3. Total Kidney and Liver Transplant Capacity

A State Secret

In 2015, Huang Jiefu, China’s former Deputy Minister of Health, admitted in a television interview that the number of transplant surgeries performed is a state secret:¹

Huang Jiefu: The death penalty is a state secret, right?

Xu Gehui (reporter): But patients are not a secret. I’m sorry, I really don’t understand.

Huang: Your organs come from executed prisoners.

Xu: Okay, so the sources of the organs can be a secret, but is the waiting list [for transplants] also a secret?

Huang: You can deduce from the number of [executed prisoners] the number of [transplants] performed. Then don’t you know the state secret?

Xu: Then it should be smaller than this number [of executed prisoners]. Another reason is.

Huang: What you’re saying is too sensitive, so I can’t be too explicit with you. It will be clear to you as long as you think about it. Because your country doesn’t have a transparent system, you don’t know where the [organs] come from. How many [transplants] are done is also a secret, so in fact, many things are actually a mess, and the number isn’t clear to you.

(End of transcript)

Due to the sensitive nature of organ sources and financial incentives, the number of transplants is falsified level-by-level, all the way down to individual hospitals and doctors. As a result, the true number of transplants performed in China may forever remain unknown.

Basic Methodology

The organ harvesting crimes are ongoing. Under the current conditions of secrecy and deception, we cannot offer a single absolute number for the annual volume of transplants or offer even a close approximation.

As a Chinese saying goes, “paper cannot wrap fire.” Such a long-lasting, nationwide massacre cannot be concealed forever. While we cannot directly observe the number of transplants these hospitals have performed, we can still make extrapolations based on capacity, growth, transplant types performed, hospital bed count and utilization rates, professional personnel, and so on. Moreover, regulations published by the government provide useful information in determining the scale of transplant centers nationwide.

Numbers & Classifications of Organ Transplant Centers

According to statistics from the Administration of Hospitals under the National Health and Family Planning Commission (NHFPC) in July 2015,² there were 20,918 hospitals in Mainland China.³ Among them were 1,151 Class 3 hospitals and 4,321 Class 2 hospitals.⁴

Class 3 hospitals are normally located in major cities. They are typically large-scale general or specialized hospitals with over 500 beds. Among them, 705 are Class 3 Grade A (“3A”) hospitals.⁵

Huang Jiefu, former Deputy Minister of Health, said in March 2006, “For a hospital to pass the evaluation to become a Class 3A hospital, it must have completed a fixed target of more than five organ transplants. Organ transplantation has become a resource for competition among hospitals to reach the standard and for their branding.”⁶

In April 2015, Wuhan University Professor Ye Qifa, Executive Chairman of the China Organ Transplant Alliance and a specialist in major organ transplantation, stated to People’s Daily Online that before the introduction of the “Human Organ Transplant Ordinance” in 2007 there were over 1,000 medical institutions in China performing organ transplants.⁷

The World Organization to Investigate the Persecution of Falun Gong completed a comprehensive investigation in December 2014 of both organ transplant hospitals and doctors and determined that 865 hospitals were involved in organ transplantation. The hospitals are found in 22 provinces, five autonomous regions, four centrally administered municipalities, and 217 prefecture-level cities.⁸

Below are the qualifications and composition of the 712 hospitals that carry out liver and kidney transplants:

On May 23, 2007, the Ministry of Health announced a list of 87 transplant hospitals⁹ approved by the Review Expert Team of the Human Organ Transplantation Skills Clinical Application Committee and authorized by the Ministry of Health. We refer to these as “national level” hospitals. Essentially, these were the most qualified and capable national level organ transplant centers at that time. Concurrently, the Ministry released a list of second-tier hospitals designated to perform organ transplants, issuing 18-month temporary permits to 77 transplant centers with weaker qualifications. We refer to these as “regional level” hospitals. In total, 164 hospitals were given permits in 2007 to conduct organ transplants.¹⁰

On August 8, 2013, the National Health and Family Planning Commission (successor to the Ministry of Health) published a list of 165 hospitals approved to conduct organ transplants,¹¹ including Wuhan University Zhongnan Hospital Human Organ Transplant Center, which performs transplants from bodies with no cardiac activity. Four more hospitals were added to the list by the beginning of 2014, bringing the number of qualified hospitals to 169.¹²

This report focuses on the 164 hospitals that received approval from the Ministry of Health in 2007, so we can categorize their qualifications as either national or regional level. If we exclude the 18 heart and lung transplant centers, 146 transplant centers remain. Among the first approved group in 2007 were 26 national-level military and armed police hospitals, 52 national-level civilian hospitals and 68 designated hospitals.

Among the 566 transplant centers that did not receive approval from the Ministry of Health, 405 were based in large-scale 3A hospitals. These included 56 military and armed police organ transplant centers, 349 mostly-3A civilian hospitals, and 161 medium-sized hospitals (including 55 Class 3 Grade B and C hospitals and 106 mostly Class 2 hospitals).

Table: Classification of 712 hospitals conducting liver and/or kidney transplants

Volume Estimation Based on Minimum Requirements

We looked at the total possible transplant volumes that could be performed by these 712 liver and kidney transplant hospitals using the minimum capacity requirements issued by the Ministry of Health for permitted transplant centers.

146 Ministry Approved Liver and Kidney Hospitals

For hospitals approved to perform liver and/or kidney transplants, we calculated the minimum transplant capacity using the Ministry’s minimum bed requirements for maintenance of certification.

On June 27, 2006, the Ministry of Health published a “Notice Regarding the Management and Regulation of Liver, Kidney, Heart, and Lung Transplantation Capabilities,” which imposed the following requirements for medical institutions carrying out organ transplants:¹³

• Liver: 15 beds dedicated to liver transplants and no fewer than 10 ICU beds
• Kidney: 20 beds dedicated to kidney transplants and no fewer than 10 ICU beds

Based on an average one-month hospital stay, each bed could accommodate up to 12 transplant patients per year. In practice, kidney transplants generally require one to two weeks whereas liver transplants require three to four weeks of hospitalization. Since we are mixing kidney and liver transplants in our volume analysis, we use the maximum hospitalization duration of four weeks as the average length of stay for each transplant patient.

Our survey of 165 hospitals found widespread facility constraints, including transplant centers with bed utilization rates exceeding 100% and a long list of patients waiting for transplants. It is important to note that Huang Jiefu has publicly announced plans to expand the number of approved transplant hospitals from 169 to between 300 and 500 and to train 400 or 500 more young doctors. This suggests that the current system-wide capacity cannot keep up with demand.^{14 15 16} Thus, we are confident in assuming that the vast majority of the existing hospital capacity is being fully utilized to perform transplantation surgeries.

Given 100% bed utilization rates, our calculations indicate that all 146 hospitals combined could theoretically conduct 69,300 transplants per year.

After 2000, liver transplants gradually became a routine clinical procedure in China.¹⁷ Soon thereafter, kidney transplants also began to be carried out on a large scale with a few kidney transplant centers already exceeding 1,000 kidney transplants. Since many liver transplant centers also conduct kidney transplants, the rapid increase in the number of kidney transplants compensate for the relative delay in scaling up liver transplants.

We then multiplied annual figures for the approved hospitals by fifteen (years), excluding the year of 2000 as ramp-up time. Following this method, we estimate that the total transplant capacity in approved centers over the 15-year period between 2001 and 2015 is 1,039,500.

Table: A volume scenario of 146 hospitals permitted to conduct transplants, based on transplant bed count requirements by the Ministry of Health.

566 Non-Approved Hospitals

Because only 164 of the more than 1,000 hospitals that applied under the Ministry of Health’s 2007 approval system received permits, in reality, there have been more than 566 non-approved hospitals performing transplants. Despite not being approved by the Ministry of Health, many of these facilities have not halted transplant activities with some of these non-approved institutions reporting significant transplant volumes

405 Large-Scale Non-Approved Military and Civilian Hospitals

All of the 3A institutions located in large cities are required to have over 500 inpatient beds.¹⁸ There are cases of centers in medium-sized cities performing 100 transplants within three months,¹⁹ which would equate to 400 surgeries per year, assuming a constant rate. All 405 hospitals in this category are 3A hospitals with larger capacities and greater demand. As there could be great variations in transplant volume from hospital to hospital, we set the baseline for each large-scale hospital at 100 transplants per year.

161 Medium-Size and “Alternative” Non-Approved Transplant Hospitals

This group includes 161 medium-size transplant institutions, 55 Class 3 Grade B hospitals, 106 Class 2 hospitals, and a few smaller ones that also conduct organ transplants. These hospitals usually perform more kidney transplants, which have lower technical requirements than liver transplants. Many of these hospitals have performed far more transplants than the minimum volume, with some performing hundreds per year.

Before the Ministry of Health released its list of 164 approved transplant centers in 2007, transplant centers across China had been qualified for transplantation by various assessment departments. For example, the minimum requirement for a qualified kidney transplant center in Guangdong Province in 2003 was to conduct at least 50 kidney transplants per year.²⁰ Between September and December 2003, 30 hospitals qualified for kidney transplants and 17 for liver transplants. We assume 50 transplants per year for each medium non-approved transplant center.

Military hospital transplant centers were minimally affected by the introduction of transplant permits in 2007 and have continued to carry out transplantation surgeries. Many non-approved civilian centers also continued to conduct transplants after 2007, but their individual situations varied. We assumed that all non-approved hospitals stopped performing transplants after 2007 and therefore multiplied the annual volumes for non-approved hospitals only by 7 years (2001 to 2007).

Added together, the non-approved transplant centers could perform up to 48,550 transplants per year. Over a period of 7 years, the total could be 339,850 transplants.

Table: Estimated annual transplant volume of non-approved hospitals based on minimum requirements.

Sum of 712 Hospitals Based on Minimum Requirements

Adding the 1,039,500 transplants performed by approved hospitals and the 339,850 transplants performed by non-approved hospitals, we arrive at a figure of approximately 1,379,350 transplants, which translates into about 90,000 transplants performed per year in China.

Table: A transplant volume scenario based on Ministry of Health requirements for permitted hospitals and local regulations for non-permitted hospitals.

This analysis is based on the published minimum bed counts under the Ministry of Health’s permit system in 2007. Even though the Ministry approved only 164 centers, most of which carry out far more transplants than minimum bed counts can produce, it is relevant that more than 1,000 hospitals applied for permits to conduct transplants under this system, logically implying that they were either close to or met these minimum requirements.²¹

This discussion is limited to liver and kidney transplants. We do not attempt to estimate a conclusive total at this stage; instead, we present only a minimum range of possibilities, which likely do not reflect the full scale of transplants performed in China. The true scale and magnitude of transplantation surgery in China is left for the reader to conjecture.

The reported transplant figures indicate that the total number of transplants performed before 2007 by the 80% of hospitals that have not received permits are comparable to that of the approved 20%. Thus, the number of transplants performed by approved transplant centers constitute only half of all transplants carried out in China.

Cross-Verification with Media Reports

Some doctors and hospitals unintentionally exposed clues of their transplant volumes when talking to the media. These numbers are far higher than the minimum requirements would suggest. Below are a few examples of such reports.

In November 2011, Sina Global News reported that Wuhan, a major city in central China, is said to be China’s largest organ transplant center. Among its hospitals, Tongji Hospital of Huazhong University of Science & Technology is the most well-known. It is also one of China’s first and most authoritative hospitals for living kidney transplants. It conducts thousands of kidney transplants each year and has China’s largest pool of kidney recipients.²²

In September 2013, Zhu Jiye, director of the Organ Transplant Institute of Peking University and the Department of Hepatobiliary Surgery of Peking University People’s Hospital told China Economic Weekly that “most of our nation’s organ transplants come from death-row prisoners. Our hospital conducted 4,000 liver and kidney transplant operations within a particular year. These organs all came from death-row prisoners.”²³

On celebrating the 100th Anniversary of the First Affiliated Hospital of Sun Yat-Sen University in October of 2010, a report posted on the news website of Xinkuai Paper stated that tens of thousands of patients had accepted liver or kidney transplants at its organ transplant center.²⁴

The First Affiliated Hospital of Sun Yat-Sen University News

When talking about the glorious history of the First Affiliated Hospital of Sun Yat-Sen University, we have to mention its organ transplant center, where tens of thousands of patients have received liver or kidney transplants …

On April 4, 2006, Asia Times published a report entitled “Japanese flock to China for organ transplants.” The report states that Mr. Suzuki, chairman of the Japan Transplant Recipients Organization, discovered that a hospital in a major city in China conducted 2,000 organ transplants in 2005 alone. Among the recipients, 30 to 40 were Japanese, and 200 were Korean.²⁵

In China, everything in the media is subject to either censorship or self-censorship. A media story in China is also a statement that the Party wants published, has allowed to be published, or that the authors and media editors believe the Party would not mind having published.

What is true for the media is also, in a sense, true of hospital websites. Although the media is subject to the closest scrutiny, nothing gets posted or published by hospitals without the approval or implied consent of the Party.

Media stories about organ transplant volumes in China often inadvertently reveal damaging information when examined in the proper context. Seemingly isolated statistics about organ transplants can provide important evidence of higher transplant volumes than those formally acknowledged. Thoughtless admissions or concessions by the Party/State have revealed that the volume of transplants is substantially higher than the minimum number we determined earlier.

Therefore, the total volume of transplants carried out by the 712 liver and kidney transplant centers since 2000 is most likely staggering.

References