Market design, kidney exchange, and health inequality
Market design, kidney exchange, and health inequality
To what extent can facilitating the bringing together of supply and demand for organs save human lives and reduce health inequality? In particular, is it possible to organise the exchange of kidneys efficiently, taking into account ethical and regulatory restrictions? To what extent is this exchange between rich and poor countries manageable on a global scale?
okay good evening good evening everyone my apologies for starting so late i know that some people are uh waiting to come inside i'll knows that very well uh he uh well you know has been invited for many years now i've been trying to have him here for a long time but not to you know to catch the headlines or because the awards you received my invitations started long before you were awarded i mean he's got a long list of titles he's a professor at a fellow of the econometric society a member of the arts and science and so on so a long long list of titles but this is not the reason why we are so interested in having him and we have invited him for a long time i do believe that well indeed his scientific career is a lecture on methods people believes that economists are persons who work on very abstract mathematical models so they do extremely complex things which are not very useful often so they are considered like a barrier a way to re-state and reinstate that their discipline is distant from other things of reality he has a long career as a mathematician he started with a degree in columbia university of applied engineering he got a phd in stanford on operational research so mathematics is something which is really important and he started the game theory market design these are subjects which contain a lot of mathematics but he was able to use analytical tools which are extremely powerful to tackle very practical problems and to save human lives the uh first issue that he faced in his long scientific career is the allocation of students in public schools in new york and boston the initial system envisaged that students could be listed or could list a ranking of the schools they preferred and they had to indicate five schools where that was sent to schools as a matter of fact uh their uh the preferences of students was assigned for schools to select students so usually it was the one ranking first giving the sign for the selection and then students making the application started uh changing and doing strategical things so he studied an algorithm to meet uh to match the aspirations of students and the needs of public schools but the reason why he is most known and the one which had a major impact in improving the qualities and the life qualities of many people was his work with the algorithm to facilitate the exchange of kidneys there are markets where there is an issue of matching there are no prices often so it's us who don't want to have prices there are laws which prevent the application of market mechanisms something where there is a bilateral matching choosing is not enough i have to be chosen this is a typical case in kidney transplantation there are problems for example just think of a family a member of the family needs a kidney transplant in that family there might be someone available to donate a kidney but there might be practical reasons because they do not match in terms of blood group so they cannot donate the kidney to the people they want to help a member of their family there are however other families other couples who have the same problem so ideally it would be possible to allow the donor to give the kidney to a person they do not know and in exchange they can have a kidney donated to their partner or the person in the family needing that that algorithm has been widely used in the u.s health care system and about 10 percent approximately of kidney transplantations in the us have been governed by this algorithm this mechanism is you know becoming used in italy also a sort of exchange chain has to be settled and that works better when there is a person donating the kidney because they are good persons they are good samaritans they can donate one of their kidney even if no relatives need that there is a baker in a city near trento who donated his kidney and that started a chain in italy so that many people could receive the kidney was donated to a couple and they in turn donated a kidney to another couple and so on and so forth that is a way of using mathematical uh tools to solve a practical problem which is indeed a major one that is saving human lives i don't want to take more time away and professor roth will explain uh the algorithm and the basic principles of matching market the floor is yours thank you thank you i'm delighted to be here i think you need a microphone it's a good idea i am not lucky with microphones today can you hear me i hope you got very good so i'm going to as tito explained i'm going to try to talk to you about health inequality today through the example of of kidney failure kidney disease that requires transplantation but i'm going to do it from the perspective of a market designer and market design is an engineering part of economics so perhaps instead of a squirrel i should be speaking with an image of a beaver uh in mind and uh let's see there we go uh so uh so so markets of course are human artifacts they are tools that we build and markets are a little bit like languages because languages and markets are both collective human artifacts we make them together and just as there are many different languages there are many different kinds of markets and i think that mostly when we think about markets we tend to think about commodity markets so here's a picture of the new york stock exchange and the new york stock exchange is is a commodity market that sells many financial commodities but all the shares of of uh at t are the same so when you buy shares on the new york stock exchange you don't care who you are buying them from and the person who's selling them doesn't care who he's selling them to you are not entering into a relationship you are just looking for a good price and so the job of the new york stock exchange and of any commodity market is price discovery to find the prices at which supply equals demand at each moment during the day for each of the financial commodities that are being sold but not all markets work like that in many markets you do care who you're dealing with and and the prices don't do all the work because you also have to make a match and in some matching markets the one i'll concentrate on today for kidney transplants we don't even let prices do any of the work at all so let's think about matching markets because you are all familiar with them i teach at stanford university and stanford doesn't decide which students can come to study at stanford by raising the price until supply equals demand right it's expensive to go to stanford but you can't just go to stanford if you can afford it you have to be admitted so university admissions is a matching market and labor markets are also matching markets you can't just work at google because you want to you have to be hired and google can't just decide who will work there they have to compete with facebook so these are markets that are a little bit like marriage you can't just choose your spouse you also have to be chosen and that's the case in matching markets so matching markets are precisely the markets in which you can't just choose what you want even if you can afford it you also have to be chosen so with that as as an introduction let me tell you a little bit about health inequality from the point of view of kidney failure kidney failure in english goes by the name of end stage renal disease and just in who gets this disease there's already a great deal of inequality so this chart shows you the incidence of kidney disease per million people for different groups of americans and the top line is for americans of african descent and the bottom line is for americans of european descent and what you can see is just in who gets this disease there's already a great deal of inequality americans of african descent have three to four times the risk of having kidney failure as americans of european descent and it seems that this is true in africa compared to europe as well now there's also inequality in the treatment of kidney disease so a temporary treatment that keeps many people alive while they wait perhaps for a transplant is dialysis and here you have uh a map of the incidents per dialysis per per patient in the population and in western europe and the united states we have a pretty high incidence it's exceeded only in japan which you can hardly see here but in much of the world and and certainly in africa where there's very high incidence of kidney disease there is very little dialysis so in much of the world kidney disease is a death sentence whereas in the developed world you can stay alive for some years on dialysis in the hope of finding a transplant but even there there's a lot of inequality because there are not enough transplants for everyone who needs them so here's a graph of transplants per million population in countries around the world ordered loosely speaking from the right to the left in in how many transplants they have and the graph is in two colors the blue art transplants from dead people from deceased donors and the orange color are transplants from living donors so uh you see that in the united states and in in most places although there are some places where they don't do any deceased transplantation and those have only living transplant but in in much of the developed world there are more deceased donor transplants than uh than living donors but not necessarily a whole lot more in italy you have a pretty good level of deceased donor transplantation per per million population but not yet such a great rate of living donor transplantation and there are parts of the world and i will talk about the philippines and mexico there are parts of the world where there are excellent hospitals where you could get good treatment but but the an obstacle for many people is that the national health insurance does not cover transplantation and post-operative care and so many people who would get transplants if they or would be eligible for transplants if they lived in in the developed world in the philippines and mexico are not able to get transplants but the big shortage in the us is not financial barriers it's the number of organs so in the us this morning there are about a hundred thousand people on the waiting list for deceased donor kidneys for kidneys from from people who have died and who have agreed that their organs can be donated in the event that they that they die in a way that makes their organs valuable but we only get about 12 000 transplants a year from deceased donors in the united states and so since we have a hundred thousand people waiting that's not nearly enough and this isn't just an american problem uh the estimates vary widely because the data in many parts of the world are not are not so accurate but we estimate that that millions of people die each year because either they can't pay for transplantation or there aren't enough organs for transplantation where they live and it's not just an american problem here is a graph of europe where the top line is the waiting list for deceased donors the the orange bars here are deceased donors and the blue bars are living donors by year so you see that in europe and in the united states wealthy countries with with lots of medical facilities there aren't enough kidneys to transplant for the people who need them so only some people get transplants so in the us as i say there are about a hundred thousand people waiting today for deceased donor transplants only twelve thousand a year get transplanted which means that thousands die every year while waiting but kidneys are special because i already mentioned you can be a living donor of a kidney that's because healthy people have two kidneys and can remain healthy with one and so if someone you loved was dying of kidney failure you might be able to save their life by giving them one of your kidneys but sometimes you are healthy enough to give someone a kidney but as tito mentioned in his introduction you can't give it to the person you love and that's where economists come in because that opens up the possibility of exchange and here's the simplest kind of exchange between just two patient donor pairs so donor one loves recipient one but they have different blood types which which is an obstacle uh to transplantation although that particular obstacle can be overcome but donor two loves recipient two it's hard for each donor to give a a transplant to who they love but you can see that there are two blood type a kidneys two i'm sorry there's there's a blood type a donor and a blood type a recipient and there is also a blood type b donor and a blood type b recipient so these two incompatible patient donor pairs can trade with each other they can exchange so that each patient gives a compatible kidney and there are many other reasons why patients and donors can be incompatible and exchange often offers the opportunity for each patient to get a compatible kidney from another patient's donor now you notice that no money changes hands just kidneys change hands here that's because in the u.s and in almost all of the world it's against the law to pay for a kidney so here's a sentence from the american law the national organ transplant act of 1984 and it says it's unlawful for any person to receive or otherwise transfer any human organ for valuable consideration for transplantation so what that's a slightly complicated legal sentence but it means for sure you can't buy or sell a kidney in the united states and it's not just in the united states but here's a sentence from the council of europe's protocol on human rights and biomedicine it says the human body and its parts shall not as such give rise to financial gain so in italy in the united states in virtually all of the world with a single interesting exception it's illegal to pay the donor of a kidney for his kidney and and to have him sell you his kidney for a transplant so so just about everywhere in the world kidneys must be a gift and their price must be zero okay that introduces some complications into the logistics of kidney exchange so here are some pictures taken in 2006 in the city of cincinnati ohio and i'm the man in the yellow gown keeping my hands out of the way so that no one hands me anything and in this bucket here is a kidney and just steps behind me not not in this picture but just steps behind me is another operating room where the operation to remove the kidney has just taken place and it's going into this gentleman who's in cincinnati ohio and at the same time in toledo ohio a nearby city in ohio another operation is going on with the other half of the exchange and when i say at the same time i mean literally at the same time the surgeon in the orange cap is a man named steve woodle and he got on his phone his cell phone from the operating room when the patients had had been prepared had that had been anesthetized and initial incisions had been made and he called up mike reese in toledo ohio and he said we are ready in cincinnati are you ready in toledo and when he was told they were ready both operations proceeded i should say all four operations proceeded two kidney removals two nephrectomies and two transplants and the reason they do them simultaneously is you can't write a contract on a kidney what the national organ transplant act says is it says you can't give valuable consideration so consideration is an american legal term that has to do with contracts it's not legal just to write a contract that says we will give you a kidney today if you give us a kidney tomorrow and therefore to make sure that both sides of the exchange go through even this very simple exchange between just two pairs involves four operating rooms that have to be available simultaneously and four surgical teams that have to be available simultaneously so if if that were true of every time we did kidney exchange we would be able to do many fewer kidney exchanges than we are would like to do and then we are able to do today so there's another way of organizing exchanges that prevents one pair giving a kidney and then not receiving one and that happens when a non-directed donor appears okay so tito mentioned that there was a nearby mayor who who was a non-directed donor what we used to do before kidney exchange when a non-directed donor appeared after he passed through many tests both both physical and psychological uh is he would be told you are eligible to give someone a kidney you can give it to someone who has been waiting for a deceased donor kidney you can give it to someone on the wait list but now that there is this relatively thick marketplace of patient donor pairs waiting to exchange kidneys we can offer a more attractive option to a non-directed donor we can say you could give the non-direct donor you could give to the recipient in an incompatible patient donor pair and the donor who loves that recipient will give to a recipient in another pair and the donor will give to someone on the waitlist so instead of instead of helping to save one life you can help to save three you can have three transplants and a better picture of a non-director donor chain with three transplants is is this one this was the picture was taken in 2007 this was also an early kidney exchange it was done in 2006 and you see that there are six people in that picture the question is why only six and the answer is that in 2006 we were doing these exchanges also simultaneously so we could only get six operating rooms and six surgical teams together at the same time and and do all three transplants and three nephrectomies so you need six operations but once you have a non-directed donor maybe we don't need to do the transplant simultaneously so let's think about why we do transplant simultaneously on the left when we have two pairs when we have two couples two patient donor pairs suppose we didn't do them simultaneously we always do them simultaneously but let's suppose we didn't then on day one donor two might give a kidney to recipient one and on day so that's and he no longer has a kidney that's what the red x is for and on day two for some reason donor one fails to give a kidney to recipient two so it's a broken link in the exchange that's a very bad thing we never want that to happen because pair two donor two and recipient two have been really harmed first they had a surgery that didn't help them they gave a kidney but didn't receive one and they no longer have a kidney with which to participate in kidney exchange they won't be able to exchange a kidney anymore the next time we do a kidney exchange so they've been really harmed so we never let that happen we always do those simultaneously but now supposing we have a non-directed donor maybe we can relax a little because suppose that the non-directed donor on day one gives a recipient gives a kidney to recipient one and on day two for whatever reason again donor one fails to give a kidney to recipient two that's very disappointing but it's not tragic pair two hadn't yet given a kidney they are no worse off than they were before the non-directed donor appears and the next time we run a kidney exchange the next day or the next week they can participate because they still have a kidney because they were planning to get a kidney before they gave one so if if the chain breaks the cost is not so great and so we can consider whether we could do better by conducting chains non-simultaneously because then we wouldn't have to schedule so many operating rooms at the same time and we could conduct more transplants so the the first non-simultaneous chain was was reported in 2009 in the new england journal of medicine and the first author is mike reese the surgeon in toledo ohio at the other end of that phone call and this is an unusual paper but but there are many unusual papers in this literature because it has surgeons and economists and computer scientists among the authors and this first non-simultaneous chain at the time that it was reported had 20 people in the picture 10 nephrectomies 10 kidney removals and 10 transplants okay and the last lady in the picture helena mckinney she had blood type a b nowadays we try not to end chains with someone who has blood type a b because it was hard to find her a match but three years later when an appropriate match was found she continued the chain and added 12 more people to the picture so so chained sometimes a lot conducted non-simultaneously sometimes allow us to do many more transplants than could be done if they had to be done simultaneously and here's a picture of a of a long chain it has 60 people in the picture there have been some longer ones today in the united states the average non-directed donor chain has five people in it that's the average made up of some long chains and some short chains so kidney exchange has been growing in the united states kidney exchange and non-directed donation and today it's about almost 14 percent of the transplants that we do from living donors in the united states but it's still not enough so i could spend my time today telling you about victory after victory in the in the battle to to make more transplants available but i would be telling you about victories in a war that we are losing when i began work on kidney exchange there were only about 40 000 people in the united states waiting for transplants from deceased donors and today there are a hundred thousand so it's good that we make more transplants available but but we are not winning the war we have to do much better incidentally kidney exchange is also growing outside of the us this is a good thing and around the world i these i have a blog called market design and these are posts from my blog when i hear about uh kidney exchanges first being done in in other countries but what i want to tell you about now is you remember i showed you the the incidence of transplantation around the world and there are some parts of the world where there's very little transplantation there's some which means they have good hospitals that can care properly for patients but very little because there are financial barriers so for instance in the united states what stops there from being more transplants is there are not enough transplantable kidneys there are not enough organs but in the philippines and in mexico and in other parts of the developing world the reason that there are not enough transplants is there's not enough money and so the question is can we help can we do something that will mutually benefit developed world countries and developing world countries rich countries and poor countries and what we're proposing what we're just starting to try to do is to arrange kidney exchange by inviting patients from developing countries to the united states to take part in american kidney exchange and subsequent lifetime post-operative care in their home country free of charge the question is why why does this make sense and i want to tell you about that okay so let me tell you about the very first global kidney exchange which involved this couple from the philippines so in the philippines the national health insurance just covers about two months of dialysis so not very much at all and does not cover transplantation so this couple had used up its life savings trying to extend jose's life getting more dialysis but but then they came to the united states to toledo ohio and they received a transplant from an american non-directed donor so jose received a transplant and christine continued the chain by giving uh her kidney not to jose but to someone in the american kidney exchange pool so in fact here's a picture of the chain to date jose received a kidney from a non-directed american donor and christine continued the chain and gave uh she had a blood type oh she she started a blood type o chain that that gave to an american with blood type o and at the at the moment there are 11 pairs in this chain and uh jose and christine have have been back in the philippines for a while now after you've had a transplant you need to take immunosuppressive drugs every day for the rest of your life so part of taking proper care of jose is making sure that these drugs will be available to him in the philippines where where the philippine national health insurance doesn't cover them but so there's an escrow fund that that he will draw on and he is he was accompanied by a philippine surgeon and and is back in the philippines under the care of of that that surgeon's hospital so there's every reason to think that he will have as good a post operative experience as as the other patients in his chain who live in america why why is this possible to finance how is it that that we can offer foreign patients from poor countries the opportunity to come to the united states and receive transplant and and post-operative care for free the reason is that dialysis is much more expensive than transplantation so kidney transplantation is one of the few areas of medicine in which the best treatment transplantation is also the cheapest and every time an american is transplanted gets a kidney transplant it saves the some part of the american health care system at least a quarter of a million dollars in the first five years and that's more than enough to pay for the surgeries that jose and christine got in the united states and to pay for their post-operative care in the philippines so so there's reason to believe that that we could if we could do this on a large scale so far we have done only four of these global kidney exchange chains uh there's reason to believe that if we could do it on a large scale it would be self-financing one of the economic questions is would it remain self-financing if you did it on a large scale because the savings come from saving the dialysis costs of americans the reason the dialysis costs are so high for kidney patients is that it takes a long time to get a transplant so you have to be on dialysis for many years if you have kidney failure if the supply of kidneys were greatly increased maybe the dialysis time we would expect the dialysis time that american patients experienced would go down and the savings would be less but it turns out that when you when you look at the steady state when you model this process as it gets large what you find is the waiting list could be reduced massively and the and the global kidney exchange would still pay for itself because the american candidates to participate in global kidney exchange would be patients who were hard to find a kidney for and who would have who who would therefore have long expected dialysis times so so we're quite optimistic that this would be a self-financing program if it could be instituted on a large scale now the medical logistics are not the hardest part we already have learned how to bring patients to in this case ohio to mike reese in in his organization the alliance for paired donation and get them transplanted with support before they come and while they are here and after they go home the the hard part now is the financial engineering okay because the savings to the american health care system come from savings on dialysis but the cost of bringing foreign patients to be transplanted in the united states come from new surgeries so the question is how to move the savings from where they are experienced to where the new costs are experienced and this is not going to be easy the american health care system is quite fragmented we don't have a single national system so right now we think our best path forward will be in companies that that are self-insuring many of the biggest american companies are self-insuring because they have a big enough workforce so that they can absorb the the risk but if you look at the the cost statements that they have each year for their medical insurance and if you look at the 10 most costly patients they are paying for each year in a in a in a big american company often eight of those 10 are kidney patients because dialysis is so expensive so so we're hopeful that the financial flows will will work through the insurance that american workers have that will help americans get transplants and get off dialysis quicker and will also help foreign pairs get transplants that otherwise would not be available to them now i should tell you when we have a session tomorrow afternoon talking about repugnance i should tell you that you can never think about things like this without keeping in mind that it's against the law everywhere in the world to buy a kidney now there are black markets for kidneys i visited one in baku in azerbaijan there are places where you can buy a kidney and there are people willing to sell them and the people organizing these markets are criminals they are criminals not just here but but there where they are operating the single exception incidentally where it is the single country where there is a legal market where you can pay a donor for a kidney is in the islamic republic of iran and that's an interesting story in itself which i won't try to tell today but here we are here i have just proposed to you that we are going to have living donors christine the wife of jose uh coming from poor countries to to a rich country like the united states and we are going to to have transplants so i can tell you that as a first reaction many people think that this looks too much like an illegal black market that you are bringing people from poor countries for their kidneys now when i say many people think this some of them are surgeons so just recently in the march issue of this year's american journal of transplantation mike reese and many co-authors of whom i'm one published a paper on global kidney exchange it's called kidney exchange to overcome financial barriers to kidney transplantation just the way i explained to you now in the same issue in the same march issue appeared an editorial saying this is not a good paper it's it was called financial incompatibility walking a tightrope or blazing a trail and what they said is you know this is a little bit like buying kidneys from people in poor countries now it doesn't look that way to us the the philippine pair that i told you about got a kidney from an american and gave a kidney to an american just as everyone else in the chain did but but i take repugnance very seriously because in order to have a successful global kidney exchange not only will we have to figure out the medical logistics and not only will we have to figure out the financial flows we will also have to make sure it is conducted in a way that does not arouse repugnants and uh there are lots of concerns that could make it repugnant you might worry that you might worry that patients come from poor countries to the united states receive surgeries go home and then don't receive proper care and don't thrive and that's why we are thinking in terms of financial funds to make sure that they get proper care and it's why we are thinking about not the poorest of developing countries but but countries where proper care can be given where there are excellent hospitals that can provide proper care and similarly you might worry if it's illegal in the united states as it is and if it's illegal in the philippines as it is to buy a kidney you might worry that when we see a pair from the philippines maybe maybe the patient has paid the donor and so for the time being we are looking for people with well-established personal relationships like married couples so we think these repugnance concerns can be addressed but we're very sensitive to the fact that these are real concerns that have to be addressed and as i said i have a market design blog and i get comments on it and some of them say you know this is a bad idea uh the plan is really not about the international recipient it's it's about the us first america first that's why that's why it's not so good and then the the second one says america first the second one says let's solve problems at home first why are we why are we trying to to bring in these foreign patients but but of course it's it's mutual aid the foreign patients are helped and the american patients are helped and the third is by a famous surgeon who who some of us know who who worries that that this is exploiting poverty in a poor country now i think and i've spoken to i think we are not exploiting poverty i think we are finding a way to mutually benefit those in poor nations and those enriched ones and i'm happy to say that that's how it looks in the poor nations with which we are doing global kidney exchange so we recently did a global kidney exchange we've now done two um with mexico and here's the front page of of a recent copy of newsweek on espanol the the newsweek magazine that publishes in mexico and latin america and on the cover they say a bridge of life and the first paragraph of the story says just as u.s president donald trump is seeking to build a wall of thousands of miles on the border with mexico a tireless surgeon that's my grease and a renowned economist joined forces to exchange organs between citizens of both countries so in mexican eyes this does not look like exploitation in philippine eyes it does not and i hope in your eyes it will not because there's a chance that we can bring together the the mutual needs of citizens in rich and poor countries in order to uh to help them all let me stop now in relation to walls and this is another example because apart and beyond the example of kidney transplantation so this is an example of a market exa design alvin roth is married with an egyptian refugee who came to the us and took a phd in cognitive psychology and one of the areas they are working on is algorithms tackling the issue of refugees that is how to set the appropriate conditions so that the countries who could welcome refugees can actually welcome them and establish channels ways by which you win the resistance of other countries so this is another example of how uh market design can be used so there is a lot of food for thought for our discussion so as always we open the lecture to questions professor remutsy microphone adjustments the mic i i am a transplant nephrologist in bergamo in italy and i've been approached by my colleagues several times in order to be part be an active part of this program and he always says look we can do something for europe we can do for europe what we have done in the united states it would be wonderful and so at the beginning i was cautiously enthusiastic about the idea and i said really this can be a good idea there are other people involved one is the former major of rome he's here i you know my great friend what i did i don't know whether in yankee or agree or not i was to try to involve the other people in thinking about what you are saying uh like and the monaco him well yeah i know david tull who is a religious person who is very famous in the united states and all of them had major problems you know they wrote a long long long letter to me and to nancy saying several things among which the most important one in my view was they said why you are doing that in mexico and philippines that are the two single countries where you have more illegal organ organ trafficking exactly for the reason you said they are very sophisticated in terms of surgeon and nephrologist and post-transplant care sophisticated enough to do that and they have a black market that is very very well known so mexico and philippines are exactly the two countries not to have been selected according to demonic so if you if you convince me i am i hope you will convince me and then i will i will try to support i'm sure the nazi will will do the same okay so the question is why the philippines and mexico and and and and part of the reason why is they can do transplants there so let me say that before we went to the philippines in mexico i went to lagos nigeria and mike went to kenya and in both places we found that they were not sufficient health infrastructure to safely send patients back home if they came from there so so although the need in in lagos is enormous they they actually don't know how great the need is because they don't identify patients with chronic kidney disease let alone end-stage renal disease so so we want to help patients in countries where they can be safely sent home and the philippines and mexico are good examples of this so now the question is how about the the black markets that exist there so so let me tell you a story that that might be better told tomorrow when ignacio and i will be on a panel about repugnant transactions tomorrow afternoon actually i i can advertise that panel now on my can i have my slides back for a minute so tomorrow uh i'm going to speak about a book but then at 1 500 and then at 1830 ignacio and i and uh mario masses and nicola are going to speak about uh the question of how about repugnant transactions how should we think about them and one of the things that ignacio sent us uh in preparation for this was a short video of an illegal kidney transplant being done in pakistan and i am not a surgeon but looking at the video i could see that the surgeons wore gloves but not gowns there were people in the room who who hadn't scrubbed in it didn't look like a great place to get a kidney exchange one reason people get kidneys in illegal black markets is that they don't have better opportunities we would like to provide them with a better opportunity one reason we don't like illegal black markets is they take advantage of poor and vulnerable people the the donor sellers in illegal markets don't get adequate post-operative care in baku many of the the sellers are are young women from moldova or ukraine and then they and they are committing a crime at home and in azerbaijan so they go home to no care at all these black markets exploit vulnerable people global kidney exchange will not we will we will give people access to american quality health care and save their lives so i i i know frank del monaco very well let me let me just take a moment to to praise frank del monaco um he was not initially so confident that kidney exchange was a good idea but he eventually became convinced and we helped him my economist colleagues and i helped him found the new england program for kidney exchange which was the first multi-hospital kidney exchange in the united states so i'm hopeful that that will convince frank and i hope that we'll convince you as well that if we are careful and transparent in how we recruit donors and patients from overseas that we can not only deal with them in a completely ethical way but that we can start to diminish the attraction of the black markets well first of all i'd like to thank you i am a kidney transplanted person from a living person from my mother so i cannot but thank my mother for giving me that opportunity and i think that uh patients in places like mexico and the philippines have the same needs of transplants of americans or italians or europeans so i agree with you that the they go to the black market because they don't have any other alternative 25 years ago i did the first transplantation i went to belgium because in italy um in it well trent had that agreement with brussels anyway and i met a roman person who was who was going to india to do a transplant a non-official transplantation let's say so the needs are the same for all the patients and the opportunity to give mexicans or philippines so giving them the opportunity to get a transplantation and then be able to continue with the post-op care well in my opinion that is something great so i cannot but thank you for this project thank you for that we are lucky that our mothers love us and of course philippine mothers and wives and husbands and sons daughters love their relatives who need kidneys also so i agree with you it would be a great thing if we could in a system of mutual benefit extend the kind of health care we get in in the developed world to those loving people in the developing world thank you yeah i have three questions but very quickly a foreign see foreign so he can help me in convincing pepe mucci that is the way uh to god don't you think that you know the what you have shown to us is exactly the opposite of the black market because everything you've shown has is happening you know in in a in a way that everybody can check is if transparent is in the open is just the opposite of a black market of organ i i myself believe strongly that you know organ trafficking is a crime against humanity because you actually take advantage of somebody that is very poor for somebody that is rich and can pay for an organ and i think it is really wrong but what al is proposing here is quite the opposite i mean you can help a lot of people and i don't know if you should have shown the figure but the figure is very impressive we we are investing a lot of money in the planet all the countries to fight the disease like tbc malaria and the hiv ideas and the you know the number of people every year that die for this disease are about three or four million and the number of people that die because they do not have dialysis not transplantation dialysis is close to seven million seven million people so i think you know don't you think that this is a way that is transparent and you can help people where probably some money are wasted like in united states where you pay a lot of money uh you know for dialysis and help people that do not have any access in africa philippines mexico or other country to any kind of treatment well i i agree you know ignacio is one of the signers of the recent statement from the pontifical academy of sciences about about crimes against humanity involved in in human trafficking uh and so he answered you as a as a surgeon who is concerned with with the issues of of exploiting vulnerable people let me try to answer you a different way as an economist in in the late 1920s the united states outlawed the market for alcohol we had something called prohibition you may have seen movies about the the gangsters who who sold illegal alcohol um and it gave rise to a lot of organized crime and a lot of um a lot of alcohol that didn't meet good health standards and in the early 1930s we repealed prohibition and made alcohol legal again well i live in california where you can buy very nice wine incidentally and going into a a wine shop in california today is nothing like buying whiskey from gangsters in 1930. the the wine shops are regulated they they you know the wine doesn't poison people tastes pretty good you should come visit us in california and and so similarly i think that if we can make legal ways for people to get kidneys in kidney transplants in in ethical exchanges it will look nothing like the black markets that that are presently available around the world including in the philippines and in mexico thank you for your presentation um supply of kidneys in the u.s is not sufficient this is my question is it a question of altruism perhaps mexico and the philippines are more altruistic in giving organs this is another question and then is there a difference in terms of donations from men and from women yeah so let's look at whether they are more altruistic in in mexico and the philippines i think they are not that these figures are donations per million population so they are population adjusted now you can't directly tell whether people in the philippines are less altruistic of course because although they have many fewer living donations there's also fewer finances available to conduct live donor transplants so it's possible so i showed you the picture of a couple where the wife is very altruistic and wants to give a kidney to her husband but is unable to for financial reasons but but i don't think that um i don't at least think that there's good evidence that that the lack of well that people are more more altruistic in one part of the world than another and in the developing world it has turned out that simple altruism doesn't fill the need right we we don't have enough kidneys for transplantation so so i think we are obliged to to think about other ways to increase access to transplantation i should mention also in in my economist mode that not only is kidney failure a terrible disease it's it's an expensive one kidney disease takes up seven percent of the medicare budget in the united states so so it's a big part of the federal budget um i think that's also true here the gender the gender issue the gender differences ah gender differences um in the united states i don't think we have a big gender difference i think that in in in some countries it may be that more women donate kidneys to their husbands than husbands donate kidneys to their wives incidentally one important gender difference it's actually appears the the surgeons can can tell us about this it appears it's actually better to get a kidney from a man you know men are bigger their kidneys are bigger being big is good in a kidney so we must be more altruistic man okay these slides so i can advertise the next meetings two of them will be held tomorrow here they are tomorrow 3 p.m and then 6 30 p.m thank you very much thank you so much you