Dr. Anthony Fauci

coronavirus pandemic, Dr. Anthony Fauci has been a widely trusted voice explaining the evolving scientific understanding of the disease that has struck the world. From the August 18, 2020, online program “A Conversation with Dr. Anthony Fauci.” Dr. ANTHONY FAUCI, Director, National Institute of Allergy and Infectious Diseases (NAID); Member, White House Coronavirus Task Force In Conversation with Dr. GLORIA DUFFY, President and CEO, The Commonwealth Club of California

GLORIA DUFFY: What’s your highest priority problem in fighting the coronavirus right now? ANTHONY FAUCI: The highest priority is something that isn’t yet a problem, but I could then tell you what a problem is. The highest priority right now, as the director of the National Institute of Allergy and Infectious Diseases, is to develop successfully more than one safe and effective vaccine, which I think is going to be essential if we really want to put a durable end to this pandemic, simultaneously with developing interventions in the form of therapies. The problem from a public health standpoint is to try and get the country to act in a uniform and consistent way to get the infection down to a very low baseline, which would make it much easier to be able to open up the country in a safe and prudent way to get the economy back. Right now, the problem we’re facing is that if you look at the numbers as a country, when we had the big spike that was driven predominantly by infections in the northeastern part of the country, dominated by the New York metropolitan area, when those came down in that region of the country, the other areas of the country began to essentially surge.

So we never got the baseline back down to a low, low level. It went up and then stayed at around 20,000 cases

per day, which is a very precarious place to be when you’re trying to open up the country. And we saw that in the southern states, as they try to open, including Southern California among other areas like Florida and Texas and Arizona, as the cases started to come up and peek at 70,000 a day. You can’t operate in a really effective way to keep the country safe at the same time as you’re opening up when you have that higher baseline. So the problem, if you want to call it a problem, Dr. Duffy, is that we need to act in a much more uniform, consistent way in carefully and prudently watching out and following the guidelines for opening the country, because I do believe we can open the country and get the economy back. We can do that successfully, but we can’t do it in a helter-skelter way. We’ve got to do it in a consistent [way]. DUFFY: Why has it been so difficult to get a consistent policy covering the entire country and, of course, to get people to adhere to it? What do you see as the main barrier? FAUCI: There are a number of barriers, but one of the things that at least contributes to it—I don’t think there’s one thing that’s the unidimensional issue that drives it—is that our country is a very large country and it’s heterogeneous geographically, demographically, and certainly with the level of infections in different regions, states, counties, cities. So you can’t look at the United States just as a whole when there’s so many different areas, having different experiences. The very nature of the federalism in our country, where the states have a lot of say as to what goes on, in many respects appropriately in their state—but when you want to get the country as a whole to pull in one direction [it becomes problematic], because one part of the country will ultimately impact the other when you’re dealing with a pandemic for the world and an epidemic in the country. You can’t have one doing it really well, having one not doing it really well without one influencing the other. That’s just the nature of infectious diseases. Operating in a vacuum could work for some aspects of behavior, but it doesn’t work very well when you’re dealing with a highly transmissible viral infection. DUFFY: So we do have a federal government, even if we are a federation of many states; what would be a few things you think the federal government could do or should do to promote uniformity among the states and regions? FAUCI: Well, obviously that’s something of a great deal of discussion. I think a consistent message from above would really be a very, very important factor in getting to where we want to be. DUFFY: States like California have been pretty stringent about their regulations regarding masking and distancing and which businesses can open and close and so on. And still some people are not adhering to the practices I’ve seen here in some regions of California. I wonder sometimes is it a lack of basic scientific understanding of how contagion occurs? Is it a sort of iconoclastic attitude that what people do doesn’t affect others? What do you think is behind the noncompliance? FAUCI: You’ve just correctly named two of them. Let me expand a little bit on it. When there is a lack of a successful implementation of a global health program, particularly if you’re trying to successfully open up the economy, there’s two issues that are a bit separate but nonetheless overlap. You can have the authorities in the states, the cities— namely the governor and the mayor—do it right and proclaim that we should be doing it this way. That only works if the citizenry of the state, the city, the county pay attention to it and do it. But what we have seen throughout the country [is] situations where certain states—not California, California, as you said appropriately, from the top, did it in a stringent way—but some states jumped over the benchmarks and jumped over the guidelines and jumped over the checkpoints.

Other states try to do it right, but the people in the states for one reason or another didn’t pay any attention to it. I think one of the compelling reasons for that is the extraordinary breadth of manifestations of this disease. That essentially for 40 percent of the people who get infected, they don’t even know they’re infected because they have no symptoms. I’ve been chasing viral outbreaks for almost 40 years, and I’ve never seen anything with that disparity of manifestations, from nothing to some people who get sick for a day or two and are fine to some who are in bed for a few weeks and now we’re starting to see that they may have some lingering cardiovascular neurological things that we haven’t even fully recognized. Some people that require hospitalization, some require intensive care, some require ventilation and some die.

We know that the people who will likely get in trouble and have a poor outcome are the elderly in general and any age who have underlying conditions, such as hypertension, obesity, cardiovascular disease, diabetes, etc. So you don’t have a uniform threat or a uniform concern and anxiety in the population, because if it uniformly affected everyone and everyone was at a high risk of getting really sick and/or dying—you don’t have that. You have some people who correctly look at the data and say, “Well, the chances of my really getting into trouble are extremely low.” Then you get people who are in a risk group, who know if they get infected, they may wind up in a hospital. They may die. So it’s very anxiety-provoking for them

Getting back to the other group—and this is the thing that I think undermines the message. There is an understandable, and I would even use the word innocent misinterpretation of what it means. If you get infected and you have no symptoms, it isn’t no harm, no foul, who cares? I get infected, but I’m in a vacuum; a young person, again, likely because they’ve got so many other things in their lives that they don’t want to be bothered with this, they can incorrectly assume that they are in a vacuum. They’re not, because by getting infected, even if they don’t get a single symptom, they are propagating a pandemic, which is greatly influencing the country as a whole and killing some people. Because by getting infected, even if they don’t get a symptom, they almost certainly sooner or later will infect someone else who then infects someone else who can be someone’s mother, father, wife, on chemotherapy for breast cancer, immuno-deficient child.

So you’ve got to appreciate—and it’s a very difficult message—that you are not in a vacuum. None of us are in a vacuum. We’re all part of a very unfortunate dynamic that’s going on in our country. By preventing ourselves from getting infected, we are helping to dampen the outbreak. By getting infected and not caring, we’re propagating the outbreak. So it’s got to be not only a sense of your own responsibility to yourself, but a societal responsibility.

That’s the reason why I say often we’ve got to all pull together on this, even though you’re assuming that this doesn’t mean much to you because you don’t have any symptoms. Boy, that’s a tough message to get across. DUFFY: Thank you for iterating that message. It underlines the importance of a strong social contract and sense of community responsibility.

Let’s talk for a moment about vaccines,

Top to bottom: Fauci with Presidents Bill Clinton, George W. Bush, Barack Obama and Donald Trump. (Photos by NIH Histo- ry Office from Bethesda; courtesy of the George W. Bush Presi- dential Library and Museum; official White House photo by Pete Souza; and official White House photo by Andrea Hanks.)

because you put that at the top of your list in terms of a challenge. I understand we’re having third-phase clinical trials of one vaccine out here in California. Can you give us a progress report? And I know everybody’s asking you when can we expect this, but can you tell us the status of the progress toward a vaccine? FAUCI: Right now there are a number of candidates that are in various stages of clinical trial, nationally and internationally. In the United States, the federal government to a greater or lesser degree is involved in enhancing, facilitating, and even developing about half-a-dozen vaccines that are at different stages of development. In a vaccine, you start in an animal model. Then you do phase one, which is safety. If it looks good, you go to phase two. If that looks good too, go to phase three. There are two and likely soon three candidate vaccines that are in phase three trial, two of which started a few weeks ago, on July 27. Those trials are large trials encompassing anywhere from 30,000 to 60,000 individuals per trial, with the goal of determining, A, are they safe, and, B, are they effective?

You need to enroll a lot of people, get their prime, get their boost, and then observe over a period of months whether or not you truly have safety and you truly have efficacy. When you say a progress report, the progress report is that patients are being enrolled in those studies. There are a few thousands of patients already in there. You would not expect at all to get any indication at this point. You likely, with the ones that are already in phase three, start to enroll it completely over a period of a month or two. Then over the next few months, you hopefully will get a signal of efficacy and a confirmation of safety. I mean, you could give a progress report on are you getting patients in the trial? Yes. That’s a good progress report. But you wouldn’t expect any results right now. You’d expect them as we get into the fall.

Now let me just say one of the things that’s important. People ask, What’s the chance of this working? Whenever you’re dealing with a vaccine, you should never ever say anything that “I’m confident that this [will

work].” You could say, as I’ve often said, that you’re maybe cautiously optimistic based on certain things. Based on the animal data, which are impressive, and the early phaseone data—which was originally for safety but you can get some inkling as to the type of response—and in the phase one of one of those and in probably more than one of those trials, that the level of antibody, which is the end point that you want to see in addition to efficacy, the level of antibody that you induce—important antibody, neutralizing antibody that blocks the virus—is at a level that’s equal to or even greater than what you would get with natural infection, which is never a guarantee, but it’s a pretty good predictor that you’re on the right track.

Having said that, that has allowed me and others to say, given the amount of effort and resources that’s put in, we would hope that by the end of this year, the beginning of 2021, we would know whether the vaccine is safe and effective—and hopefully it will be, and there’ll be more than one. We can then start distributing it to the people who need it. So we’re talking about something [at the] end of this year, beginning of next year, DUFFY: And I’m assuming there are no shortcuts of the normal scientific method here, the [Vladimir] Putin vaccine, for instance, that there’s no way to sort of short circuit this process. FAUCI: It’s very interesting, because I get asked that all the time now. People need to understand there’s a difference between having a vaccine and proving that the vaccine is safe and effective. You’re giving [vaccines] to people who are not sick; you’re trying to prevent infection. It would be irresponsible to give a vaccine to people when you haven’t even tested it yet. So if you want to say that we have a vaccine, we have half a dozen vaccines, but we wouldn’t want to do anything with them until we put them through the proper randomized placebo control trials to prove that they’re safe and prove that they’re effective. So when you hear that the Russians have a vaccine—great, congratulations. But the question you need to ask: Have you tested it appropriately to prove its safety and efficacy? And the answer to that, to my knowledge, is they have not, unless they’ve done something that I don’t know about. I doubt if they tested it in tens of thousands of people. DUFFY: Here’s a question from our audience. If and when the vaccine comes to market, how will it be rolled out? Who would be prioritized? Who will pay for it? Will there be enough syringes? Will it be made available in other countries? What if it comes to market first by a company outside the U.S.? So—what are you anticipating in terms of the rollout, and some ethical and equity questions that arise about this. FAUCI: Whenever you have an intervention, and typically it’s a vaccine in which you’re rolling it out at a time when you don’t have a dose for everyone, then you have to do some sort of prioritization. The standard way in this country, and we’ve done that, is that there’s a committee called the Advisory Committee on Immunization Practices, which recommends to the CDC who makes that final decision about who you give it to—you know, young people, old people, vulnerable people, frontline workers or what have you. With this vaccine, there’s an extra added element to the discussion and the dialogue. The National Academy of Medicine has been commissioned by the NIH and the CDC to also weigh in with an independent committee, made up of ethicists, biologists, community people, to help in the decision of what the prioritization might be. I don’t know what that’s going to be, but if it follows the general trend in situations like this, you usually make sure you protect your health-care workers and frontline workers who are putting themselves in harm’s way to take care of individuals.

Then you worry about people who are at a higher risk of having a poor outcome— the elderly, those who have underlying conditions, a variety of other individuals. So that’s what the prioritization is going to wind up being. Whether or not you have enough of the utensils as it were to distribute it, that was why as part of this Operation Warp Speed there are two leaders of that one, a scientific leader and a logistic leader. The scientific leader is Moncef Slaoui, who’s responsible for making sure all these trials get coordinated. The logistic leader is a general, Gustave Perna, who has extensive experience of supply chain and meeting supply and demand as a general in the United States Army. He’s been put in charge of making sure we get all this material, and hopefully he’ll be successful in that, cause that’s his job. DUFFY: There are a number of other questions about a vaccine. What would you say to the anti-vaxxers for instance? FAUCI: Well, you know, there are antivaxxers who are against any kind of vaccine, no matter what. Sometimes [it helps] if you discuss with them without condemning them, because if you condemn them, you’ll never win them; try and engage them at the community level in a dialogue about the facts about vaccines and try and dispel the misinformation; because some—not all, but some—of the things that fuel people’s hesitancy for any kind of vaccine is the misinformation that with social media often gets widely spread, such as the relationship between the measles vaccine and autism, which is completely, completely untrue. But when you’re dealing with a new vaccine like this, the way that you can get people to ultimately wind up vaccinating, which would be to their benefit and the benefit of the community, is to first make sure that when you do the vaccine trial, you have equitable representation of multiple demographic groups, so that you don’t only test it in one group and then distribute it; and another that you have proved the safety and efficacy in older people, younger people, minorities, people with underlying conditions, so that when you’re getting ready to distribute the vaccine, you can say, “We tested it in all of these groups and we know it’s safe and it could be effective in these groups.”

Once the vaccine is approved, then you want to make sure that the people who would benefit from it most will take the vaccine. That’s when you have got to be transparent about all the data and utilize something that we initiated during the early years of the intervention, in the clinical trials with HIV, the vaccine networks, the treatment networks, the prevention networks, is to implement what we call community engagement. Reach out to the community and get them to be part of the dialogue and part of the discussion of why it’s important as an individual and as a member of society to get vaccinated.

So it’s a whole bunch of things, including particularly community engagement. DUFFY: Just taking that community engagement point a little bit further. What role do you think there is for community assistance in addressing the coronavirus? For example, I understand that Johns Hopkins has a training program for contact tracers. How can the community at large get involved more proactively than just keeping themselves safe in their environment to [help] solve this pandemic? FAUCI: I think just what you said, it’s extraordinarily important for the community to get involved, because they’re the ones

Fauci in a March 2020 briefing at the White House. (Official White House photo by D. Myles Cullen.)

that are going to be able to successfully do a number of things, including the very important identification, isolation and contact tracing. I was just on a Zoom [meeting] a few weeks ago with the crew from San Francisco General Hospital who were very much involved with getting together and learning and getting the community involved in that kind of identification, isolation and contact tracing. DUFFY: There are a lot of questions [from our audience] about after effects and ongoing impact on health from coronavirus diseases, underlying conditions that may have a prolonged impact on people after they’ve had coronavirus and apparently recovered, for example myalgic encephalomyelitis algia and other conditions. Could you say a little bit about the long-term public health impact of this pandemic? FAUCI: Yes. I’m glad you brought that up, because that is something that is a learning

process in progress. That’s one of the things about trying to get out the scientific evidence and the data when you’re having a moving target, because we’re totally naive in our experience with this. As the weeks and the months go by, we learn more and more, and sometimes assumptions and statements that might have been made in February, March, April, as you get more clinical experience in June, July and August change, and you need to be humble enough and flexible enough to admit that you’re still in a learning process and always make your recommendations, your conclusions, hopefully flexible conclusions at the time based on the data and evidence you have.

So that’s an introduction to an answer to your question, which is we are starting to see things now that we didn’t see early on. One is that people, even those who are not hospitalized, people who have had symptoms [and] were home in bed for a couple of weeks,

essentially clear the virus and then felt they wanted to get back to a normal life who find that a substantial proportion of people don’t feel normal for several weeks beyond the socalled clearing of the virus. We don’t even know how long that’s going to last.

The other thing that is even more disturbing is that there are case reports . . . coming out—I just went through a whole bunch of them, literally a couple of hours ago—of individuals who were sick, thought they got better, and then they have cardiovascular problems. Myocarditis cardiomyopathy can lead to arrhythmias, sometimes even sudden death. Neurological abnormalities. When you do MRIs and PET [positron emission tomography] scans, both of the heart and of the central nervous system, there are things that we didn’t imagine.

So this idea that if it doesn’t kill you, you’re okay—we’re going to start modifying that a fair amount and be very careful about how benign a so-called recovered infection might be. I don’t know where that’s going to go, but there’s clearly something there [involving] lingering effects, both of things as symptomatic as fatigue and brain fog and things like that, as well as some organic things that clearly [are] demonstrable on MRIs and PET scans and things like that. So we’re in the learning process, and we need to withhold any judgment until we learn more about these post-recovery syndromes that people have. DUFFY: So a lot of people are wondering when it is safe to do X—go to school, fly, etc. So a couple of questions about that. What’s the triggering point that you think would make resuming public schools, students attending public schools, safe? FAUCI: I’m glad you asked it in that way, because it’s the same thing you always get asked. You’re asking it understandably for the United States, except that the United States isn’t one place, it’s like 30, 40, 50, as it were, different places. So the way you look at something like school is, I always say the default position should be in general that you try as best as possible to get the schools open, because of what we know about the deleterious effects on children psychologically, and even from a nutritional standpoint, the isolation, the things that are bad for the development of a child. Then there are the downstream deleterious, unintended ripple effects on family that have to disrupt work schedules.

So as a default, you should try to get the kids back, but you cannot ignore that you have to pay attention to the safety, the welfare and the health of the children, of the teachers and of the people associated with them, which means that when you make a decision about opening, you’ve got to look at where you are and what the level of infection is.

There’s a big difference between a green zone or a green county—where there’s very little infection in the community and you’re dealing with an elementary or a middle school; you can’t throw caution to the wind, but you can open with a fair degree of safety and impunity—then you have what’s called the yellow zone. We have a degree of infection there that you may need to do some mitigating things. You may need to—and this should be decided at the local level with attention to the guidelines that the CDC has put out about opening schools, because they’re very helpful [if you] read through the guidelines—you can do things like hybrid examples, part online [and] part in [person]; physical mitigations, desks that are separated, morning, afternoon classes; every-other-day classes; doing what you can do outside; good ventilation. It’s a whole bunch of things that you can do, and then know how you deal with a student or students who get infected.

Then you get the red zone, where you got a lot of infection in the community. You really have to think twice before you want to put kids back in school then, because as we’re starting to see, three things or more can happen. You go and the kids get affected; they close down. So why open it up to begin with? Parents say, “No, I’m not going to do it.” Teachers say, “I’m not going to show. I’ll do it online, but I’m not going to show.”

So it’s so much more complicated than saying either close them all or open them all. We live in a big country that’s very heterogeneous in so many ways, including the level of infection, because there are some places that [have] no problem. And there are some places [where] there is a problem. DUFFY: Dr. Fauci, what are the important steps to take in the coming months and years to help us prevent future pandemics, and improve and strengthen our public health structures in this country? What reforms do you see needed? FAUCI: Well, I think one of the things that’s so important, because I’ve been through this before with the scare of the pandemic influenza and the famous chicken virus that jumped from chickens to humans but didn’t spread efficiently from human to human, that together with the biodefense effort that we put in following the anthrax attack, we put a big pandemic preparedness program into place. The thing that I would think we need to do is to maintain corporate memory, because what happens is that as soon as we get through this ordeal that we’re going through, people tend to want to put it behind and they talk about lessons learned. But then a few years from now, people focus on resources they need for what the problem of the day is as opposed to the problem that might occur 2, 3, 4, or 5 years from now. So that’s the thing that we need to do.

There’s a lot to be done. There’s lessons learned here. I would hope when this is over—and it will end—that we sit down and talk about the fact that we need to look at what went right. Look at what went wrong. Look [at] resources, about strategic national stockpiles, all the things that people like to put behind them after they’ve gone through an outbreak. We can’t let that happen. We’ve got to realize that outbreaks like this occur, emerging infections have occurred forever. They occur now, and they will occur after you and I are no longer around. We happen to have gotten hit by a historic one this time, literally nothing like this in the last 102 years since the 1918 pandemic. But that doesn’t mean it’s not going to happen again, nor does it mean we may [not] have another different kind of an outbreak. We’ve got to be perpetually prepared, because the threat is perpetually there. So that’s the one thing I’d like to see happen. DUFFY: Would you say that should happen at the national level through a task force? World Health Organization? What should be the steps to make sure we do a thorough review and take steps needed? FAUCI: I don’t want to be the one to prescribe that now. But I can tell you some of my thoughts that I think people should appreciate—that pandemics by the very definition of pandemic means it’s global, the entire planet. So you have to have an international look at this, because there’s got to be cooperation and collaboration about transparency, about sharing of information, about making sure data is available from all countries that could be helpful to others. Then we’ve got to talk about the shared responsibilities that the nations of the world have. So it should probably be something on the international level, as well as within our own country at the national level of what we can do ourselves and then how it relates to

Top: Fauci, a member of the White House Coronavirus Task Force, gives an update briefing in April; Vice President Mike Pence looks on. (Of- ficial White House photo by D. Myles Cullen.) Bottom: Fauci has been a frequent figure at the coronavirus briefings, including one in March attended by President Donald Trump. (Official White House photo by Tia Dufour.)

the things we will do with others. DUFFY: Some people are wondering about other vaccinations, for instance, the time is coming up to get our flu vaccinations. Should we do this on the early side to make sure that we don’t contribute to straining a system that perhaps later in the winter would be providing coronavirus vaccinations? FAUCI: Even in the best scenario, I don’t think you’re going to have widespread need to be able to administer a COVID or a coronavirus vaccine until well after you’ve vaccinated most of the people with influenza, because you want to start literally in the very early fall to start vaccinating. And I cannot see that you’re going to have large quantities of coronavirus vaccine available until the end of this year or the beginning of next year. So I don’t think it’s going to be a conflict. DUFFY: I happened to be having my annual physical and told my doctor I would be speaking with you. He asked me to ask you, What are you doing to take care of yourself? How do you get through the day? What are your mechanisms? This is obviously a very burdensome and stressful time. FAUCI: I would be untruthful to you to tell you that it’s not extremely stressful. It’s the time elements involved, all the things you need to do and keep up on really make it at very best a 16-, 17-hour day. So I certainly am trying not to completely run myself into the ground. I think that happens only because I have a very intelligent and convincing wife who is also in the medical field. She reminds me that it doesn’t do any good for me to be flat on my back from exhaustion. So it’s a very good partner there.

But what I do do, to the extent I can, I try and exercise about 45 minutes to an hour every day. That usually entails a walk at night with my wife and my daughter’s dog, walking very fast, a power walk. I get a few miles in. That really releases the stress and the tension for me.