On Call: A Doctor's Journey in Public Service

On Call: A Doctor’s Journal, Dr. Anthony Fauci’s memoir published in 2024, offers a first-person perspective on his career milestones, which also serve as a history of public healthcare in the US. Fauci grapples with the ethical complexities of modern medicine, personal challenges, and political trials as his career advances. The book, which combines autobiographical prose with a medical journal narrative, recounts Fauci’s experience as a leading infectious disease expert and director of the National Institute of Allergy and Infectious Diseases (NIAID).

Cumulating more than 50 years of clinical and research experience, Fauci chronicles his responses to public health crises from HIV/AIDS to COVID-19. He also describes the shifting US healthcare landscape, noting the growing influence that matters like security and misinformation have on it. Throughout the narrative, Fauci emerges as a rigorous physician, passionate about his profession, compassionate towards patients, and dedicated to public service.

This guide delves into the themes of The Difficulty of Maintaining Emotional Composure During Medical Practice, Pioneering Scientific Discovery in the Face of Ambiguity, and The Intertwined Realities of Public Health and National Security. 

This guide references the Penguin 2024 eBook edition.

Summary

On Call starts with the Preface, in which Fauci recounts a pivotal moment in the COVID-19 pandemic when Pfizer’s CEO informed him of the COVID-19 vaccine’s success in trial, inspiring Fauci to reflect on his life’s work.

Part 1 begins with his childhood years in Brooklyn, New York, where Fauci’s Italian American family instilled in him values of community service and education. Influenced by his family’s dedication to helping others, he excelled academically and earned a scholarship to Regis High School, a Jesuit institution that inspired him to study medicine. Fauci balanced academics with sports, which taught him resilience and a solid work ethic.

Fauci started his medical journey at Cornell University Medical College, where demanding studies and close patient interactions solidified his dedication to medicine. A personal loss—the death of his mother—tested his resolve, yet he graduated with top honors. Fauci’s commitment to curing infectious diseases led him to the NIH, where he joined the National Institute of Allergy and Infectious Diseases (NIAID). Initially, he made significant advances in immunology, particularly in treating deadly vasculitis syndromes, achieving groundbreaking remission rates. Despite his success, Fauci later sought greater public health impact, setting the stage for his prominent role in global health crises.

In Part 2, Anthony Fauci details his pivotal shift toward AIDS research and advocacy as the epidemic emerged and evolved. In 1981, Fauci encountered initial reports of a mysterious disease affecting healthy men with unusual infections, which was later identified as AIDS. Alarmed, he shifted his NIH research focus from immune disorders to studying AIDS, despite skepticism from colleagues. He assembled a team of researchers, and by 1982, cases of AIDS appeared across diverse populations, confirming its broader impact.

As the AIDS crisis intensified, Fauci’s dedication led to his appointment as the NIAID director in 1984, a role in which he advocated for AIDS research funding and policy change. He established dedicated programs, such as the AIDS Clinical Trials Group. The discovery of HIV as the virus causing AIDS in 1983 enabled global efforts in diagnostics and understanding disease progression, while the development of drugs like AZT marked the first hopeful treatment—albeit one hampered by HIV’s rapid mutation.

Fauci’s partnership with Surgeon General C. Everett Koop and later relationships with activists like Larry Kramer and Marty Delaney shifted his approach to patient advocacy. Engaging with activists and political figures led him to support experimental drug access—a stance that solidified his position as an ally for AIDS patients. His continued dedication to patients and his work shaped public health policy as he navigated criticism and difficult political negotiations.

Internationally, Fauci engaged with global challenges as AIDS spread, notably in Africa, where he collaborated with doctors to assess heterosexual transmission patterns. Despite significant drug advancements, global inequities persisted, as many people were unable to access life-saving treatments. However, the introduction of combination antiretroviral therapy in 1996, which achieved near-complete viral suppression, marked a turning point as critically ill patients began recovering.

In Part 3, Fauci outlines the pivotal moments in his career during the early 2000s as he engaged with global health crises, bioterrorism, and international public health efforts. Fauci’s work with President George W. Bush’s administration focused, at first, on the global HIV/AIDS and infectious disease crisis. Working closely with HHS Secretary Tommy Thompson and the National Security Council, Fauci helped shape policies that led to the establishment of the Global Fund to combat AIDS, Tuberculosis, and Malaria.

However, September 11, 2001, marked a turning point in his life as Fauci witnessed the terrorist attacks on the World Trade Center firsthand, and the focus of his work shifted to bioterrorism threats. The subsequent anthrax attacks placed Fauci in a position of formulating a response to biological threats and managing public communication about the events.

The global AIDS response intensified after Fauci’s visit to Uganda, where he witnessed the epidemic’s devastation. This visit spurred initiatives like PEPFAR, a massive US-led AIDS relief plan aimed at Africa, later unveiled by Bush in 2003.

Fauci returned his focus to biodefense to prepare for a possible smallpox pandemic, leading to the development of Project BioShield, a program to fund countermeasures against bioterrorism. Fauci also traveled to Iraq as part of the government’s strategy to ensure care for military troops involved in combat there.

Part 3 ends with the narration of Fauci’s engagement with influenza and malaria and the development of programs that have had lasting impacts. These efforts, along with his AIDS work, earned him recognition and marked a significant shift in global health strategy.

In Part 4, Fauci reflects on challenges faced during the Obama administration, when he had to deal with several public health threats, such as the swine flu, Ebola, and Zika outbreaks, along with the ongoing HIV/AIDS crisis.

Fauci details the public health administration’s response to the 2009 H1N1 flu pandemic. The effort focused on rapid vaccine production amid delays and shortages. Public frustration grew as vaccines arrived after H1N1 had peaked and the public started mistrusting the government’s strategy.

Furthermore, Fauci recounts the failure of a South African AIDS vaccine trial. Nevertheless, effective antiretroviral treatments and PrEP (pre-exposure prophylaxis) offered new hope for controlling HIV, and Fauci envisioned a future with an AIDS-free generation.

Navigating the 2014 Ebola outbreak, which spread through densely populated West African cities, Fauci worked with global health officials to provide containment support, facing public fear and criticism of his international focus. Fauci’s efforts included public reassurances to combat the pandemic, particularly after a Dallas nurse became infected, which fueled media panic. Along with the nurse, who recovered after Fauci’s team treated her, they treated a healthcare worker who became critically ill with Ebola while working in Sierra Leone. The high-risk care demanded constant vigilance and commitment, but the team was successful in treating the patient.

The 2015 Zika virus outbreak led Fauci to address the unique threat posed by birth defects among infected pregnant women. Despite limited funding, his team quickly advanced vaccine trials, and Fauci reflected on the challenges of political interference in public health.

Fauci’s recounts Obama’s last state dinner of his mandate and the impending transition to the Trump administration. Reflecting on Obama’s steady partnership during public health crises, Fauci prepared to leave behind public health leadership in order to recommit to science and patient care.

In Part 5, Fauci recounts the tumultuous period of the COVID-19 pandemic, which required him to step into a public role even more fully. In January 2020, as reports emerged from Wuhan, China, Fauci recognized the outbreak’s gravity. Working alongside the Trump administration, he navigated initial response measures like travel restrictions and early vaccine development with Moderna. The pandemic’s rapid escalation soon led to tensions around messaging; while Fauci prioritized transparency, conflicting White House statements complicated public understanding. Fauci frequently found himself at odds with President Trump and his advisors, especially regarding unproven treatments like hydroxychloroquine and rapid economic reopening timelines.

By March 2020, the pandemic surged within the US, leading to nationwide lockdowns. Fauci’s growing public role attracted both support and threats. As a result, he was given a security detail. As death tolls mounted, Fauci stayed focused on promoting masking, social distancing, and evidence-based treatments, while contending with Trump’s push for quick solutions, such as experimental antibody treatments.

Following President Biden’s election, Fauci was relieved to adopt a collaborative approach to COVID-19, working to implement vaccination goals. Despite facing public and political backlash, Fauci continued to battle misinformation and promote vaccine equity.

In the Epilogue, Fauci reflects on a career shaped by health crises and his dedication to public service. Now a Distinguished University Professor at Georgetown University, Fauci continues to inspire future medical leaders while addressing societal divisions and the dangers of misinformation. His memoir, as he states, serves as both a personal legacy and a testament to the challenges of guiding public health during unprecedented times.