[MUSIC] Healthcare costs money, and organ transplantation is expensive. The freely given gift of deceased organ donation requires us to take a close look at fair access to healthcare. Access to healthcare is a basic human right, and one that I believe the world should be united in striving towards. But the reality is we as individuals and as countries are for various reasons, only able or willing to pay a certain amount towards our healthcare. For example, I pay for private medical insurance because it improves my family's access to healthcare resources in South Africa. Does this improve our access to transplantation? Directly not at all, the entire population competes for what is an exceptionally scarce resource allocated on medical needs, matching, and time spent waiting. Indirectly however, my family would have a better chance of being accepted onto the waiting list for the transplant because of better access to healthcare resources along the wait to transplantation. Financial constraints can affect transplantation outcomes even in the system where access to dialysis is universal, and paid for by the government, such as in the United States. Post-transplant immunosuppressive therapy is only funded by the government for the first three years following a transplant. After that, someone else has to pay. Immunosuppression is expensive and a life-long requirement after transplantation. Patients with private insurance in the United States have been shown to do better than those without because their transplant lasts longer partly on the basis of reliable access the immunosuppressive medication. The vast majority of the world battles with adequate primary healthcare provision. On a cost effectiveness scale, this is the most efficient health intervention to uplift the society. Vaccinations, reproductive health, and infectious disease treatments can save millions of lives. This means that transplantation is often not prioritized as a major health need. The single biggest individual drug expense in my hospital is for a specific immunosuppressive drug that can be used to prevent rejection. Cost is a barrier to transplantation for many countries. And after low donation rates, it's the second biggest factor affecting access to transplantation. I firmly believe that deceased organ donation rates and transplantation activity in a country is a reflection of the state of your entire healthcare system. It reflects how we treat patients at the end of their life. Are they given a fighting chance with ICU support? Is the family appropriately counselled at the end of life? And are we able to support patients with organ failure well enough to successfully transplant them. Transplantation is similar to how an apex predator can reflect to health of the whole ecosystem. If your entire ecosystem is not broad based and functioning well, you cannot naturally support apex predators such as lions. If you want to see a marker of how healthy your ecosystem or healthcare system is, just see how many lions, or transplants it can sustain. No donor family is ever required to pay the cost of organ donation. When death is certified, transplant team takes over all the cost related to donor management, organ recovery, and organ transport. What is important is that this process is not commercialized. No one can profit along the way. All transplant organizations are required to be non-profit. And there are government regulations requiring them to maintain auditable records of their practices. There are some economic models looking at legally regulated commercialization of living and related kidney transplantation given the overall cost savings, to a society of transplantation over dialysis. Iran is the only country with such a system currently in place, where donors are remunerated over and above the cost of donation. This has social implications for transplantation activity with the burden of donation being shifted on to people of lower socioeconomic groups. Most countries strive for financial neutrality in living transplantation to prevent living donors from incurring costs related to organ donation. In Canada, for example, living donors are given lifelong health insurance. Deceased donors do not put their life at risk and have no need for ongoing health insurance. Some countries will offer families assistance towards funeral costs but it is important such support is regulated and not so excessive as to be considered a perverse incentive to donate. In South Africa, disease donation is totally altruistic, and no money is handed over to the family. Probably, one of the most famous people, definitely the richest to receive a transplant, was Steve Jobs, the co-founder of Apple. His reason for needing a liver transplant was the uncommon indication of metastatic neuroendocrine cancer of the pancreas. In his home state of California he was competing against a much larger pool of potential recipients. Steve Jobs was able to be listed in multiple jurisdictions for his liver transplant on the basis that he could fly to the required center on short notice if a liver became available. He ended up receiving his liver transplant in Memphis Tennessee. Steve Jobs was the most appropriate recipient for that donor on that waiting list at that time. He didn't jump the queue, but he was able to be in more queues than an average person. This is obviously not an option is available to everyone. However, is accepted with the new American system. Some countries such as South Africa, only allow you to be on one transplant list. But that doesn't mean people in South Africa don't need money to travel for transplant. The reality for patients in South Africa is they often have to relocate. Be closer to a transplant center in a major urban city in order to maximize their chances of receiving an organ. They also maximize the chance of the operation being a success, because they can get to the hospital quicker, and limit the colder ischaemic time, and they can be followed up more closely by a specialized transplant team. We recently did a transplant for a patient living in Kuruman in the Northern Cape province in South Africa. A 10.5 hour drive from our transplant center in Cape Town. Luckily for our patient the logistics of the transplant all worked out in the end. But that might not have been the case. The socioeconomic status of recipients does influence transplant outcomes. The life-long immunosuppression required to prevent rejection carries risks, not the least of which is infection. In order to be listed for a transplant in South Africa, you need access to basic sanitation and housing. A flushing toilet, running water, and a roof over your head are directly linked to transplant outcomes. So much, so that the risk of dying from an infectious complication related to immunosuppression could offset the gain from receiving a transplant. To die from a diarrheal illness secondary to your immunosuppression following a transplant is a tragedy. For me, this once again shows how transplantation is a benchmark of even more than just our healthcare system. It is a reflection on a society in general. Over and above ensuring that money does not directly influence the allocation of organs, we need to establish fear and equal access to organ transplantation for all patients. [MUSIC]
