By Rafael Matesanz
Nephrologist, director of Spain's National Transplant Organization
The Spanish model promoted by the National Transplant Organization (NTO) since 1989 has allowed us to maintain global leadership for 25 years, with the greatest chances of receiving a transplant in a service that is public, universal and without discrimination.
This position of privilege contrasts brutally with a widespread international situation of scarcity. The numbers are outrageous. The annual demand for transplants is estimated to be between 2-2.5 million patients while the transplant process does not exceed 127,000 operations: only 5-6 percent of those who need a transplant get one. On the other hand, in Spain more than 90 percent of these patients get one in time.
These differences shine a spotlight on us for people around the world who aspire to get transplants in our country. And here comes the problem: there are not enough organs for everyone and competition for those available affects the possibilities for transplants for our patients. Spain collaborates with many countries to improve their systems and many lives are saved in this way, but our 4,800 annual transplants cannot satisfy this demand. It is called transplant tourism due to the fact that a person travels to another country for the sole purpose of getting a transplant done, obviously because in their place of residency they do not find the right conditions.
First of all, let?s clarify concepts. Spanish nationality is not required to get a transplant in our country. Up to 9.25 percent of those who received one in 2016 (446 of 4,818) were born abroad, in no less than 62 different countries, but most of them had been living in Spain for many years and had the same rights and duties as those born here (with or without papers: no one has been denied a transplant for not having them), or it was a vital emergency that required immediate treatment. There is no discussion on these cases. Similarly, 11.7 percent of donors in Spain were not born here. It is not a problem where someone is born but where they live and which province they belong to for all intents and purposes.
Attempts to access our waiting lists from other countries have been a constant in these 25 years of leadership, by well-intentioned people but who did not know or did not pause to think that despite our high rates of donation, we will never cover all the demand. Between 6-10 percent of patients on the waiting lists for heart, liver or lung transplants die each year without obtaining the savior organ. Each transplant for someone coming from abroad means that someone on our waiting list, Spanish or not, will die or stay on dialysis, even if their identity does not come to light. Evidently.
The systematic refusal of the NTO of these attempts has been generally well understood, although it has not earned us many friends. Access to transplant patients from outside (why yes to some and no to others?) is not a gracious concession of the doctor, nor of any non-profit, nor of the one making the recommendation (usually a politician), nor even the NTO: it would be the patient who at the end of the waiting list does not arrive in time for their transplantation and it is most doubtful given that knowing the conditions, he/she or their family would be giving their approval. To this must be added the real risk of the local population refusing to donate organs if they end up mostly in patients from outside the country and almost always with money in between. This is something that has already happened in countries like France or Belgium in the 1980s, when Italian patients flooded their waiting lists, with great deterioration of the credibility of their systems by mixing irrevocably spurious interests in the admission of patients.
The 2012 European Union Cross-Border Care Directive excluded the transplants from deceased organ donors, which already prevented a flood of patients from the European Union to Spain (Germany has a quarter of the donors than Spain, the United Kingdom has half, and countries like Bulgaria have 20 times less).
But it did not eliminate the problem. Transplant tourism is probably the biggest threat looming over our system in the near future. The case of Bulgarians who in 2015 traveled to Spain with false work contracts to access dialysis and transplants in Madrid, within what the Civil Guard called Operation RENIBUS, was only the tip of the iceberg that allowed us to detect similar cases among different nationalities in other communities.
The threat of transplant tourism comes from both isolated cases of people with resources or influence, and ? above all ? from waves of people coming in like the Bulgarians: well advised people who tend to look for loopholes in the legislation to fraudulently access waiting lists. Recently, the director of the autonomous organization of Catalonia exposed a number of cases in his community despite the filters applied throughout the state, and the same could be said of other places such as Madrid or Andalusia, where the pressure is rising.
The only way to stop this growing phenomenon is legislation that establishes a minimum residency period in Spain to be able to access the waiting lists: perhaps 2-3 years, except for emergencies. This law, which would be endorsed by all the international recommendations (WHO, the Council of Europe and the Ibero-American Council of Donation and Transplantation have already agreed on this), was not developed at that time by the prolonged period of rule by the caretaker government. But now it is necessary to seriously raise the issue and look for a consensus that allows a law of this kind to be carried out. Both the lives of many of our patients and the very future credibility of the system will depend on it. Looking the other way is not an option.
Disclaimer: This article is part of an Agencia EFE service which brings opinion-makers to its readers and relies on the contributions of diverse eminent figures, and solely reflects the opinions and points of view of its author.