A damaging edit from Nature-on Asbestos scandal

December 16, 2010

Asbestos scandal
Irresponsible policies could cause an epidemic of malignant lung disease.

Nature, December 15, 2010

http://www.nature.com/nature/journal/v468/n7326/full/468868a.html

Viewed through an electron microscope, asbestos fibres look like thin glass straws, some no more than a fraction of a micrometre wide. If inhaled, they penetrate the soft alveoli of the lungs and the membranes that line the chest cavity. And there they stay. Over time, damaged cells can cause a malignant disease called mesothelioma, which often kills people, horribly, less than a year after diagnosis.

Before the widespread industrial use of asbestos began in the late nineteenth century, malignant mesothelioma was unheard of, yet it is now responsible for tens of thousands of deaths around the world every year. After the link between asbestos exposure and the disease was convincingly made in 1960, responsible nations eventually took strong measures to remove the mineral from commercial products and to halt mining and export. Less responsible nations did not; this is a scandal that deserves wider attention.

The United States has still not banned asbestos, despite the millions of dollars spent to clear it from homes and from communities near mines. And Canada has been criticized for plans to expand asbestos mining operations, which export the material to India, Indonesia and the Philippines. Although Canada enforces strict guidelines on asbestos use at home to protect its own people, those in countries to which it sends the mineral have little or no protection. Asbestos exported from Canada and other countries including Russia, Brazil and Kazakhstan is routinely mixed into building materials and consumer products, prized for the same durability that makes it troublesome for living tissue. Owing to the long time between exposure and the onset of disease, 30 years or more, the asbestos trade in North America and elsewhere is creating an epidemic that may take decades to peak and subside.

The minerals industry has long tried to convince regulators that white asbestos — or chrysotile — is safe when handled properly. It argues that only the already controlled forms — blue and brown asbestos, known collectively as amphibole — are of concern.

To support this, industry advocates point to scientific data and studies. Yet although the relevant literature is a mire of conflicting results, this should not be seen as an endorsement of their position. Rather, it reflects a string of industry-sponsored studies designed only to cast doubt on the clear links between chrysotile and lung disease. These are familiar tactics and several countries, including Britain, have seen through them and made the correct decision to ban all forms of asbestos, all of which have been proven to be carcinogenic in humans.

Meanwhile, researchers are finding new causes for concern with other natural fibrous minerals such as erionite (see page 884). Complacency is the problem. Much of the developed world has seen asbestos removed from public spaces, leaving in many minds a false sense of security. The public should once again be made aware of the risks associated with exposure to mineral fibres, as well as some man-made fibres. And governments must ban the extraction, processing and use of materials that can cause serious disease

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December 13, 2010

The Hindu : News / National : India must focus on healthcare: Robert Yates

December 13, 2010

The Hindu : News / National : India must focus on healthcare: Robert Yates.


Edit from THe Hindu on Tamilnadus performance in Cadaver Transplant

October 30, 2010

From : http://www.hindu.com/2010/10/29/stories/2010102963791400.htm and http://www.thehindu.com/opinion/editorial/article855338.ece

A model programme

Tamil Nadu’s positive experience with its two-year old cadaver transplant programme has an important message for all States: strong official policy and commitment to transparency can improve the availability of vital organs to save lives. Kidneys, livers, and hearts from brain-dead donors have provided a new life to several patients with organ failure. Remarkably, Tamil Nadu has made the transition from a State with rampant kidney commerce a few years ago to one with a nationally acknowledged deceased-donor transplant programme. Some key factors have helped turn the situation around and set new benchmarks. Chiefly, Tamil Nadu created a network for sharing of cadaver organs, administered by a designated coordinator and an advisory committee. It enlisted government and private hospitals to equitably share the available organs, and opened a patient registry that helps identify recipients. A significant contribution has been made to the process by organisations such as the Multi Organ Harvesting Aid Network (MOHAN) Foundation, which trains grief counsellors and raises awareness, and the National Network for Organ Sharing (NNOS). The overriding principle has been to utilise the organs of brain-dead patients through donation rather than let them be wasted. The efforts have paid off and families of brain-dead people have come forward in altruistic spirit to donate the organs of their kin. Quite remarkably, the donor rate of one per million population a year in the State is ten times the national average.

The case for a sound cadaver organ sharing system cannot be overemphasised. Over 90 per cent of people with end-stage renal failure, for instance, die within months of diagnosis. But for such a transplant programme to inspire confidence among donors, it is vital to treat organs as the property of society, with no possibility of exploitation and commerce. This can be done through a transparent system that makes the rules public and the implementation verifiable. The Tamil Nadu programme is noteworthy for its orientation towards poor patients in public hospitals. The costs of the transplant procedure and medications for a lifetime are fully met by the government in these institutions. Moreover, the active participation of private hospitals, which contribute to the common organ pool, has helped achieve good results. Commendably, during a one-year period from October 2009, Apollo hospitals contributed 34 per cent of the donors. A lot more can be done to improve local use of organs in far-flung areas. Provisioning major hospitals at the district level with the systems necessary to maintain cadavers and the expertise to perform transplants must be made a priority


article on cadaver transplant in tamilnadu

October 25, 2010

New lives out of deaths
V.K. Subburaj, P.W.C. Davidar, J. Amalorpavanathan and C.E. Karunakaran
Tamil Nadu shows the way in organ transplantation.

If your liver has failed and you need a functioning organ to be transplanted for you to survive, and you do not have a close relative who matches your blood group and can give you a part of her liver, then go to Chennai: this is the buzz among liver-failure patients across India. In Chennai a patient stands a much better chance than anywhere else in the country of getting a liver offer from a brain-dead person, donated altruistically.
It is not as if brain-deaths do not occur elsewhere, or relatives there are not willing to donate. When the brain of a person irreversibly dies before the heart does, the heart function can be maintained for some hours through artificial breathing support; this gives a time window to obtain family consent for organ donation, decide on whom the organ should go to and get that person ready for urgent surgery. Major organs such as heart, liver and kidney have to be transplanted within a few hours of removal. Worldwide, such deaths account for roughly five per cent of all Intensive Care Unit (ICU) deaths in hospitals. Such brain-deaths occur all over India every day. Meanwhile organ failure patients too die every day, with the former’s organs not reaching the latter.
But some of them are not lost in Tamil Nadu, where the myriad and complex issues involved in converting a brain-death situation into an organ donation and transplantation situation have been addressed to a considerable extent, thanks to a combination of circumstances. The State has done 110 deceased donor liver transplantations in a period of less than two years. All other States put together have not done even half this number. Apart from liver, close to 240 kidneys and 25 hearts were transplanted from more than 120 donors. This is a donor rate of one per million population a year, which exceeds by 10 times the national average.
Tamil Nadu’s Cadaver Transplant Programme completed two years by the end of September 2010. It was started as a State-wide programme in October 2008. The second year saw a near doubling of donors, to 82, compared to the first year. There was a peak of 14 donors during July 2010.
How did this come about? Is there a lesson from this that other States can learn from? Is this the most that can be achieved? These are questions that need answers in a country where medical skills for organ transplantation are fully available, but the potential for deceased donor organ donation remains untapped. In India, the demand for such organs, especially kidneys, far exceeds availability and consequently spurs illegal organ trade — the sale of a spare kidney from desperately poor live-donors.
It is primarily to prevent those from the economically weaker sections getting trapped into selling their kidneys as live ‘donations’ and to comply with the World Health Organisation guidelines, that India passed the Transplantation of Human Organs Act in 1994. The law was also meant to pave the way for deceased donor (or cadaveric) organ donation from brain-dead persons. Such deaths result largely from road accident head injuries or internal bleeding in the head. However, this law provided only an enabling provision for this purpose and needed to be supplemented with a comprehensive regulatory framework to make organ distribution possible in a fair manner. Countries that have a vibrant deceased-donor programme have a well-laid-out hospital coordination arrangement that makes possible the transfer of organs among hospitals — because a deceased organ donation may occur in one hospital and a patient in need of that organ may be in another.
Plagued as it was by repeated “kidney scandals”, Tamil Nadu took a decisive step some three years ago to set up such a coordination arrangement and to remove glitches in the way of a successful deceased-donor programme. A crucial element of this was a wide consultation process involving transplant hospitals at a workshop and rounds of discussion with smaller groups of medical professionals and voluntary organisations. This active involvement of stakeholders made possible the release of a series of government orders over a period of six months. These culminated in the appointment of a convener for the State’s Cadaver Transplant Programme and the setting up of an advisory committee to oversee and support him.
In establishing such a framework, Tamil Nadu had advanced-country models as reference points. But it had to evolve its own model to suit the infrastructure, the social system and the learning curve differences. When a brain-dead person’s organs get donated out of humanitarian concern, the issue of who among those waiting to get transplants should be given the organs raises ethical and practical questions that have been debated in many countries. There is always a balance that needs to be established between different considerations such as how long a person has been waiting, how sick and in what dire need he/she is, and how long that organ will survive in that person if transplanted. There are also questions of how to motivate hospitals to sustain brain-dead donors, and logistics issues like the time involved in transporting the organ. Through a process of wide consultation, Tamil Nadu has been able to set up an acceptable framework that is still evolving as more experience !
 is gained.
Organs donated altruistically by the family of the deceased really belong to society as a whole. These need to be distributed based on values that are generally acceptable to society at large if the framework established has to have long-term traction. One important result of this exercise is that despite the many complex and unforeseen issues that arise in the matter of actual coordination between hospitals, a basic trust now exists that the operation of the programme is authentic and fair and hospitals can participate freely without having to worry about the decisions taken. A contributing feature is the high level of transparency in the operation of the programme, with a website providing data to hospitals and members of the public (www.dmrhs.org).
Healthcare availability in India is skewed because of the substantial level of privatisation that has occurred over the years, and the skew is even more in the field of organ transplantation, as only a small segment of the population can afford the cost of transplant procedures in private hospitals. Tamil Nadu has taken some steps to restore the balance, with a framework that favours organ allocation to public hospitals. A third of all kidney transplantations done under the programme were by two government hospitals, out of a total of 26 hospitals that did them.
A total of 27 hospitals participated in cadaver transplantation during the last two years, 26 of them in kidney, six in liver, four in heart and one in lung transplantation. The percentage utilisation of organs is 95 per cent for kidneys, 85 per cent for liver and 19 per cent for heart. The underutilisation of kidney and liver is due to medical unsuitability of the organ, while heart is largely unutilised for want of recipients. This is in spite of the fact that the number of hospitals doing heart transplantation increased from one to four during the two years.
The second year’s performance shows the donor numbers by hospital to be skewed. Out of a total of 48 approved transplant centres in the State, just three accounted for more than three-quarters of the donors and five accounted for almost 90 per cent. Of the 48 hospitals, 38 did not have a single donor. The sex ratio among the donors too has been skewed. Only 18 per cent were female, while 82 per cent were male. This probably reflects the fact that most brain-dead donors in the State were road traffic accident victims, and it is mostly men of working age that get involved in such accidents. Donor age distribution shows that most were in the active age group of 21-50.
Tamil Nadu is unique in another respect as well. This is the only State where government hospitals do liver and heart transplants free of cost, and immunosuppressant medication — a costly burden for transplant receivers — is provided free for life.
But, the State has to go a long way still. Experience shows that Tamil Nadu currently taps only 10 to 20 per cent of the realisable potential that exists for such organ donations. More than two-thirds of donors have come from just four hospitals, including a government hospital. A key limiting factor appears to be lack of awareness and motivation within the hospital itself — among the management and staff. Added to it is the lack of soft infrastructure in hospitals — adequate skills and training in certifying brain-death according to procedure, maintaining the cadaver without medical complications until the time of organ retrieval and following regulatory procedures. Some hospitals in the State need help to tackle the dilemmas relating to allocation of scarce resources — ICU beds and costly equipment such as ventilators. Public and charitable hospitals face the dilemma on what to prioritise — whether a critically ill person whose immediate life-saving!
 demands these resources, or whether a brain-dead cadaver should be preserved so that two to three organ-failed persons can be saved from future mortality.
All over India brain-deaths occur on the one side and organ failure patients die on the other. It is in the hands of governments and civil society to make the connection. Tamil Nadu has begun making that connection.
(V.K. Subburaj is Principal Secretary, Health and Family Welfare, and P.W.C. Davidar is Principal Secretary, Information Technology, with the Tamil Nadu government. J. Amalorpavanathan is the convener of Tamil Nadu’s Cadaver Transplant Programme. C.E. Karunakaran is the trustee of the National Network for Organ Sharing, based in Chennai.)
Copyright: 1995 – 2006 The Hindu

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Subject: Article from The Hindu: Sent to you by amalorpavanathan
To:
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Source: The Hindu (http://www.hinduonnet.com/2010/10/25/stories/2010102556431200.htm)
Opinion
 –
Leader Page Articles
&nbsp;&nbsp;

New lives out of deaths
V.K. Subburaj, P.W.C. Davidar, J. Amalorpavanathan and C.E. Karunakaran
Tamil Nadu shows the way in organ transplantation.

If your liver has failed and you need a functioning organ to be transplanted for you to survive, and you do not have a close relative who matches your blood group and can give you a part of her liver, then go to Chennai: this is the buzz among liver-failure patients across India. In Chennai a patient stands a much better chance than anywhere else in the country of getting a liver offer from a brain-dead person, donated altruistically.
It is not as if brain-deaths do not occur elsewhere, or relatives there are not willing to donate. When the brain of a person irreversibly dies before the heart does, the heart function can be maintained for some hours through artificial breathing support; this gives a time window to obtain family consent for organ donation, decide on whom the organ should go to and get that person ready for urgent surgery. Major organs such as heart, liver and kidney have to be transplanted within a few hours of removal. Worldwide, such deaths account for roughly five per cent of all Intensive Care Unit (ICU) deaths in hospitals. Such brain-deaths occur all over India every day. Meanwhile organ failure patients too die every day, with the former’s organs not reaching the latter.
But some of them are not lost in Tamil Nadu, where the myriad and complex issues involved in converting a brain-death situation into an organ donation and transplantation situation have been addressed to a considerable extent, thanks to a combination of circumstances. The State has done 110 deceased donor liver transplantations in a period of less than two years. All other States put together have not done even half this number. Apart from liver, close to 240 kidneys and 25 hearts were transplanted from more than 120 donors. This is a donor rate of one per million population a year, which exceeds by 10 times the national average.
Tamil Nadu’s Cadaver Transplant Programme completed two years by the end of September 2010. It was started as a State-wide programme in October 2008. The second year saw a near doubling of donors, to 82, compared to the first year. There was a peak of 14 donors during July 2010.
How did this come about? Is there a lesson from this that other States can learn from? Is this the most that can be achieved? These are questions that need answers in a country where medical skills for organ transplantation are fully available, but the potential for deceased donor organ donation remains untapped. In India, the demand for such organs, especially kidneys, far exceeds availability and consequently spurs illegal organ trade — the sale of a spare kidney from desperately poor live-donors.
It is primarily to prevent those from the economically weaker sections getting trapped into selling their kidneys as live ‘donations’ and to comply with the World Health Organisation guidelines, that India passed the Transplantation of Human Organs Act in 1994. The law was also meant to pave the way for deceased donor (or cadaveric) organ donation from brain-dead persons. Such deaths result largely from road accident head injuries or internal bleeding in the head. However, this law provided only an enabling provision for this purpose and needed to be supplemented with a comprehensive regulatory framework to make organ distribution possible in a fair manner. Countries that have a vibrant deceased-donor programme have a well-laid-out hospital coordination arrangement that makes possible the transfer of organs among hospitals — because a deceased organ donation may occur in one hospital and a patient in need of that organ may be in another.
Plagued as it was by repeated “kidney scandals”, Tamil Nadu took a decisive step some three years ago to set up such a coordination arrangement and to remove glitches in the way of a successful deceased-donor programme. A crucial element of this was a wide consultation process involving transplant hospitals at a workshop and rounds of discussion with smaller groups of medical professionals and voluntary organisations. This active involvement of stakeholders made possible the release of a series of government orders over a period of six months. These culminated in the appointment of a convener for the State’s Cadaver Transplant Programme and the setting up of an advisory committee to oversee and support him.
In establishing such a framework, Tamil Nadu had advanced-country models as reference points. But it had to evolve its own model to suit the infrastructure, the social system and the learning curve differences. When a brain-dead person’s organs get donated out of humanitarian concern, the issue of who among those waiting to get transplants should be given the organs raises ethical and practical questions that have been debated in many countries. There is always a balance that needs to be established between different considerations such as how long a person has been waiting, how sick and in what dire need he/she is, and how long that organ will survive in that person if transplanted. There are also questions of how to motivate hospitals to sustain brain-dead donors, and logistics issues like the time involved in transporting the organ. Through a process of wide consultation, Tamil Nadu has been able to set up an acceptable framework that is still evolving as more experience !
 is gained.
Organs donated altruistically by the family of the deceased really belong to society as a whole. These need to be distributed based on values that are generally acceptable to society at large if the framework established has to have long-term traction. One important result of this exercise is that despite the many complex and unforeseen issues that arise in the matter of actual coordination between hospitals, a basic trust now exists that the operation of the programme is authentic and fair and hospitals can participate freely without having to worry about the decisions taken. A contributing feature is the high level of transparency in the operation of the programme, with a website providing data to hospitals and members of the public (www.dmrhs.org).
Healthcare availability in India is skewed because of the substantial level of privatisation that has occurred over the years, and the skew is even more in the field of organ transplantation, as only a small segment of the population can afford the cost of transplant procedures in private hospitals. Tamil Nadu has taken some steps to restore the balance, with a framework that favours organ allocation to public hospitals. A third of all kidney transplantations done under the programme were by two government hospitals, out of a total of 26 hospitals that did them.
A total of 27 hospitals participated in cadaver transplantation during the last two years, 26 of them in kidney, six in liver, four in heart and one in lung transplantation. The percentage utilisation of organs is 95 per cent for kidneys, 85 per cent for liver and 19 per cent for heart. The underutilisation of kidney and liver is due to medical unsuitability of the organ, while heart is largely unutilised for want of recipients. This is in spite of the fact that the number of hospitals doing heart transplantation increased from one to four during the two years.
The second year’s performance shows the donor numbers by hospital to be skewed. Out of a total of 48 approved transplant centres in the State, just three accounted for more than three-quarters of the donors and five accounted for almost 90 per cent. Of the 48 hospitals, 38 did not have a single donor. The sex ratio among the donors too has been skewed. Only 18 per cent were female, while 82 per cent were male. This probably reflects the fact that most brain-dead donors in the State were road traffic accident victims, and it is mostly men of working age that get involved in such accidents. Donor age distribution shows that most were in the active age group of 21-50.
Tamil Nadu is unique in another respect as well. This is the only State where government hospitals do liver and heart transplants free of cost, and immunosuppressant medication — a costly burden for transplant receivers — is provided free for life.
But, the State has to go a long way still. Experience shows that Tamil Nadu currently taps only 10 to 20 per cent of the realisable potential that exists for such organ donations. More than two-thirds of donors have come from just four hospitals, including a government hospital. A key limiting factor appears to be lack of awareness and motivation within the hospital itself — among the management and staff. Added to it is the lack of soft infrastructure in hospitals — adequate skills and training in certifying brain-death according to procedure, maintaining the cadaver without medical complications until the time of organ retrieval and following regulatory procedures. Some hospitals in the State need help to tackle the dilemmas relating to allocation of scarce resources — ICU beds and costly equipment such as ventilators. Public and charitable hospitals face the dilemma on what to prioritise — whether a critically ill person whose immediate life-saving!
 demands these resources, or whether a brain-dead cadaver should be preserved so that two to three organ-failed persons can be saved from future mortality.
All over India brain-deaths occur on the one side and organ failure patients die on the other. It is in the hands of governments and civil society to make the connection. Tamil Nadu has begun making that connection.
(V.K. Subburaj is Principal Secretary, Health and Family Welfare, and P.W.C. Davidar is Principal Secretary, Information Technology, with the Tamil Nadu government. J. Amalorpavanathan is the convener of Tamil Nadu’s Cadaver Transplant Programme. C.E. Karunakaran is the trustee of the National Network for Organ Sharing, based in Chennai.)
Copyright: 1995 – 2006 The Hindu

Republication or redissemination of the contents of this screen are expressly
prohibited without the consent of  The Hindu


  visit  indianhealthfront.wordpress.com Amalorpavanathan

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 Reply |Amal Joseph to ndtn
show details 9:15 PM (2 minutes ago)
– Show quoted text –
nd

=============================================================
This article has been sent to you by amalorpavanathan ( amalj@rediffmail.com )
=============================================================
Source: The Hindu (http://www.hinduonnet.com/2010/10/25/stories/2010102556431200.htm)
Opinion
 –
Leader Page Articles
&nbsp;&nbsp;

New lives out of deaths
V.K. Subburaj, P.W.C. Davidar, J. Amalorpavanathan and C.E. Karunakaran
Tamil Nadu shows the way in organ transplantation.

If your liver has failed and you need a functioning organ to be transplanted for you to survive, and you do not have a close relative who matches your blood group and can give you a part of her liver, then go to Chennai: this is the buzz among liver-failure patients across India. In Chennai a patient stands a much better chance than anywhere else in the country of getting a liver offer from a brain-dead person, donated altruistically.
It is not as if brain-deaths do not occur elsewhere, or relatives there are not willing to donate. When the brain of a person irreversibly dies before the heart does, the heart function can be maintained for some hours through artificial breathing support; this gives a time window to obtain family consent for organ donation, decide on whom the organ should go to and get that person ready for urgent surgery. Major organs such as heart, liver and kidney have to be transplanted within a few hours of removal. Worldwide, such deaths account for roughly five per cent of all Intensive Care Unit (ICU) deaths in hospitals. Such brain-deaths occur all over India every day. Meanwhile organ failure patients too die every day, with the former’s organs not reaching the latter.
But some of them are not lost in Tamil Nadu, where the myriad and complex issues involved in converting a brain-death situation into an organ donation and transplantation situation have been addressed to a considerable extent, thanks to a combination of circumstances. The State has done 110 deceased donor liver transplantations in a period of less than two years. All other States put together have not done even half this number. Apart from liver, close to 240 kidneys and 25 hearts were transplanted from more than 120 donors. This is a donor rate of one per million population a year, which exceeds by 10 times the national average.
Tamil Nadu’s Cadaver Transplant Programme completed two years by the end of September 2010. It was started as a State-wide programme in October 2008. The second year saw a near doubling of donors, to 82, compared to the first year. There was a peak of 14 donors during July 2010.
How did this come about? Is there a lesson from this that other States can learn from? Is this the most that can be achieved? These are questions that need answers in a country where medical skills for organ transplantation are fully available, but the potential for deceased donor organ donation remains untapped. In India, the demand for such organs, especially kidneys, far exceeds availability and consequently spurs illegal organ trade — the sale of a spare kidney from desperately poor live-donors.
It is primarily to prevent those from the economically weaker sections getting trapped into selling their kidneys as live ‘donations’ and to comply with the World Health Organisation guidelines, that India passed the Transplantation of Human Organs Act in 1994. The law was also meant to pave the way for deceased donor (or cadaveric) organ donation from brain-dead persons. Such deaths result largely from road accident head injuries or internal bleeding in the head. However, this law provided only an enabling provision for this purpose and needed to be supplemented with a comprehensive regulatory framework to make organ distribution possible in a fair manner. Countries that have a vibrant deceased-donor programme have a well-laid-out hospital coordination arrangement that makes possible the transfer of organs among hospitals — because a deceased organ donation may occur in one hospital and a patient in need of that organ may be in another.
Plagued as it was by repeated “kidney scandals”, Tamil Nadu took a decisive step some three years ago to set up such a coordination arrangement and to remove glitches in the way of a successful deceased-donor programme. A crucial element of this was a wide consultation process involving transplant hospitals at a workshop and rounds of discussion with smaller groups of medical professionals and voluntary organisations. This active involvement of stakeholders made possible the release of a series of government orders over a period of six months. These culminated in the appointment of a convener for the State’s Cadaver Transplant Programme and the setting up of an advisory committee to oversee and support him.
In establishing such a framework, Tamil Nadu had advanced-country models as reference points. But it had to evolve its own model to suit the infrastructure, the social system and the learning curve differences. When a brain-dead person’s organs get donated out of humanitarian concern, the issue of who among those waiting to get transplants should be given the organs raises ethical and practical questions that have been debated in many countries. There is always a balance that needs to be established between different considerations such as how long a person has been waiting, how sick and in what dire need he/she is, and how long that organ will survive in that person if transplanted. There are also questions of how to motivate hospitals to sustain brain-dead donors, and logistics issues like the time involved in transporting the organ. Through a process of wide consultation, Tamil Nadu has been able to set up an acceptable framework that is still evolving as more experience !
 is gained.
Organs donated altruistically by the family of the deceased really belong to society as a whole. These need to be distributed based on values that are generally acceptable to society at large if the framework established has to have long-term traction. One important result of this exercise is that despite the many complex and unforeseen issues that arise in the matter of actual coordination between hospitals, a basic trust now exists that the operation of the programme is authentic and fair and hospitals can participate freely without having to worry about the decisions taken. A contributing feature is the high level of transparency in the operation of the programme, with a website providing data to hospitals and members of the public (www.dmrhs.org).
Healthcare availability in India is skewed because of the substantial level of privatisation that has occurred over the years, and the skew is even more in the field of organ transplantation, as only a small segment of the population can afford the cost of transplant procedures in private hospitals. Tamil Nadu has taken some steps to restore the balance, with a framework that favours organ allocation to public hospitals. A third of all kidney transplantations done under the programme were by two government hospitals, out of a total of 26 hospitals that did them.
A total of 27 hospitals participated in cadaver transplantation during the last two years, 26 of them in kidney, six in liver, four in heart and one in lung transplantation. The percentage utilisation of organs is 95 per cent for kidneys, 85 per cent for liver and 19 per cent for heart. The underutilisation of kidney and liver is due to medical unsuitability of the organ, while heart is largely unutilised for want of recipients. This is in spite of the fact that the number of hospitals doing heart transplantation increased from one to four during the two years.
The second year’s performance shows the donor numbers by hospital to be skewed. Out of a total of 48 approved transplant centres in the State, just three accounted for more than three-quarters of the donors and five accounted for almost 90 per cent. Of the 48 hospitals, 38 did not have a single donor. The sex ratio among the donors too has been skewed. Only 18 per cent were female, while 82 per cent were male. This probably reflects the fact that most brain-dead donors in the State were road traffic accident victims, and it is mostly men of working age that get involved in such accidents. Donor age distribution shows that most were in the active age group of 21-50.
Tamil Nadu is unique in another respect as well. This is the only State where government hospitals do liver and heart transplants free of cost, and immunosuppressant medication — a costly burden for transplant receivers — is provided free for life.
But, the State has to go a long way still. Experience shows that Tamil Nadu currently taps only 10 to 20 per cent of the realisable potential that exists for such organ donations. More than two-thirds of donors have come from just four hospitals, including a government hospital. A key limiting factor appears to be lack of awareness and motivation within the hospital itself — among the management and staff. Added to it is the lack of soft infrastructure in hospitals — adequate skills and training in certifying brain-death according to procedure, maintaining the cadaver without medical complications until the time of organ retrieval and following regulatory procedures. Some hospitals in the State need help to tackle the dilemmas relating to allocation of scarce resources — ICU beds and costly equipment such as ventilators. Public and charitable hospitals face the dilemma on what to prioritise — whether a critically ill person whose immediate life-saving!
 demands these resources, or whether a brain-dead cadaver should be preserved so that two to three organ-failed persons can be saved from future mortality.
All over India brain-deaths occur on the one side and organ failure patients die on the other. It is in the hands of governments and civil society to make the connection. Tamil Nadu has begun making that connection.
(V.K. Subburaj is Principal Secretary, Health and Family Welfare, and P.W.C. Davidar is Principal Secretary, Information Technology, with the Tamil Nadu government. J. Amalorpavanathan is the convener of Tamil Nadu’s Cadaver Transplant Programme. C.E. Karunakaran is the trustee of the National Network for Organ Sharing, based in Chennai.)
Copyright: 1995 – 2006 The Hindu

Republication or redissemination of the contents of this screen are expressly
prohibited without the consent of  The Hindu


  visit  indianhealthfront.wordpress.com Amalorpavanathan

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Your message has been sent. Invite Bruno Mascarenhas புருனோ மஸ்கரனாஸ் to Gmail Reply |Amal Joseph to Bruno
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Bruno,
   Can u pl put this in our web as well as in Facebook.Amal
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New lives out of deaths
V.K. Subburaj, P.W.C. Davidar, J. Amalorpavanathan and C.E. Karunakaran
Tamil Nadu shows the way in organ transplantation.

If your liver has failed and you need a functioning organ to be transplanted for you to survive, and you do not have a close relative who matches your blood group and can give you a part of her liver, then go to Chennai: this is the buzz among liver-failure patients across India. In Chennai a patient stands a much better chance than anywhere else in the country of getting a liver offer from a brain-dead person, donated altruistically.
It is not as if brain-deaths do not occur elsewhere, or relatives there are not willing to donate. When the brain of a person irreversibly dies before the heart does, the heart function can be maintained for some hours through artificial breathing support; this gives a time window to obtain family consent for organ donation, decide on whom the organ should go to and get that person ready for urgent surgery. Major organs such as heart, liver and kidney have to be transplanted within a few hours of removal. Worldwide, such deaths account for roughly five per cent of all Intensive Care Unit (ICU) deaths in hospitals. Such brain-deaths occur all over India every day. Meanwhile organ failure patients too die every day, with the former’s organs not reaching the latter.
But some of them are not lost in Tamil Nadu, where the myriad and complex issues involved in converting a brain-death situation into an organ donation and transplantation situation have been addressed to a considerable extent, thanks to a combination of circumstances. The State has done 110 deceased donor liver transplantations in a period of less than two years. All other States put together have not done even half this number. Apart from liver, close to 240 kidneys and 25 hearts were transplanted from more than 120 donors. This is a donor rate of one per million population a year, which exceeds by 10 times the national average.
Tamil Nadu’s Cadaver Transplant Programme completed two years by the end of September 2010. It was started as a State-wide programme in October 2008. The second year saw a near doubling of donors, to 82, compared to the first year. There was a peak of 14 donors during July 2010.
How did this come about? Is there a lesson from this that other States can learn from? Is this the most that can be achieved? These are questions that need answers in a country where medical skills for organ transplantation are fully available, but the potential for deceased donor organ donation remains untapped. In India, the demand for such organs, especially kidneys, far exceeds availability and consequently spurs illegal organ trade — the sale of a spare kidney from desperately poor live-donors.
It is primarily to prevent those from the economically weaker sections getting trapped into selling their kidneys as live ‘donations’ and to comply with the World Health Organisation guidelines, that India passed the Transplantation of Human Organs Act in 1994. The law was also meant to pave the way for deceased donor (or cadaveric) organ donation from brain-dead persons. Such deaths result largely from road accident head injuries or internal bleeding in the head. However, this law provided only an enabling provision for this purpose and needed to be supplemented with a comprehensive regulatory framework to make organ distribution possible in a fair manner. Countries that have a vibrant deceased-donor programme have a well-laid-out hospital coordination arrangement that makes possible the transfer of organs among hospitals — because a deceased organ donation may occur in one hospital and a patient in need of that organ may be in another.
Plagued as it was by repeated “kidney scandals”, Tamil Nadu took a decisive step some three years ago to set up such a coordination arrangement and to remove glitches in the way of a successful deceased-donor programme. A crucial element of this was a wide consultation process involving transplant hospitals at a workshop and rounds of discussion with smaller groups of medical professionals and voluntary organisations. This active involvement of stakeholders made possible the release of a series of government orders over a period of six months. These culminated in the appointment of a convener for the State’s Cadaver Transplant Programme and the setting up of an advisory committee to oversee and support him.
In establishing such a framework, Tamil Nadu had advanced-country models as reference points. But it had to evolve its own model to suit the infrastructure, the social system and the learning curve differences. When a brain-dead person’s organs get donated out of humanitarian concern, the issue of who among those waiting to get transplants should be given the organs raises ethical and practical questions that have been debated in many countries. There is always a balance that needs to be established between different considerations such as how long a person has been waiting, how sick and in what dire need he/she is, and how long that organ will survive in that person if transplanted. There are also questions of how to motivate hospitals to sustain brain-dead donors, and logistics issues like the time involved in transporting the organ. Through a process of wide consultation, Tamil Nadu has been able to set up an acceptable framework that is still evolving as more experience !
 is gained.
Organs donated altruistically by the family of the deceased really belong to society as a whole. These need to be distributed based on values that are generally acceptable to society at large if the framework established has to have long-term traction. One important result of this exercise is that despite the many complex and unforeseen issues that arise in the matter of actual coordination between hospitals, a basic trust now exists that the operation of the programme is authentic and fair and hospitals can participate freely without having to worry about the decisions taken. A contributing feature is the high level of transparency in the operation of the programme, with a website providing data to hospitals and members of the public (www.dmrhs.org).
Healthcare availability in India is skewed because of the substantial level of privatisation that has occurred over the years, and the skew is even more in the field of organ transplantation, as only a small segment of the population can afford the cost of transplant procedures in private hospitals. Tamil Nadu has taken some steps to restore the balance, with a framework that favours organ allocation to public hospitals. A third of all kidney transplantations done under the programme were by two government hospitals, out of a total of 26 hospitals that did them.
A total of 27 hospitals participated in cadaver transplantation during the last two years, 26 of them in kidney, six in liver, four in heart and one in lung transplantation. The percentage utilisation of organs is 95 per cent for kidneys, 85 per cent for liver and 19 per cent for heart. The underutilisation of kidney and liver is due to medical unsuitability of the organ, while heart is largely unutilised for want of recipients. This is in spite of the fact that the number of hospitals doing heart transplantation increased from one to four during the two years.
The second year’s performance shows the donor numbers by hospital to be skewed. Out of a total of 48 approved transplant centres in the State, just three accounted for more than three-quarters of the donors and five accounted for almost 90 per cent. Of the 48 hospitals, 38 did not have a single donor. The sex ratio among the donors too has been skewed. Only 18 per cent were female, while 82 per cent were male. This probably reflects the fact that most brain-dead donors in the State were road traffic accident victims, and it is mostly men of working age that get involved in such accidents. Donor age distribution shows that most were in the active age group of 21-50.
Tamil Nadu is unique in another respect as well. This is the only State where government hospitals do liver and heart transplants free of cost, and immunosuppressant medication — a costly burden for transplant receivers — is provided free for life.
But, the State has to go a long way still. Experience shows that Tamil Nadu currently taps only 10 to 20 per cent of the realisable potential that exists for such organ donations. More than two-thirds of donors have come from just four hospitals, including a government hospital. A key limiting factor appears to be lack of awareness and motivation within the hospital itself — among the management and staff. Added to it is the lack of soft infrastructure in hospitals — adequate skills and training in certifying brain-death according to procedure, maintaining the cadaver without medical complications until the time of organ retrieval and following regulatory procedures. Some hospitals in the State need help to tackle the dilemmas relating to allocation of scarce resources — ICU beds and costly equipment such as ventilators. Public and charitable hospitals face the dilemma on what to prioritise — whether a critically ill person whose immediate life-saving!
 demands these resources, or whether a brain-dead cadaver should be preserved so that two to three organ-failed persons can be saved from future mortality.
All over India brain-deaths occur on the one side and organ failure patients die on the other. It is in the hands of governments and civil society to make the connection. Tamil Nadu has begun making that connection.
(V.K. Subburaj is Principal Secretary, Health and Family Welfare, and P.W.C. Davidar is Principal Secretary, Information Technology, with the Tamil Nadu government. J. Amalorpavanathan is the convener of Tamil Nadu’s Cadaver Transplant Programme. C.E. Karunakaran is the trustee of the National Network for Organ Sharing, based in Chennai.)
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  visit  indianhealthfront.wordpress.com Amalorpavanathan

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How Doctors Think: Book Review

October 4, 2010

There are quite a few doctors who are good writers too, communicating complicated medical matters to a general audience with admirable clarity. The best example of this class of doctors is perhaps Atul Gawande, but his fellow writer Jerome Groopman also does quite well.

Here, one of our own doctors with deep interest in public health issues, J. Amalorpavanathan reviews Dr. Groopman’s book "How Doctors Think".


Starvation deaths in India

September 10, 2010

In Shining India, Over 5000 Children Die Every Day
From Hunger And Malnutrition

By Devinder Sharma

09 September, 2010
Ground Reality

The startling figure still resonates in my memory. Some 25 years back, I remember reading a report in one of the major dailies which said that some 5,000 children die every day in India. Today morning, my attention therefore was automatically drawn to a news report: 1.83 million children die before fifth bithday every year: Report (Indian Express, Sept 8, 2010).

I immediately took out a pen and paper to find out the per day child mortality rate. I wanted to know whether the child mortality rate has come down, and by how much, in the last 25 years or so. My disappointment has grown. The calculations shows that every day 5,013 children are succumbing to malnutrition. Given that a half of all children in India are under-nourished as per the National Family Health Survey III (2005-06), of which over 5,000 die every day I think every Indian needs to hang his/her head in shame.

Globally, 14,600 children die every day. This means that India alone has the dubious distinction of having more than a third of the world’s child mortality. This is ironically happening at a time when food is rotting in the godowns.

Yes, India is surely an emerging economic superpower, but building an Empire over hungry stomachs! Mera Bharat Mahaan!!

A new global report “A fair Chance at Life” by the international child rights organisation Save the Children is not only a damming indictment of the supplementary nutrition programmes that have been running for several decades now, but also is an eye-opener in many ways. While it tells us how hollow the global claims under the Millennium Development Goals (MDGs) are, nationally it shows us the stark hidden realities. A country which doesn’t get tired of patting itself in the back for creating an impressive list of 50 billionaires, and off and on does bask under the fictitious glow of Shining India, the dark underbelly remains deliberately hidden from the media glare.

Let us look at what the report says: “Of the 26 million children born in India every year, approximately 1.83 million died before their fifth birthday. “What these aggregate figures do not reveal are the huge inequities in mortality rates across the country, within States and between them, as well as between children in urban and rural areas.”

Half of these children actually die within a month of being born. In other words, nearly 2,500 children of those who die have not even survived for more than a month. This is an indication of not only the inability of the parents to provide adequate nutrition to their new born, but more than that is a reflection of the impoverished condition of the especially the mother. Does it not tell us to what extent poverty and hunger prevails in this country? Do we need to still work out more effective parameters to measure hunger and malnutrition? Do we really need to find a new estimate of people living below the poverty line (BPL)?

Madhya Pradesh tops the list, followed closely by Uttar Pradesh. The under-5 mortality rate in Kerala was 14 deaths per 1000 live births. This stood at a sharp contrast to Madhya Pradesh at 92 per 1000 and 91 per 1000 for Uttar Pradesh.

I am reproducing below a news report from the pages of The Hindu (Sept 8, 2010):

‘Children from poorest section 3 times more likely to die before age of 5 than those from high income groups’

Children from the poorest communities are three times more likely to die before they reach the age of 5 than those from high income groups, Save the Children, a non-governmental organisation has said.

In a global report titled A Fair Chance at Life, the organisation said the policy to lower child mortality in India and elsewhere appeared to focus on children from better-off communities, leaving out those from the most disadvantaged backgrounds.

“The 41 percentage decline in child mortality over the last two decades masks a dangerous expansion of the child mortality gap between the richest and poorest families in India,” Save the Children CEO Thomas Chandy said.

Child mortality is often described as the best barometer of social and economic progress. Despite being one of the fastest growing economies, there has been no visible pattern between per capita income growth and the rate of reduction of child mortality rates. In 2008, 5.3 lakh children under 5 died in the lowest income quintile in comparison to 1.78 lakh among the wealthy quintile. The rate of decline between 2005-06 and 1997-98 among the lowest income quintile is 22.69 per cent, compared to 34.37 per cent among the high income quintile for the same period.

Of the 26 million children born in India every year, approximately 1.83 million died before their fifth birthday. “What these aggregate figures do not reveal are the huge inequities in mortality rates across the country, within States and between them, as well as between children in urban and rural areas,” Mr. Chandy said.

The under-5 mortality rate in Kerala was 14 deaths per 1000 live births. This stood at a sharp contrast to Madhya Pradesh at 92 per 1000 and 91 per 1000 for Uttar Pradesh.

“Every child has the right to survive and the Indian government has an obligation to protect them. Save the Children’s research shows that prioritising marginalised and excluded communities, especially in the States lagging behind, is one of the surest ways that India can reduce the number of children dying from easily preventable causes. The National Rural Health Mission, for example, should have a clear focus on social inclusion of Dalits and adivasis in terms of access to healthcare,” he said.

Save the Children’s report comes two weeks before a high-level U.N. summit in New York from September 20-22 to assess progress against the Millennium Development Goals.

By demonstrating a political will and the right policies, MDG4 could be achieved in India. The good schemes in place needed to be matched by effective implementation. And there was enough experience in India proving that low-cost interventions can make the difference between life and death for a child, the report said.

Huge inequity in child mortality rates: Survey
http://www.thehindu.com/news/article617626.ece


on population control

August 26, 2010

> <http://www.nytimes.com/2010/08/22/world/asia/22india.html>
>
> > Ironically, the
> > targets of population control are the very people who are NOT the
> problem.
>
> But when women have multiple babies in quick succession, it does
> damage their health. So, humane, non-coercive population control (in
> the form of cash incentives for not having babies, for example),
> actually benefits women’s health, ceteris paribus. Is that not a good
> thing?
>
> ” “I want to tell you about our honeymoon package,” began Ms. Jadhav,
> an auxiliary nurse, during a recent house call on a new bride in this
> farming region [Satara] in the state of Maharashtra. Ms. Jadhav
> explained that the district government would pay 5,000 rupees, or
> about $106, if the couple waited to have children. Waiting, she
> promised, would allow them time to finish their schooling or to save
> money.
>
> “A farming district ringed with green hills, Satara has three million
> people. A 1997 survey found that almost a quarter of all women were
> marrying before the legal age of 18, while roughly 45 percent of all
> infants and young children in the district were malnourished.
>
> In response, the district began a campaign to reduce the number of
> child brides and more than 27,000 parents signed a written pledge
> agreeing not to allow their daughters to wed before age 18. Within a
> few years, the marrying age rose and the rate of child malnutrition
> dropped. Today, officials say about 15 percent of children are
> malnourished. But if couples were marrying a little later, they were
> usually producing a child within the first year of marriage, followed
> by another soon after. So in August 2009, Satara introduced its
> honeymoon package as an incentive to delay childbirths. So far, 2,366
> couples have enrolled.
>
> “The response has been good,” said Dr. Archana Khade, a physician at
> the primary health care center in the village of Kahner. “But the
> money is a secondary thing. It’s about the other things, for better
> future prospects.”
>
> Now, health officials in other states have come to Satara to study the
> program. Every day, auxiliary nurses like Ms. Jadhav canvass villages
> to disseminate information about family planning and solicit new
> couples for the honeymoon package. In India, a new couple usually
> resides with the family of the groom and it is the older generation
> that represents Ms. Jadhav’s biggest challenge.
>
> “The first time I go, they always defy you,” she said. “They say, ‘No,
> we don’t want to do that.’ The older generation believes that the
> moment a couple gets married, they want a baby in their house.”
>
> On a recent afternoon, Ms. Jadhav and Dr. Khade made their pitch to a
> 20-year-old bride, who stared silently down as her mother-in-law
> hovered in an adjacent room of their farmhouse.
>
> “You can delay your first pregnancy,” Dr. Khade said. “Have you talked
> to your husband about family planning or when you want to have a
> child?”
>
> “He doesn’t want to have children early,” the bride answered, almost
> in a whisper.
>
> “Do you think your in-laws will be happy with your decision?” Dr. Khade
> asked.
>
> The young bride was silent. Her in-laws did not know that she was
> already using birth-control pills.
>
> Many experts emphasize that easing India’s population burden will
> require a holistic response centered on improving health services and
> teaching about a full range of contraception.
>
> […]
>
> In Satara, the birthrate has fallen to about 1.9 children per family,
> partly because of the honeymoon package, with many women opting for
> sterilization after their second child.”
>
> Full: <
> http://www.nytimes.com/2010/08/22/world/asia/22india.html?pagewanted=1&_r=1


Capitalist America celebrates Medicare, socialist India dithers

July 30, 2010

To the business press and television in India, the shiny aspects of Western life appeal a lot. Capitalism, they often contend, is the ultimate solution to the ailments of our present economic system. That discussion will go on for long.

Meanwhile, one of the bedrock principles adopted even in a harshly competitive society such as the United States, where time and effort are measured mostly in monetary terms, is Medicare. The State’s support in the form of medical insurance payments for its senior citizens began a long time ago, and remains a cardinal principle of that society – despite the assaults on the general welfare systems and labour in America by market economists and market-oriented Presidents.

This official statement is a capsule of the 45 years of the Medicare system. It traces recent efforts to strengthen the provisions by President Barack Obama.

Whatever form our economic system finally takes, the message is loud and clear – sufficient resources should be devoted to care for an aging population. In a country with a large young population, it should not be so difficult to transfer that ‘risk’, to put it in insurance terms, across a broad spectrum of workers.

The important question is whether those who make our policy have the philosophical distance from the profit-seeking entities in insurance, the health sector, the pharma companies and other interest groups, to do what is just and proper.


pakistans changing scenario in organ donation

July 24, 2010

President Asif Ali Zardari of Pakistan signs up as organ donor

Islamabad — President Asif Ali Zardari of Pakistan today signals top-level personal support for a new national organ transplantation service by signing an organ donor card to bequeath his organs upon his death. The signing will take place at a ceremony at Bilawal House, Karachi.

The new service is based on donations from deceased donors. It prohibits commercial transplantation and outlaws the organ trade.

“ Pakistan has taken an important step in passing this new law to regulate organ transplantation, and is setting an excellent example to other countries,” said Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean. “The commercialization of organ transplantation is unethical, inequitable and unhealthy – both for vendors and recipients.”

Kidney transplantation took off in Pakistan in the late 1980s. To begin with, most transplanted kidneys were donated by family members but by the late 1990s, the majority of kidneys were bought from individuals from villages located around major cities. By 2003, most kidney transplants were undertaken in private hospitals in the cities of Punjab .

In 2005 (the last year for which figures are available), 1500 commercial transplantations were conducted openly in Pakistan .

An article published online in the journal Clinical Transplantation on 6 July 2010 by a group of researchers from Skopje , Macedonia , describes 36 patients who travelled from the Balkans to buy kidneys in Pakistan . Following operations in Lahore and Rawalpindi , seven patients died, while many others suffered serious complications such as infected wounds, renal artery thrombosis, active hepatitis C, steroid diabetes and acute myocardial infarctions. [1]

Meanwhile, many people who have sold a kidney say that their health has suffered as a result, citing general overall weakness and an inability to work long hours.

Organ transplantation is the only viable treatment for a range of fatal and non-fatal diseases affecting the heart, liver or lungs. Although patients with terminal renal diseases can be treated through other renal replacement therapies (notably dialysis), kidney transplantation is generally accepted as the best treatment both for quality of life and cost effectiveness. Kidney transplantation is by far the most frequently carried out form of transplantation globally.

Worldwide, approximately 100 900 solid organ transplants were performed in 2008 (based on information from the 104 countries in which 99% of the world’s organ transplants take place). Kidney transplants made up the majority of all transplants (69 300), followed by liver (5330), heart (5330) and lung (3330) transplants.

Demand for organs outstrips supply in almost every country of the world. WHO estimates that less than one tenth of estimated global needs in organ transplantation are currently met. This results in offers of incentives for donation, profiteering and exploitation of the disadvantaged.

In 1987, the World Health Assembly noted that the commercialization of organ transplantation contravenes the Universal Declaration of Human Rights and the spirit of the WHO Constitution. WHO subsequently developed a unified legal instrument to regulate transplantation, which led to the approval of a set of Guiding Principles at the World Health Assembly in 1991. The Guiding Principles emphasize voluntary donation and non-commercialization of human organs. In May 2010, the sixty-third World Health Assembly adopted a further resolution (WHA63.22) endorsing an updated set of Guiding Principles on Human Cell, Tissue and Organ Transplantation. The resolution highlights the social risks associated with trafficking in human materials, and the need for public support to stamp out the trade and increase donations from deceased donors.

Meanwhile, in March 2010, the Third Global Consultation on Organ Donation and Transplantation agreed to aim for self-sufficiency by scaling up preventive measures (such as healthy lifestyle campaigns) to reduce the numbers of people needing organ transplants, and to encourage people to do what President Zardari is doing today: demonstrating a commitment to the community by bequeathing his organs for use by others after his death. Ensuring adequate local supply of voluntarily donated organs is critical to eliminating commercial trade and “transplant tourism”.