NOTE TO READERS:
This article was published in the Washingtonian Magazine, February, 1993, when Tony Fauci was at the start of his efforts against AIDS.
Technical difficulties downloading the archive prompted the Phantom to transform it to Word, so the graphics are different.
The Phantom has taken the liberty of updating the graphics.
He has been told The Washingtonian is working at putting the original on line, but they are all working from home for now.
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| The New York Hospital-Cornell Medical Center |
In the
shadows she appeared cadaverous, and the medical student stepped back,
startled. It was past 1 AM and the patient had just arrived on the ward by
gurney from the emergency room. She had been short of breath, and her chest X-ray
showed her lungs congested with fluid, one chamber of her heart enlarged.
She
leaned forward to breathe, and the intern and the junior assistant resident
took turns listening to her heart. To his ears, it sounded like a balky garbage
disposal.
“What did
you hear?” the resident asked the student.
It’s not
easy heart sounds in a woman gasping for air. What you hear does not sound like
the recordings they play in the physical diagnosis course.
“All I
heard was noise,” said the student.
“What
about S1?”
“Sounded
normal to me.”
“Normal?
You say normal? Tell that to Fauci,” snorted the resident, as they stepped out into
the dark hallway.
“You
think Fauci’s coming?” asked the student.
“Fauci comes
by every night,” said the intern. “Probably down in the ER right now. The man does
not sleep.”
The intern
was unshaven, his white uniform splattered with bodily fluids from 40 patients
over the course of his 36 hour day.
“Only way
to stop Dr. Fauci,” said the resident, straight faced, “is to drive a wooden
stake through his heart.”
“Fauci never
sleeps,” the intern repeated. “And he’s going to ask you what you hear. And you
better describe it like Elliot Hochstein taught you.”
By which
he meant: School is out.
The
medical student went back to listen to the heart again.
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| Portrait of a Scientist as a Young Man |
When the
Chief Medical Resident of the New York Hospital-Cornell Medical Center, Anthony S.
Fauci, appeared on the ward at 2 AM, he was only a shadow at the end of the
long central corridor. They watched him move toward them, backlit in the
hallway light.
“You’d
think he was this lady’s private attending,” the intern said.
In fact,
Fauci thought of himself as filling that role: private physician and advocate
for patients too poor to have one. The patients who came in from the emergency
room had only the house staff caring for them—the interns, the junior assistant
residents, and the chief resident. The
professor would see them the next day, after their crises had passed.
Getting
them past those crises was the house staff’s job, and Fauci was there to see
the job was done properly, nothing less than what the patients got up in “the
Tower” of the hospital, where the rooms contained original art and just one bed.
The student
gave his findings to the chief resident. Then he waited while Fauci went in and
listened to the heart.
“There
are some significant differences between your findings and mine,” he told the
student when he returned, smiling faintly.
“What she
has is mitral stenosis.”
The
medical student slumped. His first time at bat and he had struck out.
“Don’t go
jumping out the window,” Fauci said. “You were where you were supposed to be.
You were in position. If you knew everything, they’d make you Chief Res and I
could go to bed.”
Twenty years
later, the striking thing is how little Tony Fauci has changed. He is not a
pound heavier, grayer, yes, but not really older. He could be 32 as easily as
what he is—52. Spiritually, too, it’s the same flinty ethos, the same emphasis
on being where you are supposed to be, when you are needed.
Hearing
the murmur of mitral stenosis got easier for me with time, but the lesson of
the night was more important: You can’t learn anything if you go to bed too
soon, if you don’t put yourself on the line.
For Fauci
it is an article of faith that all medicine begins at the bedside. There are
other articles of faith: The patient is put first, and the patient is to be
respected, whatever his social status; science demands discipline, patience,
attention to detail, accurate observation.
What’s
different now about Tony Fauci is his position: chief of the National Institute
of Allergy and Infectious Diseases. He’s the youngest man heading an NIH
institute. The immunoregulation lab he oversees does basic research on the immune
defense system at a cellular and subcellular level, and he coordinates this
bench research with research into diseases in human beings who live—and sometimes
die—on the wards of NIH.
Most
prominently, he presides over a nationwide effort to conquer AIDS—an effort
that costs $870 million a year.
In a town
where the trappings of power quickly become recognizable, Tony Fauci does ward
rounds, and he does them as he always has: seriously. When Fauci is on rounds, the
calls from the highly placed have to wait. Patients are the ones who cannot
wait.
It is the
old ethos of the hospital—the old-time religion of ward rounds—and Fauci’s
affection for it may explain why some of his best friends are older than he is,
men from other eras such as the former surgeon general C. Everett Koop, and the
noted immunologist, Sheldon Wolff.
If it has
been a long way from the dark halls of the New York Hospital to the National
Institutes of Health, it was longer still from the apartment above the
drugstore in the Bensonhurst section of Brooklyn to medical school. Tony Fauci’s
father was a pharmacist.
“Bensonhurst
was a great place to grow up,” he says. He played basketball (guard) and
baseball (shortstop) in the parks and playgrounds, and he studied hard, under
the loving, demanding direction of his mother, who was the driving force of the
family.
There is
still an “in your face” quality to Fauci. And there is Brooklyn, too. You can
still hear it in some of his inflections and cockiness. He is not coy about his
accomplishments. They are simply facts.
“Behind
that well-maintained and prepared exterior is the soul of a volatile Italian,”
says C. Everett Koop.
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| National Institutes of Health, Bethesda, Maryland |
Koop
recalls Fauci in the stands of a Georgetown University basketball game, arguing
stridently with a nine-year-old boy over what Fauci considered an outrageous
call. Koop and Fauci once toured their common boyhood homes together, stopping
at landmarks, playgrounds. It became clear to Koop that what Fauci has is what
Hemingway might have called aficion, or passion—a deep feeling for
things.
He is the
sort of person you’d want for a personal physician. Koop, in fact, asked Fauci
to be that, and Fauci said he’d be honored.
Sheldon
Wolff, now chief of medicine at Tufts-New England Medical Center in Boston and
one of Fauci’s mentors, says he saw immediately that Fauci was a “serious man”
He uses that phrase the way Mario Puzo uses it—a sense of potency, of intensity
and of specialness, a man who takes himself and his world seriously
Fauci got
into high school, he will tell you, by taking a competitive exam. He won a full
scholarship to Regis High School, a Jesuit institution in Manhattan that took
the top hundred Catholic students from the five boroughs. From there it was a
full scholarship to Holy Cross.
“We were of
very modest means, but it was at a time when scholarships were part of the
process of funding the education for highly talented students. I was fortunate.
I really had no educational expenses.”
Although
he knew from high school that medicine was his likely destination, Fauci studied
ancient Greece and Rome, philosophy and theology and he embraced the Jesuit idea
of a broad exposure to Western thought. Iliad and Odyssey, ethics,
the analysis of philosophy fascinated him. He took only the minimum science courses
required for medical school.
Summers
he worked construction, helping to raise a new library at Cornell University Medical
College on York Avenue. A few years later, he would study medicine there.
“I loved
every minute of medical school,” Fauci says. “The physicians—the practitioners—were
my heroes. You knew their reputations and saw them in the corridors and it was
exciting to know that you were going to be part of all that.”
Summers
during medical school he spent working on research projects with some of
Cornell’s then dazzling galaxy: Marvin Schlesinger, who wrote the class textbook
in gastroenterology; John Queenan, the obstetrician who later became chief at
Georgetown; and Graham Jeffries, with whom Fauci worked on a project dealing
with the immunological aspects of an intestinal disease called sprue. This was
Fauci’s first experience in immunology, then a budding field.
During
Fauci’s fourth year in medical school, his mother was found to have liver
cancer. She was hospitalized at New York Hospital and died there within eight weeks
of her diagnosis. Fauci was just at the point in his training where he could
understand and explain her situation to his father.
Internship
followed, at the same New York Hospital, then first year residency, and then
the decision to leave the hospital that had nurtured him for the National
Institutes of Health. In the world of research, it was the big leagues.
“Initially,
I had something akin to withdrawal symptoms,” Fauci says. “because I missed
being in the thick of the very intense clinical medicine I was used to at New
York Hospital.” He still saw patients, but was spending more time in the laboratory.
“There was the insecurity,” he remembers, “of not knowing whether I was going
to be any good.”
For
people outside the world of medicine, it is hard to appreciate the difference
between the wards and the laboratory.
The sort
of personal qualities that make for success on the ward—intensity, a hunger for
action and quick results, a love of teamwork and routine—can sink the bench
researcher, who often works alone, has to create his own routines, and needs to
thrive in isolation and tolerate incremental progress and slow pace.
“The thing
about Tony,” says Sheldon Wolff, who took him into the training fellowship at
NIH, “was that he was just as good in the lab as he was on the ward. He was creative,
compulsive.”
Wolff had
several projects going, and Fauci took over some, in particular a project on a
then lethal disease of the immune system called Wegener’s granulomatosis. Simultaneously,
Fauci pursued studies on the effects of cortisone therapy on immune cells—lymphocytes.
“Some
people are good in the lab but they can’t write papers,” Wolff says, “or they
can’t speak in public to present their findings. Tony could do it all. He never
had trouble writing or speaking or doing the work.”
Within
two years, Wolff offered him a senior staff position. Fauci had left medicine
early and he wasn’t ready to submerge himself in the laboratory without one
more tour through the world of patients. Wolff agreed to let Fauci return to
Cornell for one more year of clinical medicine.
“That was
one of the most exciting years of my life,” Fauci says. “I was on call every
other night and every other weekend. The night I was on, I was in the hospital literally
up all night. I saw every gravely ill patient. I was in on every decision of who
went to surgery. The nights I was on I was up to four or five in the morning.
The nights I was off I’d go home and get enough sleep to be sure I’d be
functional and then go back the next night. I was a phenomenal year. People think
I’m insane when I say that.”
Fauci
then returned to the NIH, where he helped develop a life saving therapy for
Wegner’s granulomatosis.
The
disease was a storehouse of clues about the function of the immune system.
Whenever nature makes a mistake it offers an opportunity to understand how the
inner workings are put together and Wegener’s was teaching Fauci about immunoregulation.
He was one of the few investigators able to work on the immune system as it
functions and malfunctions in human beings. Most other scientists were still
working with rats.
Working
in both clinic and lab, Fauci passed board examinations in infectious disease and
immunology/allergy.
Back at
Cornell, another investigator, Henry Masur was working on what was thought to
be a rare and arcane disease: pneumocystis. These two scientists, who some
thought were wasting their careers on side shows, then found themselves at the
epicenter of the earthquake that would shake medicine.
When the
first report of the phenomenon of pneumocystis occurring in patients who did
not have malignancy appeared in the Morbidity and Mortality Reports in
June 1981, Fauci latched on to it.
“I said, ‘Boy,
there’s something really funny about this. This could be some kind of a toxic
drug.”
But when
the next report came out that this same phenomenon had been found in intravenous
drug users, Fauci recalls, “I started to get this sinking feeling we really
might be dealing with an infectious disease. It was at this point I started to
switch my laboratory’s emphasis to this new syndrome, which wasn’t even named
yet. This was an infectious disease that was having a major impact on the
immune system. This was going to be a really big public health problem.” It was
the end of 1981.
Fauci
started to gather the elements he needed for his team. He knew he had a strong
laboratory, but he wanted people who could recruit patients. And if he was
going to recruit patients, he felt obligated to set up a service to care for what
would be some of the sickest patients imaginable.
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| Henry Masur, MD First Report of AIDS |
A peculiar
narrowness of vision back at Cornell helped Fauci. As Henry Masur collected the
patients who formed the first well studied group of AIDS patients, he needed a
laboratory to run studies of the immune system. He found one at Memorial Sloan-Kettering
Cancer Center, where lab investigators were eager to pursue this unexpected development,
but the chiefs at Memorial said no. The phenomenon represented by these
patients may be immunologically fascinating, the chiefs argued, but this was an
infectious disease in all likelihood, and the mission of the institution was to
study cancer.
Their
shortsightedness quickly became apparent. The AIDS patients developed bizarre
malignancies and studying them contributed enormously to an understanding of
the immune system’s role in cancers. Today, the most exciting frontiers in
cancer therapy are those of immune system stimulation and augmentation.
In the
early 1980’s, though, all this was still in its infancy. The Memorial
Sloan-Kettering immunology lab disintegrated as its members, eager to push on
with work on AIDS, gravitated to other institutions.
From the
beginning, Fauci seems to have understood the importance of what Memorial
immunologist Suzanne Cunningham-Rundles has described as “this meltdown of the
immune system.”
Fauci wrote
one of the first clarion calls, an editorial in the Journal of the American
Medical Association, saying that AIDS would turn out to be an infection and,
as a communicable disease, would develop into a major public health problem,
not just for select groups, but for the world.
He now
wasted no time recruiting a team. With Joseph Parrillo, a former colleague from
Cornell, already in place at NIH to run the intensive care unit, Fauci was in a
position to attract Henry Masur from Cornell. Masur’s trailblazing work in New
York produced the first well described group of patients with AIDS and he knew
as much or more than anyone else in the world about these patients. Fauci
wanted Masur to head the clinical service that was needed to bring the patients
to the NIH and to his laboratory. Another key team member was H. Clifford Lane,
who was profiling and studying the components of the immune system.
The team
was starting from scratch. There was no disease yet defined, no diagnostic test,
no isolation of the virus.
“People
said, ‘What is this? We don’t even know if it’s a disease.’ It was a question
of getting people excited and interested about it,” Fauci recalls.
As Masur
brought in the first AIDS patients, Lane began to study and dissect parts of
their immune systems, first the B cells and then the T cells. Meanwhile, the
team’s papers were appearing, step by step in the New England Journal of
Medicine. With that, other groups across the country became excited by what
was coming out of NIH, and the drive to understand the disease was launched.
AIDS
would prove more than a disease. It had sociological, ethical and professional
dimensions. It then took on a political aspect, as the groups most affected
began to wonder whether anyone cared about them. If AIDS was a disease of
homosexuals and drug abusers, would the rest of the community be willing to spend
precious health care dollars on finding the cure? Implicit in the question was
an accusation: If more money were being spent on AIDS, a cure would be found
more quickly.
It’s the “if
you had a blank check” question: How much of our inability to conquer AIDS is
tied to insufficient money, and how much of the problem is that we simply don’t
know which path to take? Fauci has heard this before, and he knows the
quicksand that awaits an answer.
“If you
give more resources,” he says, “you won’t necessarily have a one to one quickening
of the pace, but, the fact is, if you can explore more opportunities, there’s a
reasonable chance you could do it more quickly. If you don’t come out and
explicitly say that, the activist think you’re not fighting hard enough for it.
“If I say
that we did have an unlimited amount of money we could go much more quickly,
someone will use that to say” and here Fauci’s voice becomes melodramatic, imitating
the news radio—“’Top AIDS Researchers Says Present Administration’s Policy on
AIDS is Slowing Down Research!’” –then his voice drops,”And the next one is, ‘People
are Dying Because of the Administration.’”
Beyond
the social and political issues, a quiet but agonizing medical debate continues
about the obligation owed by each physician to treat HIV-infected patients.
Many have said they did not sign on for a risk the magnitude of AIDS. Others
have pointed out that it is a risk not shared equally: The surgeon or obstetrician
elbow deep in a patient’s blood resents being told by the endocrinologist or
allergist, who never bloody their hands, what risks they should be willing to
take.
But all
ethical analysis begins with establishing the facts, and Fauci begins with what he
believes is the most important one: that the risk for the most horrific outcome
is statistically small. Fauci points out that the chances of getting hepatitis
from a needle stick of an infected patient –and dying of it—are far greater
than the chances of dying from AIDS as a result of a needle stick from an AIDS
patient.
“If there
are no other options for the patient,” Fauci insists, “it is absolutely
unquestionable that it is your
responsibility to care for the patient.”
But aren’t
doctors allowed to have one nightmare they don’t want to face?
“It’s
important to distinguish between what is legally correct and what my personal
opinion is,” Fauci continues. “My personal opinion is that someone who becomes
a physician should accept the responsibility of taking care of sick people because
that is the fundamental foundation of what a physician is. I do respect the decision
on someone’s part that they might not want to do that. I don’t necessarily
think that is the morally correct thing to do.”
It is
that old time ward religion. A doctor always puts the patient first. Fauci has
had the nightmares himself—his “AIDS dreams” in which he discovers he has the
disease or dreams his wife gets it. But in the cold light of day, he concludes,
you have to do your work.
As for where
AIDS research goes next, Fauci will answer that it goes wherever results seem
promising. Anti viral drugs have been on approach, but they have failed to
provide a cure. More promising to many in the field is the research into new
vaccines. One-preventative, not curative—would prepare the immune systems to
fire off a killing volley whenever the HIV virus enters the body. Still
desperately needed is a vaccine that can cure the millions already infected.
And it is to that end—any many others—that Tony Fauci and his team continue to
devote long, long hours.
Fauci’s
colleagues have wondered how he can sustain the drive. Doctors who work in
areas of medicine where there are more defeats than successes, where some
patients die horrific deaths—oncologists, for example, and now those working
with AIDS—often look for early retirement, for a way to come in from the cold.
Fauci’s
answer: He loves his work. If anything, his laboratory and his institute seem
to be putting out more work than ever. He also now, rather late in life, has a
home life. He met his wife in the hospital—while he was making rounds.
Christine
Grady had been at NIH for only three weeks, but she’d already heard stories—mixed
equally of respect and fear—that portrayed Fauci as a forbidding, exacting general. A graduate of Georgetown University School
of Nursing, she had spent two years in Brazil with Project Hope, during which
time she’d learned Portuguese.
When
Fauci reached the bed of a Brazilian senator who spoke no English, he asked if
a translator was available. We just
happened to have a new nurse, he was told. A short while later, Christine Grady
showed up, looking as Irish as Irish can be. Fauci remembers looking her over
and thinking, “This is the Portuguese translator?”
Grady
translated the questions Fauci put to the patient and the answers coming back,
all the while thinking—as she recalls it—“This is the great Dr. Fauci?
He doesn’t look so scary.”
And he
was definitely younger than expected.
When she
was called to his office later, Grady experienced the cold sweat so many of her
colleagues described.
Fauci was
direct: He wanted to have dinner with her. He realized this might present a
problem, because they would be seeing each other at work, but they did not work
directly together, and, in any event, if it made her feel uncomfortable, he
would understand, no hard feelings.
Grady
stopped him in the middle of his disclaimer. Yes, she would like to go out to
dinner with him. And the rest, as she says, is history. They now have three
girls, the last born last year, in Fauci’s 52nd year. Christine
Grady Fauci continues to work at the NIH and Tony sets Sundays aside for his children.
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| Christine Grady, RN, PhD |
He also
stays in remarkable physical condition. He can be seen flying down Macarthur
Boulevard bicycle path—and playing basketball.
Christine
goes to Georgetown basketball games with him.
When he
becomes a volatile Italian in the stands, she pretends not to know him.
