Saint Anthony … fired?

Oh, would that it were.  But he’s essentially unfireable and the man who might have done it left the oval office last January, and he couldn’t have directly fired any career civil servant, an act that would have had to be accomplished through intermediaries.  But the diminutive octogenarian from Brooklyn was once my hero, as he was to most rheumatologists.  His training is in immunology, not microbiology or infectious disease, and he spent the early part of his career examining ways to dampen the overactive immune response behind many of the more severe diseases faced by rheumatologists.  His success at using an old chemotherapy compound derived from mustard gas – cyclophosphamide (Cytoxan) – to treat polyarteritis nodosa (PAN) won him great acclaim.  PAN is characterized by immune-mediated inflammation of blood vessels with a muscular layer – medium sized blood vessels (the aorta and its branches are large blood vessels).  Patients can be very sick with just the systemic inflammation, and organs those blood vessels feed can be compromised, with everything from severe hypertension, kidney failure, heart attacks, strokes, gangrene, and gut perforation ensuing.  Prior to Fauci’s demonstration that Cytoxan pushed to the limits of the PAN patient’s bone marrow can halt the blood vessel inflammation (vasculitis), most patients died, either of the acute disease, consequences of compromised organ function, or complications of the corticosteroid treatment, which was the only thing going before Cytoxan.  Others had used Cytoxan for PAN before, but Fauci had the manpower and organizational resources of the NIH behind him to conduct a proper trial.  But it wasn’t really a trial, just the report of 17 PAN cases treated with Cytoxan at the NIH over the previous 11 years.  I presented his report of that “trial”, which had just appeared in the New England Journal of Medicine (1), at intern’s report at Barnes Hospital, and with some excitement.  It may have been the thing that tipped me into rheumatology.  PAN cases were pretty uncommon, but getting one was one of the most exciting things that happened to this medical resident back then.  Making the diagnosis was always a coup, and the steroids did make things back off, although long term was always touch-and-go, until Cytoxan, which added the great satisfaction of what was basically a cure, although Cytoxan has long term side effects like bone marrow suppression, infections, bladder irritation and bleeding, and emerging malignancies.  Fauci turned to another vasculitic disorder – Wegener’s granulomatosis – and basically cured that too.  He wrote a slim book with older colleague Tom Cupps which became the bible for those treating vasculitis (2).  To this day the combination and timing of medications he used are still employed and referred to as the “Fauci regimen”.  Newer specifically targeted biologic compounds like infliximab (Remicade) and tocilizumab (Actemra) have become more popular for PAN and Wegener’s, but a lot of us old timers still prefer the Fauci regimen.  Just 5 years after publication of his seminal NEJM paper, Fauci bolted rheumatology to climb onto the AIDS bandwagon, like so many others around that time.  Research money spigots were wide open.  Our chief, Bill Kelley, sat down the whole department for a special meeting at which he encouraged everyone to find some way possible to tie their research to AIDS.  Sure, those afflicted needed help, but the motivation wasn’t altruistic.  Fauci probably figured that having spent his career to that point suppressing the immune response, he could deal with a disease in which mother nature was doing it.  His leap also got him the leadership post at the National Institute of Allergy and Infectious Diseases (NIAID), a post he holds to this day.  He did continue to publish on vasculitis into the early 90s – 105 of the 1,040(!) citations on PubMed that bear his name concern vasculitis – but the bulk of his output has been on HIV, although it took him a while to get much out, with only 8 publications his first year and 12 the next.  He’d eventually amassed 244, and ventured into the broader area of emerging infections.  Then December before last, the Wunan Lab provided him with a new focus.  He’s been the face of the American response to COVID ever since, for better or worse.  A Rasmussen poll in early March found 52% approving of Dr. Fauci’s performance, down from peaks as high as 80% in an April ’20 Fox news poll and 73% per Zogby same month.  People in crisis will gravitate to a seemingly kindly authority figure, and Dr. Fauci certainly has burnished that image.  But if you’ve been paying attention to what he’s been saying, you might wonder how much of that adulation is really deserved.

The National Review’s Kyle Smith assembled some of Fauci’s statements about the pandemic for a recent article (3).  My wife Kathy subscribes to National Review, and began reading a few of them to me this morning.  Once again the girl is my muse.  I’m not sure the link below will work for non subscribers, so please allow me to repeat those statements here, in chronological order.

1/21/20 [asked about the coronavirus by Greg Kelly on Newsmax TV“This is not a major threat to the people of the United States and this is not something that the citizens of the United States right now should be worried about.”

1/26/20 [interviewed by John Catsimatidis, a radio host in New York, who asked whether “the American people . . . should be scared”]: “I don’t think so. The American people should not be worried or frightened by this. It’s a very, very low risk to the United States, but it’s something we, as public-health officials, need to take very seriously.”

2/17/20 [to USA Today]: “If you look at the masks that you buy in a drug store, the leakage around that doesn’t really do much to protect you. People start saying, ‘Should I start wearing a mask?’ Now, in the United States, there is absolutely no reason whatsoever to wear a mask.” [The danger of COVID is] “just minuscule” [but consider instead the] “influenza outbreak, which is having its second wave. We have more kids dying of flu this year at this time than in the last decade or more. At the same time people are worrying about going to a Chinese restaurant. The threat is a pretty bad influenza season, particularly dangerous for our children.” (Influenza levels hit a record low around the world; the number of pediatric flu deaths in the U.S. fell from 195 in the 2019–2020 season to one in the 2020–2021 season.)

2/29/20 (asked on NBC whether Americans should go to “malls, and movies, maybe the gym”): “At this moment, there is no need to change anything that you’re doing on a day-by-day basis. Right now the risk is still low, but this could change. I’ve said that many times, even on this program . . . although the risk is low now, you don’t need to change anything you’re doing. When you start to see community spread, this could change.”

3/3/20 [to a Senate committee]: “It will take at least a year to a year in a half to have a vaccine we can use.”

3/9/20 [at a White House briefing]: “If you are a healthy young person, there is no reason if you want to go on a cruise ship, go on a cruise ship. But the fact is that if you have . . . an individual who has an underlying condition, particularly an elderly person who has an underlying condition, I would recommend strongly that they do not go on a cruise ship.” (The U.S. State Department advisory issued the previous day reads: “U.S. citizens, particularly travelers with underlying health conditions, should not travel by cruise ship.”)

3/29/20 [on CNN]: Predicts death toll of “100,000 to 200,000.”

4/9/20 [on NBC]: “looks more like 60,000.”

7/17/20 [on PBS]: “We’ve got to do the things that are very clear that we need to do to turn this around. Remember, we can do it. We know that when you do it properly, you bring down those cases. We’ve done it. We’ve done it in New York. New York got hit worse than any place in the world. And they did it correctly by doing the things that you’re talking about.” (The death toll in New York State on July 17, 2020 was under 28,000. The death toll in New York State on April 19, 2021: 51,122. A new study points out that New York had the “worst overall outcome” of any state in the pandemic.)

8/13/20 [on PBS, asked whether schools should remain online instead of in-person for “many months”]: “In some places, Judy, that may be the case.”

10/6/20 [at American University]: “I’d like to say spring, but . . . I think it’s much more likely in the late summer early fall.” (The Pfizer vaccine was approved on December 11, 2020.)

11/28/20 [on ABC]: “Close the bars, keep the schools open.” (Politico, November 18, reported that: “Data from 191 countries shows no consistent link between reopening schools and increased rates of coronavirus infection, UNICEF reported.”)

2/22/21 [at a press briefing]: “There are things, even if you’re vaccinated, that you’re not going to be able to do in society. For example, indoor dining, theaters, places where people congregate. . . . That’s because of the safety of society.”

(The Atlantic: “Advising people that they must do nothing differently after vaccination — not even in the privacy of their homes — creates the misimpression that vaccines offer little benefit at all,” writes epidemiologist and Harvard Medical School professor Julia Marcus. “Vaccines provide a true reduction of risk, not a false sense of security. And trying to eliminate even the lowest-risk changes in behavior both underestimates people’s need to be close to one another and discourages the very thing that will get everyone out of this mess: vaccine uptake.”)

3/2/21 [on CNN after Mississippi and Texas lift mask mandates and some other restrictions]: “From a public-health standpoint it’s certainly ill-advised. Just pulling back on all of the public-health guidelines that we know work — and if you take a look at the curve, we know it works — it’s just inexplicable why you would want to pull back now. . . . What we don’t need right now is another surge. . . . I understand the need to want to get back to normality, but you’re only going to set yourself back if you just push aside the public-health guidelines.”

3/14/21, Yahoo headline notes: “Fauci just warned of a fourth wave.”

4/2/21, NPR headline notes: “Fauci Expects Surge In Vaccinations To Keep A 4th Coronavirus Wave At Bay.”

4/7/21, CNN headline notes: “Fauci says new Covid-19 cases are at a disturbing level as the US is primed for a surge.” (The April 19 New York Times reads: “Case numbers nationwide have been largely stagnant for the last month.”)

(Mississippi on March 2 had a seven-day average of 582 new cases, per the New York Times tracker. On April 19, their seven-day average was 243. In Texas on March 2, the seven-day average of new cases was 7,259. On April 19, it was 3,237.)

4/6/21: [on MSNBC, asked why Texas cases continued to decline]: “I’m not really quite sure.”

I think these fuzzy, slippery and inconsistent statements can be laid directly to his training as an immunologist rather than some character flaw.  Immunology, particularly on the 70s when Dr. F got his start, was incredibly vague.  Only now are researchers beginning to get their molecular arms around this vast, vague, and complex system.  Back then, they had to make the best of some pretty slippery data.  Our U of M president, Dr. Schlissel, was an immunologist.  He’s 15 years younger than Dr. F, but some of his pronouncements bespeak someone who once had to wrestle with slippery data.  My own meager bench research background was in virology, unlike Dr. F, a field that even in the 70s was grounded in Collins’ The Language of God, not the babble of immunology.  My career in rheumatology, though, was spent wrestling with those diseases in which the immune system has gone awry, food for much babbling of my own.

If you’re a fan of Fauci’s, you’ve no doubt been triggered by now, if you’ve bothered to read this far.  Maybe you’re one of the “5-Fs” as I call them (https://wordpress.com/post/theviewfromharbal.com/1134).  If so, I feel sorry for you, to have your life controlled by a man who can’t seem to make up his mind.

Whatever side of the fence you’re on, if you want to let Dr. Fauci know how you think he’s doing, here’s how:
anthony.fauci@nih.gov

I only have one verse so far, but I thought I’d share a little tune that goes to one made famous by Mr. Deutschendorf https://wordpress.com/post/theviewfromharbal.com/825

“Fauci, on my shoulder, makes me nervous

As he tells me that I must comply

If I don’t put my mask in service

Then no doubt that I shall surely die.”

References

1.         Fauci AS, Katz P, Haynes BF, Wolff SM. Cyclophosphamide therapy of severe systemic necrotizing vasculitis. N Engl J Med. 1979 Aug 2;301(5):235-8. doi: 10.1056/NEJM197908023010503

2.         Cupps TR, Fauci AS.  Vasculitides.  Philadelphia, W. B. Saunders Company, 1981

3.         Smith K.  Anthony Fauci’s Misadventures in Fortune Telling. National Review Plus. April 20,2021. https://www.nationalreview.com/2021/04/anthony-faucis-misadventures-in-fortune-telling/?utm_source=Sailthru&utm_medium=email&utm_campaign=NR%20Daily%20Monday%20through%20Friday%202021-04-20&utm_term=NRDaily-Smart