Marijuana legalization advances in the 2022 elections

Time Magazine published this map under the headline "Why Marijuana Had a Terrible Night in the 2022 Midterm Elections"

It doesn't look so terrible to me, so much as increasingly inevitable. The grey states on the map (where marijuana remains entirely illegal) are shrinking steadily: it doesn't appear that opponents will succeed in making America grey again.

 "Nineteen states and the District of Columbia allow recreational use of marijuana; 13 states outlaw it entirely. The rest of the states—including Arkansas, South Dakota and North Dakota—allow its use for medicinal purposes. It remains illegal under federal law."

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It's going to become increasingly hard for States to enforce draconian laws against something that is legal in neighboring states.  That doesn't mean that legalization is always going to go smoothly--the end of Prohibition didn't end alcoholism, and the end of marijuana prohibition won't make marijuana chemically safer (in fact competition will develop strains that are chemically more potent).  But removing legal risks from what would otherwise be uncontrolled black markets, and taking them out of the hands of criminals, still seems to have momentum.

Black markets in abortion pills

 Americans differ in their opinions about whether American women have a right to end a pregnancy, or whether state legislators have the right to decide the issue for residents of their state.  Six American Supreme Court justices hold the latter opinion, and so overturned the constitutional right defined 50 years ago by the same court in Roe v. Wade.

This means that different states are going to have different laws about abortion. But medical technology is such that abortion pills exist, and can arrive in the mail. So even State laws criminalizing that may not stop it, when abortion and abortion pills remain legal in other states. That is, we're about to see a situation ripe for black markets. We may also see a legal conflict among the states.

The NY Times has a story on that:

Risking Everything to Offer Abortions Across State Lines. Doctors and midwives in blue states are working to get abortion pills into red states — setting the stage for a historic legal clash.  By Emily Bazelon

"When the landscape settles, abortion is likely to be illegal or severely restricted in at least 20 states — where just two years ago, in 2020, about 250,000 people had abortions. It is clear that clinicians in those states will face imminent prosecution if they continue to provide abortions. What is much less clear is what happens if providers in blue states offer telemedicine abortions to women in states where that’s against the law. These clinicians, too, could be arrested or sued or lose their medical licenses. To protect themselves, they may have to give up traveling to certain parts of the country — and it’s still no guarantee.

"In the face of so much uncertainty and an invigorated anti-abortion movement, large organizations and most clinicians are loath to gamble. But Aid Access providers think that the end of Roe calls for doctors to take bold action. Their answer is to mail many more pills to women who otherwise may be forced to carry pregnancies they don’t want.

"The court’s decision overturning Roe last June, Dobbs v. Jackson Women’s Health Organization, polarized the public while opening the door to a new threat — a direct clash among the states over abortion law. In jettisoning the single national standard Roe established, the court invited states to pass or enforce their own laws, which could be diametrically opposed to those of neighboring states."

"Sitting in her office in New York, hundreds of miles from states that could go after her, Prine, at 71, was close to retirement and willing to take chances. “I don’t want younger physicians to be embroiled in lawsuits or criminally charged,” she said. “I’m the one that should happen to. Doctors like me who are at the end of our careers, we should be the ones to step up.”

"Article IV of the Constitution, which addresses the relationships among states, says that if a person charged with a crime in one state flees to another, she must be “delivered up,” or extradited, to the first state. If a doctor from Connecticut, for example, went to Texas, performed an illegal abortion there and then went home, Connecticut would have to send that doctor to Texas for prosecution. But courts have held in the past that if the person never set foot in the state that is prosecuting her, then she didn’t flee, and her state of residence has no constitutional obligation to extradite her. 

...

"But there’s a catch. If a provider travels outside her home state while Texas has a warrant for her arrest, another state without a shield law could follow the customary practice of interstate cooperation — and extradite her to Texas. In addition, if an abortion provider in a pro-access state like Connecticut is sued in Texas rather than prosecuted, Article IV requires the states to help enforce a civil judgment. Connecticut would probably be obligated to comply in collecting damages, for example, if a family member of a woman who had an abortion won a lawsuit for the wrongful death of a fetus. To deter these sorts of suits, Cohen, Donley and Rebouché suggest that states that want to shield their abortion providers could authorize them to countersue for interfering with legally protected health care. “If you’re hoping for a $1 million judgment in Alabama, but you know New York will let someone try to get it back from you, maybe you don’t sue in the first place,” Cohen says.

"The closest historical analogy, however imperfect, for the coming clash may be the conflict between Southern and Northern states over fugitive slave laws in the 19th century. “There are genuinely significant differences between slavery and abortion, morally and legally,” says Jamal Greene, a law professor at Columbia University. “But it’s a reasonable starting point for understanding why it’s a problem, in a nation that wants to hold itself together, when individual states are allowed to make policy about basic rights that people feel extremely strongly about, on both sides.”

"Tensions among the states can become corrosive. The framers of the Constitution gave enslavers the power to recapture enslaved people who escaped to free states. As the cause of abolition gained support, some free states passed personal liberty laws that protected Black people from kidnapping. In 1842, in Prigg v. Pennsylvania, the Supreme Court weighed in on the side of the South, striking down the conviction in Pennsylvania of a slave catcher for kidnapping a mother and her children."

Spain's stolen babies (from the NY Times)

The sale of babies is widely regarded as repugnant, but it has been used for political purposes in the dark days of Spain, and Argentina.  Here's a story from the Sunday NY Times recounting some of the history, focusing on one woman's search for her birth mother.

 Taken Under Fascism, Spain’s ‘Stolen Babies’ Are Learning the Truth. Thousands of Spanish children were taken from hospitals and sold to wealthy Catholic families. By Nicholas Casey, Sept. 27, 2022

"Up to the early 1930s, Spain had been among Europe’s most progressive countries, allowing for married couples to divorce and women to seek abortions. Under Franco, those rights were swiftly rescinded. Contraception was outlawed, adultery was criminalized and women lost the right to vote. Newspapers were censored, and many books were banned altogether, including those of Federico García Lorca, Spain’s most renowned poet and playwright. (Lorca had already been murdered by Nationalists during the civil war.) 

...

"But one of the most lasting abuses of the era was borne by children. ... Franco’s men soon began the abductions on a large scale. They targeted children orphaned by Franco’s firing squads and took newborns belonging to women who had given birth in jail as political prisoners. All were sent to be raised by regime loyalists. The era of the “stolen babies” had begun.

...

"Some nuns — aided by doctors, nurses and midwives — began to abduct babies to meet demand. In certain cases, the nuns still managed to persuade mothers to give up their children willingly, though many say they were coerced into surrendering their newborns. Others say they were sedated in the delivery room and then told, when they woke up, that their babies had died. In reality, the children had been sold to other families.

"Franco’s regime was not the only one to use the theft of children as a political weapon. In Argentina, as many as 30,000 people were “disappeared” by a military junta that ruled from 1976 to 1983 and gave their orphaned children to right-wing families, prompting decades of protests and demands that the government investigate. In Spain, people often refer to the Argentine cases as offering a precedent. But unlike Argentina, Spain never established a truth-and-reconciliation commission. In fact, the country did the opposite, passing a broad amnesty law in the years following Franco’s death that absolved members of the regime of most of their past crimes. While those responsible for the abductions were not explicitly granted amnesty, the policy did reflect a consensus that had emerged in post-Franco Spain — to avoid confronting the dark legacy of the dictatorship. The agreement even had a name: the Pact of Forgetting. Spain’s leaders, on both the right and left, espoused the need for peaceful democracy, even if it meant sacrificing popular calls for justice. “Let’s not disturb the graves and hurl bones at one another — let the historians do their job,” said José María Aznar, a former prime minister, in a speech years later.

...

"In 2004, the conservative government was defeated by José Luis Rodríguez Zapatero, a Socialist who came into office with plans to address the taboos of the past.... at Zapatero’s urging, Spain passed its historical memory law in 2007, which condemned the crimes of the Franco era and recognized its victims for the first time.

"A new generation of victims began to emerge — this time led not by the mothers who had lost their babies but by their children, now grown, who were seeking their biological parents. They formed grass-roots organizations like the National Association for Irregular Adoption Victims, which estimated that as many as 15 percent of the adoptions in Spain from 1965 to 1990 were performed without consent of the birth parents."

Dismantling kleptocracy

 USAID has published a guide to combating kleptocracy--i.e. government by thieves.

DEKLEPTIFICATION GUIDE. Seizing Windows of Opportunity to Dismantle Kleptocracy

“And we’re going all in on dekleptification. Today, I’m announcing the creation of a new dekleptification guide—a handbook to help countries make the difficult transition from kleptocracy to democracy. This guide, drawn from previous democratic openings in Romania, Dominican Republic, and South Africa, provides advice to reformers on how to root out deeply entrenched corruption and technical advice on how to implement radical transparency and accountability measures, how to stand up new anti-corruption structures. Moving rapidly and aggressively in historic windows of opportunity will make these reforms harder to reverse.”  -USAID Administrator Samantha Power, remarks delivered on June 7, 2022.

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Here's the full report.

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"The Kremlin’s most common method of closing other countries’ reform windows is covertly bankrolling opposition political parties. The Russian Federation has gotten caught deploying financial interference in elections more than 100 times over the past decade.124 Until 2014, the targets were mostly limited to the former Soviet bloc. For example, Ukraine’s Orange Revolution and Georgia’s Rose Revolution ended when Russia-backed oligarchs funded pro-Russian candidates who became presidents and rekleptified the two countries.  Over the decade ending in 2014, Putin felt increasingly rebuffed by Western politicians who would not stand for his violations of the sovereignty of neighboring countries.126 His relations with the West came to a head when Ukrainians opened their dekleptification window in 2014. Since then, the Kremlin has dramatically expanded the target surface of its financial interference in elections, deploying covert foreign money all over the world, often to close windows or prevent them from opening (see Figure 7).

***********

"CONCLUSION The ultimate objective of dekleptification is to help nations that endeavor to adapt their social contract away from kleptocracy and toward new social norms about the government’s duties and the public’s intolerance for corruption. Such adaptations take many years or decades, sustained by virtuous circles of institutions that prove effective and popular enough to withstand efforts to undermine them and restore kleptocratic rule. Exceptional institutional and societal resilience is needed in strategically contested countries, where the influence of foreign kleptocracies and the pathways of transnational corruption provide enormous resources to corrupt elements seeking to undermine reform.

"The most important and essential precondition for a virtuous circle is very broad and highly mobilized demand throughout the society, driving powerful domestic political action that ushers in a window of opportunity to roll back kleptocracy. Amid those pivotal openings, reformers urgently call for rapid responses from the international donor community. They need everything from fastmoving funding to targeted communications to in-kind technical expertise. When deciding how to build cutting-edge institutions to deliver transparency, accountability, and inclusion, reformers benefit greatly from lessons learned during similar windows in other countries.

"This guide captures those insights. It draws from USAID experts who were on the ground during the windows of Georgia 2004-2012, Romania 2004-2018, Egypt 2011-2013, Brazil 2013-2019, Ukraine 2014-present, Guatemala 2015-2017, Armenia 2018-present, South Africa 2018-2019, Malaysia 2018-2020, Sudan 2019-2021, Moldova 2021-present, Bulgaria 2021-present, the Dominican Republic 2020-present, and Zambia 2021-present. USAID partnered with reformers who forged inclusive institutions that were radically transparent and aggressively accountable, generating models for other countries confronting kleptocracy and strategic corruption. These reformers tried to establish anti-corruption institutions rapidly enough to seize and sustain fleeting windows of political will. And they scoped the policy details to be far more transparent, independent, and inclusive than is common elsewhere. This a not apolitical and technocratic work; it requires overwhelming public demand, timely political analysis, vibrant civil society, well-coordinated donors and interagency partners, and Missions highly attuned to the fluid and intense political dynamics of dekleptification.

"This comprehensive approach to rolling back kleptocratic structures is central to the modern pursuit of development, democracy, and peace."

Do repugnant markets corrupt society? Kim Krawiec calls for evidence...

 Kim Krawiec, who studies taboo trades from a legal perspective, thinks that people who claim that repugnant transactions undermine society should be asked to provide evidence.

Krawiec, K. (2022). Markets, repugnance, and externalities. Journal of Institutional Economics, 1-12. doi:10.1017/S1744137422000157

Abstract: This Article considers one aspect of the ongoing debate about the moral limits of markets – namely, the purported harmful effects of market transactions on particular relations, goods, services, or society at large, due to an inappropriate valuation. In other words, the argument is that some markets are ‘repugnant’ because they degrade and corrupt a variety of nonmarket values and relations, not just to the willing parties to the exchange, but to larger segments of society. This objection contains both a (frequently unacknowledged) empirical component and a moral component. This Article critiques these empirical claims on two grounds. First, market skeptics fail to provide evidence of the negative effects they hypothesize, despite widespread variation over time and across legal regimes. Second, these objections fail to account for the well-documented human tendency to fashion repugnant exchanges in a manner that reinforces – rather than undermines – deeply held values and relationships.

...

"how do we, as a society, determine what is up for sale and what must be immune from market forces? Although all cultures and time periods have proclaimed some transactions too sacred for the marketplace, those boundaries vary greatly across times and cultures and are often contested at the margins (Fiske and Tetlock1997). Once-common practices such as slavery, commutation (a direct payment to the government in exchange for relief from military service), substitution (paying another for military service in one's place), and the purchase of indulgences are no longer acceptable in most societies ( Krawiec2009a; NY Times, 1864). At the same time, formerly taboo practices, such as charging interest on a loan or accepting money in exchange for the practice of law are now widespread – although, in the case of charging interest, not universally so (Rossman2014).

...

"Many justifications have been offered for limits on ‘repugnant’ (Roth 2007) or ‘taboo’ ( Fiske and Tetlock1997) markets. This article considers a single, but prominent, objection – that some markets degrade and corrupt a variety of nonmarket values and relations, not just to the willing parties to the exchange, but to larger segments of society. This objection often involves concerns about the purported harmful effects of market transactions on particular relations, goods, services, or society at large due to an inappropriate valuation and has both a (frequently unacknowledged) empirical component and a moral component.

"The objection is empirical because it contends that markets in certain items and activities change the way in which society and its members perceive those items and activities or the non-market relationships through which they would otherwise be supplied. It is also a moral claim, because it rests on a contention that the change is inevitably negative – that certain modes of valuation and visions of the world are superior to others, or at least unsuitable to certain situations ( Anderson1993).

...

"This Article critiques these empirical claims on two grounds. First, as noted by others, market skeptics fail to provide evidence of the negative effects they hypothesize, despite widespread variation over time and across legal regimes. Second, and more importantly, these objections fail to account for the well-documented human tendency to fashion repugnant exchanges in a manner that reinforces – rather than undermines – deeply held values and relationships. The fact that a particular transaction is deemed morally repugnant by large swathes of society does not, after all, mean that such transactions disappear, even in the face of strong legal sanctions and criminal prohibitions. But it does mean that such exchanges may be managed, obfuscated, or reframed in some way, acknowledging and reinforcing the taboo in the process.

...

"to the extent that some, including Sandel (2012), have explicitly contended that ‘market creep’ has occurred without public awareness or debate, that claim is undermined by the full extent to which participants in and third-party observers of repugnant exchange have, in fact, debated, modified, and managed those exchanges over time."

The market for alcoholic drinks in Bangladesh

Doctors can prescribe alcohol in Bangladesh.

The Economist has the story:

Bangladesh loosens its booze laws

"Consumption of alcohol has long been outlawed for Muslims, who today make up 90% of the population. Other religions are exempt but need a permit issued by the government. A loophole for Muslims was introduced in 1950, but it includes a requirement for a doctor’s certificate. The permit declares that the holder “requires liquor on medical grounds” and is “hereby permitted to possess and consume foreign liquor”. Few bother. Most drinking is illicit and feeds a lucrative black market for imported liquor. Cases of people dying after drinking dodgy home-brew are not uncommon. 

"The government has acknowledged the problem. It is overhauling the rules in a simultaneous bid to boost domestic industry and bring boozing within the law. Individuals will still require permits, but the process for restaurants and bars to get liquor licences will be made less ambiguous. The new laws, which were introduced in February, also oblige establishments to buy 60% of their stock from the country’s two licensed producers: Jamuna Group, which makes Hunter, Bangladesh’s only home-grown beer, and Carew & Co, a state-run distiller of such fine tipples as Gold Riband Gin, Old Rum and Imperial Whisky."

HT: Alex Chan

Drugs, drug regulation, and chemistry: the case of nicotine (following Rob Jackler)

 My Stanford colleague Dr. Rob Jackler has a longstanding interest in nicotine as an addictive drug that continues to be effectively marketed and ineffectively regulated.

Lately he's been concerned with novel delivery systems, such as the non-combustion vaping devices offered by sellers like Juul (which  has recently been on a regulatory roller coaster.)

You can find many of his papers at the Stanford Research into the Impact of Tobacco Advertising (SRITA) site.  The most recent of these papers concerns the fact that a lot of regulation is focused on "tobacco products," but that nicotine itself--the addictive chemical in tobacco--has been successfully synthesized in the lab, and so can be marketed as a "tobacco free" product.

Here's a recent NY Times article on his work:

The Loophole That’s Fueling a Return to Teenage Vaping. Sales are rising of flavored e-cigarettes using synthetic nicotine that evades regulatory oversight, a gap that lawmakers are now trying to close.  By Christina Jewett

And here's the paper:

Marketing of “Tobacco-Free” and “Synthetic Nicotine” Products. Ramamurthi D, Chau C, Lu Z, Rughoobur I, Sanaie K, Krishna P, Jackler RK. SRITA White Paper. March 8, 2022.

"Executive Summary:

• A 2009 US law assigned tobacco regulation to the FDA, created its Center for Tobacco Products, and defined a tobacco product as derived from any component of the tobacco plant.

• As the September 2020 deadline for submission of application to the for FDA authorization of novel tobacco products (PMTA) approached, major tobacco companies submitted application for their brands, but innumerable smaller companies lacked the resources needed to undertake the extensive studies required.

• In an effort to circumvent FDA tobacco regulations, and thus exempt their products from the PMTA process, numerous brands claimed to be formulated with tobacco-free and/or synthetic nicotine.

• Following the late 2021denial of their PMTA applications, some brands which were ordered off the market promptly relaunched claiming that they had been reformulated with tobacco-free or synthetic nicotine.

• Brands claiming to use non-tobacco derived nicotine are offered in a wide array of youth-appealing sweet & fruity flavors – which have been systematically denied market authorization during the ongoing FDA PMTA process.

• Synthetic nicotine is currently expensive, costing approximately 4x tobacco derived nicotine. 

• While residuals from tobacco leaf derived nicotine are well known, byproducts of the chemical synthesis of nicotine have not been characterized for potential human toxicity and carcinogenicity.

• Justified by concerns for unknown safety risk, the FDA should insist upon toxicity/carcinogenicity studies of synthetic nicotine products before they are marketed.

• The FDA should also consider systematic testing of products claiming to be tobacco-free as at least a portion of them may prove to have chemical signatures indicative of tobacco origin.

• Some brands marketed as “tobacco-free” or “tobacco leaf-free” use a purified form of tobacco derived nicotine and thus are legally tobacco products under US law and thus subject to the PMTA requirements.

• Terms describing nicotine products as “tobacco-free,” “non-tobacco,” and “zero tobacco” need regulation as consumers may perceive such products as having reduced addictive potential.

• Marketing claims such as “clean,” “pure,” and “free of carcinogens” should be disallowed absent modified risk designation by the FDA.

• “Tobacco-free” nicotine brands have been allowed to post paid advertisements, and are widely sold on major online stores (e.g., Amazon, eBay, Google Shopping), which prohibit sale of all tobacco products.

• Underage sales of “tobacco-free” nicotine products are common via major online stores.

• As it is a potently addictive substance, and harmful to the developing adolescent brain, there is no justification for nicotine, regardless of its source, to be exempt from regulation.

• The synthetic nicotine regulatory loophole should be closed by designating such products as unauthorized drugs requiring pre-market authorization. "

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Congress closed the synthetic nicotine loophole in March, and since July 2022 synthetic nicotine products can only be on the market if they have been authorized by the FDA – none have been so yet.   Here's the story from the Washington Post:

Congress moves to give FDA new powers over synthetic nicotine products including a youth favorite — Puff Bar e-cigarettes By Laurie McGinley, March 8, 2022

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There have also been bans on flavored nicotine, aimed at children as well as adults. These may be doomed to be at least partly ineffective. Menthol flavored cigarettes are likely to be banned in the U.S., and have already been banned in Britain and elsewhere. But just as cocktail mixes can be sold separately from alcohol (but ready to mix), so apparently can flavorings for cigarettes and e-cigarettes... e.g. search for "menthol flavour cards for cigarettes" or "menthol crush balls" to see how to add menthol back into your smokes in England.

Here's a recent NBER working paper comparing menthol smokers to non-menthol smokers:

Are Menthol Smokers Different? An Economic Perspective, by Yu-Chun Cheng, Donald S. Kenkel, Alan D. Mathios & Hua Wang, WORKING PAPER 30286, DOI 10.3386/w30286, July 2022

 **********

And here's an old NYT story in which Rob describes himself as “an accidental tourist in the world of advertising.”

When Doctors, and Even Santa, Endorsed Tobacco, By Stuart Elliott, Oct. 6, 2008

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earlier: 

Sunday, January 30, 2022

Chemistry is replacing agriculture in the supply of black market drugs

Sunday, May 2, 2021

Repugnance as paternalism: bans on flavored tobacco products

Tuesday, February 12, 2019

The new market for (and marketing of) nicotine--Robert Jackler (followed by the CDC)

The (local) labor markets for terrorists and drug traffickers

 It's so hard to hire good help nowadays, but two papers in the latest Econometrica give us some insight into how that problem is solved in the labor markets for terrorists, and for narcotics.

First terrorism, which turns out to have a local financing element, suggesting frictions in moving money and terrorists...

TERRORISM FINANCING, RECRUITMENT, AND ATTACKS, by NICOLA LIMODIO, Econometrica, Vol. 90, No. 4 (July, 2022), 1711–1742

Abstract: This  paper  investigates  the  effect  of  terrorism  financing  and  recruitment  on  attacks. I exploit a Sharia-compliant institution in Pakistan, which induces unintended and quasi-experimental variation in the funding of terrorist groups through their religious affiliation. The results indicate that higher terrorism financing, in a given location and period, generate more attacks in the same location and period. Financing exhibits a complementarity in producing attacks with terrorist recruitment, measured through data from Jihadist-friendly online fora and machine learning. A higher supply of terror is responsible for the increase in attacks and is identified by studying groups with different affiliations operating in multiple cities. These findings are consistent with terrorist organizations facing financial frictions to their internal capital market.

"I study two aspects of the relationship between terrorism financing and attacks: (1) the correlation between the timing of financing and attacks; (2) the relation between financing and recruitment in generating attacks. To investigate the first point, I follow 1750 cities over 588 months between 1970 and 2018 containing the universe of terrorist attacks (e.g.,more than 14,000 events). I also build a panel with 29 terrorist groups operating in the same number of cities and the same period. To study the second point, I combine data from multiple online fora active in Pakistan disseminating Jihadist-friendly material with the work of two judges and a machine-learning algorithm, leveraging novel techniques from the computer science literature.

"The  natural  experiment  affects  a  specific  form  of  charitable  donation  and  terrorism financing through an Islamic institution: the Zakat. During Ramadan, Muslim individuals offer this Sharia-compliant contribution to philanthropic causes. While the amount is a personal choice, the Pakistani government collects a mandatory payment through a levy on bank deposits applied immediately before Ramadan.1When the tax hits fewer people due to its unique design, there is an increase in donations. This expansion in charitable donations boosts the probability that funds reach terrorist organizations due to multiple extremist groups having a legal charity branch.2 This unintended channel through which the design of the Zakat levy promotes terrorism financing has also been acknowledged by Pakistani government officials in the past.#"

# (cited newspaper article):"Information Minister Pervaiz Rashid has advised people to pay Zakat and charity to institutions which save lives and not to those producing suicide bombers."

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And then there's narcotics production and narco-terrorism, which to some extent runs in families.  The paper begins with this quote:

"The only way to survive, to buy food, was to grow poppy and marijuana, and from the age of 15, I began to grow, harvest, and sell.– Joaquin “El Chapo” Guzman, when asked how he became the leader of the Sinaloa drug cartel"

Making a Narco: Childhood Exposure to Illegal Labor Markets and Criminal Life Paths, by Maria Micaela Sviatschi, https://doi.org/10.3982/ECTA17082, ECONOMETRICA: JUL 2022, VOLUME 90, ISSUE 4, p. 1835-1878

Abstract: This paper provides evidence that exposure to illegal labor markets during childhood leads to the formation of industry‐specific human capital at an early age, putting children on a criminal life path. Using the timing of U.S. antidrug policies, I show that when the return to illegal activities increases in coca suitable areas in Peru, parents increase the use of child labor for coca farming, putting children on a criminal life path. Using administrative records, I show that affected children are about 30% more likely to be incarcerated for violent and drug‐related crimes as adults. No effect in criminality is found for individuals that grow up working in places where the coca produced goes primarily to the legal sector, suggesting that it is the accumulation of human capital specific to the illegal industry that fosters criminal careers. However, the rollout of a conditional cash transfer program that encourages schooling mitigates the effects of exposure to illegal industries, providing further evidence on the mechanisms.

"To establish these results, I take advantage of drug enforcement policies in Colombia that shifted coca leaf production to Peru, where 90% of coca production is used to produce cocaine. In particular, in 1999, Colombia, then the world’s largest cocaine producer, implemented Plan Colombia, a U.S.-supported military-based interdiction intervention.One of the main components was the aerial spraying of coca crops in Colombia. This intervention resulted in higher prices and expanded coca production in Peru, where production doubled in districts with the optimal agroecological conditions.2 By 2012, Peru had become the largest producer of cocaine in the world.3 

"This setting yields three useful sources of variation: (i) geographic variation in coca growing  in  Peru,  (ii)  over  time  variation  in  coca  prices  induced  by  Colombian  shocks, and (iii) variation in the age of exposure, exploiting the fact that in Peru children are more  likely  to  drop  out  from  school  in  the  transition  between  primary  and  secondary education at the ages 11–14. I thus define age-specific shocks by interacting coca suitability measures and prices. Differential exposure by age arises since children within a district or village experience the changes in coca prices at different ages and due to variation in coca suitability across districts, villages, and schools."

Legal and illegal sales of body parts

 U.S. law makes it illegal to sell deceased donor organs for transplant, i.e. to save a life, but it's otherwise legal to sell body parts or whole cadavers, for research, for instruction, etc.  Nevertheless, alongside the legal, regulated market, which requires consents and precautions, is an illegal black market which is occasionally prosecuted.  Here's a recent case, as reported in the NYT:

Funeral Home Operator Pleads Guilty in ‘Illegal Body Part Scheme’.  Megan Hess, who pleaded guilty to mail fraud, sold body parts without families’ consent... By Alex Traub

"The operator of a Colorado funeral home who was accused of stealing body parts and selling them to medical and scientific buyers, making hundreds of thousands of dollars in what the authorities called an “illegal body part scheme,” pleaded guilty to mail fraud on Tuesday, the Justice Department said.

...

"Here’s how prosecutors said the scheme worked: From about 2010 to 2018 Ms. Hess was in charge of Donor Services, a nonprofit “body broker service,” and Sunset Mesa Funeral Directors, which offered to arrange cremations, funerals and burials in the small western Colorado city of Montrose.

"Ms. Hess and her mother sometimes obtained consent from families to donate small tissue samples or tumors of their dead relative, according to an indictment in the case. On other occasions, their request was rejected, and sometimes, they never brought up the topic at all.

"In any case, the documents say, on hundreds of occasions the funeral home operators would sell heads, torsos, arms, legs or entire human bodies. Frequently, they delivered cremated remains to families with the suggestion they were the remains of their relative when, in fact, they were not, according to the indictment.

...

"The scheme included forging paperwork, such as signatures on authorization forms for donating body parts, and misleading buyers about the results of medical tests performed on the deceased, court documents said. Ms. Hess altered lab reports so that they said that people had tested negative for diseases like H.I.V. and hepatitis when they had actually tested positive, according to the authorities."

Allegations of organ trafficking for kidney transplants--in England and India

 From time to time there are stories of prosecutions for organ trafficking in connection with kidney transplants.

Here's a story developing in England. (Early reports were that the alleged donor/seller/victim was a child, but apparently he's not a minor):

From the BBC:

Ike Ekweremadu: Nigerian senator faces London organ-harvesting trial

"A prominent Nigerian senator and his wife who are accused of plotting to harvest a man's kidney in the UK will face trial at the Old Bailey.

"Ike Ekweremadu, 60, and Beatrice Nwanneka Ekweremadu, 55, are alleged to have transported a 21-year-old man from Nigeria to London.

"Prosecutors allege the couple planned to have his kidney removed so it could be given to their daughter.

...

"The alleged victim is said to have refused to consent to the procedure after undergoing tests at the Royal Free Hospital in Hampstead."

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Not long ago I participated in an online conversation including Professor Janet Radcliffe Richards, who recalls that her view that bans on kidney sales are ill-conceived arose from news in the 1980's about a case involving Turkish sellers (here's an LA Times story from then):

London Kidneys-for-Cash Scandal Prompts Action to Ban Sale of Organs BY ROBERT BARR JULY 16, 1989

"“The concept of organs being bought and sold for money is entirely unacceptable in a civilized society,” Health Minister Roger Freeman told a House of Commons committee during debate on proposed legislation outlawing organ sales. The bill is expected to pass Parliament later this month.

"Not all lawmakers agree.

“The bill will cause death where there could be life, and to prolong suffering where we could provide relief,” said Sir Michael McNair-Wilson, a Conservative Parliament member awaiting a kidney transplant.

...

"Neil Hamilton, who cast the only vote against the bill in committee, said he had pondered the dilemma facing one Turk who allegedly sold a kidney.

“His daughter was suffering from a medical problem which threatened her life, but it could not be solved in Turkey without money,” Hamilton said. “If he did not get the money for the operation, his daughter would die.”

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The situation in India is complex, since there is or was something of a long tradition of kidney sales, which are against the law, and are guarded against by authorization committees that have to approve each living donor transplant. Recently, kidney exchange has become legal in India, but the law only allows close family to be the intended donor in an incompatible patient-donor pair. Below is a report of a case where it's alleged that an attempted donor was paid, and also illegally claimed to be a family relation.

Here's the Hindustan Times story:

Ruby Hall Clinic kidney transplant ‘malpractices’ probe handed over to crime branch

"Earlier on Wednesday, police officials probing the case told Magisterial court that more cases of kidney transplants based on the relationship claims have been unearthed during the interrogation of agents Ravindra Rodge and Abhijit Gatane. Both have been arrested by the police. These two agents having donated their kidneys earlier and also played the role of middlemen in at least four kidney transplants where alleged malpractices were involved.

...

"The case pertains to a kidney swap procedure, also known as paired kidney exchange, between the Moshi man and the Kolhapur woman posing as his wife, and a mother-daughter duo from Baramati."

And here's the story in the Indian Express:

Two middlemen arrested in Pune kidney transplant malpractice case. The other accused in the case, including Ruby Hall Clinic doctors, the patient who received the kidney, and the unrelated donor who was passed off as his wife--are yet to be arrested.

"Police have arrested the two middlemen over the alleged malpractices in a kidney transplant conducted at Pune’s Ruby Hall Clinic in March in which an unrelated woman was allegedly presented as the organ receiver’s wife and promised Rs 15 lakh in return.

...

"Among the 15 people named in the FIR are the hospital’s managing trustee, Dr Purvez K Grant, deputy medical director Dr Rebecca John, legal advisor Manjusha Kulkarni, nephrologist Dr Abhay Sadre, urologists Dr Bhupat Bhati and Dr Himesh Gandhi and transplant coordinator Surekha Joshi. The police also booked the two middlemen, the patient—from Pimpri Chinchwad’s Moshi area—who received the kidney, his wife, their three family members, the woman from Kolhapur who was allegedly passed off as the patient’s wife to become the donor."

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Among the most vigorous opponents of paying kidney donors--e.g. among some of those who think it's a crime against humanity--there's also opposition to extending the scope of legal, ethical, unpaid kidney donation and transplantation, particularly in poor countries.  One reason for this is the intuition that more transplantation will cause more paid transplantation.  The cases reported above, although rare, help to support this view.

But a much stronger case can be made that it is the unavailability of transplants that causes exploitative black markets, and that increasing the availability of legal transplants will reduce the demand for illegal ones.

Kidney exchange debate in Brazil

 A discussion of kidney exchange in Brazil began with this letter to the editor, describing how kidney exchange (aka kidney paired donation) could increase transplantation in Brazil:

Bastos, J., Mankowski, M., Gentry, S., Massie, A., Levan, M., Bisi, C., Stopato,C., Freesz, T., Colares, V., Segev, D. and Ferreira, G., 2021. Kidney paired donation in Brazil-A single center perspective. Transplant International: Official Journal of the European Society for Organ Transplantation.

"Kidney paired donation (KPD) represents a strategy for increasing the number of LDKT, offering an incompatible donor/recipient pair, the chance to exchange with another pair in the same situation [4]. In Brazil, KPD is still prohibited by law. We designed a study to show mathematically how KPD could increase LDKT in a single center in Brazil.

Several comments followed in a forum.. The name of the forum is ""Kidney Paired Donation is necessary in Brazil."  But not everyone agrees with that headline.

In particular, a letter to the editor from Mario Abbud-Filho & Valter Duro Garcia concludes that there are too many poor people in Brazil to allow kidney exchange:

 "We do not condemn the KPD strategy, but we disagree that it should be proposed in the actual Latin American context, where such great socioeconomic disparities do exist and could fuel organ trafficking and commerce."

That letter drew this rejoinder, in favor of kidney exchange by Marcelo Perosa:

"We do not understand the rationale behind the claim that KPD could stimulate organ trafficking and trade if the LD of an eventual KPD swap would be submitted to the same steps and rigor currently used for unrelated LDKT to be approved.

"The acceptance of KPD is growing around the world. It brings a potential technological development with advanced algorithms and softwares, unites clinicians, surgeons, immunologists in fruitful discussions and analysis of match runs, expanding and exchanging knowledge among multidisciplinary teams that currently work separately. KPD still has the beauty of not dividing, but joining efforts among different centers since the more groups participating, the more patients in the database and more matches are found.

"The main goal of KPD was to increase the chance of KT among highly sensitized (HS) patients, preventing the onerous treatment of desensitization. For a country with more limited economic resources like Brazil, KPD makes perfect sense for always contemplating compatible, cheaper, and more successful transplants."

And a final summation from two of the authors of the original paper:

Bastos, Juliana, and Gustavo Ferreira. "Kidney Paired Donation in Brazil-It is time to talk about it." Transplant International: Official Journal of the European Society for Organ Transplantation (2021), 01 Oct 2021, 34(10):1757-1758 DOI: 10.1111/tri.14025 PMID: 34431143 

"The history of kidney transplantation in Brazil began in 1965 when the first related living donor transplant. Since then, Brazil has established a public programme and now has the most extensive public kidney transplantation system in the world. Brazil has established a regulated, standardized and ethical organ procurement system, created awareness of transplantation in physicians and the public, upgraded facilities and standardized medical care, and enforced legislation for transplantation.

"The Aguascalientes document establishes that KPD and altruistic donation are acceptable. Its final recommendations also say that the country must provide access to transplantation based on ethical considerations and protect the most vulnerable population for a healthy transplant system [4]. We are failing to do that when we have a system that does not contemplate highly sensitized recipients, as shown by a recent Brazilian analysis: highly sensitized patients (PRA > 98%) had lower transplant rates (3.7% vs. 31.2%) and higher mortality (HR: 1.09, P = 0.05) in the waitlist when compared to nonsensitized patients [1]."

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Earlier related posts:

aturday, February 12, 2022

First kidney exchange in Brazil

Sunday, December 26, 2021

A call for kidney exchange in Brazil, in the Brazilian Journal of Nephrology

Evidence based medical policy: compensation for donors, by Luke Semaru and Arthur Matas in the AJT

The American Journal of Transplantation has posted ahead of print a great article proposing clinical trials of a sensible system by which kidney donors might be compensated.  It's main point is that evidence might be useful...

 A Regulated System of Incentives for Living Kidney Donation: Clearing the Way for an Informed Assessment by Luke Semaru, and Arthur J. Matas

First published: 25 June 2022 https://doi.org/10.1111/ajt.17129

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi:10.1111/ajt.17129

Abstract: "The kidney shortage continues to be a crisis for our patients. Despite numerous attempts to increase living and deceased donation, annually in the United States, thousands of candidates are removed from the kidney transplant waiting list because of either death or becoming too sick to transplant. To increase living donation, trials of a regulated system of incentives for living donation have been proposed. Such trials may show: 1) a significant increase in donation, and 2) that informed, incentivized donors, making an autonomous decision to donate, have the same medical and psychosocial outcomes as our conventional donors. Given the stakes, the proposal warrants careful consideration. However, to date, much discussion of the proposal has been unproductive. Objections commonly leveled against it: fail to engage with it; conflate it with underground, unregulated markets; speculate without evidence; and reason fallaciously, favoring rhetorical impact over logic. The present paper is a corrective. It identifies these common errors so they are not repeated, thus allowing space for an assessment of the proposal on its merits."

The article begins with some relevant history:

"The  concept  of  incentives  for  living  donation  arose  early  in  the  history  of  kidney  transplantation.  In  the 1960s, the framers of the Uniform Anatomical Gift Act noted “every  payment  is  not necessarily  unethical”,  but  “until  the  matter  of  payment becomes a  problem  of  some  dimensions,  the  matter  should  be  left  to  the  decency  of  intelligent  human  beings”.1  In  1983, the  matter  of payment  became a problem when,  in response to the organ shortage, a physician  (whose license had previously  been revoked) established a company to broker international  kidney sales. Impoverished  residents of low-income countries  were to be flown  to the United States to sell their kidneys at a nominal  price. This was met with general condemnation,  and in part, led to passage of the  National  Organ  Transplant  Act (NOTA,  Public Law 98-507) which made it a federal crime to “knowingly  acquire, receive or otherwise transfer any  human  organ for valuable consideration for use in human  transplantation...”.  At  the  same  time,  the  World  Medical  Association,  the  World  Health  Organization,   the  Council  of  Europe,  and  the  International  Council of the Transplantation  Society, among others, issued statements  of opposition to the sale of organs. "

...

"We are not tempted to conclude,  for example, that,  since in the 1920s Prohibition brought  about  an increase in political corruption  and organized crime, the sale of alcohol,  when  legal  and  regulated,  would  do  the  same.  For the same reason, we should not be tempted to conclude  that, since participants in unregulated  markets were swindled by outlaws, incentivized  donors in a regulated system will fare the same."

Pregnancy in Poland, a database and anti-abortion laws

 The Lancet recently reported on new pregnancy data being collected in Poland, and controversy on whether and how it might be used in enforcing Poland's very stringent anti-abortion laws.

Poland to introduce controversial pregnancy register, by Ed Holt, Lancet,  VOLUME 399, ISSUE 10343, P2256, JUNE 18, 2022  DOI:https://doi.org/10.1016/S0140-6736(22)01097-2

"A new legal provision in Poland requiring doctors to collect records on all pregnancies has been condemned by critics who fear it could create a pregnancy register to monitor whether women give birth, or track those who go abroad for abortions.

Poland has some of Europe's strictest abortion laws, with terminations allowed in only two instances—if the woman's health or life is at risk and if the pregnancy is the result of either rape or incest. Until last year, abortions had also been allowed when the fetus had congenital defects. Most legal terminations in Poland were carried out under this exemption. But this provision was removed by a constitutional court ruling following a challenge by members of the ruling right-wing Law and Justice party, which some rights activists accuse of systematic suppression of women's rights.

Rights groups and opposition Members of Parliament (MPs) say that, in light of the tightened abortion legislation, they worry that the collected pregnancy data could be used by police and prosecutors in an unprecedented state surveillance campaign against women. “A pregnancy register in a country with an almost complete ban on abortion is terrifying”, Agnieszka Dziemianowicz-BĄk, an MP for the New Left party, said. 

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Here's a recent NY Times story on the implementation of Polish anti-abortion law:

Poland Shows the Risks for Women When Abortion Is Banned. Poland’s abortion ban has had many unintended consequences. One is that doctors are sometimes afraid to remove fetuses or administer cancer treatment to save women’s lives.  By Katrin Bennhold and Monika Pronczuk, Updated June 16, 2022

"Today, Poland and Malta, both staunchly Catholic, are the only European Union countries where abortions are effectively outlawed.

"The consequences in Poland have been far-reaching: Abortion-rights activists have been threatened with prison for handing out abortion pills. The number of Polish women traveling abroad to get abortions, already in the thousands, has swelled further. A black market of abortion pills — some fake and many overpriced — is thriving.

"Technically, the law still allows abortions if there is a serious risk to a woman’s health and life. But critics say it fails to provide necessary clarity, paralyzing doctors."

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

 Just published in Transplant International (which is the journal of the European Society for Organ Transplantation), is a paper describing the Iranian market for kidneys in the city of Mashad, and three commentaries on it.  

 Here's the original paper:

Kidneys for Sale: Empirical Evidence From Iran  by Tannaz Moeindarbari and Mehdi Feizi

And here are three short commentaries.

Kidneys for Sale? A Commentary on Moeindarbari’s and Feizi’s Study on the Iranian Model  by Frederike Ambagtsheer1, Sean Columb, Meteb M. AlBugami, and Ninoslav Ivanovski

Kidneys for Sale: Are We There Yet? (Commentary on Kidneys for Sale: Empirical Evidence From Iran) by Kyle R. Jackson, Christine E. Haugen, and Dorry L. Segev

Criminal, Legal, and Ethical Kidney Donation and Transplantation: A Conceptual Framework to Enable Innovation  by Alvin E. Roth, Ignazio R. Marino, Kimberly D. Krawiec and Michael A. Rees

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The commentary by Roth, Marino, Krawiec and Rees contrasts the legal Iranian market with the dangerous black markets that operate elsewhere, outside of regular medical institutions.

Here's a recent long article that pulls together much of the discussion on compensation for donors and on sale of kidneys and transplant black markets:

Organ Trafficking, Can the illicit trade be stopped? By Sarah Glazer,  CQ Researcher, June 24, 2022 – Volume 32, Issue 22

HT: Frank McCormick

What might the abortion gray market look like, post Roe?

 My favorite psychiatrist points out that, before abortions became generally legal except when the woman's life was at risk, psychiatrists were often called upon to make a decision.

The ‘Open Secret’ on Getting a Safe Abortion Before Roe v. Wade  By Sally L. Satel

"Dr. Satel is a visiting professor of psychiatry at Columbia and a senior fellow at the American Enterprise Institute."

"If the Supreme Court overturns Roe v. Wade, will psychiatrists resume their pre-Roe role as arbiters of abortion access? The law once compelled psychiatrists and pregnant women to perform dishonest rituals to get abortions. Will psychiatrists once again need to be complicit post-Roe?

"Before Roe v. Wade, a number of states allowed abortions if doctors could certify that the mother’s health, not solely her life, was at serious risk. A great number of those certifications were granted by psychiatrists, some of them by the professors who taught me as a resident in the mid-1980s in Connecticut.

"Through the 1940s and 1950s, medicine advanced to the point where health problems like heart disease and tuberculosis were generally no longer considered to be indications for therapeutic abortion. As a result, psychiatric justification became the primary rationale for therapeutic abortion before Roe.

...

"It was an “‘open secret,’” Dr. Richard A. Schwartz of the Cleveland Clinic observed in 1972, the year before Roe was decided, “that a woman can obtain a safe abortion in a licensed hospital if she can find a psychiatrist who will say she might commit suicide.”

"To accommodate such women, psychiatrists used a combination of empathy and civil disobedience to declare them at risk unless they were allowed to terminate their pregnancies."

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If the Supreme Court overturns Roe, laws about abortion will go back to the individual States. One difference from the pre-Roe environment is that there will now be probably around half of the states that will continue to allow legal (and hence safe) abortions.  So the gray market in states with abortion bans will also involve travel, for those who can afford it (and perhaps mail order pills for those well organized enough and for whom travel isn't a good option).

Black market tattoos in S. Korea: “No one’s trying to go to medical school to become a tattoo artist,”

 Tattooing is illegal (but tattoos are not) in S. Korea.  The NY Times has the story:

Tattoos, Still Illegal in South Korea, Thrive Underground. Tattoo artists, long treated as criminals for their work, say that it is time to end the stigma against their business.  By Christine Chung

"Under a ruling that has been in place since 1992, tattooing without a medical license can result in fines of up to $40,000 or even imprisonment. Opponents of decorative tattoos have invoked concerns about longstanding associations with organized crime, as well as fears about inadequate hygiene and potential harm inflicted by tattoo artists, who they say lack adequate skills.

"Attempts to overturn this ban have repeatedly failed. In March, the Constitutional Court in Seoul reaffirmed the tattoo industry’s illegality in a 5-to-4 ruling. South Korean tattoo artists and customers believe that the ruling is at odds with reality, citing drastically changed social norms that have fostered a thriving underground industry, greater openness and acceptance of tattoos, and rising international demand for what are known as “k-tattoos.”

"While tattoos have grown in acceptance in most parts of the world — exceptions include several Islamic countries — South Korea remains one of the few where the artists are treated as criminals. Tens of thousands of them work in secret here, under constant threat of exposure to law enforcement.

...

“No one’s trying to go to medical school to become a tattoo artist,” she said.

...

"Mr. Kim is the founder of a 650-member tattoo labor union that advocates rights of artists. Legalization would create safer, more sanitary environments for both customers and artists, he said.

"Tattoo artists often meet clients alone and trust strangers to keep their secret. Female artists are particularly vulnerable to sexual violence. In the past, the police have conducted sweeps rounding up artists, Sanlee said. Rival shops have been known to flag artists to the police.

“Since what we’re doing is illegal, we’re in the blind spot,” she said. “Because of that, there are many people that are exploiting the situation.”

Afghanistan’s trade in organs--and children

 Here's the story in the WSJ:

‘No Father Wants to Sell His Son’s Kidney.’ Afghans Pushed to Desperate Measures to Survive. Afghanistan’s deepening humanitarian crisis fuels booming organ trade  By Sune Engel Rasmussen

"For those willing, an illegal but barely hidden business in the western city of Herat offers a reprieve from the downward spiral. Two hospitals in town offer kidney transplants that attract Afghans from across the country, performing 15-20 surgeries a month. Officials turn a blind eye. Buying and selling organs is illegal, as in most other countries. But scores of Afghans have come here to make the trade.

...

"Finding a seller of a kidney isn’t hard. Notes advertising private organ sales are plastered on walls and lampposts in Herat and other cities. Kidney brokers distribute business cards offering to put buyers in touch with sellers.

...

"Mr. Mohammad and his wife decided that unless they sold a child, they would have to sell an organ. Both of them were unsuited, as Mr. Mohammad had kidney stones and his wife had diabetes. Their oldest son made up to three dollars a day collecting plastic for recycling, so was spared. The choice fell on Khalil Ahmad, their second son.

...

"Ghulam Hossein came to Herat from the eastern Nangarhar province after a doctor told him his kidneys were failing. It took him 25 days to find a seller.

“I have no words to thank this man,” Mr. Hossein said about the donor, who needed money after being forced to sell his small grocery store, and who visited Mr. Hossein after the operation.

“I know he was poor but it takes huge courage and sacrifice to sell your kidney,” Mr. Hossein said. “I am more concerned now about his health than my own.”

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Here's an earlier story from the Guardian:

I’ve already sold my daughters; now, my kidney’: winter in Afghanistan’s slums. Crushing poverty is forcing starving displaced people to make desperate choices  by  M Mursal and Zahra Nader, 23 Jan 2022

“I was forced to sell two of my daughters, an eight-by and six-year-old,” she says. Rahmati says she sold her daughters a few months ago for 100,000 afghani each (roughly £700), to families she doesn’t know. Her daughters will stay with her until they reach puberty and then be handed over to strangers.

"It is not uncommon in Afghanistan to arrange the sale of a daughter into a future marriage but raise her at home until it is time for her to leave. However, as the country’s economic crisis deepens, families are reporting that they are handing children over at an increasingly young age because they cannot afford to feed them.

"Yet, selling her daughters’ future was not the only agonising decision Rahmati was forced to make. “Because of debt and hunger I was forced to sell my kidney,” she tells Rukhshana Media from outside her home in the Herat slum."

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And from the BMJ:

Afghans driven to sell kidneys on black market in the face of extreme poverty BMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o587 (Published 04 March 2022)  by Gareth Iacobucci

"People in Afghanistan are resorting to selling their kidneys on the black market to feed their families as the country faces extreme poverty.

"The United Nations estimates that 24 million people in Afghanistan—more than half of the population—are in need of lifesaving humanitarian aid. This is 30% higher than in 2021 when the Taliban seized control of the country.

"Illegal organ trading already existed in Afghanistan before the Taliban’s takeover, but a combination of economic sanctions, severe drought, and covid-19 have led to the black market surging as many more people experience extreme poverty.

"A lot of the trade is focused in the western city of Herat, close to the border with Iran."

Kidney transplant controversies on World Kidney Day

 Yesterday, March 10 was World Kidney Day, whose theme was "Kidney health for all."

I couldn't help noticing that reports in honor of WKD reflect some of the considerable controversy that exists about kidney transplants.

Here are two with opposite points of view on increasing access to kidney transplants, with special attention to kidney exchange.

First, from Abu Dhabi:

World Kidney Day: SEHA Kidney Care leads the way in ensuring kidney health for all

"A key area that SKC is spearheading is investing in opportunities to increase transplant activities, for patients locally and further afield.  SEHA’s recent collaborations with international organizations and the Department of Health – Abu Dhabi have ensured that it is prepared for an influx in transplant volumes, with an increased deceased donor activity from 3 donors in 2017 to 39 donors in 2021, and more opportunities for live donation with the start of a paired kidney exchange program in partnership with Alliance for Paired Kidney Donation. Through these partnerships, kidney transplants, often resulting in enhanced quality of life, are now a viable option for many patients here in the UAE. SEHA’s Transplant Program has performed more than 52 pediatric kidney transplants and almost 393 transplants in total since its inception.

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And here, from the Pakistani newspaper Dawn, is an editorial that bemoans the prevalence of black market kidney transplants in Pakistan, and worries that increasing access to  kidney exchange will only increase the black market (as opposed to giving patients a safe and legal alternative to the black market). This is an opinion that seems to underlie the policies of a number of international transplant organizations.

Swap Transplants

"IRONICALLY, the Punjab government’s recent step in the effort to stop organ trafficking may well end up providing a shot in the arm to the illegal transplant racket. At a meeting chaired by the Punjab health minister, the provincial government has given its approval to a swap transplant plan which expands the living donor pool beyond immediate family members.

...

"Organ swap transplants, or paired exchanges, work by matching a recipient-donor pair that is medically incompatible, with another pair in a similar predicament. An organ ‘swap’ can then take place between the two pairs. However, these are only the bare bones of the procedure. It must be carried out according to strict ethical and clinical guidelines if it is not to open the floodgates for illegal transplants. Among these is the requirement that each recipient-donor pair must meet the eligibility criteria laid out in the law.

...

"Thus, while paired exchanges are an accepted method of addressing donor-recipient incompatibility, the level of oversight mechanisms needed to prevent abuse are daunting — even more so in an unequal society riddled with corruption. The first paired kidney exchange in Pakistan was performed in 2015 at the Sindh Institute of Urology and Transplantation in Karachi; only seven more have taken place since then — all at SIUT — partly because of the extreme diligence that the process calls for. The troubling fact is that most illegal transplants take place in Punjab; some were found to have been carried out surreptitiously in KP and Azad Kashmir by doctors from Punjab. The situation in recent years had improved considerably after several organ trafficking gangs were busted, again mostly in Punjab. Does the province have a system in place to ensure that unethical individuals do not use the organ swap programme as a cover for illegal transplants?"

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And here's a recent BBC video, "Kidneys for Sale?" on the controversy about compensation for donors. I just saw it yesterday (HT David Klinowski) but was produced earlier this year. A number of people are interviewed, and Sally Satel makes the point that increasing access to legal, safe kidney transplants is a way of competing with and reducing the prevalence of black markets.