The Tamil Nadu Model of Equality in Transplants : How TN Solved Economic Bias and Gender Bias

The Article in Scroll about Transplants suggest this

Are there are then any credible ways to restore equity? One way out is some form of affirmative action. For example the state can mandate that every alternate organ be allotted to a public institution.

TN Govt Rules do this from day one, in fact even better

  • The author suggests 50 % (every alternate) to be allotted to Public
  • But, our rules are such at 3/4th of organs actually are allotted to Public Hospitals and when Public Hospitals Declare more brain death, this will increase even further.

The Relevant Rules are :

  • If the Organ is Donated in Government Hospital, it goes to the First Person in Waiting List in All Govt Hospitals
  • If the organ is donated in Private Hospital, it goes to the Common Waiting List (includes both Govt and Private)

That is Why MMC, Stanley and other Government hospitals Get More Kidneys from Private Hospitals than what they give. In the Data I readily have (it s a bit old, though) we had given just 7 kidneys to Private, but got 36 kidneys from Private, which is actually 84 % – far higher than 50% which Maharashtra wants to do)

Heart : The waiting List in Government is less. We have given 9 hearts to private, got 2 from them. But See the number of hearts not used. It is 54 – Way too high. Here is problem is not a foreign national getting a heart. It is our people not being ready to accept it

Our patients do not agree for transplant when it is indicated. They will refuse transplant. When they develop severe breathlessness they come for transplant and by this time, the lungs are already gone due to Pulmonary Hypertension and they need combined heart lung transplant and if that is not available within few days, they don’t make it. Westerners, on the other hand agree for transplant as soon as the doctor says. That is why few of the the hearts go to foreigners and most are wasted

In Liver alone : we (Govt hospitals) give more (to private hospitals) than what we get. Received : 4. Given 33

In the past, If we identify 100 patients who are clinically brainstem, we were able to certify only 75 % of them.
Of the 75 % whom we are able to certify,
61 % agreed for Donation
14 % did not agree
Of the 61% who agreed, Donation was successful in 59 %

ie

  • 59 % Donated
  • 2 % Agreed for Donation, but not donated
  • 14 % Did not agree for Donation
  • 25 % Patient developed Cardiac Arrest before 2nd Apnea Test

In short, Till 2013
82 % of Patients’ relatives had agreed for donation following brain stem death and in the past, it was mostly voluntary donation. Just tell them about Donation, and they used to immediately agree
Our Challenge was in maintaining the brain stem dead patient with proper ICU Care till we take the organs. The Following Slide was Presented in 2012 NSI Conference

When the above slide was presented, there was a gasp in the audience. These sort of High Acceptance is not known any where where donation is Voluntary. We were in a Very Good Society then !

Recently, Our ICU Care has increased and we are achieving more than 95 % certification – especially in the past one year
But
The figure of Relatives agreeing to donation is rapidly declining
These days, I am told, only 20 % agree to donate and that too requires persistent efforts from the Grief Counsellors. The reason I infer are

  1. Persistent, Sustained Campaign against Donation in Media and Social Media
  2. Few Recent Movies where Organ Donation has been portrayed in a negative manner
  3. Television Serials : where Organ Donation has been portrayed in a negative manner

This is a challenge we face today

Cadaver Transplant is important for a lots of Reasons

1. It is the Programme where Poor Get Organs

2. We save a life without subjecting another human to anaesthesia and surgery. There exists a potential risk in anaesthesia and surgery, however small the risk may be, there is still a risk for any anaesthesia. Why Subject a healthy individual to surgery, when the same kidney can be obtained from a brain stem dead person

3. For Liver and Heart Transplants, this programme is vital
There is a Split Liver Transplant, but again the risk to donor is high than the risk to the recipient.
4. This is the most crucial point, Which Many Miss

Few Years ago, RGGGH did its 1000th Transplant (a govt hospital doing 1000 transplants all free of cost itself is a big feat)

We did a rapid analysis about the Gender
We found that
In Live Related Transplant
The donation was almost always from Wife to Husband.
When the Husband developed Renal Failure, the Wife almost donated
When the wife developed renal failure, the husband hardly donated

But
In Cadaver Transplant, this gender bias is totally removed
This programme ensures women get kidneys at the same rate as men
At least for this single reason this programme has to sustain

Unless we effectively counter the negative propaganda, this programme may lose its sheen and once again transplants will be limited to rich and males, like how it is in most other states of India today.

The Writeup Below was added on  12th Jun 2018

Today’s Media and Social Media is abuzz with few articles https://t.co/fUYXUJ4kjm , https://t.co/tq45XaOOEG & https://t.co/4mBymbJ60f saying that there is an Organ Racket. And as expected, the Social media is full of half baked posts. Even after reading these articles many times, there is no evidence of any malpractice. All these articles rely on few facts.

  • In 2017, foreigners got about 25% of all heart transplants in the State and 33% of lung transplants.
  • Three of four hearts in Chennai in recent times were given to foreigners.
  • In 2017 alone, foreigners were the recipients in 31 heart transplants, 32 lung transplants, and 32 heart and lung transplants. During the same year, Indians were the recipients in 91 heart transplants, 75 lung transplants, and 6 heart and lung transplants.

As well as few Lies (aka half truths)

  • Interestingly, while the wait list of active patients as on June 9, 2018 had 53 foreigners, it had 5,310 Indians.

First Let us debunk the lie (aka half truth) that the waiting list has 53 foreigners while it has 5310 Indians. Reading this with the previous line that there were 31 heart transplants to Foreigners while there were 91 heart transplants to Indians, you will immediately get angry. How come only 91 indians get a heart out of 5310 indians in waiting list, while 31 foreigners have got out of 53 foreigners in waiting list. The Full Truth is that 5310 Indians include those waiting for Kidney Transplants as well as Liver Transplants while the list of 53 foreigners does not include those waiting for Liver and Kidney

In other words, Foreigners cannot get Kidney or Livers donated by Indians, but they can get Heart, Lung etc from Indian Donors
Why ?

Because the List of Indians Waiting  for Kidney and Liver Transplants are very high, while there are few indians waiting for Heart Lung etc. Of the 5310 indians in waiting list, more than 5000 is waiting for Liver and Kidney and only around 150 wait for heart transplant.

To see this further, let us look at the number of Donors and Transplants in the past ten years in TN.

In Cadaver Transplant, Each Brain Stem Dead Donor donates

  • 1 Heart
  • 2 Lungs
  • 1 Liver
  • 2 Kidneys
  • 1 Pancreas
  • 1 Small Bowel

The Following Screenshot has been taken from the Official Site of Transtan ( http://transtan.tn.gov.in ) on 12th June 2018

Transtan Data
Transtan Data

This Data shows the Donors (1137) and Recipients (3869).

Of these, the number of organs used and number of organs discarded (or wasted or unused) is as below

Organs Donated Used Discarded Percentage Used Percentage Discarded
Heart 1137 430 707 37.82 62.18
Lung 1137 292 845 25.68 74.32
Liver 1137 1060 77 93.23 6.77
Kidneys 2274 2059 215 90.55 9.45
Pancreas 1137 23 1114 2.02 97.98
Small Intestine 1137 3 1134 0.26 99.74

In any Cadaver Organ Transplant Program 5 to 10 percent of organs cannot be used for the following reasons

  1. Donor having diseases like HIV, Hepatitis B, Hepatitis C – Recipient will get these diseases
  2. Donor having Malignancy (Cancer)
  3. Donor having Organ Failure. For example, when a person who already has kidney failure cannot donate his kidneys
  4. Donor having Sepsis – Infection in the Blood of the Donor at the time of Donation
  5. Congenital Deformities of the Donor Organs identified only during Surgery
  6. Decision of the Surgeon that Donor Organ is not suited due to Ischemia Time or other factors

This 5 to 10 % rate of “not used” (wasted, unutilised) is across the world

However, we find that 62 % of Hearts and 75 % of Lungs are not used. That is around two third of hearts and three fourths of Lungs are wasted. This is way beyond the 10 %. Similarly, 97 % of Pancreas and 99 Percent of Small Bowel are also not utilised. The reason for this is

  1. Lack of Adequate Individuals in Waiting List for these organs from Tamil Nadu

As per GO Number 287 dated 05.09.2009, the criteria for allocation of hearts from Brain Stem Dead Donors are very clear and lucid. Six Levels of Priority are fixed to share an organ.

  1. First priority to the list of the Government Hospital where the deceased donor is located, for liver, heart and one kidney. The other kidney would be allocated to the general pool in the priority sequence as listed below.
  2. Second priority to the combined Government Hospitals list
  3. Third priority to the combined Private Hospitals list
  4. Fourth priority to Government Hospitals outside the State, (in order to maximize organ utilization)-provided earlier information and such a request has been registered with the Advisory committee / Convenor, Cadaver Transplant Program, Tamil Nadu.
  5. Fifth priority to Private Hospitals outside the State (in order to maximize organ utilization) provided earlier information and such a request has been registered with the Advisory committee/ Convenor, Cadaver Transplant Program, Tamil Nadu.
  6. Finally, if the organ(s) remains unutilized by the above criteria, it may be offered to a foreign national registered in a Government or Private hospital within and then outside state. (This is to ensure that there is no wastage of organs donated)

The huge number of Heart, Liver, Pancreas, Small Bowel being not used and discarded as seen from the chart below shows that Organs are allotted to Foreign Nationals as Sixth Priority ONLY When there is no one in the waiting List in the Priorities 1 to 5.

So, there is absolutely no racket or malpractice. Foreigners don’t get kidneys and liver because Indians are on Waiting List. Foreigners get heart because, most of the organs are going to be wasted since there are not enough indians on the waiting list. Tamils who are in the waiting List get hearts, like this school going kid, who has been operated in TNGMSSH and is fit for discharge now.

When people spread wrong information about Transplants, it creates a negative opinion and this will inturn reduce the number of people willing to donate. When people don’t donate, kids like the one you see here cannot get back to school. They have no option other than face an early death.

So, next time, when you hear some news about transplants, before spreading it or forwarding it,

  1. Check the official sites
  2. Understand the Data
  3. In case of difficulty, please ask doubts

Please don’t spread wrong news as you are killing (or denying life to) kids by sharing / forwarding / liking / retweeting fake news about transplants