Mark Zuckerberg & Dr. Fauci Interview Transcript July 16

Mark Zuckerberg: (01:12) Thanks for tuning in today. And I hope you're all staying healthy and good. I'm here today with Dr. Anthony Fauci, our nation's leading infectious disease expert, to discuss the recent surge in COVID across the country and how we can all stay safe and improve the country's trajectory going forward. Dr. Fauci last joined me a couple of months ago, I think, when COVID was first beginning to spread in the U.S. And, since then, we've had a lockdown and we started reopening. And I think many would say maybe we started reopening a bit too quickly before we really got it under control because, while every other developed country in the world, or almost every other country, has had a relatively smaller number of new infections, we now face a record number of new infections every day. More than 50,000, I think, daily is the recent number. Mark Zuckerberg: (02:05) At this point, it is clear that the trajectory in the U.S. is significantly worse than many other countries and that our government and this administration have been considerably less effective in handling this. And I personally think we need to take this a lot more seriously. And our understanding of the disease, of course, is evolving and our response needs to be guided by science and our latest scientific understanding, even if it's not perfect at any given moment. Mark Zuckerberg: (02:35) So, I want to say upfront that I'm grateful for the leadership and dedication of Dr. Fauci who has been working tirelessly under very difficult conditions to help us all navigate this. So, doctor, thank you for joining us. And I'd love to get started by getting your perspective on where things are now, why the U.S. response has been less effective than many other developed countries, and what do we do to improve from here? Dr. Anthony Fauci: (03:07) Well, as you described accurately, Mark, we do have a serious situation now. I mean, it's a mixed bag. There are parts of the country that are doing well. The Northeastern part, particularly the New York metropolitan area, was hit very hard. There was a period of time when more than 50% of all the new infections, and hospitalizations, and deaths were right in New York city. And there was a time when they were essentially leading, with regard from a bad standpoint, namely illness and death. They've done very, very well right now. They've come back down. They're opening in a very measured way. Dr. Anthony Fauci: (03:44) However, as you alluded to, simultaneous with that in another region of the country, Southern states particularly, exemplified by Florida, California, Arizona, Texas have seen surges that are really quite disturbing, surges, as you mentioned, that have gone up to over 60,000 cases a day. That obviously is something that we must address and address in a very, very cogent way. Dr. Anthony Fauci: (04:13) And, if you look at the reasons for that, you asked the why. Why, it's a complicated answer to that. But one of the things that became clear is that, when you look, and I'm not going to name any specific states, but there are some States that actually, when you look at what the guidelines were for opening, the checkpoints that you have to get past before you went to the next phase, some of them went to quickly and officially jumped over them. That, as I had said in previous discussions, is a recipe for getting into trouble. Dr. Anthony Fauci: (04:46) In other situations where the states actually officially, the governors, the mayors put out and delineated exactly what should be done, but the citizenry of the state or the city had the impression that you went either from lockdown to put caution to the wind. And what we saw were clips of people at bars, congregating without masks, not staying distance, in crowds. And that's what I believe is at least part of the explanation for why we've seen the surges went up. That's the first thing. Dr. Anthony Fauci: (05:22) The other thing that's important in the comparison to other countries, which is, in some respects, unfair, but in some respects is fair, that, when you looked at what happened in the European countries, when they had their peak and they locked down, they locked down to the tune of about 90 to 95% of the country truly locked down. So, they went up and then they came down to baseline. And, when I say baseline, I mean, literally handfuls of new cases, tens, twenties, thirties, not hundreds and thousands. Dr. Anthony Fauci: (05:59) When, if you look at the United States as a whole, when we went up and peaked and started to come down, we never really went down to baseline. We plateaued at around 20,000 cases a day. We really got to almost regroup, call a timeout, not necessarily lockdown again, but say, we've got to do this in a more measured way. We've got to get our arms around this. And we've got to get this controlled. If we don't do that, Mark, we're going to wind up getting a situation where in other states we may be seeing the same thing. So, it's a mixed bag in this country, some areas doing well, but some really we've got to really pay attention to and do something about it. Mark Zuckerberg: (06:43) All right. Well, doctor, I strongly agree that we need somewhat of a reset here. As someone running a business, I've said that I believe the best way to improve both public health and economic opportunity in this country is to focus on beating this virus first. Mark Zuckerberg: (06:59) And I also have to say, I think you might be quite generous in your description of the government's response here. I was certainly sympathetic early on when it was clear that there would be some outbreaks, no matter how well we handled this. But, now that we're here in July, I just think that it was avoidable. And it's really disappointing that we still don't have adequate testing, that the credibility of our top scientists, like yourself and the CDC, are being undermined. Then, until recently, that parts of the administration were calling into question whether people should even follow basic best practices like wearing masks. Mark Zuckerberg: (07:40) But, look, the U.S. is a resilient country with a lot of ingenuity, as you say. And we can't forget that the U.S. is helping to lead the way on vaccine research, which I want to make sure we get to in a bit. And I also get that our understanding of facts changes as time goes on. And we all have the opportunity to reassess what we've learned and to change course going forward. And I know I tried to do that personally. And I hope that we, as a country, can do that now too. Mark Zuckerberg: (08:06) And I know that you've also faced some critique that your guidance has evolved as we've learned more. So, I'm hoping that you can tell us a bit more about how your understanding of what we should do has evolved, and maybe some of the areas where your guidance for people around the country has changed. Dr. Anthony Fauci: (08:25) Yeah. I mean, obviously, when you're dealing with something that's changing in real time, Mark, that's really the nature of science. You look at the data and the information you have at any given time and you make a decision, with regards to policy, based on that information. As the information changes, then you have to be flexible enough and humble enough to be able to change how you think about things. Dr. Anthony Fauci: (08:52) And I think one of the important things that we're emphasizing right now that really evolved from a situation that did change is our insistence now on wearing masks. I mean, masks are very important. They protect you from giving infection to someone else, if you happen to be inadvertently infected, and I'll get back to that in a moment because there is such a significant percentage of the cases that are actually without symptoms. So, anyone at any given time could be infected, don't even know it, and feel perfectly well. So, you have a responsibility... and can get protected. Dr. Anthony Fauci: (09:34) Now, early on, when we were in a situation in which there was a real concern about the lack of personal protective equipment on the part of the health providers who needed it, who put themselves in harm's way every day to take care of people who were ill with this virus, that we were thinking we would run out of masks and other things for them. So, the recommendation was not to wear a mask because of the shortage of it. Dr. Anthony Fauci: (10:03) Two things happened. One, it became clear that we had enough of the equipment. So, there was no shortage. It became clear that cloth coverings, that you didn't have to buy in a store, that you could make yourself were adequate. And thirdly, and probably the most compelling thing is when it became very clear that anywhere from 20 to 45% of people who were infected didn't have any symptoms. So, the risk of your being in contact with someone who said, well, you look good. I look good. We're not infected, was not the case, that you could be spreading it asymptomatically. You put all of those things together, which had us evolve from saying maybe we should hold off on masks because we needed them for the healthcare workers, to saying now everybody should be wearing a mask when they're outside and should be trying to distance. That's one example of evolving as you get more data and you get more information. Mark Zuckerberg: (11:03) That makes sense. I'd like to dig a bit deeper into this idea of what doing a reset now would entail. And, to be clear, you're not suggesting that we do another lockdown. So, what steps do you think we need to take to get this under control now? Dr. Anthony Fauci: (11:20) Okay. So, if you look at had things been done perfectly, it should have been that wherever you were, a state or a city, in a particular dynamics of infection of where you are, you could judge where you should be. Should you be at the gateway waiting for 14 days going down? If so, could you go to phase one? Could you go then to phase two and then to phase three? When I see a reset button, I say, okay, timeout. Let's everybody regroup. Because, if you were in a situation where you should not have jumped over one of the checkpoints, you got to think about pulling back, starting all over again, and doing the gradual entry into quote normality in a way that's in accordance with the guidelines. Dr. Anthony Fauci: (12:16) Number two, if in fact you are in that, you've got to be really very careful that your citizenry understands the importance of abiding by these guidelines. You have to wear a mask, whether that mask is mandated, whether it can be feasibly locally mandated, I would recommend as strong as you possibly can to get people to wear masks. To avoid crowds, to keep distances, outdoors is always better than indoors. So, when you're talking about the kinds of recommendations, that's what you've got to do. And, quite frankly, Mark, if you look at it, that hasn't been done in every single instance. So, we've got to go back and relook at what we're doing and re-enter. Dr. Anthony Fauci: (13:04) The most important thing is that there has been this unusual and unfortunate mindset of there's public health measures and there's getting the economy back. And these are two opposing forces. As I've said so often, and I want to repeat it with you here, Mark, is that we should be looking at public health measures as a vehicle or a gateway to opening the country again, to getting the economy back, not as the obstacle in the way, but as a gateway. And, if we do it in a measured way, I strongly believe we can turn this around in the Southern states that are getting hit right now. And we can prevent it from happening in states that are still at that point of trying to open up. You've got to do it correctly. You can't jump over steps, which is very perilous when you think about rebound. And the proof of the pudding is look, what's happened- Dr. Anthony Fauci: (14:03) About rebound. And the proof of the pudding is look what's happened. There really is no reason why we're having 40, 50, 60,000 other than the fact that we're not doing something correctly. Mark Zuckerberg: (14:15) Yeah. That makes a lot of sense. So I want to get to your guidance for young people specifically, who are a very important part of how we slow the spread of this. And I know a lot of younger people are watching this right now. And I know this because the last time we did a live video, I think all the streams were viewed I think more than 50 million times, including by a lot of young people. And young people are going to be really critical to getting this right, because right now a lot of the new cases are younger folks. So what should young people be doing to stay healthy and to make sure that they can keep the people around them healthy. Dr. Anthony Fauci: (14:59) Mark, thank you very much for asking that question because I think it's critical to everything that's going on right now in the country. If you look at what's going on with the new infections, the age range of the infection, the median age is about a decade and a half younger today than it was a few months ago. So you're absolutely right. Young people are intimately and heavily involved in what's going on now with this pandemic. So let me just say one thing and I address it to the young people who are watching this. It's totally understandable that you see the data. Young people are smart. They know what data means and the data tells us that if you're a young person the likelihood when you get infected of getting seriously ill is much less than an older person, the elderly or people with underlying conditions. Dr. Anthony Fauci: (15:56) That's just the truth. That doesn't mean that some young people and we have ample examples of that who are young and otherwise healthy can get seriously ill. I mean really seriously ill, or can be knocked out on their back and brought to their knees pretty quickly. But let's take the majority of young people who get infected and don't even know they're infected. You can get the mindset, well, listen, if I'm infected, I don't know I'm infected. I'm not feeling sick. Who cares? I'm not bothering anybody else. That is in correct. Because by allowing yourself to get infected, you are propagating the pandemic. And let me explain what I mean by propagating it. You can't think of yourself in a vacuum because if you get infected and you don't know it, then you're going to make innocently and I'll use the word innocently because I don't think there's any malice here. Dr. Anthony Fauci: (16:52) You can innocently infect someone else who then might infect someone else. And then all of a sudden, a vulnerable person, an elderly person, a person who's immunosuppressed, a child with cancer on chemotherapy. When they get infected, then you have a serious problem. So what I would urge and almost plead with the younger people, because I know if they really understood this, they would take it seriously, that you have to have responsibility for yourself. But also a societal responsibility that your getting infected is not just you in a vacuum, you're propagating a pandemic. Dr. Anthony Fauci: (17:32) So when I see the pictures of people at bars, enjoying themselves, totally understandable. I get that. I was there at one point in my life or see people in crowds and you say, "Well, they think they're not doing anything that is particularly harmful." But they might be. So my message to young people is consider your responsibility to yourself, but also the societal responsibility, because the sooner we put this down, the sooner you're going to get back to normal and you'll be able to freely have fun, go to the bars, go with crowds. But not now. Now's not the time to do that. Mark Zuckerberg: (18:15) Yeah. And I want to push on this point a bit more because you mentioned that young folks can get sick too, but you're focusing a lot on how young people risk spreading COVID to more people. But for the people I know it seems like getting COVID, even if you're young is an absolutely brutal experience, a lot of people get sick for weeks or can be sick for months at a time. And we don't know yet what the longterm side effects are. And so I'm curious if you could just talk about that a little bit more about that part of it for young folks as well, [inaudible 00:18:49] so far about how COVID effects younger people and maybe just address that set of issues a little bit more as well. Dr. Anthony Fauci: (19:00) I mean, there are countless examples. Thank you for bringing that up Mark, because as I've often said, I've been chasing viruses and going after outbreaks for decades, I've never seen an infection with this broad range of manifestations from nothing in 20 to 40%, 45% to getting sick for a few days, to getting knocked out, literally at home in bed, feeling horrible within even post infection, syndromes to maybe in the hospital, intensive care and death. If you look at the statistics, like you said, the young people are heavily weighed towards not getting seriously impacted, but be careful when you talk about what do you mean by seriously ill? Dr. Anthony Fauci: (19:45) There are many, many young people who get infected. They get sick, they feel horrible for weeks and weeks. And then one thing they notice, and we're getting a lot more information on this that even when they clear the virus and they test negative and they don't have any virus, they can feel out of sorts for weeks and weeks, almost similar to a myalgic and cephalitis chronic fatigue syndrome thing, where they just don't feel right for weeks and weeks and weeks. So this is not an infection to take lightly, even with young people, even with young people. Mark Zuckerberg: (20:27) And what do we know so far about longterm side effects? Do we know anything about this yet or do we just simply need to watch how this plays out for longer before we're going to know if there's significant damage to organs or anything else that we need to worry about? Dr. Anthony Fauci: (20:44) Yeah. I think you hit the nail on the head. It's going to be time. We've got to wait and see in the long range. Now, if you look at likelihood and initial experience for people who get sick and maybe are out for a few days, they get a sniffle, a little sore throat. The virus tends to stay in the upper airway, maybe a little short of breath and then they're good. They get better. And they're fine. It is very unlikely Mark, that those individuals are going to have any chronic longterm issue. It's the people who really get knocked out badly, particularly those who might require hospitalization, that it's going to probably take months to a year or more to determine if there are any long lasting deleterious consequences of the infection. We just don't know that now we haven't had enough time. Mark Zuckerberg: (21:38) Okay. You made a comment recently comparing the severity of COVID to the 1918 pandemic. Can you say more about that? Dr. Anthony Fauci: (21:50) Yeah. I'm glad you brought that up because I want to clarify that I had used the word comparable and I think that may have been taken out of context because people would of thought, my goodness, we're having this now. Is it going to be the 50 to 100 million people in 1918 that thought no, they're not comparable in that way at all in severity, they're very, very different. I was just talking about 102 years then we're historically now looking at historically important outbreak because we haven't had anything like this really for 102 years, but I don't want anybody to think this severity comparability because of what was experienced in 1918. I mean, if you look at it, it was 50 to a hundred million deaths in a population of one third the size now. So I wanted to clarify that. Thank you for giving me the opportunity. This is a serious situation we're facing now, but it's not 1918. Mark Zuckerberg: (22:50) Yeah. That makes sense. Now, a lot of the comments that people have written in are asking about reopening schools or it's how should we be thinking about reopening schools? What does the science tell us on this issue? What is your view of the appropriate threshold in terms of deciding when to reopen? And a lot of parents just want to know how they personally should be thinking about this. So I'd love to hear you talk about that set of issues. Dr. Anthony Fauci: (23:17) Yeah, thanks Mark, a great question, because it's something that we're addressing now as we're into the summer and getting ready to opening the schools. So I think as a default, I have a general concept and then I'll fill in the blanks. The general concept is that to the extent possible, our default should be to try and get the children back to school. The reason I say that is that the unintended ripple effects downstream consequences of keeping the children out of school can be profound. The American Academy of Pediatrics has spoken about that. The deleterious effects on children, the impact on parents who have to modify their work schedule if their children stay home, there are a lot of unintended negative consequences. Having said that with the thought that the default should be to try and get kids to school, you've got to look at where you are location-wise because as I've said often the United States is a large country, geographically and demographically, quite different and varied. Dr. Anthony Fauci: (24:24) You could be in a part of the country, a county, a city, a state in which the level of virus infection, the dynamics is so low you could send kids back to school without any modification or any worry, but there are also some areas when you look in the dynamics of the infection is so intense you have to say, "Wait a minute, let me think about it. Do I have to close the school for now? Or can I go back? But in order to be safe, do I need to do it in a modified way? Alternate days, morning, afternoon, or wherever?" Dr. Anthony Fauci: (24:57) Because paramount to [inaudible 00:24:59] it is the safety and the health of the children, as well as the safety and health of the teachers. So you've really got to make sure that's a driving force in your decision. So a wide degree of variability default always try to get the schools open if you can't do it in a natural way, do a modification, some of the school principals and the superintendents have very creative ways of doing that, of modifying the class structure outdoors, maybe a little bit more protecting the vulnerable. It can be done. It can be done. Mark Zuckerberg: (25:38) Okay. And is there anything else that you'd say to parents who are worried about either having schools reopened or the safety of sending their kids to schools? Dr. Anthony Fauci: (25:49) Yeah, I mean, I think they have to... And I know parents, at least I, as a parent, when my children were at that age, I certainly would be concerned is to listen to the recommendations. The CDC has guidelines that health officials locally will make a decision hopefully, and I cannot imagine they won't based on a concern for the safety at the same time as the need to get the children back to school, CDC guidelines are there. They can be used very well. Mark Zuckerberg: (26:19) Yeah. So I want to talk about the racial disparities here, which I think are really troubling. The CDC has reported that black, Latinx and Native Americans are four times as likely to be an infected with COVID and twice as likely to die as white Americans. So what can you tell us about what we're seeing here and what is being done by the government to address this? Dr. Anthony Fauci: (26:47) Yeah, that's a very good question, Mark, and a very disturbing phenomenon that is a reality. And there's an explanation for it. And there are things that we can do about it immediately, but things that are going to take decades for us to correct. So if you look at the fact that if you look at minorities, as you mentioned, African-Americans, Latinex, Native Americans and Alaskan Americans. If you look at that group, although you don't like to generalize, but it is a fact that as a demographic group, the kinds of jobs that they generally have, do not allow them as much to do the kind of telecommunication that we're doing right now that put them in so called essential jobs where they're outside in a situation, exposed enough to have a greater incidence of infection than someone who could call a time out and do work from the quiet and solitude of their own home. So they have a greater chance of getting infected. Once they do get infected, as a group, if you look at the underlying conditions that lead to a higher likelihood of a bad outcome, those... Dr. Anthony Fauci: (28:03) ... likelihood of a bad outcome. Those demographic minority groups have a much higher incidence of that. And I'm talking about hypertension, obesity, cardiovascular disease, other types of chronic lung disease, diabetes. Those are the things that put you at a higher risk. So, the immediate things that we can do now is that, how do you address that? What you do is you put resources where you have a demographic concentration of individuals so they can get tested easily, contact traced easily, have access to care, get under the care of a healthcare provider quickly to try and mitigate the advancement of disease. You can do that right away. We can concentrate resources in those places, making sure they get things that they need right away. Dr. Anthony Fauci: (28:54) The broader picture of the social determinants of health that lead to minority groups having a higher incidence of diabetes, of obesity, of lung disease, of heart disease, those are the kinds of things that we as a society need to address and commit to doing over a period of decades because that's not going to change overnight. But let's at least do the things that we can fix now. And we could fix access to care. We could fix ease of testing. We could do that now. Mark Zuckerberg: (29:30) Yeah. Okay. That's important and I think it makes sense. I want to make sure we have time to discuss some of the science and potential treatments. Earlier on, I know that a lot of scientists were hopeful that there might be existing drugs, including things like hydroxy chloroquine that might've been effective against COVID. But unfortunately it seems like nothing has really emerged as a clear treatment of existing drugs that were already on the market and had already been reviewed as safe. And even drugs like remdesivir, which is probably one of the more effective newer medications, doesn't seem to have as huge of a positive impact as we might have hoped. So what's your take on the drugs that we've found so far, that we've tested, and are there any treatments that you're optimistic about over the coming months? Dr. Anthony Fauci: (30:29) Good. Great question. Thanks Mark. If you look at advanced disease and early disease, we have had two advances and this was in a randomized placebo controlled trial, not those other types of anecdotal things which give you information that generally confuses people. If you look at remdesivir in individuals who are hospitalized with lung involvement and you look at the impact of remdesivir, there was a highly significant but modest effect in diminishing the time to recovery. So that's one well-proven good drug. Dr. Anthony Fauci: (31:08) Dexamethasone, which is a glucocorticoid and anti-inflammatory steroid, clearly showed in hospitalized patients on ventilators or requiring oxygen but not people with early disease, that if you gave it six milligrams a day for up to 10 days, you significantly diminished the death rate in ventilated patients, in patients requiring oxygen, but not in early patients, which is interesting because it goes along with what we know of the pathogenesis of the disease, that when you have early disease, you want to block the virus and keep the immune system revved up and working. When you have late disease, it's less the virus doing damage than the aberrant inflammatory response, which is the reason why dexamethasone works. Dr. Anthony Fauci: (31:58) So we have two good things going. What we really need is your question about, what do we have in the mix right now? What we really need are drugs that when given early can prevent asymptomatic person from requiring hospitalization or very dramatically diminish the time that they're symptomatic, and some of the promising ones are other direct antiviral drugs which we're screening and targeting. Also convalescent plasma, which we're doing a trial to see if it works, hyperimmune globulin, and importantly, monoclonal antibodies. Monoclonal antibodies are very precise bullets that you have by developing from a person who's been infected or vaccinated, making antibodies, clone their B cells and give it to people early on. You can do it as an outpatient. You can do it as an inpatient. All of those things are being geared up now and are either in clinical trial or will soon be going into clinical trial. Mark Zuckerberg: (33:03) When you talk about things like monoclonal antibodies, how would that be administered and who could get that? Who is the audience that that might be helpful for? Dr. Anthony Fauci: (33:13) Yeah. Well, first of all, it can be administered intravenously. Once you get the right titration, you can do that subcutaneously or intramuscularly. You can do it for two things, Mark. Excuse me. Mark Zuckerberg: (33:27) Through a shot. Dr. Anthony Fauci: (33:28) Yeah. Through a shot, yeah. Either right through the vein or just like you get a gamma globulin shot, you could do it that way. Now, that can be done either for prophylaxis or for treatment. For example, if you're in a situation where you have a nursing home situation where there's an outbreak and you want to prevent people from getting ill, you can just do it that way. Or after a person is infected, you can give it to them as a treatment. This was very successfully done in a randomized placebo controlled trial. It wasn't a placebo, it was a drug that was serving as the control. You might remember, Mark, of Ebola in West Africa where we showed that two types of different monoclonal antibodies were very effective in Ebola. We hope we're going to see the same thing now with COVID. Mark Zuckerberg: (34:23) And what do you think the timeframe for something like that might be? Dr. Anthony Fauci: (34:27) Well, the trials have already started, Mark. I would hope that as we get to the late summer and early fall, we'd be able to have enough efficacy data. Because remember, whenever you do this, they may look promising in an animal model. You always got to be concerned about safety and you got to be concerned about, are you really giving someone something that works? So, the clinical trials are underway for some and we'll soon start in another. I hope by the end of the summer, we'll have enough information as we get into the fall that we might be able to utilize these. It'll be really good if we had bookends, drugs for advanced disease and drugs for early disease to prevent advanced disease. Mark Zuckerberg: (35:09) Yeah. Got it. That makes sense. And if that's coming over the next few months, I mean, that's a good cause for some optimism. Dr. Anthony Fauci: (35:18) Yep. Mark Zuckerberg: (35:19) Over time, of course developing a vaccine is going to be critical. So, I'm hoping that you can talk a bit through where we are in that process at this point and what the process from getting from where we are now is to having a vaccine that could be given to people broadly and when the soonest would be that that kind of a vaccine might be available. Dr. Anthony Fauci: (35:43) Yeah. I'm actually cautiously optimistic about this, Mark, because of what we've seen. As you probably know, given the technologies we have in the different platforms, we moved from literally the day that that sequence was put on a public database to getting that sequence, pulling the gene and sticking it into a platform to make a vaccine, was measured in days. And then 62 days later, we were in a phase one trial. So where are we right now? There are multiple candidates, not only one. So I might talk as the prototype of one, but there are more than one that will be going into advanced trials, sort of in tandem sequentially. One right now that two days ago it was published in the New England Journal of Medicine, the phase one data, which we did some time ago, for safety and to see what kind of response it was induced. Dr. Anthony Fauci: (36:38) The thing that makes me optimistic about this whole enterprise is that this vaccine, which was an mRNA vaccine for Moderna that was developed here at the NIH. But as I mentioned, it's not the only one. That induced in the people who were in the phase one trial, levels of neutralizing antibodies, which are the antibodies that are the real bullets to stop the virus. That is the gold standard of protection is neutralizing antibodies. It induced it at levels, at a moderate dose of the vaccine, that were as high or higher than what you see with convalescent plasma after natural infection. Dr. Anthony Fauci: (37:22) And one of the hallmarks of vaccinology is when you get a vaccine, you'd like it to induce a response that's at least as good as natural infection, which would predict that the vaccine would likely be successful. Even though the proof of the pudding is always, you got to do the big efficacy trial for safety and for efficacy. At the end of this month, July, we're going to be starting the phase three trial of this candidate. And as we get into the summer, a month later, another candidate will go into phase three trial, and then a month later another. So that over the next four to five months, you're going to see sequentially these candidates coming into clinical trial. Dr. Anthony Fauci: (38:06) Having said that, if everything works out the way we hope, and we don't get any unpredictable potholes and bumps in the road, we should know as we get into the mid to late fall, early winter, but probably late fall, whether we have candidates that really are safe and effective. And I hope and anticipate that we will have one or more. If that's the case, by the time we get to the end of this year, the beginning of calendar year 2021, we may have vaccine, one or more candidate, that is actually safe and effective. Dr. Anthony Fauci: (38:43) That being the case, we can start distributing doses widely at that time. The reason why I think we can do it is that even as we're doing the clinical trials now, we, we being the enterprise, the companies, are going to already start making doses at risk, which means they're going to make doses even before they know the vaccine works. Which means if it works, they've saved months; if it doesn't work, we've lost a lot of money. But we figure it's worth the risk. So the risk is not in safety and the risk is not in scientific integrity. The risk is financially to try and make these steps truncated. So that's where I think we are. I'm really quite cautiously optimistic that we'll be able to have something as we get into the end of this year and the beginning of next year. Mark Zuckerberg: (39:41) Yeah. That's a good note of optimism. I think it might be useful to talk through the process of vetting a vaccine, both so that people have some sense of what it takes to get from an initial candidate to something that's ready to go. But also because, while I know that the vast majority of people would be very excited and optimistic if they could get a vaccine that would prevent them from getting COVID today, I know that there are some people, it's a fringe but it's unfortunate, who question the overwhelming scientific evidence on the safety of these. So I just think going through the process and showing how overwhelmingly focused it is on making sure that these vaccines are safe would be helpful to go through as well. Dr. Anthony Fauci: (40:40) Sure. Very good. I'll do it succinctly. Well, you get a candidate like the one we did. You get it, you put it in the form to be administered and you put it through animal studies. Animal talk studies, animal effective efficacy studies. So before you even think about going into a phase one in humans, you got to have, is there a reason to believe that this is going to induce a response? You got to see it induced in an animal before you see it induced in a human, and does it protect any disease in an animal. Then you get that candidate and you go into phase one. Very limited number of people. Our phase one had 45 people, 15 at each dose. You want to see, is there any immediate safety signals? And you want to see if it induces the kind of response that you would predict would be protective. Dr. Anthony Fauci: (41:29) Then you go to the next phase. So if phase one is 45 people, phase two is hundreds of people. You get there, you continue safety, you continue immunogenicity. If it looks good, you then move to phase three. Phase three goes from hundreds of people to thousands of people. The trial we're going to start at the end of July is going to involve 30,000 people. So when you have that many people in a trial, not only are you looking to see if it works, but you're constantly... Dr. Anthony Fauci: (42:03) ...are you looking to see if it works, but you're constantly keeping your eye on safety to make sure that a vaccine actually doesn't enhance disease and make people work. Once you do that, at every given point in the trial, an independent group called the Data and Safety Monitoring Board looks at the data and says, trial's going okay, you can continue. Looks next month or the month later, trial's going okay, you continue or wait a minute, it looks like you're never going to really get an answer because nothing looks like it's working. You have futility, stop the trial. Or what we hoping for, Mark, that they look at the data and say, wow, this looks good enough that ethically you can't continue with a placebo. You've got to say this works, let's start distributing it. Those are the individual steps of developing a vaccine. Mark Zuckerberg: (43:02) That's very helpful to go through. While we're on kind of the basic safety measures for some of the common sense things that we're hoping to roll out, I have a question here asking if there were any known adverse effects about wearing a mask at all. There are some memes that go around, around are people breathing in more carbon dioxide? Are there any issues like that? From all of the studies around this, has anything negative been found? Dr. Anthony Fauci: (43:33) Not at all. Mark. There has not been any indication that putting a mask on and wearing a mask for a considerable period of time has any deleterious effects on oxygen exchange or anything like that. Not at all. Mark Zuckerberg: (43:48) And in my understanding because this has also been studied even in people when they're running and exercising and things like that. And I haven't seen anything that suggests that there would be any issue, but I mean, you obviously are the expert on this. Dr. Anthony Fauci: (44:01) Well, no. I mean, I wear a mask when I'm outside all the time, particularly making sure that I don't remove it when I'm close to people and it doesn't bother me. I even run with a mask on. Sometimes it gets a little moist there depending on the cloth that you're wearing. But there's nothing to indicate that wearing a mask has deleterious effects. Mark Zuckerberg: (44:27) Okay. Well, it's good to just get a chance to make sure that that is crystal clear for everyone. And just reading a few more questions from the thread here, one that has come up a bunch is some people are wondering, if someone isn't showing symptoms, then how is it that they could be contagious? I kind of get why that might not be obvious to a lot of folks so it's probably worth just taking a few minutes to talk through that and how that works. Dr. Anthony Fauci: (44:59) NO. That's a great question, Mark. I'm glad you asked it. Yes. And the reason you can be contagious, if you look at how you transmit from one person to another, the virus resides in the nasal pharynx, in the back of the throat. So that's the reason why, when you say, when you speak or cough or sing, the virus in droplets comes out. You may not see it, but when you do certain lightings and lasers, you can see it. What we have found out that when you measure the level of virus in the nasal pharynx of asymptomatic people, compared to people that who are symptomatic, there doesn't seem to be any difference. Which means there is as much virus in the nose of a person who is asymptomatic as there is in a symptomatic person. Which means it is very, very likely that when that person talks or sneezes or whatever, that enough virus will come out to infect someone else. So there is not a lot of difference in virus load, even though people can be very different with regard to their symptoms. Mark Zuckerberg: (46:09) So related to your point about droplets, there's some recent pieces that I've seen suggesting or wondering whether to the extent to which this is aerosol or droplet. There's a question from the thread about, do we have any data on how this moves around differently inside versus outside or how long this can linger in the air for? Dr. Anthony Fauci: (46:37) So the linger in the air question relates to whether or not it's aerosolized or another word people use is airborne. So there are different types of droplets. So most of the droplets when people speak and you see that little spray come out are greater than five micrometers. Those are the kind that they're heavy enough, Mark, they don't go any more than three feet, at the most six feet, which is why we say, when you're outside, stay at least six feet apart from someone. There are other droplets that are less than five micrometers. Those are the ones that can "aerosolized". And aerosolized means, instead of coming out from your mouth and dropping within three to six feet, it can kind of float around the air and stay in the air for a period of time. Right now it is unclear, and it is because we don't have enough data, that there is likely some aerosol that comes out and you could show that by these lasers and lights. Dr. Anthony Fauci: (47:46) We don't know the extent to which aerosolized or virus that stays in the air for long period of time is involved in the transmission. We certainly would like to know that, but it's very difficult to determine that even though we know that some degree of aerosolization does occur. If you turn back the clock and go to SARS back in 2002 and 2003, there was a clear cut instance in a Hong Kong hotel where aerosolization absolutely occurred, spread through different floors and infected individuals. Why that person who was the source of the aerosolized or whatever the source was, we still haven't figured out. But that was a good example of a coronavirus spreading through aerosol. But right now, today, I can't tell you with scientific certitude, what proportion is spread through aerosol. That's one of the unknowns we're just going to have to work out. Mark Zuckerberg: (48:50) Got it. Okay. Maybe go back to vaccines for one more minute. I mean, we're trying some novel strategies with some of these vaccines like the RNA vaccine. I think the Moderna candidate might be an RNA vaccine. And I'm not sure if there are any... this might be the first kind of major RNA vaccine. So I'm curious to just hear you talk about the advantages and disadvantages of the different strategies for types of vaccines that can get developed. And maybe even beyond COVID, if an RNA vaccine ends up being possible and working, what are some of the advantages for treating future outbreaks and things like that in the future? Dr. Anthony Fauci: (49:36) Good question. We refer to them, for your listeners and viewers, as platforms. So MRNA is a platform. Viral vectors are a different platform. Soluble proteins, recombinant proteins, killed and activated is another platform. So we had multiple platforms. There are three that are being actively done. One is the MRNA. The other is viral vectors where you take a virus, stick the gene of the spike protein so that it expresses itself and then you get an immune response when you inject that. The other is just taking a protein and inject it with an [inaudible 00:08:19]. The reason that the novel technologies we use that were very easy to just get out of the blocks and go with it, test assessed. What I explained to you, the timetable, we went from a couple of days, bingo, into a vaccine, done. Dr. Anthony Fauci: (50:34) So if it works, which we believe it will, it will be a major advance of ease, of facility, of scale up and ultimately of cost, we'll do it. It hasn't been proven the way some of the others have been by years and years of experience. So that's one of the things. If it works, which I hope it will, I think it will, people will be saying, wow, we have a red hot platform here. We're going to start using that for a lot of other vaccines. The other ones that we have, the viral vector ones, the ones I described, B adeno vector, vesicular stomatitis vector. That's another one that we've had some experience with, particularly with Ebola in which had worked very well. Dr. Anthony Fauci: (51:17) And then there's the ones that have been used more commonly, which is the soluble proteins that you can make with recombinant DNA technology. So there's multiple platforms, we're hoping, and I believe we'll be successful, I hope we are, that more than one of them will prove to be safe and effective. It will be good for the effort and it will be good for the field of vaccinology because it's really unprecedented that we have so many different platforms going on at the same time to determine safety and efficacy. Mark Zuckerberg: (51:50) All right. So I think we're almost out of time. So I wanted to check in and see if there's anything else that you wanted to cover or are there any other thoughts that you'd like to leave this community with? Dr. Anthony Fauci: (52:04) I just want to reiterate what I said before, Mark, and thank you for giving me the opportunity to say it. That we are all in this together. We are going to get through it. We will get through this difficult situation at best. I mean, it's a very significant issue that we're dealing with right now, but we've all got to do it together. We're in it together. And since I know we're looking disproportionately to a lot of young people that are watching this, please assume the societal responsibility of being part of the solution and not part of the problem. Dr. Anthony Fauci: (52:43) Because we're going to get through it, we're going to get this under control in the Southern states and hopefully we're not going to see these kinds of surges so that we do get down to the baseline that we hoped we would. Because once we're down to that baseline, Mark, it's going to be so much more easy when you open up the country as it were, to put your clamps on when you get individual infections. They don't soar off the ceiling, they stay clamped down. That's the message I want to get one last time. Mark Zuckerberg: (53:17) Great. Well, thank you, Dr. Fauci. I think I say this on behalf of millions of Americans who will watch this, we appreciate your leadership and your dedication to helping us navigate this. You have a lot of people's confidence and a lot of people out there continue to have faith in science and want to make sure that our response is led by science. So thank you for everything that you are doing in what are some trying circumstances and please stay healthy and good. And thank you to everyone out there for tuning in today. I hope you all stay good as well, and I'm looking forward to seeing you all soon. Dr. Anthony Fauci: (54:04) Thank you, Mark. Thank you for giving me the opportunity to be with you. I really appreciate it. Thanks.