Air cargo: fish and electronics (and flowers and armaments)

 Haaretz has the story:

120 Tons of Missiles and Salmon: A Rare Trip on Board an Israeli 747 Cargo Plane by Anshel Pfeffer and Avi Scharf

"Whenever you receive a package ordered online from abroad or eat semi-fresh imported food, there's a good chance it was transported by a 747. Over 300 of these aircraft are still flying cargo across the world despite the fact that most of them are over 20 years old. There's a good reason for this: There is no aircraft in production today that's capable of flying over 120 tons of cargo (jumbos can manage up to about 130 tons), and there's nothing even remotely similar on the drawing board. Thus, 56 years after it first entered commercial service, the 747 is still flying freight – with no retirement in sight.
...

“ In terms of volume and weight, about 99 percent of international cargo is transported by sea or overland, in trucks and trains. The lone percent of physical goods flown on cargo planes, however, is worth more than one-third of global trade, or around $6 trillion a year. That includes electronic goods, pharmaceuticals and blood plasma, perishables such as fresh seafood, and of course any shipment that needs speedy delivery, like your latest order from Amazon or AliExpress, for which you've agreed to pay an added premium.

"In 2023 the global expenditure involved in shipping all airfreight crossed the $300-billion mark for the first time. It will hit $400 billion before the end of the decade. And that's why the old 747 will still be flying for years to come.

...
“ Pandemics and wars are the best of times for cargo airlines. Normally over half of the volume of airfreight is carried on passenger flights, in the hold next to passengers' luggage. There isn't much room there, for just a few tons at most for the extra cargo, but there are many more passenger flights than cargo flights. When passenger service is canceled as it was around the world during the COVID pandemic, or to and from Israel after October 7 – while at the same time people cooped up at home order a lot more online – the cargo fleets have to supply the missing haulage capacity. In 2023, nearly half the cargo into and out of Israel (151,000 tons out of 334,000) was transported on passenger flights. In 2024, after a full year of war during which non-Israeli airlines barely flew here, that proportion dropped to a little over one-quarter (95,000 tons out of 348,000). That's when the 747, which back in the early 1960s was first envisaged as a freighter, really came into its own.

...
"The 747 freighters that still fly around the world comprise around a quarter of all global cargo fleets. But thanks to their size, they carry half the volume of all goods shipped by air. Which comes in handy especially at time of war when Israel cannot wait for large quantities of munitions and other military equipment to be transported by sea."

JAMA declined to publish this letter on kidney donation

 JAMA recently published the following Viewpoint, whose title adequately summarizes its main point:

The End Kidney Deaths Act Risks Irreversible Harm to Organ Donation
by Thomas F. Mueller, MD, PD1; Maria A. Matamoros, MD2; Gabriel M. Danovitch, MD3; Sanjay Nagral, MD, JAMA. March 26, 2025. doi:10.1001/jama.2025.2409

I promptly submitted the letter below, in reply, and received a rejection from the journal yesterday. 

“Irreversible Harm to Organ Donation”? Strong opinions based on weak evidence 

Alvin E. Roth,  Ph.D., Word count: 391
 
 From 2002- 2022, the number of Americans newly diagnosed with kidney failure increased from 99,956 to 131,194 per year (1).  The total number of Americans suffering from kidney failure nearly doubled to over  800,000, with over 500,000 on dialysis (2).   In 2024 there were only 27,759 kidney transplants in the U.S. from both deceased and living donors, so most patients with kidney failure will die without  receiving  a transplant.

Mueller et al.(3)   claim that a proposed experiment involving modest compensation of a limited group of living kidney donors “risks irreversible harm to organ donation.” Their arguments are those also used to argue against compensation of donors of Substances of Human Origin generally (4).   But the case of blood plasma suggests these strong opinions are based on very weak evidence.

Five of the twenty-seven EU nations allow plasma donors to be compensated. Those five are the only EU nations self-sufficient in plasma. The twenty-two nations in which payment of donors is banned must import a significant portion of the plasma and plasma derivatives they need. Much of those imports comes from the U.S, which also has legal, regulated markets in which plasma donors may be paid for donation (5).   Consequently, many lives are saved by American plasma, in the U.S. and around the world.  Paying plasma donors  hasn’t reduced  plasma donation: any reduction in unpaid donation has been more than replaced by paid donors.

The regulation of markets in the U.S. has been strong enough that the catastrophic predictions of black markets, exploitation, and devastation of donors that support the establishment of bans on compensation in many other countries have not come to pass in the U.S.  This provides reasons to doubt the dire forecasts also made about the consequences of a U.S. experiment involving modest payments to kidney donors.
 

Kidney donation is not the same as plasma donation, so effective regulation of compensation for kidney donors would be different. We need to experiment to gather evidence of whether and how to proceed.  Pilot programs such as the tax credits proposed by the End Kidney Deaths Act would provide evidence.  
 

New markets and regulations may need modification as experience accumulates.  If the experiment increases non-directed donations, it could be expanded to include more kinds of kidney donation. And the experiment could be abandoned if generosity to donors turned out to be uncontrollably negative, as opponents predict.

References:

1  Annual Data Report | USRDS, https://usrds-adr.niddk.nih.gov/2024/end-stage-renal-disease/1-incidence-prevalence-patient-characteristics-and-treatment-modalities.

2  The National Forum of ESRD Networks. Quarterly National ESRD Census www.esrdnetworks.org.

3. Mueller TF, Matamoros MA, Danovitch GM, Nagral S. The End Kidney Deaths Act Risks Irreversible Harm to Organ Donation. JAMA. Published online March 26, 2025. doi:10.1001/jama.2025.2409

4  Cuende, Natividad, et al. "Promoting equitable and affordable patient access to safe and effective innovations in donation and transplantation of substances of human origin and derived therapies." Transplantation 109.1 (2025): 36-47. January  https://journals.lww.com/transplantjournal/fulltext/2025/01000/promoting_equitable_and_affordable_patient_access.6.aspx

5  Elias, Julio, Nicola Lacetera, Mario Macis, Axel Ockenfels, and Alvin E. Roth, “Quality and safety for substances of human origins: scientific evidence and the new EU regulations, BMJ Global Health, Volume 9, Issue 4 April, 2024,  https://doi.org/10.1136/bmjgh-2024-015122

The debate over compensating organ donors is heating up

  It's a new year, and maybe there will be progress in increasing organ donation.  Here's a video in which Elaine Perlman explains the End Kidney Deaths Act, which might be debated by Congress this year, and would be an attempt to increase living donation by allowing some compensation (in the form of tax credits) for kidney donation.  And there are  a slew of articles in medical journals (of which I sample two) saying that the first and most important rule of organ transplantation is that donors should not be compensated (and that the same goes for other SoHOs (Substances of Human Origin) such as blood plasma. 

 

"Passing the End Kidney Deaths Act isn’t just an ethical decision—it’s a practical solution to one of the most pressing public health challenges in America.
100,000 Americans are counting on us to get the End Kidney Deaths Act to the finish line. The choice is clear and 2025 is our year. Let’s contact Congress now to pass the End Kidney Deaths Act and ensure a future where no one dies while waiting for a kidney. Because saving lives is not only ethical—it’s our responsibility."

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And here are two articles reaffirming their opposition:

Promoting Equitable and Affordable Patient Access to Safe and Effective Innovations in Donation and Transplantation of Substances of Human Origin and Derived Therapies
Cuende, Natividad MD, MPH, PhD1; Tullius, Stefan G. MD, PhD2; Izeta, Ander PhD3; Plattner, Verena PhD4; Börgel, MSc, Martin5; Ciccocioppo, Rachele MD6; Correa-Rocha, Rafael PhD7; Koh, Mickey B. C. MD, PhD8,9; De Angelis, Vincenzo MD10; Gondolesi, Gabriel E. MD, MAAC11; ten Ham, Renske PhD, PharmD12; Porte, Robert J. MD, PhD13; Hernández-Maraver, Dolores MD, PhD14; Hawthorne, Wayne J. MD, PhD15; Sureda, Anna MD, PhD16; Orlando, Giuseppe MD, PhD17; Haraldsson, Börje MD, PhD18; Ascher, Nancy L. MD, PhD19; Dominguez-Gil, Beatriz MD, PhD14; Oniscu, Gabriel C. MBChB, MD20
Author Information
Transplantation 109(1):p 36-47, January 2025. | DOI: 10.1097/TP.0000000000005169

 Note which ethical principle is at the top of the list.

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And this report speaks of global kidney exchange, but not for the poor...

 Expanding Opportunities for Living Donation: Recommendations From the 2023 Santander Summit to Ensure Donor Protections, Informed Decision Making, and Equitable Access, by
Lentine, Krista L. MD, PhD1; Waterman, Amy D. PhD2; Cooper, Matthew MD3; Nagral, Sanjay MS, FACS4; Gardiner, Dale MD5; Spiro, Michael MBBS6; Rela, Mohamed MS, FRCS, DSc7; Danovitch, Gabriel MD8; Watson, Christopher J. E. MD9; Thomson, David MD10; Van Assche, Kristof PhD11; Torres, Martín MD, MS12; Domínguez-Gil, Beatriz MD, PhD13; Delmonico, Francis L. MD14;  On behalf of the Donation Workgroup Collaborators*
Transplantation 109(1):p 22-35, January 2025. | DOI: 10.1097/TP.0000000000005124

 

"International KPE is acceptable if the donor-recipient pairs belong to a similar sociodemographic reality and are properly covered and protected by healthcare systems. GKE that exploits financial inequalities between pairs (or countries) must be prohibited."