Titans of Science: Anthony Fauci

Charting a commendable career of public service, saving millions of lives during the HIV and Covid crises...
19 September 2023
Presented by Chris Smith

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Anthony Fauci

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Time for the next installment in Titans of Science! This week's very special guest is the former chief medical advisor to the White House during the pandemic, Dr Anthony Fauci. He tells Chris Smith his fascinating story, from a boyhood flair on the basketball court, his rise to prominence handling an HIV crisis, to what it was like working with Donald Trump...

In this episode

Basketball going through a hoop

Anthony Fauci: From the basketball court to the laboratory

Anthony Fauci was born in New York on Christmas Eve, 1940. What a Christmas present. His father was a Columbia University educated pharmacist. His mother and sister worked in the pharmacy's register, and a young Anthony Fauci delivered the prescriptions. He was academically gifted as a student. He attended Regis High School, a Jesuit school in Manhattan's Upper East Side, where he captained the school's basketball team. He would later attend the Cornell University, New York Hospital Medical School, and from 1983 to 2002 was one of the world's most frequently cited scientists across all scientific journals. In 2008, president George W. Bush awarded him the Presidential Medal of Freedom, the highest civilian award in the United States for his work on HIV and AIDS. Fauci had a remarkable career in public life. He served as the director of the National Institute of Allergy and Infectious Diseases between 1984 and 2022 and as the chief medical advisor to the president from 2021 to 2022. He's advised a total of seven US presidents.

Chris - Anthony Fauci, tell us about the younger you. How did life begin? We don't have to go back to the embryo, but I heard that basketball was something that distracted you for a while and you almost ended up doing that. Is that true?

Anthony - Well, yes, I can say that with somewhat of a smile on my face. I was the captain of the varsity basketball team in a New York City high school. The good news is that I was pretty good at it, the sobering news was my height at 5'7". Although I was a quite good basketball player at the high school level - I would've loved to have continued that competitively in college - soon I found out that a very fast, good shooting, 5'7" point guard will never ever be as good as a very fast, good shooting 6'3" point guard. And so I decided that my field would not be basketball. It was a good choice, and I diverted towards science, medicine and the humanities.

Chris - Well, you have a very big brain and a high stature and have developed that stature since. I'm quite surprised by the timeline and the time that you chose to go into infectious diseases because that was the time... it's actually a misquote, but William Stewart, who was Surgeon General in the States is often quoted as having said, 'the future of infectious diseases is dull because the war's been won.' Because we were in the post-antibiotic era. Macfarlane Burnet, who won a Nobel Prize as a virologist, said it's a pretty dull future that awaits us in infectious diseases because we know everything now and we have antibiotics. I'm paraphrasing, of course. Nevertheless, despite that, you chose to study infectious diseases and the immune system. Why did you go down that path?

Anthony - Well, it's very interesting. I was very well aware of what was being said about the future of infectious diseases. And there were some people who even said that we shouldn't even train anymore infectious disease people because they won't have anything to do aside from culturing each other. Dr. Robert Petersdorf, a very famous infectious disease person, actually said that - a good friend of mine and one of my earlier mentors. But, just the idea of being able to dissect the mechanisms, the pathophysiological mechanisms, of the interaction between a pathogen and the human immune system, fascinated me. Little did I know, nor did anyone know, that over the next five decades we would see, in an unprecedented way, the emergence of new infections and the reemergence of old infections. Historically, very few people were around who were alive and remembered the catastrophic 1918 influenza that killed fifty to a hundred million people in a world population that was one third the size of what it is now. But that was such a distant memory. We did have a pandemic flu in 1957 and 1968, but the idea of a brand new emerging infection that has potentially catastrophic consequences was really off the radar screen of most people until 1981 when all of a sudden HIV AIDS thrust itself upon our consciousness. And then from there, over a period of time, the idea of emerging and reemerging infections became a very real phenomenon with things like the pandemic flu of 2009, Ebola, Zika, SARS CoV 1, MERS and now, most recently, the extraordinary circumstance of a three plus year pandemic that has really impacted in such an important way the entire world. So this whole concept of the emergence and reemergence of infectious diseases was really not fully appreciated at the time I went into infectious diseases. But now it has completely transformed the entire field.

HIV: artists impression of the virus particle

Anthony Fauci: Confronting the HIV pandemic

Anthony Fauci tells Chris Smith about his handling of the HIV crisis...

Chris - Of course, when we think about pandemics and we think about Covid, there's possibly a 20 million death toll, that nevertheless is dwarfed by that other pandemic you mentioned. The one that took us a while to realise was happening, and that was HIV which, conservatively, people say there was maybe a hundred million death toll from that. We know that right now there are north of 30 million people living with this infection, which until bright people came up with drugs to control it, was guaranteed to kill you. You were running a major division at that point. When HIV began to appear on the radar, that must have been a very interesting time to be working. Presumably, it was quite frightening because we didn't know what this was?

Anthony - Yes, it was challenging in many respects, exciting, but also it was daunting because of my dual identity as a physician who was actually taking hands on care of patients at the same time as a scientist who was trying to find answers to a problem of a mysterious disease. When I first started seeing patients and caring for them, AIDS didn't even have a name. We were calling it gay related immunodeficiency or the gay cancer because of Kaposi sarcoma, and it certainly didn't have an aetiology until 1983, 1984. So those early years, until we began to develop the therapies that have completely transformed, in a very positive way, the lives of persons with HIV, those were the very dark years of my professional career because, as hard as we tried, all of our patients up to a point, overwhelmingly, the vast majority of them, with very few exceptions, ultimately died.

Anthony - And it was a great challenge. And one of the things that my colleagues and I feel very good about is that I established a specific program in the institute that I directed, the National Institute of Allergy and Infectious Diseases, directed solely at HIV AIDS because of the compelling need to develop interventions and to bring the best and the brightest of the scientists, hopefully young scientists, into the field. And, over a period of time, that proved to be highly successful because we went from a disease with an almost uniform fatality to a disease now where you can give a combination of drugs, sometimes in a single pill once a day, that can bring the level of virus to below a detectable level and keep it there and allow persons with HIV, with few exceptions now, to lead almost the normal lifespan - maybe a year or two less than what would would be considered the normal life expectancy. That is a major, major accomplishment, which over a period of decades went from despair about no interventions that were of use to a couple of decades later being able to have transformed the lives of persons with HIV. That was a very historic accomplishment.

Chris - Well, you do say that you feel that your identity has been defined by HIV and from what you were just saying there, when I first went to medical school, I remember a patient walking in front of a packed lecture theatre of students - this is in the early nineties - and this person sat there and told us about their story and was in the terminal stages of AIDS and almost certainly would've been dead before I finished that year of medical school. And within 10 years of that experience as a virologist, as I am now, we were routinely treating people in the way you say, and that person would be alive today if they had been infected 10 years later. And then I think around the same sort of time when we see Freddie Mercury dying of HIV and you think, if time had shifted 10 years, we'd still have these people. And that I think is an amazing testimony to how medicine has delivered in this instance, isn't it?

Anthony - Well, absolutely, and I have colleagues and friends who fall into the same category that you mentioned that Freddie Mercury was in, that if you were able to hold on until 1996 when we got the combination, the triple combinations driven by the protease inhibitors, that period was completely transforming. People refer to it as the Lazarus effect. People who otherwise would've been in hospice care were turning around and essentially getting up and figuring out what they're going to do with the rest of their lives. If you were treated before you became an advanced illness, then you could actually look and feel like you've never been infected at all. The drugs were so effective.

Chris - A number of books which cover and chart the emergence of HIV in America and other western countries mention you. And you weren't always flavour of the month with a lot of these people in the early days. They were quite adversarial towards you despite the positive things you've just been saying.

Anthony - Yes, that is correct. And again, that ultimately turned out to be a very good news story. And what it was is that, despite the availability of drugs, and even before the really truly effective drugs became available, the community, the advocacy groups, those living with HIV and at risk for HIV, rightfully felt that since we did not yet have good treatments for HIV, rigid entry and exclusion criteria on clinical trials on the part of the scientific community, and the very rigid regulations of the regulatory bodies like the US FDA, were really ill suited for the very unique nature of a disease that was almost uniformly killing people - mostly young gay men at the time in the United States. And there were no really good interventions that were available. And the only ones that were available were those of an experimental nature.

Anthony - And what the community felt is that they wanted a seat at the table with the scientists and with the regulatory community to be able to have their input. But at the time, the scientific community was not really amenable to listening to the advocacy groups because they felt inappropriately that they knew best. So the community decided they needed to get the attention of a scientific community and a regulatory community that was not listening to them. Since I was such a visible person in the field, because I was leading the leading scientific institute, and, interestingly, I was always advocating for more resources, but doing more for HIV AIDS, I became a well-known public figure, the so-called symbolic face of the federal government. They would attack me and they did. They were very iconoclastic, confrontational, theatrical in saying somewhat outlandish things that caught our attention. Like, "Fauci, you're a murderer, you're killing us. You're an incompetent idiot." Things like that. Well, they certainly caught my attention and one of the best things I did was put aside the theatrics and the iconoclastic and disruptive behaviour and listen to what they had to say. And when I did that, it became very clear that what they were saying was making perfect sense, and that if I were in their shoes, I would've been as disruptive as they were. And, over a period of time, pretty quickly in the late 1980s, I became an AIDS activist and I began pushing and effectively getting the advocacy community a seat at the table in part of our advisory committees and part of our clinical trial community programmes. And I succeeded in getting the FDA to be much more flexible in making available on a compassionate basis interventions that were only available on a very restrictive clinical trial. We call that the parallel track approach, where you can do a clinical trial with all of its restrictions at the same time as you make the medication in a parallel track available to people who might need it. And an informed consent would realise that there's no guarantee that it would work. That I consider one of the most important things that I've done, and once that happened, the activists who were my adversaries wound up becoming not only my colleagues and my collaborators, but to this day, decades later, some of my closest friends.

Chris - One of them even hailed you a hero having spent considerable time, effort and energy disparaging you. So there really was a turnaround.

A cartoon of the Earth as a coronavirus particle.

Anthony Fauci: The COVID pandemic
Anthony Fauci

Chris - Of course one of the points you make about the development and elaboration of treatments and therapies and so on where we really did see things go at a pace was in COVID. And this is probably the time when you did become a familiar household name. And it's quite a turnaround, isn't it? How quickly we went from having nothing, not even any knowledge about this threat to having vaccines going into people's arms. But what went through your mind, because I know what went through my mind in January, 2020 as I began to see these reports coming out from China. What went through your mind when you started to see all these dots lining up?

Anthony - Well, for me and for what my responsibility was, it was all hands on deck to develop a vaccine as quickly as you possibly can. And fortunately, we had made investments in basic and clinical biomedical research for the development of vaccine platform technologies and structure-based immunogen design for years before January, 2020.

Chris - But when did you realise that this was the big one?

Anthony - Oh, you know, it was a gradual process over weeks. I mean, the first reports that we got, like the very, very first week of January, of things that were going on in December. It was originally thought, well, maybe this is just like the original SARS-CoV-1 that had occurred in 2002, in 2003, which was a novel coronavirus that I guess you could call a mini pandemic or an epidemic. It had about 8,000 cases and killed 781 people. But it wasn't efficiently transmitted from humans to humans except in a public health medical setting, like in a waiting room of a clinic or a hospital. And it was very well controlled relatively quickly over about a year with good public health measures of identification, isolation, contact tracing, and quarantine. So it felt, well, maybe that was it. And the reports we were getting out of China first was that, well, it's really transmitted from an animal to a human, but very inefficiently from human to human. Then as we got into the first couple of weeks in January, the information started to change and we said, 'well, wait a minute. It is effectively transmitted from human to human.' And then a week or two later, it was like, wow, it is very, very highly transmissible from human to human. And then we started to realise that a lot of the transmission was from an asymptomatic person. 50 to 60% of the transmissions were from someone who had no symptoms. So the normal paradigm or the syndromic approach of isolation, identification, contact tracing when you had a symptomatic person wasn't very efficient. And then at that point it became clear that there was widespread transmission in China and the Chinese were building like thousand bed hospitals at the end of January, the beginning of February. Then it became very clear we were in for some serious trouble. And then a cascade of events in Europe, Northern Italy, got hit badly. You know, when you could say, well, maybe you could contain it if it was a disease that was able to be contained by public health measures. But once it started becoming very clear that a country as sophisticated as Italy and other European countries and then as we knew it was just like a domino effect, it was throughout the world. And that was in the very few weeks, January into February, it became very clear we were in for some serious trouble.

Chris - I gave a television piece and I was on shortly after Donald Trump did a press conference on the same international channel. And I think you were standing in that same press briefing and this is where he was effectively saying, 'we're well prepared. We've got this.' Would you agree at that time or were you thinking, actually I'm not so sure. February, March, 2020

Anthony - <laugh> Well, that's what got me into the situation now because as you know, when the president was saying 'It's gonna go away like magic', I had to get up publicly and disagree with him and say, no, it's not going to disappear like magic. We don't have good control over it. And then he started saying that interventions like hydroxychloroquine are going to be the magical cure for it. And I had to publicly disagree in order to preserve my own personal scientific integrity and to fulfil my responsibility to the American public, I had to speak out, which was not a very comfortable thing to do. That unfortunately made me public enemy number one of the far right who were those who were essentially highly, highly supportive of what the president was saying.

Chris - Later on that year, we began to get the first vaccine trial results, and then the UK was the first country to actively start vaccinating its population. And then we realised that we had more people to vaccinate than we could vaccinate following what was written on the pill bottle or the vaccine vial, which was a certain time between two doses. And you made a few disparaging remarks about both the rate at which the UK had approved things. And also then about bending the rules, lengthening the time between doses. And then the rest of the world actually decided that this was quite a good idea and they followed. Was that a misstep or do you still stand by that?

Anthony - No, I actually publicly apologised to my British colleagues for that. I think it was taken out of context a bit. I did say that I was very concerned that the way the trial was done, whether it was the optimal way or not, but the evidence based on the clinical trial was to vaccinate and then wait three or four weeks, depending upon the product. 21 days for 1, 28 days for the other. And when I heard what the UK was doing, I expressed some concern that that was not according to the results of the clinical trial. And it sounded like a criticism. And when I went back and listened to how it sounded, I was interviewed by the BBC very shortly thereafter. And I made it very clear that I felt badly that I did not want to in any way disparage my UK colleagues who I have a great deal of respect for. So it really was actually truly a public apology for that.

Wuhan, where Covid-19 came from

Anthony Fauci: Where did COVID come from?
Anthony Fauci

Chris - How did it then play out? Vaccines began to be used. Did that give you enormous optimism, did you think 'Right. We're finally getting control of this.' Because many people thought, thank goodness for this. But then they didn't realise that another year of this lay ahead of us,

Anthony - We were following the classic historical paradigm of an outbreak of a viral disease such as influenza. And we found out, as the months and then as the years went by, that this virus was not following any classic paradigms. And one of the paradigms that was breaking in addition to important ones, like many of the transmissions were from people without any symptoms, was that in the same outbreak we saw the evolution of new variants that were able to escape the protective effect, at least against infection and symptomatic disease, not only escaped the protection of vaccines, but even escaped the protection of prior infection. And it took us a while to realise that the vaccines as highly, highly effective as they were in preventing hospitalizations and deaths were not nearly as effective in preventing acquisition of infection. But one of the things that became clear is that if you compare the benefit among those vaccinated versus those unvaccinated, it was clear that the overwhelming majority of the infections that led to hospitalisation and death were among people who were unvaccinated compared to those who were vaccinated. So it became a complicated issue. Do vaccines work really, really well? Well, if you're talking about protecting you from hospitalisation and death, they work extremely well. If you're talking about preventing you from initially getting infected, the duration of the protection is really measured in months and not years and decades. The way other vaccines like measles vaccine or polio vaccine for smallpox vaccine, which once you get vaccinated, you're protected, measured in decades, if not a lifetime. We painfully found out that the durability of protection of the covid vaccines, as good as they were, was really not very long in duration.

Chris - And of course, that handed quite a big stick with which to beat the medical profession, to the people who were very of the anti-vax mindset. But did COVID emerge naturally? Or was this someone's experiment they took home with themselves by accident and released it and unleashed on the population?

Anthony - You know, we don't know definitively what the answer to that question is, and that's the reason why it's very important to continue to keep an open mind. But when you look at the data that's accumulated over the last few years from rather competent, experienced evolutionary virologists, not only from the United States, but from Australia and the UK and the European Union, the data that this is a natural spillover from an animal to a human is pretty strong, but not definitive. And that's the reason why even though many of the most qualified evolutionary virologists feel that it weighs much more heavily as being a natural spillover from animal to human. Since you don't know definitively, you absolutely must keep an open mind that it could have been a lab leak, it could have been something else, and you must always be flexible and keep an open mind to that until we get definitive proof.

Chris - You've stepped down from your role in 2022. So what are you going to do now?

Anthony - <laugh>? Well, I'm going to do a number of things. I'm going to continue in the field of public health in writing and lecturing as I've been doing over the past few months. I will hopefully be able to get moving on the beginning of writing a memoir aimed at younger people who want to go into medicine, science, or public health. Hopefully my more than 50 year career will be somewhat of an inspiration to some people to go into medicine. So I think that will likely keep me busy for a while. And I probably will associate myself for the University Medical Center ultimately in a teaching role, particularly teaching young people who are trying to go into science. So I think that's the general direction I'm going to take over the next several years.

Chris - No more basketball then?

Anthony - Well, I'm going to go one-on-one shooting with my wife, <laugh>, who is actually not a bad basketball player, <laugh>. But I'm not going to get into any competitive games.

Chris - Anthony Fauci, thank you very much indeed.

Anthony - My pleasure. It's good to be with you.

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