On Call: A Doctor's Journey in Public Service

by Anthony Fauci

“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. If you base your advice on the truth and on scientific evidence and do not sugarcoat anything, it is likely that sooner or later you will be telling the president or the vice president something they really don’t want to hear, something that may point out a problem with how their administration is handling an issue. Sometimes when advisers do that, their opinion is no longer sought. It’s a version of shooting the messenger. Some people might fall into the trap of never wanting to disappoint a powerful figure, and so they slant their advice toward pleasing rather than informing. Don’t fall into that trap.”

“If you’re consistent and totally honest, you might risk being dropped as an adviser, but this approach with the right kind of president or vice president can also engender respect and a durable relationship.”

I had a knack, possibly related to my years of schooling under the Jesuits, for “precision of thought and economy of expression,” for explaining complicated scientific and policy issues in a way that makes sense to nonscientists.

when indinavir was combined with the drugs AZT and 3TC, which targeted a different viral enzyme (reverse transcriptase), the results were truly stunning. The level of virus in the blood dropped dramatically to below the level of detection and remained down. This was accompanied by an equally dramatic improvement in the clinical condition of the patients. The results of the triple combination indinavir trial were presented publicly as a last-minute add-on (Late Breaker) session to the International AIDS Society meeting that took place in July 1996 in Vancouver, British Columbia, and later were published in The New England Journal of Medicine. Other publications reported equally dramatic results with combination therapies using protease inhibitors produced by other pharmaceutical companies. I can remember sitting in Hall C, room B1 of the Vancouver Convention Centre filled with thousands of people on July 11, 1996, when the data were presented. The room was buzzing. I knew what was coming because I’d already seen the data, and yet I still felt like screaming out “Yes!” The audience clearly felt the same way. They erupted in sustained applause as soon as the data were presented. It was a truly historic moment. A game changer if there ever was one. No sooner did the session end than I was grabbed by Christy Feig, the CNN producer assigned to the Vancouver meeting, who hurried me out of the convention center for an interview. We ran out to the pier jutting into beautiful Vancou...

It was astounding how quickly the triple combination antiretroviral drugs began to be used throughout the developed world and even in certain regions in the developing world. We immediately adopted that approach with our patients at the NIH, and the results took my and my colleagues’ breaths away. Patients who had been close to death walked out of the hospital sometimes within weeks of initiating the combination therapy, having gained back much of the weight that they had lost. When we saw them in follow-up clinic after several more months of therapy, many looked healthy again.

This phenomenon became known as the Lazarus effect, drawing on the biblical story of Jesus performing a miracle and bringing back Lazarus from the dead. It did feel like a miracle after our fifteen-year struggle with this deadly disease. Patients who had been preparing for death soon found that they now needed to plan their futures. Many were going back to work and resuming normal relationships. It was an extraordinary time.

We were now finally acting as healers as opposed to ministers to the dying. In addition, and importantly, over time we went from requiring more than twenty pills per day given over multiple doses to the first triple-drug combination, Atripla, a single pill administered once per day, which was approved by the FDA in 2006.

When Cliff Lane, Henry Masur, and I were taking care of patients with HIV in the early 1980s prior to the availability of AZT, the median survival of our patients was roughly nine to ten months from the time they were diagnosed. This meant that 50 percent of our patients would be dead within that time frame. By 2007, more than ten years after effective combination anti-HIV therapy became available, a modeling study in the United States and Canada found that if a twenty-year-old individual with HIV was put on combination antiretroviral therapy, that person could be expected to live into their early seventies, providing a life expectancy approaching that of the general population. Without a doubt, this represents one of the greatest achievements in medical research and implementation in the history of medicine.

This high-level suppression of the virus was ultimately shown to totally eliminate the possibility that a person with HIV would pass the infection on to an uninfected sexual partner.

On several occasions, most concentrated in 1993 through 1995, I was drawn into discussions and debates with denialists, some on national television and often to the confusion of TV viewers. On the one hand, Peter Duesberg, who was a member of the prestigious National Academy of Sciences, was saying that HIV did not cause AIDS and was a harmless virus. On the other hand, Dr. Tony Fauci, also a member of the National Academy of Sciences, was saying that HIV was the unequivocal cause of AIDS. Inadvertently, the press, by attempting to report on this in an unbiased manner, was giving these senseless claims false equivalency with the established scientific facts. But the claims of each side were not equivalent. One side was overwhelmingly incorrect and the argument never should have taken place. And every time we debated the denialists, we gave them public exposure, which only compounded the problem.

My nature has always been to remain calm under very difficult circumstances. I can get animated and annoyed over trivial things like getting caught in a traffic jam, yet, when important issues are at stake, I am totally focused and unemotional.

the more stressful and demanding the challenges, the better I functioned. The stakes were high; failing to rise to the occasion was definitely not an option.

“As a rich country,” he said, “we have a moral responsibility to not allow people to die from a preventable and treatable disease because of where they happened to have been born. For those to whom much is given, much is required.”

Nothing gets done in Washington without a lot of meetings, and over the next few months we had a full dose. A memorable one came in late August in the White House Situation Room. Several minutes into my presentation Robin Cleveland and another OMB official walked into the meeting. Without even having heard the first part of my presentation, Robin interrupted me and expressed skepticism about the entire concept in general and my proposal in particular. She questioned whether Peter Mugyenyi’s model would work, even though she had never heard the details of what the model actually was. Her attitude was really starting to irritate me. Gary immediately sensed this and intervened, defending my presentation and indicating that we would get back to her with more details about the Uganda model. I got it that Robin was doing her job employing due diligence as an OMB official. But it raised a red flag for me about the internal resistance that we might consistently meet as we moved forward

Diligence - There's a fine line between diligence and being an impediment to progress.

smallpox vaccinations were discontinued in 1972.

From one year to another there is usually a slight change in the circulating influenza virus caused mostly by mutations in the genetic makeup of the virus. This slight change is referred to as a drift. Because of exposures to influenza viruses over previous years as well as the protection afforded by vaccinations, most of the world has some degree of what is known as background immunity to influenza. This at least partially protects us from actual infection or from serious disease caused by the infection. This is the reason we do not have a global catastrophic outbreak of influenza every year.

In contrast, when an influenza virus emerges that is markedly different from previous years, the phenomenon is referred to as a shift in the virus. Because this very different virus is new to most people, there is little background protection against the novel strain. This can lead to a high rate of global infection and an increased level of suffering and death. Such outbreaks are referred to as pandemics.

Zika situation. The Fourth of July congressional break was coming up and still no movement on the supplemental bill. This was truly becoming a standoff between the Democrats and the Republicans. The Republicans next proposed a budget package that would take money from the Affordable Care Act and from the Ebola account and also contained a stipulation to defund Planned Parenthood. Only in Washington, D.C., would someone link defunding health insurance, disease prevention, and women’s health programs to pay to protect pregnant women from a disease that might severely damage their unborn babies. When the president’s staff mentioned this to him during our White House meeting, he just rolled his eyes.

Republicans proposed a bill that the Democrats rejected because it still contained three “poison pill” riders: the money could not be used for Planned Parenthood; the money would come out of the Affordable Care Act; and the bill would lift a ban against the Confederate flag at military veteran cemeteries. One could understand and agree or not on the ideology driving the first two riders. But tacking on permission to fly the Confederate flag at military veteran cemeteries to a spending bill aimed at preventing devastating disease in babies…Really?

There were a number of lessons to be learned from the Zika outbreak. One of the most important for me was how detrimental to an optimal response to an infectious disease outbreak partisan politics could be. I was certain that we would experience other infectious disease outbreaks in the future. I could only hope that the specter of partisan politics would not inevitably follow.

While many things in this White House were the same as they had always been, I also picked up on little things that indicated how differently this administration operated. Vice presidents are always publicly loyal to the president. That is part of the job. But, in my opinion, Vice President Pence sometimes overdid it. During task force meetings, he often said some version of “There are a lot of smart people around here, but we all know that the smartest person in the building is upstairs.” He was of course talking about the man sitting behind the Resolute Desk in the Oval Office.

When the coronavirus task force held teleconferences with the governors, most of the Republicans started out by saying, “Tell the president what a great job he is doing.”

I have always felt compelled to tell it like it is without being offensive. So, a couple of days after Messonnier’s bombshell conference call when I got a surprise phone call from the president at 10:35 p.m., I did not flatter him. What I did do during our twenty-minute conversation about COVID-19 was to lay out the facts. I encouraged him not to underplay the seriousness of the situation. “That almost always comes back to bite you, Mr. President,” I said. “If you are totally honest about what is happening with COVID, the country will respect you for it.” He was courteous to me, and as we hung up, I felt satisfied that he had heard what I said. The next day, however, he announced at a rally in C...

But even when I did not know the journalists the president insulted, I was still taken aback by his behavior. I was also concerned that my very presence at the lectern or sitting against the wall of the press room would be interpreted as acceptance on my part of his behavior.

I took no pleasure in contradicting the president of the United States. I have always had a great deal of respect for the Office of the President, and to publicly disagree with the president was unnerving at best and painful at worst. But it needed to be done. I realized I had a critical role to play, the person who showed up and told it like it was. And I not only had to tell the truth to the president; more important, I had to tell the truth to the American people; otherwise, I would compromise my own integrity and relinquish my responsibility to my patients—the American public.

Christian evangelicals were a key part of the president’s base, and Easter, which fell on April 12, became somewhat of an obsession with him. “We’ve got to get back to normal by Easter,” he implored Deb and me. I replied, “Mr. President, the virus doesn’t understand Easter. I’m sorry, sir.”

During all of this, the president often mixed his messages. I remember him telling me two weeks into the thirty-day period, in mid-April, “Anthony, we’ll listen to you and go with the full thirty days. I know it’s risky with the economy, but let’s do it.” I went home that night feeling satisfied that the president was on board with the full thirty-day plan. I was sitting in my favorite leather chair drinking an IPA beer, watching TV, when I saw a commentator note Trump’s tweets, “LIBERATE MINNESOTA!,” “LIBERATE MICHIGAN!,” and “LIBERATE VIRGINIA.” This shocked me. I turned to Christine and said, “What the hell is he doing?” In my experience, presidents typically listen to advice and do not make a decision on the spot, saying to the advisers around them that they are taking the recommendations under consideration. Only later do you learn what final decision they made. Not so with Donald Trump. At least not always. He often made up his mind as to what he was going to do while I, and others, were sitting right in front of him. But there was a parade of people in and out of the Oval Office, and after we left, the next person to meet or speak on the phone with him might well say something that changed his thinking. I believe that was how President Trump went from agreeing to abide by the thirty-day plan to “liberating” certain states.

When the president made it clear he chose not to wear a mask, the whole issue of masks swiftly became politically charged: those who did not wear one were seen as supporting the president and rejecting the limitations the pandemic was placing on Americans’ personal freedoms. He was not basing his decision on public health, or on the nature of COVID, or on our responsibilities to each other to remain healthy. To his followers, those who did wear them were seen as thwarting the president and willingly surrendering their liberty. The battle was joined everywhere, from supermarket aisles, bars, and political rallies to the highest levels of government. We clearly had a dual problem. It was a public health problem because we were in a public health crisis and masks helped to contain the spread of the virus and saved lives. It was also a messaging problem. I remember thinking to myself how easy it would be to get the country to voluntarily wear masks if they saw the president of the United States wearing one and how this would be the most powerful message about masks that we could give the country.

As for the lab leak hypothesis, the most commonly discussed scenario is that Chinese scientists were working on viruses from the wild that accidentally infected one of them and then spread outside the lab to cause the COVID pandemic. We in the United States cannot account for all the research that takes place in Wuhan or in the rest of China. That is why, as I have often stated publicly, we must keep an open mind to the origin of COVID, as I do. Keeping an open mind about both possibilities does not mean that one cannot have an opinion. Possibility does not necessarily mean equal probability. Although U.S. intelligence agencies are not uniform in their opinion about COVID’s origin, the majority favor a natural occurrence. Importantly, experienced evolutionary virologists throughout the world, while acknowledging the lack of definitive proof, have published in the peer-reviewed scientific literature their belief, based on geospatial information from the Huanan wet market in Wuhan as well as on epidemiological and virological data, that the virus emerged as a natural spillover from infected animals brought illegally into the market.

I think it’s safe to assume that the people who were lying about me and those who believed the lies for the most part were among the people who believed that the 2020 presidential election was stolen and that the January 6 attack on the Capitol either was justified or was a harmless demonstration. It was sinking in for me that although I was being attacked directly, this normalization and ready acceptance of lies and the prevalence of belief in conspiracy theories in a broader sense were part of an assault on our very democracy, and I was considerably more worried about the country than about myself.

timpano, is a showstopper. It is a combination of ziti, mozzarella, ricotta cheese, sweet Italian sausage, garlic, and marinara sauce all encased in dough—en croûte—in a deep pot to resemble a drum,

The country was divided about masking, and during the first year the messages from the top were quite confusing. Political leaders disagreed on social restrictions and on vaccines, interventions that were clearly shown to save millions of lives. Unfortunately, the acceptance of public health measures such as vaccinations was highly politicized as exemplified by the fact that there were fewer vaccinations and more hospitalizations and deaths in states that are predominantly Republican versus states that are predominantly Democratic. Furthermore, our overall uptake of vaccines was less than most developed nations and even less than some low- and middle-income countries. That should never have happened and likely would not have happened had the right tone been set by the highest levels of government for the promotion of proper public health principles and practices right from the start of the outbreak.

All these weaknesses in our public health response to COVID were profoundly compounded by one of the true enemies of public health: the spread of egregious misinformation and disinformation enabled by the internet and social media that unfortunately remains with us today.

When you delay implementing a decision that you have already made, nothing good ever happens.

My diagnosis was well covered by the mainstream media, and I was also the butt of a couple of late-night comedians’ jokes. I had to laugh at Trevor Noah’s comment: “Dr. Fauci has COVID, which feels a little like finding out Smokey the Bear got trapped in a forest fire.”

my story is about what it means to devote one’s life to public service. It has not always been an easy life. It comes with long hours, missing out on personal and family time, an enormous burden of responsibility, and considerable anxiety and stress and, at times, opposition and even hostility. It often requires putting aside personal fears to fulfill one’s mandate, and it demands rising to occasions that others might choose to avoid. But it can be a deeply purposeful and rewarding experience, one that centers on taking care of people and working toward the common good.

But it is one thing to go on TV and deliver public health messages to millions of people where I need only to look into a camera and my impact can be felt. It is an entirely different feeling to walk down the street or into a restaurant or the post office and have most people know who I am. It is this complete loss of privacy for someone who is fundamentally a private person that can be unnerving. This is one of the many ways that COVID has affected me and my family.

At times, I am deeply disturbed about the state of our society. But it is not so much about an impending public health disaster. It is about the crisis of truth in my country and to some extent throughout the world, which has the potential to make these disasters so much worse. We are living in an era in which information that is patently untrue gets repeated enough times that it becomes part of our everyday dialogue and starts to sound true and in a time in which lies are normalized and people invent their own set of facts. We have seen complete fabrications become some people’s accepted reality.

This is not a new paradigm. Propaganda—turning words and ideas into weapons—no doubt started thousands of years ago, and we have seen it used to devastating effect many times within the life span of this country as well as over the course of world history. We have seen how easy it is to undermine the foundations of our democracy and of the social order. What is new is the dizzying pace at which information gets disseminated and amplified on the internet and through social media, disorienting and dividing us as a nation.

the diversity in our country in its myriad forms—geographic, economic, cultural, racial, ethnic, and political—makes us an attractive and great country. It is when this diversity gives way to divisiveness that society suffers. I have always been a cautious optimist, and I hope that the better angels in all of us, who tell us that we are more alike than different, will prevail and lead to a spirit of civility and respect for each other.