A Conversation with Dr. Anthony Fauci and Professor Paul Kelly

Katherine E. Bliss: Good afternoon, or good morning if you’re joining from Australia. Welcome to this conversation with Dr. Anthony Fauci, chief medical advisor to the president and director of the National Institute of Allergy and Infectious Diseases at the United States National Institutes of Health; and Dr. Paul Kelly, chief medical officer at the Australian Government Department of Health.

I’m Katherine Bliss, a senior fellow with the CSIS Global Health Policy Center. And it’s a pleasure to join with the Indo-Pacific Center for Health Security, which is part of the Australia Department of Foreign Affairs and Trade, in hosting this discussion today.

Now, in many ways Australia and the United States are really a study in contrasts when it comes to the experience of COVID-19. The number of confirmed cases in Australia has been slightly over 29,000, with fewer than 1,000 deaths total, in a population of some 25 million people. But in the United States we’ve had more than 525,000 deaths and more than 29 million confirmed cases of COVID-19, more than the entire Australian population.

Now, some of these differences may be due to cities’ and states’ different approaches to lockdowns, travel restrictions, and perhaps testing, and it may be that there are differences broadly speaking between populations in terms of tolerance for risk or following authority or rules. And yet, just as vaccine programs are scaling up in both countries, offering a tantalizing glimpse of a mask-free future, new and more transmissible variants of SARS-CoV-2, the virus that causes COVID-19, are circulating. And it appears that some of the vaccines now being distributed may not be as effective against some of the variants, prompting plans for changes in the development and uses of vaccines and therapies.

So I want to start out with a question for Paul Kelly. From your perspective in Australia, are we seeing a transition in the pandemic and the potential for a shift to seasonal recurring outbreaks as a result of these new variants? And if that’s the case, what are the steps that need to be taken and scaled up to respond to the new variants right at this moment that vaccines are being distributed?

Dr. Paul Kelly: Well, thank you, Katherine, and it’s a real pleasure to be here.

I just want to start with how we usually start in Australia, by acknowledging the traditional owners of the land on which I’m talking today, the Ngunnawal people here in Canberra, where sunrise is just happening.

So that’s a – that’s a very interesting and important question, and I’m glad that you’ve contrasted the difference between Australia and the U.S. in our experience of this outbreak. And it actually also influences how we go forward.

So we had our first case on almost the second day in late January last year that the U.S. did. We closed our borders quickly to China, as the U.S. did, and we had a first wave predominantly overseas cases as the U.S. did, but we controlled it. And I think a lot of that was due to the way that the leadership of both the – at the political level, the health level, and indeed the economic level has been so strong in Australia.

I think there was an element of luck, as well, that we – when we started this process, we were in summer rather than winter. And I think that was an important component. And we’re in the opposite now, as we’re starting to roll out our vaccines. We started our vaccination program a little later than the U.S., so we’re in week three now of our Pfizer rollout and we’re just starting an AstraZeneca rollout using local supplies soon of AstraZeneca vaccine.

But as – so – but we’re now moving into winter. We’ve at this stage had 40 – this will be the 40th day this year since 1st of January that we’ve had zero locally – local – locally acquired cases in Australia. And we’ve had no deaths since 2020, less than 20 people in hospital; so a very different experience in many ways. We can only go one way with this, which is to have more cases eventually. And as we start to open up, that will be an issue.

In terms of the variants, we’ve had our own experience here. One of the capacities we’ve really built in Australia during this pandemic has been our genomic laboratory network. And so we’re actually sequencing every single case, because we’re not having many, and we’re able to demonstrate what proportion there are of the variants of concern and variants of note or interest. So far we’ve had 140 cases of the B.1.1.7 strain, formally known as the U.K. strain, and 25 of the South African one, 351 strain; only one of the P.1 strains so far. So we – it’s starting to become the largest proportion of the cases, of the few cases that we have. But mostly they’ve remained in hotel quarantine.

We have had, though, five local outbreaks, either in Australia or New Zealand, which we’ve been able to follow very closely. And unlike the outbreaks in other parts of the world with these variants, they’ve actually been able to be controlled very quickly. So that’s an issue that we’re sort of looking at now in terms of how we can go forward with the vaccines.

You’re right. We will have to have a conversation with the Australian public about tolerance of outbreaks, because they will be inevitable. I think we have to deal with the way that people feel the vaccine is going to change their lives. It will change our lives, but possibly not as strongly as we first thought with these variants coming in. But it’s another learning experience. We’ve learned to be nimble and flexible and to incorporate new ideas and new concepts and new information when it comes. And this is just the latest of those.

Katherine E. Bliss: So I think we’ve all experienced 14 months of adjustment and innovation – (laughs) – over this period, really trying to think through new processes.

I want to turn to Tony Fauci, to ask you. You know, the United States, the number of vaccines distributed daily is accelerating rapidly, offering a great deal of hope to a population weary of pandemic-era restrictions. But the circulation of the new variants comes at a time when some states are now relaxing the rules and spring weather is on the way.

Paul Kelly was just talking about some of the seasonal changes and some of the changes that he expects to see. We’re looking at picnics and barbecues and baseball games and other outdoor gatherings really starting to scale up in the next few weeks and months.

So what are the steps that you see need to be taken to respond to the variants, including those identified in the United Kingdom, South Africa, and Brazil, as the vaccine programs scale up? And does this change how we need to be thinking about this idea of herd immunity, given the new realities?

Dr. Anthony Fauci: Thank you very much, Katherine. It’s a great pleasure to be with you and with Dr. Kelly today.

Yes, we’ve had a rather substantial difference of experience in the United States, the numbers that you just mentioned. I mean, we’ve had 525,000 deaths and about 28 million cases, which is really an extraordinary, historic negative experience for us.

You know, one of the principles that we need to examine and adhere to, which becomes particularly problematic in the United States, less of a problem in Australia, is that when Australia shuts down, they shut down, and they really do get the cases, like, almost to nothing. We’ve never had that in the United States.

If you recall the history, which I painfully have lived through, is that in the very beginning, in the winter and early spring of 2020, what we had was a surge in the Northeast which went up and then it came down and never got to a good baseline. It was like 20,000 cases. Then we had the attempt to reopen the economy in the summer. Again, the surge went up, just the way Dr. Kelly had mentioned. When you try to open up, inevitably you’re going to see some cases.

However, the baseline was so high that that magnified the impact of the surge. We went way up, we came down, and now the baseline was 40,000 instead of 20,000 per day. Then we had the massive surge up just this past winter and late fall where we were averaging an extraordinary 300,000 to 400,000 cases per day and 3(,000) to 4,000 deaths per day. That’s just a completely different galaxy than what Australia was experiencing. And now, as we’re coming way down, we are reaching a point where we’re beginning to, if not plateau, but the slope of the deflection is starting to maybe go down a little bit more slowly, which means we might plateau again at an unacceptably high level.

Why do I go through all those details for you? Because a fundamental tenet of virology is that viruses don’t mutate unless they replicate, and the more spread that you have in the community the greater chance you’re going to have of the initiation of and propagation of variants. And that’s what we’re seeing in the United States. We have the 117, which will be dominant by the end of March according to the modelers. We have a low level of the 351, which is the South African one. Now we also have a New York isolate of 526 which is spreading rapidly in New York, and a California isolate which is 427/429. So we have variants literally in multiple parts of the country.

The question we’re seeing is that, luckily for us, the vaccines that are being distributed do very well against 117. We know from the experience in South Africa with J&J that it doesn’t do as well, at least J&J vaccine, against moderate disease, but does very, very well against severe disease, including hospitalizations and deaths. We’re trying to find out now what the impact of the homegrown variants – the California and the New York variant – is with regard to monoclonal antibodies and vaccines.

So here is the challenge: Are we going to chase each variant in an almost Whac-a-Mole way, or are we going to try and get a vaccine that has a good degree of cross protection against several and get the level of virus so low that we don’t really have an outbreak proportion? This may require – may require – coming back intermittently and boosting either against the prevalent wild type or against the prevalent variant. And in that regard, both strategies are being pursued in the United States.

For example, Pfizer is planning on giving a boost of wild type because we know of the good cross protection, for example, against 117. We are working with Moderna to develop a South African isolate-specific vaccine boost that might be able to protect against that. Of note, we’ve found that in other experiments that individuals who are infected with the South African variant made a protective antibody in convalescent not only against the variant, but against the wild type. So it’s really quite interesting how there’s that cross reactivity.

Bottom line is we really cannot predict very accurately what’s going to happen on a seasonal basis, but the best thing that we can do, really, is to get as much control over the existing replication and dynamics of the virus.

Just want to close on one observation that I’ve made consistently over the years – over the months following Australia, something that we did not do as well as Australia. When Australia locked down, they really did. They got the level down very, very low. If you look at the monitoring of how well we locked down, we never really locked down completely. We had a terrible economic impact, but we never really locked down as well or as completely as Australia did. And I think a combination of the other things that Australia did correctly really led to the fact that they’ve done really quite well when you compare them to other countries in the world.

Katherine E. Bliss: So when you were talking about the surges of the different cases, I was thinking about rollercoasters, and then there was whack-a-mole – (laughs) – you know, trying to go after the different variants. But really, you know, it sounds like the push for vaccines and potentially boosters is something that really – you know, being able to roll those out across the country very quickly is something that is a key area of focus.

Paul Kelly, I want to turn back to you. So as you mentioned, the vaccine rollout in Australia is underway with the Pfizer-BioNTech and AstraZeneca products being rolled out now. There were some hiccups, I guess, in the process last week, with Italy halting a shipment of the AstraZeneca vaccine. But as you said, plans for domestic production are getting underway this month, if I’m not mistake. So with so few COVID-19 cases historically, and very few currently, how do you see the public really responding to the vaccine campaign? And I think you hinted at this earlier but, you know, do you think people will be comfortable going back to restaurants, and offices, and other places after having really complied so completely with lockdowns and social distancing in a way – you know, as Tony Fauci has said – you know, we really didn’t do as much in the United States? How do you see that?

Dr. Paul Kelly: Yeah. So the way that the Australian people have listened to the health advisors has been, I think, quite extraordinary. In my whole career I would say I’ve never been in that situation, where our epidemiologists and public health officials have become rock stars in a way, on national television every day, standing up with the heads of government – our equivalent of governors here, our state and territory premiers, and/or the prime minister. But they’ve really listened. And they’ve taken onboard all sorts of things I didn’t think they would.

So for example, I – like Dr. Fauci – was not a great fan of masks at the beginning. And I didn’t really – mainly because I didn’t really believe the Australian people would use them or use them properly. But they have. And they’ve really, really embraced that. When we’ve asked for people to limit their macro or micro distancing. So, you know, keeping part or limiting numbers of people in places, they’ve really done it. In the past couple of months, we’ve had very swift and very rapid and complete lockdowns for a very short period, as Dr. Fauci mentioned. And again, people have complied with that.

So now we’re quite open. We are essentially completely non-immune. And so people are really – they’re really embracing the vaccine program. We had a bit of a hiccup there for a while about whether Pfizer was better than AstraZeneca. But I think the real-world experience now from the U.K. in particular has shown that that’s not an issue. So I think people are embracing one or other of the vaccine. So that’s happening. And so – and I think in general it’s a program that will be very successful.

In the first two weeks we’ve got to 100,000 people for their first dose of the Pfizer vaccine, and the AstraZeneca vaccine, starting with supplies from overseas. It’s in the field now, and within the next couple of weeks our locally – our local production – locally produced vaccine will be available. So we’ll carry on. And I think that will be a very successful program. The logistics here, as in the U.S., is difficult because of the size of the country, particularly with the Pfizer vaccine and the logistical challenges there. But we’ll go with that. And I think as Dr. Fauci mentioned, this is – this is the first vaccine but not the last vaccine that people will have. And people are understanding that need for a booster probably at some time.

I think we’ll return to the concept of vaccine nationalism. And you mentioned the issue with Italy last week. That hasn’t changed our plans at all, but it does raise an issue that we need to think about. And I think it’s one of your other questions, so I won’t go into that at the moment. (Laughs.) But how we think about global solutions for a global pandemic. And Dr. Fauci’s touched on that already, about the importance of – that the virus will continue to mutate and could have variants if there is virus circulating, and many people with that virus. So we all need to think about that concept of where – if there’s virus anywhere, virus can be anywhere – or, can be everywhere, rather. And so we can – we should be working together on that.

Katherine E. Bliss: Thank you.

So, Tony Fauci, I want to just stay on this issue of vaccine demand for a second. You know, after sort of a fitful start here there has been a rapid scaleup of vaccine distribution in the United States. Nearly 60 million people have received at least one dose, and now more than 2 million people per day are getting shots at pharmacies and health centers; large stadiums, conventional centers with drive-up options. I mean, there are lots of options for people to get their vaccines.

Now that there are three approved for emergency use, it seems likely that some of the supply challenges we saw back in December and January may wane and that issue of demand may become more prominent. Polls show that more of the public is willing now to get vaccinated than back over the summer or early fall, but there’s still a pretty big number in the wait-and-see category sort of wanting to hold back. The America Rescue Plan has set aside around a billion dollars for confidence-building programs. But I just wanted to ask what you see as sort of the best way to build vaccine confidence among a somewhat-divided public, particularly with this threat of variants ongoing? And you know, just thinking about some of what Paul Kelly was saying, you know, in Australia, as people have kind of, you know, begun to think about how to emerge from these lockdowns, you know, as you think about the recent CDC guidance, how do you convince people who have already been vaccinated that they still have to modify their behaviors?

Dr. Anthony Fauci: Well, Katherine, there are a couple of questions in there. Let me – let me try and unpack one or two that are important in what you said.

Well, yes, there is a – there is a degree of vaccine hesitancy that’s different among different subgroups of people. One, for example, in our minority population, understandable hesitancy due to the history of mistreatment on the part of the federal medical initiatives dating back to the infamous Tuskegee incident – even though literally a(n) overwhelming percentage of the people who we’re trying to address were never born yet at the time that Tuskegee occurred, but it’s been passed down from generation to generation.

So the first thing we need to do is to respect that hesitancy and not confront it, but say that we understand why you are hesitant, and we have now ethical constraints in place that would make something like that impossible to happen again.

Having said that, to then address the concerns that it go too fast; explain the speed did not compromise safety, it was merely a reflection of spectacular advances in the science of platform technology and immunogen design.

Then, to explain and articulate clearly by people who they trust in their community – you know, that could be celebrities; that could be people who relate very well to the community – that the decision to make this available because of its safety and efficacy was made not by the federal government as a political organization, not by the drug companies, but by independent data and safety monitoring boards and advisory committees.

Once you get that through, then you will convince a considerable proportion of the people who are hesitant. And we’re starting to see, I think as you realize, Katherine, that as the days and weeks go by, the percentage of people who are now more confident grows literally every week. And I think what we’re seeing is that the more people that get vaccinated it will create a momentum of its own, particularly for the wait-and-see people, because they will wait and see and then when you get a hundred million, 150 million, 175 million people vaccinated, then you’re going to have people say, well, it looks pretty good so far, let me get vaccinated. So I think we’re going to do that.

Vaccination, you know, throughout the world but in any individual country – and I’ll speak only for the United States – is really the solution to the extraordinary stress that people are under right now. People do not want to tolerate any more the restraints that we have now from a public health standpoint, and a vaccine gets them quickly to somewhat of a degree of normality. That is the big carrot when it talks about vaccines. People want to get back to normal. They do not want to stay constrained from the public health measures.

So I think both of those things – and explanation of the objections that they have, addressing them in a reasonable way, respecting their hesitancy, and explaining why they should not be hesitant – as well as showing them that vaccines are the pathway to normality and everyone desperately wants to get back to normal.

Katherine E. Bliss: So let’s turn to global issues for a moment and this issue of vaccine solidarity or maybe COVID solidarity. Many people, as you’ve just said, Dr. Fauci – you know, many people are saying if we’re not all protected, then no one is protected. Australia and the United States, as we’ve discussed, have had very divergent domestic experiences with the pandemic, but they’re longstanding partners on regional and global health and security issues, including through APEC and the Quad, the informal security forum involving Australia, India, Japan, and the U.S., that may reportedly convene again soon.

So both countries have also indicated support for COVAX, which is the vaccine pillar of the ACT Accelerator, which was set up last spring to mobilize global multisectoral support for COVID-19 diagnostics, therapeutics, and vaccines. Australia has committed funds to COVAX and has made plans to purchase, I think, additional vaccines and supplies from the facility to support countries in the Southeast Asia and Pacific region. And the United States has approved $4 billion to Gavi, the vaccine alliance, for procurement and distribution of COVID-19 vaccines to the 92 lower-income countries that are part of the Advanced Market Commitment.

So I wanted to kind of end by asking each of you to reflect on what you see for the future of cooperation on regional and global health security between the United States and Australia. And how can the two countries work together and with other countries, you know, throughout the world to prepare for future pandemics and health emergencies?

So Paul Kelly, let me turn to you to start.

Dr. Paul Kelly: Yeah. Thanks, Katherine. And you’re quite right that, of course, Australia and the U.S. have a longstanding relationship on many levels. In 2020 there was a ministerial agreement in relation to the Indo-Pacific region in particular. And that covers a wide-ranging cooperation, including training, laboratory support, epidemiology, development of drugs and vaccines, and so forth, for our shared region in the Pacific and also more broadly in the Indo-Pacific.

So Australia is very much committed to exactly what you were mentioning, particularly in our region. So Pacific-island states are very much front and center for our support, not only in the vaccines themselves but the actual end-to-end rollout of the vaccines, as well as strengthening of surveillance activities, quarantine, and the like. So that’s going to continue.

We have supported the COVAX initiative, as you mentioned, a very important component of that vaccine rollout in low- and middle-income countries. And so we’ll continue to do that. And we very much welcome looking further and more closely with the U.S. in what we can do in our region.

As I said, we are a connected world. And if we ignore that, it’s not only at the peril of the lower- and middle-income countries that can’t afford the sort of things that we can afford in terms of health care and public-health interventions, but also ourselves, not only in the continued production of virus variants but in terms of threats through incursions.

So I think that’s a really important component of our work. We’re particularly looking at concern with countries in our near north, in Papua New Guinea and Timor-Leste, where there are emerging outbreaks. And so we need to really consider those in particular. But we certainly look forward to working with the U.S. on these matters into the future.

And I’ll finish this by saying that whilst we have throughout this pandemic, of course, been concentrating on COVID as a specific issue, everything we’ve tried to do here in terms of public-health strengthening in Australia and elsewhere has had an eye on the larger prize. There’s no point in planning for the – only for this pandemic. We have to consider what the next pandemic is going to be like. And so those generic strengthening elements are really important.

Katherine E. Bliss: Tony Fauci, what do you see as additional, you know, research or programmatic, policy-oriented collaborations between the United States and Australia that can help prepare for future pandemics and health emergencies while learning from the COVID-19 pandemic experience?

Dr. Anthony Fauci: Well, as Dr. Kelly said, the United States and Australia have a long, long history. I’ve been director of the institute for now almost 37 years, and I learned on day one that our strongest allies in research – or was the top two or three – Australia was clearly one of them. And we feel very strongly very strongly that, this being a global pandemic, it requires a global response.

Our collaboration – well-established, firm collaboration at both the public health and at the basic pre-clinical and clinical research – with Australia is a very strategic partnership because it will allow both of us together to be able to implement in the Pacific region involving so many other countries that Australia deals with literally on a daily, weekly, and monthly basis – the alliance between the United States and will help the United States to be value-added to the activities that go on in public health in the Pacific region.

So I just see a continuation, an amplification, and an increase in the strong strategic alliance at the basic research, clinical research, and public health level with our Australian colleagues. It has been going on for years, it’s been very productive, and I hope it will continue to go on and even amplify.

Katherine E. Bliss: Well, Tony Fauci and Paul Kelly, thank you both for taking the time to join this session today. And thank you to our audience for joining us, as well, this afternoon or this morning – early morning, I might add – (laughs) – for those of you joining from Australia. Thank you all. And I’d like to thank the staff at CSIS and the Indo-Pacific Center for Health Security for their support in organizing this meeting. Thank you very much.

Dr. Anthony Fauci: Thank you.

Dr. Paul Kelly: Thanks, Katherine. Thanks, Tony.

Dr. Anthony Fauci: Thanks, Paul. Thanks, Katherine.

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