The path of a doctor in public service

Dr. Anthony Fauci has been the most prominent figure in health care for nearly 40 years. But health care, and public health in particular, is very often not science, but the perception of science. That is the dilemma in his memoir, On call: The path of a doctor in public serviceTo understand this dilemma, two questions must be answered: What is Fauci’s real legacy and what were his goals in writing this book?

The title of Fauci’s book evokes the 24-hour on-call hours that doctors work when treating patients, but the biography is not about the clinical approach to medical practice. Rather, it is a guide to understanding the funding of medical research and the formation of our perceptions of health care.

Fauci describes himself as a quick learner of the government budget process, which is the mother’s milk of any bureaucracy. Fauci goes on to explain how he used the first challenge of his tenure as director of the National Institute of Allergy and Infectious Diseases (NIAID), the HIV/AIDS crisis, to increase his visibility, power, and the prestige of the NIAID. HIV/AIDS shaped Fauci’s leadership methodology, and he would use the same approach in tackling future public health challenges.

Fauci describes in detail his relationship with Larry Kramer, a provocative critic of the lack of resources to treat HIV and AIDS, whom Fauci calls the “father of the activist movement.” Kramer founded the AIDS Coalition to Unleash Power (ACT UP), which became the most effective and aggressive advocate for HIV and AIDS treatment.

The relationship with Kramer began after he publicly denounced Fauci, accusing him of being personally responsible for numerous AIDS deaths. Fauci used the attention Kramer attracted to justify a significant increase in NIAID’s AIDS funding.

Perhaps Fauci realized that Kramer was not fighting against him, but for his life and the lives of his friends. How Fauci handled Kramer set a precedent for how he would handle heated debates throughout his career, culminating in the contentious relationship Fauci had with President Donald Trump 35 years later.

Fauci acknowledges that “this iconic organization (ACT UP) would serve as a future prototype for advocacy for diseases beyond AIDS.” In fact, it was the success of the HIV/AIDS community that transformed patients from passive recipients of what scientists and pharmaceutical companies offered them into highly effective influence groups demanding treatments for debilitating and often fatal diseases. This approach to advocacy didn’t just transform NIAID. It also transformed the operations of the FDA and the entire Department of Health and Human Services. Patient advocacy has become a driving force for research, development, and commercialization of therapeutics to treat many diseases. In the case of the FDA, the result was a streamlined system for faster drug and device approvals.

Follow the money

As described above, Fauci’s baptism of fire during the HIV crisis taught him how to use political maneuvering to fund his agency. Fauci began his tenure as NIAID director in early 1985 with a budget of $370 million; 38 years later, he had increased the budget nearly 20-fold. In constant dollar amounts over the same period, funding increased six-fold. As a result, NIAID grew from the sixth-largest to the second-largest budget of an NIH that grew to more than double the number of institutes and centers.

This point needs to be made explicitly clear. Many critics, and especially elected officials, have accused Fauci of being focused on his personal financial gain, but there is no evidence to support this accusation. In fact, the book makes it abundantly clear that he was concerned with influence and access, not money. The sad truth is that spending more money doesn’t mean you get more or anything at all..

Dr. Fauci’s true currency

During his 38 years as head of NIAID, Fauci and the agency became synonymous. It was Fauci’s reputation that made NIAID’s reputation, and it was NIAID’s reputation that made Fauci’s reputation.

The importance of Fauci’s public reputation is evident in his memoirs from early 2020, when he said, “After a three-year hiatus following the Obama administration, I was happy to be back working in the White House.” And, “I had to tell the American people the truth, otherwise I would compromise my own integrity and abandon my responsibility to my patients – the American public.” And finally, in a comment on his disagreement with the president, he wrote, “I immediately became a hero to the millions of Americans who saw in me a doctor who courageously stood up for science, truth and rational decision-making.” This shows how important public appeal is to Fauci, who likes to portray himself as a humble and dedicated man of science, willing to undermine his personal ambitions for the good of society.

Mask or no mask, that is the question

The most problematic part of the book is probably the description of his 60 minutes extra time Interview on mask wearing. Fauci claims that in the fearful days of March 2020, when the world was suddenly struck by an invisible, mysterious and deadly disease called COVID, he told people not to wear masks to spare the shortage of medical workers. He says that at the time, science had not yet proven that masks are effective protective devices. But that was either a lack of knowledge on his part or a “noble lie,” a deception that put ordinary people in harm’s way to protect medical workers. His critics believe he was either less knowledgeable than he pretended to be or he was willing to compromise his integrity, and that is problematic.

The vaccine solution

The adage that to a hammer, everything looks like a nail fits Fauci’s stance on vaccines. He advocates vaccine solutions for every disease threat. Of course, this must be qualified by acknowledging that vaccines have saved more lives than all other therapeutics combined. However, when judging the success of NIAID’s vaccination programs in preventing disease transmission, the success is limited. Today, the common belief is that COVID vaccines and booster shots reduce the severity of the disease rather than fulfilling their original purpose of preventing transmission of the virus. And in Fauci’s own words, even the HIV/AIDS effort has been disappointing. Although hundreds of billions of dollars have been spent developing a vaccine, there is no effective vaccine against HIV.

So what happens after Fauci? Or Quo Vadis Dr. Fauci

Fauci built the greatest kingdom in the field of infectious diseases, and everyone who lived in that field was beholden to his authority, or at least had to acknowledge it. This is an important fact if you paraphrase the famous German physicist Max Planck’s scientific adage about innovation in science. He emphasized that new discoveries are only really possible when there is a major change in scientific leadership, as new theories are suppressed by the well-funded status quo.

Scientists, domestic politicians or both

Between the numerous interviews Fauci is currently giving and his memoir, the reader is left with a Dr. Anthony Fauci attempting to portray his 38 years of leadership of the NIAID as a dedicated scientist and clinician. This is a difficult undertaking, but becomes even more problematic when he extends the claim to apoliticality. This claim is very difficult to prove when, at one point, every important person in the U.S. government, global health, and American business had their phone number on Fauci’s speed dial and, more importantly, Fauci had their number on his speed dial.