Welcome to Stanford Med Live
I'm Dr Lloyd Minor, dean of medicine at
Stanford University.
I'm delighted to be joined today
virtually by Dr.
Anthony Fauci. Before we jump into
today's discussion,
I want to express my gratitude to Dr.
Fauci
for his leadership as a member of the
White House Coronavirus Task Force.
His expertise and role as a public
spokesperson
have been invaluable these past several
months.
In fact, a recent poll showed that
Americans cite Dr.
Fauci as the most relied upon official
for information regarding the COVID-19
pandemic,
and for very good reasons having served
as the director of the National
Institute of Allergy and Infectious
Diseases
or NIAID for more than 35 years.
Dr Fauci has led our nation's response
through a number of health crises
in the 1980s. For example his work was
instrumental
in addressing the HIV/AIDS crisis that
hit our Bay Area community
especially hard. Today we will discuss
the state of the COVID-19 pandemic,
our progress against this disease and
what the future of health care will look
like
in its wake. Dr. Fauci, thank you for being
with us today.
We've received over 2,000 questions
submitted in advance of today's fireside
chat, and we've tried to organize them
into several themes.
Now let's get started. Dr. Fauci, you've
been called
America's Doctor. You've advised six
different presidents.
We hear reports of 18-hour work days
which must be filled with countless
demands on your time.
Do you have time to reflect on the
unprecedented nature of what you're
managing?
How are you dealing with the stress or
confines of the pandemic,
given how much you're in the spotlight?
Well that's an interesting question.
Thank you, thank you for having me here
with you.
Yeah, this is unprecedented in what it is.
You know, one thinks about the worst
nightmare of a
infectious disease person who's
interested in global health and
outbreaks
is the combination of a new microbe that
has
a spectacular degree of capability of
transmitting and also has a considerable
degree
of morbidity and mortality, and here it
is. It's happened, you know,
your worst nightmare, the perfect storm.
How i'm dealing with it is, you know, it's
one of those things you
you really --  it it's just functioning on
adrenaline.
This is a really serious problem. It is
truly historic.
We haven't even begun to see the end
of it yet.
I mean it's still globally threatening, I
mean
some countries are doing better than
others, but until you get it completely
under control,
it's still going to be a threat. So it is
truly unprecedented.
We're doing what we can -- you know I'm
sure we're going to get into with the
other questions
various aspects of it -- but as you
mentioned in the introduction about HIV,
of all the emerging infections that I
have had to deal with
in the 36 years that I've been the
director of the institute, starting off
from HIV
in the early 80s with Ebola and Zika and
anthrax attacks,
this is clearly the most challenging.
It's the most challenging
because it's so pervasive, I mean it is
truly
a global pandemic of really
when I say unprecedented, unprecedented
back
to 1918, historic pandemic which was
called the Spanish Flu.
I think 50 years from now people are
going to be reflecting historically on
this
the way we used to reflect on the 1918
outbreak.
Perhaps we would start with a level set
on where we are right now with this
pandemic.
We're all concerned about the increasing
numbers of COVID-19 cases,
what are your thoughts about how we
navigate this surge
and what are your predictions about the
COVID-19 pandemic
and how it's going to evolve in our
country and the world in the months
ahead?
Okay, good question. If you put aside for
a moment -- and we'll get back to that --
the issue of how things could be
completely turned around
when we get a safe and effective vaccine,
and talk about
now today in the absence of a vaccine
what is going on what what can we
foresee
in the immediate future, it is very clear
and we know this from countries
throughout the world,
that if you physically separate people
to the point of not allowing the virus
to transmit
and the only way to do that is by
draconian means of essentially shutting
down a country,
we know that we can do that if we shut
down.
The Europeans have done it. People in
Asia have done it.
We did not shut down entirely and that's
the reason why when
we went up, we started to come down and
then we plateaued
at a level that was really quite high,
about 20 000
infections a day, then as we started to
reopen
we're seeing the surges that we're
seeing today as we speak
in California, your own state, in Arizona,
in Texas, in Florida, and in several other
uh states. So that when you try to reopen,
if you're not handling the surgency well,
what you're seeing is what we're seeing
right now.
So we need to drop back a few yards and
say okay
we can't stay shut down forever
economically
and the secondary unintended
consequences
on health on a variety of other things
make it
completely non-tenable for us to say
completely shut down
for a very prolonged period of time. So
you've got to shut down, but then you've
got to gradually
open, and we made a set of guidelines
a few months ago with good what we
call
checkpoints. We had situations where you
do
entry, then you would have phase one,
phase two, phase three. Unfortunately
it did not work very well for us in an
attempt to do that.
Test assessed the increase that we've
seen.
So we can get a handle on that .I am
really confident we can,
if we step back. You don't necessarily
need to shut down again, but pull back a
bit
and then proceed in a very prudent way
of observing the guidelines of going
from step to step.
All you needed to do was look at the
films on tv
of people in some states who went from
shutdown
to complete throwing caution to the wind:
bars that were crowded -- people without
masks -- there are things you can do now,
physical distance, 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
looking forward.
Understood. If we look six months from
now, if
if we do the things you recommend and
that'll transition us then into
discussing therapeutics and ultimately a
vaccine.
But what's your outlook for six months
to a year from now
um and how are you hopeful
about therapeutics
that may come on board before we get an
effective vaccine or vaccines?
Well, your points are very well taken.
Right now,
we've shown through randomized
placebo-controlled trials
that there are two interventions that
clearly
have a significant benefit in people
with advanced
disease, hospitalized patients. When
you're dealing with dexamethasone
either on a respirator or requiring
oxygen,
when you're dealing with remdesivir
best effect
not ventilator but someone with low flow
oxygen requirement, what we really need
and we're on the track
of getting them, are interventions that
can be given
early in the course of disease to
prevent people
who are vulnerable from progressing to
the requirement
for hospitalization. And those are direct
antiviral drugs,
convalescent plasma, hyperimmune globulin,
monoclonal antibodies and a number of
direct
acting antiviral agents. I believe we are
on a good
track to get there reasonably soon.
I already mentioned the two for advanced
disease
but we really want to get stuff early.
Vaccine,
as you know there are multiple
candidates that are in various stages
of clinical trial. One or two of them
will go into phase three for efficacy
literally at the end of this month, so
we're pretty
cautiously optimistic that at the end of
the year
beginning of this coming 2021, we will
have one and maybe more -- I hope more than
one  -- vaccine
that would be available. Dr. Fauci, you're
known for your candor.
How's the Bay Area doing in terms of our
response? Can you give us a grade?
No. I get into trouble when I grade
people. It's a little bit presumptuous to
do. California,
being the large state that it is,
is a bit of a mixed bag. You know,
relatively speaking the Bay Area is
doing
better than other areas in the southern
border
with Mexico, where we're seeing a lot of,
a situation where the surge
is really rather significant there. So I
think it really is a big difference
because
when you get a state like california or
like Texas,
it's so large you can't
uni-dimensionally make a statement about
it.
But I can tell you one thing is true, for
a positive note,
that I've worked with with Governor
Gavin Newsom
for for throughout these entire few
months,
and he really has his handle on it,
understands what he needs to do,
and I believe is doing a really very
good job ,as are several of your mayors
actually.
Thank you. As you know in early March,
Stanford was one of the first academic
medical centers in the U.S. to develop
its own diagnostic test
which we helped make testing available
in Northern California
in those early and very trying months.
What role can academic medical centers
play
in the current crisis, and how can we
advance pandemic preparedness
moving forward coming out of COVID-19?
Well ,that's a great question, and I'm
glad that you asked that.
We have such extraordinary talent in our
academic medical centers.
We really need to begin to leverage them
more.
Several ,such as in New York City, when
the
you know the New York Presbyterian
Cornell and Columbia
and places like that, NYU, they really got
involved and were very
contributory to getting our arms around
the outbreak.
California has a number of world-class
academic medical centers. I mean in the
Bay Area alone,
you have UCSF and Stanford right there,
two among others, that are some of the
best in the world, and I think getting
them involved, which they are actually
many of them, you
mentioned the idea about the
diagnostic test,
I think if the rest of the country
would leverage their academic medical
centers to get involved, we'd be much
better off.
Dr. Fauci, you are a physician-scientist
and
an exemplar of the physician-scientist
role model.
What are your thoughts about the
training of the next generation of
physician-scientists?
What can we be doing to encourage that
training, make it more effective
and make sure we're prepared in the
future when pandemics like this arise?
Well, that's a great, great
question. If we just
I mean training physician-scientists in
multiple different disciplines, I can't hit every discipline, but the
discipline
of response to outbreaks, I think it's so
important that so many of our people now,
amazingly performers, I mean just doing a
great job.
We're learning on the fly, learning on
the job, you know
building the plane as they're flying it.
I think what we really do need,
and I've been saying this quite frankly
for a couple of decades,
that we really need to have a very solid
pandemic preparedness plan and
operational capabilities.
Because this is not something that is
going to go away and never happen again.
We've had outbreaks before. None as
serious as this.
But we've really got to use this as a
lesson to be prepared for the next one,
as we learn our way through this one.
What types of things do we need to do to
be better prepared, if we look at
all the way from the spectrum from basic
research, translational research, clinical
trials,
the public health infrastructure in the
United States. It's a vast topic,
but can you share some ideas about the
tangible next steps that we need to be
planning for
now so we don't run into this
predicament a decade
or or any time in the future?
You know, I could address it from
multiple vantage points, but
let me take the one that I'm most
familiar with,
you know, as a physician-scientist and
that is
what can we do from a scientific
standpoint?
And there are many things that you could
do that would be applicable
to a response to any outbreak, things
that we
started to do and i think quite well and
it fared us well
in the rapidity of our response
in the arena of vaccine development and
that is to develop
new avant-garde upfront
really sophisticated platform
technologies,
where you can hit the ground running
with vaccine development
and not have to worry about growing out
the pathogen and inactivating it or
attenuating it.
We have a number of platform
technologies that, the more you perfect
them,
the easier you can make the transition
from an unknown agent
into a vaccine that's operational. That's
one thing.
The other thing is to study what you
call prototype
pathogens: in other words to get really
good
at a particular family
of potentially threatening
microorganisms. Give you an example.
The coronaviruses. This is the third
pandemic we've had in the last
18 years with coronaviruses.
We had SARS in 2002.
We had MERS in 2012.
And now in 2019, 2020
we got COVID. So it just makes sense,
if you want to do things like a
universal vaccine,
to something like a coronavirus. We've
got to do that, and we've got to do that
now. And when we get through this, the
same thing has to do with flaviviruses:
Zika and West Nile and Japanese
encephalitis.
We've got to be able to do universal
therapies
and universal platform technologies for
these.
That's the fundamental basic science.
Building public health infrastructure:
I won't do it, but I could use up all the
time just talking about that.
I mean, we have let the local
public health infrastructure in our
country
really go into tatters.
We were so, you know it's one
of those things where you're
victim of your own success. We were so
good
at controlling smallpox, polio,
tuberculosis, that we let the
infrastructure locally
essentially go unattended.
And what happened is that it attenuated
and attenuated,
and now when we need good local public
health capability,
it's not optimal. It's not as good as it
should be. We've got to build it up again.
When you look at the data and the
communities hardest hit by the
coronavirus,
it really highlights issues of
health care inequality
and access to care in our country. What
can we be doing now
and in the future to better address this
situation?
Good question, and I like the fact that
you said now and in the future.
There are things we can do now by
concentrating
resources in those demographic areas
which are suffering the most.
And you know it's like a broken record.
It's the same thing.
Minority populations are
disproportionately negatively
impacted by diseases like this.
And in your state, it's you know mostly
African Americans and Latinx,
with some Native Americans in certain
parts of your state.
And it's true, you know, when I say it's
like a broken record.
It's because I've been through this now
in two
major -- HIV,
which is what I started off with in the
early 1980s --
HIV now today in our country 13 percent
of our population is African-American
and 45
to more percent of the new cases are
among African Americans.
Of them, 65 percent are men who have sex
with men.
Of those, 75 percent are young. take
COVID-19. Same thing. If you look at the
incidence of infection, on the basis
of how  -- in general you 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 requires their physical presence, so
they're immediately at more risk
of getting infected when they do get
infected.
When you look at the prevalence and
incidence
of comorbidities
that make you at higher risk for a poor
outcome,
they have most of them more than the
caucasian population:
hypertension, diabetes, obesity,
chronic lung disease, kidney disease.
It's striking how disproportionately
they are disadvantaged.
We recently held our annual rite of
commencement for the 2020 School of
Medicine graduating class.
What advice do you have for the next
generation of physicians,
scientists, researchers, not just at
Stanford, but across the country?
Well you know -- I mean I'm
obviously quite prejudiced on this
because
it's what I've been doing, but the
opportunities in medicine,
if you just want to do medicine and just
see patients that's an incredibly noble
profession, and you could tell right now
what we're going through
how important those front line health
care workers
are. If you're interested in the
scientific bent
to what you want to do, never before in
history
have the scientific opportunities been
so spectacular
as they are right now, you know, so much
so
that I often fantasize I like to turn
the clock back
and be 25 years old again starting all
over again.
I know many of the young people would
say this guy's crazy
to want to do that, but the fact is
it's so exciting that things even
now with my experience and
what I've done, I still am in awe at
what's coming out from a scientific
standpoint.
Dr. Fauci, you've mentioned already
several times about the
HIV/AIDS pandemic, your important role in
it, the important role of
your institute. One role that you
and the institute have played very
importantly in HIV/AIDS and now
with COVID-19 is in clinical trials. In
fact,
you were instrumental in redesigning the
clinical trials
infrastructure in our country during HIV/AIDS.
How do you think about now with COVID-19,
the structure we have
for clinical trials -- you mentioned before
and perhaps we'll cover in a little bit
greater detail
now -- the focus on outpatient therapeutics.
But
is our structure the way it should be?
What do we need to tweak? What are we
learning in real time
from this pandemic about what needs to
be changed, moving forward,
about the clinical trials infrastructure,
its funding ,its oversight
in our country? No, I think what's very
clear,
and I just am so pleased that we've been
able to show it,
not too long ago there was the incorrect
assumption
that you can't do research in the middle
of a pandemic or an epidemic outbreak
because it's very important to, whatever
treatment you have whether it's proven
or not,
get it to the people because they need
it and is better than nothing.
That's an understandable approach, but it
really is flawed.
Because 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, but
you want to learn
from it so that you can help that many
more.
Until recently it was felt that
ethically
even you shouldn't do research in an
outbreak,
and we proved that wrong in the Ebola
outbreak.
We did randomized placebo-controlled
trials.
We proved that a couple of therapies
worked. A vaccine was d,eveloped,
and now already with COVID-19
the two drugs that have now definitively
shown to be beneficial
in advanced disease were proven by a
randomized
placebo control trial. So, clinical
research and clinical research
infrastructure
is a very important part of the response
to outbreaks.
And we've already proven that, and I
think we need to make sure we appreciate
that going forward.
If we think about those clinical trials
and focus for a moment here
in the outpatient setting, you mentioned
before briefly
some of the things that are being
developed. Maybe we could discuss those
in a bit greater detail.
There are monoclonal antibody therapies
being developed in early stage trials
now.
There are also trials looking at
repurposing
of other antiviral agents to see if
they're effective
in COVID-19. What are you most
enthusiastic about,
and what are your thoughts about the
pace of these trials and
whether or not, maybe by the fall or
winter, we'll have a regimen that
could be beneficial in the outpatient
setting to a person newly diagnosed with
COVID-19,
fortunately not sick enough to go into
the hospital, but hopefully
increasing the probability that they
won't have to go into the hospital
and that the recovery time will be
shortened. Where are you most hopeful?
Where do you see the progress being made?
Well, given the experiences that we've
had
with Ebola and monoclonal antibodies,
I think that that's almost a sure bet
is monoclonal antibodies directly
against the virus
to be given in a single or a couple of
intravenous infusions
in people early in the course of
disease to prevent the necessity of
their going into the hospital
in advance. So right away that's up front,
they're going in, there are multiple
clinical trials now that are doing that.
Convalescent plasma, I think we need to
have some
caution about that, want to make sure you
do it right. You've got to get the right
titre of antibody
because there's amazing variability in
titres of antibodies and people. So
the best way to get that done, it's a
little bit more work,
is to get the convalescent plasma and do
hyperimmune globulin that you could
titrate
and know exactly what you're giving to
people.
The thing I'd like to see more of, and we
will see it, is screening
of molecules that are pure antivirals
that can be given early on.
You know remdesivir is an antiviral,
but there are polymerase inhibitors
and protease inhibitors and things like
that very similar
to what we did with HIV that I'd like to
see that pursued a bit more.
So I think, by your timeline that you
mentioned,
sometime in the fall, I think we could
conceivably have a couple of more good
antivirals,
as well as anti-inflammatories.
You discussed work towards a
vaccine or vaccines earlier
in our discussion today. Perhaps we could
follow up on that
by, if you could give us your thoughts on
when a vaccine or vaccines are available,
there will be a massive push
for distribution, for immunization.
What type of an allocation methodology
should be set up
and how are you thinking about bringing
online
and distributing throughout the United
States and then the world
the vaccines, as they move through the
various stages of trials, and
and hopefully get to FDA approval?
Well one of the encouraging aspects
about the approach to this
multi-candidate vaccines
is that the companies that are involved
with substantial financial help from the
federal government
are making a commitment to start
producing
large numbers of doses of the vaccine
even before it's definitively proven to
be safe and effective.
So the risk is a financial risk ,because
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 to be effective, you've
gained multiple months
in the process. So assuming now,
I'd like to make a reasonable assumption
that sometime in the beginning of 2021
we have a couple of vaccines that are
safe and effective,
the distribution will have to be done in
as equitable way as possible.
Obviously, you ultimately want to
vaccinate everybody,
but as doses come online,
you're going to have to prioritize. And
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. Of course, having a vaccine that's
been shown through
rigorously controlled trials is
effective is a necessary
first step, but we also know that in
america today
there's a lot of skepticism about
vaccines. What can we
as physician-scientists, as leaders, do
to reassure and regain public trust in
vaccines,
which as you've said are almost
certainly going to be essential
to the control of this pandemic?
Well, it can be stated in a few words.
Community
engagement. We did that with HIV,
when we had treatments and prevention.
We've got to engage
the community, to get out there
and be people who are boots on the
ground
who look like, and are like, the people
that they're trying to convince
the importance of getting vaccinated,
particularly,
in this era of anti-vaxx and
anti-science.
We now have a network of community
workers
who are getting ready and prepping them
up to go into the community
and try and convince people of why it's
important for them
and for their families to get vaccinated.
But you've got to do it in a way
that fits the community. As I often say,
you don't really want a lot of white
guys in suits like me
going into a mostly minority community
and convincing them about something that
they're very deeply skeptical of.
You've got to get people that the
community trusts.
Dr. Fauci, if you could look at the
scientific unknowns today
about this virus and about its disease
COVID-19,
what are the top four or five things
that
if we knew today we would be much better
off in the future,
recognizing that that the knowledge
continues to evolve and
and the entire pace of this pandemic I
think is unprecedented
for all of us, in terms of first showing
us how little
we understood about the virus and about
its manifestations
uh as COVID-19. We know more now but
there's still a lot of questions to be
answered. I was wondering what your
thoughts are,
what the critical questions are at this
juncture.
Sure. The critical question, obviously, you
just mentioned a little while ago.
Will we get the body to induce a durable
response
that can protect you, whether that
response
is following recovery from natural
infection
and/or induction of immunity
by a vaccine? Is it possible to have
durable effective immunity? I think it is,
but it's still an unanswered question
that we need to prove.
Number two, what about the chronic
long-term effects of people who recover?
We're only six months into it. We're
getting
lots of anecdotal information
which needs to be verified by large
cohort perspective -- follow-up studies
is when people recover, how soon
until they get back to normal? 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. That's
the second thing. The other thing we want
to know
is what is the full extent of the
clinical manifestations? We learn things
every week,
like this bizarre,
multi-system
inflammatory syndrome in children.
That's really important MIS-C, it's
called.
And then finally, what about therapy?
Are we going to be able to get a good
antiviral, the same way as you can
essentially shut it off
completely, so the second you get a
diagnosis,
you take a few pills or you get an
injection and you've actually suppressed
the virus?
Those are the four areas that I really
want to know about
as we go forward. Returning to a point
that we discussed earlier on
public health and public health
departments within
communities within states and then the
public health infrastructure across the
country,
you know we are a nation founded on the
principle of federalism where
things are distributed between the
federal government, states and then local
communities,
and yet this virus doesn't know the
difference between one county or one
state or
indeed one country to the other: How do
we need to think about  --
you talked very passionately about
reconstructing, rebuilding our public
health infrastructure in the United
States --
how do we need to think about balancing
the local
public health departments, where the work
is actually being done with people,
and then a broader infrastructure
related to public health at the state
and national level?
Well, that's the $64,000 question
that's being debated right now in our
response.
You know, there's arguments back and
forth:
should the government, the federal
government, provide resources, direction,
guidance,
and then pull back and let the states do
it?
Or should they direct it federally? You
know you can get arguments on both sides.
Many of the states say, Give us the
resources,
we'll take care of it.' Others say, 'Tell us
what to do,
and we'll do it.' So, we're a big country.
We have 50 states.
We have 3,007 counties. So,
it really is an ongoing argument,
and there are pros and cons of each
approach.
I mean there's some advantage of a
federally-dictated and mandated approach,
but there's also advantages of a
delegating-it-to-the-states approach.
And to be honest with you, I don't have a
good,
firm answer for you, except you've got to
figure out,
on a case-by-case basis, what's the
best approach would be.
Are there topics we haven't covered or
points you'd like to make
today or like us to keep in mind moving
forward?
Yeah, I mean, I just always make the
point, because
I try to get it articulated as often as
I possibly can,
is that this is a bit of a confusing
virus.
Because I've never seen one in which the
protean
manifestations are so extreme. You get 20
to 40 percent
of the population that can be
asymptomatic infection.
They don't even know they're infected
unless they get tested.
Then you get some that get minor
symptoms, moderate symptoms, severe
symptoms, hospitalization and death.
We've got to convince ,because right now
the people who are getting infected
during this surge
are young people about a decade and a
half younger
than the group that got infected in the
first couple of months
of the outbreak, we've got to convince
them
that just because they get infected and
the likelihood
that they're not going to get seriously
ill doesn't mean
that their infection is not a very
important part
of the propagation of the outbreak. So
you've got to think not only
out of your vacuum, and think of not only
your personal responsibilities,
but your societal responsibilities.
Because although you may not get
sick, almost certainly you're going to
infect somebody else,
who almost certainly infects somebody
else. And then you will get a vulnerable
person who'll be sick,
who will go to the hospital, who might
die.
So the best way to reopen the country
and to get back to normal
is to be very prudent in protecting
yourself
from getting infected. That's a difficult
message
when people don't take something
seriously, but we've got to hammer that
home.
Well, Dr. Fauci, thank you very much. And
thank
you to all who've joined us today for
this fireside chat with Dr.
Fauci. Be safe, be well
and take care of yourself. And take care
of each other.
Thank you.
