On Call: A Doctor’s Journey in Public Service

O n Call: A Doctor’s Journey in Public Service by Anthony S. Fauci, M.D., is an inspirational and informative book that provides illuminating context, both personal and historical, for the major events the author experienced during his almost 60 yr as a physician, scientist, administrator, and public health official. The passionate and energetic Dr. Fauci, now approaching 84 yr of age, retired in late December 2022, after having served as Director of the National Institute of Allergy and Infectious Diseases (NIAID) in Bethesda, Maryland since 1984. During that interval, he advised seven presidents and guided the country through such catastrophic events as the Acquired Immune Deficiency Syndrome (AIDS) epidemic, outbreaks of Ebola, Zika, and influenza, the coronavirus disease 2019 (COVID-19) pandemic, and potential bioterrorism threats involving anthrax and smallpox. The book’s title, On Call, evokes the sentiments expressed by the great physician, Sir William Osler (1849 to 1919) in his famous 1889 farewell address to graduating medical students at the Pennsylvania School of Medicine (Philadelphia, Pennsylvania) when he said, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Dr. Fauci emphasizes repeatedly that, rewarding as his remarkable career has been, it has not always been easy. It came with long hours, sacrifice of personal and family time, an extraordinary burden of responsibility that could engender considerable anxiety and stress, as well as, at times, vitriolic opposition and hostility. Anthony Fauci grew up in a close-knit Italian American family in Brooklyn, New York, where his father, a Columbia University-educated pharmacist, operated a pharmacy, and the family resided in the apartment above the family-owned drug store. Fauci’s parents inculcated in their two children the pre-eminent values of service and generosity to others, as well as the importance of hard work and academic excellence. After excelling at Our Lady of Guadalupe elementary school, Tony was the recipient of a magnificent education under the tutelage of Jesuit priests, who are noted for their intellectual rigor, exacting standards, and insatiable curiosity. He attended the academically elite Regis High School in Manhattan, traveling an hour each way from Brooklyn to study four years of classical Latin and Greek, along with French, ancient history, theology, mathematics, chemistry, and biology, among other subjects. An outstanding student, Tony was as enamored of the classics and humanities as he was of the sciences. Importantly, the Jesuits’ motto, “Men for Others,” with its emphasis on service to the public rather than personal gain, dovetailed nicely with the ideals instilled by his parents since early childhood. In addition, during the few times that their prize student became hassled or discouraged, the wise and worldly priests helped Tony to understand the necessity for resilience, underscoring “Illegitimi non carborundum.” (It was also at Regis that the 5-foot, 7-inch Tony played point guard and served as captain of the varsity basketball team, compensating for his lack of height with agility, speed, and determination.) Predictably, after graduation Tony advanced to the Jesuit-led College of the Holy Cross (Worcester, Massachusetts), where he thrived in his premedical and classical studies, learning from his Jesuit mentors “precision of thought and economy of expression.” Next, the author attended Cornell University Medical College (New York, New York), where he graduated first in his class in 1966. (In the interest of full disclosure, I should reveal that I also graduated from Cornell, but I attended after Dr. Fauci graduated. I occasionally see him at Cornell reunions but never had a conversation with him, largely because it was too difficult to elbow through the admiring crowd surrounding him!) Dr. Fauci then trained in internal medicine at Cornell-New York Hospital and in infectious diseases at the National Institutes of Health (NIH; Bethesda, Maryland). The plurality of pages in this book is devoted to human immunodeficiency virus (HIV)/AIDS. The author skillfully takes us along the arduous journey to combat HIV/AIDS, beginning in 1981, when a mysterious disease appeared predominantly in gay men, to 1983 when the causative agent (HIV) was identified by French scientists, to 1986 when the drug azidothymidine was shown to have potent suppressive activity against HIV in the test tube, to identification of the need for combination, rather than single agent, therapy, to the transformational development of triple combination antiretroviral therapy in 1996. Unfortunately, the search for an HIV vaccine has been elusive due to the unique nature of the virus. While a subset of patients referred to as elite controllers are capable of long-term suppression of the virus, they do not eradicate it. Indeed, Albert Sabin, M.D. (1906 to 1993), developer of the oral polio vaccine, confided to Dr. Fauci that he doubted, given the unique nature of HIV, that an effective vaccine would ever be developed. Nonetheless, the Vaccine Research Center (VRC) was dedicated on the NIH campus in 1999, and scientists at the VRC played a monumental role in the development of a highly effective vaccine for COVID more than 20 yr later. HIV/AIDS has been one of the most devastating pandemics in the history of civilization. By 2023, more than 86 million cases of HIV infection had been reported throughout the world, with 40 million deaths recorded. The carnage wrought by the virus, however, could have been even more dreadful. Initially, AIDS activists, particularly the infamously confrontational Larry Kramer, were outrageously disrespectful and combatively antagonistic to Dr. Fauci. After reflecting on the probable reasons behind the activists’ behavior, the author decided to meet with them privately and listen respectfully to their concerns. Among other issues, the activists were frustrated with the lack of available therapeutic agents while their friends and colleagues died at alarming rates. This propelled Dr. Fauci to establish an innovative “parallel track” of drug testing that expanded the availability of experimental treatment beyond the rigid confines of clinical trials. Gradually, Fauci convinced the activists of a shared goal, forging a bond with even the notoriously belligerent Larry Kramer. Eventually, the author was able to make steady further progress against HIV/AIDS when President George W. Bush gave him the opportunity to play a major role in the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR), one of the most important lifesaving global health initiatives in history. After more than 20 yr, over $100 billion has been spent on the PEPFAR program in more than 50 countries, resulting in the saving of 25 million lives and counting. Sadly, during times of crisis, people in leadership positions often are targets of ridicule, insults, and even threats of physical violence. Tony Fauci is no exception. During the early years of the AIDS pandemic, he was called, among other epithets, an “incompetent idiot” and a “murderer.” During the COVID pandemic, Dr. Fauci was vilified by anti-vaxxers, anti-maskers, and conspiracy theorists. He became a political lightning rod and was the frequent recipient of death threats. Known for his calm demeanor, equanimity, and determinedly apolitical stance, he was incensed when this fearmongering was extended to his family and a security detail became imperative. Among the topics regarding COVID tackled by Dr. Fauci include possible origins of the virus, initial blunders by the Centers for Disease Control and Prevention (Atlanta, Georgia), the national lockdown in an attempt to “flatten the curve,” and the spectacular success of Operation Warp Speed, the public-private partnership that produced a safe and effective vaccine in record time. The author is candid about the waning of vaccine protection that necessitates booster shots, and he underscores that the mRNA platform is highly adaptable and can be ramped up quickly and modified as the virus evolves into new variants. Anthony Fauci addresses his complicated relationship with mercurial former President Donald Trump in a revealing chapter titled, “He Loves Me, He Loves Me Not,” notable for its measured tone. Readers will learn much about the shark tank that is Washington, D.C., complete with interagency rivalry and palace intrigue. When President Trump suggested that hydroxychloroquine as well as bleach ingestion might be effective therapies for COVID, Dr. Fauci could not compromise his integrity and remain silent. The author writes, “To publicly disagree with the president was unnerving at best and painful at worst. But it needed to be done.” In the epilogue, the author laments the “crisis of truth” prevalent in contemporary society wherein divisiveness and lack of civility have become normative behaviors. He writes, “At times, I am deeply disturbed about the state of our society. We have seen complete fabrications become some people’s accepted reality.” These concerns prompted the next chapter in his life, where he serves as Georgetown’s Distinguished University Professor at the School of Medicine and the McCourt School of Public Policy in Washington, D.C., cherishing daily contact with a younger generation of inquisitive minds and hoping to inspire them to pursue a life of public service and intellectual honesty. Lest potential readers think this book is an unremitting saga of one deadly crisis after another, I would like to offer reassurance that considerable humor and heart-warming personal vignettes enliven the pages. No doubt readers will laugh out loud when they learn of the author’s first meeting, at a patient’s bedside, with his future wife, the renowned bioethicist Christine Grady, M.S.N., Ph.D. Amusing anecdotes about the author’s experiences with such luminaries as Dr. Albert Sabin, former Surgeon General C. Everett Koop, M.D. (1916 to 2013), former Presidents George H.W. Bush (1924 to 2018) and George W. Bush (1946-), Yogi Berra (1925 to 2015), Bob (“The Cooz”) Cousy (1928-), Bono (1960-), and Stephen Colbert (1964-) among others, will also engage readers. Clearly, Dr. Anthony Fauci, recipient of the Presidential Medal of Freedom in 2008, has had a consequential career that cannot be adequately encapsulated in a tome approaching 500 pages, much less in a brief book review. The breadth and depth of his accomplishments are staggering. I enthusiastically recommend this outstanding memoir to a wide audience of both medical and non-medical readers with an interest in science, history, and the human condition. When, on August 22, 2022, Dr. Fauci publicly announced his plan to retire as Director of the NIAID, he said, “I hope to be remembered as someone who gave my all 24-7 and left it all on the field.” I would venture to predict history will reflect that Dr. Anthony Stephen Fauci did all of this—and so much more.