Sunday, November 11, 2018

Richard Baum on Chinese political science and political science methodology

I just came across this excellent comment by the late Professor Richard Baum, a celebrated scholar of reform-era China. It concerns the role of political science methodology in the field of China studies, and the perils of an overly formalistic approach to enquiry. Specifically, his concern seems to be that enquiry not be artificially circumscribed by method, but that method be subordinated to the knowledge you seek. I agree!
Much has been written in recent years about the decline in area studies in American universities. Due in large measure to the dramatically increasing influence of (deductive) rational-choice and (quantitative) econometric models, imported wholesale into political science from economics graduate students studying comparative politics at the top U.S. research universities today appear to be investing less time and energy in gaining deep cultural and linguistic knowledge of their country or region of interest, and proportionally more time studying formal modeling and statistical techniques. Most leading political science departments, for example, now require a rigorous sequence of quantitative and formal theory courses for their first-year graduate students. Many departments now also offer students the alternative of taking an advanced sequence of mathematics/statistics courses as a substitute for a foreign language requirement. Indeed, students in many graduate departments (including my own) may now choose ‘methodology’ as a subfield of political science to replace one of the traditional, substantive fields. Increasingly, if almost imperceptibly, methodology has shifted from being a set of tools, i.e. means used to study politics, to being an object of study, namely an end in itself.
If I may be permitted a personal observation, in the field of Chinese politics I have noticed a significant shift in the research interests of my graduate students in recent years, away from consideration of qualitative research problems (driven by an interest in major theoretical/conceptual issues and guided by intensive exposure to the country, its institutions, culture and its language) toward quantitative research agendas, often driven by the availability of ‘large N data sets’ incorporating several standardized socio-economic variables which can be more-or-less mechanically regressed against one another to derive ‘statistically significant’ tests of hypotheses (which were, in many cases, suggested by the availability of the data sets themselves). Such research is reminiscent of the old anecdote about the drunk who looked for his lost car keys under a street lamp. When asked why he was concentrating his search under the lamp, he answered ‘Because that’s where the light is!’ 
The problem lies not with the techniques and methods of statistical and formal modeling themselves, but rather with their tendency, when used in isolation from other, more traditional research methods, to facilitate the displacement of analytical thinking by mere technical procedure.
From: Baum, Richard. 2007. Studies of Chinese Politics in the United States. In China watching. Perspectives from Europe, Japan and the United States, ed. Ash Robert, Shambaugh David, and Takagi Seiichiro, 147–168. London: Routledge. quote from 160, italics in original.

And I found it in: Alpermann, Bj√∂rn. 2009. “Political Science Research on China: Making the Most of Diversity.” Journal of Chinese Political Science 14 (4): 343.

Thursday, March 15, 2018

China’s Organ Transplant Problem

[The following piece was originally published in The Diplomat, March 29, 2017. Authored by myself and Dr. Jacob Lavee.]

International concern over China’s system of human organ transplantation has been expressed for decades. Over the last several years, the Chinese authorities report working hard to build a voluntary organ transplant system. Last month a top transplant official, speaking at an international organ trafficking summit at the Vatican, reiterated the claim that since January 1, 2015, China has eliminated the use of prisoner organs, and now only uses organs from donors who die in the intensive-care units of hospitals.
This would be a welcome development, if it could be trusted. Unfortunately, contradictory data, misleading claims, and intense secrecy indicate that it cannot. Moreover, the history of organ transplantation in China raises disturbing questions about past, and possibly ongoing, abuses. With abuses, of course, comes the imperative of cover-up.
Untrustworthy Figures
The first problem is that China’s official figures on the number of transplants performed cannot be trusted. At the Vatican summit last month, Dr. Huang Jiefu, the director of China’s Organ Donation and Transplantation Committee, said that from 2011 to 2014, a total of 2,342 citizens had donated their livers after death.
Yet less than a week later, in an interview with The Paper, a state-owned digital news outlet, he said something different: “From 2011-2014, there were 1,910 cases of [deceased] citizen liver donation.”
These numbers, which differ by 18 percent, cannot both be true. All transplants since September 1, 2013, are supposed to have been registered in a mandated, centralized database, known as the China Organ Transplant Response System (COTRS). Yet, in our research, we have identified ten instances of such contradictory data points, offered either by Huang or other official sources. Such inconsistent accounts of donor data indicate that these official claims simply cannot be taken at face value.
Problematic Transplant Volume
Given that figures cited by top transplant officials cannot be trusted, investigators have resorted to a variety of other methods to estimate how many transplants are being performed.
One can, for instance, look at publicly available reports about the number of beds in the transplant wards of hospitals, then compare them to the reported utilization rate of those beds. These two data points, coupled with the average length of stay for a liver or kidney transplant recipient, can be used to calculate the rough transplant volume at certain hospitals.
Tianjin First Central Hospital’s transplant center, for instance — built in late 2006 — was planned to have 500 beds (but may have had up to 700). According to 2008 filings in an official construction database, the bed utilization rate for kidney and liver transplants was 90 percent in 2008; according to Tianjin official media, the entire hospital’s bed utilization was 131 percent in 2013 (meaning either that excess patients were put up in nearby hotels, or perhaps that more beds were wedged in). With an average hospital stay of one to two monthsfor transplant recipients, that would add up to thousands of transplants per year at just this one facility.
Communist Party media reports provide another indication of transplant volume. Comparing two officialpublications indicates that Tianjin First Central Hospital performed around 1,000 liver transplants a year from 2011 to 2015. Other official sources, like the 2011 liver registry, state that the hospital performs either one quarter or 12 percent of the total liver transplant activity in China. This translates to between 4,000 and about 10,000 liver transplants per year nationwide, several times the officially reported figures for that organ, which itself comprises only part of the country’s total transplant volume.
It is very difficult to know the actual number of transplants in China, but such data indicates they appear to be troublingly large relative to the claimed volume and source of organs.
The Transplant Boom
Before the year 2000, China hardly had an organ transplantation industry to speak of. From the 1980s to the end of 2000, there was a reported cumulative total of 34,832 kidney transplants. Just four years later, the figure had increased by at least 27,141, according to medical textbooks.
According to the respected business magazine Caijing, from 1993 to 2007 China’s number of liver transplants increased by 400 times — from six to over 14,000 cumulatively.
But even these figures are lowballs. They come from China’s official registries and reports, and so are only a portion of the total. The kidney transplant figures come from 106 hospitals, whereas the liver registry was formed by 25 hospitals in February 2005.
Yet in reality there were over 1,000 hospitals doing transplants in China by the year 2006, official sources say. (That figure was supposed to have been cut down to 164 in 2007.)
China’s own officials speak openly about the transplant boom. “The year 2000 was a watershed for the organ transplant industry in China,” reported Southern Weekend, citing He Xiaoshun, a top transplant official. “The number of liver transplants in 2000 reached 10 times that of 1999; in 2005, the number tripled further.”
China’s first legislation on organ transplantation came into effect in 2007. The only major regulation before that was the 1984 provision allowing the use of prisoner organs.
But despite the effort at greater regulation, what happened after 2007 is arguably more troubling
Nonstop Growth
On January 1, 2007, the Supreme People’s Court took control of death penalty reviews, triggering a sharp drop in judicial executions, cutting the annual figure down from as high as 10,000 to a few thousand. This is credible given that, as Caixin explains, “leaders from the relevant departments even worried that the public wouldn’t be able to accept the fact that there was such a precipitous decline in death penalty numbers.” Duihua, a U.S.-based human rights NGO, shows a steadily decreasing death row trend, to as low as 2,400 executions in 2013.
Yet the organ transplant industry continued to expand. For example:
  • In 2007, Tianjin First Central Hospital’s new transplant building, with 17-stories and 500 beds, paid for by the local government, went into full operation (documented above);
  • In 2008, Zheng Shusen, an architect of China’s transplant system, increased the eligible liver transplant recipient population by 52 percent, by expanding the acceptable maximum size of liver carcinomas;
  • From 2010 to 2012, the Beijing 309 military hospital expanded its transplant center’s bed capacity from 316to 393. The same hospital said its transplant center was its most profitable revenue generator, growing from 30 million yuan ($4.5 million) income in 2006 to 230 million in 2010 ($34 million), a jump of eight times.
There are numerous other examples like these. China’s entire transplant industry, in fact, appears to have developed quite separately from the trajectory of available death row prisoners.
The next question has become one of the most politically sensitive and contentious: If the transplanted organs aren’t coming from executed criminals, where are they coming from?
Troubling Sources
It is only since 2015 that China claims to have been using volunteer donors as its organ source, and officials acknowledge that the system is still in its infancy. Previously, beginning in late 2005, officials had claimed that organs came from executed prisoners (this was vociferously denied before 2005, when it was suddenly acknowledged).
Given that death row executions can hardly explain the growth trajectories of China’s transplant industry, researchers have suggested darker alternatives.
Several have suggested, for instance, that among the real sources are prisoners of conscience. This includes Uyghur Muslims, Tibetans, and potentially house church Christians, but overwhelmingly practitioners of Falun Gong, a traditional Chinese spiritual practice that has been persecuted since 1999. It is likely, of course, that other dispossessed and marginalized Chinese citizens have also been victimized.
Freedom House, in a report on freedom of religion in China published last month, said that a review of available information had “found credible evidence suggesting that beginning in the early 2000s, Falun Gong detainees were killed for their organs on a large scale.” It added that: “the large-scale disappearance of young Uyghur men, accounts of routine blood-testing of Uyghur political prisoners, and reports of mysterious deaths of Tibetans and Uyghurs in custody should raise alarm that these populations may also be victims of involuntary organ harvesting.” The U.S. Congress and the European Parliament have expressed condemnation.
The trajectories certainly match up: mass incarceration of Falun Gong in July 1999 preceded the transplant boom by just six months. And this organ source would explain the continued growth of transplants even as death row dried up. There is also a large amount of evidence — including dozens of cases collected by journalist Ethan Gutmann in his book — of detailed blood tests and organ examinations of Falun Gong detainees in China.
A full accounting of the evidence base would take hundreds of pages. But some of the most disquieting material is to be found right in official Chinese literature.
Zheng Shusen, for instance, one of China’s most prominent transplant surgeons, is also the chairman of the Anti-Cult Association of Zhejiang Province. Such associations were established by the Party in the year 2000 specifically to vilify Falun Gong and oversee the forced ideological conversion of detained practitioners.
Why is a leading Chinese liver surgeon and transplant official also heavily involved in the anti-Falun Gong campaign? In 2009, Zheng wrote in the preface to an anti-Falun Gong book: “‘Falun Gong’ and similar evil religions are like viruses corroding the organism of humanity, warping the souls of believers, destroying social order, disrupting economic development, and have become a public nuisance to mankind and a cancer on society.”
Language like this is disturbing under any circumstances. Coming from a prolific liver surgeon, in the context of the current accusations, it is highly alarming. (Zheng also attained recent notoriety for lying about the source of organs in a paper in Liver International, leading to a retraction.)
Huang Jiefu, China’s top transplant spokesman, is also on record in 2001 making similar remarks: “Opposing Falun Gong is a grave political struggle. We must not be softhearted when dealing with a little group of hardcore reactionaries.”
The rapid and unexplained growth of China’s transplant system in 2000, the robust trajectory of transplant activity post-2007 despite declining judicial executions, the blood tests and organ examinations of Falun Gong practitioners in custody, the disappearance of young Uyghur men and accounts of blood-testing of Uyghur political prisoners, and the involvement of transplant officials in the anti-Falun Gong campaign, have never been explained by the Chinese government. Instead, such evidence is simply dismissed as “ridiculous.”
Given that Huang Jiefu is now supplying apparently falsified data in international medical fora, while transplants with unexplained sources in China continue, answers to these questions are a matter of urgency.
Unannounced visits to hospitals by international medical inspectors, and the disclosure of historical and current hospital-level transplant data, would be a place to start.

Wednesday, October 11, 2017

Thoughts on The Washington Post's article on China's organ transplant reforms

On September 14, 2017, The Washington Post's Simon Denyer published an article on reforms to China's organ transplantation system, titled “China used to harvest organs from prisoners. Under pressure, that practice is finally ending.”

This post examines the article and explores some of the flaws in its argumentation and use of evidence.

The issue of immunosuppressant consumption — the only clear, factual claim made in the article — will be addressed in a later post.

The piece makes two chief contentions:

1) ​T​hat China's organ transplantation system has undergone a successful reform and no longer sources organs from prisoners, instead sourcing them only from voluntary deceased donors in hospitals (and in making this contention it also endorses the official numbers);

2) That prior to 2015 the only type of prisoners used for organs were death row prisoners; i.e. that there has not been significant organ harvesting from non-death row prisoners (Falun Gong and other prisoners of conscience).

In my view the evidence presented for both of these major contentions does not sustain the claims.

For the first — basically there is no real evidence presented, just ​quotes from officials and long-term allies. (Michael Millis, for instance, served on the board of a medical device company that engaged in clinical trials in China using livers sourced from prisoners, even as he penned articles with Huang Jiefu. This strikes me as an obvious conflict of interest, which went undeclared.) Granted, the official claims of reform are extremely difficult to verify, but there are ways of doing it.

There is no doubt that voluntary organ donations are indeed taking place, and taken on its own terms this is wonderful and unprecedented. But the system has a huge number of obstacles, and the numbers claimed in the official system are extremely high and cannot be independently verified due to the intense secrecy that surrounds the matter.

On the other hand, it is relatively easy to demonstrate that nonvoluntary donors are still being used at a ​significant ​scale by nationally-renowned doctors, including lung transplant specialist Chen Jingyu and liver transplant surgeon Zheng Shusen (who happens to be the chairman of the anti-cult association of Zhejiang Province - i.e. the outfit set up specifically to do anti-Falun Gong agitprop and training sessions for brainwashing specialists. ​Surely a peculiar side hustle for a transplant surgeon.) ​In both cases the sources showing this are public, official documents. These sources cannot be shared now due to a pending publication, but they will be a matter of public record before too long. ​Transparency is still lacking.

My colleagues and I count 12 official databases or registries of ​transplant data; none of them are open, though the contents of a number of them are sometimes reported in clinical papers and other official and semi-official sources. The only data made public is extremely sparse, making it difficult to test for integrity and authenticity. (But it's possible.) One would think that this sort of secrecy would be worth mentioning. If China simply published the equivalent of the data on — all of which it ought to have on hand — it would be simpler to assess their claims. At the moment there is simply no way to know if the official claims are ​based on real data or made up from the whole cloth.

The next ​major contention in Denyer's article ​— that there has been no widespread use of non-death row prisoners since 2000 — is a far more complex topic. Suffice to say that Denyer ignored almost all the evidence suggesting this has taken place and instead used the claim of 60,000 - 100,000 transplants per year as a straw man. Who knows what the real numbers are​? ​(Kilgour-Gutmann-Matas authors ​seem to be using these figures as ​measurements of capacity, not necessarily hard number claims.)

​The relevant question is not whether transplants have been 60,000 - 100,000, but whether death row has been the sole source. There are many, many ways of probing that question. Attacking the biggest number that has been suggested circumvents the abundance of well-documented evidence that death row has not been the sole source, which is the actual question at hand.

The only positive evidence adduced to argue against the claim of non-death row prisoner usage is a) ​quotes from ​several lawyers who defended ​Falun Gong ​who said they'd never heard of the practice, and b) immunosuppressant data from IMS ​said to be "​r​oughly in line with the proportion of the world’s transplants China says it carries out."

Regarding a) ​anyone in custody who had a lawyer is not going to be a particular target for ​vanishing into the bowels of the system. Even those who are visited by family are less likely candidates. ​So this sort of evidence is not at all probative as to whether or not Falun Gong have been used​ for their organs​ . It would be similar to asking a lawyer who has defended death row inmates whether they know their client had their organs harvested, and then using their not knowing to suggest that it ​has never happened. (There's a slight difference in the case Denyer referred to, in that the people didn't die, but nevertheless - non-probative evidence used to make a major point on a highly contested topic for which a vast number of other evidence exists - unusual blood tests and organ-specific X-Rays and ultrasounds directed at Falun Gong detainees, for instance, or reports of vans coming at night and taking people away, never to be seen again.)

Regarding b), this is an *extremely* complex issue. Given that "the proportion of the world’s transplants China says it carries out" is not specific enough a statement to evaluate (in which year(s)? which organs? which number is being used?), one would expect some kind of data and methodology. In March this year Denyer and I exchanged some documentation related to this. I gave him a range of official documents, one of which was an academic paper prepared by pharmacologists and statisticians with the Guangdong Provincial Pharmaceutical Society Information Network, an official source, showing that the consumption of capsule-form immunosuppressants in 2011 for 98 hospitals in Guangdong alone was 8.5bn RMB, up from 4.6bn RMB in 2007 (Note: a doubling in immunosuppressant consumption in the four years following the significant reduction in death row sentences caused by the Supreme People's Court's centralization of death row review, yet when China had no voluntary organ source.) The same paper identified the top three forms of capsule immunosuppressants as tacrolimus, mycophenolate mofetil, and cyclosporine, all of which are either exclusively or almost exclusively used for transplants. These are massive numbers.

There are a very large number of variables when trying to figure out transplant volume based on immunosuppressant sales (type of drugs, cost of drugs, dosage amounts, patient survival rates, and on). Denyer uses this claim to sweep aside a large body of other clearly documented evidence, yet he does not provide the data or the methodology. When I asked him about this on Twitter, he blocked me: What's with that?

Presumably Denyer has a spreadsheet where it's all set out. It would be helpful to analyze this data in the interests of advancing understanding of China's transplant system, which is a very complex and treacherous area of study. I believe that some of the transplant doctors interested in the topic will be following up with him to request this data and his methodology.

There is a large amount of other evidence I sent to Denyer's editors, all of which was also ignored.

To put the severe problem with the piece yet another way, some basic formulations may help:

Anecdotes of hospital bed usage in 2016/2017 bed usage for transplant purposes from 2000-2015, the first seven years of which were completely unsupervised by central authorities;

Human rights lawyers saying they've never heard of cases of organ harvesting probative evidence about organ harvesting;

Human rights groups having little knowledge or expertise in the area evidence that it has not or is not happening. The last study by a major human rights organization, as far as I'm aware, is Robin Munro's Human Rights Watch report in 1994. There has been nothing substantive subsequent to 2000, when the system exploded in activity. To me this is almost unbelievable;

A prisoner of conscience database, run by any organization all prisoners of conscience in China from 2000 to today, many of whom would be off the grid;

Minghui's 4,100 confirmed deaths — that is, cases where family have seen the body, confirmed the identity, and reported this to Minghui the undocumented, unknown number who have vanished into the system, never to be heard from again (who are the primary candidates for organ harvesting).

The issue of organ transplantation in China is treacherous, complex and subject to intense misinformation by the Chinese Communist Party. Descriptive inference about how the system works requires careful treatment of large amounts of complex evidence.

I find it difficult to see how walking through hospital wards in 2016/17 would provide new information, especially regarding the 16 years prior. With 173 transplant hospitals in China performing one transplant every two days, that's slightly over 30,000 transplants a year (I'm not endorsing that number). If you go to a hospital, what does one transplant every two days look like? The organs are not procured on-site, but come from other facilities (we can infer this based on cold ischemic times and other detail in clinical papers). So, 30,000 transplants a year, certainly sufficient to justify alarm about a mysterious donor pool, is going to be completely undetectable using such a method of investigation. There were 600-1,000 hospitals performing transplants before 2007.

And if that indeed was happening, would any of the claims made in the Post article actually be useful ways of testing it? I don't see how. The actual evidence — again, completely ignored in the piece — resides elsewhere. It involves suspiciously rapid organ waiting times, organs matched and transplanted within hours or days (indicative of a pool of blood-typed donors on standby), organ transplant marathons, significant transplant activity continuing but not appearing in the official figures post-2007, and on and on. One of the most remarkable anecdotes I've seen is the time they flew a living donor to Tibet, in order to kill him or her, to be able to claim the highest altitude liver transplant in China. It wasn't possible to do the kill earlier, because the removal of the original liver and the transplantation of the new one had to be done at the same time. There are numerous remarkable anecdotes of that kind. None of it will be apparent from any of the above.

I will be the first to say that more research is needed in this area. The topic has been ghettoized and almost entirely ignored in journalism, scholarship, and human rights research. Formal qualitative social science methodologies have not been applied to the study of the topic. In light of that, a more appropriate response is: "That looks extremely troubling. What's the official explanation? How can we advance knowledge in this field? Let's sit down and think through a really solid way of either falsifying this theory or proving it out. How do we make reliable inferences about the dimensions of China's transplant system?" etc. etc. Studying the issue scientifically means not excluding, cherry picking, and misrepresenting evidence.

The Post's article ignores the vast body of available evidence on the issue, makes a straw man of a small amount of the evidence, and uses erroneous assumptions and non-probative evidence to misleadingly reject well-founded and thoroughly evidenced arguments without actually addressing their substance. I find it highly surprising that The Washington Post published it.

Monday, May 29, 2017

Hello world

This is designed to be a simple research blog about a complex topic: China's organ transplantation system.

It will be used to document primary source findings from China's medical literature and elsewhere that are too unwieldy for formal publication. It will also be used to collate information resources and, it is likely, the occasional actual blog post on matters of interest related to China's organ transplantation system.

Visitors should check out this article by me and Dr. Jacob Lavee at The Diplomat: "China's Organ Transplant Problem."