Comment: Why Fauci is optimistic about science and health

In a Q&A, the outgoing infectious disease expert critiques the covid response and what we’ve learned.

By Lisa Jarvis / Bloomberg Opinion

Anthony Fauci will step down as director of the National Institute of Allergy and Infectious Diseases this month, leaving behind a government career that spans 54 years, 38 in his current role.

Only a few years ago, his biography would have been dominated by his prominent role in addressing the HIV epidemic. Then came a novel virus that challenged the world like none other in our lifetimes. As director of NIAID, and later as chief medical adviser to President Biden, Fauci became the American public’s main guide to combatting (and now cohabitating with) covid; a role complicated by extreme partisanship, the outsized influence of social media, and our ever-shifting understanding of a virus that keeps evolving.

As he prepares to depart NIAID, I talked with Fauci about the scientific challenges left on the table, trying to craft public health messaging amid rampant disinformation, and the state of our country’s preparedness for the next pandemic. This transcript has been lightly edited for clarity.

Q: During your career, you’ve taken on a long list of infectious diseases. What are the outstanding scientific questions you still hope to see answered in your lifetime; or, conversely, challenges you’ve come to believe might be too far out of reach?

A: There aren’t very many that are too far out of reach, ultimately. Because if you take that attitude, then you’ll never accomplish some of the difficult, challenging things. There were so many things that we thought were out of reach we found out they were within reach.

I think the most recent example is the fact that we were able to develop safe and highly effective vaccines within 11 months of the recognition of a brand-new virus. That is completely and totally unprecedented. Something like that, a few years ago, would have taken an average of seven to 10 years to accomplish. So you just want to assume that anything is possible.

Some unfinished business that I would like to see [resolved] is getting a safe and effective vaccine for HIV. Even though we’ve done spectacularly well with the development of drugs that have transformed the lives of persons with HIV, both from a treatment standpoint, and from a pre-exposure prophylaxis standpoint, there is that one challenge that we still haven’t met: a safe and effective vaccine. And it’s very difficult because of the nature of HIV that it makes it very different from any other virus that we’ve confronted.

The other challenge is if you look at the real killers in infectious diseases, such as malaria and tuberculosis, again, we still don’t have a highly effective vaccine that can prevent the hundreds of thousands of deaths of malaria each year, particularly among stricken babies.

So there are a lot of things that we can do that we haven’t accomplished yet. But the research that’s being conducted looks quite promising and every one of those areas.

Q: Covid felt like the first time that the general public was paying such close attention to the minutiae of the scientific process. Did the advent of preprints and open discussion and debate on social media change your approach to communicating with the public?

A: It really is a very complicated and complex issue. Unfortunately, although social media can be a very positive vehicle for the dissemination of important, factually based information, the fact is, it can also be the source of the dissemination of disinformation and misinformation. And we’ve seen a lot of the latter, where you have wild theories — be it conspiracy theories or outright untruths, [or] distortions of facts — that have made communication regarding covid, very, very difficult.

Q: If you could change anything about how you conveyed health information and messaging during the pandemic, what would it be?

A: Well, it would be something that I might not have any control over: Getting the public to appreciate that when you’re dealing with a moving target like the evolution of an outbreak, you don’t have all the information you need to make appropriate decisions, recommendations or guidelines. The public, understandably, often doesn’t appreciate the dynamic nature of an outbreak and the fact that you get certain data and evidence at a particular time and you make a decision that is guided by that data at the time. And then a month or two later, the data changes. And things change because you learn a lot more about the virus.

There are so many examples. In the beginning, we were not fully appreciative of how very efficiently the virus spreads from person to person. We were not fully appreciative of the fact that it spread by aerosol. And it’s much, much more than just staying away from somebody who’s sneezing and coughing, because somebody can be just breathing next to you and transmit the virus. We were not fully appreciative of the fact that 50 percent to 60 percent of all transmissions come from someone who has no symptoms at all.

We didn’t know all of that in the first month or two or three of covid. And when we finally found out, we changed many of our approaches towards the outbreak, we changed many of our recommendations. The general public would interpret that as flip-flopping, when it isn’t flip-flopping. It’s going along and modifying your understanding of the outbreak depending on the most recent accurate data. That’s a very, very difficult thing to have the public understand. That’s been a big source of confusion and even a big source of the mistrust that we see in science.

Q: Do you worry that the value of expertise and experience is being undermined in our hyper-partisan era?

A: Yes; oh, it is, of course. When you have social media that’s unchecked and unedited, anybody could pronounce themselves an expert. And how is the public going to know whether that person really is an expert? That’s a big danger. We have a lot of self-professed experts on things that can be really confusing to the general public.

Q: The statistics on deaths based on vaccination status are a stark reminder of the cost of the polarization around covid. What does that polarization mean for the overall health of the American public? And are there areas of public health where you worry we might lose ground?

Q: The pushback on covid vaccines [could] lead to a hesitation in people getting vaccines that they have accepted for decades and decades. That would be a disaster.

A: Do you feel like we’re coming out of the past three years prepared to address another pathogenic threat?

Q: That’s up to us really. There are lessons to be learned. If we heed those lessons, we’ll be much better prepared. If we don’t heed those lessons, then we may not be as well prepared as we could be.

One of the resounding success stories of this pandemic has been the investment that was made in basic and clinical research, which led to the unprecedented accomplishment of getting a safe and highly effective vaccine available in less than one year from the time the virus was recognized. So that’s a good lesson that we’ve learned continue to invest in basic and clinical research.

The lesson that’s a negative lesson [is] that our public health infrastructure was ill-prepared at the local level to meet the requirements of a good response to an outbreak. So we’ve got to make sure we reestablish the strength of the local public health system and are able to get important data in real time, not with a delay of weeks to months. But that has a lot to do a lot with the fragmentation of our health care delivery system.

Q: If you were making a list of the biggest priorities for future pandemic preparation, what would be on it?

A: Well, I think it’s mostly strengthening the public health infrastructure and that takes many forms. You’ve already heard that the [Centers for Disease Control and Prevention] is trying to reinvent themselves, which they really do need to make it a more flexible organization to get data out in real time. But a lot of that is not their fault. It’s that the system doesn’t allow them to accumulate the data in real time. But that’s one of the things that needs to be improved upon.

Q: When we last talked, it was about the value of pursuing universal covid vaccines. Are we running out of time for better vaccines to become a reality?

A: I don’t think we’ve run out of time. When you’re doing research and public health, you’ve got to keep pushing the envelope and pushing the envelope. That’s one of the important tenets of doing research and discovery and implementation: You can’t get discouraged by failures.

Q: What’s next for you? Are there scientific problems you hope to still have a hand in?

A: I’ll be indirectly involved in that mostly in an advisory capacity. But I don’t see myself continuing to do my own research program. I think I can accomplish a lot more in a broader 40,000-foot advisory capacity to get people to benefit from my decades of experience, both as a scientist as well as the director of the Institute for almost 40 years. That’s where I think I have the most to contribute to society.

Q: What does waking up on day one after being at NIAID for 54 years feel like?

A: I don’t know. We’re gonna see, aren’t we?

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.

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