Farewell, Fauci

In this exclusive video, Jeremy Faust, MD, editor-in-chief of MedPage Today, sits down for a conversation with Anthony Fauci, MD, before his departure from the NIH at the end of the year.

The following is a transcript of their remarks:

Faust: I am joined today by a man who needs no introduction other than for me to simply state his name: Dr. Anthony Fauci. Thank you so much for taking the time to join us here today.

Fauci: My pleasure, Jeremy. Good to be with you. Thanks.

Faust: What's one thing that you accomplished during your career that wouldn't have happened if not for you, Tony Fauci? This is not a "we did this." What's a Tony Fauci intervention that wouldn't have happened without you?

Fauci: I don't think there is anything that a person really completely does totally on their own. There's always colleagues and people who anteceded them that made possible what they've done. I mean, I could name things in my career -- which is, as you know, 54 years here at the NIH, 38 of which I was the director of the institute [National Institute of Allergy and Infectious Diseases] -- that had a lot to do with what I would consider my vision and my leadership, but there isn't anything that happens alone.

I mean, one of the things as director was to create the HIV/AIDS program, which played a major role in the development of the drugs that, ultimately in collaboration with the pharmaceutical companies, we showed and proved that you could actually have a person living with HIV, live an essentially normal life if they take these life-saving drugs. That's, I think, something that's very big.

The other thing, again, that wasn't me alone because it was in collaboration with President George W. Bush and others in his administration, was that he gave me the honor and the privilege to task me to be one of the architects of the PEPFAR program, the President's Emergency Plan for AIDS Relief, which we're celebrating today as having saved now at least 20 million lives. Again, that's not something you do alone; it's something that you may play a major role in, but it always requires others to be part of the collaboration.

Faust: Okay. The humility comes out, but maybe this angle will be different. How about the opposite? What's a decision that you, Tony Fauci, made that maybe you would've done differently in hindsight, or you would've gotten there sooner? Something that you say, "I should have done this differently or sooner"?

Fauci: Well, I think if you go back several decades to the early years of HIV -- the general dogma of infectious diseases is that you only under special circumstances use prophylaxis against infections that have not yet occurred. The reason for that is the concern that the toxic effects may be worse than what the benefit is, or you might induce the resistance of certain pathogens.

But we learned quickly that that was really not the correct approach for the unique situation with HIV, where prophylaxis in a very aggressive way against everything from Pneumocystis [pneumonia] to CMV [cytomegalovirus] to any variety of fungal infections like Cryptococcus and others was lifesaving as opposed to having the risk be more than the benefit.

Faust: With HIV as you mentioned, there were these clinical sorts of networks and there was a fast track for getting medicines, and I think to some extent during COVID we saw the benefit of Operation Warp Speed, but we didn't lead on therapeutics.

Why do you think the United States doesn't have a RECOVERY trial or the same level of organization you've seen elsewhere, and also on vaccine effectiveness? Why do we have to look to Qatar and Israel? Do you think that we'll be able to do better next time?

Fauci: Well, you know, I think that relates a lot more to the nature of our healthcare delivery system than it does to the research endeavor.

We don't have a totally integrated system. We have a fragmented system, whereas in places like the U.K. and Israel and even South Africa, you are correct, they can get data in real time, not data that's 2 and 3 months old. And when you have a moving target, the data becomes less relevant when you're trying to keep up in the real-world evolution of an outbreak.

So I think the cure of that or the remedy of that is really important, and it will take many years, overhauling of our healthcare delivery system.

Faust: You've been through a lot, your New England Journal article that just came out, "It Ain't Over Till It's Over [...but It's Never Over -- Emerging and Reemerging Infectious Diseases]," has a great timeline of things that you've experienced and all the different emerging pathogens that we've had to confront that you've helped us with.

What was the single moment in the COVID-19 story when you looked at this and thought, "Uh-oh, this is going to be a horrible global outbreak?" What was the piece of information that you needed to realize that this was a different level?

Fauci: Well, because of the lack of transparency between China and the rest of the world, it was really unclear what was going on in China. We saw that they were starting to build almost overnight these thousands-bed hospitals, and we knew something strange was going on even though they were insisting that "things are under control. It's not that bad. It doesn't spread that readily between person to person."

We knew that that wasn't entirely the case, but then when it became clear as the virus got out of China and into the rest of the world, the thing that got me a really cold splash of reality was when our colleagues in Europe, particularly in northern Italy, which got hit first in the very first few months of 2020. They were very transparent because these are our allies who we interact with a lot, literally every day from a scientific and public health standpoint. Their system, particularly in northern Italy and Lombardy, was being overrun.

When the hospitals of a modern up-to-date country like Italy are almost being overrun, that's when it became that moment of, "Oh my goodness, this unquestionably is going to happen here," because there's no reason to believe that something that's happening in a developed European country is not also going to happen here.

Faust: Yeah. I have a couple of questions from my readers on Inside Medicine, and I'll read three of them and you can just choose one you want to answer.

First one's from John Rubin, a physician: "Going forward, how do we get the public to regain confidence and trust in the healthcare system?" That's option one.

Option two, from Darin Neven: "Do you think the mRNA vaccines should receive the Nobel Prize?"

And lastly, from Glenda Delenstarr: "What's keeping the CDC or just the federal government in general from being stronger on masking right now?"

You can answer all three, but take a pick.

Fauci: Okay. Well, I do believe for sure that the mRNA technology deserves the Nobel Prize. I mean, this has been a really transformative advance in vaccinology together with immunogen design, which should not be downplayed, because you married an extraordinarily adaptive platform technology, which is the mRNA, with structure-based immunogen design to stabilize the spike protein in its prefusion form, which made it a highly effective immunogen. Certainly that would be, I believe, worthy of a Nobel Prize.

To the question about masking, I believe that we need to make recommendations. See, one of the things, Jeremy, that's a real problem is that there's such an -- I guess understandable, though I don't always agree with it at all -- this profound libertarian streak that we have in this country, that "don't tell me what I have to do." Which is understandable -- that's one of the things that made our country great.

But when you're dealing with public health challenges, sometimes things like masking really are important for public health. So, I don't recommend mandating anything, but I'm saying that when you get to a point where you're in the middle of the winter and you have RSV [respiratory syncytial virus] and flu and COVID, that it makes sense under certain circumstances that you might electively decide -- and I underline that, so we don't get the radioactivity associated with mandating -- that you electively decide that for your own benefit and that perhaps of your family or someone who is a compromised host, that you wind up wearing a mask in an indoor congregate setting.

Very quickly, what was the first one? I want to answer all three.

Faust: How do we restore public trust in the public healthcare system?

Fauci: Well, that's going to be tough because, as you know, we are living in a very, very divisive society. I've never seen anything like it. I've been at the NIH for almost 60 years -- 54 years -- and although there have been ideological differences, they've always been in the spirit of trying to get to a common goal and a common good.

Right now, we have such a divisiveness that it spills over into an anti-science approach, which spills over into an anti-vax approach, which would be extremely counterproductive to the whole issue of trying to get a good public health system going.

Faust: Alright. What's the most underrated and most overrated medicine in our armamentarium?

Fauci: Well, I think the most underrated medicine is probably aspirin. I mean, if used properly, particularly avoiding the issues of bleeds, it's just extraordinary what aspirin can do. I think that's the most underrated.

I don't know what the most overrated is. Certain antibiotics they use too often; I don't want to name what they are.

Faust: You don't want to drive stock prices down, right?

In terms of public service, these attacks that you and your colleagues have received can have a chilling effect. People won't want to go into these positions, where there's the possibility of getting in the crosshairs. Do you anticipate spending more time in the next coming years doing things you like or having to be dragged in front of Congress? And how do you prepare for that?

I'm also interested not just in the anti-science faction, but actually a different faction that's so concerned about public health that they almost think we don't ever do enough. How do you respond to both extremes?

Fauci: Well, you've asked a lot of questions there, Jeremy. Let me quickly try and see.

Yeah, I'm going to be dragged before Congress. I mean, this has become quite politicized, as you well know. I have no problem with testifying before Congress. Some people know, maybe you don't, that I've testified before Congress literally hundreds of times over the last 40 years. I have a great deal of respect for the concept of oversight; I'd be happy to testify and defend and explain and stand behind everything that I've done. That's not a problem.

What I hope to do in the next few years after stepping down at the end of this year, one of the things I hope to do relates to one of the questions you asked me a few moments ago, and that is to hopefully by my experience of 54 years as a scientist, 38 years as director, and having the privilege of advising seven presidents, that I could have others benefit from my experience, particularly younger people who are in science, who are considering going into science and public service. Perhaps by my writings, my lectures, my consulting, my advising, I might be able to restore some of that lost faith we have in science as we go forward.

Faust: You have thousands of papers. What's a Tony Fauci paper that you love that kind of never gets its play; it gets overlooked in the shadow of other accomplishments? A little piece in the literature that you just think, "Ah, that one I really love."

Fauci: Well, it isn't a little piece. I mean, before HIV and before anybody but my wife knew who I was, I was working on developing effective therapies for a group of inflammatory autoimmune diseases called vasculitis.

Almost no one except people who were around in the late '60s and early '70s knew that was, I believe, one of my most important accomplishments. I developed the therapy that is lifesaving for diseases that were almost uniformly fatal. And I wrote a series of papers in the New England Journal of Medicine and the journal Medicine ... as well as several others, which has now become the standard therapy for those types of diseases.

Very few people know that. They know my work in HIV and there are a few papers that I and my colleagues have written on HIV that I think stand out as sort of semi-classic papers in understanding pathogenesis.

Faust: In 1918, H1N1 is thought to have killed 675,000 Americans. COVID has killed 1.1 million, albeit our population is triple in size. We've got modern medicine, we have ICU care. Which of these two pathogens do you think is just natively worse for a person?

The follow-up is a slightly different question: if you had to drop somebody into one epidemic or the other, which takes into account both the reproductive number and how serious it is, which would you say is the one you'd like to avoid more?

Fauci: Definitely the 1918 pandemic. Absolutely. I mean, the mortality of that, as you said it, in a population one-third the size of what the world's population is now, killed anywhere from 50 to 100 million people, which means it would've been 150 to 300 million people it would've killed. (Editors' note: The population in 1918 was approximately 1.8 billion, so the number killed today might have been roughly 220 million to 440 million.) I mean, that is significantly worse. And as a pathogen, it killed selectively middle-level younger people as opposed to the elderly and the very, very young, which also has a very important negative impact on society.

Faust: People admire you and of course there are detractors, so you're very polarizing, which is unfortunate because your public service has just been immense. I would love people to get to know Dr. Fauci as a person.

Favorite book, favorite movie, favorite place to visit?

Fauci: My favorite place to visit in the United States is Northern California.

Faust: That's my home!

Fauci: Yeah. That's where I went on my honeymoon with my wife. It is just very beautiful, and my daughter lives out there.

Outside of the United States, it's Italy. That's one of the most endearing countries.

I have a lot of favorite books, mostly biographies, you know, of JFK, Robert FK, and others.

My favorite movie overwhelmingly is "The Godfather."

Faust: Part I or Part II?

Fauci: Part II.

Faust: Yeah, you gotta go Part II.

You said, "it ain't over till it's over." That's a famous Yogi Berra line. Any other last piece of advice for all of us in public health from you or Yogi Berra otherwise?

Fauci: Well ... it is one that I think we should all take seriously: that we've got to not forget the lessons that we've learned from this outbreak. There were scientific lessons and public health lessons.

The scientific lesson is a positive lesson. We've invested for decades in basic and clinical biomedical research, which actually was responsible for us accomplishing an unprecedented feat in getting a virus that was unrecognized until January of 2020, and within less than a year, 11 months to be exact, we were able to have a vaccine that was highly effective and safe and ready to go into the arms of millions of people, which has saved millions of lives. That's a testimony to the lesson of why it's important to make investments in basic and clinical research.

The negative lesson is: we have a public health system that we thought was top of the line, and it's failed us. It's failed us at the local level and in many respects throughout the country. So we've got to rebuild our public health system at the local level.

Faust: Well, I hope that you continue to advocate for all of these issues, mentoring the next generation. Thank you for your service to the community locally and around the world. I wish you luck in the years to come for many more years of productivity and influence, because we need you around.

Fauci: Thank you, Jeremy. It's always good to be with you. I appreciate it.

Faust: Thank you.

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