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Tue Aug 19 02:26:43 BST 2003

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August 19, 2003
Downside to Fewer Violent Deaths: Transplant Organ Shortage Grows
By RICHARD PÉREZ-PEÑA

Whatever you call the opposite of the silver lining in a dark cloud,
this is it.

In the last dozen years, there have been at least two great positive
social trends in America: fewer people die on America's roadways, and
fewer people die at the hands of others.

But this ray of sunshine has a dark shadow. "In my field, we make
morbid jokes about repealing the seat belt laws and air bag laws and
gun-control laws," Dr. Jonathan Bromberg, director and chief surgeon
of the organ transplant program at Mount Sinai Medical Center in
Manhattan, said with a heavy sigh. "I guess we're kind of the ghouls
of medicine."

Even as the demand for organs has steeply climbed, the transplant
field has been hit in the last decade by a decline in young people —
the ideal donors, with the least wear on their organs — who die and
become donors. That decline has come as traffic accidents and
homicides have claimed fewer young lives, trends that have stretched
across the country but have been much more pronounced in New York.

"The number of young donors has definitely declined, and more in the
New York area than anywhere," said Dr. Stuart M. Greenstein, chairman
of the organ availability committee of United Network for Organ
Sharing, the national organization that maintains transplant waiting
lists and distributes organs when they become available, and a
transplant surgeon at Montefiore Medical Center in the Bronx. "We
don't have so many young people getting killed, and that's a
wonderful thing that we can all celebrate, but it also really
highlights the need for more people to donate."

There are not nearly enough donor organs to go around, from any
demographic group. Donation groups say too few people fill out donor
cards or discuss with their families their desire to donate organs.
Each year, more than 6,000 people nationwide die while waiting for
organs. 

Searching for new sources of organs, transplant doctors have pushed
hard at the boundaries of their field, especially in New York. They
now harvest organs that are far from perfect, and they take a
significant number from middle-aged and even elderly donors,
practices that were rare a decade ago. In the region that includes
New York and Vermont, more than 40 percent of dead organ donors in
recent years have been over 50, compared with less than 30 percent
nationally.

"Now, when I hear a 70-year-old's liver is available, I say, `Great,
let's have a look,' " said Dr. Patricia Sheiner, director of the
liver transplant program at Westchester Medical Center. "A few years
ago, I wouldn't even have considered it. We've been forced to learn
how to make that work. I'd much rather have a young organ, but there
are fewer of them available."

Over all, more people donate organs each year, but they cannot keep
up with a much faster rise in demand. And the increase in donors has
been driven mostly by living donors, who can only give kidneys and
partial livers.

The number of dead donors has climbed much more slowly, and the
number who are young has actually declined, particularly in New York,
where both the homicide rate and traffic fatalities have fallen more
sharply than they have elsewhere in the country. Younger organs are
more likely to work when transplanted, and they are more likely to
last for decades, though the success rate with less ideal organs has
improved significantly.

The decline in young, dead donors has had a disproportionate effect
on quantity as well as quality. A living donor gives up a single
organ. A 60-year-old dead donor might have two or three usable
organs, while the rest might be too damaged. But a 20-year-old,
doctors say, is likely to have a usable heart, pancreas, liver, two
kidneys, two lungs and intestines, all in fairly good condition,
enough to save a half-dozen or more lives in some cases.

The demand for organs has grown sharply, as medical science has
improved the health and chances of survival for people with a wide
range of ailments, like hepatitis C, making them candidates for new
organs that no doctor would have tried to give them a few years ago.
And the rise in obesity, diabetes and longevity has meant that many
more people need new organs, particularly kidneys, which account for
most transplants.

All of this produces seemingly contradictory trends. Each year, more
than 12,000 people in the United States, living or dead, donate
organs — twice as many as in the late 1980's. But over the last 15
years, the number of people waiting for organs has more than
quadrupled, to 82,000.

For transplants, the nation is divided into 11 regions. Region 9
covers New York and Vermont, but the bulk of the population, the
organ donations and the transplants in the region are in New York
City and its suburbs.

People who need organs are on waiting lists by region, so that when
an organ becomes available, it is first made available to suitable
recipients within that region. If no one near the top of the regional
list can take the organ, for any number of reasons, including illness
or failure to match blood types, the organ is made available to
people in other regions. But a harvested organ has a short shelf
life, often making it impractical to transport between regions or
even long distances within a region. So recipients are usually
dependent on their own areas to produce the organs they need.

In the early 1990's, dead donors outnumbered live ones by two to one,
according to figures kept by the Organ Procurement and
Transplantation Network. Today, there are more live donors.

The number of dead donors has increased slowly but steadily around
the country, but in Region 9, it has fallen in recent years, so that
there are fewer now than there were in the mid-1990's. People who
work in the transplant field cannot fully explain that regional
difference, but the figures show clearly that New Yorkers lag the
nation in organ donation.

Nationwide, the number of dead donors under age 35 declined 4 percent
from 1990 to 2002. In Region 9, that group fell by 29 percent, and
those under age 18 dropped 36 percent. Yet when vehicle deaths and
killings are taken out of the equation, the region's figures in those
age groups remained roughly the same as they were over the last
decade. 

The transplant network did not begin keeping records of donors'
causes of death until early 1994. By then, the decline in traffic
deaths was already under way, reflecting the advent of air bags,
campaigns against drunken driving, and tougher laws on seat belts,
helmet use and child safety seats. Similarly, homicide began to
decline before 1994, as the crack epidemic eased and police
departments grew larger and adopted new, more aggressive tactics.

Even so, the change from 1994 to 2002 is striking. Around the
country, the rate at which road accidents and homicides produced
organ donors rose 3 percent, but it fell 28 percent among people
under age 18. In Region 9, it dropped 26 percent in all age groups,
and 51 percent among people under 18.

"It's not something people like to talk about, but it's been a pretty
significant change that everyone in the transplant world has
noticed," said Dr. Sheiner of the Westchester Medical Center. "We
don't want to sound like we're complaining about fewer people getting
killed. The answer is for more people to be donors."

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