CAN THIS MAN CURE SARS?
23 May 2003
Source: Financial Times (London), May 22, 2003
Can this man cure Sars?
By Geoff Dyer
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 (£9.2bn) 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.
Geoff Dyer is the FT's pharmaceuticals and biotechnology correspondent