On Call: A Doctor's Journey in Public Service

by Anthony Fauci

Influenza vaccines typically have between 40 and 60 percent effectiveness at best in any given flu season. Often, it is much less. The fact that they were projecting at least 90 percent effectiveness for the COVID vaccine was astonishing.

We walked to and from school every day unaccompanied by an adult, even at six or seven years old. The neighborhood was so close-knit and protective that this walk alone by children through several city blocks was considered entirely safe.

there were always a few people sitting or standing in front looking out for children like us going and coming from school.

drugs at much lower doses than those used to wipe out cancers, but high enough doses to suppress the out-of-control inflammatory and immunological responses that were harming the patients whom I was personally taking care of.

the preliminary results were striking, resulting in a 93 percent remission rate.

First, this type of pneumonia was usually seen only in individuals whose immune system was significantly compromised, as was the case with people who were receiving chemotherapy for various forms of cancer.

could no longer pass this off as a curiosity. I had not yet searched the literature, but this had to be a brand-new disease. I could not believe that all of these men had taken some toxic drug that had destroyed their immune systems. It was acting as if it had to be an infectious agent.

I could easily spot several young men with AIDS as I passed by them. The telltale dark spots on their faces due to Kaposi’s sarcoma, what people used to refer to as gay cancer, easily identified them. The drawn faces and appearance of physical wasting were now all too typical.

In those hospitals, 20 to 40 percent of the beds were occupied with AIDS patients.

I rejected the concept held by many that I was paying too much attention to a disease that had afflicted only a few thousand people in the United States and that many still thought would probably disappear in a year or two.

the drug azidothymidine, or AZT, had potent suppressive activity against HIV in the test tube.

One of the characteristics of RNA viruses, particularly those such as HIV that replicate very rapidly, is that they make mistakes in copying themselves during the replicative process. These mistakes, known as mutations, may impart various characteristics to the virus. One characteristic can be resistance to an agent meant to kill the virus, such as an antiviral drug.

During the course of therapy, AZT was killing those HIV viruses that were sensitive to its killing effects, but not those viruses that had mutated to become resistant to the drug.

The problem was that when it was administered alone, the virus almost inevitably outsmarted the drug as a result of its uncanny ...

When a person is treated with two or more drugs that individually are effective, the virus finds itself “boxed in” and ultimately suppressed, so long as the patient continuously takes the combination of drugs.

Meanwhile drug side effects often took their toll. In some respects, this was similar to the toxicity that cancer patients experience with chemotherapy aimed at destroying their cancer.

What was fascinating to Peter and those of us closely following the evolution of the AIDS epidemic was that many of these patients with an African connection were heterosexual. They had a disease identical to what we were seeing among gay men.

At about the same time Piot was noticing these cases in Belgium, the CDC reported in 1982 that a disproportionate number of Haitians in the United States, many of whom were heterosexual, were being diagnosed with AIDS.

this time highly effective AIDS drugs were available and had transformed the lives of people with HIV. I did not see anyone with the telltale Kaposi’s sarcoma lesions on their faces or the hollow looks that stared back at me as in 1985. We had come a very long way since then,

True, his politics were conservative. But what was most apparent to me was his kindness and empathy to the suffering of others.

The era of highly effective and lifesaving anti-HIV treatment had begun. AIDS was no longer an inevitable death sentence.

This would have the dual effect of preventing them from getting ill while also suppressing the level of virus in their body to levels undetectable by standard tests. 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.

especially in sub-Saharan Africa, were dying purely because they did not have access to these lifesaving drugs.

I was told that, in addition to HIV and tuberculosis, the majority of the people in the wards, especially the children, had malaria. Now that it was 2001, the blood supply was being screened for HIV. I could only imagine how many children had been infected with HIV just a few years earlier, before the transfusions that were given for malaria were screened. I am still haunted by the faces of the patients on the ward. Blank stares and silence. No one made a sound, not even the sickest of them.

mother-to-child transmission of HIV. A study published in 1999 indicated that a single dose of a drug called nevirapine administered during labor and delivery together with a single dose of the drug to the baby within seventy-two hours of birth substantially reduced the risk of HIV transmission from mother to infant.

The pandemic of 1918 is thought to have originated from a bird influenza that jumped species to humans.

We started to notice a growing number of reported H1N1 infections. This was much earlier than usual. Typically, most people who would get vaccinated receive the vaccine in October or early November, several weeks or even months before the bulk of the flu cases appear. Now we were seeing infections in September and early October, and yet there was little if any vaccine to distribute.

really began to deteriorate when it was reported on November 5 that Goldman Sachs, Citibank, and other Wall Street firms had received vaccines from the CDC while pregnant women in clinics throughout the country were waiting in line for the scarce supplies.

Here was a classic example of the unpredictability of influenza. As mentioned, seasonal outbreaks usually peak in January. Here we were in November and the pandemic had already peaked.

Ebola is a virus that causes severe disease characterized by the acute onset of fatigue, headache, muscle pain, severe vomiting, diarrhea, and skin rash, and often progresses to multisystem failure particularly of the kidney and liver, very often leading to death. The virus was first discovered in 1976 during two simultaneous outbreaks in the Democratic Republic of the Congo (DRC) and South Sudan.

The virus got its name from the Ebola River, which is adjacent to a village in the DRC where the first outbreak occurred. It was formally referred to as Ebola hemorrhagic fever because of early reports of oozing of blood from the gastrointestinal tract and other mucosal surfaces such as the eyes, nose, and gums.

The natural animal reservoir of Ebola is not entirely clear, although fruit bats are strongly suspected to harbor the virus and pass it on to humans who come into contact with bats or other infec...

From 1976 until 2014 there had been at least eighteen separate outbreaks of Ebola virus disease, nearly all occurring in Central African countries.

The boy’s home was near a large colony of Angolan free-tailed bats. Soon after he died, his mother, sister, and grandmother became ill with Ebola and died, as did several people close to the family who had helped care for the boy or who had attended his funeral and burial rites.

the sacred traditions and customs of the West African people in expressing respect and affection for their deceased loved ones were a tragic source of spread of the infection.

Traditional funerals became a major source of spread of the disease.

With Ebola, the term applied mostly to nurses but also to physicians and laboratory workers, who were specially trained and whose responsibility was to ensure that each step in the donning and doffing of those who entered and exited Robert’s room was followed to the letter. The multistep donning was strictly prescribed: underlying scrubs, impermeable gown, multiple layers of gloves with extended cuffs, shoe covers, disposable aprons, full face shield, and PAPR (powered air-purifying respirator). Before we entered the anteroom, the WatSan in the hallway would carefully inspect our PPE to verify that every area of the body was covered. When we left Robert’s room by way of the anteroom, the WatSan carefully checked off every step in the doffing process.

which made it temperate compared with the extreme heat that our colleagues in West Africa were experiencing with PPE, one still became exhausted at about two hours, and that is when most mistakes and accidents occur. And so, the rules were two hours and out; doff, take a shower, put on a fresh set of scrubs, and report back to the lounge to brief the next shift.

He had a high fever; a rash covering his body; was extremely weak, though able to communicate; and was putting out copious diarrhea (typical of Ebola infection) through and around a rectal tube. His platelets (cells that prevent you from bleeding) were rapidly dropping, and most of his blood chemistries were abnormal to a greater or lesser degree. In adjusting his rectal tube, positioning his urinary catheter, attending to the various intravenous lines plugged into him, and listening to his frequent coughing as we moved him about in bed to examine him, it was clear that we were being exposed to a fair amount of Ebola virus because the level of Ebola in his blood was still very high according to our lab tests. The team in the room was thinking the same thing: thank goodness for our PPE.

Zika is a virus in the same viral family (flavivirus) as dengue, West Nile virus, and yellow fever. It is transmitted by the bite of a mosquito, usually the Aedes aegypti species, a notorious bad actor in the transmission of serious mosquito-borne diseases.

The Zika virus was first discovered in the Ziika Forest of Uganda in 1947, hence the name Zika (the second i was dropped from the name). The first human cases were described in 1952 in Africa, and then the virus seemed to disappear until outbreaks occurred in Micronesia in 2007 and French Polynesia in 2013. Zika virus infections are generally very mild. Eighty percent of people have no symptoms, and the 20 percent who do have symptoms develop a rash, low-grade fever, muscle and joint aches, inflammation of the eye (conjunctivitis), and headache.

Microcephaly means “small head” and results from the destruction of the developing brain of the fetus by the virus. When the fetal brain does not develop properly, the skull assumes a smaller size and shape. Babies born of mothers who were infected during pregnancy also had other brain abnormalities that did not show up as microcephaly.

Zika fear was a different type of fear from Ebola. When pregnant women and their babies are involved, it strikes a special chord, and the possibility that we could have a Zika outbreak in the continental United States was real and frightening.

People associate science with absolutes that are immutable, when in fact science is a process that continually uncovers new information. As new information evolves, the process of science allows for self-correction.

Peter made that very difficult. I think he truly believed that his Ph.D. in economics qualified him to weigh in on all matters relating to public health and medicine.

criteria and benchmarks for states to safely open after the thirty-day extension. The time frame would differ for each state depending on how well the infection rate was controlled and whether and when they reached the indicated benchmarks.

It was another example, like hydroxychloroquine, of the president’s tendency to try to wish away COVID with solutions that had no scientific basis. Because the president’s off-the-cuff comments created a firestorm around the world, his staff suggested that he hold fewer press briefings going forward.

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.

The president then switched topics, venting that we were seeing more cases only because we were doing more testing. The other countries looked good because they were not testing, he claimed.

Increased testing does not cause cases. When you increase testing, you will of course pick up asymptomatics whom you might not otherwise notice. However, when you have increased percent positives, increased hospitalizations, and increased deaths, that means that there are truly more cases.”