Anthony Fauci on COVID-19, scientific communication, and the future

Dr. Anthony Fauci, Chief Medical Advisor to the President of the United States and Director of NIAID, is standing down at the end of 2022. He joins Gavin and Jessamy to discuss becoming a household name during the COVID-19 pandemic, why scientific discourse in the USA is broken, and how the pandemic could end.

Read The Lancet's profile of Dr. Fauci here:
Anthony Fauci: moving on

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Jessamy: Hello and welcome to The Lancet Voice. It's October 2022 and I'm Jessamy Bagenal. I'm here with my co host Gavin Cleaver. Throughout COVID 19, there were trusted voices of reason among a lot of noise. Dr. Anthony Fauci became an icon and a leader over the pandemic to many. But he also became a target and a victim of disinformation and misinformation.

After 50 years of public service to advance health, he decided to step down as Director of the National Institute of Allergy and Infectious Diseases, Chief of the NIAID Laboratory of Immunoregulation, and Chief Medical Advisor to President Biden, in August 2022. Not to retire, but to pursue the next chapter of his career.

Today we speak to him. about his career and about what next. 

Gavin: Yes, thanks Jessamy. And it's worth noting as well that if you're not already subscribed to The Lancet Voice, then you can subscribe wherever you usually get your podcasts. So here's Jessamy and I talking with Dr. Anthony Fauci. Dr.

Jessamy: Fauci, welcome to the podcast and thanks so much for joining us. You really became a household name during the COVID 19 pandemic. How do you find that affected you? 

Anthony: Well, it really changed my life because there were positive aspects to it, and I welcomed the opportunity to use my credibility and my experience and position as someone who had been doing it for almost four decades, with outbreaks going from HIV to Ebola to Zika to pandemic flu.

So, I had considerable experience in the scientific and public health aspects of an outbreak. But as we all know from painful experience, this outbreak is unprecedented in its impact, the likes of which we have not seen in well over a hundred years. That would have been stressful enough to be the principal advisor to two presidents, one a somewhat contentious Tenure, to say the least, and one somewhat more classical in a purely scientific approach.

The thing that has been really wearing, despite the fact that any of us who have been involved from the healthcare worker in an emergency room to the scientists who were trying to develop vaccines to the public health officials, it has been a terrible strain. But the thing that was really different than anything I experienced.

Is that all of this, at least in the United States, has taken place in an environment of very, very profound divisiveness within our country, which really spilled over into how you handle a public health crisis. And it seemed at times that instead of a realization as a unified country, that we have a common enemy, which is the virus and let's all pull together.

It seems like we were at enemies with each other. We had political ideology determined whether or not you got vaccinated or not. And that is very disturbing when you're a public health official and a scientist like myself, that. People make decisions in the arena of public health based a lot, not entirely, but a lot on what their political ideology was.

That, that made the experience very, and continues to this day, I never would have imagined in my wildest dreams when I was studying medicine, NIH campus. As a 27 year old physician out of his residency training in New York and I walked onto the campus in Bethesda, Maryland to do a fellowship in infectious diseases, that on that same campus I would have to have armed federal agents guarding me because people have been credibly threatening my life and harassing my wife and my children.

I mean, that's something that just, you can't imagine that when you're going through the kind of training and experience that you've been through. So it's a little bit of a long winded answer to your question. Jesse, me, but that's the, the, the nature of, of the reality of that we're in right now. 

Gavin: I think you've touched on it there, but I'm interested to get your opinion on how the last three years has kind of changed scientific discourse in the USA, of course, the scientific conversation and, and people's health and how we deal with that as a kind of society are a lot more at the forefront of the conversation now.

So how do you think the discourse has been changed by all of this? 

Anthony: Well, the discourse is guarded now because there are so many public health officials who when they would normally have very naturally made recommendations about what the best thing to do for your public health, they are now getting harassed.

I mean, I'm not the only, I'm a very visible person who has been harassed and my family's been harassed. But throughout the country, many public health officials, when they say something, they're that is interpreted by some as an encroachment upon their liberties and their independent need to make a decision on their own.

When anything is, approaches a guideline or, or God forbid, a mandate to do something, they get threatened. And that, that is an interference with the normal discourse of the explanation of why something is important. Not only for the individual health, but the health of the community. It seems that the health of the community is no longer a consideration.

It's what I want to do with myself and don't tell me what to do, which it's understandable. And I don't criticize that because people are independent entities, but they shouldn't forget that they're part of a community. Also, often you have to realize that you have communal responsibilities in addition.

to worrying about 

Gavin: yourself. What do you think is going to happen over the next few years in terms of how the public comes to kind of understand future scientific research? So I guess, moving away from just research talking about COVID, do you see the kind of public health conversation outside of COVID being fundamentally changed by this?

Anthony: Well, I hope it is not, Gavin. I really hope so. I mean, I hope, well, when I say I don't want to see it change, I want it to be much more of an open dialogue where we respect each other's opinion and discuss differences. Right now, differences are almost synonymous with hostility as opposed to differences being things that we need to work out.

And this is particularly relevant in the field of public health, because when you have differences, it's imperative to work them out, if you really want to get the best out of the public health endeavor. Because if you have differences and then you walk away in, in a hostile disagreement, What suffers is the public health.

And that's, that's an outcome that's not acceptable. 

Gavin: Is there anything during the pandemic that you think could have been done better in terms of disseminating scientific findings? 

Anthony: We as scientists and officials, myself included, could have done a better job of explaining the complexity of how science in a moving target Looks like it's waffling and changing and flip flopping, but it's not.

It's to explain, and part of this is our lack of, of, I guess, being crystal clear about the vicissitudes of an emerging outbreak. At the same time as we're battling an enormous amount of misinformation and disinformation, particularly on social media. So, yes, we could have done better. We, but we will. We were pushing against some very strong headwinds when we should have had tailwinds, we were having headwinds where we were trying to explain, and we could have done better, I, I have to say that, that, for example, in the early weeks and months, if we knew then what we know now, we would have done things clearly differently, we would have articulated risks differently, we would have articulated the need for different types of interventions differently.

And what we did is that we made statements based on the data at hand without first clearly emphasizing over and over again that this is what we know today, but tomorrow it might change because we're dealing with truly an unprecedented moving target. We tried, but it was very clear that the combination of having could have done it better together with an enormous amount of, of misinformation that gets propagated on social media, that anything you say could easily.

Get distorted. That made it very difficult to communicate. 

Gavin: Yes, it's a very difficult balancing act to strike that messaging, isn't it? Because, as I'm sure you're aware, the messaging over here in the UK was always follow the science. And it always made it seem, at the time, as if was, you know, we have the kind of gospel answer here, right now, for this problem.

But actually, as you're talking about there, it's, it's a lot trickier to explain to the public that this is a kind of moving conversation. 

Anthony: Right. It is. And the terminology, Gavin, follow the science. gets thrown back in your face, because if you say, you know, we're, we, we believe, which was the first week or so, based on what we were hearing from China, that this is a virus that's not readily spread from person to person.

And be very similar to SARS CoV 1, which was not readily spread from person to person, and was not readily spread in an asymptomatic way. So if we said that on week one, follow the science. You know, things, you know, you don't have to worry about congregate setting. If you're sick, stay home. If you're not, you don't need to wear a mask.

Then all of a sudden we find out that it's aerosol spread, that it's spread very easily, I mean extremely easily, and that 50 to 60 percent of the spread is from an asymptomatic person. And then we tell them that and they say, wait a minute, you just told me to follow the science. And the science yesterday tells you this.

So what are you talking about? The science doesn't know what they're talking about, and as it turns out, that's exactly the nature of science, and that is a difficult item to sell to people who aren't used to that. I'm not blaming them, but it's just, that's not the way the general public perceives things.

They perceive science as completely immutable. What you said yesterday has to be true what you said today, even if things change, and we all know that That that's not the nature of science. 

Gavin: Just me and I have asked several public health officials this next question. We've always got kind of an interesting breadth of responses.

So I wanted to ask you if there were any assumptions that you held going into the pandemic that you now realize subsequently were false assumptions. 

Anthony: Oh yeah, I mean, I, I had the assumption based on, again, information beyond what I do with myself on a daily basis that like other respiratory diseases, this was predominantly a syndromic situation.

That a person's clinical symptoms was a very accurate reflection of what was going on with the disease. And the idea that you could have a virus that was killing people, fast forward, testis est, it has killed over one million people in the United States. That that same virus in many, many people doesn't even cause any symptoms or merely a sniffle and a sore throat.

That is something, as an infectious diseases person, that is very much a different paradigm than we're used to. So we made that assumption that, boy, a virus that can kill so many people, you'll know it when you see it. And then as we were thinking that, underneath the radar screen, the virus was spreading throughout our community.

And when you get a virus that has a number of characteristics, that when you conflate them together, it spells out a public health disaster. And that's exactly what's happened. You know, a virus That can kill so many people and that can spread throughout the community where many, many people don't even know they're infected.

I mean, if ever a virus wanted to pick a diabolical set of characteristics, that would be it. And another one, I just, I thought of it, but it's been dominating my anxiety for the past two and a half years. The assumption, Gavin, this might be a better example. When you're dealing with outbreaks, like a big outbreak of flu, it's seasonal, it's wintertime, respiratory, you're indoors, you get a big blip, it could be a bad blip, but it always comes down.

You might get a moderate blip and then it'll come down, or you might get a minimal blip and it'll come down. That's the way we look at the so called seasonal respiratory viruses. Then we're faced with something that truly is unprecedented. We get a virus that not only goes up and comes down, but gets another variant that goes up and comes down, and another variant that goes up and comes down.

And it's year round. We all experienced it. You guys experienced it in the UK, we experienced it here, and people experienced it throughout the world. We get the original ancestral strain, then you get alpha, and then beta, and some countries get gamma. Then you get Delta when you think things are all over, and then you think you're doing well and you get Omicron, and then you think you do well and you get multiple sub lineages of Omicron.

The other assumption that really is, is, is a kick in the butt to the infectious diseases community is that one always says the best form of protection is to get infected because infection induced immunity gives you almost lifelong protection. Take a look at the examples. Measles. I got infected with measles as a kid.

It's very likely at my elderly age, I still have a substantial degree of protection from measles. You get infected with smallpox, you're protected for life. You get infected with polio, the chances are you're going to be protected at least decades and maybe lifetime. Whenever do we see an infection that not only changes with new variants, but even within the same variant, your immunity wanes, not over decades.

Not over years, but over months. So, I mean, the assumptions that we made that are reasonable assumptions that all of a sudden literally every few months would hit us with another, eh, wrong assumption, you know, you go back another few months, eh, wrong assumption. And that's the reason why you have to be nimble, flexible, and above all, humble to realize that we are learning month by month.

And that's something that for most, not all, but for most infectious diseases is a completely different paradigm than what we faced previously. Now, if you think that's difficult for we scientists to deal with, could you imagine how it feels in the general public who's trying to understand what goes on and what that does?

to the messaging that you're trying to get. And when that messaging is countered by a variety of misinformation and disinformation on social media, it becomes a very, very difficult situation. 

Jessamy: WHO recently said that they think that the, there's an end in sight to the pandemic. What, what do you think about that, that statement from a sort of global perspective?

And how does COVID 19 end? 

Anthony: Jessamy, I'm, I'm glad you asked that question because even in the United States today, there's There is, you know, concern about what you actually mean by a pandemic is over. And it really relates to exactly what multiple characteristics of a pandemic are you talking about. And in fact, over 10 years ago, my colleagues and I wrote an article in the Journal of Infectious Diseases, I think it was.

And the question is, what is a pandemic? For that simple reason. Because. Is a pandemic something that's widespread or is it widespread with serious disease that could kill or maim you or is it a combination of the two? So if your definition of a full blown pandemic is one in which it's fulminant, and you have, take the United States as an example, because I don't know the numbers of each and every country, but in the United States several months or a year ago, we were having 800 to 900, 000 infections or recognized cases a day, which means it's probably an undercount.

We were having 3, 000 to 4, 000 deaths per day. I would consider that the fulminant stage of the pandemic. Now, we went down over a period of time to now we have about 60, 000 new cases a day. Again, probably an undercount, but we have around 300 to 400 deaths per day. So if you're comparing today with today, months to a year ago, we are way, way, way down.

So you can imagine someone, but people would say, well, the fulminant stage of the pandemic is behind us or their pandemic is behind us. But in reality, three to 400 deaths per day, as far as I'm concerned, is not an acceptable baseline. So it gets confused about what you mean when you say something is over is the worst part of it over.

Likely, it's certainly, you know, we can always get another variant that will just hit us. That's always a possibility, but I think that's what Tedros was referring to. We still have a problem, but you can kind of see the light at the end of the tunnel, because a number of things have changed. One, if you look at immunity throughout the world, either infection induced immunity, vaccine induced immunity, or a combination of both.

We're not that virgin, immunologically virgin population that we were in the winter of 2020. We're different. So whatever happens if it stays within the realm of SARS CoV 2, almost certainly won't be as bad as it was then. I said almost certainly because I've been bitten by this virus. But I believe that's what Tedros meant when he said we're seeing the light at the end of the tunnel.

Jessamy: So Dr. Fauci, you're retiring, of course, at the end of the year. If you had to pick one career highlight, what would it be? 

Anthony: You know, Jessamy, it's very difficult to pick one career highlight because I have been in a privileged to be in a somewhat unique position. that I wear multiple hats. I'm a scientist.

I'm the director of a very large, the largest research institution of infectious diseases in the world. And I also have had the privilege of being advisor to all seven presidents that I've served under in the 38 years that I've been director of the institute. And I believe that in each of those realms, I feel good about a lot of things, but certain things stand out, so if you allow me, I'll just really briefly go through Maybe one element of each of those three hats.

Jessamy: Yes, that would be delightful. 

Anthony: Yeah, so as, as a scientist, before HIV, I had the opportunity to be involved in the development of remission inducing drugs for several formerly fatal autoimmune vasculitic syndromes such as polyarteritis nodosa and Polyangiitis with granulomatosis, unusual diseases that very few people have heard of.

And I was fortunate that I had a mentor that put me on a project that turned out to be really quite successful. I think it was successful because I put a lot of work and imagination into it, but it wouldn't have been successful without a very generous mentor. And I became reasonably well known at a very young age.

Of course, that was during my, and just following, my fellowship here at NIH and I did that for several years and then when HIV came along I started in 1981 and to this day have continued work on the delineation of the pathogenesis of HIV disease, which I think, at least according to my peers, who I believe are always to Coldly honest with me, that this has made, I believe, a significant contribution to understanding.

pathogenesis of HIV disease. So that's my scientific hat. In 1984, I became the director of the National Institute of Allergy and Infectious Diseases, which at the time was a rather small, not very leading, profoundly impactful institution because of its small size. So it was about sixth in size among the NIH institutes.

And over the last 38 years, I have grown it obviously with the generosity of resources from our government to an institution that is now about 6. 3 billion dollars. So it went from 360 million dollars to 6. 3 billion dollars during my tenure as director. And during that period of time, we've accomplished a lot, but I believe one of the things that I'm most proud of is the development and creation of an AIDS program, which has been responsible, not alone, but together with industry, in the development of the life saving combinations of drugs, which have clearly transformed the lives of persons with HIV.

to the point where they now, throughout the world, can live an almost normal lifespan. And I think anybody who fairly judges this knows that the work on the development to basic science and the clinical trials of the institute that I led have led to, together with a lot of other people, not alone, the development of these transforming drugs.

So I feel quite good about that. And then, the third hat is as a public health official that had the opportunity and the privilege to advise seven presidents, beginning with Ronald Reagan. And among those experiences, the one that stands out to me is my partnership with President George W. Bush when he asked me to be, and I gladly did it, to become the architect, the principal architect, of the President's Emergency Plan for AIDS Relief, which, as you know, we started it in 2003.

And to this day, it has resulted in saving an estimated 18 million lives. So that makes me feel, I believe, pretty good about what we were able to do with all the credit in the world to the fact that it was supported by a president of the United States. So those are the three hats that I've worn and those why the reason.

I asked you permission to take them separately because they're really quite different from each other. 

Jessamy: Just taking it back to the United States, I mean there's been hard lessons learned in each country. What do you think it means for healthcare in the United States or what do you hope it means for healthcare and what do you hope it means for public health in terms of how that needs to be reorganized or what needs to happen there?

If you could give us some thoughts on those two things. 

Anthony: You know, Jessamy, that's a very, very complicated issue. And, and I, I'll try to make it as brief as possible because, you know, you can almost have a seminar on this. And I know we only have a few more minutes left, but the situation is we have somewhat of a fractured or patchwork healthcare system in this country, unlike the UK, unlike in Israel.

And that really came back to bite us a bit because, A, we were not getting uniformity and data that was coming in that we could make decisions in real time. The way we had to, I mean, I had to get on the phone, which I did. You know, every 10 days or two weeks with Sir Chris Ritty and Sir Patrick Valens to get information about what was going on in the healthcare system that you could get data in real time.

And the same thing with our Israeli colleagues. That's the first thing that we've got to get a really uniform healthcare system here. The other thing is that we have a great disparity. in accessibility to health care in our country. And the differences in the dichotomy and the disparity between the morbidity and mortality among brown and black people is very, very striking and very, very disturbing that we've seen in our country.

So we've got to address health care disparities and access to health care. I hope, I'm a cautious optimist, I hope That the difficult experience that we're going through now and have been through Will trigger us to realize how we have to have much more equity in access to health care in this country.

Jessamy: Thanks. I mean, I think that's a hopeful note to end on. Does that mean universal health coverage, do you think? 

Anthony: Well, you know, some version of everybody being I mean, I don't know what you want to call it, Jessamy. You know, there are certain trigger words that I avoid because they get taken out of context, but you know what I mean.

I do. Yeah. 

Gavin: Well, thank you so much, Dr Fauci, for your time. It's been a real honor and pleasure to, to, to talk to you and I hope you, I hope you enjoyed it. 

Anthony: I did. I did. I think it was a really good conversation, Gavin and Jessamy, and I've enjoyed very much being with both of you. Thank you.

Gavin: That's it for this episode of The Lancet Voice. If you want to carry on the conversation, you can find Jessamy and I on Twitter, on our handles at Gavin Cleaver and at Jessamy Baganal. You can subscribe to The Lancet Voice if you're not already, wherever you usually get your podcasts. And if you're a specialist in a particular field, why not check out our In Conversation With series of podcasts, tied to each of the Lancet specialty journals, where we look in depth at one new article per month.

Thanks so much for listening, and we'll see you again next 

time.