You Be the Giant (3)
Today the Nature editorial office was as peaceful as ever. Dr. Fairchild scratched his head. He still couldn't figure out what kind of man this was.
"Don't American doctors ever sleep? How many papers has this person sent in this year alone? It's not as if he's a paper-writing machine."
This was already the umpteenth time. He was growing weary of it.
"Maybe he really is a paper-writing machine."
After all, he wasn't the youngest Lasker Award winner for nothing. Dr. Fairchild glanced around the room.
"We can't very well reject this one, can we?"
The Nature editor sitting beside him merely shrugged.
"Stanford is where heart transplantation was invented. If we turn this down, people will say we were the fools who rejected an Einstein-level paper."
"Ha… You're right about that."
That much was true. The very reason a journal's editorial board existed was to find important papers. They couldn't afford to let a big fish slip away. The problem was that one man kept tossing things onto Dr. Fairchild's desk that looked so much like big fish they couldn't simply be ignored.
-I have found the fundamental principle of acquired immunity!
-Thanks to a rare bacterium that lives in hot springs, I have found the Holy Grail of molecular biology!
-I have discovered a new type of pneumonia!
Good grief. The man was even invading his dreams now. Dr. Fairchild skimmed the manuscript in question once more. The structure resembled a book of prophecy more than a scientific paper. Its central claim was that, judging from its lymphocyte-suppressing properties, cyclosporine could dramatically reduce organ rejection. That was the gist.
"Come to think of it, this is the same doctor from before, isn't it? The one who elucidated the precise mechanism of acquired immunity."
"Ah, that paper…"
Dr. Fairchild fell into thought. That insane manuscript. Several years earlier it had thrown the entire Nature editorial office into an uproar. The structure alone had been absurd. At the time, Dr. Fairchild, a traditional British biologist, had found papers written by these American physicians rather… unhinged. Physicians, after all, considered it a virtue to scribble something down the moment they thought it might help a patient and rush it into print. Their work was closer to conjecture than to science. This man had been especially guilty of that habit.
'Thought experiments in biology? He's no Einstein. These damned doctors…'
Of course, after carefully reading the immunologist's paper, even Dr. Fairchild had been forced to acknowledge the logic. That accursed thought experiment. The reasoning had been simple. Following the doctor's logic: H-2 proteins were involved in acquired immunity. Lymphocytes mediated acquired immunity. Therefore H-2 proteins must be related to lymphocytes.
And the only realistic way a cell could convey information to a lymphocyte was by presenting it directly. Presenting what? Here, too, the simplest answer had been written down: simply cutting up the target molecule of the immune response and handing the fragments to the lymphocyte. That had been the entire content of that accursed paper.
What sort of human being writes thought experiments into a medical paper? This man was not in his right mind. Even back then Dr. Fairchild had been horrified by the manuscript, yet it had been impossible to reject. The logic was simply too flawless. Like Columbus's egg. One could not go down in medical history as the editor who rejected the first paper to elucidate the principle of acquired immunity…
It was the same this time. The hypothesis that cyclosporine might be the new key to organ transplantation was immensely attractive. It was also something that needed to be made known. Dr. Fairchild let out a sigh.
***
I sat quietly in the internal medicine residents' office. My work for the day was finished. In addition, Nature had sent back word that they would publish the paper I had just submitted. The editorial office seemed to find the whole thing rather strange, but that was their problem.
While I was getting ready to leave, Alice dragged herself into the office. She looked tired today, but since it was nearly quitting time it probably didn't matter much. She turned her gaze toward me.
"Another paper accepted, I hear?"
I nodded. Alice plopped down on the office sofa, chewing on a chocolate bar. Whenever there was a quiet on-call shift she sometimes napped there. If anything came up, someone would come wake her. It happened often enough.
"They approved it pretty quickly this time."
"That's unusual…"
Alice stared blankly into space. She was an intelligent person and a good doctor with patients and children, but research had never been her strong suit. Still chewing her chocolate, she rummaged in her pocket and pulled out another bar, offering it to me.
"Ah. Thanks."
"You need sugar if you want your brain to work."
Alice gave a small laugh. Things were about to get busy. It all depended on how quickly Dr. Shumway could move the hospital, but we would soon begin researching the new method of organ transplantation. Tomorrow, once I arrived at work, I would have to write it up. I needed to start drafting the clinical trial proposal I would hand to Dr. Shumway. He hadn't set a deadline, but he had said to write it quickly.
"Let's head home."
Alice stood by the office door with her bag in hand, staging a one-woman protest that it was time to leave.
***
Dean Rich pressed his temples. Dr. Shumway was one of Stanford's most distinguished physicians and researchers. His opinions were not easily dismissed. Even if the request was somewhat unreasonable, the man had invented heart transplantation, after all.
Dr. Shumway's proposal for a cyclosporine clinical trial lay on the dean's desk. Yet Dean Rich did not miss the peculiar arrogance contained within it. This had clearly been written by that East Asian resident. A thoracic surgeon—no, at the very least, Dr. Shumway's own mind would never have produced such literary flourishes and emotional appeals. This was the sort of thinking one expected from an internal medicine physician.
"You want to begin the clinical trial right away?"
"Yes."
"Wouldn't it be better to conduct a little more research first?"
"Isn't this research?"
It was an irrefutable point. Still, the dean hesitated for a moment. The truth was that the evidence still seemed insufficient.
"Even so, moving straight from animal experiments to human trials with a drug that has barely been tested is no simple matter. Let's wait just a little longer."
Dr. Shumway shook his head gravely. His expression said there was no time for that.
"Dean, do you know what the five-year survival rate is for transplanted kidneys in kidney transplant patients?"
"Roughly fifty percent, isn't it?"
"That's the patient survival rate. The five-year survival rate of the transplanted organ itself is around thirty percent."
If a transplanted kidney failed, it sometimes had to be surgically removed again, depending on the case. But since the patient could still survive by returning to dialysis, patient survival was inevitably higher than graft survival. One in three. The number was shocking.
"That's low."
"When a child donates a kidney so that a parent can live comfortably for a few more years, and even that kidney only lasts five years in one out of every three cases—"
Dr. Shumway let out a long breath.
"Isn't that heartbreaking? I wonder whether it's even right to tell donors about these odds. All we're doing is increasing their burden of responsibility."
"It isn't an easy situation."
Dr. Shumway looked at the dean again.
"But if we had a drug with a new mechanism of action—one that could extend the life of a transplanted organ by even a single year…"
The dean scratched his head. Dr. Shumway was right. Stanford performed a considerable number of kidney transplants. Even now there were patients admitted for the procedure.
"Isn't this a bit premature?"
"Among the current inpatients there is also a patient scheduled for a kidney transplant. If a new treatment can produce better results right away… then we should begin the clinical trial as soon as possible."
"But the trial would target kidneys?"
"Yes."
"Why is that?"
"Because people have three kidneys."
Dean Rich frowned for a moment. Three kidneys? It took him several seconds to understand the joke. When a kidney transplant was performed, the patient's own failed kidneys were usually left in place. A patient who received one transplanted kidney would therefore live with three kidneys unless something went wrong. Two of them simply wouldn't function. On reflection, it was a rather funny joke. And it was probably that East Asian resident's work. Dr. Shumway was not the sort of man to come up with such jokes.
"I suppose that's true."
Dr. Shumway continued.
"Heart transplant cases aren't common. Kidney transplants, on the other hand, are frequently performed between family members, which means a lower immunosuppressive burden and makes them more suitable as a research target."
The dean nodded.
"That was the resident's opinion, wasn't it?"
"He said that since kidney transplants are far more common than heart transplants, it would be best to apply the clinical trial to kidney transplants first. When you think about it, it's an obvious point."
"He really is an odd one. Where on earth do these ideas come from…"
It was a mystery of the highest order. From the dean's perspective—having watched the East Asian doctor since the moment he first set foot on the Stanford campus—the strangeness was even more pronounced.
Dr. Shumway cleared his throat.
"So. I take it we should proceed with the clinical trial?"