Just before midnight on March 22nd, the President of the United States prepared to tweet. Millions of Americans, in the hope of safeguarding their health and fighting the rapidly escalating spread of covid-19, had already begun to follow the sober recommendation of Anthony S. Fauci, the country’s leading expert on infectious disease. Fauci had warned Americans to “hunker down significantly more than we as a country are doing.” Donald Trump disagreed. “we cannot let the cure be worse than the problem itself,” he tweeted.
Trump had seen enough of “social distancing.” In an election year, he was watching the stock market collapse, unemployment spike, and the national mood devolve into collective anxiety. “I would love to have the country opened up, and just rarin’ to go by Easter,” he said, on Fox News. “You’ll have packed churches all over our country. I think it’ll be a beautiful time.”
Trump’s Easter forecast came more than two months after the first U.S. case of covid-19 was identified, in Washington State, and more than a hundred days after the novel coronavirus emerged, first from bats and then from a live-animal market in the Chinese city of Wuhan. Every day, more people were falling sick and dying. Despite a catastrophic lack of testing capacity, it was clear that the virus had reached every corner of the nation. With the Easter holiday just a few weeks away, there was not a single public-health official in the United States who appeared to share the President’s rosy surmises.
Anthony Fauci certainly did not. At seventy-nine, Fauci has run the National Institute of Allergy and Infectious Diseases for thirty-six years, through six Administrations and a long procession of viral epidemics: H.I.V., sars, avian influenza, swine flu, Zika, and Ebola among them. As a member of the Administration’s coronavirus task force, Fauci seemed to believe that the government’s actions could be directed, even if the President’s pronouncements could not. At White House briefings, it has regularly fallen to Fauci to gently amend Trump’s absurdities, half-truths, and outright lies. No, there is no evidence that the malaria drug hydroxychloroquine will provide a “miracle” treatment to stave off the infection. No, there won’t be a vaccine for at least a year. When the President insisted for many weeks on denying the government’s inability to deliver test kits for the virus, Fauci, testifying before Congress, put the matter bluntly. “That’s a failing,” he said. “Let’s admit it.”
When Trump was not dismissing the severity of the crisis, he was blaming others for it: the Chinese, the Europeans, and, as always, Barack Obama. He blamed governors who were desperate for federal help and had been reduced to fighting one another for lifesaving ventilators. In one briefing, Governor Andrew Cuomo, of New York, said, “It’s like being on eBay with fifty other states, bidding on a ventilator.” Trump even accused hospital workers in New York City of pilfering surgical masks and other vital protective equipment that they needed to stay alive. “Are they going out the back door?” Trump wondered aloud.
As a reporter who writes mainly on science and public-health issues, I’ve known Fauci since the H.I.V./aids epidemic exploded, in the mid-eighties. He once explained to me that he has developed a method for dealing with political leaders in times of crisis: “I go to my favorite book of philosophy, ‘The Godfather,’ and say, ‘It’s nothing personal, it’s strictly business.’ ” He continued, “You just have a job to do. Even when somebody’s acting ridiculous, you can’t chide them for it. You’ve got to deal with them. Because if you don’t deal with them, then you’re out of the picture.”
Since his days of advising Ronald Reagan and George H. W. Bush, Fauci has maintained a simple credo: “You stay completely apolitical and non-ideological, and you stick to what it is that you do. I’m a scientist and I’m a physician. And that’s it.” He learned the value of candor early. “Some wise person who used to be in the White House, in the Nixon Administration, told me a very interesting dictum to live by,” he told me in 2016, during a public conversation we had at the fifty-year reunion of his medical-school class. “He said, ‘When you go into the White House, you should be prepared that that is the last time you will ever go in. Because if you go in saying, I’m going to tell somebody something they want to hear, then you’ve shot yourself in the foot.’ Now everybody knows I’m going to tell them exactly what’s the truth.”
Americans have come to rely on Fauci’s authoritative presence. Perhaps not since the Vietnam era, when Walter Cronkite, the avuncular anchor of the “CBS Evening News,” was routinely described as the most trusted man in America, has the country depended so completely on one person to deliver a daily dose of plain talk. In one national poll, released last Thursday, seventy-eight per cent of participants approved of Fauci’s performance. Only seven per cent disapproved.
On March 23rd, Fauci failed to appear at the daily briefing in the White House pressroom. Twitter promptly lost its mind. #NoFauci became a top trending topic, followed closely by #whereisFauci and #letTonyspeak. There was speculation that Trump, who is inclined to fire anyone who disagrees with him or, worse, garners some praise in the media, had lost patience with Fauci. As one of Fauci’s old friends told me, “This is a President who doesn’t give a shit about Fauci’s accomplishments, his history, or his learning. If anything, they’re negatives.”
The truth was less alarming. “I was tied up in a task-force meeting, and we were trying to work out some difficult policies,” Fauci said. “I have no trouble with the President. When I talk to him, he listens.” My experience with Fauci suggested that this last statement was perhaps a triumph of pragmatism over accuracy. His priority, as he’s made clear, is to do what is necessary to save lives. So I was not surprised to receive an e-mail from Fauci the following day, saying that he had been asked to refrain from participating in personal profiles. It seemed that it was one thing for him to talk about the news with reporters or even to chat on Instagram with Stephen Curry, the Golden State Warriors star. But focussing on himself, rather than on the President, was another thing entirely.
Fauci and Trump are about as odd a duo as American political life has ever produced. Both men are in their seventies. Both come from the outer boroughs of New York City. Both are direct, even blunt. But that’s where the resemblance ends. Fauci has always been a person of unusual discipline. Nearing eighty, he works about eighteen hours a day. Long ago, when his three children were young, he and his wife, Christine Grady, who runs the bioethics department at the National Institutes of Health, decided to maintain the sanctity of family dinners by starting them when he got home from the office, at around nine o’clock. For decades, Fauci has taken long lunchtime runs, but, during the crisis, he’s cut back his routine to power walking––and only on weekends. Fauci parses his words with care and believes, above all, in the power of facts and the efficacy of data.
David Baltimore, a Nobel laureate and a pioneer of molecular biology, told me, “Tony is unique, in that he has such credibility with politicians that he’s been able to insert hard facts into the conversation. That has been wonderful for our country and the world.” According to David Relman, a microbiologist at Stanford University who for years has advised the government on biological threats, “Tony has essentially become the embodiment of the biomedical and public-health research enterprise in the United States. Nobody is a more tireless champion of the truth and the facts. I am not entirely sure what we would do without him.”
Fauci can be impatient with the compromises of politics. In my conversations with him, he has responded furiously when a dicey amendment, a bogus rider, or a “poison pill” is attached to a public-health bill. He recalled one congressional provision, in 2016, that tried to make it “legally permissible to fly the Confederate flag at national cemeteries. I am not kidding.” When dealing with politicians, he told me, he relies on the pseudo-Latin expression Illegitimi non carborundum:Don’t let the bastards grind you down. But he has inspired respect throughout the political world and beyond. Fauci’s office walls are covered with scores of photographs of him with Presidents, senators, visiting Prime Ministers, business leaders, actors. In October, 1988, George H. W. Bush, during a Presidential debate with Michael Dukakis, was asked who his heroes were. “I think of Dr. Fauci,” Bush replied. “You’ve probably never heard of him. . . . He’s a very fine researcher, a top doctor at the National Institutes of Health, working hard, doing something about research on this disease of aids.”
These days, nearly everyone has heard of Fauci. Pandemic-memorabilia entrepreneurs have put his face on bottle openers, coffee mugs, and bumper stickers: “In Dr. Fauci we trust.” The National Bobblehead Hall of Fame and Museum has produced a seven-inch likeness of him, partly to raise money to produce protective gear for medical workers. There’s a Facebook group called Dr. Fauci Speaks, We Listen, and another called Dr. Fauci Memes for Social Distance Teens. A petition has circulated to nominate him as People’s“sexiest man alive.”
On right-wing social media and talk radio, Fauci has a different image: he is routinely disparaged as a closet lefty who is exaggerating the threat of the coronavirus. “Has anyone else noticed that every suggestion by Dr. Doom Fauci just happens to also be the worst possible thing for the economy?” the conservative Internet TV host Bill Mitchell tweeted. “That’s not an accident folks.” An analysis in the Timesfound more than seventy Twitter accounts that have pushed the hashtag #FauciFraud, with some tweeting out anti-Fauci bile hundreds of times a day. “There seems to be a concerted effort on the part of Trump supporters to spread misinformation about the virus,” Carl Bergstrom, a professor of biology at the University of Washington who has studied misinformation, told the paper. “There is this sense that experts are untrustworthy, and have agendas that aren’t aligned with the people.” Fauci has received so many personal threats that the Justice Department recently approved a security detail for him. Fauci shrugged it off, telling reporters, “I’ve chosen this life.”
The crisis that the world now faces comes as no surprise to Fauci. On January 10, 2017, ten days before Trump took the oath of office, Fauci delivered the keynote address at a conference at Georgetown University, titled “Pandemic Preparedness for the Next Administration.” After describing his years of managing epidemics, he posed a series of questions to the audience: “Will there be a resurgence of Zika? We’re getting into the summer in South America. Are we going to see a resurgence or not? What about influenza? Are we going to get a new pandemic?”
Fauci’s last point, he emphasized, was almost certainly the most important: the possibility that some unknown, powerfully infectious pathogen could emerge to threaten the world. “What about things that we’re not even thinking about?” he said. He let the question drift out over the hall. “What is for sure,” he concluded, “is that, no matter what, history has told us definitively that it will happen.”
On the day that Anthony Stephen Fauci was born, the front-page headline in the Timeswas “president to give emergency facts to nation on radio.” It was Christmas Eve, 1940. The Second World War had begun, and the United States was less than a year away from joining the fight.
Fauci grew up in southwest Brooklyn, first in Bensonhurst and later in Dyker Heights, where his family ran a pharmacy and lived in an apartment upstairs. The pharmacy was across the street from the Shrine Church of St. Bernadette. When Mass was finished on Sundays, Fauci recalled, people would walk over to get prescriptions filled and to buy whatever else they needed for the coming week. Tony’s father, Stephen, dispensed medications, and was known to customers as Doc. His mother, Eugenia, worked the register, along with his older sister, Denise. From an early age, Tony spent evenings and weekends riding around the neighborhood on his Schwinn, making deliveries.
Fauci’s parents were born in New York; one set of grandparents had emigrated from Naples, the other from Sicily. Anthony first took Communion at the age of seven and was confirmed at twelve. He went to elementary school at Our Lady of Guadalupe, in Bensonhurst. “I had no idea at the time when I was there, being taught by the Dominican nuns, that I would be interested in science,” he said. “I was interested in a lot of things, mostly sports, but certainly not science.”
In those days, baseball was the social glue of Brooklyn. The borough was Dodger territory and Ebbets Field was consecrated ground—but Fauci was devoted to the Yankees, who played in the faraway Bronx. In the midst of the coronavirus crisis, I e-mailed to ask about this anomaly, not necessarily expecting an answer. He replied almost instantly. “You probably are unaware, but half the kids in Brooklyn were Yankee fans,” he wrote. “We spent our days arguing who was better: Duke Snider versus Mickey Mantle; Roy Campanella versus Yogi Berra; Pee Wee Reese versus Phil Rizzuto and on and on. Those were the days, my friend.”
Fauci has often referred to his father as “laid-back,” which, if true, must be a characteristic that skips a generation. “Tony has always been driven,” Michael Osterholm, the director of the University of Minnesota’s Center for Infectious Disease Research and Policy, and a longtime friend of Fauci’s, told me. “Whatever he was doing, he had to do it better than anybody else. I don’t know if it was certainty or something else. But he was meant to lead. Always. Everyone who knew him knew that. And Tony knew it, too.”
In 1954, he began attending Regis, a private Jesuit high school on the Upper East Side. Rigorous, small, competitive, and tuition-free, Regis is considered one of the finest all-male schools in the country. Fauci thrived there, though the commute between Dyker Heights and Eighty-fourth and Madison was long. He once estimated that he had spent the equivalent of seventy days of his teen-age life on the various subways and buses he took to get to and from school.
Fauci revelled in the demanding coursework. “We took four years of Greek, four years of Latin, three years of French, ancient history, theology,” he recalled. He developed an ability to set out an argument and to bolster it with evidence—good preparation, it turned out, for testifying before Congress. Last year, at a dinner that Regis held in his honor, he said that the school had taught him “to communicate scientific principles, or principles of basic and clinical research, without getting very profuse and off on tangents.”
At the time, though, Fauci had no interest in becoming a doctor. “I was captain of the Regis High School basketball team,” he once told me. “I thought this was what I wanted to do with myself. But, being a realist, I very quickly found out that a five-seven, really fast, good-shooting point guard will never be as good as a really fast, good-shooting seven-footer. I decided to change the direction of my career.”
At school, Fauci’s accomplished peers were headed to careers in medicine, engineering, and the law. At home, he was steeped in the humanities: “Virtually all my relatives on my mother’s side—her father, her brother, and her sister’s children—are artists.” His mother helped tip the balance. “She never really pressured me in any way, but I think I subtly picked up the vibrations that she wanted very much for me to be a physician,” Fauci said. “There was this tension—would it be humanities and classics, or would it be science? As I analyzed that, it seemed to me that being a physician was the perfect melding of both of those aspirations.”
From Regis, Fauci went on to another Jesuit institution, Holy Cross, in Worcester, Massachusetts. His high-school faculty had left him little choice in the matter. “They just wouldn’t write a recommendation for you if you wanted to apply to Harvard or to Cornell, or Columbia,” he said. Fauci enrolled in 1958 and was pleased to find that the university took a broad view of premedical studies. He signed up for a program called Bachelor of Arts–Greek Classics–Premed. “It was really kind of bizarre,” he recalled. “We did a lot of classics, Greek, Latin, Romance languages. . . . We took many credits of philosophy, everything from epistemology to philosophical psychology, logic, etc. But we took enough biology and physics and science to get you into medical school.”
During the summers, Fauci worked construction jobs. One year, he found himself assigned to a crew that was building a new library at Cornell Medical College, on the Upper East Side. “On lunch break, when the crew were eating their hero sandwiches and making catcalls to nurses, I snuck into the auditorium to take a peek,” Fauci recalled in 1998, at the medical school’s centennial celebration. “I got goosebumps as I entered, looked around the empty room, and imagined what it would be like to attend this extraordinary institution. After a few minutes at the doorway, a guard came and politely told me to leave, since my dirty boots were soiling the floor. I looked at him and said proudly that I would be attending this institution a year from now. He laughed and said, ‘Right, kid, and next year I am going to be Police Commissioner.’ ”
Fauci graduated first in his class from Cornell in 1966, just as America’s involvement in Vietnam was accelerating. Every new physician was required to perform some kind of military service. “We were gathered in the auditorium at Cornell, early in our fourth year of medical school,” Fauci recalled. “Unlike today, we had only two women in the class and seventy-nine men. The recruiter from the armed forces came there and said, ‘Believe it or not, when you graduate from medical school at the end of the year, except for the two women, everyone in this room is going to be either in the Army, the Air Force, the Navy, or the Public Health Service. So you’re going to have to make your choice. Sign up and give your preferences.’ ”
Fauci wanted to work in the U.S. Public Health Service; his fallback was the Navy. He got his first choice, and ended up at the National Institutes of Health, which was then establishing itself as the country’s primary center for biomedical research. Nearly everyone in academic medicine spent some time at one of its branches; except for three years back at Cornell to complete his internship and residency, Fauci has spent five decades there.
In 1972, Fauci started as a senior researcher at the National Institute of Allergy and Infectious Diseases. He was drawn to investigating ailments that were difficult but not impossible to treat. “I wanted something that could make you very sick and kill you unless I intervened. And if I intervene, you’re essentially cured,” he told Ushma Neill, the editor of The Journal of Clinical Investigation, in 2014. “Now, that seems a little bit too simplistic, but that’s really the nature of most infectious diseases.”
Working in the lab of Sheldon Wolff, Fauci studied the molecular nature of fever. The field of immunology was still young, but scientists were rapidly learning how to manipulate the smallest components of individual cells, which opened the way to a decade of discovery.
Chronic fevers can have a number of underlying causes, among them an uncommon condition known as vasculitis—an inflammation of the blood cells that often occurs when the body’s immune system mistakenly attacks its own blood vessels. Many of Fauci’s vasculitis patients suffered from rare inflammatory diseases, such as granulomatosis with polyangiitis, which damages blood vessels in the lungs, kidneys, and other organs. The disease was almost always fatal.
Fauci and his infectious-disease colleagues at the N.I.H. were frequently asked to visit the National Cancer Institute, which was in the same building as his lab, to consult on patients who were receiving chemotherapy. The drugs suppressed tumors, but they were highly toxic. And they had another side effect, Fauci told me: “Those people are susceptible to a lot of things like infections and bleeding, because the treatment has destroyed their immune systems.”
Fauci, together with Wolff, his mentor, wondered if this side effect could be harnessed to help vasculitis patients, whose immune systems were overactive. “I thought if we could somehow give a cancer drug at a low enough dose perhaps we could turn the disease off without any of the secondary complications,” he recalled recently. “First we did it in a few patients, and, much to our delight, they had a total remission. Before you know it, we ended up curing a very, very lethal, albeit uncommon, disease.”
For the first time, this technique enabled researchers to do effective work on lupus, rheumatoid arthritis, and transplant rejection. “If you look at immunology, it has from the very beginning been inextricably linked to infectious diseases,” Fauci said. “What is the immune system for? The immune system protects you against invaders from without—microorganisms—as well as, in some cases, the emergence of certain tumors from within.”
In 1981, a strange new syndrome emerged that transformed Fauci’s research and, eventually, the lives of millions of people around the world. “All of a sudden, this new disease comes along,” Fauci recalled, referring to what would soon come to be known as aids. “Even before the cause of it was proven to be H.I.V., everybody in the field knew that it had to be a virus. I said to myself, ‘Here it is, a virus, still to be determined, that’s affecting profoundly and destroying the human immune system.’ ” Fauci believed that he had been training all his life for a threat like this one. He was an expert in viruses and in the immune system—and he had always been attracted to combatting serious, even fatal diseases. “I wanted to be where the action was,” he said.
At first, few public-health officials seemed to care. In June of 1981, the Morbidity and Mortality Weekly Report, a publication of the Centers for Disease Control, issued a paper that included an account of five young men, all gay, who had contracted pneumocystis, a form of pneumonia that had previously been reported only in people with dramatically impaired immune systems. The young men described in the study had all been healthy. “I thought it was a fluke,” Fauci recalled. “I put it aside on my desk, thinking that maybe this was some drug that they had taken that suppressed their immune system.”
A month later, an even more alarming report arrived from the C.D.C. Fauci read it with an uneasy sense that a disaster was looming: “I made the decision that I was going to stop what I was doing, much to the chagrin of my mentors, who were saying, ‘Why do you want to give up a great trajectory of a career to study a handful of gay men with this strange disease?’ But, deep down, I really knew that this was going to explode.”
Fauci wrote a paper to sound the alarm. “I called it my apologia pro vita sua—an explanation for what I’m doing,” he said. In the paper, Fauci pointed out that, although the disease “seems to selectively affect a particular segment of our society,” it demanded a medical solution. Moreover, he warned, “any assumption that the syndrome will remain restricted to a particular segment of our society is truly an assumption without a scientific basis.” Fauci sent the manuscript to The New England Journal of Medicine, in late 1981. It was rejected. “One of the reviewers said I was being alarmist,” Fauci said. He tried a different journal, TheAnnals of Internal Medicine, and the following June the paper was published.
In the laboratory, Fauci began making progress. He had been investigating B cells, which are involved in the production of antibodies. In 1983—before H.I.V. was even known by that name—his lab became the first to report that B cells became hyperactive in patients with aids. When a healthy person is invaded by a virus, antibodies mount a defense, but, when H.I.V. hijacked B cells, the antibody system went awry. Fauci and his team had identified one of the crucial features of aids. “We made that observation without having any idea of what we were dealing with,” he said in an interview for an N.I.H. oral history. “I think that speaks for sound scientific and clinical observation.” The politics of seeking a cure, though, would be far harder to manage.
On October 11, 1988, more than a thousand aids activists gathered outside the headquarters of the Food and Drug Administration, in Rockville, Maryland, to protest the agency’s glacial reaction to the epidemic. The activists knew that their community needed new treatments if they were to avoid catastrophe—but they were stymied by the F.D.A.’s drug-approval process, a remarkably inflexible system that typically took years.
That same day, another group of protesters marched onto the campus of the National Institutes of Health, in Bethesda, Maryland. They were headed for Building 31, the home of the National Institute of Allergy and Infectious Diseases. Fauci, who had become the institute’s director in 1984, was now the government’s leading scientist focussed on the aids epidemic. Even though he was not running the F.D.A., he appeared almost daily in the media to discuss the crisis. “My face was the face of the federal government,” Fauci told me. He was asked the same question nearly every day: why wasn’t the government moving faster? It didn’t help that the Reagan Administration seemed so indifferent to the plague.
Fauci watched from his office window as activists surrounded the building and tried to scale its walls. Some were dressed in black robes and carried scythes. Many waved pink-and-black banners, bearing the words “NIH Wake Up!” or “Stop Killing Us!” All over campus, a chant could be heard: “Fuck you, Fauci!”
“God, I hated him,” Larry Kramer, the writer and activist who helped establish the two most important aids advocacy groups in the country, the Gay Men’s Health Crisis and act up, said. “As far as I was concerned, he was the central focus of evil in the world.” Kramer attacked Fauci relentlessly in the media. He called him an “incompetent idiot” and a “pill-pushing” tool of the medical establishment, insulted his wife, and even compared him to Adolf Eichmann. In 1988, Kramer published a scathing open letter. “Anthony Fauci, you are a murderer,” he wrote. “Your refusal to hear the screams of aids activists early in the crisis resulted in the deaths of thousands of Queers.”
As the epidemic spread and the death toll rose, it was common for gay activists to view Fauci and niaid with rage. Fauci did not control the drug-approval process, but he was seen as a barrier to opening access to clinical trials, in which volunteers could receive potentially lifesaving medications.
For most people infected with H.I.V., taking experimental drugs was the only alternative to simply waiting for death. Yet the F.D.A.’s arcane rules prevented the vast majority of patients from qualifying for trials. For instance, a significant number of H.I.V. patients suffered from pneumocystis pneumonia. The condition—the same one observed in the initial C.D.C. report—could be fatal, so many who had it used an experimental antimicrobial medication called pentamidine, which had proved highly effective. But people who took experimental medications were barred from participating in other clinical trials.
At first, Fauci held to the standard N.I.H. line that research need not focus on the immediate welfare of patients. “When we had clinical trials, we, the scientific community and the regulatory community, did not listen” to the activists, he recalled. “It was, at the time, an attitude that many of us had, and I probably had it myself.” He was right about that. I covered the aids epidemic for the Washington Post, and it was clear to me that Fauci was inclined to enforce the paternalistic medical tradition in which he had trained: doctors and scientists were unquestioned authorities, and drug development had to follow a rigid process that included animal testing and rigorous clinical trials. Otherwise, the benefits and the risks of these drugs could not be adequately assessed.
In 1987, the F.D.A. approved the first drug to treat H.I.V.—azidothymidine, or AZT—and the announcement was met with a burst of hope. But the drug’s liabilities were evident almost instantly. It had harsh side effects, and the benefits wore off; the virus itself soon became resistant to the drug. When new clinical studies began, involving cocktails of AZT and similar compounds, tens of thousands of people asked to participate. Again, though, volunteers were not accepted if they used other experimental drugs. The anger among activists grew more intense. “They started becoming amazingly iconoclastic and confrontational, and that scared the hell out of the scientists, who were fundamentally quite conservative,” Fauci told me at his medical-school reunion. “When they were demonstrating on the N.I.H. campus, disrupting Wall Street, disrupting St. Patrick’s Cathedral, instead of listening to them, scientists withdrew.”
Without entirely understanding his own motives, Fauci decided to look beyond the activists’ furious rhetoric and style. He recalls telling himself, “Let me put aside the goth dress—the earrings and the Mohawk haircuts and the black jackets—and just listen to what they have to say. And what they were saying made absolutely perfect sense.” It helped that Fauci had something in common with the activists: “They were all New York guys. I had a little affinity to them because I’m a New Yorker. And I said, What would I do if I were in their shoes? And it was very clear: I would have done exactly the same thing.”
The activists knew that they were facing a mercilessly lethal disease. In the summer of 1985, I travelled to New York to write my first long story on the toll that the epidemic was taking on the city’s gay community. I interviewed dozens of men. To the best of my knowledge, only two of them are still alive: Larry Kramer, who is now eighty-four, and a political activist who prefers to remain anonymous.
Fauci, too, came to understand the severity of the crisis. “Everyone died,” he said. “I was used to treating people who had little hope and then saving their lives––that was so wonderful. But, with aids in those days, I saved no one. It was the darkest time of my life.” Faced with mounting evidence that his cautious approach made no sense, he did something that few public officials do: he reversed himself. Fauci transformed from a conventional bench scientist into a public-health activist who happened to work for the federal government. “I had to change,” he told me.
When the demonstrators marched on the N.I.H. campus in 1988, Fauci no longer saw a threat. “I looked at them, and I saw people who were in pain,” he recalled in an article in Holy Cross Magazine. He asked the police and the F.B.I. not to arrest any of them. Then he invited a handful of protest leaders to his office. “That began a relationship over many years,” Fauci said. “They let me into their camp. I went to the gay bathhouses and spoke to them. I went to San Francisco, to the Castro District, and I discussed the problems they were having, the degree of suffering that was going on in the community, the need for them to get involved in clinical trials, since there were no other possibilities for them to get access to drugs. And I earned their confidence.”
Fauci, in his mid-forties, was the youngest director of an N.I.H. institute in a century, and he lacked the political influence to act independently. Even in his own field, he struggled to recruit allies. “I couldn’t convince my own people in infectious-disease leadership to take on H.I.V./aids,” he told me. So he created a division within his institute devoted to the disease.
One day, in the late eighties, Fauci asked me to stop by his office in Building 31 on the N.I.H. campus. He told me that he had a wild idea: he wanted to hire Mark Harrington, act up’s point man on drug-treatment trials. Harrington, a prominent aids researcher and activist, had no formal scientific training. But Fauci, like most of those who had seen him testify before Congress or speak to a crowd, was dazzled by his brilliance.
Harrington discussed the idea with Fauci, but decided that the job would be a disaster for him. “There’s no way I could have functioned within that bureaucracy,” he told me recently. “The people I respect would have seen me as a sellout.” Yet Harrington continued to make a profound impression on Fauci’s thinking.
Harrington was passionately committed to loosening up the F.D.A.’s restrictive regime. “It was murder,” he told me. “I don’t know any other way to describe it.” Harrington, who went on to win a MacArthur “genius” grant for his work on the disease, established himself as the most knowledgeable student of the agency’s byzantine regulations. In meetings with Fauci and other officials, he urged them to move faster and with greater compassion for those who were suffering.
There are three stages in most F.D.A. clinical trials. The first tests whether a drug is safe. The second assesses its efficacy. The last stage, conducted in larger groups, confirms that the drug works and that there are no serious adverse reactions. Harrington argued that people with no alternative should be granted access to those drugs as soon as they had been proved safe, even if their effectiveness remained unknown.
At first, Fauci was concerned that, if people taking multiple experimental medications joined clinical trials, the results would be hopelessly muddled. He was also afraid that granting sick people unrestricted access to unapproved drugs would deter them from participating in the trials at all. Harrington and other activists reassured him that they were committed to strictly monitored drug trials that would provide enough data to know what worked and what did not.
Fauci is a realist, and the facts were obvious to anyone who cared to look. Traditional methods of testing drugs weren’t working. Underground networks were growing everywhere. With so many aids patients taking untested medications, federal health officials had to concede that their system was broken. Even the most fundamental protocol of a clinical trial—giving some participants a placebo—came into question. In a study conducted in San Francisco in 1989, nearly all the volunteers had their medicine analyzed, to see whether they were receiving an active dose. Those who learned that they had been given placebos almost invariably dropped out.
“There was a feeling in science that doctors know best, scientists know best,” Fauci said. “We love our patients, but they don’t really know what’s best for them. Then, when we dealt with this disease that was brand new—that was frightening, that was killing people in a way that was historic—the people who were impacted by the disease wanted to have something to say about how we conducted research.”
There were still moments of confrontation. In May, 1990, hundreds of act up activists returned to the N.I.H., demanding more aids treatments and greater representation of women and people of color in clinical trials. At a planning session for the protest, a young activist named Tony Malliaris performed a rap song called “Storm the NIH,” which included the lyrics “I don’t know what Fauci thinks, but this ain’t Denmark, and something stinks.” (Malliaris died five years later, still in his early thirties.)
Fauci was undeterred. He threw his influence behind a program called Parallel Track, which made unapproved aids drugs available as soon as they were demonstrated to be safe, even as clinical trials were continuing. The initiative would not have succeeded without Fauci. But he always acknowledged that his approach had been shaped largely by the constructive pressure he received from aids advocacy groups and from leaders like Harrington.
This more inclusive approach ushered in a revolution in American medicine. Patients today demand as much information as possible about treatments they might receive, and no longer act as if their doctors’ advice came straight from Mt. Olympus. They scour the Internet, assemble statistics, and often arrive at the hospital with a folder full of medical information. The F.D.A., for its part, will no longer consider approving a new drug until it has consulted representatives of groups who would use it. “There are strict scientific principles that have to be adhered to in medicine,” Fauci told me. “At the same time, a humanistic touch is needed in dealing with people. You have to combine social aspects, ethical aspects, personal aspects with cold, clean science.”
In 2002, I wrote a Profile of Larry Kramer for this magazine. By then, he and Fauci had become friends, with each expressing gratitude for the other’s work in those years. Fauci told me, “In American medicine, there are two eras: before Larry and after Larry. There is no question in my mind that Larry helped change medicine in this country. When all the screaming and the histrionics are forgotten, that will remain.” Kramer, who spent years in a constant rage at Fauci, now calls him “the only true and great hero” among government officials in the aids crisis.
As Trump defends his Administration’s response to the pandemic, he has suggested repeatedly that covid-19 was impossible to predict. “There’s never been anything like this in history,” he said, at a press conference on March 19th. “Nobody knew there would be a pandemic or epidemic of this proportion.”
As everyone with even a casual interest in the history of science knows, pandemics have altered the destiny of humanity at least since 430 B.C., when Athens was struck by a plague that killed as many as two-thirds of its residents, just as the Spartans were laying siege. Beginning in 165 A.D., smallpox helped ruin the Roman Empire, sowing more destruction than foreign armies ever could. And, in the fourteenth century, the Black Death swept through Europe, killing more than half the population, according to recent estimates.
Yet, by the middle of the twentieth century, many scientists had begun to conceive of a world that was largely free of infectious epidemics. In 1951, Sir Frank Macfarlane Burnet, a future Nobel laureate in medicine, wrote, “The fever hospitals are vanishing or being turned to other uses. With full use of the knowledge we already possess, the effective control of every important infectious disease”—with the exception of polio—“is possible.” His optimism was understandable. Antibiotics had made many lethal diseases easy to treat; improvements in sanitary conditions had transformed the lives of hundreds of millions of people. In developed countries, typhoid, cholera, and measles—major killers throughout history—had largely passed into memory; even tuberculosis, one of the great scourges of humanity, had been in decline for nearly half a century. By 1972, Macfarlane, writing with the microbiologist David White, was predicting that the “most likely forecast about the future of infectious diseases is that it will be very dull.”
When Fauci was a young trainee, these kinds of predictions sometimes made him wonder if he had picked the wrong career. “I became concerned that I was entering . . . an area of biomedical research that was disappearing,” he recalled in one speech. But, since 1984, when Fauci became the director of niaid, there has not been a single day in which some epidemic has not threatened the globe. According to the World Health Organization, aids has killed more than thirty million people, and nearly forty million are now living with H.I.V. Tuberculosis, far from sliding into obscurity, infects roughly a quarter of the human population; the W.H.O. says that one and a half million people died from the disease in 2018.
But the greatest threat that humanity faces, by far, is a global outbreak of a lethal virus for which no treatment has been found. In just a few months, covid-19 has forced billions of people, in nearly every country on earth, into a panicked withdrawal from society. Another pandemic like this might appear in two years, or in ten, or in a century. But I have never met a virologist or an epidemiologist who believes we won’t encounter one.
For a deadly virus to flourish, it must meet three critical conditions. First, a new virus—one to which no one has yet developed immunity—must emerge from the animal reservoirs that produce and harbor such pathogens. Second, the virus has to make humans sick. (The vast majority do not.) Finally, it must be able to spread efficiently, through coughing, sneezing, or shaking hands. That combination is rare, but, when it appears, the consequences are almost always disastrous.
The Nobel Prize-winning molecular biologist Joshua Lederberg, who died in 2008, was for years the world’s most visionary voice about emerging infectious diseases. “Some people think I am being hysterical, but there are catastrophes ahead,” he once wrote. “We live in evolutionary competition with microbes—bacteria and viruses. There is no guarantee that we will be the survivors.”
In 2003, Lederberg joined the future F.D.A. commissioner Margaret Hamburg and the pandemic specialist Mark Smolinski to edit a seminal report, in which prominent scientists argued for a much more aggressive defense of the planet. Titled “Microbial Threats to Health,” the report recommended that the U.S. greatly expand its early-warning systems, particularly in the developing world. It also urged leaders to strengthen their ability to respond to microbial threats, with new efforts on the federal, state, and local levels. The recommendations were almost completely ignored.
The next year, a highly pathogenic form of avian influenza, H5N1, leaped from waterfowl to chickens and then to humans. Public-health officials were petrified. In Bangkok, I met with Scott Dowell, who led the Thailand office of the C.D.C.’s International Emerging Infections Program. “The world just has no idea what it’s going to see if this thing comes,” he told me. He paused and then reframed his thought. “When, really. It’s when. I don’t think we can afford the luxury of the word ‘if’ anymore.”
In a sense, the world was lucky with H5N1. Although the U.S. and other countries mounted a diffident response, the virus turned out to be deadly but not very contagious. Five years later, the situation was reversed. A new influenza virus, designated H1N1, infected nearly a quarter of the global population before vaccines became widely available. This time, the virus was highly contagious but not nearly as deadly as most strains of influenza. The fact that the outbreak was less virulent than public-health officials had feared created its own danger; by encouraging complacency, it did more to expose the world to the risk of a devastating new pandemic than anything else that had happened in decades.
Although Congress had appropriated money to stockpile antiviral medications and protective gear, many scientists felt that the effort was grossly insufficient. “We spend many billions of dollars every year on missile-defense systems,” Seth Berkley, a medical epidemiologist who leads the Global Vaccine Alliance, told me. “And yet we will not spend pennies on the dollar to prepare for a catastrophe that is far more likely to affect us all.”
After the Ebola outbreak of 2014, Barack Obama implemented one of Lederberg’s central recommendations: he established the White House’s National Security Council Directorate for Global Health Security and Biodefense, an early-warning system for disease in the developing world. Trump disbanded it in 2018, as part of an effort to streamline the N.S.C. In an appearance before Congress, Fauci was asked if the decision was a mistake. He responded diplomatically: “I wouldn’t necessarily characterize it as a mistake. I would say we worked very well with that office. It would be nice if the office was still there.”
The combination of money and political will can have extraordinary effects on public health. Under the George W. Bush Administration, Fauci was the principal architect of a landmark program called pepfar, the President’s Emergency Plan for aids Relief.
By the time Bush took office, therapies for H.I.V. had become widely available in Western countries. But, for millions of people in the developing world, these drugs were too expensive or too difficult to obtain. Bush felt that it was unacceptable for the poorest people on earth to die because they could not afford medication that was dispensed routinely in the rich world. He asked Fauci to implement an initiative to prevent and treat H.I.V. on a global scale. It has been uniformly held up as a model of the ways in which global public-health programs can save lives. “pepfar has turned around declining life expectancies in many countries and likely saved some countries—even an entire continent—from economic ruin,” Harold Varmus, a former director of the N.I.H. and of the National Cancer Institute, wrote in the quarterly journal Science & Diplomacy.
But Fauci has at times struggled to compel politicians and businesses to attack the problems that he considers most worrisome. Over the years, he has become concerned about the possible impact of new viruses, particularly a lethal strain of influenza. Other viruses are more consistently deadly; some, like measles, are more contagious. But no virus that we know of is capable of killing as rapidly and as efficiently. “We need a major paradigm shift with influenza vaccines,” Fauci told me, four years ago. “The situation is a mess.”
Because the flu virus evolves so rapidly, experts deciding how to formulate vaccines can make only a highly educated guess about which strains are most likely to make people sick. Each February, epidemiologists study outbreaks around the world—especially in the Southern Hemisphere, where flu season is under way—to assess which strains might make their way north. The result is always better than nothing. In many years, though, it is woefully inadequate. In the flu season of 2014-15, the vaccine protected less than a fifth of the people who received it. In 2017-18, it worked for a little more than a third.
Fauci has long supported the development of an alternative: a universal influenza vaccine, which would provide lasting defense against all strains. “Similar to tetanus, a universal flu vaccine probably would be given every ten years,” he said. “And, if you get one that is really universal, you can vaccinate just about everyone in the world.” But such a vaccine would cost hundreds of millions of dollars to develop and test—and would replace a product that most consumers already think of as good enough. No one has come close to raising the money that such a project will require.
By the beginning of the new millennium, it had become clear that the next microbial threat might not come from a bat or a duck. It could just as well be created by a human being. After the terrorist attacks of September 11, 2001, anonymous letters laced with deadly anthrax spores began arriving at media companies and congressional offices. In the following months, twenty-two people were infected by inhaling anthrax and five died. Suddenly, biological terror posed an entirely new threat—one that has become only more significant and complex in the ensuing years. In 2016, James Clapper, who was the director of National Intelligence during the Obama Administration, listed gene editing as a potential weapon of mass destruction. Many scientists were furious, but he had a point. Researchers have deployed these tools to rewrite the genes of mosquitoes so that they are unable to transmit malaria. If their success in the lab translates to the field, it will be a historic triumph. But the research also raises an alarming possibility: if a scientist can modify the genes of an insect to protect people from malaria, he could almost certainly use the same technology to add a deadly toxin.
Fauci often cites a similar but more immediate paradox. Thanks to genetic engineering, we are more equipped than ever to respond to the threat of a viral pandemic. After the covid-19 outbreak began, it took scientists less than a month to sequence the genome of the virus. By the end of February, the instructions were on the Internet, and the virus had been re-created in laboratories around the world, by scientists seeking to develop drugs and vaccines.
And yet, despite our mastery of molecular biology, we live in an era in which someone can wake up with an infection in China—or France, Australia, or any other place with an airport—and fly to San Francisco in time for dinner, spreading the virus long before he suspects that there’s anything wrong. For most of human history, a virus like covid-19 might have killed many people in the community where it originated, but then stopped spreading. According to a comprehensive analysis carried out by the Times, at least four hundred and thirty thousand people have arrived in the U.S. on direct flights from China since the outbreak began. Forty thousand have arrived in the two months since Trump imposed restrictions on travellers from China trying to enter the country.
Fauci insists that an adequate defense against future pandemics will have to be flexible. “I have been saying for eight, ten years that we should make a list of microbes and try to develop a basic platform vaccine,” he told me in 2016. A platform vaccine addresses an entire class of virus, not just a particular strain. “We keep trying to develop a vaccine for one thing—usually the last one—and it’s a waste of time,” he said. “Every time we get hit, it is always something we didn’t expect. So, instead of predetermining what it is you’re going to prepare for, make universal platforms.”
Such an approach is eminently possible. Using gene-sequence information and synthetic DNA, biologists are now capable of making parts of a vaccine in advance. It takes almost no time to sequence a viral strain, and with that information it should be possible to complete a bespoke vaccine in a matter of weeks. “You could build a chassis for the vaccine, and you would have it on the shelf,” Fauci said. “Then all you would need to do is insert the gene of the protein you want to express and make a gazillion doses and send it out.”
There are even more futuristic aspirations: the genomics pioneer J. Craig Venter has proposed using a sort of 3-D printer to manufacture vaccines on demand. It is already possible to print the nucleotides that make up DNA and assemble them. Venter argues that, in the time it takes for an infected person to fly from one side of the world to the other, we should be able to print, assemble, and administer a vaccine.
To even contemplate creating these kinds of treatments, Fauci says, would require building an entirely new system for making vaccines before a pandemic arises. But, in addition to the scientific obstacles, this would cost billions of dollars, and no company or politician has been willing to spend the money. Perhaps, just as aids transformed our approach to clinical trials, our experience with covid-19 will change our attitudes about preventing infectious diseases. A proper investment in both research and emergency preparedness would have prevented at least some of the unspeakable human loss we are now experiencing and the economic crash that has just begun.
The covid-19 epidemic will eventually fade, but the public will demand a reckoning. Inevitably, there will be an investigation, along the lines of the 9/11 Commission, to look into the ramifications of the President’s denialism, the shortages in testing and medical equipment, and the dismissal of so many warning signs. Fauci will not necessarily escape criticism. He is an excellent spokesman for the value of scientific research, but he runs a single institute, and he lacks the authority to broadly reshape our response to pandemics. “The kinds of things we really desperately need as foundational tools for dealing with this stuff aren’t necessarily research enterprises,” Harold Varmus told me. “Tony isn’t running C.D.C. He’s not running fema. To tell him to stockpile defense mechanisms or to move forward surveillance tools into massive operations around the world—that’s just not his remit.”
Even Fauci’s current value as a scientific adviser has been limited by the President’s contempt for expertise. Trump’s coronavirus kitchen cabinet consists of people like his son-in-law, Jared Kushner, who has no medical knowledge or experience managing crises—yet has been appointed to direct the response to the biggest medical emergency since the influenza pandemic of 1918. Trump has also turned for advice to Dr. Mehmet Oz, who for years has endorsed worthless treatments and used his television show to promote notorious quacks. Trump even seems to think that his trade adviser, Peter Navarro, should debate Fauci about the value of specific drugs. When Navarro, who has a doctoral degree in economics, was asked about his medical qualifications, he said, “I have a Ph.D. And I understand how to read statistical studies, whether it’s in medicine, the law, economics, or whatever.”
Among Navarro’s enthusiasms is the malaria drug hydroxychloroquine, which he believes could cure covid-19. There is currently no evidence to support this conclusion, as Fauci has pointed out on several occasions. On April 5th, as Trump continued to tout the drug as a miracle cure, a reporter at the daily briefing asked Fauci to comment. Trump refused to allow him to speak. In an appearance two days later, Trump kept up the hype. “I say try it,” he said. “You’re not gonna die from this pill.” Not long afterward, he even suggested that zinc might help.
To plan a coherent biological future, rather than simply scramble to contain each new pandemic, will require an entirely new kind of political commitment. It would certainly include the creation of a permanent position, a special assistant to the President for biological defense. Similar jobs have existed in the past, but not for long, and not with enough influence to matter. David Relman, the Stanford professor, told me, “This kind of job needs somebody with the authority to preside over domestic and international threats, both natural and deliberate. And that person has to sit in the White House with immediate access to the President. Without that, we will really have nothing that can work.”
Until then, we have Fauci, a seventy-nine-year-old infectious-disease expert pinned between Donald Trump and the American people. It can’t be easy. As Fauci recently put it, with characteristic candor, “I give the appearance of being optimistic. But, deep down, I just do everything I possibly can, assuming that the worst will happen, and I’ve got to stop the worst from happening.” ♦
https://www.newyorker.com/magazine/2020/04/20/how-anthony-fauci-became-americas-doctor
