The representative of the Ministry of Health: In 3-4 years transplantation in Ukraine may disappear
In society, a lot of noise was caused by a recent initiative to adopt a new law on transplantation. Director of the Coordination Centre of Cell, Organ and Tissue Transplantation of Ministry of Health Ruslan Salyutin told UNIAN what would happen to organ transplantation in Ukraine, if it was not revived in time..
In the last few years the transplantation in Ukraine was mentioned only in scandal or trial. The case of “black transplantologists” and dubious stories about the export of organs from cadavers abroad, in fact, are almost everything that everyman heard about this branch of medicine in our country. For those, who are lucky enough not to run through life with this kind of medical care, transplantation in Ukraine as if does not exist at all because television and Internet are filled with announcements of raising funds for patients leaving for organ or bone marrow transplantations abroad. Thus, it seems that there isn’t such kind of medical care in our country.
That is why the initiative of the Ministry of Health, proposing to amend the Law of Ukraine on the transplantation after the model of 1999, caused a lot of criticism and even fear. The most heated debate broke out around the “presumption of consent”. This rule in the law requires that any killed citizen of the country can automatically be an organ and tissue donor, if he did not bequeath the opposite, and his relatives do not mind. Supporters of these rules are talking about thousands that could be saved. Opponents are worried that the victims of these rules will become other thousands who would not be saved by doctors for certain compensation for the sake of the recipient (person in need of a transplant).
Generally, the debate on transplantation and the need for its reform in Ukraine is not new. But this time it requires an immediate solution, because for the first time an international community of transplantologists voices serious intentions to ban transplant tourism. Thereby the Ukrainians in need of organ transplants have to be treated exclusively in their country, which today means to die.
Ruslan Salyutin, Director of Coordination Centre of transplantation of cells, tissues and organs of the Ministry of Health of Ukraine told UNIAN about the problems of transplantation in Ukraine; how many lives can be saved with regulating of the legislation; and the temptations of Ukrainian doctors.
What is the situation in Ukrainian transplantology today?
Dr. Ruslan Salyutin: Today it is catastrophic. 1.6 transplantations are performed every year per million people. In Spain, for example it is 85.6 tpm. So we are in a deadlock and we have two choices: to die or try to get out.
How transplantation of organs and tissues is regulated in our country nowadays?
Dr. Ruslan Salyutin: It is working by a law passed in 1999. At that time it was quite normal and even modern: it almost corresponded to European standards. But it was passed in a hurry; and some aspects were either missed or not registered clearly enough. It needs to be improved. That’s why we have registered a number of urgent changes and offered to discuss them. A “draft” came to our Parliament not for registration but for internal discussion. The final document will be gained from the discussions spent among professional.
Which aspects, for example?
Dr. Ruslan Salyutin: It is very difficult to understand article 16 of this law (about cadaver donation, UNIAN). It is written incorrectly. It includes presumptions of consent and dissent. That’s why cadaver donation does not work at all. Any way we have to change this article. But we doubt, which presumption should be left.
Which practice is most common in the world and, particularily, in Europe?
Dr. Ruslan Salyutin: It is approximately equal. A half of the countries has the presumption of consent and a half has the contrary one. But the number of transplantations is almost the same in both. For example, in the USA there are 24.000 transplantations per year therewith presumption of dissent. It is because the system of transplantation and social donation advertisement are working clearly.
Who can become a potential recipient? Is there some risk group that is the most likely to need transplants?
Dr. Ruslan Salyutin: It can be anyone. Even banal flu can cause the kidney stops functioning. An overeating, for example, on New Year’s Eve, can lead to liver failure and the need for liver transplantation. A simple viral conjunctivitis can make a person blind and require a corneal transplant. Moreover, there is disbelief that transplantation is a luxury for only the rich. Out of 900 people with transplanted organs in Ukraine, there are no very rich people. But there are doctors, teachers, workers, farmers and children. And only well informed person can say that transplantation is prolonging of life for all people.
Only 900 people?
Dr. Ruslan Salyutin: Yes, only 900 people with transplanted organs are living in Ukraine. Among 46 million people. And 4-5 thousands need for transplantation.
How many surgeries do you do every year?
Dr. Ruslan Salyutin: One hundred.
How many Transplantation Centers do we have?
Dr. Ruslan Salyutin: Seven. For example, there are 45 in Spain. Moreover, these centers (just offices in general hospitals) have not target financing, but they should become productive.
How much does transplantation cost for our Budget?
Dr. Ruslan Salyutin: It is expensive. But kidney transplantation, for example, costs less than hemodialysis. Hemodialysis for one patient costs from 140 to 250 thousand hryvnyas per year. Immunosuppressive therapy, which is necessary after organ transplantation for patient throughout life, costs only 80 – 90 thousand hryvnyas per year. It’s a great difference. The operation itself and the first year of therapy are about 120 – 140 thousand hryvnyas. For our citizens an operation itself is free, but the patient buys only medicines. Immunosuppressive drugs are also provided free, but sometimes there are delays in deliveries from Kiev to some regions…
If, after the adoption of the presumption of consent, the number of operations increases at least twice, will our centers cope with it?
Dr. Ruslan Salyutin: Even if we introduce presumption of consent tomorrow, nothing will happen. It cannot start working instantly. We need to establish a system of transportation of anatomical material, coordination and control of the whole process. It is necessary to create a single register of donors, recipients etc. This process needs a transitional period. We need a year and a half. During this time, the Centers will get ready.
Why does not the head of the Parliamentary Committee of Health support your initiative?
Dr. Ruslan Salyutin: Tatyana Bakhteeva agreed about the need of changing the law but we have a disagreement about presumption of consent. It is a discussion. I do not see any problem. I think that most deputies will support our proposals. But the change of chapter 16 is important and it’s not the main thing that is being discussed.
What is the main one?
Dr. Ruslan Salyutin: It is important to start discussion. It is also important to register a clear range of persons who may become living donors, individuals who can deny or allow the removal of the deceased body material. In the final draft of the law that will be. Also we need to create a public service of transplantation and donation, which would be able to organize the process of removal and transportation of organs, register and control all of these. We hope that such a decree will be signed by the president. It’s his prerogative.
But, what about presumption?
Dr. Ruslan Salyutin: It is not the main. If there is an efficient and clear system of transplantation, there will not be the difference. Moreover, in any case, relatives can block the removal of anatomical material, even if there was the consent of the deceased.
Is there any reason to fear the flourishing of “black market” of organs in Ukraine and their exports in case of the presumption of consent?
Dr. Ruslan Salyutin: It is greatest nonsense. Every organ has its expiry date: 12 hours for kidney, 8 – for liver and 3-4 – for heart. It is unreal to transport it abroad for such a short period of time.
We often connect disappearance of people in Ukraine with such illegal transplantology…
Dr. Ruslan Salyutin: Yes, there is a myth, but I do not think they are interrelated events. Unfortunately, people disappear all over the world, and it is not the doctors’ fault. All Ukrainian transplantologists know each other. All are closely monitored by prosecutors. Who will take the risk? Nobody.
Nevertheless, there always appear ads from Ukrainians wishing to sell their organs on the Internet. Hence, the “black” market exists.
Dr. Ruslan Salyutin: It is generally complete nonsense. For that matter, then, for example, in Pakistan, officially the kidney can be bought for 5000 dollars. And we have patients who went there for transplant. In Iran, you can also buy a kidney officially, so it makes no sense to risk purchasing organs illegally here and, especially, to steal and kill someone.
Can we be sure that after the adoption of the presumption of consent reanimatologists will do their job honestly?
Dr. Ruslan Salyutin: We cannot allow such doubts even. Thinking differently, we never change anything. Why does reanimatologist need it? Brain death, without which it is impossible to remove the bodies, is stated by the council – five or six doctors. The transplant process involves several dozen people. How to bribe all? How to keep it all a secret? And how much should be paid for this conspiracy? This is just unreal.
How can we make donation popular in our country?
Dr. Ruslan Salyutin: The most important way is social advertisement. We should explain everything to our people. But we don’t have any money for it. Public organizations do not support us. For them it’s easier to raise money and send a patient abroad. Journalists also don’t help us…Church is also passive…
How can people express and record their intention to become a posthumous donor?
Dr. Ruslan Salyutin: In no way. Only if the family after your death declares that you have consented to the removal of anatomical materials and does not prevent this. Presumption of consent also requires consent of relatives. Therefore, it is important that we have raised this issue at all and that people will be able to discuss it in their kitchens.
Can every deceased be a donor?
Dr. Ruslan Salyutin: Absolutely not. Only the patients, who were diagnosed with brain death, can be donors. Those, who died from pneumonia or peretonitom, do not fall into this category. In general, it concerns only killed in the road accident. In our country there are 5 – 6 thousand people annually. Let’s take at least 25% of them, which are suitable on medical grounds, who was pronounced dead brain and whose relatives have agreed to intake anatomical material. These are approximately 1500 hearts, livers, and about 3000 kidneys per year. Such amount is sufficient for transplants throughout Ukraine.
Why does the law say nothing about expanding of the circle of living donors?
Dr. Ruslan Salyutin: Generally, the circle of living donors is not clearly delineated by our legislation. It is still necessary to write it out, and we have such a plan. But, if we had a sufficient number of post-mortem donors, why would we need alive ones for it?
But if their relatives need it?
Dr. Ruslan Salyutin: And if you knew that, given the experience accumulated system of transplantological help, your loved one would get the desired organ in just six months? Would you need to give your organ? Now I do not see such a need, and I think the expansion of the circle of the living donor is not correct.
Are you considering some options to stimulate donors or potential donors?
Dr. Ruslan Salyutin: Any material reward of donors is the wrong position. According to the International Convention on Action against Trafficking organs and other anatomical materials, any material or other compensation for the human organ or posthumous donation is illegal. However, there are other incentives. For example, there could be possible priority in the queue for organs for someone, who previously expressed the wish to become a donor posthumously. Also each donor can receive a ticket to a sanatorium for rehabilitation. That is correct.
What do you know about the experience of Russia and Belarus, where there is a presumption of consent to donation after death?
Dr. Ruslan Salyutin: About Russia, I do not want to talk, because for such a large country, the number of transplantations that they perform is very small, and they are saying it themselves. But in Belarus the situation is following: the law on the presumption of consent was passed there in 2003, but it did not work due to lack of an established system and sabotage of doctors until President intervened. As a result, for the first 9 months of last year there were performed 149 liver transplantations. It is very many for such a small country. By the way, in our country kidney transplantation and the first year of therapy cost, for example, 120 – 140 000 hryvnyas. In Belarus, the production cost is about the same, but for Ukrainian citizens operation there costs about 50 thousand dollars. That’s how they earn for their patients.
When are you going to submit to Parliament the final draft of the law?
Dr. Ruslan Salyutin: We are at the beginning. We do not have strict deadlines. We’re going to work on the law, and now the main thing is to raise a discussion.
In the next year would we like to adopt the law and get a decree on the establishment of a service?
Dr. Ruslan Salyutin: Certainly.
And what if there is no decree or law?
Dr. Ruslan Salyutin: Another three or four years and we will not have transplantology in the country. Only a couple of fanatics of the business will be left.
How many people are in the queue for an organ transplant today?
Dr. Ruslan Salyutin: Four thousands. And more than 2000 people are in the queue for a corneal transplant. But you know … Many do not even stand in the queue. It is difficult and expensive. Even the drive for hemodialysis is problematic, especially from remote villages and areas…
How many lives, do you think, could save cadaverous donation?
Dr. Ruslan Salyutin: Three or four thousand people a year, including those who are in need of a corneal transplant. If the process starts, the number of necessary transplants will be less. After all, we have a growing number of recipients because many simplest diseases were neglected at the primary stage. I believe that transplantology and its development could be a real reform in health care.
How many scandals with “black” transplantology do you remember?
Dr. Ruslan Salyutin: Six or seven. And they all came to nothing.
That’s why people are afraid of it.
Dr. Ruslan Salyutin: Let’s remind those cases. Mikhael Zis’ case, who recruited donors for recipients… He was punished. Doctors have nothing to do with it. A donor and a recipient came to a doctor with documents. Doctors did not know that the documents were forged. Also there were cases in Krivoy Rog, Nikolaev and Ivano-Frankovsk. But all of them were related to a struggle for the ritual service market. The criminal trial over surgeons from Shalimov Institute is not finished yet. All three surgeons are free and do their work.
So you can say that there isn’t such problem in Ukraine.
Dr. Ruslan Salyutin: What do you mean? That people are killed and their organs are taken out. There isn’t such situation. That documents about relationships are falsified. Doctors have nothing with it and criticize it. I’m sure if we can provide enough organs we will not have such problem.
How much do Ukrainian transplantologists earn?
Dr. Ruslan Salyutin: A doctor from the Department of Kidney Transplantation and Hemodialysis earns 2500 hryvnias per month. As a Director of the Coordination Centre of Cell, Organ and Tissue Transplantation of Ministry of Health and Doctor of Medicine, I earn 3200 hryvnias per month.