Inside Anthony Fauci’s ‘On Call’: 9 health and science takeaways from the memoir of America’s most famous doctor

Anthony Fauci spent 40 years in the top echelons of government. It was no accident.

To read the forthcoming memoir by the country’s former top infectious disease expert, “On Call: A Doctor’s Journey in Public Service,” a copy of which was obtained by STAT, is to get a sense of his finesse while advising seven presidents. He strove, he writes, to speak with complete candor and stay out of politics, while remaining strategic in pushing for policies he considered vital to public health.

He maneuvered for more HIV funding in the Reagan administration; pushed George H.W. Bush to expand access to experimental AIDS medicines; worked with Bill Clinton to set up the National Institutes of Health’s Vaccine Research Center; and teamed up with George W. Bush, on whom he lavishes particularly effusive praise, to set up the global HIV medicine initiative PEPFAR and several biodefense efforts.

Separating science from politics was not always possible for Fauci, particularly in the latter years of his service, when he found himself being screamed at and taunted by former President Donald Trump.

Beyond that revelation, “On Call,” which is officially being released Tuesday, provides plenty of other insights into how Fauci, the longtime director of the NIH’s National Institute of Allergy and Infectious Diseases, managed his role and how public health was conducted over the past several decades. Below are top takeaways from the 455-page book:

Of course, he would do things differently on Covid-19 if given another shot.

Mostly, that’s a reflection of new information gleaned over the course of the pandemic. He wished he’d known sooner about the importance of aerosol transmission, for example — which would have affected masking and distancing guidance — as well as about how fast immunity against infection might wane while immunity against severe disease endured. An earlier understanding of that latter point “would have avoided some of the confusion about what vaccines can and cannot do,” he writes. More broadly, though, Fauci believes he and other health officials should have made clear to the public at the start of the pandemic how much they didn’t know and “to expect the unexpected because the virus was rewriting the history of pandemic outbreaks.”

The U.S. response to the pandemic succeeded on science, and failed on public health.

The country developed safe and effective vaccines in record time, Fauci writes, along with effective antiviral drugs, mostly because of years of prior investment in basic and clinical research, particularly around HIV. “The lesson here is clear,” he writes. “We must sustain this critical investment in the biomedical and health sciences and continue to nurture collaborations between the public and private sectors.”

Public health was another matter. The U.S. had far too many deaths, in part because public health infrastructure, underfunded and antiquated, broke when put under stress, Fauci writes. He notes that people in the United States were older and had more comorbidities than in other countries. There were already widespread disparities in access to basic care, which led to disparities in treatment during Covid. There was a shortage of local public health professionals. Many local health departments relied on fax machines, making it much more difficult for the federal government to assist.

Federal authorities also did not have access to real-time data. The government’s failure to track the pandemic has been widely reported, but Fauci writes that as early as the end of January 2020, he and other top officials stopped relying on the Centers for Disease Control and Prevention and instead used the Johns Hopkins University coronavirus dashboard. That’s in part because the CDC depended on local health departments, which often report late or incomplete data, giving an incomplete picture. It’s also, Fauci writes, because the CDC traditionally approached epidemics “syndromically”: The agency only tested people with symptoms and then interviewed and tested others they came in contact with.

“This is highly effective when, for example, there is an outbreak of a disease that is overwhelmingly spread by people with symptoms — think Ebola,” he writes. “But the CDC’s syndromic approach was not adequately suited to dealing with COVID, a swiftly spreading disease in which, it would later turn out, more than a substantial portion of the transmissions come from people who are asymptomatic. The CDC was slow to recognize and act on that.”

Local health officials tried to warn Fauci, who tried to warn the White House, that contact tracing was failing.

Contact tracing, Fauci writes, was effective in curbing previous outbreaks in many countries. But around late June 2020, Fauci got on a call with an old friend from ACT UP and a group of city health department leaders. “Contact tracing is a sham!” they told him. “It is done by phone, and people do not trust the government. And when tracing does occur, there is no isolation.” Fauci writes that “we were in trouble if citizens were growing distrustful of the government’s approach to COVID.” He warned White House chief of staff Mark Meadows, who blamed Robert Redfield, director of the CDC, who Fauci then tried to defend.

Fauci grew increasingly concerned about the politicization of science during the 2015-2016 Zika outbreak.

The scientist had always tried to stay out of partisan politics, but he grew disturbed by the negotiations over funding to address the Zika virus, which could induce encephalitis in newborns if pregnant individuals are infected. “It seemed to me that Republicans were pushing back on the $1.9 billion request for Zika funds mostly because President Obama was asking for it,” he wrote. Officials at the Department of Health and Human Services shifted around money to fund vaccine efforts, while negotiations dragged on, with Republicans trying to pin funding to cuts to the Affordable Care Act, Ebola work, and Planned Parenthood.

“Only in Washington, D.C., would someone link defunding health insurance disease prevention and women’s health programs to pay to protect pregnant women from a disease that might severely damage unborn babies,” Fauci writes. Later, Republican lawmakers tried to tack on a provision allowing the Confederate flag to be flown at military funerals. “…. Really?” Fauci writes.

The outbreak petered out but Fauci was left shaken. “I was certain that we would experience other infectious disease outbreaks in the future,” he writes. “I could only hope the specter of partisan politics would not follow.”

But Covid was unlike anything else.

Ideological divisions led to mixed messages from the top of government and then to divergent outcomes, with more hospitalizations and deaths in predominantly Republican states than Democratic ones. Fauci found himself in the center, as the lightning rod for any frustration toward the pandemic and measures to slow it. He had long received some hate mail. But now it was a torrent. He was subject to one anthrax powder scare, protests outside his house calling him a murderer, and conspiracy theories involving abusing beagles, manufacturing Covid, and conjuring up a sequel to Covid. At least twice, people were arrested for credible death threats against him.

“At times, I am deeply disturbed about the state of our society,” he writes. “But it is not so much about an impending public health disaster. It is about the crisis of truth in my country and to some extent throughout the world, which has the potential to make these disasters so much worse.”

An HIV vaccine may be far, far off, if it’s possible at all.

Fauci appears as pessimistic as he’s ever been on the prospect for an HIV vaccine. Albert Sabin, inventor of the oral polio vaccine, once told him that he doubted there would ever be an HIV vaccine, given the virus’s uniquely devious properties. As recently as 2016, Fauci thought Sabin was wrong. Several key trials have since failed. That’s left the field “back at square one,” and researchers have still “not even proven the concept that a vaccine would work.” Fauci notes that a promising approach is in development, but “that approach is still aspirational, and as I write this, any success is still years away, if it is at all possible.”

He advocated for efforts on TB, HIV, and malaria that didn’t see the light of day.

Fauci largely speaks positively about the presidents he worked under — except Trump and, obliquely, Ronald Reagan — but he didn’t succeed in getting across every program he hoped to see established. He tried to convince the George W. Bush administration to make a major push to fight tuberculosis and malaria, two of the world’s leading infectious killers, before Bush’s last State of the Union address. Malaria was mentioned but without a call for funding. TB wasn’t mentioned at all.

During the Obama administration, Fauci tried to push for a new initiative aimed at creating an “AIDS-free generation.” Several top officials expressed interest, and he was even asked to design a $2.5 billion “blue-sky proposal.” But the money never materialized. When Fauci tried writing an op-ed in The New York Times about the possibility of ending the AIDS pandemic, a White House official noticed a draft included a call for funding and demanded he pull back the submission for being “off message.” It’s the only time a White House has asked him to withdraw an op-ed. The episode was a reflection of the “frustrating realities of Washington, D.C.,” he writes, while noting Obama himself probably was never involved in the incident.

Fauci turned down an offer, in 1989, to become NIH chief.

He didn’t want to lose his work in the lab and with people with AIDS in exchange for a job with immense administrative responsibilities. “Mr. President,” he recalls telling George H.W. Bush, “I believe that I can serve you and the country better if I remain where I am.” On his way out, a smiling White House chief of staff John Sununu said, “You son of a bitch. Nobody says no to the president.”

He tried to squeeze greater and greater funding for HIV out of administrations with a deft hand.

Fauci recounts how Larry Kramer, the vituperative ACT UP founder, once suggested he get more attention for HIV: “Chain yourself to the White House fence or give a quote to The New York Times that the administration of George H. W. Bush are a bunch of murderers.”

It was a fitting suggestion from an activist who once called Fauci himself a murderer. But Fauci told him it was a terrible idea. He would lose access forever. Instead, he tried to make changes from the inside.

When he first believed he needed more AIDS funding under Reagan, he was told the NIH’s division directors weren’t supposed to challenge the budget. Still, he worked with a few key members of Congress, administration officials, and constituency groups to get the AIDS budget doubled. Later, when there was debate in the second Bush administration over exactly what form a new global HIV initiative should take, Fauci suggested the White House bring in Paul Farmer and several other leading global health doctors for advice. After promising not to pre-brief them, he gathered them at an Italian restaurant in Bethesda, Md., and prepped them for the White House meeting, which helped win support for PEPFAR, the multibillion-dollar program that dramatically expanded access to HIV treatment and prevention services worldwide.

“I joked that this secretive meeting in a quiet Italian restaurant reminded me of that iconic scene The Godfather where Michael Corleone, played by Al Pacino, meets with and ultimately shoots and kills New York City police captain Mark McCluskey, played by Sterling Hayden, and the drug trafficker Virgil ‘the Turk’ Sollozzo, played by Al Lettieri,” he writes, in one of several “Godfather” references peppered throughout the book. “This meeting turned out to have a happier ending.”