To learn how to find a way out of this situation in Ukraine, ForUm has decided to asked director of the Coordination center on transplantation of organs, tissues and cells of the health Ministry of Ukraine Ruslan Saliutyn.
Presumed non-consent: to keep or to change
In 64% of countries, where transplantation is carried out, there is the system of presumed non-consent to organ donation, and only in 36% - the system of presumed consent. In Ukraine, unlike in many European countries, we have the system of presumed non-consent, which complicate the process of organ transplantation. Moreover, Ukrainian mentality plays very important, and often fatal part in this issue. After death of a patient doctors have to ask relatives for permission to donate organs to another patient, but in our countries such request gets taken as an insult - a family is mourning the dead and does not think that they can save other lives.
However, according to Ruslan Saliutyn, the amendments to the legislation will not save the situation. "In my opinion, the system of resumed consent will be more adequate for Slavic world - Russia, Ukraine, Belarus. But the introduction of this system will not change the situation fundamentally. The number of transplantations with presumed consent almost equals to the number of operations without it. We do need to change the law, but the problem is that if doctors develop the document following the European legal base and politicians amend it then, we will have the same law we have now," Saliutyn shares his concern. According to him, the doctors, not MPs must have the last word on this issue.
"We make 100 transplantations per year, while there are five thousand people who need these operations. Let's talk frankly, other people die. Many people do not get medical assistance at the local level. Not everybody gets hemodialysis, as there is a long waiting list. One dead donor can save four lives - two kidneys, heart and liver, let alone intestinal tract. We have a huge medical and social problem. People with short bowel syndrome do not have a possibility to get adequate medical assistance in Ukraine," the transplant surgeon says.
Cadaveric donation does not exist as such in Ukraine. Dead donor organ recovery is carried out only in several centers (Zaporizhya, Donetsk, Dnipropetrovsk). For 2011 they recovered only 27 organs, which is 0.2 donors per million of population.
At the same time, according to the preliminary calculations, about 40-60 potential donors per million die annually in Ukraine. It makes about 3 thousand donors in total, who could have saved lives of 10 thousand patients. To compare, 24 thousand organs were transplanted in 2008 in US: 18 thousand from dead donors and 6 thousand from live donors. In Ukraine there are only 876 people living with transplanted organs. Such poor figures are the result of the absence of single service, engaged into transplantology development.
Mythical transplantation service
According to the law, the single transplantation service must already work in Ukraine, as the whole regulatory system has been worked out and adopted. The system also includes the creation of the State transplantation service, formed on the basis of the Coordination center on transplantation of organs, tissues and cells. This State service is supposed to be engaged into coordination and calculation. Similar idea has already been introduced in Belarus, but in Ukraine we lack financing. "Since the law came into force the State service has not been financed. And in 2013 the government does no plan on financing either, as it does not have money. This service could have coordinate all the actions and to count people on the waiting lists. The service could have promote the development of the transplantation activity and register citizens, who agree or stand against cadaveric donation," he says.
According to Saliutyn, with this system the doctors will be able to monitor patients. "The monitoring will allow to know the exact number of patients, who underwent transplantation, and to provide them with necessary assistance and medicines. There are people in Ukraine who are waiting for transplantation for decades and stay with maintenance hemodialysis unit for all this time. Hemodialysis service is not the cheap one. In the first year it costs 180 thousand hryvnias. The cost of transplantation operation with drug provision is UAH 160-180 thousand in the first year. Every next year it costs about UAH 20 thousand annually with cyclosporine and azathioprine or UAH 45-50 thousand with cyclosporine and myfortic," the doctor explains.
Thus, transplantation of kidneys costs 3-4 times less that hemodialysis maintenance, and the patient is completely socially recovered. There are more four thousand people under hemodialysis maintenance currently in Ukraine.
In the shoes of recipient
We cannot consider the problem from one side only. We should start working on the very attitude towards transplantation. "The problem is that we do not have social promotion of transplantation. We have billboards with washing powder, but we do not hear a word about necessity of organ donation. People do not think they may become recipients. Everybody believe it will never happen to him. But in fact, even a person who had banal flu may need a kidney transplantation," the director of the center warns.
Mass media also plays its roles, and it is not the positive one. "Journalists exaggerate the situation on various reasons, most of them commercial. Some articles are of the stove-piping character. We should understand that any industry which brings money or helps to keep it at the state level is competitive. If we start developing transplantology in Ukraine, we can become a decent competitor to Belarus, Israel, USA," Saliutyn notes. The development of transplantology is beneficial for very Ukrainians first all.
Thus, bone-marrow transplantation in Ukraine costs UAH 400-500 thousand (40-50 thousand euro), while abroad it costs 200-300 thousand euro. Kidney transplantation in Belarus costs about $60 thousand, while in Ukraine it would cost about UAH 200 thousand. "In an independent country a citizen must feel that the state protects him. Now in Ukraine we see people collecting money for transplantation and then bringing their kids abroad for operation. WE have our own hands and heads," the doctor believes.
Development of cadaveric donation may solve of the problem of long waiting lists. But to do so we must first solve a number of tasks. First, it is modernization of the law and introduction of presumed consent. Second, it is the creation of the State transplantation service. Third, it is the development of social advertisement of organ donation. But even with realization of these three tasks we will have to deal with the human factor. "Every chief doctor is a local duke, who believes he does not report to the Ministry, but to the local government. Chief doctors and coroners refuse to cooperate with transplant surgeons, fearing problems with law enforcements," Saliutyn explains.
No black transplantology in Ukraine?
To be a good transplant surgeon a doctor must study continuously and upgrade his skills. In this sector the reputation and authority are hard to come, thus, according to Ruslan Saliutyn, no earnest doctor will agree for illegal operations. "The state has powerful means of control, including Security Service, police, intelligence. What's the point to engage into black transplantology, if the control system in Asia or Latin America is softer? What's the point to kidnap and cut to pieces people here? There is no point. Transplantation is not a one-doctor-operation. It requires a brigade of medics and high-skilled professionals. 'When two know, all know', thus if similar groups operates somewhere, law enforcements will learn about it. I wouldn't hide that some of our fellow citizens want to earn money selling their organs. But it is illegal. Only live relatives can be donors, and doctors will never operate if know in advance that the organ is not from a live relative. Yes, we had several scandals, and there were several trials, and not of the doctors, but of those people, who forged documents presenting themselves as relatives. Doctors are not investigators, and it's not their job to check documents for authenticity. Thus, before speaking about black transplantology in Ukraine, foreign colleagues should look at themselves," the transplant surgeon explains.
As an example, he recalled the scandalous situation on alleged illegal tissue recovery in Mykolaiv region. "Within the time the Security Service department of Mykolaiv region reported that doctors did not make anything illegal, but mass media blared out about it anyway. Now people will be afraid to leave organs for donation, fearing their organs will be torn apart illegally. No doctor recovers organs without the consent of relatives. This is a matter of free will. Abroad people understand this situation. But here one of the show business stars declared on air she would never become a donor. If similar situation happened in America or Europe, this person would be never again allowed on air. People there understand that anyone can become a recipient," he says.
Due to scary stories in media, the profession of transplant surgeon is often characterized as 'black', while good words about doctors who save lives are difficult to find and hear. "When the first transplantation surgery was performed in Belarus, Lukashenko personally came to the hospital, thanked all the personnel and awarded with medals. We have so many talented doctors, like Oleh Kotenko or Oleksandr Nykonenko in Zaporizhya, who is a pillar of transplantation service. Has anybody ever said thank you to him? No. They only know to speak about black transplant surgeons," Saliutyn sighs.
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