Online Event: Year-End Reflections on 2020 with Dr. Anthony Fauci
December 14, 2020
J. Stephen Morrison: Hello and good afternoon, evening, or morning, wherever you happen to be. I’m J. Stephen Morrison, senior vice president here at the Center for Strategic and International Studies, where I direct the Center for Global Health Policy. We’re delighted and honored to be joined today by Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious diseases. He’s a member of President Trump’s COVID-19 Taskforce. And he agreed to President-elect Biden’s request that he serve as chief medical advisor to the incoming Biden administration.
There are many congratulations to begin with today, Tony. Congratulations on your new appointment, and thanks for taking time December 2nd to come and speak to the CSIS Commission on Strengthening America’s Health Security. And congratulations on this day in which we have the first vaccines being delivered to Americans. It’s a historic moment. I know you’re at the very thick of all this, and that means even more to me that you’ve taken time to break out and be with us. So thank you so much and congratulations.
Anthony Fauci: Thank you, Steve. Good to be with you, Steve.
J. Stephen Morrison: We’ve asked Dr. Fauci to reflect on 2020. We’ll, of course, speak to issues looking forward, that’s inevitable. But the main aim today is to pause, look back, and reflect on this extraordinary year. 2020 is unlike any other year in modern times. We’d have to look back 102 years to the Spanish flu of 1918-1919. We’d have to look back 80 years to World War II for analogous moment. It’s ending with a strange discordant atmosphere. We have celebration, hope, optimism as vaccines begin to be administered today to Americans and elsewhere, in the U.K. and other countries. But we also have a moment of fatalism and fatigue as the virus rages to new destructive heights.
We’ve heard from Dr. Fauci, we’ll hear more today, hope is on the way. CDC Director Dr. Robert Redfield last week argued publicly that we’re in the midst of the most destructive and dangerous public health catastrophe in modern history – 300,000 dead, 16.3 million cases, over 2,470 deaths per day over the last seven-day average. Saturday we had 231,000 new cases. The surge is going to continue for the next 60 to 90 days. It’s projected by IHME to generate an additional 200,000-plus deaths. Life expectancy among Americans has dropped one year in 2020. And it’s now the – COVID-19 is now the leading cause of death.
The introduction of vaccines will ultimately contribute to our getting out from underneath this tragedy, but the introduction of vaccines in this next phase will not materially slow or change this crisis surge in the first quarter of 2021 and possibly beyond. We know that this universal spread in communities has forced our hospitals into a maximum – into a hospitalization level at 108,500 beds, as of December 12th. That compares with a peak in April of 60,000. So we’re at risk of our health systems straining and breaking, in which we may have to resort to a wartime-like triage medicine in many places. And we know the causes. It’s staff shortages and fatigue. It’s staff illnesses, quarantine. It’s shortages of beds. It’s the surge itself.
As we head towards year’s end, it’s becoming clear that the world has profoundly changed. The crisis dominates and it’s crowded out many things. And we’ll hear about those things, those very important things, that have had to be put on shelf at home and abroad for a temporary period.
We’ve witnessed here at home a deterioration of civility and governance. We are today seeing our Electoral College report out the returns in 50 states and District of Columbia, a very hopeful sign of progress. Bipartisanship, which is central to sustaining U.S. commitments on health security at home and abroad, in Congress and elsewhere, is being put to the test. It’s very difficult to find bipartisanship today. We have to hope that we can move beyond partisan antagonism, which is acute right now. We’ve entered economically desperate times.
We know there’s gridlock in the search for new stimulus that could help provide safety nets to pull people, schools, small businesses, local and state governments, back from the precipice. And we’ve discovered the disturbing fact, which we’ll talk more about, that a very sizable portion of America’s population simply continues to deny the reality of COVID-19, despite everything that we’ve just talked about. We’ve cleaved ourselves into perhaps two separate nations with two separate sets of beliefs and sources, pipelines of information.
Mixed in with that is our polluted digital world, a world of disinformation, misinformation, paranoia, and wild conspiracies, which has driven down trust and confidence as well.
The flip side of this is the side of hope and optimism that rests really fundamentally in our science and in the rapid research and development of new vaccines, therapies, and tests. Never before, we have discovered in just less than 340 days, were we able to develop, in the midst of a raging pandemic, safe vaccines at remarkable levels of efficacy, 95 percent, at the very same time producing and having vaccines ready to distribute.
There’s still considerable uncertainty. We’ll talk about some of that. We know – we don’t know how much immunity is conferred. Does the vaccine prevent transmission? Those who are vaccinated, are they still able to transmit? We’re reading a lot about building trust. There has to be a national messaging campaign. We haven’t seen that yet. And there’ll be continued debates around supplies, manufacturing capacity, fairness and transparency, ending or warding off cheating.
Dr. Fauci has been at the center of these rollercoaster dramas. You’ve taken a number of hits, including threats to your life and safety of your family. As COVID-19 has become more and more politicized, you’ve had at times found yourself in the middle, targeted by the White House itself at points. Your unique role has taken on many dimensions. Trust is Dr. Fauci’s currency, a trusted voice expected to speak clearly against falsehoods, even when those are propagated by powerful forces.
You’ve been asked to deliver the core messages about essential behavior and individual responsibility over and over again and to make tough calls, as we heard recently in the roll-up to Thanksgiving about the need to see this as a possible threat of a surge superimposed upon a surge.
You’ve been very active in defending our institutions – FDA, CDC, NIH. And you continue to care for those who are ill and you continue to provide the translation of evolving science, whether it’s about therapies, vaccines, about controversial matters, masking, asymptomatic transmission, things that are evolving in the course of this pandemic.
So you’ve survived. You’re still intact, and you’ve become the bridge between the two administrations, which is pretty damn unusual, frankly. So congratulations on that.
Let me move to ask you to reflect on your own personal role. First question: Did you ever, in your wildest dreams, imagine this – you’d find yourself in this role?
Anthony Fauci: Honestly, Steve, no. You know, as I’ve always said, I’ve always been concerned, when people ask me what my worst nightmare would be, would be a respiratory-borne illness that’s a new virus that jumps species, that has a high, high, high degree of transmissibility and has the capability of high degree of morbidity and mortality, either in general or among certain subsets of the population. And here we are, living that nightmare.
You know, you mentioned the year 2020. It has been such a unique, unbelievable year in so many respects, but it’s – it is what it is, Steve. And we, as people who are members of and interested in the scientific public health approach to things that we can end this, it is very, very challenging.
I think you mentioned some important things in your introduction. The fact that we have a vaccine that is now shown to be highly efficacious. We need to make sure that vaccine gets implemented. Today is an unusual day in that it’s historic. Two-point-nine million doses have been distributed to over 100 sites throughout the country to begin vaccination of the first tier of individuals. I don’t think I could have imagined five years ago that we would be in such an intense situation now as a country, as a scientific community, and as of myself personally.
J. Stephen Morrison: As you look back over this past year, how do you explain – what explains your resilience and your survivability in this – in this work, where a lot of people have not had that experience, but you have?
Anthony Fauci: (Laughs.) You know, I can’t say, Steve. I mean, I am who I am. I do what I do. And I focus on the enormity of the problem. And I focus like a laser on what I need to do. There’s a lot of things going on, you mentioned some of them, that could be distractions. You know, the pushback, the divisiveness in society, the misinformation, the conflictual nature of where we are in our society. That makes responding to a public health challenge all the more difficult. But nonetheless, despite these circumstances we find ourselves in, we have to just move on and continue to apply the best public health measures at the same time that science, in the form of the development of a safe and highly efficacious vaccine is going to be the light at the end of the tunnel.
J. Stephen Morrison: So looking back on 2020, what is your – what is your proudest moment personally from this year?
Anthony Fauci: I think the proudest moment would be the fact that we have successfully done what people would find to be the unimaginable, namely to have a virus that was brand new and first recognized and sequenced in January of 2020 and then in December of 2020 speaking to you today – as we speak, Steve, people are getting vaccine injected into their arms with a vaccine that’s 94-95 percent effective against clinical disease, and very, very effective against serious disease. I mean, that is a historic, unprecedented achievement. So that’s something that I feel the best about and the proudest about, that we played a significant role in the actual success and development of that vaccine.
J. Stephen Morrison: Yeah. Do you have any regrets looking back, or are there the darkest moments that come to mind when you look at 2020?
Anthony Fauci: Well, Steve, the darkest moments are the disease burden and death. You mentioned the numbers yourself. I mean, we have almost 300,000 deaths. That’s the worst public health catastrophe in 102 years, since the 1918 pandemic. I mean, that’s just extraordinary. As you said, we have almost 110,000 hospital beds that are occupied. I testified before the Congress a few months ago when we were having 40,000 cases a day. And I said, I would not be surprised, if we did not handle this properly, that we could have 100,000 cases a day. And now we have over 200(,000) – between 200(,000) and 300,000 cases a day. Those are the dark moments, Steve. Those are the things that, as a physician, a scientist, and a public health official, are very painful to have to deal with, that we have such an extraordinary burden of disease and death in this country.
J. Stephen Morrison: We know that in our society a gap has appeared. I mentioned this astonishing fact that a remarkably large portion of our population is not taking this seriously and continuing to deny the reality. But when it comes specifically to you, what we see is a partisan divide increasing that among Democrats over 80 percent have a very high trust level in you. When you look at Republicans it’s 30 points lower than that. And I take that as a measure of the politicization that has occurred and the degree to which this has been driven into partisan camps. How are you going to – how can you use your good office and your reputation – remarkable and unique reputation – to try and reverse course here and bridge that chasm? Because that is going to be – that is going to be one of the biggest challenges we face in the next two years.
Anthony Fauci: No doubt, and it’s a very difficult situation. I and – anyone who’s been in Washington for a while and has seen me operate over six administrations, soon to be seven administrations, knows that I’m not a political person. I do not take any ideological side. I just focus on the public health issues for which I am responsible. And I rely on that mantra of independence and lack of any, you know, political favoritism in one direction versus another. That’s the way I’ve been able to survive over multiple administrations with very different ideologies, and I stick to that, and I’m going to stick to that.
And I think as we get further and further into this situation, which is very bad right now, that we will – we will turn it around despite the divisiveness. I mean, I have – I’m a realist, but I have some cautious optimism in the spirit of the American people that they’ll realize that this is a real challenge – it’s not make believe, it’s not a hoax, it’s not fake news; it’s real – and we’ve got to deal with it. Unless you realize and admit to the problem, you’ll never be able to fix it. And as you alluded to, and it’s true, when a certain proportion of the population don’t even admit that this is a serious problem, we have a lot of work to do.
So the bottom line, Steve, we do still have a lot of work to do. Despite the scientific advances of a vaccine, despite the fact that we’re capable from public health measures to do a lot, we still have a long way to go to get everybody onboard to pull together. The only way you’re going to get this pandemic under control is if we all pull together as a country and not in different directions as a divided nation.
J. Stephen Morrison: Do you think that it’s going to be – that we need to try something different, it would seem to me, to reach this – to solve this problem and reach this populace? And I’m not sure what that is, but it’s a shocking revelation. It’s one of those things that no one anticipated we’d be sitting here on December 14th talking about this problem six months ago or eight months ago. We were a united nation, relatively, in the polling data that came forward in early March, when the first lockdowns were put in place. I remember Kaiser and Pew both coming back and saying there’s a national consensus; we’re shocked at this. But that’s gone. How do we get back to that point?
Anthony Fauci: Well, we’re just going to have to try and keep reaching out to each other and realize that we have to come together. I mean, that sounds idealistic but it’s the only way.
J. Stephen Morrison: Yeah.
Anthony Fauci: We need to just keep trying and trying to get people to appreciate that this is a problem that involves all of us. We can’t deny it. It’s a problem that is involving the entire nation.
J. Stephen Morrison: I’d like to ask you a question about the transition. I mean, you’re the bridge between these two administrations. How is it going? Is the cooperating moving forward between the two teams?
Anthony Fauci: You know, it is, Steve. There’s more of it than I think the public realizes. There’s an increase in cooperation between the Trump administration and the incoming Biden administration. They have what’s called agency teams, agency review teams, or ARTs. That’s another word for transition team. We have had meetings here at the NIH, virtual meetings like you and I are having, over the last couple of weeks that have been very productive. So even though I don’t think the general public fully realizes it, but there is a good degree of cooperation going on.
J. Stephen Morrison: Thank you.
Let’s shift to the virus and our national response over the course of this year. How do you think historians are going to make sense of this catastrophe? Are they going to put greatest weight on systemic weaknesses, on leadership, on political culture? How are they going to explain how America finds itself in this catastrophe that sets it apart from the rest of the world?
Anthony Fauci: Well, Steve, I think it isn’t over yet. And I think when you talk about how people are going to explain it, I think we’re going to have to find out how it ultimately turns out.
There are so many complicated interdigitating factors that I do believe we will need a scholarly approach to sit back and look at what has happened – what went wrong, what were the factors that were positive factors, what were the factors that were negative factors – and hopefully be able to articulate that in whatever a review is, a commission, a white paper or what have you, so that we could look at that and make sure that, when we get a challenge like this again, which I hope will not be for a long time, if ever, that we respond in a way that was better than we responded this time.
J. Stephen Morrison: Well, that brings me to my next question, which is around the idea of a 9/11-style commission. There are many people that are arguing that such a thing, which will be difficult to organize and execute and make bipartisan, but it can be done, as we saw with 9/11, with Governor Kean and Lee Hamilton and Phil Zelikow.
That was a remarkable success story when you look back now almost two decades, and a success in capturing what happened and what did we not catch, when and why, and trying to clear the air and trying to lay the basis for a new national consensus, and try to enumerate and reach consensus around what has to change looking forward.
Are you in favor of something like that?
Anthony Fauci: Well, I’m –
J. Stephen Morrison: Do you think it’s realistic?
Anthony Fauci: Yeah. Steve, I don’t know what form it will take. I don’t want to be making any declarations about what it should be. But I think there needs to be a formal retrospective review process to go through each and every one of these things.
I agree with you that we’re going to have to try very hard to make it a bipartisan approach, because if we go into it with the divisiveness that we’ve seen characterize the response over the last 11 months, I’m not so sure how successful it would be. I think if we get people of good will on both sides of the aisle to come together and realize this has been a really big, bad problem – let’s all admit it, OK. It’s real and it was bad. So let’s figure out what happened and how we can make sure it doesn’t happen again.
J. Stephen Morrison: Yeah. So I think, you know – and when you look back at the Spanish flu, as John Barry’s documented in his grand history, “The Great Influenza,” when we got to the end of that flu, we forgot. We turned away. There’s only one memorial to the 670,000 victims in all of America, and it was a – I think it was turning away for a combination of things – of sorrow, of pain, of regret, of shame, and a desire to simply move on. And, of course, it was happening at the end of a world war as well. So, of course, there were many other factors that came in.
But I do think that we need to guard against the possibility that we slip into a complacency and a forgetfulness –
Anthony Fauci: Well –
J. Stephen Morrison: – around this.
Anthony Fauci:– you know, there’s a thing about corporate memory that’s really short, Steve, particularly when you get through a very challenging situation. Then you focus on what the problems at hand are now. And having been through multiple cycles of this, it’s very difficult to get even well-meaning Congresses and well-meaning administrations to focus on preparing for something that hasn’t occurred yet when you have enough problems that are already ongoing. And that’s what I’m afraid of, that when this is over, which it will end for sure, that the memory of it will be fleeting and it’ll be the same thing post-1918.
You know, it’s very interesting. If you go back and reread, which many of us have – I’m sure you have – John Barry’s book, it’s eerie that there were things that went on back in 1918 that are so strikingly similar that we see now, including the denial in some states and cities that there really was a problem, the reluctance to wear masks on some parts of the country, the reluctance to shut down things. Some cities shut down. Some didn’t. And it was clear that those that shut down did better, both from a health standpoint and an economic standpoint.
That was 102 years ago, and it’s sort of almost repeating itself now in 2020. So I hope we don’t have that kind of forgetfulness after this.
J. Stephen Morrison: Yes. I want to ask you, what are the most vitally important things that we’ve learned over the course of 2020? I mean, there’s been debate around testing, fragility of markets, vulnerabilities, systemic aspect, the perniciousness of this virus. What, in your mind, are the most important things that we learned? We started with zero knowledge of this virus. OK, what did we learn?
Anthony Fauci: Well, we’ve learned that this is one of the most, if not the most, unusual virus that any of us have ever dealt with. Certainly in my 36 years as director of the institute I have not seen anything where you have a virus that in the – in 40 percent of the people has no symptoms. Then those who have symptoms, 80 percent have very mild to moderate symptoms that don’t require any significant medical intervention. And then you have 20 to 25 percent of people who are devastated, at attests the almost 300,000 deaths. There’s something very strange about a virus that in most people barely bothers them and in others it kills them. We still don’t understand why that’s the case right now. We need to find that out. We need to find out how a virus can have almost no symptoms in so many people – 30, 40, 45 percent of the people. That’s the first thing.
The next thing is the situation that we’ve learned the importance of science and the investment in science to be able to do something that was unprecedented and in fact unimaginable, to go from a new virus in January to giving out highly effective vaccines in December. I mean, that is something that if you had told any of us five or 10 years ago we would tell you you were imagining things. There’s not a chance in the world that that would happen.
So I think this serves as an impetus for us to continue to make major investments in basic and clinical biomedical research, because the exquisite science of platform technology that got us to where we are right now, the structural biological approaches to the confirmation of the spike protein, that all came from fundamental basic research that long antedated the appearance of this puzzling new virus. So if ever there was a testimony to the importance of investment in basic and clinical biomedical research, it’s what we’ve been able to accomplish in the last 11 months since the recognition of this new disease.
J. Stephen Morrison: Were you surprised to discover that we had – actually had acquired the capacity to accelerate the development of vaccines in the midst of a ranging pandemic?
Anthony Fauci: You know, I’d have to say, I wasn’t surprised because that’s what we’ve bene working for all along, that you can do research – good, randomized placebo-controlled trials – in the middle of an outbreak. And that’s what we did. And that’s why we knocked it out of the park because, you know, there would have been an argument, well, there’s such a dire need for all this let’s just give it to people and not do the appropriate randomized placebo-controlled trials.
You know, after our experience with Ebola in Africa – in West Africa, we had an evaluation of the response by the National Academies and the National Academy of Medicine, who came up with the strong recommendation that you can do ethically sound, scientifically sound research with the randomized control trial being the absolute gold standard right in the midst of an outbreak. And that’s exactly what we did here. And 11 months later, we have a highly efficacious group of vaccines. It’s not just one. It’s more than one.
So I’m not surprised at this. I’m gratified. I think Operation Warp Speed, putting hundreds of millions if not billions of dollars into facilitating the technical aspects of the trial, the clinical trial, the pre-purchasing of hundreds of millions of doses of vaccine is unprecedented. So it’s really quite a success story, I must say, Steve.
J. Stephen Morrison: Can you say a bit more about these models, these platforms for developing vaccines? These evolved over the last 20 years. These were kind of quiet transformations that came to the fore now. I mean, for most people I don’t think that there’s the full recognition of we’re benefitting from things that evolved over the last 20, perhaps longer, years, in a way. And maybe you can explain a bit about that because when you try to unpack, how did this happen that we could do what we’ve done? It didn’t just happen overnight. It wasn’t pure luck. There was some luck, but it was the result of transformations in science.
Anthony Fauci: Well, it was. I mean, the classic way – and quite successful, but somewhat cumbersome, and absolutely lengthy in time – of getting vaccines was to isolate a particular pathogen, in this case let’s say a virus. Then to get that virus to grow in large quantities – either in eggs or in cells or what have you. Then to purify it and either enactive it or attenuate it. That was a classic way of vaccines. And then it became clear that scientific advances in what we call platform technology allowed you to truncate that timeframe, which usually was measured in years and years, by using the advances in biomedical research. So that platform technology changed and was able to be highly adaptable, quick, and you didn’t even need to get the virus itself. All you needed was a sequence to which you could then pull out whatever gene you wanted that would express the protein that would serve as the immunogen and put it in whatever your particular vehicle is. That could be an mRNA. That could be a viral vector. It could be viral-like particles. That could be nanoparticles. It just transformed completely the flexibility and your capability of rapidly getting a vaccine against a brand-new pathogen.
But as you said correctly, Steve, that isn’t something that happened overnight. That was the result of years of fundamental basic research on these various platforms on the extremely efficient capabilities we have now of sequencing technologies, that you could do it essentially almost overnight as opposed to months or a year or more. Those are the kind of things that are the fruits of fundamental basic research. So we’re seeing the practicalities of a vaccine, but that didn’t just spontaneously happen. And again, as I said a little bit ago, this is the perfect argument for continued investment in basic and clinical research.
J. Stephen Morrison: So you think that there’s a – there will be a permanent institutional shift to making this type of capacity –
Anthony Fauci: Oh yeah.
J. Stephen Morrison: – a permanent part of U.S. global health security approaches?
Anthony Fauci: Oh, absolutely. Absolutely. I mean, we tried new things. Some of them were risky. You know, you might recall there was a lot of concern, if not criticism, about trying to go with something like an mRNA, which people said never had an approved product. And now it just sort of ran around the bases, you know, right now, and here we are with a highly efficacious vaccine. And there are probably going to be improvements on that technology over the years. This could now be used to go back and see if we could utilize these technologies for pathogens, particularly viruses, for which we have not yet had successful vaccines.
J. Stephen Morrison: Yes.
Anthony Fauci: So this is not only good for COVID, it may be good for vaccinology in general.
J. Stephen Morrison: Thank you.
There have been important gains in therapies, particularly monoclonal antibodies, but there’s been disappointment and there’s been controversy around many other therapies – hydroxychloroquine, remdesivir, convalescent plasma. Why haven’t we seen more progress in this area, in the area of therapies? And are you – do you think as we look forward this is going to change and we’ll see more progress?
Anthony Fauci: You know, I think what we need – and it’s going to take a little bit of time – we need some potent antivirals that are orally administered that can be given when a person develops symptoms to prevent them from going on to requiring hospitalizations. And I’m looking forward to the possibility of getting – you know, what we did with HIV, targeted antiviral therapy, you don’t need to give it for a lifetime. You probably, Steve, would only have to give it for five to seven days before you knock the virus out and prevent it from turning into a systemic disease.
Now, there are other things that we’ve tried because we needed it rapidly – we needed it today; not eight months, a year from now – and those are the things that you mentioned. Some of them were done in trials that were well-conducted and some were not. I mean, we just gave convalescent plasma in a manner that was not a randomized controlled trial, to give an answer. So we had a lot of data with convalescent plasma that now is in EUA, but we still need to definitively prove when it’s effective and if it’s effective.
J. Stephen Morrison: So our approach to trials on therapies could be different. It could be improved.
Anthony Fauci: Oh, I think in the beginning some of the – some of the approaches were just give it to people and not put it into trial.
J. Stephen Morrison: Yes.
Anthony Fauci: That was not good.
No, now I think it’s promising. We have a couple of – more than a couple of monoclonal antibodies that – some of which have gotten an EUA already and which it’s going to be determined – I would think it’s very clear that there are those – like those therapies that you really need to give early in the course of infection. You don’t want to give a monoclonal antibody when somebody’s in the hospital on a ventilator. It probably is not going to do any good. I mean, you want to give them dexamethasone or some other anti-inflammatory. But if you want an antiviral to really work, you’ve got to have a diagnostic that is sensitive, specific, easy, get the diagnosis right away. If you’re dealing with COVID-19, give the person a direct antiviral, a monoclonal antibody, or a hyperimmune globulin, something that could block that virus early on.
J. Stephen Morrison: Yes.
We know there’s a big push now to refocus on opening schools. This is something that has surfaced in President-elect Biden’s statements recently. And we know that tests are going to be very important to that. We know that there’s a lot of talk about trying to do more – have rapid, inexpensive antigen tests that can give us a better grip on what’s going on in order to be able to reopen schools, as well as businesses and travel. Are we going to finally move, in your – in your mind, to a national testing strategy that is going to make that possible? Because the patchwork, ad hoc, fragmented system is not getting us very far where we need to be.
Anthony Fauci: The answer to your question is yes. And one of the things that I think we should have as a high priority is to get testing of asymptomatic people. There has been a reluctance to do that and even some misunderstanding that it shouldn’t be done. There are tests for someone who’s symptomatic where you’re trying to prove definitively whether they’re infected or not. That’s generally a PCR test, very sensitive. You’re not going to get the results in an hour or two or three. At best it’ll take a day, usually two days or longer. What you need is to essentially flood the system with rapid, sensitive, specific point-of-care tests that you can actually do at home without a prescription. That’s what I think we should be doing a lot more of. And therefore, you could be testing groups of people and then doing surveillance.
Now, it isn’t as sensitive as a PCR, but if you do it often enough you can get a really good feel of the penetrance of the infection in the particular group you’re looking at, whether that’s a college population, whether that’s a nursing home, whether that’s a prison, whether that’s a factory. You could get a good feel for what the level of infection is and act when you do identify an infection. But that’s mostly screening asymptomatic people. We’ve got to get past that seeming roadblock in wanting to test asymptomatic people.
J. Stephen Morrison: Thank you.
I want to talk a little bit about the international side. Outside our borders there’s an urgent need to focus on safe and effective vaccine access by low- and middle-income countries. As the rollout proceeds in America and other wealthy and powerful countries, that gap is going to become much more visible between what’s possible in the wealthiest and most powerful countries and what may be subject to continued delay and uncertainty in low- and middle-income countries. There is the ACT Accelerator, and within that the COVAX Facility launched by the Gates Foundation, Wellcome Trust, the EU, WHO, and others back in the spring, which has moved forward. European leaders are eager for U.S. leadership to return to the international stage, where international diplomacy on COVID-19’s been very thin. And so there is this outstanding question: Will the U.S. come forward and renew its leadership in the world? And will it come forward to the ACT Accelerator with some pledge around cash, around political commitments for summitry to bring people together – and perhaps some percentage of surplus vaccines, which I understand will only be possible once we know how much immunity do those vaccines, how much surplus do we have? Can you say a bit about what the prospects look like for U.S. leadership coming back in this way?
Anthony Fauci: Well, Steve, I don’t know. I can’t. I’d like to give it to you, but I don’t know what we’re going to do. That’s not under my control.
You know, you know how I feel about the responsibility of the United States to the developing world, particularly when there are issues which are implementable in the developed world but not so easy in the developing world. I think the classic example of that is what we as the United States did under the leadership of President George W. Bush with the PEPFAR program, where it became clear when we had drugs that were saving the lives and completely transforming the lives of people who were living with HIV in the United States, that those drugs were not available to people in the developing world, particularly Southern Africa; yet President Bush established the President’s Emergency Plan for AIDS Relief, or PEPFAR, which essentially – according to what he said directly to me and to others – that we have a moral responsibility as a rich nation to make sure that if we have assets and resources that are saving the lives of Americans that we make sure that those who live in countries that don’t have those assets or the resources don’t die merely because of where they live.
So I do feel that we in the developing world, not only the United States – in the developed world, that is – but other countries have a responsibility to make sure that ultimately there’s equitable distribution of highly effective and safe vaccines against COVID-19, because this is a global problem. It’s not a national problem. It’s a global problem. So I believe we do have that responsibility. Whether we act on that responsibility, Steve, I don’t know. I don’t have the power or the control to do that. But I can tell you how I feel about it.
J. Stephen Morrison: Well, I think it’s very helpful to hear you say that, and to draw the references back to the launch of the President’s Emergency Plan on AIDS relief, which is the – which is the most powerful historical reference that we have. It is going to be difficult in terms – money is going to be short. The domestic crisis dominates. We have to make the case to a frightened and anxious American people that acting outside our borders with multilateral partnerships is going to protect Americans and it’s going to be very cost effective. And I think part of that’s going to be demonstrating that we are not only acting as a humane force on – under ethical principles, but we’re also reopening the global economy, and we’re also regaining ground with the Europeans that’s been handed over to the Chinese and the Russians. Do you have any thoughts on that?
Anthony Fauci: No, I think that’s absolutely the way to go. I mean, again, it gets back to what I said. This is a global problem and it will be a global solution. What happens in the rest of the world when you’re dealing with a pandemic absolutely will ultimately impact us. That’s the reason why right now with other diseases like smallpox and polio, globally we’ve handled it, eradicating smallpox, eliminating polio for most of the world. That’s what we want to do with COVID-19. And we can do it. We can absolutely do it. There’s no reason why we can’t do that.
J. Stephen Morrison: Thank you.
Getting back to the distribution of vaccines now in the United States, we don’t know how much immunity they will confer, how long it will last. We don’t know whether they will prevent the infection and we don’t know if they will block someone who is already carrying the disease but vaccinated – block that person from transmitting to others. These are big uncertainties. How long do you think it’s going to take us to reach that point in our science where we have clarity on those points, because that’s going to be terribly important in the effectiveness of the vaccine campaigns, but also it’ll tell us if we have massive surpluses we can put towards helping others.
Anthony Fauci: I think we will probably know if the vaccine rollout works the way I hope it does, that we get the overwhelming majority of the people vaccinated in this country by the end of the 2nd quarter, and we have the veil of protective immunity. We should know by the end of 2021 as we go into – excuse me – yeah, by the end of 2021 as we go into 2022 what the durability is and whether or not we’re dealing with something that needs to be re-boosted every year. So it’ll probably be a year or more – a year or more from now we’ll know.
J. Stephen Morrison: Yes. And can you describe for us what is – I mean, people are concerned that as this – we’ve got a surge that’s going to carry us into the year, we’re going to have the introduction of the vaccine with all these uncertainties surrounding it. And it’s very important that people control their behavior in terms of masking, social distancing, avoiding congregant settings. How do these pieces come together? Let’s say we hit June and we have a 75 or 80 percent coverage of the American population with this new vaccine, but still some uncertainty hanging over it. What is the reopening look like? People may be tempted to get rid of their masks and let their guard down, or they may be reminded they have to, and for what period? And how does this reopening happen in terms of vacations, travel, all of the parts of the life that we want to regain?
Anthony Fauci: Well, first thing, it’s not going to be like turning a light switch on and off. It’s not going to be overnight. It’s going to be gradual. And I think we will know when we see the level of infection in the country at a dramatically lower level than it is right now that we can start gradually tiptoeing towards normality. I don’t believe we’re going to be able to throw the masks away and forget about physical separation and congregant settings for a while, probably likely until we get into the late fall and early next winter, but I think we can do it.
The numbers will guide us, Steve. You know, we’re having 200(,000) to 300,000 new infections per day, as you and I are speaking right now. If we get that down to less than 10,000 a day, to 4,000, 3,000, then we’ll be in a very good place, because, as you know, with the dynamics of the outbreak, the lower number of infections is, the less the virus has a chance to spread, particularly if you have people who now are protected with the vaccine.
So I don’t think it’s going to be subtle. We’re going to see a dramatic change in the dynamics of the outbreak. And when we do, then we’ve got to cautiously and prudently begin to pull back a bit on mitigation methods, not just abandoning them all but gradually and prudently pulling back.
J. Stephen Morrison: So do you anticipate next fall that most people will be back in classrooms, people will be eating in restaurants, people will be traveling on planes to take vacations or engage in business?
Anthony Fauci: It’s a big if. And the if is it’s up to us. If we get 75, 80 percent of the population vaccinated, I think that’s eminently doable, what you just said, by the fall –
J. Stephen Morrison: Yeah.
Anthony Fauci: – because we will start vaccinating the general population, people that don’t fall in any of the high-priority groups, probably as we get into April. We’ll have April, May, June, and July. We’ll have three months, four months of vaccinating everybody with a prime and a boost by the time you get into the fall, September and October. If we get that proportion of the population vaccinated, we should be able to clearly be feeling very comfortable about schools, as well as getting some of the other functions that we have withheld up to now – theaters, restaurants, things like that.
J. Stephen Morrison: Tell us, what do you worry the most about in terms of the vaccination campaign in our country? It’s complicated. It’s historic.
Anthony Fauci: Yeah, I worry that –
J. Stephen Morrison: Epic scale.
Anthony Fauci: Yeah, I worry that we don’t convince the majority, overwhelming majority – not majority; majority is 51 percent. (Laughs.) I think we want to go much better than that. When we get, you know, 75, 85 percent of the people vaccinated.
I worry – I’m a realist, but I’m a cautious optimist. I think we can do it. But we have got to be out there, explaining to people why it’s good for them, their families, and the country to get vaccinated.
J. Stephen Morrison: Thank you.
I want to talk a little bit about HIV. Next June, 2021, marks the 40th anniversary of the discovery of HIV-AIDS, something you were quite involved with. You’ve been at the forefront of the response since the early ‘80s. And that’s another pandemic that requires considerable commitment and investments over many decades.
We’re not out of the woods yet with HIV. Some are calling it a residual epidemic. We’ve made huge progress. But it’s fragile. There’s no vaccine or cure. We know many of the therapies and behavioral things that can change this and control this. But it’s still a major enterprise in the world. And now we have layered over it a new pandemic, an extraordinary fast-moving virus, that also is not going to be eradicated from the globe any time soon; could become a next sort of residual pandemic.
First question is, when you look back on this year, how do you estimate the threat and damage that COVID-19 has likely imposed on global HIV efforts?
Anthony Fauci: I think it has been damaging, Steve, not only to HIV efforts but to virtually every aspect of medicine – screening for breast cancers, screening for colon cancers, the supply chain of drugs for people with HIV, getting people into prep, getting people tested. When you shut down most of the globe, all of that suffers.
So what that means to me, Steve, is that we’re going to have to be playing public-health catch-up with a variety of other diseases that have been negatively impacted by what we have had to do to address COVID-19, including, I believe, some damage that has been done to the efforts of HIV.
J. Stephen Morrison: Do you have any – I mean, do you think this has been, for the global HIV efforts, the U.S. government’s put over $100 billion into that, and we’re not the only donor. And countries themselves, other donors, this is a vast enterprise over the last two decades. Do you think this has been set back – the damage has been deep and lasting, or do you think it’s something where the recovery is possibly within a short period of time?
Anthony Fauci: I think we can recover in short period of time, but there’s no doubt there’s been damage, no doubt – in every field, including HIV.
J. Stephen Morrison: What do you think the future of HIV is going to be, coexisting with this new pandemic? What’s the future of HIV? The future of HIV’s going to inexorably change, the way we understand it, because the world has changed. We’re now living in a world of coronavirus pandemics.
Anthony Fauci: Yeah. I think that we can – as I said, it depends on how we here in this country, as well as the rest of the world, vaccinate the population. I think we can crush this outbreak. And I don’t think it has to be lingering, looking over us like the specter of doom. I don’t think we – I don’t think we need that. I don’t think it’ll happen, Steve, if we do the right thing. We can get rid of it and then get back to doing what we have been trying to do, is end the HIV pandemic as an epidemiological phenomenon. I don’t think we’re going to eradicate it but, you know, we had that plan that we started in 2020. It actually started in 2019, but it became operational, to end the epidemic in the United States as we know it by 2030. I think we had a setback with that with COVID, but I don’t think we can abandon that because I still think we can do it.
J. Stephen Morrison: Thank you. Thank you very much. We’re going to close by asking you – first of all, we’re going to close by thanking you for being with us today. We’re going to close by thanking you for your service to the nation, which is – which is just astonishing. And we’re all grateful, all in your debt for that. We want to wish you happy birthday, which I know is coming up soon. Christmas Eve day, I believe.
Anthony Fauci: Christmas Eve, right.
J. Stephen Morrison: And so we wish you a happy birthday – 80th birthday in advance. Thank you for your service. I want to thank also my staff, my colleagues: Anna McCaffrey, Amith Mandavilli, John Monts. And some of your staff – Patricia Conrad and David Awwad – have been enormously helpful over the course of the year, and for this – putting this all together. So thank you so much.
I wanted to ask you to close with some final thoughts around why we need to remain optimistic in this period.
Anthony Fauci: Well, thank you for having me, Steve. I, as usual, always enjoy these conversations with you. It gets us to think more deeply about some of the really important problems.
I think we should – we can, and we should remain optimistic. Getting back to what I said early on is that the science of what we do is – seems to always be the mechanism of getting us out of dire straits. You and I both remember the very early years of HIV. I was taking care – and I still do, but much more then – on a daily basis scores of patients who were suffering from AIDS. It was the dark years. We didn’t know if we were ever going to have any solution. And then on the basis of science structured antiviral drug design, understanding the replication cycle of the virus, we developed a series of drugs which have completely transformed HIV from a death sentence to people living essentially a normal life. We now have undetectable equals untransmissible. You treat someone, they don’t transmit to somebody else. That’s all the fruits of science.
We’ve had a terrible year in 2020, and yet science in the form and the development of safe and efficacious vaccine is going to get us out of this, for sure. So I am very optimistic as we continue to pursue scientific approaches to these extraordinary public health problems that we will be able to solve them if we all pull together and follow the science. And I’ve said that so many times and I’ll end by saying it now. (Laughs.) Follow the science and get solutions.
J. Stephen Morrison: Thank you so much, Dr. Fauci. And we wish you the best holiday. We hope you get a break in this madcap schedule that you follow. And we thank you for agreeing to serve the incoming Biden administration. Having continuity will be enormously valuable and having your continued role here. Thank for your agreeing to do that.
Anthony Fauci: My pleasure. Thanks for having me, Steve. Take care.
J. Stephen Morrison: