Address correspondence to: Anthony S. Fauci, MD, Building 31, Room 7A-03, 31 Center Drive, MSC 2520, National Institutes of Health, Bethesda, Maryland 20892-2520, USA. Phone: (301) 496-2263; Fax: (301) 496-4409; E-mail: email@example.com.
First published October 1, 2007 - More info
Thank you very much, John [Gallin], for your kind comments. It is at the same time a great honor and a humbling experience to be recognized by one’s peers. It serves to remind me that I did not get here in a vacuum; I was helped along the way by many talented and generous people and organizations. Due to time constraints, I cannot name them all but some deserve special mention. From the earliest days of my memory my parents ensured an environment of love and warmth and planted the seed in my mind and heart of the attractiveness and substance of a life of public service. I am forever in their debt.
My experience at Cornell University Medical College and the New York Hospital-Cornell Medical Center exposed me to the sheer joy and excitement of clinical medicine and the importance of the role of academic medicine in driving the excellence of clinical care. At Cornell, Marvin Schlesinger befriended me and literally insisted that I go to the National Institutes of Health (NIH). He introduced me to Sheldon Wolff (Figure 1); Shelly set me on the road to becoming a physician-scientist. Besides being a generous mentor, he became one of my closest friends and ultimately the best man at my wedding. From my earliest experiences with Shelly Wolff until today, I owe an enormous debt to NIH. I am grateful also for the 35-year relationship that I have had with John Gallin, my scientific colleague and dear friend with whom I have shared so many stimulating conversations and fun experiences. As my career advanced, my fellows and students assumed an important role in my accomplishments. Notable within a group too large to name everyone are Cliff Lane, my colleague, confidante, and close friend for almost 25 years, as well as Bart Haynes, Gary Hunninghake, Joe Parrillo, and Mark Dybul.
The late Sheldon M. Wolff, MD — mentor, confidante, and close friend to the author.
Another important group of individuals who have provided an enormous amount of stimulation and fun for me have been my colleagues and co-editors of Harrison’s Principles of Internal Medicine. I have been an editor of this textbook for the past 23 years and besides the extraordinary camaraderie that these individuals have provided for me, they have been extremely influential in helping me maintain my primary identity as an internist.
In preparing for these brief remarks, I struggled with the issue of what aspect of my experiences might be unique and of interest to you and what message or lessons learned I could relate to you. I consulted a number of people including my good friend Gene Braunwald, who pointed out that among the prior Kober Medalists going back to 1925, I am the only one that has spent his or her entire career in the federal government. Hence, for better or worse, I have a 30-year perspective from Washington, D.C., and the NIH that is relatively unique among physician-scientists and science administrators. And so, taking up Gene’s suggestion, allow me to discuss briefly from my personal perspective the kinds of things that can happen in that setting that can have a significant impact on biomedical research and public health.
In Washington, first and foremost, it is about carefully nurtured and long-term relationships with individual people. It starts with developing trust and mutual respect with the Congress (including their staffs) and with the constituencies that you represent to the Congress. Over the years, I have had mostly agreements, but some disagreements, with many of the prominent figures in the Congress whose authority impacts biomedical research in general and the NIH in particular. Most of all, I have tried to be an honest broker on behalf of the biomedical research community. It is an honor and a privilege to be able to call Tom Harkin, Arlen Specter, Ted Kennedy, Nancy Pelosi, Henry Waxman, and many others as my friends. Since I am one of your de facto representatives in the government, this means that they are your friends as well. I show this picture of Senator Edward Kennedy (Figure 2) since he was among the first to embrace me as a partner in support of biomedical research and health issues when I became Director of the National Institute of Allergy and Infectious Diseases (NIAID) in 1984 and has been a good friend and supporter ever since.
Senator Edward M. Kennedy speaking with the author on a visit to NIH in December 2006.
Of particular note is the fact that the importance of building relationships extends to the executive branch, and by that I mean the Secretary and senior staff of the Department of Health and Human Services (HHS), the Office of Management and Budget (OMB), and the White House itself, including the President and Vice President. Equally important are White House staff, even very junior staff who have a way of graduating up to ever more influential positions over the years. Let me tell you a brief story that will give you a flavor of the extraordinary potential for the promotion of biomedical research and public health in that environment.
In the mid-1980s, during the early years of the AIDS pandemic, then–Vice President George H.W. Bush visited the NIH (Figure 3) because he wanted to learn more about HIV/AIDS. It was clear that one of his motivations was that he was preparing to run for President and wanted to be up to speed on a topic that was gaining considerable momentum and for which the Reagan administration was being severely criticized for lack of interest and involvement. Because of my clinical and research interest in HIV/AIDS, and because I was the Director of NIAID, I was chosen by Jim Wyngaarden to show the Vice President the NIH Intramural AIDS Program. After I got over being star-struck by the fact that I was actually dealing with the Vice President of the United States, it became clear to me that he was a genuinely decent person, who was concerned, interested, and really wanted to help. After showing him around, I thought that like many other visitors I would never hear from him again; however, to my surprise, soon thereafter he began calling me and even inviting me to the White House with questions about AIDS as well as other topics of medical importance. This evolved into a personal friendship as he invited my wife and me several times to the Vice President’s mansion for social events. I realize that I was very lucky to have been in the right place at the right time in this accidental twist of fate, and so besides the excitement and fun of getting to know the Vice President, I saw this as an opportunity to educate a willing and clearly influential person about health and biomedical research.
Vice President George H.W. Bush visits the NIH in April 1987 and discusses the HIV/AIDS Program with the author and NIH Director James B. Wyngaarden, MD.
Soon the Vice President was elected President and the relationship continued. Importantly, relatively junior members of his administration also became acquaintances and friends. I did not appreciate at the time that these new young friends were to become senior members of the current administration a dozen years later. The new President’s interest in HIV/AIDS and the role of the NIH in addressing this problem intensified. He visited the NIH again together with Mrs. Barbara Bush in 1989 to actually meet and speak with a group of AIDS patients. Importantly, as he was learning about HIV/AIDS, he was also learning about the enormous potential of biomedical research to solve health problems in general. As bright and kind a man as he is, biomedical research was not his primary interest, but the more he learned, the more he really understood, and he was a good listener. A little-noticed member of that contingent who visited the NIH that day was the President’s son, George W. Bush. I met him for the first time that day and it was clear to me that he shared his father’s interest in this disease.
I cannot continue the story of the importance of building relationships within the executive branch without mentioning President Bill Clinton. The 8 years of his administration provided ample opportunity to engage with him in issues related to biomedical research. He visited the NIH often (Figure 4) and, consistent with his well-recognized intellectual brilliance, he really wanted to understand the details as well as the overarching importance of science and basic and clinical biomedical research. On an AIDS briefing visit to the White House Oval Office in December, 1996, with NIH Director Harold Varmus and other NIH and CDC officials, I described to President Clinton the binding and conformational change of the HIV envelope protein as it anchors to its coreceptors on the CD4+ T cell. There is no doubt in my mind that he actually understood me. On the way out of the Oval Office, he asked Harold Varmus and me: what was the area of AIDS research that needed the biggest boost? We both said that we needed to marshal the best and the brightest to develop an AIDS vaccine, and an NIH Vaccine Research Center would be extremely helpful. He turned to Leon Panetta, his Chief of Staff, and said, “Make it happen.” Soon there was the groundbreaking and within just a couple of years we had the now highly productive NIAID Vaccine Research Center, for which we recruited as Director Gary Nabel from the University of Michigan Medical Center. Gary’s wife, Elizabeth (Betsy) Nabel, accompanied him to the NIH to join the National Heart, Lung, and Blood Institute (NHLBI); as you know, Betsy is currently the Director of NHLBI. Clearly, that visit to the White House was time well spent.
President Bill Clinton visits the NIH in 1995 and hears about the latest advances in HIV/AIDS research from the author. Next in line to update the President on the Human Genome Project is Francis S. Collins, MD, PhD, Director of the National Human Genome Research Institute, seated at the lower left.
Now back to the story of the current President Bush and HIV/AIDS. Based in part on the early interactions with his father and our meeting at the NIH regarding AIDS 12 years earlier, President George W. Bush, soon after becoming President, asked me to work with his staff in the arena of global HIV/AIDS since he was interested in having the United States take a leadership role in Global Health Diplomacy centered around HIV/AIDS. He brought me together with Josh Bolten, who was then his Deputy Chief of Staff and was one of those young staffers whom I had met in his father’s administration. Josh Bolten went on to become Director of the OMB, a position of vital importance to NIH. Mr. Bolten is currently the Chief of Staff to the President.
Josh sent me and HHS Secretary Tommy Thompson to Africa to develop some ideas about how the USA could help in the global AIDS effort. Tommy Thompson is a classical “politician” with a heart of gold. He knew relatively little about health and medical research but when he got to HHS, he dove into it and wanted to learn. He was a good friend to the NIH. It was partly under his watch that the NIH budget doubled. It is amazing the relationship you can build during an endless flight to Africa on an uncomfortable Air Force jet and the Secretary needs some of your Ambien to get to sleep or when you treat his traveler’s diarrhea with Cipro after he ate the salad in Cote d’Ivoire that you had insisted he avoid.
We visited several Southern African countries and came back with a proposal for a $500 million plan to prevent mother-to-child transmission of HIV in Africa using the recent breakthrough of single-dose nevirapine. Soon we were in the Roosevelt Room of the White House, presenting this plan to President Bush with his entire senior staff in attendance. The President was excited about the proposal and approved it on the spot. As I walked out of the Roosevelt Room, the President pulled aside Josh Bolten and me and told me to now develop a plan that went well beyond the $500 million mother-to-child transmission prevention program. It was made clear to me that there was no guarantee that he would approve it; he needed to see what it looked like and it had to be, in his words, “transforming, practical, and above all accountable.”
In the early summer of 2002 I began the arduous task of actually putting flesh on the new big plan. Throughout the summer and fall of 2002, I dealt on a weekly basis with a small group of the same former “young” White House staffers, old friends that I had met more than 12 years ago, who were now functionally running the West Wing. Nothing would get to the President without their facilitation and approval. I enlisted the help of one of my former fellows, Mark Dybul, who was then my Special Assistant. Mark had come to NIH as a superb house officer from Arthur Rubenstein’s Department of Medicine Program at The University of Chicago. We put together a $15 billion 5-year plan designed to treat 2 million people, prevent 7 million infections, and provide care for 10 million people in Southern Africa and the Caribbean (Figure 5).
The goals and scope of PEPFAR.
Then, from late October through December 2002 things went dark; we heard nothing from the White House and I thought for sure that the program was now off the table. As you can imagine, I was very discouraged thinking that all of that effort was for naught. However, in mid-January, I received a call to come down to the White House immediately. When I got there, Josh Bolten told me that the President had accepted the proposal and he introduced me to Mike Gerson, the influential and skilled speech writer for the President. Mike told me that we needed to work together on some paragraphs for the State of the Union address the next day, where the President would announce the program. Here I thought that they had given up on the project, but now it was going into the State of the Union Address.
Four years later, the President’s Emergency Plan for AIDS Relief (PEPFAR) has been enormously successful and transforming, already putting more than 1 million people on antiretroviral therapy. Of note, Mark Dybul, my former fellow and Arthur Rubenstein’s former Resident, is now Director of PEPFAR with the rank of Ambassador.
As you could imagine I feel very fortunate and truly quite humbled to have been given the opportunity to participate in these activities. I mentioned “lessons learned” earlier in the discussion. There are several. First, we should never underestimate the potential impact of developing close and enduring personal relationships with the Congress or the executive branch. They do want to get to know you. They are real people, usually outstanding people, and many of their concerns are similar to ours. However, they cannot help us unless they are informed. They need to be informed in an atmosphere that is transparent, honest, and respectful of differences of opinion, and there will indeed be differences of opinion. In Washington, you have to invest time in informing 50 people for every one that will actually help you. Those are the odds of the game.
Next lesson: you cannot give up when you perceive that you may not be succeeding. There was a time during the development of PEPFAR when I feared the program would not be accepted by the President. Importantly, you must leave your political opinions and inclinations out of the equation. I have shown you some specific examples of my interactions with government officials of widely different political leanings. When it comes to garnering support for biomedical research or public health programs, regardless of your own political persuasions or ideology, you must deal with the people who are there, not the people who you might wish were there. Probably the most important lesson that I have learned is that you must be flexible, but you must stick with your fundamental principles. It could be tempting in the heady atmosphere of a Congressional chamber or the West Wing of the White House to give someone an opinion or answer that you think they might want to hear for fear that if you upset them you may fall into disfavor. The tough reality is that when you operate in this environment, you must be prepared to challenge and even upset a very important person with the truth, and as a consequence you may never get asked back to the inner circle. That is the chance that you have to take if you want to be effective.
Finally, I left one thing for last and certainly not least and that is to recognize and thank my wife, Christine Grady, and our children, Jenny, Megan, and Alison, without whose love and support I truly believe I would not be here today (Figure 6). My ladies have been at my side through it all with sage advice, support, humor, constructive criticism, a healthy irreverence towards me, and above all warmth and love. They are my anchors and at the same time the wind in my sails. Thank you.
The Fauci family. (A) The author and wife Christine Grady in a village square in Toscana, Italy, in the summer of 2006. (B) The author with daughters (left to right) Alison, Jennifer, and Megan at the family’s favorite Mexican restaurant in Washington, D.C. Mom took the photograph.
This article is adapted from a presentation at the ASCI/AAP Joint Meeting, April 13–15, 2007, in Chicago, Illinois, USA.
Citation for this article: J. Clin. Invest.117:3136–3139 (2007). doi:10.1172/JCI33691.