Eighteen months ago I wrote an article called “Profit Over Patients: The Remdesivir Scandal and the Cost of Corporate Influence.” My concern then was straightforward. During the pandemic, an extraordinarily expensive antiviral became embedded in COVID-19 treatment while the evidence for a mortality benefit remained limited. Dexamethasone—a generic drug costing very little—subsequently demonstrated a clear mortality benefit in the sickest patients. The financial incentives surrounding that contrast deserved far more scrutiny than they received.
What I did not have then is the context now emerging from the Fauci diaries. One sequence in particular has made me return to the remdesivir story.
The 42 Days That Caught My Attention
On 18 March 2020, an email attributed to Anthony Fauci discussed proposals for the distribution of both hydroxychloroquine and remdesivir. What interests me is the distinction drawn between the two drugs. Hydroxychloroquine was described as an approved drug with known adverse effects but enormous accumulated clinical experience. Remdesivir, by contrast, was to be linked to a much stricter protocol.
That distinction was perfectly understandable. Hydroxychloroquine was an old drug; clinicians knew its pharmacology and its toxicities. Remdesivir was an investigational antiviral with far more limited clinical experience behind it.
Then something changed. Just 42 days later, on 29 April 2020, Fauci publicly described the remdesivir results as sufficiently important that the drug would become the emerging “standard of care.”
That transition is the part I want explained. There may be an entirely legitimate explanation: new evidence became available and changed the assessment. But that should be the beginning of the investigation, not the end of it. What happened during those 42 days?
What Had Remdesivir Actually Demonstrated?
The pivotal ACTT-1 finding being discussed was not that remdesivir had dramatically reduced COVID-19 mortality. It was recovery time. The preliminary result presented at the end of April was a reduction in median recovery from approximately 15 days to 11 days.
That is not meaningless. In a pandemic with hospitals under enormous pressure, getting patients out of hospital several days earlier potentially matters. It frees beds, reduces resource utilisation and may represent genuine clinical improvement. But it is not the same outcome as saving lives.
That distinction matters because of what happened next. Remdesivir did not merely become another therapeutic option. It acquired the authority of standard of care. And once something becomes standard of care in American medicine, the consequences extend far beyond one press conference. Protocols change, hospitals change, regulators elsewhere take notice, purchasing decisions follow, and billions of dollars can follow with them.
Then Dexamethasone Changed the Picture
Less than two months later, another result emerged. In June 2020, the UK RECOVERY trial reported something fundamentally different: dexamethasone reduced mortality among patients with severe COVID-19 requiring respiratory support. This was not an expensive experimental antiviral. It was an old corticosteroid, available virtually everywhere, and cheap.
This is the comparison that bothered me when I first examined this story. Remdesivir improved time to recovery. Dexamethasone reduced mortality in the patients for whom it was indicated. Those are different drugs acting at different stages of disease, so presenting this as a simple either/or therapeutic contest would be scientifically wrong. Antiviral therapy and anti-inflammatory therapy address different components of COVID-19 pathophysiology.
But once dexamethasone’s mortality benefit was established, I would expect its omission in eligible hypoxic patients to have become extraordinarily difficult to justify. Yet American prescribing data raised precisely that concern.
The American Data Still Troubles Me
A large retrospective study examined almost 140,000 adults admitted with COVID-19 across 43 US health systems. The pattern of treatment changed dramatically as evidence and regulatory decisions evolved. What concerned me was the underuse of dexamethasone or related corticosteroid therapy among some patients who appeared eligible for it.
In my presentation, I described this as roughly 20% of hospitals not using dexamethasone. I need to make an important distinction here: the underlying study’s finding concerns the proportion of eligible patients who did not receive corticosteroid treatment, not simply 20% of US hospitals choosing remdesivir instead of dexamethasone.
That distinction matters. The stronger question is therefore not whether 20% of hospitals deliberately chose remdesivir instead of dexamethasone, because the data do not establish that. The legitimate question is why substantial numbers of eligible, severely ill patients were apparently not receiving corticosteroid therapy after evidence of mortality benefit had emerged. And if remdesivir was simultaneously embedded within institutional treatment pathways, what factors determined those prescribing decisions?
Then I Followed the Money
This is where my original article becomes relevant again. Remdesivir was not a cheap drug. A treatment course cost thousands of dollars. My presentation contrasted approximately $2,000–$3,000 per course with dexamethasone costing only a few dollars.
But cost alone proves nothing improper. Pharmaceutical development is expensive, and companies are entitled to make money from successful medicines. The more interesting issue is what happened when commercial incentives became intertwined with healthcare reimbursement. During the pandemic, the United States introduced extraordinary mechanisms to support hospitals financially and facilitate adoption of new COVID-19 treatments. Those policies created additional reimbursement around qualifying COVID-19 therapies, which changes the economic environment in which treatment decisions occur.
Again, this does not demonstrate that an individual physician withheld dexamethasone because a hospital could make more money from remdesivir. I have seen no evidence that would justify making that accusation. But it does establish something much more important at the system level: the financial incentives surrounding the two drugs were profoundly different. Dexamethasone was generic and inexpensive. Remdesivir was proprietary, expensive and commercially enormously valuable. That should make us more demanding about transparency, not less.
And Remdesivir Became Enormously Valuable
The commercial numbers are striking. My presentation tracks reported Veklury—Gilead’s brand name for remdesivir—sales of approximately $1.9 billion in the fourth quarter of 2020, followed by approximately $5.6 billion in 2021, $3.9 billion in 2022 and $2.2 billion in 2023. We are therefore discussing a medicine that became a multibillion-dollar commercial product.
That fact does not prove wrongdoing either. A pharmaceutical company making billions from a medicine is not evidence that the medicine was fraudulently promoted. But this is precisely why conflicts of interest matter. When enormous amounts of public money, private revenue, regulatory authority and clinical decision-making converge around one product during an emergency, the standard of scrutiny should become higher, not lower.
The Endpoint Question Needs Careful Handling
Another allegation raised in the discussion concerns ACTT-1 and changes to the trial’s primary endpoint. This is an area where I think we have to be precise. Critics have argued that changes to the outcome measures during the trial undermine confidence in the result. In the material I reviewed, this was characterised much more strongly—as evidence that the endpoint was changed because mortality was not going to provide a positive result.
That causal allegation cannot simply be assumed from the fact that an endpoint changed. Adaptive changes in a rapidly developing trial are not automatically scientific misconduct, particularly if they are prospectively documented before investigators have access to unblinded outcome data.
The correct question is therefore more forensic. When was the endpoint changed? Who authorised it? What information was available when the decision was made? Was the change prospectively documented? And would the interpretation of the trial have been materially different under the original endpoint? Those are answerable questions. They are also much harder to dismiss than simply declaring the trial fraudulent.
The Fauci Diaries Do Not Prove a Financial Conspiracy
This is where I want to draw a very clear line. The Fauci material does not, by itself, demonstrate that Anthony Fauci promoted remdesivir because of pharmaceutical money. It does not demonstrate that Gilead bought the decision. It does not demonstrate that clinicians deliberately allowed patients to deteriorate because hospitals could obtain additional reimbursement. Those would be enormous allegations, and they require enormous evidence.
But neither should we make the opposite mistake. The absence of proof of corruption does not mean there is nothing worth investigating. What the diary material gives us is something different: a contemporaneous timeline against which the subsequent scientific, regulatory and financial decisions can be examined.
On 18 March, the internal discussion reflected caution around remdesivir and considerable familiarity with hydroxychloroquine. Forty-two days later, remdesivir was being publicly positioned as standard of care. Then came regulatory adoption, large-scale purchasing, reimbursement mechanisms and ultimately billions of dollars in sales. That sequence deserves reconstruction.
I Am Less Interested in Pharma Than in the System Around Pharma
There is another point I made in my presentation that I think is important. I do not find it particularly surprising that a pharmaceutical company tries to maximise the commercial value of its product. That is what corporations do. They have shareholders.
The more important responsibility lies with the institutions designed to protect the boundary between commercial interest and medical judgement: regulators, government agencies, research institutions, guideline committees, hospital systems and clinicians. If those safeguards work properly, a pharmaceutical company can advocate aggressively for its product and the system should still arrive at a decision based predominantly on evidence. If those safeguards fail, commercial incentives can become embedded within what eventually appears to clinicians simply as “the protocol.”
That possibility concerns me far more, because once a treatment becomes protocol, people stop asking how it became protocol.
That Is Why These Diaries Matter
I wrote the original remdesivir article before seeing this new material. My argument then rested on the strange juxtaposition of clinical evidence, treatment adoption and enormous financial incentives. The Fauci diaries have not proven that argument. But they have given me another reason to revisit it. They allow us to see what some of the people making these decisions were discussing before the public knew where COVID-19 treatment policy was going.
And that creates an opportunity. Instead of arguing endlessly about personalities, we should reconstruct the decisions. What evidence was available, and who saw it? What changed, and who participated in those discussions? What financial relationships existed? When were contracts negotiated, and when did reimbursement decisions occur? What did guideline committees know at each stage? And, above everything else: did the incentives of the system ever diverge from the interests of the patient?
The Lesson Is Bigger Than Remdesivir
This is not ultimately an article about whether remdesivir was a good or bad drug. There were circumstances in which an antiviral could reasonably have had clinical value, particularly when given sufficiently early and in patients at substantial risk of progression.
The bigger issue is how medicine behaves during an emergency. Fear compresses decision-making. Evidence is incomplete. Political pressure becomes enormous. Industry has products to sell, governments desperately need solutions, hospitals need money to remain operational, and clinicians need protocols they can follow. That combination creates precisely the environment in which conflicts of interest matter most.
The danger is not somebody sitting in a room deciding to harm patients for money. The danger is far more mundane. Every participant can make a decision that appears individually defensible while the system as a whole drifts towards the option with the strongest institutional and financial momentum. That is the lesson I take from remdesivir, and it is why I am looking so carefully at the Fauci diaries.
The transcript of my latest discussion ends with a principle I think clinicians should never lose sight of: look for conflicts of interest, and remember who we are supposed to be advocating for. Patients. Not governments, not institutions, and certainly not pharmaceutical companies.
We cannot rewrite 2020. The question is whether we are prepared to examine these decisions closely enough to prevent the same incentives from determining what becomes “standard of care” the next time.
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Sources and Evidence Notes
Primary record: Senators Johnson and Paul release the Woodcock email. US Senate press release, 16 August 2026. Includes the 27 May 2021 email and Fauci’s 28 May forwarding message.
FDA role: Janet Woodcock, FDA biography. Confirms that she served as Acting Commissioner from 20 January 2021 to 17 February 2022.
Myocarditis review: CDC MMWR, ACIP benefit-risk assessment. Documents the 23 June 2021 review and the concentration of risk among younger males.
FDA warning timeline: Comirnaty clinical review memorandum. Records the 25 June 2021 addition of myocarditis and pericarditis warnings.
Federal workforce: Executive Order 14043. Signed 9 September 2021.
Federal contractors: Executive Order 14042. Signed 9 September 2021.
Healthcare workers: CMS emergency vaccination regulation. Issued 4 November 2021 for covered Medicare and Medicaid facilities.
Large employers: OSHA vaccination and testing ETS. Issued 4 November 2021 and later withdrawn.
Patient experience: Krumholz et al., Post-Vaccination Syndrome. A 2023 descriptive study of 241 self-selected participants; useful for symptom characterisation, not incidence or causality.
Exploratory immunology: Bhattacharjee et al., immunological and antigenic signatures. A small 2025 preprint requiring independent validation.
Long COVID context: Català et al., effectiveness of vaccination against long COVID. A 2024 systematic review and meta-analysis reporting reduced risk of persistent symptoms after vaccination.
