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Monday, March 15, 1993
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 30 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 spinoffs 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 spinoffs from the research that we could not possibly imagine, in the same way that spinoffs 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 31 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 32 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.