Fireside Chat with Dr. Anthony Fauci: Is the Pandemic in Transition?

J. Stephen Morrison: Good afternoon and happy new year. Welcome to everyone in the online audience for today’s event, “A Fireside Chat with Dr. Anthony Fauci: Is the Pandemic in Transition?”

I’m J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies, CSIS, a Washington, D.C.-based nonpartisan independent foreign policy and international security institution. I head up the CSIS Commission on Strengthening America’s Health Security, which yesterday issued a white paper entitled “2022 is the Year of Decision.” I coauthored that with our cochairs of the Commission, Susan Brooks, former congresswoman Republican from Indiana, and Julie Gerberding, former CDC director and executive vice president at Merck. Please do read that paper and please do send your thoughts to me. I would welcome those.

For the next 30 minutes, I have the great honor and pleasure to speak with Dr. Anthony Fauci, President Biden’s chief medical advisor. Welcome, and thank you so much, Dr. Fauci, for taking the time to be with us this afternoon. And thanks for your prodigious service to our country over these decades. And that includes, of course, your remarkable leadership and service to both President Trump and President Biden during these two trying years of the pandemic.

Anthony Fauci: Thank you very much, Steve. It’s a real pleasure, as usual, to be with you. Thank you for having me.

Dr. Morrison: Just as an aside, I did watch today Senate Health Committee hearing addressing variants and witnessed again the twisted and dangerous attacks that are visited upon you in the Senate. Just another stark reminder of how radically distorted and politicized the discourse over this pandemic has become. I’m sorry, Dr. Fauci, that such venom is so focused on you personally. It’s unjust. It stokes threats to your life and safety of your family, and frankly it’s a disgrace.

You kindly agreed at the end of last year that we could use this occasion today to reflect on where things stand in the pandemic. Of course, in the meantime Delta was surging across the country, followed most recently by Omicron, which is spreading like wildfire worldwide, reaching unprecedented heights and threatening to overwhelm our health systems and destabilize other critical societal institutions. It may infect half of the country before it peaks in the coming weeks. Let’s get started.

We’ve entered a murky transition. And I want to talk to you a bit about that. There are increased calls to pause, to pivot, to reset. And there are also calls to be cautious and careful. Omicron is driving some of this, but it’s not just Omicron. It’s also our accumulated experience of the last two years, the mixed results from vaccination campaigns, coming to terms with the realities of variants, waning immunity, large segment of our society unwilling to be vaccinated, continued gaps. It’s shaped by weariness and exhaustion and a popular turn away, mass lockdown, closure of businesses and a greater emphasis on individuals taking control.

We now have people that are actively arguing that we’ve entered a new phase of the pandemic. Some very respected figures, Robert Wachter, Monica Gandhi, Chris Murray, Jeremy Farrar, who are arguing that accumulating immunity acquired through mass infection and mass vaccination puts elective evolutionary pressure on the virus to be faster, pierce immunity, and perhaps become less virulent. It’s an intriguing big idea, early and untested, but it does force us to acknowledge what is changing here under Omicron, and just consider that there may be a wall of immunity that brings some silver lining in the future after the worst has passed.

Members of the Biden administration’s own advisory – transition advisory group led by Zeke Emanuel just recently in JAMA argued that we have entered a new normal, that we need to exit the emergency phase and enter a period of learning to live with the virus. They’re arguing for a new national strategy, a different calculus of risk, deeper investments, and some of those areas are very familiar – digital data surveillance, genomic sequencing testing, our public health system. And you yourself, Dr. Fauci, have signaled a rethink in terms of the focus on hospitalization, acknowledging that mass infection may create an immunological memory and you’re favoring the shift towards shortened isolation procedures.

So let me open with the big question of how do you make sense, Dr. Fauci, of this complicated moment we’re in and have we, in fact, in your view, entered a new phase of sorts?

Dr. Fauci: Yeah. Well, the short answer to the question, Steve, is that I believe we have but we’re not there yet, and let me explain what I mean. I think, in many respects, Omicron, with its extraordinary, unprecedented degree of efficiency of transmissibility, will, ultimately, find just about everybody. Those who have been vaccinated and vaccinated and boosted would get exposed. Some, maybe a lot of them, will get infected but will very likely, with some exceptions, do reasonably well in the sense of not having hospitalization and death.

Unfortunately, those who are still unvaccinated are going to get the brunt of the severe aspect of this, and although it is less severe on a case by case basis, when you quantitatively have so many people who are infected, a fraction of them, even if it’s a small fraction, are going to get seriously ill and are going to die, and that’s the reason why it will challenge our health system.

Having said that, as you probably remember, Steve, on October – well, you wouldn’t remember the date but you remember because we stay in such close touch – that on October the 13th at a press conference at the White House, I showed a slide on one of my scientific briefs that showed the different phases. You go from pandemic to deceleration to control to elimination to eradication, and if you work your way up from the bottom up, there’s no way we’re going to eradicate this. We’ve only done it with one infection and that’s smallpox. It’s no way, I believe, likely – I mean, aspirational but not likely that we’re going to eliminate it because, A, it has a high degree of transmissibility; B, variants arise; and C, there are so many people that are unvaccinated. And we eliminated polio because we got almost everybody vaccinated. We eliminated measles because we got almost everybody vaccinated.

So what’s the box that we’re all looking at now? That box is control, namely, getting the level of infection that causes severe disease low enough that we can incorporate this infection – some people have said learning to live with it – that I believe we are possibly approaching that.

Now, the reason I say possibly is that we still now have close to a million infections a day, we have 150,000 people in the hospital, and over 1,200 to 1,300 die. So we’re not at that point where this is an acceptable “let’s live with it” now. But I believe we will get there.

As Omicron goes up and comes down, I do hope that we will see a situation where there’ll be enough protection in community, enough drugs available, so that when someone does get infected and is in a high-risk group, it will be very easy to treat that person be that with Paxlovid or a monoclonal antibody or whatever the drugs are, that we have a combination of good, basic background immunity together with the ability to treat someone who is at risk.

When we get there, there’s that transition. Now, we may be on the threshold of that right now, see. It’s entirely possible. So when you refer to my friends and colleague, Zeke Emanuel, and others who’ve written those, in so many respects I agree with them and, in fact, I’ve been talking about that since October the 13th when I put that first slide up.

Dr. Morrison: So do you agree that we need to think about a new national strategy as we get past the worst of this? Obviously, the urgent emergency operational challenges have to be front and center and we have to deal with those. As you point out, we’re in an extraordinary moment in this pandemic. But when we look beyond that, do you believe that we are going to need a new strategy? And if so, what’s that going to mean? What are we going to change in the way we think about this and what we do about it?

Dr. Fauci: Well, ultimately we will need a new strategy. Well, put it this way: We should have a new strategy now; ultimately we’re going to implement it, because, you know, I don’t think we can implement it right now with this stress on our health care system. But the ultimate strategy is what a lot of people are talking about. I mean, a lot of people, even people with diverse and sometimes conflicting viewpoints on things. We cannot let this virus dominate our lives much longer; we’ve got to get into a situation where we get enough people protected, either from vaccination or boosters, and whether that’s going to be a regular boost or the next boost will be the one that keeps us going with a big duration. We don’t know that, Steve. We don’t know what the answer to that is. But we’ve got to get to the point where all of us are going to get our lives back and not be dominated by this and always looking over our shoulder. And I believe that that’s what everybody’s talking about a transition. And the sooner the better we get there, but there are some things we can do.

And this is where we may differ with some people. The easiest way to get there is to do the kinds of things we’ve been talking about, is to get people vaccinated, get people boosted, because if you look at the things we worry about – the hospitalizations and the deaths – that if you compare – and the data are very clear – vaccinated people with unvaccinated people – if you are unvaccinated, you have a 10 times greater chance of getting infected, a 17 times greater chance of getting hospitalized, and a 20 times greater chance of dying. So if we could only get that extra group, and they may not ever want to get – I mean, we realize that there’s a reality in life they may not want to, but I would hope that they look at what’s going on and say, why don’t we all pull together to end this thing? That’s the only message I have. It’s very clear and it’s very compatible with what the CDC and the FDA and everybody else is saying.

Dr. Morrison: Yeah. Let me just turn to a few of the issues that make this transition more difficult and confusing to people. You’ve mentioned that of course there are many unknowns: how many unvaccinated, never infected, what about waning protections, what about long COVID? We have a lot of unknowns. Probably the biggest is, of course, what will the next variant or the next variant after that look like? So we can’t let our defenses down. We can’t be left – if we regress, we’ve got to still be prepared against that, even as we try to move to the – back towards this normality. There’s a couple other things that are entering the equation; one is – that have to do with public behavior and thinking at the moment. This transition’s compounded by repeated communication stumbles and difficulties. It’s complicated by public confidence has waned. We’re seeing a pretty – a disturbing level of kind of a widespread distrust and skepticism, and it cuts across political lines, too, with respect to science, scientists, public health authorities, and the like. And a lot of people are moving on or they’re turning off, and that I find disturbing.

We also know that this transition has some risk. It could move towards a narrative we don’t want to see – i.e., we don’t want to see the narrative turn to, it’s just a cough. We don’t want the narrative to turn to the Scott Atlas Barrington Declaration of vaccines don’t matter, it’s all about herd immunity; just focus on protecting a few populations. We don’t want that to happen. So how do we – this is very complicated and my question to you is, how do we explain this to a public that’s exhausted, that’s turned – a good part of it is turning off, we’re quite polarized, and we also have these counternarratives that are out there that many people are embracing?

Dr. Fauci: Yeah. Well, I think you said it all by your introductory question, Steve. It is a very complicated issue. And this is a moving target. I mean, if anybody looks at it, it’s a moving target. We’ve had four waves, and the omicron is sort of like the fifth wave. You know, we had the early one, in the early spring-late summer. Then we had the winter one. And then we had the 4th of July surge. And now we’re on this. So we’re not dealing with something that’s static. And I think we’ve got to be able to get the American people to pull together and realize that everyone really wants the same thing. We want to end this. And there are well-proven ways to do that. And we all have the same goal.

I mean, it almost looks like with the divisiveness we have in society that it’s such a hindrance to our all pulling together. I think you saw an example of that at the hearing today. That was just so unfortunate that there was that degree of ad hominem and clash, when we all really want the same goal. So hopefully we can get the American public to all pull together and realize: This is really tough.

You know, we always use the metaphor “we’re at war.” You know, it’s kind of like we want to end the war, and we’ve landed on Normandy, and all of a sudden a lot of people are getting knocked off, and everybody’s yelling, “was it a mistake to land on Normandy? Should you have waited for the weather to be better? Should you have done something different?” Everybody’s out guessing everybody, but sooner or later you get off the beach, you wind up going inland, you get to Germany, and you end the war. And that’s what’s going to happen. It’s like a very, very foggy war, because the enemy is very, very elusive, this virus.

Dr. Morrison: Dr. Fauci, do we – do we need to have a conscious and deliberate strategy or effort to improve communications and restore trust and confidence by the public? Has the time arrived for a very concentrated and deliberate effort? Because, I mean, we know the stress. We know that this pandemic changes constantly. We know the challenges of trying to make adjustments and explain these complicated things. But we are in a moment where there’s – you could argue there needs to be a reset in this area – and I’m not sure what that means, what it would mean if it were to happen – but led by the White House, led by whoever’s going to join with the White House on this effort?

Dr. Fauci: Steve, yes. If it were possible to do that, we should have it. And maybe it is possible. But the degree of divisiveness and politicization is profound. We can’t run away from that, Steve. It’s there. I mean, it’s there. The amount of misinformation and disinformation that you would think maybe it’s a small, little group that’s doing that. But there’s so much misinformation and disinformation being bantered about that of course it’s confusing the public.

So we – I mean, how do we stop the misinformation and disinformation? And anybody who really wants to be objective and look at some of the preposterous things that are said out there, that are based on no fact – just, you know, everything from wild conspiracy theories to just not really understanding or understanding but putting out something that isn’t true. I mean, that’s going to make this whole thing tough.

I wish we could reset this and say: You have your political differences. I’m not a political person. You know that. You know me for decades. Zero political interests. But maybe we could put the political stuff aside and say: If we want to fight politically let’s end this outbreak first, get back to normal life, and then go back to our political ideologies.

Dr. Morrison: Thank you. Let’s turn to the external world, and our strategy of trying to bring gains to particularly overcome the gross inequities in vaccine access, delivered capacity, and the like. Omicron – you know, Omicron could be a wake-up call. It could be one of those moments where there’s a greater realization and a greater determination to control – to bring – to control what is now uncontrolled transmission in much of low and middle-income countries, which is giving rise to the proliferation of variants, and to show new resolve in tackling the gross inequity in vaccines, delivery capacity, human and financial resources.

There’s also a danger though, it seems to me, that if the wealthy and most powerful countries believe they’ve turned a corner and they transition, that they can turn their back on much of the rest of the world. And many of the low and middle-income countries are really struggling. And the gap is widening for many of them. It’s narrowing for others. The new normal – you know, we’ve talked over and over again about the cycle of crisis and complacency. We could see that. We could see a return to complacency amidst our fatigue and our exhaustion. And Omicron is definitely going to worsen inequities. We know that. We know that the push towards boosters, the push towards mRNA, the push towards vaccinating children, it’s going to generate a large gap. WHO is estimating 3 billion doses gap for low- and middle-income countries this year. We had one big study that was a much bigger number by advocates of 22 billion. So it’s really an enormous challenge right now.

Do you think that Omicron is going to trigger greater resolve within the U.S. government to tackle this inequity in new and different ways? I know we’ve done a lot, but it’s still falls far short, doesn’t scale to the need, and we don’t have enough partners in this mix.

Dr. Fauci: Well, I think, as usual, Steve, you’ve nailed the two or three important parts of that. One, we are doing a lot. Do we need to do more? Absolutely right. More importantly, does the rest of the developed world need to do more? Because we cannot as a nation do it alone.

As you well know, dating back from when I worked with President George W. Bush to develop the PEPFAR program, I felt then and decades later I feel now that we have a moral responsibility as a rich nation to make sure that those nations of low and middle income that don’t have the resources to do the kinds of things that we can do to have equity. And we can provide it, but we can’t do it – the United States – alone. If you look at what the United States has done, as I said, we always can do more and we will, but if you look at we’ve given over 300 million doses to over a hundred countries. We have either given or will pledge and deliver at least 1.1 billion doses to the developing world, to low- and middle-income countries. We’ve given 4 billion to COVAX. And we’re going to do more. We’re going to try and expand the capacity to get more drugs there.

But again, the United States has done more than the rest of the world combined. Is that enough? No. But we have done a fair amount. I hope that our example will get the other countries that have wealth and resources to pitch in and do the same thing.

But you’re absolutely right: It is not only a moral responsibility; it’s almost self-interest that if you continue to have the virus freely circulating throughout the world there is always the danger that there’s going to be another variant that will come back to bite us. And I think we realize that. So there’s two really good reasons to reach out and help the lower- and middle-income countries.

Dr. Morrison: We, you know, in this paper, this white paper that I shared with you and that I referenced at the front end, in that paper were arguing like you’re suggesting that the danger of uncontrolled transmission and new variants is a national security matter. It’s something that we need to see as a national security matter. It’s something where we’ve not been very successful at getting other wealthy partners to join with us. We’ve been inhibited in any dialogue with the Chinese, as well. We do have a new government in Germany, which is promising. We are seeing the EU stepping forward in significant ways. I do believe the leadership within the Global South is looking for new engagement and new forms of partnership and the like. So I am sort of hopeful in that regard that a higher level of diplomatic engagement by the U.S. could deliver some results.

But we are running out of money right now. You know, we spent $19 billion in the last year – appropriated, not all spent out, but obligated and committed. We’re running out of money. We need something comparable over the next several years. In our paper we argue 18 to 20 billion (dollars) over the next five years. We need something like PEPFAR in order to really address the acute response and the pandemic preparedness over time.

We’re also arguing that AP3 – the American Pandemic Preparedness Plan, which you had a great hand in preparing, working with Eric Lander and others – that’s terribly important, building the vaccines, therapies, diagnostics, surveillance capacities over the next 10 years. And it’s affordable. We can spend 6 or 7 billion (dollars). But that money’s not there yet either.

So how do we – how do we think about getting to the next spot, which is we need AP3 funded and supported adequately to move that forward, which is essential, and to get U.S. diplomatic capacity and engagement on a secure footing so that we can do the things that we need to do?

Dr. Fauci: I agree with you, Steve. We do have to do that. And the one thing of my concern is that when we do get back to living reasonably well with a virus that we likely will not eliminate or eradicate, that people don’t lose corporate memory of what we have been through right now, what it has cost us in both suffering and death as well as resources that we’ve invested that far, far, far, you know, are overwhelmed by the cost of what the epidemic has cost us.

So the investment is trivial, in some respects, compared to what this pandemic has just done to us economically. So I agree with you. We’ve got to hopefully let this horrific experience we’ve been through embed in our memory that it doesn’t go away a year from now when you get a commitment for a 10-year plan, and you get money for the first two years, and then all of a sudden nobody wants to go through with it. We’ve been there. We’ve been to that movie before.

Dr. Morrison: Yeah. Yeah, yeah. Let’s talk about WHO. We have about five minutes left and I want to talk about WHO, China, and DOD. On WHO, you almost exactly a year ago, as President Biden was inaugurated, one of the first things you did as his chief medical advisor was very eloquently and powerfully restore membership in WHO and speak to the executive board meeting of WHO in January of last year. We now have a process of intergovernmental negotiation underway on a pandemic agreement that’s going to look at inequities. It’s going to take some time, but it’s also going to focus on WHO as an institution – as a core partner institution as part of a broader multilateralism that we need to make a key component of our strategy. What’s your thinking right now? In the next year or two years, what should we be focusing on in terms of strengthening WHO as one of our key partners?

Dr. Fauci: Well, we’ve got to do what, as you said, I did literally the first day of the Biden administration, is be explicit in our commitment to strengthening WHO. And the United States – what I’ve learned through these decades is that other countries follow us. Steve, they do. They use us as the shining light example of what needs to be done. The very fact that we got back into WHO was a big positive shot in the arm for WHO. We’ve got to continue to get them to know they need to improve. As with all of us, they’re not a perfect organization. But I think that they’ve done really very well of late, particularly under Dr. Tedros. They’ve done a really good job. We’ve just got to make sure we continue to support them, and we don’t let signals out that we’re not supportive of them. Despite their imperfections hopefully they will improve, because they have improved a lot over the last year or so.

Dr. Morrison: And does that include, do you believe, closer partnerships in terms of our skilled personnel working inside, but also budgetary – revamping the budget, revamping the expertise and levels of performance?

Dr. Fauci: Yeah, you know, Steve, I don’t want to get into that, because you know with me it’ll likely be taken out of context. (Laughs.) And not by you, but by others. I think we need to do whatever it takes to both strengthen our relationship with WHO, but strengthen our interactions with countries throughout the world so that the next global pandemic is truly a global response – with resources, with equity, with all the things that you need to have an adequate and very appropriate and successful response to the next pandemic.

Dr. Morrison: Let me ask you about China. We’re arguing in our paper with a détente with China to explore areas where there are critical global health issues – global health security issues, and where it’s in the U.S. national interest to cooperate, whether it’s travel, public health infrastructure, information sharing, other areas. We’re arguing we need to keep the pressure on China to cooperate in the WHO-led COVID-19 origins investigation, but that that can’t stop everything else in its tracks. What’s your thought on how to move ahead with some form of testing whether détente can get us some results that serve our own national interests?

Dr. Fauci: I think it’s absolutely critical that we develop a new détente there because that is where the SARS-CoV-1 originated very clearly, it was shown. That that is the country in which it originated, right now accumulating evidence is becoming stronger and stronger that, even though we keep an open mind about all the aspects of origins, that it was almost very, very likely that it was a jump from an animal species either to an intermediate host or to a human to start this outbreak. In order for us to really be able to be prepared for the next, we have to have relationships with China, with Southeast Asia, with all the countries there where these types of viruses sometimes emerge. We have to be able to have détente with the rest of the world so that we know we’re connected. We can’t have an adversarial relationship when you’re trying to be partners in a public health effort.

Dr. Morrison: Thank you. One last question. On DOD, we’re arguing in our paper that we need to take fuller advantage of the special assets that DOD brings, whether it’s planning, contracting, logistics, lift. We’re already doing some of that in the Pfizer purchases and some of the other contracts for our international effort. We’re also arguing that they bring special assets, biomedical R&D, and partnerships overseas, and that we should integrate them into our – in support of our civilian-led international strategy. What’s your thoughts on that?

Dr. Fauci: Yeah. We have had very successful relationships, at least at the NIH level – and not only the NIH, but the CDC –

Dr. Morrison: Yeah.

Dr. Fauci: – for decades and decades with the Defense Department. They have an awful lot to offer in their ability to move quickly on things and the fact that they have a very good cadre of scientists and public health people. They’re fundamentally devoted toward force protection, but there’s so much overlap between force protection and protection of the whole community. So I have – I have been involved in major collaborations with the Department of Defense for years and years, I think we need to strengthen that.

Dr. Morrison: Thank you. Thank you so much. We’re at the end of our time. I want to make sure that I’ve thanked all the people who worked really hard to make this all happen, Dr. Fauci. On your staff, Patricia Conrad as usual, David Awwad, Hugh Auchincloss. Very grateful to all of them. On our staff, Humzah Khan and Michaela Simoneau from the Global Health Policy Center, but also Mary Wright, Dhanesh Mahtani, and Stefan Welsh. Great thanks to all of you for all the great work you put into making this happen.

And Dr. Fauci, just thank you so much for your leadership and your contribution, and thank you for taking the time to be with us and to share your thoughts today. It’s just a great honor to be with you again.

Dr. Fauci: Thank you very much, Steve. Thank you for having me. I look forward to our next encounter, as it were. (Laughter.) Take care.

Dr. Morrison: Bye bye. Thank you.

Dr. Fauci: Bye bye.