On Call: A Doctor's Journey in Public Service

Fauci reflects on the challenges and breakthroughs in HIV research, particularly focusing on vaccine efforts and preventive treatments. The chapter begins with a major setback: Larry Corey, a colleague overseeing an HIV vaccine trial in South Africa, reported that their trial, modeled after a moderately successful Thai study, failed to replicate positive results, offering no protection against HIV.

In contrast to these vaccine trials, 2010 and 2011 saw major advances in HIV prevention. Carl Dieffenbach reported positive outcomes from an NIAID-sponsored study that demonstrated that Truvada, a PrEP (pre-exposure prophylaxis) medication, significantly reduces HIV transmission rates, especially among high-risk groups. Further groundbreaking research, led by Myron Cohen, proved that early antiretroviral treatment can prevent HIV transmission, leading to the concept of “undetectable equals untransmittable” (272). This finding had great implications for stigma reduction and prevention efforts.

Fauci points to the potential of comprehensive antiretroviral treatment and PrEP deployment to eventually halt the HIV/AIDS pandemic. Despite the enormous resources needed to address the pandemic, he remains optimistic, stating that he believes that scientifically driven policies could make an AIDS-free generation achievable.

Chapter 3 describes the challenges posed by the 2014 Ebola outbreak in West Africa. Ebola, first identified in 1976, reemerged in 2014 in Guinea and rapidly spread to Liberia and Sierra Leone, overwhelming countries with limited healthcare infrastructure. The virus, often transmitted through contact with infected bodily fluids, had a high fatality rate and spread through traditional burial practices, where mourners touched the deceased, unknowingly spreading the infection. Despite past containment successes in remote areas, this outbreak proved unique, as it affected densely populated cities and was spread by international travel. Although initially under-reported, the outbreak drew global attention as cases reached Nigeria and, eventually, the US.

Fauci recounts his collaboration with colleagues like Tom Frieden and Cliff Lane, who coordinated research, healthcare, and containment efforts with Liberian officials. The US deployed healthcare experts and resources, working to build local response capacity. Fauci also reflects on the resistance he faced to policies advocating international support rather than isolating West Africa—a stance that generated criticism and hate mail.

Fauci recounts how, after treating an Ebola patient in Dallas, nurse Amber Vinson traveled to Cleveland and back with CDC clearance, even after reporting a mild fever. Although her risk to others was low, the CDC’s contact tracing of fellow passengers intensified public fears and criticism, particularly directed at CDC director Tom Frieden. Fauci calls the public reaction to this case the “epidemic of fear,” stating that it required extensive government communication to reassure the public (299).

To counter misinformation in this context, Fauci appeared on major TV programs, clarifying Ebola transmission facts. Then, nurse Nina Pham, also infected after treating an Ebola patient, arrived at the NIH for care. As a result, Fauci and his team took exhaustive precautions. The medical team discovered that Pham’s infection likely stemmed from inadequate protective protocols rather than any fault on her part. Later, Fauci publicly embraced Pham upon her discharge, in order to signal that she was safe and to counter stigma around Ebola. However, Fauci had to face several political challenges, such as disputing state-imposed quarantines on returning healthcare workers.

Fauci recounts the intense experience of caring for “Robert,” a pseudonym for a healthcare worker infected with Ebola in Sierra Leone (314). Robert was transported to the NIH, where Fauci’s team, in protective equipment, prepared for the high-risk protocol the patient required. Unlike other cases, Robert’s illness progressed rapidly, and multiple organs were affected, including his lungs, kidneys, brain, and heart. Despite their best efforts, the team faced continuous challenges as each system failure brought Robert closer to death.

Fauci notes One critical moment during the care for Robert when the patient unexpectedly woke up and had a violent reaction, pulling out the tubes that connected him to the medical apparatuses. Nurses Neil Barranta and Kim Adao finally managed to subdue him, though they risked exposure to the Ebola virus through his bodily fluids. A tense moment ensued when Neil suspected potential contamination through a cut on his hand, and felt relief when he found his glove intact.

As Robert’s condition stabilized, he eventually recovered, expressing deep gratitude to Fauci and the team. Shortly after Robert’s discharge, Fauci recalls how the physician Dan Chertow, who had been one of the most dedicated medics working on Robert’s case, was denied entry to the Dominican Republic due to his recent contact with Ebola, interrupting a well-earned vacation. Reflecting on these events, Fauci admires his colleagues’ heroism and humanity in spite of endless challenges.

In Chapter 5 of Part 4, Fauci reflects on his daughters’ successful careers and his connection with his family. As his children pursued their professions—Jenny in psychology, Megan in teaching, and Ali in computer science—Fauci recounts how he and his wife, Christine, resumed their routine from before their children were born, enjoying long walks together.

The narrative then shifts to a new public health crisis: the 2015 Zika virus outbreak. Fauci explains that Zika was thought to be a relatively mild virus until it emerged in Brazil, where infections during pregnancy led to tragic cases of microcephaly—a severe fetal brain abnormality. The virus spread through mosquito bites, and as it threatened the US, Fauci and other officials worked closely with the CDC and the White House to contain it. However, political challenges hindered funding, necessitating resource shifts from other health programs.

Despite obstacles, Fauci and his team pushed forward with Zika vaccine research, achieving unprecedented speed in initiating trials. The outbreak eventually subsided, rendering vaccine efficacy trials difficult. Fauci reflects on lessons learnt from the Zika outbreak and emphasizes the harm of partisan politics in responding to public health crises—a concern he foresees for future outbreaks. As the Zika crisis subsided, Fauci also marked the 50th year of his medical career, reaffirming his dedication to patient care despite the evolving demands of his public role.

In the last chapter of Part 4, Fauci reflects on the final state dinner held by President Obama on October 18, 2016, which also honored Italian Prime Minister Matteo Renzi. Fauci describes the event as a warm, nostalgic evening with Italian American guests and entertainment by Gwen Stefani. Reflecting on his years working with Obama on public health crises like H1N1, Ebola, and Zika, Fauci says he felt a sense of imminent change that night as Obama’s presidency drew to a close. A week before Trump’s inauguration, the Obama administration organized a session to brief the incoming cabinet on crisis management, including potential infectious disease threats.