In defense of Dr. Fauci

I wasn’t sure what to do with her. She’d now been in the hospital with her COVID pneumonia and respiratory failure for 10 days when she started to rapidly deteriorate. The night before she was intubated which is never a good thing with this virus. When I saw her she was thrashing in the bed with a cacophony of beeping alarms and agitated nurses. Her blood pressure and oxygen saturation were dropping. Was this the COVID progressing? Was it a new infection? Did she aspirate? Was fluid backing up into her lungs? Should I change her ventilator settings? What if my ventilator changes worsen her oxygen levels and she codes? Should I give her diuretics? That may worsen her kidney function. Should I broaden her antibiotics? This may lead to side effects or induce resistant bacteria. Should I more heavily sedate her? This could lead to terrible brain dysfunction and worse outcomes if I give too much for too long.

That was just a small sample of what was swirling in my head outside that patient’s room that morning and that was just one moment with one patient on one day. Those moments happen multiple times throughout the day with multiple patients every day I work in the ICU.

Situations like this were on my mind when I came across the twitter thread of one Dr. James Todaro. He is a physician who has grown popular in various internet spheres where he posts primarily anti establishment information that is highly critical of the recommendations of public health authorities. He is particularly critical of Dr. Fauci and is not alone. Poor Dr. Fauci has become the focal target of much ire.

The twitter thread I read claims that there is latent T cell immunity that is present in the population. The claim is that there is cross reactivity with other coronavirus infections that creates a situation where herd immunity could exist with only 10-20% of the population infected, not 60-70% as currently predicted. This would mean that we could end lock downs and ease restrictions earlier and more aggressively than currently recommended. His argument is appealing.

The problem is that his claims are based on very small studies ( only 27, 38, 40, and 68 people). This is not exactly the numbers necessary to instill great confidence in the results. He also shows population data cherry-picked from specific regions to support his claims but there are numerous confounders that could explain these data.

Essentially, he is claiming that immunity is much more widespread than people are being made aware. He not subtly suggests the nefarious and conspiratorial influence of the “the mainstream media, possibly due to political and pharmaceutical interests”.

Dr. Todaro is unfortunately typical of the current age. We live in a world where anyone can log on and criticize or second-guess those that make the decisions that impact lives. Anyone can write a review, post a response, or tweet indiscriminately without consequence. No specific training, credentials, knowledge, fact checking, or peer review is necessary.

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We live in a world where anyone can log on and criticize or second-guess those that make the decisions that impact lives.

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Its easy to second-guess, especially after the fact. It’s easy to criticize when you have no real skin in the game.

The reality is that Dr. Todaro is a young ophthalmologist who doesn’t have to make life and death decisions every day. In his practice, if he’s wrong, someone will need a new set of glasses. How often does he have to make a decision where someone could die if he’s wrong?

And that’s the hardest question to ask and the hardest to answer in this line of work. What if you’re wrong? It’s a question us ICU doctors have to grapple with every day. We are faced with situations where we have to make life and death decisions with imperfect and uncertain information where someone could easily die if we’re wrong. It is a very heavy burden.

Now take that uncertainty and increase it by orders of magnitude. What happens if Dr. Fauci, the CDC, the WHO, or other public health authorities are wrong? Millions could die. Imagine making a recommendation under those conditions. It is for this reason that the people who run these institutions have no choice but to err on the side of caution. They sometimes make recommendations that sacrifice GDP to save lives. They do not have the luxury of believing a few association studies of less than 100 individuals especially when other studies are available that say differently. Dr. Todaro can find and quote the minority of studies and the few epidemiologists or immunologists that support his presuppositions and if he’s wrong, he may lose a few twitter followers, but nobody dies. Dr. Fauci and his colleagues need to weigh all the data and consider the outcomes from all sides. Will they get it right every time – of course not. There will always be moments where, when looked at in hindsight, their recommendations were wrong (e.g. their early recommendations against masking). There will also always be vocal haters who overemphasize the minority they get wrong and underemphasize the majority they get right. Any betting man, however, would look at the totality of the data and say the odds always favor listening to Dr. Fauci over listening to twitter.

Does that mean that Dr. Todaro is wrong? Of course not. He may be right, I don’t know. In fact I sincerely hope he’s right. I hope dormant T cell immunity from other coronavirus infections drops the number of infections needed to create herd immunity. He is recommending lifting restrictions in previously hard hit areas like New York which would be great, but would you bet your life on it? Would you bet your mother’s life on it?

What if he’s wrong? What if the restrictions are lifted and really 60-70% of people need to get infected to create herd immunity? This would lead to a huge second wave the way it did with the flu in the winter of 1919. Tens of thousands would die and the country would be crippled again. Would you take that risk if you would ultimately be responsible for the outcome? If you or a loved one are high risk, do you want others to take that risk for you?

Dr. Todaro and his ilk can continue to criticize, but I’m sticking with the CDC, WHO, and, of course, Dr. Fauci. I dig his hard core New York accent too. I find it oddly reassuring. Perhaps it’s because, if you close your eyes, it sounds like you’re listening to one of the characters typical of mobster films. I guess I like the idea of Tony Montana telling the virus to say hello to his little friend (his friend being the vaccine). My money’s on Fauci and I think yours should be too.

_{Special thanks to Raffi Billek for editing help. Check him out at www.baltimoretherapycenter.com}