Each year about 20-25% of foreigners who are registered with the Transplant Authority of Tamil Nadu (TRANSTAN) get heart or lung transplants in Tamil Nadu. This has been happening for the last few years. No systematic study has been undertaken to understand the reasons why foreigners have received hearts and lungs and if they have received them at the expense of Indian patients. At the same time there have been instances when organs have been wasted.

A“fter every transplantation TRANSTAN [Transplant Authority of Tamil Nadu] prepares a report with all details — donor’s name, hospital that harvested the organs, the organs harvested, time of harvesting, and reasons for becoming brain dead. The report also has details of the hospital that received the organs, the hospitals that rejected the organs and the reasons for rejecting them,” says Dr. J. Amalorpavanathan, who was heading Transtan until he retired from government service in October 2016.

According to him, the report is shared with all stakeholders in the government and hospitals that harvested, transplanted and refused the organs. “All donations and allocations are fully documented. If Indian patients are overlooked then everyone will know it. We did not receive any complaints from any patient till I left,” he says countering Prof. Vimal Bhandari, Director, National Organ and Tissue Transplant Organisation (NOTTO) who said three of fours hearts harvested are given to foreigners.

“All donations are minuted and the summary is shared with all the stakeholder hospitals, including NOTTO. Tamil Nadu has the best and most transparent system, and it received the best State award from the Health Ministry for three consecutive years [2015, 2016 and 2017],” says Dr. Sunil Shroff, Managing-Trustee of Chennai’s MOHAN Foundation, an NGO that has been promoting organ donation and transplantation since 1997.

Much ado about transparency

Despite the transparency that is claimed to exist in Transtan, all my attempts to get information failed. I had sought information on the following: 1) number of heart and lung donations received from within Tamil Nadu and from other States in 2016, 2017 and till May 2018, 2) and the number of heart and lung transplant done on Indian and foreign patients in the last three years, 3) number of donated hearts and lungs that have not been used and gone wasted for various reasons, 4) number of heart and lung transplants done in government hospitals in Tamil Nadu, 5) how many Indian and foreign patients are currently waiting for heart and lung transplant.

After repeated calls to Transtan and twice speaking to the Member Secretary Dr. Kanthimathi who is a Chief Civil Surgeon at the Rajiv Gandhi Government Hospital in Chennai I got a mail from her assuring that my queries will be answered. In an email sent to me she said: “The details are being collected and will be sent to you shortly.”

But after about nine hours I received another mail from her stating: “As regards the data, as I have assumed office just recently I will have to look at the data in a detailed manner, method of it’s collection and validate it with individual recipient hospitals before I can comment.

“With respect to your question regarding national statistics you will have to approach NOTTO as we do not have access to data from other states.

“The reasons for number of transplants in government hospitals have to be addressed elsewhere as TRANTAN is not empowered nor has the surgical expertise to comment on what is a highly technical service.

“…I would like to be allowed to get on with the important task of both consolidating and building upon the initiatives started in the last six months by my predecessor towards improving transparency and accountability at TRANSTAN.”

In a TV discussion on the recent controversies in transplant in Tamil Nadu, Dr. Amalorpavanathan had said: “While transplant community is not a group of saints, it is unfair to slander them without any evidence. As of now no hard evidence exists. This sort of scare mongering will only result in drop in the number of donors.” About transparency and putting systems in place he said: “Every suspected violation should be investigated and if there is any transgression the guilty must be severely punished. As we evolve, there is a growing need for more transparency. So more data like how many patients were offered the organ, grounds for non acceptance etc can be posted in public domain without compromising privacy. More transparency breeds more confidence.”

How the system works

When organs are harvested from brain-dead patients, an alert is sent to all registered hospitals which carry out transplant surgeries. It is for the hospitals to indicate their willingness to accept the organs, and patients who have registered earlier will be given preference. Generally, preference is given to hospitals in the same zone (Tamil Nadu is split into three zones) as the one that harvested the organs. This is done to reduce the time taken to transport the organs and increase the success rate of transplantation. The order of preference is then for hospitals in other zones in the State, neighbouring States and other States and finally to patients from other countries.

“As a starting point it is important to know that in a given donor pool only 15-20% of lungs and 30% of hearts are suitable for use after assessment and this is across the board in most countries. The usual causes given for non usage in hearts include poor contractile function, coronary artery disease, elderly donor, blood stream infection. In lungs it is poor lung function, aspiration and infection,” Dr. Kanthimathi says.

“Each year about 20-25% of foreigners who are registered get heart or lungs. This has been happening for the last few years,” Dr. Shroff says. No systematic study has been undertaken to understand the reasons why foreigners have received hearts and lungs and if they have received them at the expense of Indian patients. At the same time there have been instances when organs have been wasted. In March this year alone, three hearts harvested from brain dead patients in Tamil Nadu were wasted as Transtan insisted that Indians on the waiting list be given priority.

“If there are no Indians available the organs are given to foreigners. This will keep happening till we have enough patients on our waiting list. When the liver transplantation programme was evolving we had some foreigners getting livers but over the last six-seven years we have not seen any foreigner getting liver transplant,” says Dr. Shroff. Now, liver transplantation is carried out even in tier two cities such as Tiruchirappalli in Tamil Nadu, says Dr. Amalorpavanathan.

But there also have been instances when Indian patients have died waiting for transplants since they could not afford the huge cost. In a Facebook post Parul Bhasin Verma has said that Yashoda Hospital in Hyderabad had given a cost estimate of Rs. 27 lakh for a liver transplant. “The doctors at Yashoda Hospital would quote a fee from Rs. 24-29 lakh to the different patients for a liver transplant,” she notes.

When heart from a brain-dead donor becomes available a matching recipient is chosen based on blood group, size of the donated heart, condition of the heart, age of the donor and the recipient, lung pressure (more the lung pressure greater the chances of failure of donated heart), and clinical conditions of the recipient. As a result, the utilisation of hearts is only 20-25%.

Only three centres in the entire country, all of them in Chennai, do lung transplants regularly. So majority of lungs in other states are not utilised.

“The waiting time for Indians for a heart is barely a few weeks, the median seldom more than a month. Hence the perception that organs are diverted to foreigners while thousands of Indian patients are currently awaiting a heart transplant is not true,” avers Dr. K.R. Balakrishnan, senior heart transplant surgeon at Fortis Malar hospital, Chennai.

But last month, a private hospital in Salem had retrieved organs from a brain-dead accident victim without the consent of the family. The heart taken from the brain-dead patient was shifted to Chennai and transplanted in a Ukrainian patient and the lungs were given to an Israeli national. The police are investigating the case.

More organs available

Across the country, there are more number of donated hearts available than being utilised. That is because only about six-eight hospitals in the country have active heart/lung transplant programmes. Of these, only four hospitals do more than 10 transplants a year. Even government hospitals in Tamil Nadu have a transplant programme with three hospitals in Chennai and one in Madurai. While no lung transplantation has been undertaken in government hospitals in Tamil Nadu, 10-15 heart transplantations have been carried out since 2008.

While AIIMS has not done more than about 75 heart transplants, many premier hospitals in the country such as JIPMER, PGIMER Chandigarh, CMC Vellore and Sree Chitra Tirunal Institute for Medical Sciences and Technology in Thiruvananthapuram do not have a heart transplant programme.

“There are plenty of donations happening in India but in places where there is no transplantation programme or hospitals that do very few a year,” says Dr. Balakrishnan. The time for a heart to be harvested from a brain-dead person and start pumping in the recipient is just four hours. Given the poor infrastructure of roads and lack of airports and/or flights from smaller towns, the logistics of transporting the organ to the nearby transplantation centre is often a nightmare. “We have not been able to utilise 40 hearts and 40 pair of lungs in the past 18 months only due to logistical reasons,” says Dr. Balakrishnan.

“We [Fortis Malar hospital] have so far done more than 100 heart transplants by airlifting them from other places. Initially, it was from Trichy, Coimbatore and Viskhakapatanam but now even from Mumbai and Kolkata,” says Dr. Balakrishnan.

In the last three-four years, there have been very few instances when a heart was taken from Tamil Nadu to other States. About 230 heart transplants have so far been carried out at Fortis Malar hospital alone. “A majority of the recipients were those from outside the State. Only about 20% were from Tamil Nadu,” says Dr. Balakrishnan.

Tamil Nadu has undertaken the largest number of transplantations, be it on Indians or foreigners. Some of these patients are from SAARC countries where there are no heart and/or lung transplant programme and also from countries like Palestine and Ukraine.

One of the reasons for more patients from families earning is less than Rs.72,000 per annum undergoing transplantation in Tamil Nadu is the generous funding of Rs.25 lakhs for heart transplant and up to Rs.30 lakhs for lung transplant by the government under the Chief Minister’s Comprehensive Health Insurance Scheme.