Sigrid fryrevere, founder president for the site for Ethical Solutions is next year to travel to iraq or selling of organs is illegal. The set of the country solve the problem of organ shortages and a major problem today u. S. This is just under an hour. Good evening and links for coming. You may be wondering about the similarity in their names. Its because sigrid is my wife and so it is my great privilege to be able to introduce her here tonight. And in case youre in familiar with her career, i want to just say a few words at the beginning. Sigrid is a person has accomplished many first and her allies. Shes the first person to have as a joint law degree and phd in bioethics in the united state which eminently qualified her for another of her first. She was the first to travel to and to see the donation for kittens. Shell tell you about what motivated her and what was unique about it and whether or not she has sold this shortage. Without delay, sigrid fryrevere. [applause] im not doing this right. I know why. Its supposed to take this one, right click got it home okay. You can hear me, right . Thank you, bob. That was three. I am very happy and excited today and when i am less it, i like to think that maybe i am the herriot teachers go of the kidney transplant world and that people who read my book will see a human face on kidney sellers and herein and diplomate to see change in how the u. S. Looks at living donation. For those of you who might not know what harriet beechers airwaves, she wrote the book Uncle Toms Cabin at the time of the u. S. Civil war and because of her book, she put a face on this offering is played in this house she brought the debate about slavery home to family and people feeling in the life is really like for them. That is what i hope to do with my book. I hope to bring home what it is like to be a kidney sellers and it ran. So my book is nonacademic. It not a polemic. It is a book of stories. Nice. Discovery in the story of the kidney sellers whom i interviewed. Im going to do three things today. Im going to give you a tiny bit of background on the organ crisis because without that you dont have a context for the book. Then we are going to be a short book trailer that my friend made for me because she doesnt reminisce what i could do in 20. After that will put a question because it is my herein but that is really the most important part to answer your questions about the book in the system and herein. So what about this area . The history starts really 35 years ago with the development of immunosuppressive drug that made it possible to transplant one oregon from one person into another. The organ they use with kidney. The reason they use kidneys is that we all have to kidneys and both the donor and the if you could live with just one. But with this realization that we could save people who needed kidneys and we could use immunosuppressant drugs to do that, the brilliant scientist and medical researchers at my goodness, why dont we use cadaver organs. And then the whole development of transplant history really is dirty growing fast with figured out that we can these people who needed heart, who needed loans, needed livers, needed and test. Every other paths of major organ that we could get from cadavers, but we obviously cant get from living donors because the living donors need to. They kidneys then and now, living donors can be fine with just one. Thats very, very important because what happened about five years later is the arabian islamic revolution. And the significance they are is that the time iran was participating in the european organ transplant network. So they were developing like the west was a cadaver Organ Donation. But when the unlike revolution had, they were cut off from the west in part because of religious and. The koran has been problems with using dead bodies and because the west shortly thereafter impose sanctions and they didnt have the research is coming at Technology Review structure to really continue deceased Organ Donation. So they decided to focus on living donation. The simpler sort of oldfashioned way of dealing with the transshortage. This wasnt as irrational as you may think because 80 to 90 of people who need organs they kidneys. So they focus on the largest part of the population that needed help, while we focus on everybody at the same time and we focus on finding the type ologies we could to keep organs viable and transport them quickly into every them we could to get them from cadavers. Why put a living person at risk for a kidney if you can get it from a cadaver. The important point here is we went in two different directions. He ran than 30 years improving it Living Donor Program while we spent 30 years concentrating on our deceased Organ Program. Now if you look at today, there is a real and that you can get from them is old. If you need a heart or liver, better live here. If you need a kidney, being iranian. Because imuran axiomatically qualified to get a kidney, you get one. In the United States, out of the 120,000 people who need organs, 100,000 of them need kidneys. 15 to 20 american die every day because he cant get a kidney. And that is not happening in iran. For the last 10 years iran has houses in order to work on it deceased Organ Program but slowly catching up. And theyre looking to us for a lot of technology in the developments in that direction. But until i went to iran, americans were not looking at alternative landuse fee how to deal with the kidney shortage. They had thought that are reclaiming the ball pit and it kind of my mind that no one wanted to go. No one believed they could done it for said maybe they were awaiting the poor are forcing people to donate. And welfare claiming to solve the shortage coming maybe someone should go work. Maybe someone should see what is going on. Getting there was not easy, but the book talks about that in the book also talks about, you know, just the ring and cut them. But ultimately what it really comes down to is people helping people and people being willing to donate a hit away a lot of american studio. A lot of american donate kidneys all touristic lee. But only 15 to one of the population that needs a kidney and that getting one. They all touristic donation is clearly not enough. The only other thing you really need to know is even a families angloamerican were a donor, we still wouldnt have been half kidneys because fewer than 1 of the population dies under conditions that makes sharing organs feasible. The reason is they die too far away from the hot widow but they are too old or too sick. Even if every single american were a donor, that might increase the amount by 10, 15,000 kidney and my feeling is, you know, we really want to take a look at what arenas doing. The analogy i like to use is if you have a neighbor down the street that you really dont like him you dont get along with them, they have different traditions you do, you can avoid them no problem. Stay away from them. You dont have to interact with them. But let say that it placates your street and people start getting sick and your neighbors are dying and people in your household are dying. But for some reason that person done this tree, the one you really dont like, no one in their house with his dying. How long does it take before you have the courage to go up to the person, knock on the door and say hey, share with me what you are doing because i dont want my people to keep dying and you seem to be doing something right. Well, it has taken us 30 years. I would like to go ahead and show you guys the trailer now you can get an overall sense of the book. Is. One is historic. Namely, this 1983 right before the National Organ act was passed, dr. Jacobs suggested that we import people from developing countries, pay them a couple thousand dollars, take their kidney and send them back home. Just a few people, okay . They thought this might be exploitation or taking advantage of people from developing countries, and so it was pretty much a straight out ban was written into the act. At the same time, people were telling congress dont worry about it, we can solve our organ shortage with deceased organs. Now, two things are important. One, we havent solved our organ shortage with deceased organs, and its never going to happen. The second thing is that they kind of threw the baby out with the bath water because iran isnt a case like what youre talking about in the black market, you know . Were not one of the first things they did was close their system to foreigners, okay . So you dont have they did at first, but they learned their lesson. You dont have foreigners coming in and purchasing or selling kidneys in iran. So if there were some kind of system that compensated donors in this country, it would be with one only available to americans and not available to foreigners, okay . Either for selling or buying. And the other thing that happens on the black market that a lot of people dont understand is you look around and you think of kidney selling, you think of the black market. Because thats what you hear about on the news, and thats at 0 thats 90 of whats going on. The reason the black market really is unethical and abhorrent is because theres no rule of law, theres no enforcement of donors rights, theres no protections for donors. So if in this country we can manage to enforce informed consent and fair dealings which were really pretty good at, i mean, were not corruptionfree, but were pretty good at maintaining, you know, fairness in our society then we should be able to help people who are donors be altruistic and donate. The system that we have now actually has a disincentive for donation because our system will cover your medical costs, but they wont cover incidental costs. You know, people who have given a kidney usually have thinker from a month to three anywhere from a month to three months of recovery, and that kind of depends on whether or not theyre a blue collar worker. But how many people can afford to be out of work for three months, right . In this country you have to be able to support yourself during that time. We have charities that can help people who have the transplants, and you can imagine you go to the hospital, and a charity puts up the whole family of the transplant recipient, and if the donor wants to have their family come stay with them or pay for a babysitter or anything like that, charities cant help them. Its against the law. It would be considered paying for the organ. Now, i have created an organization, stop organ trafficking now, which is working on getting the law changed. So hopefully, something will happen there. Our goal is removing the disincentives that exist in the american system to make Organ Donation easier. Now ill go ahead and open it up to questions. If you wouldnt mind coming to the center mic so that everybody can hear you if you have a question, that would be really great. How would you know if [inaudible] you experience frequent urinating maybe because of sugar overload, but if it continues, how would you know if you had maybe a kidney problem, or maybe it could just be overactive by caffeine . How would you really know . Well, im not a physician, but clearly diabetes is one of the greatest causes of people losing their kidneys in this country. So if you talk about solving the organ shortage, longterm solution would be improving our diets and helping prevent things like diabetes and hypertension. But that would take many years. So Something Like allowing a program that would help compensate living donors is her of an immediate solution that would help save lives now. Because remember i said theres anywhere from 2025 americans dying every day. So while fighting diabetes is certainly a longterm solution, its not an immediate one. So even if compensated Organ Donations were put in place in this country, theres going to be some kind of intrinsic undertone of exploitation, because the people who are more likely to donate their organs are those in financial need, i would presume. And i think that seems to also be the case in iran. So i was wondering if you could just comment on the ethical points of that. Okay. No, thats a very good question. But part of what happens when you legalize something is you normalize it. And actually in iran, the most people who both buy and sell organs are the middle class. If you have a black market for selling organs, you have to be a really desperate person, desperate for money to do something illegal, to take such a health risk of, you know, going into unofficial hospitals or hospitals that dont have permission. And if youre on the black market, statistics say that 50 of those people dont get paid what they are promised. And in pakistan the last survey i saw 100 of the people in the survey werent paid what they were promised. So if you have, as you do in iran, they have ngos, nonorganizational nongovernmental organizations, so Nonprofit Charities that do the donor recipient matching. Those people dont get paid. So they arent the brokers like we have on the black market. In the United States, if youre a rich person and you decide you dont want to bear the burden of trying to get a kidney on the waiting list because your chances are too slim and you decide to go to the black market, youre probably going to pay 1 200,000 to a broker. Then the poor guy who donates the kidney gets 2,000, and then that person is afraid to go to the hospital to get after care because hes done something illegal, and for all you know, gets an infection and dies at home, okay . If something is legal, that doesnt happen, you know . When we were in iran in the hospitals, you had the donors were in the Recovery Room right near the transplant patients, and they were in the rooms near each other, too, while they were waiting for the operation. And they come to the same clinics for after care, and they get the same doctors, and they get the same care. And when its not illegal you have, yes, you have people who might need money, but you also have people who are doing it not because they are desperately poor, but because they want to improve their lives. My book is full of stories of people who sold a kidney to start a business or to build an addition on their house or to do the equivalent of pay off their mortgage. So these arent people who are desperate, these are middle class iranians who are taking advantage of a way to make money. In iran theres also a whole different attitude. You know, on the black market you think of it as the person who is selling their kidney is a resource for the person whos getting it. Like theyre selling a commodity or something. The iranians dont look at it that way. The way they look at it is as a service to humanity. And that both parties are saving each other in a way. One is saving a person from dying, and the other is saving a person from a financial need they have. And they also heard over and over again you cant put a price on a kidney. You cant put a price on saving someones life. This is a good deed im doing. The money so i have two questions. First would be what is the response from iran, like, to you personally . Because, arguably, this is good press. And the second one is if regulation was in place here, we kind of know what the end would look like. Something like this, but maybe not that. How do you see the transition in terms of allocating the rising number of kidneys available and what factors should, i dont know, government consider . Excellent questions. Actually, its kind of funny. The reactions out of iran are a hitting mixed. A little mixed. I just got an email yesterday from a very nice physician, and it says dangerous country on the front. Did she feel threatened . Did she feel not safe in my home . And im like, well, a couple months after i got back a journalist was arrested and imprisoned for four months, you know . [laughter] so i just wrote him back, it wasnt living with you that was dangerous, it was the filming that was probably dangerous. And ive had other iranians like a physician from tehran said what do you mean you didnt like the way were doing it in iran . What do you mean . So, you know, but i liked the way they were doing it in certain place, and i was critical of how they were doing it in tehran. I hope that once they calm down they will look at it as a way to improve their own system. But it has not been a lot of people are very excited about it, and a couple physicians have contacted me and said, thank you, thank you, theres something we can learn from this. But ive also had a couple funny reactions, i think, to the book from iranians. As far as your second question is concerned, my book in its conclusion actually suggests that we do a Pilot Project. But i was lucky enough to get the law firm of dixie and shapiro to work for me pro bono on trying to move government in the right direction on this. And they thought that a Pilot Project was not the right approach because it requires funding. So they actually suggested that we work on changing the definition of valuable consideration. Which has been chipped at already several times over the last few years like with paired donations. Congress decided thats not valuable consideration, thats fine. Theyve created funds for people who are 300 of the poverty line. So we want to continue chipping at the limitations for who is allowed to to be reimbursed as a donor. And the way to do that is to broaden the exception to what is considered the type of payment thats not allowed, okay . And thats what were working on right now. Im going to go testify next month in front of the finishing das trans the fdas transplant committee. I dont know if thats going to make any difference. They suggested ten years ago that we study compensation, and it doesnt go anywhere. It didnt go anywhere. But the thing is the good thing about what dixie and shapiro is suggesting is that it would be a gradual change that would not require additional funding from congress. We would have two approaches. One would be to change medicare because to keep the patient on dialysis costs 300,000 approximately more per year, per patient than to give them a transplant. So were going to move some of those funds towards compensating donors for their expenses. And that will save medicare money. And so we think we have a rate good argument for them to do that a pretty good argument. And that would only go to donors who are at the top of the waiting list, who are in the host need. So that would be medicare funded. And the second thing we would do is broaden the exceptions that allow charity to get involved. So like the situation where i talked about where youd have the family of a transplant patient, their housing taken care of, their meals taken care of, their babysitter taken care of, all of that by some charity. Were going to allow that kind of thing to happen for donors because right now thats illegal. So were going to allow private charities to get more involved. The one thing we are not going to allow, and this is one reason, you know, the organization is called stop organ trafficking now, is we believe that we need to outlaw any kind of brokering. So it has to be charities like in iran. And iran learned this too, because iran had a system where people were making money making matches, and it backfired on them. And some of thats starting to happen again in iran. But its much better if you have Nonprofit Charities helping donors, i think, than if you have a profitmaking mechanism. So our organization will suggest that congress continue to ban any kind of brokering, so anyone getting a fee for doing matches. And also encourage charities to step in. Thank you. I have a question about will you please come to the mic so we all can hear you . Dr. Patel, come on, she can my question here is this, theres been concern in reference to some people madam . Could you please come to the mic so we all can hear you . What about this business of organ that muching . Taking orr snatching . Taking organs without peoples consent . Theres been a question as to whether a person is really deceased. They havent really come up with a definition of a person whos deceased. Uhhuh. Before they take organs. And how do you, what would you tell seem here how to tell people here how to protect themselves from organ snatching when a person is not able to speak for themselves ask can that sort of thing . You know, this is the fear thats come up in part because of the push. Theres such a huge push in the United States for people to donate, and we have such an extreme shortage that people are afraid of things like or began snatch organ snatching. Now, theres no evidence that that has happened in the United States other than in Funeral Homes for tissue and bone, not for major organs. Well, i that also, the tissue right, right. Well, that, that has been known to happen once that someone at the Funeral Homes were engaged in taking tissues from the people they were sewed to prepare for burr they were supposed to prepare for burial. And those people have been prosecuted. [inaudible] widespread, its a widespread problem. Well, i dont know how widespread it is, but ive been concentrating on major organs in the hospital setting, and, you know, no ones ever been accused through the legal system of any kind of organ snatching. But people have that fear because in america the shortage so severe and the doctors and ask and ask. So the fear comes up. I also have on the center for Ethical Solutions theres an article and also a book that i wrote on the definition of death. So that question has come up. And, you know, so far really the issue is when do you ask really. I mean, thats really what it comes down to. I mean, i think were pretty sure when someone is dead, but that is a debated issue. But again, if you using living donors, you dont have problem, you know . I had a couple people in iran tell me, i was just flabbergasted, he said, oh, i would because now theyre starting to have the option of having deceased organs, so they can be on both lists, and often people take whichever comes first which usually is the living donor. But i had a couple people tell me i would never take a deceased organ . Why . Because i cant look the person in the eye and make sure theyre okay with it. I thought that was very interesting. So if you have a living donor, you can look them in the eye and see if theyre okay with it. Thats another, it brings up another point which is kind of interesting is the charities that do the organ matching, its kind of like open adoption. 50 of iranians would want to know their donor or their recipient, and the other 50 didnt want to know. And it was really up to them. Only if the toe nor and the recipient if the donor and the recipient wanted to know each other, could they know each other. Thats an issue that comes up sometimes in the United States about whether it should be anonymous or not to, in iran they let you choose. My question is whats the ethics underlying that whole process, and whats the difference green, lets say between, lets say, the antics of the u. S. Which michigan might have some kind of rule on it or the ethics of iran or maybe im going to say china or oh things . Other thingsesome so whats the ethics . You said anything goes. Like french something. Right, right. The ethics is a question of whether or not it exploits the poor to offer them the option of selling a kidney or being compensated for a kidney. On the black market, there is a real threat to vulnerable populations because they are lied to, they are cheated, they arent given their money, their organs are taken sometimes without their permission, okay . If you have a system where there is a rule of law and informed consent and guarantees for fair dealings, you have a Civilized Society with a civilized way to make sure people know what theyre getting into. Now, we allow people to do living donation. Its not dangerous. A third of the kidneys that are transplanted in America Today are from living donors. So we dont think its inherently dangerous, right . But what were worried about, at least what we were worried about when we banned it, was foreigners who couldnt speak the language, vulnerable populations coming in and selling their organs. Now, everyone whos a living donor goes through psychological tests and medical tests. So anyone who is a compensated donor would go through the same tests. And youd want to make sure that they though what theyre getting into, they understand the risks and that, you know, this donation is happening pause they really want because they really want it. Now, if youre only compensating expenses, its not like theyre doing it because theres no incentive to do it other than a good deed. Youre just taking away the financial disincentive. And, actually, i have not heard any ethicist argue about that. Compensating someone for their expenses is fine. The question is how do you do it. Right . Some of the processes we have now like credit on your taxes for expenses for Organ Donation dont do a poor to person or even a middle class person much good. Because you have to have the 8 or 10,000 up front, and then you only get the money back a year later. So those people have relatives and friends that they cant afford to help. And thats whats wrong with the system. So i think that if you have a Civilized Society with a decent rule of law, you dont prevent difficult choices, you headache them safe. You make them safe. And you make them safe with informed consent and something that assures fair dealing. Dr. Patel . Do you have a question . Yeah, i have a question about how the insurance companies, the Health Care InsuranceCompanies Take these living donors, donation, are they going to exclude them as a reexisting condition because preexisting condition because they knowingly donated and if they have problems later on, are they going to [inaudible] as regular patients with bad kidneys like two kidneys . Are they going to be excluded as, hey, you know, you voluntarily gave one out, and now you have a problem with the one kidney you have, is that going to be preexisting . Very good question, and, you know, that has happened in the United States. A woman called me who said that she had her, she donated a kidney, and she had a problem afterwards, and she didnt know if it was related to her kidney or not, but her Insurance Company decided it was, and five years later and 300,000 later the hospital and the Insurance Company are still arguing about who should be paying her bills, because the hospital is supposed to cover anything directly related to the kidney transplant. To s so the Insurance Company was arguing it wasnt, and so this oar woman was stuck poor woman was stuck with 300,000 in medical bills because her Insurance Company wouldnt cover it until the suit was settled. In iran it is against the law to discriminate against someone because they have donated a kidney. But i also think that because of obamacare, hopefully, most seem will be insured, and it wont be a problem if youve donated a kidney. Ive heard of someone who switched jobs under the, you know, old system who was denied coverage because of a preexisting condition argument. But im hoping that that wont be a problem going forward. Thank you. Hi. My name is emily. I wanted to asco zm a questiont your comments on how you think so im assuming the system in america would be all government based and not privatized, so that would cause other problems, right . Well, it would with private in the sense that private charities could help, right . Okay. I think the procurement organizations should take it on and distribute those organs the same way they distribute the deceased organs, namely according to priority of matching i mean, a point system. So it would be done based on who needs the organ most and who is the best match. But we have this vast network, so it would just be a question of expanding their responsibilities a little bit. Thank you. Youre welcome. Hey, i know this guy. [laughter] iran isnt a country thats known for getting a lot of american tourism. How did you get permission to travel there and conduct research in iran . [laughter] i like to talk about the issues, but all the reviews on the book are coming back that the story of how i got there and what it was like to be there was, for some people, the best part of the book. Im not then of the royalties will come to he, they all go to solving the organ shortage project. But the story itself, i must say, is a little bit exciting. I wasnt allowed in. My visa was denied at first. I decided i would apply to speak at a conference in iran, and speaker said youre american, right . Yeah, im american. You sure you want to come . Most americans dont want to come. So i went and my visa to go to this conference in shiraz was processed along with a thousand other visas. So i got in for ten days. And then the drama begins with, you know, who do i want to take with me, and person after person famous documentary film maker pulling out on me, medical anthropologist pulling out on me last minute. And finally a doctor, bahar bass tanny whos an americaniranian physician takes a medical saw pat call from his University Sabbatical from his university and comes with me. He doesnt need a visa, because hes got an iranian passport. Theres a lot of high drama. Someone just emailed me that their favorite part was when i had go to the Police Station and walk past guys with ak47s to get my visa renewed. So those are the dramatic parts of the story. And, you know, dr. Boustany called me three days before we were supposed to leave, and he said, did you see the news . What news . A japanese tourist was just kidnapped for ransom, and no one knows where he is. I said, oh, great. Every time i was somewhere without dr. Boustany, i had a stand for my camera, right . And i would take it with me, and i would swing it, id go walking down the street in back alleys swinging this. You know, im in my full black regalia, you know . I just figured no one is going to kidnap the crazy lady swinging a metal club, you know . Theyd probably pick some easier target, you know . So thats in the book too. Another question . My name is lee. Where do we find the book . Itll with right here. Okay. My husband will help people buy it. On the grander scale of things, i guess this is about solving the organ shortage overall, and thatll entail more than living toe nations. I was donations. I was, im curious as to what your ideas are about optin versus optout systems for [inaudible] Organ Donations in the u. S. As well as iran. Does iran, i believe iran has an optout system. No. No, iran does not have an optout system. What hes talking about is when you die, are you considered, you know, like communal property, or is it assumes that you were going to donate. And if you dont want to donate, you have to call or email a registry that says you do not want to be a donor ahead of time. There are softer provisions and harder provisions. Soft provisions would allow your family still to say no. Hard provisions would say if you have said if you have said nothing about or began donation Organ Donation, your families cant stop it. My problem with that is i think it kind of goes against the grain of what americans believe. They believe they kind of are control of their own fate and their own bodies, and they like the idea of their families deciding if they havent decided. But that aside, that aside would only increase the number of organs by maybe 10,000. I think through living donations we could solve the organ shortage. And the reason, you know, maybe not with just getting rid of the disincentives, but thats something, you know, people had asked me, so is that what they did in iran, they got rid of the disincentive . No. The average package of money and services that people were getting when i was there was close to 45,000. Okay . Thats in u. S. Dollars equivalence. Because when i was there, three million [inaudible] was the average income for an iranian, and the average going price was four or five million, okay . So more than the average iranian made in a year. And then on top of that they would get free health insurance, they would get job services, they would get access, job loans, they would get free dental care, they would get free eye care, all sorts of things that were available this the after care in the after care clinics. So the sea change i was talking about is the institutions that provide the charity for transplant patients and their donors. The sea change i was talking about is that where it worked well in iran, they treated both the donor and the recipient as their client. They wanted to solve both their problems. Okay . So if the donor was out of work, they would try to help him find a job. Sometimes they would even help him find a job so he wouldnt have to to donate. Or if he wanted to start a business, they might, some of the money might come from the organ sale, and then they might give him a Business Loan in addition to that to help him solve his problem to start his business. We came across zell people who were several people who were apprentices ask couldnt get out from underneath their apprenticeship because they couldnt save enough money to start their own businesses. So some people sold their organs to do that. So did i answer both your questions . Yeah . Okay. Okay. Any other questions . Do you want to come to the mic, please . Hi. What about, like, the fact that theyre poisoning the water, youve got gmos that cause cancer in the foods, and youve got marijuana which cures cancer and, you know, theres been numerous, many, many studies now there universities in america and abroad, so why dont we talk about those things instead of donating organs . Why dont we fix the problem . It seems like, you know, everyone likes things to fail and break down so everybody makes money. Ooh, sorry. How about we, you know, how about we stop poisoning ourselves . Youve got gmo poison in the breast milk in mothers now and this toxic levels. And also in baby formula. Why dont we talk about that stuff instead of okay. Okay, well, thank you for your question. Those are clearly issues that somebody needs to talk about, but, you know, it isnt my book or my, my particular cause. Those are also longterm solutions. Im talking about something that if the law changed tomorrow, wed immediately start saving american lives. While the things youre talking about are longterm environmental changes. Which i also believe in. It isnt what im sorry, you are a medical doctor . No. Oh, okay, sorry. No. Im a lawyer oh, youre a lawyer. Ph. D. In ethics. Oh, you could sue em. [laughter] you know, its like the doctors taking an oath just like veterans taken an oath to protect the constitution which they have failed. Doctors take an oath to save people except cannabis cures cancer, but they dont sell anything. Lawyers could very interesting. Is there anyone else that has a question thats related to my book . How you doing . [laughter] im fine, how are you . Good to see you. Okay. The first question is about data. Do you have or have you heard from [inaudible] in the book pertaining to the fact that [inaudible] and also some other studies have been done, but i mean specific to your book. Is there anything like [inaudible] i interviewed 216 people. Okay. And system of those interviews some of those interviews were with doctors and the ngos that do the brokering, but 50 of them were actual kidney sellers and another 40 or so were recipients, and then there was a bunch of dialysis patients as well. But one thing is that if you have people who need kidneys who arent getting them, where would they be . They would be in the dialysis center. Or as one iranian doctor told me, they will be in rural areas dying without even being recognized as having kidney disease. And iran says they have that problem. They have the problem that some people arent identified at all or are identified too late in the rural areas. But when dr. Boustany and i went from person to person to person in the Dialysis Centers and we asked why are you here . Oh, im getting my kidney last month. Why are you here . I lost my kidney, i dont want to go through that again. So we went in five different Dialysis Centers. We went patient to patient to patient, and there wasnt anyone who said im too poor to get a kidney or they wont let me have one. So where are they hiding those people if they exist, right . [inaudible] right. Thats right. And that they can always be [inaudible] and the second question i want to ask you is more informal. Are you going to go back . [laughter] thank you. Well, in the name of small successes, there is a gentleman who called me a couple days ago and said i was about to head to the philippines to buy an organ illegally, and i saw your book. And i said, yeah . [laughter] what my book doesnt tell you how to get a kidney. He said, yes, it does, if youre an americaniranian. Im flying to tehran in two days. So i dont know if its safe for me to go back, to be honest, and i also think that if i had asked for permission, im pretty sure they would have denied it. So if i go back, they might know what im up to x theyll probably deny and theyll probably deny my visa right up front. Although the academy of medicine and science, in Science Education asked me to come. To talk to them about my findings. But i, i dont know. Im hesitant about doing that. Hi there. I also have two questions for you. The first being youd mentioned earlier in your talk about how deceased Organ Donation wasnt really used as much in iran as it is in the United States and other country, and i was wondering if you could talk about the cultural shifts that might have caused that to become more practiced in iran now. And then i was also interested in hearing about why living donation, the implementation of the program differs from region to region in iran. Was it seems like some of them are implementing it a little bit better than others. Right. Excellent questions. One of the problems with the data coming out of iran is you had articles based on information that was collected 20 years ago in one region in iran or the other region in iran, and then more recent data again, from just one hospital in iran and, you know, some of this data is like saying you can judge the u. S. Medical system by looking at rural mississippi 20 years ago. Right . Is that fair . No, right . So the same thing in iran. Iran has poor areas, and it has wealthy areas, it has big cities, and it has small villages. And, you know, the big cities that are rich are the ones that have the best programs. And in particular theres two. I was very, very impressed with programs there. Keremamsha, there were interviews 20 years ago when iran hasnt really started regulating yet. So it was kind of what they call a gray market at the time. And those donors felt horrible about what theyd gone through. The money they were given hadnt solved their problems, they were still poor, thereq e no control over their after care and all those things. Well, iran learned from its early mistakes. And so over 30 years while we were improving our deceased Organ Donation program, they were experimenting from region to region and over time with how to improve their Living Donor Program. Theres a lot more we can learn from places than tehran and exactly nothing we can learn from some, so, you know, but thats not unexpected, you know . I mean, if you want to, want to see a shining, efficient cancer hospital, you go to sloan sloankettering in new york. You dont go to some tiny town in the mississippi, right . But because of that, also, i think i got a good view of how things could be different and why in iran, because we did go to six different regions, spending a week interviewing in each. Now, as to your second question, this is really fascinating. I think because before the islamic revolution, they were working towards doing deceased Organ Donation just like we were. But the quran has warnings against using deceased boys. So when the ayatollah deceased bodies. So when the Ayatollah Khamenei came in and there was strict interpretation of the quran, people also thought the use of deceased organs would be bad. And it took the mullahs and the ayatollahs, essentially, ten years of debating about whether it would be acceptable to save lives by using parts of a corporation. Because corporation. Because youre not allowed to eat corpses if youre starving, so, you know, what happens if you want to use a corpse to save another life by taking an organ . And after ten years of debate, they decided it was okay, and then shortly after that the Iranian Parliament made it legal to do deceased Organ Donation. And be and so now theyre behind, but theyre starting to catch up. Theyre starting to do more liver transplan