As the date of his stem cell transplant approached, Graham Lewis kept an eye on the news: the young woman who was his rare genetic match lived in the UK. COVID-19 cases there were rising; a few hundred, now a thousand.
"I said why don't we try another donor? They said there's not another donor available," the 74-year-old Victorian told Hack on Wednesday.
The transplant was scheduled for late March at Royal Melbourne Hospital. The stem cells would have to be extracted in the UK and then whisked fresh across the world by special human courier and through Australian borders.
Already, borders were closing as authorities tried to stem the outbreak. Italy went into lockdown. Then France. Then Germany. Governments called on their citizens and residents to come home. By the start of this week any human courier briefly leaving the UK might doubt they would be allowed back through customs.
Earlier this year, as the words 'pandemic' and 'quarantine' began to be muttered, blood cancer specialists considered a fearful scenario.
About 350 bone marrow or stem cell transplants are performed in Australia every year to treat diseases like leukaemia and Hodgkin's lymphoma. Because finding a match is incredibly rare, often there isn't a suitable donor in the country. Eighty per cent of donated stem cells come from international donors.
What would happen if the fragile international network of co-operation around matching donors with recipients broke down?
What if donors became too scared to visit hospitals?
That scenario is playing out for at least 17 Australians who are intended to be recipients of international stem cell donations in the coming fortnight. Some will have their transplants deferred. Others may find other remedies. But for some, stem cells from a matched international donor are the only cure.
The situation is doubly urgent for Graham, who has already begun the process of 'conditioning' - the shutting down of his immune system to prepare for the transplant. For the last month, he hasn't been taking the drugs that usually keep him alive. On Tuesday, in strict isolation at Royal Melbourne Hospital, he was given high doses of chemotherapy to kill the last white blood cells that repel foreign invaders. As his immune system goes offline he's become exceptionally vulnerable to disease and infection.
If the donor pulled out, he'd be in serious trouble.
On Wednesday morning this week, the clinicians treating Graham Lewis received the news they had all dreaded: the UK donor had pulled out.
"She thinks she's been in contact with somebody with the virus," Graham told Hack.
It's been in the back of my mind ever since it started.
"It's come true, unfortunately for me."
Border closures impacting donations
As countries close their borders, donor registries and medical professionals are frantically working to allow the urgent international delivery of live cells.
In the US, the White House has quietly waived the ban of arrivals from Europe. In Europe, where commercial planes have stopped flying, military aircraft are ferrying medical cooler boxes and their human couriers.
'Use your common sense': The Govt says don't go overseasHowever, finding couriers willing to travel internationally and risk being locked out of their own country is proving hard.
Among those looking after Graham is Jeff Szer, a clinical haematologist at Royal Melbourne Hospital and president of the World Marrow Donor Association.
The vast majority of stem cell and bone marrow donations to Australia come from Germany, which has a large pool of young donors.
"Most of Europe is proving to be difficult right now," Dr Szer said.
Northern America is hard. Israel is another source we occasionally tap into and they're completely locked down at the moment.
Everything has changed in the last week, he says. Bone marrow and stem cell transplants are no longer taking place in Australia unless the donor is within the country, or the stem cells have been already delivered and then frozen.
As much as possible, transplants are being deferred.
"We have a couple planned for the next week or two that we have deferred for a couple of weeks, but there is one who we do not think can wait so we are frantically trying to ensure that we can get the cells here in some way."
This patient, who is not Graham, has a willing donor in the UK. The problem is to do with transporting them to Australia - live cells have to be accompanied by a human courier. Two weeks ago the hospital would have sent a member of staff to the UK, but it's no longer allowing staff to leave the country to do this.
One solution would be to contract an accredited courier company.
"There are a couple of accredited courier companies that can do this for us, but they're both based in Germany," Dr Szer said.
There are issues with getting those couriers out of Germany to the UK.
Another solution is training up couriers within the UK.
"Again there's an issue, the bulk of the volunteers are retirees which of course are higher risk individuals for exposure to the new coronavirus," he says.
"The other issue is massive reduction in international flights. Getting the couriers here in the first place is increasingly a logistical challenge."
"There are a number of factors working to make this a very complicated issue."
'Pulling out the stops' to make it happen
The Australian Bone Marrow Donor Registry is representing clinicians in the discussions with health and border authorities. Lisa Smith, the CEO, says the Federal Government has been "very supportive and offering all assistance".
She's met with Border Force, the Department of Health, Qantas and others to secure agreements on the delivery of live cells. The Department of Foreign Affairs and Trade has offered consular support.
"Everybody's pulling out the stops for this," she said.
"We've reached some very practical agreement around such things as handing over of cells on airport premises and allowing couriers to come into the country.
"We certainly expect that the uncertainties and the complexities will increase over the next few weeks. I'd like to think that at some point this will stabilise.
"But I don't think we're at that point yet."
However, Dr Szer, the clinician, appears less optimistic.
He says guardedly: "A number of exemptions will almost certainly come into play to allow these cells to come into the right place at the right time."
Asked if some blood cancer patients who urgently need international donor transplants might not make it through the coming weeks, he replies: "I think it's not impossible that will happen. We will try our best to avoid that."
How young people can help
Graham Lewis lives in Avenel, a small Victorian bypassed by the Hume Highway, an hour and a half north of Melbourne. The former motor mechanic plays lawn bowls at the local club and for many years operated the school bus.
Forty-one Australians are diagnosed with blood cancer every day. After he was diagnosed in December 2018, Graham's doctors worked out he'd probably had the cancer in his bone marrow for at least the previous five years.
"When I started to get sick I sold my bus and my contract," he told Hack.
His wife, Joy, said his condition had gotten worse as he'd stopped taking drugs in preparation for the scheduled transplant.
"It's happened at a bad time this coronavirus thing," she said.
"It's pretty upsetting - we just can't do anything about it."
They're now waiting for the UK donor - who believes they've been exposed to coronavirus - to inform them in the coming days of their test results.
"Just gotta hope she hasn't got the virus, otherwise I'm in big trouble," Graham says.
"I haven't had any treatment for five to six weeks and I've started to go downhill a bit."
To find matches within Australia for people like Graham, the Bone Marrow Donor Registry is urging young Australians aged 18-30 to register as donors: You fill in a form online and then receive a simple mouth swab kit in the mail.
The health and safety of donors is the utmost priority of the donor registry, Lisa Smith says.
"The need for local donors is acute," she said.
"If you are called to donate, bear in mind it is literally a life or death matter for the recipient.
"You may be the only person in the world who is a match for that particular patient.
"If you do get that call, please please proceed with the donation."