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Hi I'm Wendy Zukerman and you're listening to Science Vs from Gimlet

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Yeah - this is the second episode we're doing about Monkeypox. And today - we're talking to- the Chief Medical Adviser to the President of the United States…  Dr Anthony Fauci

AHHHH

about, well, what went wrong here..

Because the thing is... at first it felt like the US… was weirdly prepared for this outbreak. They had millions of doses of vaccines made for smallpox^[1] – which should work for monkeypox. And we had a drug - T Poxx^[2] – Why haven't we controlled this outbreak??

And it'll help to have a little context around this conversation. So most people who are getting vaccinated for monkeypox in the US - are getting a vaccine called Jynneos.^[3] But there is actually another one on the shelf called ACAM2000. It kinda sounds like a cool terminator – ACAM2000 –  But this is NOT like a lot of the vaccines y' know and love. For ACAM2000, they're literally putting a LIVE VIRUS into you^[4].^[5]  - which leaves you with a wound you might have to nurse for weeks^[6]. The virus that they're using is called vaccinia… which is in the same family as smallpox and monkeypox. but It's way less dangerous.

Still though -  there are some people who can get really sick from this - particularly if you're  immunocompromised - like people with HIV, pregnant folks, –  even if you have eczema^[7] you're not supposed to get this shot^[8][9] 

But even if you don't have these conditions, there are some other concerns..^[10]. Like, 1 in roughly 200 people get myocarditis. Which the FDA says can be very serious^[11]. And what may be even more serious is that – the wound where the vaccine has a virus in it that can infect other people. So you’ve got to be careful - because if someone else touches that wound, they can get sick, which, like we said, can be really dangerous if they're immunocompromised.^[12] 

And a big curve ball is that when it comes to this monkeypox outbreak, it's looking like roughly a third of the people who have monkeypox also had HIV^[13]. So you wouldn’t want to give a ACAM2000 jab.  

Ok, now we’ve got all this sorted - we’re ready for Fauci! We started off by asking him about his first thoughts - when he saw how this outbreak was starting …when he started to see this the numbers ticking up and up: what was going through his mind?

AF: I said, uh oh, if this is efficiently spread from person to person, that those are the kind of things that’s very reminiscent of what we saw in the early days of HIV. When you have a lot of people, you know, and it's celebratory areas where there's multiple sexual partners that this thing is going to get bigger than just a few cases. It was sort of a gradual oh my goodness. But from the very first beginning, the epidemiological circumstances under which it occurred was very troublesome to me, having been there 41 years ago with HIV.

WZ: Tell me, how is this situation with monkeypox different to the beginning of COVID?

AF: Well, the differences are really rather substantial. In Covid, there were many unknowns, but we had a very important task of developing diagnostics, therapeutics, and a vaccine. With Monkeypox, it was, you know, by some strange quirk of circumstances, we had experience with the virus - we knew a lot about it. And in an attempt to develop countermeasures against smallpox associated with the bioterrorist scare following 9/11, we invested an extraordinary amount of money to stockpile both vaccines, namely the ACAM2000, as well as a lesser amount of Jynneos, which was really supposed to be for people who couldn't tolerate the ACAM2000 - like kids with eczema and people who were immunocompromised. So right from the very beginning, we had countermeasures, having diagnostics, therapeutics and vaccines for monkeypox. And then what we were faced with was more of an implementation issue.  

WZ: Yeah tell me about that because there is this feeling of like there are all these doses and they're just sitting there and this frustration that I think people are feeling it's like this was the one example where like we did it, we, we predicted almost we did what the scientists have been telling us to do. We had the vaccines, we had the things ready to go. Why are we now in the situation we're in?

AF: Well, I can't explain it. I wasn't involved in the contractual … So you're asking me to explain something that I'm not involved in. Okay. We were involved in testing the vaccine and showing that it worked and in developing the drug, which is now known as T Poxx. We have 100 million doses of ACAM2000 ready to go right now, here. And that was the original reason. This is not an excuse. This is just the fact. That was the original reason, is that if we had a smallpox attack, that the danger to the general population would be – that the benefit / risk ratio of giving a vaccine that had a significant amount of adverse events, myocarditis, possible spread to people who might be immune compromised. But the people who made it felt that that benefit would be worth the risk. And the Jynnneos which was then contracted to be made outside of the United States - was for an exception for those who could not tolerate the 100 million doses that were readily available for everyone. Now what happened by a quirk of fate, is that those people who were vulnerable to this, namely the men who have sex with men, many of them fell into the population, that it would be risky to give them the hundred million doses that we have at the tips of our fingers ready to go. So we had to rely on what was the backup vaccine – was Jynnneos. Which was the opposite of what the plan was.

WZ: Uh huh. And so our audience understands. I mean, ACAM2000 is a pain in the ass to get. I mean, you have to be very careful when you get it. It's not the vaccines that we have become accustomed to, I think.  

AF Right, right. It is a vaccine which was against a historically horrible disease that influenced societies throughout the centuries, smallpox. And so the adverse events, the inconvenience in administering it, you know, you have to scratch it into the skin – those who were felt worth the protection against a deadly disease. So now you have a disease, although there are a lot of painful consequences associated with monkeypox, it is not a deadly disease in general, comparatively speaking

So whenever you have a disease like that, you've got to balance the benefit and the risk of what the intervention is. So rather than saying, hey, we have 100 million doses of ACAM2000, just give it to everybody. All of a sudden, those who are responsible for the distribution found that they had to really play catch up in getting those doses, There have been over 130,000, which pretty quickly was put out. Another 400,000. And then by the end of next week, we hope we'll have a total of 1.1 million doses.

With regard to the Tpoxx. That was another logistic issue because given the approval of it that in order to get it, the amount of paperwork was very prohibitive and became very difficult for physicians in the community to get it in an expeditious manner to their patients. The CDC has now and the FDA cut down dramatically on the bureaucratic and logistic constraints in getting the drug to the people who need it. And with regard to the diagnostics, again, the CDC had their own, that was about 6000 per week. But now we have at least five commercial companies that are making it. So they'll be 80,000 tests available per week.

WZ Okay. So things things are improving in terms of how we're tackling this. But you have said, you know, 'We could have done better. Everyone could have done better.' What do you wish we could have done differently to tackle monkeypox?  

AF I think a more rapid mobilization of the countermeasures that we have. Right from the very, very beginning, from the very first day.

WZ: Do you think? Because I think some people in the gay community are feeling left behind again in a way that they felt during the beginning of the HIV epidemic. What do you think about that? Do you think there was some delays because of the community that was affected here?

AF: Absolutely not.  

WZ: Tell me about that.

AF:  I mean. No, it's just. No, it isn't. It had nothing. It's just zero. It had nothing to do with the fact that it's a gay community. Obviously, that's something that people would think. But I don't believe that's the case, at least not from the standpoint of the people making the decisions about getting things out. I just think there was a lot of bureaucratic obstacles in the way, and I don't believe at all that it was bureaucratic obstacle that says, ‘Well, they're mostly gay men. Let's slow it down.’ I mean, that just, I'm sorry that didn't happen.  

WZ:  And so you've said that when we are thinking about lessons learned from the HIV epidemic, you've said we have to recognize who the enemy is. It's the virus, not the people infected by it. Tell me more about why that's important.

AF: Well, I spent most of my professional career in HIV/AIDS. And I understand very well the issue of stigma and the issue of turning a disease that afflicts a group through no fault of their own. The way it happened with HIV, the way it happened with monkeypox, and how stigma easily enters into it. And I have said that years and years ago that when people start being judgmental and pointing fingers at behavior, you have to remind them that the virus is the bad guy here, you know, not the individuals who have been afflicted with the virus.

WZ: And what happens if we can't get monkeypox under control? A researcher that we spoke to said that, you know, in a worst case scenario, monkeypox could enter the like wild animal population in the U.S. and then become endemic in a similar way that it does in certain countries in Africa. Do you think that could happen here?

AF: You know, Wendy, anything is possible. You know, I hesitate to answer questions because as you know with me, I will say one sentence. It will get completely taken out of context and it'll be the headlines somewhere.

WZ: But what do you think.?

AF: Anything is possible, but it is unlikely if we continue to put our foot on the pedal, get as many people vaccinated as possible, get control of it. I believe we can do that. But, you know, in order for anybody to say, ‘oh, no, that's impossible, it won't happen,’ that's nonsense. We don't know. There's a lot of unknowns here. So you can't say with certainty what absolutely will happen or what absolutely won't happen right now because it's a moving target.  

WZ: I guess more from the perspective of - I think there are some people who are not in the gay community who are like ‘I don't have to worry about it. I don't have to think about it. I can ignore this.’ What do you want to say to them?  

AF Well, whenever you have an infectious disease of which you don't have all of the understanding of the capability of that infectious disease, then I would tell people who say, oh, I don't have to worry about that. I would say, well, maybe you wouldn't want to lose any sleep over it tonight, but keep an eye out on it because it's a moving target. And don't be so confident that everything is going to be okay. And that's the reason why I and my colleagues take these things very, very seriously. You don't want to panic anyone because that's not productive. On the other hand, you don't want to give a false complacency.

WZ: I know you hated the worst case scenario question - I think you’re going to love this one. Where do you think this is likely to go in the next few weeks, next few months, say?  

AF: Yeah, I would hope that we get all of these countermeasures distributed in an equitable manner, not just to the people who understand how to get it, because there are a lot of people that are vulnerable throughout the country, and I would hope that this gets distributed in an equitable manner. And by distributed I mean availability of tests. I mean Tpoxx when you need it. And obviously enough vaccines not only to do post-exposure prophylaxis, but also pre-exposure prophylaxis for people who might be at risk.

WZ My last question, you were preparing to leave your position soonish. Did Monkeypox just blow up your plans?

AF: It depends on what you mean by as soonish as there has been a lot of misperception about what my plans were.

WZ: Yeah, that’s why I said Soonish!

AF: Yes, that's for sure. I will make an announcement when I'm ready to make an announcement

WZ: You don't want to make it on Science Vs?

AF: No, sorry about that.  

WZ Thank you so much for your time. I really appreciate it.

AF: My pleasure. Take care. Bye bye.  

That was Dr Anthony Fauci. If you haven't listened to our first episode on monkeypox - go do that. We look at the fact that the virus is mutating – and find out what does it mean?? How worried do you need? What it's like to have monkeypox. And we give you a lesson in why you might not want to have a Giant Rat for a pet. Go Check it out. The episode is called Monkeypox: What's Going On?

I'm Wendy Zukerman.. fact ya next time