A year ago last week, Jeanne Marrazzo stepped into a very big pair of shoes.
Marrazzo became the first new director of the National Institute of Allergy and Infectious Diseases in decades, taking over a job held for 38 years by Anthony Fauci, whose long-term status as a science god in Washington gave way to Covid-19 fall guy in some quarters during and after the pandemic.
The months since have been a whirlwind for Marrazzo, a veteran researcher in the field of sexually transmitted infections — especially their effect on women. She has been climbing a steep learning curve, getting to know the research institute she now leads. Lots of time has been spent repairing relations between the NIAID and the lawmakers who sign off on its $6.6 billion annual budget.
In that time Marrazzo, who pronounces her first name as “Jeannie,” has mainly opted to stay out of the limelight.
Last week, though, Marrazzo sat for an interview with STAT to discuss all kinds of issues, including the U.S. outbreak of H5N1 bird flu in cows — and maybe in health workers in Missouri — as well as the mpox outbreaks in Africa and her hopes for NIAID. (The interview took place the day before Rwanda announced it was dealing with its first Marburg outbreak, so there was no discussion of that highly concerning situation.)
The transcript below has been lightly edited for length and clarity.
It feels like you haven’t done a ton of one-on-one interviews since taking the job. Am I wrong about that?
I haven’t done a ton, for sure. I’m happy to talk about things we do. I’m happy to talk about things that are in the news like H5N1. But part of that, I think, is that a lot of what people have wanted to and needed to hear has been from CDC, or from some of our funded investigators. And frankly, I am and have always been — as I like to describe myself — I am media friendly but not media hungry.
I needed to get my feet on the ground. I needed to get my head around what this job is about, and especially in the post-Fauci era, what the job is about. And I really needed to focus on what was most helpful for us as an institute and what’s most helpful in terms of communicating the science.
I think I was told: She doesn’t want to do interviews comparing herself to Fauci.
But that inevitably comes up.
You’ve inherited a very important research institute that was run by somebody who was adored on both sides of the aisle for a very long time — until he wasn’t. I do wonder what kinds of challenges that creates for you.
Part of the job that I think people don’t appreciate and I think Tony did so well is what I call scientific diplomacy. I felt my first responsibility was to really take a look at some of the relationships that had been really ruptured during the pandemic.
Remember, when I walked in last year, a week before the end of the fiscal year, at that point the budget proposed by the House was cutting the NIAID budget by 23.9%. We were the only NIH institute [being cut]. That is what I walked into. And that was a result of the majority really feeling like they did not believe that that much should be in the control of one institute.
That was an urgency, if not an emergency. I had all these people reaching out and saying, ‘Well, what are you guys going to do? This is really bad.’ Not surprisingly, we’re the bread and butter for most [infectious diseases researchers] in terms of funding.
So I would say a lot of those first several months were working with our legislative staff, trying to get to know people on the relevant committees, trying to create relationships. Offering to come to talk to people about all the incredible stuff we do that just doesn’t make it to the front page.
It was the kind of work you have to do to have those relationships on both sides of the aisle. And I guess my modest measure of success in that regard is that this year the House budget proposed a flat budget for us — although the House did propose to split us up into two institutes, the Institute of Infectious Diseases and the Institute of Immunology, each getting the same amount.
I guess the other thing I would say is I spent the last seven years, including the pandemic, in a deeply red state.
I would say it’s a restart, but that’s a disservice to Tony. I don’t think things needed to be restarted. I just think that we need to be humble about the way we talk to people about science. We need to not admonish people for not doing what we want them to do and, unfortunately, I think that happened during the pandemic.
In my business, people were really used to an NIAID director who was very available. And when a press release went out about newly published NIAID-funded research, the person offered for interviews was often Dr. Fauci. And now it is generally one of the scientists who did the research.
That was purposeful. That was not escapism. I think the people who do the science and are super communicators should get the publicity and the credit.
Can we talk about H5N1 and Missouri? What are you seeing there?
I am concerned.
There has been an effort to be really cautious. The CDC’s kept their assessment of the situation fairly constant since it’s come out.
To acknowledge the obvious, we are in a hangover period from Covid. There is not a lot of willingness on the part of anybody to be thinking about anything that would bring us back to something like that.
Can I make a quick digression? We recently had a long Covid [research] meeting where we had about 200 people, in person. And we can’t mandate mask-wearing, because it’s federal property. But there was a fair amount of disturbance that we couldn’t, and people weren’t wearing masks, and one person accused us of committing a microaggression by not wearing masks.
And I take that very seriously. But I thought to myself, it’s more that people just want to live a normal life. We really don’t want to go back. It was so painful. We’re still all traumatized. Let’s be honest about that. None of us are over that.
So there’s not a lot of appetite for raising an alarm, especially if it could be perceived subsequently as a false alarm.
Would we like more information about what’s going on in Missouri? Absolutely. There are these wisps of a hint of a potential — and I say all those words because I don’t want to be alarmist — of person-to-person spread. In the absence of further information, you just can’t help but worry, knowing that we are seeing in animal models that there is transmissibility of this H5N1 through the respiratory route, which we would totally expect from this virus.
I think the other thing I worry about is that CDC has this sentinel surveillance for influenza-like illness, which is very non-specific, and I am very concerned if we start to see spread of this, we are going to see it in people who are immunocompromised like this person, who had structural lung disease is my understanding. That’s a group that is vulnerable to getting infected with a lot of things. And I worry there’s going to be delayed diagnosis and delayed detection. In other words, they may not show up in your regular surveillance systems where you’re looking in ERs.
And I think this virus, you’ve just got to respect it.
One of the other things I wanted to ask you about is mpox. In particular, do you think this new clade Ib outbreak is stoppable? It feels like these viruses found the HOV lane by getting into sexual networks.
I don’t think you can put it back into the box. When you’ve got planes, or people having sex or human contact, and when you have people breathing, the genie’s out of the bottle.
I think it’s probably going to be a matter of time before we see cases of clade Ib in other countries and I think the hope is that we can at least get a handle on what’s going on in the worst affected areas. The problem is, I don’t even think we know what the magnitude of the problem is there, because some of those places are so remote.
I do think it’s a very high alert situation. I think the fact that we have delivered now over half a million vaccine doses — that is really important. But we need more vaccines. We need to study vaccines in adolescents and children. And we need to understand durability [of vaccine protection].
At this point I think the emergency just sort of trumps everything and we need to get vaccine in there. And if we can just sort of blunt the pace of the outbreak, we can take a step back and say: OK, how can we really figure out what the next phase of control can be?
Do you think at this point the world will ever get an HIV vaccine? Scientific challenges aside, because of the existence of effective pre-exposure prophylaxis (PrEP), you can’t do placebo-controlled trials. How likely is it that an HIV vaccine will get over the finish line, even if people figure out how to make one?
In terms of figuring out how to do it, there have been about four amazing papers out, largely from Scripps Research Institute and Duke University, in the last year. And I think the field is getting really exciting in terms of understanding and training the body’s ability to elicit broadly neutralizing antibodies. I don’t know if it’s going to be two years, three years, five years, but I do feel like there are some incipient breakthroughs. So I don’t think it’s time to give up.
The real question, I think, is why should we focus on vaccines at all and continue to invest in this thing when we have now lenacapavir, which is pretty perfect over the course of a six-month injection?
What worries me is if we don’t have durable individual immunity, which I think you only get from a vaccine. And by durable I mean you do not have to have an encounter with a health care system every six months. So I still think that a vaccine is the Holy Grail. I do. Also, women in particular don’t take oral PrEP, especially in sub-Saharan Africa. Yes, PrEP works. But if you don’t take it, it don’t work.
Frankly, I think if we could get data showing that women could use event-driven PrEP, oral PrEP, like men do around sex, then I think it would probably work well. Take two pills before and then take two pills after. But event-driven PrEP was frankly designed for men’s sexual pleasure. They could have safe sex whenever they wanted. It is very different for women. When you think about the expectations around sexual pleasure, sexual behavior, sexual frequency, and the purpose of having sex, which is often to get pregnant, I think that you can say we have effective PrEP, but we don’t have efficacious PrEP for women. It’s biomedically effective, but it is not hitting it out of the park. It’s not even getting a single.
I saw you quoted talking about having a strategic vision for NIAID. Can we talk about that? Where do you want to take the institute?
We’re working on a new refresh of our strategic plan. We haven’t had one since 2017; I think it got derailed by the pandemic. We really want a living document that’s going to be refreshed annually, and we’ll have individual pages that will talk about specific topics. So, what are the metrics for mpox, say? What are the metrics for H5N1 or highly pathogenic avian influenza?
If I were going to be here for five years — I hope I’m here a lot longer — I would love to see the promise of the malaria interventions realized. The monoclonal antibodies and the new vaccine, which was actually studied in women who intended to get pregnant, actually reduced malaria. The fact that they included these women in the study is such a signal achievement to me.
I think if I could see some sort of comprehensive strategy to use the monoclonals, use the vaccine, think about specific allocation seasonally, age-wise, around pregnancy, you could make a huge dent. And showing that could create a path for serious control of malaria in the worst areas.
I’m encouraged about tuberculosis. There’s still work to do, but the Gates Foundation-funded study of the experimental vaccine M72 will be very interesting. Hopefully we’ll make some inroads there.
And we’ll see what happens with HIV. I don’t think we’re going to end it by 2030. I wish I could 100% buy into that idea. But I think we can aim for some incredible game-changing interventions by 2030.