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.

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