Wednesday, July 17, 2024

Anthony Fauci’s Side of the Story

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Some fifty pages into his autobiography, “On Call: A Doctor’s Journey in Public Service” (Viking), Anthony Fauci, the former head of the National Institute of Allergy and Infectious Diseases (NIAID), describes a moment of horror when he and his colleagues realize that the scale of the epidemic they are dealing with is far greater than previously supposed: “Thousands and thousands of people had been getting infected before we knew that the disease existed, and they were passing the infections on to others long before they showed symptoms of the disease itself.” Later, as the government response—of which he is the “public face”—comes under fire, Fauci will be called a murderer.

The year is 1985, and a blood test for H.I.V. has recently become available. By the end of the year, it will be evident that, for each of the nearly sixteen thousand people in the United States suffering from AIDS, more than seven others are infected but asymptomatic.

Even if the COVID-19 pandemic had not occurred, Fauci’s career would still have been one of the most consequential and most prominent in American medicine in the past fifty years. But it was the pandemic that made him, as he writes, “a political lightning rod—a figure who represents hope to so many and evil to some.” Long renowned as a clinician, a researcher, and a public servant—George W. Bush awarded him the Presidential Medal of Freedom in 2008—he became demonized as a liar who hid evidence about the SARS-CoV-2 virus, funded dangerous laboratory studies, misled Congress, and was responsible for countless unnecessary deaths. So it is telling that his memoir is less dominated by recent events than one might expect. Although most readers will surely first turn to the part that relates Fauci’s dealings with the Trump Administration, the forty-fifth President is only one of six whom we meet in person, and AIDS gets more pages than COVID.

The book thus presents an implicit demand for us to see Fauci’s career whole, from medical training to retirement. When, at the start of this month, he was questioned by the House Select Subcommittee on the Coronavirus Pandemic, the Republican firebrand Marjorie Taylor Greene insisted upon addressing him as Mr. Fauci, rather than Dr. Fauci. “Because you’re not ‘Doctor,’ you’re ‘Mister’ Fauci,” she said. “That man does not deserve to have a license. As a matter of fact, it should be revoked, and he belongs in prison.” Against this absurd charge, “On Call” maintains that Anthony Fauci is a doctor first and foremost.

The book is also something of a diptych. The resonances between the two greatest public-health crises of Fauci’s tenure at NIAID are impossible to ignore. Both cases involve asymptomatic infection, a scramble for tests and treatments, public-information campaigns, and the search for a vaccine—miraculously fast for COVID-19, still unfulfilled for H.I.V. And, each time, he is vilified—first by militant AIDS activists, later by anti-vaxxers and anti-maskers, populist Republicans and libertarians, and a panoply of conspiracy theorists. But the differences are as revealing as the similarities, in ways that, by the end of the book, test even Fauci’s resistance to pessimism.

The title “On Call” suggests that medicine is not merely a job but a calling, and Fauci traces the roots of this sensibility back to his childhood in Brooklyn. His parents were first-generation Italian Americans, both college-educated. His father worked as a pharmacist, and the Faucis—a close-knit family, proud of their heritage—lived above his pharmacy. Dedication to caring for others was exemplified by Fauci’s father. “Dad was generous to a fault when it came to accommodating customers who could not afford to pay their pharmacy bills,” he writes. “He kept a running account for them, much to the frustration of the whole family.”

Fauci was educated in Catholic schools, initially by Dominican nuns who demanded achievement and graded students down to a tenth of a point. At Regis, an élite Jesuit high school in Manhattan, he immersed himself in Greek and Latin. Regis’s motto is “Men for Others,” making personal gain secondary to public service, and Fauci notes the school’s spirit as a “natural extension” of that of his upbringing. He went on to a Jesuit college, Holy Cross, in Worcester, Massachusetts, and then to medical school at Cornell, where he graduated first in his class.

Fauci joined the National Institutes of Health in 1968, rising through its ranks as an infectious-disease specialist and immunologist. He cared for patients with rare autoimmune disorders, and discovered that low doses of chemotherapy and steroids could be life-saving, because they blunted these patients’ aberrant inflammatory responses. It was serendipitously perfect preparation for studying H.I.V.—so much so that Fauci describes feeling “the illusion of fate” when the disease’s first victims, mostly young gay men, began arriving at the N.I.H. Clinical Center. “I was trained for years as an immunologist and an infectious disease specialist,” he writes. “Here was a disease that certainly was infectious. It also was destroying the immune system and rendering the patients highly susceptible to opportunistic infections.”

Fauci redirected his efforts from inflammatory diseases to H.I.V. At first, there was no medication to block the virus, and half the admitted patients died of infections or cancer within nine to ten months. During the early years of the epidemic, I crossed paths with Fauci at various scientific conferences; at my hospital, at Harvard, I had been enlisted as an oncologist to care for AIDS patients with malignancies, specifically Kaposi’s sarcoma and lymphoma. Fauci became a frequent target of gay activists, who saw that the government was failing them. Larry Kramer, in the San Francisco Examiner, wrote a piece headed “i call you murderers: An open letter to an incompetent idiot, Dr. Anthony Fauci.” He accused Fauci of facilitating the deaths of hundreds, if not thousands, of people with H.I.V. “His rationale for the attack was that I had not demanded enough money for AIDS,” Fauci writes. “He ignored the fact that I had requested from Congress and the president the largest increase in resources given to an NIH institute since the famous ‘war on cancer’ in the 1970s.”

The first major advance in the treatment of aids was AZT, a drug that had originally been tested as a chemotherapy agent. Although AZT was not effective against tumors, laboratory results showed it to be a potent inhibitor of H.I.V. I was among several physicians who participated in the pivotal clinical trial of AZT for the treatment of AIDS patients. Fauci presents these results succinctly: “Over a twenty-four-week period in 1986, 145 individuals with HIV received AZT, and 137 received the placebo. At the end of the study, 19 patients who received the placebo had died compared with only 1 death in the group that received AZT. Opportunistic infections, such as Pneumocystis pneumonia, developed in 45 subjects receiving the placebo, compared with 24 subjects receiving AZT.”

The drug was clearly a turning point, and not long after the publication of these results, in a New England Journal of Medicine article that I co-authored, I joined colleagues on a panel presenting the results of the clinical trial to physicians, nurses, and other caregivers. During the discussion, a group from ACT UP barged into the meeting room. I vividly recall how they yelled that AZT was poison and handed out Kool-Aid to the attendees, a reference to the deaths of Jim Jones’s cult followers. They turned to the physicians on the panel, calling us Nazis. This stung; many members of my mother’s extended family were murdered in Auschwitz. Having worked to care for people with AIDS, and having participated in a clinical trial that proved for the first time that a drug could combat the virus, I was indignant at the group’s slander.

But this is where one distinctive facet of Fauci’s mentality reveals itself. Although he writes that he was hurt to be called a murderer by Kramer, he goes on to say, “Yet, in a strange way, I still did not blame Larry. If I had been in his position, I would have been just as angry.” When activists protested at the N.I.H., demanding the development of better drugs than AZT, Fauci made a key decision, bringing a handful of the demonstrators inside to meet with him. “They were shocked,” he recalls. “This was the first time in anyone’s memory that a government official had invited them to sit down and talk on equal terms and on government turf.” Fauci was able to clarify what drug development involved, while the activists, as he writes, “played an increasingly important role in shaping my thinking and policy in these areas.” This culminated in an innovative “parallel track” of drug testing that expanded the availability of experimental treatments for AIDS beyond the rigid confines of clinical trials.

Ultimately, Fauci’s vision of convincing activists of a shared goal was realized, and even Larry Kramer forged a bond with him. Shortly before Kramer died, in May, 2020, he had one last phone conversation with Fauci, which ended with Kramer saying, “I love you, Tony.” Fauci writes, “I tearfully responded, ‘I love you too, Larry.’ A complex relationship, indeed.”

Fauci’s commitment to his work on AIDS was such that when, in 1984, he was offered the directorship of NIAID, a purely administrative role, he insisted on being allowed to continue doing research and treating patients. He writes of a piece of advice a mentor gave him as his influence increased: “It’s a good rule when you are walking into the West Wing of the White House to advise the president, vice president, or the White House staff to remind yourself that this might be the last time you will walk through that door.” In other words, sooner or later there would likely be a choice between sugarcoating unwelcome news and losing influence, so one should mentally prepare to do the right thing.

Fauci was neither naïve nor cynical about the ways of Washington. He understood that politicians were obliged to grandstand for the press and the public, and that even allies could occasionally make trouble. During a hearing in 1988, Senator Ted Kennedy selectively quoted him in a way that implied that a dinner invitation from Vice-President George H. W. Bush had made him soft-pedal his demands for more AIDS funding. Fauci writes, “At the end of the hearing Senator Kennedy called me over, put his arm around my shoulder, and said warmly, ‘Sorry I had to do that, Tony, it was nothing personal, but I just have to keep the pressure on. Anyway, keep up your great work.’ ”

Fauci was known for being apolitical and having friends on both sides of the aisle. This, along with his reputation for integrity, bore fruit in both Republican and Democratic Administrations. He writes with affection about Bush, Sr., who offered him the N.I.H. directorship—a position he turned down, as it would have required him to give up hands-on medical care. He worked with Bill Clinton on creating a center devoted in part to H.I.V.-vaccine research, with George W. Bush on providing life-saving medication to people with the disease in the developing world, and with Barack Obama on combatting outbreaks of Zika and Ebola.

And so to Donald Trump. Seeing Fauci’s expressionless face during the President’s pandemic press conferences, I often wondered what he was thinking. Once, while listening to Trump, Fauci moved his hand to his forehead in disbelief. That seemed to answer my question.

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