By Zubeida Mustafa
Organ transplantation technology was introduced in the West in 1904 when the first corneal graft operation was performed in a New York hospital. The first kidney was transplanted in Boston in 1954. Today, surgeons in the Third World have adopted the technology with a growing measure of confidence and success. Nearly 40,000 transplantations are being performed every year all over the world and this technology has come to stay.
As happens in the case of any scientific breakthrough, many related issues, especially of an ethical nature, are now being debated. The 1 Institute of Urology and Transplantation, Civil Hospital Karachi, which has kept up a constant exchange of views and expertise with transplantation surgeons in Western centres, recently played host to two eminent gentlemen from the Royal Free Hospital, London. Dr Oswald Fernando, a surgeon from Sri Lanka, and Dr Zac Verghese, a basic scientist from India, have worked in Britain since 1963. They are therefore well placed to understand the challenges transplantation technology faces in the socio-economic conditions of the Third World.
Neither of them felt that our surgeons were in any way handicapped in terms of scientific know-how and transplantation skills. Dr Fernando even pointed out that in Britain some of the best transplantation surgeons were of Asian origin. “In fact the Asians are at an advantage. When transplantation surgery was launched in Europe many mistakes were made initially and mortality rates were high. The Asians do not have to make the same mistakes and thus they can make a good start. Moreover, with improved dialysis services a patient with a failed graft does not have to die. He goes back to dialysis,” Dr Fernando said.
“A kidney transplantation programme must be integrated with a dialysis plan,” Dr Verghese added. “When renal failure patients receive an organ transplantation, they in effect make room for more dialysis patients. But without dialysis you cannot have a transplantation programme, because the prospective transplant patients have to be dialysed until a matching organ can be found. Hence either of the two in isolation makes little sense.
” But in the absence of a sufficient number of organs, transplantations will always be a step behind dialysis. This is the case even in the most advanced countries of the West. Dr Verghese quotes figures to prove his point. In Britain 58 in every million people are on dialysis but only 35 per million receive a kidney transplantation. At any time 4400 patients of end stage renal failure are waiting for an organ.
Dr Fernando can understand why procuring organs can be so difficult here. Even in the Asian communities in Britain he finds people are more superstitious and rather reluctant to make a will for organ donation. Yet cadaveric donation of organs is the only solution to the problem, Dr Fernando observes “For this a public awareness and communication campaign must be launched to inform people about organ transplantation and donation. In Australia, they have begun to teach young children of twelve and thirteen about organ transplantation in their health education classes. Something of the sort must be undertaken in other countries as well to create public pressure in favour, of the necessary legal framework for an organ transplantation .programme,” Dr Fernando said. “May be an award or honourable mention could be instituted for multi-organ donors to motivate and encourage people,” Dr Verghese suggested.
Dr Fernando and Dr Verghese felt equally concerned about the ethical dimension of any transplantation programme. For instance the criteria for brain stem death must be very unequivocally defined and two ‘consultants who are in no way related to the transplantation programme should certify the death of the donor, Dr Fernando said.
To ensure that an organ is grafted in the patient whose tissue type is the closest and not due to any other considerations, the cross matching should be done through a computer in organ banks. In order to check unethical practices, especially the commercialisation of the programme which could damage its credibility, Dr Fernando recommends the setting up of a National Registry as in Britain and the US. Every transplantation carried out, whether in a private hospital or in a public sector health facility, has to be duly reported to the Registry. Of .course Pakistan still has a long way to go before cadaveric donation of organs will become the norm. However, until then the transplantation surgeons here will have to protect the credibility of the programme.
The impression must not be created that only the rich can get an organ because they can pay for it. It is in that context that the easy availability of organs through a cadaveric donation programme is so important.
Source: Dawn 18 June 1993