More on non-anonymous kidney exchange in India

 Here's some further description of how kidney exchange is conducted in India without authorization* to use nondirected donors (so that all exchanges are conducted in cycles, i.e. in the absence of chains of exchange).

Vivek B. Kute, Himanshu V Patel, Subho Banerjee,Divyesh P Engineer, Ruchir B Dave, Nauka Shah, Sanshriti Chauhan ,Harishankar Meshram , Priyash Tambi  , Akash Shah, Khushboo Saxena,Manish Balwani , Vishal Parmar, Shivam Shah, Ved Prakash ,Sudeep Patel, Dev Patel, Sudeep Desai, Jamal Rizvi , Harsh Patel, Beena Parikh, Kamal Kanodia, Shruti Gandhi, Michael A Rees,  Alvin E Roth,  Pranjal Modi “Impact of single centre kidney-exchange transplantation to increase living donor pool in India: A cohort study involving non-anonymous allocation,”Nephrology, September 2024, https://onlinelibrary.wiley.com/doi/10.1111/nep.14380  

"In India, 85% of organ donations are from living donors and 15% are from deceased donors. One-third of living donors were rejected because of ABO or HLA incompatibility. Kidney exchange transplantation (KET) is a cost-effective and legal strategy to increase living donor kidney transplantation (LDKT) by 25%–35%.

"3.3 Non-anonymous allocation

"The THOA*, which regulates KET in India, is silent on the need for anonymity, so there is no legal requirement for anonymity in India, as compared with other countries, such as the Netherlands and Sweden. Our experience was that 90% of iDRP [incompatible Donor-Recipient Pairs] requested the opportunity to meet their matched donor and recipient pair (mDRP) and 10% asked the treating physician to decide if they should meet. None of the iDRP requested anonymity. Therefore, we have practiced absolute non-anonymity, meaning that all mDRPs meet and share medical reports after a potential exchange is identified, but before the formal allocation of pairs. If an iDRP requests anonymity, we would be willing to accommodate them, but to date, none have done so.

"Upon meeting with their mDRP, the iDRP can refuse the proposed exchange option without reason and continue to be on the waitlist and active in the KET pool. iDRPs must complete transplant fitness and legal documents required for transplant permission from the health authority before they are given the opportunity to meet their mDRP. A meeting between mDRPs occurs in the presence of a transplant physician, who can help solve any query before the proposed match is accepted by the involved pairs. iDRP are introduced to their mDRP prior to scheduling transplants to avoid chain collapse due to iDRP refusal of the mDRP. The mDRP shares medical reports of donors with each other, can also discuss with their other family members, and consults with their family physician/nephrologist before deciding whether to proceed. Living kidney donors are fully informed of perioperative and long-term risks before making their decision to donate. In India, donor age group matching is most commonly expected for all iDRP in the KAS."

###########

Earlier:

Monday, September 18, 2023

Kidney Paired Donation in Developing Countries: a Global Perspective

*Here's the THOA, THE TRANSPLANTATION OF HUMAN ORGANS AND TISSUES ACT, 1994

Blood donation by family members in India: LGBT donors still banned

 In India, where the shortage of blood supplies is addressed by having family members donate, the ban on donation by LGBT people is a serious constraint.

The BBC has the story:

LGBT Indians demand end to 'discriminatory' ban on blood donation  by Umang Poddar

"In 2018, India's top court legalised gay sex in a landmark ruling - but the country still doesn't allow transgender people and gay and bisexual men to donate blood.

"People from the LGBT community say the decades-old ban is "discriminatory" and have gone to court to challenge it.

...

"Activists argue that apart from it being discriminatory, the ban is also irrational because of the high demand for blood transfusions in the country.

"A study published by the Public Library of Science in 2022 estimated that India faced an annual deficit of around one million units of blood."

HT: Vincent Jappah

###########

Earlier:

Tuesday, November 28, 2023

"Professional blood donors" in India (where paying blood donors is illegal)

Expanding kidney exchange in India

 The Ahmedabad Mirror reports on the success of kidney exchange at the Trivedi Institute in that City, and on discussions underway to build a national kidney exchange infrastructure in India.

City Tops In India. City’s IKDRC Accounts For 539 Swap Transplants Out Of 1,808 Such Surgeries In India Till Date

"Ahmedabad leads India in the number of Kidney Paired Donations (KPD) or ‘kidney swap transplants’ carried out till date, having conducted 539 such surgeries out of 1,808 in 65 hospitals in India, shows data from the registry made by the Indian Society of Organ Transplantation (ISOT). These include two pairs of surgeries conducted in 2024 so far.

"Gujarat accounted for 565 such transplants of which 539 were conducted at the state-run Institute of Kidney Diseases and Research Centre (IKDRC) in Ahmedabad.

"In fact, in 2013, doctors and staff at IKDRC conducted 10 kidney swap transplants in a day, operating on 10 donors and 10 recipients in a 24-hour period.

"One Nation, One Swap?

"Mirror has now learnt that a consultation on whether a national Kidney Paired Donation programme should be instituted or not, and what should be its guidelines. 

"This is currently under deliberation between stakeholders at the National Organ and Tissue Transplant Organisation (NOTTO).  

"Its director, Dr Anil Kumar, told Mirror, “It is currently at the conceptual stage and in-principle discussions are underway for a swap organ transplant programme and guidelines are yet to be framed on this issue.”

"If implemented, the biggest benefit will be decrease in waiting period for those on dialysis and waiting list due to an incompatible donor if they match with a swap pair. This will also decrease the number of patients on the transplant waitlist.

"However, there are many challenges to this. Apart from the safeguards regarding consent and transparency, other problems include the lack of a nationwide guideline on documentation and approval of swap transplants and a national swap allocation system. The logistics of long-distance organ transport also needs attention.

#########

Earlier:

Wednesday, May 22, 2019

Kidney exchange in India: the legal framework

Tuesday, February 27, 2024

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

Stanford Impact Labs announces support for kidney exchange in Brazil, India, and the U.S.

 Stanford Impact Labs has announced an investment designed to help the Alliance for Paired Kidney Donation (APKD) increase access to kidney exchange in Brazil, India, and the U.S.  Here are three related web pages...

1. Stanford Impact Labs Invests in Global Collaboration to Increase Access to Kidney Transplants.  $1.5 million over three years will support solutions-focused project led by Stanford’s Dr. Alvin Roth and the Alliance for Paired Kidney Donation (APKD)  by Kate Green Tripp

"Stanford Impact Labs (SIL) is delighted to announce a $1.5 million Stage 3: Amplify Impact investment to support Extending Kidney Exchange, a solutions-focused project established to increase access to lifesaving kidney transplants.

"The team, led by Stanford’s Dr. Alvin (Al) Roth, who shared the 2012 Nobel Prize in Economics for his work on market design, and the Alliance for Paired Kidney Donation (APKD) is working in close partnership with organ transplant specialists and medical centers in Brazil, India, and the U.S., including Santa Casa de Misericórdia de Juiz de Fora, the Institute of Kidney Diseases and Research Center and Dr. H L Trivedi Institute of Transplantation Sciences (IKDRC-ITS), and Walter Reed National Military Medical Center.

"Over the course of the next three years, the team aims to increase the number of transplant opportunities available to patients who need them by creating and growing kidney exchange programs in Brazil and India, where millions of people suffer from kidney disease yet exchange is minimal; and explore the effects of initiating donor chains with a deceased donor kidney (DDIC) in the U.S., an approach which could unlock hundreds more transplants each year.

..."

2. How Does Applied Economics Maximize Kidney Transplants? A project aimed at expanding kidney exchange and saving lives puts Nobel Prize-winning matching theory into practice.  by Jenn Brown   (including a video...)

"APKD uses open source software developed by Itai Ashlagi, Professor of Management Science and Engineering at Stanford University, to facilitate the matching process for its NEAD chains, and they currently average 5 non-simultaneous transplants per chain.

3. Extending Kidney Exchange

"In Brazil, our team has launched a kidney exchange program within Santa Casa de Misericórdia de Juiz de Fora and Hospital Clínicas FMUSP in São Paulo and aims to expand to facilitating exchanges between these centers and others with the ultimate goal of kidney exchange transitioning from a research project to an officially approved practice in Brazil.

"In India, our team has deployed kidney matching software and resources for growth to the Institute of Kidney Diseases and Research Center and Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS) to support kidney exchange programs. We aim to develop an evidence base for potential updates to organ transplantation laws that expand criteria for who can give and receive lifesaving kidneys.

"In the U.S., we are working with Walter Reed National Military Medical Center to test the use of deceased donor-initiated chains (DDIC) so as to generate hundreds of additional life-saving transplants each year that are not currently supported by today's practice of utilizing a deceased donor kidney to save the life of a single person on a transplant waitlist. "

 

Cash for kidneys report in the Telegraph

 The Telegraph has this story, by Samuel Lovett, Nandi Theint,  and Nicola Smith. For some reason I can't copy the headline, but the URL is pretty informative: https://www.telegraph.co.uk/global-health/science-and-disease/kidney-organ-trafficking-scandal-private-healthcare-india-myanmar/   3 December 2023 • 9:00am

"One of the world’s biggest private hospital groups is embroiled in a ‘cash for kidneys’ racket in which impoverished people from Myanmar are being enticed to sell their organs for profit.

"India’s Apollo Hospitals, a multi-billion dollar company with facilities across Asia, boasts that it conducts more than 1,200 transplants a year, with wealthy patients arriving for operations from all over the world, including the UK.

"Paying for organs is illegal in India, as it is across most of the world, but a Telegraph investigation has revealed that desperate young villagers from Myanmar are being flown to Apollo’s prestigious Delhi hospital and paid to donate their kidneys to rich Burmese patients.

“It’s big business,” one of the racket’s ‘agents’ told an undercover Telegraph reporter. Those involved “work together to get around the obstacles between the two governments,” she added. The hospital “asks the official questions. And on this side they tell the official lies.”

"The scam involves the elaborate forging of identity documents and staging of ‘family’ photographs to present donors as the relatives of would-be patients. Under Indian and Burmese laws, a patient cannot receive an organ donation from a stranger in normal circumstances.

"Apollo Hospitals said it was “completely shocked” by the Telegraph’s findings and would launch an internal investigation. “Any suggestion of our wilful complicity or implicit sanctioning of any illegal activities relating to organ transplants is wholly denied,” it added.

"Professional blood donors" in India (where paying blood donors is illegal)

 India allows only unpaid blood donation, from altruistic donors or from "replacement donors" who are friends or relations of particular patients in need of blood (who must procure it before receiving it). There is a severe blood shortage, some of which is filled by black market "professional" blood donors, who are paid to pretend to be unpaid replacement donors.

Here's a story from the Indian news service Quint:

Out for Blood: Why Are Many Indians Forced To Seek 'Professional Blood Donors'? Although it is illegal, why is there a thriving market for paid blood donors in India?  by ANOUSHKA RAJESH and MAAZ HASAN

"Donating blood in exchange for money was banned in India in 1996. However, paying 'professional blood donors' to meet this requirement is still fairly common.

...

"To see how easy it would be to 'arrange' a paid blood donor, FIT went to one of the busiest government hospitals in Delhi.

...

"All leads – from vendors to patient families and bootleg pharmacists – point us to Ashok (name changed). He sits, surrounded by 4-5 men, and is guarded when we make inquiries.

"He begins with the following line of questioning: 'Where is our patient admitted?  What surgery do they need?  Why couldn't we just get friends and relatives to donate?

"Posing as a patient's friend, the FIT reporter gives him preplanned answers. In the emergency ward.  He had an accident and needs surgery on his leg.  I donated blood a month ago. He has no family here, and everyone else we reached out to has refused.

"Only when he's satisfied with the answers, he says he would be able to 'arrange boys' by the next day, and that it would cost between Rs 3,500 to Rs 4,000.

...

"According to the Ministry of Health and Family Welfare, India's annual requirement for blood is around 1.5 crore units per year, while in reality, only around 1 crore units are available.

"This gap in supply and demand of blood poses a major public health crisis in the country. For example, around 70 percent of postpartum hemorrhage (PPH)-related deaths in India are due to lack of immediate availability of blood.

...

"The paid donors are generally young boys, between the ages of 20 and 25, from very poor backgrounds," says Dr Dubey. ""This will no doubt be detrimental to their health," he adds. Moreover, if caught, they face the risk of jail time.

"The protocol is to ask every donor a set of questions before we take their blood. "If they seem suspicious, we ask them questions like, 'how are you related to the patient?', 'what is the patient's name?', and 'what surgery are they having?', to sus them out. If we get enough proof, we either defer them, or hand them over to the cops," Dr Priyansha Gupta, PG resident, Public Health, who has worked in Delhi's AIIMS blood bank in the past.

"What, then, happens to the families who desperately need blood when their donors are deferred?

"Dr Dubey says they are referred to the social workers attached to the hospital to get them help.

...

"But you have to understand, blood is a scarce commodity, and there's only so much we have."

##########

Here's a story from the Hindustan Times (in 2022), which begins with some relevant background (before debunking myths that lead to a shortage of voluntary donors):

Common myths on blood shortage in India  "The article is authored by Dr Parth Sharma, researcher, Ranita De, researcher in Lancet Citizen's Commission on Reimagining India’s Health System and Dr Vaikunth Ramesh."

"The shortage of blood products has been a major public health problem in India. It is estimated that nearly 12,000 people lose their lives every single day due to the lack of blood products. Supporting a population of 1.4 billion, the present blood transfusion service is fragmented with a little over 3,700 blood centres of which about 70% are located in eight states only. As of 2020, 63 districts in India do not have a blood centre. Space crunch and a burgeoning population have led to the establishment of health care facilities without blood centres on their premises, which in turn depend on nearby blood or storage centres for access to safe blood.

"Unfortunately, India has one of the largest shortages of blood supplies globally, while several diseases requiring blood transfusions are on the rise.

"A recent study by Joy Mammen, et. al. estimated the shortage to be around 2.5 donations per 1,000 eligible donors which equals a shortage of 1 million units. Blood products are required not only for surgeries but also for patients suffering from various medical conditions causing severe anaemia. At present, the source of donated blood is a combination of voluntary donors and replacement donors. Although professional donors are forbidden by law, they still continue to persist in our system under the guise of replacement donors. Voluntary non-remunerated donors, who donate based on altruism and a sense of doing greater good for the community, unfortunately, account for only 80% of the donors in India.

#######

HT: I was directed to the above links from the Indian posting

India Policy Watch #2: Regulating SoHO  by Pranay Kotasthane, which was in part about the recent move in the EU to further restrict payment for Substances of Human Origin (SoHO), as discussed in

Saturday, November 4, 2023

The EU proposes strengthening bans on compensating donors of Substances of Human Origin (SoHOs)--op-ed in VoxEU by Ockenfels and Roth

Organ transplantation in China: in transition--and controversy about paying funeral costs

 I recently spoke at the CAST transplant conference in Hong Kong (see picture), and the underlying theme of my talk, and of many talks there, was the transition of transplantation in China, and what its future might hold.

Jie-Fu HUANG is the other speaker on Zoom (to my right and your left), and Haibo Wang is on the far left on stage.

Here are two of my opening slides (using 2021 data from the Global Observatory on Donation and Transplantation)

On the left, you see that, today, China and India already perform more kidney transplants than any country in the world except the U.S.  On the right, you see that, by virtue of their large populations, they accomplish this despite their quite low rates of transplants per million population, compared to the U.S. and countries in Europe.  So if China and India can raise their transplant rates to rates comparable to the U.S. and Europe, most of the transplants in the world will be done in Asia, and many many additional lives will be saved.

Note that China mostly transplants kidneys from deceased donors, while India mostly transplants kidneys from living donors. So they have different paths (and plenty of untapped potential) for raising donation and transplantation rates.  And their paths to their current positions have also been very different.

Here is a recent account reflecting China's recent progress:

Chen, Zhitao, Han, Ming, Dong, Yuqi, Zeng, Ping, Liao, Yuan, Wang, Tielong, et al. (2023). First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China: 5-year Experience at a High-volume Donor and Recipient Liver Transplant Center. Transplantation, 107, 1855-1859. https://doi.org/10.1097/TP.0000000000004561

" In 1972, our center performed the first living donor kidney transplantation in China. Since then, kidney and liver transplant programs have evolved. By the beginning of the 21st century, organ transplantation had advanced, and clinical liver transplants have been performed successfully at the First Affiliated Hospital of Sun Yat-sen University.1

"Organ shortage has been a prominent feature at our institution as it has been around the world. Starting in the early 1980s, many organs had been procured from inmates on death rows. This unethical approach has been rightfully criticized by the worldwide community. As a consequence, the source of organs for transplants has solely been replaced by voluntary donations from Chinese citizens since January 1, 2015.

...

"Moreover, policies and methods for humanitarian aid to donor families were established. Those policies follow WHO guidelines while recognizing specific aspects of the Chinese culture. The State Ministry of Health and the Red Cross Society of China launched a pilot project on organ donation after the death of citizens in 2010 and established the China Organ Donation Committee. The principle of this pilot project was to learn from the experiences and standards in developed countries while recognizing national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system.2

**********

In the same issue of Transplantation as the above article is this invited commentary by Ascher and Delmonico, both former Presidents of The Transplanation Society (of which Transplantation is the official journal). They largely approve of the effort China has made in transplants, but they have a big reservation.

Ascher, Nancy, MD, PhD & Delmonico, Francis. (2023). Organ Donation and Transplantation in China. Transplantation, 107, 1880-1882. https://doi.org/10.1097/TP.0000000000004562

"The date of 2015 is important for the review of any organ transplantation report from China because of the public proclamation in the media in 2015 prohibiting the use of organs from executed prisoners. Clinical transplantation articles antecedent to 2015 have been consistently rejected by Transplantation and the international community because the source of the transplanted organs was most often an incarcerated prisoner. China took a major step to condemn this practice publicly in 2015. However, because there is no law or regulation that prohibits this unethical practice, there has been ongoing concern that this practice may be continuing. Notwithstanding such a reality, there have been regulations that are citable and may be reflective of the changing experience of organ donation and transplantation in China that are consistent with the World Health Organization (WHO) Guiding Principles.

...

"WHAT CONTINUES TO BE OBJECTIONABLE

"The Chinese Red Cross is prominent in the organ donation process and a center of support for deceased donor families designated by the Red Cross as humanitarian aid to donor families.7 However, such humanitarian aid, although not limited to China, should not be misinterpreted to be an effort because it includes payment to elicit consent for donation. The Sun Yat-sen publication suggests that the Red Cross policies follow WHO guidelines while recognizing specific aspects of Chinese culture without elaboration as to the cultural details. A payment to donor families for funeral expenses or other monetary incentives should be recognized as a form of commercialization and would not comply with WHO guidelines."

**********

Some background may help put this objection in perspective. Doctors Delmonico and Ascher are prominent signatories of a declaration that payments to families of organ donors are crimes against humanity (as are payments to living donors, and both are declared comparable to transplanting organs from executed prisoners, and to be organ trafficking. See my 2017 post.)

So, they raise the question of whether saving many lives by increasing deceased donation in China will be justified if it involves paying funeral expenses of donors.  

My guess is that Chinese health authorities, thinking of the many lives to be saved, will think that this act of generosity to families of deceased donors will indeed be justified, taking account of (see above) "national conditions and the social reality in China aiming to build an ethical and effective scientific organ donation and transplantation system." 

Many people in China and elsewhere might even think that little if any justification is needed for generosity, particularly generosity to families of deceased donors, that is to families who are themselves generous.

Kidney Paired Donation in Developing Countries: a Global Perspective

 Vivek Kute and his colleagues argue that one of the lessons from the developing world is that kidney exchange can save many lives, but may need to be organized differently in some ways than in the developed world.

Kidney Paired Donation in Developing Countries: a Global Perspective by Vivek B. Kute, Vidya A. Fleetwood, Sanshriti Chauhan, Hari Shankar Meshram, Yasar Caliskan, Chintalapati Varma, Halil Yazıcı, Özgür Akın Oto & Krista L. Lentine, Current Transplantation Reports (2023)  (here's a link that may provide better access]

Abstract

...

"Despite the advantages of KPD programs, they remain rare among developing nations, and the programs that exist have many differences with those of in developed countries. There is a paucity of literature and lack of published data on KPD from most of the developing nations. Expanding KPD programs may require the adoption of features and innovations of successful KPD programs. Cooperation with national and international societies should be encouraged to ensure endorsement and sharing of best practices.

Summary

KPD is in the initial stages or has not yet started in the majority of the emerging nations. But the logistics and strategies required to implement KPD in developing nations differ from other parts of the world. By learning from the KPD experience in developing countries and adapting to their unique needs, it should be possible to expand access to KPD to allow more transplants to happen for patients in need worldwide."

...

" Despite the advantages of KPD programs, they remain rare in the developing world, and the programs that exist have many differences with those of developed countries. Program structure is one of these differences: multi-center, regional, and national KPD programs (Swiss, Australia, Canada, Dutch, UK, USA) are more common in the developed than the developing world, whereas single center programs are more common

...

"kidney exchanges frequently take weeks to months to obtain legal permission in India despite the fact that only closely-related family members (i.e., parents, spouse, siblings, children, and grandparents) are allowed to donate a kidney [47].

...

"Protecting the privacy of a donor, including maintaining anonymity when requested, is common practice among developed countries but uncommon in developing nations. Anonymous allocation during KPD is a standard practice in the Netherlands, Sweden, and other parts of Europe, but this is not the case in countries such as India, Korea, and Romania [14, 48, 49]. In areas where anonymity is not maintained, the intended donor/recipient pair must meet and share medical information once a potential exchange is identified, but before formal allocation of pairs occurs. The original donor/ recipient pair may refuse the proposed exchange option for any reason and continue to be on the waitlist. In India, nonanonymous KPD allocation is standard practice and has the goal of increasing trust and transparency between the transplant team and the administrative team [14, 49]. Countries differ in philosophical approaches to optimizing trust and transparency, and objective data on most effective practices would benefit the global community."

********

Tomorrow I hope to have a few words to say about the equally unique situation in China.

######

Update:

Tuesday, September 19, 2023

Organ transplantation in China: in transition--and controversy about paying funeral costs

Affirmative action in India

 Here's an interesting paper by Orhan Aygün and Bertan Turhan. It comes with something of a backstory, which accounts for its quite delayed publication (delays both in initial acceptance and then in publication after acceptance*). I gather it will appear in the next issue of Management Science.

How to De-Reserve Reserves: Admissions to Technical Colleges in India by Orhan Aygün and Bertan Turhan, Management Science (forthcoming),  Published Online:11 Nov 2022 https://doi.org/10.1287/mnsc.2022.4566

Abstract: "We study the joint implementation of reservation and de-reservation policies in India that has been enforcing comprehensive affirmative action since 1950. The landmark judgment of the Supreme Court of India in 2008 mandated that whenever the OBC category (with 27% reservation) has unfilled positions, they must be reverted to general category applicants in admissions to public schools without specifying how to implement it. We disclose the drawbacks of the recently reformed allocation procedure in admissions to technical colleges and offer a solution through “de-reservation via choice rules.” We propose a novel priority design—Backward Transfers (BT) choice rule—for institutions and the deferred acceptance mechanism under these choice rules (DA-BT) for centralized clearinghouses. We show that DA-BT corrects the shortcomings of existing mechanisms. By formulating India’s legal requirements and policy goals as formal axioms, we show that the DA-BT mechanism is unique for the concurrent implementation of reservation and de-reservation policies."

*This paper spent a long time waiting to be published, because of what seems to have been a priority dispute that, after the paper was accepted for publication,  was pursued through  allegations of research misconduct. The editorial office of Management Science conducted an investigation that determined that there was no reason not to proceed with publication.

#######

Update: here's the citation to the published version

Orhan Aygün, Bertan Turhan (2022) How to De-Reserve Reserves: Admissions to Technical Colleges in India. Management Science 69(10):6147-6164.

https://doi.org/10.1287/mnsc.2022.4566

An upside to dowries, by Natalie Bau, Gaurav Khanna, Corinne Low & Alessandra Voena

 Dowries (like bride prices*) are often criticized, but may have indirect effects that aren't so easy to see, as in this recent NBER paper:

Traditional Institutions in Modern Times: Dowries as Pensions When Sons Migrate by Natalie Bau, Gaurav Khanna, Corinne Low & Alessandra Voena  NBER WORKING PAPER 31176, DOI 10.3386/w31176

Abstract: This paper examines whether an important cultural institution in India - dowry - can enable male migration by increasing the liquidity available to young men after marriage. We hypothesize that one cost of migration is the disruption of traditional elderly support structures, where sons live near their parents and care for them in their old age. Dowry can attenuate this cost by providing sons and parents with a liquid transfer that eases constraints on income sharing. To test this hypothesis, we collect two novel datasets on property rights over dowry among migrants and among families of migrants. Net transfers of dowry to a man's parents are common but far from universal. Consistent with using dowry for income sharing, transfers occur more when sons migrate, especially when they work in higher-earning occupations. Nationally representative data confirms that migration rates are higher in areas with stronger historical dowry traditions. Finally, exploiting a large-scale highway construction program, we show that men from areas with stronger dowry traditions have a higher migration response to reduced migration costs. Despite its potentially adverse consequences, dowry may play a role in facilitating migration and therefore, economic development.

********

*Recall this earlier paper:

Ashraf, Nava, Natalie Bau, Nathan Nunn, and Alessandra Voena. "Bride price and female education." Journal of Political Economy 128, no. 2 (2020): 591-641.

Is an End to Child Marriage within Reach? Not yet... Unicef report, and Lancet summary

 Unicef has issued the following report focused on the continued prevalence of child marriage, particularly in the poorest communities:

Is an End to Child Marriage within Reach? Latest trends and future prospects. May 2023

"The practice of child marriage has continued to decline globally. Today, one in five young women aged 20 to 24 years were married as children versus nearly one in four 10 years ago. Yet progress has been uneven around the world, and in many places the gains have not been equitable, leaving the most vulnerable girls behind.

"This year marks the halfway point to the deadline for achieving the Sustainable Development Goals, and when it comes to ending child marriage, a number of challenges loom large. Despite global advances, reductions are not fast enough to meet the target of eliminating the practice by 2030. In fact, at the current rate, it will take another 300 years until child marriage is eliminated."

***********

And here's an article in the Lancet:

Child marriage could be history by 2030, or last 300 more years, by Claudia Cappa, Colleen Murray and Nankali Maksud 

"UNICEF's analysis reveals only slight declines in child marriage in west and central Africa, which is the region with the highest prevalence of child marriage.1 There has been no change in Latin American and the Caribbean, which, if the current trajectory continues, would have the second highest prevalence of child marriage worldwide by 2030.1 After steady progress between 1997 and 2012, the Middle East, north Africa, eastern Europe, and central Asia regions have all seen stagnation in reducing child marriage in the past decade.

...

"Countries in sub-Saharan Africa with the highest projected population growth have the highest levels of child marriage, meaning the number of marriages is expected to increase there.

...

"declining child marriage prevalence is concentrated among girls from wealthier households. Girls from the richest quintile are less likely to become child brides and are the first to benefit from progress in averting child marriage, resulting in a widening gap in child marriage prevalence between rich and poor.1 In south Asia, wealthier households had three times more averted cases of child marriages than poor households in the past 25 years.1 If the rate of success in the richest quintile of south Asian families had been achieved globally, only 9% of girls would be married in childhood, far less than the current 19% worldwide prevalence of child marriage.1 Further progress in reducing child marriage largely depends on reaching girls who are otherwise left behind, including girls from the poorest households living without the resources and opportunities of their wealthier peers."

NPR on black markets for kidneys from Nepal, for India

Here's an 8-minute video from National Public Radio about the black market for kidneys, trafficked from Nepal to India.  Some of the people interviewed indicate that they were duped; others decline to cooperate with prosecutors against the black market recruiters. A particular Indian hospital is named. Frank Delmonico makes an appearance near the end.  

(The video doesn't discuss any of the larger issues about the causes and consequences of the shortage of organs for transplant that make black markets busy and profitable, or how these might be addressed through legal and ethical efforts to increase the availability of transplants.)

.

HT: Frank McCormick

**********

Here's a post on the legal market for kidneys in Iran.

Monday, June 27, 2022

A Forum on Kidneys for Sale in Iran, in Transplant International

******* 

Here's an article from earlier this week in the Washington Monthly

We Have to Make Organ Donors Whole. by Sally Satel, January 17, 2023 

"I’m alive because of kidney donations, but there wouldn’t be an organ shortage if we made it easier for those willing to literally give a piece of themselves. New York is taking a good first step."

*******

related earlier post:

Sunday, January 1, 2023

New York State's Living Donor Support Act (LDSA, S. 1594) was signed by Governor Hochul on Dec. 29

Affirmative action in India--a market design perspective, by Ashutosh Thakur, Orhan Aygün, Bertan Turhan, and M. Bumin Yenmez

 The policy portal Ideas for India has an e-symposium on recent developments in affirmative action in India, with an informative introduction by Parikshit Ghosh, and short papers by Ashutosh Thakur, and by Orhan Aygün, Bertan Turhan,  and M. Bumin Yenmez. It's encouraging to see that the attention to these issues by such serious market designers is getting prompt exposure to policy makers in India.

Here's the introduction (which I've copied in it's entirety, with links):

Introduction to e-Symposium: The architecture of affirmative action 12 December, 2022 by Parikshit Ghosh

The Supreme Court of India recently upheld an amendment that excluded Scheduled Castes, Scheduled Tribes and Other Backwards Classes from the Economically Weaker Section (EWS) quota, restricting it only to general category applicants. However, the specifics of how this reservation policy is executed can have important social and political implications. 

Across this week, from 12-16 December, this I4I e-Symposium brings together articles that provide a theoretical basis – using principles of market design, and search and matching theory – for more efficient implementation of reservation policies. Anchored by I4I’s Editor-in-Chief Parikshit Ghosh, the e-Symposium aims to open a discussion on the architecture of affirmative action, from the mechanisms of vertical and horizontal reservations, to ensuring efficiency in meeting diversity targets.

The authors of the Indian Constitution had the wisdom to see that our tryst with destiny will be unfulfilled if we do not confront the ghosts from our past. Even as Articles 14 and 15 pronounced equal treatment for all, Article 15(4) paved the way for reservations targetted at socially disadvantaged groups. The founders of the Indian republic understood that a newly independent nation had a historic opportunity to not only break the shackles of colonialism, but also oppression in all its forms. A narrow, ahistorical notion of meritocracy did not suit this mandate. 

Still, after more than seven decades of experience, questions swirl around our reservation policy. Who deserves protection? When should it be withdrawn? Is social disadvantage synonymous with economic deprivation? Grappling with these difficult issues requires not only input from the social sciences, but also an engagement with ethics and politics. Unlike the design of airports or the sale of spectrum, this is an area where the public interest cannot entirely be left to academics and bureaucrats. 

However, affirmative action does not involve only the setting of diversity targets – which is fundamentally an expression of democratic will – but also calls for the design of concrete institutional rules to achieve these targets with the least sacrifice of the meritocratic ideal. Should general category seats be filled before the SC/ST seats or vice versa? If an OBC candidate with disability is recruited, should it count towards fulfilling both the OBC and disability quotas, or just one of them? How exactly these finer points are settled can be profoundly consequential, as economists have learnt from several decades of research on market design (Roth 2007). 

While affirmative action targets have been well articulated by legislatures, the rules for implementing them have been left ill specified, requiring courts to step in time and again. Many landmark judgments of the Supreme Court are attempts to reduce the confusion and conflict arising from procedural ambiguity. 

Unfortunately, this design aspect of reservation policy, what I call the architecture of affirmative action, has not only received scant attention in the media and public debate, but its importance seems to go largely unrecognised. Our aim with this e-Symposium is to start that conversation. 

In Indra Sawhney vs. Union of India (1992), the Supreme Court mandated the earmarking of certain positions for caste-based categories (like SCs, STs and OBCs) – what has come to be known as vertical reservation – but left the fulfillment of diversity targets for other categories (such as persons with disabilities) more flexible – an arrangement referred to as horizontal reservation. In the opening article of this symposium, Ashutosh Thakur revisits this issue and provides a critique of vertical reservations. Among other things, it has no built-in sunset clause and requires legislatures to continuously revise quotas as disadvantaged groups economically catch up with others. 

The next two articles come from researchers who have studied how to devise efficient ways of meeting diversity goals, as well as matching two sides of a market (for example, assigning students to schools or colleges) in a sensible way. In the second article of the series (their first), Orhan Aygun, Bertan Turhan and Bumin Yenmez point out that though the five judge bench upheld restricting the Economically Weaker Section (EWS) quota to general category applicants, SC/ST/OBC candidates could still make themselves eligible for these positions by not declaring their caste identity, and explore the implications of such a loophole. 

The final article examines the process through which rank holders from the joint entrance examination (JEE) are assigned to the various Indian Institutes of Technology (IITs) and other technical colleges. The assignment must respect student merit ranks, their stated preference over institutions and programmes, and the quota requirements within each institution. In addition to that, the judgment in Ashok Kumar Thakur vs Union of India (2008) stipulates that unfilled OBC quota seats (but not SC/ST quotas) should be made available to general category applicants to reduce wastage. This is clearly a complex task.   

The system currently in place was designed by the government, in consultation with a group of computer scientists and market designers (Baswana et al. 2019). It is based on the celebrated Gale-Shapley algorithm¹ and tries to ensure that within the constraints of the diversity requirement, the allocation is fair and efficient. Many readers may be unaware that a rare confluence of legislative will, judicial oversight and technocratic finesse has designed the staircase to success so many Indians aspire to step on. Yet, as Aygun, Turhan and Yenmez point out through simple and illuminating examples, when it comes to de-reserving unfilled OBC seats, the current system has subtle flaws that can and ought to be corrected. 

After 75 years of Independence, we can take some pride in our quest for an affluent and just society, yet be vigilant about the gaps in that attempt and strive to bridge them. 

Design choices for implementing affirmative action

Ashutosh Thakur

Ashutosh Thakur explains the various ways in which affirmative action policies can be implemented, and discusses the underlying trade-offs and issues at hand...

Read More

Challenges of executing EWS reservation efficiently

Orhan Aygün, Bertan Turhan, M. Bumin Yenmez

Aygün, Turhan, and Yenmez look at the implications of reserved category members having to choose between applying for positions on the basis of their caste or income...

Read More

Improving admissions to technical colleges in India

Orhan Aygün, Bertan Turhan, M. Bumin Yenmez

Aygün, Turhan, and Yenmez examines the process through which JEE rank holders are assigned to the various IITs and other technical colleges...

Read More

Note: 

1. The Gale–Shapley algorithm is an algorithm used for finding a solution to the stable matching problem, and has been described as solving both the college admission problem and the stable marriage problem.

Further Reading 

• Baswana, S, P Chakrabarti, S Chandran, Y Kanoria and U Patange (2019), ‘Joint Seat Allocation 2018: An algorithmic perspective’, arXiv Technical Report.
• Roth, AE (2007), ‘The Art of Designing Markets’, Harvard Business Review, October.

Paired liver exchange in India

 Here's a report on 2-way liver exchanges conducted at Max Center for Liver and Biliary Sciences, Max Saket Hospital, New Delhi, India, each between two manually matched, non-anonymous patient-donor pairs.

Paired Exchange Living Donor Liver Transplantation: A Nine-year Experience From North India by Agrawal, Dhiraj MD, DM1; Saigal, Sanjiv MD, DM, MRCP, CCST1; Jadaun, Shekhar Singh MD, DM1; Singh, Shweta A. MD, DM1; Agrawal, Shaleen MS, MCh1; Gupta, Subhash MS, MCh1 

"Background: Paired exchange liver transplantation is an evolving strategy to overcome ABO blood group incompatibility and other barriers such as inadequate graft-to-recipient weight ratio and low remnant liver volume in donors. However, for the transplant team to carry 4 major operations simultaneously is a Herculean effort. We analyzed our experience with liver paired exchange (LPE) program over the past 9 y."

...

"Although the basic framework for LPE was adopted from the kidney paired exchange program, LPE or swap LDLT is inherently distinct, more complex, and associated with more technical, logistical, and ethical challenges.11 Both recipient and donor surgeries are long-duration surgeries and must be flawless to ensure minimum morbidity and mortality. The living donor partial hepatectomy is associated with approximately 10 times greater mortality than living donor nephrectomy, and the morbidity ranges from 9% to 24%, depending on the type of hepatectomy performed.12,13

"The logistics involved in a single-center simultaneous LPE are extensive with 4 simultaneous operations: 4 sets of teams of anesthetists, surgeons, nurses, and technicians. The blood bank must be equipped with requirements for major surges. For a single LDLT operation, it is estimated that >18 skilled team members may be needed, and in LPE, this number is doubled. Furthermore, any unanticipated difficulty due to operative anatomical variations may potentially impact both recipients’ outcomes. These constraints limit the LPE to a few high-volume centers.

...

"After the recipients and donors of an incompatible pair showed willingness for LPE, the medical suitability of each donor and recipient pair and the equity of the exchange were confirmed by a multidisciplinary forum comprising transplant hepatologists, transplant surgeons, social workers, and psychiatrists. Once 2-by-2 donor-recipient pairs were successfully matched, the transplant team informed the pairs and arranged a meeting wherein each recipient could meet their intended donor in the presence of the transplant team to discuss any anticipated issues. All participants who participated in the exchange program underwent a thorough psychosocial assessment to minimize the possibility of conflict. Donors have clarified that a poor outcome is possible in any LDLT, and in rare circumstances, their intended recipient can have a poor outcome. Through several in-depth counseling sessions, all 4 parties were independently and jointly informed about the suitability and structure of the exchange, the entire procedure, and the expected results. They were also provided with alternative options such as ABOi transplantation, deceased donor liver transplantation (DDLT), and associated risks and cost-effectiveness. Donors were allowed to opt out at any step during the process, and care was taken to avoid coercion. After the development of basic trust between all 4 participants, informed consent and a confidential agreement were signed. In India, there is a strict legal requirement for LDLT that the donor and recipient should be related to either blood or marriage. However, since LPE is an unrelated, directed donation, special approval was obtained from the ethical committee of the local authority.

...

"The 17 pairs of LPE donations included 34 directed living donors with a median age of 38.5 y (19–51 y), of which 27 were females. All donors were first-degree relatives of the recipients and included 18 spouses, 11 children, and 5 siblings. 

...

"ABO-incompatible donor-recipient pairs are encouraged to visit our center regularly, and as this is a common problem, not surprisingly, they are often able to meet another ABOi pair at the center. Furthermore, our coordinators have the telephone numbers of recipients looking for paired exchanges, and they facilitate such pairs to speak to each other on the phone. Once they show willingness to participate in the paired exchange program, their papers are submitted to the government-appointed authorization committee for clearance. Theoretically, in LPE donations, there is a potential for emotional disconnect, as opposed to ABO-incompatible LDLT. Interestingly, in our series of 34 transplants, the donor felt that they had donated to their own recipient, and on follow-up, all 4 participants seemed to have developed great emotional bonding.

"At our center, >75% of donors are first-degree relatives as “nonnear relatives” find very difficult to get governmental clearance. LPE is a transplantation between unrelated people and is, therefore, liable for exploitation. However, The Transplant Act has built in safety features as it allows only “first degree relatives” to be considered for paired exchange and also bars the organ exchanges between Indian and foreigners.

...

"It is possible that, in the future, transplant centers in India will act in tandem, and we will be able to operate pairs at 2 different centers. However, under the existing hospital-based government-appointed authorization committee, this may not be feasible unless a central clearing agency is set up."

Kidney exchange in The Times of India

 The Times of India covers my talk at the Indian Society of Transplantation meeting:

Alvin Roth for legal boost to kidney exchange pool in India by Chaitanya Deshpande, Oct 15, 2022c

 The site makes it hard to extract text, but here's a photo of some comments, which make me hope that some action may be taken:

Update: 

The Dr H.L. Trivedi Oration at the Indian Society of Transplantation (ISOT) Meeting 2022

Here's the meeting announcement:

ISOT 2022 NAGPUR

32^nd Annual Conference of The Indian Society of Organ Transplantation
2^nd Mid-term Meeting of Liver Transplantation Society of India
15^th Annual International Conference of NATCO
Dates : 12^th - 16^th October 2022 | Venue : Hotel Le Meridien, Nagpur

My talk, the Dr H.L. Trivedi Oration   is scheduled for 11:00am on Friday the 14th in Nagpur, which means I'll be giving it by zoom tonight, Thursday evening at 10:30 pm Pacific Time.

The presentation, which  will be about "Increasing the availability of transplants in India" is in honor of the late Dr. Hargovind Laxmishanker "H. L." Trivedi (August 1932 – October 2019), who I had the privilege of meeting,

Here's his obituary : 

Kute, Vivek, Himanshu Patel, Pankaj Shah, Pranjal Modi, and Vineet Mishra. "Professor Dr. HL Trivedi pioneering nephrologist and patriot who cared for his country (31-08-1932 TO 2-10-2019)." Indian Journal of Nephrology 29, no. 6 (2019): 379.

*********

Here's my concluding slide:

• India has enormous talent and accomplishment in living-donor transplantation
• To more nearly reach it’s potential, India needs to invest in recovering deceased donor organs.
• In the near term, it can build on it’s accomplishments in kidney transplantation, by 
• establishing national (not just regional) kidney exchange
• Continuing to explore international exchange for the hardest to match pairs
• Reducing restrictions on who can be an exchange donor
• Allowing non-directed donors and chains
• Allowing some chains to begin with a deceased-donor kidney
• Reducing financial barriers by increased investment in public hospitals and government health insurance, for organ donors as well as recipients

***********

Update: 

Learning and competition in the lab, in France, and in India

 Three NBER working papers this week particularly caught my eye: a lab experiment, a natural experiment, and a field experiment.

The first is a reminder of why simple reinforcement learning models have as much predictive power as they do. It's an experiment that shows that even when others' experience is made clearly visible, there's a tendency to rely on 'own experience'.

Not Learning from Others by John J. Conlon, Malavika Mani, Gautam Rao, Matthew W. Ridley & Frank Schilbach  WORKING PAPER 30378 DOI 10.3386/w30378 August 2022

Abstract: We provide evidence of a powerful barrier to social learning: people are much less sensitive to information others discover compared to equally-relevant information they discover themselves. In a series of incentivized lab experiments, we ask participants to guess the color composition of balls in an urn after drawing balls with replacement. Participants' guesses are substantially less sensitive to draws made by another player compared to draws made themselves. This result holds when others' signals must be learned through discussion, when they are perfectly communicated by the experimenter, and even when participants see their teammate drawing balls from the urn with their own eyes. We find a crucial role for taking some action to generate one's `own' information, and rule out distrust, confusion, errors in probabilistic thinking, up-front inattention and imperfect recall as channels.

******

The second is a careful study of affirmative action for women in French chess tournaments: a requirement that teams include a woman had many effects, including improvement in the quality of play by French women.

Trickle-Down Effects of Affirmative Action: A Case Study in France by José De Sousa & Muriel Niederle, WORKING PAPER 30367 DOI 10.3386/w30367 August 2022

Abstract: "The introduction of a quota in the French chess Club Championship in 1990, an activity many players engage in next to playing in individual tournaments, provides a quite unique environment to study its effects on three levels. We find that women selected by the quota improve their performance. We show large spillover and trickle-down effects: There are more and better qualified women. International comparisons confirm that the results are unique to France and that there are no substantial adverse effects on French male players. We discuss the properties of this quota and how to implement it in other environments."

The concluding paragraph:

"We speculate that one reason for the success of the French chess quota was due to the fact that it was an “output” rather than a “pure representation” quota. At least one ninth of the performance of teams in the Club Championship was determined by the performance of female players. Such an “output” based quota provides organization with different incentives than a pure representation quota does. We use economic departments to discuss the different gender quotas and how each of them might be implemented. We hope that future work will provide theoretical properties of various quotas as well as find other areas where output quotas are already, or could be, implemented."

*********

The third is about the difficulty of inducing competition in close quarters.

Does the Invisible Hand Efficiently Guide Entry and Exit? Evidence from a Vegetable Market Experiment in India by Abhijit Banerjee, Greg Fischer, Dean Karlan, Matt Lowe & Benjamin N. Roth, WORKING PAPER 30360 DOI 10.3386/w30360, August 2022

Abstract: "What accounts for the ubiquity of small vendors operating side-by-side in the urban centers of developing countries? Why don’t competitive forces drive some vendors out of the market? We ran an experiment in Kolkata vegetable markets in which we induced (via subsidizing) some vendors to sell additional produce. The vendors earned higher profits, even when excluding the value of the subsidy. Nevertheless, after the subsidies ended vendors largely stopped selling the additional produce. Our results are consistent with collusion and inertial business practices suppressing competition and efficient market exit."