Anthony Fauci Back When

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.

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.

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.

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.

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 52^nd year. Christine Grady Fauci continues to work at the NIH and Tony sets Sundays aside for his children.

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.