International concern over China’s system of human organ transplantation has been expressed for decades. Over the last several years, the Chinese authorities report working hard to build a voluntary organ transplant system. Last month a top transplant official, speaking at an international organ trafficking summit at the Vatican, reiterated the claim that since January 1, 2015, China has eliminated the use of prisoner organs, and now only uses organs from donors who die in the intensive-care units of hospitals.
This would be a welcome development, if it could be trusted. Unfortunately, contradictory data, misleading claims, and intense secrecy indicate that it cannot. Moreover, the history of organ transplantation in China raises disturbing questions about past, and possibly ongoing, abuses. With abuses, of course, comes the imperative of cover-up.
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The first problem is that China’s official figures on the number of transplants performed cannot be trusted. At the Vatican summit last month, Dr. Huang Jiefu, the director of China’s Organ Donation and Transplantation Committee, said that from 2011 to 2014, a total of 2,342 citizens had donated their livers after death.
Yet less than a week later, in an interview with The Paper, a state-owned digital news outlet, he said something different: “From 2011-2014, there were 1,910 cases of [deceased] citizen liver donation.”
These numbers, which differ by 18 percent, cannot both be true. All transplants since September 1, 2013, are supposed to have been registered in a mandated, centralized database, known as the China Organ Transplant Response System (COTRS). Yet, in our research, we have identified ten instances of such contradictory data points, offered either by Huang or other official sources. Such inconsistent accounts of donor data indicate that these official claims simply cannot be taken at face value.
Problematic Transplant Volume
Given that figures cited by top transplant officials cannot be trusted, investigators have resorted to a variety of other methods to estimate how many transplants are being performed.
One can, for instance, look at publicly available reports about the number of beds in the transplant wards of hospitals, then compare them to the reported utilization rate of those beds. These two data points, coupled with the average length of stay for a liver or kidney transplant recipient, can be used to calculate the rough transplant volume at certain hospitals.
Tianjin First Central Hospital’s transplant center, for instance — built in late 2006 — was planned to have 500 beds (but may have had up to 700). According to 2008 filings in an official construction database, the bed utilization rate for kidney and liver transplants was 90 percent in 2008; according to Tianjin official media, the entire hospital’s bed utilization was 131 percent in 2013 (meaning either that excess patients were put up in nearby hotels, or perhaps that more beds were wedged in). With an average hospital stay of one to two months for transplant recipients, that would add up to thousands of transplants per year at just this one facility.
Communist Party media reports provide another indication of transplant volume. Comparing two official publications indicates that Tianjin First Central Hospital performed around 1,000 liver transplants a year from 2011 to 2015. Other official sources, like the 2011 liver registry, state that the hospital performs either one quarter or 12 percent of the total liver transplant activity in China. This translates to between 4,000 and about 10,000 liver transplants per year nationwide, several times the officially reported figures for that organ, which itself comprises only part of the country’s total transplant volume.
It is very difficult to know the actual number of transplants in China, but such data indicates they appear to be troublingly large relative to the claimed volume and source of organs.
The Transplant Boom
Before the year 2000, China hardly had an organ transplantation industry to speak of. From the 1980s to the end of 2000, there was a reported cumulative total of 34,832 kidney transplants. Just four years later, the figure had increased by at least 27,141, according to medical textbooks.
According to the respected business magazine Caijing, from 1993 to 2007 China’s number of liver transplants increased by 400 times — from six to over 14,000 cumulatively.
But even these figures are lowballs. They come from China’s official registries and reports, and so are only a portion of the total. The kidney transplant figures come from 106 hospitals, whereas the liver registry was formed by 25 hospitals in February 2005.
Yet in reality there were over 1,000 hospitals doing transplants in China by the year 2006, official sources say. (That figure was supposed to have been cut down to 164 in 2007.)
China’s own officials speak openly about the transplant boom. “The year 2000 was a watershed for the organ transplant industry in China,” reported Southern Weekend, citing He Xiaoshun, a top transplant official. “The number of liver transplants in 2000 reached 10 times that of 1999; in 2005, the number tripled further.”
China’s first legislation on organ transplantation came into effect in 2007. The only major regulation before that was the 1984 provision allowing the use of prisoner organs.
But despite the effort at greater regulation, what happened after 2007 is arguably more troubling
On January 1, 2007, the Supreme People’s Court took control of death penalty reviews, triggering a sharp drop in judicial executions, cutting the annual figure down from as high as 10,000 to a few thousand. This is credible given that, as Caixin explains, “leaders from the relevant departments even worried that the public wouldn’t be able to accept the fact that there was such a precipitous decline in death penalty numbers.” Duihua, a U.S.-based human rights NGO, shows a steadily decreasing death row trend, to as low as 2,400 executions in 2013.
Yet the organ transplant industry continued to expand. For example:
- In 2007, Tianjin First Central Hospital’s new transplant building, with 17-stories and 500 beds, paid for by the local government, went into full operation (documented above);
- In 2007, a $2.8 million (20 million RMB) national policy loan was extended to North China Pharmaceutical for the industrialization of a series of immunosuppressants (used almost exclusively by transplant recipients) in Hebei Province;
- In 2008, Zheng Shusen, an architect of China’s transplant system, increased the eligible liver transplant recipient population by 52 percent, by expanding the acceptable maximum size of liver carcinomas;
- From 2010 to 2012, the Beijing 309 military hospital expanded its transplant center’s bed capacity from 316 to 393. The same hospital said its transplant center was its most profitable revenue generator, growing from 30 million yuan ($4.5 million) income in 2006 to 230 million in 2010 ($34 million), a jump of eight times.
There are numerous other examples like these. China’s entire transplant industry, in fact, appears to have developed quite separately from the trajectory of available death row prisoners.
The next question has become one of the most politically sensitive and contentious: If the transplanted organs aren’t coming from executed criminals, where are they coming from?
It is only since 2015 that China claims to have been using volunteer donors as its organ source, and officials acknowledge that the system is still in its infancy. Previously, beginning in late 2005, officials had claimed that organs came from executed prisoners (this was vociferously denied before 2005, when it was suddenly acknowledged).
Given that death row executions can hardly explain the growth trajectories of China’s transplant industry, researchers have suggested darker alternatives.
Several have suggested, for instance, that among the real sources are prisoners of conscience. This includes Uyghur Muslims, Tibetans, and potentially house church Christians, but overwhelmingly practitioners of Falun Gong, a traditional Chinese spiritual practice that has been persecuted since 1999. It is likely, of course, that other dispossessed and marginalized Chinese citizens have also been victimized.
Freedom House, in a report on freedom of religion in China published last month, said that a review of available information had “found credible evidence suggesting that beginning in the early 2000s, Falun Gong detainees were killed for their organs on a large scale.” It added that: “the large-scale disappearance of young Uyghur men, accounts of routine blood-testing of Uyghur political prisoners, and reports of mysterious deaths of Tibetans and Uyghurs in custody should raise alarm that these populations may also be victims of involuntary organ harvesting.” The U.S. Congress and the European Parliament have expressed condemnation.
The trajectories certainly match up: mass incarceration of Falun Gong in July 1999 preceded the transplant boom by just six months. And this organ source would explain the continued growth of transplants even as death row dried up. There is also a large amount of evidence — including dozens of cases collected by journalist Ethan Gutmann in his book — of detailed blood tests and organ examinations of Falun Gong detainees in China.
A full accounting of the evidence base would take hundreds of pages. But some of the most disquieting material is to be found right in official Chinese literature.
Zheng Shusen, for instance, one of China’s most prominent transplant surgeons, is also the chairman of the Anti-Cult Association of Zhejiang Province. Such associations were established by the Party in the year 2000 specifically to vilify Falun Gong and oversee the forced ideological conversion of detained practitioners.
Why is a leading Chinese liver surgeon and transplant official also heavily involved in the anti-Falun Gong campaign? In 2009, Zheng wrote in the preface to an anti-Falun Gong book: “‘Falun Gong’ and similar evil religions are like viruses corroding the organism of humanity, warping the souls of believers, destroying social order, disrupting economic development, and have become a public nuisance to mankind and a cancer on society.”
Language like this is disturbing under any circumstances. Coming from a prolific liver surgeon, in the context of the current accusations, it is highly alarming. (Zheng also attained recent notoriety for lying about the source of organs in a paper in Liver International, leading to a retraction.)
Huang Jiefu, China’s top transplant spokesman, is also on record in 2001 making similar remarks: “Opposing Falun Gong is a grave political struggle. We must not be softhearted when dealing with a little group of hardcore reactionaries.”
The rapid and unexplained growth of China’s transplant system in 2000, the robust trajectory of transplant activity post-2007 despite declining judicial executions, the blood tests and organ examinations of Falun Gong practitioners in custody, the disappearance of young Uyghur men and accounts of blood-testing of Uyghur political prisoners, and the involvement of transplant officials in the anti-Falun Gong campaign, have never been explained by the Chinese government. Instead, such evidence is simply dismissed as “ridiculous.”
Given that Huang Jiefu is now supplying apparently falsified data in international medical fora, while transplants with unexplained sources in China continue, answers to these questions are a matter of urgency.
Unannounced visits to hospitals by international medical inspectors, and the disclosure of historical and current hospital-level transplant data, would be a place to start.
Matthew Robertson is an independent researcher and translator based in New York City.
Dr. Jacob Lavee is the immediate past president of the Israel Transplantation Society, the founder and director of the heart transplantation unit at the Sheba Medical Center, Israel’s largest hospital, and a professor of surgery at the Sackler Faculty of Medicine, Tel Aviv University. The authors are currently preparing a monograph about the reforms to China’s organ transplantation system since 2010.