Fauci, in conversation with Dr. Lloyd Minor, dean of the Stanford University School of Medicine, minced no words in describing the task ahead, but he offered several bits of encouraging news. Treatments for managing the coronavirus will continue to grow and could help control the disease in its beginning phases as soon as this fall. One or more vaccines might be available by early 2021, he said.
But Fauci warned that this virus is daunting, and surprising, even to an expert such as he, who has fought a pantheon of infectious diseases, including HIV/AIDS and the Ebola virus during his more than three decades as the nation's top infectious disease expert.
"This is truly historic. We haven't even begun to see the end of it yet," Fauci said of COVID-19. "It's still globally trending. Some countries are doing better than others, but until you get it completely under control, it's still going to be a threat. It is truly unprecedented."
"We're doing what we can. Of all the emerging infectious diseases I've had to deal with in the 36 years that I've been the director of the institute, starting off with HIV in the early '80s, with Ebola and Zika, this is clearly the most challenging. It's the most challenging because it's so pervasive. It is truly a global pandemic of unprecedented -- when I say unprecedented, back to (the) 1918 historical pandemic. I think 50 years from now, people are going to be reflecting historically on this the way we used to reflect on the 1918 outbreak," he said of the influenza pandemic, which killed an estimated 50 million people or more worldwide.
Fauci said that the virus' protean nature can be seen in how it affects so many people in so many different ways: Some have no or mild symptoms, while others are hospitalized or die. For some who survive, the virus causes protracted illness, long-term disability and organ failure, he said.
Minor avoided the current controversy between Fauci and the White House, which has criticized the doctor and his advice.
But the currently grim outlook on COVID-19 could be completely turned around with the development of a safe and effective vaccine, he said. Before then, in the absence of a vaccine, the only means to stop the virus is to physically separate people to the point of not allowing the virus to transmit, he said.
Fauci said that the stay-at-home orders clearly helped reduce the number of infections in the United States, but the country has opened too soon and too drastically, resulting in the surges now taking place in many states, including California, he said.
"We gave a set of guidelines a few months ago that had good checkpoints (phases 1, 2 and 3) unfortunately, it did not work very well for us. ... The increase that we are seeing, we can get a handle on that. I am really confident we can if we step back. We don't necessarily have to shut down again, but pull back a bit and then proceed in a very prudent way observing the guidelines and going step by step," he said, adding:
"All you need to do is look at the (videos) of people in some states going from shutdown to completely throwing caution to the wind: bars that were crowded, people without masks. There are things you can do now: physical distancing, wearing a mask, avoiding crowds, washing hands. Those things, as simple as they are, can turn it around."
Asked by Minor to grade the Bay Area on its efforts to control the outbreak, Fauci said Texas and California are so large and so varied, that he could not make a definitive statement.
"California is a bit of a mixed bag," he said, although the Bay Area is doing better than other areas of the state such as the southern California border where there is a higher percentage of vulnerable populations. He said that Gov. Gavin Newsom is doing "a very good job," as are some mayors.
Fauci said there are a few important developments regarding drug developments and he is hopeful for a vaccine.
Remdesivir, an experimental antiviral drug that was originally developed to treat Ebola, and dexamethasone, a corticosteroid used as an immunosuppressant and anti-inflammatory, are two medications that clearly are working in hospital settings with severely ill COVID patients, according to Fauci.
But he said there needs to be other medications to treat the virus in its earlier stages, and a few are being developed, including direct antiviral drugs, convalescent plasma and monoclonal antibodies. The latter can bind to specific molecules on the outside of a cell and can, among other things, block specific molecule functions on the virus.
"I believe we are on a good track to get there reasonably soon," he said.
By fall, conceivably there could be good antiviral and antibody therapies and potentially, vaccines. "One or two will go into Phase 3 clinical trials, which evaluate the overall risks and benefits of the drugs, at the end of this month.
"So we are pretty cautiously optimistic that by the end of the year ... by 2021, we will have, I hope, one or more vaccines that will be available," he said.
The manufacturers are taking the unusual step of producing large amounts of doses before the drugs' proven safety and effectiveness in order to be ready if the vaccines are approved, he said. If the drugs fail, that would cost any millions of dollars, but if successful, the country would gain many months toward widespread vaccination, he said.
Vaccines are essential to controlling the virus, he said. The distribution of vaccines would undergo a process to determine the ethics of who should have access to a limited supply. Asked how he would address getting people who are resistant to being vaccinated to comply, Fauci said community engagement through "boots on the ground" messaging would have to be done by people who look like the communities they are trying to reach -- like the community did when battling HIV, he said.
Fauci did not commit to a position on a national face mask requirement, saying instead that enforcement by the federal government would not likely be effective and might better be dealt with locally.
He had a message for young people, however, to think outside of their "vacuum" and to realize that if they don't mask up, even if they don't show symptoms of the virus, "almost certainly you are going to infect someone else" and that person will infect others -- one of whom may become highly sick and could die, he said.
A poor public health infrastructure, which has languished for many years, has also contributed to the existing crisis, he said.
The impact of those lapses are also evident in the staggering statistics related to people of color, who disproportionately bear the brunt of COVID-19 infections, he said. The country hasn't made much progress addressing those disparities, he noted. Although advances on HIV control steadily gained since the 1980s, African Americans, who represent 13% of the population, account for 45% of new HIV cases today, he said. It's the same with COVID-19, he said.
The African American population and the Latino population "find themselves with jobs that don't allow them to properly protect themselves. As everybody's locking down, they're doing the essential jobs that require their physical presence, so they're immediately at more risk of getting infected," he said.
The prevalence and incidence of underlying diseases such as diabetes, heart, chronic lung and kidney disease and hypertension make for a poor outcome if they contract COVID-19, he said.
"It's striking how disproportionately they are disadvantaged," he said.
"We have let the local public health infrastructure in our country really go into tatters," he said. Instead, federal public health focused on successfully controlling subsets of diseases such as smallpox and tuberculosis, while local infrastructure went unattended.
"It attenuated, and it attenuated, and now when we need good local public health capability, it's not as good as it should be. We've got to build it up again," he said.
Fighting and preparing for future pandemics, which are sure to come, will require rebuilding that public health system and thinking about research in different ways, such as developing avant-garde technologies ahead of potential pandemics and studying prototype pathogens to understand a particular family of diseases.
Coronavirus is at the top of that list. The world is currently in its third coronavirus pandemic in the past 18 years, he said: In 2002, there was severe acute respiratory syndrome (SARS); in 2012, Middle Eastern respiratory syndrome (MERS), and in 2020, COVID-19, he said.