Dr. Anthony Fauci: Preparing for Pandemics Takes an ‘All-of-Government Approach’ 

As the nation heads into year three of the coronavirus pandemic, the nation’s top infectious disease expert is doubling down on pandemic preparedness, which he says is an “all-of-government approach.” 

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and chief medical advisor to President Biden, has been the face of the pandemic response and has been elevated to celebrity status by some and subjected to criticism and scrutiny by others. His agency recently released a new pandemic preparedness plan, but Fauci said they’ve been working on similar efforts for quite some time now. 

Government Executive interviewed Fauci on Wednesday afternoon via video conference about the new plan, the pandemic response and more. The interview has been edited lightly for length and clarity.

GE: Can you start off by describing what’s in this preparedness plan and what that will mean for the day-to-day work at your agency?

Fauci: We have been involved in pandemic preparedness really for some time now, actually, going back to original preparedness for emerging infections—the Ebola, the Zika, the pandemic influenza, our response in 2002 to the original SARS and then MERS in 2012, and then our really rather I would think highly successful scientific response to the COVID-19 outbreak by being the agency with our vaccine research center, particularly to be responsible in large part for the development of the successful vaccines in a record period of time. The reason I introduce my answer to you with that is even though we've recently put out a pandemic preparedness official plan, we had been on that track for a considerable period of time, but in the plan, we’ve solidified it and it's based on a concept that has proven to be successful with COVID-19. 

So let me give you an example. We had been studying intensively since 2002 the issue of coronaviruses and how to best get vaccine platforms and immunogen design if we were faced with yet again another SARS outbreak. Remember the original outbreak that was less impactful than the current one by far was [in] 2002-2003 and it was our getting cumulative knowledge about the entire family of coronaviruses that allowed us to respond so effectively against COVID-19.

So, we are extending that to do what is referred to as the prototype pathogen approach. In other words, to take multiple families of potential pathogens, there are about 20 of them (about seven of them are of the higher priority, but all 20 are important) and to establish certain fundamental commonalities within each family and work out things that would be diagnostic tests, platform technologies for vaccines, multiplex diagnostics and therapies, particularly directed discovery of molecules that would have therapeutic or preventive effect against these pathogens. And if you do that, that doesn't mean you have to develop a vaccine against all of the seven families, but you take a few steps, such as developing a prototype vaccine, putting it through phase one and then having it ready so that if you do have an outbreak within that particular family, you don't have to start from scratch, You already know that there are certain commonalities within the family that would be applicable and there are a number of families, you know, rhinovirus, flavivirus, alpha virus, coronavirus, et cetera. So that's one aspect of the plan. 

The other is a pandemic antiviral program to take a look at the development of and discovery of small molecule antivirals that can be used across all lines of certain viruses and particularly within individual given families. So, everything is focused on not going all the way with a particular family, but getting enough ready information, so that if the next outbreak is a flavivirus or arenavirus or alpha virus, we won't be starting from scratch. We will already have these things in tune.

So that really is what the pandemic preparedness strategy is founded on. It's more of a formalization and a building on the success that we've experienced with the coronavirus, particularly the vaccine, but to some extent, also the antivirals. For example, the now [Food and Drug Administration]-approved antiviral remdesivir was part of that program, but remdesivir was not developed for coronavirus, it was developed for something else. Yet we saw a certain commonality of capability of that antiviral. And now it's one of five antivirals that have been approved either by full approval or by emergency use authorization to be utilized as an outpatient [treatment] to prevent people from going from infection to severe disease leading to hospitalization.

GE: Now I know the plan mentions that it will involve collaboration with other U.S. government agencies. Can you talk about what the appetite has been for that from other health agencies such as the Food and Drug Administration and Centers for Disease Control and Prevention or maybe the White House? What have they been saying about pandemic preparedness and how they could potentially work with your agency and your parent agency, the National Institutes of Health?

Fauci: Well, first of all, that's a great question. Thank you. It's an all-of-government response. You might recall, it must've been, you know—I lose track of time with this outbreak—a month or two ago when the [White House] Office of Science and Technology Policy came out with a pandemic preparedness plan, they gave an arbitrary number to it. It was $65 billion. It likely will wind up ultimately over time being more than that. But noteworthy, in that, is a multi-agency approach. But if you look traditionally at how we at NIH, particularly my institute, NIAD, over literally, you know, I've been the director now for almost 38 years, and we've been doing this continually in very close collaboration with the CDC, which was responsible for the broad surveillance and picking up when there is the inkling of an outbreak; [it] would be extremely important for us to work with them. We also, interestingly, had very close collaboration with the Department of Defense because although their main mandate is force protection of the military, [many] of the things that they want to protect the military against we want to protect the general population against. So, you're talking about [collaboration with] NIH, CDC, FDA, Biomedical Advanced Research and Development Authority as well as with other organizations, for example, like the Department of Defense or even [U.S. Agency for International Development]. Because as you know, USAID is very much involved in getting the capability of getting vaccine doses into the arms of individuals, into the developing world. Bottom line: it's an all-of-government approach of which the NIH is an important component. 

GE: Pivoting off of that point of being an all-government-of-approach and working with other government officials and agencies, the surgeon general issued an advisory—his first under the Biden administration—over the summer about the threat of health misinformation. And you know, this has been an issue since the start of the pandemic: disinformation and misinformation from everyone from politicians to podcast hosts to just people posting on social media. I'm wondering, has that had any impact on your response to the pandemic, or as you work to prepare for future pandemics? 

Well, unfortunately, Courtney, it has a very negative impact on anything we do. You know, misinformation and even worse, disinformation, and as you know, the definition of misinformation is incorrect information that might inadvertently get out with no nefarious purpose, whereas disinformation is deliberately misleading people. Particularly in the arena of the impact of social media this disinformation and misinformation has really [had] an extraordinarily negative impact on what we want to do and I think the most important example of that is the mis- and dis-information associated with vaccination. 

We started the conversation talking about and continuing to talk about the pandemic preparedness plan. You can prepare for a pandemic, you can get a vaccine that's highly effective and safe (the way the COVID-19 vaccines are), you can get an operation to make hundreds of millions, if not billions of doses, but if the disinformation campaign prevents people from taking it, that in many respects is a major, major obstacle in the optimal fulfillment of what the goal of the pandemic preparedness plan is: to protect the American people primarily, but then secondarily the rest of the world because the United States plays such a leadership role in every aspect of global health.

You know, from the [U.S. President's Emergency Plan for AIDS Relief] program with HIV to the Global Fund [which works to fight AIDS, tuberculosis and malaria] and now to the effort that we're putting into getting doses of vaccines to low- and middle-income countries who don't have the capability of providing for themselves with doses of vaccines. So good question. It's the bane of our existence, disinformation and misinformation. 

GE: The COVID-19 pandemic has had a disproportionate impact on people of color. I'm wondering, how that is playing into how you think about future pandemics and how they could affect some groups versus others?

Fauci: Well, I hope it will be yet another example of lessons learned. This would not be the first time that an outbreak has a disproportionately negative impact on people of color. I mean, we've seen that with HIV/AIDS. I mean, we've been with HIV for 40 years right now. Thirteen percent of the population is African American, 45% of the new cases are African American men who have sex with men. But also, it really tells us something about something that's rooted in our society that hopefully something as profoundly impactful as the COVID-19 outbreak gets us to make a long-range commitment to correcting it. And that's what I refer to as the social determinants of health, which as we all know, unfortunately, are founded in many respects in the issues of racism that have been a real issue in our country since the beginning of the country and before. 

Mainly if you look at the social determinants of health, African American [individuals], particularly, but also Hispanic [individuals] have underlying medical conditions that make it more likely that if they do get infected, they will have a severe outcome. Things like obesity, diabetes, hypertension, chronic lung disease: those are not racially determined co-morbidities, those are comorbidities that are directly associated with social determinants of health. Like the lack of easy accessibility to a proper diet or economic situations that put people into a situation where they don't have adequate preventive health care.

Those are the things that make it much more difficult when you get to a circumstance like COVID-19. We're not going to solve that in a week, a month or a year. I hope that it reminds us that yet again, this is another example of how disparities among racial and ethnic groups come out in their most profound way when you're dealing with a public health emergency like COVID-19. This is not only no exception, it is an absolutely cogent example of that. 

GE: What has it been like to lead NIAD the past two years in I'm assuming a largely remote environment? You and your staff have been at the center of a lot of praise but also targeted for a lot of criticism, so how has that been to keep up maybe employee morale or just get the work done that you need to do for this once-in-a-generation event? 

Fauci: Well, I'm extremely proud of our team here at NIAID because we really stepped up and actually delivered because if you look at the broad, comprehensive, complicated issue of response to an outbreak, there's the scientific response, there's the public health response and there's an implementation response. We have very high morale in our group here. We've been very successful. If you look at the vaccines that we played a major role in; not the only role, but certainly a major, major role in the development of those vaccines. Science Magazine deemed it the scientific breakthrough of the year.

So, morale is very high. Obviously, everyone is stressed in our country when you're dealing with the fact that you're having a cloud of a deadly pandemic over you. But even though people physically at work certainly are not the full component of what we'd have normally, we have very good communications through Zooms through teleconferences.

But the real answer to your question is that the spirits are very high. I mean, we all take this outbreak very seriously, but we all know we have a job to do, and I'm very proud that everybody is doing their job and then some.