With the goal of harnessing the untapped potential of Iranian-Americans, and to build the capacity of the Iranian diaspora in effecting positive change in the U.S. and around the world, the Iranian Americans’ Contributions Project (IACP) has launched a series of interviews that explore the personal and professional backgrounds of prominent Iranian-Americans who have made seminal contributions to their fields of endeavour. We examine lives and journeys that have led to significant achievements in the worlds of science, technology, finance, medicine, law, the arts and numerous other endeavors. Our latest interviewee is Bijan Safai.
Dr.Bijan Safai is a MD-DScphysician-scientist-leader excelsior, specializing in dermatology, immunology and microbiology, with 50 years of experience. He has been the Professor and Chairman of the Dermatology Department at New York Medical College for 25 years, while serving as the founding president of Physician Affiliates, a consortium of nearly 3,000 independent physicians in the northeast U.S. What has distinguished Bijan is his stellar medical practice, professorship and leadership anchored on his prolific publications of over 200 manuscripts in premier journals, books and monographs that at the zenith of his mid-career led to him earning a second Doctorate DSc. from the University of Gothenburg, Sweden, and an honorary doctorate from the New York School of Podiatric Medicine.
Tell our readers where you grew up and walk us through your life from inception. How did your family and surroundings influence you in your formative years?
I was born in Ardestan (aka Ark Dastan), in the outskirts of the central grand desert of Iran. My father’s fine and affluent character afforded him the opportunity to marry my mother; she came from an aristocrat family with a history of over 350 years of community leadership and medicine (Hakims) practice. Soon after their marriage and the birth of my sister and I, my father went bankrupt when his retail merchant customers failed to pay him back their debts, all due to the devastating impact of WWII on Iran. To salvage his honor and pay for his debt, he grudgingly had to auction off my mother’s inherited real estate and continue walking with his head held with pride. Their third child a son, was born at this excruciating juncture.
The silver lining emerging out of my family’s ordeal was to even more emphasize education as the most effective outlet to secure our future and to serve community. Our parents had to work arduously to rebuild our lives so to provide us the prime educational opportunities. The highest and most prestigious level of education-then and still now in Iran-was Medical Sciences. Both my sister and I were admitted to the top medical school right after high school, passing the national entrance exam Konkor, for which I was ranked fifth in the nation and earned my medical doctorate from Tehran University. In retrospect, the pivotal nurturing role of my mother, a home schooled young woman versed in math, history and literature, cannot be sufficiently acknowledged. She impressed upon us her children that we only had one option of ascension amongst peers and that was through academic achievements. She spent countless hours teaching, guiding and helping us study and define the path of life.
You have received many prestigious awards and accolades. What are your most significant accomplishments that has brought you to this point in life?
The most significant accomplishment in my career was the establishment of a Dermatology program at Memorial Sloan-Kettering Cancer Center (MSKCC). MSKCC is one of the two largest and most advanced Cancer Centers in U.S; and in the world. It was surprising that the Center didn’t have a Dermatology program. I was fortunate to have such a unique and exceptional opportunity to create a Dermatology program for the Center. Creating a Dermatology program for patient care, research, and education from scratch was a daunting task, but a worthwhile challenge. I was very excited and rose to the occasion. I used common sense and logical approach to establish the program which provided care for hundreds of thousands of patients, educated many students, residents, and fellows; and initiated many research programs with valuable outcome.
My research findings on skin cells, demonstrating for the first time the production by skin cells of factors influencing immune cells, was recognized as seminal and most innovative. The work on Kaposi, describing its etiologic virus, and subsequent work on AIDS were quite important and impacted the health care for many. The work on HTLV -1 in Iran and its related neurologic and lymphoma disorder was also a major medical discovery with a considerable impact on public health.
The most exciting award was the one I received from the Minister of Health and the President of Alborz High School for being the first student during my high school years. At the time and place it was most definitely a significant accomplishment. A student from a small, unknown sleepy hamlet had the first position several years in a row at Alborz High School, formerly the American college, the best high school in Iran and perhaps the region, was very impressive; my parents were quite thrilled. Looking back, I believe this accomplishment was so impressive that it gave me the impetus to try to repeat my success.
You instituted a skin cancer-screening initiative for the employees of MSKCC, which was adopted for the City of New York, and earned you a Citation from the Mayor of the City. Could you tell us more about it?
In 1978 I was elected to the position of Chief of Dermatology Service at Memorial Sloan Kettering Cancer Center (MSKCC). I then had the chance to create a service for research, education and patient care. The scope of the program was to deal with a variety of skin cancers and all the side effects of cancer therapies. There are basically 5 different skin cancers arising from skin, including Kaposi’s sarcoma, Lymphoma of the skin, Melanoma, Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC). I established a program dealing with patient care and research of these skin cancers.
I realized we were facing a rapidly increasing number of skin cancers: namely BCC, SCC and Melanoma. We also knew that early diagnosis could cure them. There was very little public information and no real awareness of these rapidly increasing human cancers. My goal was to create more public awareness and bring the patients in for early detection and treatment. As part of this plan I started a pilot study at MSKCC, where in the beginning of summer I offered the employees of the Center a free skin checkup. The program was successful and well received. The following year, with the participation of the Dermatology Department, of most medical schools located in New York City, we initiated a skin cancer screening program for which Mayor Kotch issued a proclamation. There after this program was annually conducted nationwide.
In addition to this annual skin cancer screening, with the help of one of my patients who had melanoma, who was also a radio show anchor on WOR, we convened a monthly radio show where I provided educational materials for the listeners and answered their questions. She called the program Molie Pollie and was broadcast for a long period of time, this educating people and saving lives.
You have been involved in research and practicing in dermatology, immunology, cancer, microbiology, specialized dermatology. Could you highlight your work in these areas?
In science and medicine, when the knowledge from two or more disciplines is integrated, new understandings are recognized which in turn may result in major breakthroughs, and consequently, the creation of new frontiers. I believe that I have been fortunate to serendipitously enter uncharted crossroads, thereby benefiting from the new field of immunology as it applied to medicine, dermatology and microbiology. Adding to this fortunate momentum was my challenge-seeking nature, and my desire to lead the charge. The description of factors produced by skin cells impacting the immune cells, and opening the field of Immunodermatology, viral etiology of Kaposi’s Sarcoma, and description of its’ pathogenesis, and the work on the AIDS epidemic are all the result of combining different disciplines.
The Kharazmi (Algorithm) Award was born from teamwork, as well as bringing together several disciplines to answer a simple question: I saw an Iranian Jewish woman with lymphoma of the skin. I found her to be infected by a retrovirus (HTLV1). With the work of a group of clinicians in Northeastern Iran (Mashahd and Gorgan and Gonbad Kavous) combined with the research work at NIH, lymphoma work at MSKCC, and genetic analysis of the virus, we were able to determine that this virus existed in the Northeast part of Iran among the population at-large. Both Jewish and Muslim populations may be infected. The virus causes lymphoma of the skin and a neurologic disorder. The virus is also transmitted from male to female by sperm, and from mothers to babies via milk; so it is possible to prevent the spread of this infection. More interestingly, the genetic fingerprint of the virus suggested its origin in Africa, perhaps brought to Iran by slaves.
Your early work on Kaposi’s sarcoma led you to be among the initial investigators of the AIDS epidemic. Can you elaborate on this?
In studying Kaposi’s sarcoma (KS), I realized that this tumor does not have all the characteristics of other cancers. Namely, it does not metastasize, and it develops in elderly patients who have some degree of impairment of the immune system. We hypothesized that this is a good model of a virally induced human cancer. The findings of our research were reported in a few publications. I described that the presence of a virus could infect immune cells, and in the right genetic setting and presence of immune aberration, could cause immune deficiency and cancer. We demonstrated that patients with Kaposi’s sarcoma have a 25-fold increase in getting lymphomas. And finally, we showed that Kaposi’s sarcoma tissues contain a viral particle similar to the CMV virus. These publications appeared in the late 1970s (1978, 1979, & 1980). A year later in 1981, we were faced with a serious epidemic where very young men were developing Kaposi’s sarcoma and dying within 12–14 months of immune deficiency and opportunistic infections. With my recent work and publications on Kaposi’s sarcoma, I was instantly placed in the forefront of then ongoing serious epidemic and had to step up my work on it.
To me it was very obvious this was an epidemic of a new viral infection similar to the one I described two years earlier. The search for a virus causing this epidemic became our number one priority. I started to collaborate with a group of investigators at NCI who also were looking for a possible virus causing this epidemic, and had the laboratory expertise and technologies to explore the existence of such a virus. My contribution to the team was essential and proved to be most useful. They were culturing white blood cells from terminally ill AIDS patients; however, because these patients had few or no viable cells, the cultures were negative. I provided the team with blood samples from patients with Kaposi’s sarcoma who had almost intact and viable immune cells. This resulted in the isolation and description of the AIDS virus.
The next step was to develop a test for identifying the AIDS virus. Here again, my contribution was essential. I provided serum from patients with AIDS-Kaposi’s sarcoma who were relatively healthy, and their immune system was still cable of producing a high level of an anti-viral antibody. These patients’ serum helped identify and isolate the GP21 antigen of AIDS virus, which was then used to develop the first blood test for AIDS. We published the first paper (Lancet) describing the first AIDS test and showed that 91 of the 100 patients who were tested were positive for the virus.
The nine patients who were found to be negative for HIV infection had Kaposi’s sarcoma but not AIDS. This further indicated that the Kaposi’s sarcoma virus was different from the AIDS virus. Fourteen years later, when more advanced techniques became available, two investigators from Columbia University demonstrated that Kaposi’s sarcoma virus is Herpes Virus type 8, a virus from the same family of CMV, which my team had described 14 years earlier.
The investigation into other aspects of the AIDS epidemic were carried out, including but not limited to: 1) demonstration of the presence of the AIDS virus in the sperm of the infected individual and is the source of transmission in homosexual men. 2) The use and effectiveness of interferon alfa in treating Kaposi’s sarcoma. 3) Development of the first two drugs for the treatment of AIDS infection, namely DDC and DDI.
Your book “Imunodermatology”, defined the discipline and focused more attention on the relationship between dermatology and immunology. Could you tell us more about your book?
Following my training in medicine and dermatology I was very fascinated by the new field of Immunology and decided to enter in a fellowship studying immunology at Memorial Sloan Kettering Cancer Center (MSKCC) in New York. In the same year The Center had recruited two prominent Immunologists, Dr. Robert A. Good and Dr. Louis Thomas, to develop the field and expand immunotherapy for cancers. I was fortunate to be given the opportunity to work as a fellow in MSKCC during this period. I entered a melting pot of investigators coming from across the US, and many other countries participating in learning and exploring the immune system and its impacts.
During my fellowship in Immunology I realized that the structure of the Thymus gland is the same as skin, both containing keratinizing epithelial cells. The Thymus gland is one of the organs of the immune system, which involutes (not a word) after birth and is responsible for the development of one of the two arms of immune system (T cell arm of immune system). So if the skin has the same cellular structure, therefore skin should be able to produce factors similar to those of the thymus. I was able to show for the first time that skin cells (keratinocytes) can produce factors that impact immune system. This observation provided support for the idea that skin could be an immunologic organ. The field expanded and today there are more than 150 different factors and cytokines shown to be produced by skin.
As I learned more about immunology, I became more aware of the role of the immune system in skin diseases. Practically every skin disease I was looking at had some degree of immunologic involvement. And it was so exciting to see that skin plays such an important role in our immunity and that so many skin disorders are immunologically mediated. I thought a book describing these exciting information could help open up the field of immune-dermatology and spread the word much faster. And that is how the book was given birth.
What is the biggest obstacle you’ve faced along your career path? How did you overcome this?
As an optimist, whenever a curve astringent lemon ball is handed over to me, I would sweeten it with the elixir of life and drink and share my lemonade kool-aid!We have myriad novel ideas to probe and implement so to prevent or mitigate diseases; the necessary technologies are lagging, however. In the mid 1970’s, we were able to show that skin cells produce factors that impact immune cells. But we did not have the mature technologies needed to isolate and characterize them. It took several years for this to be achieved. Today, there are over 150 different growth factors and cytokines identified and characterized that are secreted by skin cells, documenting further that skin is an immune organ. In the case of Kaposi’s sarcoma, we have shown the presence of a herpes virus like particles similar to Cytomegalo Virus (CMV) in tumor tissues of Kaposi’s sarcoma; but it was 14 years later when the investigators from Colombia University developed techniques to isolate Herpes type 8 as the causative agent of Kaposi’s sarcoma.
One is challenged to highlight one over the other brain-childs per se. Each one is unique in its’ own manifestations, as it must have been tackled with considerable interest, excitement, and enthusiasm. The three areas including skin cell production of growth factors, viral etiology of Kaposi’s sarcoma and the research studies on AIDS do stand out and have been the pioneering work that has been expanded by other investigators and have had serious impact on patient care.
You have been the president of Physician Affiliates Group of New York (PGNY) for the past six years. Could you describe your involvement?
New York Health and Hospitals Corporation is the largest health care provider in the U.S; with over 6,000 physician employees. In 2010, the NYHHC was envisaged to create a Physician Group and assigned approximately 3,000 of its physician employees to this new company, PAGNY. A consultant group was hired to oversee the corporation. During the first two years, it faced major operational dilemma and the complex issues of running PAGNY reached an insurmountable level, when no one believed it could even survive. In 2012, with eighteen members, a Board of Director was formed and I was elected to serve as the president of the corporation, one of the toughest assignments I have ever had. Although I had never served as executive for a large position, I rose to the occasion and the responsibilities relying on common sense, logical standards, and fairness in approach. I was able to move the company forward and improve its operation. Scrupulous due diligence, hiring experienced leadership, and extensive supervision, allowed the corporation to operate better and grow to serve over 3,000 physician members, providing health care to millions of underserved New Yorkers. Today, almost 6 year later, PAGNY is a well-run physician group with an excellent reputation, expanding its services beyond its initial plan. In this area of transformation in health care, PAGNY with its large physician bodies may be able to play a major role in developing a futuristic model of health care consisting of rapid, low cost and cutting edge quality care for the US population.
After becoming a certified dermatologist in the U.S., you opted to concurrently pursue intensive research at Memorial Sloan Kettering, the internationally renowned Institute on cancer research; this later led to you earning your second doctorate. How did you move away from the path almost physicians take worldwide when they by and large become clinicians?
This is a very interesting question and when I think about it, I feel that the stride to innovate and do well was perhaps inherited from my family and encoded into my genetic traits. My curious nature, my challenge-seeking personality and my deep interest in discovering answers for unknown would not have been satisfied and fulfilled, had I only ventured just in clinical practice. Moreover, I feel I was fortuitously lucky to be provided with the opportunity to tackle topics “outside the box.” It is only perhaps once in a lifetime that an internationally acclaimed institute for cancer such as MSKCC is founded without a dermatology program. Dermatology is a field where skin cancers are increasing at an exponential rate. And for me to walk right into such an opportune environment, at a time when a new discipline of immunology is being exploited by a melting pot of young, aggressive scientists and clinicians, was simply breathtaking. I reckon it is all luck and serendipity. It is definitely not possible to plan for it.
I also saw a similar situation when I wrote about the very rare cancer Kaposi’s sarcoma appearing in elderly men, and suddenly, a year later, an epidemic starts where tens of thousands young healthy men are getting this rare cancer and dying in a few days. And my write up about rare Kaposi’s sarcoma placed me just at the forefront of the epidemic, giving me an opportunity to be involved and try to come up with answers.
Again, the same is true about PAGNY where one of the largest groups of physician in US was formed and a total complex mismanaged set up created which the use of common sense, and logical approach was urgently needed to bring it to normalcy.
Integration of advances in scientific discoveries and technological breakthroughs has irrevocably impacted, and as many believe, enhanced the practice of medicine? How would you envisage the future of medicine, patient care, and possible emerging cures for incurable diseases?
We are facing a transformation period in all aspect of health care. Medical schools and hospital centers have proven to be very effective for advancing medicine and providing care, resulting in the best medical care in the U.S. However, the system has become too cost prohibitive to sustain. New paradigms of providing healthcare, research and education will emerge to respond the needs of the nation. The aging population will bring novel medical challenges to be dealt with. Imminent and future technological breakthrough will inextricably play a pivotal role in medicine and healthcare. Advances in genetics, newer understanding of the pathogenesis of diseases, use of new and innovative biologic agents, designer drugs, tissue and or organ re-engineering, cell transfer technologies and a plethora of modern cutting edge and game changing approaches will enhance the health care system.
Hence, the most fascinating aspect of medicine is perhaps the use of artificial intelligence in aiding the individualized health care by providers. Implanted or surface mounted devices will measure real-time and report vital signs, metabolite or biochemical concentrations, and optimize the drug delivery to specific organ from the in vivo reservoirs. All this is monitored and transmitted by a smart computer aboard. Block chain, mass predictive data analytics, etc. are other aspects of such endeavors are already on the horizon.