Editor's Note: In this exclusive interview, former Vice President Al Gore speaks with Medscape Editor-in-Chief Eric Topol, MD, about what he believes to be the most stunning advances in the practice of medicine. Mr. Gore talks specifically about the promise of precision medicine, the pros and cons of fetal genome sequencing, the healthcare race that the United States is currently running with China, and why health policy has failed to adequately address the problem of antibiotic resistance.
He also discusses Twitter and digital medicine, the microbiome, and his decision to become a vegan.
The Future of Medicine
Eric J. Topol, MD: Hello. I'm Eric Topol, Editor-in-Chief of Medscape. Joining me today for a Medscape One-on-One is former Vice President Al Gore. We're really thrilled to have you as part of our own version of Dos Equis' most interesting people in the world, as applied to medicine. It's really terrific to have a chance to talk with you and get into your phenomenal book, The Future: Six Drivers of Global Change, especially the part that discusses the reinvention of life and death.
It's really very interesting that you delve so much into medicine because you're known, of course, for your efforts in climate change and energy. But you really discuss this topic of biomedicine and genomics in a large way. How do you keep up with all of this stuff?
Al Gore: Well, first of all, thank you for doing this interview, and congratulations on your 7th annual Future of Genomics conference. Thank you for helping me with the chapter in which I delved into life sciences and genomics and their related fields. I've spent 8 years researching in an effort to get my arms around these 6 drivers of global change, and the stunning advances in the life sciences and related fields were really surprising to me.
I used to have a lot of hearings in Congress, when I was in the House and Senate, on some of the early breakthroughs in genetic engineering and related fields. I remember when Dolly [the sheep] was cloned and the debate on the bioethics of cloning and the like. Then, when I was in the White House, I kept that collection of issues under my purview, but after leaving public service and trying to serve in a new and different way, I checked back in on the advances in life sciences that had been made since I last took an in-depth look, and I was really amazed. It was helpful to me to learn from your book, The Creative Destruction of Medicine, and from our talks.
Dr. Topol: Thanks. I'm amazed at what you covered in this section. But I've got to ask you -- you have these diagrams. These diagrams are amazing; they're really intricate. How do you come up with these things?
Mr. Gore: Yes, somebody said it looked a little like the Unabomber's diagrams, but I never intended to put them in the book itself. The diagrams that begin each chapter began as an organizing tool for me to map out the relationships between the different topics and subtopics. My editor at Random House, Jon Meacham, was quite taken with them and he said, "We've got to put these in the book." They're not for everyone, but I must say that a lot of readers, students in particular, have given me very positive feedback on those diagrams.
Antibiotic Resistance, Special Interests, and Precision Medicine
Dr. Topol: It kind of gives us a little sense of the workings of your mind. I want to get into some of the topics you delve into. The first one, in terms of genomic medicine, is precision -- precision healthcare and precision medicine. I want to talk about something you discuss in the book, about how the US may have the most difficulty in making the transition to precision medicine because of the imbalance of power and unhealthy corporate control. What are your thoughts on that?
Mr. Gore: In another chapter of this book, I write extensively about what has happened to the balance of power -- political power, decision-making power, economic power -- inside the United States. The US rose to be the most powerful and respected nation in the world for a lot of reasons, but maybe the main one is that we made better decisions over time than any other country because we had a free flow of ideas and a focus on values. We maintained the ability of people who felt strongly about the deepest human values to speak up and gather agreement from others who also shared that commitment, and then have an influence on the shaping of public policy. But over time, for a variety of reasons, chiefly the influence of money in our political system, corporate interests and other powerful organized special interests have come to dominate the decision-making processes in our country. I hope that doesn't sound like a politically radical statement. I think, unfortunately, that it's pretty widely agreed upon across the ideological spectrum now, and it's really a shame.
Let me give you a quick example of what I mean. Antibiotics have been such a wonderful blessing for humankind, and our policy that guides the use of antibiotics should be dominated by the public interest. Let's not overuse them. Let's use them appropriately. Let's allocate sufficient R&D to continue discovering new antibiotics even if they don't necessarily shape up as a big profit center for the companies that develop them.
But what are we doing instead? Well, 80% of the antibiotics used in the United States today are fed to livestock in subtherapeutic doses, which inoculates the bacteria against antibiotics. And now there are proven examples of bacteria that are vulnerable to antibiotics in humans, that jump to livestock. The bacteria are then dosed constantly with the antibiotics and become immune to them. Then they jump back to humans. Now, there are other factors that have contributed to the looming threat of a post-antibiotic world, but that's one of the main ones. Public policy should address that. It's a no-brainer, but because of the dominance of wealthy special interests, it's just not even considered politically possible.
Dr. Topol: It's amazing. It really is. It's so sad. Giving antibiotics so broadly is the opposite of what should be done. We're so imprecise.
Getting back to precision medicine, the promise of genomics, sensors, and other related things could change medicine, but do you think it's going to wind up being done outside of the US because of some of these obstacles we have?
Mr. Gore: I hope not, but at this point we are likely to see the new models that unlock the potential for precision medicine or individualized medicine develop first in other countries.
The powerful presence of pharmaceutical companies, device manufacturers, hospitals, caregivers, and also insurance companies has such control over the development of policy and the making of political decisions, that any new models that are introduced here in the US to unlock this potential for precision medicine -- but impinge on the profit centers of these organized interests -- will encounter tremendous political resistance. Our democracy has been hacked, and public policy makers and elected officials now feel as if they have to spend the majority of their time catering to the wishes of these powerful interests because they provide the money that determines the outcome of elections and primaries. Of course, there are a lot of good people trapped in a bad system; there are exceptions to that rule.
The Influence of Insurers on Health Policy
Dr. Topol: While we're on the subject of special interests, I do want to get your further comments on the insurance industry because you have a section in the book on insurance companies. And you talk about how legislators, with exceptions, are no longer serving the public interest because they are so dependent on campaign contributions from these corporate interests and are so vulnerable to their lobbying.
Health insurers are a powerful force. Are they part of the problem or part of the solution?
Mr. Gore: Right now, I would say they're more a part of the problem than a part of the solution. We are beginning to see the emergence within the insurance industry of some adaptations to the new realities of precision medicine. It's just now starting, but not where the public policy makers and politicians are concerned.
Let me break it down into a very simple comparison. In 1976, a long time ago, when I first went to the US Congress, I had the luxury of being able to spend almost all of my time talking with my constituents in town hall meetings and individual meetings, taking their ideas back to the nation's capital, finding out facts there, sharing them back home. It gave me such a thrill to be a part of this majestic design that our founders bequeathed to us.
That's what happened back then. Here's what happens today. The average member of Congress is told on the day that he or she arrives in Washington, DC, that they have to spend between 4 and 5 hours every single day on the telephone or at cocktail parties begging rich and powerful people and [special] interests for campaign contributions. Now, it's just human nature that if you spend more than half of your working hours begging powerful people for money, you're going to begin to think more and more about how they will react to what you do and say. So now you have these interests actually writing the exact words of amendments to laws and of the laws and regulations themselves. And all of the work of Congress is distorted by that. I wish I was overstating this but I'm not.
Dr. Topol: Well, getting your insights is remarkable, because here we have the biggest and most exciting time in the history of medicine. These are some of the things that may hold us back.
Mr. Gore: Yes, and it goes beyond that, because these new developments also bring with them some very difficult choices that we as human beings and we as Americans will have to make. We'll have to make them on trait selection, for example, and on some of the crossing of species lines. There are so many examples. Making these decisions is hard enough if you're just focusing on what is right and what is wrong, and what's going to be in the best interest of ourselves and our children, grandchildren, and generations ad infinitum. But when that decision-making process is distorted by the constant pressure of groups that wield influence and want a particular kind of decision because it's going to mean more money for them -- I'm not against the profit motive; I think that it's great. But it has to take its place within the democratic context and not dominate decisions in ways that hurt the public interest.
Healthcare and Privacy
Dr. Topol: Right. Now, another area that you really drilled into, not only in the section of the book on life sciences but throughout the book, was privacy. Obviously, we have so much data and information on each individual. What are we going to do to ensure the privacy of all of this medically related information for each individual and for populations of individuals?
Mr. Gore: When I first started writing about it, this issue was hardly a blip on the public's radar screen. But now, after WikiLeaks, Edward Snowden's leaks, and all of the revelations in the commercial sphere, it is really becoming a major public policy issue. We have to address it. A lot of the focus has been on the National Security Agency (NSA) and the monitoring of the metadata of everybody's telephone calls, email messages, texts -- that is obscenely outrageous.
It's just incredible. I mean, if you have a suspected terrorist in middle Tennessee, where I live, in area code 615, then absolutely go after all of that person's communications if you've got reasonable cause, and don't tie it up in red tape. But does that justify collecting information on every single user of the telephone system in area code 615? No.
Dr. Topol: Talk about precision, right?
Mr. Gore: And just in practical terms, it's ridiculous. One of the great experts on the security system, James Bamford, who famously wrote The Puzzle Palace: Inside the National Security Agency, America's Most Secret Intelligence Organization and many other books, used this metaphor that I often use too: "If you are looking for a needle in a haystack, it's often counterproductive to go out and pile lots more hay on top of the haystack." Of course, the metaphor applies because if you're looking for a sliver of relevant information within a vast quantity of irrelevant information, your default reaction to a new threat shouldn't be to say, "Oh, let's go get a lot more irrelevant information."
They've justified the recently publicized intrusions by going back to 9/11 and saying that these 2 terrorists, who later were part of the hijacking team, were in San Diego and calling Yemen, and we had no way of knowing that they were there calling Yemen because we weren't collecting all of this data. But here's the truth of it: Those 2 men were in the telephone book under their own names and they were on the terrorist watch list. So, by piling a lot more hay on the haystack, the NSA already had missed the fact that they were there. People who understand this far better than I do have gone back and reconstructed all of those events and they've said, "Here are 15 or 20 ways that we could have and should have identified what was going on."
The case is overwhelming. But there is always a desire on the part of bureaucrats. It sounds like a pejorative word, but when you get these governmental organizations that have big budgets, they just collect everything and keep going. But democracy is, among other things, a state of mind. If we as citizens in a free country have to think twice about whether every communication is being logged and stored and is going to be available for others to see potentially, then that has a chilling effect. It violates not only the Fourth Amendment, against unreasonable search and seizure, but also the First Amendment, designed to protect freedom of speech. Because if people feel a chilling effect to the point of feeling like they can't speak freely lest somebody misinterpret what they're saying, then that's really contrary to the bedrock of what it means to be an American citizen.
Can We Really Protect Patient Data?
Dr. Topol: When we get to the point of where you have all your genomic data sequenced and whatnot, and you have sensors collecting your metrics, like your blood pressure, are we going to be able to handle that? Or do you think that a lot is going to have to change?
Mr. Gore: A lot is going to have to change. I've talked about the NSA and related government activities, but there is also the so-called stalker economy, where a lot of private companies that live in the Internet space are treating their customers as their products. They're collecting all of the data they can possibly collect and constructing these voluminous digital profiles on people so that they can sell that information to advertisers, or sell the selling opportunity to advertisers, based on the proposition that they can identify exactly who, for example, has a particular health condition or a particular genetic vulnerability. So, all of a sudden, people get advertisements based on that intimate knowledge. That, too, can have -- and is already having -- a chilling effect on a lot of people.
What about a young person who has some medical condition or psychological condition and they want to get help? We want them to be able to get help. That's one of the blessings of the digital age. But if they come to feel that when they reach out for help that they are going to be digitally stigmatized in a digital record that is eternal and there for the rest of their lives, some are going to be reluctant to reach out and get the help that they need and deserve to have.
Dr. Topol: We clearly have a lot to do to get that in a state that's going to work.
The Race With China: Is the United States Losing?
Dr. Topol: You write about China in your book. Obviously, they've already set out to be the genomics capital of the world. They are sequencing people to understand the genomics of intelligence. You have a good global perspective here -- are they going to dominate in genomics and in life science in the years ahead?
Mr. Gore: They have, according to some reports, already spent over $100 billion in the past decade alone on basic R&D of technologies in these areas.
Dr. Topol: And they have more high-throughput DNA sequencers than anywhere in the world.
Mr. Gore: The Beijing Genomics Institute (BGI) has more sequencers than the entire United States of America, and that's just one of China's institutes. They have identified this effort as one of the pillars of their new economic blueprint. They're seemingly determined to spend unlimited sums of money. They've attracted in the last 3 years 80,000 Chinese-born Western-educated PhDs in these fields to come back to China. Now, maybe that's a great thing, and no one begrudges them that, but it's another indication of the size and scope of the commitment that they're making. I don't want to sound like a jingoist or an American beating my breast in a prideful way, but many do fear that the Chinese simply do not have the same commitment to the protection of individual values in the way that we in the West have come to love and appreciate those human values. And again, maybe that's a prejudiced way of thinking about it.
Dr. Topol: But the fact that they're sequencing high-IQ people and are trying to understand the genomics of intelligence, which isn't being pursued in the US or Europe or anywhere else -- that's kind of distinctive in a way.
Mr. Gore: It is distinctive, even when you consider what many regard as the practical difficulties of that design.
Dr. Topol: Exactly. They may not come up with anything.
Mr. Gore: But the idea that they are marching toward what some believe will be a practice in the future of sequencing every child, and using that knowledge in an effort to match people with the professions in which they are most likely to unlock their potential -- that's quite a startling development.
Of course, as you know far better than me, the speed with which sequencing is becoming cheaper is absolutely startling. We're all familiar with Moore's law, in which [Intel cofounder Gordon Moore observed] that the number of transistors on a chip doubled approximately every 2 years, and how that's correlated with a drop in pricing of computer chips, and computers themselves, by half every 18-24 months. And we understand what the implications of Moore's law are: We now have smartphones with more power than the biggest supercomputers of 30 or 40 years ago had.
So here's the point: The cost down-curve for genetic and genomic sequencing followed Moore's law up until roughly 2007. Then it started going down much faster than Moore's law. The cost of sequencing a genome went from $3 billion 20 years ago to just $1000 at the time of this interview. And at that current rate, we have to look at what the implications will be of a $10 sequencing cost, which will happen within a few short years. What will that do to the diagnostic ecosystem? What new opportunities and things to guard against will come about when we have a cost of sequencing that low? It'll be routine. It'll be a part of a routine exam all the time.
Dr. Topol: I know, and you pinpoint in your book that this is the first time in history that man has transcended what has been regarded as the most technological triumph of our existence -- Moore's law as it relates to computer chips, and it's being done through genomics and sequencing. What you are saying is so incredibly important. I'm dismayed that we, as a country, aren't supporting efforts in this regard. I'm sure you've watched the lack of support that we've had in genomics and how it compares to what's being done and what needs to be done on the global landscape.
Mr. Gore: I don't want to go back and dwell on the imbalance of political power, but let me use a quick example. We just saw the passage of a farm bill that funnels billions of dollars in unneeded, unwise, counterproductive mass subsidies to factory farmers and industrial agriculture operations that hurt the environment and that hurt the health of the American people. And it's going to people who are already extremely well-off. At the same time, we see billions cut that should be spent on R&D and basic science opportunities in these incredibly exciting fields that can revolutionize healthcare and improve the quality of life for Americans. But we don't have a lobby to campaign for that money, and there are no campaign contributions being made to encourage funding in science. So the rich get richer, and the need for an allocation that benefits the public interest is diminished.
Fetal Genome Sequencing and the Threat of Designer Babies
Dr. Topol: You also write about fetal genome sequencing, which was a big breakthrough. We can now obviate the need for amniocentesis; it's just remarkable. But it also circles back to the question of what do you do with the information? Will it lead to designer babies? What are your thoughts about that?
Mr. Gore: I have many thoughts about it. We all should be paying attention to this because some of the choices that parents will now have are benign, nonsignificant outcomes -- blue eyes, black hair, whatever. But if we make choices that affect not only the individual but also the germline, and introduce changes that we do not understand into generations stretching far into the future, we need to be pretty careful that we understand the full implications of those choices. And what we're currently seeing is a determination to make those choices even though we don't understand what the implications are.
The ethics of not making these choices are so clear that nobody is going to argue with it. But we see things like parental competition and what it's done to the test-preparation industry. We see competition that has driven too many kids to take these [ADHD] concentration enhancing drugs that many doctors say can have really harmful side effects, and all because the competitive pressures drive them in that direction. And if we are allowed trait selection choices that have competitive implications, you bet some parents are going to feel real pressure and desire to make those choices. They need to be informed of the risks by physicians and geneticists who have had an adequate amount of time and opportunity to really understand the full implications of these choices.
Dr. Topol: I give you special credit; not only do you talk about this issue in your book, but as a Senate subcommittee chair, you pushed to understand the ethics, social implications, and legal aspects of the Human Genome Project. We have to continue to fund and support these implications in genomics.
Gore on the Microbiome and Why He Went Vegan
Dr. Topol: I'd like to ask a couple more things. The first is about the microbiome, and the other is that I know you've been on a vegan kick. Have you had your gut microbiome assessed?
Mr. Gore: I have not. Do you recommend it?
Dr. Topol: Well, some people are starting to do it. Obviously, it's having a bigger impact on medicine than we ever had anticipated. It's kind of interesting to think about whether that's going to become the norm in healthcare. In addition to having your genome sequenced, will people with various conditions start to look at their microbiome?
Mr. Gore: Over a year ago I changed my diet to a vegan diet, really just to experiment to see what it was like. And I felt better, so I continued with it. Now, for many people, that choice is connected to environmental ethics and health issues and all that stuff, but I just wanted to try it to see what it was like. In a visceral way, I felt better, so I've continued with it and I'm likely to continue it for the rest of my life.
Dr. Topol: If we had done your gut microbiome sample before and after, I bet it would be drastically different, you know? It's really interesting.
Mr. Gore: Probably so. A friend of mine is now having his microbiome assessed all the time. But the thing that interests me most about this, and what's most startling to me, is that the number of cells that make up the microbiome, represented by the bacteria mainly, but also to a smaller degree by the viruses and yeast and amoebas -- they are 10 times that of human cells. When people first encounter that statistic they think, "What? That's incredible."
The fact that part of the gut flora is an active extension of the acquired immune system in humans and that we are actually a cooperative life community -- only part of a life community -- is yet another humbling realization in line with those caused by Darwin and others along the way. Copernicus, even. We are part of the web of life and more intricately interwoven with it than we have allowed ourselves to realize. If those cells are 10 times ours, we obviously need to spend a lot of time understanding what that relationship is and how we affect it. And of course there are lots of examples already where doctors are discovering that this is an amazing new dimension in medicine.
Dr. Topol: No question about it, and we're still really in the early stages of it.
Gore on Twitter and Digital Medicine
Dr. Topol: Before I get to the last question, I did want to ask you about Twitter. You have 2.7 million followers, and at one point, according to Nick Bilton's Hatching Twitter, you were going to buy Twitter. Of course, it's flying high in this digital world. What are your thoughts about Twitter? Do you use it much?
Mr. Gore: My former business partner, Joel Hyatt, and I did try to buy Twitter at a very early stage in its development. We spotted this as a really up-and-coming opportunity. I am actually invested in Twitter now through Kleiner Perkins Caufield & Byers, a venture capital firm where I'm a partner.
I think the future of Twitter is just incredible. It has become a global information utility, and the opportunities for them to monetize what they do are also going to grow dramatically. It's all part of the global mind, where people are now connected to the thoughts and feelings of billions of others and to databases that give us answers to almost any question virtually instantaneously, and through a growing array of sensors and intelligent devices. Of course, part of the development of precision medicine is digital medicine. The current practice of medicine is already beginning to be completely disrupted by the use of all of these information flows to focus on the individual precisely, rather than aggregating people into these large groups.
It's evolving to where individuals can connect with other individuals who are dealing with the same health challenges and where individuals can connect their physicians to the constant streams of data from monitoring devices they're wearing on their bodies and inside their bodies, which is going to be a growing area. It's also where individuals can connect increasingly to intelligent medical systems like IBM's Watson to get diagnoses that, hopefully, doctors will review and be a part of.
Changing the Being in Human Being
Dr. Topol: To wrap up the section of life sciences in your book, you start with a sentence that I would like to use to end our discussion, because it really captures what's meant by transhumanism. You write, "For the first time in history, the digitization of people is creating a new capability to change the being in human being." What were you thinking about when you wrote that?
Mr. Gore: What separates us from the rest of life as we know it is our unique enhanced ability to make informational models of the world around us by learning from and manipulating those models to gain the ability to change and transform the real world in which we live and of which we're a part. What's most significant about this particular moment in time is that we're gaining the ability through this same methodology to change the physical form of human beings and the mental functioning and nature of a human being. In some ways that's not entirely new. There were antecedents, but what's now emerging is a difference not of degree but of kind.
When you see the insertion of digital devices into the grey matter of human brains and the connection of human thoughts to the operation of machines, and the crossing of the boundaries between our species and other species, there is a word that comes up over and over again, both in the digital space, where we were talking about privacy, to the biomedical space and genetic space: creepy. It is one that people use quite a lot. It's important to think for a moment about what that word means. It's not fear. It's pre-fear. People who are familiar with and sometimes entranced by the miraculous potential of these new breakthroughs just brush right past that momentary feeling of creepiness and diminish it into insignificance. Often that's the right thing to do. But there are others who say, "Wait a second -- maybe it's not completely irrelevant." Maybe it is a proxy for the processing of information that's been built up over many, many generations and should cause us to pause at least long enough to ask the question, "What are we doing here, and are we sure that it's the right thing?"
One of my predecessors in the US Congress from Tennessee was the famous Davy Crockett. In those days, people used to sign their name with a little slogan. There are deeds in my home county courthouse where he signed his name, "Davy Crockett. Be sure you're right, then go ahead." That's all I'm suggesting.
Dr. Topol: This has been fantastic. You've covered so much ground. You have this truly unique perspective from the governmental side and as a real scholar transcending climate change. You brought up a lot of inconvenient medical truths here. We have to deal with that, but it's wonderful to have the chance to delve into your thoughts, your book, how you keep up with all of this stuff, and how you have all of this medical knowledge without ever having had the formal training. It's just beyond me, so thanks so much for joining us. We really appreciate it.
Mr. Gore: Thanks for your kind words, and if you continue to be willing to teach me, I'll keep on trying to learn.