Infection
Fauci’s replacement is the person America’s STI crisis needs
The National Institutes of Health announced Wednesday that Jeanne Marrazzo, a leading researcher of sexually transmitted infections (STIs), will replace Anthony Fauci as head of the National Institute of Allergy and Infectious Diseases (NIAID), raising the possibility of a meaningful response to recent crisis-level STI transmission trends in the US.
Marrazzo’s career has been devoted to finding new ways to test for, prevent, and treat infections spread through sex. And her appointment comes as sexually transmitted infection rates — especially syphilis and gonorrhea — are screeching upward at an alarming pace, while funding to address them is being slashed at the federal level following contentious debt limit deal negotiations. Her appointment has led to a rare moment of hope, and even jubilation, among experts in the field.
“For STIs, we need better therapeutics, vaccines, and point-of-care diagnostics,” said David Harvey, director of the National Coalition of STD Directors. “These are all things that Dr. Marrazzo happens to be an absolute expert at, and we’re very excited and hopeful that more resources will be put into these priorities.”
Although Marrazzo’s new role will give her a lot of power over the scientific community’s research priorities, it will also require her to tangle with political decision-makers who’ve often been overtly hostile to science. But even here there’s a sense that her forthright and sensitive communication style will be a strength, given her track record as a public commentator on a range of public health issues.
As the head of NIAID, Marrazzo will lead decisions on which scientific priorities deserve backing from the agency’s multi-billion dollar budget — and will be responsible for convincing Congress she’s made the right choices. And if Fauci’s precedent stands, she may also play an important role helping the public navigate confusing moments in public health (and I’m sorry to say this, the next pandemic).
Marrazzo brings lots of skills to this job, and she’s going to need all of them
Since she led her first NIH-funded research project on chlamydia testing in 1997, Marrazzo’s career has focused on preventing, diagnosing, and treating conditions of the female reproductive tract.
Some of her most influential work has been in the area of STI prevention in women: She led an important 2015 study among African women that showed how strongly stigma could interfere with HIV prevention efforts. Marrazzo has also conducted a lot of research on gonorrhea and a non-sexually transmitted but extremely common condition, bacterial vaginosis.
Her background in STIs is particularly well-suited to this moment in public health. The Centers for Disease Control and Prevention reports that over the five years between 2017 and 2021, the US has seen a 28 percent increase in gonorrhea, which is fast becoming an antimicrobial-resistant infection. Meanwhile, syphilis rates have increased by 75 percent, many of them among women. The shift has led to a threefold increase in congenital syphilis cases, which can portend death among newborns.
Meanwhile, STI funding has dropped 40 percent since 2003, and capacity to combat surging infections decreased further when the CDC was forced to slash STI contact tracing funding by $400 million after funding cuts were written into the latest budget.
Marrazzo is an out lesbian, and as a researcher, educator, and speaker, she has advocated tirelessly for LGBTQ health equity. In a statement, HIV prevention advocacy organization Prep4All said, “At a time where infectious disease threats are on the rise globally and preventive and sexual health has come under attack for women and LGBTQ communities around the world, Dr. Marrazzo’s demonstrated commitment to addressing HIV and STIs in marginalized populations will be of enormous value in ensuring that the research needs of vulnerable communities are met.”
She is also, and critically, a respected health communicator. Currently the director of the infectious diseases division at the University of Alabama at Birmingham, she was a fixture of local and national news outlets during the Covid-19 pandemic, and became known for her unshakeable and forthright demeanor.
All of that will serve her well as the director of an often embattled government agency, said Harvey. NIAID frequently faced heated criticism from many directions during Fauci’s tenure, beginning with ACT UP’s antagonism over the agency’s slow response to the HIV/AIDS epidemic, and ending with GOP criticism of Fauci’s legitimacy and calls to eliminate the agency altogether in the wake of its Covid-19 response.
Although he expects she will face some tough questions from Congress, “she is a force to reckon with in her own right,” he said, and “one of the best communicators I’ve ever seen. In this area, she is like Fauci — she can take complex clinical issues and translate them for a lay audience, as we saw her do day after day in Covid.”
Marrazzo will need all of those skills in the role to respond to tough congressional inquiry and combat misinformation, said Carlos del Rio, president of the Infectious Diseases Society of America, the professional society that represents scientists and clinicians working in the infectious diseases field.
“When Rand Paul says we need to break up the institute into three institutes, we need to decrease your budget,” del Rio said, “the NIAID director has a very important role.” Whether the country is in the middle of a pandemic or merely between emergencies, it will be up to Marrazzo to help Congress understand why the NIH and NIAID budget are important.
Experts have high hopes for Marrazzo, but remember: She doesn’t run Congress
As the director of NIAID, one of Marrazzo’s most important jobs will be to oversee the $6.3 billion in funding the agency grants to scientists for research that answers important questions related to allergy, immunology, and infectious diseases. The NIH is the leading funder of scientific research not only in the US, but worldwide — so in that sense, she’ll help set and support the world’s research agenda for as long as she’s in the job.
Among the most important public health crises for Marrazzo to address in that role, “antimicrobial resistance is a huge one,” said del Rio. He’d also like to see Marrazzo prioritize continued work on HIV — especially finding an HIV vaccine, something Fauci had strived to achieve but ultimately did not while in the role — and that she will lean into climate change’s role in fueling changes in infectious diseases.
There’s also a lot of hope that, because Marrazzo’s already so familiar with the biggest challenges to pushing back the tide of STIs, she’ll be able to accelerate progress on the key elements of a coordinated response to the crisis.
For example, Harvey would love to see Marrazzo’s leadership help speed the development of STI tests that give immediate results. That kind of progress would reduce the number of infected people who go untreated because they don’t come back to a clinic when their test turns positive after a couple of days, he said.
He’s also excited about the possibility her appointment could lead to alternative treatments for syphilis — we’re still currently relying on penicillin, the standard of care since the 1940s that’s currently in short supply in the US. And he’s hopeful she will prioritize the development of new vaccines against a range of STIs.
“If we can make progress on better, faster diagnostics, a new class of therapeutic drugs, and vaccines, this will bring us a long way to lowering STI rates in America. No one understands this better than Dr. Marrazzo,” said Harvey.
Although Marrazzo will have a lot of say over biomedical research priorities in the coming years, she doesn’t control the US Congress — and that may limit what the agency is able to accomplish under her leadership. The US Congress controls NIAID’s purse strings.
She’ll likely face difficult questions from the legislative body about the agency’s goals at points throughout her tenure in the role, and it will be challenging to make headway in a deeply polarized climate.
“I have doubts about her ability to do something in the current poisoned political environment against NIAID in the post-Covid era,” said del Rio. However, he said, it’s important that she try to minimize the harm of politicians’ attempts to demonize the agency.
“That, to me, is a huge job. And not an easy job, either,” said del Rio.
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