slides crossing borders in search of health, welfare, and safety al
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Crossingbordersinsearchofhealth,welfare,andsafety
MarketDesignPerspectivesonInequalityHCEO,Chicago,August2016
AlRothStanfordUniversity
1
(Kidneyfailure, Surrogacy,andRefugeequalification)
Healthinequality
• Kidneyfailure
2
U.S.Incidentcounts(newpatients)&
adjustedratesofESRD,by
raceFigure1.5(Volume2)
Incident ESRDpatients.Adj:age/gender;ref:2005ESRDpatients.USRDS2012ADR 3
KidneysTransplantedpermillionpopulationU.S.A.
Nigeria,Phillippines (GlobalObservatoryonDonation&Transplantation)
Nigeria
Philippines
4
5
Patientsreceivingrenalreplacementtherapy(dialysis)in2010(estimate)
LiyanageT,NinomiyaT,JhaV,etal.Worldwideaccesstotreatmentforend-stagekidneydisease:asystematicreview.Lancet2015;385:1975-82.
Elsewhere,2-7millionpeopledieeveryyearworldwideduetoinabilitytopay
foreitherdialysisorkidneytransplantation
IntheU.S.,100,000peopleareonthedeceaseddonorwaitinglist,butweonlyhave12,000deceaseddonortransplants
peryear
Papers• GlobalKidneyExchange,MichaelA.Rees,TyB.Dunn,ChristianS.Kuhr,ChristopherL.Marsh,JeffreyRogers,SusanE.Rees,AlejandraCicero,LaurieJ.Reece,AlvinE.Roth,ObiEkwenna,DavidE.Fumo,KimberlyD.Krawiec,JonathanE.Kopke,Samay Jain,MiguelTanandSiegfredo R.Paloyo,submitted.
• “FinancingTransplantCostsofthePoor:GlobalKidneyExchange,” AfshinNikzad,MohammadAkbarpour,MichaelRees,andAlvinE.Roth,workingpaper,2016
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Kidneyexchange—U.S.background• Manymorepeopleneedkidneytransplantsthanthereareavailableorgans.
• ThewaitinglistintheUShasabout100,000people– Thewaitcanbeyears,andmanydiewhilewaiting(4,448in2015,withanother4,377removedfromwaitinglistas“toosicktotransplant”).
– In2015wehad12,250 transplantsfromdeceaseddonors
• Transplantableorganscanalsocomefromlivingdonors.– In2015wehad5,628transplantsfromlivingdonors
• Sometimesdonorsareincompatiblewiththeirintendedrecipient.
• Thisopensthepossibilityofexchange .
Simple two-pair kidney exchange
Donor1Bloodtype
A
Recipient1
BloodtypeB
Recipient2
BloodtypeA
Donor2Bloodtype
B9
Noticethatnomoneychangeshands…
• Kidneyexchangeisan“inkind”exchange
• Section301,NationalOrganTransplantAct
(NOTA),42U.S.C.274e1984: “itshallbe
unlawfulforanypersontoknowingly
acquire,receiveorotherwisetransferany
humanorganforvaluableconsiderationfor
useinhumantransplantation”.10
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2-wayexchangeinvolves4simultaneoussurgeries
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Chains initiated by non-directed (altruistic) donors
Non-directeddonationbeforekidneyexchangewasintroduced
Waitlist
Non-directeddonor
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Chains initiated by non-directed (altruistic) donors
Non-directeddonationbeforekidneyexchangewasintroduced
Non-directeddonationafterkidneyexchangewasintroduced
Waitlist
Non-directeddonor
R1 D1
D2R2
Waitlist
Non-directeddonor
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14
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O O A A B A A A A A
1Jul 2007
AZ
2Jul 2007
OH
3Sep 2007
OH
4Sep 2007
OH
5Feb 2008
MD
6Feb 2008
MD
7Feb 2008
MD
8Feb 2008
NC
9Mar 2008
MD
10Mar 2008
OH
62%CaucWife
Husband
0%Cauc
DaughterMother
23%Cauc
MotherDaughter
0%Cauc
BrotherSister
82%Cauc
HusbandWife
78%HispanicDaughter
Father
64%CaucWife
Husband
100%Cauc
BrotherBrother
46%AA
MotherDaughter
3%CaucFriendFriend
Transplant Date:Recipient's State:
Recipient's PRA:Recipient's Ethnicity:
Recipient-to-DonorRelationship:
1 The initiating donor was an unpaired altruistic donor from Michigan.2 The recipient of Transplant 6 required desensitization to HLA DSA by T and B cell flow cytometry.3 The recipient of Transplant 9 required desensitization to blood group (AHG titer of 1:8).
Recipient's Sexand ABO type:
Donor's Sexand ABO type: AO AO B A A A AB A AB1
2 3
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KPD and NDD Transplants in U.S.
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KPD and NDD as % of LD in the United States
Kidney exchange outside the U.S.
• Wednesday,August3,2016FirstkidneyexchangeinNepal• March7,2016FirstpairedkidneyexchangetransplantdoneinSingapore• Friday,July24,2015KidneyexchangeinTurkey (1st exchangesthere)• April10,2015Afirstnon-directeddonorkidneyexchangechaininItaly• March30,2015AfirstkidneyexchangeinArgentina• March5,2015FirstkidneyexchangeinPoland• Friday,November7,2014KidneyexchangeinSpain:nowmorethan100transplants• June7,2014KidneyexchangeinFrance• December19,2013KidneyexchangeinVienna• August19,2013TenkidneyexchangetransplantsonWorldKidneyDayinAhmedabad,India• July28,2013FirstKidneyExchangeinPortugal:• July23,2013KidneyexchangechaininIndia• June6,2013KidneyexchangebetweenJewishandArabfamiliesinIsrael• December26,2012KidneyexchangeinCanada• December1,2012KidneyexchangeinIndia• June1,2012MikeReesandGreece:anintercontinentalkidneyexchange• March27,2012KidneyexchangeinBritain• February5,2012KidneyexchangeinAustralia,2011• April29,2011FirstkidneyexchangeinSpain• December8,2010NationalkidneyexchangeinCanada• August3,2010KidneyExchangeinSouthKorea• Tuesday,August3,2010KidneyExchangeinSouthKorea• Friday,July30,2010KidneytransplantationadvicefromtheNetherlands• March9,2010KidneyexchangenewsfromBritain (1st 3-waythere)• January27,2010TheAustralianpairedKidneyeXchange (AKX)goeslive• June25,2009KidneyexchangeinCanada (1st exchangethere)• February27,2009KidneyExchangeinAustralia (inWesternAustralia) 18
Globalkidneyexchange:apossibilityofmutualaid
DevelopingWorld
UnitedStates
Transplantsunavailable 19
Two-wayexchange
Firstglobalkidneyexchange,withapairfromthePhilippines—January2015,
AllianceforPairedDonation(Reesetal.)
JoseMamaril receivedakidney fromanon-directedAmericandonor inGeorgia.Hiswife,Kristine,donatedoneofherkidneystoanAmericanrecipientinMinnesota,whosedonorcontinued thechainbydonating toapatientinSeattle.THEBLADE/JETTAFRASER 20
•
Jose Kristine
D2R2
…
Non-directeddonor
Thechaintodate
Safelyhome…
• $50,000escrowfundforpost-surgicalcare
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GlobalKidneyExchange
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TheGKEproposalis“self-financing”.• Backoftheenvelopecalculation:– costofhemodialysis≈$90,000peryear– averagetimeunderdialysis≈5years– costoftransplant≈$120,000persurgery(plus$20,000inmaintenancetherapycostsperpatientperyear)
• Butinsteadystate,waitingtimedecreases.Sodialysiscostswillgodown…howlongwillGKEremainselffinancing?
GKEremainsselffinancingevenwhenitbecomeswidespread.
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Intuition:• Somedomesticpairsimmediatelyfindamatch• Someotherdonotfindamatchuponarrival.– Theyincreasetheaveragewaitingcost
• Internationalpairsgetmatchedtothosethelattertypeofdomesticpairs
• Soeveniftheaveragedialysiscostislessthanthesurgerycosts,GKEcanstillbeself-financingbecauseitmatchesdomesticpatientswithhigher-than-averagedialysiscosts.
Themedicallogisticsmaynotbethehardpart
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Financialflows• Savings:–Medicare—complexlegislative/bureaucratic– Privateinsurers(33months)
• Costs:– Surgeries—transplantcenters– Postsurgicaltreatmentinhomecountries– Infrastructuredevelopmentinhomecountries
• USAID?--SameFederalbudget,butnochangeneededinMedicare
• Allowinsurancecompaniestonominatepatients?26
Repugnanceconstraints
• Livingdonors–Frompoorcountries
• Asafirstreaction,manypeoplearegoingtoconflateglobalkidneyexchangewithbuyingkidneys(whichisillegaleverywhereexceptIran—a‘repugnanttransaction’)
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Repugnance• 1.“theplanisreallynotabouttheinternationalrecipient(nor…abouttheinternationaldonor),butonlyaboutgettingorgansforUScitizens.Soitisexploitative."
• 2.“Letssolveproblemsathomefirst…We shouldencourageprogramsthatallowAmericanstohelpAmericans."
• 3.“Thereisanexploitationofasocialcondition(beingdestituteinaforeigncountry)thatkidneytransplantationshouldnotbetheremedyofresolvingsocialinequities."
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• RepugnanceConcerns:– Inadequatepost-surgicalcare• Escrowfundsforimmunosuppressivedrugsandpostsurgicalcare(inPhilippines)• Basicinfrastructure(inNigeria)—USAID?
– Inappropriate/illegal/unethicaldonorsolicitation(howcanweensurethatforeigndonorsaren’tsellingtheirkidney?)• Familyrequirement?• Fornon-directeddonorstoo?
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Fertilitytourism
• Theurgetohavekidsisstrong.
• Somefertilityservicesarerepugnantinsomeplacesbutnotinothers.
• non-bordercrossing:wombtransplants(WombtransplantsinSweden(wheresurrogacyisillegal)
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GermanSurrogacyLawSurrogacycontractsinwhichawomandeclaresherreadinesstoundergoartificialornaturalinseminationortohaveanembryo,whichisnothers,transferredtoherortocarryababyotherwisetothefulltermareviewedasunethicalandthereforetreatedasvoidinGermany.PursuanttotheEmbryoProtectionActandtheAdoptionPlacementAct,theactivitiesperformedbythosearrangingsurrogatemothersandbyphysiciansinconnectionwithsurrogacyarepunishableoffences.UnderGermanlaw,thewomanwhocommissionsachildinsuchaway(commissioningmother)isnotthemotherofthechild.Themotherofthechildisthewomanwhogavebirthtohim/her,thatis,thesurrogatemotherandnotthecommissioningmother.…Forthisreason,Germanauthoritiescannotrecognizethematernityofacommissioningmotherevenifaforeignbirthcertificateconfirmsherastheostensiblemother.FederalForeignOffice:http://www.auswaertiges-amt.de/EN/Infoservice/FAQ/GermanFamilyLaw/Leihmutterschaft.html?nn=479790
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SurrogatechilddeniedGermanpassport09May2011
By Nisha Satkunarajah AppearedinBioNews 606Achildborntoa surrogatemotherinIndiahasbeenrefusedaGermanpassportdespitethecommissioningGermanparentsbeingnamedonthebirthcertificate.TheGermancouplemadetheapplicationtotheGermanEmbassyinIndiabutapassportwasrefusedaftertheembassysaidithaddoubtsoverthechild'sGermancitizenship.Theplaceofbirthonthechild'sbirthcertificatewasstatedasanagencywhichspecialises insurrogacy.AcourtinBerlinruledtheembassywasentitledtorefusetheapplication.…'ThephenomenoniswidespreadinIndiawheremanychildlessGermansgotofulfil theirwishtohavebabies',aspokesmanforthecourtsaid.'TheythinkitispossiblewithoutanyproblemstotakethechildtoGermany.Butthat'snotthecase'.
Canada:AssistedHumanReproductionAct (2004)
• Paymentforsurrogacy:6. (1) Nopersonshallpayconsiderationtoafemalepersontobeasurrogatemother,offertopaysuchconsiderationoradvertisethatitwillbepaid.
• Actingasintermediary:(2) Nopersonshallacceptconsiderationforarrangingfortheservicesofasurrogatemother,offertomakesuchanarrangementforconsiderationoradvertisethearrangingofsuchservices.
• Surrogatemother—minimumage:(4) Nopersonshallcounselorinduceafemalepersontobecomeasurrogatemother,orperformanymedicalproceduretoassistafemalepersontobecomeasurrogatemother,knowingorhavingreasontobelievethatthefemalepersonisunder21yearsofage.
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Surrogacy• marketdesign/ruleoflaw"Blackmarket"surrogacyinEngland,andsubsequentlegalcomplications
• Ruleoflawisaworkinprogresshttp://www.nytimes.com/2014/07/28/us/surrogacy-agency-planet-hospital-delivered-heartache.html
• Californialaw:escrowaccounts:http://www.leginfo.ca.gov/cgi-bin/displaycode?section=fam&group=07001-08000&file=7960-7962
• Indiaisattractivetosomeforothercontractingcapabilities—e.g.supervisionofthesurrogate’sbehaviorregardingnutrition,sleep,exercise(nottomentiondrinkinganddrugs) 34
Migrationbyrefugeesandothers:• Steps:Qualification(forrefugeestatus,etc.),Determination
ofcountryofasylum,settlementinthatcountry.• Settlement:AlexandWill--settlingrefugeeswhohave
alreadybeengrantedasylumsomewherehassomestrongsimilaritieswith—anddifferencesfrom--schoolchoice.TommyAnderssonandLarsEhlers:matchingrefugeestohousing/landlords.
• Determinationofcountry:thathassomeelementsthatresembleschoolchoice(refugeepreferenceswillbeinformative)butalsohasamuchbiggerpoliticalelementinvolvingcountryquotas—HillelandJesúsFernández-HuertasMoraga haveinterestingideasonchoosingcountrycapacities.
• Butqualifyingforrefugeestatusisadifferentkindofproblem,moreakintopoliceinvestigation,sincetherearesomekindsofinformation(e.g.foreignfighter)thatitmayneverbesafeforapplicantstoadmit…andthisispotentiallyafirstorderproblem,nowthatsecurityissuchahighprofilepoliticalissuewithfar-reachingconsequences
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Brexit:AntiEU/anti-immigrantposters
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Designingproceduresforelicitingandverifyinginformation
• Dominantstrategymechanisms—powerfulbutrare.– “DoyouspeakEnglish?”– DoyouspeakBulgarian?– Didyoucarryagun?
• Policestyleinvestigationsaregoingtobeeasierformigrantswhoarepartofanaccessiblenetwork
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