On Call

On Call Plot Summary

Introduction

In the early morning hours of a sweltering summer day in 1981, a young immunologist at the National Institutes of Health picked up a medical report that would forever alter the trajectory of his career. The document described five previously healthy young men suffering from a rare form of pneumonia - all homosexual, all with mysteriously compromised immune systems. Dr. Anthony Fauci, then 40 years old, immediately recognized the significance of what he was reading. "I remember putting the paper down and thinking, 'My God, this is a new disease,'" he would later recall. This moment marked the beginning of a remarkable journey that would see Fauci emerge as America's doctor, guiding the nation through the most significant infectious disease challenges of the modern era. For more than five decades, Anthony Fauci's career has embodied the ideal of science in service to humanity. From the darkest days of the AIDS epidemic to the global crisis of COVID-19, his unwavering commitment to following evidence, communicating truth, and prioritizing public health has shaped American medicine and saved countless lives. Through his journey, we witness not only the evolution of modern infectious disease research but also a masterclass in scientific leadership under pressure. Fauci's story reveals how intellectual brilliance, moral courage, and genuine compassion can combine in one remarkable individual dedicated to a singular purpose: alleviating human suffering through the rigorous application of science.

Chapter 1: Brooklyn Roots: The Making of a Physician-Scientist

Anthony Stephen Fauci was born on December 24, 1940, in Brooklyn, New York, to Stephen and Eugenia Fauci, owners of a neighborhood pharmacy in Bensonhurst. Growing up in this working-class Italian-American neighborhood during the 1940s and 1950s shaped young Tony's worldview in profound ways. His father, a pharmacist, and his mother, who worked the register alongside his sister, instilled in him the values of hard work, education, and service to others. The family lived in an apartment above the pharmacy, where Tony witnessed firsthand the intersection of healthcare and community service as his father provided medications and advice to neighborhood residents, sometimes extending credit to those who couldn't afford to pay. The intellectual foundation for Fauci's future career was laid at Regis High School, an elite Jesuit institution in Manhattan where he commuted daily by subway. The rigorous classical education emphasized precision of thought, ethical reasoning, and the Jesuit principle of being "a man for others." Despite standing only five feet seven inches tall, Fauci excelled as captain of the basketball team, displaying the tenacity and competitive spirit that would later characterize his professional life. His teachers recognized not just his academic brilliance but also his unusual ability to explain complex concepts clearly to others – a skill that would prove invaluable in his future public health role. At the College of the Holy Cross in Massachusetts, Fauci pursued a unique educational path, majoring in classics with a pre-medical concentration. This combination of humanities and science gave him a broader perspective than many of his future medical colleagues. He graduated in 1962 and entered Cornell University Medical College, where he graduated first in his class in 1966. His decision to join the National Institutes of Health in 1968 as part of his service during the Vietnam War era – rather than pursuing a lucrative private practice – reflected both pragmatism and his growing interest in clinical research. What was initially planned as a three-year detour became the beginning of a remarkable five-decade career in public service. Fauci's early research at NIH focused on immunoregulation, studying how the immune system controls its responses to foreign invaders. He developed expertise in inflammatory diseases and autoimmune disorders, publishing groundbreaking papers that established him as a rising star in immunology. His laboratory work was characterized by meticulous attention to detail and creative experimental design. Colleagues noted his extraordinary work ethic – often arriving before dawn and leaving late in the evening – and his ability to synthesize complex data into coherent theories about immune function. These years of focused scientific work built the foundation of knowledge that would prove crucial when unprecedented infectious disease challenges emerged. By the late 1970s, Fauci had established himself as a respected physician-scientist with a growing reputation in immunology circles. His career trajectory seemed set – continuing his research on inflammatory diseases while gradually ascending the ranks of NIH leadership. He was building a comfortable professional life, balancing laboratory research with clinical care of patients suffering from rare immune disorders. Then, in the summer of 1981, reports began appearing of a mysterious new disease affecting previously healthy young men. This moment would transform Fauci's career and ultimately place him at the center of the most significant public health challenges of the next four decades.

Chapter 2: Confronting AIDS: A Career-Defining Crisis

When the first cases of what would later be known as AIDS appeared in medical literature in June 1981, Dr. Fauci made a career-altering decision that many colleagues warned against. He shifted his research focus entirely to this mysterious new syndrome, recognizing its potentially catastrophic implications. "I felt that this was going to be a public health problem of historic proportions," he later recalled. This intuitive understanding of the disease's significance, before its viral cause was even identified, demonstrated Fauci's remarkable scientific foresight and his willingness to take professional risks in pursuit of urgent public health needs. The early years of the AIDS epidemic were marked by profound scientific uncertainty, public fear, and the devastating reality of a disease that killed nearly everyone it infected. Fauci immersed himself in both laboratory research and clinical care, often working eighteen-hour days. He and his team at NIH were among the first to demonstrate how HIV progressively destroys the immune system even during the asymptomatic phase of infection. This discovery helped explain the disease's insidious nature and informed subsequent treatment approaches. As his scientific contributions mounted, Fauci was appointed Director of the National Institute of Allergy and Infectious Diseases (NIAID) in 1984, a position that gave him both the platform and resources to address the growing crisis. The human dimension of the AIDS crisis affected Fauci deeply. Unlike many laboratory scientists, he maintained direct contact with patients, conducting rounds at the NIH Clinical Center where some of the first AIDS patients were treated. He witnessed firsthand the physical suffering and social isolation experienced by those with the disease. One patient, a previously healthy young man who suddenly went blind from cytomegalovirus infection despite treatment, particularly affected him. "It was as if someone had stuck a spike in my chest," Fauci remembered. After leaving the patient's room, he burst into tears in his office – a rare emotional display for the typically composed scientist. These personal encounters with suffering reinforced his determination to find effective treatments. Fauci's relationship with AIDS activists evolved in ways that would transform both medical research and his own approach to public health. Initially, he was a target of their anger. Larry Kramer, the playwright and founder of ACT UP (AIDS Coalition to Unleash Power), famously called Fauci a "murderer" in the San Francisco Examiner for what activists perceived as an inadequate government response. Rather than dismissing these critics, Fauci took the unprecedented step of engaging with them directly. He attended community meetings in Greenwich Village, invited protest leaders to his office, and listened to their perspectives. This willingness to engage with affected communities represented a radical departure from traditional scientific aloofness. The dialogue with activists led to concrete changes in how clinical trials were conducted. Fauci championed the "parallel track" approach, which allowed patients who couldn't participate in clinical trials to access experimental drugs. He incorporated community representatives into the clinical trial design process, recognizing that their lived experience offered valuable insights that laboratory scientists lacked. These innovations accelerated drug development while maintaining scientific rigor. The collaborative model Fauci helped establish – bringing together scientists, clinicians, industry, and affected communities – became a template for addressing future health crises. By the mid-1990s, the development of highly active antiretroviral therapy transformed HIV/AIDS from a death sentence to a manageable chronic condition. Fauci's institute had played a central role in the basic research that made these treatments possible. His ability to navigate the complex scientific, political, and social dimensions of the AIDS crisis established him as not just a brilliant scientist but as a public health leader who could translate laboratory discoveries into real-world solutions. The lessons learned during this period – about engaging affected communities, communicating scientific uncertainty, and maintaining scientific integrity amid political pressures – would prove invaluable in the challenges that lay ahead.

Chapter 3: Building Bridges with Activists and Communities

The evolution of Fauci's relationship with AIDS activists represents one of the most remarkable aspects of his career. When ACT UP demonstrators first descended on the NIH campus in Bethesda, Maryland in 1988, they came with anger and desperation. They staged die-ins, carried coffins, and hung Fauci in effigy. Their message was clear: the government's response to the AIDS crisis was inadequate, clinical trials were too slow, and experimental drugs remained inaccessible to dying patients. Many government officials dismissed the protesters as radical troublemakers, but Fauci saw something different – he recognized their anger as a rational response to an existential threat. In a move that surprised both his colleagues and the activists themselves, Fauci invited several ACT UP leaders into his office for a conversation. "This was the first time in anyone's memory that a government official had invited them to sit down and talk on equal terms," Fauci later noted. During this meeting, he listened more than he spoke, absorbing their criticisms and perspectives. He began to understand that the activists possessed valuable knowledge about the realities of living with HIV and the practical challenges of clinical trial participation. Their demands for changes to the clinical trial process – which many scientists initially rejected as undermining research integrity – contained legitimate insights about how to make studies both more accessible and more relevant to patients' needs. The relationship with Larry Kramer, one of Fauci's fiercest critics, evolved in particularly striking ways. Despite Kramer's public denunciations, the two men developed what Kramer later described as an "extremely complex" friendship. Their heated debates about trial designs and drug approval processes ultimately led to mutual respect. When Kramer became seriously ill with liver disease years later, Fauci personally arranged for his treatment at the NIH Clinical Center and visited him regularly. Their last phone conversation before Kramer's death in 2020 ended with expressions of mutual love – a remarkable evolution from their contentious beginnings. Fauci's willingness to incorporate community perspectives into scientific processes represented a paradigm shift in medical research. He established community advisory boards for clinical trials, ensuring that those most affected by the disease had input into study designs and priorities. This approach not only improved the practical aspects of research but also built trust between scientific institutions and marginalized communities. The model of community engagement pioneered during the AIDS crisis has since been applied to research on numerous other conditions, from cancer to Alzheimer's disease, demonstrating how Fauci's innovations extended far beyond HIV/AIDS. The bridge-building extended to religious communities as well. Recognizing that faith leaders played crucial roles in many communities affected by HIV, Fauci engaged with religious organizations that were providing care and support to patients. He spoke at churches and synagogues, explaining the science of HIV while acknowledging the moral and spiritual dimensions of the epidemic. This willingness to engage across cultural divides helped reduce stigma and increase access to prevention and treatment services in communities where mistrust of government and medical institutions ran deep. By transforming adversarial relationships into productive partnerships, Fauci demonstrated a leadership approach that valued diverse perspectives and prioritized practical outcomes over institutional ego. The lessons he learned through these experiences – listening to affected communities, adapting institutional practices to meet real-world needs, and building trust through transparent communication – became central to his approach to subsequent public health challenges. The bridges he built during the AIDS crisis created pathways for collaboration that would prove essential in addressing future epidemics, from Ebola to COVID-19.

Chapter 4: Global Health Leadership and PEPFAR

The devastating impact of HIV/AIDS in sub-Saharan Africa became increasingly apparent in the late 1990s, as the epidemic ravaged communities while effective treatments remained largely unavailable in resource-limited settings. During a visit to Uganda in 2001, Fauci witnessed firsthand the catastrophic human toll. In crowded hospital wards, he saw patients with advanced AIDS receiving palliative care at best, with no access to the antiretroviral therapies that were transforming outcomes in wealthy nations. One encounter particularly affected him – a seventeen-year-old girl, just two years older than his own daughter, dying of fungal meningitis with no access to the medications routinely used in the United States. This experience crystallized his conviction that expanding global access to HIV treatment was not just a scientific challenge but a moral imperative. When President George W. Bush expressed interest in addressing the global AIDS pandemic, Fauci seized the opportunity. Working with colleagues including Dr. Mark Dybul, he developed a proposal that would evolve into the President's Emergency Plan for AIDS Relief (PEPFAR). Announced in Bush's 2003 State of the Union address, PEPFAR initially committed $15 billion over five years to combat HIV/AIDS in the hardest-hit countries, with a focus on prevention, treatment, and care. The scale of this commitment was unprecedented – the largest initiative by any nation to address a single disease. Skeptics questioned whether complex antiretroviral treatment regimens could be effectively delivered in settings with limited healthcare infrastructure, but Fauci was convinced it was possible. Fauci's approach to implementing PEPFAR reflected both scientific rigor and practical wisdom. Rather than imposing American solutions, the program established partnerships with local organizations and governments, building on existing infrastructure while providing resources to expand capacity. Fauci insisted on evidence-based interventions while acknowledging the need for adaptations to local contexts. The program invested not just in medications but in training healthcare workers, strengthening laboratory systems, and building supply chains. This comprehensive approach created sustainable improvements in healthcare systems that extended beyond HIV/AIDS to benefit broader public health. The success of PEPFAR exceeded even optimistic projections. By 2020, the program had saved over 20 million lives and prevented millions of HIV infections. Regions once devastated by AIDS saw dramatic reductions in mortality and new infections. Children who would have been orphaned grew up with their parents; workers who would have been lost to the economy remained productive; communities that might have collapsed maintained their social fabric. The program demonstrated that with political will and adequate resources, effective health interventions could be implemented at scale even in the most challenging settings. Beyond the direct impact on HIV/AIDS, PEPFAR transformed global health approaches in several important ways. It established a model of accountability, with clear targets and rigorous evaluation of outcomes. It demonstrated the effectiveness of integrating prevention, treatment, and care rather than focusing narrowly on any single approach. Perhaps most importantly, it showed that investments in global health security ultimately benefit everyone, including Americans – a principle that would prove crucial during subsequent global health emergencies. For his contributions to PEPFAR, Fauci received the Presidential Medal of Freedom in 2008, the highest civilian honor in the United States. Yet he remained characteristically focused on the work still to be done, advocating for sustained funding and expanded programs. The relationships and infrastructure established through PEPFAR created a foundation for addressing other global health challenges, from tuberculosis to maternal mortality. When COVID-19 emerged as a global threat, the networks built through PEPFAR provided channels for information sharing and coordinated responses, demonstrating how investments in global health systems yield dividends far beyond their original targets.

Chapter 5: Bioterrorism and Emerging Disease Preparedness

The terrorist attacks of September 11, 2001, followed by the anthrax letter attacks weeks later, thrust Fauci into a new role at the intersection of public health and national security. On that fateful September morning, he was in Manhattan for a meeting when the first plane hit the World Trade Center. Like millions of Americans, he watched in horror as the towers collapsed, but his scientific mind immediately turned to the possibility of subsequent biological attacks. This concern proved prescient when letters containing anthrax spores began appearing in media offices and congressional buildings, ultimately killing five people and infecting seventeen others. Secretary of Health and Human Services Tommy Thompson asked Fauci to serve as the department's point person for biodefense, a role that required him to balance scientific expertise with national security considerations. Overnight, Fauci found himself participating in high-level security briefings and helping develop strategies to counter potential bioterrorism threats. The anthrax attacks highlighted vulnerabilities in America's public health infrastructure that Fauci had long recognized but that now gained urgent attention. He advocated successfully for increased funding for biodefense research, including the development of new vaccines, therapeutics, and diagnostic tools. Fauci's approach to biodefense reflected his characteristic blend of scientific rigor and practical action. He recognized that effective preparedness required not just stockpiling countermeasures against known threats like anthrax and smallpox but developing flexible platforms that could be rapidly adapted to novel agents. Under his leadership, NIAID established a network of regional biocontainment laboratories and research centers focused on emerging infectious diseases. These investments created capacity that would prove valuable not just for biodefense but for responding to naturally occurring outbreaks. The anthrax crisis also highlighted Fauci's exceptional communication skills during public health emergencies. As fear spread across the country, he became a calm, authoritative voice explaining the nature of the threat and the appropriate responses. On NBC's Meet the Press, when asked how Americans should deal with their anxiety about bioterrorism, Fauci delivered a message that would become familiar in future crises: there was reason for concern but not panic. "We should productively channel that anxiety and concern into heightened alertness and preparedness," he advised. This balanced approach – acknowledging legitimate concerns while providing context and practical guidance – would become his hallmark in crisis communication. Fauci's work in biodefense prepared him for a series of naturally occurring disease threats that emerged in the early 21st century. When SARS (Severe Acute Respiratory Syndrome) appeared in 2003, followed by concerns about H5N1 avian influenza, Fauci led efforts to understand these pathogens and develop countermeasures. The Vaccine Research Center, which President Clinton had established at Fauci's suggestion primarily for HIV vaccine research, expanded its focus to address these emerging threats. Through these successive challenges, Fauci refined approaches to pandemic preparedness that emphasized surveillance systems to detect new pathogens, rapid diagnostic capabilities, and platforms for developing vaccines and treatments that could be quickly adapted to novel threats. The 2014-2016 Ebola outbreak in West Africa represented another pivotal moment in Fauci's career. As the deadly virus spread through Guinea, Liberia, and Sierra Leone, causing international alarm, NIAID took a leading role in developing and testing experimental treatments and vaccines. Beyond directing research, Fauci personally cared for Nina Pham, a nurse who contracted Ebola while treating a patient in Dallas, at the NIH Clinical Center. This hands-on involvement – putting himself at the same risk he asked of his staff – exemplified his leadership approach and his continued connection to clinical medicine despite his administrative responsibilities. The successful containment of Ebola validated many of the preparedness measures Fauci had championed, while also revealing gaps that informed subsequent planning efforts.

Chapter 6: The COVID-19 Pandemic: Science Under Pressure

When reports of a mysterious pneumonia in Wuhan, China emerged in late December 2019, Dr. Fauci immediately recognized the potential threat. At 79 years old, when many of his contemporaries had long since retired, he drew on decades of experience with emerging infectious diseases to mobilize a rapid response. Within days of the novel coronavirus's genetic sequence becoming available, Fauci directed the Vaccine Research Center at NIAID to begin developing what would become the mRNA COVID-19 vaccines – a decision that would ultimately save countless lives. This early action, taken before most Americans had even heard of the virus, reflected both scientific foresight and the preparedness infrastructure he had built over decades. As COVID-19 spread globally and reached American shores, Fauci emerged as the scientific face of the U.S. response. His daily press briefings and media appearances provided clear, fact-based information during a time of profound uncertainty and misinformation. Speaking with his characteristic Brooklyn-accented directness, he explained complex concepts like viral transmission and vaccine development in terms the public could understand. When scientific understanding evolved – as it inevitably does during a novel outbreak – Fauci acknowledged these changes transparently, maintaining public trust even as recommendations shifted. His ability to communicate both what was known and what remained uncertain became an essential counterweight to confusion and conspiracy theories. The political environment surrounding COVID-19 presented unprecedented challenges for Fauci. Serving in the Trump administration, he frequently found himself navigating between scientific evidence and political pressures. When early hopes that the virus would "disappear" proved unfounded, Fauci delivered unwelcome truths about the pandemic's severity and likely duration. His public statements sometimes contradicted optimistic political messaging, creating tensions that played out in press briefings and social media. Despite these pressures, Fauci maintained his focus on providing accurate information to the American people, appearing on news programs across the political spectrum and adapting his communication style to different audiences while keeping his scientific message consistent. The development and distribution of COVID-19 vaccines represented both a scientific triumph and a logistical challenge of unprecedented scale. Operation Warp Speed, which accelerated vaccine development while maintaining scientific standards, reflected principles Fauci had advocated throughout his career: streamlining processes without compromising safety or efficacy. When the first vaccines received emergency authorization less than a year after the pandemic began – a timeline previously considered impossible – it validated decades of investment in basic research and scientific infrastructure. Fauci became a leading voice explaining how the vaccines were developed so quickly without cutting corners on safety, addressing public concerns with transparency and detailed information. As the pandemic evolved through successive waves and viral variants, Fauci continued to adapt guidance based on emerging evidence. This necessary scientific flexibility – changing recommendations as new data emerged – sometimes created public confusion and opened him to criticism. Yet Fauci maintained that honesty about uncertainty and willingness to revise approaches based on new evidence were essential to scientific integrity, especially during a rapidly evolving crisis. When asked about changing guidance on masks or booster shots, he consistently explained the scientific rationale while acknowledging the frustration that such changes could cause. The personal toll of leading through the pandemic was significant. Fauci received death threats that necessitated security protection for him and his family. His name and image became political flashpoints, with some viewing him as a trusted expert while others cast him as a symbol of government overreach. Despite these pressures, colleagues noted his unwavering commitment to scientific integrity and public service. When asked about the personal attacks, Fauci typically redirected attention to the pandemic itself and the importance of following evidence-based guidance. This focus on the mission rather than personal vindication exemplified the servant leadership that had characterized his entire career.

Chapter 7: Legacy of Scientific Integrity and Public Communication

Throughout his seven-decade career spanning seven presidential administrations, Anthony Fauci established a remarkable legacy defined by scientific excellence, public service, and unwavering integrity. From his early research on immunoregulatory mechanisms to his leadership during multiple public health crises, Fauci maintained a consistent commitment to following the evidence wherever it led. This principle guided his approach to both research and public communication, even when facing political pressure or public controversy. Early in his tenure as NIAID director, he received valuable advice from a mentor: "When you are walking into the West Wing of the White House to advise the president, remind yourself that this might be the last time you will walk through that door." This counsel underscored that telling uncomfortable truths might mean not being invited back, but Fauci embraced this philosophy, resolving to base his advice "purely on scientific evidence and best judgment, and nothing else." Fauci's approach to science communication evolved significantly over his career. In his early years, he spoke primarily in the technical language of scientific journals. As he assumed greater public health responsibilities, he developed the ability to translate complex scientific concepts into accessible terms without oversimplification. During the AIDS crisis, he learned to address not just the scientific aspects of disease but also the human dimensions – the fear, stigma, and social impacts that affected how people responded to health information. By the time COVID-19 emerged, Fauci had mastered the art of the sound bite – delivering concise, memorable statements that conveyed essential information – while maintaining scientific accuracy. This skill proved invaluable during countless congressional testimonies, press briefings, and media interviews. Perhaps Fauci's most significant contribution to science communication was his willingness to acknowledge uncertainty and adapt recommendations based on new evidence. Rather than presenting science as a fixed set of facts, he portrayed it accurately as an evolving process of discovery. During the COVID-19 pandemic, when preliminary findings sometimes led to revised guidance, Fauci explained these changes transparently, helping the public understand how scientific knowledge develops. This approach – being honest about the limits of current understanding while providing the best available guidance – built trust even when the messages were complex or changing. It offered an alternative to both absolutist claims of certainty and nihilistic rejection of expertise. Fauci's legacy extends far beyond his scientific contributions through the generations of researchers and public health officials he mentored. As a laboratory chief at NIH, he trained dozens of scientists who went on to leadership positions throughout the biomedical research world. As NIAID director, he created institutional cultures that valued both innovation and rigor, encouraging young researchers to pursue bold ideas while maintaining scientific standards. His example of bridging laboratory science with clinical medicine and public policy inspired countless physicians to pursue careers in research and public health. The "Fauci effect" – a surge in medical school applications during the COVID-19 pandemic – reflected how his visible public service motivated a new generation to enter healthcare professions. Throughout his career, Fauci maintained his fundamental identity as a physician despite his high-profile leadership roles. Even as he advised presidents and testified before Congress, he continued to treat patients and conduct rounds at the NIH Clinical Center. This clinical connection grounded his policy recommendations in the reality of individual suffering and healing. It reminded him daily of the ultimate purpose behind the research programs he directed and the public health measures he advocated. This integration of scientific expertise with medical humanism – understanding both the molecular mechanisms of disease and the human experience of illness – defined Fauci's unique contribution to American medicine and public health. As new infectious disease threats inevitably emerge in the future, the institutions Fauci built and the principles he championed will continue to shape responses. His legacy reminds us that effective public health requires not just scientific knowledge but also moral courage – the willingness to follow evidence where it leads, communicate honestly with the public, and persist through criticism and controversy. In a world where health challenges grow increasingly complex and globalized, Fauci's example of bringing science, compassion, and clear communication to bear on seemingly insurmountable problems offers an enduring model for those who follow in his footsteps.

Summary

Anthony Fauci's extraordinary career embodies the ideal of science in service to humanity. From his early days treating AIDS patients when others feared to enter their rooms, to his steady leadership during the COVID-19 pandemic, Fauci consistently demonstrated that scientific excellence and human compassion are not competing values but complementary strengths. His willingness to engage critics rather than dismiss them, his ability to communicate complex scientific concepts in accessible language, and his unwavering commitment to evidence-based approaches transformed how government scientists interact with the public. Through successive crises spanning more than five decades, he maintained his focus on a singular purpose: alleviating human suffering through the rigorous application of science. The lessons of Fauci's career extend far beyond medicine or public health. His example teaches us about maintaining integrity under pressure, balancing scientific precision with practical action, and persevering through criticism when guided by evidence and principle. For scientists, his career demonstrates the importance of communicating beyond academic circles and engaging with the communities most affected by their work. For public servants, he models how to navigate political realities without compromising professional ethics. For citizens, he illustrates how expertise, when combined with compassion and clear communication, serves the common good. In an era of increasing polarization and misinformation, Fauci's insistence that truth matters – that facts exist independent of political preference or personal convenience – stands as a powerful counterweight to cynicism and a beacon for those committed to evidence-based approaches to our most pressing challenges.

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Anthony Fauci

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