The Ward of Last Resort

By Dick Thompson

This afternoon the kids in the pediatric isolation ward have come together for something called Cell Mates. Most are bald and towing IV trees behind them as they gather. In Cell Mates they play games that help them come to terms with their diseases--with the blood cells that are failing them, the cancers and immune deficiencies that are attacking them, and the new replacement cells that are helping them. Many of the kids, like Caroline Strother, 6, are old hands at medical games. She swabs her doll's arm and prepares to insert a central line, but asks, "Hey, don't we need clamps?"

For these kids, who range in age from five weeks to 15 years, this clinic represents their last hope. "They came in here with zero survival chances," says a physician. But thanks to a new treatment that swaps good cells for bad, the 16 kids here now have at least a fifty-fifty chance of survival.

The treatment is called cord-blood transplantation. It is an approach that is being used at several medical centers, but Duke has done more of it than anyplace else.

The treatment is based on the belief that the placenta and umbilical cord are rich in powerfully therapeutic cells, called stem cells. Frequently discarded, the placenta and umbilical cord from a few new mothers, like Christina Crosby, are now being donated right in the delivery room.

Technicians drain the afterbirth of its blood and process the material to concentrate the stem cells. Theoretically, stem cells can rebuild the body's bloodmaking machinery so that it produces the full array of effective blood cells the body needs to defend itself against germs, close wounds and transport oxygen. Scientists speculate that cord stem cells are more adaptable and will transplant more successfully, even in patients with imperfect biological matches, than stem cells harvested from adult bone-marrow donors.

The prelude to transplant is brutal, however. The children receive near lethal doses of radiation and chemotherapy that kill the rapidly dividing sick cells. This leaves the patients without any immune system, so the most minor infection could kill them. It also kills the cells lining the gut, making digestion difficult, and those lining the mouth, producing painful sores.

When doctors are confident the sick cells have been destroyed, the cord cells are dripped into the children's arms. The lucky ones wait up to 100 days for their stem cells to start functioning. The cost to save a child's life: $350,000.

"I'd like to treat everybody," says Joanne Kurtzberg, the cord-blood-program director. "But Duke is not going to let me practice here if all I do is lose money."

While the kids are playing Cell Mates, Kurtzberg spends part of her afternoon sorting through the dozens of pleas she receives daily from frightened parents and suffering children. A fax lying on her desk today is from a Russian boy. "I beg you to help me," it reads in part. "I don't want to die at 16."

To find the money to save these young lives, Kurtzberg is always searching for ways to cut treatment costs. She and her staff spend long hours on the phone each day trying to wring money out of insurance companies. But the bottom line for the cord program is not healthy, which means constant battles with Duke's bureaucracy as well. "I'm not fighting for me to take a vacation to China," says Kurtzberg, who puts in 100-hour workweeks. "I'm fighting for the patient. But this administration has gotten much more business oriented."

The Duke bureaucracy, she complains, has become removed from the patients, which she thinks is just the way they want it. Kurtzberg picks up the fax from the Russian boy and says, "You can't make those decisions with a letter like this on your desk." Then she adds, "If this kid showed up in my clinic, I wouldn't turn him away."

--By Dick Thompson