Has Tamil Nadu turned the tide on the transplant trade?BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2155 (Published 12 April 2013) Cite this as: BMJ 2013;346:f2155
- Sandhya Srinivasan, freelance journalist and researcher, Mumbai; consulting editor, Indian Journal of Medical Ethics; consulting editor, public health, Infochange News and Features
India is a world leader in the commercial kidney trade. An estimated 3200 transplants put India second only to the United States (with 6435) in 2006,1 but national data are not reliable, and estimates range from 3000 to 6000 live donor transplant operations (commercial and non-commercial) a year.
The transplant industry is highly profitable, and private hospitals, which conduct most transplant operations, are subject to little regulation.2 3 Regulation improved in 2008 after the arrest of doctors running a transplant business in Gurgaon, near Delhi, who had transplanted 600 kidneys removed from poor people without consent. They were convicted on 22 March 2013 and sentenced to prison. Still, paid-for transplants are thought to make up a considerable proportion of live transplants in India.
The Transplantation of Human Organs Act 1994 bans the buying and selling of organs,4 but clause 9 of chapter II permits live donation by an unrelated donor “by reason of affection or attachment towards the recipient.” Authorisation committees have often turned a blind eye when there has been reason to suspect that the “donor” is being paid.3 This has left medical professionals free to exploit desperate patients with renal failure and desperate poor people ready to sell a kidney to pay their debts.
The commercial transplant business thrives in the absence of strong transplant programmes that harvest organs from dead donors. Each year in India 134 000 people die in road traffic incidents.5 Some 70% are declared brain dead and are potential sources of organs for transplantation.6 Deaths from snakebite and brain haemorrhage also give rise to potential donors. Yet organs from fewer than 200 cadavers are transplanted each year, and not more than 11% of the estimated annual 3000-6000 kidney transplants come from dead donors. The problem is that to harvest organs for transplantation brain dead patients must be identified in hospitals at the right time; trained counsellors must approach their families for consent to donate; and hospitals must have the infrastructure to maintain brain dead patients until their organs can be retrieved and transplanted.
But one state’s introduction of a deceased donor transplant programme may change all this. Tamil Nadu was once a world centre for, and India’s capital of, the “transplant tourism” industry, and hospitals here still conduct up to 20% of all transplant operations in India.
“Tamil Nadu has shown that it is possible to run a publicly supported programme of deceased donor organ retrieval, sharing and transplant, with transparency,” said Sanjay Nagral, transplant surgeon at Jaslok Hospital, Mumbai, and joint secretary of the non-profit Zonal Transplant Coordination Committee in the city.
Between the programme’s launch in October 2008 and February 2013, 573 kidneys, 286 livers, 52 hearts, and 15 lungs from 317 dead donors were retrieved and transplanted in the state. The number of dead donors rose from 59 in 2009 to 83 in 2012.7 In 2012 almost half of organ donations from dead donors in India were from Tamil Nadu.8 The state’s cadaver kidney donation rate has gone up from 0.3 per million population9 to 1.3 per million population,6 compared with the national average of 0.08 per million population.6
Since 2008 the Tamil Nadu government has issued 10 orders to make organ donation from cadavers “procedurally and structurally possible.”10 Hospitals doing transplant operations must register with the state authority, run a counselling department, employ a transplant coordinator, submit records of transplants they conduct, and make their charges public. Hospitals with a minimum of 25 beds, an operating theatre, and intensive care facilities are designated potential sources of cadaver organs. All cases of brain death must be certified. And because 80% of cadaver donations come from road traffic incidents,6 organ retrieval is permitted before postmortem examination if necessary.
The programme involves collaboration between government, non-profit organisations, and public and private hospitals. The Multi Organ Harvesting Network (MOHAN) Foundation has transplant coordinators in government hospitals who counsel grieving relatives and run education programmes for hospital staff and the public. The National Network of Organ Sharing (NNOS) helps hospitals strengthen their infrastructure and processes to enable transplant operations from dead donors and it supports the programme’s administration.
Joseph Amalorpavanathan, professor of vascular surgery at the government Madras Medical College, and a vascular surgeon at the associated Rajiv Gandhi Government General Hospital, is the government appointed unpaid convenor of the programme.
“We work with two and a half people, a couple of computers, and a budget of just Rs 10 lakh [Rs 1m; £12 100; €14 300; $18 400] a year, yet we are able to generate half as many donations as a typical organ procurement organisation in the West does, with more than 100 staff,” he told the BMJ.
He maintains a waiting list of patients and allocates organs from cadavers, following guidelines for sharing organs among hospitals and for prioritising patients.
“Organ transplants have always been shrouded in mystery,” he said. This contributed to public suspicion of transplantations of organs from dead donors. “Right from the beginning we resolved to be transparent to the public.” Information on the waiting list, the number of deceased donor organs transplanted, the hospitals involved, and the guidelines for organ sharing are all in the public domain.
“The programme was preceded by extensive consultation with hospitals and surgeons doing transplants, so everyone felt involved,” said C E Karunakaran, a trustee of NNOS. Rather than confront the medical profession, the focus was to get doctors to “own” the cadaver transplant programme rather than to punish law breakers.
“We never interfered in doctors’ and hospitals’ autonomy, whether their fees or their medical decisions,” said Dr Amalorpavanathan. “They are free to change the patient’s place on the waiting list if the status changes. We just ask them to explain such decisions for our records. Doctors also see that the system works in their favour—their patients get organs.”
Still, the influence of commerce is ever present. For example, a brain dead patient in a non-transplant centre may be transferred to a private transplant hospital before certification of brain death, giving the hospital first choice regarding the organs and the profits from performing any transplantations.
Organs that originate in private hospitals are shared with government hospitals, however, which conduct transplant operations for free. This may encourage families who may otherwise be reluctant to donate because the private hospital and transplant surgeon stand to gain personally from performing transplantations.
It helps that the convenor is seen as neutral, said Dr Nagral, who is also a founding member of the Forum for Medical Ethics Society and on the editorial board of the Indian Journal of Medical Ethics, which has campaigned against the transplant trade. Transplant surgeons may be seen as having an interest in the programme, discouraging retrieval of organs from dead donors.
NNOS trains doctors in the procedures and non-technical skills needed to make the programme work. “Doctors may hesitate to get involved in the various procedures supporting cadaver transplantation,” said Mr Karunakaran. “We need to give them confidence that an agency will guide them to prevent mistakes.” Doctors may worry about being questioned on their decision to certify brain death. Hospitals may not know the procedures needed to maintain the body before organ retrieval. This training could quadruple the number of dead donors in Tamil Nadu, according to Mr Karunakaran.
When staff in intensive care units are educated to identify brain dead patients, and trained counsellors ask relatives of these patients to donate the dead person’s organs, the consent rate is about 50%, close to that in developed countries.11 Transplant coordinators trained by MOHAN have a consent rate of 50-60%, said the MOHAN trustee Sunil Shroff, transplant surgeon at the private Sri Ramachandra Medical College and Research Institute, Chennai.
Tamil Nadu’s programme gained momentum with media coverage of a couple who donated the organs of their son who died in a traffic incident. And coverage of the search for a cadaver liver for a senior politician with liver failure may be behind the increase in organ donations in Mumbai in 2012, said Dr Nagral.
“We need to improve the capacity of district hospitals to treat patients as well as to maintain brain dead patients in an appropriate condition,” said Tamil Nadu’s health secretary Jagannathan Radhakrishnan. A handful of hospitals in the state provide 80% of all organs for transplantation. “Our infrastructure to treat [people involved in] road traffic accidents is abysmal, even in Chennai,” said Dr Amalorpavanathan.
“Brain death certification should be the byproduct of good surgical management. Improved head injury services will increase the number of people saved, and also the number of brain dead cadavers actually available for transplant,” he said.
Also, few laboratories outside Chennai operate around the clock to do the cross matching necessary for organ transplantation.
Without these facilities it is not possible to designate hospitals as non-transplant organ retrieval centres or insist that doctors certify all cases of brain death.
In 2012, 496 kidneys from live donors were transplanted in Tamil Nadu; 482 kidneys were donated by a near relative (child, parent, sibling, or spouse), and 114 were “for reasons of emotional attachment,” according to Varadan Rukmangathan, deputy director medical education in the state. Dr Rukmangathan said applications under clause 9 are reviewed by experts and statements videotaped. Still, some observers say that some of these 114 kidneys would have been bought for a price. But the government has only recently started tracking transplants from live relatives, and Mr Karunakaran of NNOS estimates that about 1000 transplantations take place every year in the state, of which about 150 involve kidneys from dead donors.
“The Tamil Nadu programme has made a small but significant impact on commercial transplants. Earlier, a person with kidney failure had two options: live related donation or commercial donation. Today, cadaver transplants are a real option, and people will consider that if they are willing to wait once they get registered, a cadaver kidney should be available in 1-2 years,” he said. That may be optimistic: as of 8 April 2013, 2044 people in Tamil Nadu were waiting for a kidney.12
The Tamil Nadu programme works because it has strong government support, it serves the poor through public hospitals, and possibly because of the commitment and abilities of the individuals involved. It is an example for other states to follow.
The state’s programme is the most advanced of the deceased donor organ programmes in India. In 2012 Tamil Nadu had 83 dead donors, Maharashtra 29, Gujarat 18, Karnataka 17, Andhra Pradesh 13, and Kerala 12.8 Government orders supporting dead donor transplant programmes have been issued in Karnataka (in 2004), Andhra Pradesh (2009), Kerala (2012), and Maharashtra (in 2012).
Prevention of kidney disease
An estimated 175 000 Indians develop end stage renal disease every year, according to Dr Shroff. More than 90% don’t have access to either dialysis or transplantation and die within months of diagnosis.9
More than 70% of healthcare expenditure is in the private sector, and more than 86% of private healthcare expenditure is out of pocket.13 At Rs 3-500 000, “transplants are an option for the middle class,” said Mr Karunakaran.
Even the best cadaver based transplant programme will reach only a fraction of patients who need it. The only effective response is to prevent kidney disease. NNOS is initiating a pilot screening project for hypertension and diabetes with medical follow-up and finds it possible to treat patients for as little as Rs 50 per head of population per year.
Cite this as: BMJ 2013;346:f2155
Competing interests: I have read and understood the BMJ group policy on declaration of interests and declare that I have no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.