The BMJ interview: Anthony Fauci on covid-19

Abstract

Fauci was at President Trump’s side when the US declared a national state of emergency in March and remains a member of the White House Coronavirus Task Force, even as his dedication to communication and evidence based science has at times put him at odds with the administration. A decorated scientist, particularly for his work on understanding HIV, he played a key role in creating the President’s Emergency Plan for AIDS Relief (PEPFAR) and was recently awarded the Gustav O Lienhard Award from the US National Academy of Medicine for decades of work, including public health and leadership in shaping the covid-19 pandemic response. Because of the sensitivity of the subject I’m not going to be pointing fingers or doing any blaming. There are areas that are doing quite well—I was just on a press conference with the governor of Vermont, and their test positivity is 0.2%—but when you put it all together and look at a country as a whole, there are always these blips that you have to continually put down.

There are few better known authorities on the covid-19 pandemic than Anthony Fauci. One of the world’s most respected infectious disease experts, he spoke with The BMJ’s editor, Fiona Godlee, about the pressures of advising the US president, the challenging nature of the new coronavirus, and how the pandemic might end.

He’s become a familiar face and voice in America: on television, radio, podcasts, YouTube videos, and congressional hearings, talking through the intricacies of covid-19 in a calm Brooklyn accent, with everyone from JAMA to Julia Roberts.

Fauci was at President Trump’s side when the US declared a national state of emergency in March and remains a member of the White House Coronavirus Task Force, even as his dedication to communication and evidence based science has at times put him at odds with the administration.

The son of a pharmacist of Italian descent, Fauci was born in 1940 in New York. He graduated from Cornell University Medical College in 1966 and in 1968 joined the National Institutes of Health, in the Laboratory of Clinical Investigation at the National Institute of Allergy and Infectious Diseases (NIAID), later becoming head of clinical physiology and chief of the Laboratory of Immunoregulation.¹

He was made NIAID director in 1984—a post he holds to this day—and went on to lead the US response to diseases such as HIV/AIDS, SARS, MERS, swine flu, and Ebola. A decorated scientist, particularly for his work on understanding HIV, he played a key role in creating the President’s Emergency Plan for AIDS Relief (PEPFAR) and was recently awarded the Gustav O Lienhard Award from the US National Academy of Medicine for decades of work, including public health and leadership in shaping the covid-19 pandemic response.

“It’s always very humbling to get awards when you’re involved in something that depends on so many people working with you,” he said of the award. “Right now there is a distrust of science, not only in the United States but globally. I think it’s an affirmation of the confidence of my peers in the scientific process and the clarity and transparency of what we try to do in science.”

This interview has been edited for length and clarity.

People may be surprised to hear that you continue to see patients. Why is this important to you?

I wear a number of hats, as you know: as a researcher, as someone who runs a large institute, and as someone who deals with the policy issues I’m in right now. But if you asked me what my underlying identity is, that always grounds me in the reality of what we need to do and gives me insight into the kind of emphasis we need, it’s my identity as a physician.

I’m a scientist, to be sure. But I’m a scientist because I’m a physician scientist. And it really helps me to understand the disease, understand pathogenesis where you get to see people, but also to understand the impact it has on them. And it inspires me. I think it gives me energy to know what it is that I’m dealing with first hand—the way I did for a very long time with HIV, and with Ebola, and the way we’re doing now with covid-19.

Many people will remember you for the way you pressed for revisions of drug policy to allow people who were dying from HIV/AIDS to access experimental drugs. What did you learn from the experience, and how does it compare with the situation we’re in now?

It’s in some respects similar because it’s pressure. And whenever you have pressure, you’ve got to make sure you act in a very measured way based on evidence and science. But at the same time, it was a different situation. Early in the 1980s the federal government was really not either paying attention to or being sensitive enough to the needs of people who were directly impacted by this terrible new disease of HIV/AIDS.

One of the things that I think was important was to keep an open mind and realise that, although science is built on evidence and facts, we’ve got to make sure, when we apply science to human beings, that we take into account their special needs.

One of the problems we had back then was the design of clinical trials and the accessibility to them. We used paradigms and models that were geared toward diseases that were not at all like HIV/AIDS, which at the time we had no therapy for at all. And we were talking about clinical trials that had very, very rigid entry criteria and restrictive criteria for excluding individuals. What we did was in good intentions until the activists brought to our attention the fact that it just was not working for them.

I became a proponent of the parallel track approach, where you don’t want to interfere with the integrity of a clinical trial but you recognise that, by excluding the only available therapy for an individual—because they were [for instance] geographically not in a place where the clinical trial was going on—we really don’t take into account that they have no other options.

A typical example of that is that we were testing the antiviral ganciclovir for cytomegalovirus retinitis in individuals who were going blind. The criteria said that, if you’re on the early HIV drug azidothymidine [AZT], the fact is that you can’t get ganciclovir, because we were going to make sure we wouldn’t mix up with the toxicities. When you come to think of it, the only people who really needed ganciclovir at the time were the people who were living with HIV, who also needed AZT at the time.

I remember a conversation with a person living with HIV that brought me to tears and rage at the same time. He said, “So in other words, Dr Fauci, what you’re telling me is that I have a choice: I could either have AZT without the ganciclovir and go blind, or I can have ganciclovir without AZT and die.”

That was just one example of my awakening to the fact that you’ve got to adhere to the fundamental principles and tenets of science, but at the same time you’ve really got to keep an open mind and be flexible.

Why is there no equivalent in the US to the UK’s RECOVERY trial, which looks at multiple approaches to covid-19?

We have a clinical trial structure in the United States through the National Institutes of Health that works well. But the reason we don’t have something like RECOVERY relates to the fact that you have a unified healthcare system in the UK and can essentially capture virtually every patient through your healthcare system. That puts you guys at a real advantage, and you’re doing a very good job with it.

One could say that the US and the UK share the tragedy of being among the world’s worst performing countries in the developed world in relation to covid-19. Why do you think this is?

Because of the sensitivity of the subject I’m not going to be pointing fingers or doing any blaming. So, let me talk of one of the factors that I don’t think blames anyone but is very clear for anybody who pays attention: the United States is a very large country. It’s heterogeneous in so many ways: demographically, geographically, but particularly in the level of infection that we have in different places.

Enough flexibility was given to the [individual] states, such that when we had things like the shutdown we went partially down. Then when we decided to open up the economy, to get the jobs back, some states decided to jump from the gateway to stage 2 and jumped over stage 1 or disregarded it completely.

There are areas that are doing quite well—I was just on a press conference with the governor of Vermont, and their test positivity is 0.2%—but when you put it all together and look at a country as a whole, there are always these blips that you have to continually put down. The most recent challenge is bringing the college kids back to campus and finding out that there are variable ways that we’re handling that. We’ve done well in some respects, but it is patchy and not uniform.

Can the UK learn lessons from the ways in which the US has responded?

I think the lesson for the UK is to try to have a unified approach that’s centrally mandated. I know there are regions of the UK, but it’s nothing like the 50 independent states that we have in the US. I love our state system—it’s a wonderful system in some respects—but I think in this respect, it is one of the times when it didn’t work well.

Should we focus on people who are positive but asymptomatic? I’ve heard you say that they can’t be driving the pandemic because it’s pretty rare that they actually caused transmission. Was that wrong?

Yes, we were incorrect. What we did not know early on was that about 40-45% of the cases are asymptomatic. And recent modelling studies show that perhaps up to 50% of the transmissions occur from an asymptomatic person to an uninfected person. We cannot ignore asymptomatic infection, because that is a major component of the outbreak.

Sometimes you make a statement based on the data that you have. One of the things that I’ve learnt over the years is that you’ve got to be humble enough and flexible enough, as the data evolve, to change your guidelines and recommendations.

What about “long covid”? The original coronavirus public health messaging was about vulnerable and elderly people. But with long covid, younger people who get infected can have this prolonged, multi-system illness. Does this change the message?

It doesn’t change my public health messaging, because I have always said that we’ve got to be really, really committed to preventing infection and preventing disease—that’s why we talk about universal wearing of masks, avoiding crowds, keeping your distance, outdoor better than indoor, washing hands—and we need to do everything we can to get a vaccine so that we can get this thing under control, because it is not something to be taking in a trivial way at all.

Clearly, there are people who have been sick enough to stay home and maybe not even be in the hospital, who go for a significant period of time with myalgias, fatigue, and what they refer to as brain fog or just inability to concentrate.

And there’s another thing that we’re learning that we need to keep an eye on. There have been some studies, one from Germany and now a more recent one from the US, on cardiovascular effects, even on people without symptoms who’ve recovered biologically. When you do MRIs [magnetic resonance imaging] on their hearts, you sometimes see a degree of inflammation that might even be asymptomatic. Does that lead to arrhythmias and cardiomyopathy? We don’t know.

One issue that has come up is ethnic minorities being more affected by covid-19. Can we use this moment to tackle racial disparities in health?

Yes, it is a very unfortunate situation for all of these groups, not only with covid-19 but with other diseases.

Look, for example, at the population of African-Americans: they’re about 13% of the US population, but well over 40-45% of all new covid-19 cases are among African-Americans. They get hit by two disparities: jobs that do not allow them to easily protect themselves from the close, person-to-person contact that we know transmits the virus, and a disparately larger percentage of the underlying conditions that lead to a serious outcome—diabetes, hypertension, cardiovascular disease, obesity.

There’s something that we can immediately do, and that’s to focus and concentrate resources and accessibility in areas that are demographically over-represented by African-Americans. If there’s ever a silver lining in this, it may be that it jolts us into realising that we have to correct disparities in minority health—because otherwise, in the next situation that we have like this, we’re going to see the same painful disparity that we’re seeing now.

There’s a worry about political pressure to approve a covid-19 vaccine too quickly—particularly before the US election on 3 November. The US Food and Drug Administration will oversee approval, but could its parent agency, the Department of Health and Human Services (DHHS), over-rule the decision and approve a vaccine before it’s ready?

Theoretically that’s possible, but that would be so obvious to everyone that I think it would be difficult to do that. The [Trump] administration has said that they want to make decisions based on science. And the FDA commissioner has made that very clear and has written an op-ed saying that that would be the case.² So, I have confidence in the FDA, and I have confidence in their promise to make sure that political considerations don’t enter into their decisions (video 1).

vid1Video 1

Fauci on the FDA

fauciQA20201003-vid1

The other thing we have is that, with every trial, there’s a data and safety monitoring board looking at the data at predetermined times and analysing not only safety but also efficacy issues. And [if a trial were to fail that] we’d make a statement or a determination that this trial likely should stop, because it’s effective enough that it would almost be unethical to continue with the placebo. We’ve had that situation many times, and you make a declaration.

There have been reports of political interference from the White House and the DHHS with the Centers for Disease Control and Prevention (CDC). What does this say about the political environment within the agencies?

The CDC is an extraordinary public health agency. And, yes, you’ve seen in the media reports about people trying to manipulate it. But just remember one thing: the assistant secretary [of the DHHS, Michael Caputo] who wrote that the CDC is doing this and that, is out.³ There were issues there that I didn’t want to get into. And the person who was hired to help out is no longer with the department.

As for the National Institutes of Health, it’s beyond any political influence. I will guarantee you that with absolute certainty (video 2).

vid2Video 2

Fauci on the CDC

fauciQA20201003-vid2

The UK plans to spend £100bn on mass testing.⁴ Michael Mina at Harvard University is talking about cheap, quick tests. Is this a feasible approach?

I think there’s not enough information to judge. But the one thing that is going to be implemented in the US is the antigen tests, the cheap 15 minute tests. Right now, universities want a screening test that relies much more not on sensitivity but on rapidity of the test, with a reasonable degree of sensitivity and specificity. One of the things we need to be careful of is that we don’t let the perfect be the enemy of the good (video 3).

vid3Video 3

Fauci on testing strategy

fauciQA20201003-vid3

Has the Trump administration failed to respond to the science in a way that you would have liked?

I don’t think that it’s failed to respond to the science. I feel honoured and privileged to be on the Coronavirus Task Force. I have always spoken based on pure evidence and science, and that has been the case all along. You know, there’s always a lot of things in the press about a frayed relationship between the president and I, and that’s just not the case.

How do you think the pandemic will end?

I believe it will end with an effective and safe vaccine that ultimately will be widely distributed throughout the world. But that has to happen together with public health measures. You’re not going to do it only with a vaccine: you’ve got to do it with the vaccine together with public health measures, until the overall umbrella of protection is over all the world. That’s not going to happen in a few months. It’s probably going to take a year or two.

Finally, you have widespread support from clinicians and researchers but also the public. You can buy socks saying, “I love Dr Fauci,” and there’s even a bobblehead figure of you. One of my colleagues says that she doesn’t have heroes but that you’re pretty close, because you’ve continued to speak truth to power from the inside. How do you feel about this sudden fame?

You know, you just do it: you tell things the way they are. Sometimes that’s not in agreement with what people would like to hear. But I learnt a long time ago that people will ultimately have sustained respect for you if you give them the information based on science and are not afraid to tell people things they do not want to hear. Whether they act on the things you tell them is beyond my power.

The only thing that I can do is analyse the situation, look at the scientific data, and make whatever recommendation they ask me to make. But you can be assured that it will be always based on scientific evidence and data.

Footnote

Competing interests: None declared.

Provenance and peer review: Commissioned, not peer reviewed.

¹ Gallin JI. Introduction of Anthony S. Fauci, MD: 2007 Association of American Physicians George M. Kober Medal. J Clin Invest 2007; 117: 3131 - 5. 10.1172/JCI33692. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994641/.  17909634

² Hahn SM. FDA commissioner: no matter what, only a safe, effective vaccine will get our approval. Washington Post 2020 Aug 5. https://www.washingtonpost.com/opinions/fda-commissioner-no-matter-what-only-a-safe-effective-vaccine-will-get-our-approval/2020/08/05/e897d920-d74e-11ea-aff6-220dd3a14741_story.html.

³ LaFraniere S. Trump health official apologizes for Facebook outburst. New York Times 2020 Sep 15. https://www.nytimes.com/2020/09/15/us/michael-caputo-coronavirus.html.

⁴ Iacobucci G. Operation Moonshot: Leaked documents prompt questions over cost, evidence, and reliance on private sector. BMJ 2020; 370: m3580. https://www.bmj.com/content/370/bmj.m3580. 32938638