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If the people who were working in the laboratory were afraid, then we would find something else for them to do. We would not begrudge them their fear, but we would find something else for them to do. There was never a situation where there was a lot of concern about getting infected from an unknown cause, because it was clear from very early on that this disease was not spread casually. All we wanted was to make sure that when we handled material we handled it in a careful way. This is what we still do.
Harden: As I recall, your wife is a nurse who deals with AIDS patients. Have either of you had any personal repercussions? One nurse told us that her children did not want to tell people that their mother worked with AIDS patients.
Fauci: I have had no personal repercussions at all. My wife, Christine Grady, was specifically involved, not only in taking care of AIDS patients, but in teaching other nurses the special problems that are associated with the nursing care of HIV-infected individuals. She was, and still is, totally committed to AIDS research and AIDS nursing. We have never had any repercussions from outside or within the family. We have the same attitude. This is what we do with our lives. This is our job. We are just trying to do it as best as we can. Not doing it was never even a consideration.
People would sometimes raise their eyebrows because we have three young children and my wife took care of AIDS patients throughout the entire three pregnancies. She worked from the very beginning of her pregnancy with our first daughter, who is now almost seven years old. She would take off a couple of months after the pregnancy and then come right back to taking care of HIV-infected individuals.
Rodrigues: I have a follow-up question on your recognition early on that AIDS was caused by an infectious agent and that AIDS was something new, that it was an emerging disease. Many of the materials that I have read describe how AIDS took everyone by surprise, how it was unexpected. But many other people were saying that the microbial world cannot be taken for granted.
Fauci: If the question is was I surprised, the answer is that I was not surprised at all. In fact, from my earliest editorial in 1982, I was singing the tune that this could turn out to be a global disaster. You do not fool around with infectious diseases, particularly those that are transmitted by a mechanism, sexual interaction, that virtually everybody in the world does sooner or later. It was foolish for people to think that this disease, being an infection, was not going to explode into a global pandemic.
Harden: When you wrote your 1982 editorial, had you heard about the infections in Africa and other places?
Fauci: No. My editorial was still related to gay men and intravenous drug users in the United States.
Harden: Do you have anything else that you would like to say about your own laboratory research before we move into a discussion of your duties as an administrator?
Fauci: One of the things to note is the spirit that permeates the laboratory. I have had two interesting and unusual perspectives working in the area of basic research in immunology and immunopathogenesis. First, I have worked on diseases that were important but were not of major public health significance. They were fruitful areas of basic research that in and of themselves were very exciting. Second, I have worked on AIDS. When you superimpose upon exciting basic research the fact that AIDS is a major pandemic of extraordinary public health proportions, the excitement that this creates in the laboratory is extraordinary. It is an indescribable experience knowing that what you are doing will have an impact on the lives of tens, if not hundreds, of millions of people. That gives you a lot of energy to do what you are doing.
Rodrigues: From your perspective as the Director of NIAID, do you think that there is now more public support for basic research in order to be prepared for other emerging diseases?
Fauci: I think that, unfortunately, given the constraints on resources not only for AIDS but for other diseases that are deserving of support, it is very difficult to get people to appreciate a vague concept of the next emerging microbe. I have been working very closely with the Institute of Medicine, with people like [Dr.] Joshua Lederburg, who is a staunch advocate of making the public more aware of the possibility of emerging microbes, and with Dick Krause, who is still very much involved in this area in his position at the Fogarty International Center, to make sure that the science base in microbiology, infectious diseases, and immunology is prepared for the next emerging microbe.
In fact, because of the competition for resources related to problems that are now ongoing, it is very difficult to convince people that an extra investment for emerging microbes is needed. We are not going to give up though. There are a group of us around that are pretty dogged about that. There is a hard-core group that is trying very hard to keep the public perception of the importance of support of biomedical research for the next emerging microbe very high.
The difficulty is that this is being carried out in a situation where the resources are limited because of budgetary constraints. I do not think the American public is willing to support throwing a lot of money into basic research for the next emerging microbe. They are too worried right now about AIDS, cancer, and all those other diseases they perceive as a threat to them. The potential threat of a microbe that they have never heard of is very vague and nondescript, even though the lessons of AIDS are part of their generation.
Back in 1918, when influenza wiped out twenty to fifty million people worldwide and hundreds and thousands of people in the United States, the people who lived through that, I think, had a good idea of what an emerging microbe might do. But then as the decades went by, they forgot it. Here we are with AIDS and people still have not had the foresight to understand that this can happen again. We are not even half over with this yet.
Harden: By 1984, you were deeply into your AIDS research. You were a successful laboratory chief. Suddenly the opportunity to become Director of NIAID arose. You did not give up your laboratory position; you just added another on. People still marvel at how you get everything done that you get done. Why did you decide to accept the job as Director?
Fauci: There were a couple of reasons. Certainly one of the conditions in my own mind and that I put forward in my discussions with Dr. [James B.] Wyngaarden and [Dr.] Ed [Edward] Brandt, who was Assistant Secretary [for Health and Human Services] at the time, was that I would maintain a heavy commitment to my laboratory. I would just have to work harder, put in more hours, and be more efficient. Fortunately, this has worked out very well. My work, in many respects, has trained me to do that. My perception of what I wanted to do at that stage in my career was to have a broader impact on the field of immunology and infectious diseases. However, I wanted to do it from a scientist's vantage point and not necessarily from a fundamental administrative standpoint. I wanted to bring a much more scientific flavor into it.
I had administered a laboratory, but that is nothing like administering an institute. But I quickly learned how to do it and found out–I did not know this before– that I have administrative skills. This is fortunate because it is not only making my job easier, but it is allowing me to continue to do my research. My goal was to have a broader impact on the field, not only of AIDS, but of all the infectious diseases and immunology, and only if I can do that in the context of continuing to be a very actively practicing scientist. Fortunately for me, I have been able to do it.
Harden: With regard to work on AIDS, what did you find when you became Director? What was bequeathed to you in the way of an overall AIDS program?
Fauci: We did not have much of an AIDS program. However, what Dick Krause had done, which showed, I think, great foresight, was to establish the Multicenter AIDS Cohort Study, to look prospectively at 5,000 gay men and to follow them over years. We are still following that cohort in 1993, which is about ten years from the time the project was established by Dick Krause. But we did not have an overall AIDS program. There was AIDS research going on. There was myself and my laboratory but not very many other people involved in the intramural program. There was some modest–small to modest–support for AIDS extramurally.
When I, someone who was very interested in AIDS, became Director of NIAID at the same time that the epidemic was taking off in an exponential fashion, it became clear to me that we would need to have a big push in AIDS research. I did something that was considered very bold at the time. I went to Jim Wyngaarden with a budget that would seem outlandish. I wanted to quadruple the amount that we were doing in AIDS research in one year. I explained to him that this increase was necessary because the AIDS epidemic was going to explode in our faces. We had to be out front, ahead of it. Jim agreed, and I am very grateful to him for that because he allowed the Institute to put a budget forward requesting a substantial increase.
Then it became clear that the administrative structure was not in place to handle the exploding amount of research that was being done on HIV and AIDS. At that point, I established the Division of AIDS within NIAID. I got a lot of resistance about that from the classic and traditional infectious disease people and from immunologists, not only in the institute, but outside. “Why are you having a special division of AIDS? Why not have a special division for every infectious disease?” My response to them, with all due respect to the importance of other infectious diseases, was “Right now in our era there is going to be nothing like AIDS, and so we need a separate division.” The Division now has turned into one of the largest divisions, if not the largest, that NIAID has.
Harden: When I talked to [Dr.] Jim [James] Hill early on in our interview process, he told us–perhaps this is the same budget that you are referring to–that NIAID actually was the first institute that pressed strongly for a large increase in AIDS funds. Once a larger budget had been approved by Congress, other institutes jumped on the bandwagon. Do you recall if you felt you were being courageous in view of the political climate at the time?
Fauci: It is obviously difficult to respond to such a question about being courageous.
Harden: I realize that.
Fauci: I think it did take some guts on my part because I went out on a limb. I was, in many respects, like the Lone Ranger out there. I can remember very clearly, sitting in my library, right over here, with Mike [Michael] Goldrich, with Jim Hill, and one or two of the younger staff, and I said, “I am going to surprise you, but I am going to ask for a budget that will make your hair stand on end.” They looked at me and said, “Do you think we will be able to get it through?” I said, “I do not think we have any choice. We have to get it through. I think we would be negligent if we did not stand up and be counted and say we must have major growth in our effort on AIDS.”
Harden: You were, in effect, taking a risk. The administration's policy had been that if an institute wanted to do more AIDS research, the money should be taken from somewhere else in the budget.
Fauci: That was the great concern of the immunologists and the infectious disease people. They said, “Tony, be careful. If you go out and ask for it, they may tell you to do the research but they might not give you the money for it.
Harden: But, as I recall, under your proposed budget, if they had said that, everything else in NIAID would have folded up.
Fauci: We would have been in serious trouble. It was a big chance. But I knew I was going to win. The reason I knew this was because I knew I would have the support of the Congress, and Jim Wyngaarden was the first step. He allowed me to ask for the increased budget. Ed Brandt was very sympathetic to it. Then after that, the Congress even piled more money on it. But I do not think the Congress would have done that if we had not come in asking for an outlandish amount. This was the time when Congress always put more money in than the administration asked for, unlike today when resources are so constricted. But I knew if I could get the budget past the administration and have the Director of NIH and the Assistant Secretary go along with my request, that the Congress would come in and help out even more. That is exactly what happened.
Harden: This was the 1986 fiscal year budget that you would have been asking for in early 1985. When we graphed budget figures for AIDS research, it was clear that fiscal year 86 was the year in which AIDS budgets began increasing dramatically.
Fauci: That is exactly what happened.
Harden: My recollection is that Rock Hudson died of AIDS about this time. Perhaps that was another factor persuading Congress and the administration to increase the AIDS budget. I do not recall whether the budget hearings were before or after that event.
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