By DAVID MATAS
David Kilgour, Ethan Gutmann and I released in June an update to our previous work on transplant abuse in China by looking at transplant volumes. Our update is posted on our joint website, endorganpillaging.org. The report is 680 pages and has almost 2,400 footnotes. Trying to summarize such a report in just a few minutes is a daunting task.
We had, in the past, taken Chinese government official statements of overall transplant volumes at face value and focused on attempting to identify the sources for those asserted volumes. One effort which needed to be made and which we finally have made is to determine on our own what Chinese transplant volumes are.
For Communists, statistics are the pursuit of politics by other means. Statistics in China may be accurate, but only if the Party believes that their accuracy serves some political purpose. Determining the accuracy of Chinese statistics, when the source data on which the statistics are based are not available, requires evaluation.
For organ transplant statistics, the Communist system has had competing political considerations. One has been to show how advanced they were in transplant technology, a consideration which pushed them in the direction of large numbers. The other was not to create undue suspicion about sources, which pushed them in the direction of lower numbers.
The first tendency prevailed initially, leading to generation of inexplicably large number of transplants. The Party then realized that this manner of boasting was causing them a political problem, because it raised the question of the sources of all these organs, at a time when they had no donation system and no national organ distribution system. They were stuck with the numbers they had produced. But, once they realized that those numbers were creating a problem for them, the numbers, 10, 000 transplants a year, stopped increasing.
This is a simple enough analysis when we are looking only at national figures. Once we start to look at local figures, the analysis gets more complicated. Individual hospitals are less concerned about accounting for sourcing since, at least to date, there has been no international focus on their numbers. The tendency for individual hospitals to generate large numbers for boasting purposes is accordingly not as constrained as the national Party tendency is.
The numbers we get for transplants from individual hospitals, when added up, far exceed the totals coming from the national system. But, we had to ask ourselves, how much of this is just touting, the fiddling with statistics at a local level, generated by different political considerations than operated nationally?
We have answered this question by looking, hospital by hospital, at a wide variety of other factors besides what hospitals claim there transplant numbers to be. We looked, for instance, at bed numbers. Bed numbers give us totals for physical entities and are likely to be accurate. Yet, they are not in isolation a perfect indicator of transplant numbers because beds are fungible and can be used for non-transplant purposes. This is less likely in a transplant hospital or a transplant wing of a hospital, but still possible. Even if beds are used only for transplants, we need to make allowances for use of beds for waiting and recovery times, which are not fixed.
We also looked at staff numbers. Again these are numbers of physical entities and themselves likely to be accurate. Presumably transplant staff are hired to work. Yet, numbers of staff do not tell us about the rate of work.
We looked at grants and awards. Grants and awards are indicators of activity. Award citations or acceptances may mention a figure. But is the recipient here too just boasting in order to justify the award? Grants may mention a projected figure. But is the projection realized?
We looked at publications, both newsletters and research studies. Again, we had to evaluate what those newsletters and research studies produced. Chinese organ transplant research is mostly not published in reputable journals, because those journals mostly reject research which relies on organs from sources not demonstrably proper. Chinese organ transplant research is often vanity published by journals attempting to give respectability to those researchers despite their inability to demonstrate proper sourcing of organs.
The result of these considerations means that no one piece of evidence for any hospital can tell us with certainty what its transplant volume is. Rather, as we did for our previous research, we suspended coming to any conclusion until we looked at all the data. What that data tells us consistently, hospital by hospital, looking at all factors in combination, is that transplant volumes in China are far larger than the official national figures.
The inclination of individual hospitals to engage in competitive boasting cannot alone account for the discrepancy between the total of local figures and national figures. The discrepancy is too consistent, over too many variables, for that. There may, on the contrary, be a greater likelihood of accuracy locally than nationally because the temptation to downplay figures in order not to raise questions about sources has been less likely to hold sway locally than nationally.
The claims of local hospitals that they are transplanting huge numbers do not have to be taken at face value. That is one reason why we have not come up with a specific figure about transplant volumes. But they surely make ever more urgent the need to comply with the duties of transparency, openness to scrutiny and accountability. The large numbers the national system claims already impose the need to comply with those duties. The much larger numbers the totals which individual hospitals, in combination, claim impose this duty of compliance with even more force.
For hospitals approved to perform liver and/or kidney transplants by the Ministry of Health, we calculated 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 these requirements for medical institutions carrying out organ transplants:
• liver: 15 beds dedicated to transplants and no fewer than 10 intensive care unit beds, for a total of 25 beds.
• kidney: 20 beds dedicated to transplants and no fewer than 10 intensive care unit beds for a total of 30 beds.
• liver and kidney: 35 beds dedicated to transplants and no fewer than 20 intensive care unit beds for a total of 55 beds.
There were 21 liver hospitals, 65 kidney hospitals and 60 combined liver and kidney hospitals given permits or a total of 146 hospitals. Based on a onemonth 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 hospitals indicate widespread facility constraints, including transplant centres that exceed 100% bed utilization and have a long line of patients waiting for transplants. In addition to the 146 certified kidney and liver transplant centres, there are 23 certified heart and lung transplant centres, giving us a total of 169 certified transplant hospitals. The Government plan to expand the number of approved transplant hospitals from 169 to 300 suggests that the current systemwide capacity cannot keep up with demand. 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 would conduct 69,300 transplants per year.
We arrive at that figure by multiplying 21 liver hospitals by 25 beds and then by 12 months, or a figure of 6,300. We add 65 kidney hospitals by 30 beds by 12 months for a figure of 23,400. We then add 60 combined liver and transplant hospitals by 55 beds by 12 months for a figure of 39,600. If we add up 8,052 plus 23,400 plus 38,600, we get 69,300.
More than 1,000 hospitals applied for permits to conduct transplants. Simply in order to apply, those which applied would have met the minimum requirements or were close to meeting them.
Another way to approach the problem is to start at the micro level by thinking about how many transplants one doctor at a nationallevel 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. A nationallevel transplant centre 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 Ministryapproved transplant centre credible? It would be exceedingly difficult to reject one transplant per day as unrealistically high. For the 146 certified kidney and liver hospitals, if we multiply 146 by 365 we get 53,290 transplants a year.
The minimum requirement scenario based on beds and the low scenario based on transplant per day are understatements; neither one fully takes into account highly productive transplant centres. Most national transplant centres have the capacity to perform more than 1,000 transplants a year, with some far exceeding that. For example, Beijing No. 309 Hospital has 393 beds and has the capacity to perform more than 4,000 transplants per year. On the civilian side, Tianjin Central Hospital’s Oriental Organ Transplant Centre has at least 500 transplant beds and claims to have a 131% utilization, which means that it is performing almost 8,000 transplants a year. The Shanghai Orient Hepatobiliary Surgery Centre had 742 beds but later moved to a new campus and further expanded.
Looking just at minima for bed and staff and looking just certified kidney and liver transplant hospitals, we get to between 53,000 and 60,000 transplants a year. If we add to that the heart and lung transplant centres, the fact that many certified hospitals are operating far beyond minimum levels and that some hospitals not certified still continue to do transplants, we get a much larger figure. We would say that the transplant volume range is between 60,000 to 100,000 a year. We would place an emphasis on the higher numbers.