INK Conference
Susan Lim: Transplant cells, not organs
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Pioneering surgeon Susan Lim performed the first liver transplant in Asia. But a moral concern with transplants (where do donor livers come from ...) led her to look further, and to ask: Could we be transplanting cells, not whole organs? At the INK Conference, she talks through her new research, discovering healing cells in some surprising places.
Susan Lim - Surgeon
A surgical pioneer in Singapore, Susan Lim is a researcher and entrepreneur. Full bio
A surgical pioneer in Singapore, Susan Lim is a researcher and entrepreneur. Full bio
Double-click the English transcript below to play the video.
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So I was privileged to train in transplantation
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under two great surgical pioneers:
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Thomas Starzl,
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who performed the world's first successful liver transplant
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in 1967,
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and Sir Roy Calne,
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who performed the first liver transplant in the U.K.
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in the following year.
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I returned to Singapore
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and, in 1990,
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performed Asia's first successful
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cadaveric liver transplant procedure,
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but against all odds.
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Now when I look back,
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the transplant was actually the easiest part.
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Next, raising the money to fund the procedure.
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But perhaps the most challenging part
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was to convince the regulators --
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a matter which was debated in the parliament --
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that a young female surgeon
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be allowed the opportunity
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to pioneer for her country.
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But 20 years on,
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my patient, Surinder,
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is Asia's longest surviving
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cadaveric liver transplant to date.
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(Applause)
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And perhaps more important,
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I am the proud godmother
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to her 14 year-old son.
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(Applause)
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But not all patients on the transplant wait list
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are so fortunate.
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The truth is,
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there are just simply not enough donor organs
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to go around.
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As the demand for donor organs
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continues to rise,
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in large part due to the aging population,
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the supply has remained relatively constant.
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In the United States alone,
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100,000 men, women and children
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are on the waiting list for donor organs,
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and more than a dozen die each day
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because of a lack of donor organs.
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The transplant community
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has actively campaigned in organ donation.
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And the gift of life
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has been extended
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from brain-dead donors
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to living, related donors --
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relatives who might donate an organ
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or a part of an organ,
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like a split liver graft,
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to a relative or loved one.
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But as there was still a dire shortage of donor organs,
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the gift of life was then extended
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from living, related donors
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to now living, unrelated donors.
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And this then has given rise
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to unprecedented and unexpected
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moral controversy.
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How can one distinguish
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a donation that is voluntary and altruistic
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from one that is forced or coerced
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from, for example,
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a submissive spouse, an in-law,
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a servant, a slave,
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an employee?
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Where and how can we draw the line?
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In my part of the world,
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too many people live below the poverty line.
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And in some areas,
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the commercial gifting of an organ
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in exchange for monetary reward
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has led to a flourishing trade
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in living, unrelated donors.
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Shortly after I performed the first liver transplant,
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I received my next assignment,
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and that was to go to the prisons
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to harvest organs
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from executed prisoners.
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I was also pregnant at the time.
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Pregnancies are meant
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to be happy and fulfilling moments
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in any woman's life.
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But my joyful period
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was marred by solemn and morbid thoughts --
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thoughts of walking through
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the prison's high-security death row,
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as this was the only route
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to take me to the makeshift operating room.
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And at each time,
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I would feel the chilling stares
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of condemned prisoners' eyes follow me.
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And for two years,
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I struggled with the dilemma
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of waking up at 4:30 am
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on a Friday morning,
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driving to the prison,
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getting down, gloved and scrubbed,
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ready to receive the body
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of an executed prisoner,
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remove the organs
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and then transport these organs
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to the recipient hospital
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and then graft the gift of life
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to a recipient the same afternoon.
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No doubt, I was informed,
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the consent had been obtained.
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But, in my life,
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the one fulfilling skill that I had
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was now invoking feelings of conflict --
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conflict ranging
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from extreme sorrow and doubt at dawn
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to celebratory joy
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at engrafting the gift of life at dusk.
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In my team,
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the lives of one or two of my colleagues
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were tainted by this experience.
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Some of us may have been sublimated,
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but really none of us remained the same.
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I was troubled
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that the retrieval of organs from executed prisoners
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was at least as morally controversial
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as the harvesting of stem cells
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from human embryos.
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And in my mind,
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I realized as a surgical pioneer
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that the purpose of my position of influence
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was surely to speak up
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for those who have no influence.
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It made me wonder
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if there could be a better way --
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a way to circumvent death
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and yet deliver the gift of life
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that might exponentially impact
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millions of patients worldwide.
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Now just about that time,
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the practice of surgery evolved
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from big to small,
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from wide open incisions
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to keyhole procedures,
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tiny incisions.
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And in transplantation, concepts shifted
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from whole organs to cells.
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In 1988, at the University of Minnesota,
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I participated in a small series
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of whole organ pancreas transplants.
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I witnessed the technical difficulty.
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And this inspired in my mind
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a shift from transplanting whole organs
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to perhaps transplanting cells.
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I thought to myself,
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why not take the individual cells
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out of the pancreas --
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the cells that secrete insulin to cure diabetes --
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and transplant these cells? --
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technically a much simpler procedure
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than having to grapple with the complexities
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of transplanting a whole organ.
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And at that time,
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stem cell research
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had gained momentum,
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following the isolation of the world's first
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human embryonic stem cells
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in the 1990s.
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The observation that stem cells, as master cells,
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could give rise
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to a whole variety of different cell types --
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heart cells, liver cells,
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pancreatic islet cells --
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captured the attention of the media
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and the imagination of the public.
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I too was fascinated
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by this new and disruptive cell technology,
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and this inspired a shift in my mindset,
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from transplanting whole organs
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to transplanting cells.
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And I focused my research on stem cells
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as a possible source
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for cell transplants.
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Today we realize
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that there are many different types of stem cells.
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Embryonic stem cells
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have occupied center stage,
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chiefly because of their pluripotency --
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that is their ease in differentiating
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into a variety of different cell types.
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But the moral controversy
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surrounding embryonic stem cells --
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the fact that these cells are derived
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from five-day old human embryos --
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has encouraged research
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into other types of stem cells.
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Now to the ridicule of my colleagues,
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I inspired my lab
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to focus on what I thought
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was the most non-controversial source of stem cells,
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adipose tissue, or fat, yes fat --
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nowadays available in abundant supply --
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you and I, I think, would be very happy to get rid of anyway.
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Fat-derived stem cells
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are adult stem cells.
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And adult stem cells
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are found in you and me --
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in our blood, in our bone marrow,
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in our fat, our skin and other organs.
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And as it turns out,
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fat is one of the best sources
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of adult stem cells.
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But adult stem cells
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are not embryonic stem cells.
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And here is the limitation:
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adult stem cells are mature cells,
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and, like mature human beings,
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these cells are more restricted in their thought
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and more restricted in their behavior
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and are unable to give rise
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to the wide variety of specialized cell types,
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as embryonic stem cells [can].
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But in 2007,
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two remarkable individuals,
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Shinya Yamanaka of Japan
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and Jamie Thomson of the United States,
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made an astounding discovery.
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They discovered
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that adult cells, taken from you and me,
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could be reprogrammed
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back into embryonic-like cells,
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which they termed IPS cells,
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or induced pluripotent stem cells.
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And so guess what,
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scientists around the world and in the labs
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are racing
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to convert aging adult cells --
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aging adult cells from you and me --
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they are racing to reprogram these cells
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back into more useful IPS cells.
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And in our lab,
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we are focused on taking fat
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and reprogramming
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mounds of fat
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into fountains of youthful cells --
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cells that we may use
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to then form other,
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more specialized, cells,
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which one day may be used as cell transplants.
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If this research is successful,
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it may then reduce the need
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to research and sacrifice
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human embryos.
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Indeed, there is a lot of hype, but also hope
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that the promise of stem cells
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will one day provide cures
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for a whole range of conditions.
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Heart disease, stroke, diabetes,
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spinal cord injury, muscular dystrophy,
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retinal eye diseases --
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are any of these conditions
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relevant, personally, to you?
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In May 2006,
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something horrible happened to me.
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I was about to start a robotic operation,
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but stepping out of the elevator
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into the bright and glaring lights of the operating room,
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I realized
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that my left visual field
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was fast collapsing into darkness.
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Earlier that week,
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I had taken a rather hard knock
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during late spring skiing -- yes, I fell.
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And I started to see floaters and stars,
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which I casually dismissed
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as too much high-altitude sun exposure.
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What happened to me
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might have been catastrophic,
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if not for the fact
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that I was in reach of good surgical access.
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And I had my vision restored,
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but not before a prolonged period of convalescence --
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three months --
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in a head down position.
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This experience
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taught me to empathize more with my patients,
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and especially those with retinal diseases.
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37 million people worldwide
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are blind,
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and 127 million more
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suffer from impaired vision.
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Stem cell-derived retinal transplants,
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now in a research phase,
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may one day restore vision,
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or part vision,
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to millions of patients with retinal diseases worldwide.
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Indeed, we live
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in both challenging
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as well as exciting times.
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As the world population ages,
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scientists are racing
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to discover new ways
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to enhance the power of the body
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to heal itself through stem cells.
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It is a fact
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that when our organs or tissues are injured,
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our bone marrow
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releases stem cells
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into our circulation.
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And these stem cells
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then float in the bloodstream
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and hone in to damaged organs
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to release growth factors
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to repair the damaged tissue.
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Stem cells may be used as building blocks
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to repair damaged scaffolds within our body,
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or to provide new liver cells
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to repair damaged liver.
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As we speak, there are 117 or so clinical trials
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researching the use of stem cells
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for liver diseases.
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What lies ahead?
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Heart disease
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is the leading cause of death worldwide.
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1.1 million Americans
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suffer heart attacks yearly.
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4.8 million
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suffer cardiac failure.
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Stem cells may be used
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to deliver growth factors
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to repair damaged heart muscle
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or be differentiated
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into heart muscle cells
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to restore heart function.
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There are 170 clinical trials
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investigating the role of stem cells in heart disease.
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While still in a research phase,
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stem cells may one day herald
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a quantum leap in the field of cardiology.
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Stem cells provide hope for new beginnings --
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small, incremental steps,
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cells rather than organs,
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repair rather than replacement.
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Stem cell therapies
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may one day reduce the need for donor organs.
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Powerful new technologies
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always present enigmas.
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As we speak,
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the world's first human embryonic stem cell trial for spinal cord injury
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is currently underway
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following the USFDA approval.
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And in the U.K.,
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neural stem cells to treat stroke
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are being investigated in a phase one trial.
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The research success that we celebrate today
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has been made possible
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by the curiosity and contribution and commitment
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of individual scientists
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and medical pioneers.
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Each one has his story.
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My story has been about my journey
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from organs to cells --
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a journey through controversy,
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inspired by hope --
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hope that, as we age,
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you and I may one day celebrate longevity
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with an improved quality of life.
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Thank you.
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ABOUT THE SPEAKER
Susan Lim - SurgeonA surgical pioneer in Singapore, Susan Lim is a researcher and entrepreneur.
Why you should listen
Dr Susan Lim is the current Co-chair of the Global Advisory Council of the International Society for Stem Cell Research (ISSCR). She performed the first successful cadaveric liver transplant for Singapore in 1990, the second woman in the world to have done so at the time .
Her academic recognitions include election as Fellow, Trinity College (2005), University of Melbourne, the Monash University Distinguished Alumnus Award (2006), and an Honorary Degree of Doctor of Medicine by The University of Newcastle, Australia (2007). In 2007, the American Academy of Continuing Medical Education (AACME) 28th award, was named the “Dr Susan Lim Award” for the advancement in Laparoscopic & Minimally Invasive Surgery. Her more recent public lectures include “Robotic Surgery - Engineering from a surgeon’s perspective”, as visiting scholar to UC Berkeley, and a 2016 TEDx Berkeley talk “The Dawn of a New Ecosystem in Organ Replacement.”
For her humanitarian work, she was recognized in the Australian House of Parliament (House of Representatives Official Hansard no. 17, 2005) for treating Australian victims of the second Bali bomb blast. In giving back to society, the family have established the Dr. Susan Lim Endowment for Education and Research, which supports medical and research scholarships at Trinity College, University of Melbourne, the University of Newcastle, Australia, and the International Society for Stem Cell Research (ISSCR).
Susan Lim | Speaker | TED.com