How we can beat COVID-19 and face down future pandemics

Anthony Fauci discusses the nation’s coronavirus response with Lloyd Minor, dean of Stanford University School of Medicine

2020 Issue 2 Apart yet together

Anthony Fauci, MD, has been called America’s doctor for good reason. Director of the National Institute of Allergy and Infectious Diseases for 36 years, he has advised six presidents and has led the U.S. response to many health crises, most notably (until recently), HIV/AIDS.

Today, he’s a trusted source of information for the public about the COVID-19 pandemic, which he calls an infectious disease fighter’s worst nightmare.

Fauci’s involvement in medicine goes way back: He delivered prescriptions for the Brooklyn, New York, pharmacy his parents owned and was on the pre-med track in college. He graduated first in his class from Cornell University Medical College, now known as Weill Cornell Medicine.

His knack for leadership goes way back, too: He captained his high school’s basketball team, despite his less-than-advantageous height of 5 feet, 7 inches.

Lloyd Minor, MD, dean of the Stanford University School of Medicine, spoke with Fauci in July, when the United States was seeing the largest surge in COVID-19 cases to date. When Minor asked Fauci how he saw the pandemic unfolding, Fauci channeled his inner team captain, giving motivating, clear advice on how to win.

“There are things you can do now,” he said. “Physically distancing, wearing a mask, avoiding crowds, washing hands. Those things, as simple as they are, can turn it around. And I think we can do that. And that’s what we’ve got to do.”

During the discussion, which was streamed live online, Minor talked with Fauci about the state of the COVID-19 pandemic, keys to controlling it and how to prepare for future outbreaks. Their conversation has been edited and condensed for this Q&A.

Minor: How are you dealing with the stress of the pandemic?

Fauci: The worst nightmare of an infectious disease person who’s interested in global health and outbreaks is the combination of a new microbe that has a spectacular capability of transmitting and has a considerable degree of morbidity and mortality.

And here it is, it’s happened — the worst nightmare, the perfect storm.

Lloyd Minor, MD, dean of the Stanford University School of Medicine (Photo by Timothy Archibald)
Lloyd Minor, MD, dean of the Stanford University School of Medicine. (Photography by Timothy Archibald)

It’s one of those things where you’re really just functioning on adrenaline. Of all the emerging infections that I’ve had to deal with — starting from HIV in the early ’80s, then Ebola and Zika, and anthrax attacks — this is clearly the most challenging because it’s so pervasive.

Minor: What do we need to do to better prepare for future pandemics?

Fauci: Let me answer that from the vantage point that I’m most familiar with — as a physician-scientist: What can we do from a scientific standpoint? One thing is to develop new, sophisticated platform technologies — where you can hit the ground running with vaccine development and not have to worry about growing out the pathogen or activating it or attenuating it.

Another thing is to study prototype pathogens to get really good at understanding a particular family of potentially threatening microorganisms.

For example, this is the third major coronavirus outbreak we’ve had in the past 18 years. We had SARS in 2002. We had MERS in 2012. And now in 2019 and 2020, we have COVID. We’ve got to be able to do universal therapies and universal platform technologies.

Also, we have let the local public health infrastructure in our country really go into tatters. We were so good at controlling smallpox, polio and tuberculosis, we let the infrastructure go unattended. Now, when we need good local public health capability, it’s not optimal. We’ve got to build it up again.

Minor: When you look at the data in communities hardest hit by the coronavirus, it really highlights health care inequality and issues of access to care in our country. How can we better address this situation?

Fauci: Concentrate resources. In those demographic areas that are suffering most, it’s like a broken record. Minority populations are disproportionately negatively impacted by diseases like this. With HIV, 13% of our population is African American, and 45% or more of the new cases are among African Americans.

Look at the incidence of COVID-19 infection on the basis of how, in general — I don’t like to generalize, but here you have to generalize — how the African American population and the Latinx population find themselves with jobs that don’t allow them to properly protect themselves. As everybody’s locking down, they’re doing the essential jobs that require their physical presence. So they’re immediately at more risk of getting infected.

When you look at the prevalence and incidence of comorbidities that make you at higher risk for a poorer outcome, they have most of them: hypertension, diabetes, obesity, chronic lung disease, kidney disease.

Minor: What are we learning from this pandemic about conducting clinical trials during an outbreak?

Fauci: Not too long ago, there was the incorrect assumption that you can’t do research in the middle of an epidemic outbreak because it’s very important to get whatever treatment you have, whether it’s proven or not, to the people. The idea is, they need it and it’s better than nothing. That’s an understandable approach. But it really is flawed.

The best research you can do is in the middle of an outbreak because you want to help the people who are experiencing the outbreak. You also want to learn from it so you can help that many more people.

Until recently, it was felt that, ethically even, you shouldn’t do research in an outbreak. We proved that wrong in the Ebola outbreak. We did randomized, placebo-controlled trials, we proved that a couple of therapies worked, and a vaccine was developed.

With COVID-19, two drugs have already proved to be beneficial in advanced disease. So clinical research and clinical research infrastructure is a very important part of the response to outbreaks.

Minor: Can you share your thoughts on when a vaccine or vaccines might be available, and about allocation methodology for vaccines as they move through the various stages of trials and hopefully get to FDA approval?

Fauci: One of the encouraging aspects of having multi-candidate vaccines is that the companies involved, with substantial financial help from the federal government, committed to start producing large numbers of doses even before they’re proven safe and effective.

If you make a lot of doses and it’s not safe and effective, you’ve lost a few hundred million dollars. If you make a lot of doses ahead of time, and it proves effective, you’ve gained multiple months in the process.

I’d like to make a reasonable assumption that sometime at the beginning of 2021 we will have a couple of vaccines that are safe and effective. Obviously, you want to vaccinate everybody, but as doses come online, you’re going to have to prioritize.

That’s where you put together committees of people who understand vaccinology, community representatives and, above all, ethicists who can make sure your decisions about distribution are based on ethical principles of justice and fairness, etc.

Minor: In America today, there’s a lot of skepticism about vaccines. What can we, as physician-scientists and leaders, do to gain public trust in vaccines so we can control this pandemic?

Fauci: We’ve got to engage the community by getting out there, with boots on the ground, to convince people why it’s important to be vaccinated, particularly in this era of anti-vax and anti-science. We have a network of community workers who are being prepped for that outreach.

You don’t really want a lot of white guys in suits like me going into a mostly minority community and trying to convince them about something that they may be deeply skeptical of. You’ve got to get people the community trusts.

Minor: If you could look at the scientific unknowns about this disease, what are the top questions to answer now so we will be much better off in the future?

Fauci: The critical question is, will we get the body to induce a durable immune response that can protect us. No. 2: What about the long-term effects for people who recover? You’re hearing about people who get sick, go to the hospital, come out, and then it takes weeks, if not months, for them to begin to even feel slightly normal.

Another thing we want to know is, what is the full extent of the clinical manifestations? Finally, what about therapy? Are we going to be able to get a good antiviral that can shut it off completely?

Minor: What would you say to the next generation of physicians, scientists and researchers?

Fauci: If you’re interested in scientific research, never before in history have the opportunities been so spectacular as they are right now. So much so that I often fantasize — I’d like to turn the clock back and be 25 years old, starting all over again. I am in awe at what’s coming out from a scientific standpoint.