On 23 September at 8 p.m., Anthony Fauci was standing in his living room in Washington, D.C., still in his suit and tie, chatting on his cellphone with an assistant, exasperated that his day was far from over. It had begun at 6 a.m. and included testifying at a 3-hour Senate hearing on COVID-19. In the early evening, he spoke with actor Alan Alda about the pandemic on a live-streamed event. Fauci, head of the U.S. National Institute of Allergy and Infectious Diseases (NIAID) and a key scientist on the White House's Coronavirus Task Force, still had to read and reply to more than 200 emails. "I'm going to be up until 3 a.m.," he said.
Fauci, who that week appeared on the cover of Time magazine's issue of the 100 most influential people of 2020, went upstairs and changed into jeans and sweatshirt. When he came down, his wife, Christine Grady—a bioethicist at the National Institutes of Health (NIH) Clinical Center—brought him an India pale ale and salmon sliders out on their back deck, where he sat down for an hourlong, socially distanced interview with Science. Fauci discussed everything from his relationship with President Donald Trump and White House staff to the COVID-19 vaccines being tested by the government's Operation Warp Speed, the emergency use authorizations (EUAs) issued by the U.S. Food and Drug Administration, and his confrontation at that day's hearing with Senator Rand Paul (R–KY), who has a history of needling the NIAID director.
The 79-year-old Fauci, who has led NIAID since 1984 and established a reputation as a world-renowned HIV/AIDS researcher, had no regrets about tangling with Paul. "I said to myself, you know, I'm sorry, I'm not gonna disrespect him, I'm not gonna be aggressive, but I'm not gonna let him get away with saying things that are cherry-picked data."
This interview was edited for clarity and brevity.
Q: Why aren't you afraid of speaking your mind at the White House?
A: I'm walking a fine line of being someone who is not hesitant to tell the president and the vice president what they may not want to hear. There are some people in the White House, who, even when I first started telling it like it was in the Task Force meetings, they were like, "Oh my goodness." That's when I got that nickname "the skunk at the picnic." When they would strike an optimistic note, I would say, "No, wait a minute."
I used my experience with the activists during the early years of the AIDS pandemic to say, "If you really want to know what's going on, you have got to talk to the people in the trenches." So when people were saying, "Testing is fine, everybody who wants to test can have a test," I'd get on the phone at night and talk to the individual people who are either the assistant health commissioner, the health commissioner, or somebody who's running an intensive care unit from New York, Chicago, New Orleans, Seattle, and Los Angeles. I'd do that regularly, and what they were seeing in the trenches was not always what was happening in the discussions. So I bring this perspective to the Task Force and I say, "I'm sorry, I'm not trying to undermine the president. But there is something that's called reality."
When you have 70,000 [COVID-19] infections a day and that plateaus at 44,000, that's really not very good news. Some might say, "Well, you know, we should be positive since there are parts of the country that are doing well." I do not disagree: Yes, there are parts of the country that are doing well, where the test positivity is 1% or less. But other areas are not doing well, and this country is a big forest, and when you have fires in some parts of the forest, the entire forest is at risk.
Q: It's not rocket science, Tony.
A: The point that I sometimes make is the analogy of crew racing. I never knew anything about crew until my daughter became one of the captains of the Stanford varsity team a few years ago. And then I decided I'd learn about the subtleties of it. Unless every one of those eight people, the ninth person being the coxswain, is doing it exactly the way you should be doing it, you will never win the race. You need one person, sometimes two, God forbid, who are out of sync and you are done. You've lost the race. Everyone has got to work together. And that is a concept that I try very hard to get across.
Debbie [Birx, a scientist on the Task Force] is constantly out in the field now and she's absolutely seeing that in spades: When you get an increase in test positivity, it predicts there is going to be a surge of infections. And then the surge gets under control when people start implementing public health measures. It's almost like whack-a-mole. And that doesn't work in the long run.
Q: Operation Warp Speed wanted vaccines that could be mass produced quickly. But what do you think of its portfolio? The obvious missing component is the inactivated virus vaccine. That's moved very far with China-made vaccines and now Europe is investing big time in it.
A: In a perfect world, you would want to get all those platforms going. A decision was made regarding the broad effort. I wasn't the primary person in making that decision. I was and am responsible only for the NIH component of that multifaceted effort. We do the research, and we say, these are the things we need to do. A decision was made that they were going to have an overarching process involving multiple agencies of the federal government. It wasn't completely in my hands. The one thing that I'm glad happened, because we were pushing for that, was to get a broader portfolio, a wide range of vaccine platforms including the more traditional one of recombinant proteins with an adjuvant.
Q: Most COVID-19 vaccines being tested in the United States only contain versions of the viral surface protein, spike. The inactivated virus vaccines have all the viral proteins. What do you think about broadening to include more viral components?
A: You know, it's an interesting psychodynamic, saying we are in this catastrophic outbreak and we've got to move as quickly as we possibly can. We're relying on the companies that come forth and say, we're willing to make an investment in this approach. There was an emphasis on needing to do something about it right now, right away, because that's the only thing you have, as opposed to approaches with other diseases where there was less of an emergency nature to the process. Other antigens besides the spike likely will be pursued in the second generation of SARS-CoV-2 vaccines.
Q: The EUA situation raises an interesting problem. The way convalescent plasma was approved for an EUA combined with the EUA of hydroxychloroquine is tied together with confidence in the vaccine dropping.
A: I understand the need for and importance of EUAs, but I have long been of the opinion that the gold standard of determining conclusively if an intervention is safe and effective is conducting a randomized controlled clinical trial. An EUA is based on the principle that the benefit outweighs the risk in a situation where there is a reason to believe that the intervention may be effective. I am all for that—this can get life-saving interventions out quickly for people who need it. But this should only be done in a situation that doesn't interfere with the process of ultimately proving whether that intervention is truly safe and effective. For convalescent plasma, an EUA was issued, and I hope that when the clinical trials are completed, we get a definitive answer.
Q: Convalescent plasma didn't work in Ebola.
A: Yes, exactly. And Cliff [Lane, a deputy director of NIAID] did a study in Southeast Asia, and convalescent plasma didn't work in influenza.
Q: And the data for convalescent plasma against COVID-19 are really soft.
A: One of the things that I learned, and that's the fun of continuing to learn as you get older and older, is the sophistication of modern-day statistics. When you examine something in a post hoc analysis of a non–pre-determined endpoint, boy, can you be led down the garden path. We used to kid around saying if you torture the data enough, it's going to ultimately tell you what you want it to tell you.
Q: I know it's late for you on a very long day. And you also had a wonderful interchange with "Senator Rand." [Fauci mistakenly said "Senator Rand" at the hearing.] You feel good about it?
A: I do. I was born and raised on the streets of New York, but I'm a creature of Washington, and I have a great deal of respect for government institutions. Just like I have a great deal of respect for the presidency, I have a great deal of respect for the Senate. And in that regard, I have a great deal of respect for senators. But I am not going to let Senator Paul get away with saying things that are cherry-picked data. And he compared us to Sweden, and said, Sweden let everybody get infected and they have much lower death rate than us. And I say, sir, with all due respect, you're comparing apples and oranges, you should not be comparing Sweden with the United States, you should be comparing Sweden with demographically similar populations, like the Scandinavian countries such as Norway and Denmark. And Sweden has done much less well, particularly regarding deaths, compared to the other countries.
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