Economics of pandemic vaccination in Oxford Review of Economic Policy

Vaccine development and distribution during the Covid pandemic has had some notable successes and some significant shortcomings. 

Here's the latest issue of the Oxford Review of Economic Policy, which has collected articles by economists concerning some of those successes and failures and their lessons for future pandemics.

Volume 38, Issue 4, Winter 2022

Economics of Pandemic Vaccination

ARTICLES

Vaccines and the Covid-19 pandemic: lessons from failure and success 

Scott Duke Kominers, Alex Tabarrok

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 719–741, https://doi.org/10.1093/oxrep/grac036

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Expanding capacity for vaccines against Covid-19 and future pandemics: a review of economic issues 

Susan Athey, Juan Camilo Castillo, Esha Chaudhuri, Michael Kremer, Alexandre Simoes Gomes ...

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 742–770, https://doi.org/10.1093/oxrep/grac037

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Covid-19 vaccine supply chains and the Defense Production Act 

Chad P Bown

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 771–796, https://doi.org/10.1093/oxrep/grac026

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Clinical trials for accelerating pandemic vaccines 

Witold Więcek

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 797–817, https://doi.org/10.1093/oxrep/grac029

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The race that stopped a nation: lessons from Australia’s Covid vaccine failures 

Richard Holden, Andrew Leigh

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 818–832, https://doi.org/10.1093/oxrep/grac028

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Financing vaccine equity: funding for day-zero of the next pandemic 

Ruchir Agarwal, Tristan Reed

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 833–850, https://doi.org/10.1093/oxrep/grac032

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Is it possible to prepare for a pandemic? 

Robert Tucker Omberg, Alex Tabarrok

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 851–875, https://doi.org/10.1093/oxrep/grac035

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Seven finance and trade lessons from Covid-19 for future pandemics 

Ruchir Agarwal, Gita Gopinath

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 876–886, https://doi.org/10.1093/oxrep/grac031

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Covid in the nursing homes: the US experience 

Markus B Bjoerkheim, Alex Tabarrok

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 887–911, https://doi.org/10.1093/oxrep/grac033

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Optimal allocation of vaccines in a pandemic 

Joshua S Gans

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 912–923, https://doi.org/10.1093/oxrep/grac027

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Reserve system design for allocation of scarce medical resources in a pandemic: some perspectives from the field 

Parag Pathak, Govind Persad, Tayfun Sönmez, M Utku Ünver

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 924–940, https://doi.org/10.1093/oxrep/grac034

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Distributing a billion vaccines: COVAX successes, challenges, and opportunities 

Eric Budish, Hannah Kettler, Scott Duke Kominers, Erik Osland, Canice Prendergast ...

Oxford Review of Economic Policy, Volume 38, Issue 4, Winter 2022, Pages 941–974, https://doi.org/10.1093/oxrep/grac038

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Covid vaccine coverage in middle and lower income countries, and preparations for future pandemics

 Vaccine rollout to lower and middle income countries left something to be desired.  Some of that has to do with initial distribution when vaccines were scarce, and some has to do with vaccine hesitancy in poor as well as rich countries.  Here are two related views in Science and Nature.

The global plan for COVID-19 vaccine fairness fell short. Will next time be different?  BY GRETCHEN VOGEL, Science, 13 DEC 2022 

"On 8 December, the board of Gavi, the Vaccine Alliance—a key partner in the project—voted “in principle” to phase out much of its support for COVID-19 vaccines in middle-income countries starting in 2024, and to incorporate COVID-19 vaccinations into its regular vaccine programs for the poorest countries—if they still want them.

"The decision isn’t final, but critics of COVAX—many from poorer countries—would not mourn its demise. The effort has delivered some 1.84 billion vaccine doses to 146 countries, but many, if not most, arrived too late to have a big impact. “COVAX was completely useless for developing countries,” says Claudia Patricia Vaca González, an expert on access to medicines at the National University of Colombia, Bogotá. “It was a failure and we should admit it,” says Christian Happi, a molecular biologist at Redeemer’s University in Ede, Nigeria.

"Others have a more positive take. “Gavi and COVAX were in my mind transformational and inspirational in their aims,” says Lawrence Gostin, an expert on global health law at Georgetown University. “It got a lot of shots in a lot of arms.” Still, “I totally understand Gavi’s reasoning,” Gostin adds. Demand for COVID-19 vaccines dropped sharply after the pandemic ebbed, and Gavi wants to refocus on campaigns that have lagged during the crisis, including vaccination against the cancer-causing human papillomavirus, and ensuring no child fails to receive routine childhood vaccinations.

...

"Making vaccines where they are needed is the way forward, says Gostin, who thinks it’s unrealistic to expect wealthy countries not to put their own populations first. “Vaccine nationalism is a fact of life.” Vaca González agrees. She says COVAX’s basic premise—buying vaccines developed in wealthy countries from large pharmaceutical firms—was flawed from the start: “That was the original sin of COVAX.”

*********

Even after COVID, the world’s vaccine strategy is failing. Without a global, publicly funded strategy, the market will fail to deliver vaccines to stop pandemics before they surge. By Seth Berkley, Nature, 13 December 2022.

"Despite rallying to produce billions of doses of vaccines in the face of COVID-19, when it comes to developing vaccines to prevent a disease in the first place, the world is still asleep at the wheel. There is still no incentive for markets to deliver vaccines that can prevent outbreaks, even when the technology is available. If we can’t even have vaccines ready for known severe threats such as Ebola, then what hope is there for future unknown pandemic threats?

...

"The World Health Organization keeps a list of nine priority pathogens with pandemic potential, including severe acute respiratory syndrome (SARS) and Ebola, as well as ‘disease X’, which represents a possible, as-yet-undiscovered pathogen. All nine deserve a full effort: development of several candidate vaccines through the animal-model and early clinical testing stages; vialed and quality-tested vaccines that are ready for immediate testing in an outbreak; and stockpiling of enough doses to control the disease if the vaccine is shown to be efficacious. For disease X, a set of viral vectors and messenger RNA delivery systems should be ready to carry the sequences of whichever antigens prove effective against the disease, and the manufacturing and clinical trials should be worked through as far as possible. By doing much of the preclinical and clinical work in advance, we can have doses as close to ready as possible when we need them.

...

"A key first step is the establishment of an adequate, publicly subsidized market. This will enable a coordinated global strategy with the support of G20 governments to drive the research, development and flexible small-scale manufacturing needed to produce vaccines to prevent epidemics, even if, as we hope, they will not be needed."

Preparing for a drug-resistant bacteria pandemic---vaccines and challenge trials

 Axel Ockenfels recently alerted me that "The German National Academy of Sciences Leopoldina has established a working group to analyze the economic causes of the problem of global increase in pathogens resistant to antimicrobial agents, and develop better incentives for developing antibiotics and possible solutions. "

I sent him some quick thoughts, as follows:

"one direction that seems potentially worth exploring is vaccines for bacteria pathogens.  Most of our vaccines are antiviral, but there are some vaccines against bacterial infection, even though we mostly deal with bacteria through post-infection antibiotics.  But antibiotic discovery has lots of problems, both economic and technical. And it appears that vaccine technology has advanced a lot, given the speed with which Covid vaccines were developed.  So I wonder if it wouldn’t make sense to start now to develop vaccines against some of the bacteria that we think might be candidates for developing antibody resistance, so that when those variants show up, we’ll be able to protect lots of people from getting infected by vaccinating them. 

 And challenge trials would be very useful for that, since pre-pandemic it’s hard to do conventional trials of a vaccine against a disease that most people don’t get. Challenge trials wouldn’t necessarily be very hazardous if the relevant bacteria aren’t yet highly antibiotic resistant, since the diseases would be curable… (The assumption here is that a vaccine against say, conventional tetanus, would also be protective against antibiotic-resistant tetanus, which might be true since the evolutionary pressure to evade a new vaccine is likely very different from the long evolutionary path that leads to resistance to an existing antibiotic..)"

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Earlier posts, on antibiotics here, and vaccine challenge trials.

Biden Signs Bill to Protect Same-Sex Marriage Rights

 With little delay after the Senate passage of the bill, the House followed, and now President Biden has signed into law a bill protecting same sex marriage from easily reversing the decision of a previous Supreme Court to make it legal throughout these United States.  The new bill requires states to recognize marriages made legally in other states...

Here's the NYT on the story:

Biden Signs Bill to Protect Same-Sex Marriage Rights. Proponents of the legislation argued that Congress needed to be proactive in ensuring a future Supreme Court would not invalidate same-sex marriages around the country.  By Michael D. Shear

"President Biden signed the Respect for Marriage Act into law on Tuesday, mandating federal recognition for same-sex marriages and capping his own personal evolution toward embracing gay rights over the course of a four-decade political career.

...

"The landmark legislation, passed by a bipartisan coalition in Congress, officially erases the Defense of Marriage Act, which a quarter of a century ago formally defined marriage as between a man and a woman. The new law prohibits states from denying the validity of out-of-state marriages based on sex, race or ethnicity.

...

"For Mr. Biden, who voted for the Defense of Marriage Act as a senator in 1996 and wavered on letting gay men and lesbians serve in the military, the signing ceremony was an indication of how much the president has changed when it comes to championing L.G.B.T.Q. equality.

"It is also another example of how Mr. Biden’s gradual transformation as a politician more broadly has matched the evolution of his own party since he started in public life as a junior senator on Jan. 3, 1973.

...

"Since the Supreme Court’s ruling in June to end the constitutional right to an abortion, Mr. Biden has been fervent in his condemnation of the decision in Dobbs v. Jackson Women’s Health Organization and has repeatedly called for legislation that would replace the 50-year-old court precedent with legal protections for the right of women to have an abortion.

...

"no issue represents Mr. Biden’s tendency to adapt to societal and political change as well as gay marriage. Polls show a sea change in public opinion across the political spectrum in the past decade, with nearly 70 percent of Americans now saying they support the right of same-sex couples to be married, with all the rights that heterosexual couples have under the law.

...

"But it is also a mark of ongoing fear that newfound gay rights may be fragile. The push for passage of the law was driven in part by the Supreme Court opinion overturning abortion rights, in which Justice Clarence Thomas raised the possibility of using the same logic to reconsider decisions protecting marriage equality and contraception rights."

Lobster traps, whales, and the enforcement of informal property rights

 An experiment to protect whales from becoming entangled in the long ropes that connect lobster traps on the sea floor to buoys on the surface might also change some equilibria among lobster fisherman.

The WSJ has this story:

Endangered Whales Get Lifeline From High-Tech Lobster Traps. Lobstermen are testing equipment designed to help North American right whales avoid deadly entanglements   By Eric Niiler

"Lobstermen have long used buoys to mark the location of their traps. The ropeless systems are designed to limit whales’ risk of entanglement by keeping the buoys and their ropes stowed underwater on the traps until it is time to check the traps. 

...

"Another challenge that could stand in the way of broad use of ropeless gear involves alerting other fishermen to the presence of lobster traps—whose location, in the absence of buoys, can be harder to identify. Conflict between lobstermen with fixed gear and fishermen who drag nets along the seafloor has long been a problem along the New England coast, federal officials said.

"Computer scientists at the Allen Institute for AI—a Seattle-based nonprofit research organization founded by late Microsoft co-founder Paul Allen—are developing an app to share the location of ropeless gear with other fishermen and regulators, according to Henry Milliken, supervisory research fishery biologist at NOAA’s Northeast Fisheries Science Center in Woods Hole."

********

Earlier, on a different aspect of the lobstering equilibrium:

Thursday, September 3, 2009

Policing the lobster commons

"Lobsters are caught in traps that sit on the sea floor, marked by (and recovered via) buoys that float above, connected to the trap by a rope. Lobstermen in Maine are known for policing who sets traps where by cutting the lines (or threatening to cut the lines) of lobstermen who set traps outside of their territory. From time to time there's a question about whether the state should limit certain areas to local lobstermen. Now is such a time..."

Lin Ostrom coauthored a paper on this:

Schlager, Edella, and Elinor Ostrom. "Property-rights regimes and natural resources: a conceptual analysis." Land economics (1992): 249-262.

"The enforcement of the de facto proprietor rights was borne entirely by the lobstermen of each village. The sanction that  they used against anyone who violated communal rules was gear destruction. ...The easiest means of destroying traps is to cut the rope by which the traps are attached to buoys."

Compensation for kidney donors, reconsidered in Value in Health

Here's a paper and a commentary in the journal Value in Health, focusing on the possibility of reducing deaths from kidney failure by offering some form of  regulated compensation to kidney donors. They point out that the potential effects of such a policy are very much greater than than we have so far achieved through uncompensated donation and kidney exchange

McCormick, F., Held, P.J., Chertow, G.M., Peters, T.G. and Roberts, J.P., 2022. Projecting the Economic Impact of Compensating Living Kidney Donors in the United States: Cost-Benefit Analysis Demonstrates Substantial Patient and Societal Gains. Value in Health. Volume 25, Issue 12, December 2022, Pages 2028-2033

Their paper begins as follows:

"Losing the War Against Kidney Failure

"Economics Nobel Laureate Alvin Roth has played a crucial role in developing paired kidney donation, which is currently saving >1100 US patients with kidney failure per year from suffering on dialysis and dying prematurely. Nevertheless, Professor Roth often points out that this is a victory in a war that we are losing.1 The number of patients diagnosed with kidney failure each year in the United States is not only much greater than the number who receive kidney transplants; it is rising at a faster rate.2,3 Thus, the number of patients diagnosed with kidney failure who are fated to suffer on dialysis for an average of 4 to 5 years while their health steadily deteriorates until they die prematurely has trended upward and is now >100 000 per year.

"How to Win the War

"Many researchers have argued that the government can substantially increase kidney donations and transplants by compensating living kidney donors.4, 5, 6, 7 Indeed, there is virtually unanimous agreement in the transplant community that the government should remove all financial disincentives to kidney donation.8 This study extends that line of reasoning to its logical conclusion by asking (1) how many patients diagnosed with kidney failure each year could avoid suffering on dialysis and premature death by receiving one or more kidney transplants and (2) what level of government compensation of donors would be needed to induce this number of donations."

**********

The paper was preceded in the issue by this commentary:

Garrison, Louis P. "Paying for Kidneys: Reflections on Welfare Economics, Political Economy, and Market Design." Value in Health 25, no. 12 (2022): 1925-1928.

The commentary begins this way*:

"British philosopher Janet Radcliffe Richards at the University of Oxford has written: “If you die through mistakes in moral reasoning, you are just as dead as if you die through mistakes in medicine.”1 The aim of the authors of this thought-provoking cost-benefit analysis is to estimate and inform us about the cost to American society of the limits—perhaps owing to mistakes in both moral and economic reasoning—on the ability of healthy individuals to donate or supply their second or “extra” kidney to those who have kidney failure.2 The 1984 National Organ Transplant Act makes it unlawful to share anything of value between organ donor and recipient, prohibiting exchange for “valuable consideration” (meaning, specifically, payments beyond “reasonable” expenses for removal, implantation, etc)."

*It also includes this great parenthetical aside:

"(As an aside, our health economics and outcomes research field should pay more attention to “market design:” a good place to start is a visit to the blog of Roth30.)"

**********

The commentary also refers to the symposium I blogged about below at the University of Chicago, which you can follow on video:

Friday, July 15, 2022

The Future of Living Donor Kidney Transplantation (videos)

On May 7, 2022 the University of Chicago hosted a Symposium on "The Future of Living Donor Kidney Transplantation: Evolving National Perspectives in Kidney Transplant "

HT: Philip Held

Euthanasia in Canada

 The NYT columnist Ross Douthat considers the medical aid in dying policies in Canada, and warns us that conservative politics is what protects us against the slippery slope that might lead us down the Canadian path.

 What Euthanasia Has Done to Canada

"In recent years, Canada has established some of the world’s most permissive euthanasia laws, allowing adults to seek either physician-assisted suicide or direct euthanasia for many different forms of serious suffering, not just terminal disease. In 2021, over 10,000 people ended their lives this way, just over 3 percent of all deaths in Canada. A further expansion, allowing euthanasia for mental-health conditions, will go into effect in March 2023; permitting euthanasia for “mature” minors is also being considered.

...

"The rules of civilization necessarily include gray areas. It is not barbaric for the law to acknowledge hard choices in end-of-life care, about when to withdraw life support or how aggressively to manage agonizing pain.

"It is barbaric, however, to establish a bureaucratic system that offers death as a reliable treatment for suffering and enlists the healing profession in delivering this “cure.” And while there may be worse evils ahead, this isn’t a slippery slope argument: When 10,000 people are availing themselves of your euthanasia system every year, you have already entered the dystopia.

"Indeed, according to a lengthy report by Maria Cheng of The Associated Press, the Canadian system shows exactly the corrosive features that critics of assisted suicide anticipated, from health care workers allegedly suggesting euthanasia to their patients to sick people seeking a quietus for reasons linked to financial stress.

...

"in the Canadian experience you can see what America might look like with real right-wing power broken and a tamed conservatism offering minimal resistance to social liberalism. And the dystopian danger there seems not just more immediate than any right-authoritarian scenario, but also harder to resist — because its features are congruent with so many other trends, its path smoothed by so many powerful institutions.

...

"without a potent conservatism, the cultural balance tilts too much against these doubts. And the further de-Christianization proceeds, the stronger the impulse to ... rationalize the new order with implicit reassurances that it’s what some higher power wants.

"It’s often treated as a defense of euthanasia that the most intense objections come from biblical religion. But spiritual arguments never really disappear, and the liberal order in a dystopian twilight will still be infused by some kind of religious faith.

"So I remain a conservative, unhappily but determinedly, because only conservatism seems to offer a stubborn obstacle to that dystopia"

*********

Update, January 14: in a followup column, Douthat responds to supporters of Canada's euthanasia policies,* and summarizes his position with this concluding sentence: 

"And if euthanasia is kept within limits or rolled back from its advances, I suspect it will be the old taboos and Christian prohibitions that make the difference, not a libertarianism that so quickly and easily yields to pagan destinations."

*See in particular

Canadian Euthanasia as Moral Progress. Individual liberty, the common good, and human dignity. by Richard Hanania

Here's a summary paragraph:

"First, I will show that the MAID program is currently small, and likely represents cases of the most extreme suffering given the data that we have. I then go on to refute arguments against MAID that have appeared in the popular press. Sometimes, these arguments are simply false, as when it is claimed that it will eventually lead to large numbers of healthy young adults killing themselves with state sanction. Other times, the arguments may be correct but actually make the case for euthanasia. It is true, for example, that some people might feel “pressured” to commit suicide because they don’t want to be burdens on their families or the government. I don’t think there’s anything wrong with this — in practically every other kind of situation, it is usually considered pro-social to care about the impact your life has on others. This gets to the point that my support for euthanasia does not simply rest on libertarian and utilitarian grounds, but also on the idea that people should behave in ways that consider the common good and that, yes, preserve human dignity. The state’s interest in saving costs, as long as it’s going to pay for healthcare, is also legitimate, although I won’t dwell on that here."

Amnon Rapoport (1936-2022)

 Amnon Rapoport, a pioneer of experimental game theory, has died. 

Here's a brief obituary:

Amnon Rapoport, Distinguished Professor Emeritus of Management and Organizations at the University of Arizona, passed away on December 6th

I don't find his date of birth on the web, but in August of 1996 I participated in a conference in honor of his 60th birthday, at the University of North Carolina at Chapel Hill, where he had both studied and taught in the Department of Psychology.  Amnon had already had several heart attacks by then, and his students, who loved him, thought it prudent to have a celebration of his work at that relatively young age, but that caution proved unnecessary. 

Here's the volume of papers presented at that conference, edited by three of his students:

Budescu, David V., Ido Erev, and Rami Zwick, eds. Games and human behavior: Essays in honor of Amnon Rapoport. Erlbaum, 1999.

I first learned of his work when, as a grad student, I took a course in game theory taught by Michael Maschler, who told us about Amnon's experiments on the bargaining set.

He was a man ahead of his time, and maybe situated in the wrong discipline.  It seemed to him natural that psychologists should take a leading role in the experimental study of game theory, and he noted with some regret that instead that literature had been ceded to economists. Here's a paragraph from the introduction to 

Rapoport, Amnon. Experimental studies of interactive decisions. Vol. 5. Springer Science & Business Media, 2012.

"The history of experimentation in psychology is rich and old. It would have been quite natural and highly desirable for psychologists to extend their scope of research and assume a major role in the study of economic decision behavior. Psychology professes to be the general study of human behavior. Most psychologists are trained to regard their discipline as an observational science; they do not have to overcome the conditioning of many economists who think of economics as an a priori science. Psychologists' knowledge of experimental techniques is comprehensive. and their experience in conducting experiments. analyzing data. and discovering empirical regularities exceeds that of most economists. However. with the exception of research on individual choice behavior - where psychologists like Tversky, Kahneman, and Slovic have played a major role - psychologists have not contributed in any significant way to the growing research in experimental economics. Social psychologists for whom interactive behavior is the core of their discipline, have virtually abandoned the study of economic decisions in small groups to their colleagues in economics and related disciplines. "

Here's his cv as of 2017, and his google scholar page.

**********

Update: here's an email that Rami Zwick sent to the Economic Science Association (ESA):

"Dear ESA community,

It is with great sadness that we announce the passing of our teacher, mentor, colleague, co-author and friend, Professor Amnon Rapoport, in Tucson Arizona on December 6, 2022. 

Professor Rapoport served on the faculty of the University of California, Riverside School of Business; University of Arizona; UNC Chapel Hill; University of Haifa, Israel; and the Hebrew University of Jerusalem, Israel. He earned his Bachelor of Arts degree in psychology and philosophy from the Hebrew University of Jerusalem, then went on to earn his M.A. and Ph.D. in quantitative psychology at UNC Chapel Hill. 

Professor Rapoport was one of the pioneers and leaders in the experimental study and quantitative modeling of human decisions in social and interactive contexts. During his distinguished career, he published four books (and edited others) and more than 300 research papers and chapters in leading psychological, management, operation, marketing, decision theory, economics, and political science journals, and is recognized as a leading authority in many of these areas. His most important and influential work was on experimental studies of interactive decision-making behavior. This includes theoretical and empirical research on: 

• Coalition formation 

• Bargaining 

• Social dilemmas 

• Behavioral operations management 

• Behavioral game theory 

• Dynamic pricing 

• Directed networks 

 Professor Rapoport’s work was theory-driven, and, in most cases, the theory was represented formally by mathematical (primarily, but not exclusively, game theoretical) models. At the same time, he was a meticulous and rigorous, yet imaginative and creative experimentalist. In fact, he was one of the pioneers of computerized experimentation in the domain of individual and group decision making. 

With a career spanning over 60 years, Professor Rapoport nurtured and supported the careers of generations of scholars and researchers. He will be greatly missed by his family, friends, colleagues, co-authors, and students."

Two illegal (former) kidney transplant networks analyzed: the Netcare -and Medicus cases, by Ambagtsheer and Bugter

 There aren't many successful prosecutions resulting from illegal organ trafficking, despite the fact that the prevalence of illegal kidney transplants is estimated by many sources to be high.  Here's a paper that tries to understand the nature of the black market supply chain for kidneys, by examining two prosecutions that led to convictions, connected to a hospital in Kosovo and another in South Africa.

Ambagtsheer, F., Bugter, R. The organization of the human organ trade: a comparative crime script analysis. Crime, Law and Social Change (2022). https://doi.org/10.1007/s10611-022-10068-5

Abstract: "This study fills critical knowledge gaps into the organization of organ trade utilizing crime script analysis. Adopting a situational crime prevention approach, this article draws from law enforcement data to compare the crime commission process (activities, cast and locations) of 2 prosecuted organ trade cases: the Medicus case and the Netcare case. Both cases involved transnational criminal networks that performed kidney transplants from living donors. We further present similarities and differences between illegal and legal living donor kidney transplants that may help guide identification and disruption of illegal transplants. Our analysis reveal the similar crime trajectories of both criminal cases, in particular the extensive preparations and high degree of organization that were needed to execute the illegal transplants. Offenders in the illegal transplant schemes utilized the same opportunity structures that facilitate legal transplants, such as transplant units, hospitals and blood banks. Our results indicate that the trade is embedded within the transplant industry and intersects with the transport- and hospitality sector. The transplant industry in the studied cases was particularly found to provide the medical infrastructure needed to facilitate and sustain organ trade. When compared to legal transplants, the studied illegal transplant scripts reveal a wider diversity in recruitment tactics and concealment strategies and a higher diversity in locations for the pre-operative work-up of donors and recipients. The results suggest the need for a broader conceptualization of the organ trade that incorporates both organized crime and white collar crime perspectives."

***

"Although reliable figures of the trade’s scope are lacking, the World Health Organization (WHO) has estimated that approx. 5000 illegal transplants are performed annually (WHO, 2007). The organ trade is reported to rank in the top 5 of the world’s most lucrative international crimes with an estimated annual profit of $840 million to $1.7 billion (May, 2017). While illegal organ transplants have been reported to take place in countries across the globe, knowledge of the trade’s operational features remains scarce (Pascalev et al., 2016)

...

"At the time of writing, only 16 convictions involving organ trade have been reported to the case law database of the United Nations Office on Drugs and Crime, which is far less than would be expected based on global estimates of the problem (UNODC, 2022). The Organization for Security and Co-operation in Europe (OSCE) has reported 9 additional cases (OSCE, 2013). All reported cases had cross-border features and most involved the facilitation of living donor kidney transplants.

...

"In 2014 the Council of Europe established a new convention against ‘Trafficking in Human Organs’ which calls for a broad prohibition of virtually all commercial dealings in organs. Accordingly, sales that occur with the consent of donors are considered to be ‘trafficking’ regardless of the circumstances involved (Council of Europe, 2015)"

...

[Netcare]"Israeli and Romanian donors were promised $20,000 for their kidneys, the Brazilian donors were promised between $3,000 and $8,000. Most donors were recruited in Brazil by 2 retired military officers (Ambagtsheer, 2021; De Jong, 2017; Scheper-Hughes, 2011). 

Payments and reimbursements: Payments took place throughout all stages of the crime commission process. Patients paid Perry/his company up to $120,000 prior to their travel and transplant. Perry, and later also Meir, subsequently paid Netcare. Netcare in turn disbursed payments to various actors in the scheme, including the transplant surgeons and the blood bank. ... Occasionally, additional payments were made directly in cash to the surgeons by Perry, his company, or his agents. Perry also paid an escort/fixer (Rod Kimberley) and a nephrologist. Kimberley paid low-tier offenders in the scheme, including the interpreters. Kimberley additionally covered the costs of recipients’ and donors’ accommodations and he gave donors pocket money upon arrival in South Africa as an advance to their kidney payment. All donors received the promised amount in cash after their operations. 

...

"Contrary to donors in the Netcare case, none of the Medicus’ donors received the promised amount. Some did not receive payment at all but were promised payment only if they recruited new prospective kidney sellers. Withholding payments to kidney sellers in order for them to recruit new prospective kidney sellers is a tactic in organ trafficking schemes to sustain the transplant program (De Jong, 2017).

...

"The cases diverge with respect to the locations and legal embeddedness. Contrary to the Medicus case where transplants were organized in one clinic that was not licensed to conduct transplants, transplants in South Africa were facilitated in at least 5 hospitals across the country that were legally mandated to perform transplants."

Three way liver exchange in Pakistan, reported in JAMA Surgery by Salman, Arsalan, and Dar, in collaboration with economist Alex Chan

 Here's an exciting account, just published in JAMA Surgery, of a three way liver exchange in Pakistan, achieved in part by collaboration with economist and market designer Alex Chan (who is on the job market this year).

Launching Liver Exchange and the First 3-Way Liver Paired Donation by Saad Salman, MD, MPH1; Muhammad Arsalan, MBBS2; Faisal Saud Dar, MBBS2, JAMA Surg. Published online December 7, 2022. doi:10.1001/jamasurg.2022.5440 (pdf)

Here are the first paragraphs:

"There is a shortage of transplantable organs almost everywhere in the world. In the US, about 6000 transplant candidates die waiting each year.1 In Pakistan, 30% to 50% of patients who needed a liver transplant are unable to secure a compatible donor, and about 10 000 people die each year waiting for a liver.2 Kidney paired donations, supported by Nobel Prize–winning kidney exchange (KE) algorithms,3 have enabled living donor kidneys to become an important source of kidneys. Exchanges supported by algorithms that systematically identify the optimal set of paired donations has yet to take hold for liver transplant.

"The innovation reported here is the successful implementation of a liver exchange mechanism4 that also led to 3 liver allotransplants and 3 hepatectomies between 3 incompatible patient-donor pairs with living donor–patient ABO/size incompatibilities. These were facilitated by one of the world’s first documented 3-way liver paired donations (LPD) between patient-donor pairs.

"Since 2018 and 2019, we have explored LPD as a strategy to overcome barriers for liver failure patients in Pakistan in collaboration with economist Alex Chan, MPH.2 With LPD, the incompatibility issues with relative donors can be solved by exchanging donors. The Pakistan Kidney and Liver Institute (PKLI) adopted a liver exchange algorithm developed by Chan4 to evaluate LPD opportunities that prioritizes clinical urgency (Model for End-stage Liver Disease [MELD] scores) while maximizing transplant-enabling 2-way or 3-way swaps that ensures that hepatectomies for every donor within each swap has comparable ex ante risk (to ensure fairness). As of March 2022, 20 PKLI liver transplant candidates had actively coregistered living and related but incompatible liver donors. Evaluating these 20 incompatible patient-donor pairs with the algorithm,4 we found 7 potential transplants by two 2-way swaps and the 3-way swap reported. In contrast to ad hoc manual identification of organ exchange opportunities, the hallmark of a scalable organ exchange program is the regular deployment of algorithms to systematically identify possible exchanges. Regular deployment of LPD algorithms is novel.

"A total of 6 procedures took place on March 17, 2022. Patient 1, a 57-year-old man, received a right liver lobe from donor 2, a 28-year-old coregistered donor of patient 2 (56-year-old man), who in turn received a right liver lobe from donor 3, a 35-year-old woman who was a coregistered donor of patient 3. Patient 3, a 46-year-old man, received a right liver lobe from donor 1, a 22-year-old woman who was a coregistered donor of patient 1, completing the cycle (Figure). Five PKLI consultant surgeons and 7 senior registrars led the hepatectomies and liver allotransplants; 6 operating rooms were used simultaneously. One month postsurgery, all patients and donors are robust with no graft rejection. All the donors are doing well in the follow-up visits and have shown no psychological issues."

Here's a sentence in the acknowledgements:

"We thank Alex Chan, MPH (Stanford University, Palo Alto, California), whose initiative and expertise in economics were the key driving forces for launching liver exchange."

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NB: this is a "Surgical Innovation" article, for which the journal requires that there be no more than three authors.

And here are the references cited:

1.

Chan  A, Roth  AE. Regulation of organ transplantation and procurement: a market design lab experiment. Accessed April 28, 2022. https://www.alexchan.net/_files/ugd/a47645_99b1d4843f2f42beb95b94e43547083b.pdf

2.

Salman  S, Gurev  S, Arsalan  M, Dar  F, Chan  A. Liver exchange: a pathway to increase access to transplantation. Accessed April 1, 2022. http://www.hhpronline.org/articles/2021/1/14/liver-exchange-a-pathway-to-increase-access-to-transplantation

3.

Henderson  D. On marriage, kidneys and the Economics Nobel. Wall Street Journal. October 15, 2012. Accessed March 5, 2022. https://www.wsj.com/articles/SB10000872396390443675404578058773182478536

4.

Chan  A. Optimal liver exchange with equipoise. Accessed April 23, 2022. https://www.alexchan.net/_files/ugd/a47645_36e252f4df0c4707b6431b0559b03143.pdf

5.

Hwang  S, Lee  SG, Moon  DB,  et al.  Exchange living donor liver transplantation to overcome ABO incompatibility in adult patients.   Liver Transpl. 2010;16(4):482-490. doi:10.1002/lt.22017PubMedGoogle ScholarCrossref

6.

Patel  MS, Mohamed  Z, Ghanekar  A,  et al.  Living donor liver paired exchange: a North American first.   Am J Transplant. 2021;21(1):400-404. doi:10.1111/ajt.16137PubMedGoogle ScholarCrossref

7.

Braun  HJ, Torres  AM, Louie  F,  et al.  Expanding living donor liver transplantation: report of first US living donor liver transplant chain.   Am J Transplant. 2021;21(4):1633-1636. doi:10.1111/ajt.16396

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Here's a Stanford story on this collaboration:

Stanford student devises liver exchange, easing shortage of organs. A rare three-way exchange of liver transplants in Pakistan was made possible with a new algorithm developed by a Stanford Medicine student.  by Nina Bai

"The liver exchange idea actually came out of a term paper in a first-year market design class at Stanford," Chan said.

"As he learned more about liver transplants, Chan realized there were important biological and ethical differences from kidney transplants. 

...

"Instead of just finding compatible swaps, we want to find swaps that prioitize the most urgent patients first in order to prevent the most deaths," Chan said.

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Here are some contemporaneous stories from March in the newspaper Dawn (now that the JAMA embargo on the story is lifted):

Liver transplants at PKLI under 'swap' plan - Newspaper - Dawn

Mar 18, 2022 — A highly-trained team of the surgeons headed by PKLI Dean Prof Faisal Dar had performed liver transplants at the institute and other members ...

• First swap liver transplant surgeries at PKLI today - Dawn

  
  

  Mar 17, 2022 — An official told Dawn on Wednesday the treating doctors had recommended liver transplant of all the three patients due to their end-stage ...