Infectious disease expert reflects on 50-year career

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Dr. Donald Blair is among the 1,200 Upstate employees honored at Upstate's annual Employee Recognition Day this year. He's a professor of medicine specializing in infectious disease, and he's been at Upstate for 50 years. I invited him to talk about his career. Welcome to "The Informed Patient," Dr. Blair.

[00:00:34] Donald Blair, MD: Thank you.

[00:00:36] Host Amber Smith: So you started at Upstate in 1974. Where did you get your medical training before coming to Syracuse?

[00:00:45] Donald Blair, MD: I went to pre-medicine in Cleveland, Ohio, Western Reserve University, and then went to their medical school as well, graduated in 1965. And from there I went to University of Michigan in Ann Arbor for my internship. That brought us to 1966, which was when the Vietnam War was active. And so I left there for three years and came back in 1969 and did my residency in internal medicine, and a fellowship in infectious diseases and clinical pharmacology.

[00:01:31] Host Amber Smith: So what interested you in infectious disease and pharmacology? Why do you think you were drawn to that specialty?,

[00:01:38] Donald Blair, MD: I've always sort of assumed that it was because in that three years that I was gone, interrupted my training, I spent two and a half of that with the Peace Corps, mostly in Ethiopia and a couple months in Yap in the South Pacific. And then I went to Washington and was with the Food and Drug Administration for about eight months or so. And I did research in clinical pharmacology there.

So in Ethiopia, I saw a lot of infectious diseases. I saw two of the last cases of smallpox in the world. And I saw lots of leprosy, tuberculosis of course, and then malaria was a constant problem, hepatitis A was kind of embedded in infectious diseases for the volunteers. I mostly took care of the volunteers. And I think that carried over to when I returned to Michigan.

[00:02:41] Host Amber Smith: So what was it like at Upstate 50 years ago when you started here? Do you remember anything about your first day?

[00:02:49] Donald Blair, MD: I can't honestly say I remember the first day, but I do remember my first impressions. It was a new situation, of course. And I was impressed by the fact that there were the three hospitals in such close proximity, with Crouse Hospital being connected to Upstate, and the Veterans Hospital just across the street.

And, that was so much more convenient than we had in Ann Arbor where everything was a car's reach away. And, this resulted, it was a major factor, I think, at that time in providing a real variety of training sites and in a convenient way for both faculty and for the residents and students.

[00:03:43] Host Amber Smith: I'd like to have you tell us about the field of infectious disease over the past 50 years. AIDS was something you dealt with earlier in your career. Do you recall what it was like at the beginning of the AIDS crisis?

[00:03:57] Donald Blair, MD: Well, before going to AIDS, I should show where my mindset When I left Ann Arbor and came to join the faculty at Upstate, I sort of thought that all of infectious diseases had been discovered -- maybe a rare exception -- but probably we just had to concentrate on good diagnostics, better treatment, better management, good epidemiology, public health, and so forth.

, Nothing can be further from the truth, of course. There have been 40 to 50 new or newly recognized newly activated infectious diseases since I left training. One of the first three I encountered was legionellosis. We don't think much of legionella now, but it has become a routinething we test for when pneumonias of certain types come into the hospital. And, it was a big deal at that time. It may be before your time, Amber. I'm not sure. But it was, it was the first, and we realized, well, maybe it's not all over.

Another one, babesiosis, which is now, you can catch in Green Lakes (State Park) and elsewhere in Central New York, was just being discovered on the coast of New England, particularly Block Island. A lot of people here know Block Island, and it became a hotbed of babesia. So that was the setting that I.... I wasn't really prepared for all of the, for new diseases.

And then as you mentioned, the big one came. We didn't know it was Human Immunodeficiency Virus at first. It wasn't called that. It wasn't even clear that it was a virus. We went through a whole variety of possible etiologies as we were dealing with it. We had our first case that we recognized at the time in 1981. Now, 1981 was a year that the CDC -- Centers for Disease Control -- published a report of five or six cases of Pneumocystis pneumonia in their publication, called the MMWR, (Morbidity and Mortality Weekly Report.)

In retrospect we had a case in about 1977 or 76. It was a man from Africa, West Africa. He came in to the hospital, crashed, went to the intensive care, and died. We hadn't the foggiest idea of what was going on with him. But, later when the testing became good, we were able to retrieve his tissues from the pathology department and demonstrate that he had HIV disease.

The earliest case in the United States that I'm aware of was a young man in St. Louis in 1968. But in terms of Syracuse, we had one case in 1981, and then it doubled the next year, but that's only two. But by 1986, we were seeing quite a few. And around 1986-87, we started the Designated AIDS Center because we had enough, we had to have a dedicated clinic. And we started doing research on treatment, and it was, important to have a clinic.

[00:07:42] Host Amber Smith: But it took, it sounds like, years to pinpoint what this was and...

[00:07:48] Donald Blair, MD: Yeah. It did.

[00:07:48] Host Amber Smith: ...what to do about it.

[00:07:50] Donald Blair, MD: It did. I well remember, I think it was 1983, I went to a conference in Rockville, Maryland. It was a two-day conference, and they had a half hour to two hours dedicated to all kinds of theories: it's herpes virus, it's cytomegalovirus, it's the chemicals used for birth control, and just any number of theories because no one knew. And, by that time, actually, by the time that meeting, one of the theories was that it was HTLV-3, which was a human T-cell lymphoma virus, which later the name was changed to HIV.

So by '83, we knew what it was but didn't really know that yet. We knew what became known as the virus. And another year or so, it was widely known, and we could test for it accurately and quickly.

[00:08:55] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Donald Blair. He's a professor of medicine at Upstate, specializing in infectious disease, and he's celebrating 50 years at Upstate this year.

What impression did you have about COVID-19 when it began emerging?

[00:09:16] Donald Blair, MD: I became aware of it um, in January of 2020 and was following it, of course, as everyone was, but I had no particular knowledge of it from, we hadn't seen any yet in Syracuse. And I well remember as in March, I was in the Atlanta Airport, and three xpeople went by with masks on. Those were the first masks I saw. And, we went on home. We were supposed to leave in a week and go out to California. And just in that period of time, the amount of disease increased so greatly that we canceled that trip. And, you know, I didn't get to see my grandson for over a year. So, my thoughts were, this is really bad. We don't know exactly what we're dealing with here.

I had lived through SARS, the Severe Acute Respiratory Syndrome disease that had come out of China a few years before and was aware of MERS, the Middle Eastern coronavirus disease, (Middle East Respiratory Syndrome.) And so when this came out, as SARS type 2, also known as COVID-19 I was concerned that this was going to be a pandemic. And indeed that's what materialized, and well, we all experienced that. We know how bad that was.

[00:10:56] Host Amber Smith: People are talking about bird flu now. Are you concerned about bird flu affecting more humans?

[00:11:02] Donald Blair, MD: Bird flu is a very interesting one. Influenza, of course, has been around, and we even could test for it when I finished my training. I first became aware of bird flu maybe 30, 35 years ago or thereabouts. It's a variety of things. Flu is a designated "h-this" and "n-that," (referring to two kinds of proteins, hemagglutinin and neuraminidase) And, the bird flues, there've been, I've seen at least a half a dozen, and I'm not sure just how many there are, of different types.

They are a big problem in the poultry interest industry. And then the wild birds. And they can spread. And our latest iteration of this where it's spread to the cows and to at least three farm workers is just an example of what we saw before with other types of bird flu in Vietnam and Cambodia and so forth. Right now, this exact one, I think there's very little danger of it spreading to many people without very close contact. But, it does not take much in the way of mutations to convert it to a rapidly contagious and easily contagious virus. And yes, I am concerned about that.

[00:12:26] Host Amber Smith: So that's one to keep an eye on?

[00:12:28] Donald Blair, MD: Very, very, very much so. And if it follows the way other influenzas have, and if we meet this same kind of mindless resistance to a vaccination that we've encountered, there will be a fearful toll to pay for that.

[00:12:45] Host Amber Smith: So a bird flu that was spreading in humans could be more devastating than Covid?

[00:12:51] Donald Blair, MD: It could be. Yeah. There's no way of predicting that, of course. That's pure speculation. But it could be. Covid is a very bad clinical disease, Same as with flu in this sense: 1,000 get infected, some of them have no symptoms at all, and some of them die. Flu versus Covid, different percentages died, and different rates of mutation, different speed of transmission and there are differences. But both have the capacity for pandemics, and all we have to do is look at the great influenza epidemic in 1918-17 and we can realize what can happen.

[00:13:31] Host Amber Smith: Can you talk about how the field of infectious disease has changed over 50 years?

[00:13:37] Donald Blair, MD: I would say that the biggest changes in infectious disease involve the ability to diagnose things and, increasingly, to treat, be able to treat things. We had influenza when I was an intern resident. We had what became known as mycoplasma pneumonia, so-called walking pneumonia. We had, of course, pneumococcal pneumonia. We had a lot of things like that. But now somebody comes into the hospital with a pneumonia, and they get a sputum specimen, and you can test within an hour or two for 23 different etiologies for different pathogens. That's pretty cool. Still not enough. That still leaves over half undiagnosed.

But it does point it, it's pointed to some dramatic things. I mentioned mycoplasma. We used to think that most of these so-called "viral-like pneumonias" were really due to mycoplasma. Turns out they aren't. Turns out they are viruses that do it. There's a lot of coronaviruses other than Covid that cause serious infections. And of course there's influenza, and then there's a bunch of others as well. So I think diagnosis is one of the big ones.

The other obvious one is treatment. To a great extent, we've been chasing our tail. I was born the year penicillin was first used in a human, 1940. And, the story of antibiotics and bacteria is, first we treat them, and then they develop resistance. And it's kind of a lock step proceedings, all the way up. And so now, we have these fancy, very expensive antibiotics, and we know full well that next year, the following year, they'll be resistant and we'll need others. So our original model -- which is treat the pneumococcus with penicillin, then treat whatever develops with new antibiotic -- that's a bad model, and we need something better. And we don't have that yet. So that's where we need to go is a better diagnosis and better approach to these infectious agents.

[00:16:03] Host Amber Smith: I'm wondering if more medical professionals are attracted to infectious disease after COVID. Are you seeing more interest from students?

[00:16:13] Donald Blair, MD: The students, I think, are more interested. I think that is true. But as far as I know, and this could be quantified and I just don't know the numbers, there's not actually an increased number of medicine residents going into infectious disease. As fellowships go, it lacks a procedure. And we pay physicians in this country best if they do procedures. And that procedure can be a scoping of some kind or a surgery, or catheterization of some kind. Well, infectious disease just doesn't have one. And we also get some of the most complex difficult cases to diagnose, which is actually why I was attracted to it because it was a fun discipline for me, but it's not that attractive to those who are a little more focused than I was on a good income, I guess.

[00:17:14] Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast with your host Amber Smith, talking with Dr. Donald Blair about his 50-year career in infectious disease.

[00:17:24] Host Amber Smith: You had a lot of duties over the decades. You were chief of infectious disease for 21 years. You oversaw the medicine residency program for doctors going into medicine. You took care of patients. You've done research. What's been the most fulfilling for you?

[00:17:40] Donald Blair, MD: Well, I've enjoyed it all, frankly, including running the TB (tuberculosis) program for the (Onondaga) county for a decade or more. But the most gratifying, and sometimes this sounds trite, but truly the most gratifying is to work with students and residents, and then -- that's good; that's gratifying in real time -- but then learn later how much you contributed or how much they feel you contributed to their education, their career, and so forth. I just found that immensely gratifying over the years.

[00:18:24] Host Amber Smith: So is it a field that you would recommend new graduates to consider?

[00:18:29] Donald Blair, MD: Oh, absolutely. I don't think anybody would be foolish enough to conclude that there's going to be no more infectious diseases. Just the opposite. We now see that as the population gets denser and denser, there are going to be more and more and more infections. And, I would urge anybody who likes problem solving. If you don't like problem solving, then it would be more frustrating than rewarding. But if you enjoy the process of problem solving -- which many of us do. I think it's a characteristic of infectious disease physicians -- go for it.

[00:19:12] Host Amber Smith: What about the public? Do you think the public understands infectious disease?

[00:19:17] Donald Blair, MD: I think that people should, the population really needs better training in infectious diseases and the pathophysiology of it, not to treat, not for anything like that, but to develop a reality-based appreciation of what we're facing. I hear comments that just make me cringe because I think, "boy, you just really don't know the score, do you?" And it's hard to communicate. We have not, as a culture, developed a approach that will not turn people off. We'll educate them and allow them to then consider things for their own welfare as well as their, wellbeing of peers. It's a tough problem.

[00:20:07] Host Amber Smith: You mentioned the mindless resistance to vaccines, and there doesn't seem to have become a solution yet. Do you have any ideas? I mean, what do you say to people that are just vaccine resistant?

[00:20:23] Donald Blair, MD: I have not personally discovered what you can say to them. They seem so resistant, and there may be a core issue below that, and that is, I'm not sure how many are aware of the scientific method. That is posing questions, testing hypotheses, assessing the results and basing your therapies and approaches on the result of the scientific investigation. Science is being rejected, broadly, in our culture, and this really is a social science venue to try to solve, I think.

I can tell you my own family. My brother died of COVID-19, my older brother, trusting that God would protect him, and not getting the vaccine. Now, how big a failure can one be to lose your brother because he just absolutely will not listen to anything science-based? So, it's a very difficult issue. Very difficult.

[00:21:42] Host Amber Smith: Well, thank you so much for making time to talk about your career.

[00:21:46] Donald Blair, MD: Sure. Well, thank you very much, Amber. I appreciate it.

[00:21:49] Host Amber Smith: My guest has been Dr. Donald Blair, a professor of medicine at Upstate for the last 50 years, specializing in infectious disease. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen, too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple Podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.