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.
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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.
Fauci mentions this incident in his memoir, and his handling of it is characteristic. Trump, he writes, “was being especially flippant” and made a joke that gave him “a moment of despair mixed with amusement.” Catching the eye of a journalist who shot him “one of those ‘What the . . . ?’ looks,” Fauci recalls, “I put my hand to my forehead to hide my expression.” He was dismayed when a photograph of this gesture was seized upon by his critics as proof that he was “a naysaying bureaucrat who deliberately, even maliciously, was undermining President Trump.” Fauci, then, does not deny that he was aghast at what Trump was saying, but he is adamant that he had no intention of communicating disrespect—a line he maintains consistently—and that, indeed, the notorious gesture was an attempt to conceal his reaction. The word “flippant” is notable, too. As criticisms of Trump go, it’s decidedly mild, and it does capture something about his character; namely, his love of playing to an audience.
The chapter about working with Trump is called “He Loves Me, He Loves Me Not.” At first, Fauci found Trump “far more personable than I had expected.” But, early on in the pandemic, Fauci encountered “the first, but not the last, whiplash effect that I would experience in dealing with this complex man.” On a nighttime phone call in February, 2020, Trump listened as Fauci advised him against underplaying the severity of the situation—“That almost always comes back to bite you, Mr. President”—and suggested that honesty would win the country’s respect. The next day, at a rally in Charleston, South Carolina, Trump called COVID the Democrats’ “new hoax.”
Similarly, Fauci was impressed that, despite the economic consequences, Trump agreed to shut down the country for fifteen days in March, in an attempt to “flatten the curve.” The difficulty came when fifteen days turned into longer and longer still. “I think Donald Trump thought that COVID would be temporary: a little time goes by, the outbreak is over, everyone goes back to work, and the election cycle can begin,” Fauci writes. But, “with the ghastly reality setting in that COVID was not going to go away, Trump began to grab for an elixir that would cure this disease.” When the President started touting the benefits of hydroxychloroquine, Fauci realized that “sooner or later I would have to refute him publicly.” Knowing that the press would seize on divisions between Trump and his COVID team, he evidently tried to make these corrections as measured as possible, and he writes of being struck that Trump did not seem to hold them against him.
Nothing that Fauci says will change the minds of those who believe he was trying to undermine the President, but Democrats may be surprised that he enjoyed cordial relations with much of the Administration. He finds Mike Pence, Marc Short, and Hope Hicks to be supportive and sees “positive attributes” in Jared Kushner. Even Trump often seems guilty more of wishful thinking than of something darker, pleading with Fauci to find some sort of silver lining. The villains in the account are the White House chief of staff Mark Meadows and the press secretary Kayleigh McEnany, who Fauci feels try to silence him, and Peter Navarro, an economic adviser, who berates him about hydroxychloroquine. Fauci shows quiet scorn for Scott Atlas, a doctor who becomes Trump’s special assistant on COVID. Atlas is against lockdowns, putting his faith in herd immunity, and acquires influence by “telling the president what he wanted to hear.”
The relationship with Trump certainly soured, something Fauci attributes in part to the people who had the President’s ear, and there is an alarming account of Trump at his most furious. In June, 2020, after Fauci said that the duration of immunity from the vaccines then in development might be such that booster shots would be needed, he got a call:
Fauci himself evinces anger only when he tells of death threats to him and his family, which required him to have a security detail at home. In the AIDS era, he recalls, he got maybe a couple of abusive letters a month. Things were very different this time: “Now my family and I were barraged by emails, texts, and phone calls.” He is particularly outraged at the harassment of his daughters, writing that he “wanted to lash out at the people who were terrifying these innocent young women.”
Fauci’s troubles did not end with Trump’s departure. Once Joe Biden was President, the abuse got worse, he writes, because attacking him became a badge of loyalty for extremist Republicans and a way to wage war on Biden and the Democrats—“as well as established principles of public health.” In 2022, Fauci decided to retire, but the polarization that he laments is as virulent as ever, as the rhetoric at the recent congressional hearing shows.
Parts of the book were obviously written with an eye to the ongoing scrutiny of the government’s handling of the pandemic. He is open, if a little general, about things that went wrong. “If we knew in the first months what we know now, many things would have been done differently,” he writes. “We learned, for example, that aerosol transmission of infection was important, and asymptomatic spread of virus played a much greater role in transmission than originally appreciated. This knowledge clearly would have influenced earlier recommendations for mask wearing, social distancing, and ventilation.” He also thinks that mask mandates could have been relaxed earlier but explains that although he privately made this recommendation to the C.D.C., he was hesitant to criticize the agency openly.
More broadly, he emphasizes that “people associate science with absolutes that are immutable, when in fact science is a process that continually uncovers new information.” People look to medical science for definitive answers, but the advice during the pandemic had to change as the understanding of the virus developed. This idea governs Fauci’s stated attitude toward the debate that still rages about whether the pandemic started with the virus naturally jumping species to humans, perhaps in the Wuhan wet market, or whether a leak from a laboratory in Wuhan working on coronaviruses could have been to blame. (The latter possibility is made more politically fraught by the fact that the Wuhan lab indirectly received funding for some coronavirus research from the N.I.H.) Fauci states that there is no proof either way, but that “keeping an open mind about both possibilities does not mean that one cannot have an opinion.” In the book, as in the recent hearing, he continues to argue that a natural spillover from another species is more probable. He notes that this is the prevailing opinion among evolutionary virologists and the majority opinion among U.S. intelligence agencies; he also asserts that seventy-five per cent of all new infectious diseases originate in this manner.
While somewhat open-minded about the origin of the virus, he is vociferous about the way that the lab-leak theory has been used to erode confidence in public-health provisions. He relays in detail his rebuttal, in May, 2021, of Senator Rand Paul’s claim that N.I.H. money directly funded the creation of the virus in Wuhan.
“At times, I am deeply disturbed about the state of our society,” Fauci writes near the end of his book. “We have seen complete fabrications become some people’s accepted reality.” If this “crisis of truth” persists, the effects of future pandemics will be much worse. Such is the grim lesson of Fauci’s career in public service. In the nineteen-eighties, by listening to his critics, he managed to turn them into allies. Larry Kramer, famously combative, went from calling him a murderer to saying he loved him. Which of Fauci’s current adversaries would be capable of such a transformation? ♦
