually value in this quote. As we know, there are known knowns. There are things we know we know. We also know that there are known unknowns. That is to say, we know there are some things we do not know. But there are also unknown unknowns, the ones we don't know we don't know. And with an experimental technology like CRISPR, I think there are unknown unknowns. We've learned a lot in the last 10 years since CRISPR really came onto the scene as a gene editing tool, but I think there's still a lot we need to learn. And so we have to be extremely cautious about implementing this in human beings. We have to go through the rigorous scientific process, and that means preclinical studies, by which I mean doing studies in mice and monkeys, and I've showed you some of that work. And then ultimately, try it in a few human beings and make sure that it is safe. And then if it looks like it's okay, then expand it to a larger group of people and then an even larger group. And you do staged clinical trials in a very thoughtful and deliberate way at every step, asking, is it working as we expect? Is it safe? Are we seeing any issues at all that need to make us cautious and have to go back to the drawing board or even pull the plug? This is how all medications are developed.. But with an experimental technology like CRISPR, the bar has to be really high since we're doing something that we've never as a medical community done before. And so you can imagine the scientific community, the biomedical community, everyone who's at all invested in using CRISPR to benefit humankind were absolutely devastated when the first use of CRISPR in human beings was to make gene-edited babies. Believe it or not, this happened before there was actually any clinical trial where CRISPR was administered into the body of a patient. And that is because most of us were doing things in a responsible, rigorous way, and it takes time to do that. Whereas what happened here, as I found out in a very, very strange way, as I'm about to tell you, did not adhere to any of that. It was basically shooting from the hip. So how did I get embroiled in this? Now, let me say at the outset, I didn't get embroiled in this because of anything bad I did, okay? It was for the best of reasons. Long story short, I was approached by a reporter, a journalist— she's now retired— but a very well-respected journalist with the Associated Press. And she and I had talked over, you know, the last the previous few years, she knew I did work in research and gene editing. And so every so often she'd get in touch with me and ask me questions about gene editing. And she was excited about the technology and reporting on clinical trials of genetic therapies. And so we had a, you know, we had a good relationship where I teach her about genetics and genetic therapies. And then, and she would do a very, very creditable job of communicating it to the public. So she reached out to me saying, I want to share this manuscript. I don't have it yet, but I want to share this manuscript that's going to be submitted for publication. It's about gene editing, but I can't tell you anything more than that right now. It's like, OK. And I assumed it was going to be about some exciting results from a new clinical trial. And it was going to be a big splash when it was reported. It was like, oh, we've cured disease X. And properly, that should get attention. And I'm happy to comment on that. But it was really weird because it took a while before she was able to give me the manuscript, which is not the way usually things happen. Usually a journalist gets a manuscript under embargo, and then they have some amount of time, like a week or so, to run it by expert scientists and get feedback and comments and so forth. And then they release their articles at the pre-specified time, uh, from the medical journal's direction, right? Because you want it all to be coordinated. You don't want anyone to jump the gun and report it before it's actually out and published. But this was a weird situation where she didn't even have the manuscript yet, but she seemed certain that this was going to be big news. So I was like, okay, well, I'm playing ball. Like, whenever you have it, give it to me. And so finally, about a week later, she sends it to me, and I start reading it.. And I'm absolutely— I don't even know what the right word is— blown away, I guess, when I read the title of the manuscript and then start reading, because it is the manuscript describing the world's first gene-edited babies in a scientific publication. And so to briefly encapsulate what I learned as I was reading this, with fresh eyes, with no expectation that this is what I was going to get sent to me, a scientist in China, this guy, his name is He Jiankui. He goes by JK, so we'll just call him JK, his initials, I guess. He had, and he's reporting this in a manuscript, a scientific manuscript, he had decided that he wanted to make babies who are resistant to HIV infection, HIV being the virus that causes AIDS. And scientifically, it turns out that about 1% of people who have European ancestry have both copies of a gene called CCR5. Again, the letters and numbers don't really matter, but a certain gene turned off. And it turns out that this gene is important because it provides one of the gateways through which the virus gets into T cells and causes disease. And it turns out if you have this disease— or I'm sorry, this gene naturally turned off— so you're hearing a lot about turning off genes. So if they happen to inherit copy from mom, copy from dad, this gene inactivated, naturally turned off, and so you're not making any of this protein, the virus has no gateway to get into cells. And so we know that 1% of people, it's very hard for them to get infected with HIV. So he had this notion, hey, let me take human embryos, let me use CRISPR and just knock out this gene, as we say, turn off this gene, and then establish pregnancies, and then you'll have babies who are born protected with HIV. And this will be— clearly in his mind, this was going to be a pivotal accomplishment. It was going to earn him the Nobel Prize someday. You know, it was going to be viewed like in vitro fertilization back in the '70s. Not that I was around, or at least not old enough to have any recognition of what was going on. It was apparently very controversial, and doesn't take much imagination to see why. And nowadays, we think of it as is just part of the ordinary fabric of life, as you heard about during the panel discussion. We don't think twice about it. And so perhaps he had a notion that his work was initially going to be controversial, but eventually would come to be accepted, and then widely used, and then be seen as a medical breakthrough. Things haven't turned out that way, needless to say. And what he did was recruit 8 couples into what he called a clinical trial. And one of those couples dropped out, thought better of it afterwards. He recruited 7 couples. And I'll share with you more details about exactly what happened and how he was able to recruit them. And then offer them this opportunity. You'll undergo in vitro fertilization. But before we establish the pregnancies, I'm going to put CRISPR. And I'm going to turn off this gene. And your babies are going to be resistant or protected from HIV. And it turned out that in each of these 7 couples, the father was HIV positive. That was one of the recruitment criteria. OK, so you can see why there was an incentive for these couples to be involved. OK, so he somehow recruited these couples into a study, and he started doing this. And you'll hear more of the details about exactly how he was able to do this and under what circumstances, the dubious circumstances he was able to do this. But he established pregnancies. And in October of 2018, one of these couples had twin girls. They go by the pseudonyms Lulu and Nana, which I gather have some mythological significance in Chinese culture. Nana, as it turned out, or at least as was reported in this manuscript I was reading— remember, I'm reading all this, like, for the first time in this manuscript, and, like, where on Earth is this coming from blew up like a tornado in my mind. And Dara, it was reported in this manuscript, had both copies of the gene turned off. Lulu, the sister, only had one copy of the gene turned off, raising the question, OK, well, what is this actually going to do for her? Put that aside for a moment. And they were born. Apparently, they were born prematurely, although it didn't actually say that in the— manuscript, and they were actually in the neonatal intensive care unit at the hospital where they were born in China for a while. But they made it out OK. And the manuscript went into detail about scientifically what was done and what was actually in the genes of the embryos that became the twin girls and so forth. So I read through the text. It's like, OK, I'm really, really, really horrified and disturbed already, then I start looking at the data and start looking at information on what's actually going on at the DNA level. And, you know, there's some pictures with curves and colors and won't mean much to the average person, but someone who makes a career out of thinking about DNA and editing, this is actually incredibly important information. And within a couple of seconds of seeing the data, I realized that something very horrible had happened. Now, let me step back a moment, because as I eventually pieced it all together, the reason that this journalist, that this reporter was asking for my opinion on this manuscript is because she was really concerned that the whole thing was a fake. So the backstory is that the scientist, if you want to call him that, we'll call him JK, had hired an American publicist and had shopped the story around. We have gene-edited babies and they're going to be born soon. And they went to the Associated Press because they have the greatest worldwide reach and offered them the exclusive. And so this reporter, she's very savvy. She said, okay, this is obviously potentially a big story. She started talking to them, but in the back of her mind, she's like, well, what if this is a hoax? So I think a lot of you will remember back in about 2003, there was a cult that had reported that they had cloned the first human baby, who they named Eve, which to me is— I'm not even that religious, and to me, that's sort of sacrilegious. But in the fullness of time, it turned out to be a hoax, and it was just a play for attention and whatnot. And so she was worried that was happening again, and she had no way of sorting out whether this was for real or whether this was just another fraud, another hoax, another play for attention. So she very cleverly insisted that he share the manuscript that he was writing up and was planning to submit for publication in a scientific journal. And she would be able to distribute it to a small number of experts under conditions of confidentiality. And get feedback. And for her, this would be helpful in trying to get a sense, is this real or not? Okay, so I have the manuscript of one of 2 or 3 experts she sent it to. I read the manuscript, I see the pictures that describe the DNA, and within a few seconds, I start screaming. I'm in my office, I literally start screaming. And the reason for that— I'm screaming in horror. And the reason for that is because I immediately knew two things. One, I knew that this was real, unquestionably real. This was not fake. And the second thing, the reason I knew that it was real is because it looked absolutely horrible. There were clear signs of just genetic damage, of just patchwork genetic edits so that different cells in the embryos had different edits. It was like all the things that I knew as a practitioner of gene editing could potentially go wrong if you don't use CRISPR carefully and responsibly. And there was the evidence right before my eyes that things had gone awry. It was a total mess. And the reason I was screaming, because I realized this, and I realized that he must have had the same data from the embryos before they were transferred to surrogate mothers And he knew what he must have— like, he had these data in front of him, and he allowed the pregnancy to go forward. And one of these pregnancies had given rise to Lulu and Nana. This was their embryos, and there were signs of just things going awry. And to me, there were only two possibilities. Either he knew what was happening and just ignored it because he was so keen to make the world's first gene-edited babies, which in my mind would just make him totally monstrous, or he was so ignorant of his craft that he didn't actually understand what the data in front of him was showing, which to me is, is just as bad, actually. You shouldn't be doing this stuff if you don't have a clue. And so I'm out of my mind, like, I'm just freaking out in a way I've never freaked out in my life, understanding what happened here. He made the world's first gene-edited babies. He was trying to hack the code of life, and it was a total hack job. It's just utterly— every adjective you can think of, that was what was going on. So I call up the reporter, and I confess, I'm not proud of this, but I was basically cursing through my conversation. What on earth is this? Where did this come— what, what, what, what, what? Except much more explicit than what I just said. And I apologized to her afterwards at the end of the conversation, but she was like, I totally understand. And I told him, look, this is for real. If he had been faking the data, he would have made it look perfect. You can't— I've tried in my own laboratory to fake the data as I saw it, and I couldn't actually quite do it because it just looks so messy. It's not fakeable. These are real human beings. It is just such an undermining of the dignity of human life, what was done here. But it happened. It happened. Now, here's the problem. I was under conditions of confidentiality. I couldn't tell anyone. I was sworn to secrecy. So I'm carrying this, knowing that this happened, carrying this, this burden. And I honored it. I mean, maybe I shouldn't have honored it, but I honored it. And this was actually right before Thanksgiving. And so everyone around me, it was the worst holidays ever. Everyone around me could tell I was really upset about something. But I couldn't tell anyone what it was about. And part of the reason I was so upset is because there was no real clear game plan. It wasn't clear when this news was actually going to come out. The babies had been born. He was writing up this paper. He was preparing to submit this paper to a scientific journal. And it could be weeks, it could be months before the news actually came out. And what ended up happening, to my great relief, because it would have been like this unthinkable ethical dilemma for me, like, do I keep my mouth shut knowing that this atrocity— and I really do think of it as atrocity— was committed? Or do I try to get the word out? Fortunately, the decision was taken out of my hands because an interpreter reporter at MIT Technology Review somehow, like, caught wind of this in a very, like, roundabout way, like, found some evidence of it on a Chinese clinical trials website and was able to deduce that shady stuff was happening. And then, and then basically was able to get confirmation from J.K. himself and then broke the story. And so not that I was sleeping much at night, but, you know, one morning I woke up, checked my phone, and there were, like, dozens and dozens and dozens of emails from reporters wanting to know what was going on. And it turned out that when this story was broke, the AP— the AP's journalist released her story because now the genie was out of the bottle. And so she was able to publish the full story that this story just said that babies were being made. The story from the AP gave the full story that the babies had been born. And I was quoted very prominently, basically. You know, there was J.K. who was quoted as, this is a wonderful thing for humanity. And then the next paragraph is quoting me saying this is utterly unconscionable, like a scientific and ethical and moral failure. You can look it up if you want. It's there for all the rest of time. All right, so let's dissect this a little bit. It was a scientific failure. It was a total disaster. But it was a big ethical failure and moral failure. And so in medical ethics, not to belabor this, but medical ethics, We think very deeply about how to do things in the proper way when we do clinical trials. And a lot of this comes out of the war crimes trials for Nazi scientists at the end of World War II, because there were unspeakable things done in the name of scientific experimentation being done in concentration camps. And this has shaped how we do things for the next 70 years. And so there are all these different principles that are very carefully laid out. I'm going to walk through them briefly one by one just to show you how this is actually a textbook example of how he flunked on every single point. It's breathtaking. It truly is a textbook case. So one important criteria— the people who are doing the clinical trials should be scientifically qualified to do so, typically physicians. Doesn't have to, but it should be someone with clinical training. This guy was not a licensed physician. He was a scientist who had earned a PhD in genomic sciences. His expertise was in DNA sequencing. Wasn't with CRISPR. He'd never actually published on CRISPR before doing any of this. Had no medical training. He certainly didn't know anything about clinical research. But he felt that he was qualified to start this clinical trial using this brand new experimental technology with unknown unknowns, as I said before. And he even obtained informed consent from the patients himself. That takes a lot of gall. Respect for persons. So it's enshrined. One of the principles is that individuals should be treated as autonomous agents. They should have agency of their own. If a person has diminished autonomy, for example, a prisoner, or more subject to exploitation, they're entitled to protection. And that doesn't mean they can't be involved in clinical trials, but there has to be a much higher bar. And we do this with children. We enroll children in clinical trials. Parents are able to give informed consent on behalf of their children. We discussed this earlier in the panel discussion, assuming that the consent is informed to the parents. But the bar has to be higher. And then this question of unborn descendants, if you're editing the germline and you're potentially impacting future generations, well, future generations have no autonomy at all. They don't even exist yet. So you'd have to think that you have to have a very, very high bar, the highest possible bar. Beneficence. There has to be some potential for good, and not just a little bit of good, but a lot of good. Otherwise, you really shouldn't be doing this. So what was the potential benefit here? Well, it was all sold on the premise that your kids are going to be protected from HIV. And then, you know, the longer-term good could be if this actually worked, well, maybe this could eventually benefit millions of people, this idea of editing genes in embryos. And in his manuscript, it was very explicit what he was thinking, because he literally says, could benefit millions of people in the future. No question that there was a lot of delusions of grandeur right there embodied in this manuscript. Now, I told you Nana, one of the sisters, had both copies turned off. So she might actually be resistant to HIV. There's no way we're ever going to test that. But in principle, she may be protected. Lulu only has one copy turned off. HIV can still get into her cells. She's not protected, which begs the question of why was that embryo used for the pregnancy if it wasn't actually going to benefit her? Now, the fathers in the various, you know, couples I told you were HIV positive, they're all on antiretroviral therapy. They all had undetectable virus in the blood. And we know that casual contact is not going to pass the virus, even if you had some in your blood. That's not how this works. A mom during pregnancy, and particularly during the process of childbirth, can potentially pass it to, to a child who's being born because there's disruption, um, you know, communication of blood and so forth. But there's no way a father is going to pass it to a child. These twins' risk of getting HIV, no greater than that in the general population. And actually getting full-blown AIDS is basically impossible now because we have therapies. And we're talking about their lifetimes. They're only a few years old. We're talking about the entirety of their lives. I should hope that in the next few decades, we come up with something more definitive, like a vaccine or whatnot for AIDS. So there's really very little potential for benefit. Non-maleficence, do no harm. All right, well, you have to do some good, but you also have to— if you can't do no harm and there's always risk with new therapies, at least minimize the chance of harm. And we know that gene editing, it's not well worked out. There are these unknown unknowns. We know even the known unknowns are problematic. You can have mutations that are unintended happening elsewhere in the genome, that GPS I mentioned. Can go awry. And just like if you type in an address or start to type in an address in a GPS because you're trying to go somewhere, brings up various options. And if you're not careful, you might hit the wrong one and end up in the wrong town over. That can sometimes happen with CRISPR. And you can get a mutation in a gene on a different chromosome that has nothing to do with what you're trying to do. And that could cause health problems. That could cause cancer and so forth. We know this. And there was evidence of this in the manuscript. The mutation, the gene that he was trying to turn off, the CCR5 gene, turns out if you actually study the 1% of Europeans who have the gene naturally turned off, yes, they're resistant to HIV, but guess what? They're more susceptible to West Nile virus, to tick-borne encephalitis virus. You might be asking, I don't even know much about, I don't hear about those at all. Is that really a big deal? Flu infection. We definitely know about the flu. And we have some data that suggests if you're one of those 1% and you get the flu, you're more likely to die of it. So yeah, maybe you protected these kids from a theoretical risk of HIV, but have you made them much more vulnerable to flu, which would not be a good thing, and they're much more likely to get flu than HIV? It's not just Nan and Lou. It's their descendants, potentially. And there is this potential for them to be treated as experimental subjects for the rest of their lives because they were an experiment. Let's call it what it is. They were experimented upon. And the parents certainly know. When they will in their lives learn that they were the subjects of these experiments, who knows? Will their parents tell them? Will they not find out? Will others in the family know? Are there going to be negative perceptions from their family or their friends if they should find out about them because they're effectively human guinea pigs? What does it mean for their marriage prospects? Are they going to be viewed as more desirable because they're protected against HIV and maybe a prospective spouse likes the idea of passing that on to the next generation? Or will they be shunned? How will they view themselves? Can't even begin to answer these questions. And he couldn't even begin to answer these questions when these questions were posed to him shortly after all this broke out. It's clear he'd given no thought to it whatsoever. He'd just gone ahead and done the experiment. So lots of potential risks and downsides. You got to look at the balance. And there's got to be a favorable ratio. There has to be much more potential for good than for harm. And we've already said there are many risks and relatively few benefits. And it's not even clear that we fully can define the risks yet because, again, unknown unknowns. Now, another very important principle— there has to be justice in the selection of subjects. They shouldn't be recruited into a study simply because it's easy to do so, because they're in a compromised position, because they're easy to manipulate. It has to be related to what it is you are actually studying. And here's where— this is one of the aspects that bothers me the most. This trial was restricted to HIV-positive fathers. No particular reason why it needed to be if the goal was just to make babies that were resistant to HIV, but it was restricted to HIV fathers. And it turns out in China, I don't know if it's still the case, but at least at that time, HIV-positive parents were not allowed to undergo assisted reproduction, to do in vitro fertilization. So if they had fertility issues, forget it. They were not having children of their own. And this is telling. This was a direct quote from J.K. when he was pushed on this. And I quote, "And also for this specific case, I feel proud, actually. I feel proudest because the father thought that he lost hope for the life. But when the babies were born with this protection, he sent a message at their birth saying, 'I will work hard, earn money, and take care of his two daughters and his wife.'" To me, and perhaps you'll agree, this doesn't sound like someone who's grateful that, oh, this guy did me a good deed, and now my kids are protected against HIV. This is great. This sounds like someone who's just grateful to have had the chance to have children. I'm absolutely certain that this was sold to them as the way they can skirt around the law and actually be able to have children. If that isn't exploitation, I don't know what is. And then there has to be informed consent. You have to be able to reasonably communicate the risks and benefits to the subjects, or in this case, the parents of the prospective children, so they actually can make an informed decision. Do they fully understand everything that's happening? Are they voluntarily giving consent? Are they free of coercion? Are they free of undue influence? In other words, are you not threatening them with harm or offering them something that's so extravagant that you'd feel obligated to sign? If I offered you $100 million to sign up in this trial, any one of us would probably at least give serious thought to it, right? That would be an undue influence. So I'm going to read you some of the language from the informed consent. OK, so the benefits— this research project will likely help you produce HIV-resistant infants. I object to the word likely, but okay, that is the premise. The project team purchases health insurance for the babies born. That's not so unreasonable. That's probably within limits. The risks, I don't know, I'm reading this language. The primary risk of gene editing DNA targeted CRISPR-Cas9 endonuclease is the off-target effect of generating extra DNA mutations at sites other than the intended target. This is due to that the technique can cause nonspecific cleavage resulting in mutations in non-targeted genomic sites. I'm pretty sure that the couples who enrolled in this trial had absolutely no clue what that meant. I'm sure that unless you got a PhD in the biological sciences in the last 10 years, you probably don't have a great sense of what that means. And then it gets really worrisome, some of the language, because now it sounds like a waiver of liability. This project team is not responsible for the risk of off-target, which is beyond the risk consequences of the existing medical science and technology. In other words, If there are unknown unknowns, not our problem. We're not, you know, not our responsibility. The rights and obligations in the testing shall be based on the contract between you and the medical institution. Okay, never really think of informed consent documents as contracts, but hey, here we go. In case of any disputes over rights and obligations during the project period between you and the medical institution, the contract signed shall prevail and the project team is not responsible. This, again, waiver. It is normal if the infants do not have the capacity of natural immunity to AIDS. The project team does not assume legal responsibility in the situation. The risk of transmission to HIV to the baby is not caused by this project, and this project team will not take responsibility. Regarding the characterization of the project results— and now I'm just going to kind of skim— the project team has the right, a final interpretation announcement to the public. You have no right— this is, by the way, quoted, so that bolding and uppercase, that's in the actual informed consent document. You have no right to explain, no right to announce the project or any information without permission. Violation of this will be dealt with as breach of contract. And the volunteers, you, will need to compensate us for the damages. The baby's photo on the day of birth will be kept by the project team. The project team has the portrait right of the infant. The project results, only we the team has the right of final explanation, announcement to the public. Have no right to talk about any of this without permission from us. For the project team's trade secrets— and now it's getting ridiculous. Now it's like, what on earth is this? It's like, this is not part of informed consent. This is like non-compete clauses and confidentiality this and waiver of liabilities. The second point is the key one for me. After the implantation IVF, You know, if you decide to leave the study due to other reasons other than specific ones listed above, you will need to pay back all the costs that we paid for you. If we don't receive this within 10 calendar days from notification, you will be charged an extra 100,000 renminbi, which it turns out to be something like $15,000, which for the average Chinese citizen is often greater than the annual salary. Now, if that is not coercion— all right, I think you're all sufficiently disturbed by all of this, right? The last thing is, ordinarily, something like this has to go before an IRB, a research ethics committee. And so in the manuscript, it says, oh, yes, this hospital had their ethics committee sign off on this. And there's actually a certificate signed by 7 people. There's a seal from the chairperson. That chairperson was later quoted in the press as saying, "We think that this was a great historic thing." That was before there was a big backlash. Now, of course, once there was a backlash, the hospital said, "No, we had nothing to do with this. We had no idea. This is clearly a falsified document." And then an investigation by the Chinese government found that ethical documents had been forged, not clear by whom. What we do know is that in the wake of all this breaking and a big backlash by— started by me, I guess, since I was the first one who actually knew about this and started condemning this publicly, but basically the entire scientific community afterwards. And I'm sure you all remember what a big hullabaloo was in the press. He went to jail. I think whether he actually broke a law or not— Chinese law is not clear— but he did end up getting sentenced to 3 years in prison. And he just got out of prison last year. Now, here's the most disturbing thing. So after the news broke, and there was a big backlash, and properly, there was just widespread condemnation of what he had did, and a lot of hand-wringing about how this was allowed to happen. I was curious. This was about a week after the news broke. I've never heard of this guy. I'm in the CRISPR gene editing field. I've never heard of this guy. I've never— I don't know who this is. I've never interacted with him before, have I? And I did a search of his name on my laptop, and I got a hit. And it turned out, as I reconstructed this, that about a year earlier, He had had his graduate student reach out to me by email for help, asking me about cholesterol genes and whether I could send them laboratory reagents, like tools, like CRISPR editing tools, as well as advice on how to target these cholesterol genes in human embryos. There was no mention of the fact that they might actually establish pregnancies, but clearly wanted help. And I was like, I want nothing to do with this. So I said, I don't think this makes any sense. Why would you want to do this in human embryos? Sorry, you know, I don't want to be involved in this. And then I didn't really hear anything again. But what I later found out is that that didn't deter him. He went ahead anyway. And so he was targeting with CRISPR cholesterol genes, same ones I was working on, in human embryos. And his original plan, as it turned out, was that the world's first gene-edited babies would be protected from heart disease, not from HIV. And it later became clear that he was using the data from my own papers, all the work I showed you before about, hey, this is how you turn off cholesterol genes in the liver in mice and so forth, as a way towards building towards a potential therapy for patients who are very sick with familial hypercholesterolemia. He was just taking that information. It was just free for the taking. It's published. It's out there. And he was using that information to turn off the genes in human embryos. And his original plan was that those were going to be the world's first gene-edited babies. And then the story goes that he happened to visit an HIV village in China where a large proportion of the villagers have HIV, and that has to do with unscrupulous practices by blood banks. And we won't get into that. But apparently was so moved, he said, you know what, I wanted HIV to be first. I think what he actually was thinking was, I think HIV is going to get more sympathy than heart disease if I do that first. But in a slightly alternate universe, the world's first gene-edited babies would be babies who had had a cholesterol gene turned off, and it would have been directly traceable to my work using the information right out of my papers. You can imagine how that made me feel. So learning about this work in the first place and reading that manuscript was like, being hit by a truck in a figurative sense. And then this was like being hit by another truck right after that. It's like, oh my gosh, I found myself embroiled in this without even having any clue or expectation. So there it is. OK, so putting all that aside, although it's hard to, let's say that the technology is eventually worked out. We figure out the unknown unknowns. It's eventually safe. We're nowhere near that point. We should not be doing anything. We shouldn't be going anywhere close to embryos with CRISPR at this point. But let's say down the road, some number of years, we actually do feel it's safe. Is there any scenario where it'd be acceptable to edit embryos? And I don't want you to actually answer the question or raise your hand or anything. I just want you to think about it. Do you think it would be acceptable for parents to use embryo editing to have a healthy biological child when there is no other means to do so? These are unusual cases, but there are cases where both of the parents have a rare genetic disorder, and they will pass it on to their child. You can't do in vitro fertilization and select embryos that are free of disease because all of the embryos will be affected. The only option to have a natural biologically related child would be editing. If you ask the general public, and there have been a number of polls, and I've done some of them myself, and aggregate all the data of the general public, not any particular audience, but just aggregating across the general public, various audiences, you'll find that the majority of people, or at least the very strong plurality of people, actually find sympathy for this situation and say yes. Next question. Do you think it would be acceptable for parents to use embryo editing to reduce the risk of their child having a serious medical condition, like premature heart disease or Alzheimer's disease? Well, I think most of us can certainly see why that might be appealing. And if you ask, again, the general public, you find it's about evenly balanced between yes and no. And there's always a contingent that says, I don't know, or I'm unsure. So now we're talking like 40% yes, 40% no. It's more evenly balanced. Do you think it would be acceptable for parents to use embryo editing to increase the odds of their child having a desired trait, like athletic ability? So now we're crossing that line from medical intervention to, enhancement, and everyone's going to have their own opinion where the line is divided. As we were talking about in the panel discussion earlier, it's totally fuzzy. And what one person thinks is medical is going to be viewed as an enhancement by another person. And so it's tricky. But let's say we're talking explicitly about enhancements. If you ask this question of the general public, to my gratification, the number plummets. Like almost no one's on board with this. Everyone hates the idea, or almost everyone hates the idea of using this technology for enhancements. Here's the last question to think about. So forget about embryos. Think about yourself as a potential patient who has a very bad disease. Now, if you had the opportunity to receive a one-shot gene editing therapy that would cure you of that disease, and with the caveat that we're assuming that therapy is 100% safe, would you do so? Would you take advantage of that? And as we've seen today, that can be a very nuanced discussion. But what I want to close is by showing you that it is possible. It is within reach. It is already starting to happen. And you will have these options. And I mean the collective you, as in all of us as a member of a society that has developed the technology to be able to cure ourselves of certain grievous genetic disorders. And not even just genetic disorders, but even the world's leading killer. And so it took us a lot longer than it took this guy to just shoot up some embryos and establish pregnancies. It took us years. It took us years of work in the laboratory. It took raising hundreds of millions of dollars, starting a company, because that's the only way you could reasonably develop something like this into an effective and rigorously safe therapy and actually start the process of clinical trials. But we finally got to the point where this, quote unquote, vaccination against heart disease, although at this point I'm thinking of it more as a treatment for familial hypercholesterolemia, it's actually gone into human beings. We started the clinical trial earlier this year. The first patient was dosed just 2 months ago in July. We don't know yet what's going to happen. We'll find out next year, but it's underway and it's because we did everything properly. We checked all the boxes. We did everything we could in cells in a dish and mice and monkeys, made sure to the best of anyone's expectations, going above and beyond in many cases what was required by regulatory agencies like the FDA to ensure that it was safe before we would put this into a single human being. But we finally passed that threshold. As you can see from this headline, the first patient was in New Zealand. And, you know, as time goes forward, there'll be more in New Zealand. There'll be some in the United Kingdom and eventually maybe later this year in the United States. And so it's happening. It's actually gone to human beings. The first study is always about safety. So we always start with very low doses. So the first patients may not get any benefit because we need to establish safety first with these very low doses, then slowly climb. And make sure everything's OK. And then you start to ask the question, OK, is it actually reducing their cholesterol? Is it actually benefiting them? But we have pretty good confidence that this is going to work because we're not the only ones in this game. So here's another disease or another patient. This is Patrick Dougherty. So early last year, he was diagnosed at the age of 65, if I remember correctly. He was diagnosed with a disease, a rare disease called amyloidosis, which probably almost none of you have heard of. That's OK. It's a rare disease. It's a genetic disease. It's inherited. His father had the same disease and died at age 64. So he's right around the age where, you know, the disease tends to happen. Fortunately, it's a late-breaking disease. But still, his father died of this disease. And now he started to feel short of breath. He started to feel weird things going on in his hands and feet, you know, like neuropathy issues. And he was diagnosed with amyloidosis. And when you get diagnosed with amyloidosis, it's a pretty grim prognosis. Like, you know, 50% of people are dead within 2 to 3 years once it starts affecting the nerves and starts affecting the heart. But he was fortunate to be able to enroll in a clinical trial of a CRISPR gene editing therapy. And this disease is caused by a toxic protein that's made by the liver. It has a mutation. It's a protein that normally does good things, but if you have a mutation, it's a toxic protein that forms into clumps in the bloodstream, and those clumps eventually settle in the nerves in the heart, gum up the works, so to speak, and then cause heart failure. And that's what eventually kills you. So the goal here was let's use CRISPR to turn off this gene so it's no longer making the toxic protein, clear it out of the blood, and then at least you'll halt the progression of disease, stop it from getting worse, and maybe make it get a little bit better. So he was one of the very first patients in this trial. And this is the paper in the premier medical journal, the New England Journal of Medicine, that was published last year, last summer. It was really— to me, this was a big milestone in modern medicine because this was the first time that gene editing was successfully done in the body of a grown-up human being. Forget about the embryos. In a grown-up human being, fully consenting human being. And here's what happened. Even though it was very low doses were being used, because again, this was the first study, phase 1, as we call it, and use very low doses to assure safety. Patrick Doherty was one of these 3 patients. We don't know which one. But what was remarkable was even receiving this very low dose, look what happened to the amount of this toxic protein in the blood. Within a few weeks, it dropped by an average about 90%. Almost clearing it from the blood in the body. This will almost certainly improve the condition, hopefully extend these patients' lives. If you could diagnose the disease even earlier, you know, that would just increase the potential that you could actually help these patients. It's working. It's happening. It's not around the corner. It's here. We are in the CRISPR era. And I think most of you have heard about sickle cell disease. This is a little bit different because with sickle cell patients, you don't actually put CRISPR in the body. You take their blood stem cells out of the body. You do the editing outside of the body. And then you put them back in in sort of like a bone marrow transplant. It's actually quite a big deal and costs a lot of money. And you have to be in the hospital for weeks. The hope is to someday be able to directly deliver CRISPR into blood stem cells in the body. So you can just give them one infusion, one shot, and then have the cure happen from within. But we're not there yet. That's an aspirational goal. But that trial got underway 2 years ago, and it is working. This is one of the first patients. This is Victoria Gray with her 3 children. She suffered horribly from sickle cell disease. After getting this treatment, she has not needed any blood transfusions. She has not had any sickle cell pain crisis. It was utterly transformative to her. And it's been long enough now that I think we can reasonably start to call it a cure. And something like 70, 80 patients have now been treated, and the results have been very good. It's happening. Like it or not, it's happening. And to me, as a scientist, this is very exciting because the technology is all the same. All these different diseases, the technology is more or less the same. All we're really changing is that GPS. We're putting in a different address. And sending CRISPR to a different place in the genome, a different gene, to turn off a gene or to correct a mutation. And so it actually doesn't take much to develop a therapy for an entirely different disease. So I've talked mostly today about cholesterol genes, our one-and-done therapy, our vaccination, if you will, to protect against heart disease. We can take that same exact drug lipid nanoparticles, messenger RNA, this GPS RNA, change 20 letters in that GPS. That's the only change we would need to make. Change just 20 letters, and it becomes a treatment for amyloidosis, this rare disease. And what I'm working on in the laboratory now, because tackling the leading cause of death worldwide wasn't enough, is we changed the 20 letters again, but now we're targeting a very different disease, phenylketonuria, one of those inborn errors of metabolism that we heard about earlier, PKU. And I think most of you probably heard of PKU because it's newborn screening, and every, you know, every kid who's born in the United States gets— in most countries gets screened for it. And a devastating disorder, not a fatal disorder, but pretty devastating because it causes neurodevelopmental and neuropsychiatric issues if you are any able to keep it under control. There's never been a cure for this disease. And now just by taking— repurposing the drug that we've already made for heart disease for amyloidosis, potentially cure PKU. And this is just the beginning. We can repurpose it again and again. And I think we're going to be able to treat a whole variety of diseases for which there previously was not any cure or even any good treatment. Of any kind, it is going to be utterly transformational for human health. We're on the cusp of something amazing, but also in many ways daunting. All right, so I want to end on an aspirational, more positive note rather than depress you all with the misdeeds of JK and that whole misadventure. But it's hard to disengage the two. The good often goes with the bad. And it's our responsibility as human beings citizens of the world to try to do things in the most responsible way and mitigate the bad, the negative aspects of the technologies we use. And so I'm happy to discuss as long as you want, really, any of the issues that came up today. I'll just make a quick plug. The book on the left is written for a lay audience. It's a more popular science book Reverend Jackson mentioned at the beginning. I was so traumatized by my whole experience with the gene-edited babies that— and I was talking to so many journalists and so many people about it over over again that I eventually just thought, you know what, I'm just going to get it down on paper. It was a therapeutic exercise to just put it down on paper. It's available on Amazon for like $3, like the minimum you can charge, because I'm not trying to make money off of this. I just wanted to get the word out about what actually happened. And there's actually a lot of scientific explanation in there about all the things that went wrong in what I hope is a lay-friendly way. And if you're a scientist, I don't know that there are many in here, but if you're a scientist and you want to learn how to do gene editing in the laboratory and actually apply it to research projects, to actually try to develop therapies. The book on the right is a sort of how-to manual, not intended for people like JK, but intended for serious, responsible scientists.

Thank you so much.

Thank you so much.

Thank you so much for that. I think I can kind of safely say that minds are collectively blown. But at this time, we would open up the microphone for questions. You can leave questions in the chat as well for Dr. Musonuru. I, yeah, I saw a lot of people taking notes and I heard a lot of, oh, so all right, no prodding necessary. Yeah, thank you so much. That's very exciting and just, yeah, amazing to see how much progress has been made in such a short time and to see this being applied to some really troubling diseases. So thank you for that. My question is, as these lipid nanoparticles are being used to deliver the components of the CRISPR mechanism to liver cells and other cells too, does the immune system ever end up seeing the Cas9 protein as a result of this?

Yeah, it's, it's, it's a good question. What we do know is that when you use lipid nanoparticles and they get delivered to the liver, the components clear out of the body very quickly. So within days, everything is gone. And we have not seen any evidence of an immune reaction in any of the monkey studies that we've done. For example, human beings, the patients in the amyloidosis trial, all appearances, it appears the treatment's well tolerated. There has not been any issue of an immune response reported yet. The trials are still undergoing. They're still underway. So we'll have to see, especially as higher doses are used. But so far, it's looking pretty clean.

Which is encouraging. Yeah, that's good to know. One of my concerns would be if an immune response developed after the first use of this technology in somebody, and then 10 years later another disease comes along, they want to— yes, again, for the other disease, would the immune system then cause severe inflammation for the tissues that were undergoing?

No, it's a great point and a very legitimate concern. What we have done, which again I think is promising, is, you know, I didn't show you the data because at some point it's just, you know, scientific whatever showmanship, and we don't really need to go there for today's purposes. But what we've been able to do is give a treatment, an LNP treatment, to turn off one cholesterol gene and then come back a month later. This is all in monkeys, by the way. Come back a month later and then give another LNP treatment, but now tuned to turn off another cholesterol gene. So really trying to drive cholesterol down, not just by turning off one gene, but two genes. And it worked beautifully. The second treatment was just as effective as the first one, and you end up with two genes entirely turned off. So that suggests that exactly what you are talking about will be possible going forward.

Thank you. Very interesting. Thank you. My biggest concern with this is the role of responsibility of the patient and the medic. I did some research with the Cleveland Clinic And what we were able to do was we developed a cognitive mathematical equation which predicted HbA1c in diabetic patients. And that model, which is essentially how patients think, was more predictive of HbA1c levels in the blood than whether or not the patient was taking insulin.

Oh, wow.

That's radical. So the implications from those results are, and it's why I threw out the 30% to your question on what percent of patients do you think take their medication. So I've published some adherence rates in the Journal of Clinical Oncology, and even in oncology they're plummeting. So why is that, right? So the psychology of it has to keep pace with, with this. Your questions that you put up, you, you, the first one I answered yes, you know, which was if there was no other, other treatment and this was available to you, would you take it? Yes, I'd take it. But we don't do that. We don't wait until there are no other options. Yeah, right. So in Cleveland Clinic, when they don't have diabetes patients coming to goal, they don't say Okay, you need to cut out, you know, the burgers and fries, and the patient doesn't take responsibility for cutting out the burgers and fries. If they've tried every regimen in the, in the protocol, they go to bariatric surgery and they slice the fat out of them, and that works for 6 months, and then they put the 200 pounds right back on again. So at some point, we need to stop just feeding consumers what they want to take the easy way out. Now, your case with the girl in hospital, I'm glad it's an option for her. She's not taking the easy way out, she's taking the only way out. I would take the only way out. But now, as you say, that this is already, you know, the horse has already bolted, and I'm glad it's, it's there. You know, it's going to get to the end of the line. Yeah. And how do we mitigate the abuse for athletic abilities? I answered no to that one. Certainly for, you know, eye color, absolutely no for that. But we have to keep, you know, the psychology of it runs right alongside with the ethics of it. It's got to, you cannot run ahead of the psychology and the ethics.

You raise a very excellent point that actually weighs on me. So, Again, if someone has a grievous genetic disorder, they're suffering. I don't think anyone is going to quibble about the benefit there and worry too much about unintended consequences. But you're right, I worry a lot about the moral hazard of a vaccine against cardiovascular disease because cardiovascular disease, heart disease, it's complicated. It's not just your genes. It's not just, you know, the choices you make, although that's a big part of it, whether you smoke, whether your blood pressure is high, whether you have a bad diet, whether you don't exercise. The environment you live in, is it polluted? Or, you know, are you exposed to a lot of things that you may have no control over? A lot of different things come into the picture, and there's a very complicated interplay. And so it's nice to say, hey, we have a vaccine against cardiovascular disease. It doesn't mean you're not going to get cardiovascular disease, you're not going to have a heart attack. And if you don't take care of yourself and make good decisions on behalf of your own health, you might undo the good that comes along with having a gene modified to turn down your cholesterol levels, and it could end up being counterproductive, not just with respect to heart disease, but if you now have— feel like you have license— oh, you know, my heart's great, I don't need to worry about it, I'm gonna eat indiscriminately and smoke and do this, that, and the other thing— you know, it brings up all sorts of other medical issues— obesity, diabetes, arthritis, etc., etc., that come about if you don't take good care of yourself. So I do worry exactly about what you're talking about, that if not framed in the proper way—

right. And it's, it's, it's getting back to the title of the conference again. What is it that makes us humans? Well, it's being responsible for who we are and making the right decisions to live as real beings and not just be forced into and mechanicalized into what medics say this is what you should have.

Yeah, thank you for that. We have a question from Zoom from Jane Montana. In your research, what are the implications, if any, on Alzheimer's disease?

Can the mechanism be reversed to turn targeted genes on as opposed to turning them off? A very provocative question. So what we know about Alzheimer's disease is there is one very strong genetic risk factor for Alzheimer's disease. It is a gene called APOE, A-P-O-E. And depending on which versions of APOE you happen to have inherited from your parents has a pretty strong influence on your risk of getting Alzheimer's disease earlier rather than later in life. So the most common flavor is called E3. If you have two copies of E3, you know, you're pretty average. There's a bad version called E4. If you have 2 copies of E4, you're at much higher risk of getting Alzheimer's disease in your lifetime. And if you do get it, it'll be earlier in life. And if you have 1 copy of E3 and 1 copy of E4, then you're kind of in the middle. There's another version, E2, that also comes into play. And so you could either be like, you know, depending on which one you have, you either are like relatively protected or relatively vulnerable. Now, I've had my genome sequenced. I took advantage of a Black Friday special a few years ago. This company called Dante Labs in the UK offering it for just $200. But I think it backfired because so many people signed up for it that they just had a huge backlog and it took them like 6 months to give me my data. One of the things I learned is I'm E3/E4, so I'm at higher than average risk of getting Alzheimer's. And so when you ask the question, if you could change one thing about yourself using CRISPR, that definitely crossed my mind. Wow, I'd love to turn that E4 into E3 and reduce my risk. And such a thing is not outside the realm of possibility. The actual edit, if you will, the change you would have to make, it would just be changing essentially a single letter that would change E4 into something like E3. If you could somehow get CRISPR into the brain, into the right places— and one part of the problem is we don't know exactly the right places. And so if we don't know the right places, we can't even talk about delivery. But so you have several challenges. But if you could, and you could edit it, yeah, you could reduce the risk of Alzheimer's. Now here's the fly in the ointment. You could say, well, wow, that sounds really hard. You'd have to take a live breathing human being. You'd have to go into the brain. You'd have to, you know, somehow get things into the right cells and make all the edits in every single one of those cells to have the full effect. And someone could reasonably say, well, if that's really your goal, then wouldn't have been much easier to have done that as an embryo where there's a single cell and all you have to do is make the one edit and you're done. And every cell in that person's body the person that arises from that embryo has the benefit of that protection. And so that's why one of the questions I explicitly asked was, if you as parents had the opportunity to do embryo editing to reduce your child's future risk of something like Alzheimer's disease, would you do it? And it becomes a very tough question, right?

My question relates to if this technology can greatly improve the lives of people, When do you think it becomes not just a matter of individual decision, but a fundamental change in our social contract where the state might compel us to take a vaccine that prevents heart disease because of the greater— because of the societal benefit, eradicating this disease? And also, how do we tell the difference between a disease that would be good to remove, or a condition that we should address differently as a society and change our societal structures to accommodate individuals that are disabled, but not in deadly ways?

How do we tell the difference between those two? Yikes. Wow, that's probably another hour and a half lecture from someone much smarter than me. I'm going to fall back on the, I don't have any answers. But you raise some of the complexities that we're going to have to address. It's being thrust upon us because the technology is here. My observation would be that for something like heart disease, obviously, because it is the leading cause of death in any society, basically in any country in the world now, you could see a strong public health argument that, yeah, everyone should receive it. It should be mandated. I'm going to use that word mandate because it is to the benefit of society. As long as it's safe, as long as it's essentially 100% safe and there's no potential of doing harm to anyone, you could see how a particular constituency, a particular country or whatever, would think that it would be a good idea to mandate it on behalf of the citizens because it's going to improve life expectancy. It's going to improve overall quality of life. Life in aggregate across the population. The case is not nearly as compelling as the use case that we all live under now, which is infectious diseases, because there, there's a feeling that, well, if you're talking about a highly transmissible disease— and I'm not even talking about COVID I'm talking about, you know, all the childhood vaccinations that we've been getting for decades, uh, you know, these highly infectious and transmissible diseases that cause a lot of death death, you know, things like, you know, measles or smallpox or whatnot, you know, in their time, mandatory vaccination had a strong motivation because it wasn't just about you. It was about society. Just because you might feel violated if it was forced upon you, the chance that you could then be a focus of infection that you spread to many people is what made the use case so compelling that there just needs to be mandatory vaccination across the population. And this goes back to late 1800s, early 1900s. The Supreme Court weighed in on this and allowed for mandatory smallpox vaccinations in the Commonwealth of Massachusetts. So it depends on the use case, right? For something like heart disease, I could see an argument being made. But the flip side is, well, if I refuse to get the vaccine, The only person I'm hurting at the end of the day is myself, really. I'm the one who's going to potentially die decades earlier, myself and my family members who would suffer from my dying earlier than I otherwise would have. You know, there is the overall productivity cost to society, these larger scale calculations that, you know, don't involve individuals as, you know, citizens as individual actors, but just thinking about the overall good to society. And I can't even begin to tell you how to properly weigh those interests, how to balance those interests. Thank you. We have time for one more question. Thank you so much. My question is about arthritis. Do we know anything about on a gene level what would need to be tweaked in order to make that go away? That's a good question. There's certain types of arthritis, like the more autoimmune flavors of arthritis, like rheumatoid arthritis and psoriatic arthritis and so forth, where there is much more understood about the genetic basis. It's not my specialty, so I can't really speak to exactly how far progress has gone, but I know there have been some number of genes that have been identified that underlie. And so given time and given a better understanding of how each of these individual genes influences the onset and progression of arthritis, there might be something you can intervene on there. There are colleagues of mine who work intensively on this, and they're very, very intelligent and capable people. So I give them the full benefit of doubt that give it enough time, they'll figure something out. Osteoarthritis is a little bit different. I mean, no doubt there are genetic influences, but I think a lot of osteoarthritis is from the environment, if you will. Factors like how much weight you have on your body and how much wear and tear you're putting on your bones and your joints over time. It's a more complex situation, but that's not to say that there's not some genetic strategy you could use to mitigate it. I just don't know what it would be. I was just curious what factors go into deciding what's next in terms of what you work on. So you said you were working on heart disease and now you're working on PKU.

I'm just curious, is that related Is it related to how closely a disease is related to the disease before it that you were working on?

If you could just talk about that. Yeah, so I'm a cardiologist. There's really no logical reason for me to be working on PKU. As far as I know, the heart is like the one organ that's not affected by PKU. So why am I working on PKU now? Why have I made this shift? Well, part of it has to do with the art of the possible. So what I showed you today was that you could use LNP treatments to deliver CRISPR into the liver and essentially hit every single liver cell and turn off a gene close to 100%. And I also mentioned that if you wanna go to some other organ somewhere else in the body, a lot of that is not figured out yet. We'll figure it out in time, but we're not there yet. But if you wanna get something to the liver, if you wanna get CRISPR into the liver, we know how to do that. So in my mind, the door is wide open. So about a year ago, after we had, you know, squared away the work, with the heart attack vaccination, if you want to call it that, and we're on course to start clinical trials. That was for me an opportunity to step back and ask, what more can I do with this? It'd be great to wipe out heart disease. And I hope in the fullness of time that will eventually happen. But what else can we do with this? And so I went through this exercise with a few of my colleagues who think a lot about pediatric diseases and metabolic diseases. If you could do anything in the liver, what are the diseases, what are the low-hanging fruit, the opportunities where there is real unmet need because there just are not good therapies? What are the diseases where we can make the most impact? And the one that was at the top of the list was PKU. Treatment options are relatively poor for PKU. There's, there's no curative therapy that exists for it. It's not a fatal disease, but there is a lot of morbidity. With the disease. It has the advantage that everyone who has PKU is identified basically from the time of birth. So there are a lot of factors, a lot of characteristics of the disease that make it— at least for me, made it a compelling opportunity to go after it. And it turns out that if you can make this fix, in the responsible gene and fix the mutation in the liver, and just in the liver, that'll be enough to cure the disease. So I don't have any, you know, human data to point to, but I didn't show it today. I thought about it, I said, well, maybe that's trying to cover too much. But our very latest data, which is only a couple months old, which was very exciting, is we've made a mouse model that has PKU but doesn't just have PKU, but we actually altered the gene responsible so that actually matches the human gene. So mouse genes, human genes are somewhat different because mice are not humans, right? We're different species. We, you know, if you think to talk about evolution, as we were talking about this morning, we diverged tens of millions of years ago. So we're related, but we share like a lot of letters in the genome, but we also have a lot of differences. But what we did is we changed the gene so it matches the human gene. And the mutation that we put in is one of the more common PKU mutations. So it makes what we call a humanized mouse. It allows us to test whether a potential therapy works in the mouse, and then you could take that same exact therapy and eventually put it in a human being because the code matches, if that makes sense. And what we found is we had this mouse model. There's no question it had PKU at extremely high phenylalanine levels. That's the amino acid that builds up in patients with PKU because they can't break it down. That's what causes the damage to the brain. And, you know, even for all the time I've been in this field, it still kind of blew me away what we found. We gave the LNP injection. We had switched the GPS so it matched the gene, the mutation responsible for PKU. We, you know, gave it through the bloodstream, one injection. Within 48 hours, cured. The phenylalanine levels, the amino acid levels, had come down to normal. It is not possible to do that with any sort of therapy in any PKU patients. Like, you can get their levels down and manageable to the point where they're not harmful, but to actually get them to normal— I mean, unbelievable. So that's just a mouse, but I feel confident that with some effort, and again going through all those careful, rigorous preclinical studies, and then eventually doing clinical trials in the right way, give us a few years, and I think we'll be at the point where we're actually using this to help patients with PKU. And that was the top one on our list. And I have half a dozen others that we're starting to work on, other liver-centered disorders. Most of them are inborn errors of metabolism, where I'm hoping over the next few years we're going to make a lot of strides and be able to help a lot of patients with rare diseases. Wow.

Well, I think I can speak for most folks here when I say that we are sufficiently CRISPR'd out. No, inspired and horrified in equal measure. Thank you for your unique insights, both as somebody who is a practitioner and who is researching this, and somebody who has been on the inside of when it's gone wrong. Just one final thing. Are there any international efforts to curb some of the embryonic research, or like in some of the less scrupulous countries, or are we just relying on the court of public opinion on this?

The answer is yes, in the sense that both of those. There are international efforts. So one over the last few years has been spearheaded by the World Health Organization. They convened a special committee to exhaustively look at this issue, and they published a multi-hundred-page report, which you can find online if you want to read it. And there was a parallel effort from the National Academy of Sciences, Engineering, and Medicine here in the United States, the Royal Society of London, and a few other similar organizations around the world. They got together, and they made a similar report after a couple of years of deliberations, and that's also available. And the upshot is they, you know, they made recommendations over what regulations should be in place. They carefully looked at all the use cases and what might be an acceptable use and what would clearly not be acceptable uses. And people are free to read them and decide if they agree or not. The problem is that these organizations don't actually have any legal authority. In every single country in the world. Yeah. Right. So what they recommend is non-binding. It is up to each individual jurisdiction to decide whether they want to actually implement any of these recommendations. Countries like the United States, you can't do this stuff. It's like, you know, the ways allowed— there's no law that explicitly prohibits embryo editing. But if you take a combination of FDA regulations and other laws and put it all together, it basically makes it impossible for anyone to legally do. Do that kind of work in the United States and actually establish pregnancies. You can do— you can study what CRISPR can do in an embryo for safety purposes, but you can't actually establish a pregnancy. Wouldn't be possible in the United States. I don't think it's going to be legally possible for many, many years because laws would have to be changed and regulations would have to be changed. China, because of what happened with what I think of as the JK affair, clearly had a very permissive environment before. Now at least publicly have done a 180 and are strongly against it and apparently have enshrined in their constitution a ban against doing this kind of work and, you know, that kind of thing. Now, what happens behind closed doors, who knows? But at least outwardly, you know, China is now on what I think most of us would think of as the right side of the fence now. And many peer countries, same thing. There are regulations, but there are a lot of countries where this is not on their list of priorities. They have much bigger issues that they're dealing with, failed states and developing countries that are dealing with a lot of other crises. This is not going to get much attention. And I don't know that there's much to stop someone from setting up an illicit in vitro fertilization clinic and then deciding to do this. Not to stop on a depressing note, but What I didn't mention with JK's clinical trial is he just was able to, like, recruit somebody who worked in in vitro fertilization clinic. They made embryos just like you would in any clinic that does in vitro fertilization. His team bought CRISPR from a, from a couple of research companies in the United States. So reagents, supplies that were never intended for use in human beings, were only intended for use in the laboratory for research purposes, but was able to buy his, you know, he's a scientist, so just bought it off the shelf, if you will. And then they just decide, hey, let's take this reagent. It's not even the best quality, but we're just going to inject it into the embryo. And any in vitro fertilization clinic has the tools to do that if they want to do it and just inject it in there. It's very easy to do if you don't care whether you are doing it badly. That's the depressing part about this. It's really easy to do, but if you want to do it well, if you want to do it right, if you want to do it responsibly, it's very hard to do. And that's what we're dealing with.

That sounds a lot like pastoral ministry.

Yeah.

Well, thank you. This is certainly going to be an issue that will be important to people in the public in the next couple of years. Those who have never heard of CRISPR will absolutely know what it is within the next decade.

So thank you so much. My pleasure. Thanks for having me.