 I'm delighted to welcome you to this session in our seminar series on ethical issues in organ transplantation. The speaker today is going to be Mike Millis, who will be talking about ethical issues and transplantation in China. As many of you know, Mike is a professor of surgery, the director of the transplant center here, and also the medical director of transplantation services at the university. He trained in medical school at Tennessee and residency and fellowship at UCLA. His research in recent years has been closely related to health policy and ethics, particularly working with the vice minister of health of China, J-Fu Wang, himself a transplant surgeon to try to modify and change transplantation policies in China. I think that will be the topic that Mike is going to discuss today. It's wonderful to welcome you, a member of the American College of Surgeons, Mary Sider Transplant Surgeons, et cetera. Michael, welcome. It's a great honor to be asked to speak in the faculty series following such great talks that we've had all this year. And hopefully this will live up to the standard, and the rest of the talks from the rest of our speakers for the rest of the year will be similarly as good as at least our past ones. So with that, as Mark said, over the last several years worked very closely with the vice minister of health in China to enact some reforms that have improved the field of transplantation in China. And I'll be talking about that. I have to obviously start off with a conflict of interest statement, and I don't think I have any conflict of interests. The work that I've done has been supported by a grant from the China Medical Board, which is to improve the practice and policy of transplantation in China. It was originally funded in 2007 and renewed in 2011. When people find out that I'm a transplant surgeon and that I do work in China, the first thing that people ask me is, oh, so do you go over and do transplants in China? And I quickly respond that I do not. And I mention this at the conflict of interest slide because frequently those activities have been associated with a high compensation for those surgeons who have gone to other countries and done transplants like this. And so I can assure you I have never done a transplant in China, much less gotten any money from doing them in China if I were to go. So then the follow-up question is, then, well, what do you do? And so I had a hard time answering that up until the McLean Fellows Conference when Peter Singer introduced me, at least, to the term of social entrepreneur. And I think that really does describe what I'm trying to do. And this is a picture of Bill Drayton, who is a founder of an organization that funds and supports social entrepreneurs. And in the quote, it says that social entrepreneurs are not content to just give a fish or to teach how to fish. They will not rest until they have revolutionized the fishing industry. And so putting that into what I do in China, my goal is not to just do a transplant or to teach the Chinese how to perform transplants, but to revolutionize the transplant system. And so we'll kind of use that as the benchmark of what I'm trying to do and how successful I may have been or not have been, as your opinion may vary on that. So the first thing we have to really discuss is, why does transplant need policies and regulations? We certainly know that if many of the physicians in this room were in their lab working on their research and had developed a small molecule that they wanted to try to test in humans, they would have to go through a rigorous FDA approval process in order to do the clinical trials much less than get approval to do them. However, if a surgeon develops an operation either in his lab or even in his mind and wants to try it on a patient, probably at most he needs an IRB approval and informed consent for that. So surgery is remarkably absent of regulatory oversight. That the surgeon-patient relationship is one of the most sacred in medicine. We have individualized pre-op planning of unique operations and intraoperative decisions that we cannot discuss with the patient. And so the care between a surgeon and a patient is very personalized and very much lacking of regulation. So in general in the hospital, if you just take it out to the hospital, non-transplant medical care, there's regulation on general hospital care, drugs, diagnostics, things like that, that the FDA and JCAH, et cetera, goes through. But regulation is absent on process, priorities, resource allocation, et cetera. So if a patient with a pancreatic cancer with a minimal chance of survival really wants a Whipple operation, then as long as the risks and benefits are described to the patient, then more than likely that patient will receive the operation. But transplant surgeons are, by their nature, conflicted in our practice. We have the care of the patient and the care of the potential donor simultaneously. And so regulations must be provided. And for transplant care, regulation, in fact, drives all processes, priorities, allocation decisions, and quality assessments. It's not just up to the doctor and the patient. So this is obviously Michelangelo's depiction of the gift of life from God to man, Sandy. I think that's right. Your husband, the art history. Sandy here? No. Oh, she's not here today. Okay. I certainly know Michelangelo in terms of art. I was able to connect this mother and her daughter through the gift of an organ. And this is indeed why we have to, transplantation is different and why we have to be concerned both about the donor and the recipient. And in fact, I say that transplantation and the regulatory aspects that we deal with the most is because of the concern for that third party, for that donor. And we have to protect the rights and concerns of that donor before and after donation, and that's whether they are a living donor or a deceased donor. We have to protect their gift, and that drives much of the regulation on the recipient side. Patient selection is part of the decision-making process, is determined if the recipient will be able to take care of the graft, the program quality. If we don't have guidelines for the quality aspects of the program, then the gift will be wasted as well. And once the aspect of an equitable allocation system we know is part and parcel to a society that will support organ donation in the long term. So now we change a little bit, hopefully having provided you the background and reasons why transplantation has to be regulated. And we can see, in fact, that when transplantation grows up in an unregulated fashion as it did in China, there are many abuses and problems. And these were finally started to be addressed in 2006 by Jaifu at a WHO conference in 2006 in which the first public and then subsequently scientific recognition of the problems of transplantation in China occurred. The press focused, of course, on the organs from executed prisoners of which is certainly a problem, but there were also many other problems, quality, lack of a database, lack of transparency at every level, transplant tourism, and payment of organs were in fact just a few of the additional problems that needed to be addressed in order to try to clean up the transplant system in China. So the bottom line in China, having transplantation grown up in a nonregulated fashion, were that patients who needed transplants were getting harmed, living donors were being harmed, transplantation's reputation worldwide was being harmed, patients were not receiving maximal benefits from their transplant because of physician compensation systems and feudal transplants were performed just in order to get the compensation. Organizations were not provided adequate informed consent either on the donor, the recipient, or the payer. There was no transparency. Centers had exclusive relationships with prisons and centers could do whatever they wanted to with the organ, eliminating any appearance of equity. And there was also concerns that the need for organs would drive executions at least the time of the execution. And at least at that level, if not at potentially even at the judicial level of someone being paid off to, a judge being paid off to sentence someone to death in order to receive ultimately the organs from that person. So this is, so now we're kind of switching now to what we've gotten to in 2012. And a recognition by China and Jaifu, both in April and May at two different talks that the reliance on deceased donors, organs from executed prisoners will stop. And that the reason for that is that the death rope inmates in his words may feel oppressed to become a donor. So transplant tourism is driven by profits. Some hospitals trade with illegal organ agencies and forged identifications in order to sell organs to foreigners. Transplant tourism has made the sale of organs even more lucrative. And unfortunately this practice continues in China, although regulation has been established to ban transplant tourism. And that really talks about the lack of the rule of law overall in China, and not just within transplant or health care in general. If you talk to enough people from China who know about China, the whole rule of law aspect and pushing down regulations to the individual level is frequently a problem. But the commercialization of transplant services with organ trafficking and agencies is a huge problem and it violates the principles of equity and the goal of establishing a harmonious society. So one of the things that we've seen with the regulations is a dramatic decrease in the number of transplants performed. You see the curve of transplants going up and it really peaked in in 04. And then soon after that in 06 is when the regulation started and you're seeing a drop. And today, well the most recent data that we have, 2010, it's essentially at the same level as this for kidneys and this for liver. So one could certainly say that we haven't been successful in terms of providing transplant services to those Chinese who need it. And I think that we would all have to agree that that is true. But the issue is that we have to go through a period of time in which to get into a more ethical scenario and a sustainable ethical scenario that fewer transplants are being performed. And ultimately the greater good of a better system that ultimately will provide more organs for China will be developed. Even at the most extreme estimates of the number of executed prisoners that have been postulated out there, there's no way that that number, even if they were able to use all of them as organ donors, would be able to satisfy the demand. And a citizen-based system would be much more likely to get to a closer scenario of demand and supply. So if we look at the world activity in organ transplantation, those are the numbers. China does approximately 10% of those. And those are the numbers there for each organ with kidney a little lower and liver at 9.9% and heart and lung in very small amounts. So once again, in 06, if we go back to that point in time, we had over 95% of the donors were from executed prisoners. Transplant tourism was widespread. There were over 600 hospitals performing transplants, and then there were no regulations. The vice-minister called all the programs that were operating at that time to Guangzhou for a meeting in which all the transplant centers were notified that they must apply to the Ministry of Health in order to continue to perform transplants in general. And they provided the criterion which programs would be judged. And they are very similar in fact to FDA and UNOS regulations regarding transplant centers as well. Experience of primary surgeon, the center volume, institutional support, and the field strength of the institution in order to be able to provide transplant services. And on the donor side, there was regulations that the prisoners and or the prisoners family must sign the consent. There were four principal areas of focus, regulating quality, regulating transplantable organs, regulating transplant tourism, and regulating the source and rights of the organ donor. So in 06, the interim provisions on the clinical application and management of human organ transplantation was promulgated from the Ministry of Health and that those once again now codified those areas of criteria of ethics, medical and surgical expertise, ICU, care, et cetera. And in April of 06, the Committee of Organ Transplantation was established. And in November of 06, the National Summit was to announce all these changes. This is the regulation that came out in 07 that from the State Council and then the decree which was adopted by the legislature. So the impact of these regulations decreased the number of transplant centers from over 600 to 161. They had 18 months to fully comply with the Ministry of Health regulations. And currently there are 161 fully approved Ministry of Health transplant centers. There were applications that were turned down because they didn't want to increase that number and they were still reviewing the first group. All provinces in China have at least one transplant center. So I go through the liver regulations just as a highlight, basically all the other organs have similar regulations. You must have a Ministry of Health license to perform, in this case liver transplantation. Only they have different levels of hospitals, the highest level is a 3A hospital. So you must be a 3A hospital. You must have departments of surgery, gastroenterology and ICU. The facility requirements you have to have more than 80 beds, 10 years of experience in hepatobiliary surgery, over 500 hepatobiliary or pancreatic operations per year. And that you have to have a separate liver transplant OR and a liver transplant ward. Surgery requirements, three senior surgeons, greater than 10 years of experience and five years, greater than five years of experience in liver transplantation and the volume requirements as well. So you can see that those of us who are very familiar with the requirements for CMS and for UNOS, in general they are in the same flavor as those regulations. So how have they tried to enforce the regulations? As I mentioned before, there are issues regarding the rule of law and enforcement of any regulation in China. And this slide is just documenting too, but there have been others with similar consequences. The vice minister was informed of two cases of transplant tourism back in 08. The response was after a full investigation that confirmed these cases. Each of the hospitals was not allowed to perform the transplant that they transplanted a transplant tourist on for a year. So it found out at least the penalties are severe. The issue is once again how to kind of police that as they don't really have the manpower to do audits, UNOS audits like we see here, CMS audits, or even an ability to track each organ that is procured at the current time. So one of the issues is living donation and as the number of organs from executed prisoners has decreased, the number of living donors has increased, the Ministry of Health does not officially condone or support living donation, but it does address it in regulation and has become even more prescriptive than the U.S. in this area in terms of who should be accepted for donors, including BMI, hypertension and anatomy issues that get down to who can and cannot be a living donor. And part of that is that the Ministry of Health feels that China's legal, social, economic and health systems are not yet mature enough to support living donation in the way that Western countries have been able to support it. So these regulations were published in The Lancet by Jaifu, myself, and Eli Mao, who is Jaifu's kind of right-hand man back in 08. And then, soon after that, the registry was formed, and the key people for the registry are ST Fan here and Haibo here. Both ST is a transplant surgeon in Hong Kong and chairman of the Department of Surgery, and Haibo, I don't know what kind of physician he is, but he's also getting his Master's of Public Health currently in the States and has been instrumental in developing and working with the registry to make it as efficient as possible. And it is a post-transplant registry, so Ministry of Health approved hospitals have to provide information regarding their transplants to the registry. And if you have access to it, you can get your own data. It is certainly not the same as you know those of us who, in transplant, you know, we can go to SRTR and find out not only your stats, but stats for every other program that you, in the country, it is not that robust. It is not that transparent at the current time. Something that we'll certainly be working on, but there's a lot, just as it was when the U.S. started that, there's a lot of apprehension of putting your own data out publicly. So brain death has been a big issue in Asia in general, and it has not been particularly effective or embraced by any of the Asian cultures. That, however, didn't stop us from at least trying. As we know that in the U.S. it's been the standard since 69, it's the standard in Europe. The primary criteria are established in the etiology of the disease causing brain death, excluding other potentially reversible syndromes, demonstrating clinical signs of brain death, and all of these were, in fact, generally accepted by this conference that I was at by the medical community, but because of issues regarding kind of the Ministry of Health, the Justice Ministry, et cetera, there was no way to get a law passed. And so we have, as of today still, have failed in getting a brain death law happening in China. At the same time, I show this, at the same time that the brain death meeting was occurring, I think a couple of days before, there was a meeting in the Chinese Organ Transplant Council. I think I was the only Westerner that has been a part of that, but that is not the significant part. The significant part is this person here who's in military garb, and it was the first time, in fact, that the military had attended a Chinese Organ Transplant Council meeting. And that is significant because in China there are at least two different hospital systems. There's the Ministry of Health system, which is the larger, and then there's a military system. Military system essentially does not have to abide by the Ministry of Health policies, rules, and regulations. And so just by them joining the Organ Transplant Council meeting is at least a first step in the process of them understanding that hopefully they will get into a similar type of regulatory environment in the future. So what do we do when we're trying to develop a citizen-based voluntary system of organ donation without a brain death law? So this is the standard Western and our current way of looking at the deceased owner pool. We have the blue ones, the brain death ones, and the salmon color that are depicting the donation of cardiac death. And we think of them as different groups, and we treat them in a totally different manner in terms of their workup, the ethical underpinnings, et cetera. And when you don't have a brain death law, it's really hard to kind of move forward in a deceased owner pool. So what we had to do was think of an innovative way to reclassify things. And so what we did was we redefined deceased organ donation in China. And so now we have this whole pool and we have those blue donors who are brain dead donors, but we will treat them like the salmon, the donation after cardiac death donors. And that way every donor will be treated the same way, just like a DCD donor. Some of them will be brain dead, but will not be necessarily classified as brain dead, but they will obviously die more quickly than those that in our traditional fashion of looking at a donation after cardiac death. And so we looked at this innovative way of redefining deceased organ donation in China. We published that once again on Lancet Article in 2012 and also noted that we were going to begin a pilot project of donation utilizing these types of terms and processes. And so as I mentioned, we will treat all potential donors as DCDs and especially at first because in fact many of the hospital's ICUs, they would have brain dead donors just hanging around because they had nothing else that they could do with them. They couldn't take them off life support because that would be killing them because they didn't have a brain death law even that they were brain dead. And so they just had these people taking up and at the brain death meeting it was estimated that up to I think 10% of the healthcare costs in China were programmed for these types of patients who were in ICUs just hanging out as brain dead but not being able to do anything about them. And so we also wanted to establish a national organ donation system with an allocation system, etc., moving towards what would be closer to be considered to be a Western type of scenario. So we were treating everyone as a DCD donor. The demonstration project ran from April of 11th to January of 12th and 26 OPOs were utilized slash established and 292 organs went to 31 hospitals and 50% were occurred in the last six months of the project. An update from that is now that there's up to 546 organs from 207 donors in 16 regions. And for the first time under this system organs were actually allocated in a transparent way and a sharing policy was established. As I mentioned before previously there was a one-to-one relationship between prisoners and hospitals which allowed the hospitals to transplant whoever they wished. And now there's a sharing policy and an allocation system. If a donor was identified in one of the transplant hospitals the transplant hospital was guaranteed to get at least one kidney out of that donor similar to the early stages of UNOS in which there was some feeling of propriety in an organ and a donor within your organization. So the essentially UNOS type of system, the China organ transplant response system was launched in April of 11th and there were 26 OPOs, etc. And this is how they signed in and there was a decision made on how to allocate and prioritize candidates with transparency. And this is how the system looks when you open it up with a donor. Very similar to how we would see a donor and recipient characteristics with melds of 40 down to melds of 22 although in our UNOS systems they're not Chinese characters. So one of the aspects that was truly remarkable at the meeting that really summarized the experience of the pilot project was the donor story. And although I've been to China several dozens of times and spent anywhere from a couple of days to a month there in one trip I've learned very little Chinese. I'm generally tone deaf, it's a tonal language, I'm terrible at languages and I'm fortunate and they always are able to provide me with an interpreter so the need is not there to learn either. But at this meeting with the donor story you didn't need to know the language. It's the same that we hear from our own donor stories with this was a migrant worker who lost his son and was fortunate enough in his terms to be able to allow his son to be a donor. I had always thought that the cities like Shanghai would be the leaders in developing a voluntary deceased donor program because there's a more youth-oriented culture with less reliance on the traditional cultures. But this was a man who in fact proved that wrong. Like I say he was a migrant worker of little means and really was very emotional in being able to provide his story and his son's organs to other people. So some of the things that are moving on since then there's a manuscript under current review utilizing ECMO and Will and I were talking about ECMO and other scenarios today and they have started using ECMO for their DCDs so they pronounce someone dead after the usual five minutes and then initiate ECMO in order to improve the preservation system of the organs while they're doing now a more standard organ procurement. They were initially concerned that the heart might reanimate after initiation of ECMO but at least as of the last I spoke with them they had not seen any reanimations of the heart with ECMO and that they are you know worrying about whether to try to move up go from five minutes to four minutes but also the concern that that would be in terms of reanimating the heart. So but this is a nice step in terms of trying to improve the quality of the organs that they receive from their donors. So let's kind of encapsulate what we've seen already in terms of social changes when I first started going over to China and really talking about transplantation and thinking about their system the general sense was not only from the physicians but even from people that I talked with you know cab drivers etc that there was nothing wrong with using executed prisoners as donors. Transplant tourism was good for the system and that Chinese would never embrace living donor transplantation because they wanted to have their body whole up until the time of burial. Well now in 2010 the government wants to eliminate the death penalty recognition that transplanted tourism and payment for organs is unacceptable living donation is increasing and deceased donor donation is definitely on the agenda and being executed now in many projects. So this is just one of the many stories that are in the press in China the idea of donating one kidney to my daughter had been lingering with me for some time and he was you know in the new system more willing and able to do that. A quote from Jaifu in recent meetings the evolution of organ transplantation provides one of the best windows through which to view contemporary Chinese society while it struggles with the search for a cultural identity and late modernity. And that the deepest significance of organ transplantation lies in its gift exchange dimension and the nature and magnitude of what is given taken and received. There's a feeling that organ donation will help China and its constant quest for a harmonious society and that having a fair ethical organ transplant system is part and parcel to that harmonious society. So how have we done in the last six years? We've improved the quality of patients so patients are not getting harmed by setting the standards for being a Ministry of Health approved transplant center. Transplantation's reputation is improving and that we're trying to address these problems and that's globally. China's organ transplant committee has provided clinical guidelines regarding candidacy, perioperative and postoperative care. We've improved informed consent to the patients and donors including the prisoner donors and develop strategies and voluntary deceased donor systems with transparent allocations. In terms of a social entrepreneur, I think that we're about halfway there to a sustainable social entrepreneurial success with entrepreneurship, innovation and social change. What we need to accelerate it, I think number one is some time, obviously funding that's going to take a lot of money to really broaden this out and to extend the rule of law in China. And so our goals, my goals at least for the next five years in regarding this aspect is to make a voluntary deceased donor program robust enough to eliminate the use of prisoners as organ donors, improve the enforcement of regulations, provide on-site audits of transplant activities, expand the policies and procedures to non-ministry of health hospitals such as the military hospital. So one of my goals as you saw was to eliminate the need for, eliminate the use of donors from executed prisoners. So the recent notice from the Ministry of Health says that they want to eliminate this use of organs from prisoners in 2013. So in the year that we are currently in, they want to eliminate it. And I highlight Haibo's name here who's quoted significantly in this article so that we really see that this is a truly a Chinese effort. I have, I think, provided some assistance, counseling, guidance and consultation to the Ministry of Health as well as others in order to try to guide them through both their own issues as well as the issues in terms of international acceptance. Frank Delmonico, who was our first speaker in this series, sometimes has been very vocal and animated regarding the use of, the use of executed prisoners in the whole transplant system in China and kind of maneuvering through all of those types of concerns and critics and still keeping China on a path that is sustainable. At times has been a challenge and many phone calls to all people but I'm really encouraged at the process that China has gone through and the progress that they are making and will continue to make. So once again, Mark, thank you very much for inviting me. Thank you, Mike. The paper is open for questions. I'm going to ask Dr. Chapman. Would you introduce yourself as you start? Please. Sure, thank you. My name is Will Chapman. I'm a transplant surgeon at Washington University in St. Louis head up the Transplant Center and abdominal transplant programs there. Mike, that's a great summary of the problems that have existed. One area I'd be curious about for you to comment on is term transplant tourism and the elimination and punishment of centers that have been, that have engaged in any transplant tourism. I guess I'd like you to define it a little more because I'd have to say we practice transplant tourism very commonly. In fact, centers work to have transplant tourism in the U.S. We think it's good. And United Network for Organ Sharing is established that you can have as much transplant tourism for living donation as you like. You're restricted to 5% of your transplant volume annually for cat of Eric donation. There's some really busy centers. There's some not so busy. But I've never had the view that that was something that shouldn't be done in the United States. Right. So I think it's an excellent point. And I've had that same concern regarding transplant tourism and how we allow it here and its banned in China. And I think that the difference is that when patients go to China to get an organ, they are paying a broker a lot of money. Would they have to? Yes. That has been the system. Now, yes. I mean, in a different system in which there is not payment for organs, then I think you at least have to readdress the concept of whether transplant tourism is allowable or not. But in the U.S., there is no difference. So when Wash U and the University of Chicago performs a transplant on someone who specifically came to the U.S. for their transplant, they are getting charged the same amount, at least their charged bill, as any other patient in the U.S. In China, that is not true. The foreigners are charged more. In addition to, they are paying for an organ. And I think those two differences make the ethical practice of transplant tourism in China a real challenge right now. If we were 10 years, 15 years, whatever, in the future and the payment of organs has gone away in China, there is a transparent system, all that other stuff, then I think at least we can readdress it. You know, if we were to fully utilize the potential of deceased donors in China, it would probably overwhelm currently the number of patients who can at least afford transplantation in China. And so then you'd have to think, well, what should you do with those organs? You know, should the government, you know, provide more insurance to get, allow more Chinese people to get organs, or should you open that up to transplant tourism? I think that those are reasonable things to think about 10 or 15 years from now. How did Vice Minister Wang do in the recent reshuffling? He did fine. So there's a mandatory retirement age of 65, and similar to what I talked about with the rule of law, that doesn't apply. Jaifu is 70 or so, I think, something like that, certainly over 65. And in the previous power shift before the most recent one, one of the ways they got around the Ministry of Health, the governmental age restriction was, is that they defined him as the personal physician for all the leaders. And so I think that that continues. And he has continued to be Vice Minister even with the new power shift. Wow, lots of questions. Well, Mark came with a microphone first. Perhaps I'm a little dense, but I'm having a hard time understanding your blue and the salmon with the cardiac death and being ready. Do they preline these people ready to go get on ECMO? Yes. And so how do they anticipate that? I mean, how much, there must be a lot of manipulation there as to who's going to have a cardiac death. Tell me who, you know, if you can predict within... No, no, no. So it's, so it's just as, in that system, it's just the way the same way that we do it, right? It's just that someone, you know, is on life support, has no chance of survival, etc. So the organ procurement organization goes to the family and says, would you like to be able to provide organs for donation? And they say yes. And they, so they, they withdraw life support. Okay. And once the heart stops for five minutes, they're declared dead. So, but if there's no brain dead, how do they, they're still allowed to withdraw life support? Yeah. Yeah. Right. Okay. And once their heart stops, then they're declared dead. So before you do that, you line them up with an echo. Yeah. But it sounds like a little manipulation as far as, it's just not really a brain dead, just still disconnecting. Well, there, there are patients who have been identified as, as, and their families have identified that they want to withdraw life support. Is there an EEG on one of these individuals? What's that for? No. Well, the EEG wouldn't make it a difference in China. There's no brain death. They're basing it on the cessation of circulatory function. Well, if they're re-establishing circulatory function, they're bypassing the heart. Right. They may block it. They do it. Mike. Shola. Yeah, Mike, as declared social entrepreneur now, and with some of the successes that you've had in China. I'm curious as to what you intend to do next, since issues related to transplant tourism and all of those issues actually prey on the unexplored vulnerable populations. Since you're so close to India, have you ventured to actually look at what operates there? I've never been to India. India is far away from China, actually. But there are a lot of vulnerable populations in between the two, too. I thought actually the elimination of executed prisoners would pretty much take the rest of my professional career. I'm really amazed at how quickly it seemingly is coming around. It does bring up the issue, well, what am I going to do next? I think there's still a lot to do in China, and I want to continue to work in that area. I'm open to looking at other areas as well. I think that the experience has been a learning experience, and it's very gratifying that it's moving along so quickly. I'm going to raise two, I hope, controversial issues. That's the intent. The first is about the use of ECMO to prepare a donor for donation post-cardiac death. As it's practiced in China, do they prevent cerebral re-blood flow, or as it's done in the United States, do we prevent cerebral re-blood flow? My understanding in both of those scenarios is that they do not. So there's no blockage of it, but there's also no retesting of whether... That's correct. That's my understanding. As far as I know, there's a balloon catheter that's put in the aorta to prevent re-flow to the heart, but not flow to the brain. And that's how this is practiced in the U.S. and in some areas of Europe. So I think it's the same. The second issue has to do with the somewhat... I'm going to label it disingenuous stance that transplant tourism is practiced in a wide-open completely transplant mechanism in the United States. While I am certainly part of it, we must recognize the fact that there isn't... While there may not be a difference in charges established for transplants for foreign visitors, there is certainly a difference in revenue generated. No question about that. Huge difference. So that individual programs may survive on doing as few as one foreign national on an annual basis, because that's the difference between losing money and... Making money. Can you comment further on that? Yeah, so that's absolutely true. And there's more transparency coming in terms of transplant tourism, with UNOS regulations requiring public dissemination of the number of transplants that you've done on patients that are non-U.S. nationals. So there's more transparency in the numbers. In terms of the financial aspect, you're absolutely right. Programs get a lot more money from doing transplant tourism than they do for doing transplants on Medicaid patients. No question about it. Or Medicare. Or Medicare. Or any other private payer. Yes. But the charges are the same. Charges are the same. So Mike, I wonder if you can tell us a little bit more about your own personal story of how you got from being a professor at University of Chicago to advise the United States government and maybe what lessons you've learned about how to be effective in that situation and maybe pitfalls to avoid. Repeat the question. So I think this got that, right? So the question is how did I get involved in moving from a professor of surgery at the University of Chicago to advising the Ministry of Health and doing this and then how kind of some lessons about why I've been so successful perhaps. So my first experience with China and transplantation was a self-preservation experience. I was a fellow at UCLA and we were doing 250 liver transplants a year and I was the only fellow. And so C.M. Lowe, who is ST Fan's junior person, came over for a year starting in January of my first year of my fellowship. And as bad as the first year of the fellowship was going to be, the second year of the fellowship was going to be worse. Because during the second year of the fellowship, you go out on all the procurements with the first year fellow and teach them how to procure. And I was going to have to go out every night with the first year fellow and that was going to be just a killer. And so when C.M. Lowe came over for a year starting in January, my first order of business for self-preservation was to teach him how to procure so that he could go out some of the nights with the first year fellows instead of me. And so C.M. Lowe and I became very close and then he went back to Hong Kong after he finished and helped ST Fan with the liver transplant program there. And he would invite me over fairly frequently to Hong Kong and I started not only going to Hong Kong but to some areas of China giving talks and all that, as I said, not doing transplants. And so I got fairly familiar with the transplant system there and many of the transplant surgeons. And then in the old six time period, and Mark will know this very well, Roy Schwartz, who at that time was the head of the China Medical Board and also the head of the visiting committee of the dean of the University of Chicago here was talking with Jaifu regarding the need for transplant reform in China. Jaifu agreed and they said that they needed a U.S. partner to help them with and so Roy being on the visiting committee here said, well, we've got a great transplant program at the University of Chicago, why don't you talk with them? And it was through then that relationship that I got involved and helped write the grant ultimately to get, they got China Medical Board funding and then the renewal in 11. And so it was through that specific relationship. The broader picture of that relationship is that Jaifu, in addition to being vice minister of health, is also head of the liver surgery section at Peking Union Medical College, which is the most prestigious and best medical school in China. And that PUMC was established by Rockefeller, which the China Medical Board was as well and obviously the University of Chicago. So we all have Rockefeller roots as well. So I think that helped cement a relationship. And so how I've been successful, I think that one thing is that you always have to recognize that it's not about you. It's about them and getting them to improve. And I think that I think your question about being a professor is really important. I'm not sure that an assistant professor could do that but an assistant professor is looking at ways to promote his career and would probably look at that more, can I be a first author, can I be a last author, can I do this, can I get this published, etc. And having already been a professor, it was less important for me to feel that any of these specific steps along the way were attributed to me, but the fact that I really wanted to help China and to be a social entrepreneur and get that established. It always has to be a Chinese initiative. It has to have Chinese roots and a Chinese flavor. My contribution has been to make sure that they understand what's ethically acceptable, how to maneuver from sometimes Frank's extreme thoughts and comments about the executed prisoners and payment for organs and this and that and the other and where they want to go and to try to find that ground that doesn't hit the third rail on either side. I know there are more questions, but I always think that that answer is an effective place to stop. I mean it is quite remarkable as you think about how much you and J-Fu and the Chinese transplant programs have accomplished and changed in six or seven years to think about moving a major system in the largest population base in the world in a relatively short time. And even though there are still critics out there like Frank, Lady mentioned Art Kaplan's article, which he doesn't think anything has changed, I think things are really different now from when you started. Of course, in a very selfish way, I think your background in ethics, you know, beginning with the Broch program here and including that critique of living donors for right hepatectomies in the New England Journal in 2000 gave you a certain perspective on some of the ethical problems that are associated with Chinese transplant policy before you and J-Fu began to work. Of course, having a helper like J-Fu, who is safe and secure in the Chinese system, was fabulous. Well, I want to thank you. It was fabulous. Thank you.