On Call: A Doctor's Journey in Public Service

Fauci details his experience on September 11, 2001, starting with his arrival in New York for a board meeting and witnessing the terrorist attacks. He describes seeing the planes strike the Twin Towers, the shock and horror among his colleagues, and his concern for his family’s safety back in Washington, D.C. He was particularly worried about his daughters, whose school, the National Cathedral School, is situated in the most elevated place in Washington and could be vulnerable to a terrorist attack.

While on the ground in Manhattan, New York, Fauci received a call from HHS Secretary Tommy Thompson, who tasked him with reporting on-site, but authorities prevented him from approaching Ground Zero. After struggling to return to Washington, D.C. Fauci finally caught a train. As the train was leaving, Fauci witnessed the collapse of Tower 7 due to the damage to the other structures at the World Trade Centre—a sight that greatly marked him. Eventually, Fauci arrived home, relieved to see his family. However, he found the city on high alert, with military planes flying overhead and closed airports.

Immediately after the attack, Fauci’s role at HHS shifted as bioterrorism threats took priority. Fauci became a key figure in strategizing defenses, especially regarding potential smallpox bioterror attacks. He started directing NIAID’s new focus on developing vaccines and countermeasures for biological threats.

Fauci describes the anthrax attacks of 2001, which began with the death of Robert Stevens after being diagnosed with inhalational anthrax. The attacks increased the fears of bioterrorism in the US after the recent 9/11 attacks. Fauci, along with HHS Secretary Tommy Thompson, became a central figure in managing public anxiety and leading efforts to counteract biological threats.

In time, more anthrax cases emerged, seemingly caused by spores in the mail. The general anxiety escalated, especially after high-profile targets like Senators Daschle and Leahy received contaminated letters. Working around the clock, Fauci provided media reassurance, urging the public to remain alert but avoid panic.

In addition, high-level discussions between HHS, Vice President Cheney, and health experts focused on bioterror defenses. They were particularly worried about a possible smallpox pandemic. Fauci worked with bioterror experts to address potential smallpox risks, trying to counteract the limited vaccine supply and the vulnerability of the unvaccinated population.

Disputes surfaced between HHS and the CDC regarding crisis management in the anthrax crisis, as more anthrax cases emerged. Ultimately, it took seven years for the FBI to conclude that Bruce Ivins, a Fort Detrick microbiologist, might be responsible. However, his suicide in 2008 left the case unresolved. Fauci reflects on this period as a challenging chapter in the nation’s response to biological threats.

Fauci describes his experience visiting Uganda in 2001, where the AIDS epidemic was devastating communities. In Kampala, he observed overcrowded hospitals, with few patients able to afford even basic treatments for infections related to HIV. Facilities were overwhelmed and many patients were lying in hallways or outside. At Mulago Hospital, he encountered many visibly ill individuals. Traveling further to rural Rakai, he saw even greater challenges, such as inadequate resources and minimally trained doctors performing complex procedures. Fauci urged an expanded response to the crisis, advocating for HIV treatment and infrastructure improvements, as well as comprehensive health measures which would address malaria, tuberculosis, the access to clean water, and vaccinations. The trip solidified his commitment to address the health disparities plaguing southern Africa.

In January 2002, after the US-supported Global Fund was established, President Bush sought a more direct approach to fighting AIDS in Africa. He sent Fauci along with a governmental delegation to assess the crisis in countries like Mozambique, Botswana, and South Africa. Witnessing severe AIDS challenges, Fauci focused on preventing mother-to-child transmission of HIV using nevirapine, a cost-effective method he and Dr. Mark Dybul proposed to the president. This five-year plan aimed to save thousands of infants annually. Bush supported the initiative despite bureaucratic disputes. Fauci’s interactions with White House officials like Josh Bolten led to a multi-billion dollar plan to address the health challenges in the African countries.

In early 2003, Fauci’s efforts to develop a US-led AIDS initiative culminated in the formation of the President’s Emergency Plan for AIDS Relief (PEPFAR). Encouraged by the advocacy work of Bono (Paul David Hewson, the lead singer of the band U2), Fauci and his colleagues crafted a comprehensive $15 billion, five-year plan, with a focus on prevention, treatment, and mother-to-child transmission. After intense negotiations, President Bush announced PEPFAR in his State of the Union, marking it as the largest single-country health initiative devoted to a single disease. The initiative targeted the most affected African countries, along with Haiti and Vietnam, aiming to transform AIDS care globally.

In Chapter 5 of Part 3, Fauci addresses the continuous bioterrorism threat of smallpox, the US’s limited vaccine stockpile post-9/11, and efforts to stretch supplies through dose dilution. A second-generation vaccine for smallpox was also in development, promising a stock of over 280 million doses by late 2002. There was continuous debate over mass vaccination of first responders. Fauci, citing serious vaccine risks and residual immunity among older Americans, opposed universal vaccination, while Vice President Dick Cheney leaned toward a broader military-focused vaccination initiative.

This chapter describes the smallpox vaccination program as part of NIAID’s broader biodefense strategy. Presenting the plan to key White House figures, Fauci advocated for regulatory flexibility, sole-source contracts, and a special fund to secure pharmaceutical industry collaboration in developing countermeasures against bioterror threats like smallpox, anthrax, and Ebola. The proposal evolved into Project BioShield and a substantial budget was allocated to counter bioterrorism.

Although President Bush received the smallpox vaccine as a gesture of leadership, his family did not, which reflected his belief in low risk for the public. Fauci agrees with him, stating that he would choose the same for his family. Few civilians sought vaccination after adverse events were reported.

However, Fauci states that, as a general rule, he fears naturally occurring pandemics rather than bioterrorism. When the SARS outbreak began in Asia in 2002, Fauci addressed public concern. Project BioShield, alongside PEPFAR, was mentioned by President Bush during his State of the Union address, which marked a pivotal step in national preparedness. Fauci’s intense efforts during that time led to tension and fatigue, but the program demonstrated a vital commitment to biodefense.

Fauci describes finding a brief respite from the pressures of bioterrorism and SARS at the Ellis Island Family Heritage Award ceremony in April 2003. Fauci received the award, celebrating his contributions to society as a descendant of Italian immigrants who arrived at Ellis Island. He felt deeply moved by the ceremony, which included a tribute to his heritage, featuring his grandfather’s immigration records from 1902.

Another important moment for Fauci is meeting his childhood baseball idol, Yogi Berra—an encounter that brought nostalgia and joy, as they discussed Berra’s legendary career and Fauci’s childhood memories of cheering for the Yankees.

Chapter 8 describes how the post-Iraq War climate heightened concerns about bioterrorism among White House officials, emphasizing the need for Project BioShield to safeguard against such threats. Fauci spent intense days lobbying on Capitol Hill, which included a memorable exchange with Senator Robert Byrd, who firmly defended Congress’s budget control. Although Congress ultimately restricted BioShield funding to $6 billion over ten years, other provisions remained intact. The program provided resources for developing vaccines and treatments, empowered NIAID to expedite contracting, and granted the FDA emergency authorization capabilities. BioShield laid groundwork for the 2006 influenza Pandemic and the All-Hazards Preparedness Act.

Fauci describes his experiences visiting Iraq as part of a US delegation in February 2004. The purpose of the trip was to assess the country’s healthcare needs post-invasion and explore potential US medical support initiatives.

Fauci’s wife, Christine, and their three daughters were anxious about his Iraq visit. His oldest daughter, Jenny, in particular was strongly opposed to it. However, Fauci explained the symbolic importance of his visit and his personal desire to go to Iraq, and assured them that he’d have extensive security. Ultimately, while still worried, his family gave their reluctant support.

Fauci recounts the stark security challenges the team faced while going to Iraq, such as the hair-raising “corkscrew landing” at Baghdad airport to traveling along “ambush alley”—an area with continuous infighting (232). At the Ibn Sina Hospital in Baghdad’s Green Zone, Fauci witnessed the grim impact of combat injuries, far more intense than his stateside experience with Vietnam War casualties. Soldiers, medics, and even doctors moved around the hospital with weapons, which confirmed to Fauci the harshness of a warzone hospital.

Fauci met wounded US soldiers and Iraqi civilians. He was deeply moved by the severity of their injuries. He also observed the resilience and bravery of the medical personnel on the ground. The trip left a lasting impression, emphasizing for Fauci the importance of bringing stability and healthcare to a war-torn region.

Fauci reflects on returning from Iraq to his relieved family but has little time to rest due to a global concern over an avian influenza virus. The virus, originating in chickens and infecting humans in China, raised fears of a potential pandemic. Fauci details how influenza viruses mutate: minor mutations often cause annual flu seasons, while major ones can lead to pandemics due to lack of immunity.

Fauci recounts the re-emergence of H5N1 in 2003, which raised concerns over potential human transmission. By early 2004, his team at NIAID began preparing for a possible pandemic. They launched projects to track, sequence, and develop vaccines against H5N1. However, during the 2004 flu season, the US faced a vaccine shortage because of an incident of high contamination at Chiron’s Liverpool facility reduced the supply. This issue became politically charged, as it occurred during the 2004 election.

In 2005, H5N1 transmission to humans in Asia reignited pandemic fears. Fauci’s team then worked to secure vaccine supplies and improve production methods, eventually initiating research into a universal flu vaccine. By 2008, NIAID had developed and stockpiled H5N1 vaccines, although a pandemic did not occur.

Fauci describes the final months of the Bush administration. The President’s Malaria Initiative (PMI) was launched in 2005, with support from the Gates Foundation, reducing malaria deaths substantially over a decade. Fauci collaborated closely with Bill Gates, and they became allies on malaria and HIV research. Although tuberculosis did not make it into Bush’s 2008 State of the Union speech, PEPFAR and PMI were the main focus.

Fauci was awarded the National Medal of Science in 2007 and the Presidential Medal of Freedom in 2008 for his HIV/AIDS work. President Bush’s personal support for Fauci marked a high point in his career, emphasizing the administration’s commitment to infectious disease relief worldwide.