At the end of last year I had a fabulous time meeting and interviewing Professor Fiona Wood. While some of my interview was used in this piece for Vice, there was a lot more we discussed that could not be included. I have decided to post an earlier draft here, as well as some additional paragraphs written after talking with her colleague Professor Peter Maitz.
Fiona Wood is the only person I know who can, by the sheer force of her enthusiasm, compel us exhausted medical students to put down our iPhones and listen. When this tiny but formidable woman speaks about her patented ‘spray on skin’ and her dream of ‘scarless healing’, you can’t help but be drawn in. A world leader in burns research and surgery, I’m both excited and nervous to finally meet her. As I’m ushered us into her office at Fiona Stanley Hospital (a small well-lit room that still has the feeling of being recently moved into), her dry English humour makes me feel a little more comfortable.
Born in a Yorkshire mining village in 1958, the power of education was instilled in the naturally inquisitive Fiona from a young age. Education was something her parents (a coalminer and a teacher) valued highly, and in high school she was encouraged to question everything ‘not as a criticism, but as an opportunity for nudging things forward.’ After considering studying physics and maths at Cambridge, and even Olympic running, it was the opportunity for a solid science-based career that drew her towards medicine, a decision she does not regret. ‘I think medicine is an extraordinary career for anybody. To be able to do something you enjoy and have such positive benefits for others is really special.’
A practical person who is ‘more comfortable doing things than not’, Fiona knew early on in her medical training that she was surgically inclined. ‘It was the doing that hooked me. I wanted to be the person who fixed things.’ But it was at the Queen Victoria Hospital in West Sussex, home to many remarkable developments in burns surgery, where Fiona (then a junior surgeon in training) discovered her calling.
‘It was looking at the scarring and the devastation in people’s lives, and thinking, ‘could I actually change that? Could I change that person’s life trajectory?’’
The journey from novice to pioneering burns surgeon was not easy one though, and there was a time when she was tempted to give it all up. ‘1992: a 29-year-old with 90% burns.’ As she tells the story of this high school science teacher burned in an explosion while helping his roofing contractor friend, her voice becomes much quieter. ‘I thought I’d done a good job, and then he got polyneuropathy (nerve deterioration) of the critically ill. Paralysed. Spent nine months in (rehabilitation). I thought ‘I’m not cut out for this. I can’t do it’’. It took a few days, but what kept her going was the thought that she had done her best and that she could learn how to do better. After hearing this devastating story, I’m delighted to learn that Fiona and this patent still meet up for coffee and that he’s doing well. ‘I don’t think he realises how pivotal he almost was,’ she muses.
Not content with simply performing the surgery, Fiona began to explore ways in which burns treatment could be done better. The options then were using skin grafts from an unburned part of a patient (which is fast and reliable but requires a lot of skin and causes scarring), artificially grown skin from a donor (which, being foreign, can be rejected by the body) or growing skin from a patient’s own cells. This latter option is more reliable and only uses a small amount of the patient’s skin, but it takes three weeks to grow, leaving the patient at risk of infection while their burn is unhealed.
In 1993, with the aim of increasing wound-healing speed and decreasing scarring, Fiona and her colleague Marie Stoner began work on what would eventually become ‘ReCell’. This medical device works by taking a small amount of healthy skin from a patient, dissolving the structures holding the cells together with an enzyme, and then spraying the resultant solution over the affected area (this whole process takes only minutes). Instead of growing in a tissue culture flask, the skin grows directly on the patient, cutting the healing time down from weeks to days. The principle behind this technology was that the sooner you could get skin cells onto a burn, the better the cells functioned and therefore the better the burn healed. How they came up with the idea of a ‘spray’ is a classic eureka moment: after trying skin cells in sterile gloves for hand burns (limited) and cells under adhesive dressings (fiddly), the exasperated researchers said to each other ‘jeez, you know, we should just spray this stuff on.’ It only took them a moment to realise that this throwaway suggestion was their way forward.
While ‘spray on skin’ has been a standard part of Fiona’s practice for many years, it was events in Bali in 2002 that brought this technology to the world’s attention. On October 12, the violent Islamist group Jemaah Islamiyah detonated two bombs in the tourist areas of Kuta, resulting in 202 deaths and many more injuries. 28 of the most gravely injured victims, some with over 90% burns to their bodies, were airlifted to Royal Perth Hospital for urgent treatment. As head of this hospital’s burns unit, it was Fiona’s job to coordinate four operating theatres, nineteen surgeons and 140 other medical staff, as well as using her skills and technology to help save the lives of 25 of these people. When I ask her what that time was like, her answer catches me off guard. ‘I sense that you ask me the question because you think it might have been different from normal. But interestingly, yes the hospital was full, yes there was a level of intensity, and there were burned patients who needed treatment, but there was also an element of ‘that’s what we do’ and ‘business as usual.’’
When discussing disaster as an impetus for innovation, she grimaces and states that it’s a vexed issue for her emotionally. ‘I remember looking down the ward post-Bali, looking at those lives changed, and thinking there was nothing that I could have done to influence that event. But that there was an opportunity for me to influence the outcome, and to minimise the outcome, and that’s where I put my energy.’ ‘You have to be pragmatic,’ she continues. ‘There’s no mileage in being churlish and saying ‘I’m not doing this because it’s on the back of a devastating event.’ What I’m going to do is learn as much as I can right here right now so I can change as much as I can going forward.’
Post-Bali there was some discussion from Fiona’s peers about the lack of clinical trials confirming ‘spray on skin’s’ efficacy. Indeed, Concord Hospital burns unit medical director Peter Maitz stated that ‘patients who come from a terrorist attack like Bali should not be subjected to an experimental procedure’. When I ask Fiona about this, she is quick to describe the body of evidence that currently exists and did exist in 2002 for her ‘logical’ and ‘very low-risk’ technology. These include tests on animal models, work using the skin graft donor site as a control wound, and a comparison of treatments randomised in scald injuries, all of which demonstrate positive effects. ‘To say that there is no evidence would be erroneous’, she replies. In addition, the technology had also received provisional approval from the Australian Therapeutic Goods Administration, the authority responsible for regulating medicine and medical devices. While clinical trials are currently taking place in the US and are about to start in the UK, Fiona states that it is difficult to conduct these types of studies for burns treatment. For one, doing blinded trials with burns is problematic (blinding is when a study participant does not know what treatment they are receiving, and this helps to reduce bias), and each burn and burn patient is completely unique.
In the same year as the bombings, Fiona and Marie decided to commercialise their research, forming Clinical Cell Culture (later Avita Medical). What originally started out as a ‘splendid idea’ to create both innovative technology and sustainable research funding (Fiona says funding is the ‘one thing that keeps me awake at night’), soon turned into ‘an awful lot of hard knocks’. Part of the difficulty was the extra workload coupled with Fiona’s desire to be a surgeon first and foremost. Convincing physicians to overcome their inertia and adopt new technology was also challenging. ‘Maybe we didn’t try hard enough,’ she concedes. Things are now looking better though, with the company recently signing a contract worth over $50 million and the product being used successfully worldwide.
While Avita Medical runs as a not-for-profit in Western Australia, the cost of ReCell does vary worldwide. When I ask Fiona generally about the ethics of making money from technology that could, if free, help many more people, she acknowledges that this is a dilemma but that it is difficult to make a difference without the money to do so. While we unfortunately won’t be seeing ReCell given out for free in the company’s current phase, Fiona is taking some steps to changing the treatment of burns in the third world. ‘There’s an awful lot of work we can do that will get us further forward than ReCell in those environments, such as infection control and first aid.’ Her team also makes regular trips to Nepal (a relationship that developed from an AusAID grant) to perform burns and plastic surgery.
It’s plain to see that despite her struggles with commercialisation, the research itself brings her a lot of joy. Her most current interest has even been given a snappy title: ‘Can we think ourselves whole?’ ‘The nervous system is an untapped resource when it comes to understanding how we heal. I want to understand how a burn injury influences the brain and the whole of the nervous system, and then can we use this understanding to drive scarless healing.’ Knowing how emotionally difficult research can be, I’m interested to know how she maintains this drive. Her answer is simple:
‘Connect with positive energy. There are so many people who will pull you down; you don’t have to do it to yourself. If you take notice of them, it’s not sustainable emotionally. Go find the positive energy. Go find the people who want to help you.’
Engaging in positivity and dismissing negativity appears to be her central philosophy, and thus it takes her a while to think of the worst part of her job. ‘The thing that irritates me is when people criticise without helping solve the problem,’ she eventually responds, before clarifying that it’s not really part of her job because she makes a conscious decision not to engage in it. Not letting the ‘bastards get you down’ (as her dad would say) is also advice she would give her younger self. ‘I think I may have lost a bit of energy worrying about what people said. As you get more mature, criticism is less impactful. You kind of shrug it off.’
Fiona’s passions outside of burns include family (especially her six children), sport and optimising our problem solving capabilities. ‘I’d like to solve problems by having a group of people with different experiences in the room (and go) ‘There’s the problem. C’mon guys. What do you think?’ I think we have a phenomenal capacity but we hold ourselves back by being blinkered and being afraid of diversity.’ ‘How is it,’ she continues, ‘that we can have all these brains on this planet and not have enough food in the right place, and clean water? It boggles the mind!’
Does Fiona think she is a genius? ‘I’ve done what I’ve done on the back of the energy of a lot of individuals. Whether it be my parents giving me the education I’ve got, the patient’s that made me think slightly differently, my colleagues and working closely with Marie.’ ‘True geniuses are very few and far between’, she continues. ‘There aren’t to many Newton’s and Einstein’s hanging around. But there’s an awful lot of human energy that can make a difference.’
‘Do I think I’m a genius? No. Do I think I live in an environment where we have the capacity for genius? Yes. Do I think it’s realised often enough? No. I think part of that is our belief. We need to believe we live in an environment with a capacity for genius. To drive innovation. To change lives.’
Extra Paragraphs Following Discussions with Professor Peter Maitz
Royal Perth was the only hospital that used spray on skin after the Bali Bombings, and Fiona was later lauded for their reduced incidence of scarring. Three people died under her watch, which was tragic but also miraculous considering the scale of carnage. Yet, post-Bali there was some discussion from Fiona’s peers about the lack of clinical trials confirming ReCell’s efficacy. Speaking to Fiona’s friend and colleague Peter Maitz, who is also the burns unit medical director at Concord Hospital, he tells me that while Fiona’s technology is great research and a ‘fantastic development’, in 2002 the only evidence for it was Level 5 (case reports, expert opinion or personal observation), the lowest level of evidence. ‘A medication like Panadol would need Level 1 evidence (a systematic review of randomised control trials) to be brought onto the market.’ While he acknowledges that obtaining clinical trials for burns treatments is complicated and expensive, and therefore they cannot always expect Level 1 evidence, he and his colleagues in Adelaide and Brisbane were concerned because there was ‘not even level 2 or 3 evidence (randomised or pseudo-randomised control trials).’ ‘In a disaster setting, you don’t want to be using unproven technology. You want the safest, fastest and easiest procedure.’ Following the Bali Bombings, Peter and his team chose to treat their dozen severely burned patients using evidence-based bioengineered products and skin grafts, and they all survived. He further explains that skin cultures are not routinely used on infected wounds because they do not work as well (all of the patient’s from Bali had an element of infection). Does he believe the claims that people treated with spray-on-skin healed faster and were out of hospital earlier? ‘No’, he is quick to state, explaining that ReCell only replaces the superficial epidermis of the skin, and not the deeper dermis layer.
Starting Clinical Cell Culture was not without controversy. Fiona’s public comments about how her product would help heal the victim’s burns, as well as subsequent calls from two members of parliament to make the Federal Government pay for spray-on-skin for all Bali victims, was another cause of concern for Peter Maitz and his colleagues. This was because at the time Fiona was a major shareholder, Chief Medical Officer and a Medical Director of the company, and therefore stood to make money if the Government supported this plan. Peter contrasts this with his own similar research which, if proven to work, will be owned by an academic institution and provided free of charge. Despite this difference, Peter does not believe making money was Fiona’s main driver, stating she’s a ‘good person working in a difficult situation’ and that she was ‘so excited by (her technology) that she just ran with it’. Fiona no longer has such control over the company she started: she is a non-executive director, and owns less than 0.2% of the company’s shares.