Global kidney exchange: continued controversies, perhaps moving towards resolution

As 2019 came to a close, several articles reminded us that global kidney exchange (GKE), while gaining increasing acceptance, still is regarded as repugnant in some quarters.

Here's an article in Forbes:
Why The Global Kidney Exchange Remains Controversial by Christine Ro, Dec. 15

"The GKE has been philanthropically funded so far, but it’s possible that US health insurance companies might assume the expenses in the future. The exchanges are cost-effective on the rich-country side because the costs of medical care are smaller in lower-income countries. As well, dialysis is an unusual medical procedure in that every US citizen is entitled to it. Kidney transplants work out to be much cheaper than years of dialysis.

"This lopsided cost-effectiveness is one of the main sources of controversy around the GKE. One argument is that, to use the example of the first GKE match, the US ultimately benefits much more than the Philippines. If the Filipino pair is already a match, but the first US pair isn’t, the Americans are receiving a kidney matching service (kickstarting a daisy chain) that the Filipinos didn’t need. What the Filipinos did require was payment of their expenses. If they had the financial resources, they wouldn’t need an exchange program at all. They, or their medical system, could have covered the costs of the transplant.
...
"The medical team involved in the first Filipino match are adamant that it was positive. In an impassioned letter to the editor of the American Journal of Transplantation, they write:

“Let us be clear: without GKE, the Filipino husband was never going to receive his spouse’s kidney. Without GKE, the husband was going to die, the wife was going to lose her spouse, and their son was going to be fatherless.”

“No alternative existed for this Filipino pair and millions more like them. GKE did not exploit this Filipino couple—it provided the mechanism for the wife to literally save her husband’s life. They could not afford dialysis.”

“For 3 years on Father’s Day, the couple’s child has written our team to thank us for saving his daddy’s life.”

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The Forbes article also links (without pointing it out) to the recent robust defense of GKE in the Lancet (see Global Kidney Exchange in the Lancet, by Minerva, Savulescu and Singer ).

And I've written earlier about other, welcome support.

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But in Spain, the National Transplant Organization has organized opposition against allowing patients and donors from poor countries to participate in kidney exchange.  So I was glad  to see a Spanish healthcare blog questioning their reasoning:

From the Spanish blog Avances en gestión clínica (Advances in Clinical Management):

¿Nobel de Economía o traficante de órganos? ["Nobel economist, or organ trafficker?"]
by Pedro Rey, Dec. 30

It turns out that isn't meant to be an inflammatory headline, rather it is a reaction to the inflammatory announcements that issued from the Spanish ONT (National Transplant Organization) in connection with global kidney exchange.  Below, for example, is one of many such stories, using just such words:

La ONT frena la entrada en Europa de «una nueva forma de tráfico de órganos» propuesta por un nobel de Economía  ["The ONT slows the entry into Europe of "a new form of organ trafficking" proposed by a nobel economist"

Beatriz Domínguz Gil, directora de la ONT, denuncia que la iniciativa de Alvin Roth es «una nueva forma de tráfico de órganos, pero presentada como una iniciativa buena y ética» 

[  "Beatriz Domínguz Gil, director of the ONT, denounces that Alvin Roth's initiative is "a new form of organ trafficking, but presented as a good and ethical initiative"]
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Coming back to Professor Rey and his question ¿Nobel de Economía o traficante de órganos?. He points out that while the Spanish ONT is a world leader in recovering deceased donor organs, it doesn't have the same kind of leadership in living organ donation or in kidney exchange.  He says, in part (via Google translate):

"we may find it worrying that Spanish morals have slowed, before 28 countries, the development of an idea that could benefit many patients and reduce the economic burden to keep them on dialysis for a long time.To solve this problem, a public and serious debate that clarifies the specific interests of an ONT that has based its prestige on the proven effectiveness in transplants from deceased donors and not so much in cross-transplants and, even less, living transplants, would be desirable."
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Professor Rey goes on to note that we shouldn't naively assume that problems in dealing with cross border issues, especially between rich and not so rich countries, can be easily navigated.  I agree, and I'm confident that the GKE chains that have been conducted so far will pass close scrutiny, and point the way towards finding global solutions to the global problem of kidney failure.

I hope this is an indication that in the coming year, some of the early, hysterical reactions to GKE in Spain may continue to give way to more reasoned discussion, that will let legitimate concerns be expressed and addressed, and separated from other personal and professional motivations that may have obscured the initial reception of GKE in Europe.

Kidney exchange explained in 1 minute (video), and a BBC story

Here's a link to a 1 minute BBC video that was recorded when I was in Berlin recently, discussing how changes in the German transplant law (which presently allows only immediate family members to donate a kidney to someone) could be minimally modified to allow kidney exchange also.

 (a short ad comes on first--my part is only 48 seconds:-)


Here's an accompanying story that somewhat confusingly (it seems to me)  mashes together discussions of kidney exchange, global kidney exchange, and compensation for donors.

How an economist helped thousands get a new kidney By Ian Rose, BBC News
Berlin
...
"Roth, working with Tayfun Sönmez and Utku Unver, has revolutionised kidney donation around the world by using an economic theory to make kidneys more available.
...

"German exchange change?
"We meet in Berlin as Nobel laureates and other luminaries gather to discuss the future of healthcare. Alvin Roth is there in part because Germany is one of the only major industrialised countries where kidney exchange is not lawful.

"I think that the bureaucratic rules and regulations for kidneys as for every market have to be revisited from time to time in the in the light of new developments, and should be modernized and adapted to current capabilities," he says.

"When contacted about the issue the German Health Ministry tells me that they are planning to organise a public debate on the issue but have no schedule for that yet.

"Prof Roth says he understands the concerns behind the German ban. "They're worried about organ trafficking.

"They're worried that if I showed up and wanted to give you a kidney, it would mean that you had paid me and it may be I was a poor and desperate person. But on the other hand, if your brother shows up and wants to give you a kidney, they're not worried about that."
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update:
The BBC publishes in many languages, and so you can read the story in Chinese, Indonesian, Turkish, Spanish, Portuguese, and here's a site that has translated it to Hungarian.

The year in passings

I noted a number of deaths this year (and memorials for earlier passings):

•  Michel Balinski (1933-2019)
•  Alan Krueger (1960-2019)
•  Dr. Oscar Salvatierra, Jr. (1935 - 2019)
•  Special issue of NRL in honor of Uri Rothblum, February 2019
•  Memorial service for Martin Shubik today at Yale
• In Memoriam: Martin Shubik
•  Xenotransplants, Baby Fae, and the complex pioneering efforts of Dr. Leonard Bailey, RIP
• Mark Kleiman (1951-2019)
• Marty Weitzman, 1942-2019
• Ed Green, 1948-2019
• Egon Balas, 1922-2019
•  Who is a refugee? Remembering U.N. High Commissioner for Refugees Sadako Ogata

Some kinds of privacy may be gone forever

Lots of family secrets are revealed by DNA analysis, and it may no longer be possible to keep those secrets.  That is part of the argument made by Dr. Julia Creet, in an interview published at Bill of Health under the title "The End of Privacy?"


Dr. Julia Creet: I made the statement that any idea we had about privacy is over in response to a number of troubling trends in genetic genealogy. DTC genetic tests have revealed long-held family secrets, biological parents and siblings of adoptees, and the identities of sperm and egg donors. In each case, the question of the right of the searcher trumped the rights of those who wanted their privacy protected. In a few cases, sperm donors have sued for invasion of privacy. What these cases show is that even if we think we are protected by the privacy provisions of donor agreements or closed adoptions, genetic tests can leap over those privacy barriers. Many genealogists have declared that there will be no more family secrets in the future. So, family privacy is a thing of the past, which may or may not be a good thing. On a larger scale, law enforcement use of DTC genetic testing databases has demonstrated that data uploaded for one purpose can be used in the future for a completely unanticipated purpose. Without the ability to predict future uses of this information, we cannot put a privacy policy in place that will anticipate all the unforeseen future uses. I think the most telling cases in the last few weeks are the recent warrant that allowed law enforcement access to the GEDmatch database even though most users had opted out of having their results included in searches, and the rather frightening report for Peter Ney about the ease of malware intrusions on genetic genealogy databases.

U.S medical school enrollments by sex: women outnumber men for the first time

There are now more women than men applying to U.S. medical schools, being accepted (to the first year class) and enrolled (in all four years). See the 2019 Fall Applicant, Matriculant, and Enrollment Data Tables from the American Association of Medical Colleges (AAMC)

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Here's the recent history leading up to this:

In the 1950's, almost all medical school grads were men. As the number of women grew, the medical labor market had to start accomodating married couples both looking for residencies.  This is the first year in which the total enrollment of women exceeds that of men, but of course the last few years have seen that coming in the number of women matriculating: women first-year medical students outnumbered men already in 2017..

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Here's a news story from the Washington Post about these statistics:
The Big Number: Women now outnumber men in medical schools
By Linda Searing Dec. 23, 2019

"In the medical profession overall, male doctors still outnumber female doctors, 64 percent to 36 percent, according to 2019 data from the Kaiser Family Foundation. But that may be changing, according to a report from the health-care company AthenaHealth. Its survey of 18,000 physicians at 3,500 practices on its network found that, in 2017, 80 percent of doctors 65 and older were men, but 60 percent of doctors younger than 35 were women. The disparity between male and female doctors appears to extend to their chosen field of specialization. A joint report this fall from the American Medical Association and AAMC finds that male doctors dominate orthopedic surgery (85 percent), neurological surgery (82 percent) and interventional radiology (81 percent), and female doctors dominate obstetrics and gynecology (83 percent), allergy and immunology (74 percent) and pediatrics (72 percent). Specialties with a nearly equal balance of male and female doctors are sleep medicine, preventive medicine, pathology and psychiatry. Overall, medical schools this year experienced about a 1 percent increase in applicants and in new enrollees, which the AAMC says contributes to an enrollment growth of 33 percent since 2002. Still, it notes, the country faces a projected shortage of 122,000 doctors by 2032."

A liver exchange in San Antonio, Texas

Here's a story of a liver exchange in Texas, between an incompatible pair and a compatible pair.

Living organ donors reunite with recipients at University Hospital

"The hospital transplant teams paired the two living donors with two patients who needed transplants in April.
...
"Although D'Angelo and Sanchez were a match, Sanchez was approached about possibly being a living donor for someone else.

"The other recipient was Mark Blair.
Blair's daughter, Anna Moreno, wanted to be a donor for her father, but she was not a match.
...
"The transplant teams paired Moreno with D'Angelo and Sanchez with Blair.

"We can now have incompatible donors successfully donate to recipients that are not originally intended recipients but somebody else," said Dr. Tarunjeet Klair, surgical director of the Living Liver Donor Program for University Health System. "The eventual outcome is a successful transplant of multiple parties, and that's saving lives."

KIDNEY EXCHANGE AND THE ETHICS OF GIVING by Philippe van Basshuysen

 Philippe van Basshuysen considers various forms of kidney exchange, including non-directed (altruistic) donor chains, but not global kidney exchange (GKE), which he defers for future consideration. His work is motivated by the effective ban on kidney exchange in Germany, and, he writes, in " Bulgaria, Estonia, Finland and Hungary, among others." He also notes that non-directed donors are excluded in " Belgium, France, Greece, Poland and Switzerland..."

KIDNEY EXCHANGE AND THE ETHICS OF GIVING
Philippe van Basshuysen,  December 2019
Forthcoming in Journal of Ethics and Social Philosophy

"The arguments given here are not wedded to a specific moral theory. They will appeal to effective altruists, but because of their weak, conditional premises, many people who are not committed effective altruists will welcome them as well. They are also consistent with conservative views on donor protection and allocative justice concerning patients on waiting lists. I hope that these arguments will lead to a clarification of the debates about the ethics underlying KE programmes, particularly in countries that have hitherto banned these programmes."

Effective altruism and (non-directed) kidney donation

In their Christmas day discussion, the podcast Here Be Monsters considers the Quality Adjusted Life Years (QALYS) that can result from non-directed kidney donation, and how that qualifies it as a form of effective altruism.

December 25, 2019 Here Be Monsters HBM127: QALYs

"In 2014, a post showed up on effectivealtruism.org’s forum, written by Thomas Kelly and Josh Morrison.  The title sums up their argument well: Kidney donation is a reasonable choice for effective altruists and more should consider it. 

They lay out the case for helping others through kidney donation.  Kidney disease is a huge killer in the United States, with an estimated one in seven adults having the disease (though many are undiagnosed).  And those with failing kidneys have generally bad health outcomes, with many dying on the waitlist for an organ they never receive.  There’s currently about 100,000 people in the country on the kidney donation waitlist.  An editorial recently published in the Journal of the American Society of Nephrology estimated that 40,000 Americans die annually waiting for a kidney. 

The previously mentioned post on the EA forums attempts to calculate all the goods that kidney donation can do, namely adding between six and twenty good years to someone’s life.  Quantifying the “goodness” of a year is tricky, so EAs (and others) use a metric called “Quality Adjusted Life Years” or QALYs. 

The post also attempts to calculate the downsides to the donor, namely potential lost wages, potential surgery complications, and a bit of a decrease in total kidney function.  

The post concludes that kidney donation is a “reasonable” choice.  By the EA standards, “reasonable” is pretty high praise; a month or so of suffering to give about a decade of good life to someone else, all with little long term risk to the donor.  

On this episode, Jeff interviews Dylan Matthews, who donated his kidney back in 2016.  His donation was non-directed, meaning he didn’t specify a desired recipient.  This kind of donation is somewhat rare, comprising only about 3% of all kidney donations.  However, non-directed donations are incredibly useful due to the difficulty of matching donors to recipients..."
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The discussion of kidneys and effective altruism starts about minute 7 in the podcast:

Scandia Transplant Kidney Exchange Program (STEP) takes its first steps

Here's a timely story of gift giving from the Karolinska University Hospital in Sweden:

Karolinska University Hospital part of the first kidney transplant program across Scandinavia – Scandia Transplant Kidney Exchange Program (STEP)
MON, DEC 23, 2019

"For the first time two kidney replacements have been performed involving donors and transplant patients who are part of the Scandinavian kidney exchange program STEP organized by Scandiatransplant.  The organization coordinates organ donations and transplants in Denmark, Estonia, Finland, Iceland, Norway and Sweden. During 2018 and 2019 Karolinska University Hospital performed and coordinated three STEP exchange programs with a total of six couples in cooperation with other hospitals in Sweden.
...
"Both kidney replacements performed during the autumn  involved two couples and  two other university hospitals in Scandinavia, says Lars Wennberg, Chief Physician and Patient Flow Manager Kidney Transplant at Theme Trauma and Reparative Medicine Karolinska University Hospital"

"STEP enables exchange of kidneys between medically accepted but immunologically incompatible donor-recipient pairs. A donor who wants to help a relative that needs a kidney donates anonymously to another unknown person in need of a kidney. In exchange, the next of kin receives a kidney from another recipient's kidney donor. Kidney changes can take place between two or more participating couples.

"Today, a total of 2261 people in the six countries that are included in STEP are waiting for a new kidney compared with 2208 in 2018. The ability to carry out kidney changes between the different countries means that we can shorten waiting times says Bo-Göran Ericzon, Chairman of Scandiatransplant and Professor of Transplantation Surgery Theme Trauma and Reparative Medicine Karolinska University Hospital.

"The necessary database to investigate immunological compatibility has been developed by Scandiatransplant, while the matching algorithm has been developed by Professor Tommy Andersson at the Department of Economics, Lund University in collaboration with Karolinska University Hospital."

Handbook of the Shapley Value

Google books makes available excerpts from the new
Handbook of the Shapley Value
edited by Encarnación Algaba, Vito Fragnelli, Joaquín Sánchez-Soriano
CRC Press, Dec 6, 2019

I wrote a Foreword:
The Shapley Value: a giant legacy, and ongoing research agenda,
the final paragraph (p6) of which is

"Lloyd Stowell Shapley was one of the founding giants of game theory, who helped lay the foundations of both cooperative and non-cooperative game theory, and who influenced everything and everyone in the field. He was born in 1923. His paper defining the Shapley value was published in 1953, when he was 30 years old.  A previous volume on the Shapley value, Roth (1988), was published in honor of his 65th birthday. The present volume brings up to date the important stream of research on the Shapley value that has continued, unabated, ever since Shapley first proposed it, and that I expect will continue for the foreseeable future."

In this connection, see my recent post about the use of the Shapley value for explaining particular predictions made by machine learning algorithms:

Sunday, December 22, 2019  The Shapley value and explainable machine learning

Paul Milgrom's Marshall Lectures are now available on video

Auctions are ancient, but the linked auctions Paul talks about in his lectures are stunningly modern, and depend on high powered, thoughtfully deployed, state of the art computation.

"Market Design When Resource Allocation is NP-Hard," in two lectures.
Here they are:

Lecture 1

and Lecture 2:

"The Ethical Algorithm" by Michael Kearns and Aaron Roth (book talk at Google)

Here's a talk about "The Ethical Algorithm--The Science of Socially Aware Algorithm Design"
by Michael Kearns and Aaron Roth.


IMHO it would make a fine last minute holiday gift for those interested in econ and market design as well as for fans of computer science and algorithms:) 

The Shapley value and explainable machine learning

Machine learning via deep neural nets is famously a black box approach to prediction, but efforts are being made to open the black box and explain why a given prediction was made, using the Shapley value.

Here's a story from Datanami:

December 9, 2019
Real Progress Being Made in Explaining AI, by Alex Woodie

"Google made headlines several weeks ago with the launch of Google Cloud Explainable AI.  Explainable AI is a collection of frameworks and tools that explain to the user how each data factor contributed to the output of a machine learning model.

“These summaries help enterprises understand why the model made the decisions it did,” wrote Tracy Frey, Google’s director of strategy for Cloud AI, in a November 21 blog post. “You can use this information to further improve your models or share useful insights with the model’s consumers.”

"Google’s Explainable AI exposes some of the internal technology that Google created to give its developers more insight into how its large scale search engine and question-answering systems provide the answers they do. These frameworks and tools leverage complicated mathematical equations, according to a Google white paper on its Explainable AI.

"One of the key mathematical elements used is Shapley Values, which is a concept created by Nobel Prize-winning mathematician Lloyd Shapley in the field of cooperative game theory in 1953. Shapley Values are helpful in creating “counterfactuals,” or foils, where the algorithm continually assesses what result it would have given if a value for a certain data point was different.

...

“The main question is to do these things called counterfactuals, where the neural network asks itself, for example, ‘Suppose I hadn’t been able to look at the shirt colour of the person walking into the store, would that have changed my estimate of how quickly they were walking?'” Moore told the BBC last month following the launch of Explainable AI at an event in London. “By doing many counterfactuals, it gradually builds up a picture of what it is and isn’t paying attention to when it’s making a prediction.”

Further scrutiny of Organ Procurement Organizations (OPOs), now by the Senate Finance Committee

The Senate is piling on to the the recent regulatory changes that have been announced for OPOs.

Here's a letter from the Senate Finance Committee, asking for financial investigations.  The letter begins this way:

December 18, 2019
Ms. Joanne M. Chiedi
Acting Inspector GeneralOffice of Inspector General
U.S. Department of Health & Human Services3

"Dear Acting Inspector General Chiedi: We write  today  to  request  that  your  office  conduct  a  comprehensive  examination  of  the adequacy of the organ procurement and transplantation system in the United States."
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Here's the story from the WaPo:

Senate Republicans seek probe of organ transplant system  By
Kimberly Kindy and Lenny Bernstein Dec. 19, 2019

"Members of the Senate Finance Committee Thursday requested an in-depth examination of the nation’s organ recovery and transplant system, raising questions about suspected financial fraud and criticizing the system for its “poor performance.”

"The request to the Office of the Inspector General comes one day after the Trump administration announced a sweeping proposal to boost the number of organs collected for transplant by dozens of underperforming organ collection agencies and increasing federal payments to living kidney donors.

"In their letter to the Inspector General, Sens. Charles E. Grassley (R-Iowa) and Todd C. Young (R-Ind.) praised the proposed regulations but pointed out it will be years before they take effect. In the meantime, they said, Americans are dying each day as they wait for organ transplants and more action should be taken now.
...
"Grassley, finance committee chairman, said in a statement that “more can be done right now to improve a system that is mired by inefficiency, waste and a serious lack of accountability.”

Like a virgin? Controversy surrounding "virginity tests."

Virginity testing has been in the news.

In the NY Times:
After the Rapper T.I.’s Remarks, N.Y. May Ban ‘Virginity Tests’
Legislation was introduced after the rapper said he subjects his daughter to a yearly hymen exam, sparking outrage on social media.
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In the Guardian:
'Now I have to check your hymen': the shocking persistence of virginity tests
In the US, it is still perfectly legal to doctors to perform ‘hymen checks’ as proof of virginity

"a small 2017 study found that of 288 US obstetrician and gynaecologists who were asked, 45 (16%) had been asked at least once to perform virginity testing or virginity “restoration”. Thirteen of those doctors complied.
...
"At present, it is not considered medical malpractice to perform a hymen examination – in fact, it’s completely legal. But one New York assemblywoman is hoping to make a tangible difference by changing the law.

"Michaelle Solages’s bill hopes to take the question completely out of a doctor’s hands. If passed, it will ensure that virginity testing is banned; that any medical professional undertaking such a practice will face losing their license; and that if the examination is performed in the US, whether inside or outside the medical office, it should be constituted as sexual assault.
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Here's an old blog post that claims that many young Zulu women in S. Africa are glad to be able to send a signal about their virginity, in defiance of a ban on virginity testing there.

Friday, September 26, 2008

Virginity testing: Repugnant under S. African law...

Zulus Eagerly Defy Ban on Virginity Test
S. Africa's Progressive Constitution Collides With Tribal Customs
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Here's a review of the scientific literature:

Reprod Health. 2017; 14: 61.
 doi: 10.1186/s12978-017-0319-0
Virginity testing: a systematic review
Rose McKeon Olson and Claudia García-Moreno

"Main Results: Seventeen of 1269 identified studies were included. Summary measures could not be computed due to study heterogeneity. Included studies found that hymen examination does not accurately or reliably predict virginity status. In addition, included studies reported that virginity testing could cause physical, psychological, and social harms to the examinee.

"Conclusions: Despite the lack of evidence of medical utility and the potential harms, health professionals in multiple settings continue to practice virginity testing, including when assessing for sexual assault. health professionals must be better informed and medical and other textbooks updated to reflect current medical knowledge. Countries should review their policies and move towards a banning of virginity testing."
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And here's an update featuring a story published this morning in the Washington Post--apparently the recently defeated Republican governor of Kentucky hadn't been an avid reader of the scientific literature...

Kentucky’s ex-governor pardoned a child rapist because the 9-year-old victim’s hymen was intact By Antonia Noori Farzan  Dec. 20, 2019

"Already under fire for handing out pardons to relatives of his supporters, Bevin is now facing an onslaught of criticism from medical and forensic experts. Scientists have debunked the notion that inspecting an alleged victim’s hymen can prove whether they were sexually assaulted, and found that most survivors of child sexual abuse do not have any physical damage. George Nichols, an expert in evaluating child abuse who also served as Kentucky’s chief medical examiner for 20 years, told the Courier-Journal on Thursday that Bevin “clearly doesn’t know medicine and anatomy.”

"Bevin, who had a reputation for making controversial and unproven claims during his single term as Kentucky’s governor, was narrowly defeated by Democrat Andy Beshear in November. Before leaving office, he issued 428 pardons, a group that includes multiple convicted murderers and sex offenders, the Courier-Journal reported."

International kidney exchange between Israel and Czech Republic

The news embargo is over for last week's kidney exchange chain between Israel and the Czech Republic. (On the Israeli side, the necessary software was supplied by Itai Ashlagi, here at Stanford.)

Itai writes:
"Some background: in August 2019 there was an agreement between Israel and Czech republic to check the possibility of kidney exchanges. This was initiated by Prof. Eitan Mor from Israel  and Dr. Proniak from the Czech Republic and the whole operation was conducted by the national Israeli center for transplantation led by Dr. Tamar Askenazi and their counterpart in Czech republic."

The Israeli database contains a list of all pairs, and uses kidney exchange software donated to Israel by Itai Ashlagi and Sukolsak Sakshuwong.   Czech software was used in Prague to identify the chain.

Here's the story from News1 in Israel:

6 transplants thanks to the exchange of kidney donations between Israel and the Czech Republic

"At 5 a.m., two kidneys from two donors were removed from Beilinson Hospital. One kidney was packed in ice cooler and transported by ambulance to Ben Gurion Airport.

"About an hour after taking off from Israel, an operation to remove a Czech donor kidney was started at the Prague Hospital. At the same time, Bilinson's second kidney was transplanted, and surgery was performed to remove a kidney at Hadassah Hospital – which was transported by ambulance to Bilinson's transplant.

"At 12:30 the kidney cooler from Israel landed at the Prague airport. A vehicle was waiting by the plane and moved to the mirroring spot. At this point, Dr. Jiri Froniac, director of the Prague Transplant Program and Dr. Ashkenazi from Israel, met and exchanged documents while the coolers were [scanned].

"At the same time, the kidney from Hadassah Hospital was transferred to Beilinson for a transplant. An hour later, the Israeli plane took off from Prague back to Israel with a cooler containing the kidney from the Czech donor. The kidney came to the operating room in Hadassah and before the evening was transplanted in a patient.
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Diagram of the exchange between IKEM in the Czech Republic and Hadassah and Beilinson Hospitals in Israel

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Here's the story in the Jerusalem Post (I don't have a link yet, this is a picture):

And see this related older story about Itai Ashlagi's software:

New software to help increase kidney matches for transplants

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And here is the story in the Czech news, forwarded by Pavel Chromy.

Čeští lékaři poprvé provedli párovou výměnu ledvin s Izraelem
[Google translate: Czech doctors first performed paired kidney replacement with Israel]
"In the first half of December, doctors from the Prague Institute of Clinical and Experimental Medicine (IKEM) and two Israeli hospitals performed their first paired kidney exchange between the two countries. Three beneficiaries from the Czech Republic and three from Israel received the new authority. This is the first time a pair exchange has taken place with a non-European country, said IKEM director Michal Stiborek at a press conference."

New U.S. rules proposed for organ donor reimbursements and Organ Procurement Organizations

Here's the press release from HHS.gov:
Trump Administration Proposes New Rules to Increase Accountability and Availability of the Organ Supply  December 17, 2019

"The U.S. Department of Health and Human Services (HHS) today took major steps to increase the availability of organs for the 113,000 Americans on waitlists for lifesaving organ transplants – 20 of whom die each day. As directed by President Trump in his July 10 Executive Order on Advancing American Kidney Health, the Centers for Medicare & Medicaid Services (CMS) is issuing a proposed rule to change the way organ procurement organizations (OPOs) are held accountable for their performance, and the Health Resources and Services Administration (HRSA) is issuing a proposed rule to remove financial barriers to living organ donation.
...
"Removing Financial Disincentives to Living Organ Donation

The President’s Executive Order on Advancing American Kidney Health emphasized that supporting living organ donors can help address the current demand for kidney transplants. HRSA’s proposed rule would expand the scope of reimbursable expenses for living donors to include lost wages, and childcare and eldercare expenses for those donors who lack other forms of financial support. This proposal could increase the number of transplant recipients receiving a better quality organ in a shorter time period from living donors. In general, recipients of kidney transplants from living organ donors have better clinical outcomes than those who continue on dialysis or those who receive a deceased donor kidney transplant. HRSA also is reviewing a notice that would increase the income threshold for living donors eligible for reimbursements.

"Organ Procurement Organization (OPO) Conditions for Coverage Proposed Rule

OPO act as a link between organ donors and organ recipients, procuring organs from hospitals and delivering them to transplant centers. Federal law tasks CMS with conducting inspections (“surveys”) of OPOs and certifying them for participation in Medicare based on whether they meet Medicare’s Conditions for Coverage – which are basic quality and safety regulations – including outcomes and process requirements.

OPOs’ performance is currently assessed through self-reported data based on measures that were last overhauled in 2006. Today, CMS is proposing much needed changes to hold OPOs accountable and incentivize them to actively collect donated organs and improve transplantation rates in their donation service area (DSA).

CMS estimates that if all OPOs were to meet both the donation and transplantation rate measures, the number of annual transplants would increase from about 32,000 to 37,000 by 2026, for a total of almost 15,000 additional transplants in that time.

The proposed rule would improve the current measures by using objective and reliable data, incentivize OPOs to ensure all viable organs are transplanted, and hold OPOs to greater oversight while driving higher OPO performance. To better serve organ transplant recipients and the many people waiting for a transplant, CMS is proposing:

• Donation rate measure: The donation rate would be the number of actual deceased donors as a percentage of the donor potential, which would be defined as total inpatient deaths in the DSA among patients 75 years of age or younger with any cause of death that would not preclude a potential donor from donating an organ.
• Transplantation rate measure: The organ transplantation rate would be the number of organs transplanted as a percentage of the donor potential, which would be defined as total inpatient deaths in the DSA among patients 75 years of age or younger with any cause of death that would not preclude a potential donor from donating an organ.
• Top 25 percent benchmark: CMS is proposing that all OPOs meet the donation and transplantation rates of the current top 25 percent of OPOs, which would be made public.
• 12-month reviews: At the end of each re-certification cycle (every four years), an OPO would have to meet the CMS requirements for both the donation rate and transplantation rate measures. CMS is proposing to review OPO performance every 12 months throughout the four year re-certification cycle to more quickly identify OPOs that need improvement and ensure fewer viable organs are wasted and more timely transplants occur.

Most of the proposed changes would not take effect until 2022. "

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

Here are the particular announcements:

Notice of Proposed Rulemaking (NPRM) to amend the regulations implementing the National Organ Transplant Act of 1984 (NOTA)

Fact Sheet | December 2019

and

Organ Procurement Organization (OPO) Conditions for Coverage Proposed Rule: Revisions to Outcome Measures for OPOs  Dec 17, 2019 

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Earlier post:

Tuesday, July 16, 2019

President Trump's Executive Order on kidney care

Notice of Proposed Rulemaking (NPRM) to amend the regulations implementing the National Organ Transplant Act of 1984 (NOTA)Fact Sheet | December 2019

Notice of Proposed Rulemaking (NPRM) to amend the regulations implementing the National Organ Transplant Act of 1984 (NOTA)Fact Sheet | December 2019

Market design workshop in Santiago, SUSPENDED

Politics can certainly get in the way of economics, even academic economics, as it turns out.  The organizers of a conference on matching and market design that I had planned to attend prudently decided  several weeks ago to postpone it, in light of the street demonstrations taking place in Chile.

Market Design Workshop, 17 - 20 December, Santiago, Chile: SUSPENDED
Organizers: Itai Ashlagi, José Correa, Juan Escobar

"This workshop is a venue to discuss recent developments and methods in the area of market design, both from a theoretical and applied perspective. Central to the workshop is the multidisciplinary nature of the area so that an important goal is to bring together top researchers from three related scientific communities: Economists, Computer Scientists and researchers from Operations Management."
***********

Some background news:
How a $0.04 metro fare price hike sparked massive unrest in Chile
Thousands of people in Chile have taken to the streets to protest against the government.

and here's a more recent update:
Chile protests: UN accuses security forces of human rights abuses

United frequent flier updates as market design, by Scott Kominers

Scott Kominers, at Bloomberg (possibly written while flying):

United’s Frequent-Flier Program Gets Some Game Theory
The change is a case study in marketplace design.
By Scott Duke Kominers

"In United’s old program, those who reached top frequent-flier status were given a number of upgrade certificates that could be used to boost tickets from one class of service to another, typically from economy to business. 2  Some of these upgrades were regional, meaning that they could only be used on a select set of flights -- mostly all within North America -- whereas others could be used globally. To obtain an upgrade, customers often had to join waiting lists, where priority was determined by a mixture of flier status, ticket type and request date. As a result, plenty of fliers didn’t get the upgrades they wanted.

"The new program replaces the fixed-format upgrades with a currency-like system called PlusPoints, which, like the old certificates, are awarded to those with top status. Different types of flight upgrades now have different PlusPoints costs, at an exchange rate corresponding to the old upgrade format. Many upgrade requests will still be placed on waiting lists, but there's a new option to skip the waiting list if you're willing to pay a large PlusPoints premium.
...
"the change is also likely to reduce congestion in the upgrade market; under the old system, transnational long-haul flights such as those from Boston to San Francisco were frequently glutted with upgrade requests, because they were among the longest flights that qualified for regional upgrades.
...
"There’s also some funny game theory around the option to skip the waiting list. Whereas before everyone ended up on the same upgrade waiting lists, now some people will skip the line. But that means fewer upgraded seats will be available for those on the waiting list, which in turn creates more incentive to jump ahead. So we might see some customers buying the option of skipping the waiting list just to preempt others."

Market design, in Farsi

Here's an article in Farsi, from an Iranian blog:

طراحی بازار؛ حیات جدید اقتصاددانان دنیا

امروزه اقتصاددانان تنها برای تحلیل بازار فراخوانده نمی شوند بلکه از آن ها برای طراحی بازارها نیز کمک می‌گیرند. این نخستین شماره از پرونده راهبرد معاصر در معرفی زوایایی کمتر شناخته شده از دانش اقتصاد است.

Google translate: "Market Design; The New Life of World Economists.  Today, economists are not only called upon to analyze the market, but also to help design markets."

Matching in Marathi (the language of Maharashtra)

Ashutosh Thakur points out to me this article in the main Maharashtraian newspaper, ''Loksatta.''

संज्ञा आणि संकल्पना : ..जिथून पडल्या गाठी
अर्थशास्त्रात असलेली, पण आर्थिक व्यवहार नसलेली आपली आजची संकल्पना म्हणजे-मॅचिंग मार्केट्स.

Google translate doesn't make much headway with the top headline, but renders the subheading as
"Matching markets today are our concepts of economics, but not financial transactions."

Skin donation, by the square foot, for New Zealand volcano burn victims

CNN has the story, about a little-publicized part of the market for body parts:

New Zealand has ordered more than 1,290 square feet of skin for volcano victims

"New Zealand has ordered 1,292 square feet of skin to treat patients injured in Monday's volcanic eruption on White Island, authorities said Wednesday.

"A total of 47 people were on White Island, off the coast of North Island, when the eruption occurred. Eight people have been confirmed dead, and more than 20 others are currently hospitalized in critical condition.
...
"The skin is now needed to treat patients severely injured by the volcanic ash and gas. On Tuesday, medical officials said 27 people in hospital had burns to at least 30% of their bodies and many have inhalation burns that require airway support.
...
"We anticipate that we will require an additional 1.2 million square centimeters (1,292 square feet) of skin for the ongoing needs of the patients."

"To put that into context, the average human body has about 11 square feet (1 square meter) to 21 square feet (2 square meters) of skin surface area.

"The skin order has been placed and will come from the United States, Watson said. Skin and tissue banks from neighboring Australia, like the Donor Tissue Bank of Victoria, are also providing skin grafts and supplies.

"The skin grafts come from donors -- like organ donors, skin donors register to donate their skin after death. When skin is donated, usually only a thin layer is taken, like the skin that peels when you are sunburned, according to the Australian government's donation site. The skin grafts are usually taken from donors' backs or the back of their legs.

"The demand for skin is particularly high given the unprecedented number of severe burns to the victims, authorities said Wednesday"
**********

Here's a story with some other detail:
Aussies donate skin for volcano survivors

"The layers that we provide are essentially the epidermis which is the top layer of skin and a small lawyer of dermis underneath the skin," said Dr Stefan Poniatowski, head of the Donor Tissue Bank of Victoria.

"The immune system of the recipient will reject the epidermis layer, but the dermis will actually incorporate and provide a nice healthy wound bed for the patients' own skin to be grown or applied over the top.

"The allograft skin will be rejected, but it becomes a temporary biological dressing."
...
"The allograft skin is stored in liquid nitrogen and safely kept at ultra-low temperatures for up to five years."




HT: Philip Held

Might there be enough deceased donor organs if we used them efficiently?

It's hard to know how many deceased donor organs could be made available if we used them as efficiently as possible. Here's an essay in the WSJ by Stanford pulmonologist Dr. David Weill, who thinks that, with no wastage, the supply might be sufficient to meet the demand.

Supply Isn’t the Problem With Organ Transplants
There are plenty of donors to meet the need, but the system is so inefficient that available organs often don’t reach desperate patients
By David Weill
Dec. 6, 2019
"One of the first things that transplant doctors learn is that there are not enough organs to go around. We repeat it to our patients and ourselves and, in a way, it helps us to temper our expectations of saving every patient on our waiting list. But there isn’t really an organ shortage. We are just failing to make effective use of the organs that we could transplant."


HT: Alex Chan

Matching and market design in the latest issue of Theoretical Economics

Theoretical Economics, Volume 14, Number 4 (November 2019) has several articles on matching and market design

Common enrollment in school choice
Mehmet Ekmekci, M. Bumin Yenmez

Abstract: Increasingly, more school districts across the US are using centralized admissions for charter, magnet, and neighborhood schools in a common enrollment system. We first show that, across all school-participation patterns, full participation in the common (or unified) enrollment system leads to the most preferred outcome for students. Second, we show that, in general, participation by all schools may not be achievable because schools have incentives to stay out. This may explain why some districts have not managed to attain full participation. We also consider some specific settings where full participation can be achieved and propose two schemes that can be used by policymakers to achieve full participation in general settings.


School choice under partial fairness
Umut Dur, A. Arda Gitmez, Özgür Yılmaz

Abstract: We generalize the school choice problem by defining a notion of allowable priority violations. In this setting, a weak axiom of stability (partial stability) allows only certain priority violations. We introduce a class of algorithms called the Student Exchange under Partial Fairness (SEPF). Each member of this class gives a partially stable matching that is not Pareto dominated by another partially stable matching (i.e. constrained efficient in the class of partially stable matchings). Moreover, any constrained efficient matching that Pareto improves upon a partially stable matching can be obtained via an algorithm within the SEPF class. We characterize the unique algorithm in the SEPF class satisfying a desirable incentive property. The extension of the model to an environment with weak priorities enables us to provide a characterization result which proves the counterpart of the main result in Erdil and Ergin (2008).


Full substitutability
John William Hatfield, Scott Duke Kominers, Alexandru Nichifor, Michael Ostrovsky, Alexander Westkamp

Abstract: Various forms of substitutability are essential for establishing the existence of equilibria and other useful properties in diverse settings such as matching, auctions, and exchange economies with indivisible goods. We extend earlier models' definitions of substitutability to settings in which each agent can be both a buyer in some transactions and a seller in others, and show that all these definitions are equivalent. We then introduce a new class of substitutable preferences that allows us to model intermediaries with production capacity. We also prove that substitutability is preserved under economically important transformations such as trade endowments, mergers, and limited liability.

Medically assisted suicide.

Several recent stories caught my eye on the controversial subject of medically assisted suicide, aka death with dignity, medical assistance in dying (MAID), and some other names.

He died by suicide in front of Alberta’s legislature. He said he wanted to bring attention to Medical Assistance in Dying   By Nadine Yousif, Star Edmonton, Sat., Dec. 7, 2019

"In his own final moments, Chan, 62, wanted people to know about the struggles of his loved ones, and how increased access to medical assistance in dying could help many end what may otherwise be a lifetime of suffering."
***********

The Champion Who Picked a Date to Die by ANDREW KEH, NY Times, Dec. 5, 2019

"Knowing she had the legal right to die helped Marieke Vervoort live her life. It propelled her to medals at the Paralympics. But she could never get away from the pain.
Andrew Keh and Lynsey Addario spent almost three years reporting on Marieke Vervoort as she and her parents wrestled with her decision to die by euthanasia. They visited her multiple times at home and in hospital stays in Belgium, and accompanied her on trips to the Canary Islands and Japan."
***********

Aid in Dying Soon Will be Available to More Americans. Few Will Choose It.
By October, more than one in five U.S. adults will be able to obtain lethal prescriptions if terminally ill. But for those who try, obstacles remain.
By Paula Span, July 8, 2019  NY Times

Unraveling has made investment banks the farm teams of private equity...

...at least that's the argument made in this article (full of nitty gritty detail) at Vanity Fair:

“IT’S, LIKE, LAWLESS”: HOW PRIVATE-EQUITY HEADHUNTERS ARE BLEEDING WALL STREET
In the battle for young talent, investment banks have been reduced to prep schools for private equity. Inside the cutthroat recruiting process launching the next generation of the superrich—and what it reveals about the status realignment rocking Wall Street.
BY WILLIAM D. COHAN

"The recruitment calendar keeps accelerating. Two years before he started at Morgan Stanley, the former analyst said, the private-equity vultures began circling the investment banks in March. The following year, recruiting began in April. Today, analysts who begin at Morgan Stanley in August are being courted by private-equity firms in mid-September—just weeks after they arrive.

"This super-charged dynamic can make for very odd interviews. “It’s so accelerated. Basically what you’re doing at the private-equity firm is you are saying, First of all, can this person hold a conversation?” the former analyst says. After that, the private equity people want to know what members of the new class are specializing in, and at which Wall Street bank. “Kids that are working in the mergers and acquisitions group at Morgan Stanley are probably going to get a great experience 8 times out of 10,” he explains. “Nine times out of 10. So I will want to interview those people that I consider to be in good groups at strong banks, where I hope and I assume that they are going to get the experience that they need that, by two years from now, when they come in the door, they are educated and their analytical skills and financial skills are up to snuff.”
...
"Somewhat surprisingly, most firms don’t seem to object. Rather, they have come to grips with the reality of the situation, even if they don’t like it, and recognize that they risk not getting the analysts at all if they put up too much of a stink. Some firms even encourage the analysts to go to private-equity firms—because that gives them a better chance of getting the very best college graduates. A partner at one firm even went to bat for one of the analysts who made it through the second round of recruiting at a big private-equity firm, but did not make it to the final round. The partner called up someone he knew at the private-equity firm and got the analyst back into the process. He got the job. “It’s like, I’m going to get you whatever job you want, but you’re going to bust your balls for me for the next two years,” the partner tells me.

"One young banker who got an offer from Blackstone recalled the supportive response when he walked into a partner’s office to share the good news. “He said, ‘That’s great. I’ve got to do a good job training you so that Jon Gray’”—Blackstone’s new president and chief operating officer—“‘thinks that I did a good job with you.’” (There is one exception to this good humor: Goldman Sachs, which has a three-year analyst program. “If they find out you are recruiting, they’re going to fire you,” says one analyst. “It’s official policy.” A Goldman spokesman says while that is true, some of their analysts still get recruited away from the firm.)".
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Earlier post:

Monday, September 23, 2019

Private equity races for young talent even earlier this year

Black markets for drugs in Europe: report of the European Monitoring Centre for Drugs and Drug Addiction

Here is the 2019 report from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Europol, the EU's police organization:

EU Drug Markets Report 2019
EMCDDA, Europol, Lisbon, November 2019

Summary: The EU Drug Markets Report 2019 is the third comprehensive overview of illicit drug markets in the European Union by the EMCDDA and Europol. The analysis presented in this report spans numerous topics such as the links between drugs and other crimes, the licit economy and society more generally as well as the processes and players involved in the trade, from production and trafficking to distribution. Taking an evidence-based approach, the report reviews the markets for heroin, cocaine, cannabis, amphetamine, methamphetamine, MDMA and new psychoactive substances. It also provides action points to inform policy development at EU and national level. This publication is an essential reference for law enforcement professionals, policymakers, the academic community and indeed for anyone seeking up-to-date information and analysis on drug markets in Europe.

Here is the full report.

From the Executive Summary:

"The drug market is a major source of income for organised crime groups (OCGs) in the EU, with minimum estimated retail value of EUR 30 billion per year. In addition to the economic impact, drug-related deaths and other harms to public health, there are broader consequences of drug markets, such as links with wider criminal activities and terrorism; the negative impact on the legal economy; violence in communities; damage to the environment; and the increasingly important issue of how the drug market can fuel corruption and undermine governance.
...
" All data indicate that overall drug availability within Europe, for both natural and synthetic drugs,
remains very high. The European drug market is increasingly characterised by consumers having access to a wide variety of high-purity and high-potency products that, in real terms, are usually equivalent in price or cheaper than they have been over the past decade.
...
"Cannabis
Europe’s biggest drug market is for cannabis and significant production of the drug takes place within the EU. With around 25 million annual users, the retail market for cannabis was estimated to be worth at least EUR 11.6 billion in 2017. Around one in seven young adults in the EU reports having used cannabis in the past year, with prevalence rates generally stable but with early signs of possible  increases in some countries.
...
"Herbal cannabis is extensively produced within the EU, with estimates indicating that at least 20 000 cultivation sites are dismantled each year, and is a major source of income for the criminal economy. Despite efforts to counter production, the Western Balkans, and Albania in particular, appear to remain an important source of origin for seized herbal cannabis
...
"Heroin and other opioids
The use of heroin and other opioids still accounts for the largest share of drug-related harms. The retail value of the heroin market in 2017 was estimated to be at least EUR 7.4 billion. There are indications that heroin availability in the EU may increase: recent opium production estimates from Afghanistan, levels of seizures in Turkey and intelligence assessments of activity along the main trafficking routes to Europe are all high, and large consignments of heroin have been detected within the EU.
...
"Cocaine
The cocaine market is the second largest illicit drug market in the EU, with an estimated minimum retail value in 2017 of EUR 9.1 billion. Surveys estimate that about 4 million people in the EU will have used cocaine in the past year. Use is still concentrated in the west and south of Europe but appears to be becoming more common elsewhere.
...
"While Colombian and Italian OCGs have historically played a central role in the trafficking
and distribution of cocaine, increasingly other groups are becoming more significant, including Albanian-speaking, British, Dutch, French, Irish, Moroccan, Serbian, Spanish and Turkish OCGs. At the same time some European OCGs have established a presence in Latin American countries, developing a new ‘end-to-end’ business model for managing the supply chain, with large quantities of cocaine purchased near production areas at lower costs. This may be driving competition and conflict within the cocaine market and leading to increasing cocaine market-related violence and corruption within the EU.
...
" The global market for cocaine appears to be growing and a knock-on effect of this is that the EU appears to be increasingly used as a transit area for cocaine destined for other markets such as Australia, New Zealand, Russia, Turkey and countries in the Middle East and Asia. The cocaine market is increasingly enabled by digital technology, including darknet markets and the use of the surface web, social media and mobile phone apps to advertise and facilitate the delivery of cocaine to consumers. Innovation seen in the supply chain at the consumer level is suggestive of both high
availability and attempts by OCGs to increase market share.
...
"Synthetic drugs: amphetamine, MDMA and methamphetamine
Europe’s synthetic drugs market, particularly in respect to stimulants like amphetamine, MDMA and methamphetamine, is evolving rapidly. Within the stimulant market, these drugs compete for market share alongside cocaine and a number of new psychoactive substances. Of the two closely related stimulants, amphetamine continues to be more commonly used than methamphetamine in most EU countries, though there are growing signs of a gradual diffusion of methamphetamine use. The value of the EU retail market for amphetamines (amphetamine and methamphetamine combined) in 2017 is estimated to be at least EUR 1 billion, and for MDMA EUR 0.5 billion.
...
"New psychoactive substances
Policies relating to new psychoactive substances (NPS) appear to be having some impact, especially those aimed at reducing open trade in the EU as well as measures taken in source countries, such as China. There has been a slow-down in the number of first detections of NPS in Europe. Currently around 50 new substances are reported annually, giving a total of over 730 that have been reported to the EU Early Warning System."