Over the last few days a storm has been raised following publication of an article in The Hindu (June 12, 2018) based on a leaked WhatsApp message from the head of the National Organ and Tissue Transplant Organisation (NOTTO) claiming that foreign patients who are waiting for a donor heart transplant are being prioritised over Indian patients by private hospitals in Chennai. This article has angered many. Unfortunately, amidst the din, the basic concepts of organ donation, allocation and transplantation have been completely lost.
Tamil Nadu’s advantage
A forward thinking bureaucracy, committed non-governmental organisations and a willing political dispensation took up promotion of cadaver organ donation as a must-have in Tamil Nadu around 10 years ago. This was primarily in response to a widely publicised and unrelated kidney donation racket unearthed in the late 1990s. The initial kick-start and continuing efforts have made Tamil Nadu the undisputed leader in organ donation in India. Thousands of lives have been saved through organ donation.
Many southern States have successfully emulated Tamil Nadu’s road map and have developed organ donation programmes on their own. The uptake of the concept of organ donation, however, has been disappointing in north India. This has led to a steady stream of patients from north India to travel to the south for a cadaver donor organ as their chance of getting a timely transplant in their own State is close to zero. While the organ donation rate in Tamil Nadu is over 10 times greater than most of the northern States, there is a lot of work to be done to achieve the West’s donation rates.
Every country goes through an evolution process in terms of organ donation, and this is different for each organ. Kidney transplantation has been practised in India for over 25 years. There is public confidence in the procedure, and it is not surprising that there is a massive waiting list for cadaver kidney transplants. On the other hand, liver transplant as a treatment option for liver failure remained an esoteric idea in India until 10-15 years ago. The results of liver transplantation in India were poor in the early stages. That has changed in the last 10 years. With increasing success, an increasing number of patients who need a liver transplant are getting waitlisted. So there is no real possibility of a foreigner getting a cadaver liver or kidney in India, as there will always be a patient to whom a donor liver or kidney, irrespective of its characteristics can be matched. Among 2,100 liver transplants performed by our group in south India over the last nine years, not a single foreign patient has been transplanted with a cadaveric liver.
Cardiac and lung transplantation have been the last to develop in India. Until five years ago, results of heart and lung transplantation were dismal in India. Many doctors would have been reticent to put their patients forward for transplantation even if they would have benefitted from the treatment. However, over the last two-three years, results have improved significantly with the influx of talented and trained surgeons. But the number of patients being assessed and listed are still fewer in comparison to those listed for livers or kidneys. Waiting lists for heart transplantation are still small, and in such a situation while a donor liver or kidney can be immediately matched to a suitable Indian patient, this is not always possible for a heart or lungs.
This is where the claim for utilising the organ for a foreign patient comes in as otherwise the organ would be wasted. Even though occasional abuse of the system may be a possibility, it is important to point out that even with the current practice of allocating an organ to a foreigner when there is no suitable Indian patient, one-third of all hearts and lungs are still not being used due to “lack of a suitable recipient”. As public and physician confidence in the success of heart and lung transplantation improves in India, the waiting list of Indian patients will increase and it will be possible to match every organ to a suitable Indian patient. Once that stage is reached, there will not be even a remote possibility of a foreigner getting an organ.
An additional issue with heart and lung transplantation is the strict criteria for size and quality and the very tight timeframes within which these organs should be transplanted. While a kidney can be preserved for 12-18 hours and a liver for 8-12 hours, hearts and lungs should be transplanted within six hours, otherwise outcomes are likely to be poor. So while sharing of livers and kidneys across the country is possible, it is very difficult as far as hearts and lungs are concerned, considering the size of our country. In the absence of a viable and accessible air ambulance service to transport organs, feasibility will depend on the timing of the donation and the flight schedules of commercial airlines. Remember, most organ donation procedures happen in the night as logistics permit. So, at least for hearts and lungs, exceptions notwithstanding, sharing is feasible only by adjacent States.
Fine-tuning the process
What can be done to improve the situation? The government can decide that no foreigners can receive a cadaver donor organ in India even if it means that an organ is wasted due to lack of a suitable Indian recipient. But this may be an extreme step as local governments and corporate hospitals are still very interested in medical tourism. Another option is to develop a system of zonalisation across the country (like in the U.S.) so that more efficient sharing of organs across States is feasible, possibly with the development of a publicly-funded air ambulance service. This will significantly benefit transplant programmes in government hospitals.
Organ donation is based on public trust that due process is being followed. Currently, the donation process and organ allocation in Tamil Nadu is fully monitored by Transplant Authority of Tamil Nadu (TRANSTAN). Every organ that is transplanted, even to a foreign patient, is only done after approval from TRANSTAN. The authority of course depends on the clinical judgment and decisions of the transplant team as to the best use of each organ. The process should be made more transparent and accessible to the public. If donation and the allocation of each organ can be tracked, that will be a strong deterrent to mischief. Most importantly, the outcome of every transplant should be monitored. TRANSTAN should make it mandatory that the transplanting centre should report the outcome of the organ and the patient with updates at one week, one month and one year after transplantation.
Organ donation is a highly emotive topic. When a family agrees for organ donation, they are making a decision to be generous to some unknown person in the midst of a great personal crisis. For this to succeed, they should have utmost trust in the process of organ donation and allocation. Even in highly developed countries, donation rates drop temporarily when news of suspicious practices surfaces. In India, this is even more important as controversies such as these can break a developing programme and bring us back to square one. A reduction in donation rate will affect patients waiting for organs as each donor can save up to seven lives. The issue must be thoroughly investigated before newspapers and televisions proclaim a “scandal”. It does no good to the system and can cause immeasurable harm to sick patients desperately waiting for the call that “they have an organ”.
Mohamed Rela is professor of liver surgery, King’s College Hospital, London and Director, Institute of Liver Disease and Transplantation, Global Hospitals Group, Chennai