by David Kordahl
Accusatory reevaluations of the COVID-19 era are underway. Anthony Fauci’s new memoir addresses the accusations—or does it?
Oversight and Accountability
Some six weeks ago, Dr. Anthony Fauci appeared before the Committee on Oversight and Accountability, an investigative panel of the U.S. House of Representatives. I watched the first hour (the full session lasted roughly three-and-a half), but that was enough to get the gist. Republicans portrayed Fauci as the malevolent demiurge of the COVID-19 pandemic, with his suggestions leading to mask mandates, school closures, forced vaccinations, and possibly even the virus itself. Democrats, conversely, lamented these attempts to smear Fauci, painting them as Big Lies beginning in and persisting from the Trump era, and apologized to Fauci for the attacks on his professionalism.
Since then, an assassination attempt on Donald Trump and the candidacy withdrawal of President Biden have shifted the political focus in American politics away from Dr. Fauci. But for better or worse, I’ve stayed fixated. When I saw Anthony Fauci’s memoir, On Call: A Doctor’s Journey in Public Service, on the NEW BOOKS shelf at my local library, I knew that I would review it here.
I read On Call while I was on a long car trip with my wife and kids, during family vacation. And while I didn’t start the book any strong feelings about Fauci, I should admit a few preconceptions. For one thing, I’m instinctively suspicious of doctors. When I had appendicitis, I refused to go in until my appendix had fully burst. Also, I’m usually drawn to memoirs by people who are basically unreliable. The other memoir I read this summer—Glenn Loury’s Late Admissions: Confessions of a Black Conservative—contrasted Loury’s sexual and chemical adventuring with his “cover story” as a moral crusader.
On Call was not written for me. It’s for Fauci’s preexisting admirers, and is the opposite of a confession—more like an unapologetic self-defense. The book eventually gives readers what they want (in “Part Five: COVID”), but after 300+ pages detailing Fauci’s demonstrable successes, this part ultimately seems embarrassing, an unsatisfying conclusion to a triumphant career.
The chapters of On Call are each just a few pages, and they go by quickly. I got both the hardback and the audiobook, and alternated between them, sometimes reading, sometimes listening as I watched the red vistas scan by, the vastness of Fauci’s story complementing the vast southwestern landscapes outside. But like any visitor in unknown territory, I tried to keep alert for any unexpected movements—signs that this narrator was unreliable after all.
Fauci’s “Steep Ascent”
Anthony Fauci is undoubtedly the hero of his own version of his story. The Brooklyn child of first-generation Italian-Americans, Fauci only briefly discusses his Catholic schooling and early disappointment at being too short to play college basketball. (He was captain of the varsity team at Regis High School, but did not play at the College of the Holy Cross.)
After college, Fauci skipped from success to success. He graduated at the top of his Cornell Medical School in 1966 and then was drafted—those were the Vietnam years—by the U.S. Public Health Service for a three-year stint at the National Institute of Health (NIH). After that, Fauci spent one year as the chief medical resident at The New York Hospital-Cornell Medical Center before returning to the National Institute of Allergy and Infectious Diseases (NIAID), a sub-campus of the NIH. He entered this new position as a senior tenured investigator. As Fauci laconically notes, “My upward career trajectory was steep.”
At some point, the difference between Fauci the research physician and Fauci the private man all but dissolved. The breakup of a first marriage is mentioned in one paragraph on page 45, but his personal problems have a single cause: he’s always working. It’s appropriate, then, that when, in 1983, he met his second (and final) wife, Christine Grady, she was a nurse at the National Institute of Health, where he was an attending physician. He wants us to know that this was okay:
I was not crossing any lines of authority here. Christine did not work for me; she worked for the nursing department. I just happened to be the attending physician on the floor where she was assigned.
The family material is plucked out of an entirely different era. The concession he makes to fatherhood is that eventually, after he and Christine have three girls together, he strives to leave work by 8 pm, so the family can eat supper at nine.
These humanizing touches are secondary to the main story of On Call. The main story has basically three parts. In the 1980s-1990s, Fauci turned much of his attention toward the AIDS crisis. In the 2000s-2010s, he was involved with international efforts, including preparations for the “War on Terror” and extending AIDS relief to the wider world. And in the 2020s—well, we all know what kept Anthony Fauci busy in the 2020s. The fact that his directorship at NIAID lasted so long allows him to tease out connections among the stories.
The AIDS Years
As Fauci tells it, the hinge point in his career was in 1981, when he decided to change the topic of his research. “I decided to transfer to others the highly successful research that I had been conducting on immune-mediated diseases and the basic research that I had been conducting over the previous nine years on the regulation of normal human immune response and focus my efforts completely on this mysterious new disease seemingly restricted at this point to gay men.”
Fauci’s previous research had helped small groups of people suffering from rare disorders, but this new research aimed to serve a much larger group, the previously healthy men who were developing AIDS symptoms. When Fauci published his first paper on the subject, only 290 reported cases of AIDS (or “GRID,” gay-related immune deficiency, as it was then called) had been tracked.
When Fauci took over as the NIAID director in 1984, he learned quickly that much more funding could be obtained from Congress just by asking for it. The budget for AIDS research when he came in was $66 million. Fauci asked congress to double this, they did more than that, raising the AIDS budget to $147 million.
Fauci also learned to work with AIDS activists, though cynical readers might call this setting up the controlled opposition. Fauci credits his interactions with activists with helping him to be responsive to the needs of the community for whom the scientific research was being conducted. Still, it’s a little disconcerting to find out that Fauci discussed with ACT UP activists (“over glasses of Pinot Grigio and Jim Hill’s famous Cuban pork”) exactly when they would be storming the NIH campus with the explicit goal of getting arrested.
Since Fauci had become the public face of AIDS research, many activists blamed him for the slow process of drug development. In response to this pressure, Fauci announced—“I threw away my remarks and gave an impassioned speech”—that the usual process of rigorous trials before drugs were made available would be replaced for AIDS patients with a “parallel track approach,” which would allow patients to access promising drugs before they had been approved by the FDA, extending their uncertain benefits even as trials continued.
To readers (like me) who mainly know Fauci as the face of the COVID-19 response, some elements of the AIDS response act as foreshadowing. For instance, the parallel track approach prefigures the innovations of Operation Warp Speed, where the accelerated trials and pre-manufacture of vaccines allowed them to reach the public as soon as their safety and efficacy could be established.
Spanning the Globe
As AIDS treatments became more effective in the 1990s, Fauci became one of the players pushing to extend them to other countries. He was especially effective in this role because he had the ear of many successive presidential administrations.
Anthony Fauci’s ability to befriend powerful politicians of different parties has been widely noted. There is a chapter on Fauci’s relationship with George H. W. Bush whose title—“A President, a Gentleman, and a Friend”—reveals its tenor. Though Fauci was less involved with with the Bill Clinton administration, he credits Clinton with helping to build the Vaccine Research Center (VRC)—another piece of Operation Warp Speed foreshadowing. When George W. Bush took office in early 2001, Fauci could reminisce about a time “less than twelve years earlier when he came with his father to visit the NIH in 1989.”
Fauci would work extensively with Bush II, both in AIDS relief efforts and in “War on Terror” efforts like Project BioShield. I will admit that I was not familiar with either of these before reading On Call. (As a high school and college student in the 2000s, I heard very little about Bush II that was positive.) The book never sneers at George W. Bush, but it does hint that his interest in global AIDS relief, and not just his interest in Iraq, was carried over as the legacy of his dad, H. W.
The numbers, at this point in the book, shift from those one would expect for scientific research, in the tens or hundreds of millions of dollars, to those of major U.S. federal efforts. He recalls Nancy Dorn, an official from the Office of Management and Budget, pulling him aside before a meeting to whisper, “Every time you come into the White House, it costs us billions of dollars.”
So were these billions well spent? On Call is a document for the defense, but readers who are uncertain may find themselves skeptical. $6 billion was the initial appropriation for the administration’s preemptive response to bioterrorism, Project BioShield—so named because it sounded like “Operation Desert Shield” of the 1990 Gulf War. Smallpox vaccines were produced for the entire army, without any hard evidence of the threat of bioterrorism involving smallpox. “The inability to find any weapons [in Iraq] had a dampening effect on the intensity surrounding the biodefense effort,” writes Fauci, without any apparent regret.
The case for PEPFAR (the U.S. President’s Emergency Plan For AIDS Relief) is almost certainly better than that of Project BioShield, though with an even steeper price tag. I confess—and this is not to my credit—that I didn’t know anything about PEPFAR before reading On Call. The website for this program claims that from the $110 billion that the U.S. government has invested in it since its inception, 25 million lives have been saved via AIDS treatment and prevention.
As W.’s time in office ended, Fauci writes, “It was already clear that PEPFAR would be a major part of the Bush legacy.” This could be true, in some abstract sense, unconnected in any way to the public memory of Bush II as a dangerous idiot. Maybe we are wrong, and the utilitarian calculus of suffering should be tallied differently, with the Patriot Act, offshore torture sites, etc., all as comparatively minor blemishes. But public memory doesn’t like that, and I’m not sure that it should. In any case, Fauci bore no stigma for his work with Bush II, and he continued on as the NIAID director under Barack Obama with no hiccups.
The Great Explainer
Fauci’s retreat to the NIAID during the Obama administration provides some of the best stories in On Call, though I will not retell them here. Those years had plenty of incident—recall the swine flu (H1N1), Ebola, MERS, and the Zika virus—but no catastrophic failures. Little fires were identified and extinguished. Quarantines were established, and vaccines were developed. These stories are exactly the sort that politicians might point toward to say, look, the system works.
Whether or not one reads the last section of On Call—finally, “Part Five: COVID”—as the system working will depend upon the reader. This section features a lot of direct dialogue, including comments from the grovelling VP Mike Pence (“There are a lot of smart people around here, but we all know the smartest person in the building is upstairs”), to the stable genius himself, President Donald Trump (who at one point screams at Fauci that the influence of his comments on the stock market have cost the U.S. “one trillion fucking dollars”). During this time, Fauci “was getting four hours of sleep a night at most and often less.”
This reads a bit like reputation management, with Fauci taking pains to delineate exactly which parts of the crisis management were up to him, and which weren’t. The part that he most proudly claims is Operation Warp Speed, the remarkable—and remarkably expensive—plan for accelerated vaccine development.
Operation Warp Speed (OWS) had the following structure. Normally, pharmaceutical companies bring vaccines to market by first designing them, then testing in stages—starting with small trials to determine safety, then moving on to midsize trials to gauge efficacy and dose size, and only carrying out large-scale clinical trials with thousands of participants if the earlier stages have been successful. But OWS ran all these steps in parallel. Production on vaccines began even as testing continued, and many parallel trials were combined to vet safety.
This echoed the “parallel track” approach of the AIDS crisis. Of course, one might ask: If OWS managed to deliver multiple effective vaccines for COVID-19, why is this method not used more commonly? The answer is that it was tremendously expensive, with agreements to pay manufacturers for their products whether or not they worked. To state it bluntly, billions of dollars were spent on producing multiple vaccines that ended up being ineffective. (OWS was originally budgeted at $10 billion; by October 2020, this sum had increased to $18 billion.)
On Call only briefly discusses this. Much more space is spent on Trump’s agonizing over the lockdowns, or Trump’s unwillingness to wear a mask on television, or Trump’s insistence on recommending hydroxicloriquine. Several of Trump’s gaffe-filled press conferences are recounted in detail.
Shortly after Joe Biden was inaugurated in January 2021, the vaccines became widely available, but masking and “social distancing” recommendations persisted. Fauci notes that “while the White House had returned to its pre-Trump normal, I noticed that the political divide in the country had not closed.”
The congressional committee meetings where Fauci was called to speak became increasingly contentious that spring. Fauci recalls being grilled by Representative Jim Jordan, who asked when Americans would get their liberties back.
Fauci replied, “We’re not talking about liberties. We’re talking about a pandemic that has killed 560,000 Americans,” as though it could not be about both.
In the next paragraph, Fauci reflects on this exchange:
In the car on my way back to the NIH from the hearing, I was thinking that even though Jordan had attacked me, I could understand where he was coming from. I was not locking down the country; I had no power to do so, even though he said I had. That was a local decision based on the level of infection in a given community. But that did not change the fact that people were frustrated. Jim Jordan figured that someone needed to be scolded, and he decided that this was me.
The remainder of the book includes quite a bit more of this sort of bland commentary, with MAGA Republicans attacking Fauci as a proxy for the virus itself, and Biden Democrats greeting him with spontaneous applause.
Suspicion and Propaganda
Before I left on my family vacation, I’d already read a few books on the pandemic response, and I’d already written one draft of an essay grumbling about the need for truth and reconciliation. But as I read On Call, Fauci’s legacy began to look more complicated. If his own account is to be believed, Anthony Fauci is a truly great man whose achievements have improved public health around the globe.
As readers will no doubt realize from my catty comments, I think that the record is somewhat less clear. Certain facts about me—college professor, Biden voter, twice-vaxxed and once-boosted—predict the usual distribution of my sympathies, but as the aftershocks of the pandemic continue to reveal themselves, I find myself having less and less in common with my former self, the self who raised no objections during the first full year of the crisis. The talking points I could now rehearse (that the data concerning lockdown efficacy is quite unclear, or that the age-distribution of risks made school closures quite irrational) are likely to be greeted either by a knowing nod or an exasperated eye-roll. Those readers who find them unconvincing will likely have the standard rebuttals on hand. Very few of us are confused. Opinions have hardened, while taboos differ by individual.
In the last pages of On Call, Fauci notes the dangers of division and propaganda—notions that sound good, so long as they remain entirely abstract. What better source of cohesion and unity than science? Unfortunately, those readers who view the COVID years as major drivers of American division, and interpret many of the public health efforts as having been indistinguishable from propaganda, will find nothing to contradict their views in Dr. Fauci’s long and interesting book.