Podcast: Advocating for science and truth

Jim Dryden (host): Hello, and welcome to “Show Me the Science,” conversations about science and health with the people of Washington University School of Medicine in St. Louis, Missouri, the Show-Me State. In this episode, we revisit the 2023 graduation ceremony for the new doctors who just completed their medical degrees at Washington University School of Medicine. This year’s speaker was Dr. Anthony Fauci.

Anthony S. Fauci, MD: Over the past few years, you’ve been immersed in scientific courses and schooled in the scientific method of inquiry. As you well know, data and evidence leading to new insights are the stepping stones of science and enable progress in scientific and medical research. Unfortunately, however, during the COVID pandemic, significant anti-science forces accelerated in our society and became louder and more entrenched over time.

Dryden: Graduation ceremonies are called commencements for a reason. Although they mark the end of a period of study, they also represent the moment that students officially commence, or begin, the next phase. Washington University School of Medicine just honored its new graduates with diplomas and hoods and a visit from Fauci, a speaker so popular that the school’s dean, Dr. David Perlmutter, had some trouble actually getting through the introduction.

David Perlmutter, MD: It’s now a very special pleasure for me to introduce Dr. Anthony Fauci. The recent —

Dryden: As the graduates have completed medical school to get on with the next phase of their lives and their training, these particular graduates also are leaving behind the experience of training during a pandemic that significantly altered their learning in the classroom and in the clinic. Dr. Fauci, the retired head of the National Institute of Allergy and Infectious Diseases, addressed the impact of COVID-19 on the future lives of the medical school graduates and he also spoke about his own experiences almost 40 years ago now when he guided the nation’s response to the HIV/AIDS epidemic. Both situations, he says, were complicated by medical misinformation.

Fauci: Consciously or subconsciously, each of you will carry an imprint of this public-health crisis that intruded upon your formal education as well as on your personal lives. I have enormous respect for your dedication that allowed you to successfully complete your medical school training under these trying circumstances.

Dryden: Fauci became a staple on news channels during the pandemic, and he met with members of the St. Louis press corps while he was at Washington University to speak at the School of Medicine’s graduation ceremony and to receive an honorary degree himself. Fauci stressed that, although the emergency is officially over, COVID-19 has not gone away.

Fauci: Just a couple of days ago, the United States declared the end of the public health emergency, and on May 5th, WHO did the same thing. But I think it’s important to point out that although the emergency is ended, we are still not completely out of the woods with COVID-19. The reason I say that is that everybody wants to, and we all should, really begin to get back to normal life. That’s appropriate, but there are still vulnerabilities in society, particularly people like the elderly and those who have underlying medical conditions and those who are immune compromised, who continue to have to be careful of it. So bottom line, short answer is, it’s not over in the sense of totally behind us, but the emergency nature of it certainly is behind us.

William G. Powderly, MD: I am Bill Powderly. I am professor of medicine, director of the Institute for Clinical and Translational Science and director of the Institute for Public Health.

Dryden: A few days after Fauci’s visit, I sat down with Washington University’s Dr. Bill Powderly, a longtime colleague of Fauci’s, to further discuss some of the themes that Fauci discussed during his visit. In the 1990s, while Fauci was working on the HIV response at the National Institutes of Health, Powderly was directing the NIH-funded AIDS Clinical Trials Unit at Washington University School of Medicine. And in more recent times, Powderly also was a principal investigator of a national study called the ACTIV trial that involved trying to identify effective treatments for COVID-19 during those days before vaccinations and paxlovid were available. Powderly says the situation today is much different than it was when that clinical trial was launched because science now has discovered much more about the virus that causes COVID-19 than when that virus first appeared.

Powderly: People don’t understand that science is not an absolute. It starts with the unknown. And it starts with people generating an idea that may or may not be true. Sometimes, we’re right in our original hypothesis, our original thinking. Sometimes, we’re completely wrong. I think one of the challenges that happened when you get something that is completely new is you’re building on a less-than-solid foundation. So COVID is a very good example. Completely new virus spreading rapidly across the world. We knew nothing about COVID. So the inferences we used were our experience with other viruses, like influenza. And some of the inferences or some of the thoughts we had were correct. But others were incorrect. And when we got the data and the information, it changed the way we thought about it. If you’re a member of the public or press or whatever, you’re asking a scientist to tell you what he knows now, it would be based on all of the accumulated information. But you could come back three months later and ask the same question, and the scientist, the physician-scientist, the clinician would say, “Well, we have some new information now and it has changed the way I think about it.” And because it’s not absolute and because it changes, people don’t necessarily understand that there’s always an element of uncertainty.

Dryden: And I guess, with the example of COVID, for instance, I mean, you oversaw a big national trial looking for therapies that might work. And as that was being undertaken, we didn’t have paxlovid, for instance. And now, if I test positive and call my doctor, my doctor’s going to offer me a therapy that didn’t exist when you were beginning those trials.

Powderly: Absolutely. That’s a really good example. But it’s also an example of the power of science. Because we didn’t have that armamentarium. We didn’t have the vaccines. We didn’t have antiviral drugs at the beginning. So we were basing, again, our assessments on trying to avoid infection through minimizing contact and then using drugs that we had, to see if they would work. But because of the scientific method and because of the investment we had made over the last 60, 70 years in science, we were able to rapidly accelerate the development of a vaccine and the development of effective therapeutic agents such as paxlovid. And of course, all of these things changed the question, because the question now is not that we don’t have an effective vaccine or an effective treatment. It is, “Will the virus evolve to get around these? And if it does, will we have alternatives?” So the science will evolve, just like the virus will evolve. The science will evolve to meet the needs of now.

Dryden: Dr. Fauci was here to talk to medical school graduates. From where you sit, what are the main difficulties these new doctors face in the current environment? An environment that, frankly, you didn’t enter when you were graduating from medical school because there weren’t things like social media.

Powderly: I think one of the things that Dr. Fauci said to the medical students was a critical one, and that is that as physician-scientists, as physicians who care about their patients and want to do the best for their patients, one of the things they have to be able to do is distinguish between truth and untruth, and be advocates for truth. And to counter untruth when they hear it, to do it in a way that’s reasonable, that isn’t confrontational, that doesn’t accuse patients or their families, but helps patients and their families understand what we know and what we don’t know. And where there is untruth, unpick that and try to explain what the truth actually is.

Fauci: Embrace science and beware of the insidious nature of anti-science. Over the past few years, you’ve been immersed in scientific courses and schooled in the scientific method of inquiry. As you well know, data and evidence leading to new insights are the stepping stones of science and enable progress in scientific and medical research. Unfortunately, however, during the COVID pandemic, significant anti-science forces accelerated in our society and became louder and more entrenched over time. During the past three years, we’ve witnessed an alarming increase in the mischaracterization, distortion and even vilification of solid evidence-based scientific findings. At the same time, conspiracy theories arose that became intermixed with these anti-science sentiments. The net result was that these dissonant information streams sowed public confusion and eroded trust in evidence-based public health principles.

Dryden: The solution, Fauci says, is to push back.

Fauci: Do not hesitate to push back on these destructive forces with civility, but also with all the strength you can muster. As physicians with insights into evidence-based medicine, do your best to listen to doubts and concerns, and in turn, communicate with plain language and compassion to your patients, to the media, and to anyone who will listen, and explain what is known and what is not known. An increasingly important and vital part of your career will be helping people to understand and to follow the best available science-based information.

Dryden: Fauci reiterated that sentiment to the St. Louis media.

Fauci: It appears — all you need to do is to go to social media — that the people who are spouting a distortion of truth appear to be really energetic about it. And the people who have the capability of spreading valid evidence-based information, as I say somewhat tongue-in-cheek, usually have a day job that they need to worry about. So what I encourage people in medical school or people beyond professional school or college is to don’t be shy about going out there and speaking and promoting the things that are evidence-based and truthful because you’ve got to counter it. You can’t give them an open field and surrender. I don’t demonize the people who demonize me. I always look to see, is there something there, some message that they have for me that I could actually learn from?

Dryden: Powderly and Fauci both were very involved in the response to the AIDS epidemic, which began nearly 40 years ago. And Powderly says, although modern social media has changed some things, there are similarities between the two events.

Powderly: When HIV first appeared, there were theories about HIV and where it came from that were completely false. And part of the discussion with patients, particularly when they were first diagnosed, and with their families who often were very surprised by the diagnosis, was to tell them the truth as we knew it, what the options were available, and to recognize in those early days that we didn’t have effective therapy, but that we would get there because we believed in the power of science answering these questions.

Dryden: I mean, you and Dr. Fauci were doing the same kind of work. What are some similarities and differences between the early days of the AIDS crisis and these early days of the COVID pandemic?

Powderly: It’s very true that patients and patient advocates in the early days of the AIDS epidemic did not trust the establishment. They did not think that the NIH or the FDA or the academic community cared enough about them that they would prioritize research and treatment. And they were very angry. What was different then from now is that you could sit down with people and have a dialogue, come to a middle ground. And one of the things that was, to me, most impressive about Tony Fauci’s leadership in those early days was his willingness to embrace the other side, to talk to people as to why they were objecting to the way the NIH was approaching the AIDS crisis, to listen to them and to actually modify some of the things, some of the ways we engaged with patients and patient advocates in those early days. And that was actually a model for what the NIH ultimately has done in other diseases. I think the challenge now is it is harder to find that middle ground, to have those discussions about what is reasonable and what is not reasonable. That, I think, is one of the problems that we need to solve as a society.

Dryden: And Fauci agreed.

Fauci: Comparing the pushback from the activist community during the HIV/AIDS outbreak to the divisiveness we have now is comparing apples and watermelons. It’s totally, totally different because the AIDS activists were trying to get the attention of federal authorities like myself, scientists and regulators like the FDA, to appreciate that the nature of that outbreak, and the way we were responding to it, was in a very rigid way. Rigid inclusion and exclusion criteria in clinical trials, rigidity in the approval process of drugs, where people had a disease where they were dying a few months after they became clinically, apparently ill. What they were doing was trying to gain our attention. Once they gained our attention, what they were saying made absolutely perfect sense. And we learned from them and we did a better job by listening to what they had to say.

Dryden: Am I wrong here, because I kind of think this applies to both sides, that there are people that believe that some things are settled, that may not be settled when it comes to COVID. Am I engaging in too much both-sides-ism?

Powderly: I think that’s a really astute observation because there are some things that I think the scientific community, the medical research community would accept as being, if not settled, no longer major questions. But there are other areas of significant uncertainty. I think one of the things that we all have to recognize — and this is very, very much the case in medicine across the board if you look at it — is that for many diseases, not just COVID, there are unanswered questions. There is uncertainty. It is arrogant on the side of scientists to assume that they have all the answers. I’m going to give you a little bit of history that I think puts this into perspective. When I was a medical student, the assumption was that peptic ulcers were caused by excess acid. And the most common treatment, definitive treatment, was a type of surgery that cut the nervous supply to the stomach so that acid wouldn’t be produced. And then in 1984, a young gastroenterologist from Australia discovered that peptic ulcers were caused by a bacterium. So for 30 years, the establishment in medicine was doing a surgery that turned out to be completely unnecessary. And I won’t say overnight, but within a couple of years, the definitive treatment for a peptic ulcer is now a six-week course of antibiotics. So we should never assume that we know everything because we’re going to be proven wrong. But equally, we have to be definitive about the things that we do know that have been shown to be effective and advocate for them for our patients.

Dryden: That’s pretty much what Dr. Fauci said to do when he addressed the new doctors who were graduating from Washington University School of Medicine.

Fauci: Nearly a century ago, Dr. Francis Peabody told medical students at Harvard, and I quote, “One of the essential qualities of the clinician is interest in humanity. For the secret of the care of the patient is in caring for the patient.” Simple words they are, but they are as true today as they were then. In our modern world of technology, a CT scan does not care for your patient. Robotics does not care for your patient. AI does not care for your patient. You and your humanity are the keys to optimal patient care. I have tried never to forget that and I urge you to do the same.

Dryden: Fauci and Powderly worked in tandem decades ago to help improve the understanding of HIV/AIDS and to test and develop treatments that eventually turned that once-deadly infection into more of a chronic illness. More recently, they were among the hundreds of physicians and scientists who were scrambling to understand and then to treat COVID-19. As that was going on, the recent graduates were trying to learn anatomy, working the clinic and figure out what area of medicine might work best as a future specialty. Now, as newly minted doctors, they’re going to actually care for patients themselves.

“Show Me the Science” is a production of WashU Medicine Marketing and Communications. The goal of this project is to introduce you to the groundbreaking research, lifesaving and just plain cool stuff being done by faculty, staff, and students at the school of medicine. If you’ve enjoyed what you’ve heard, please remember to subscribe and tell your friends. Thanks for tuning in. I’m Jim Dryden. Stay safe.