Ann Mossop: Welcome to the UNSW Centre for Ideas podcast, a place to hear ideas from the world's leading thinkers and UNSW Sydney's brightest minds. I'm Ann Mossop, Director of the UNSW Centre for Ideas. The conversation you're about to hear is the first David Cooper lecture. It's between Dr. Anthony S. Fauci and Tegan Taylor, and was recorded live.

Tegan Taylor: Hello, and welcome to the inaugural David Cooper lecture with Dr. Anthony S. Fauci. My name is Tegan Taylor, and I'm a health and science journalist at the ABC. Firstly, I would like to acknowledge the Bidjigal People that are the traditional custodians of this land. I'd also like to pay my respects to Elders both past and present, and extend that respect to other Aboriginal and Torres Strait Islanders who are joining us today. This event is co-presented by the UNSW Centre for Ideas, the Kirby Institute and UNSW Medicine and Health and we're thrilled to be joined by Dr. Anthony Fauci. Dr. Fauci, thank you for joining us.

Anthony S. Fauci: Good to be with you. Thank you for having me. 

Tegan Taylor: Dr. Anthony Fauci, for those of you who don't know, is Director of the National Institute of Allergy and Infectious Diseases at the US National Institutes of Health, where he oversees research on infectious and immune mediated diseases. Dr. Fauci’s contributions to research are too many to mention here. In fact, he's one of the world's most cited biomedical scientists. He was one of the principal architects of the President's Emergency Plan for AIDS Relief, a program that has saved millions of lives throughout the developing world. So Dr. Fauci, let's jump right in. Australia often likes to compare itself with America, but our COVID experience has been very different. Why do you think that is?

Anthony S. Fauci: Well, you know, I think it's important that what what the Australians did is that they had, I believe, at least looking at it from a distance, and in discussing with my Australian friends and colleagues, that you had the capability and the uniformity of your citizens that when you shut down, you really shut down, very effectively, you got to level down to essentially, as low as you possibly could get. And then when you had a situation where you opened up again, you responded quickly and efficiently. And I'm sure not everybody in Australia was excited about having to shut things down. But you did it in a way, which was really quite uniform. But importantly, effective. If you look at the United States, you know, we have 50 separate states, and territories, in addition to the 50 states, and part of our government structure is that the states have a degree of independence to do what it is that they want to do. They have interactions with the central government, but they have a great deal of leeway. And we had an inconsistent response, which allowed us, unfortunately, for us, to really do worse than essentially any other country, which is really extremely unfortunate. We now have over 555,000 deaths. And as of this past weekend, we had up to 80,000 new infections in this country. So it's a complicated situation. Australia, I believe, was one of the better countries in the entire world and how you responded. And unfortunately, we have not done nearly as well as we should have done.

Tegan Taylor: It's sort of a cultural thing, though, isn't it? Like, Australia has a quarantine culture, with the biosecurity. And America is very, very proud of its independence, and independence of its citizens. How do you change something like that at a country level?

Anthony S. Fauci: It was very difficult to do. You know what we had, again, I'm a, I'm a very loyal American, but I am a realist, too. And I see what is going on, you know, in our country, it is unfortunate that we are living, right now in our country, in a time of profound divisiveness. I think anyone who pays any attention to what's going on in the United States sees that. Now, in some respects, that happens in different countries. But when it spills over in the middle of the worst, most historic pandemic of a respiratory disease that we've had in over 100 years, if there's anything you want, is you want people to be pulling together in uniform. It's sort of like being at a war. The common enemy is the virus, and we should all be fighting the virus and not fighting with each other. So that has really been one of the real difficulties that we've had to face during this now 14 months and still counting with this epidemic.

Tegan Taylor: And that needs to be led from the top, and it's no secret that you and President Trump had… there were difficulties in having a consistent, cohesive approach there. Has that shifted now that Biden's taken office?

Anthony S. Fauci: You know, it certainly has from the top, there's no doubt about it, that President Biden wants to be… wants science to rule. He said that behind the scenes to us on his medical team. And he has said publicly that we are going to be driven and ruled by science and facts. And when something goes wrong, we'll try and fix it, and we won't blame anyone. That has worked extremely well. However, we still have a degree of divisiveness in the country. And we still have situations where governors, because of their independence, are essentially defying some of the recommendations and the guidelines of public health, which is one of the real reasons together with the variance, why I believe despite our great success with vaccines, we're of course, we're sort of in a race between the potential for a real surging of cases, and the fact that we're putting vaccines into people's arms extremely efficiently.

Tegan Taylor: That's been a constant challenge for you throughout your career, though, you've advised seven Presidents over decades. And there's sort of two jobs that you're doing, isn't there? You’re, sort of, managing up to the president, but you're also the head of, you're managing communication to an entire nation. How do you balance that managing up, and also that public health messaging?

Anthony S. Fauci: Most of the time, it is, I wouldn't say easy, it's never easy. But with some challenges, it works well. One of the difficulties that we had, over the previous months, not recently, but you know, last year, in the middle of the height of what was going on, is that I had to, and it was very painful to do, but I had to do it, come out and essentially contradict what the President was saying, which is a very difficult thing to do. And it led to some, obviously strain and stress between us, which even now after the former president is no longer in office, he still talks about that, which is unfortunate.

Tegan Taylor: So we put out the call to our audience for questions, and we've got hundreds of questions, and I'm not going to pepper you with all of them. But you mentioned before the vaccine rollout and UNSW alumnus Carla Burnett said, the US struggled at the start of its vaccine rollout, but has seemed to have picked up the slack. And Australia is also struggling with its vaccine rollout at the moment and wondering what advice the US can give to Australia in this regard?

Anthony S. Fauci: Yes, to the extent that it's possible, what President Biden did, is that he made it the very, very top priority, he put in a substantial amount of resources. He made equity a very important part of this. And what he's done, for example, is open up community vaccine centres, get vaccines to the pharmacies, develop mobile units to go out to get the people who are in poorly accessible areas, and got vaccinate tours, namely people who would be administering the vaccine, he got as many of them out into the field as he possibly could. Those are retired physicians, military personnel, nurses, medical students, as many people as you possibly can, to get out there and administer it. So it was really making it the highest priority to get vaccines into people's arms. And it works. I mean, when we had just the day before yesterday, I believe it was, we had 4.6 million vaccinations performed in a single day. That was a record that was really quite impressive. If we keep doing that, over the next few months, I believe we will finally get the overwhelming majority of the people vaccinated in the next several months, which I hope will then turn things around and get that level of daily infections down to a manageable level.

Tegan Taylor: How worried are you about variants?

Anthony S. Fauci: I mean, I'm always concerned about variants in general, there are some variants that are handled extremely well, by the vaccine. Fortunately for us, the B 117, which is sometimes referred to as the UK variant, we don't like to say that because that makes it seem like the UK is at fault, which they're not. It just happened, we believe, to take hold there, and now it is becoming the dominant variant in the United States. The vaccine works well against it. The trouble is, that variant has the capability of spreading much more efficiently than the original virus that seeded this country. So we're going to have an issue of what I would call a race between getting people vaccinated and not getting another surge. There are other variants that are of greater concern. Fortunately, they are not dominant in this country. And I refer specifically to the South African variant, to 351, which actually diminishes by several fold the capability of a vaccine to protect someone against infection. You do still pretty well, against severe disease and death, but against infection, it diminishes it below with the standard degree of efficacy is against most of the strains. 

Tegan Taylor: So you mentioned before about vaccination being something everyone's to do, that idea of health equity. And Sophia Henning, who's a UNSW student was asking about, whether you think that the COVID-19 health crisis in the USA has increased American public support for universal health care, or if it's further entrenched the current model?

Anthony S. Fauci: Well, as you know, the Affordable Care Act was one that attempted to get to that point that you're referring. It needs to be improved, and will be improved. As you know, there were attempts to essentially destroy that, and that has been unsuccessful, because there's been no alternative for it. But we really feel strongly that if we get the Affordable Care Act with some improvements in it that we would have what would be the equivalent to universal health coverage.

Tegan Taylor: So everyone has been pretty good — everyone — epidemiologists and virologists and infectious disease experts have been predicting a global pandemic for years. And it was called disease X, and it was inevitable, but it happened. When was the moment that you realised that COVID-19 was going to be a big deal?

Anthony S. Fauci: Well, it was a gradual issue. And one of the things that prevented us from knowing right off that it was going to be a big deal was the early lack of transparency on the part of China, which is really unfortunate. Not all Chinese, but the Chinese officials, because the scientists that had been our colleagues for years, in some respects, some of them were not allowed to really openly talk about it, because you might recall that the first inkling of something goes wrong was a new type of pneumonia, was coming out of Wuhan. And it was felt that well, it was similar to SARS, the original SARS, where a jumped species from an animal somewhere in the environment of the wet market in Wuhan. So the standard line then was, well it doesn't really spread very efficiently from human to human it’s merely just jumping from an animal to a human. And then after a little bit, it was, well it goes from human to human, and then after another little bit, well it goes really efficiently from human to human. And then finally, and by the way, it's a very unusual virus, because it spreads from people who aren't even symptomatic. So we knew there was a problem when China was doing all the things they were doing, building like field hospitals, you know, practically overnight, that they wouldn't be doing that unless there was a situation that they felt was really dire. When we got hit in New York City, and it was very clear that we were having rapid spread of this virus with a very dire consequence among certain subgroups, such as the elderly, and those with underlying conditions. You know, it became very clear after that second month or so that this was not going to go away. This was really a serious historic problem.

Tegan Taylor: Yeah, I suppose China perhaps wasn't transparent at the beginning, but they did mobilise really quickly which the rest of the world has also had to learn to do. And despite that early hesitancy to be transparent, the pandemic has really been characterised by international collaboration.

Anthony S. Fauci: Well, there's no doubt. I mean, a global pandemic requires a global response. And a global response includes transparency. And includes sharing of information, includes international clinical trials, which is, you know, the reason why I was so pleased, when on the first day of President Biden's presidency, he asked me to represent him at the Executive Board of the WHO, and to announce to the world that we were reentering the World Health Organization, and we were going to become an active part of COVAX. So, that I think is something that took a while. But finally, we're back where we should be. The United States as an important part of a global effort.

Tegan Taylor: So, obviously, the United States has a lot of work to do to protect its own citizens. But what responsibility do you think that wealthy nations like the US and Australia have to the developing world?

Anthony S. Fauci: You know, I think we do. I mean, it was my strong feeling about responsibility, which prompted me to play a major role in developing the PEPFAR program, the President's Emergency Plan for AIDS Relief, which as you probably know, has saved now up to 14 million lives. I believe that the developed world has a responsibility to assist the developing world and things that are not readily available to them. And that's the reason why we started COVAX, we didn't start COVAX, we joined COVAX. Namely, we have a situation where we pledged, or given $4 billion. We will clearly, when we get our people vaccinated, be very seriously considerate, and I'm saying not only consider, but we will do, share some of the excess vaccines that we have. And I think we also would like to perhaps be part of a movement to allow some of the developing countries to produce vaccines on their own, to give them the capability of being able to produce it, rather than relying on outsiders to give it to them.

Tegan Taylor: Because it's not just about… it is philosophic, philanthropic, to go and help developing nations. But it also helps all of us, we're all human, with the same biology and variants that emerge in other nations still threaten the developed world as well.

Anthony S. Fauci: No, you're absolutely right. And I think that's the critical issue that I have, you know, personally, as a public health person, have felt so strongly about that, particularly when you have a disease, an infection that spreads so easily and so efficiently as this virus does, that, even if you control it well, in your own country, the way Australia is done, the way we hope to do. The way many of the European countries, even though they're going through a terrible time with surges now, in several of the countries of the European Union, when you ultimately get it controlled, if you want to maintain the control, you want to have control throughout the entire world. Because as long as there's the dynamic of virus replication somewhere, there will always be the threat of the emergence of variants, which could then come back, and even though most of the rest of the world is vaccinated, it can threaten the world that has felt that they've controlled the virus, when they're still quite vulnerable.

Tegan Taylor: What is our way out globally, then? because last year, it was all like we just gotta get through 2020, and now we’re 2021 and it still hasn't quit. Where to from here?

Anthony S. Fauci: Yeah, I believe vaccination is the answer. I mean, variants are a problem, no doubt. But we are fortunate, given the investments that were made in biomedical research over so many years, due to the extraordinary advances in vaccine platform technology and structure based design of immunogens that are optimal immunogens, that we now have several vaccines that are highly efficacious, and when put into the field that efficacious, becomes quite effective. And we're seeing that, in my country, in which when we vaccinate people, we see that it really does work out there in the field. The issue is, we've got to get the overwhelming majority of the population vaccinated, which brings us, you know, to another one of the potential stumbling blocks that we have in the United States, is what we call vaccine hesitancy. Where people don't want to get vaccinated for reasons that don't seem to have anything to do with public health. It's unjustified scepticism. It's a political ideology, where you look, I mean, how could it be that a certain proportion of people of a particular persuasion don't want to get vaccinated? That just doesn't make any sense. What does vaccine, which is directly related to public health, and over decades, if not centuries, has proven to be the most extraordinary preventive modality that you have for infectious diseases, how does the acceptance of that or not become a political issue? But unfortunately, in many respects, it has.

Tegan Taylor: Vaccine hesitancy is nothing new. People have been hesitant about vaccines since they were invented. But it does seem to be a real issue at the moment and like you say, political. How do you think that's evolved to be the case?

Anthony S. Fauci: You know, I think it's… first of all, it's complicated. So I think I'm not gonna give you a five word, you know, quick answer to it. It really is a complication of an anti-science atmosphere that has evolved, again, with a certain type of political persuasion, that scientists don't know what they're talking about, a lot of this is fake news, a lot of it doesn't really exist. I mean, to say things like that, when you have a terrible pandemic looking you straight in the eye, you know, in some respects, is almost inexplicable. But unfortunately, it's happening. And that's one of the real issues that I said right from the get go. One of the more difficult aspects of this entire endeavour here, has been, is that, it  has occurred in a situation of very intense divisiveness in our country. And also, not just the United States, we're seeing some of that in the European Union also.

Tegan Taylor: So this is the David Cooper Memorial Lecture, David Cooper pioneered AIDS research in Australia. And one of the things that really worked for his work here in Australia was partnering with the LGBTQ community. And I know that that's something that you came around to as well, in your work. Does a similar approach need to be taken for COVID-19, where there's some more, kind of, community level, public health messaging happening for these people who are really resistant?

Anthony S. Fauci: You know, I wish that were the case. I really do. When we, when I dealt — and that has been a very important part, I believe, of what I did, and what David did in Australia. And you know, David and I were very good friends for many, many years, way before HIV and AIDS came along, actually, when he was a fellow with Ron Penny. So we had the same attitude, that you needed to reach out because the community, when they were essentially pushing back against the scientific establishment, and against the regulatory establishment, because they felt, justifiably and correctly, that we were not giving them a voice in what was directly affecting them, in the design of clinical trials, in the loosening of the regulatory issues. That we were taking years and years to make decisions about drugs, when they at that time had had a lifespan measured in a year or less. So although they were being iconoclastic, they were being disruptive. It wasn't a political difference. It was a difference in saying, listen to us, because we feel we should have a voice in what gets done. And they were absolutely correct. So when I extended myself to them, and said, let me listen to what you have to say, what they had to say made absolute sense. And I said to myself, you know, if I were in their shoes, I would be doing exactly what they're doing. That is an entirely different situation, from someone that tells you that this is all a hoax. And it's fake news. And it doesn't exist. There's a big difference there. So although I would love, and do extend myself, with a substantial investment of time, to get people to get vaccinated, the hardcore ones that don't want to, for political reasons, I don't think I could change their mind. If someone has a hesitancy because they have a doubt about, was it done too quickly, or, we have a very important situation in our country with all minorities, our African Americans and Hispanics, our Brown and Black people, because they justifiably are somewhat sceptical about anything that government does, because of the way they have been treated. So the way we get to them, is we totally respect their scepticism and say, let's together try to work our way through this. Because the reason for your scepticism, even though we have many, many guardrails in place now, to prevent those injustices from coming now, the fact is, the history of the injustice’s to you, are real. So we respect it. Once you get past that, then you could say, lo, it wasn't done too quickly. It was only a reflection of spectacular advances in science. It wasn't done carelessly, there's a good reason to do it. Here are what the data look like, look at the data. When they see the data, they say, you know, I'm convinced, I think I'll do it. But the hardcore people who do it, who are resistant, for other reasons, it's going to be very tough to turn them around.

Tegan Taylor: So when you can, you're coming alongside people and earning their trust first, and then kind of blasting them with facts later. What do you do about the hopefully, minority, who’ve just got their fingers in their ears?

Anthony S. Fauci: Well, what we hope happens is that when they see more and more people get vaccinated, and they see the actual protection among those people who are getting vaccinated, that they will ultimately have common sense take over and say, this is good for me, and quite frankly, is also good for the country. Because there are a couple of reasons to get vaccinated. One is for your own personal health. And the other is for what you consider your societal responsibility, to have your society protected by this overwhelming veil of immunity that comes over the country when you get so many people vaccinated.

Tegan Taylor: So we mentioned before that you're early in your career with the AIDS epidemic. What did you learn during that time that has, sort of, informed the rest of your career up until now?

Anthony S. Fauci: Well, there are several things about it. I mean, scientifically, what I learned, and I've been dealing with this now, HIV AIDS is still very much on the radar screen. I've been doing it for 40 years now. But it is, you know, impressed upon me that new infections have always emerged. They are emerging now. And they will continue to emerge. So the lesson learned is that to the extent possible, prepare yourself as best as you possibly can. And there are a couple of ways to prepare. You can prepare by building a good public health, global infrastructure, the global health security network, for example. By having the kind of transparencies that we mentioned a little bit ago, when we were talking about China. The idea that we make investments in public health infrastructure, which interestingly, in the United States, we've let be a victim of attrition, the local public health. The other thing that I feel as a scientist, is as important of all of that, is the investment in fundamental basic and applied science, which will allow you to respond quickly, when you do get an emerging infection. And by quickly I mean, doing things like building on prototype pathogen experience, what we mean by that is, for example, we developed, I'll give you a very brief story about the immunogen that's so successful right now, to spike protein in the right conformation, to induce the best immune response. That was an interdisciplinary effort of structural biologists, X-ray crystallographers, Cryo EM experts, that were able to study the conformation of molecules that you can then, by mutating them, keep them in a stable form to be used as an immunogen. It was years of work, developing new platform technologies, like the mRNA. It's that kind of investment in research that generically forwards and advances all of the things that you can do. So that when you get confronted with an outbreak, that outbreak doesn't turn into a global pandemic. And that's what I've learned over the years.

Tegan Taylor: Yeah, I think the public and politicians as well often want scientists to just be able to pull a rabbit out of a hat. But you need to be laying that groundwork in the good times so that when these pathogens emerge, you're ready, like you say. So, people, so, the Kirby Institute's involved in some major NIH sponsored COVID and HIV trials, and we've called there's been a lot of talk about the current global research effort as being unprecedented. But actually, a lot of the foundations for this will aid in the AIDS epidemic. What sort of international collaborations that began with HIV have helped the COVID research effort? 

Anthony S. Fauci: Well, there's one that is really important, and that is, back in the mid to late 1980s, mostly the mid 80s. I began in my institute to build a Clinical Trials Network that was global. And what we did is that we made major investments into clinical trials sites, to train and fund investigators throughout the world, including people like my good friend, David Cooper, and others, including many of the very talented Australian investigators. We did it in Africa. We did it in Asia, we did it in South America, we did it in the Caribbean, and we did it in Europe. So now, when you have the need to do international clinical trials, you can actually call upon the experienced investigators, who for decades, both they, and their trainees, and their mentors, had successfully done clinical trials with HIV. Be they prevention trials, be they vaccine trials, be they drug therapy trials, they had a lot of experience. So it was that investment. And that experience that was gained, very successfully, with HIV AIDS that allowed us to spring out of the box quickly and very effectively in clinical trials with COVID-19. 

Tegan Taylor: What is the benefit, practically, of having the ability to do those sorts of trials in different parts of the world?

Anthony S. Fauci: Well, because sometimes disease is not uniform in different countries. And when you have a network that expands throughout the world, there may be a hotspot in one area, and you do the trials there, that would benefit the rest of the world. Or, there may be different conditions, in different parts of the world that you want to learn about, what the best ways to prevent, under various conditions. I mean, what goes on, for example, in KwaZulu Natal in South Africa, in many respects, is different from the profile that you see in Sydney, or Melbourne, is very different than what you might see in Italy, or in Canada, and the same thing holds true for Thailand versus Haiti. So you really gotta have a broad umbrella of clinical trial sites and capabilities of studying very different aspects of the outbreak under different conditions.

Tegan Taylor: And, sort of, on that theme of, really, equity, global equity. Jane Costello, whose partner of the University of New South Wales, she's the CEO of Positive Life New South Wales, which represents people who are HIV positive. She was asking about your reflections on the role that stigma has played in both the AIDS epidemic and the COVID epidemic.

Anthony S. Fauci: Yeah, well, stigma has clearly played almost an acute, negative impact on HIV, the stigma associated with a disenfranchised group, namely gay men, back then, who were not too long before 1981, finally were able to express their own sexual identity freedom with the famous Stonewall riot in the bar in Greenwich Village, which allowed them to finally be out there with their own identity. But the stigma against gay men then, and against commercial sex workers, and against injection drug users, in a disease that was mysterious, was really, it's much more improved, now, much better. But it was really a problem back then, and in some respects, still lingers. Stigma in some other countries, still to this day, 40 years later, is a problem in certain regions, in sections of Southern Africa, the stigma associated with HIV is still there. And again, that has, in some respects, attenuated a bit, but it still lingers less than stigma. With regard to COVID-19, I have found that at least in my own country, it has shed a very bright light, the disease has on the health disparities in my country, cause we know that African Americans and Hispanics have a higher incidence of infection, because of the nature of the jobs they have, they’re essential workers in society, more often than not. But also, importantly, due to the conditions that they have been under, the social determinants of health, as we call it, they have a higher incidence and prevalence of the underlying medical comorbidities, that when they are present, they view a greater chance of getting a serious outcome with hospitalisation and death. And in fact, that is the case in my country, that if you look at the rate of hospitalisation, per 100,000, population of African Americans, Hispanics versus whites, it is multi fold greater among the minority populations. And if you look at deaths, it's one or two times greater among minority populations. Those health disparities are a reflection of things that have been inherent in our society for forever. And if there's one, I think, positive thing that comes out of this outbreak, is the realisation that we really need to do something about those health disparities. So, I think it's a little different than stigma. It's related indirectly to stigma. But it goes beyond stigma, it goes to the structure in the country that has allowed that to happen.

Tegan Taylor: These health disparities have been known about for years, though, what is it about COVID-19 that's put them into such stark relief?

Anthony S. Fauci: Well, the consequences of a person who is an African American or Hispanic, who the incidence of diabetes, hypertension, obesity, chronic lung disease, heart disease, is much higher in that population. You don't notice it, even though you should, when it's shorter there, a long period of time. Then when you get a disease, like COVID, that specifically kills people with that type of underlying condition, then all of a sudden, a bright spotlight goes right on that and says, oh, my goodness, we really need to do something about this. And like I said, I hope if anything comes out of this terrible ordeal that we're going through, that it is a realisation that we've got to address these health disparities.

Tegan Taylor: On that, and probably our last question, question sent in from Pejman Kejmadush, who says, there's a whole new generation of doctors who are training as medical students right now. What do you hope they've learned from this pandemic that they can take into their practice?

Anthony S. Fauci: Yeah, I think what they can take into their practice, on the outside is that bad things can happen. And bad things are pandemics. And that we really do need to be prepared for that, at every level. Not only just in a public health level, but in a local level, of taking care of patients. The other thing, I think, that we've learned is how extraordinarily courageous our healthcare providers have been, they should be very proud of themselves. If there ever is a hero and a heroine in this, it is doctors and nurses and our other health care providers, they've really risen to the occasion. And I think they've proven to themselves that they can do that. So I think when all this is over, they will feel that they've accomplished something that's most extraordinary and historic.

Tegan Taylor: And what do you hope the general public takes away from it, apart from just general public health messaging of cleanliness, and being aware of pathogens?

Anthony S. Fauci: Well, I think it's what you said, it is an awareness that this can happen. And I think the resources that we as a global community need to put into this. I mean, I don't think you could have any more cogent reason to do that, than to just look at what we've been through as a global community over the last 14 or 15 months. That's got to be a big lesson learned.

Tegan Taylor: Absolutely. Well, thank you so much to our audience, for tuning into the inaugural David Cooper lecture with Dr. Anthony S. Fauci. Dr. Fauci, thank you so much for joining us and for sharing your insights.

Anthony S. Fauci: My pleasure, thank you for having me.

Ann Mossop: Thanks for listening. For more information, visit centreforideas.com, and don't forget to subscribe wherever you get your podcasts.