Thirty years ago, I consulted on a young boy with a puzzling constellation of symptoms. He was fourteen years old and developed a poison ivy-like rash that covered his body. He had blood in his urine indicating a disease of the kidneys. I diagnosed an ailment called Henoch-Schoenlein purpura (HSP) a kidney ailment found in children. It was self-limited and the patients do well if you leave them alone.
Surprisingly, his disease persisted, which was not typical. His symptoms worsened. Several days later I did a biopsy of his kidney and examined the tissue under a microscope. It showed a vasculitis or inflammation of the kidney but there was something unusual, something did not fit with the diagnosis of HSP.
I reviewed the biopsy with a famous pediatric kidney pathologist who said that there was no staining of IgA antibody in the mesangium, the microscopic center of the kidney, which was needed to make, and confirm the diagnosis of HSP. By all indications, this was not HSP but something else, and the case became stranger by the day.
“This is Henoch-Schoenlein purpura,” the pathologist said.
“But there is no staining of the mesangium. There is no IgA antibody in the center,” I said.
“The boy is fourteen years old. He has HSP. This is not Harvard. Here, when you hear hoofbeats think horses, not zebras.”
I had been taught to think of both.
No mesangial IgA meant no Henoch-Schoenlein purpura. But what else could it be?
I went along with the famous pathologist’s assessment because he was a lot older and more famous than I and he was a big deal in this community hospital. I thought it best not to challenge his diagnosis.
The boy continued to decline. He coughed up blood, his lungs failed, and I put him on a ventilator. This was not HSP, but Wegener’s granulomatosis, a deadly disease seen mostly in adults. Ninety percent die in one year without treatment.
I changed course and emergently treated the youngster for Wegener’s granulomatosis. It was a difficult tenuous course but I got the disease under control with steroids and the cancer drug; Cytoxan.
The patient went into remission, but four months later he had a convulsion. The disease had recurred in his brain. Once again he was placed on a ventilator and I increased his dose of steroids. He recovered and remains alive and well thirty- five years later. That’s when its’s nice to be a doctor.
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I learned of another case in a middle-aged man who had the same disease and also presented with seizures following prolonged treatment. I researched further and came across work done by a Doctor Anthony Fauci. Early in his career Dr. Fauci studied Wegener’s granulomatosis which is now called polyangiitis with granulomatosis. The name had been changed because Dr. Wegener was an enthusiastic Nazi. Several German doctors, it turned out, were powerful Nazi supporters, and several diseases, named to honor such men, have recently been changed.
In a paper published in 1983, Dr. Fauci stated that relapse of polyangiitis with granulomatosis (Wegener’s granulomatosis) in the brain does not occur following three to four weeks of Cytoxan.
My cases took exception to the observations of Dr. Fauci. I wrote a paper published in the American Journal of Medicine that documented the disease can recur in the brain despite prolonged treatment with Cytoxan. Today we treat the patient with polyangiitis with granulomatosis as a chronic disease requiring years of treatment and are alert that the disease can recur in the brain and other organs despite prolonged treatment.
Dr. Fauci abandoned the study of polyangiitis for diseases of opportunity. His career took off with his contributions in HIV. He remained one of the senior editors for “Harrisons Principles of Internal Medicine,” and the Director of Allergy and Infectious Diseases at the NIH.
Early in the pandemic I was relieved that a doctor with the credentials of Anthony Fauci was at the helm to guide us through the crisis. I was somewhat concerned as his observations on polyangiitis with granulomatosis (Wegener’s granulomatosis) were incorrect, hasty and premature. It seemed a small matter and not characteristic of his renown scholarship. The Covid -19 virus increased his fame and made him “prime time” and some said “sexy.” He did look like George Hamilton minus the carcinogenic suntan as he sat poolside for a picture on a magazine spread.
We needed a figure from the world of medicine and science to help the President who was a businessman, not a scientist, not a public health expert, not a doctor and definitely not a politician.
The Centers for Disease Control failed to provide a leader when one was desperately needed. The Center fumbled the early development of a reliable Covid test. I had not been impressed with the CDC’s handling of Ebola. That Ebola was so deadly was a benefit, albeit a catastrophe for the stricken individual, as the afflicted would die before the disease could spread. It would also keep the inchoate incompetence of the CDC known only to a few.
Ebola entered the United States in 2014. The first patient was admitted to the Texas Health Presbyterian Hospital. Two nurses cared for the patient around the clock. The patient died. Days later both nurses contracted the disease. Imagine the terror of the stricken nurses. They observed the patient die a horrible death, a fate that could, in hours have been theirs. Fortunately, they survived.
Dr. Thomas Frieden, the director of the CDC at that time, opined a breach of protocol led to the nurses becoming infected. It struck me as an insensitive, misogynistic, reprimand. Later, Dr. Frieden admitted the CDC was largely to blame as the brave and trusting nurses had followed the faulty CDC protocol to the letter.
Months later I saw a picture of Dr. Frieden being led out of a Brooklyn police station. A woman complained he grabbed her posterior. He was charged with misdemeanors of forcible touching, third-degree sexual abuse and second-degree harassment. The charges were dropped after he pled guilty to a charge of disorderly conduct.
Dr. Frieden led an aggressive fight against the use of tobacco. He got tobacco banned from New York City. Ironically, his successor at the head of the CDC, Dr. Brenda Fitzgerald, had to resign because she purchased tobacco stocks while in her esteemed position.
Dr. Fauci appeared to be the doctor to come to our rescue.
In January 2020 Dr. Fauci said the average American had nothing to fear from Covid-19. His words brought relief and reassurance such that I thought the virus would be confined to a few nursing homes in Washington State and New York. In retrospect it made no sense to treat a unique respiratory virus in such a cavalier fashion. Once again his advice was incorrect and premature as it had been with polyangiitis decades earlier. His initial response regarding a highly infectious respiratory virus was incorrect and doomed any attempts at containment.
Reviewing the 1918 respiratory virus should have alerted the scientific community and those in charge of our public health to the potential catastrophe. A novel virus is nothing to fool around with. Evidently we had to re-learn what was appreciated by my historical colleagues of 1918. In 1918 they didn’t know viruses existed but it was realized that strict isolation worked to prevent the contagion from infecting others. Such isolation when employed successfully as in Gunnison, Colorado stopped the contagion. Gunnison did not employ face masks or social distancing, they simply would not let anybody in. Barricades were placed on the roads entering the town making their isolation complete. Nobody died of the 1918 flu in Gunnison.
If strict isolation was not feasible then containment measures if instituted early appeared to help. They key word was early. In 1918 St. Louis limited interpersonal interaction at the first evidence of infection. In contrast Philadelphia enacted such measures later. The result was that St. Louis had a death rate that was one-eighth that of Philadelphia. The delay was only two weeks but seemed to have made the difference.
In January of 2021 Dr. Fauci stated, “a primary lesson of the 1918 influenza pandemic is that it is critical to intervene early.” This contrasts with his January 2020 statement. On March 8, 2020 Fauci said masks were not necessary. It was thought that masks actually increased the likelihood of infection. Really? In retrospect Dr. Fauci said he knew that masks were helpful but that he made this statement to protect healthcare workers that could run short of masks. Yet those of us working in the hospital, were told not to wear masks as it increased the risk of infection. By April we were allowed to wear thin masks and only later were N-95 masks used.
For Dr. Fauci to say that masks didn’t matter, when he knew they helped, was upsetting and another erosion of trust. Trust requires transparency and honesty and consistency. And yes, we can handle the truth as we had no choice.
I had high hopes for Dr. Birx as she seemed to be someone you could trust and like Dr. Fauci had an impressive resume. She lectured us on how to flatten the curve. She warned us about visiting loved ones on Thanksgiving, yet on Thanksgiving she travelled to her vacation home in Delaware to celebrate with her family. Some of whom were elderly.
The knock on President Trump was that he didn’t follow the science. But it seemed the science was flawed. What science and when should he have followed it? The advice in January or March or October? Trump was a businessman, not a doctor. The advice was ever changing and it should not have been. Elementary pandemic management means: take a respiratory virus seriously as had already been learned in 1918 and prepare for the worst case scenario which would mean immediately close the borders, wear masks, and quarantine and identify the sick, contagious and vulnerable. Prepare the hospitals for incoming, and don’t send infectious patients back to the nursing home. It was not rocket science but it must be done without delay as evidenced by St. Louis’ response in 1918.
While doing this, work on therapeutics and a vaccine. Despite little consistent scientific leadership President Trump focused on the development of a vaccine beginning in January of 2020. His mantra was “Warp Speed.” For a non-medical person to realize that a vaccine was our only way out and focus on its development despite a lot of conflicting noise from the scientists was clear headed leadership. Fauci said it would take a year and one half to produce a vaccine but Warp Speed delivered in nine months. Lucky for us.
President Woodrow Wilson ignored the pandemic of 1918 and a six hundred and seventy five thousand Americans died, which, if extrapolated to the population of today, would be three million. Unlike Covid-19, the victims of 1918 were very young, often infants.
Vaccine development was rapid because a businessman financed and contracted the vaccine supply before knowing it would be approved by the FDA thus having the government take the financial risk. It took a businessman to talk to businessmen. The result was five-hundred million doses contracted from Moderna, Pfizer, and Johnson and Johnson before their production.
The scientists and the doctors worked incessantly to develop the vaccine. Credit belongs to them, but also to whomever took the risk and made the decision to underwrite vaccine development and thus unleash their intellect.
On October 23, 2020 Dr. Fauci said masks should be mandatory. In January of 2021 he said two or maybe three masks should be worn. In March of 2021 he took credit for the decision to develop the vaccine. However, the fingerprints are those of a businessman and not a doctor. Good doctors are horrible businessmen. A businessman, not a doctor, made the blueprint for vaccine development for pandemics yet to come.
Dr. Fauci’s advice was wrong from the start, but I didn’t want to say anything because he was a lot older and more famous than I and a big deal in the U.S. and the world. His scientific supporting staff was not very bright either. The CDC and NIH came up short. They should be investigated and not only for risky gain- of -function research or covering up potential lab leak theories but basic policies and procedures. We had to learn from the doctors of 1918 as ours failed us.
We must not forget what was learned in 1918 or 2020.
Respect, but question authority.