PART 2
DR: I’d like to acknowledge all the frontline health-care workers and first responders and servicemen and -women who are helping our country in this very difficult time. Dr. Fauci, thank you very much for agreeing to do this. I know that your time is very precious, and I appreciate your giving us this time.
My first question is, what do you think of Brad Pitt’s imitation of you on Saturday Night Live? Were you disappointed that somebody else didn’t play you?
AF: No, Brad Pitt is one of my favorite actors. And I think he did a great job. He got the raspiness of my voice right. He got the hand movements right. He’s got to work a little on the Brooklyn accent, but I think he did a great job. He was really very funny.
What he did at the end was a class act, I thought, when he took the wig off and thanked me and the health-care workers, just the way you did. I’ve never met him, but he seems like he really is a classy guy.
DR: Did you know that was happening, by the way?
AF: I didn’t know until literally a few hours before.
DR: You have been heading up the National Institute of Allergy and Infectious Diseases since 1984. In those thirty-six years, has anything come close to the type of crisis or health-care calamity that we’re now having?
AF: Well, we’ve had multiple emerging outbreaks, both naturally occurring, like HIV, and deliberately imposed upon us, like the anthrax attacks, and then the things that we’ve recently spoken about—Ebola, Zika, the pandemic flu of 2009. Each of those have different characteristics.
HIV-AIDS started off under the radar screen, slowly. It was not recognized, but has extended over now thirty-eight, thirty-nine years. The total of deaths right now is something like thirty-seven, thirty-eight million, but it’s taken place over a very long period of time, and selectively has involved individuals who are in certain demographic groups associated with certain behaviors.
The thing about the current pandemic that’s so unique—you asked me years ago what keeps me up at night. What keeps me up at night is the emergence of a brand-new infection, likely jumping species from an animal, that’s respiratory-borne, highly transmissible, with a high degree of morbidity and mortality. And, lo and behold, that’s where we are right now.
The reason it’s so unprecedented, it exploded upon us. Remember, the first recognition that it even existed was the end of December, the beginning of January. Here we are, just a few months into it, and we’ve had almost a million cases. In the United States, we’ve had 55,000 deaths. [By late June 2020, that number had risen to in excess of 120,000.]
Globally it’s exploded in a way that’s unprecedented in a compact period of time. And everyone is at risk, unlike some infections like Zika. If you don’t live in a mosquito zone, you really don’t have much to worry about with Zika. With HIV-AIDS, if you don’t belong to a certain risk category, it is very unlikely you’ll get infected, whereas with this, everyone seems vulnerable to a disease that’s highly transmissible.
So the short answer to your question, David, this is really unprecedented.
DR: Do you have any doubt that this came about from a wet market in China? Do you subscribe to the view that it might have come from a lab in China, or do you dismiss that?
AF: Well, you never dismiss things out of hand, but you just look at the scientific data. Evolutionary biologists have looked at the evolution of virus mutations in bats over a period of time, with the extraordinary likelihood that they infected an intermediate host that has yet to be identified. Everything is compatible with the virus jumping species from an animal host to a human. That’s the first unfortunate step.
The second thing that is really unfortunate for the human species is that this particular virus immediately was able to adapt itself to a high degree of efficiency in human transmissibility. Unlike SARS, which came and then disappeared, unlike some of the bird flus that we’ve dealt with, where it jumps species from a chick to a human—bad news, but the encouraging news is that it was very, very inefficient at, if not incapable of, going from human to human. This virus has all those bad characteristics, but it’s very transmissible and it has a high degree of morbidity and mortality, relatively speaking.
DR: In hindsight, is there anything the Chinese could have done to warn people about how lethal this was, or really was there nothing they could have done?
AF: I think there is something a little bit remiss that people are going to look at when this is all over. Right away, the Chinese said this was a virus that jumped species in an animal market, and that it only goes from animal to human, and there was no evidence whatsoever that it was transmissible from human to human, or, if so, very inefficiently. As they were saying that, it had already become clear that there was human-to-human transmissibility in China.
Not only was it bad for the rest of the world, they hurt themselves. Soon after the realization that there was this new infection—and, to their credit, they put the genetic sequence of the virus up on a public website very quickly—what they also did is by not letting their own health authorities know that there was transmission from person to person, they held something like a forty-thousand-person block party in Wuhan. The worst possible thing you could do is to have a congregation of people when you have a virus circulating that has a high degree of transmissibility.
DR: To date, 55,000 to 56,000 Americans have died from this. What will the likely death toll be, based on all the modeling you are now looking at?
AF: As I’ve often said, although models are helpful, they’re only as good as the assumptions that you put into them, and you can be misled as often as you can be helped. Right now, we’re at 55,000. The model now has been upgraded to say that instead of 60,000, it’s probably going to be 70,000-plus.
That assumption is based on how we respond. Here is what’s going to determine how many deaths we have.
Hopefully everyone will follow the guidelines for opening America again, which were very carefully designed, and which I played a role in making very conservative and very careful. As we open up the country economically and otherwise, when new cases occur—which they will—there’s no doubt that they will as you try and relax mitigation—if we have the capability of identifying, isolating, and contact-tracing in a highly effective and efficient way, then the numbers will stay lower.
It may be 80,000 or 70,000, like the model says. If we are unsuccessful, or prematurely try to open up, and we have additional outbreaks that are out of control, it could be much more than that. There could be a rebound that gets us right back in the same boat we were in a few weeks ago.
That’s why we’ve really got to be careful and very circumspect as we go from a lockdown to a gradual, rolling reentry into some sort of normality.
DR: You have said you think it’s likely that in the winter this virus could come back, as the Spanish flu of 1918 came back fairly lethally. Why do you think this will come back?
AF: I’m almost certain it will come back because the virus is so transmissible and it’s globally spread. Remember, when people are indoors and congregated in the cold dry weather, these kinds of viruses tend to do better than in a warmer climate.
I don’t know whether that’s going to make a major difference here. What we do know is that right now, as we start to stabilize, places in southern Africa, like KwaZulu-Natal and Cape Town in South Africa, are starting to see the emergence of cases. So it’s not going to disappear from the planet, which means as we get into next season, in my mind it’s inevitable that we will have a return of the virus—or maybe it never even went away. When it does return, how we handle it will determine our fate.
If by that time we have put into place all of the countermeasures that you need to address this, we should do reasonably well. If we don’t do that successfully, we could be in for a bad fall and a bad winter.
DR: So how do you look at testing? In other countries that have taken on testing, the nation has taken on the testing. Here, we’re letting the states take it on. Why is that the best way to do it, and if somebody wants to get a test today, can they realistically get one?
AF: Early on, our testing capability was not really properly designed for what we had to deal with in such an acute way. And it actually did fail us early on. I’ve said that before, so I’m not creating any new dialogue here.
However, we have responded now in a very aggressive way, and appropriately for the way our country is built. Namely, we have engaged the private sector, the big companies who know what they’re doing, who do this for a living. Over the past several weeks and into the future, the testing situation has improved very rapidly.
Whether or not we’re exactly where we want to be remains to be seen. I think we are either there or getting very close to being there. Yesterday, the plan that was rolled out was a blueprint for testing as we open America again. The thing in that plan that’s now different, and everyone should understand that, it is really a true partnership between the states and the federal government, where the implementation on the ground should be at the state level, because they know what they’re doing. But the federal government has a role in providing strategic direction and technical assistance.
That’s something that wasn’t fully in place early on. Right now there’s a commitment of that partnership between the federal government being kind of the supplier of last resort but also the group that allows inter-action with the states so that we can give them strategic direction and then let them do at the local level what they do very well. So I believe we are much, much better off now than we were several weeks ago.
DR: Do the tests work? Are there a lot of false positives or false negatives on these?
AF: The validated tests that are out there are sensitive and specific. No test is 100 percent perfect.
I think people sometimes get confused about what test you’re talking about. There are two major categories of tests. One is a test for the virus itself. With those tests, there are multiple different platforms that get you there—some more rapid than others, using different approaches. But the bottom line, the test tells you whether you are infected or not at this particular time.
There’s another test now being worked on—many of them out there have not been validated, but a few have been validated by the FDA—and that’s an antibody test. It doesn’t test for whether you are infected now. It tests whether you have been infected and likely recovered and now have antibodies, which are proteins that the body produced in response to an infection. And most of the time that protects you against being infected by the same virus again. The degree to which that protection exists still needs to be worked out for this particular virus, because this is the first time that we’ve had any experience with it.
So one group of tests for the virus is quite solid. The other is working its way now toward being more solid.
DR: What is the status of vaccines? There’s a report in the New York Times today that your lab and Oxford University are working on something that seems to have worked in monkeys. What’s the likelihood that that vaccine could actually turn out to be good for humans?
AF: Certainly it’s possible. I’m cautiously optimistic about not only that vaccine candidate but a number of other candidates that we at the NIH are partnering with our pharmaceutical colleagues on, and some companies and countries are developing vaccines totally independent of us. There are going to be a lot of candidates out there. As you know, a few of them are already well into phase one studies in humans to determine if they’re safe.
Hopefully we can move along to get an answer to whether they are safe and effective in a timely manner, which I’ve said right from the beginning would likely be a year to a year and a half. I said that a few months ago. Hopefully, by the time we get to this coming winter, we will know whether or not we have a safe and effective vaccine.
Then the challenge will be to scale it up enough to be able to distribute it meaningfully, both in this country and throughout the world. That’s the reason why as important as getting a vaccine that works and is safe is the ability to scale up enough doses so that it isn’t confined only to rich countries—that the rest of the world can have access to it.
DR: We never really came up with a vaccine to prevent one from getting HIV. Why are you optimistic we can get a vaccine for this? Because a lot of work’s been put into HIV as well.
AF: There’s a big difference with HIV, David. Whenever you make a vaccine, what you rely on is the ability of the body to make an adequate response to natural infection.
So we know that measles is a serious disease, but the body clears measles in the overwhelming majority of individuals and leaves those people with an immune response that protects them against reinfection. So measles has already proved the concept that the body can make a good response.
That’s not the case with HIV, for reasons that are very perplexing. The body does not make a very good response against HIV that can protect it, which is the reason why, of all the millions and millions of cases of HIV, there have been really no instances of spontaneous removal of the virus from the body purely on the basis of the natural immune response.
However, with other viruses, including respiratory viruses, we know the body does make a good immune response. Many, many, many people recover from coronavirus infection, from this novel coronavirus that is giving us so much trouble. So the very fact that people can mount a natural immune response that gets rid of the virus makes me cautiously optimistic that we can develop a vaccine that can mimic natural infection enough to induce that same sort of response that would ultimately protect people.
There’s no guarantee. There’s never a guarantee of success. But the fact that the body can do it gives me cautious optimism.
DR: But could the virus that causes COVID-19 mutate such that the vaccine wouldn’t be adequate?
AF: That is always possible. It likely would mutate less to make it evasive of the vaccine than to make it a little more or less virulent, or a little bit more or less resistant to a drug. For it to mutate so that the vaccine doesn’t work is possible and could occur. That’s the reason why you need to do carefully designed and well-controlled studies to look at the efficacy and match it against immune response to the particular virus that happens to be currently circulating.
DR: Why do you think this virus has been so damaging to people who are elderly—people over, let’s say, sixty or sixty-five—or people who are African American or other people of color?
AF: If you look at influenza, which we have a lot of experience with, influenza and other types of viruses always hurt the elderly and people with underlying conditions more than they hurt healthy young people.
The interesting thing about this infection is that, for the most part, with some exceptions, people who get into trouble are those who have underlying conditions—mostly hypertension, diabetes, obesity, some chronic lung disease.
We don’t fully appreciate and understand what I call the pathogenic mechanisms of this virus. But as we learn more about it, we see that it has a complicated way of hurting the body. If you have an underlying condition, as with many viruses, it puts you at much higher risk, not of getting infected but of actually getting a deleterious consequence.
With regard to African Americans, unfortunately there’s a disparity in health that has nothing to do with coronavirus. We’ve known forever that the African American community suffers disproportionately with diseases like hypertension, like diabetes, that give you a greater possibility of having a poor or adverse outcome.
So it’s a double whammy. They disproportionately have these diseases that are bad enough to begin with, and that puts them at additional risk of getting a very poor outcome when they do get infected.
DR: There are 330 million people in the United States who are worried about your health every day. How are you avoiding this virus? Because nobody wants you to be incapacitated. What are you doing to stay healthy?
AF: I’m not doing things that I would recommend to others because my day is just, you know, ridiculous. In the beginning I was foolish, because we had so many things to do that I was getting three hours of sleep a night. That doesn’t work very well for more than a few days in a row. So, listening to the advice of my very clinically skilled wife, who was formerly a practicing nurse, the thing I do now that I didn’t do before is get at least five or six hours of sleep. That and staying away from people, to the extent that I can, doing everything virtually, the way we’re doing now, is I think keeping me okay. I’m running a little bit on fumes. But they’re pretty good fumes.
DR: What about your voice? People keep commenting that it’s a little raspy. What are you doing? Are you talking too much or what?
AF: It’s exactly that, David. In December, unfortunately for me, I got influenza A, H1N1. I developed a tracheitis that gradually was getting better. And then came coronavirus, which had me briefing, at least in my mind, almost every congressman, every senator, every governor, and doing five, six, seven interviews a day. When you get your trachea damaged a little—I probably have a polyp there—the only way you’re going to make it get better is to keep your mouth shut. But that’s not in the cards right now.
DR: Tell us what the coronavirus task force is like. Everybody sits around saying how everything is great and people argue with each other? What are those meetings like?
AF: No, no, it’s a good meeting. We have a good bunch of colleagues in it. It’s led by Vice President Mike Pence. Various Cabinet members are there, predominantly Alex Azar. We have Ben Carson. We have Chad Wolf and others who are actually active members. We have medical people—myself, Bob Redfield [Director of the Centers for Disease Control and Prevention and Administrator of the Agency for Toxic Substances and Disease Registry], Debbie Birx [U.S. Global Aids Coordinator & U.S. Special Representative for Global Health Diplomacy], Steve Hahn [Commissioner of Food and Drug Administration]. So we have a good group of individuals who actually go over the data from the night before, what the pattern and the dynamics of the outbreak are, and we address the different issues, some of which you’ve already mentioned. Things like testing, the ability to have enough ventilators, PPE, plans for the states, interacting with them.
We do that for about an hour and a half or more, then we gather and the vice president and his staff decide what the topic for the press briefing is going to be. Then we brief a little summary after we brief the president. Then we go out and do the press conference.
DR: People get nervous when you don’t show up at those press conferences. When you don’t show up, is that because you’re doing something else that’s more important?
AF: The press conferences are often topic related. When there is a topic where it’s more appropriate for someone else to be the backup, they do that. For example, yesterday it was testing. The people predominant there were the people involved in testing. I’m a health physician, a scientist, a public health person. I’ve been involved in most but not all of the briefings. A lot of times when people don’t see me, they think there’s some problem between the president and me. And that’s really not the case at all.
DR: So you’re seventy-nine years old, but in great shape. You power walk three miles a day. Power walking means you’re walking fast, right?
AF: Power walk means I’m trying to catch up with my wife, who’s walking faster than I am.
DR: Your goal is to do this for another ten years or so? How much longer would you like to do this job?
AF: You know, David, that’s a good question. You’ve been asking me that for decades. I’m going to do it until I feel I’m not doing it as effectively as I can. Right now, I think I’m as good as I’ve ever been, because not only do I still have the energy I had, I have a lot more experience.
DR: Do you think, in hindsight, that had you been a couple inches taller, you could have been a one-and-done college basketball player? Because you were a high school basketball star. Did you aspire to go to the NBA or not?
AF: The answer is that every young kid in New York City who plays in the schoolyards and gets good at it and does well in high school always has aspirations, and often the aspirations are not connected to the reality.
I inherited a couple of things from my father. My father, interestingly, when he was in high school was the New York City champion of the 220- and the 440-yard dash. He was very fast. So on the basketball court, you couldn’t catch me on a fast break. However, I also inherited his height. And I found out something that’s the rule in basketball—that a very fast five-seven point guard who’s a good shooter will always get crushed by a very fast six-three point guard who’s a good shooter.
DR: I had the problem I wasn’t a good shooter either. I wasn’t anything, so I didn’t get very far either.
Tony, thank you very much for this. Thank you for what you’re doing for the country. Stay well. Get some tea and honey. Keep your voice in shape. And keep working as hard as you can. Thank you.
AF: Thank you very much, David. It’s always a pleasure. Take care.