July 1, 2001hen Harold Varmus, the Nobel Laureate who ran the National Institutes of Health to wide acclaim during the Clinton years, suggested in 1999 the idea of consolidating some of NIH's rapidly proliferating fiefdoms, Anthony S. Fauci was quick to offer a tongue-in-cheek suggestion on how best to proceed. Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), brandished the roster of 19 separate disease institutes and eight research centers and told Varmus: "If you look at this list, we should have just two institutes-the Institute for Suicide and Unintentional Injuries, and the Institute of Infectious Diseases."
These are heady days at NIH's leafy 300-acre campus in Bethesda, Md., as Congress pours more money into biomedical research. President Bush proposed a $23 billion NIH budget for fiscal 2002, a 13.5 percent, $2.7 billion increase that will nearly double NIH's 1996 funding level, if legislators approve it. The budget for Fauci's
NIAID is growing even faster. During Fauci's 17-year tenure, the $2.4 billion NIAID has grown from the sixth-largest NIH institute to the third, trailing only the National Cancer Institute ($4.2 billion) and the National Heart, Lung and Blood Institute ($2.6 billion). It now spends more than 10 percent of the NIH budget. When Fauci became director in November 1984, the institute had only a 7 percent share of NIH's $5.1 billion budget.
The dreadful AIDS virus, which has infected almost 1 million Americans and killed 430,000 of them, accounts for much of that growth. But so do exciting developments in understanding how disease spreads and a growing awareness that in this era of jet travel, no country is an island, immune from old scourges such as tuberculosis and malaria and newer, equally terrifying ones, from HIV and hepatitis C to hantavirus, Ebola virus, West Nile fever, mad cow disease and hoof-and-mouth disease. NIAID provides the major support for scientists developing better ways to diagnose, treat and prevent infectious immune system disorders and allergic diseases.
In the early days of the AIDS epidemic, Fauci and some colleagues (including Clifford Lane, the institute's longtime clinical research director; John Gallin; John La Montagne; and Margaret Johnston), retooled the institute's work, devoting major resources to understanding the virus and devising treatment protocols for a disease for which there remains no cure. The work of NIAID's own scientists, the extramural research at hundreds of sites across the country and now around the world, breakthroughs by the pharmaceutical industry and preventive efforts have cut the annual U.S. death toll from AIDS by two-thirds, from 50,610 in 1995 to 16,273 in 1999. And work continues apace on finding a way to block transmission of the virus, just as polio and other infectious killers were stopped in their tracks by powerful vaccines.
In addition to managing this burgeoning research enterprise and playing his very visible role as the government's leading authority on AIDS, Fauci still performs medical research and is chief of the Laboratory of Immunoregulation, one of the institute's 15 labs. He is shown not only atop NIAID's organizational chart, with an aerie in Building 31 where most of the institute directors hang their hats, but also on the staff of the Division of Intramural Research with an office in Building 10, where the scientists work. He still sees patients on rounds at NIH's Warren Magnuson Clinical Center at least once a week.
The 60-year-old Fauci maintains a schedule that even he calls "crazy." He arrives each weekday before 7 a.m. and routinely clocks a 14-hour day, leaving around 8:45 p.m. to pick up his daughters from gymnastics classes. He then sits down with wife Christine Grady and their three daughters (ages 9, 11 and 14) for dinner at 9:30 p.m. He calls it quits on Saturdays at 4:30 p.m. and tries to stay home on Sundays, although he is known to sneak back to work for a few hours if the girls are busy at gymnastics or track meets. It translates to an 80-hour workweek, and Fauci has kept up this pace for decades. He's also a main editor of Harrison's Principles of Internal Medicine (McGraw-Hill, 15th Edition, 2001), a top-selling textbook that he updates during "free" time at home at night and on weekends. "There are weeks when he has to go in on Sunday, like this past weekend when he just got back from Uganda and he really needed to catch up. He thrives on it," says Grady, his wife of 16 years, a former nurse and now a Ph.D. bioethicist who also works full time at NIH.
NIAID thrives on it, too. The allergy and infectious disease institute is considered a model of how a large and rapidly growing medical research program should be run. It moves adroitly in response to breakthroughs in research and creates robust new programs designed to speed development of vaccines. And it plays an expanding international role in the fight to stop the spread of infectious diseases. An NIH review panel in 1996 described Fauci as "the prototype of a highly effective institute director at the National Institutes of Health."
"NIAID is a leader among the institutes on strategic planning. It has moved very quickly to meet a large number of challenges and epidemics. That's one of Tony's strengths," says Barton Haynes, a Duke University immunologist and Fauci protégé who trained at NIAID a quarter-century ago. "He is a master organizer with a wonderful vision for how things could be."
Fauci is famously productive, with an ability to move meetings along and cut to the chase, whether discussing scientific questions with laboratory fellows or building renovations at NIH. John La Montagne, NIAID's deputy director, who helped build the successful influenza vaccine program and was the first director of the Division of AIDS, calls Fauci "very much of a delegate-and-hold-accountable kind of executive" who gives a lot of latitude to his division directors.
"Tony's tough. He's not an easy person at times. He's demanding. He's exceptionally intelligent. He's a very good judge of character," says La Montagne. And he attracts "very original people" drawn to the challenge of working for someone who sets the bar high. When Varmus, in his first year as NIH director, remarked to a New York Times reporter that Fauci ran his institute "with an iron fist," Fauci canvassed his staff members to ask whether they felt that was true. "Most giggled nervously and said variations of, 'Well, yes, but you're always fair,'" Times science writer Natalie Angier recounted in a 1994 profile.
Douglas Brust, a fellow in Fauci's Laboratory of Immunoregulation, says Fauci "usually knows about stuff before we do because he sees everything. He writes articles. He reads the same journals I read. He's brilliant at taking a very complex scientific question and breaking it into its essential components. He's famous for saying, 'What is the question?' If it's not important, we stop right there." Lynn Hellinger, who was NIAID's director of human resources for five years and recently became associate director for management and operations, says NIAID's 1,600 workers thrive on the challenge of working "for someone who is passionate about what they are doing. The research that we're doing here is important. It's easy to get caught up in what's going on, even if you're just supporting the science."
Donna E. Shalala, Fauci's boss for eight years as Secretary of Health and Human Services in the Clinton administration, calls the NIAID director "a Renaissance man, a world-class scientist and a world-class human being. NIAID may rank third in size among the NIH institutes, but "not in prestige," says Shalala, now the president of the University of Miami. "It's first among equals. It's an extraordinary place." Shalala continues, "Tony Fauci is one of the great scientists of this world, and I treated him accordingly. Tony did not go through [NIH Director Harold Varmus] to talk to me . . . . He's been a close scientific adviser to every Secretary that I've known of and certainly was a close friend and an adviser to me." For his part, Varmus, who left NIH in 1999 to become president and CEO of Memorial Sloan-Kettering Cancer Center in New York, calls Fauci "an exceptionally organized, energetic, dedicated person. He runs not just a lab, but a very large lab; he manages one of the biggest institutes. He also is a leading spokesperson on AIDS research in the country, has a lot of dealings with the press and advocacy groups, and is in the middle of a politically turbulent landscape. And he makes rounds." Varmus believes that "being involved in the day-to-day science is extremely good for someone trying to manage a scientific program. NIH would go downhill if we didn't have good scientists running the programs. Management there is developing scientific programs and overseeing the grants that are funded. It's not bean counting; when you have bean counters, it's all over."
Would NIAID be better off if its director were not also a full-time researcher and part-time clinician? It's hard to argue with Fauci's success at wearing all these hats. "The evidence would be that none of them suffer, that they all seem to prosper," says La Montagne. Fauci says seeing patients is "part of my identity. That gives me a lot-to see the HIV-infected patients and the problems they have, and what they are facing, and then to go back into the lab and tell my basic scientists, 'You know, this is the critical question we need to answer. Let's design some experiments to take a look at that.' And then I put my administrator's hat and now I have this $2.3 billion armada that I'm steering here [he simulates turning a helm], and it's 'We really need to torque it a little bit this way, because that's where the field is going.' So doing all these three things I think makes me a much better person at each. I am totally convinced of that." Far from being surprised when the famous Fauci turns up at their bedsides, the AIDS patients "expect it," says Cliff Lane. "It's been that way since the beginning of the epidemic. It's like, 'Well, where is he? I was hoping to see Dr. Fauci.'" Fauci weathered personal attacks in the late 1980s from AIDS activists who criticized the government for a lack of urgency in its response to the epidemic, but he won them over. He gave AIDS patients a voice in the NIAID advisory process and set an example that other institutes now follow with patients with breast cancer, prostate cancer, Alzheimer's disease and other debilitating illnesses.
NIAID's official goals, under the 1993 Government Performance and Results Act, include helping researchers find an AIDS vaccine by 2007. Fauci increasingly is setting his sights on fighting this plague abroad, especially in Africa and Asia, where the lethal virus has claimed most of its 20 million victims, prevention is weak and drugs are unavailable or too expensive.
Fauci has 1,008 scientific articles to his credit. He has a knack for explaining complex scientific topics in language that nonscientific people can understand. When the press or television calls, he handles the interviews himself. Fauci often credits the Jesuits who taught him at Regis High School in New York City and the College of the Holy Cross in Worcester, Mass., with teaching him to value "precision of thought and economy of expression. I think the Jesuits played a major role in helping to formulate what I am and what I do now, my modus operandi as a scientist, as a clinician, as an administrator, as a leader," says Fauci. "I never took any management or business courses. But I strive for excellence, and I demand that. We have a lot of responsibilities. We're in the health professions. We're dealing ultimately with the lives and deaths of people. We are public servants. We are consuming tax dollars. We've got to be excellent. That's the first thing. And the second is I surround myself with the best people I can find," he says. "I've been here a long time and virtually everybody that's here-in fact, the second generation in some jobs-was picked by me."
The other thing he learned from the Jesuits was "the discipline. It was tough love and gentle disciple. You were expected to do something, and there was no excuse if you didn't. I liked that. The Jesuits expected you to be excellent. If you goofed off, they just didn't tolerate it. You knew who the boss was."
Fauci came to NIH as an infectious disease specialist in 1968 after receiving his M.D. degree from Cornell University Medical College (he was first in his class) and completing a two-year residency at The New York Hospital-Cornell Medical Center. He tells of hearing then-U.S. Surgeon General William Stewart say that it was time to "close the book" on infectious diseases and concentrate on chronic ailments, and wondering whether he had chosen the wrong specialty. He needn't have worried.
"The NIH is a very, very unique and wonderful place to be," says Fauci. "With the breakthroughs that now are coming with sequencing the genomes of microbes, not to mention the human genome, and with all the recent emphasis on international health, particularly with HIV/AIDS, malaria and tuberculosis, it's a very exciting place to be. In many areas, our work has just begun . . . . In my life, it's never 'Miller time.' There's always something to do." But from another perspective, it's all Miller time for Tony Fauci-his work is his play. He enjoys the celebrity of his position, from the television appearances to the cocktail parties at ABC news correspondent Sam Donaldson's house to strangers asking for his autograph or spontaneously giving him a hug and a "God bless you."
"The fact that you're known by Presidents and by Cabinet members-that feels good, obviously. It's crazy to say that it doesn't," says Fauci. "But it's for a purpose and to me that purpose-and I don't care how corny it sounds-is public service. Whenever they are making me up for McNeil-Lehrer or This Week, I'm always saying to myself: Sic transit gloria mundi. I know that this is transient. The real substance is going into the patient's room and figuring out what's wrong and how you can move some projects to not only make them better, but make a lot of other people better. The stuff you do in the lab, the stuff you do at the institute level. That's the thing that's nontransient. That other stuff is going to go away."
July 1, 2001