US Waitlist Registrants who Received Transplantation Abroad

 Here's a recent article about patients waiting for a deceased-donor organ transplant in the U.S. who (instead) received one overseas (and so removed themselves from the U.S. deceased-donor waiting list, from 2010 to 2023. In that period, the total number of deceased donor transplants in the US rose from about 20,000 per year to about 40,000 per year. Around 60 patients a year are removed from the waitlist for this reason, i.e. on the order of one tenth of one percent.

 The tone of the paper is captured by the statement that this is "not universally unethical".

 Landscape of US Waitlist Registrants who Received Transplantation Abroad
Terlizzi, Kelly MS1; Jaffe, Ian S. MD, MSc1; Bisen, Shivani S. MD1; Lonze, Bonnie E. MD, PhD1; Orandi, Babak J. MD, PhD1,2; Levan, Macey L. JD, PhD1; Segev, Dorry L. MD, PhD1; Massie, Allan B. PhD   Transplantation ():10.1097/TP.0000000000005467, July 14, 2025.  

Abstract:

"Background.
Transplant waitlist registrants in the United States may be delisted because of receipt of a transplant abroad. Although not universally unethical, “travel for transplantation” poses risks to posttransplant care. To better understand this phenomenon, this study identifies temporal trends, geographic patterns, and demographic factors associated with cross-border transplantation.

Methods.
Using Scientific Registry of Transplant Recipients data, we identified 818 US waitlist candidates who were removed because of transplantation abroad between 2010 and 2023. We described recipient characteristics overall, by organ, and by top transplant destinations. We used a Cox regression framework to identify characteristics associated with waitlist removal due to transplantation abroad.

Results.
Transplants abroad averaged 58.4 per year. Incidence peaked at 80 transplants in 2017, with an upward trend after 2021. Kidney transplants made up 92.1% of cases. The most common destinations were the Philippines (19.8%), India (16.5%), Mexico (9.4%), China (8.4%), and Iran (4.4%). India and Mexico experienced the smallest drop-off during the height of the COVID-19 pandemic 2020–2021. Most recipients were US citizens (65.0%) or residents (23.5%). Female (adjusted hazard ratio [aHR], 0.520.610.71; P < 0.001) and Black candidates (aHR, 0.120.180.26; P < 0.001) were less likely to travel abroad compared with Asian candidates (aHR, 5.927.108.52; P < 0.001). Nonresidents (aHR, 6.708.6911.26; P < 0.001) and, among registrations in 2012 or later, nonresidents who traveled to the United States for transplantation (aHR, 27.2738.9155.50; P < 0.001) had a greater chance of undergoing transplantation abroad.

Conclusions.
Understanding patterns of international travel for transplantation is key not only for preventing resource drains from destination countries but also for providing adequate posttransplant care for recipients."

International trade in prison cells: Sweden and Estonia

 The Guardian has the story:

Sweden set to rent cells in Estonian jails as it runs out of room for its prisoners by Miranda Bryant

"Sweden is moving away from criminal rehabilitation in favour of US-style mass incarceration, experts have said, as the country prepares to rent places in Estonian jails to help house its rapidly expanding prison population.

...

"Under an agreement signed by Stockholm and Tallinn in June, up to 600 prison places in the Baltic country are expected to be made available.

"According to a recent Kriminalvården report, Sweden’s prison population could – in the most extreme scenario – grow from 7,800 this year to 41,000 in 2034 as a result of more punitive policies driven by the far right.

...

"The number of children facing lengthy periods in prison is particularly striking: in recent years, a change in approach has led to children as young as 15 being jailed for 10 years or more.

"The government, which depends on the support of the far-right Sweden Democrats, is now considering a proposal to lower the age of criminal responsibility from 15 to 14 for severe offences.

"The main opposition party, the centre-left Social Democrats, have said they would support such a move. The Sweden Democrats have called for the age to be lowered to 13."

Wine barrels, barrel brokers, and tariffs

 Wine barrels are traded and reused internationally.

The Guardian has the story:

Stained, warped and terroir rich: the global and shockingly sustainable lives of wine barrels
Wood barrels circle the world and can be used for more than a century. They tell a story, but they’re imperiled by tariffs  by Kiki Aranita

"In the alcohol industry, when ageing liquor can easily take decades, the vessels that house them can also become more covetable over the years. In an age of disposable materials and dire news of plastics polluting our environment, reused wooden barrels exist in stark contrast. The lives of barrels are long, shockingly sustainable and currently imperiled by trade war.

"Many circumnavigate the globe and end their days in distilleries in remote corners of the world, originating in the forests of Hungary and moving from mountain towns in Canada to distilleries in the Caribbean and Mexico. At Hamilton, new American oak barrels hold fresh distillate, alongside the dinosaurs: French cognac barrels that show their age

...

“We think of barrels as teabags. It gets used first for bourbon, like the first steep of a teabag. You get a lot of color and flavor from the barrel quickly. If you use the barrel again, it’ll take longer to impart, so maybe it’s used for scotch, which sits and ages longer. You mute the barrel’s flavors along the way.”

...

"The international use of barrels is part and parcel of the global liquor industry. Large conglomerates like LVMH, Brown-Forman and Suntory have multiple spirits brands in their portfolios, and barrels make their rounds internally. A Kentucky-made barrel might end up in Scotland to age scotch because Brown-Forman owns both the Jack Daniel’s and Glendronach brands.

...

"Distilleries that aren’t owned by large conglomerates enlist the help of a barrel broker who can source unique barrels. Mara Smith sources old pinot noir barrels from France through a broker, as they give her Inspiro tequila a rosy hue and flavors like “berries, some nuttiness, a floral [aroma] on the nose”.

...

"Rizzo outlines a Laws Whiskey barrel’s typical lifespan. “We age our Four Grain Bourbon and send those used bourbon barrels [after four to 10 years] to a local apiary, Bee Squared, in Berthoud, Colorado. They age their honey in those used barrels for 90 days to produce a glorious local barrel-aged honey. We then get those barrels back and put more bourbon into them to make a natural honey-aged bourbon [which takes a year and a half of ageing]. One went to our friends at Lady Justice Brewing, who aged a honey bock beer in the honey barrel. Once that was finished in six months to two years, they put malted barley grain inside the barrel for another six months to two years to flavor the grain to produce another beer. And then the barrel is made into furniture.” These barrels had seven lives.

"Recent tariffs are making the very aspect of manufacturing barrels, distilling alcohol and selling its finished product more expensive. In American winemaking, particularly in California, French oak barrels will be affected by the EU’s retaliatory tariffs. Since barrels are essentially an ingredient in any given type of alcohol’s recipe, a winemaker would not be able to easily switch out a type of wood they have used previously for something available domestically."

American guns fuel Haiti's gangs

The U.S. is an importer of illegal drugs, and an exporter of illegal firearms (i.e. firearms whose sale is legal, even protected in the U.S., but illegally smuggled into countries that would like to control firearms...)

The Guardian has the story:

Guns and weapons trafficked from US fueling Haiti gang violence. Experts say most guns smuggled from states with lax firearms laws such as Florida, Arizona and Georgia.  by Oliver Laughland

"As Haiti has again plunged into violent chaos, images of gang members bearing high-powered rifles, pump-action shotguns or automatic weapons in the streets of Port-au-Prince have become ubiquitous.

"But this weaponry is not made in Haiti, a country with no firearms or ammunition manufacturing capabilities.

"It is an arsenal that largely comes directly from the US, with most guns, experts say, likely to have originated from states with lax firearm laws, and many trafficked into Haiti from Florida.

"This clandestine trade has left Haiti’s gangs with a vast cache of illegal arms and much greater firepower than the country’s dispirited and underfunded police force.

...

"Joly Germine, a 31-year-old leader of 400 Mawozo, directed specific requests for high-powered weapons via WhatsApp messages sent from a Haitian prison. The requests were made to US citizens in Florida, including Germain’s romantic partner, and the weapons were then stuffed in garbage bags, loaded into large barrels and hidden under “clothes, shoes and Gatorade” ready for shipment.

The trade in guns and drugs on the Mexico-US border

 It's well known that a lot of illegal drugs enter the U.S. over the border with Mexico.  Less well known in the U.S. is that a lot of guns cross illegally into Mexico over that border, destined for Mexican drug cartels.  

Here's a story from the Guardian:
How Texas’s gun laws allow Mexican cartels to arm themselves to the teeth by Sam Garcia.

"Despite Mexico’s well-documented high levels of violence, legally purchasing guns there is actually quite difficult. The nation of nearly 130 million people has a single store that can legally sell guns.

...

"Mexican foreign affairs ministry legal adviser Alejandro Celorio Alcántara estimates that half a million guns annually are purchased legally in the US and then brought into Mexico illegally. About 70% of guns seized in Mexico from 2014 to 2018 and submitted for tracing had originally come from the US, according to officials with the American bureau of alcohol, tobacco, firearms and explosives (ATF).

*******

Here's another report:

Dribs and Drabs: The Mechanics of Small Arms Trafficking from the United States

"Robust arms export licensing regimes are necessary but not sufficient for stopping small arms trafficking. Many of the traffickers studied did not apply for arms export licences or attempt to exploit licensing exemptions; they simply bypassed the licensing system entirely. At the same time, recent examples of attempted and successful diversion of authorized small arms exports highlight the continued need for rigorous licensing and post-shipment end-use monitoring.

"Arms trafficking from the United States goes well beyond gun-running to Mexico. Traffickers in the 159 cases studied shipped weapons, parts, ammunition, and accessories to at least 46 countries and foreign territories on six continents. Intended recipients of these items range from Honduran farm workers to a Finnish motorcycle gang 

"The illicit trade in parts and accessories for small arms is more significant than commonly assumed. Networks that traffic in firearms parts are among the most prolific and geographically expansive of the smuggling operations studied"

HT: Sarah Hirsch

Global chocolate production and consumption

This map  of cocoa production and consumption from the Cocoa Barometer 2020 would make it easy to guess which way is North (were it not for Australia)...

 

Global markets in antiquity: olive oil and wine

Markets are ancient human artifacts, and a recent paper in the EJ suggests that markets of global scale, based on comparative advantage and international trade, are older than previously recognized.  Global (or at least international) agricultural markets are ancient, according to pollen data on crops and population in ancient Greece:

Landscape Change and Trade in Ancient Greece: Evidence from Pollen Data  by Adam Izdebski, Tymon Słoczyński, Anton Bonnier, Grzegorz Koloch, Katerina Kouli, The Economic Journal, Volume 130, Issue 632, November 2020, Pages 2596–2618, https://doi.org/10.1093/ej/ueaa026

"Abstract: In this article we use pollen data from six sites in southern Greece to study long-term vegetation change in this region from 1000 BCE to 600 CE. Based on insights from environmental history, we interpret our estimated trends in the regional presence of cereal, olive and vine pollen as proxies for structural changes in agricultural production. We present evidence that there was a market economy in ancient Greece and a major trade expansion several centuries before the Roman conquest. Our results are consistent with auxiliary data on settlement dynamics, shipwrecks and ancient oil and wine presses."

" We demonstrate that in a period of apparent population growth southern Greece decreased its relative production of cereals. We also observe a simultaneous increase in the relative importance of olives and vines. Since southern Greece had a comparative advantage in the production of olive oil and wine, we interpret this result as evidence of a trade expansion. The growing demand for wheat could only have been satisfied by massive grain imports, perhaps from the Black Sea region, which were offset by exports of olive oil and wine. These commodities were in high demand in Greek colonies and other neighbouring areas, which needed them for cultural reasons but were not always able to produce them locally."

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

These days I'm thinking about corona virus covid-19 convalescent blood plasma, which I blogged about yesterday, and about which I hope to say more soon. But that has gotten me to think again about blood plasma generally, which is a source of many therapies, including antibodies, immunoglobulins, that defend against a large variety of diseases.

The U.S. is the Saudi Arabia of blood plasma and plasma products, with both a large domestic commercial market and annual exports valued in the billions of dollars. The reason is largely that it is legal in the U.S. to pay plasma donors, so there's ample supply through a big network of hundreds of  for-profit and nonprofit blood and plasma centers (the nonprofits mostly don't pay donors, I think). In many countries, paying their residents for plasma is repugnant and illegal. Fortunately for their citizens, they mostly don't also suffer from severe shortages of life-saving plasma medicines, because it can be bought from the U.S. (See e.g. my posts on Canada's plasma policies.)

Here are some relevant export figures. They make clear that the U.S. exports billions of dollars of plasma, and tens of billions of dollars of plasma products.

For those who would like to study these data, let me explain where they come from.  (They  include some things that aren't plasma products, and may miss some that are...) It's not so easy to find the U.S exports of exactly blood plasma and plasma products (I needed some help).

In Chapter 30 of the U.S. International Trade Commission (USITC) Harmonized Tariff Schedule (HTS),is the code:
HTS 3002: "Human blood; animal blood prepared for therapeutic, prophylactic or diagnostic uses; antisera, other blood fractions and immunological products, whether or not modified or obtained by means of biotechnological processes; vaccines, toxins, cultures of micro-organisms (excluding yeasts) and similar products:
 Antisera, other blood fractions and immunological products, whether or not modified or obtained by means of biotechnological processes"

That sounds good, but it includes (aside from plasma products) things that I don't want to include e.g. Malaria diagnostic test kits, and Fetal Bovine Serum.

On the other hand the subcategory 3002.12.00  is for "Antisera and other blood fractions" which includes sub-subcategories for things I do want to include:
3002.12.10 Human blood plasma.
3002.12.20 Normal human blood sera, whether or not freeze-dried
3002.12.30 Human immune blood sera

And then there are are codes 3002.13.00, 14.00, and 15.00 which cover the promising (very similar) categories in which most of the immunoglobulins are probably found, but maybe some other things too:

Immunological products, unmixed, not put up in measured doses or in forms or packings for retail sale
Immunological products, mixed, not put up in measured doses or in forms or packings for retail sale
and
 Immunological products, put up in measured doses or in forms or packings for retail sale.

The place to go to turn these numbers into export figures is dataweb.usitc.gov  (But getting data there isn't completely straightforward, and I got help from Julia Fabens.)  The table above shows that whole plasma itself has over $2 billion of annual exports from the U.S., and together with plasma products, including those involving antibodies (immunological products) there are almost $20 billion of exports from the U.S.

So, I'm guessing that soon, if clinical trials show that antibodies against covid-19, are useful, they will become readily available, commercially, in plasma and in pharmaceuticals.  A year ago, those human antibodies didn't exist, and so there was no way to use it to help patient zero or the next many thousands.  But now there's a lot of it, more each day, in the blood of recovered patients.  And there's a whole industry devoted to collecting it and purifying the antibodies into "immunological products." 

I hope human antibodies against covid-19 are clinically useful, to help mitigate and cure the disease if not to prevent it, because my sense is that a vaccine is (at least) many months away.

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