 I'm introducing Dr. Michael Millis, the professor of surgery as well as vice chair of global services as well as consultant to the Chinese Ministry of Health and he'll be talking today about living liver organ donation in China. That's the most. Okay, that's working. So first off I want to thank Mark and the organizing committee for asking me to talk today. And I'd also obviously like to thank the board of the McLean Center, those of whom are here as well as those who are not able to be here for their continued support of the McLean Center as well as this conference. So thank you all very much. I am humbled and honored to be listed in that five group of people that Mark noted in his talk. Obviously one person that was notably missing was Mark himself. He has been a leader in the ethical conduct of transplant, the pursuit of the cutting edge of transplant, and he deserves to be on that list far more than I and although I do thank Mark for his support over the years of that. So Mark asked me to give the talk on living donor liver transplantation in China and my first conflict of interest. I have received grants from the China Medical Board for this work. I think it's important also to note what I haven't done and what financial conflicts I do not have and that is I have never performed a transplant in China. There are surgeons in the U.S. and around the world who certainly during the period of time in which the donor source was known to be from an unethical source would nonetheless go over for VIPs in China and perform transplants. And I have never done that. I have also never received money from the Chinese government. So what I discuss is truly what I believe we have accomplished and I'm happy to share with you that. So in every country living donation is linked to deceased donor transplantation. To understand the role of living donor liver transplantation in China, one must understand the history of liver transplantation in China. In 2004, over 2,000 organs were transplanted in China, only behind the U.S. in terms of number of organs transplanted. Essentially all of these organs were from executed prisoners and most were transplanted into four nationals, so called transplant tourists. The transplants were performed in over 600 hospitals with no requirement for quality, qualifications, field strength or institutional support. The system to obtain donors was rife with corruption, paying judges to declare a death sentence, timing the execution according to the need for the organ. Lack of consent of the prisoner, the prisoner's family, kickbacks to the chief of security in numerous cities throughout China, kickbacks to the prison system, etc. The corrupt system generated millions of dollars in revenue to all parties, except of course the prisoner. Human rights abuses have received a lot of negative press and much of it justified based on past practices. It is far easier to criticize a system than to work to reform and develop new ethical systems. In 2006, Vice Minister of Health Jai Fu Wang announced to the world what those of us in transplantation already knew, that the organs China was using were from executed prisoners. What the world did not know was that the vice minister and I had shared a vision of changing the system. Soon after that, Jai Fu and I submitted a grant to the China Medical Board to fundamentally change the transplant system in China. The changes started with transplant center regulation, requirements for quality and experience, banning transplant tourism, requirements for a prisoner of consent, a post-transplant registry, central government and Supreme Court review of all death penalty sentences, among many others. The next step was to determine how to develop a voluntary citizen-based deceased donor system in a country that today still does not have a brain death law. We defined a new type of donor, BDCD, patients that were brain dead by medical criteria, but had to wait until circulatory death prior to them being able to be declared legally dead and become donors. We instituted a pilot program of the system which was successful and then expanded it to a nationwide system. In January 2015, the government banned the use of organs from executed prisoners and some of those who were involved in the corrupt prior system, including some surgeons, are now in jail. The voluntary citizen-based deceased donor system generated 2,766 donors in this past year, providing 7,393 organs for transplantation and is on a pace for over 4,000 donors in the current year. The changes over the years have had a significant change in living donation in China. Now we'll focus on living donation, liver transplantation in China for the remainder of the talk. So in 2014, I visited over a dozen transplant centers in China. This was following visits to Hong Kong in which I had started to hear about what was going on in China and I wanted to learn more. So I questioned a number of medical and non-medical transplant and non-transplant affiliated people in China during my visit to China. And I asked them about living donation and other sources of organs, etc. And the common response was that Chinese would never accept living donation. The reasons were that they wanted to be buried whole, that Confucianism and Buddhism was not supportive of living donation. But the real reason was that they thought that the prisoner donation system that they had would take care of the need and therefore there was no need to look for other sources of organs. So that obviously did not deter me from working with Jifu to develop a better system. And so this is the first legislative codicelle regarding organ transplantation that China had ever had. And this was effective in May 2007. This followed a very interesting meeting with this document in draft form that was held. We were talking earlier and someone asked the question about getting people in the same room without Skype, etc. This, Mark, I'm sure you will remember this, we had a meeting in my office with Mark, one or two of my other colleagues, my son who had gotten interested in this topic as well and who is now a third-year medical student here. And Jifu and others from China, they joined us by phone and we went through this document, article by article, making sure that it essentially brought China to the level of international standards in as many ways as we could. One of my guiding principles in working with China on this issue was that I did not want to put in harm's way those people in China who needed transplants. And if we immediately excluded organs from executed prisoners, it would indeed do that. So in this article we still allowed organs from executed prisoners because there was no other choice for China at the time. And we went through and we tried to make sure, Mark and others in the room, that it embodied what the international standards were, except obviously for that part, banning transplant tourism, establishing quality metrics, etc., etc. And following this, following that discussion of the preliminary draft, ultimately this final document was passed by the State Council and put into effect in China. So it did address, and other regulatory documents subsequent to that, living donation. And that the rights and outcomes of the donor were the first priority, that the recipient outcomes were second. And despite what was commented on earlier, I have always felt that donors were my patients. They are not just suppliers of organs, they have always been my patients. That there was a comment regarding selection of living donors, and that is that spouses and blood relatives up to the third degree could be reviewed only by the hospital committee before being allowed to donate. If it was suggested that the potential donor only had an emotional bond, then it must be reviewed at the provincial level. Based on essentially the code of conduct based on the WHO and the Transplantation Society. The Ministry of Health continues not to really encourage living donation. And the reason for that is that they recognize that the legal, social, economic and health systems are not in China, are not yet mature enough to support living donation as they require. But it is progressing living donation nonetheless. Health issues, the issues that they are concerned about are obviously health issues, post donation without insurance. In China, health coverage is generally based on the province in which you were born. So even if you are living in Shanghai, you might have more permissive insurance policies for post donation health issues. If you are born in a province out in the western part of China, your health benefits may not be so permissive and you may not have health benefits for any complications of the donation. The Ministry of Health developed criteria for living donor centers and essentially this is a subset of the currently Ministry of Health approved centers. They are much more proscriptive in regards to the potential donors as well as the clinical pathway as we would look at them than we are in the U.S. They have national standards for BMI, hypertension, anatomy, et cetera that would regulatorily be universally dismissed by U.S. centers. Paying for organs and organ brokering is a criminal offense. That was one of the statements in subsequent regulatory articles with penalties against the surgeon, hospital and broker. So does this mean that all organ transplant tourism has ceased or that there are not some people who continue to break the law? It does not. China is 1.4 billion people and there are certainly cases in which have been noted that have either been from organs from executed prisoners, transplant tourism, et cetera. The difference is that when these are brought to the Ministry of Health with documentation, the Ministry of Health does investigate it. And they have investigated a number of them and the summary is there. Of interest, right before the International Transplant Meeting in Hong Kong this past summer, the Ministry of Health received a letter up on the right hand side here, this letter here. Obviously you cannot read it, it's not meant to be read really. It's stating that someone had provided evidence that there had been a transplant tourist who had received an organ in China and that the Ministry of Health needed to investigate. And they did and in the brief time between that letter and the meeting, they had investigated and that the doctor's license was revoked as well as the hospital's transplant license and the criminal investigation was still ongoing. Importantly at this International Meeting, Jifu showed this slide and gave everyone an email that if in fact you see patients that have received organs in China that they want to be notified of that through that email address and they will investigate. So they are committed to developing a system that is ethical. So in terms of numbers, the red bars here are a living donation as you see. This is in 2010 when we started the pilot program for the disease donor program and for the first time in 2015, the number of donors from the disease donor program is greater than the number of organs from living donors. These are all living donors, both kidney as well as liver. And obviously most of them are kidneys but we will talk a little bit about livers. Specifically most of the living donor liver transplants are in pediatric patients and it's interesting the number of pediatric transplants in the U.S. and in China are roughly equivalent, 529 in the U.S., 524 in China. But in the U.S. we only do about 51 living donor transplants with the majority obviously getting their organs through the deceased donor system. In China because of the fact that only about 18% of the donors are actually what we would consider brain dead and actually go through a brain dead type protocol. So almost all of the organs are deceased DCD type donors with significant ischemia time and thus not suitable for reducing or splitting that has provided the U.S. and other countries with organs that are of good quality to use parts of them into kids. Since they don't really have a system for that because of their organ donor system, they rely heavily on living donation. So this past year, 358 pediatric living donor liver transplants were performed. Almost all and I'll show in another slide in just a couple of centers. So here we have 817 organ transplants every month. Almost twice as that many people are now listed. There are 36 deaths every month including two pediatric candidates. So their need is clearly there in China just to take care of Chinese patients. Here's the waiting list. The largest liver waiting list is 550 patients and obviously it's increasing. The time of active waiting even though we see here they're not happy with this and if we look at it from a western perspective, these are pretty good waiting times. Over half of the patients who are waiting for a liver transplant get one within a year and essentially 75% or over get it within two years. As a reflection of the special qualifications really needed for pediatric liver transplantation, medical migration which they look at as if patients are leaving their province to go somewhere else for their transplant, 75% of the pediatric patients are transplant or medical migration into essentially two centers, one in Shanghai and one in Beijing. How much does it cost? I specifically asked this at one of the meetings. So for a living donor liver it's about 200,000 RMB which equates to about 30,000 US dollars and it is more expensive for a deceased donor organ in China. In the US it's about the same so it's interesting that in China it's about three times more. So what is the current state? So despite living donation not being promoted by the Ministry of Health that is thriving especially in the pediatric population. Two centers in China are doing the vast majority of them and it counts for the majority of medical migration in China. China has established regulations that attempt to minimize abuses and a living donation found in other Asian countries. Currently Korea and Japan continue to perform more adult living donor transplants than China. So back once again I will refer to a meeting that Mark and I had this time not in my office but in my chairman's office at the time actually mid-2000s in which we were discussing whether the University of Chicago should get involved at all in trying to help China change their transplant system. And in that conversation Mark and I, my chairman of the time Bruce Gowertz and on the phone was Rory Schwartz who was head of the China Medical Board who obviously knew much more about China than any of us and still does. He was in China for many parts of his adult life and to make sure that the people that we were going to get involved with were truly committed in the same way that we wanted to be. And so he gave us certainly assurances that Jaifu and his team wanted to go in the same direction that we wanted to go. And so two institutions are my primary colleagues at Peking Union Medical College in the University of Chicago with the support of the China Medical Board were brave enough to engage and change the Chinese transplant system by establishing a system that allows the 1.3 billion Chinese citizens to be partners in the medical community and one of the greatest advances in modern medicine and in the process improve human rights in China. So this is a photograph at the founding of Peking Union Medical College and this is at the time the president of the Board of Trustees at the University of Chicago. This is John D. Rockefeller and other people who helped establish the Peking Union Medical College. This is a current picture. You still see the Portico. The photo was taken from this direction. And then this is Rockefeller's chapel obviously here on the campus, the logo of the China Medical Board, and then many of the people who have helped make this happen visiting my home several years ago with Jaifu Huang here in the middle and members of his hospital entourage and his academic entourage. Once again, I thank Mark for all of his support over the years for allowing us to do this, to being involved and saying that it's ethically the right thing to do and I appreciate Mark and I appreciate the audience here. I don't know if I have any time. Yeah, that's all right. Yes. Thank you very much, Mike. Thank you.