Washington National Cathedral

Dean Lloyd: Good morning and welcome to the Sunday Forum, our weekly conversation at the intersection of faith and public life. There’s something going on you might have heard about—this swine flu thing, the H1N1 virus that’s circling the globe. We are now well in the flu season, with lots of questions about what’s happening and why and where it’s going.

Well, that’s the bad news. The good news is that the doctor is here today. Dr. Anthony Fauci is one of the world’s experts on new and infectious diseases such as the H1N1 virus and, a few years ago and still today, AIDS. For the last 25 years, Dr. Fauci has overseen US efforts to fight diseases of all kinds, serving as director of the National Institute of Allergy and Infectious Diseases in Bethesda. He was one of the early and leading voices in AIDS research and continues to be a key White House adviser on global AIDS issues. Since September 11, Dr. Fauci has also worked on bioterrorism prevention, something we’re going to hear more about later on in our conversation.

Dr. Fauci is the recipient of numerous honors and awards, including the Presidential Medal of Freedom, the National Medal of Science, some 35 honorary doctorates. It must be hard to know who to cheer for in a basketball season that way. [laughter] Tony, thanks for being with us here today.

Dr. Fauci: It’s great to be here.

Lloyd: Wonderful to have you here; lots to talk about. So about this H1N1 swine flu, a number of us have tried to get vaccinated, others already been vaccinated, there’s talk about availability of this vaccination, give us a quick picture. Where does H1N1 stand as it makes its way as an epidemic around the globe, and what about the availability of the vaccine?

Fauci: Well, it’s already a pandemic. As we know, it started off right here in the western hemisphere, in California, Texas, and Mexico. And within a few months—and that was in April of 2009—and it did something which really categorized it as a pandemic. It was a brand-new virus that we have had no prior experience with, and it spread extraordinarily rapidly throughout the world.

It’s now in over two hundred countries. Right at the time when it first came out in April, we started making a vaccine, and we were quite successful in making it. We did testing right here at the NIH on looking at the right dose, is it safe, how do you administer it.

The problem that you pointed out is that the technology for making hundreds and hundreds of millions of doses of vaccine is a time-honored but fragile technology, which is the only technology available, which is almost humorous when you describe it.

You take the virus, you grow it in embryonated eggs, you let it grow up in the eggs, you spin it down, purify it and activate it, and there’s your vaccine. The time-honored nature means that for decades we’ve used it for seasonal flu and it’s been very successful, safe, and effective.

The sobering news is that it’s variable how fast the virus grows in eggs. So although there was a plan with multiple companies to get a certain number of doses to cover the people that would need it by a certain date, the fact is the virus grew very slowly, and to any attempts to get it to grow faster were unsuccessful; so that the projected number of doses that we were supposed to have in October when people would start to really need it was much less.

So we have a gap between supply and demand. We have the right vaccine, it’s an effective vaccine, but what you hear about people who are standing in line trying to get it, that gap is starting to close so that every week that goes by we get closer and closer to a concordance of supply and demand, but we’re not there yet.

But we have a pandemic raging. Fundamentally it’s a relatively mild to moderate as far as pandemics go. The difference is that the people who get into serious trouble are younger people, pregnant women, and people with underlying conditions—as opposed to seasonal flu, where the overwhelming majority of the people that get into trouble are elderly people over the 65 and mostly over eighty years old. So there is that extra tension about it because you want to protect the young people.

Lloyd: Tell us a little bit about where the swine flu came from and maybe a little short course on how this pandemics spread so rapidly across the globe.

Fauci: Well, every time in front of a congressional committee I slip and use the word swine flu, all of the states that have hog farming email me to death. (laughter)

So I’m not going to call it swine flu. It’s the 2009 H1N1 influenza. Having said that, influenza viruses evolutionarily are fundamentally viruses of animals, mostly birds, waterfowl.

The pig is an interesting species because the pig, in its body, has the capability of being infected with bird viruses, human viruses, and pig viruses. So it’s kind of a mixing bowl for viruses to come into the same species and exchange their genes.

So influenza is a very interesting infection. It is very, very facile in re-exchanging or re-assorting its genes. So some time ago, likely more than ten years ago, pigs got infected—and they didn’t get sick—with the bird virus, pig virus, human virus. And they exchanged their genes and it jumped species, about 75 percent of the new infections in the world come from infections that jumped from an animal to a human.

Usually when they do, they’re very inefficient in spreading from human to human, because they’ve adapted themselves to animals. This particular virus did jump from a pig to a human likely sometime in late winter, early spring of 2009, and infected a human. But when it did it had the unfortunate capability of very efficiently going from human to human. In contradistinction for example to the bird flu that we’ve been hearing about for years, the H5N1, that’s really good at killing chickens, it jumps into humans and only a few hundred humans have been infected for more than over ten years. The bad news is that half of them have died, but the good news is it just doesn’t spread very well from human to human.

This one spreads extremely well from human to human, but it isn’t particularly lethal. You hear about the deaths in the newspapers, but in reality the deaths are very, very few vis-à-vis the relative proportion of cases. The issue is they’re mostly in young people.

Lloyd: Are we seeing more pandemics than before? Is there an accelerating development of these?

Fauci: Yeah. If you look at new infections in general, not just influenza, we had three pandemics of influenza in the twentieth century. The really bad one was in 1918, which devastated society globally. Fifty to a hundred million deaths.

There were a couple of others—1957 and 1968. But if you look at new diseases that just spring up as humans encroach on the environment, as there is more interdigitation between certain species that are generally excluded, as you perturb the relationships in the environment. That’s when you start to get new infections emerge: when you inappropriately treat certain species like chickens and other animals that you used for domesticated purposes, for food, you develop new microbes that are resistant to antibiotics.

As society goes from encroaching on a rainforest, you may have a very unusual, bizarre virus that has never had contact with humans goes into humans.

So fundamentally, it’s how we intersect with the environment.

Lloyd: And so you all keep an eye out for this developing and then it becomes a matter of your outsmarting the virus, figuring out what makes a tick and beginning to develop something that can respond to that, to keep it from spreading.

Fauci: And that exactly what it is, you said it very well, and it’s not a static situation, its ongoing dynamic all the time. We have the WHO, but we have the CDC which is an extraordinary organization which has its contacts throughout the world—

Lloyd: —Center for Disease Control—

Fauci: Centers for Disease and Control and Prevention, a United States government health and human service agency which, essentially [its] purpose is surveillance. People always ask what’s the difference between the CDC and NIH.

The CDC is the radar screen out there, they’re trying to figure out what’s new, is it really new, is it going to be dangerous. The NIH then does the research to identify it, develop a vaccine, develop drugs, et cetera. But it’s an ongoing process and you always try to stay a step ahead of it.

The difficulty is, when you get support for that, it’s difficult to get support for something that’s a threat as opposed to a reality. And then, when the threat becomes the reality, the question is why didn’t you have something ready for it? So it’s an interesting situation that you’re in.

Lloyd: You’ve been at this for a long time, how many years at NIAID?

Fauci: I’ve been the Director of the institute for 25 years but I’ve been in NIAID, I hate to say this Sam, but for forty years….

Lloyd: Forty years…

Fauci: I came when I was eleven. (laughter)

Lloyd: What drew you into that, and what made you stay there?

Fauci: Ever since I was, actually a child and entering into high school, I always had a strong feeling, mostly I think because of my training in high school and college. I went to Jesuit high schools and Jesuit college, and the thing that we learned, and also from my family, was public service. So I always wanted to do something that serves the large number of people.

I chose medicine because I was interested in people and because I like science. And that to me was the right combination of being able to interact with people as well as to implement a talent that I had in science and medicine, so I went into medicine.

I came into the NIH to train. I was going to go back and be a physician. I didn’t think I was going to be in research. I didn’t think I was going to be a science administrator, and only when I saw the potential for having an effect on a large number of people in a public service way that I fell in love with it and really cannot think of myself doing anything else but that.

Lloyd: And you were a researcher pure and simple for a while and then became head of NIAID 25 years ago.

Fauci: Right. Exactly.

Lloyd: Let’s talk about maybe the most significant and most public and most political piece of work you probably ever did, and that was dealing with AIDS.

Give us a little sense of how it was that AIDS began to come on the screen for you all and how you began to address it, and then how you made your way through the very tricky political waters of responding actively enough to suit your critics who were looking at you from every side.

Fauci: It was a very interesting evolution. I have been at the NIH for about eleven years and had a rather successful career doing the kinds of interface between immunology, which is the body’s response to infections, and infections. And I really liked it and I was enjoying it, but there was something that was missing there and when the first cases—and I remember it as it was yesterday—in June of 1981, five gay men who presented in Los Angeles with a very strange infection called pneumocystis pneumonia, who were otherwise well.

I remember looking at that, saying, “Gee there’s something different here, it’s strange.”

A month later, in July, 26 gay men, also otherwise well, came down with other bizarre diseases: Kaposi’s sarcoma, pneumocystis chronic pneumonia. And it was at that point that I made a very retrospectively profound and interesting decision. I decided I was… if ever I was trained for a disease that I know it was an infection, but I had no idea what it was, because we hadn’t discovered the virus yet. We know that it would attack the body’s immune system, and I was a trained immunologist. And it was a very wrenching type of disease because it, at the time, hit a disenfranchised population, the gay men who were just beginning to assert their own freedom of expression back in the late ’70s and in early ’80s.

So I changed completely the direction of my career much to the dismay of my mentors and advisers, like what are you doing, studying this strange disease among a few gay men?

But I knew that this was going to go well beyond gay men and it was going to be a problem, because it was an infection with the same capability of spreading.

The fact that it spreads sexually was even more compelling for me because if there’s one thing universal thing in the world its sex. I mean, that’s how we propagate ourselves. So this isn’t something you can stop doing. So I did that, and that was the beginning of a very interesting period for me and, you know, you talked about the impact on you as a person Sam, but prior to that time, every patient I took care of… I developed the cures for few disease that were rare diseases but it was a great feeling some would come in with a deadly disease, you treat them, they get better and they would think that you were some sort of a great hero, and they would love you and thank you and you’d get the great feeling of accomplishment.

For the first eight or nine or ten years of my taking care of patients, they all died. Every one of them. So it was a very wrenching period of my life. When I write about it I call it the darkest moment of my professional career. And then as we started to get drugs because of the research that we did, then we had the major impact.

But in the beginning, when it was a disease that had a political, sociological, personal, and other implications… You mentioned the interaction with the constituency groups. Probably to… I wouldn’t say our shame, but something that if we do it all over again, the leaders and the federal government at that time barely even mentioned this as a disease, because there were other issues they were involved with. But to their credit they let me do it.

So myself and others were out there publicly trying to figure out what’s going on, going to San Francisco, going to New York, finding out what’s going on in the bath houses, in the crack alleys. So I was the public face of the government. So when the population that wanted more attention on the part of the government—greater access to drugs, greater inclusion in the decision of how clinical trials are made, started demonstrating against the government. The government was me.

So I became the target of the gay activist group. And I don’t know whether it was my training in the Jesuit years about listening to everyone and making your own decision, because they were so confrontative and theatrical—

Lloyd: They came to your offices.

Fauci: Smoke bombs on the NIH campus. They closed down Wall Street. They invaded St. Patrick’s Cathedral in New York. You remember? Those were the ’80s. Some people may have forgotten that.

Lloyd: This was ACT UP…

Fauci: This was ACT UP, AIDS coalition to… AIDS coalition to something. I forgot after all these years; it must be Freudian. (laughter) So what they did is that they actually confronted us; and probably the best decision I made in my life from a constituency standpoint, they had hundreds of them invaded the NIH campus, and the FBI were there, the Montgomery County Police, and the NIH police, and they were just getting ready to do a mass arrest.

So I came down from my office and I told the Montgomery County Police and the FBI to not arrest anybody, but to just bring five or ten of their leaders to my office and to talk about what it is that was on their mind.

Because I had been reading what they’d been writing.

And if you take the theater away, it made perfect sense. They were suffering, they were dying, and they wanted somebody to listen to what they have to say about how they thought the government should be handling it.

So to their great shock, I met with them in my office. They couldn’t believe that they were there, because they would constantly get arrested every time they had a demonstration. And that began a relationship with the activist community that I think is transformed how we interact with constituency groups. They have become my colleagues, my friends and my advisers up to this day. And some of them now play a major role on our advisory committees. People who were blasting us in demonstrations are now our great allies.

Lloyd: What is your sense now, Tony, about the progress of AIDS across the globe, the fact that Washington D.C. is… per capita, one of the most infested cities in the country on a level of some African nations in terms of the number of people who have AIDS. Are we making progress in stopping it? Is it still a battle being waged?

Fauci: It’s a global catastrophe. The numbers are shocking.

If you look globally, there are 2.7 million new infections each year. There are two million deaths. There are 33 million people living with HIV, ninety percent of them in the developing world, 67 percent in southern Africa.

That is something that is terrible that we need to do something about, and I’ll get quickly in it in a second to telling you a little bit about what’s being done. In the United States, it tends that’s falling off the radar screen. But there were 56,300 new infections each year in the United States. That’s the bad news. The worse news is that it’s been that way for the last twelve years, so back in the early days when 75 percent of the Castro District and 65 percent of the East Village was infected because that’s where all the gay men congregated. That the number of infections was about 150,000 a year of new infections and then it went down to [56,000], but it stood there.

But the demography has changed in the United States that is fundamentally now a disease of… Again, first it was the disenfranchised gay population who pulled themselves out, educated themselves, demanded the kind of things that they've got.

Now it’s fundamentally a disease of new infections among the African American population. Sixty-five percent of the women who get infected in the United States now are African American women, and they comprise twelve percent of the population of the United States. Of the new infections in men, 48 percent of them are among African American men, and again that’s twelve percent of the U.S. population. So there are a lot of suicidal issues, the lack of access to good counseling, lack of acceptance in society of being a gay man because of the stigma that is much, much more there. So there were so many intertwining sociological issues, which is the reason why Washington, D.C., amazingly so… Three percent of the population of Washington is infected, 6.5 percent—6.5 percent—of African American men in the District of Columbia are infected—which, if the District of Columbia, which ha s a 600,000 population, about 65 percent African American… If the District of Columbia were a country in Africa, it would be ahead of about twenty African countries in infection.

So we have a real problem right here. So the problem has not gone away. It’s been displaced on the radar screen by a lot of other things.

But one very good thing has happened. And again, I had the opportunity, the privilege, of participating in this. A few years ago in the last administration, when President Bush decided that he really wanted to do something globally about this infection, and sent me and Secretary Thompson to Africa to figure out what it is that could be done, because everyone was saying in Africa you could never get drugs to people because it’s just a primitive society, which obviously had a considerable degree of subliminal if not overt racism to that.

And as it turned out, when I went there and I looked around, I saw that with the small money that they had they were able to get drugs to people. So I came back and I put forth first a plan for pediatric mother-to-child transmission which the White House accepted—mother-to-child transmission prevention, for about $500 million. And then he sent me back again to Africa with the help of Josh Bolten, who is very quite connected to St. Albans here, to get me to go back and come back with a big big plan which turned out to be the President’s emergency plan for AIDS relief which started off as PEPFAR, and I presented it to the White House and to the Congress and they accepted it.

So it was to the credit of our government, which is being continued by President Obama with the global health initiative, that now that Africans who are getting infected are getting treated—good news. The sobering news is that for every person we put on therapy, 2.5 people get newly infected and only thirty to 45 percent of the people who need drugs are getting it. So the big issue now is some serious global prevention efforts that we really need.

We’re trying—we, a global society. But it is very difficult to change behavior in a society in which the behavior is part of the societal way of behaving for centuries. You just don’t get, as I joke around—not so jokingly, you don’t get a white guy in a suit, like me, to go there and say, “We want you to change customs that have been going on for centuries.” You need to have leadership within the country to do that.

Lloyd: But you are developing medication now that can keep people alive a long time even though they are infected?

Fauci: The success story of the development of drugs for HIV/AIDS ranks among the top two or three success stories in biomedical research and science, from fundamental research to develop the drug, the translation and collaboration with pharmaceutical companies to make the drug. I told you the story of the dark years of my professional career. Take 1982, 1983, someone would come in to see me at the NIH, they would very sick because they would never get to you until they got very sick.

The median time of life that they had from the moment they walk in my door was 26 weeks before they died. If a twenty-year-old comes in to my clinic now, at the NIH or anywhere—it doesn’t have to be the NIH, any place in a developed world, and just recently gone infected and I start them on drug, you can project that they will live till they’re seventy years old, which to me, it couldn’t possibly get a better success than that.

Lloyd: It’s been an enormously complex thing to develop the drug for it hasn’t it, and enormous complex treatment?

Fauci: Well, it started off very complicated because they were… If you look at the number of drugs and the number of the time, it really goes to show you how things advanced. A typical patient would have to take 28 pills, six to seven times a day with alarm clocks going off in the middle of the night to take a pill. Some you could take with a meal, some you have to take with water… I mean, it was horrendous for them.

Now, one pill once a day could do it. One pill once a day.

Lloyd: What a difference! So are you hopeful that we can make some progress in slowing down the spreading, and getting the treatment and medications out?

Fauci: I think we can do it, but I think it has to be prevention, Sam. The reason it has to be prevention is because, logistically and realistically, it’s going to almost be impossible from an economic standpoint to get drugs… Because it isn’t like you come in and have pneumonia, I give you a shot of penicillin and you’re cured. You don’t need any more penicillin, a week later you’ll going to look good and feel good.

With HIV you’ve got to give them drugs every day for the rest of their lives. So for every new person that becomes infected, you have a commitment to treat that person for the rest of their lives. So we have, I believe, a moral obligation as a rich society—not just the United States, but the developed world—to partner with the developing world to be able to sustain treatment. But you have to do it together with prevention because otherwise the mathematics are against you. You will never be able to treat everybody who gets infected at this rate.

Lloyd: Let’s move to another issue before we open this for questions, another one that is a pretty dark and troubling subject and that’s bioterrorism. Especially since 9/11 you’ve been working a great deal on that—the intentional spreading of diseases because apparently has some precedent that’s going through history but is something we are worried about now. Should we be worried about that?

Fauci: That’s a loaded question, because it could turn out into a bad sound bite for me. But the risk is… probably not, I wouldn’t worry, and I mean that seriously. I’m not being facetious about a deliberate bio-terror attack that’s going to have enormous implications on society. There may be a bio-terror attack you have to be prepared for it. And your preparation is probably the biggest disincentive for you to happen.

But apropos to our conversation over the last several minutes, nature is the worst bioterrorist. I am much more concerned about a naturally occurring infection like a pandemic killing a lot of people.

If the number of people that would get killed from a bioterrorist attack equaled the number of people that get die from influenza every year, we would consider that from the enemy standpoint, a very successful bio-terror attack. So although you really want to be prepared for it, luckily the same preparation for a bio-terror attack is the science that you talked about, the surveillance of new naturally emerging infections. So you can actually kill two birds with one stone. You could prepare for the release of an agent that would be devastating if it continued to spread in the same way as you prepare for a naturally occurring pandemic.

Lloyd: We want to go to questions from the audience, so feel free to pass your cards forward. Quick question as questions come forward. Quick question about the anthrax incident. Did that tell us about our preparedness or lack thereof?

Fauci: Anthrax is an inefficient way to cause… because you know… I used to lecture a lot of that, we don’t do that much now, it’s mostly AIDS and pandemic flu. I break up the word bio-terror. In bio-terror there’s not a lot of bio but there’s a lot of terror. So the anthrax killed five people with 22 cases. It tells us a couple of things—that we need to be prepared with counter measures—but it also tells us that we need to be careful of the people who are actually working to make sure that we have good screening because that was an internal bio-terror attack, that was not Al-Qaeda, that was an unfortunately a member of the United States government.

Deryl Davis: We’re going to start with a couple of questions, both of which deals with AIDS so I’ll ask them in conjunction. The first is, can you conceive in the near future of an actual cure for AIDS? And the related question is about the reported long term negative effects of the AIDS cocktails on those who take them.

Fauci: Okay, two good questions. The answer is… I always keep the word “cure”—it depends on what you mean by “cure”. I mentioned to Sam the idea—he comes into my office with pneumococcal pneumonia, I give him penicillin, he’s cured. The pneumococcus is gone and he doesn’t need any more medicine.

To cure HIV means that you treat the person and you either have an eradication cure—the virus is no longer in the body—that’s going to be very difficult because… I can really make it simple, that’s the only virus we know that integrates itself into the genes of your own cell, so it’s going to be very difficult to excise that. We’re working on it, there were some very interesting molecular techniques of sort of splicing out that little bit of the virus, but we’re years away from that.

There’s also a functional cure, which means you can treat someone early enough and aggressively enough that the level of virus is so low that the body’s own immune system will prevent it from bouncing back. We did an experiment in my own lab years ago in which we treated people who have no detectable virus in their plasma, we stopped the drug empirically on them.

Every one of them bounced back with the virus within a period of two or three weeks, so we obviously didn’t cure them. The answer to the question: we can try it, it’s a long shot, but I think it’ll work.

Second question: the deleterious effects of long-term therapy on people. We have clearly shown that whenever you give a drug, there’s always some degree of toxicity. AIDS drugs have them, but the long term toxicity of having the virus be present and replicating at a certain level in your body is much, much more deleterious to your health than the long-term effects of the drugs itself.

And that’s not a guess, we looked at that very very carefully and what we were thinking was the effect of the drug actually was the effect of virus just circulating and inappropriately activating a lot of your cells to cause dysfunction. So drugs do cause toxicity but I, if I were HIV infected, would much rather have the drugs than the virus.

Davis: This questioner suggests that… today in America, even among those very well educated, there’s still a view that vaccines are somehow harmful, vaccines in general somehow have long-term deleterious effects. How do we overcome that perception?

Fauci: Well, I think we need to continue to try and educate people. The reason why, in our day and age, some people believe that vaccines are “harmful” to you is because we’re the victims of our own success.

When you have a lot of disease out there during the polio years, when people were frightened of polio, you didn’t have a lot of people saying “I don’t want a polio vaccine.” They were running all over each other to get it.

But when you’re successful of getting rid of measles, mumps, rubella, smallpox, polio, the vaccine is to prevent you from getting that and the only thing people see is the complications that usually isn’t associated with the vaccine, but because they’re temporally related… A lot of bad things happen to some kids when they’re young. A lot of kids get vaccinated. It’s kind of like you get vaccinated and you walked outside and got hit by a car in Wisconsin Avenue and “Ah, it was the vaccine that did it!”

But that’s not the way it works. So what we need to do is to try and educate people as to what we call—not saying… and because you get into trouble when you say the vaccine is perfectly safe.

There’s no such a thing as a perfectly safe intervention.

When you make a decision for your family, to yourself to get vaccinated is, what is the risk of the vaccine? First is the risk of the disease. So right now, let’s take flu as an example. We know from decades of experience with seasonal flu vaccines that they have a very good track record. Are they a hundred percent safe? Nothing is a hundred percent safe.

Look at the risk of not getting vaccinated. Look at what’s going out in the world, there are tens of millions of cases of flu and there are people dying—pregnant women, young children, people with underlying conditions. There is no doubt that the risk of getting the complications from the disease is overwhelmingly greater than the risk of the vaccine.

But no one can ever say a vaccine is a hundred percent safe. So you make a decision based on the risk-benefit. And for me and my family… Well, we haven’t been able to get the vaccine yet… (laughter) But for people who actually have vaccine available to them the risk clearly is a very small risk. So that’s how you try to educate people on thinking about it in a risk-benefit way.

Lloyd: When are you and your family be able to get the vaccine?

Fauci: Soon I think…I think one of my daughters already had the flu and the other is… hopefully we’ll going to get it soon.

Lloyd: Before we go on to the next question, as we’re coming in you were talking about the brouhaha over Goldman Sachs getting a whole stock of the vaccine as opposed to other people in New York City. Give us a window into what was going on there?

Fauci: It falls into my category of “Welcome to Washington.” What happens is that, unlike seasonal flu where the CDC or the government buys about ten percent of the doses, and ninety percent of them are actually transactions between pharmacies and distributing and the companies who make it, and then you go to a clinic, you go to the Doctor’s office.

For the pandemic flu, the government has bought it all so that it’s going to be free for people. But how you distribute it is that the CDC distributes the vaccine to the states and the cities, prorated on the population. So California obviously gets a lot more than Delaware. New York gets more than Utah. But it goes out to the locations.

The state and the city decide best how do they distribute that in an efficient way to the people in their communities. Some cities and states say, let’s do it through the schools, through the clinics, through the pharmacies. They make up their own mind. In New York, the New York City officials made the decision that they would get some to the hospitals, et cetera, but there are big corporations that have clinics, that are actually as large as some clinics and hospitals, and one of them are some of the Wall Street firms.

So the City of New York sent it to the Goldman Sachs as the example, with the understanding that they would give the vaccine only to the people who are at risk and needed it. They’re pregnant women, people with underlying conditions like asthma and diabetes, et cetera. They wouldn’t give it to people who are otherwise healthy, who don’t need it. But once you hear—the newspapers—Goldman Sachs gets these amount of doses and these hospital gets the other, you think that some fat cat with a cigar they’re getting vaccinated while some pregnant woman is on line trying to get it.

There couldn’t be worst optics for a message than that. But I think if you put that aside, having the local authorities distribute the vaccine is the way to go, and that’s what that fell under. Unfortunately the optics of it were very bad.

Davis: We have two questions here that again I will put together here, both relating to an earlier question in the conversation. The first part is, is there something in the way that we live today and possibly the foods that we eat that make us more susceptible to disease; and do you anticipate the emergence of new diseases as epidemics in humans, and with what kind of frequency?

Fauci: Let me answer the second one first. I absolutely anticipate and will guarantee you that there will be new diseases that emerged. If you look at over a period of the last couple of decades, there have been dozens and dozens of new diseases that either have emerged as brand-new diseases—SARS—or diseases that emerged in a different location like West Nile which has existed in Africa and the Middle East for centuries and then came to New York, and now its endemic here.

So the answer to that question is a resounding not only do I anticipate it, I will guarantee it, that there will be new diseases.

The other question is a little bit more complicated. Certainly that if you are malnourished and you don’t have a healthy immune system, that your susceptibility to not being able to fight an infection that if you were otherwise healthy… But I don’t think I can make a scientific connection that if you eat a lot of French fries you’re going to wind up getting more susceptible to a new disease.

I think healthy living in general, which goes beyond just what you eat, it’s the environment, it’s not living in a completely smog-ridden place where there is a lot of environmental toxins, I think getting sleep, eating well, and nutrition, all help you to stay healthy but there’s not a direct relationship to what you eat necessarily and what do you going to be susceptible.

Davis: This question is asking about our research and education programs and, as we look into the future fighting disease, we do hear about a shortage of scientists and researchers… are even at the high school level, development in terms of math and sciences. Do we have a lot of work to do in the future to be prepared as a nation for future diseases?

Fauci: Unfortunately we have had a disturbing slippage in our leadership at the young student level in the sciences in general, they could be the physical sciences and biological sciences.

The United States of America still overwhelmingly leads the world in the biological sciences. We are slipping when you look at what youngsters in other countries—China, India, Japan and places like that—and their interest and aptitude and opportunity to learn sciences, that we really need to rethink how we look at the sciences.

We’ve had a very interesting shift over the last couple of decades for people who are really smart to go and pursue science as at least an option in their career. A lot of it turned to other things now, maybe the difficulty we have in Wall Street over the last few years may get some of those smart people to, instead of going to Wall Street, to maybe go and do engineering and science and medical school.

But we really have slipped and we’ve really got to re-infuse interest in science, because science is knowledge, and knowledge is the way forward.

Lloyd: Let me jump in with another question. You described very dramatically the hard decision you made to step in with all of your energy into addressing the AIDS epidemic as it was taking shape.

That clearly was a time when you had to draw on your own moral and spiritual background to do what you thought was right even though it wasn’t being encouraged around you. It occurs to me in the world you’re working in, there must be ethical decisions coming your way all the time about how you allot resources and what seems to be the most urgent thing going on and also getting pressured from different sides on what you ought to do. You were taught by the good Catholic Jesuits. You’ve got a firm foundation there. Can you think of some other times or an instance where you have had complex moral decisions to make, whether it’s about deployment of resources or something else?

Fauci: Well, I also have the advantage of my wife is an ethicist, so I’ve got a counsel that’s free…

Lloyd: Ph.D. ethicist.

Fauci: Yes indeed, a Ph.D. ethicist. But yes, it happens not infrequently at a… I wouldn’t say at a lower level, but at a level of allocation of resources for diseases for example that you have to be the advocate for… And I faced that years ago, when it was clear to me, as I was trying to look more at a global look at how we can ameliorate diseases; and when I went to Africa and saw AIDS, I’d been studying malaria and teaching about malaria and teaching about tuberculosis. I have experienced with tuberculosis mostly when I was training in New York City, where there was a lot of tuberculosis at that time particularly, in some of the economically-deprived populations.

But it became clear to me that there were no advocates to bring the research of malaria and TB into the 21st century. And yet 1.7 million people a year die of TB.

So I began to face the ethical and moral challenges of pushing for something that people were not interested in.

Lloyd: These were all in the developing world so less on the screen of…

Fauci: Absolutely! And you know when you get in front of the Congress you argue for a President’s budget which I defended, and you go in front of the Congress and you try to get them interested in something and to their credit, they have been as we’ve developed more interest in globalization.

But to spend $20 million on a disease that kills a million people—mostly African babies—like malaria or 1.7 million people, mostly in the developing world, when you’re spending five times that on something that has less of an impact—that really is a dilemma that you have to face, and you have to bring in ethical principles, moral principles, commitment to global health—it’s a struggle.

Davis: Here’s a question about something that we encounter or deal with every day, and it’s about hand sanitizers. How effective are they really? And the question is do they just kill bacteria but not viruses and how much should we rely on that hand sanitizer on our desk?

Fauci: We should use them. You know you could always find a study that says that if you go with a hand sanitizer, there’s still some viruses that survive—that’s red herrings! You need to wash your hands when you’re dealing with a respiratory-transferred virus. The reason is that, even though it is transferred by droplets back and forth, you can get a droplet on your hand, shake hands with someone else, and then that person, it’s on their hand, rub their nose, their mouth—that’s how you get infected.

So anything you do, whether you wash your hands. The good thing about hand sanitizers is you don’t need to be running around looking for a bathroom anywhere. You just have it on your pocket. The difficulty is that every time I go to the airport they take it away from me because I’m getting on the plane. (laughter)

Davis: This questioner brings us back to the concerns around AIDS here in Washington D.C. And we know there’s a… Recently in the Washington Post a study coming out and I believe you were related to, this person asked, what can we do to better address this question and, in specific, to create a needle exchange program?

Fauci: Let’s just take the needle exchange program. This has been very frustrating for me for a long time. Back in the Clinton administration, Donna Shalala asked me and a few others to go out and look at the evidence of “does providing clean needles and syringes… Two questions. Does it promote drug abuse among people who wouldn’t otherwise not be abusing drugs, namely is it a bad thing? Or does it prevent HIV infection—which is when you use a clean needle you’ll not going to get it.

And we reviewed all the literature, overwhelmingly the data said that needle exchange programs worked and they don’t do any harm. So I thought it was a slam dunk. We’re going to get pass a federal funding for needle exchange program and amazingly the intertwined political and other things that went into not allowing funding for needle exchange programs.

Happily now, that’s changing, that they’re going to be allowed to use it. There are some hang-ups about it because in the bill, it says to cannot have a needle exchange program within a thousand yards of the following places: schoolyards where kids congregate et cetera, et cetera, et cetera. Trouble is you put up a map of the city and you draw the thousand yards from all of those things, you’re left with nothing. So it’s… We still have a problem and it’s being debated in the Congress right now.

Davis: This person is asking in regard to the H1N1 vaccine, people who are more elderly, 75 years perhaps and above, what effect does this vaccine have on them, particularly those whose system may already somewhat compromised through cancer treatment and other forms of treatment.

Fauci: Well I think we have to separate elderly people and people with underlying conditions, because they overlap. There are a lot of elderly people with underlying conditions.

It’s interesting that almost certainly because in the ’50s… 1950s… there were viruses that were circulating that were clearly different from the current H1N1, but that had some degree of cross-reacting similarity, that induced in people who are now in their sixties and seventies and even eighties, a degree of responsiveness that seems to be relatively protecting them against the current H1N1.

So you have an almost paradoxical situation where most of the time the elderly are the most susceptible. They’re not getting infected. There are not a lot of outbreaks in nursing homes for older people. So this is one of the few situations where age works in your favor, in the sense of the older you are the better it is for you, as opposed to a younger child who never had any experience with this or even the young adult in their twenties or thirties. So if you just think about age, there seems to be this almost paradoxical shift of the curve away from the elderly to the younger.

But when you have an underlying condition, you need to get those people vaccinated. Someone who has cancer, cancer chemotherapy, immuno-suppression, the thing that you wanna make sure they get is the seasonal flu vaccine because the seasonal flu much more readily kills the elderly. 36,000 people a year die from seasonal flu in this country. Ninety-two percent of them are older than 65 years old, so it’s really a bad disease for the elderly.

Lloyd: This has been a very rich conversation. My last quick question is, any single piece of advice for us as we live in a world of pandemics, anything we should pay particular attention to?

Fauci: I think we should pay particular attention to trying to get the correct information. Don’t overreact to almost hysterical stories that you hear, and try to make a decision, not based on what the headline is, or what the subject matter or is something that’s in the newspapers. But now with the access to the internet you could get away from the blogosphere. Go to the CDC website and kind of figure out what is going on there as opposed to what you read about—that there’s sort of a balance between both extremes. Sam, we’re in a very interesting situation, you know the polls, half of the people don’t wanna get the vaccine because they think it’s not safe and half of the people want the vaccine but many of them can’t get it because there’s a gap between the supply and demand. I mean what a crazy message that is?

Lloyd: This has been enormously helpful. I hope you all will come bac