Harm reduction is not a panacea: drug use and drug policy in Portugal, and San Francisco

 The Washington Post has a story about Portugal, and the SF Chronicle has one as well. Both stories touch on the tensions between treating drug addicts with respect, and assuring that cities remain safe and livable.  

Here's the Washington Post:

Once hailed for decriminalizing drugs, Portugal is now having doubts  By Anthony Faiola and Catarina Fernandes Martins

"Portugal decriminalized all drug use, including marijuana, cocaine and heroin, in an experiment that inspired similar efforts elsewhere, but now police are blaming a spike in the number of people who use drugs for a rise in crime. In one neighborhood, state-issued paraphernalia — powder-blue syringe caps, packets of citric acid for diluting heroin — litters sidewalks outside an elementary school.

"Porto’s police have increased patrols to drug-plagued neighborhoods. But given existing laws, there’s only so much they can do. 

...

"Portugal became a model for progressive jurisdictions around the world embracing drug decriminalization, such as the state of Oregon, but now there is talk of fatigue. Police are less motivated to register people who misuse drugs and there are year-long waits for state-funded rehabilitation treatment even as the number of people seeking help has fallen dramatically. The return in force of visible urban drug use, meanwhile, is leading the mayor and others here to ask an explosive question: Is it time to reconsider this country’s globally hailed drug model?

“These days in Portugal, it is forbidden to smoke tobacco outside a school or a hospital. It is forbidden to advertise ice cream and sugar candies. And yet, it is allowed for [people] to be there, injecting drugs,” said Rui Moreira, Porto’s mayor. “We’ve normalized it.”

...

" In the United States alone, overdose deaths, fueled by opioids and deadly synthetic fentanyl, topped 100,000 in both 2021 and 2022 — or double what it was in 2015. According to the National Institutes of Health, 85 percent of the U.S. prison population has an active substance use disorder or was jailed for a crime involving drugs or drug use.

"Across the Atlantic in Europe, tiny Portugal appeared to harbor an answer. In 2001, it threw out years of punishment-driven policies in favor of harm reduction by decriminalizing consumption of all drugs for personal use, including the purchase and possession of 10-day supplies. Consumption remains technically against the law, but instead of jail, people who misuse drugs are registered by police and referred to “dissuasion commissions.” 

...Other countries have moved to channel drug offenses out of the penal system too. But none in Europe institutionalized that route more than Portugal. Within a few years, HIV transmission rates via syringes — one the biggest arguments for decriminalization — had plummeted. From 2000 to 2008, prison populations fell by 16.5 percent. Overdose rates dropped as public funds flowed from jails to rehabilitation. There was no evidence of a feared surge in use.

...

"But in the first substantial way since decriminalization passed, some Portuguese voices are now calling for a rethink of a policy that was long a proud point of national consensus. Urban visibility of the drug problem, police say, is at its worst point in decades

...

"A newly released national survey suggests the percent of adults who have used illicit drugs increased to 12.8 percent in 2022, up from 7.8 in 2001, though still below European averages.

...

"Porto’s mayor and other critics, including neighborhood activist groups, are not calling for a wholesale repeal of decriminalization — but rather, a limited re-criminalization in urban areas and near schools and hospitals to address rising numbers of people misusing drugs."

...

"After years of economic crisis, Portugal decentralized its drug oversight operation in 2012. A funding drop from 76 million euros ($82.7 million) to 16 million euros ($17.4 million) forced Portugal’s main institution to outsource work previously done by the state to nonprofit groups,

...

"Twenty years ago, “we were quite successful in dealing with the big problem, the epidemic of heroin use and all the related effects,” Goulão said in an interview with The Washington Post. “But we have had a kind of disinvestment, a freezing in our response … and we lost some efficacy.”

*******

And here are some related paragraphs about San Francisco, in a story in the San Francisco Chronicle about a concentration of drug dealers from Honduras:

THIS IS THE HOMETOWN OF SAN FRANCISCO’S DRUG DEALERS By Megan Cassidy and Gabrielle Lurie |  July 10, 2023

"Like many other U.S. cities, San Francisco shifted years ago to treating drug use more like a disease than a crime. The heavy policing approach of the War on Drugs era failed to slow dealers or decrease demand while overcrowding jails and disproportionately punishing people of color, studies show.

"Now one of the most progressive cities in the nation is fracturing over concerns that it has become too permissive. What to do about the Honduran dealers is a key political issue as a major citywide election approaches in 2024.

"On a weekday afternoon in June, a man in his early 30s lay motionless on a SoMa sidewalk outside the Federal Building. On his right, a dozen users smoked fentanyl and crack cocaine or hung bent at the waist, heads suspended at their knees. To his left, a handful of dealers, cloaked in black but for the space around their eyes, continued selling while a passerby revived the man with Narcan, the nasal-spray antidote to opioid overdoses, and as paramedics arrived to treat him a few minutes later.

“I’m so mad at them for ruining my neighborhood,” said Kevin DeMattia, who owns Emperor Norton’s bar and has lived in the Tenderloin for the past 25 years. “Businesses are dying because people don’t want to come to the Tenderloin.  They’re ruining the neighborhood in so many ways. They’re poisoning people. … They’re this cancer, this aggressive, metastasizing cancer on the Tenderloin — the dealers and the addicts.”

Laurie Lee interviews me about kidney exchange, repugnance, and more (podcast)

 Laurie Lee interviews me in her podcast Donor Diaries.

Donor Diaries

Coffee and Kidneys with Al Roth

https://www.buzzsprout.com/1748941/13094958?t=35 (You don’t have to log in; just click on “Listen Now”.)

***********

Here is her written description:

"Exchanging kidneys is a complicated process that involves multiple collaborations between kidney patients, living donors, transplant centers, insurance companies, airlines and more.  It’s truly remarkable if you stop to think about the number of people and organizations that need to come together to make 1 paired exchange possible.  We only started exchanging kidneys between non-compatible pairs a little over 20 years ago, so it’s a somewhat new process.  Have you ever wondered how this was made possible?

"Meet Nobel Laureate Al Roth who is an economist and Stanford University professor.  Al designs markets.  He’s one of the prominent players who has made kidney exchange possible.  In a nutshell, his work has revolutionized kidney exchange around the world by using economic theory to make kidneys more available.

"In October 2012, Al was the co-recipient of the 2012 Nobel Memorial Prize in Economic Sciences, together with Lloyd S. Shapley, for “ the theory of stable allocations and the practice of market design."

"Al Roth is well known for his application of economics to real world problems.  In this podcast episode we touch a wide range of topics ranging from paired exchanges, prostitution, surrogacy, and more.  All of these markets are examples of repugnant markets.  Kidney Donation can be characterized as a repugnant market, and Al will tell us all about it! 

Links:

Abundant/ CrowdSource for Life Film
Al Roth’s Blog
Al Roth’s Website
Freakonomics Make Me a Match Episode with Al Roth

Donor Diaries Website
Donor Diaries on Facebook
Crowd Source for Life

The harmful human rights impact of unjustified criminalization of individuals and communities: ICJ statement

 The International Commission of Jurists (ICJ) has published a set of legal principles  for a human rights-based approach to criminal laws proscribing conduct associated with sex, reproduction, drug use, HIV, homelessness and poverty.

The 8 March Principles for a Human Rights-Based Approach to Criminal Law Proscribing Conduct Associated with Sex, Reproduction, Drug Use, HIV, Homelessness and Poverty

It opens with a foreword by Edwin Cameron, Retired Justice, Constitutional Court of South Africa, Inspecting Judge, Judicial Inspectorate for Correctional Service.  The first paragraphs are:

"From long years in the law, and as a proudly gay man, I know profoundly how criminal law signals which groups are deemed worthy of protection – and which of condemnation and ostracism. In this way, the criminal law performs an expressive function – and it has dramatic consequences on people’s lives. It sometimes entails a harshly discriminatory impact on groups identified with the disapproved or stigmatised conduct.

"To add to this, criminal proscriptions may reinforce structural inequalities; they may codify discrimination, invest them with the law’s power and may foster stigma. All this may wreak terrible harm.

"Criminal law may thus impel hostility, exclusion, inequality, discrimination and marginalization of individuals and groups, sometimes to the point of violence. As a result, human rights, democratic values and social inclusiveness all suffer." 

...

"The Principles are based on general principles of criminal law and international human rights law and standards. They seek to offer a clear, accessible and workable legal framework – as well as practical legal guidance – on applying the criminal law to conduct associated with:

† sexual and reproductive health and rights, including termination of pregnancy;

† consensual sexual activities, including in contexts such as sex outside marriage, same-sex sexual relations, adolescent sexual activity and sex work;

† gender identity and gender expression;

† HIV non-disclosure, exposure or transmission;

† drug use and the possession of drugs for personal use; and

† homelessness and poverty. 

***********

And here are the first paragraphs of the Introduction:

"Criminal law is among the harshest of tools at the disposal of the State to exert control over individuals. As such, it ought to be a measure of last resort, where other less restrictive means of achieving legitimate interests are insufficient. However, globally, States have exhibited a growing trend towards overcriminalization.

While retribution, deterrence, incapacitation and rehabilitation are generally considered to be its main purposes, criminal law may also perform an expressive function, through public condemnation of certain conduct seen as deserving reprobation and punishment. The desire to harness this expressive function is a critical factor contributing to the proliferation of criminal law.

The unjustified criminalization of individuals and sometimes entire communities is increasingly impeding progress in advancing human rights in many areas, including: racial and gender equality; reproductive autonomy; disability; economic justice; civil liberties; sexual orientation; gender identity; education; youth development; and public health.

Moreover, in recent years, in some quarters, there has been a backlash against human rights, especially against sexual and reproductive health and rights and the human rights of women, lesbian, gay, bisexual, transgender, non-binary, gender diverse and intersex persons, as well as against sex workers, people who use drugs and people experiencing homelessness and/or living in poverty.

"In particular, there has been continued use and, in some cases, a new proliferation of arbitrary criminal laws proscribing conduct associated with sex, reproduction, drug use and the possession of drugs for personal use, HIV, homelessness and poverty. These laws have led to egregious human rights violations, including by engendering and perpetuating stigma, harmful gender stereotypes and discrimination based on grounds such as sex, sexual orientation, gender identity, gender expression and other protected fundamental characteristics. 

"Unless criminal laws proscribing the above-mentioned conduct are directed at coercion or force or otherwise at the absence of consent, their mere existence – let alone their threatened or actual enforcement – violates human rights."

**********

See Saturday's post, concerning Canada's "The Protection of Communities and Exploited Persons Act," which is designed to protect sex workers.

NYC police officer receives a kidney through Kidneys for Communities (KFC:)

 Police magazine has the story of an anonymous living kidney donor who wanted his/her kidney to go to a first responder, facilitated by  Kidneys for Communities.

NYPD Officer Received Kidney Transplant with Aid of Nonprofit Group and PBA. Kidneys for Communities' Kidneys for First Responders initiative is designed to improve access to and facilitate living kidney donations by connecting those who want to help first responders with those who are in need of a lifesaving kidney donation.  July 7, 2023

"Kidneys for Communities, a national community-directed living kidney donation program, launched its Kidneys for First Responders initiative with its first kidney transplant recipient, New York City Police Officer Melissa Quinones, with assistance from the Police Benevolent Association of the City of New York.

******

And here's the KFC press release (doesn't that acronym already sound familiar?):

Kidneys for Communities Announces their ‘Kidneys for First Responders’ Initiative

"Kidneys for Communities’ Kidneys for First Responders initiative is designed to improve access to and facilitate living kidney donations by connecting those who want to help first responders with those who are in need of a lifesaving kidney donation"

"As Dr. Lloyd E. Ratner, who performed Quinones’ transplant, affirms, “The community-directed model, now available to interested communities and pioneered by Kidneys for Communities, is a common-sense approach to growing the pool of living kidney transplant donors. As more communities come on board, we expect it will shorten the critical waiting time for transplant recipients and save lives.”."

Compensating kidney donors: a call to action by Brooks and Cavanaugh in the LA Times

 Here's a clarion call for compensation of living kidney donors, from two nondirected kidney donors.  It's not the first, and very likely not the last, given the difficulty of modifying the existing law.  But it makes the case very clearly (and proposes that a tax credit spread over ten years might be the way to move foreward).

Opinion: A single reform that could save 100,000 lives immediately BY NED BROOKS AND ML CAVANAUGH, JULY 9, 2023 

"Never in the field of public legislation has so much been lost by so many to one law, as Churchill might’ve put it. The National Organ Transplant Act of 1984 created the framework for the organ transplant system in the United States, and nearly 40 years later, the law is responsible for millions of needless deaths and trillions of wasted dollars. The Transplant Act requires modification, immediately.

"We’ve got skin in this game. We both donated our kidneys to strangers. Ned donated to someone who turned out to be a young mother of two children in 2015, which started a chain that helped an additional two recipients. And Matt donated at Walter Reed in 2021, after which his kidney went to a Seattleite, kicking off a chain that helped seven more recipients, the last of whom was back at Walter Reed.

"Ned founded, and Matt now leads, an organization that represents nearly 1,000 living donors

...

"eight years ago, when Ned donated, the number of living kidney donors was 6,000. With all the work we’ve done since, the number of living donors is still about 6,000 annually. In the United States, nearly 786,000 people suffer from end-stage kidney disease, more people than can fit in the 10 largest NFL stadiums combined.

...

"More Americans die of kidney disease than of breast or prostate cancer, and one in three of us is at risk. This illness is widespread, but what makes it worse is the staggering financial burden borne by everyone. The head of the National Kidney Foundation testified in March that Medicare spends an estimated $136 billion, nearly 25% of its expenditures, on the care of people with a kidney disease. Of that, $50 billion is spent on people with end-stage kidney disease, on par with the entire U.S. Marine Corps budget.

...

"The National Organ Transplant Act prohibits compensating kidney donors, which is strange in that in American society, it’s common to pay for plasma, bone marrow, hair, sperm, eggs and even surrogate pregnancies. We already pay to create and sustain life

...

"The ethical concerns regarding compensation are straightforward. Nobody wants to coerce or compel those in desperate financial straits to do something they would not have done otherwise. The challenge, then — until artificial or nonhuman animal substitutes are viable options — is to devise a compensation model that doesn’t exploit donors.

"Compensation models have been proposed in the past. A National Institutes of Health study listed some of the possibilities, including direct payment, indirect payment, “in kind” payment (free health insurance, for example) or expanded reimbursements. After much review, we come down strongly in support of indirect payment, specifically, a $100,000 refundable federal tax credit. The tax credit would be uniformly applied over a period of 10 years, in the amount of $10,000 a year for those who qualify and then become donors.

"This kind of compensation is certainly not a quick-cash scheme that would incentivize an act of desperation. Nor does it commoditize human body parts. Going forward, kidney donation might become partly opportunistic rather than mostly altruistic, as it is now. But would it be exploitative? Not at all."

...

Ned Brooks and ML Cavanaugh are living kidney donors, and Brooks is the founder of the Coalition to Modify NOTA.

********

Here are all my posts that mention Ned Brooks, starting with this one:

Friday, February 26, 2016

A Freakonomics listener was inspired to become a non-directed kidney donor by the podcast on kidney exchange

Sex work contracts are enforceable in small claims court, in Canada

 In Nova Scotia (where selling sex is legal but buying it is not), a sex worker sued a delinquent client for her fee and won (despite his argument that contracts requiring a party to commit a crime were unenforceable).

Former sex worker's victory in small claims court sets precedent, lawyer says. Decision clarifies that contracts for sex work are enforceable. by Moira Donovan · CBC News 

"A former sex worker in Nova Scotia has successfully sued a client in small claims court for non-payment of services. She and her advocates hope the decision will change the legal landscape for sex work in Canada.

"The case relates to an incident in January 2022 when Brogan, whom CBC News is only identifying by her first name because she is a survivor of human trafficking, spent an evening with a client.

"Afterward, the client refused to pay the agreed-upon fee.

"Brogan then turned to small claims court to recover the money — in what advocates believe is the first time such a case has come before the courts in Canada — and won a judgment that she was entitled to the unpaid amount, plus interest and costs.

...

"Brogan met the client in question, ... through a website called LeoList that's used by sex workers and their clients. After some discussion about rates and services, Brogan travelled to Samuelson's apartment, where she spent the evening.

...

"There was offer, there was an acceptance of the offer, there was certainty of terms, so all the hallmarks of an enforceable contract were there," said Jessica Rose, Brogan's lawyer.

"But the central question in the case was whether contracts for sex work are enforceable — a question that relates to the legislation governing sex work in Canada. 

"The Protection of Communities and Exploited Persons Act, which passed in 2014, is supposed to protect people from the risks involved in sex work. It amended the Criminal Code to remove the criminal penalty for individuals who sell their own sexual services, and eliminated criminal charges for those who support sex workers, such as drivers or security personnel.

"But aspects of that work remained criminalized, including the purchase of services.

"In this case, the defendant argued that contracts for sexual services were not enforceable because you could not have a contract in which one party — in this case, the client — had to do something illegal.

...

"adjudicator Darrel Pink concluded that because sex work is legal and the business arrangements supporting sex work are legal, it follows that the benefits of commercial law apply, including access to a civil claim — the same as any other service provider.

...

"Failure of the court to provide a remedy for a wrong or a breach of duty owed by a client would contribute to the very exploitation the legislation was designed to prevent," he wrote."

HT: Kim Krawiec

Liver exchange in Turkey

Here's a forthcoming article in the AJT, reporting on a collaboration between physicians and market designers with experience in kidney exchange:

The First 4-Way Liver Paired Exchange from an Interdisciplinary Collaboration between Healthcare Professionals and Design Economists by Sezai Yilmaz, MD, FACS  Tayfun Sönmez, PhD  M. Utku Ünver, PhD  Volkan Ince, MD  Sami Akbulut, MD, FACS  Burak Isik, MD  Sukru Emre, MD  American Journal of Transplantation, BRIEF COMMUNICATION|ARTICLES IN PRESS, Open Access Published: July 05, 2023 DOI:https://doi.org/10.1016/j.ajt.2023.06.016 

Abstract: We report initial results of a Liver Paired Exchange (LPE) program established at the Liver Transplant Institute at Inonu University through collaboration with design economists. Since June 2022, the program has been using a matching procedure that maximizes the number of living donor liver transplants (LDLTs) to the patients in the pool subject to the ethical framework and the logistical constraints of the program. In one 4-way and four 2-way exchanges, twelve LDLTs have been performed via LPE in 2022. The 4-way exchange, generated in the same match run with a 2-way exchange, is a first worldwide. This match run generated LDLTs for six patients, revealing the value of the capacity to carry out larger than 2-way exchanges. With only 2-way exchanges, only four of these patients would receive LDLT. The number of LDLTs from LPE can be increased by developing the capacity to perform larger than 2-way exchanges in either high-volume centers or multi-center programs.

 

Regulating legal prostitution isn't easy, even in Amsterdam

 The NYT has the story:

Amsterdam Tries to Dim the Glare on Its Red-Light District. The mayor wants to improve the neighborhood for residents, but sex workers oppose measures recently put in place. Now the city is looking to set up legal prostitution elsewhere.  By Claire Moses

"It has been a goal sought after by Amsterdam for years: dissuading rowdy, brawling tourists from overtaking the red-light district.

...

"Now the city is pushing a more drastic move: setting up a location for legal prostitution in another neighborhood to spread out demand — an idea that has set off mixed reactions from the industry.

...

"Last year, Amsterdam saw about 20 million visitors, according to figures provided by the city. It has about 900,000 residents and is on track to have 30 million annual tourists by 2030

...

"Prostitution is legal in the Netherlands, but it is not allowed everywhere or without a permit. It is illegal to practice sex work at home, in a hotel room or in the street, for example. It is unclear how many sex workers are active in Amsterdam, and experts are wary of estimates. The red-light district has about 250 active windows.

"The local government is planning to decide on a final location early next year. But the erotic center, which would not be funded by the city, is still far from becoming a reality. Some people are adamantly opposed, and the city cannot force sex workers to move to an erotic center.

...

"Even before it was made legal, prostitution was associated with the red-light district for hundreds of years because of its original proximity to the port of Amsterdam. The commercial nature of the neighborhood and of its window prostitution, which has helped make it such an international draw, originated in the late 1960s, Mr. Verlaan said."

Cryopreservation of organs for transplants, and Sebastian Giwa in Forbes

 Forbes has a long, interesting, somewhat breathless story about the progress and promise of freezing organs for transplants, including not only the usual eight organs, but also bone marrow/blood stem cells. It focuses on one of the entrepreneurs in the field, Dr. Sebastian (Seb) Giwa, and his colleague Jedd Lewis among others

New Breakthroughs In Cryopreservation Poised To Transform Organ Transplantation, by Alex Zhavoronkov, PhD, Jul 5, 2023

"To understand how this came about I delved into the career of the founder and CEO of Sylvatica Biotech, Dr. Sebastian Giwa (called “Seb” by his friends). Seb is credited by many as the chief architect of the surge of scientific interest in cryopreservation over the last several years.

Sebastian Giwa, PhD, MBA 

BRIDGET BENNETT

...

"Trying to donate organs (without cryopreservation) is a lot like trying to donate perishable (non-canned) food: there are certainly a lot of starving people in the world, but good luck finding a recipient for every single ounce before it expires. 

...

"[Organ Preservation Alliance]  partnered ... to publish position papers, including a peer-reviewed article in Nature Biotechnology outlining the need for an organ cryopreservation research effort. The paper was co-authored with all of the major U.S. transplant societies and a star-studded lineup of scientists including Robert Langer, George Church, and Ed Boyden, and even Nobel Prize-winning economist Alvin Roth – whose work has focused on finding new ways to ameliorate the organ shortage. It is currently in the top 1% of the most widely read scientific articles published since its release.

...

"Donor bone marrow is lifesaving for many kinds of  cancers and a variety of other blood diseases. Successful bone marrow transplants have been performed since the 1950s, but the challenge is finding a source of bone marrow to transplant – especially since donors and recipients must be matched for genetic factors even more precisely than some organ transplants.

...

" if bone marrow could be cryogenically banked, why not procure it from deceased organ donors who were already providing hearts, livers, and other organs for transplantation? There are nearly 40,000 such donors worldwide each year, and each could potentially donate enough marrow for multiple patients in need. For many patients, when a transplant was needed the matching bone marrow would already be available in the bone marrow bank.

"From the perspective of the deceased organ donor and the OPOs, this would be like providing an opportunity to donate an additional lifesaving organ. Traditionally, each donor can provide up to eight lifesaving vital organs: a heart, two lungs, two kidneys, a liver, intestines, and a pancreas. In essence, bone marrow would be the ninth. And if a donor could provide bone marrow to multiple recipients, this might even double the number of lives that each donor could save.

...

"Alex: What’s something we haven’t covered that excites you about what cryopreservation can do for the organ shortage?

"Seb: In the long-term, one of the things that I’m most excited about is how these technologies can remove barriers to developing transplant systems in new countries. Most of the world still doesn’t have access to deceased donor transplantation. For instance, Africa has 16% of the world’s population but only 0.5% of transplants are done there. Meanwhile the U.S. has less than 5% of the world’s population but does about 25% of the world’s transplants. Many developed countries, like my father’s home country Ghana, have limited live kidney donation programs. But they don’t have deceased donor programs, which are needed to carry out large numbers of kidney and liver transplants as well as any sort of heart or lung transplantation.

"That’s partly because the logistical demands to source organ donations prospectively require so much infrastructure: a waitlist, rapid matching of donors to recipients, OPOs that need to be overstaffed in order to deal with unpredictable surges in organs available, rushed activities that require tight coordination between donor hospitals, OPOs, transplant centers, and even third party service providers like organ couriers. Many organs have also needed expensive transportation (private jets and helicopters).

"It’s a very different situation when there’s a source of cryopreserved hearts, livers, etc., that can be donated in a much more flexible way and are simply waiting to be matched to patients. Even things like Doctors without Borders and perhaps “OPOs without Borders” become possible for transplantation, helping train and develop new organ recovery, heart, lung, and liver transplant programs. So many more possibilities open up when you don’t need to create every part of a transplant system from scratch and have all of those parts acting in synchrony on Day 1."

**************

Here's the original article referred to:

The promise of organ and tissue preservation to transform medicine 
 Sebastian Giwa, Jedediah K Lewis, Luis Alvarez, Robert Langer, Alvin E Roth, George M Church, James F Markmann, David H Sachs, Anil Chandraker, Jason A Wertheim, Martine Rothblatt, Edward S Boyden, Elling Eidbo, W P Andrew Lee, Bohdan Pomahac, Gerald Brandacher, David M Weinstock, Gloria Elliott, David Nelson, Jason P Acker, Korkut Uygun, Boris Schmalz, Brad P Weegman, Alessandro Tocchio, Greg M Fahy, Kenneth B Storey, Boris Rubinsky, John Bischof, Janet A W Elliott, Teresa K Woodruff, G John Morris, Utkan Demirci, Kelvin G M Brockbank, Erik J Woods, Robert N Ben, John G Baust, Dayong Gao, Barry Fuller, Yoed Rabin, David C Kravitz, Michael J Taylor & Mehmet Toner

Nature Biotechnology 35, 530–542 (2017) doi:10.1038/nbt.3889
Published online 07 June 2017

Abstract: The ability to replace organs and tissues on demand could save or improve millions of lives each year globally and create public health benefits on par with curing cancer. Unmet needs for organ and tissue preservation place enormous logistical limitations on transplantation, regenerative medicine, drug discovery, and a variety of rapidly advancing areas spanning biomedicine. A growing coalition of researchers, clinicians, advocacy organizations, academic institutions, and other stakeholders has assembled to address the unmet need for preservation advances, outlining remaining challenges and identifying areas of underinvestment and untapped opportunities. Meanwhile, recent discoveries provide proofs of principle for breakthroughs in a family of research areas surrounding biopreservation. These developments indicate that a new paradigm, integrating multiple existing preservation approaches and new technologies that have flourished in the past 10 years, could transform preservation research. Capitalizing on these opportunities will require engagement across many research areas and stakeholder groups. A coordinated effort is needed to expedite preservation advances that can transform several areas of medicine and medical science.

************

Here's a recent related post:

Wednesday, June 28, 2023

Freezing, thawing and transplanting a rat kidney: a first step towards organ banking

Eric van Damme is moving on

 It appears that the great Dutch game theorist Eric van Damme is retiring from Tilburg.

Here's the announcement from Tilburg:

Outgoing professor Van Damme: Economics serves people, 20th June 2023

"Game theory supports design markets

"Game theory is a mathematical theory that allows us to better understand how people resolve conflicts and can benefit from cooperation. Game theory is used in designing markets so that they function well, and auctions (such as this summer's auction of FM radio frequencies) to ensure that predetermined goals are met. The theory is also important in competition policy, such as in detecting cartels and preventing the abuse of dominant positions.

"In his speech, Van Damme discusses three examples from his own work: the theory of "Global Games," which predicts how coordination problems are solved and provides insights for regulating financial markets. Also, work on platform markets that played a role in a US Supreme Court ruling on the credit-card market. And finally recent research for the Ministry of Economic Affairs on the effectiveness of legislation on abuse of dominance.   

"Eric van Damme worked at Tilburg University since 1989. He started as a research professor at the then newly founded CentER and later served as director of TILEC, the Tilburg Law and Economics Center. He is a Fellow of the Econometric Society (1993) and has been a member of the Royal Netherlands Academy of Arts and Sciences, KNAW, since 2003. In 2009 he was appointed Knight of the Order of the Dutch Lion for his scholarly achievements."

*********

And below is a link to and some excerpts from his valedictory speech, in which (among other things) he explains game theory and economics to non-economists, and gives very eloquent thanks to those who have influenced him.  Among those are Stef Tijs, his undergraduate mentor, who he calls "the Godfather of Game Theory in the Netherlands," and later Reinhard Selten. (Selten wrote in his 1994 Nobel autobiography that  "Eric van Damme needed very little advice and is now a well known game theorist.").

Eric's lecture has a bilingual title:

The beauty and the beast; Het spel en de knikkers, Prof. dr. Eric van Damme

"I should still explain the first part of the title. The “beauty” refers to the world of science, and the “beast” is reality (including the economy).

...

"In this lecture, I will talk about how I tried to navigate between the beauty and the beast.

...

"An example: school choice

"Let me give an example of a “market” on which I did not work on myself, but which is important and which the non-economists among you might not view as a market. The question that we want to address: how, in a given city (or region), to allocate children to (high) schools? Schools differ in quality and parents prefer their children go to good schools. Furthermore, everything else equal, a school that is closer by is more attractive. It can easily happen that some schools are oversubscribed, i.e., there are more applications than there is capacity. Hence, there is scarcity of positions. In such a case, which kids should be allowed to enter their preferred school and which one not? There will be some criteria, which will be reflected in allocation rules. But what should these rules be? Lotteries are simple but may not lead to a good allocation. We also do not want to give the places to the kids of which the parents are willing to pay the most. What should we do? Note that if we really want a good solution, we should look at all the schools in the region or city together. How can we solve this problem? And what criteria should we use for judging allocations?

"There is an active line of research on these questions, with important contributions from economists from Amsterdam, who influenced the way the allocation is done there. (De Haan et al, 2023). The current literature is based on a pure mathematics paper, Gale and Shapley (1962) that was inspired by the process by which teenagers taking their first dancing lesson were matched: the girls standing on the side and the boys asking them to dance, with each boy moving on to another girl after a rejection until he found a partner or was rejected by all. Two very different situations, but with the same solution. Based on the ideas developed in this literature, we can now also match donor organs to patients in a more efficient way, and can save more lives; see Roth (2015) for a popular account. "

...

"I thank my parents. They always stimulated me to get the best out of myself and stressed the importance of education to get a better life than had been possible for them. For somebody in my generation and coming from Koewacht (Zeeuws Vlaanderen) it certainly was not common to go to university. I am grateful that my mother can be here today, healthy and strong, and still caring, not only for me, but also for the rest of our (extended) family. If I recall well, my parents’ dream was that I would become an engineer. Being all thumbs (met twee linkerhanden), this was impossible for me, but with a PhD

from Eindhoven University of Technology and with Nobel Prize Winner Al Roth speaking about “The economist as engineer” (Roth, 2002), I think I have come reasonably close.

"My headmaster of elementary school, Meester Lammens, told my parents that my Cito-toets was not representative of my capabilities and urged them to not take it too seriously. I was fortunate that, when I went to high-school, the Mammoetwet had just entered into force so that I could go from Mavo, through Havo and Atheneum, to the university without delay.

"Studying mathematics in Nijmegen showed me its beauty and taught me the importance of learning by doing. After the lectures, we had tutorials to practice the material, but, at first, it frequently seemed that the questions had nothing to do with what had been taught. But then discovering the link and the corresponding solution by oneself (with only a little bit of help) was always exciting. I am immensely grateful to Stef Tijs, the Godfather of Game Theory

in the Netherlands. Everybody who has interacted with Stef knows what an inspirational figure he was. After having followed his courses, it was clear that Game Theory would be my area and I wrote my thesis under his supervision. Stef also helped me on many other occasions and more than could be expected, and he also ensured that I got my first job in Eindhoven to do my PhD there.

"In Eindhoven, I had the privilege to work in the Operations Research Group of Jaap Wessels. This was a fantastic environment offering excellent conditions for research and stimulating supervision. The research culture forced me to go out at an early stage and present my work at conferences. When it became clear that I preferred to work on Game Theory problems rather than things like inventory management, Jaap allowed me to follow my interests, although it was only a side interest of the group. Jaap, however and rightly, insisted that I should find a “true expert” who was willing to testify that my work was indeed pushing the research frontier forward. When I met Reinhard Selten at a conference in Oberwolfach (Germany), he was willing to act as a second supervisor, even if at first I had tried to convince him that his concept of subgame perfect equilibrium did not make sense

and had thus demonstrated how much I still had to learn. Reinhard and I had many discussions, for which he also invited me to his home in Rheda-Wiedenbrück. I think these were the most intensive discussions I ever had. I am very, very grateful to Reinhard. Throughout my career I have kept Reinhard, Jaap and Stef in mind and I tried to treat my students as they (my teachers) had treated me."

Market shaping ideas sought at U. Chicago

 The Market Shaping Accelerator at the University of Chicago is seeking to find innovative proposals: MSA Innovation Challenge 2023

"MSA’s inaugural Innovation Challenge 2023 will award up to $2,000,000 in total prizes for ideas that identify areas where a pull mechanism would help spur innovation in biosecurity, pandemic preparedness, and climate change, and for teams to design that incentive mechanism from ideation to contract signing.

...

"Pull mechanisms are policy tools that create incentives for private sector entities to invest in research and development (R&D) and bring solutions to market. Whereas “push” funding pays for inputs (e.g. research grants), “pull” funding pays for outputs and outcomes (i.e. prizes and milestone contracts). These mechanisms “pull” innovation by creating a demand for a specific product or service, which drives private sector investment and efforts towards developing and delivering that product or technological solution.

"One example of a pull mechanism is an Advance Market Commitment (AMC), which is a type of contract where a buyer, such as a government or philanthropic organization, commits to purchasing (or subsidizing) a product or service at a certain price and quantity once it becomes available. This commitment creates a market for the product or service, providing a financial incentive for innovators to invest in R&D and develop solutions to meet that demand.

"An AMC was used in the early 2000s in the case of developing a pneumococcal vaccine for the strain of the virus affecting children in low and middle income countries. Another current example is Frontier, led by Stripe, which is an AMC to accelerate carbon removal.

"In general, pull mechanisms are useful when we know we need an innovation, but we don’t who is best placed to develop it or how."

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Earlier:

Friday, May 12, 2023

Market Shaping at the University of Chicago: Promoting needed innovation

Representatives Matsui and Wilson have introduced legislation that, if passed, could allow pilot programs involving compensation of organ donors.

  Congresswoman Doris Matsui (D-CA) and Congressman Joe Wilson (R-SC)  have introduced legislation that, if passed, could allow pilot programs involving compensation of organ donors.

Here's the press release:

WASHINGTON, D.C. – Today, Congresswoman Doris Matsui (D-CA) and Congressman Joe Wilson (R-SC) introduced the Organ Donation Clarification Act, a bipartisan bill to reduce barriers to organ donation and increase the supply of organs for transplantation.

Every day, 17 Americans die waiting for a lifesaving organ transplant. As of this month, over 114,000 Americans are on the national waitlist. In 2022, although over 42,000 patients received a transplant, over 68,000 additional patients were added to the national waitlist.

With over 95,000 patients in need of a kidney transplant, the average wait time is between three to five years. Those delays cause tens of thousands of Americans to go through lifesaving yet burdensome and disruptive dialysis treatments in the hope that they live long enough for a kidney to become available.  However, thousands of Americans every year will become too sick to receive a transplant and die waiting for one. Not only can thousands of lives be saved, but getting everyone the lifesaving transplant they need can also save billions of dollars a year in dialysis costs.

“Every day that our country suffers from an organ donation shortage means more preventable loss of life,” said Congresswoman Matsui. “By removing disincentives and barriers for prospective donors, we can reach more patients and save lives. The Organ Donation Clarification Act is a bipartisan solution that will help us bridge the gap in organ donations and give hope to patients and families waiting for a lifesaving transplant.”

“I am grateful to introduce this bipartisan bill with Congresswoman Matsui to address the severe organ donation shortage in our country,” said Congressman Wilson. “An average of 17 people in the U.S. succumb to their illnesses every day because they could not survive the wait for a viable organ. In certain parts of the country, the waitlist can be over five years for a kidney. Current law lacks clarity and prevents potential organ donations. This legislation addresses those issues by removing the hurdles for potential donors and allowing new, innovative ways to increase organ donation. This would not only save taxpayer dollars but, most importantly, it would save lives.”

“We appreciate Congresswoman Matsui’s leadership on this bill, which improves the chances that a living donor can make the choice to save a life,” said Dr. David Lubarsky, CEO of UC Davis Health. “UC Davis Health is enormously proud of our Transplant Center, which is one of the largest in the country and has saved more than 5,000 lives in its 38 years of operation.”  

Organ transplantation is governed by the National Organ Transplant Act (NOTA) of 1984. This law prohibits buying or selling organs for “valuable consideration.” Confusion about what constitutes valuable consideration has hampered donation by scaring people away from reimbursing living organ donors for things like medical expenses and lost wages. Both are legal under NOTA, but the law's lack of clarity and its criminal penalties have created uncertainty and prevented reimbursements in many cases.

Moreover, current law does not allow for any entity to test the efficacy of providing benefits to encourage donation. The bill would allow for government run pilot programs to test the provision of non-cash benefits in order to increase organ donation, subject to ethical review, and mandates a report so the broader transplant community can understand best practices for encouraging additional organ donation. These benefits could include funeral benefits for deceased donors and health insurance, tuition assistance, or other proposals to increase the number of living donors. A 2019 American Economic Review survey indicates that between 65 and 80 percent of Americans would support such a program to encourage additional donation.

Finally, when determining eligibility for reimbursements for donation expenses such as travel and medical costs, current law requires the government to take into account the income of the recipient, rather than solely focusing on the income of the donor. This often disqualifies potential donors by creating additional financial burden.  

The Organ Donation Clarification Act would:

• Clarify that certain reimbursements are not valuable consideration but are reimbursements for expenses a donor incurs;
• Allow government-run pilot programs to test the effect of providing non-cash benefits to promote organ donation;
• Clarify that the National Living Donor Assistance Center (NLDAC) can’t consider the organ recipient’s income when determining whether to reimburse a donor’s expenses.

This bipartisan legislation is endorsed by the Americans for Tax Reform, American Transplant Foundation, Foundation for Kidney Transplant Research, National Kidney Donation Organization, Transplant First Academy, Chris Klug Foundation, Flood Sisters Kidney Foundation, American Liver Foundation, National Kidney Donation Organization, Kidney Transplant Collaborative and Wait List Zero.

Text of the legislation can be viewed here.

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HT: Frank McCormick

Who marries whom?

 The Washington Post "Department of Data" presents some census data on who marries whom.

What does your job say about whom you’ll marry?  Analysis by Andrew Van Dam  June 16, 2023 

Africa continues to suffer severe shortages of blood and plasma

 Blood and plasma are in short supply in Africa, partly due to the insistence, by the WHO and others, that  blood and plasma be supplied domestically from unpaid donors. (Much of the world buys blood plasma from the United States, where donors can be paid.)

Here's an update from the Lancet:

The status of blood supply in sub-Saharan Africa: barriers and health impact, by Lucy Asamoah-Akuoko Bernard Appiah  Meghan Delaney  Bridon M'baya  Claude Tayou Tagny  Imelda Bates Published:June 13, 2023DOI:https://doi.org/10.1016/S0140-6736(23)01164-9

"Sub-Saharan African countries continue to struggle with chronic, year-round blood shortages, limiting their ability to support patients and deliver on the health-related Sustainable Development Goals (SDGs).1 Most blood recipients in sub-Saharan African countries are children and women around the time of childbirth,2 so achieving the health-related SDGs depends on blood and blood product availability to reduce maternal mortality, end preventable deaths of newborn babies and children younger than 5 years, and achieve universal health coverage. Blood shortages in sub-Saharan Africa can have devastating consequences. An estimated 70% of 287 000 pregnancy-associated deaths in the world in 2020 occurred in sub-Saharan African countries,3 predominantly due to obstetric haemorrhage. Insufficient blood supply for transfusion contributes substantially to such maternal deaths in hospitals in sub-Saharan Africa.4 Blood transfusions are also essential for managing sub-Saharan Africa's high rates of traffic accidents5 and childhood anaemia, which is commonly due to infections such as malaria, helminthiasis, and haemoglobinopathies. Sub-Saharan Africa is home to more than 75% of the 300 000–400 000 babies born each year globally with sickle cell disease;6 blood shortages contribute to 50–90% of these children dying before their fifth birthday.7

...

"But there are several barriers to achieving an adequate and sustainable blood supply in sub-Saharan Africa. The average number of blood donations across the WHO African region is less than 6 units per 1000 population, with some countries such as Cameroon, Eritrea, and Madagascar collecting less than two units per 1000 population.8 Insufficient blood supply in sub-Saharan African countries is due to many factors, including inadequate organisation, regulation, and coordination of national blood services, and challenges with geographical distribution of blood for transfusion. There are also cultural barriers and stigma associated with knowing HIV status9 that deter some voluntary blood donors, compounded by inefficient donor recruitment programmes, and inadequate funding and sustainable financing models for blood services. Several sub-Saharan African countries including Kenya, Lesotho, Malawi, and Uganda, built their national blood transfusion services on the back of HIV funding from donor agencies such as President's Emergency Plan for AIDS Relief, The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the EU, but this funding has reduced considerably.

...

"WHO recognises three types of blood donors: voluntary non-remunerated blood donors (VNRBD); family replacement blood donors (FRD) who donate blood for family members, friends or acquaintances; and paid donors. In high-income countries such as Denmark and the UK, the use of VNRBD ensures reliability of adequate national blood supply. In the WHO Africa region, the number of VNRBD increased from 1·89 million in 2008 to 3·42 million in 2018 (increasing total donations from 2·41 million units to 4·46 million units).11 Despite this, donations from VNRBD are unable to meet the demand for blood in many sub-Saharan African countries. For example, of 21 sub-Saharan African countries with more than 80% VNRBD, only five (Botswana, Mauritius, Namibia, South Africa, and Eswatini) have met the minimum blood requirement of 10 units per 1000 population2—a target that, although globally adopted, is not based on robust evidence.12 Paid donors have a lower safety profile as compared with VNRBD and do not contribute to achieving adequate an cd safe blood supply.13"

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And here is reference 13, a WHO pamphlet published in 2010 calling on all donations to achieve self sufficiency in unpaid blood donation

13. WHO, 2010, "Towards 100% voluntary blood donation: a global framework for action"  

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Earlier:

Monday, May 18, 2020

Plasma and plasma products (such as antibodies) are a big business (and the U.S. dominates the international market)