Interview: Dr Nehal Masood
How relevant is stem cell research and therapy in Pakistan, considering how expensive it is and that only a few people can afford the treatment?
I think it is as important to develop modern therapies in Pakistan and other third world countries as it is in the rest of the world. Right now we only offer haematopoietic stem cell therapy in Pakistan, which is used to treat bone marrow cancers like leukaemia, thalassaemia, sickle-cell anaemia and immunodeficiency disorders. In certain cancers, a bone marrow transplant (BMT) is the only cure, and if treatment is available then we should definitely be able to offer it in our country.
Certain treatments are very expensive, but we should at least offer them to the public. This way people who can’t afford treatment in the US, for example – where a BMT costs about half a million dollars – can avail it in Pakistan, where the same treatment costs about two to three million rupees.
We are really talking about two different issues here; the treatment itself and then the politics and cost of the treatment. And one should not put a damper on the other.
There’s also a lot of philanthropic activity in Pakistan, and there are people who are willing to financially support entire transplants for those less fortunate. If cost was such a big hurdle to stem cell treatments in Pakistan, then Adib-ul-Hassan Rizvi of SIUT could not have spent 30 years performing renal transplants. It’s not a luxurious treatment only available to the rich and the famous. People have helped Rizvi make the treatment available to the common man too.
Moreover, money is not the only issue when it comes to stem cell therapy; there are several other things that have to be sorted out. Patients have to find a healthy match donor, the expertise of the doctors performing the procedure is important, the machines that are used, the mortality rate, etc.
The politics and the economics of stem cell therapy are very real issues, but this does not mean that the treatment’s expertise should not be developed. It should be kept separate from scientific progress.
What are the side-effects and dangers of stem cell therapy?
The main side-effects of BMT are those that arise after chemotherapy and the actual engraftment process (that transplants donor stem cells into the recipient’s body).
Following treatment, the patient’s blood count, and therefore immunity, remains low for a significant period of time. Most patients will contract a fever, which can become very complicated, even life-threatening at times. The patient therefore needs to be cared for in a controlled environment. In Pakistan we usually keep the patient in a closed room with filtered air to limit the amount of dust and other bacteria, visitors are restricted, the patient is given a special diet and his/her caregiver must strictly maintain their hygiene. Neutropenia, which is characterised by a very low white blood cell count, is the main side-effect of chemotherapy and it makes patients vulnerable to infections. Another side-effect of chemotherapy is mucositis, which causes the lining of the mouth, throat, stomach and intestines to become inflamed.
The engraftment process itself sometimes causes patients to develop Graft Versus Host Disease (GVHD), which causes skin rashes, diarrhoea, vomiting, weight loss, loss of appetite and liver malfunction, and can be life-threatening. Another complication that can develop following BMT is veno-occlusive disease of the liver, which causes blood clotting in the liver. Although graft failure, the rejection of the donor bone marrow by the patient’s body, can also occur, it is rare; GVHD is far more common, occurring in about 50-60 per cent of the patients. Something called Graft versus Tumour (GvT) effect is another danger in BMT, but this is actually considered beneficial to the patient, because it means that the donor bone marrow generates GVHD against the blood cancer, with the potential to completely eradicate the cancer.
How open to stem cell therapy have you found people in Pakistan?
It’s not a matter of how open; the real issue for people in Pakistan is financing the treatment and finding a donor. For example, our youngest donor was a two-year-old baby who had thalassaemia minor. Her parents signed the consent for her to donate her bone marrow to her siblings who had thalassaemia major. All three children are now doing well. This family was from a remote area in Balochistan. We are thrilled to see that patients come in from Sindh and Balochistan to avail treatment. You don’t need to be highly educated and living in a city like Karachi to understand the significance of stem cell therapy. It’s actually the city people whom we find it difficult to convince; they question, and are sceptical about everything.
In your experience, do patients in Pakistan and other countries avail stem cell therapy only as a last resort, instead of in the first instance?
Firstly, it’s not up to the patient to make this decision; it is made by the treating oncologist. More importantly, not every patient requires stem cell therapy, which is usually only recommended for high-risk cases. For people with leukaemia, multiple myeloma, relapsed lymphoma or thalassaemia, for example, BMT is often the only cure, and if the patient is healthy enough to undergo the procedure then it will be recommended to them. There are specific scenarios for which BMT is recommended, and it’s different for every disease.
Those patients who do hesitate to avail the treatment, it’s usually because of fear of the side-effects, a lack of donors, no access to a transplant centre, logistics, perceptions and taboos.
Do induced pluripotent stem (iPS) cells make the ethical debate surrounding embryonic stem cells irrelevant? Is this the way forward for a conservative country like Pakistan?
I think embryonic stem cell research should be conducted and therapies developed, because if this is successful then people don’t have to wait for a liver transplant. Everybody has iPS cells in their body that can be extracted, but the technique of extracting and developing these cells is still a distant dream in Pakistan. And until it becomes a reality, scientists should use embryonic stem cells to do that job.
Stem cell research has had its fair share of scandals. Like the most recent one in Japan, where a scientist claimed to have found a way to transform ordinary cells into iPS cells. To what extent can we trust the research and treatments being developed in Pakistan?
I don’t think this is an issue for us right now, because there is not a whole lot of lab-based stem cell research going on anyway. All we’re doing are bone marrow transplants and manipulating special blood stem cells. We are only conducting very basic research, and the time when people will start to manipulate this research for their own purposes is a little distant for us. We haven’t even developed any stem cell line of our own yet. So I think we still have a long way to go.
This interview was originally published in Newsline’s September 2014 issue.
Hiba Mahamadi was an Editorial Assistant at Newsline
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