Big Think

Question: What do you do?

Anthony Fauci: Well right now I really wear several hats. I’m fundamentally a physician, but a physician scientist. I’m the director of a very large institute – the National Institute of Allergy and Infectious Diseases – that has a $4.6 billion dollar budget and is responsible for carrying out essentially the vast majority of government-funded research on infectious diseases, particularly diseases like HIV/AIDS, for which we have a major responsibility; malaria; tuberculosis – vaccine preventable diseases.

So I have the administrative responsibility of looking over and looking after the appropriate spending of government resources on those very important areas that have to do with public and global health.

I also am a scientist. And I have in my laboratory. I run a modest-sized laboratory that’s looking specifically at what we call the pathogenic mechanisms of HIV disease, or AIDS. And I’ve been doing that literally from the very first weeks of the AIDS epidemic when we first realized we were dealing with a new disease in the summer of 1981.

I also continue to see patients. Not as much as I used to before I assumed the administrative directorship of the Institute; but I still see patients a couple of times a week to keep my hands and my heart in knowing what the real world of medicine is all about. I don’t want to essentially distance myself from that.

So I have the three hats of: I’m a physician, and I see patients and take care of patients; I’m a scientist; and that I run a laboratory that’s looking at a specific aspect of HIV/AIDS. And I’m also assigned to be administratively responsible of the conduct, the research, the broad arena of infectious diseases.

One of the areas that is of growing interest is the area of global health. We also have situations in our own country [USA] in which, if you look at the burden of disease, there are great disparities in health. And if you’re poor or a minority in an inner city area, the opportunity for you to get the kind of healthcare and access to the research advances which we work on in my Institute at NIH are much less than if you were a relatively well off, middle class, white person living in the middle of the country.

So those are the kind of things that you have to pay attention to because you see them all the time. It doesn’t necessarily change the fundamental direction of the research that you do. But for example, if you do a clinical trial in prevention of HIV, you’ve got to take into account the socioeconomic conditions with which some members of the society have to deal with in their lives.

So the whole area of prevention of infection, the access to therapy; we develop drugs for HIV. We’ve been quite successful in that. We do the clinical trials that prove the safety and the efficacy of these drugs. Yet once you get the drug, you’ve got to know, is it used differently or not in different populations of people, both in the United States and globally. Of late – I would say the last decade and a half with the realization on the part of so many people about the important globalization, the health of other nations – particularly nations that are low and middle income nations – in Sub Saharan Africa, Asia, the Caribbean, and South America – is of great consequence to the interest of people in our country. So we are considerably increasing our effort on global health research in addition to the important problems we have in this country.

So in answer to your question, the socioeconomic and other political issues play a role. Well they certainly don’t necessarily, directly shape what they do; but you must pay attention to those things when you’re doing health work.

Well the joy is intense. It’s wonderful. And that is knowing that what you are doing will ultimately be for the benefit of your fellow man. And that can be either directly taking care of someone who is sick as a physician; or in a more indirect way – which ultimately could have a much broader and wider impact than you taking care of an individual patient – is in overseeing the research that will come up with a discovery, a new drug, a new vaccine, a new understanding of a disease that would ultimately help countless people.

And it was that aspect of the biomedical research arena that was very attractive to me. I first started off with classical training in clinical medicine, and went through the many years of training that you have to go through to be first an internist, and then an infectious diseases specialist. I got a great deal of gratification out of that, a great deal of joy.

But as I started to realize, your impact could be much broader either by your own personal research, which can help many, many more people than you individually can get to; but also if you run an institute the way I run, in which there are many, many scientists who are being funded and helped in their direction of their research, the impact you can have brings you a considerable degree of gratification. And that’s the kind of thing that drives me and many of my colleagues to put in the kind of hours that it takes to stay on top of this very, very rapidly moving field.

Well the struggle is that the lack of immediate gratification in the world of research, and the considerable amount of failures that come along with the intermittent successes. Research is discovery. And discovery, by its very nature, is uncertain.

So you don’t go in, do an experiment and have a guarantee that you’re going to come up with something that’s worthwhile for anybody. So the stress and the tension is that you may be working on something for a considerable period of time, and it turns out to be a bust. That’s counter-balanced by you could be working on something, and then all of a sudden it turns out to be a sensational finding that has enormous, enormous impact.

I can recall the very first years of the HIV/AIDS epidemic from the first patients that we admitted to our hospital in 1981, until the first drug was developed – AZT [azidothymidine] – in 1985, ’86 and early ’87. It’s that we were in a very, very difficulty psychological position where virtually all of our patients died. And when you’re a physician, like I am, who’s an infectious disease doc who’s used to curing people. Because you know, when you get somebody who’s sick, they look very sick. They’re otherwise young and healthy. You treat them with an antibiotic and you take good care of them, they get better and you get a phenomenal feeling of gratification that you’ve really saved someone’s life and you turned it around.

For the first several years with HIV/AIDS, it was very dark years because everyone who we took care of ultimately died. Then over a period from 1986, ’87 up through around mid-1990s, 1995, 1996, when the combination – what they call the cocktail of anti-HIV drugs – became available, there was an almost miraculous turnaround in the results of treating people with HIV where people would otherwise waste away and die before your very eyes, were now getting back to leading normal lives.

So that story of the interval between the early 1980s ‘til the mid-1990s really runs the spectrum of the dark years of great discouragement – of saying, “Oh my goodness. Every day I go to work and everybody that I’m taking care of ultimately dies” – to the hints of a good possibility that something good was happening from the mid-80s to the early ‘90s when drugs were coming along, but not quite the right combination until we got to the mid ‘90s. Up until today when the drugs that we have now, and the combinations have completely transformed how we take care of HIV-infected individuals.

So it’s been a very interesting journey with very, very high peaks and very, very low valleys.

Well I think the media has a very powerful influence on almost anything and everything we do, because the general public gets their perception of what is going on in things they don’t have immediate access to from what they get through the media.

I think the media can be a very positive influence by essentially holding people to task about the importance of high quality medical care. And when the media is scrutinizing you, then I think that’s a very good, positive thing for the field of medicine.

Also, the media makes the world and the general public aware of advances that may be of benefit to them much sooner than if it trickled down through the usual channels.

So if you look at our society today with the media in general, and in particular with the Internet, the degree of sophistication of the general public about their health, what’s out there for them, the kind of things they need to avoid if they do get into a situation with a health problem, the kinds of things that are available to them, is really unprecedented.

So the role of the media is really huge.

I see what’s going to happen – and I hope it does, and I think it will – is that we concentrate a lot more on being predictive, and preemptive, and preventive; as opposed to waiting until someone gets sick, and going through the pain, and the suffering, and the expense of taking care of so many sick people, is to try and shift the balance of how medicine and the health profession interacts with the public to try and anticipate. And we’ll get the tools for that – each year that goes by with molecular diagnoses; understanding the role of certain types of habits in disease; understanding the genetic makeup of someone – to make medicine more personalized, more predictive, more preventive and preemptive so that you can actually prevent, or at least forestall many of the things.

Like diseases will occur, and for sure there’ll be many, many situations where there’s nothing that you can do about it. But if, for example, you’re at a particular genetic risk for a disease, there are other environmental and other factors that you can control so as not to make it more likely that you will get this disease either earlier than you would, or even to prevent you from ultimately getting it.

So I look at the future as one much more of trying to anticipate a problem and do something about it. And I think the cost effectiveness of that is going to be enormous. Because if you look at how much it costs to try and prevent someone from getting sick by lowering their cholesterol, watching their blood pressure, making sure their diet is right, avoiding smoking and things like that, the amount of money that it takes to get those things in effect balanced against the enormous expense of taking care of someone with a very serious disease that leads to their death until there’s no contest. It’s much, much less expensive to try and prevent it.

What we’ll face is we’ve got t get the attention of the American people. We’ve got to get the leadership from the federal government. We’ve got to get the pharmaceutical companies involved in knowing that it will be to their benefit in trying to get diseases prevented as opposed to treating diseases. That seems somewhat paradoxical, but that would be the case.

But no. For example, lowering cholesterol and lowering blood pressure is much better than treating the stroke, or treating the heart attack.

So we need leadership from above. We need the public to be informed. And we need collaboration and cooperation with the public sector.

It’s tough to say, but one of the things that I’m most proud of is something that is on the border between policy and science. And that is that a few years ago, in 2002, when we had the drugs available in the developed world to have a major transforming impact on HIV/AIDS, we started to question what could be done in the developing world – particularly Sub Saharan Africa and the Caribbean. And Tommy Thompson and I were sent to Sub Saharan African countries by President [George W.] Bush to look around and come back with a proposal of how the United States government might help in the arena of HIV/AIDS to those countries that are poor and don’t have the resources that we do.

And we came back with a proposal first to try and block mother to child transmission of HIV. We presented it to the President and his closest advisors. They accepted it.

But then they said they wanted to do something even much more broad than that with a much greater impact. And I spent a lot of time on that – probably about six or seven months of my life working hard on that, which was well worth it – to put together a program of how we can get drugs, prevention, and care to millions of people in Sub Saharan Africa and the Caribbean. And we worked on it, presented it to the President, and with a lot of help from a lot people inside government, outside of government, faith-based organizations, advisors to the President, and people who really cared about it who were able to get the program to be accepted by the President, and to put it into effect by law. And that is the President’s Emergency Plan for AIDS Relief – or PEPFAR – which started out as a $15 billion dollar program over five years, which the president has now doubled to a $30 billion dollar program for the next five years, to aim at preventing millions of infections, treating millions of people, and caring for people.

It has been a huge success.

The fact that I played a role in getting the thing developed, established and implemented is something that I feel very good about.

Recorded On: July 6 2007