In this part of the test, there are two texts about different aspects of healthcare. Choose the answer (A, B, C or D) which you think fits best according to the text.
Text: 1 Umbilical cord blood banking in Australia: Public good or private gain?
Allogeneic haematopoietic stem cell transplantation (HSCT) is a curative therapy for many malignant and non-malignant conditions, including leukaemia, bone marrow failure syndromes, immunodeficiencies and inborn errors of metabolism. Unfortunately, only 30% of patients in need of HSCT will find a suitably matched related donor. The only option for other patients is to search for an unrelated volunteer donor. Over the past decade, these difficulties have led to umbilical cord blood (UCB) being increasingly used as an alternative source of stem cells for HSCT in patients who do not have a matched bone marrow or blood donor. Over 7000 UCB transplants have now been performed worldwide, with more than 150 paediatric UCB transplants performed in Australia alone. Successful UCB transplant programs have led to the establishment of two types of UCB banks: public banks and for- profit private banks. In the case of Australia, I argue that there is adequate social and medical justification for public UCB banks; however, based on current knowledge of the therapeutic uses of UCB stem cells, private UCB banking is not similarly justified.
The two types of UCB banks in Australia differ in both their scientific rationale and their medical utility. Public UCB banks are altruistic, store donated UCB for public access, and are analogous to volunteer bone marrow donor registries. In contrast, private UCB banks will, for a fee, store a child’s UCB for personal or family use. It should be noted that transplant centres themselves also store directed family UCB donations if a family member is known to have (or potentially has) a disease that can be treated with transplantation. Public UCB banks have, for the most part, been very successful in making HSCT a real option for Australian patients who require a transplant. These banks attract considerable public support and donation from a broad range of Australians. However, there are a number of political and structural challenges facing public UCB banking in Australia.
Firstly, collecting and storing UCB is expensive and requires considerable and continuous government support. In addition, there are only a limited number of collection centres and these tend not to be located in regional or culturally diverse areas, resulting in continued low donation and recruitment rates from ethnic minority and indigenous groups. Although Australian public UCB banks show significantly more ethnic diversity than their bone marrow registry counterparts, public UCB banks are still characterised by under-representation of many ethnic groups, particularly Aboriginal Australians and Pacific Islanders. Given the increase in UCB transplantation and the persistent under-representation of indigenous Australians and ethnic minorities in UCB banks, recruitment strategies that best meet the needs of potential transplant recipients need to be developed. This will not be a simple task, as such policies must take account of equity concerns and specific population needs.
In contrast to public UCB banking, questions have been raised about the assumptions upon which private UCB banking is based. These assumptions include: that UCB will provide a valuable and appropriate resource for use in transplantation and regenerative medicine; that stem cells present in UCB could not easily be collected from other sources (e.g., from peripheral blood or bone marrow) at the time that they are needed; and that the likelihood of needing UCB stem cells is sufficiently great to justify the expense of long-term storage of UCB. Each of these assumptions is questionable — the promise of regenerative medicine is yet to be shown in clinical trials; the conditions for which HSCT is performed often require stem cells from allogeneic sources rather than from the patient, and stem cells can generally be obtained from alternative sources when required for HSCT; and the vast majority of people will never develop a haematological malignancy or any other indication for HSCT, so will never require the use of their own haematopoietic stem cells (estimates of the likelihood of requiring one’s own stem cells for autologous transplantation later in life vary between 1 in 20,000 and 1 in 200,000).
Much of the excitement surrounding UCB research is based on hope, rather than evidence. However, should UCB stem cells prove to have wider therapeutic application, another set of different but equally serious questions will surely arise regarding the maintenance of social equity in health care. For example, only a small proportion of the population may be able to afford UCB storage for personal or family use. While state-provided storage of all UCB for personal use may, although extremely costly, satisfy social justice concerns, such a solution may also threaten the real and symbolic value attached to altruistic donation of tissues and, perhaps in the end, the very existence of public UCB banks.