On Call: A Doctor’s Journey in Public Service by Anthony Fauci

My rating: 5 of 5 stars


A wonderful read about a great man, who arguably saved more lives through medicine than any other human being in history.

Dr. Fauci is one part compassion (think Mother Theresa), one part brilliant scientist (the Albert Einstein of the immune system), and one part a great leader with the political skill to marshal US and global resources for the 25 year battle to defeat HIV.

To keep the book readable, it is light on the science of our immune system (for that read An Elegant Defense: The Extraordinary New Science of the Immune System: A Tale in Four Lives .
But it does describe the major health problems (and responses) since 1970, including HIV, Ebola, Anthrax, SARS, and Covid.

I will describe 3 topics that were highlights for me.

HIV

Dr Fauci was the first to realize HIV was no ordinary virus and changed career paths to lead the effort. His colleagues thought he was making a career mistake, but his leadership brought incredible advances in our knowledge about viruses, the immune system, and vaccines.

The book is full of interesting decision points. Early on, he was the target of ire for the AIDS activists who accused him of mass murder (for not distributing AIDS drugs before FDA approval), calling him an “idiot” and a “murderer”.

Fauci decided to begin a campaign of engagement with AIDS activists: listening to their concerns, showing up at their meetings and inviting them to NIH meetings. What they said made perfect sense to him: “The existing and well-proven scientific approach towards clinical trials and disease … was not appropriately matched to the crisis that these young men, mostly, were going through. You’re talking about a process that’s taking years to do, and they’re looking at their friends and they’re dying in months. So something has gotta change.”

He worked with them and backed a new “parallel track” scheme that let patients access experimental drugs before they had been approved by the FDA (while clinical trials were still ongoing).

He publicly announced his support for a parallel track in San Francisco at a town hall meeting on HIV and he knew it would cause a stir in DC and maybe get him fired. The New York Times immediately called it a “major shift” in US policy.

When his plane landed in DC, his office told him the FDA was furious with him. Within hours, he got a call from the White House. Fauci told President George HW Bush’s chief of staff that it “was absolutely the right thing to do and we should have done it a long time ago.” President HW Bush showed his great leadership as Dr Fauci soon got a call back, saying the President was OK with it, and that the FDA and HHS would be on board going forward. Two leaders working together to redirect the bureaucracy.

The firebrand activist playwright Larry Kramer initially said things like “God, I hated him [Fauci]. As far as I was concerned, he was the central focus of evil in the world.” [Larry Kramer told The New Yorker in 2020]. Decades later, Kramer declared Dr Fauci “the only true and great hero” of the HIV/AIDS crisis.

Dr Fauci was apolitical and an Oval Office adviser to 7 presidents- from Reagan through Biden.
He was especially close with the two Presidents Bush, working with Bush 43 to establish PEPFAR.

Covid and the mRNA vaccines

Our “stunning Covid vaccines” were developed at record speed and saved millions of lives. How?

3 different strands of research came together to give us mRNA Vaccines. Before the Clinton presidency, there were 3 key research inquires that were independent: RNA research, gene therapy research, and HIV vaccine research. (First 2 were privately funded, but the HIV vaccine was Government funded as the private sector did see a good return on investment in it). [This paragraph is my own summary, not directly from the book.]

Dr. Fauci, leading H.I.V. research in 1996, briefed Pres. Clinton and VP Gore on the need to get these 3 groups of researchers working together to get an HIV vaccine. He convinced them, and they made it happen: the Vaccine Research Center (VRC) opened its doors in 2000 at the National Institutes of Health’s campus.

Basically, these 3 research efforts combined forces under Dr Fauci’s VRC to produce our mRNA technology over the following 20 years. With funding from the Trump administration, Covid vaccines were developed at warp speed.

One more interesting (if bizarre) moment

In late 2000, the vaccines were ready to distribute widely to US citizens. One challenge was the bizzarro world of the Trump White House during the months between Biden winning the 2020 election and Trump leaving office.

These months included the first Christmas since Covid arrived, and holiday travel caused deaths to spike again to as many as 4,000 per day. Hospitals were close to being overwhelmed, meaning people might die from treatable injuries and illnesses.

At this point, the Trump White House could care less about the pandemic. They were focused on overturning the election results, and creating fraudulent slates of electors. Trump’s inner circle instead vilified Dr. Fauci publicly, Steve Bannon even calling for him to be beheaded. White House advisers Peter Navarro and Scott Atlas advised the public to just take horse tranquilizer and let Covid run rampant (to achieve “herd” immunity at the cost of perhaps millions of lives). And Trump followers were (of course) bombarding Dr. Fauci and his family with constant death threats, requiring security details for everyone.

Meanwhile, the incoming Biden team was meeting with Fauci regularly to plan how to distribute the vaccine to all Americans and others around the world. They recruited a team of top doctors ready to make an impact on Covid starting on Inauguration Day.

It never occurred to me how strange these 3 months must have been for Dr. Fauci. The outgoing administration was mostly ignoring the pandemic and causing death threats to come his way, while the incoming administration was simultaneously working with him on how to keep hospitals from being overwhelmed and keep people from dying from Covid.

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