AN UPDATE TO ‘BLOODY HARVEST’ & ‘THE SLAUGHTER’

When asked about transplant volume in recent years, Chinese officials have usually responded with the figure of 10,000 transplants per year. By this point in the text, we suspect that any reader will have come to the conclusion that the 10,000 figure is not a serious estimate, but rather a throwaway number to shield the Chinese medical establishment from questions regarding the sourcing of the organs. Unaccustomed to the idea of questioning a sovereign nation’s medical statistics, and eager to promote Chinese transplant reform by not offending the Chinese medical establishment, most Western medical bodies have essentially played along, and publically accepted the 10,000 figure at face value.

Of course, in an ethical world, the responsibility for providing actual transplant volume numbers would fall on China, not on us. We do not live in that world. Yet, simply by adding up a handful of the hospitals that have been profiled in this update, it’s easy to come up with higher annual transplant volume figures than 10,000. Therefore, it is our responsibility not to simply present this large volume of new information without providing any sort of tool for interpreting it. A quick calculation of a handful of extremely productive transplant centers does not tell us the real annual volume of transplants in China, either. What is the volume when we add in all those other, perhaps more conventional, transplant centers and hospitals?

In 2015, Huang Jiefu, China’s former Vice Minister of Health, admitted in a television interview that the number of transplant surgeries performed is a state secret:¹⁸⁷⁶

Huang Jiefu: The death penalty is a state secret, right?

Xu Gehui (reporter): But patients are not a secret. I’m sorry, I really don’t understand.

Huang: Your organs come from executed prisoners.

Xu: Okay, so the sources of the organs can be a secret, but is the waiting list [for transplants] also a secret?

Huang: You can deduce from the number of [executed prisoners] the number of [transplants] performed. Then don’t you know the state secret?

Xu: Then it should be smaller than this number [of executed prisoners]. Another reason is…

Huang: What you’re saying is too sensitive, so I can’t be too explicit with you. It will be clear to you as long as you think about it. Because your country doesn’t have a transparent system, you don’t know where the [organs] come from. How many [transplants] are done is also a secret, so in fact, many things are actually a mess, and the number isn’t clear to you.

(end of transcript)

In China, the number of executed prisoners is a state secret. The number of organs taken from executed prisoners is also a state secret. Due to the sources of the organ the and financial incentives cannot be explained, the number of transplants is falsified level by level, down to the local hospital and the individual doctor. The true number of transplants performed in China may forever remain unknown.

Since the organ harvesting crimes are ongoing, digging for the true volume data could be likened to probing the dim light from a distant star. Yet while we cannot directly observe the number of transplants these hospitals have performed, we can create a numerical range based on their capacities, record of growth, hospital bed counts and usage rates, and number of professional personnel. Moreover, regulations published by the Government provide useful information in determining the scale of transplant centers nationwide.

Under current conditions of secrecy and deception, in which the Chinese authorities have actively removed information previously published on particular hospital websites, we cannot offer a single absolute number for the annual volume of transplants or offer even a close approximation. We can, however, construct a common-sense calculation and make our assumptions transparent. To avoid giving a sense of false precision to a calculation which is made from an incomplete data set, we can also compare this to a range of back-of-the-envelope calculations that will be highly transparent to even the casual reader.

Mainland Chinese critics publically attacked Bloody Harvest for using the terms “about” and “approximately” when discussing numerical estimates. Yet, we are less interested in their attacks and more interested in not misleading readers. We use those terms to avoid false precision. We will continue to use them here. After presenting the calculated numbers, we round the results in the chart for the same reason.

We first look at the total transplant volume performed by the 712 liver and kidney transplant hospitals using the minimum requirements for permitted transplant centers from authorities of all levels.

For hospitals approved to perform liver and/or kidney transplants by the Ministry of Health, we calculate their minimum transplant capacity using the Ministry’s minimum bed requirements to maintain certification.

On June 27, 2006, the Ministry of Health published a “Notice Regarding the Management and Regulation of Liver, Kidney, Heart, and Lung Transplantation Capabilities,” which imposed the following requirements for medical institutions carrying out organ transplants:¹⁸⁷⁷

• liver: 15 beds dedicated to liver transplants and no fewer than 10 ICU beds
• kidney: 20 beds dedicated to kidney transplants and no fewer than 10 ICU beds

For the 146 hospitals with kidney and/or liver transplant permits (national-level civilian and military transplant centres and designated transplant centres), the minimum bed counts are as follows:

Table 10.1: Minimum transplant bed count requirements by the Ministry of Health.

Based on a one-month hospitalization period, each bed can accommodate up to 12 transplant patients per year. In practice, kidney transplants generally require one to two weeks, and liver transplants take three to four weeks. Since we are mixing kidney and liver transplants in our volume analysis, we use the maximum hospitalization duration as our average.

Our survey of 165 hospitals indicate widespread facility constraints, including transplant centers that exceed 100% bed utilization and have a long line of patients waiting for transplants. It may also be germane that Huang Jiefu’s plan to expand the number of approved transplant hospitals from 169 to 300 suggests that the current system-wide capacity cannot keep up with demand. ^{1878 1879} Thus, we assume that the vast majority of existing capacity has been utilized to perform transplants.

Assuming 100% bed utilization, our calculations indicate that these 146 hospitals combined could theoretically conduct 69,300 transplants per year.

In China, liver transplants gradually became a routine clinical procedure after 2000, ¹⁸⁸⁰ shortly after kidney transplants also began to be carried out on a large scale. By then, a few kidney transplant centers had already exceeded 1,000 kidney transplants. Since many liver transplant centers also conduct kidney transplants, their lead in conducting kidney transplants compensates for the relative delay in scaling up liver transplants.

We thus multiply annual figures by 15 years for approved hospitals, excluding the year of 2000 as ramp-up time. Following this method, the total number of transplants performed over 15 years is 1,039,500 total transplants.

Table 10.2: A volume scenario of 146 hospitals permitted to conduct transplants, based on transplant bed count requirements by the Ministry of Health.

Because only 164 of the more than 1,000 hospitals who applied under the Ministry of Health’s 2007 approval system received permits, in reality there are more than 566 non-approved hospitals performing transplants. Despite not being approved by the Ministry of Health, many of these facilities have not halted their transplant activities and some of these non-approved institutions had significant transplant volumes. Compared to the Ministry-approved hospitals, these institutions have more flexibility to obtain living organ sources through various channels and to continue organ harvesting. In addition, several dozen non-approved military and armed police hospitals face no restrictions and are performing organ transplants as usual, because they control abundant supplies of live organ sources. They are not regulated by the Ministry of Health or local governments; the military has designated PLA organ transplant centers at many of these hospitals.

All these 3A institutions are located in large cities with over 500 inpatient beds. There are cases of centres in medium-sized cities performing 100 transplants in three months, ¹⁸⁸¹ which would translate to 400 per year assuming a constant rate. All 405 hospitals in this category are 3A hospitals with larger capacities and greater demand. There could be great variations in transplant volume from hospital to hospital, we set the baseline for each large-scale hospital at 100 transplants per year.

The group includes 161 medium-size transplant institutions, 55 Class 3 Grade B hospitals, 106 Class 2 hospitals, and a few smaller ones that also conduct organ transplants. These hospitals usually perform more kidney transplants, which have lower technical requirements than liver transplants do. Many of these hospitals have performed far more transplants than the minimum volume, with some performing hundreds per year.

Before the Ministry of Health released its list of 164 approved transplant centers in 2007, transplant centers across China had been qualified for transplantation by various assessment departments. For example, the minimum requirement for a qualified kidney transplant center in Guangdong Province in 2003 was to conduct at least 50 kidney transplants per year.¹⁸⁸² Between September and December 2003, 30 hospitals qualified for kidney transplants and 17 for liver transplants. We assume 50 transplants per year for each medium non-approved transplant center.

Since the military controls ample organ sources, its transplant centers have been almost unaffected by the introduction of transplant permits in 2007 and have continued to carry out transplants. Many non-approved civilian centers also continued to conduct transplants after 2007, but their individual situations varied; we assume that all non-approved hospitals stopped performing transplants after 2007 and therefore we multiply the annual volumes for non-approved hospitals by 7 years, ending in 2007.

In total, non-approved transplant centers can perform up to 48,550 transplants per year. Over a period of 7 years, the total comes to 339,850 transplants.

Table 10.3: Estimated annual transplant volume of non-approved hospitals based on minimum requirements.

Adding the 1,039,500 transplants by approved hospitals and 339,850 by non-approved hospitals yields 1,379,350, approximately 1.4 million transplants, which translates into about 90,000 transplants a year.

Table 10.4: A transplant volume scenario based on Ministry of Health requirements for permitted hospitals and local regulations for non-permitted hospitals.

This analysis is based on the published minimum bed counts under the Ministry of Health’s permit system in 2007. Even though the Ministry approved only 164 centers, most of which carry out far more transplants than the minimum bed counts can produce, it is relevant that more than 1,000 hospitals applied for permits to conduct transplants under this system logically implies that they also met these minimum requirements or were close to meeting them.¹⁸⁸³ The reported transplant figures indicate that the total number of transplants performed before 2007 by the 80% of hospitals that have not received permits are comparable to that of the approved 20%.

Throughout this report we have tried to avoid selectively using Chinese state claims. We did not inspect these hospitals to make sure that they have the minimum number of beds for transplant patients. Presumably the Ministry of Health did that. Yet it is difficult to verify the Ministry of Health’s approval process. It could be plagued with corruption. Many state approval processes throughout China are. So it is legitimate for the skeptical reader not to assume that an approach which uses minimum requirements set by the state to count transplants will be perfectly accurate.

The skeptical reader is entitled to ask us to wipe the slate clean and, assuming that they have been following the text this far, to come up with a simple estimate which can plausibly capture a low scenario within the bounds of common sense. Yet the cumulative effect of the evidence presented here is not merely numerical. Clearly the Chinese transplant system is highly competitive, state-sponsored, and much more productive than was previously understood. In short, the individuals in the system work very hard.

So one way to approach the problem is to start at the micro level by thinking about how many transplants one doctor at a national-level transplant centre performs in a year. For example, in a report from 2013, a surgeon describes performing 246 transplants in a year. When you subtract weekends and holidays, the average year contains approximately 250 working days; so the surgeon essentially performed one transplant for every working day of the year. Obviously this surgeon is a very hard-working fellow, but that’s not actually such an extraordinary schedule; because prisoners of all stripes are often made available in batches, organ transplants are usually performed in batches as well. The surgeon might have performed two or even three on a single day and then gone for several days without performing any transplants at all. Transplant teams have to work on weekends and holidays too, and the tendency of organ sourcing to careen between feast and famine means that a national-level transplant center does not operate with only a single transplant surgeon; even at a bare minimum, a centre will have at least two or three transplant teams.

So we can begin by premising a common sense proposition, a notional number, to represent the absolute lowest end of the range for the average national level transplant centre: one per day, or 365 transplants per year.

Is the average of one transplant per day for each Ministry-approved transplant center credible? The short answer is yes, providing one is wedded to a skeptical approach. Put another way, even if one hadn’t read this report at all, it would be exceedingly difficult to reject one transplant per day as unrealistically high. To reflect the size differences, we assumed that while national-level civilian and military transplant centres perform one per day on average, a designated transplant centre performs one transplant every two days. To reflect differences of opinion over the ramp-up time for approved transplant centres we assumed 14 years of operation rather than 15. We further assumed that a non-approved transplant centre performs two transplants a week, while a non-approved transplant centre performs one transplant per week (and these centres were active for seven years).

Table 10.5 The low scenario: back-of-the-envelope estimate of total transplants conducted by 712 liver & kidney transplant centers since 2000

The low scenario is just short of one million transplants over 15 years and instead of 90 thousand per year, the rate is 60,000. Earlier in this chapter, we determined that minimum requirements set by the state is equivalent to about 1.4 million transplants performed by the 712 transplant hospitals. This total includes 1 million carried out by the 146 approved transplant centers over 15 years, which translates to an average of 456 transplants per hospital per year, or in back-of-the-envelope speak, 1.25 transplants per hospital per day. In short, the differences are far less glaring than one might expect.

However, because we are immersed in the data, it is hard for us not to see the low scenario and the minimum requirement scenario as understatements; neither one fully takes into account highly productive transplant centers. For example, most national transplant centers have the capacity to perform more than 1,000 transplants a year, with some exceeding 4,000 and even 8,000 per year. For example, Beijing No. 309 Hospital has 393 beds and has the capacity to perform more than 4,000 transplants per year. ¹⁸⁸⁴ On the civilian side, Tianjin Central Hospital’s Oriental Organ Transplant Center has at least 500 transplant beds and claims to have a 131% utilization, which means that it is capable of performing more than 8,000 transplants a year. The Shanghai Orient Hepatobiliary Surgery Center had 742 beds but later moved to a new campus and further expanded.

Even the minimum requirement scenario is not very taxing for the average transplant center’s resources: 456 transplants a year requires fewer than 40 hospital beds, assuming a 30-day hospitalization period (or 25 beds for a 20-day hospitalization period, because many hospitals have set up transplant clinics, which greatly reduce the length of hospitalization).

Where hospitals listed extremely low bed counts online, our investigators made recorded calls to verify the number of beds available for transplants. In some cases, they were told that the hospital could appropriate additional transplant beds as needed. They also found a few hospitals in which liver transplant patients typically stay for less than two weeks, such as the hospital of Xi’an Jiaotong University and Zhongshan Hospital of Fudan University.¹⁸⁸⁵

Transplant surgeries are conducted in both dedicated transplant centers and in regular surgery departments. For each hospital with adequate data available, we estimate the number of beds used to perform transplants by adding the reported bed counts for dedicated centers and a fraction of reported bed counts for hepatobiliary and urologic surgery departments known to conduct transplants.

The question, then, is what fraction of beds in non-dedicated departments are used for transplants. The Ministry of Health’s “Notice Regarding the Management and Regulation of Liver, Kidney, Heart, and Lung Transplantation Capabilities” issued in 2006 imposes the following requirements for non-dedicated surgery departments carrying out organ transplants: ¹⁸⁸⁶

• Hepatobiliary surgery departments: 80+ beds in total, including 15+ beds dedicated to liver transplants and no fewer than 10 ICU beds;

• Urologic surgery departments: 40+ beds in total, including 20+ beds dedicated to kidney transplants and no fewer than 10 ICU beds.

Excluding ICU beds these requirements translate to nearly 20% of beds in non-dedicated departments used for liver transplants and 50% for kidney transplants. It should be noted that the distinction between dedicated and non-dedicated transplant departments is becoming increasingly blurred, as we have observed hospitals that have nominally merged their dedicated transplant centers back into their more generic surgery departments in recent years, perhaps to avoid scrutiny over the capacity of their dedicated transplant centers.

Our data set is gathered from publicly available information and likely understates the presence and scale of dedicated transplant centers these hospitals operate. Furthermore, it has been shown that these transplant centers can add beds or even relocate beds from other departments as needed, so the stated bed counts are not absolute.

Finally, the hospitals we analyzed place a heavy emphasis on transplant operations; many of their transplant departments are elevated as key disciplines, transplantation is their most profitable activity, and at least 50 of the hospitals’ presidents are transplant specialists and/or simultaneously director of their transplant organizations.

Given these factors, we also created a high scenario which doubles the rate of permitted hospitals; national-level civilian and military transplant centres perform two per day on average, while a designated transplant centre performs one transplant per day.

Table 10.6 The high scenario: back-of-the-envelope estimate of total transplants conducted by 712 liver & kidney transplant centers since 2000

The result is 1.5 million over 15 years; 100,000 transplants a year. We believe that the data that has been presented in this update makes this a defensible estimate, not an outlier. Now it is also possible to come up with a third scenario (simply because we have been mugged by reality). By doubling the per day rate once again, we reach a total of 2.5 million over 15 years, approximately 170 thousand per year.

We mention this not because the evidence is fully in place to support such an estimate at this time. It may surface in the future. At this time, we would say that the range is between 60,000 to 100,000 a year, with an emphasis on the higher numbers. But what number most likely reflects the truth is left to the reader; we encourage the reader to make their own calculations as we do not claim that this is the final word on the subject.

Transplant recipients must take immunosuppressants for life to prevent rejection. The explosive growth of transplantation in China led to an unprecedented expansion in the immunosuppressant market, which reached 10 billion RMB by March 2006. ¹⁸⁸⁷

The cost of immunosuppressants for each transplant recipient is the highest in the first year and decreases thereafter. This cost is roughly between 30,000 and 70,000 RMB, averaging 40,000 RMB per year.¹⁸⁸⁸ However, this cost can be even lower. According to liver transplant expert Yan Lvnan of West China Hospital in 2006, the hospital can control the cost to be around 30,000 RMB for the first year and an average of 10,000 RMB per year for subsequent years.¹⁸⁸⁹ How many transplant recipients are covered by the 10-billion-RMB immunosuppressant market?

We assume the number of organ transplants performed each year is constant and the average survival period is 5 years.¹⁸⁹⁰ We also assume the cost of immunosuppressants for each recipient is 30,000 RMB per year.

Total market value for immunosuppressant RMB = total transplant recipients * annual cost of immunosuppressants

10 billion RMB = total transplant recipients * 30,000 RMB

Hence, the total number of recipients in the five years before 2006 is 330,000, which amounts to an average of 66,600 per year. Scaling it to a 15-year time period from 2000 to 2015, the total number of transplant recipients by 2015 would be 66,600 * 15 = 999,000 ≈ 1 million.

This number is quite close to and provides good cross-verification for the number of transplants we estimated earlier based on the minimum number of hospital beds.

Moreover, the market size for immunosuppressants after 2006 should be larger, and continued increase in the market share of domestic immunosuppressants would have reduced the drug cost further. In addition, the immunosuppressant costs for many foreign patients who received organ transplants in China are not included in the 10 billion RMB (especially during the peak of transplant tourism prior to 2007).

Although each person has multiple organs, not all of them can be used for transplantation purposes. Human organs are a “non-reusable resource with an expiration time limit.” When an organ is removed from the donor, it must be kept in preservation solution, and the transplant operation must take place within a limited time. According to the Notice on Management Regulations for Liver, Kidney, Heart and Other Transplantation Technologies issued by the Ministry of Health, the time should not exceed 24 hours for kidneys, 15 hours for livers, and 6 hours for hearts.¹⁸⁹¹

The other main factor affecting the usable ratio is geography. Until 2013, China did not have a formal national organ sharing network. Tissue matching was mostly done within specific hospitals or regions.¹⁸⁹² Unavoidably, given the time limits involved in how quickly organs must be used after being extracted from a body, many organs in China were wasted as a result. In fact, for many bodies, only one organ has been utilized.¹⁸⁹³

It was not until October 2013 that the National Health and Family Planning Commission announced the “(Trial) Regulations for Obtaining Organs from Voluntary Donors and Organ Assignment,”¹⁸⁹⁴ which required all 165 approved hospitals to use a new National Organ Sharing Network; it also required all donated organs to be allocated by this system. Since then, the National Health and Family Planning Commission has required all transplant centers to register their patients to build a national waiting list.

There is an unwritten allocation rule that organ sources can be accessed locally only. Local hospitals have local monopoly control over local organ sources. Some local hospitals have abundant organ sources but cannot find suitable matching recipients so many organs are wasted. Hospitals in other regions, short of organ sources, have to try to obtain them from hospitals in localities which control abundant organ sources.¹⁸⁹⁵

Due to the strict limitations of the enduring times of the organs for transplantation, there are high technical demands on the transplant centers to conduct transplant with multiple organs from the same donor in order. Until recently, very few institutions in China were capable of procuring and transplanting multiple organs from a single donor. According to a media report from December 2011, only two hospitals in China had this capability in December 2011:¹⁸⁹⁶ one was PLA No. 303 Hospital, and the other was the Tongji Organ Transplant Research Institute of the Huazhong University of Science and Technology.

We believe that the utilization ratio of “donor organs” in China’s transplant centers are much lower than those of well-established organizations in other countries. In the past two years, the Chinese regime intentionally advertised in its state-run media that, in certain cases, one donor’s organs were used in several transplants. Our findings indicate that such cases are rare, and we believe that most reports serve to cover up organ sources.