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KHN’s ‘What the Health?’: What Would Dr. Fauci Do?

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Since the mid-1980s, whenever there’s been a public health crisis, America — and six U.S. presidents — have turned to Dr. Anthony Fauci. As director of the National Institute of Allergy and Infectious Diseases (one of the National Institutes of Health), Fauci has helped guide the U.S. and the world through the HIV/AIDS epidemic, as well as various flu epidemics and outbreaks of SARS, Ebola and Zika.

Now Fauci is facing the difficult task of navigating the turbulent waters between the outgoing Trump administration and incoming Biden administration in the midst of an escalating pandemic. As a member of the Trump administration’s COVID-19 task force, Fauci has taken heat from President Donald Trump and his supporters for delivering news and advice that does not match what the president wants to hear. And with the transition delayed because the federal government has not yet recognized Joe Biden as president-elect, Fauci is not free to meet with Biden’s team.

On this special episode of KHN’s “What the Health?” podcast, Fauci sits down for an interview with KHN Editor-in-Chief Elisabeth Rosenthal, a fellow physician. They explore the thorny political landscape and discuss how regular Americans should prepare to get through the coming months — as the pandemic surges and we wait for vaccines to become available.

Dr. Anthony Fauci: Hello.

Elisabeth Rosenthal: Hello. Here we are.

Fauci: How have you been?

Rosenthal: Busy, but not as busy as you. Thank you for taking the time to do this, Dr. Fauci, especially at this really pivotal moment in the pandemic.

I think Americans are barraged each day with varying and conflicting messages, and the pandemic’s been politicized. There are ongoing important scientific developments. And on top of that now we have a somewhat chaotic transition between old and new administrations. So I think a lot of people just don’t know what to think or how to behave. And, of course, our mutual hometown, New York, was kind of the canary in the coal mine for how bad things could get. And it’s apparent now that some of the country didn’t take away that message, and so now we see cases exploding. So I hope your view will help inform people how to get through the next six to nine months and be valuable and calming and maybe help them determine how to behave.

So let’s jump right in.

Fauci: Let’s do it.

Rosenthal: So, are there two or three things you think an incoming Biden administration could or should do on day one?

Fauci: Well, what I have been saying, Elisabeth, is that there are certain things that we uniformly should be doing in the country. There has been, as you alluded to in your introduction, that there were some states in some regions of the country that somehow didn’t seem to have learned from the lesson that could have been learned or should have been learned when New York City and then other big cities got hit: New York, Chicago, Boston, New Orleans, etc. And that is to do some fundamental public health measures. And I want to really be explicit about this, because whenever I talk about the simple things of uniform wearing of masks, keeping physical distance, avoiding crowds in congregate settings, particularly indoors, doing things to the extent possible with the weather, outdoors preferential to indoors, and washing hands frequently, that is not something that means shutting down the country.

You can still have a considerable amount of leeway for business, for economic recovery, if you just do those simple things. But what we’re seeing, unfortunately, is a very disparate response and not a uniform response to that. And the lack of doing that inevitably leads to the kind of surges that we see now. And it becomes particularly more problematic when you’re doing something that you have to do indoors rather than outdoors.

Now, one of the things that I just want to mention that’s important, Elisabeth, is that when you have a background of community spread that’s so high, the bigger the impact of the community spread, the more difficult it is to have anything you do mitigate it. So we’ve got to say we don’t want to shut down. We want to do some things that would start to bring that curve down so that mitigation becomes more efficient, the lower the baseline level becomes. So when you don’t abide by it and you get a surge that compounds the challenge that you’re going to be faced with to get it back down to normal. So if everybody had been doing that at the beginning — and I’m totally aware that COVID fatigue is something that’s a real thing. People are tired of being restricted. But as I said, help is on the way. You know, I use the metaphor “The cavalry is coming,” and that’s the vaccine. And it’s not going to be here tomorrow, but it’s going to be here soon. So I would hope that the opportunity of the vaccine being there reasonably soon will give people more incentive to hang in there and even double down on some of the public health measures until we get real relief from the vaccine.

Rosenthal: I want to go into those in a little more detail in a moment. But first of all, do you think we need a national policy like a national mask mandate? The current administration has left a lot of COVID management to the states, with varying results.

Fauci: Yeah, I think that there should be universal wearing of masks. If we can accomplish that with a local mayor, governor, local authorities, fine. If not, we should seriously consider national. The only difficulty, Elisabeth, that I shy away from making a strong recommendation in that regard is that things that come from the national level down generally engenders a bit of pushback from an already reluctant populace that doesn’t like to be told what to do. So you might wind up having the countereffect of being pushing back even more.

I would like to see people appreciate the importance and the effect and the efficacy of wearing a mask. And if that needs a little urging at the local level by mandating, fine.

Rosenthal: What does that mask mandate look like to you?

It means different things in different states. Many states require face covering, not specifically a mask. My two kids weathered the pandemic in Brooklyn, where “face covering” often meant a bandanna among a certain generation. What should we think about now that we know more about the virus in terms of classic masks versus face coverings?

Fauci: You know, I don’t think it makes that much difference. There have been some articles written about depending upon the fabric and the weave and the thickness or what have you. I think it is unlikely that there’s a substantial difference. I mean, the typical type of a mask is this kind of a mask, which is the surgical mask. It’s not an N95. This is perfectly fine.

Rosenthal: I’ve got mine, too.

Yeah. But one like this that has a thick cloth, you know, can be equally as effective, we believe. There may be some small differences between, but something that would have two purposes. The main purpose is that if you are a person who is infected but don’t know it — you’re without symptoms — that you prevent yourself from infecting others. But recent studies have shown that there is also a good effect of partially protecting you. So it goes both ways.

Rosenthal: And many places that have mask mandates have had trouble enforcing them. Until the pandemic gets so bad that everyone kind of knows someone who’s been sick, and really sick, what do you want to see in terms of enforcement?

Fauci: Well, that’s really one of the reasons why there’s a reticence on the part of many people, including myself, is that if you have a mandate, you have to enforce it. And hopefully we can convince people when they see what is going on in the country. But I have to tell you, Elisabeth, I was stunned by the fact that in certain areas of the country, that even though the devastation of the outbreak is clear, that some people are still saying it’s fake news, it’s not really happening. There is an NPR piece from last Friday where an intensive care nurse in Billings, Montana, was saying we have the biggest health system in the state in Billings. They have a 25-person ICU. And today or whatever day they had the NPR piece, which was last Friday, there were 41 ICU patients, namely 25 plus additional beds were in the emergency room, in the recovery room that were running out of personnel. And yet some people in that location were saying, “Oh, that’s nonsense, it’s fake news, it’s not real” — when it’s right in front of you that your hospital is being overrun. So, I mean, that is a very difficult thing to get over. Why people still insist that something that’s staring you right in the face is not real. That’s very difficult to get around that. I don’t have the real magical solution to that.

Rosenthal: Well, many of the mask mandates say you should wear a mask in places where you can’t social-distance. We’re heading into the winter months. You could be able to social-distance in a restaurant or in an indoor gathering. But would you feel OK being in there without a mask, even though you could technically social-distance?

Fauci: If we’re in the hot zone the way we are now, where there’s so many infections around, I would feel quite uncomfortable even being in a restaurant, particularly if it was at full capacity.

First of all, you have to take your mask off to eat. You take the mask off to drink. And we know that there is some degree — we don’t know exactly how much — but there’s some degree of aerosol spread in the classic sense where even if you speak forcefully or even speak normally, you could have these tiny droplets that go around and recirculate if you don’t have good ventilation in the restaurant. That’s the reason why in many of the locations that today we’re hearing are really having an acceleration of cases, the governors and the mayors are shutting down bars or telling restaurants you can’t have full capacity or even maybe no capacity at all. You don’t like to do that.

Rosenthal: Of course not.

Fauci: That’s inconvenient, but sometimes you just have to do that until you shut down. You don’t need to shut down all businesses, though. That’s the important point.

Rosenthal: People often think of shutdowns as binary: You’re open or you’re shut. And often when you answer these questions — when someone says, “Dr. Fauci, would you fly?” — you start with “Well, I’m in a high-risk group.” So I would love to hear Dr. Fauci’s Hierarchy of Safe and Important to Keep Open, if we can do it with appropriate precautions, including a low background rate and things that just can’t be safe under any circumstances likely.

Fauci: I’ll tell you, Elisabeth, but the reason I say with some degree of trepidation, because then the people who are the proprietors of these people start getting very, very upset with me. But what you want to do, when I say you don’t need to shut down, there are some essential businesses that you want to keep open. I mean, you want to keep grocery stores open, supermarkets open, things that people would need for their subsistence. You might even, if it’s done properly, keep open some nonessential businesses, things like clothing stores, department stores.

As long as people appreciate that, when you’re waiting on line to go in — I’ve seen it around the area where I live. You have marks in the street: Sit, stay here. Don’t proceed until the next person goes ahead of you. That’s in pharmacies, food stores, places like that. A lot of business and a lot of economy can be kept open while still doing the fundamental public health things that I’m talking about.

Rosenthal: And I see … one thing I hear a lot about is hair salons. I see you’ve been getting your hair cut. What do you think about those? I’m going to ask you a few different …

Fauci: Yeah. I mean, again, it depends. I used to get a haircut every five weeks. I get a haircut every 12 weeks now.

Rosenthal: With a mask.

Fauci: Yeah. With a mask on me as well as a mask on the person that’s cutting the hair, for sure.

Rosenthal: OK, and what about — we’re going to get into more difficult territory now —transportation? Trains, planes, Metro. Where are we at the moment, especially since it’s the holidays coming up, the airlines are all promoting special fares and saying this is safe. And again, you know, of course, the answer is going to be: It depends on a lot of different things. But where are you on trains and planes?

Fauci: I hate to give you the answer that you fed me with, Elisabeth, but it is true. It really depends. And I think that when you talk about the kinds of things that you’re going to be doing, you don’t want to waffle on it. But you have to add: It depends on your individual circumstances. If you are someone who is in the highest risk category, I would as best as possible don’t travel anywhere. Or if you go someplace, you have a car, you’re in your car by yourself. Getting on a crowded subway, getting on a crowded bus, or even flying in an airplane. If you’re a 25-year-old person who has absolutely no underlying conditions, that’s much different than a 75-year-old person, a woman who’s on chemotherapy for breast cancer. I mean, it makes a big difference.

Rosenthal: How about some harder ones even? Bars?

Fauci: Bars are really problematic. I have to tell you, if you look at some of the outbreaks that you’ve seen is when people go into bars, crowded bars. I used to go to a bar. I used to like to sit at a bar and grab a hamburger and a beer. But, you know, when you’re at a bar, people are leaning over your shoulder to get a drink, people next to each other like this. It’s kind of fun because it’s social, but it’s not fun when there’s virus in the air. So I would think that if there’s anything you want to clamp down on for the time being, it’s bars.

Rosenthal: We see some places trying to do workarounds, like, OK, the bar will stay open, but there’s going to be a curfew. Does that make medical sense?

Fauci: You know, in some respects it does, because if you look at what happens as you get into the evening, people have a few drinks, they get a little bit more loose, they start taking masks off, if they have masks on.

They let down their guard as the evening goes on. We know that as a matter of fact.

Rosenthal: How about some of the airlines and some states are now telling people, oh, you have to get a COVID test before you go to the state? You know, I heard a couple on NPR this morning saying they were going from Omaha, Nebraska, to Hawaii.

Well, Omaha is a hot zone. Is one COVID test before you go going to keep COVID out of Hawaii?

Fauci: Well, you know, yeah, I mean, if you’re negative when you get on the plane — if you’re absolutely negative — you know, except in the rare circumstances, if you were in that little bit of an incubation window before you turn positive, that’s a good thing. I think testing of asymptomatic people has been somewhat controversial. But the idea of getting as many tests as you possibly can for people to get, for surveillance purposes, not like “I’m feeling symptomatic. I need to know if I’m infected.” It’s more, what is the penetrance of infection in a particular area, in a particular factory, in a particular school? Surveillance testing, in my mind, Elisabeth, should be ramped up, not down.

Rosenthal: I wanted to talk about testing. In some places it’s really easy to get a test that anyone can go in and get one. In other places, it’s much harder. So if you had a national plan for testing, what should we be doing?

Fauci: Yeah, what I would like to see sooner rather than later is literally flooding the system with tests, getting a point-of-care home test that doesn’t require sending it out that you could do yourself, that’s highly sensitive and highly specific. And you know why that would be terrific? Because if you decided that you wanted to have a small gathering with your mother-in-law and father-in-law and a couple of children, and you had something that you could do a test right there. It isn’t 100%. Don’t let the perfect be the enemy of the good. But the risk that you have, if everyone is tested before you get together to sit down for dinner, that risk dramatically decreases. It might not ever be zero, but, you know, we don’t live in a completely risk-free society.

Rosenthal: So I quickly want to move on to vaccines. There are a number of candidates that are promising nearing the EUA stage. But there’s also a lot of skepticism because we’ve seen the FDA come under both commercial and, increasingly, political pressure. When will we know it’s OK to take a vaccine? And which vaccine? It may well be before the new administration comes in there are multiple vaccines that have EUAs.

Fauci: Well, it’s pretty easy when you have vaccines that are 95% effective. Can’t get much better than that. So that’s a good situation to be in. I think what people need to appreciate, and that’s the reason why I have said it like maybe 100 times in the last week or two, is that explain the process by which a decision is made by the FDA that a vaccine is safe and effective. First of all, the bodies that examine the data are independent bodies, an independent data and safety monitoring board that is not beholden to the government, to the company or to anybody else. They examine the data. If they see the data indicates safety and efficacy, they then open up the trial to scrutiny by others. The company looks at the data. I look at the data. Then the company puts the data to the FDA. The FDA will make a decision to do an emergency use authorization or a license application approval. And they have career scientists who are really independent. They’re not beholden to anybody.

Rosenthal: And you feel the career scientists will have the final say? You’re confident …

Fauci: Yes. Yes. Wait … but there’s another important thing in there, Elisabeth, and that is that there’s an advisory board that’s another independent group called VRBPAC, the Vaccines and Related Biological Products Advisory Committee, which is advisory to the FDA commissioner. The FDA commissioner has vowed publicly that he will go according to the opinion of the career scientists and the advisory board. So, A, it’s transparent, and B, it’s independent. We’ve got to keep emphasizing that.

Rosenthal: And that’s part of the next thing. The transition hasn’t been exactly smooth. Have you been in touch with the Biden COVID task force as of yet?

Fauci: No, not yet, but I’m sure we will be because hopefully we’d like to get a smooth transition.

Rosenthal: And will the decisions that are being made in this transition period — the EUAs, the distribution plan — in any way limit the options of a new administration?

Fauci: No, I don’t think so. I think a new administration will have the choice of doing what they feel. But I can tell you what’s going to happen, regardless of the transition or not, is that we have people totally committed to doing it right that are going to be involved in this. So I have confidence in that.

Rosenthal: Is there anything you’re afraid will fall through the cracks in the transition if it doesn’t go smoothly, if the new COVID task force doesn’t get all it needs from the current COVID task force?

Fauci: Well, there’s always a concern about that. That’s the reason why I have said over and over when asked that transitions are important. I’ve served six administrations and I’ve been through five transitions. And I can tell you the smooth transition is important to the smooth functioning of the government.

Rosenthal: When do you think we’ll all be able to throw our masks away? It won’t be with the first vaccine.

Fauci: No, I think that we’re going to have some degree of public health measures together with the vaccine for a considerable period of time. But we’ll start approaching normal, I think, if everybody takes the vaccine. We’ve got to make sure that the overwhelming majority of people take the vaccine. If they do, we likely will be in a situation where it will be approaching normal as we get into the third or fourth quarter of this year.

Rosenthal: Will kids get the vaccine before they go to school?

Fauci: I don’t know. I would imagine so. I hope so, that we’ll have children tested by then.

Rosenthal: OK, terrific. Well, thank you so much. And have a good Thanksgiving.

Fauci: Take care. You too, Elisabeth.

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