Origin of Marrow Stromal Cells and Haemopoietic Chimaerism following Bone Marrow Transplantation Determined by in Situ Hybridisation

The origin and cell lineage of stromal cells in the bone marrow is uncertain. Whether a common stem cell exists for both haemopoietic and stromal cells or whether these cell lines arise from distinct stem cells is unknown. Using in situ hybridisation for detection of the Y chromosome, we have examined histological sections of bone marrow from seven patients who received marrow transplants from HLA-matched donors of the opposite sex. Stromal cells (adipocytes, fibroblasts, endothelial cells, osteoblasts and osteocytes) were identified in these recipients as being of host origin. This result is consistent with the concept of a distinct origin and separate cell lineage for cells of the haemopoietic and stromal systems. It also shows that engraftment of marrow stromal cell precursors does not occur and that host stromal cells survive conditioning regimens for marrow transplantation. With the exception of one case, with a markedly hypocellular marrow, mixed chimaerism was seen in haemopoietic cells, indicating that this is not a rare event after marrow transplantation. Stromal tissue in bone and marrow consists of a heterogeneous collection of loose and dense connective tissues including fibroblasts, adipocytes, endothelial cells and cells of bone and cartilage (Owen, 1985). Little is known of the cell lineage of each of these cellular elements. The ontogenic relationship of cells of the stromal system to cells of the haemopoietic system is also uncertain. In particular, it is not certain whether a common stem cell exists for both the haemopoietic and stromal cell systems in the post-natal animal (Dexter, 1982; Loutit et al., 1982). One approach to this question has been the investigation of the origin and lineage of stromal cells present in the haemopoietic microenvironment following bone marrow transplantation. A donor origin for these cells suggests that there is a common stem cell for both haemopoietic and stromal cell systems in the marrow. Support for this concept has come from both cytogenetic and enzyme marker studies of adherent stromal cells in long-term marrow cultures derived from allogeneic transplant recipients (Keating et al., have shown a host origin for stromal cells, suggesting that a common precursor cell does not exist for both systems. The cells collectively called stromal cells in the above studies represent a heterogeneous population of cells which share the common property of adherence to the substratum in vitro (Dexter, 1982; Tavassoli & Friedenstein, 1983). It is not possible to characterise fully and identify the cells …

The book focuses on the population that ''has not'' and does not receive access to healthcare. There is no specific focus on the issue of integrated care: clearly patients with no access to care at all are not accessing integrated care. However, there is a lot of attention to integrated problems in the ''has not'' population. For example, lack of healthcare is associated with lack of income, lack of income with lack of education, lack of education with early pregnancies and low birth weight, low birth weight with lack of prenatal care and so on. In the concluding chapters on how to change the system, some references are made to small grass roots initiatives, which, however, have no modeling significance, as there are no statistically significant data on whether the experiences and results are replicable.
The book is excellently researched and well written, with a very full bibliography following each chapter. The book is written by fifteen different professors from nine fields of study, from public health to social epidemiology to political science. This myriad of perspectives enriches the reading experience, leaving the reader with the rich texture of a multi-professional effort. The section on inequality and poverty is extremely interesting for any reader interested in understanding the poverty of one of the richest countries in the world. The section on the barriers to reform is an interesting compilation of different professional perspectives, which together explain how the system is inherently unfair. However, it is not clear who the editors imagined the ideal reader of the whole book might be. The jacket suggests that it is ''indispensable to all those who care about health, inequality and American democracy''. However, the length of the work (400 pages) and its level of detail require an extremely committed reader.
The last section of the book is a big disappointment: the concluding proposals on what to do to change things do not seem to have anything to do with the extensive research presented in the preceding sections of the book itself. After such minute research into the causes and the history of the US health system, the expectation of the reader is that all this research is going to have been useful for producing a compelling and great idea for change. Unfortunately, the proposals are extremely far away from the research itself.
The authors of the concluding section on how to change things promote a two-pronged approach. Minute incremental improvements on the one hand and sweeping federal healthcare reform on the other. Both need to happen at the same time. The authors point out that incremental improvements can already be observed on an extremely local level. The authors themselves suggest that it is unreasonable to expect such grass roots examples to solve a 70-million person problem, however, it is considered encouraging.
The authors then go on to observe that global markets have caused economic inequalities in household income everywhere. However, the inequalities have been much greater in the United States than in its European and Canadian counterparts, which have centralised systems for guaranteeing that wealth gets redistributed to contain extreme poverty.
The authors therefore suggest that along with the grass roots experiments, there needs to be a centralised reform. They even point to a very interesting paradox, which, however, is not explored in the book: there is a lack of evidence that government social policy inhibits economic growth through taxation and social responsibility.
The excellent extensive social, political and economic history and research provided by the authors of the first two sections are not drawn on by the authors of the concluding chapters. The book ''Healthy, Wealthy and Fair'' leaves the reader with little hope but to ''dream on'', for a healthy, wealthy and fair healthcare system in the United States.