head Doc

Anthony Stephan Fauci, M.D., Head of the National Institutes for Allergy and Infectious Diseases (NIAID), is a hero to many. Not me. But once upon a time he was. Just as I was entering Rheumatology (’82), Fauci had been publishing the results of his breakthrough treatment of the rare, sexy, and serious rheumatic disease polyarteritis nodosa. In affected patients, medium sized arteries, like the coronaries that supply the heart or the renals that feed the kidney, would become inflamed, often block up, and sometimes rupture, with sheer misery from the ongoing systemic inflammatory response followed by organ failure and death all too commonly. Corticosteroids could dampen the inflammation, but the doses needed were so massive as to leave the patient wracked with the complications of steroid excess: profound weight gain, weakened muscle, bones and skin, diabetes, hypertension, and susceptibility to infection. Fauci added an old chemotherapy poison – cyclophosphamide (Cytoxan), derived from mustard gas (yes, think WWI) – which knocked back the blood vessel inflammation much more effectively. Docs had been doing this now and then for 2 decades, but Fauci had the patients and organization of the NIH behind him, culminating in a nice New England Journal paper (N Engl J Med 301:235–238, 1979 https://www-nejm-org.proxy.lib.umich.edu/doi/full/10.1056/NEJM197908023010503). The “Fauci regimen” is still used for vasculitis, although some newer biologics, like rituximab, have begun to replace it. Many articles followed and there was a slim book with coauthor Thomas R. Cupps that became the bible for treating vasculitis.

I’ve never met Dr. Fauci, but I must have heard him speak. He used to be everywhere in rheumatology. But my friend Deb from Barnes has. She’s 4 years behind me so we never overlapped as house officers. As a 4th year medical student from Louisville, she rotated for a month at the NIH. Dr. Fauci was her main attending. Deb found him to be an excellent teacher, but was “intimidated by his intellect”. Deb towered over him (she’s 5’10” to his barely 5’7″), and couldn’t help but notice how he was turned out sartorially. In the NIH of the early 80s, everyone “dressed like janitors”, except for Deb’s attending. He showed up to work every day in a fresh 3 piece suit, his Phi Beta Kappa key on proud display. I guess dressing for success worked, as not long after that he left the world of vasculitis and jumped on the AIDS bandwagon. Immunosuppression – doing it and dealing with the complications – was what he was all about anyway, so why not look at it from the virus’ point of view? He quickly was placed at the top of his new institute – NIAID, funded for 2020 to the tune of $5.89 billion – and is into his fourth decade on the job. His training and experience is in immunology not infectious diseases, although he certainly bumped up against viruses in his time with AIDS. I wish they would trot out his boss – the esteemed future Nobel Prize winner and head of the NIH Francis Collins, once of U of M and a serious, devout and thoughtful doctor.

Once of my favorite writers – Victor Davis Hanson of Stanford’s Hoover Institute – has a piece today that begins with his take on Dr. Fauci. The whole piece also gets into presidential politics and racial issues (https://amgreatness.com/2020/07/05/an-industry-of-untruth), but I paste in below just the section on Dr. Fauci and coronavirus.

Viral confusion

Unfortunately few in authority have been more wrong, and yet more self-righteously wrong, than the esteemed Dr. Anthony Fauci. Given his long service as the director of the National Institute of Allergy and Infectious Diseases and his stature during the AIDS crisis, he has rightly been held up by the media as the gold standard of coronavirus information. The media has constructed Fauci as a constant corrective of Trump’s supposed “lies” about the utility of travel bans, analogies with a bad flu year, and logical endorsement of hydroxychloroquine as a “what do you have to lose” possible therapy.

But the omnipresent Fauci himself unfortunately has now lost credibility. The reason is that he has offered authoritative advice about facts, which either were not known or could not have been known at the time of his declarations.

Since January, Fauci has variously advised the nation both that the coronavirus probably was unlikely to cause a major health crisis in the United States and later that it might yet kill 240,000 Americans. In January, he praised China for its transparent handling of the coronavirus epidemic, not much later he conceded that perhaps they’d done a poor job of that. He has cautioned that the virus both poses low risks and, later, high risks, for Americans. Wearing masks, Fauci warned, was both of little utility and yet, later, essential. Hydroxychloroquine, he huffed, had little utility; when studies showed that it did, he still has kept mostly silent.

At various times, he emphasized that social distancing and avoiding optional activities were mandatory, but earlier that blind dating and going on cruise ships were permissible. Fauci weighed in on the inadvisability of restarting businesses prematurely, but he has displayed less certainty hedged about the millions of demonstrators and rioters in the streets for a month violating quarantines. The point is not that he is human like all of us, but that in each of these cases he asserted such contradictions with near-divine certainty—and further confused the public in extremis.

In terms of how the United States “fared,” it is simply untrue that Europe embraced superior social policies in containing the virus. The only somewhat reliable assessments of viral lethality are population numbers and deaths by COVID-19, although the latter is often in dispute.

By such rubrics, the United States, so far, has fared better than most of the major European countries—France, Italy, the United Kingdom, Spain, Sweden, and Belgium—in terms of deaths per million. Germany is the one major exception. But if blame is to be allotted to public officials for the United States having a higher fatality rate than Germany, then the cause is most likely governors of high-death, Eastern Seaboard states—New York, New Jersey, Massachusetts, and Connecticut in particular. They either sent the infected into rest homes, or did not early on ensure that their mass transit systems were sanitized daily as well as practicing social distancing.

New York Governor Andrew Cuomo, more than any other regional or national leader, is culpable for decisions that doomed thousands of elderly patients. He did not just suggest long-term-care facilities receive active COVID-19 patients, but ordered them to take them—knowing at the time that the disease in its lethal manifestations targeted the elderly, infirm, and bedridden.

Then in shameful fashion, after thousands died, Cuomo claimed that either the facilities themselves or Donald Trump were responsible for the deaths. In truth, in the United States, the coronavirus is largely a fatal disease in two senses: the vulnerable in just four states on the Eastern Seaboard that account for about 12 percent of the nation’s population but close to half of its total COVID-19 fatalities, and/or patients in rest homes or those over 65 years old with comorbidities.

Why are there currently spikes in cases among young people in warmer states and those of less population density in late June? No one is certain. But one likely reason is that millions of protestors for nearly a month crammed the nation’s cities, suburbs, and towns, shouting and screaming without masks, violating social distancing, and often without observant hand washing and sanitizing—most often with official exemption or media and political approval.

The period of exposure and incubation is over, and the resulting new cases—for the most part asymptomatic and clustered among the young—are thus no surprise. Still,  what is inconvenient is the rise in these cases—given that the Left either had claimed its mass demonstrations would not spread the disease, or, if they would, the resulting contagion was an affordable price to pay for the cry of the heart protests.

Perhaps, but the real cost of four weeks of protesting, rioting, and looting was to undermine the authority of state officials to enforce blatant violations of the quarantine. Obviously, if some can march with impunity in phalanxes of screaming, shoulder-to-shoulder protestors, while others are jailed as individuals trying to restart a business, then the state has lost its credibility with people and they will simply ignore further edicts as they see fit. Now what adjudicates quarantines are the people’s own calibrations of their own safety.

Mismanagement of the virus? There have been four disastrous official policy decisions: sending patients into rest homes; allowing millions en masse for political reasons to violate state mandates on masks and social distancing; retroactively attempting to reissue quarantine standards that their advocates and authors had themselves earlier de facto destroyed; and consistently issuing pandemic alerts solely on the flawed basis of new positive cases, without distinguishing those who were asymptomatic, or who were infected and recovered without ever being tested, or who were asymptomatic and tested positive for antibodies, or who were only briefly ill, recovered, and by no means still a case-patient.