Could You Withstand A 50+ Year Career, 2 Major Pandemics, 7 Presidents, and Not Burnout? 

My Interview with Dr Anthony Fauci

[00:00:05] John Marshall, MD: You know, I've interviewed a lot of people in my career, but I don't think I've ever had quite the joy of interviewing someone who, honestly, I think almost everybody in this country, there's some who don't feel this way, but, almost everybody, in this country who think is a real modern day hero, and this is Dr Anthony Fauci, and he has agreed to join us and talk about a few subjects that sort of near and dear to maybe both of our hearts and share them with us all. And on a second note, I want to welcome him as he's flying the Georgetown University flag behind him. I've been here on the faculty for 31 years and I'm not sure I've, I don't want to insult any of my other colleagues, but I'm not sure I've ever had quite so, such an esteemed colleague from my own university, join me. So, Dr Fauci, first, thank you very much for joining us today. And let me give my own personal Hoya Saxa welcome to Georgetown University.

[00:01:00] Anthony Fauci, MD: Thank you so much, John. Pleasure to be with you.

[00:01:03] John Marshall, MD: Well, you're awfully nice. Part of what has sparked my interest in talking with you just beyond all that you've been through and all that you've led us through over the years, is really some subjects that came forward in your book. It was really an impactful book. If you haven't gotten it yet, gang out there, it's called On Call. It’s a terrific book available on audio as well for those of you who like to walk and listen at the same time. It's really an extensive review of your own life and the impact that you've had in your own reflections on very, very dramatic moments in medical history. And I wonder if you just start by kind of sharing the sort of inspiration to write it and sort out the emotion. And what it took to stop and get all of that down.

[00:01:49] Anthony Fauci, MD: Yeah, well, thanks, John. I decided to write the book because when I came to what I was projecting to be the end of a 54 year career at the NIH, Almost 40 years of which was as the director of the NIAID, which positioned me to essentially be in the eye of the hurricane in the evolution of, as you mentioned, the most impactful pandemics in modern history HIV in the early eighties and through the next 40 years, and then followed by COVID-19.

[00:02:21] That started, at least in the United States, we had the impact of it in the early months of 2020. when I decided I was gonna step down, I thought it would be important, given I had the unique experience of this, journey through these two major pandemics, but also in between advising seven presidents of the United States from Ronald Reagan through the Bushes, through Clinton, through Obama, through Trump, and then finally the seventh. when I spent two years as the Chief Medical Advisor to Joe Biden. I thought that that was such a unique experience. My thoughts were two-fold. One, I thought from a historical standpoint, I thought it might be useful for people to see what that was like to go through the early years of the pandemic with HIV and then throughout COVID, but also hopefully to serve as an inspiration for younger individuals who might have an inkling they might want to go into science or medicine or public health. And my description of the early years I believe were, were important because right now with HIV, we have a single pill with three antiretrovirals that can put a person into complete remission by bringing the level of virus to below detectable and keep it there essentially indefinitely.

[00:03:52] But I hearken back in the book, in the memoir, to those early years from 1981 through the mid-80s, the late 80s, and the early 90s, when we did not have adequate therapy. And I found myself as a physician who, prior to HIV AIDS, was rather successful in developing remission-inducing therapeutic protocols for auto inflammatory disease, where most of my patients who thought they were going to die actually went into remission. Then entering the arena of caring for and studying persons with HIV. I describe it in the memoir as the dark years of my medical career and the stress and the strain. Of seeing virtually all your patients, mostly young, otherwise previously healthy gay men who are dying terrible deaths, no matter what you did. And it was like putting bandages on hemorrhages. You know, I described in the book, I still to this day have flashbacks of what I call a version of post-traumatic stress. Because. When you were taking care of these people early on in the early 80s, you could not get emotionally involved in it because you had too much work to do, and your job was to take care of the patients. So, you suppressed it. It only was years later when you reflect on what you've been through that you understand that you didn't have time to burn out because you had too many people to that you had to take care of. But it was an extraordinary experience, which was an important part of the book to describe those early years of HIV.

[00:05:42] John Marshall, MD: Yeah, well, and taking care of yourself was had to be last on the list because everybody else needed you and there were no, you know, it was sleep, eat and take care of people. I remember in 1988 when I became an intern here at Georgetown walking the halls and those floors still exist. There’s new tile, but the floor still exists. And, you know, I remember the faces of the young men that you describe in there and being the guy who had to go in the gown and get the blood because we didn't have phlebotomists back then and being afraid actually to have a needle in my hand and have an HIV patient that I needed to get blood on or to put a line in or something like that. But, at the same time, they were alone and you wanted to be there with them because the way the rules were in hospitals as they frequently couldn't have visitors. And certainly that was traumatic for me, and I, like you say, I probably tucked that away. Then I decided to take on the easy task of trying to cure GI cancers. Not done nearly as well as you've done with viruses

[00:06:40] My experience was then my wife gets breast cancer. And I thought she was going to die. And now all of a sudden I knew what it felt like to be a caregiver or to be a patient. when in fact, I had probably tucked that away for many, many years. And then I tried to, back to we're busy and we’ve got to cure people, deliver that care for every cancer patient that was here. I realized there was no way that you could deliver that level of cancer care, the cancer care that we received as patient and caregiver. I couldn't turn around and give that to everybody who walked in the door. And that was in essence my source of burnout because I was feeling the impact. I was feeling the shortcomings, and actually had to get away for a while. And, and part of our book reflects on that. I think the young people today, and I would love to hear your sort of comparison because I experienced both, you experienced both pandemics, but a lot of our gang around here, you know, they cut their teeth on a pandemic. The interns and residents were on call, and you know, burning their clothes at their door on the way home in that same sort of way we felt with HIV.  Do you have a sense of how they might be different or how they were different for you, the two experiences?

[00:07:53] Anthony Fauci, MD: Well, yeah, they were different for me, John, for the following reasons, that through the early years of HIV, even after I became Director of the Institute, I was very actively involved in the individual care of individuals, which led to that very stressful, emotional experience that I mentioned to you a moment ago. When it came to COVID, for me personally, it was a different experience because I was in a position of public health influence where I was, you know, as part of the Coronavirus Task Force in the White House, making decisions that were difficult because we had an evolving outbreak that was not just selectively impacting a subpopulation, it was global and everyone was at risk. So, we had a true global health and domestic health catastrophe with COVID, and we had to, to the best of our capability, make decisions about what public health recommendations would be that would involve everyone, not just a small subset of people.

[00:09:10] At the same time I had the responsibility, together with the pharmaceutical companies, to develop the vaccine. And I could say that was one of the things that we're very proud of, is that my group at NIAID, the Vaccine Research Center that I established 20 plus years ago, was the group and the organization that developed the vaccine the highly immunogenic immunogen that partnered with the mRNA platform to create a vaccine in 11 months, which as you well know, that is a fraction of the normal time it takes to develop a safe and effective vaccine, which usually averages, seven to 10 years. So, a combination of major investments on the part of the government, the scientific input from my group, and the incredible work that the pharmaceutical companies did. We had a vaccine in 11 months. So that was very, very different from the multiple years it took before we could get a drug for HIV. Remember the first patient that I admitted with HIV was in 1981. The first drug that had any effect on HIV was 1987, and it wasn't until 1996 that the triple combination of drugs were made available, which actually dramatically diminished the viral capability and viral load.

[00:10:42] John Marshall, MD: I used to say back in the day that the only reason the HIV success happened was that gay men, essentially, became very powerful self-advocates, and demanded this when there was probably a public sentiment that you were up against even then to do this. With the pandemic, even though you did have global support. You did also have to climb a hill over some who thought this was all some sort of conspiracy. We all know that, but so we are grateful for that. But it does require that sort of will to do it. But to your point, if the will's there and the science is ready for it, it can be done. And so to reflect on that, you coaching me as an oncologist, do you think that if the will were there and we spent the money that we are spending every year on cancer care and cancer medicine, if we spent it more wisely, could we in fact have better outcomes than we do now? What's your thought on that?

[00:12:00] Anthony Fauci, MD: I think so. I mean, if you look at the focus concentrated effort that was put into drug development for HIV, it is one of the greatest success stories of modern medicine. I mean, where all of your patients are dying from an infection that you just could not treat at all to years later when you have a single pill that can essentially drop the level of virus to below detectable and keep it there, not only saving the life of the person, but making it impossible for that person to transmit the virus to someone else.

[00:12:36] John Marshall, MD: And, at the time, we had like 90 percent accrual rate on clinical, everybody was on a trial, right? It was uncool. Not to be on a trial.

[00:12:44] Anthony Fauci, MD: Yeah, that's exactly what it was. You mentioned a moment ago, John, the importance of the AIDS activists in getting community involvement in everything from the design of clinical trials to make it more user friendly to them, to challenging the rigidity of the regulatory process to get drugs approved. Because the FDA process prior to AIDS was very well accepted. It provided safety for the American public, and it got drugs out. But it was ill suited to the emergent nature of HIV, where when someone had clinical disease, it was 12 to 15 months before they died, and interventions before they got through the FDA process would take six years, seven years. It just didn't work for them. So, they pushed back, and the scientific community and the regulatory community didn't listen to them. So, they became very provocative, theatrical, iconoclastic, disruptive. And then I finally listened to them. And when I did, it became clear that they were making perfect sense. And if I were in their shoes, I would have been doing exactly what they were doing. So, it's a very interesting part of our history, the very positive role of the activist community. In getting HIV drugs out sooner and getting them out in a more efficient manner.

[00:14:20] John Marshall, MD: And I've always wondered why the cancer community hasn't been able to sort of create that same unified, not just a pink tent or a brown tent in my case, but a unified rainbow tent to go up and say, we need to change how we do this increase, you know, we're at 8, 9 percent at best on clinical trial accrual now accepting bad diseases and not really pushing. And yet, spending whole lots of money on health, you know, on both screening and on therapy. And it's always been a disconnect.

[00:14:49] But, let me shift gears a little bit because one of my favorite interviews I've ever heard of yours was on a Saturday morning driving around for Wait, Wait, Don't Tell Me. It was just the best thing ever. It's a great show, best show ever. And as you know, on that, they bring famous people like you on and they say, well, we're not going to ask you about viruses. In that case, they asked you about computer viruses. If my memory is correct. Well, I'm going to do the same thing and ask your advice to all of us. You know, what are the secrets to avoiding burnout? What are the secrets? What do you do? What are some of the things you would advise those of us behind you, if you will, to do a better job of taking care of ourselves? You know, we have a common friend who, you know, you played three on three basketball with. I know you're a basketball junkie, but what sort of your advice to us on that?

[00:15:39] Anthony Fauci, MD: Yeah, I, I think it has, you have to have an outside, source of, of support. I was very fortunate in my wife, at the time, was a nurse, who specialized in the clinical care of persons with HIV. She currently is the chair of the Department of Bioethics at NIH, and she actually is a Hoya all the way down. She went to undergraduate nursing school. She got her PhD at the Kennedy Institute of Ethics with Ed Pellegrino. She was very helpful in grounding me when I would come home after losing two or three people, mostly, as I mentioned, young, otherwise previously healthy, gay men to just get me to realize to focus on the potential good that you can do and not the disappointments. Because if you focus on the fact that you didn't succeed, even though you tried, you can really get very discouraged.  So, what you got to do is focus on the positive nature of the effort that you put in, hoping that someday that effort is going to result in something that's much, much, much more favorable. And that's exactly what happened because years later, what went from everyone dying to essentially people leading normal lives on medication. So, support structures are incredibly important.

[00:17:21] John Marshall, MD: so disappointed that you didn't list bourbon as one of the options, but apparently that should be lower on my list. And famously, it is 1 of my vehicles, but never, never before 6:00, let's make this be clear. But anyway, I hear you loud and clear. And I think it's great advice for all of us. Not the bourbon, by the way, you out there listening. That's not good advice. Let's close, you know, you've as you mentioned, and you reflected in your book this incredible duration of advice, you know, the folks that you have provided insights to in our leadership of our country. And one of the areas of focus on our series right now is what's called the Inflation Reduction Act, lots of us are not really aware of it, but why it's coming to a head in oncology is in fact, they're starting to talk about negotiating drug prices. And so, I'm actually taking our audience back to the beginning when Bush II signed it into law the revised Medicare support bill you know, no importing of drugs and no negotiation of drug price because more and more oral agents were needed, and Medicare didn't cover oral agents. So, we needed a vehicle to do that to now Biden's institution of the Inflation Reduction Act. To now a new administration that might wipe that away. And I realize you don't know everything and can't see the future, but I'm just wondering what you're thinking is about what we should look forward to in terms of health care policy and changes

[00:18:53] Anthony Fauci, MD: Well, John, that is the big unknown question right now that's causing a lot of anxiety in the medical community. For my colleagues at the NIH, for my colleagues at the CDC, at the FDA, is that, will there be a dissolution of things that were very helpful to us, and will there be new things that are put into the hopper that might impede what our ultimate common goals are. And the answer is we don't know. And that's the reason why we're in a state of somewhat heightened anxiety because of not really knowing what exactly is going to happen. So, my only advice would be to, you know, think positively that the better angels will prevail and that we'll have things that are sensitive, you know, to the needs of our patients and to the things that we're responsible for doing.

[00:19:51] John Marshall, MD: But bourbon wasn't on the list for that one either. But I understand completely. Why not? We're all talking to those angels right now to make sure that what we can do and what progress we have can continue in the years to come.

[00:20:05] I've kept you long enough. You, I could keep you all day. Dr Anthony Fauci, who is really a world leader in healthcare and global health. think of the number of people out there in the world that he has saved. He wouldn't take credit for that personally, but we should give it to him. So, Dr Fauci, thank you very much for joining us.

[00:20:22] Anthony Fauci, MD: Thank you, John. It's a pleasure being with you. Appreciate it.

[00:20:26] John Marshall, MD:  Amazing to talk to Dr Anthony Fauci on his own personal experience, the impact that he's had as an individual on so many around us, but also his own reflection on his own health and his own well-being and some advice to us all. So, I hope you enjoyed our talk with Dr Anthony Fauci and will join us again on Oncology Unscripted.

This transcript has been lightly edited for clarity.