By Dr George Jacob
Kochi: Organ transplantation is one of the most complex and complicated surgical procedures that has been fine-tuned and made available for humanity’s benefit.
This is a procedure where monitory considerations in the form of transactions between recipients and the donors, or transactions involving any member of the transplant team is grossly unethical, and something which cannot be accepted or condoned.
Besides being technically complex and demanding as a procedure, it involves a large number of personnel. They are doctors, nurses, physiotherapists, respiratory therapists, social workers, counselors, laboratory and blood bank technicians. The doctors are not just surgeons, but transplant hepatologists, gastroenterologists, nephrologists, neurosurgeons, neurologists, pathologists, radiologists, anesthesiologists, intensivists, and psychiatrists.
All of them well trained to provide focused and determined efforts towards a focused goal- that of sending the patient, who have been given a ‘second and new lease of life’, home.
To put it simply, organs can be donated by (a) live people (people who are otherwise healthy). Here, altruism is the driving force. Here donors usually belong to the recipient’s family, or are well known to them. (b) Organs can also be donated by patients who are brain dead, otherwise called ‘cadavers’. Whoever donates, transplantation will proceed only if blood groups of the recipient and donor match, and other screening tests are passed.
Live donation is more demanding simply because an organ is harvested from a normal person, whose health cannot be compromised by donation. Here only a single organ can be harvested. The treating team’s responsibility is tremendous here, while in cadaver donation, no such burden exists, as the donor is already brain-dead, and is beyond recovery.
Here, multiple organs can be harvested to benefit many recipients. Organ retrieval from cadavers will be proceeded with only after ascertaining that the patient is brain-dead-through tests, which entails that recovery is nonexistent, through a number of stringent tests such as the Apnoea test and EEG by a team of doctors.
It is a tedious and an emotionally draining procedure that involves extreme human drama in terms of grief, disbelief, sense of loss and reactions to it, and one which demands empathy, and selfless concern for a fellow human being. Kerala was slow off the blocks in the field of organ donation and transplantation, unlike in other areas of healthcare dispensation.
In 2012, when the Kerala government first launched Mritasanjeevani, a deceased (cadaveric) donor organ transplant program coordinated by the Kerala Network for Organ Sharing (KNOS), the state had witnessed only 18 kidney and 4 liver transplants.
Involvement of two prominent individuals in Kerala changed the grim scenario for the better by many a mile.
(1) Industrialist and humanitarian, Kochouseph Chitilappilly (founder of V-Guard Industries and Wonderla Amusement Parks) donated one of his kidneys to a stranger.
(2) A priest, Father Davis Chiramel followed suit by donating his kidney. These two donations which were entirely altruistic in intention caught the imagination and attention of Kerala, to form the fulcrum of a rejuvenated organ transplantation scenario in the state.
People realized the existence of an option, though complex, technically demanding and manpower and man-hours intensive, and safe conduct of the same for patients with end-stage organ failure. These two gentlemen are now referred to as ‘organ evangelists.’ Since then, it seemed as though organ donation will never lose the newfound impetus within a reluctant Kerala.
Many specialized hospitals offered transplantation, most of them being living related transplants. Thanks to the ‘evangelists’, the number of organ donors shot up from 19 in 2012 to 76 in 2015. Though a change for the better, the ideal remained cadaveric transplantation, which somehow refused to take off in Kerala.
A large number of organs which could have given new chance at life to innumerable patients with end-stage organ failure were buried or burnt with the dead bodies of the brain dead. This was contrary to the scene in neighboring Tamil Nadu, where relatives of brain-dead patients showed tremendous benevolence in agreeing to donate organs for the benefit of absolute strangers.
Slowly but surely, the quantum jump in living-related organ donation rubbed off positively on cadaveric donation too in the state, which saw an almost 95 percent increase in cadaveric organ donation in five years.
Kerala came to top the country in terms of per million population. At 2.3 donors/million population, Kerala went on to outdo Tamil Nadu. The most crucial element in this success story has been the high levels of transparency and accountability that KNOS has been able to maintain, through its on-line portal and registry of patients on the waiting list for transplantation, with clear rules guiding the allocation of organs to patients, with none allowed to jump the queue. At one time, Kerala even topped the country in deceased organ donation in terms of per million population at 2.3, piping Tamil Nadu to the post.
As per the figures with KNOS, August 2012 to February 2017 saw 416 kidney, 191 liver,43 heart, 2 lungs, 4 pancreas 3 small intestine and 370 cornea transplants. The rapid takeoff of deceased organ transplantation in Kerala was helped to a great degree by (1) a Mollywood blockbuster ‘Traffic’, which dwelt on cadaveric transplantation (which educated the public about the concept in a big way), (2) instant Creation of the ‘green corridor’ for transporting organs at high speed, with cooperation of the state police, which stamped the government’s endorsement for a noble cause (3) long lingering involvement of the two ‘organ evangelists.’
However, even though deceased organ donation took off in a big way, it failed to cater to demands for organs. As of 29 January 2017, 1526 formed the queue for kidneys, not to speak of the waiting list for other organs.
Just as the two organ evangelists gave the much needed fillip to cadaveric organ donation in Kerala, two individuals’ mudslinging act at the noble field of cadaveric donation did much to clamp down the brakes hard on a burgeoning and path breaking progress Kerala had managed in the field of cadaveric donation.
The saying ‘too much of anything, including good is bad’ was proved right in Kerala.
The first one is a medical doctor himself, who approached the Kerala High Court alleging that the present system of allowing a team of private-hospital doctors to declare a patient ’brain-dead’ for the purpose of organ transplantation is open to wide abuse. He alleged that ‘organ trade’ is rampant in private hospitals in Kerala in total violation of the spirit of the statute, and that it is being done with silent approval of the authorities-by no means a small charge to brush ‘neath the carpet.
The other serious charge made by the doctor was that private hospitals charge 1 million to 1.5 million rupees to transplant a kidney, 1.5-2 million for pancreas, the same amount for intestine, 2-3 million rupees each of the two lobes of the liver, 3-5 million for the heart, thus accounting for 12 million private hospitals make from each brain dead patient.
The second person to sully cadaveric transplantation was a Mollywood actor (who incidentally had a leading role to play in the blockbuster Traffic, who termed organ transplantation as a ‘business fraud’ where hospitals and drug mafia benefitted from the ‘fraud.’ A patient, also a heart recipient came down heavily on the actor for shooting from his hips, after which the actor apologized profusely. But the damage was done.
The government decided to step in, in the face of these serious allegations, and logically so. From the present practice of three doctors from the hospital where the patient is being treated, and another doctor from a private hospital jointly certifying a patient brain-dead, the government made it mandatory that at least two of the doctors in the four-member panel should be government doctors and that the remaining two shouldn’t be from the hospital where the brain-dead patient is being treated.
It was also made mandatory to videograph the conduct of the crucial Apnoea test, which is not an action-oriented exercise to be caught on video, but an investigation-heavy procedure which a video can never informatively capture.
All these moves only resulted in doctors and institutions taking on a feeling of being accused of foul play, and being mistrusted despite all the hard work put in to make resurgence of a noble service to humanity like organ transplantation possible in a state inherently hesitant to provide organ transplantation to its citizen at the receiving end of end-stage organ failure.
The good work done by the evangelists was in no time taken apart by the doctor and the cine actor. Hospitals and personnel involved in the demanding and grinding exercise of organ transplantation felt dispirited. They felt they were not being trusted with a procedure which is no child’s play. Their motivation fell by the wayside.
From 72 who donated organs in 2016, the number came down to just 2 in 2017. What shot through like a meteor across Kerala’s skies fizzled into a dim flicker of a distant firefly.
With one fell swoop, these two denied chances for patients with end stage organ failure to return to normal life, through a noble procedure that modern medicine held out.
WHAT IS THE GROUND SITUATION?
What actually goes on in a hospital when a patient is declared ‘brain-dead’?
Nobody jumps up in excitement. No balloons are hung. No champagne bottle is uncorked. No cracker is burst. The first reaction by every member of a large team involved in transplantation is ‘OH NO!’
Coincidentally, serious head injuries leading to brain death take place on weekends when people chose to ‘unwind’. Alcohol is an inevitable ingredient in the process of ‘unwinding’. This leads to bad accidents on the roads, causing brain death of motorists, especially two wheelers.
Declaration of brain death and organ transplantation throw spanner in the works to happiness of the entire group of personnel involved in transplantation that calls for personal sacrifice at many levels, where precious man-hours and manpower is called for, until the patient goes home, without a hitch.
The entire process stretches over a number of days, and involves extreme dedication, hard work and unstinted cooperation from a huge team, and even their families, whose understanding and cooperation is as vital. The ground reality is that nobody really enjoys having brain death declared in a hospital. This is something people throwing stones at organ transplantation in Kerala might as well realize.
Then, who has being doing these transplants which changed Kerala’s dismal reputation in the field of organ transplantation? There indeed has been a group of conscientious and extremely duty-minded individuals. It is exactly these people that the doctor-cine actor team succeeded to dishearten.
WHAT WENT WRONG
what are the factors that has almost managed to put paid to a procedure(by no means simple, but yet taxing, and one that demands great deal of man-hours and manpower, effort, dedication and selfless readiness to answer the call of duty by the medical fraternity for the benefit of the populace of an entire state)?
• The hospitals, especially private ones went on an advertisement spree through the media whenever organ transplantation took place. Hospitals took on each other through the media, using transplantation as a tool. They went to the press laying bare the details of the donors and recipients creating hype, which was entirely unethical. Certain reports resembled a soap opera in print! Creating News out of organ donation had its place when transplantation was in its infancy, for the sake of public awareness. But once the procedure attained a routine status, going to the press every time a transplant took place had the public suspect foul play. The very procedure lost its credibility. At one point in time, people were wary to admit patients with head injury to hospitals doing transplantation for fear of having their organs harvested, instead of the patient being treated. Hospital authorities or even the government should have stepped in to douse this unhealthy trend.
• Hospitals, especially the private ones offering transplantation were accused of ‘minting money’ through the process. Indeed transplantation entailed a hefty bill. This is because a complex procedure such as organ transplantation requires extremely costly equipment and instruments. Even the solution used to transport and perfuse organs is prohibitively expensive.
• Private hospitals have no choice but to levy a huge bill. The solution to this is to equip and upgrade hospitals in the public sector, especially the government medical colleges to undertake organ transplantation, as the procedure would be rendered affordable to the common man. This is not a Utopian dream, or wishful thinking. In February of 2015, liver transplantation was successfully performed in Pariyayam Medical College in North Kerala. In September 2015, Government medical college in Kottayam became the first among government medical colleges in Kerala to perform heart transplantation. A public-private participation in organ harvesting from the brain-dead and conduction of transplantation has been mooted at a meeting between the Directorate of medical Education and principals of Government Medical colleges. If this is realized, it could be a huge boost to transplantation in the state as a whole.
• Involvement of non-medical personnel in private hospitals and their modus operandi have given room for casting a cloud of suspicion over the intentions and motive behind organ transplantation. These personnel, under stress ‘to perform’ and to ‘meet targets’ often tend to arm-twist and ‘hurry up’ through an extremely sensitive process of broaching the news of brain death to the family of the brain-dead and offering them the option to donate organs. A great deal of empathy, patience and selflessness is required here.
• Organ transplantation has traditionally been associated with the involvement of ‘agents’ and touts. It has to be accepted that this true regarding live-related transplants. Almost all major hospitals have well-known ‘agents’ operating openly to ‘make available’ organs for the money they demand. This has rubbed on the wrong side of cadaveric transplant program too, where no such agents operate, or can possibly operate. The only solution to this unhealthy trend in the state is for doctors to refuse to undertake transplants where the donor is one provided by an agent.
• A procedure that took time to establish itself, but later blossomed into an expansive tree must not be allowed to wither. Precious organs that will serve to give a second chance at life to hundreds should not be allowed to be wasted in the state, simply because it is criminal to do so.
Kerala must retrace its steps to a burgeoning organ transplantation program running, bereft of mistrust, suspicion and showmanship.