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Harden: We all remember that George Bush, when asked to name an American hero, named Dr. Anthony Fauci and thus brought honor to you, to the NIH, and, by extension, to all biomedical scientists and physicians. He also invited you to the White House and put some pressure, I believe, on you to accept the NIH directorship. Do you want to talk about that?
Fauci: I was very flattered and surprised that he listed me as one of his heroes. I knew him pretty well at that point. I was very gratified and pleased. I did not hear the Presidential debate in which he called me his hero. I had been on a trip, and as I walked into the elevator at the NIH when I came back, people said, “You must feel terrific.” I said, “What happened? What are you talking about?” I finally got to my office and they told me about it.
With regard to the NIH directorship, I am very grateful to President Bush for understanding why I did not want to be NIH Director. I wrote to him early on when my name was being sent down to the President from the Secretary as the top choice for the NIH Director's job. I wrote to President Bush when he went up to Kennebunkport [Maine], and I sent him a message through some people I knew at the White House that I was going to turn the offer down. I wanted him to understand that it had nothing to do with my admiration for, and friendship with, him. It is not an easy thing to say no to a President who offers you such a prestigious job. But I explained to him the reasons why I wanted to turn it down, which were my science and my commitment to AIDS and to the NIAID.
Bush wrote me a beautiful letter back saying that his respect and admiration for me was even increased by understanding how devoted I was to the cause, and that he was looking forward to continuing to work with me. I was afraid that he would say, “Get out of here. You are insulting me by not saying yes.” That was the first time. The second time was even more anxiety provoking. [Dr.] Jim [James] Mason, the Assistant Secretary [for HHS], asked me if I wanted to take the job. This was after I had written to the President and said no the first time. Several months went by and we still did not have a Director at NIH following the departure of Jim Wyngaarden. Jim Mason asked me if I wanted the job, and I said I did not for the same reasons as before. People thought that it was because of the fetal tissue issue. It had nothing to do with fetal tissue. No one ever made any conditions to me about fetal tissue. That never even came up in the conversation. It was purely my not wanting to be in any way dissociated from my laboratory, my science, and the AIDS research at the NIAID. Jim Mason said, “You will have to say no to somebody higher than me.” I said, “Jim, don't do this to me.” He said, “You will have to talk to Lou Sullivan.” Secretary Louis Sullivan called and said “Tony, what do you think? Would you like to do it?” I said, “Lou, I do not want to do it. Please do not put me in a position to create any embarrassment.” He said, “All right. Fine.”
About a week, two weeks, went by and Lou got on the phone and said, “We are going to the White House.” I replied, “Oh my goodness, what are you doing to me?” He said, “I am sorry, Tony. You are going to have to say no to the President. We have spoken to [John] Sununu, and we have spoken to the domestic policy people. They do not think you are going to say no to the President.”
I remember that I went into the White House and I was waiting outside the Oval Office. John Sununu came over to me and said, “You are not going to say no to the President, are you?” I said, “Governor, I am very sorry, but I am going have to do it, because nothing has changed. I think that the President will understand that.” He said, “But nobody says no to the President in the Oval Office.” I said, “Well, I do not think it is a macho thing to do. I am just very uncomfortable about being here. I am only here because Lou Sullivan asked me to be here.”
I figured this was the end. This would really get the President upset. I walked into the Oval Office and sat down next to the President, who said, “Well, Tony, do you want to revisit this?” I replied, “Mr. President, everything I said before goes in spades. I have a great deal of admiration for you. I am very proud to serve in your administration. But what I do best is what I am doing now. I think I would contribute more to you and to the country if, in fact, I were able to continue my job.”
I told the President that the same reasons governed my thinking as when I had spoken and written to him the previous time. I wanted to stay very closely involved with the science. He paused for a moment, and he looked at me. Then he said, “Is there anything that we can do to create a situation where you would want to do the job? How about if you do it for two years then you go back to being the Director of NIAID? Or we will give you enough administrative help that you could continue to run your laboratory and you could continue to do the AIDS research? You can do anything you want, AIDS, laboratory, OAR [Office of AIDS Research], everything you want to do.” I said, “Mr. President, this is very painful for me, but, with all due respect, I will serve you much better if I stay where I am.”
I thought, “This is the end. I have tried the man's patience.” But Bush is such a wonderful human being that he looked up at me and said, “Tony, once again I keep having more and more admiration for you. Good luck to you. If there is anything I can do to help you, just give me a call.” And he actually gave to me his secretary's private number. “Just call me. I want to talk to you right up front if you have anything that I can help you with.”
I figured that he was just saying that and that now he would be angry with me. As we walked out of the Oval Office, Governor Sununu said to me. “I cannot believe you did that.” Sununu was not upset with me. He was actually very friendly. I had good relations with him too.
That was it. After a while, I guess it was a few weeks to a month, I thought that this would be it because Bush would go off and find someone else who would be his favorite medical person, as it were. But, sure enough, he gave me a call about a month later and asked me a question that was of some importance. Then, two months later, he invited me to the White House for a small dinner so we continued our friendship. I have always felt very fortunate that I was able to act the way I believed I should act, namely, turn the President down, without having him feel that I was turning him down personally. As it turned out, it served to make our relationship even stronger right up until the end of his presidency. I hope it will continue even now if I get the opportunity to deal with him.
Harden: Dr. Bernadine Healy became the NIH Director instead. Would you comment on her tenure as Director, especially with regard to AIDS research. What kind of relationship have you as head of the NIH AIDS effort had with her as the NIH Director?
Fauci: She has been very supportive of AIDS research. There is no question about that, if you look at the record. Unfortunately, she came in at a time when the NIH budget was very constricted in its growth. If you look at the two years she was Director the resources were very constricted. That was not her fault; that was just the way it was. Moreover, the exponential growth of AIDS was beginning to plateau. Although AIDS did not do very well during the couple of years that Dr. Healy was Director, it was not because she did not try to get more for AIDS. She was very much in favor of full support for AIDS research. It was just that she happened to be Director at a time when the resources were much more constrained than they had been previously.
Harden: Some people seem to think that we will make greater scientific progress if we have a so-called AIDS research czar. We have had two things happen recently, one is the new NIH Reauthorization Bill, which if I read it correctly, says that new AIDS monies will have to go through the OAR [Office of AIDS Research]. Please comment first on the bill in terms of whether this is just another layer of bureaucracy, and then I want to come back and talk about the AIDS czar, Ms. [Kristine] Gebbie, who has been appointed.
Fauci: The institute directors, including myself, were from the very beginning against the legislation to have the money go first to the OAR and then be distributed. We thought it might be a layer of bureaucracy that would interfere with getting the money to the people who execute the science. However, all things considered, the Administration and the Secretary wanted to go with it. We will do everything we can to make it work and not, in any manner or form, be obstructionist about it. There is a concern that we expressed in an official letter to Dr. Healy, which was then sent to the HHS Secretary, but that is water under the bridge. The law has passed and we will live with the law and make the best of it.
Harden: Let me clarify. Is this law only for extramural funds, or is it for intramural ones as well?
Fauci: All the money goes to the OAR, and then it gets redistributed to the institutes. The institutes ultimately get the money, but it stops in the Office first.
Harden: But grant applications will not come to the OAR; they will still come to the institutes?
Fauci: Yes. They will still come to the institutes. The OAR is the place where the money goes first and then it gets distributed, with the rationale that that Office will have the flexibility, if things change rapidly, of redistributing the money. But things do not happen that way in science. You could accomplish that with a small discretionary fund.
Harden: With reference to Ms. Gebbie, who has been appointed as the White House AIDS Policy Coordinator, she will not, as I understand it, have a great deal of line power, so the term AIDS “czar” may not be appropriate.
Fauci: She is not an AIDS czar. President Clinton has not called her that; she is AIDS Policy Coordinator. “AIDS czar” is an unfortunate term.
Harden: What would her relationship be to biomedical research? She is not a scientist.
Fauci: No. But the Policy Coordinator will have the responsibility of coordinating policy across agency lines. The AIDS epidemic has an impact on virtually every government agency. The purpose of an AIDS Policy Coordinator is to see that the interactions among the agencies are unified and conform to a broad national plan for AIDS. That is one of her major responsibilities, to develop a broad national plan.
Since the Department of Health and Human Services, and the NIH as a component of the Department of Health and Human Services, is a major player in the AIDS epidemic, we will obviously be a major part of the things that need to be coordinated with the other agencies. But there will be no directives telling an agency what to do. It will go through the individual secretaries. There is no anticipation that Kristine Gebbie will be telling the NIH Director, or myself, or anyone, what to do scientifically. Policies will be broadly coordinated across agencies, but it will be done through the secretary of that agency.
Harden: Scientists are always interested in serendipity. I have spotted a couple of results from research on AIDS that had applications in other places. Are there any that you would like to highlight?
Fauci: Certainly. What we know about the immune system has grown exponentially in the last ten years on the basis of having an unfortunate, but nonetheless extraordinary model of the destruction of the immune system. We have learned what components of the immune system are needed for the system to function properly, how they interact or rely on each other, particularly the focal nature of the CD4-positive T cell. It has markedly enhanced our understanding of the immune system.
Secondly, it has given us insights into the whole area of drug development and vaccinology, because right now targeted drug development has gotten a great boost with HIV and AIDS. Diagnostics, the use of the polymerase chain reaction as a diagnostic tool for other infectious diseases, and the understanding of the role of activators and enhancers of gene function have had major spin offs from looking at, and dissecting with such great scrutiny, the regulation of the HIV genes. There are many areas that, even in such a short period of time, have benefited from the research on AIDS. I would expect that twenty or thirty years from now we will see spin offs from the research that we could not possibly imagine, in the same way that spin offs from the war on cancer were unpredictable twenty years ago. For instance, the entire field of retrovirology emanated out of the war on cancer. In addition, much of the molecular biology that we know today has emanated out of the war on cancer as well as out of the study of microorganisms. I think there will be an extraordinary benefit for all of science.
Harden: Do you think we will have a vaccine or a therapy first for AIDS?
Fauci: We already have a therapy for AIDS. It is not a very good therapy, but we have one. Are we going to find a cure? I do not think that we will have a cure in the classic sense. I think we will have a combination of drugs that will suppress the virus so efficiently that an infected person could have a much greater prolongation of a disease-free state than we have with the currently available therapies. The nature of the virus may not allow us completely to eliminate all of the virus from the body. You would have to suppress chronically virus replication. The goal is to have a combination of drugs which, when administered early in the course of infection, would be able safely to extend the disease-free state to ten, twenty, thirty, or more years.
Vaccines probably will be more of a problem because this is a virus that is transmitted by cells, as well as cell-free virus. You would have to protect against both. Whether or not that is feasible is unclear; I am hopeful that it will be. I am operating with the guarded optimism that we will have a vaccine by the end of this decade, but I cannot guarantee that.
Harden: The National Research Council recently released a report predicting that AIDS will sink into the inner cities, and that the middle class will not have an epidemic in the United States. In that case, because people in the inner city are often not active politically, the prediction is that AIDS will become a political non-issue and research will stop. What is your response to this?
Fauci: I think that the way that was “spun,” as it were, to the public was unfortunate. Although I do not believe that the virus is going to be spread homogeneously throughout the population in the U.S.A., and it will be more focused in certain groups, cities, and areas, I do not believe that it will be as marginalized as the National Research Council report indicated. Take a look at the reports that came out two months ago that, in sixty-four cities in the United States, the leading cause of death among people between the ages of twenty-five and forty-four is AIDS. That goes beyond marginalization, I think. AIDS is not going be spread homogeneously, but it will not be a forgotten marginalized disease. I do not think there is any question about that. The data already tell us that.
If I were, out of nowhere, to tell you that there is a single communicable disease that is the leading cause of death in sixty-four major cities in this country between the ages of twenty-five and forty-four, what would you consider that? I would consider it a public health catastrophe.
Harden: What about on the larger, worldwide scale? What is our obligation to Thailand, let us say?
Fauci: What is our obligation? You are talking about a social-politico-ethical issue on which I am certainly not qualified to give a definitive statement. But our obligation exists only insofar as we have an obligation to our brothers and sisters throughout the world. You can make the same case for malaria, from which two to three million people a year die; for tuberculosis, from which three million people die; and for parasitic diseases, from which millions of people die. We have the same obligation, I guess, to worry about them as we do about people who are HIV-infected. I think we do have an obligation insofar as our resources, or neighborliness, enable us to execute those obligations. But I do not see how we can possibly be responsible for the entire world, given the fact that we are in somewhat of an economic crisis here in the United States.
Harden: Given our economic limitations, do you think we are doing what we ought to be doing?
Fauci: Absolutely. We have very good collaborations and cooperation with international scientists, public health ministers, and public health officials throughout the world.
Harden: Thank you very much, Dr. Fauci, for talking with us.
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