An Ode to Hope If you still have Faith

Hope and Faith. They might seem to be synonymous at the first look, but they are not. Let’s see. If I say- ‘ I hope you will do well’, would you feel the same if I had said- ‘I have faith that you will do well’! While both are abstract in pure scientific terms, the first statement probably derives from my past experiences under similar circumstances, which might allow me to raise my expectations for a favourable outcome. In modern scientific parlance, this is called grade 4 evidence, which is based on anecdotes! But when I express my faith on the outcome, science demands the evidence should be derived from a double blinded randomised phase 3 study. And people of science swear by such studies as if they have resolved all the unpredictability associated with human mind, body and life.

In fact, recently a Nobel Award in economics was given for carrying out randomised studies on poverty. Impressive indeed. Define poor people. Divide them in two groups through random picks. Give some money to one group and not the other. And then observe how the intervention changes their lives. Unfortunately there’s no placebo equivalent of hard cash. Or is there? But imagine the arrogance and audacity of the white world- who have become rich by looting the once richer parts of the world, such as Asia and Africa. And now they send the McCauley defined ‘not so white interpreters’ to study poverty in the lands where they have inflicted the same. The loud claps in the award ceremonies, seminars, and conferences, where the randomised studies on poverty are discussed obscure the real and stark truth behind the western interpretation of the current world order. An awarded African wears his traditional robe and an Indian wears a designer dhoti in front of the cameras to smudge the reality. The reality is their urgency to come out of the indigenous clothes and be wrapped again in the coconut shell to enjoy all the whiteness that lies within. While the Guinea pigs in Asia and Africa wait for their turn to be randomised- with Hope? Or with Faith?

In the real world, Faith is not derived from randomised studies and Hope is our eternal weapon for survival. That’s the reason why most of the affluent world needs medications to keep hopes alive and the slum dwellers or the farmers in India, find enough hope to live the next day, if they had a full meal on the day. They repose their faith on nature, on Gods, which might reside in a book, or a tree or a piece of stone in the courtyard- but surely not borne out of randomised studies. Something, I myself had found difficult to understand for a long time due to western tutelage and an overdose of communism at a young age.

Medicine and particularly the art of Bone Marrow Transplantation, which I have been practising for last 30 odd years have blurred the lines for me. With several thousands of scientific studies published every day, we can no longer assimilate the information- we are dependent on Artificial Intelligence. Drowned in the age of information aided and abetted by the technological explosions and big businesses owning them in whole, we have lost the ability to decipher the truth from the lesser truth. Right from the one that seems to be right. And this hits individual doctors with conscience, right on the face. The percentage game- often quoted by young doctors in full Faith, like lines from religious text, the words spoken by the all and mighty in the field, who are often affiliated to multiple big businesses as advisors, consultants and even shareholders. Yet, with time they shall learn that the magic drugs don’t cure them all. The probabilities of survival as predicted by randomised studies are often not what you see in the real world. But you can’t get disillusioned because you are bombarded with more information on more drugs every day. Give A, and then B and then C and go on until the sufferer gives up or your Faith gets shaken by your conscience!

Today, we have suddenly found the magic lamp of Aladdin. We know of all 20,000 odd genes in human body. And more importantly we know how to manipulate every single gene if we want. We now have the ability to weaponise our own immune cells with genetic engineering enabling them to target and kill cancer cells. These have produced unprecedented results, but with toxicities little heard of before. The cost is unprecedented as well, so is the zeal to ignore toxicities and outcomes. If one weapon doesn’t work, I can create another. Nature had created our immune system in a way that it doesn’t harm us and yet keeps us safe. Somewhere in this mad rush and excitement of the newfound power of manipulation of human genes, we have forgotten the fact that abdication of natural laws of the human immune system can only provide a short term gain. We want these genetically altered immune cells,which have overridden the natural function of these cells, to stay in our body forever. Is that the right way ahead? I have Faith in what nature has created and how nature has designed us. So my Hope rests on utilising the laws of natural immune system to cure a cancer. Like we have done for last 50 years.

I am talking of allogeneic BMT. An art form which I have learnt from the wisdom of the pioneers in this field. With limited scope of randomised studies, meticulous understanding of the human immune system and how it behaves in presence of another in the same human body has slowly made us realise that if things fall in place, you live happily ever after. But if you don’t- it falls apart. The frailty of our current understanding of how two cells belonging to two different human beings would behave in the physical entity of one of them, has led to uncertainty and unpredictable outcomes. I wish it was done through a stroke of knife like any other organ transplantation and you would walk on to the next surgery like the quintessential ‘surgeon’ from the movies. With all the swag or arrogance.

Saying that, I was surprised to learn that some of my colleagues are claiming to do the same. Something which even Che Guevara would have shuddered to think of. It’s easier to simultaneously bring about socialist revolutions in several countries than attempting to pull off allogeneic BMTs in different centres, districts or states of a country at the same time. This leaves me with little Hope for the fast forward generation and no Faith on the system, which perpetrates such abomination of the most challenging therapeutic art form.

Do I sound pessimistic? No, I am not. I chose to return to India from a permanent position in another western country. Because I had Faith and I rode on Hope. I was beaten up by the top management and it’s goons in a hospital in Kolkata, where I dreamt of setting up a BMT unit- because I questioned their malpractices! I lost hope for a while but I did not loose Faith. I set up the first BMT unit in Eastern India in another 12 months. Started the first Haploidentical or HLA half matched family donor transplantation in India in 2010. Was again pushed by the hospital management and the Bengali population alike- to challenge the Faith which brought me back to my motherland. But, as Hope never fades and Faith trumps, I met Dr Suversha Khanna. Another person brimming with passion. Met Mr Anil Kumar- who held his nerves and got me at Dharamshila Hospital ( I don’t carry a management friendly reputation). What I witnessed over the next 6 months was a lot of idiosyncrasies but an undying passion and zeal in Suversha Khannah, who made sure that every single requirement for a state-of-the-art BMT facility and a highly equipped research lab that we so desired, is provided in no time. I was proved right once again. If there are people in the country who would feast on your blood, there are people who would pull you out of that as well. Have Faith, Hope would follow.

The last part of the story is like a fairy tale but the princess is yet to wake up. As unbelievable as it might be, we found a way to do to haploidentical BMT, very different from the rest of the world. No genes were engineered, no magic bullets were created. We only analysed a problem in its natural space and found an answer in the most serendipitous manner. The results surprised us to no end. Dr Sarita Jaiswal, who I had initially taught abcd of this discipline like the greats had done to me in late 1990s, returned to India after her training in Italy and USA. And despite all my idiosyncrasies and intolerable behaviour, continue to work together. A lot of doctors, nurses and technicians have come and gone. Usha had started as our coordinator and still remains our heart and soul, scavenging funds for the poorest. We had reposed our Faith in the ‘mission’ undertaken in 2010 and then in 2013. A lot of young doctors express Faith in the way I have looked at science and the nature in the context of human biology. We still search for the ideal donor as per the laws of natural immunity, which is an ever evolving process. Often we succeed. At times we fail- a life crumbles in front of us. With all the experience, expertise, drugs and technology, the frailty of the human life is laid bare. We cannot shed tears. We have to be ready for the next battle. All patients who have spent months or years with us are a part of our family. When we loose one of them, We mourn with their families in our own way by abandoning all festivities for next 14 days. We silently remember them in our work, try to figure out what we could learn from one loss, to save another in the future. Each time a sense of despair and hopelessness sets in, I find my Faith in the many lives that were saved, with the Hope that many more would be saved in the future if we hold on to the Faith. Nature is not always kind- but I have Faith in the absoluteness of Nature.