This past May, I was fortunate to have the opportunity to attend some of the sessions of a month-long Transplant Coordinators’ Training Program at the MOHAN Foundation in Chennai. I was traveling for a full year as a Thomas J. Watson Fellowi, examining different types of corporal donation in three countries. In two of the three countries I visited – South Africa and India – I spent significant time learning about organ donation and transplantation. I sought to better understand the systems and infrastructure surrounding organ donation, the available technologies and resources in public and private sectors, the attitudes and beliefs about donating, the challenges and barriers that exist, and in what directions the field is heading. My four months in India – the final four months of my year were greatly enhanced by the prior six months I had spent in South Africa; being able to compare and contrast two distinct systems enriched my understanding of the field and led me to identify pros and cons of both systems and ways in which both countries could learn from each other.

I am in the process of applying what     I learned in these distinctly dynamic countries towards what I hope will be an enriching and comprehensive comparison of organ donation and transplantation in South Africa and India. I believe that looking to other countries and gaining a broad understanding of different systems, protocol, cultures, and technologies can aid in creating the maximal system in one’s own country. Though my in-depth comparison is not yet complete, I would like to share some basic facts about organ donation and transplantation in South Africa in the hopes that this information may spark ideas and conversation in the context of India.

South Africa is a famous place when    it comes to organ donation and transplantation; the first successful heart transplant was carried out in Cape Town in 1967. Despite its historical significance, however, present day South Africa has a relatively low donation rate, both absolute and relative to population, and faces a number of challenges, some of which are also faced in India.

There are 16 transplant centers across South Africa, which is home to  around 53 million  people  (about  1/50th  of  the population of India!). Transplants, including kidney, liver, pancreas, and heart, are carried out in both the public and private sectors.

According to a 2014 WHO reportii, South Africa’s organ donation and transplantation services are classified as Level 4:

“Deceased donor kidney and liver transplantation have been performed for at least five years. Heart and lung transplantation also available, either locally or via formal international cooperative organ-sharing agreements such as Eurotransplant and Scandiatransplant. Legislation permits and regulates organ donation and transplantation.”

Currently, India is listed as Level 3: “Countries that have commenced deceased donor kidney transplantation within their own borders. Sufficient local capacity – including local medical expertise – exists to perform kidney recovery surgery from deceased and living donors, kidney transplantation and recipient management. Activities may also include liver transplantation and isolated cases of heart and lung transplantation.”

Though South Africa’s transplantation rate remains low, compared to countries with a similar Human Development Index, South Africa is still a leader in the fieldⁱⁱⁱ.

In South Africa, approximately 600 transplants (solid organs and corneas) occur each year, about half of which are solid organ transplants. There are an average of 4,200 people on the waiting list at any given time, and less than .2% of the population are registered  organ donors^iv. Though India carries out a greater absolute number of transplants per year (around 5,000 kidneys, 1000 livers and 15 hearts are transplanted annually^v) compared to South Africa, relative to population there are fewer transplants being done.

According to 2012 data from the Global Observatory on Donation and Transplantation^vi, both India and South Africa carry out between 2.5-9.9 solid organ transplants per million population (pmp), though South Africa has a slightly higher rate^vii. In 2010, the number of kidney, liver, and heart transplants in South Africa was 5.29pmp, .73pmp, and .51pmp compared to 4.26, .26, and .01 in India, respectively^viii.

However, looking at more recent data from India, it appears that despite India’s previously cited lower rate  pmp compared to South Africa, there are large changes going on. According to    data from 2014, India’s deceased donation rate is increasing tremendously^ix. There does not appear to be such a trend in South Africa^x. One area where South Africa and India differ greatly is with regards to the percentage of organs coming from live donors. Whereas the majority of transplanted organs in South Africa come from deceased donors,  the overwhelming majority in India still come from live donors. Recent efforts across India have worked to promote deceased organ donation, and as the country begins to rely more on deceased donors, the relative rate of transplantation in India compared to South Africa and other countries may rise substantially. In only two years, from 2012 to 2014, the deceased donation rate in India pmp has doubled, from .16pmp to .34pmp^xi.

In terms of infrastructure, both South Africa and India have legal frameworks governing the topic of organ donation and transplantation, and both countries have specific organizations in place that educate the public, distribute  donor cards, and oversee this topic on a  national  level.  In  South  Africa, the Organ Donor Foundation (ODF), a non- profit founded in 1988, is a centralized body that promotes organ donation and educates the public through distribution of information and resources. In India, MOHAN Foundation has been extremely successful in carrying out similar tasks, as well as other organizations such as ORGAN India, Gift A Life, and others.

Whereas in India health is a state subject, in South Africa, the whole country is governed by a national policy. Nonetheless, waiting lists and allocation is done by state. With the development of the National Organ and Tissue Transplant Organization (NOTTO), India may finally have a centralized government body in place, which has the potential to greatly improve communication and collaboration between states, and better documentation of statistics.

In South Africa, donation after circulatory death (DCD) has been taking place in the public sector for several years^xii. Though across the world, donation after brain death (DBD) is the far more common form of organ donation, implementation of DCD is another way of increasing the number of viable organs. DCD is not yet occurring in India, but the topic is one of rising interest; the first DCD conference in India was held in August 2015^xiii.

One major area of focus in the field of organ donation and transplantation in South Africa is that of HIV. South Africa has one of the highest rates of HIV in the world; in 2013, the estimated prevalence was 19.1% of the adult population, compared to .3% in India^xiv. Due to the prevalence of HIV, many brain dead patients in South Africa – potential donors – were once deemed unsuitable due to their HIV status. Over the past decade, transplant surgeon Elmi Muller has studied the transplantation of kidneys from HIV-positive deceased donors to HIV-positive recipients. In her 2015 study published in the New England Journal of Medicine, results show that at 3-5 years post transplant, outcomes of transplants from HIV-positive donors are similar to those from HIV-negative donors^xv. This is hugely important as a large number of once unviable organs may now be viable, which may lead to increasing deceased donation rates. With exciting developments in deceased organ donation taking place in both countries, it is important to remember that this is not a race. By looking at the situation in South Africa and thinking critically about what is working and what is not, one can reflect on the situation in India and adopt practices that may be effective in an India context. As India continues to move forward in the promotion of deceased organ donation, I hope that the goal of helping patients, both in  the private and public sectors, stays at the forefront of the movement. With the talented medical personnel, motivated staff, and dedicated organizations such as MOHAN Foundation, I have no doubts that India will continue to improve deceased donor rates in a way that is effective, ethical, and sustainable.

- Simone Schriger