Organ Sourcing in China: The Official Version
The following are remarks prepared by David Matas, a human rights lawyer, for a symposium in Bern, Switzerland, on April 16, 2015. Matas is the recipient of numerous awards for his human rights work, including the 1999 human rights achievement award from the League for Human Rights of B’nai Brith Canada Midwest Region, and the 2009 Human Rights Award from the German-based International Society for Human Rights. He is a 2010 Nobel Peace Prize nominee and a member of the Order of Canada. Since 2006 he has researched and published on organ harvesting of Falun Gong prisoners of conscience in China. A version of these remarks with footnotes may be found here.
Chinese health officials over the years have made a wide variety of contradictory statements about the sourcing of organs for transplants. The statements can not all be right. But they can all be wrong, and, in my view, are all wrong.
I could spend a very long time going through the many contradictory statements emanating out of the Chinese health system, pointing out the contradictions and incoherence. To be comprehensive on this subject would exhaust my time and your patience. So let me just give you some idea of what has been happening.
Wang Guoqi a doctor from the Tianjin People’s Armed Police General Brigade Hospital testified before the U.S. Congress on June 27, 2001 that he helped remove corneas and skin from more than 100 prisoners. A few days after the testimony, Foreign Ministry spokeswoman Zhang Qiyue called it “sensational lies” and “vicious slander” against China. “With regard to the trade in human organs, China strictly prohibits that,” Zhang said. “The major source of human organs comes from voluntary donations from Chinese citizens.”
2005 – 2010
In July of 2005 Huang Jiefu, then Chinese Deputy Minister of Health, indicated as high as 95% of organs derive from prisoners. Speaking at a conference of surgeons in the southern city of Guangzhou in mid-November 2006, he said: “Apart from a small portion of traffic victims, most of the organs from cadavers are from executed prisoners”. In October 2008, he said “In China, more than 90% of transplanted organs are obtained from executed prisoners”. In March 2010, he stated that: “… over 90% of grafts from deceased donors are from executed prisoners”. As one can see, at some points, Huang Jiefu refers to deceased donor sources and at other points to all sources.
Shi Bingyi, a Chinese health official, said in an article posted on Health Paper Net in March 2006 that there were about 90,000 transplants in total up until 2005. The text stated, in part, in translation:
“Professor Shi said that in the past 10 years, organ transplantation in China had grown rapidly; the types of transplant operations that can be performed were very wide, ranging from kidney, liver, heart, pancreas, lung, bone marrow, cornea; so far, there had been over 90,000 transplants completed country wide; last year alone, there was close to 10,000 kidney transplants and nearly 4,000 liver transplants completed.”
David Kilgour and I referred to this total and this article in our reports and book, Bloody Harvest. Manfred Nowak, the United Nations Rapporteur on Torture, asked the Government of China to explain the discrepancy between volume of organ transplants and volume of identified sources, relying, in part, in our report and its reference to the article quoting Shi Bingyi. The Chinese government, in a response sent to the Rapporteurs by letter dated March 19, 2007 and published in the report of Professor Nowak to the UN Human Rights Council dated February 19, 2008, stated that
“Professor Shi Bingyi expressly clarified that on no occasion had he made such a statement or given figures of this kind, and these allegations and the related figures are pure fabrication.”
Shi Bingyi was interviewed in a video documentary produced by Phoenix TV, a Hong Kong media outlet. That video shows Shi Bingyi on screen, wearing a military uniform, saying what the Government of China, in its response to Nowak, indicates that he had said, that the figures we quote from him he simply never gave. He says on the video:
“I did not make such a statement because I have no knowledge of these figures I have not made detailed investigation on this subject how many were carried out and in which year. Therefore I have no figures to show. So I could not have said that.”
Yet, the actual source, the Health News Network article, in June 2008, remained on its original Chinese website, though it has been taken down since. The original source of the information remained available within China through the internet at the time Shi Bingyi denied the information. It is still available for anyone outside China to see through the Wayback Machine Internet Archive.
In a 2008 presentation, Chinese health official Haibo Wang states that there were 11,179 liver transplantations as of March 8, 2008. Wang showed that there were 240 liver transplants between January 1 and March 8, 2008.
A speech of Huang Jiefu at a 2010 Madrid conference produced, in a slide show presentation, one slide showing the number of kidney and liver transplants in China over the past decade. He produced a second slide showing living donor vs. deceased kidney transplantation from 2003 to 2009. The second slide produced totals for living and deceased donations (nonheart beating donations NHBD). So there were two slides which have kidney transplant totals for the period 2003 to 2009.
The figures are these:
The first slide shows kidney transplants for 2009 to be 6,458. The second shows the figure 6,485. There is presumably a transposition error here. However, because we cannot check the original figures, we do not know which is correct.
For 2008, the figure for both slides is 6,274. This is useful information because it shows we are not considering two different types of data.
For 2007, the figure for the first slide is 7,700 and for the second slide is 3,974. This is a significant difference, without explanation.
For 2006, the difference is also large, 8,000 for first slide, 3,021 for the second slide. Similarly for 2005, we have 8,500 for the first slide and 3,441 for the second. For 2004, we have an astonishing figure of 10,000 for the first slide and 3,461 for the second. For 2003, we have 5,500 for the first slide and 3,171 for the second.
Because, for 2007 and earlier years, for the first slide we have rounded numbers and for the second slide precise numbers, it appears that, for the earlier years for the second slide we are not looking at totals but rather a subset. The first slide, it seems, presents estimates. The second set presents, it would seem, the subtotal of reported kidney transplants which provide the necessary differentiated information to allow the construction of the second table.
The second Huang Jiefu table differentiates between living and deceased donor kidney transplants. Kidney transplant information which does not distinguish between living and deceased sources would be useless for the construction of this table. So, presumably, it was just pushed aside.
Huang Jiefu, mind you, says none of this. He just blithely presents contradictory information without explanation and hides the data sets from the public on which he based his tables.
If the analysis here is correct, then the larger totals of the first table are the better ones. The larger though the totals, the more that is needed to explain the sources.
Huang Jiefu talks, in his Madrid speech, about how organ transplantation was initially an unregulated business. He does not say this, but the overall impression he leaves is that any hospital which wanted got into the business of transplants and sold transplants to whomever they wanted, getting organs from whatever source on which they could lay their hands. It is apparent that this sort of system would not produce reliable statistics, that any information about volumes would just be estimates.
A law which took effect on May 1, 2007 required that transplants take place only in registered hospitals. The law set up a registration system for hospitals. The statistics we see for 2008 and 2009 come, presumably, from the registered hospitals which is why we get precise figures in both slides for those years. From 2009, estimates from a hospital free-for-all became unnecessary.
Where in the world did 10,000 kidneys and 2,265 livers come from in 2004? It was not from living donors. Huang Jiefu, in his March 2010 Madrid presentation shows sixty four living donor kidney transplantations. He also shows that living donor liver transplantations in 2004 were .4% of total of liver transplantations.
Another table Huang Jiefu presents is living vs. deceased donor liver transplantation. That table shows significant living donor sources starting from 2007. Living donors are 23.5% of liver transplants in 2007, 19.1% in 2008 and 13.6% in 2009. However, for 2004, living donors are a mere .4% of total donations.
Living donations, according to the Huang Jiefu text, are given to “related or kinship recipients”. The Madrid presentation shows a significant increase in living donations from 2006 to 2007. There were 300 kidneys from living donors in 2006 and 1720 in 2007. 3.2% of transplanted livers came from living donors in 2006 and 23.5% in 2007. What caused this big jump?
The law in China allows for living donor sourcing from relatives. The State Council of the People’s Republic of China Regulations on Human Organ Transplant effective as of May 1, 2007 states
“The recipient of a living organ must be the donor’s spouse, lineal descent or collateral relative by blood within three generations, or they must prove they have developed a family like relation with the donor.”
The Government of China is trying to discourage sourcing from living donors, because of the risks to the donors. In an article in the China Daily, Chen Shi, an organ transplant expert with the institute of transplantation at Shanghai based Tongji Hospital, is quoted as saying
“Living organ donations, which can cause health risks for the donor, should always be the last resort when no suitable organ from a deceased donor is available.”
There has been fraud in the use of living relative donor exception which the authorities have been trying to control. Identities of donors have been disguised to pretend that they are relatives when they are not. This has led to a clampdown on living donor sourcing.
In Dongguan, doctor Zhou Kaizhang and seven others were prosecuted in August 2012 for this type of fraud. According to the Chinese Medical Doctor’s Association, Dr. Zhou had performed 1,000 kidney transplants. The prosecution related to 51 kidneys transplanted between March and December 2010.
The large increase in live donations from 2006 to 2007 may be the product of the corrupt black market system which in theory China is trying to discourage. Alternatively, the Chinese health system may have begun or increased the classification of prisoners killed through organ harvesting as live donors as a way of disguising the suspiciously large number of dead donors.
In an interview dated September 18, 2012, then Deputy Health Minister Huang Jiefu stated that 65% of organs come from prisoners and 35% from living donors. He added that live donations should be a last resort and not advocated. Living donations can cause damage to healthy donors and violates the “no harm” principle of medical ethics. Chinese medical insurance does not provide long term coverage to donors for complications from living donor transplants.
He noted that a living donor black market has emerged, inducing the poor to sell organs to wealthy people willing to pay high prices. This practice, he added, violates the principles of health care reform. The Ministry of Health issued a policy directive that live organ donor transplants must be approved by a provincial health department.
Another statistical glimpse came from an article published by six Chinese authors including Haibo Wang in August 2013 titled “Liver transplantation in mainland China: the overview of CLTR 2011 annual scientific report”. The actual report is not publicly available and not cited in the article. The article has neither footnotes nor endnotes. It cites three references, all foreign.
The article makes no reference to sourcing of organs from prisoners. It distinguishes between sources as either China category donors or non China category donors. The article defines the China category in this way:
“The classification was designed to be consistent with international classification standard for deceased organ donation and respect the current cultural and societal value of Chinese people.”
The “current cultural and societal value of the Chinese people” is a euphemism for Communist Party values.
The article states that 42.98% of the donors were deceased after circulatory death (DCD). In response to a query from a reader, the authors replied that
“The organ donation from death penalty prisoners with informed consent from prisoners themselves and their family is currently allowed by Chinese policies. Medically and scientifically, it was classified as the uncontrolled donation after circulatory death (DCD) in the scientific reports.”
The Government of China in March 2010 set up an organ donation system in 11 provinces and municipalities which has since expanded. This system is limited to deceased donation. It does not contemplate living donation.
Huang Jiefu gave a press conference in May 2013 at the Health Ministry Office Beijing stating that China is phasing out its reliance on executed prisoners for donated organs, but that ingrained cultural attitudes were impeding the rise of donations. He noted that Chinese have traditionally held that a person’s body should be interred intact, and while such attitudes are gradually changing, they remain strong among older Chinese. He added that China is a Confucian society. It’s strongly hierarchical and the family’s concerns usually trump those of the individual. An objection from even one family member can block a donation.
Reconciling figures from 2008, 2010 and 2013
The difficulty of reconciling figures becomes ever greater each time new figures are released. The figures in the August 2013 article are not consistent with the figures in the Madrid 2010 speech and, again because the sources are not available, there is no way of determining which of the contradictory figures is right.
If one compares the Haibo Wang statement in 2008 that there were 11,179 liver transplantations as of March 8, 2008 with his 2013 article, with its total of 20,877 transplants up to and including 2011, we can calculate that there were 9,698 transplants between the two dates. Yet, the 2013 article shows that the total liver transplants for 2008 to 2011 was 8,588.
So the two figures show a discrepancy of 1,350 transplants, a large number. How do we explain the discrepancy? Without access to the original figures, an explanation is impossible.
Huang Jiefu in Madrid in 2010 said that there were 16,961 liver transplants in China from 1993 to 2009. The 2013 Haibo Wang article shows a total of 20,877 liver transplants performed from 1980 to 2011. The difference between the two figures is 3,916. The 2013 article shows the liver transplants for 2010 to be 2,171 and for 2011 to be 1,897, for a total of 4,068. So there is a difference between the two presentations of 152 transplants. There is no explanation for this difference.
Inconsistency is more the rule than the exception. The year by year comparison for the volume of liver transplantations in the three presentations is this:
The figures in the three presentations did not coincide, not even once. Two of the three presentations produced the same figure only one year, 2000. It may be that the registered reporting hospitals are constantly revising their data. Yet, the figures do not consistently increase from earlier to later data. Why registered hospitals would be revising reported data downward, if that is what is happening, is not clear.