KATHMANDU: In Nepal, over 3,000 new cases of blood cancer are reported each year. Alongside this, the number of patients suffering from various blood disorders—such as sickle cell anemia, thalassemia, and hemophilia—is steadily rising.
While the government has announced that medications for these conditions will be provided free of cost, experts point out a critical gap in care: the lack of focus on bone marrow transplantation, the key treatment for many of these diseases.
Bone marrow transplantation is widely recognized as one of the most advanced and effective treatments for blood cancers and other serious blood disorders. Despite its proven success globally, Nepal has yet to prioritize this life-saving procedure.
Although the country has trained medical personnel capable of performing bone marrow transplants, the service remains limited to just one hospital due to the absence of essential equipment and infrastructure.
As a result, many patients are left with no choice but to seek treatment abroad—primarily in India—at extremely high costs.
What exactly is bone marrow? How is a bone marrow transplant performed? And what is the current status of this procedure in Nepal? Hematologist Dr. Neeraj Kumar Singh of Bir Hospital discusses these questions in the following interview:
Bone marrow transplantation is considered effective in treating leukemia and various blood disorders. To begin with, what exactly is bone marrow?
Bone marrow is the soft, spongy tissue inside our bones where blood cells are produced. It houses what we call stem cells. These stem cells are essential; they’re constantly being created and destroyed throughout a person’s life.
They perform vital functions like producing blood cells and strengthening the body’s immune system to fight disease.
So stem cells originate in the bone marrow?
Not exactly. Stem cells originate from various microenvironments in the body, including what’s known as microglia. However, they migrate to and live in the bone marrow, which acts as their main residence.
When these cells become damaged or stop functioning properly, we may need to replace them through a process known as stem cell transplantation—or more commonly, bone marrow transplantation.
What’s actually transplanted are these stem cells, which regenerate blood, boost immunity, and help form various tissues and essential components of the body.
How is a bone marrow transplant performed?
Bone marrow transplantation is a well-established and successful treatment. It’s especially effective for many blood-related diseases. While it is primarily used for conditions like leukemia, it’s also been found effective in certain rheumatic disorders and some solid tumors. Interestingly, some research even suggests that HIV/AIDS may be treatable through bone marrow transplantation in specific cases.
There are two main types of bone marrow transplantation:
Allogeneic transplantation, where stem cells are transferred from one person to another—usually a family member or a matched donor.
Autologous transplantation, where the patient’s own stem cells are harvested in advance, then reintroduced after diseased marrow is destroyed.
Lately, bone marrow transplantation has been increasingly used in children with blood cancer. Is it more effective in children than in adults?
That’s a great question. Blood cancer is, in fact, the most common cancer found in children. While it has existed for decades, recent increases in diagnosis are due to better awareness, earlier detection, and the availability of pediatric cancer specialists.
In children, stem cell transplants are used—but more often for non-cancerous blood diseases. For example, in conditions like aplastic anemia (where blood isn’t produced), thalassemia, sickle cell disease, and some genetic blood disorders, transplantation is often the only curative option.
For most cases of childhood blood cancer, chemotherapy is highly effective. Only a small number of children with blood cancer require a bone marrow transplant. In contrast, adults are more likely to need transplantation for blood cancer.
So, whether transplantation is more effective in children or adults really depends on the type of disease and the individual case.
In some pediatric blood disorders, transplantation offers a near 100% cure. In other situations, it may even be used preventively. So again, effectiveness is tied to the condition being treated, not necessarily the patient’s age.
That’s insightful. Like other organ transplants, are there complications involved when bone marrow is transplanted from one person to another?
Bone marrow transplantation is quite different from solid organ transplants. It’s much more like a blood transfusion. Stem cells are collected from the donor’s blood using a special machine and then infused into the patient. No actual organ is removed.
Because of this, the donor experiences minimal risk—similar to donating blood. This is not like kidney or liver donation, which involves surgical procedures and potential long-term health considerations. The process of donating stem cells for a bone marrow transplant is safe and generally well tolerated.
You mentioned autologous transplantation earlier. Could you explain a bit more about how it works?
Of course. In autologous bone marrow transplantation, we collect stem cells from the patient before starting treatment. The disease is first brought under control, and then the patient’s diseased bone marrow is destroyed—usually through high-dose chemotherapy. After that, we reintroduce the healthy stem cells back into the patient. These stem cells help the body produce new, healthy blood.
On the other hand, in allogeneic transplantation, stem cells come from a donor. Siblings are usually preferred because of better genetic compatibility. If a sibling match isn’t available, we look at other relatives or even unrelated matched donors.
Before proceeding with the transplant, we carefully assess the donor’s health—especially their heart, liver, and other vital organs—to ensure they’re fit to donate.
Earlier, you mentioned that a patient’s own bone marrow can also be transplanted. Could you explain how that works?
Certainly. As I mentioned before, there are two main types of bone marrow transplantation. The first is called an autologous transplant, where the patient’s own stem cells are used. This is typically done in cases of short-term or manageable diseases.
First, we bring the disease under control. Then, we destroy the affected bone marrow—where the diseased stem cells are located—and reintroduce the previously harvested healthy stem cells back into the patient. These cells then begin producing healthy blood cells once again.
The second type is an allogeneic transplant, where the stem cells come from a donor. In most cases, the best matches are siblings. If a sibling match isn’t available, we look to other family members or unrelated donors with compatible tissue types.
There are well-established methods for finding suitable donors through global registries if no match is found within the family.
Before any transplant—especially in the case of allogeneic transplants—we conduct thorough health screenings of the donor. This includes evaluating the heart, liver, kidney function, and overall physical fitness to ensure that the donor is healthy enough to proceed.
After a bone marrow transplant, is the patient completely cured, or does treatment have to continue?
That depends on the goal of the transplant. In many cases, we perform bone marrow transplantation with the intent of a complete cure. When successful, this can lead to a 100% recovery.
However, in some instances, the disease can relapse. If that happens, a second transplant or alternative treatments might be necessary.
In other situations, we perform the transplant not to cure the disease completely, but to control it. For example, in conditions like multiple myeloma, lymphoma, certain solid tumors, or recurrent childhood cancers, patients may require repeated rounds of chemotherapy.
This often damages the bone marrow’s ability to produce blood. In such cases, we reintroduce stem cells to help the body tolerate more chemotherapy.
So, the primary goal of bone marrow transplantation is usually to cure the disease. But when a cure isn’t possible or chemotherapy alone is not sufficient, it serves to help manage and control the illness more effectively.
What is the current status of bone marrow transplantation in Nepal?
Frankly, the situation is quite disheartening. None of the hospitals under Nepal’s Ministry of Health currently offer bone marrow transplant services. Based on our estimates, around 10 Nepali patients travel to India each month for a transplant, where the cost ranges from 3 to 3.5 million rupees.
We’ve been urging the government for years to establish this facility within the country. Nepal does have medical professionals who are trained and capable of performing bone marrow transplants.
But at present, only the Civil Hospital has the necessary setup, which is not nearly enough to meet national demand.
What are the consequences of this gap in services?
The consequences are severe. Due to limited capacity, patients have to wait 6 to 8 months just to get in line. But bone marrow transplant is not like kidney transplant, where patients can survive on dialysis while they wait.
These patients need the procedure within 15 days to a month. A delay can mean the difference between life and death.
Those who have financial resources go abroad for treatment, but many patients lose their lives simply because they cannot afford the cost. If performed in Nepal, a transplant would cost around 500,000 to 600,000 rupees.
The government even provides financial assistance of 300,000 to 400,000 rupees, just like it does for kidney transplants. So there’s no reason why patients should be forced to spend over 3 million rupees abroad or die without treatment.
The government often speaks about helping sickle cell and thalassemia patients. Isn’t bone marrow transplantation essential for them?
Exactly. The only curative treatment for sickle cell anemia and thalassemia is bone marrow transplantation. In addition, there are many children in Nepal suffering from aplastic anemia, a condition where their bone marrow simply doesn’t produce blood cells.
These children have no other treatment options, and yet the government has shown little urgency or commitment to help.
Nepal has specialists trained in bone marrow transplantation. What then is holding back the system?
The main challenge is the lack of technical equipment. A stem cell collection machine alone costs around 100 million rupees. During the COVID-19 pandemic, several hospitals built infection-free isolation rooms, which could be adapted for transplant use.
The total cost to set up a basic bone marrow transplant center, including equipment and infrastructure, would be about 100 to 120 million rupees. It’s not a question of resources—it’s a matter of political will and prioritization.
There was once a plan to start bone marrow transplants at Bir Hospital. What happened to that?
I’ve personally submitted proposals to every health minister and secretary since the COVID-19 crisis, both individually and on behalf of the hospital. Despite repeated follow-ups, there’s been no political interest or initiative. That’s why the plan at Bir Hospital never moved forward.
What causes bone marrow to deteriorate? And how can we protect it?
The primary cause is genetic. About 90 percent of bone marrow failure is due to inherent genetic problems—either inherited from parents or resulting from spontaneous mutations.
These factors are largely unpreventable. While environmental and lifestyle factors may play a minor role, the root cause is often in the genes, which is why early diagnosis and timely treatment are so critical.
You mentioned genetics as a major cause of bone marrow failure. But can environmental factors also contribute to gene-related problems?
Absolutely. While we can’t change our inherited genes, our environmental impact can influence how those genes behave. For example, toxic substances in food, air pollution, and exposure to petrochemicals can all worsen genetic mutations.
These environmental exposures can activate or intensify harmful genetic tendencies. So while we can’t stop inherited traits, we can certainly reduce external triggers that make them worse.
That’s why we say a healthy bone marrow requires healthy stem cells, and to keep those stem cells healthy, the body needs to be free from harmful substances. Maintaining a clean environment and a nutritious diet plays a crucial role in this.
What precautions should be taken after a bone marrow transplant?
There are two main things to focus on post-transplant. First is infection prevention. The patient’s immune system is extremely weak after the procedure, so a clean, healthy environment and a balanced diet are critical to recovery.
Second is monitoring the status of the disease. Sometimes, infections or complications can cause the transplant to fail. That’s why lifestyle, nutrition, and regular follow-ups are essential for long-term success.
As a hematologist, what advice do you have for the government and the public in light of the rising number of blood-related illnesses?
My first advice to the public is to focus on prevention and early treatment. If diagnosed early, most blood diseases can be treated before they cause severe complications.
Secondly, if a bone marrow transplant is recommended, patients should not delay it. Delays can be fatal. To the government, I would say this: We’ve been urging for years that each province should have at least one bone marrow transplant center. As diagnostic services expand, we’re naturally seeing more cases that require transplantation.
If action isn’t taken now, even one center per province won’t be enough in 10 years. Right now, the government spends more on managing complications than on curing the disease. Investing in transplant infrastructure can save lives and reduce long-term healthcare costs. It’s time to act decisively.
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