[Ip-health] FT on Tony Fauci, SARS and AIDS

[James Love]

This is a long and interesting article about Tony Fauci, but also about
policy making in the US on AIDS, SARS and  other important issues.   It
begins with a story about Karl Rove's involvment in the $15 billion for
AIDS.  Also:

*  When health secretary Tommy Thompson spoke at last summer's UN Aids
conference in Barcelona, the stage was invaded by activists shouting the
slogan "Where is the 10 billion?" - a reference to the amount of money
experts say needs to be spent on Aids programmes in the developing world
each year. Later Fauci was called in by the White House and asked to help
come up with a programme for Aids in Africa that Bush could adopt.

*  The night before the president's State of the Union address in January,
he got a call from senior staff at White House to come and help them
prepare the text. Bush had adopted the most generous version of the plan
Fauci had proposed, which involves spending $15bn on Aids over the next
five years, including the use of generic copies of Aids drugs. The
legislation was passed last week.


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Can this man cure Sars?
By Geoff Dyer
Published: May 22 2003 12:42 | Last Updated: May 22 2003 12:42

Tony Fauci boards the Washington metro and scans his BlackBerry for
messages. He has come from a briefing with health secretary Tommy Thompson
about the Sars virus and is rushing back to his office to discuss an Aids
vaccine project with a colleague.

On the screen, there is an e-mail from the president's closest adviser
Karl Rove. Fauci is writing an opinion piece for a Washington newspaper on
a plan the president announced recently to spend $15bn (=A39.2bn) on
combating Aids in Africa. Fauci helped to put the plan together and Rove
has returned his draft with some comments.

A day earlier Fauci was in the front row before an invited audience in the
East Room of the White House where President George W. Bush was appealing
to Congress to pass his Aids bill, which he says could save two million
lives. "I love Tony's commitment to humans, to what's best for mankind,"
said the president. "I'm glad you are here, Tony."

Dr Anthony Fauci runs the infectious diseases department at the National
Institutes of Health (NIH), a government-funded research organisation that
this year will spend a mammoth $27bn on the work it does from its 300-acre
tree-lined campus in the Washington suburb of Bethesda. The campus is so
vast it has its own metro stop.

Since the 1980s both Republican and Democrat administrations have eagerly
sought his counsel. The reason is that infectious diseases frighten us,
both privately and on a mass scale, and politicians are not good at
dealing with that fear. They tend to try to sound positive, and are then
contradicted by fast-changing circumstances. Reliable information from a
trustworthy doctor, even if it is bad news, can have a balming effect.

"I am basically just a nerd," says Fauci.

Nerd, or family doctor to the nation, Fauci is now manning the nation's
defences against Sars. When it comes to Iraq, the Pentagon wheels out
Tommy Franks and when the economy is looking poorly, people hang on Alan
Greenspan's every word. When there is a new health threat, it is Fauci who
is called on. And in the post-9/11 America, where fears about new bacteria
and viruses are ever-present, this short man has taken on an ever-larger
role.

Fauci is one of those rare people who routinely works a 16-hour day. Sars
has turned that into 20. "We are in the middle of a public health crisis
here and so I tend to get pulled in lots of different directions."

Across the world in Beijing and Hong Kong, a World Health Organisation
team is grappling to contain the Sars crisis. Led by David Heymann, the
WHO official who was also one of the scientific pioneers in the early days
of Aids, the team has found that the virus does not seem to transfer quite
as quickly as it initially seemed. Swift public health steps have also
brought the pneumonia-like infection under control in other developing
countries with large populations, such as Vietnam. But, with a mortality
rate of around 15 per cent, it is highly dangerous. And if it were to
become entrenched in a society with a weak health system, such as the
western provinces of China, it could be devastating.

Fauci says he was worried by Sars as soon as it first came to light in
March. "The thing about infectious diseases is that most of the time they
are just a blip on the radar screen." (In 1976, for instance, when more
than 200 legionnaires fell ill in hotels across Philadelphia, it was a
horrific event - but it didn't spread.) "Then once in a while you get one
that looks really scary," he says.

When he first heard about Sars, some experts were saying it might be a
form of "avian" flu, a disease that killed six people in Hong Kong in 1997
but was quickly brought under control. "But the people in Hong Kong, they
are real smart, and they insisted it was not avian flu," says Fauci. "I
thought, oh my God, this is not just a blip on the radar."

Just how scary is it? Last year 1.12m people died of malaria, disease
older than the bible. Aids, a relative newcomer, killed 2.86m. (These are
not the sort of statistics you round up or down to the first decimal
point.) As many as 500,000 people died from influenza, which was fewer
than the 745,000 who succumbed to measles, but many more than the 21,000
victims of dengue fever.

Sars has killed nearly 700. Yet Hong Kong and other parts of China have
been gripped by something approaching panic, Toronto has been placed
off-limits in the minds of many (even though the World Health Organisation
has lifted its travel advisory on the Canadian city) and the ailing
airline industry has been dealt another blow.

Over-reaction? Not from the public health point of view. Officials live in
constant fear of a repeat of the Spanish flu, an epidemic that in 1918
killed 20m people around the world in just one season. The early reports
of Sars out of Hong Kong raised a terrifying spectacle of rapid transfer.
After one of the first recorded victims stayed at the ninth floor of the
plush Metropole Hotel, 13 other guests fell ill, perhaps from having
touched the same door handles or elevator buttons. When another person
with Sars flew from Hong Kong to Beijing, several passengers were
infected. When there is a risk that such a virus might be transferred
easily by air, health officials say tough measures are essential.

The day I met Fauci, he received an anxious call from a Washington radio
station at 6.30am. They wanted to know about the risks of bringing Sars
patients to the NIH clinical centre for examination. Some disgruntled
staff had complained to a local paper about the decision. Fauci said that
all the necessary precautions were being taken to protect staff, including
new special face masks moulded to the individual's face.

Afterwards, he pointed out that many years ago his wife Christine Grady,
who was a nurse at the NIH, continued to work with HIV patients while she
was pregnant with their first child - even though they were not sure then
how the disease spread. "And anyway, we are the National Institutes of
Health. This is what we do."

The NIH pours billions of dollars every year into the basic medical
research that underpins new drugs. It has sponsored the work of 80 Nobel
prize winners and a large slice of the decoding of the human genome was
conducted around the corner from Fauci's office on the seventh floor of
Building 31.

Fauci has been running the NIH's institute for infectious diseases and
allergies since 1984. This makes him the central figure in the search for
treatments and vaccines for Sars. Many other researchers will be involved,
of course, in both the public and private sectors. The US Army's
infectious diseases unit is currently screening existing drugs to see if
they might work, while a number of companies are discussing vaccine ideas.
But at the centre of the process is Fauci, pulling the strings and
allocating funds.

Fauci is the complete opposite of the scientist as engaging eccentric -
with a shock of unchecked hair and new insights scribbled on bits of paper
falling out of a white lab-coat. He is short and trim and has a firm
handshake. He wears glasses that give him a scholarly look, but he is
dressed in jacket and tightly knotted tie, which makes him look like a
Washington bureaucrat, especially beside his young researchers at NIH. He
is a meticulous man who carries a comb in his back pocket and tidies his
short-cropped hair between meetings he hurries to and from.

The grandson of a Sicilian immigrant, Fauci grew up in the working-class
Brooklyn neighbourhood of Bensonhurst. The family lived above his father's
drugstore, where he ran errands from an early age. In his teens he
commuted to a Jesuit high school on Manhattan's Upper East Side where he
was a top student and captained the basketball team. Before going to
medical school at Cornell he did a degree in Greek, Latin and philosophy
at another Catholic institution, College of the Holy Cross in Worcester,
Massachusetts.

Fauci likes to keep his 62-year-old body in shape and his head clear.
Every lunchtime - work permitting - he slips into his jogging gear and
trots the half mile to the bike path on Beach Drive in Bethesda where he
runs for an hour. Not that Fauci is a lunch-time only athlete. He and
Grady have completed a number of marathons. They met at the NIH 19 years
ago, when, having lived in Brazil for two years, Grady was called in to
translate for a Brazilian Aids patient. In his serious doctor's tone,
Fauci told the man, who had a problem with his legs, to change the
dressings every day and to keep his legs constantly up. The man replied
that he was so sick of hospital he planned to spend all day on the beach
and to dance all night. Grady assessed the situation and translated for
Fauci: "He said he will do exactly as you said."

Even by the standards of workaholic Washington, Fauci's schedule is
demanding. As well as his political role, he is the one of the few heads
of the NIH's 18 institutes to run his own research lab, where he does work
on the basic functioning of the immune system and the impact HIV has on
it. I am half his age, yet by midday in his company I was tired. Zeda
Rosenberg, who worked for him at NIH for seven years, describes how at 7am
each day they would meet for two hours to go through all the relevant
academic journals to keep track of the advances in Aids research. Fauci
himself has published 1,045 scientific papers. "He is just a very
dedicated man," says Rosenberg.

On an average day Fauci is home by nine every night to have dinner with
his three teenage daughters at their Washington house just north of
Georgetown. Then he is usually working again until at least midnight,
catching up on the latest research, writing papers or working on the
revised edition of one of the most widely used medical textbooks he wrote.
Every Saturday and some Sundays are also taken up with work. He rarely
takes holidays anyway and has not managed one since September 11, 2001. He
likes to fish and occasionally goes to the movies but looks somewhat
perplexed when asked what he does for entertainment. "There are some
people who fit work in around having fun and then there are others who
like to work and have fun only occasionally," he says.

Now Sars could deprive him of a break this year. He is blunT about the
challenges posed by the disease. Even if it is brought swiftly under
control, it could turn out to be seasonal, like flu, with another possible
outbreak this time next year. "None of the current therapies is working
very well at the moment," he says. "Unlike bacterial infections, there are
not many therapies for viruses. There is not one for smallpox, or for West
Nile fever. There really are only a handful that work, such as for
hepatitis and herpes." (Viruses are pieces of genetic material that infect
a cell and direct it to produce new viruses. Some are transferred in the
air, others by blood and some by sex. But when they infect an animal or a
human who is not immune they can quickly invade the cells of their host.)

There are few "Eureka" moments in medical research, dramatic discoveries
that quickly lead to new treatments. Instead, there is the hard graft of
chipping away at complex problems from many different angles, until
solutions appear, a process that is only just beginning with Sars. In the
case of Aids, for instance, after 20 years work, there is still no
vaccine. Fauci does not think a Sars vaccine will be ready for at least
two years, but he is quietly confident about the scientific chances of
getting one. "Unlike HIV, about 85 per cent of the people who are infected
with Sars actually recover. What that means is that the human body can
respond in a way that will eradicate the virus," he says. "In HIV, there
are no instances of people spontaneously eliminating the virus from the
body."

When Tony Fauci began his career as a researcher in infectious diseases in
1968, many scientists considered it to be yesterday's field, an area where
the big problems had already been solved. With the development of
antibiotics from the 1940s, diseases such as diptheria and scarlet fever
went from life-threatening afflictions to treatable infections. Jonas
Salk's vaccine had taken the dread fear out of polio and the tuberculosis
sanitoriums were being emptied. Euphoria governed medical science.
Researchers liked to think they were on the crest of a wave sweeping away
the threat from parasites, viruses and bacteria.

In 1967, William Stewart, the US Surgeon-General, captured the mood of
inevitable scientific progress harnessed to American power, around the
time of the launch of the Apollo space missions, when he testified that it
was "time to close the book on infectious diseases". Scientists, he
suggested, should concentrate instead on chronic diseases such as cancer.

Fauci was planning to stay at the NIH for a couple of years before
returning to New York to be a physician, but even then he thought there
were still some interesting challenges in infectious diseases. And, as he
says about Stewart's remarks 35 years later: "He could not possibly have
been more incorrect."

Infectious diseases are back. For a start, the drugs do not work as well
as they once did. With increased and sometimes incorrect use, resistance
to antibiotics has grown, breathing new life into some old pests. In the
late 1980s, patients turned up in New York hospitals with new strains of
tuberculosis that did not respond to drugs. These later swept through
Russia in the 1990s.

On top of that there have been new and frightening diseases. In Zaire in
the mid-1970s, a man walked in from the jungle with a severe fever that
made him vomit black blood. He died shortly after. Within days, many of
the nuns who took him in had also fallen ill with Ebola, one of the most
easily transmissible viruses.

Viruses continue to jump from one species to another, including humans,
and the new host often has little immunity. Every year brings a different
strain of influenza, many of them originating in China. In 1999 and again
last year, several people in the US died from West Nile fever, a virus
indigenous to the Middle East which is transmitted by mosquito.

Microbes (a virus is one type of microbe, bacteria and fungi are others)
love chaotic economic development. Teeming new cities with poor sanitation
that lack strong health systems, rapid migrations of populations from
country to city, changing sexual habits, the breakdown in traditional
family structures - all these provide fertile territory for the spread of
new diseases. Foreign travel exacerbates the problem, quickly transferring
a virus from a small African village to a large, western city. The
microbes that caused the 1918 Spanish flu were transported around the
world by boat. Today, they would catch a flight.

And then there is HIV/Aids. In the slightly more than 20 years since the
human immunodeficiency virus was identified, more than 20 million people
have died. By 2010, the total number of infected people is expected to
reach 105 million, most of them in poor countries. It is the biggest
public health disaster since the Black Death in the 14th century.

Bookshops are full these days of grim warnings that the advances made in
the last century were no more than a truce in the battle and that
infectious diseases will come back with a vengeance. Richard Krause, a
predecessor of Fauci at the NIH, called his 1981 book on microbes The
Restless Tide - a reflection of the tug-of-war between science and
disease, the never-ending capacity of hostile microbes to renew
themselves.

This alarming view is not universally shared. Medical science still has
its utopian streak, these days in the form of genetics. The decoding of
the human genome has raised hopes of big advances in the understanding and
treatment of diseases. Some researchers talk of an era of "personalised
medicine", with each patient walking around with a card that shows his or
her genetic make-up so that treatments can be tailored specially. "We will
look back on 1950-2050 as the greatest period of human intellectual
endeavour since the Renaissance," says George Poste, who used to run
research at drugs company SmithKline Beecham.

For Fauci, these advances will generate some useful tools for the study of
infectious disease. Researchers were able, for instance, to pin down the
genetic make-up of the Sars virus within weeks of its appearance. However,
genetics technologies will not alter the capacity of infections to
reinvent themselves. "It is extremely unlikely that all of a sudden we are
going to discover a completely new cancer or arthritis," he says. "But it
is possible all of a sudden to get hit by a new microbe." Indeed, the
events of the last few years have been a form of vindication for
infectious disease specialists such as Fauci. "We will never be free of
emerging diseases," he says. "I am not blowing smoke. Look at what has
just happened."

At Least Once a Week Fauci still still does roundS in the NIH Clinical
Center, its on-site research hospital, to visit Aids patients who are
usually undergoing some form of experimental treatment. The junior doctors
who guide him along the ward are a little wary, for as well as being the
head of one of the NIH's institutes he is the author of one of their
textbooks. He fires questions at them in a friendly but brisk manner. As
he has to run off to a meeting downtown, he asks them to be brief. "You
don't need to tell me his heart rate. I mean if he has a heart rate of
170, you should tell me, but if it is 80 you don't need to."

It was the HIV/Aids epidemic that changed Fauci's life. Shortly after he
first read in 1981 about a strange disease afflicting gay men in Los
Angeles, he shut down the research he had been conducting in his lab and
devoted it entirely to Aids. His mentors told him he was risking his
career and there were few resources made available by a hostile Reagan
administration. And for several years every patient he treated died.

In the early years, most of the victims of Aids in the US were gay men,
many of whom viewed the disease as a form of persecution. Fauci soon found
himself in the middle of a fierce battle. Colleagues at the NIH attacked
him for focusing too much on Aids and predicted that other important
diseases would be neglected. The growing band of highly-educated Aids
activists were outraged, however, at what they thought was government
indifference to the epidemic. And they picked a target for their anger:
Tony Fauci. In May 1990, about 1,000 activists blockaded the NIH campus,
setting off pink smoke bombs and building a fake graveyard on the lawn.

In the ego-driven science world, Fauci has been followed by whisperings
that he is really an administrator, rather than a top-notch scientist.
"Science in a suit," as he is sometimes described. Oft-cited research he
published in the 1990s, which showed that HIV could be found in the body's
lymph nodes where it interferes with the immune system, has only partly
dispelled this impression. Behind the quick-fire Brooklyn banter lurks a
need for professional approval. The walls of his waiting room are covered
in honorary degrees, as are those in his office and the walls in the
meeting room next door. He has 25 in total and is due to get another three
this summer including one from Yale. Rivals mutter that he lobbies heavily
for the honours.

Despite the huge investments, an Aids vaccine is still a long way off and
some researchers doubt the current crop of candidates will work. However,
there are now 19 anti-retroviral drugs on the market, many the result of
NIH research, and in rich countries Aids is no longer a guaranteed death
sentence.

Fauci, meanwhile, has won round many of his critics in the activist
community. His most complicated relationship has been with Larry Kramer,
the writer who helped form protest groups ACT UP and Gay Men's Health
Crisis and who used to regularly call Fauci a "monster" and an
"incompetent idiot". In 1991 Kramer wrote a play called The Destiny of Me
in which an Aids patient spends much of his time attacking his physician,
a man called Anthony Della Vida - Anthony of Life. No prizes for guessing
who he is based on. "The mystery isn't why they don't know anything, it's
why they don't want to know anything," the lead character shouts.

Gamely, Fauci turned up to the premiere at the Lucille Lortel Theater in
Greenwich Village. After the show, the two men met in the lobby and
embraced. Kramer was overheard to say, "Will you still take care of me?
Will you still be my doctor?" Fauci replied: "I will always take care of
you Larry."

When health secretary Tommy Thompson spoke at last summer's UN Aids
conference in Barcelona, the stage was invaded by activists shouting the
slogan "Where is the 10 billion?" - a reference to the amount of money
experts say needs to be spent on Aids programmes in the developing world
each year. Later Fauci was called in by the White House and asked to help
come up with a programme for Aids in Africa that Bush could adopt.

The night before the president's State of the Union address in January, he
got a call from senior staff at White House to come and help them prepare
the text. Bush had adopted the most generous version of the plan Fauci had
proposed, which involves spending $15bn on Aids over the next five years,
including the use of generic copies of Aids drugs. The legislation was
passed last week.

The plan's critics point out that it only covers 14 countries and most of
the money bypasses international organisations set up to deal with the
crisis - a sort of healthcare unilateralism. Some say that Fauci is not a
development expert, yet he is designing treatment plans for Aids. His
advice is sought on the risks of smallpox attack and the necessary
quarantining procedures for Sars, areas well beyond his expertise.

Donna Shalala, who was health secretary for most of the eight years of the
Clinton administration, explains why Fauci has so much influence: "He can
discuss complex issues in plain English, but he is not afraid to tell you
the truth. He does not compromise on the science." She adds: "We learned
from the British experience with mad cow disease. You have to let credible
scientists do the talking and get the politicians out of the way. The
public trust them."

Added to that is the phenomenon that has changed almost every aspect of
public life in America: September 11. (Fauci was in Manhattan that day and
watched the unfolding horror from a 23rd floor window.) After the attacks
and the anthrax scare that followed, vice president Dick Cheney, said to
be obsessed with the dangers of microbes, asked if he could visit Fauci's
facilities at the NIH. He was so impressed that he arranged for Bush to
visit later. "It has been a remarkable two years," said health secretary
Thompson at that briefing.

And Thompson should know how important Fauci is to this administration.
The health secretary was accused of bungling the initial response to the
anthrax attacks by playing down the risks. Within days new cases appeared.

Some things are better left to a doctor.

- At 62 Anthony Fauci works a 20-hour day, runs every lunch-time and
rarely takes a holiday

Geoff Dyer is the FT's pharmaceuticals and biotechnology correspondent
--
James Love, Director, Consumer Project on Technology
http://www.cptech.org, mailto:james.love@cptech.org
tel. +1.202.387.8030, mobile +1.202.361.3040



--
James Love
http://www.cptech.org mailto:james.love@cptech.org
mobile +1.202.361.3040