Transplant volumes and anti-rejection drugs

by David Matas

(Remarks prepared for delivery at a Campfire Session, The Transplantation Society Congress, 2018, Madrid, Spain)

David Kilgour, Ethan Gutmann and I released in June 2016 an update to our previous work on transplant abuse in China by focusing on transplant volumes.   We concluded that the transplant volume in China is 60,000 to 100,000 a year, with an emphasis on the higher numbers in the later years.

Given the short time I have available here, I want to address only one response of Chinese officials to our update. Huang Jiefu, director of China Organ Donation and Transplantation Commission, said that transplantation surgeries performed in China annually accounted for 8.5 percent of the total number of transplantation surgeries worldwide. To support that point, he said that

  “consumption of anti-rejection medications … account for 8 percent of global consumption”.

On what is that 8% figure based?  To justify that number, we would need to know the names and production volumes of antirejection medications of all the pharmaceutical companies in China. We would also need to know the names and import volumes of all the importers of antirejection medications into China. 

Yet, that evidence is not available. The Government of China is making no effort to make it available.

Even if those figures were available and verifiable, and even if those figures said what Huang Jiefu says they say, they would not establish what Huang Jiefu says they establish. The figures of Huang Jiefu do not take into account transplant tourism.  Transplant tourists get their life time supplies of antirejection drugs back home, on return from the transplantation in China.

The Washington Post reported in September 2017:

“Data compiled by Quintiles IMS …  shows China’s share of global demand for anti-rejection drugs is roughly in line with the proportion of the world’s transplants China says it carries out.”      

The information from Quintiles IMS (now IQVIA) which The Post quoted is not publicly available. Nonetheless, even without looking at the source material, we can see that there is a problem with what The Post reports.

Japan’s anti-rejection drug sales, as set out in an excerpt from the Quintiles IMS report which we do have, are 38% higher than China’s. Yet, its transplant volumes are only 1520% of the official Chinese transplant volume figures. The cause of this is either significantly higher drug prices in Japan than in China or significant levels of Japanese transplantation abroad, or both.

If we relate anti-rejection drug sales to transplant volumes, Japan would have performed 38% more transplants than China or more than 18,000 in 2016.  Yet Japan performs about 2,000 transplants a year.

Reversing the calculation, calculating Chinese transplant volumes from Japanese transplant volumes using Quintiles IMS anti-rejection drug sales as the basis for calculation, we get Chinese volumes of about 1,500 transplants in 2016.

There is substantial evidence that the vast majority of Japanese transplant tourists travel to China for their organs. Japan’s rate of prescription anti-rejection drugs does not mirror its transplant activity because there are many Japanese who get their organs in China. Given that this is so, it is impossible to dismiss transplant tourism as a factor affecting the volume of anti-rejection drugs sold in China.

Because the share of global drug sales in Japan is significantly greater than their share of global transplants, there must be other countries whose share of global of drug sales are significantly lower than their share of transplants.  The global total of transplants is itself different from the official figures, due to the misleading official figures of the Government of China.

Global drug sales data reflect only part of the actual size of the Chinese anti-rejection drug market.  A large portion of drug sales in China take place through unofficial pharmacies, which are widespread in Chinese hospitals. As well, China’s local drug prices are not the global average.

The Chinese literature shows that anti-rejection drug prices have been driven down significantly with a shift to reliance on locally produced drugs, sold through unofficial pharmacies, which by 2016 comprised at least 70% of the market. If we took the middle range of figures in the various Chinese literature reports, we see an annual cost of $6,300 US for anti-rejection drugs. Annual anti-rejection drug costs in the US are 2.5 to 4 times that of China.

Because of locally produced drugs in China sold at unofficial pharmacies, using Quintiles IMS figures on global drug sales as an indicator of volumes may underestimate actual Chinese volumes by a factor of up to four. Because of the lower cost of these locally produced drugs, using Quintiles IMS figures of global drug sales as an indicator of volumes may underestimate actual Chinese volumes also by a factor of up to four.  Combining these two considerations, using Quintiles IMS figures of global drug sales as an indicator of volumes, we get a potential underestimate by a factor of up to eight.

When the Government of China was public about the matter, it stated that transplant tourism was 20% of transplant sales.  If we factor in transplant tourism today of 10% and include the factor of eight, we get a combined factor of close to nine.  If we estimate Chinese transplant volumes by using Quintiles IMS figures of global drug sales as an indicator of volumes and multiply by a factor of up to nine, we get a total for transplant volumes which is consistent with the estimate in the update David Kilgour, Ethan Gutmann and I wrote.

This is not to say that the Quintiles IMS figures anti-rejection drug sale figures corroborate our transplant volume figures.  Rather it shows that the Quintiles IMS figures do not tell us very much at all about transplant volumes in China.

What is the source of Chinese Quintiles IMS figures?  There are three main possibilities.  One is that they come from anti-rejection drug sellers. A second is that they come from anti-rejection drug buyers. A third is that they come from government officials. It would be hardly surprising that Chinese Quintiles IMS anti-rejection drug sale figures would be consistent with official figures of transplant volumes if both figures came from officials.  But one figure would not corroborate the other if both came from the same source.

The estimate of transplant volumes that David Kilgour, Ethan Gutmann and I made comes from a wide array of verifiable figures, mostly from official Chinese sources – 2,200 out of the 2,400 endnotes in our update.   It is frivolous to reject such a wide array of consistent cross-checked data by reliance on figures for share of global demand for anti-rejection drugs which in other countries produce nonsense figures for transplant volumes. 

…………………………………………………………………………………………………………………….

David Matas is an international human rights lawyer based in Winnipeg, Manitoba, Canada