Anthony Fauci has spent the past year trying to curb the worst health crisis the world has seen in a century.
In a recent University of Chicago event, Fauci reflected on how the COVID-19 pandemic has been a “painful learning experience” for he and other health officials. On this episode of the Big Brains podcast, please enjoy Fauci’s conversation with Prof. Katherine Baicker, dean of the Harris School of Public Policy, who presented him with the 2020 Harris Dean’s Award.
Tape: The instinct is to say, “We have a really good vaccine. I’m vaccinated. I got a 95% effective vaccine. Why can’t I do whatever I want to do?”
Paul Rand: If you don’t know that voice by now, you might be quarantining from the world just a little too intensely. That, of course, is Anthony Fauci.
Anthony Fauci: Ultimately, you may be able to do that, but not right now because there are things we don’t know.
Paul Rand: Last week, the Harris School of Public Policy here at the University of Chicago awarded the 2020 Harris Dean’s Award to Dr. Fauci, presented naturally by friend of the podcast, Dean Kate Baicker.
Katherine Baicker: Dr. Fauci, it is an enormous honor for me to be able to bestow this Dean’s award on you this year. As a health economist, I am a huge fan. So it’s a personal thrill as well.
Paul Rand: After the presentation, the ever-gracious Dr. Fauci agreed to do an interview with Dean Baicker, and we couldn’t pass up on the opportunity to share that interview with you on the Big Brains podcast. In their conversation, Dr. Fauci discusses what he wishes we would have done differently at the start of the pandemic, and more importantly, what we need to do now to put it behind us.
Anthony Fauci: It’s been quite surrealistic, the existence that we’ve lived right now. I’m wondering how long it’s going to take us to reacclimate to being social beings in a physical way with each other.
Paul Rand: From the University of Chicago Podcast Network, this is Big Brains, a podcast about the pivotal breakthroughs and pioneering research that’s reshaping our world. Today, a very special episode featuring Anthony Fauci.
Katherine Baicker: So the Harris School and the University of Chicago are particularly dedicated to evidence-based policy and analytical approaches. It’s been a challenging year for evidence-based policy. I want to start by asking you a little bit about what we’ve learned over the last year. What does the evidence say?
Anthony Fauci: First of all, the fact that this virus is spectacularly capable in transmitting from human to human, number one. Number two, unlike any virus that I’ve had any experience with, about 30% to 40%, 45% of people never get any symptoms at all. So whenever have you seen a virus in which almost half the people get no symptoms, and yet it can kill a half a million Americans thus far and a couple of million more plus globally? But the real showstopper for us that slapped us into a recognition, into what we were really dealing with is that anywhere between 50% to 60% of all transmissions occur from someone who will either never get any symptoms or is pre-symptomatic, which means they are transmitting it before they have manifestations of disease. That’s just not the way respiratory viruses have worked historically.
Anthony Fauci: So we have knowledge that evolves as the weeks and the months go by. Sometimes you need to make policy changes or policy decisions when you have not all the information that you need. One of the things that this outbreak has taught us, that scientific investigation and the collection of data and evidence will almost naturally have you evolve your own stance, opinion guideline, or what have you because when you’re dealing with virgin territory, you have to make adjustments, be flexible enough and humble enough to know that you may need to essentially, modify what you’ve said before. The very sobering part and the humiliating part, the things that have made us very humble about this is what this virus has taught us. It’s been a very painful learning experience.
Katherine Baicker: Well, as you highlight, that makes it awfully hard to communicate both to the public and to policymakers, recommendations that are evolving over time, but that don’t then undermine public trust in the advice that they’re hearing. How do you think about threading the needle between conveying enough certainty that people will feel comfortable following recommendations with enough uncertainty that you’re realistically conveying what we know—and that the advice might change?
Anthony Fauci: Well, one of the several lessons that I’ve learned is first of all, don’t guess. Keep the foundation of what you do on data. When you don’t have the data, make it very explicit so that no one gets any misinterpretation that you are saying something that is possible, maybe likely, but you do not know for sure. Now, one of the problems is that often something is taken out its contextual context. We feel we likely should be doing this. However, we are waiting for the full data to be able to make a decision. The soundbite will be, “We said this in January. Now, it’s March. Things have changed,” you’re flip-flopping. It’s not flip-flopping. It’s the accumulation of data and making decisions, guidelines, recommendations according to the data that you have at the time. You’ve got to go with the data that you have. If that means changing something that you said, you should not feel badly or even guilty about having to do that as long as the science drives what you say.
Katherine Baicker: It’s not flip-flopping, it’s learning. So what data do you wish that you’d had? If we’re thinking about doing even better the next time around. What data collection systems do you think we should have in place in terms of population surveillance, in terms of bringing together data from multiple sources across the country? What do you wish you’d known sooner and what infrastructure do we need to know it for next time?
Anthony Fauci: Oh, yeah. I think what we really do need to do is strengthen the local health systems to be able to do things on the ground and see them as they evolve. One of the things that I wanted to do from the very beginning was to flood the system with testing, even if it was not as sensitive as true PCR testing, but antigen testing to just get a feel for what it is under the radar screen. People always ask me for similarities with my multi-decade experience with HIV/AIDS. One of the similarities is that we thought the only people who had AIDS were people who were very sick, and others were in the midst of taking care of a lot of them. Little did we realize that below the radar screen were multi, multi, multi times the number of people who were infected, but were not yet sick, and they were spreading the infection inadvertently.
Anthony Fauci: Here, when you see very, very sick patients and you don’t know that there are people under the radar screen who are never getting ill, who are spreading it, when you see people who are sick, you’re seeing the tip of the iceberg of the extent of the outbreak. There are several things. If we had known early on that the community spread was A, real and B, inevitable if you didn’t screen very intensively the asymptomatic cohort in the population, if we had known that I believe things would have done very differently. Not to mention things that got in the way of everything we did was the fact that we were fighting an epidemic in the middle of one of the most divisive periods in the history of, at least in recent memory, maybe 100 or so 200 years ago, there was more divisiveness in the country, certainly during the Civil War, but this is coming close where you have public health measures that are assuming almost a political stance; whether or not you should wear a mask, whether or not you should avoid congregate setting. That makes it extremely difficult to address a pandemic of this proportion.
Anthony Fauci: One of the things that we’ve learned from this outbreak, which again has some analogies to HIV, is the extraordinary health disparities that we have in this country for our brown and Black populations. You see discrepancies that are stunning. Brown and Black people, by the nature of the jobs they have, that they’re essential workers keeping the country going, they’re interfacing with people. They’re not talking to a computer person the way you and I are talking to each other safely in wherever we are. Then what they have is a much higher incidence and prevalence of the co-morbidities that put them into that category at whatever age they are of having a serious outcome of hospitalization and deaths. The reason for that is a variety of causes.
Anthony Fauci: One of them that’s so prevalent is the social determinants of health, that we’ve got to make a commitment now of what we’re going to do for the next few decades so that there’s no racial prevalence of diabetes, hypertension, obesity, kidney disease. It’s how you were brought up, the diet you have, the poverty conditions that you were brought up. It’s the lack of access to good medical care. So I always say that and I kind of use anytime I get a chance to say it as the bully pulpit of we can’t let this be forgotten when we get out of COVID-19.
Katherine Baicker: Well, I want to ask you to elaborate even further on the crucial point you raised about the disparities in preexisting conditions, in vulnerability to the consequences of getting COVID. Of course, there are parallel tragic disparities and economic circumstances for the people who are most likely to be hit by a recession, least likely to be able to sit comfortably at home, safely at home and continue to get paid are those same Black and brown populations who have the greater health burden to begin with and are then more exposed both to the physical consequences and to the economic consequences of the current situation. They are also less likely to be vaccinated. They’re lower distribution rates and lower take-up rates. What messages or strategies do you think that we can do to increase access to and successful administration of vaccines among these very vulnerable populations?
Anthony Fauci: So this is something that we’ve discussed in great detail. President Biden has made a very, very strong commitment of equity. So what actually in a concrete way has been done? It’s the putting up of community vaccine centers, about 440 of them with a clear recognition that we’ve got to put them geographically into those areas where the demography is heavily weighted towards minority populations. You can’t have it in places that are completely inaccessible. Number two, you’ve got to put a lot of vaccine in pharmacies, including pharmacies in areas, again, that serve minority populations. Thirdly, you’ve got to have a situation where you use mobile units to get into relatively inaccessible underserved situations. I’ve got to tell you, the reason I get more humble as the years go by because I realized how much I don’t know. Even though I thought I did know a lot about the access of minority populations, when you go deep down, you realize that some of them in situations where they’re in deserts, pharmacy deserts, food store deserts, healthcare deserts.
Anthony Fauci: They don’t have a car to get to where they need to be. They don’t have a computer to sign up for something, all of those things that you’ve really got to realize that are there and you say, “Yeah, I should have really figured that out.” That’s the reason why you’ve got to extend yourself. In order to make that happen is that the president has also established an equity task force with people who are full-time doing this, as well as a chair of the task force, Marcella Nunez-Smith, who is actually not full-time, part-time, she’s at Yale, but that’s one of the things she’s done, Cameron Webb and a bunch of other people who think about this all the time. Bottom line is it’s a really high priority that we put equity into the implementation of these programs, whether it be vaccine, whether it be healthcare, whether it be treatments when they become available. It’s got to be done in an equitable manner.
Katherine Baicker: So you mentioned as well the importance of resourcing localities, particularly those who serve underserved populations, but local public health infrastructure for surveillance and distribution and the variation in local conditions that cities and states have to deal with. At the same time, we’d seen distribution challenges, shortages particularly early on ranging from PPE to therapeutics to vaccines. If you got to command and control resources at a national level, where do you think the choke points were that we could alleviate with a different distribution or production strategy? And how would you like to see that changed?
Anthony Fauci: Well, I hope that we have enough corporate memory to remember what we had to do, and I remember it because I was sitting in the situation room of the White House every single day, about the lack of PPE, the lack of the proper equipment that you need to perform your functions safely. Then you find out that most of it is made in another country. So we wound up having to get the military to fly these cargo planes back and forth, and you’re sitting there saying, “You’re kidding me. We actually have to have it flown in to then distribute.” So we want to talk about things that we can make ourselves, that we don’t have to rely on other countries who might have the same problem we have. That’s one of the things about pandemics.
Anthony Fauci: To think if you’re relying on supplies from out of the country, but you’re dealing with a global pandemic, why do you think that the countries that have to take care of themselves are going to put you before them? And understandably, they don’t. So one of the lessons is we’ve got to be much more self-sufficient. That’s for sure. The other thing is that the infrastructure at the local public health area has almost been a victim of our own success. It was really strong decades ago when you needed it for the local care of tuberculosis and sexually transmitted diseases. Then we get a lot of technologies, a lot of vaccinology. We get good interventions. The local kind of attritted away that some of them are not equipped with 21st century, not even 20th century capabilities, still using fax machines and things like that, lack of the ability to do things electronically. That’s got to be fixed if you’re looking at what happens in the future for future outbreaks.
Paul Rand: Come up after the break, what we need to do to get back to normal.
Paul Rand: If you’re getting a lot out of the important research that’s shared on Big Brains, there’s another University of Chicago Podcast Network show that you should check out. It’s called Capitalisn’t. Capitalisn’t uses the latest economic thinking to zero in on the ways that capitalism is and more often isn’t working today. From the debate over how to distribute a vaccine to the morality of a wealth tax, Capitalisn’t clearly explains how capitalism can go wrong and what we can do about it. Listen to Capitalisn’t, part of the University of Chicago Podcast Network.
Katherine Baicker: So I, that we are all hoping that there is such a thing as a post pandemic world, but is that the right way to be thinking about things? Are we going to get over the pandemic once everybody’s vaccinated, or are we going to be living in a world where we are constantly fighting variants, delivering booster shots, tweaking vaccines, and this is just going to be something we worry about all the time, but hopefully at a lower grade level?
Anthony Fauci: OK. So this gets to what I mentioned to you a bit ago of being honest and humble. I don’t know the answer to that question. I just don’t. The reason I don’t is that there are too many variables in there that I don’t have control over, nor do my public health colleagues have control over. In a perfect world, you would get everybody or almost everybody vaccinated. I’ve estimated that the level of herd immunity for a virus with this degree of transmissibility and with the efficacy of vaccines being 95%, 94%, that you would need maybe 70% to 85% of the population to either be vaccinated or to be having already been infected. One of the sad and alarming things we’ve learned is that when you get variants, like the ones we’re tracking in South Africa, you’re not protected against the variant with pre-infection. You’re likely more protected with a vaccine, but not with that.
Anthony Fauci: So that’s a variable that’s as constantly getting asked, “Well, when are we going to get back to normal? Is it going to be September? It’s going to be November? Is it going to be the end of the year?” We don’t know because there are variables. How many people are going to get vaccinated? How many variants are you going to have? Then you get to the thing that we really don’t have individually a lot of control over, and that is a global pandemic requires a global response. So we can do everything we need to do for the United States. The European Union can do it for the European Union and the UK, but there will be parts of the world, unless we address the response as a global response, we could have variants coming back and forth, and just when you think you have everything under control, because there’s a disease that’s raging in Africa, in Asia, in South America, in the Caribbean, and then all of a sudden, you wind up receding your population with a really troublesome variant.
Anthony Fauci: In fact, that was one of the things I was speaking with today with my colleague, from the European Union about we all agree that we’ve got to treat it as one planet, not 185 countries or whatever it is that we have, one planet that’s really got to look at this pandemic in the same way.
Katherine Baicker: Well, that suggests the need for ongoing vigilance and proactive addressing of the variants by policymakers and public health officials. It also suggests ongoing caution and care at the individual level that even people who have been vaccinated were learning should still exert some caution, should still be limiting activities. That’s a tough message for people to hear at the end of all of this pandemic fatigue and with the vaccine on the horizon that’s been billed as the thing that’s going to save us all, which in many ways it will. How do you think that contributes to people’s willingness to get the vaccine and how, in a humble way, should we be communicating about the upside of getting the vaccine and keeping you safe and letting you resume some activities, but the need to maintain caution and limitations in what you do? How do you talk to people about that?
Anthony Fauci: Were you on the phone call that I was on today with the White House?
Katherine Baicker: I’m always listening. You think I’m not, but I’m always there.
Anthony Fauci: No, that’s an extraordinarily relevant question because it becomes a messaging issue. The instinct is to say, “We have a really good vaccine. I’m vaccinated. I got a 95% effective vaccine. Why can’t I do whatever I want to do?” Ultimately, you may be able to do that, but not right now because there were things we don’t know. The primary endpoint of the vaccine trial was clinically recognizable disease. We don’t know yet whether or not it prevents you from getting infected where you’re not with symptoms, you’re asymptomatic, but you have virus in your nasal pharynx, that you could then infect an unvaccinated person who might be vulnerable, and you will inadvertently and innocently get them sick. So we say, “You’ve got to wear a mask.” People say, “Why do I going to wear a mask? What did I get vaccinated?” You get vaccinated to preserve your health, the health of the family, and to help to crush the dynamics of the outbreak.
Anthony Fauci: When we find out whether or not people who are vaccinated have such a low level of infection, a viral titer, if they get a breakthrough infection. So likely you’re going to cut down not only on symptomatic infection, but on asymptomatic infection. We don’t know that yet. I think it will be the case. I think also, again, I think, I don’t know, I think also that if you do get a breakthrough infection and you’re vaccinated, that the level of virus in your nasal pharynx will be substantially lower than the level of virus in an asymptomatic person who wasn’t vaccinated. There’s a study from Israel that strongly suggests that, but we’re doing a study now to try and nail that down. If in fact we find that out, then you’re going to see a pulling back on some of the restrictions, but we’re not there yet. When we get there, then you’ll see changes in regulations, but not quite yet.
Katherine Baicker: So can I ask you for a little bit more information on a study like that, what kind of data do you need to collect from whom to be able to learn about that risk of infection of other people among vaccinated folks?
Anthony Fauci: There’s the indirect way and there’s the direct way. The indirect way is the one that I just mentioned. You can make a reasonable assumption that if the level of virus in the nasal pharynx of a breakthrough infection from someone who’s vaccinated is dramatically lower than in the other individual who was not vaccinated, I think you could make a reasonable assumption that the risk of transmission just like we proved with HIV and it took years. You know the HIV undetectable equals untransmissable? You may not know that as an economist, but it’s true, is that if the level goes below a certain level, you just don’t transmit it. So it may be that we will show that if the level of virus in your nasal pharynx, because you vaccinated, is so low that you don’t have to worry about transmitting, that’s going to be a game changer for what a vaccinated person can or cannot do.
Anthony Fauci: The way you do it directly is you do a cohort study where you, for example, vaccinate people in a closed group. Best way to do that? College campuses with dorms. You vaccinate people and anybody that gets infected, you do sequencing of the virus, and you find out that does a person who is vaccinated who gets infected, is that the virus that transmits it to the unvaccinated placebo group, or is it only the unvaccinated transmitting it to each other? If there’s no transmission from the vaccinated group, that’s it. That’s your study and you’re in good shape.
Katherine Baicker: I want to leave with one more question. Forward-looking, what are you most looking forward to doing in this post-COVID world, whatever that looks like, that you haven’t been able to do for the last year?
Anthony Fauci: I think it’s reconnecting with society. It’s been quite surrealistic, the existence that we’ve lived right now. I’m wondering how long it’s going to take us to reacclimate to being social beings in a physical way with each other. I’m looking forward to that. I’m looking forward to a number of simple things like my wife and I when we like to come home, she works with me at the NIH, sometimes we get home very late. We go to a really nice pleasant bar/restaurant up the block. We know the owners, we know the people, we sit down, we have a beer, we have a Hamburger and we come home and we go to bed. We haven’t done that in a year. That’s part of the fun of natural living that is interacting with society.
Katherine Baicker: Well, that sounds like something that you have more than earned. I know it’s a sentiment shared by so many people, is the eagerness to return to three-dimensional human interaction and to be able to gather in person. So I’m so grateful to you for taking the time, so honored to have you as our 2020 Harris Dean’s Award recipient. I hope that you get that burger and beer around the corner very, very soon.
Anthony Fauci: Thank you very much, Dean Baicker, and it’s a real pleasure to have been with you. Thank you for having me, and thank you so much for this wonderful award. I will cherish it.
Katherine Baicker: Display it with pride.
Anthony Fauci: Thank you, I will.
Paul Rand: If you’re getting a lot out of the important research shared on Big Brains, there’s another University of Chicago Podcast Network show you should check out. It’s called Not Another Politics Podcast. Not Another Politics Podcast provides a fresh perspective on the biggest political stories, not through opinions and anecdotes, but through rigorous scholarship, massive datasets, and a deep knowledge of theory. If you want to understand the political science behind the political headlines, then listen to Not Another Politics podcast, part of the University of Chicago Podcast Network.
Matt Hodapp: Big Brains is a production of the UChicago Podcast Network. If you like what you heard, please give us a review and a rating. The shows hosted by Paul M. Rand and produced by me, Matt Hodapp, with assistance from Alyssa Eads. Thanks for listening.
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