After more than five decades at the National Institutes of Health, physician-scientist Anthony S. Fauci, MD recently stepped down as director of the National Institute of Allergy and Infectious Diseases (NIAID) and President Biden’s chief medical advisor. Here he discusses his thirty-eight years as NIAID director, the international response to the COVID-19 pandemic; the latest developments with emerging infectious diseases; and how countries should prepare for the next pandemic.
HAASS: Well, good evening. Welcome to the Council on Foreign Relations, whether you’re here in New York, home of the great New York Giants—(laughter); whether you are in Washington, D.C.—I will not extend any comparisons—or nationally. It’s great to have you all.
Thrilled to have Dr. Anthony Fauci here with me. As you heard, we’re going to have a conversation at first that will be on the record, then we’re going to take questions where I am going to bias it, shall we say, in those under thirty. It’s the Abbie Hoffman rule applied to the Council on Foreign Relations, so be prepared for that.
Before we begin, I want to thank the Marc Haas Foundation—no relation unfortunately—and the Stanley S. Shuman Family Foundation for their support of this series, the Daughters and Sons Series, also known as the nephews, grandchildren, and neighbors series. (Laughter.)
We’re glad to have Stan and Michael Shuman joining us virtually tonight. I gather Matthew Haines of the foundation also virtually—where’s David Shuman, saw David here—is with us in person. I gather we also got some global kids. Fantastic to have you here.
This is now the first time we’ve ever tried this at the Council, and by this I mean having two speakers from Bensonhurst. (Laughter.) This is—we’re 101 years old, and this has never happened before, though I should warn—I want to warn you.
So this afternoon when I was preparing, I Googled—I typed in famous people from Bensonhurst, and neither one of us showed up. (Laughter.) Just saying. So, you know, it’s perspective for you.
Dr. Fauci, who unlike me is what we call a real doctor, has had this just extraordinary career of public service—no less than thirty-eight years running the principal, I’d say, public health—one of the principal public health institutions in the United States, in the world—really, really extraordinary.
So before we begin, I really want to thank him first for being with us tonight, but above all, I want to thank him for just an extraordinary life of public service. We’re all in your debt, sir. (Applause.)
FAUCI: Thank you.
HAASS: So I wanted to then begin a little bit with—I doubt, though—something tells me—fifty or sixty years ago when you were a young man, and you were at med school and the rest, you said to yourself, I want to spend the next fifty years running this place in, you know, Washington, and so forth.
How did it happen that you are not my internist and instead you are doing this? (Laughter.)
FAUCI: You know, that’s a good question because I actually thought, Richard, that I would be your internist—(laughter). I went to medical school for the real purpose of being a practicing physician. I mean that was my one goal, and I think that’s a pretty good lesson when you talk to the young people in that audience that sometimes when you set your direction in one way, very often things sometimes beyond your control, circumstantial, happen to change the direction of where you are going.
I was all set. I did medical school, internship, a couple of years of residency, and I wanted to do a fellowship in infectious diseases and immunology, so I came down to the NIH, which had a very good program in that, to train. My total purpose was to go back to New York City and practice medicine on 68th Street and New York Avenue somewhere near the New York Hospital, Cornell Medical Center.
However, when I got to the NIH, I got bit by the clinical and biomedical research agenda, and I really fell in love with the discovery that goes along with biomedical research. And that’s where my career took a real pivot
and turned around, and I started to do the kinds of things that I’ve been doing over the last now fifty-four years at the NIH, which led me into a number of other things, including my job as the director of the institute. So I wasn’t planning it that way from the beginning.
HAASS: I just want to underscore something you said—not to over plan your careers or your life; just do stuff that is exciting, and interesting, and stretches you. And who knows what sorts of good things will come of it. If you take nothing else away from tonight, take that away.
Dr. Fauci, what I’d like to do is start with COVID-19, which I think is—most of us; at least many of us got to think we knew you during that, we saw you so often. When did you first sense that this was going to be qualitatively different; that we were—whether it’s humankind or the country—that we were on the edge of something qualitatively different?
FAUCI: Well, it was probably a two- or three-step progression, Richard. You know, the first information that came out of China was rather garbled and opaque. We weren’t really quite sure.
The first SARS-CoV-1 in 2002 was very well controlled by public health measures. There was about 8,000 cases and 781 deaths. And when we had this new coronavirus come out—it was very quickly identified as a coronavirus, there was the natural extrapolation that this was going to be like SARS-CoV-1, which did not have a very effective and efficient way of transmitting from person to person, and it wasn’t really transmitted by asymptomatic people; it was mostly symptomatic people.
But then what started to happen is that over a period of a few weeks, it became clear that it was efficiently spread from person to person. And it was quite efficiently spread from person to person. But we weren’t really sure what the morbidity-mortality aspect of it was going to be. We got kind of suspicious when we saw that the Chinese were building, like, in a week, ten-thousand-bed hospitals saying, they must know something that we don’t know about this, but it wasn’t quite sure whether or not they were just being overly cautious and prepared. And it was thought that you could contain it by the standard public health measures.
When I really got very anxious about there being a problem is, at the same time, we were getting a few cases in the United States that we thought we could trace and do contact tracing with isolation, which would have been OK for SARS-CoV-1, but not for a virus that’s transmitted mostly by asymptomatic people. When Northern Italy got hit so badly that their hospitals were being overrun, the Italians were very transparent about what was going on there, and they are very good physicians, and they have a very good health care system. And when my Italian colleagues were calling me up, saying, you’re not going to believe what’s going on here in the Lombardy district of Italy; we’re being overrun with people who were deathly ill and actually dying. That’s when I really got anxious because I knew that there is not a big difference between northern Italy, and New England, and the middle Atlantic States, and that’s when I knew we were in serious trouble.
HAASS: When you’ve written and talked about the issue, if you were a Harvard professor—or since you are from New York, a Columbia professor, you said you would give it something like an A for the scientific response, but a decidedly lesser grade for the public health response. Can you elaborate on that a little bit?
FAUCI: Yeah, I described the preparedness and response into two major buckets. One is the scientific bucket and one is the public health bucket. If you look at scientific bucket, Richard, the years of preparedness that were put into the science that led to the platform technology leading to the mRNA vaccine, the structure-based vaccine design that led to the ability to have a mutationally stabilized immunogen that is used in all the successful vaccines for COVID, allowed us to do something that was completely unprecedented and unimaginable ten years ago, and that was to go from a recognition of the sequence of the virus on January 10th of 2020 to have tens of thousands of people in a clinical trial so that eleven months later you have a highly effective and safe vaccine that’s going into the arms of individuals in eleven months. That was beyond unprecedented. That was a scientific, bases-loaded home run, clearly.
However, the situation with public health was not the same. We were judged by the Hopkins School of Public Health to be the best country in preparation for a pandemic, and now we have a million-plus people who’ve died. And if you look at the missteps along the way, they were related to any of a number of things. But one of the things was our inability to get data in real time. In other words, we had an antiquated, somewhat ossified public health system where, in order to find out things like what’s the dominant strain, what is the effect of a particular intervention or not, we didn’t have that in real time. Sometimes there would be a lag of a month or two, or more to get the data.
We were in the somewhat—I don’t want to be over determining it—but somewhat humiliating situation where we had to get on the phone with our South African colleagues, or our Israeli colleagues, or our U.K. colleagues to find out, in real time, what was actually going on. So we needed to—we really need to improve that. To their credit, the CDC is now trying very hard to really modernize the way they get information in real time as opposed to the lag that we experienced when we were trying to get information from them.
Our health care system is also a reason why this did not work well because we have such a fragmented health care system. We can’t get a unified amount of data in a reasonable amount of time.
HAASS: You mentioned the CDC. When I taught at the Kennedy School years ago, we used to hold up certain institutions in the U.S. government as the jewels. But they were small places of concentrated excellence, and the CDC was one of them. But then throughout COVID, I would say its performance didn’t quite live up to that reputation—I’ll speak like a diplomat here.
What went wrong? It’s obviously a place—and I don’t mean about individuals, but what—was it something about the culture? Was it just that people weren’t—their imaginations didn’t allow them to prepare for something of this scale? Why is it that one of the crown jewels of this country didn’t step up?
FAUCI: Well, Richard, let me begin the answer by saying the individual people at the CDC are outstanding. They are really excellent. You know, I’ve known them for decades and I’ve dealt with them. They are really good. I think it’s something that, in their own self-examination—and Dr. Walensky has articulated this very well—they’ve come to the realization that it was really a culture problem. It was not functioning as a real public health agency. It was almost like it was functioning like an academic agency and not an agency that needed to get data out in real time. And that was one of the flaws that led to the disappointments that you are talking about.
I think—I hope and I believe that they are on the road to turning that around right now and getting back to being more of the agency that is quite flexible in their response, as opposed to slow and deliberate in an academic way.
HAASS: So all things being equal, if next week something called COVID-23 is identified or some version of that—all things being equal, do you think we will have internalized and basically—and to a degree that we would be better positioned to deal with COVID-23, or a year from now, COVID-24, than we were with COVID-19?
FAUCI: I hope so. You know, I—
HAASS: That’s not reassuring, sir. (Laughter.)
FAUCI: Well, Richard, no doubt, as I said, if you get back to those two buckets of scientific preparedness and response and public health, there are really clear lessons that needed to be learned and hopefully have been learned if we heed those lessons, and we have good corporate memory of what we did not do as well, and what we could do better.
The only trouble is that my experience over the decades that I’ve been involved with this is that corporate memory of these things sometimes wanes the way immune responses to the virus wane. And people forget what went wrong, and then you wind up getting into the same situation you were in to begin with.
So I don’t mean to be pessimistic about it, but I really think we’ve got to keep reminding ourselves that, you know, we don’t know when the next outbreak is going to be. It could be a year from now; it could be thirty years from now, but we still have to be perpetually prepared.
HAASS: Let’s talk a little bit about the public reaction. The skepticism of vaccines, particularly on social media; the resistance to masking up—to what extent did this surprise you, and what is your thinking about how we combat this? How do we basically—what are our tools of persuasion when there is everything from misinformation, to conspiracy theories, to you name it. What is your takeaway from all this?
FAUCI: Well, my takeaway is that it really upsets me as much as anything has ever upset me because when you have misinformation, and disinformation, and conspiracy theories in any venue, it’s a negative thing. But when it’s interposed in a venue of public health where people’s lives are going to be influenced by the spread of misinformation, and disinformation, and conspiracy theories, that’s really serious stuff, Richard. I don’t know how effectively to counter that. I can say the best way to counter misinformation and disinformation is to flood the system with correct information.
The only trouble and observation that I have made personally is that it appears that the people who are spreading the misinformation and disinformation do it in a very energetic, aggressive way as if they don’t have anything else to do—(laughter); whereas the people who are capable of spreading the correct information actually have a day job—(laughter)—and we’re kind of fighting, you know—we’re going into a gunfight with a knife, which is really something that I think we’re going to have trouble overcoming that.
HAASS: Are you seeing serious signs, by the way, that vaccine skepticism is spreading to other vaccines; that it’s not, if you will, a COVID-only phenomenon, but we’re beginning to see it more broadly?
FAUCI: Yeah, I think we’re starting to see inklings of that, and that could really be a disaster because we know—in individual countries and in sections of countries that do well, when you have skepticism that leads to an anti-vax approach, no doubt you get outbreaks of diseases that are clearly preventable by vaccines. The typical example of that in our own country is there are pockets of people in cohorts who are under-vaccinated to the tune of maybe 50 to 60 percent of the people are vaccinated against measles. That’s when you see the outbreaks of measles, which can be a very serious disease.
So the answer to your question, Richard: I’m very troubled by that; that we’re going to see this anti-vax—this feeling and trend spread into other areas and say, well, you know, if you don’t want to tell people they need to get vaccinated for COVID, why should you get vaccinated for measles, or polio, or hepatitis, or meningitis? If that happens, we’re in a lot of trouble—a really lot of trouble.
HAASS: You mentioned before what we did with the vaccine was the equivalent of a grand-slam home run, I think that was. Let me switch sports.
If you were allowed a mulligan when you look back at the last three, four years, would you take a—would you do anything different, knowing what you—it’s not fair to say knowing what you know now, but are there times along the way that you kind of—you look back and you say, I wish we’d done this differently?
FAUCI: Well, I’m not—I guess mulligan refers to golf. I’ve never golfed in my life. (Laughter.) So I don’t even know what a mulligan is.
HAASS: It reinforces that you are a very intelligent man.
FAUCI: But it doesn’t sound good. (Laughs.)
You know, Richard, there are always things that you could have done better and differently. One of the reasons why—when the answer to that question can get confused and misinterpreted, is that when you are dealing with an outbreak like COVID, you are dealing with a moving target, and that’s one of the things that I really—looking around the room at the younger people—to appreciate that what was true in January 2020 with regard to our understanding of the virus was not true in February, March, July 2021. For example, we did not realize at first that this was aerosol transmitted. The big showstopper is that we didn’t realize that in fact 50 to 60 percent of the transmissions occur from someone who has no symptoms at all because that has a big, big impact on how you monitor where the disease is going. If you take what’s called the syndromal approach where you only worry about people with symptoms, you’re going to miss an awful lot. So when recommendations were made, they were made on the basis of what you knew at that given time.
The problem is as you get more information, you change the recommendation, and the people who want to be mischievous say scientists are flip-flopping; they don’t know what they are talking about. Well, the fact is if we had the data in January that we had in April, we likely would have given a different recommendation. So, yes, there are many things we would have done differently.
One of the caveats—but people don’t hear that—is that when you are dealing with a dynamic and not a static situation, you’ve always got to give the caveat that this might actually change as we get more data; whereas the mindset of the public when they think of science, they think it’s static and immutable. So in January of 2020, Richard, two plus two equals four. You know, in January of 2023, two plus two still equals four, but the virus in January of 2020 is very different from the virus that we’re dealing with right now—it’s multiple variants different. So it isn’t the same; it changes. That’s a tough one to get people to appreciate. They want definitive facts that don’t change, and when you are dealing with a dynamic situation, it changes very frequently.
HAASS: It reminds me of that famous exchange of economist, John Maynard Keynes, when he was attacked for changing his mind. He said, well, when the facts change, I change my mind. What do you do, sir? (Laughter.) And this echoes that.
Let’s talk about China for a second. The Chinese had an approach to COVID: massive public testing, massive lockdowns, and then a few months ago, people basically increasingly started protesting at the constraints. The Chinese are ripped off the constraints; now we see massive outbreak of COVID. Mortality estimates could hit the country upwards of one million to two million. Who knows?
What is your take on what’s going on there?
FAUCI: Well, the Chinese implemented a strategy that has merit under certain circumstances. When you are going to lock down, you lock down, A, for a reason, but with an end-game purpose in mind. For example, if your hospitals are being overrun, and you really need to dramatically and quickly shut down the tsunami of infections, you can lock down. It must always be a temporary process with a goal of what are you going to do during the lockdown to allow you to ultimately open up safely. And that was the lesion that the Chinese fell into because what they did is that they locked down in a draconian way, and if they had used that time of the lockdown to get the people vaccinated, particularly the elderly, which were under-vaccinated, to use a really good vaccine, then they could have opened up, and they would have had a population that wasn’t vulnerable.
What they did is they locked down to the point when the population would not tolerate it anymore, and for reasons of disruption in society, they opened up completely, but they opened up as vulnerable as they were when they locked down.
So you ask yourself the question, what did the lockdown accomplish? They didn’t do, within that period, what they needed to do to protect the public to make then not vulnerable when they opened up. So right now they are
suffering the consequences of not utilizing the lockdown time to get something done that would be protective of their population.
HAASS: Just out of curiosity, did you or any of your colleagues tell the Chinese, your Chinese counterparts that—that, hey, folks, if you are going to do a lockdown, use it. We can’t see what you are doing, or take our vaccines. Was there a conversation with them about their strategy for fighting COVID?
FAUCI: There wasn’t a formal conversation, Richard, but I was very public about saying that if you are going to do something like that, you have to have an end game. There needs to be a reason. If the reason is to get more ventilators, and get more hospital beds, fine. If the reason is get people vaccinated, fine. But you have to have an end game.
You know, when you say Chinese, Richard, you know you have to make sure that there are two groups here. There are the Chinese authorities who are dictating what happens, and there are our Chinese scientists and public health colleagues who are really smart, who really know what they are doing. There is really quite a separation there, as you probably can imagine.
HAASS: Yes, I think that’s consistent with the field I work in.
One last question about China—have you formed any of your own conclusions or judgments about the origins of COVID? You’ve watched it. You’ve seen what happened. You know, there’s two competing theories essentially and subsets of each. But basically do you feel you’ve got enough evidence to support the so-called wet-market, animals-to-human theory as opposed to the lab theory?
FAUCI: Yeah. Well, first of all, we have an open mind. Since we don’t definitively know, you’ve got to keep an open mind that either one is possible.
What I do feel strongly about is that one is much more probable than the other because if you look at the data that has been accumulated by unbiased, highly competent, and internationally recognized evolutionary biologists and virologists, they have done a study, both of which were published in the peer-reviewed journal, Science, strongly indicating that this was a spillover from an animal species to a human in the wet market.
Having said that, we still need to keep an open mind that it is not that; that it is perhaps something that leaked out from what they were doing in the lab. But I think it’s much more likely that it was a natural spillover.
HAASS: Last question, at this point, before I open it up. The other public health issue you are so associated with was HIV/AIDS. And, you know, that was an issue when it—you know, when it first originated you were involved, you know—more than a little controversy.
And then I looked at what has happened in this country and what happened in Africa, and it seems to me it’s one of the more extraordinary public health successes of any time—not just modern times—of any times. Would you say a little bit about it because, particularly for the younger people, they are living, in some ways, in a world which is no longer so dominated by that. But if we had had this meeting forty years or so ago—give or take—or thirty years ago, that would—we wouldn’t be talking about COVID; we’d be talking about HIV/AIDS.
FAUCI: Yeah. Well, you are absolutely right. As much as the fact that there still is an ongoing pandemic of HIV, more so in the developing world than here in the United States, but we still have a problem in the United States.
It is, as Richard said, an extraordinary success story. I had the opportunity, the experience, the privilege, and the pain all in one of having taken care of persons with HIV from the very first months that the disease was recognized. I spent several years of my career on-hands taking care of people who—it was essentially a death
sentence. Virtually every one of my patients died—and this was from 1981 into the late 1980s, early 1990s—from a disease that was just relentless in its destruction of the body’s immune system.
What was done from a scientific standpoint over a period of time, based again on the investment in basic and clinical biomedical research, together with partnering with the pharmaceutical companies to develop life-saving drugs—that we went from what was essentially, with very few exceptions, an inevitable death sentence from a disease to a disease now where you have anti-retroviral drugs which used to be given in twenty-eight pills over a period of time can now be given in one pill per day that can bring the level of virus to below detectable to the point where a person living with HIV can have essentially a normal lifespan with maybe a year or two off that lifespan. And now we have drugs that are highly effective in preventing the transmission or the acquisition of HIV.
So you’re right, Richard. It is one of the most dramatic biomedical research success stories where you take a disease which had almost a hundred percent mortality to have people now living productive, comfortable lives that they could feel that they could live essentially a normal lifespan. That’s very unusual that you have that in medicine.
HAASS: And is there a lesson or two that—or an explanation or two, other than the scientific breakthrough—because it seems to me it’s also about distribution, availability; you know, issues which came up again during COVID, which wasn’t as good. Are there takeaways from the HIV/AIDS experience—
HAASS: —that we should bottle?
FAUCI: Yeah, there is one that I think is an example of why this country is wonderful, and why leadership can make a major, major difference, and that is the development of the PEPFAR program—the President’s Emergency Plan for AIDS Relief—that George W. Bush—you know, if you look at one of the things that I feel most proud of and privileged was when the president tasked me with the task of putting together a program that would be transformational in the developing world and accountable. And that was a program that turned out to be the PEPFAR program, which we initially put $15 billion in, and now we spend over $110 billion. And that program has been responsible for saving 20 (million) to 25 million lives. So the lesson learned is that a president of the United States had a vision of why we have a responsibility to not have people die because of where they happen to be born and live when there are resources and interventions that are lifesaving in other parts of the world. So I think that’s a very important lesson to be learned.
HAASS: Amen to that.
(Note: The audience Q&A portion of this event was off the record and not transcribed.)