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Dr Anthony Fauci on politicising public health, lessons from HIV, and COVID challenges to come

Register here to attend a #CroakeyLIVE event covering breaking news from the United States election – from 3pm AEDT on Wednesday, 4 November.

Just days out from the United States presidential election, with President Donald Trump still insisting the nation has “turned the corner” on the coronavirus pandemic, his top — but sidelined — advisor Dr Anthony Fauci has warned the US is going to be “really challenged now”, heading into Thanksgiving and winter.

Fauci, long-standing director of the National Institute of Allergy and Infectious Disease who has been famously at odds with Trump over his pandemic handling, was the star turn last week at a one-hour Melbourne University webinar, Conversations on COVID-19: The Global View, as Marie McInerney reports below.

You can watch the full one-hour discussion here: https://www.youtube.com/watch?v=1-eD-J8MLv8


Marie McInerney writes:

Dr Anthony Fauci has been variously described by his many admirers as a “public health rock star” and by United States President Trump as “an idiot” and “a disaster”.

The much trusted household name on infectious diseases has advised six US Presidents on multiple epidemics, including AIDS, SARS, Ebola, and Zika, but has had to hire security to protect himself and his family after receiving death threats in response to his work to stop the spread of coronavirus.

Asked at a Melbourne University webinar last week what it’s been like for public health experts to come under such a huge public spotlight in the coronavirus pandemic and how it was working out for him given the “political overtones” of COVID-19, Fauci said:

Well, it’s working out with some bumps, and the bumps are that you have to be always letting the data and the science guide your recommendation.

“You need to be humble enough to know that you don’t know everything at any given time, you need to be flexible enough to know that as more data evolves, you may need to change your recommendation.

“And the critical issue is that when you are involved, as you said, on the same podium with politicians, you should never be afraid to tell somebody something that they may not like to hear.”

Fauci warned that one of the “traps” that some scientists get into is that they like the idea about having impact at the national and global level and sometimes might hesitate to say something that is not popular to the politician.

“You should always remember that in order to maintain your credibility, you’ve got to continue to speak consistently, based on the science…that is really, really important”.

But lack of hubris and clear communication were also critically important: the scientist’s role must be “not to impress people about how smart you are” but to get people “to understand what the heck you’re talking about”.

Often he said scientists will try to be “very, very arcane, in how they present it, and nobody has any idea what they’re talking about”.

“That’s a problem,” he said. “Because if they don’t understand you, they say those scientists, they don’t know what they’re talking about, we can’t understand that.

“You’ve got to make sure you don’t talk down to people, but you got to make sure they understand what you’re talking about.”

Accused by Trump during a presidential debate of “changing his mind” on masks, Fauci told the webinar it’s a challenge to convey the evolving nature of scientific discovery, “that information changes, it isn’t static”, observing that much has changed from early understanding and advice about the coronavirus pandemic versus what is known and advised now.

Science is a dynamic process. And it’s self-correcting.”


Mixed signals and politicisation

Fauci was speaking during a wide-ranging discussion with fellow panelist, leading Australian epidemiologist Professor Sharon Lewin, Director of the Peter Doherty Institute for Infection and Immunity, in a University of Melbourne webinar on 28 October, moderated by Professor Shitij Kapur, Dean of Melbourne University’s Faculty of Medicine Dentistry and Health Sciences and Assistant Vice-Chancellor (Health).

While not directly referring to Trump during the discussion, Fauci made clear his frustrations and deep concerns about the “politicisation” of the pandemic in the US where he said he would be in “serious trouble” if he even used the words ‘shutdown’ or ‘lockdown’

As has been widely reported, Fauci praised Victoria’s mandatory mask wearing, saying it has been “painful” to watch how such a straightforward public health issue has been politicised in the United States and lamenting “mixed signals” from government that was driving vaccine hesitancy.

He was, however, “fairly certain” there will be a vaccine for coronavirus “in the next few months”.

Observing that Australia was one of the countries that has done “actually quite well” with the pandemic, he said he would like to say the same for the US, “but the numbers speak for themselves”, with almost 9 million infections, 225,000 deaths, and a continuing surge  that is essentially “on a day by day basis getting worse and worse”.

Balancing lives and livelihoods

As in Australia, Fauci said there have been significant arguments in the US, which “weren’t as transparently honest as they should have been”, about how to walk the fine line between maintaining the public health, without so damaging the economy that it has a worse impact on health.

But he said he was sure that balance can be found, with other countries and some parts of the US showing it was possible to “prudently” open up countries and economies.

However, he said the US was facing tough times, heading into winter, and with Thanksgiving on the horizon, bringing with it family gatherings which have been shown to be high risk settings.

That’s already been seen in family events that see “six to eight people get together for dinner and you have one person who is infected but has no symptoms, (and) the next thing you know, three or four people in that group are infected, and if one or more of them is a vulnerable person, that’s when you get hospitalisations, and even deaths.

It’s a warning he has repeated in an interview with the Washington Post that was published on the weekend and has been making headlines across the US, three days out from the election.

“We’re in for a whole lot of hurt,” he was quoted as saying. “All the stars are aligned in the wrong place as you go into the fall and winter season, with people congregating at home indoors. You could not possibly be positioned more poorly.”

“We’re going to really be challenged right now.”

Below are some other key takeaways from the event.

Lessons from HIV/AIDS

Both Fauci and Lewin have worked for many decades in HIV/AIDS research and policy.

The first lesson from that work for COVID-10, Lewin said, is that “science matters”: science had absolutely turned around diagnosis and treatment of the virus, “transforming it from being a death sentence to allowing people to have a normal life expectancy”.

Other big lessons for her included the importance of partnerships with community — “that you can’t do this top down, you need bottom up”, and of global collaboration, where HIV/AIDS has seen “great stories about how countries have banded together, rich and poor, to overcome issues like access and equity”, she said, adding that will also be a very big issue with COVID as well.

Fauci agreed, particularly on the role of science, saying it is “unquestionably one of the greatest success stories, I believe, in the history of medicine, to take a disease as potentially devastating as HIV AIDS, and bring it to the point where … you can have that person lead essentially, a normal life”.

He was also hopeful with COVID-19 that, as well as rolling out a vaccine — “which would really be the show-stopper for COVID” — resources will be put into developing a combination of potent antivirals that “can really take away the fear and the dread of this particular disease”.

Dexamethasone is looking to be “quite effective in dampening the aberrant, hyper-immune or hyper-inflammatory response”, and there were promising developments for monoclonal antibodies, with a number of randomized placebo controlled trials now going on in the US for that as well as for convalescent plasma and hyperimmune globulin, he said.

Fauci said the “extraordinary disparity” in COVID-19 related illness, hospitalisations and death for Black and Latin Americans highlighted the need for public health to engage better with communities and to “shine a bright, bright light on the social determinants of health” in the pandemic.

What do we need to know now?

Asked what they would next like to know about COVID-19 to help prepare better public health responses, Fauci nominated two priorities.

First, he wants to know what the durability of immunity for COVID-19 is following infection, amid concerns that re-infection can occur. “That would really be a very, very difficult situation to have a potentially deadly disease that you can continue to have year after year,” he said.

The other relates to those people who are called (inappropriately, he said) ‘long haulers’, people who recover virologically, but have a substantial persistence of almost debilitating symptoms, shortness of breath, muscle aches, dysautonomia, memory losses, and difficulty concentrating, issues observed in people who have become moderately sick with COVID, those who have been hospitalised, and in those who have required intensive care, he said.

Fauci cited a study on cardiovascular effects in COVID-19 patients, that found ongoing myocardial inflammation in 60 per cent of patients, independent of preexisting conditions, severity and overall course of the acute illness, and time from the original diagnosis.

That may “just clear itself up with no problem”, he said. “But I don’t know that right now.”

Lewin is hoping for far better quantitative assessment of ‘non-functional, non-pharmacological’ interventions where the current approach is “pretty crude”.

Jurisdictions currently throw “a ton of things” at outbreaks  — masks, stopping gatherings, working at home, closing schools — and then “peel them back on one at a time hoping that we got the one right”.

Vaccine hesitancy or scepticism

Fauci said the US anti-vaccine movement in the US has a long history of opposition to vaccination for measles, mumps, rubella, but there was now COVID-19 vaccine scepticism that has been “partly fuelled” by mixed signals coming out from the Government, which he says are “not being very helpful”.

That meant, he said, that public health officials and scientists in the US will need to be extremely transparent in the analysis of the data, that will eventually convince people to be vaccinated.

“I think what will happen is that there will be a reluctance on the part of a certain proportion of the population, but as more and more people get vaccinated, and show that it’s safe, and …diminishing the incidence of infection, I think more and more people who want to come in to get vaccinated,” he said.

Lewin said although Australia probably had higher levels of trust in science than does the US currently, it also has vaccine hesitancy, with one University of Sydney study finding that 20-30 percent of people — driven by education level and experiences with flu vaccines — will be reluctant to have a COVID-19 vaccine.

But, she said, unlike infectious diseases like measles, where very high vaccine uptake levels are needed, current predictions are that 60-70 per cent take up may be effective for COVID-19.

Given first generation vaccines largely protect against diseases rather than infection, she said they should be targeted in the first instance at people who are more likely to get sick from COVID-19.

Global vaccine availability

Despite fears that the US will lead “dog eat dog” race in the world of COVID-19 vaccines, Fauci said he was “reasonably confident” that a vaccine will be made globally available, given companies like Johnson & Johnson are talking about the capability of making billions of doses.

While he said it makes him unpopular in some circles, he believes the rich countries of the world, including the US, “have an almost moral obligation” to make sure a life-saving vaccine is given an equitable distribution across the globe.

That was the “entire rationale and moving force” behind the US President’s Emergency Plan for AIDS Relief (PEPFAR), fostered in 2003 by then US President George W Bush, out of the conviction, Fauci said, that “just because a country is poor and doesn’t have resources, doesn’t mean they should die from a disease that we can help them with, merely by getting them the resources they need, in the form of drugs and prevention”.

“I think the same is going to hold true for vaccines to COVID,” he said.

Lewin said the global COVAX collaboration, the vaccines pillar of the Access to COVID-19 Tools (ACT) Accelerator, co-led by Gavi, the Vaccine Alliance, the Coalition for Epidemic Preparedness Innovations (CEPI), and the World Health Organization (WHO) will play an important role (although it has been shunned by Trump, apparently in part because it involved the WHO).

Early investment in that collaboration several years ago, including by Australia and another 70 plus nations, meant that many groups could rapidly pivot to start developing coronavirus vaccines.

It will allow for procurement of the best vaccines and hopefully good pricing, and then allocation to both rich and poor nations, she said.

“If we are just going to vaccinate our own countries and we’re not going to get out of this position…we’ve got to get that vaccine into rich and poor countries around the world.”

On Australia’s performance on COVID

Asked why Australia had done better in managing the coronavirus given the science was relatively universal, Fauci said being a “gigantic island” made it easier for Australia to contain movement in and out, unlike the US, where the southern border in particular was problematic because of problems Mexico was also having with the pandemic.

He also blamed federalism for many US problems: “when you’re dealing with a pandemic, and you say ‘we want everybody to do A, B and C’, and all of a sudden state number 43 does this and state number 27 does that it becomes very difficult.”

Fauci had helped develop guidelines on how to best “gradually, safely and prudently” open up the country but he said the responses from states were “like a free for all”.

“There were some states that didn’t even pay attention. Some states jumped over one benchmark to the other. And some states tried to do it well but yet, when you looked at the TV screens, you’d see people crowded at bars with no masks, just essentially causing super spreading,” he said.

Lewin noted that Australia is also a federation but said that it had “good national leadership” at the start through the National Cabinet, and had been largely led by science, even in the face of significant pushback by business, particularly during Victoria’s recent extended Stage 4 lockdown.

She agreed being an island was an important factor, as was widely available testing early, universal health coverage, and a “very, very robust public health system”. Although Melbourne’s ‘test, isolate, trace’ system was initially not as good as Sydney’s, it had significantly improved, she said.

Lewin saw the difference with the US as less about individualism of the states than ‘individual individualism”, describing how Victoria now has universal mask wearing, despite early reluctance, via the imposition of $1,000 fines for non-compliance.

It has been, she said, a painless and really effective intervention.

Fauci said he wished he could transplant that kind of mentality to the US where masks have become “almost become a political statement” in an extraordinarily vitriolic debate.

“(Your view) depended upon which side of a particular political spectrum you’re at, which is so painful to me as a physician, scientist and a public health person to see such divisiveness centered around a public health issue,” he said.

“I mean, if there’s one area of life that this should not be divisiveness, it’s in the health of your nation.”

Getting back to normal

Fauci told the webinar he believed it will be “some time” before we get back to what was considered normal a year ago, and would likely rely on the “successful implementation of a COVID-19 vaccine campaign globally”.

Even with that though, it would “be easily by the end of 2021, and perhaps even into the next year, before we start having some semblances of normality”, he said, adding that he believes global sensitivity to the potential devastating effects of the pandemic will be “extraordinarily heightened” beyond it and will see mask wearing become “very commonplace”.

He predicted people would be back in theaters with spaced seating, and perhaps masks, by maybe the third quarter of 2021.

“(But) if normal means you can get people in the theater without worrying about what we call congregate setting super infections, if you can get restaurants to open at almost full capacity, if you can have sporting events, to be able to be played with spectators, either in the stands or in the arena, then I think that’s going to be well into 2021 and perhaps beyond.”

Fauci said he expected the dramatic shift to online meetings and gatherings for work to continue even as the pandemic is contained, but warned he would not like to see personal interactions abandoned, particularly for the scientific community where they play such an important role in collaborations and for school children, “because psychologists tell us that the physical interaction with the children in school is very important to their development”.

Lasting positive legacy of COVID-19

Fauci said he did not know what would be the lasting positive legacy of the coronavirus pandemic, but he hoped it will be a much stronger commitment to global inter-connectivity in health, “that we really are a one world health, as opposed to individual countries”.

“Because if ever there’s something that shakes you into that it’s a global pandemic, that has already affected 30 plus million people and killed over a million globally,” he said.

“And we’re not through with it yet, by any means.”


Join us for #USvotesHealth discussions

Croakey is hosting a #CroakeyLIVE event from 3pm AEDT on 4 November to discuss the United States election as results begin to roll in from the 2020 presidential election.

The event will be moderated by Croakey contributing editor Associate Professor Lesley Russell and James Blackwell, a Wiradjuri man and Research Fellow (Indigenous Policy) at the Centre for Social Impact UNSW.

See all the details here: https://www.croakey.org/as-covid-explodes-in-the-united-states-join-us-on-4-november-to-track-critical-election-results/

Register here.

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