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Joint Standing Committee on Foreign Affairs, Defence and Trade
08/06/2018
Human organ trafficking and organ transplant tourism

FRASER, Dr Campbell, Private capacity

O'CONNELL, Professor Philip, Immediate Past President, The Transplantation Society

Evidence from Professor O'Connell was taken via teleconference—

CHAIR: I now welcome Professor Philip O'Connell, via teleconference, and Dr Fraser, here in person. Do you have anything to say about the capacity in which you appear before the subcommittee?

Prof. O'Connell : I am here as a transplant physician, and I'm the immediate past president of The Transplantation Society.

Dr Fraser : I am speaking today in a private capacity, so the opinions I give are entirely my own and not those of any organisation that I have an affiliation with either here in Australia or overseas.

CHAIR: Thank you. Would you like to make some opening comments, Professor O'Connell?

Prof. O'Connell : I guess the only opening comment that I would like to make is that there is a strong coordinated effort worldwide to combat organ trafficking. There have been a lot of new instruments that have come out internationally in this space, including the EU dialogue on organ trafficking. The United Nations have brought out new things on organ trafficking, and the WHO have linked with the UN to look at the health issues. The Transplantation Society has been working closely with those organisations to try to combat these crimes.

CHAIR: Dr Fraser?

Dr Fraser : Since we last spoke, during the last year, most of my activity has been done in the capacity of a transplant patient as well as an investigator of organ trafficking, I am a kidney transplant recipient myself, and in that capacity I've spent a lot of time talking with transplant patients, particularly in China, the Philippines, Egypt and other areas of the Middle East. What I've been trying to do is really get a grip on the perspective of the patients who have been receiving transplants in countries where there either are or have been concerns about organ trafficking, to really try to establish a basis for what is actually happening in the domestic market in these countries as opposed to just looking at foreigners going to these countries for transplantation. I've been doing that in conjunction with a number of organisations, particularly the World Health Organization and the Pontifical Academy of Sciences. We've made a number of trips to China during the last year and to the Philippines and to the Middle East. So I'm happy to give an update today on what we're ascertained from that, particularly the information that we've got and, more importantly, the information that we haven't got from that. I can certainly talk through each of those countries. I can do that now or I can wait. Do you want me to go ahead?

CHAIR: I'm happy for you to do that now.

Dr Fraser : I'll go ahead and do that now—okay. I will start with China, which has clearly been the country of most interest to a number of the people involved in this inquiry. We've made major inroads in China, I'm pleased to say. We're now working collaboratively with specific members of the Chinese Ministry of Health, particularly those who are responsible for reforms taking place in Chinese transplantation. Professor O'Connell will know who those people are. Related to that, we've had a number of visits to universities in China, as well as a number of hospitals and hospital authorities, and talked with a number of surgeons, doctors, physicians, hospital administrators and what we call OPOs, organ procurement organisations. These are the organisations that are set up to identify organs available for transplantation. They are responsible for finding a surgeon who will recover those organs; they are responsible for the transportation of organs to another location; they're responsible for the allocation of those organs to specific recipients; and they are responsible for finding the surgeon and the hospital that will actually do that transplantation. We've spent a lot of time with them and a lot of time with the patients themselves who have received organ transplants. And I personally have spent quite a bit of time in the paediatric area, looking at what children's hospitals are doing and looking at Chinese children who are now able to receive transplantation.

Within that context, we're certainly aware that there are still concerns about China. We are not in any way trying to say that our group has eradicated the problem of organ trafficking in China. We're also not saying that there are not prisoners of conscience in detention in China. We're not saying that at all. We accept a number of the testimonies that individuals have given about certain human rights issues in China, and we're not trying to escape from that. We're also perfectly aware of the way the Chinese government will present facts. Some will call that propaganda. We have spent a lot of time trying to understand that there's going to be that element but, within that, we try and really hone down into what is really happening.

We'll certainly never be able to know exactly everything that happens in China, but I believe, and a number of the colleagues I work with believe, that the best way to get that information is not to protest from outside but to get in there, develop collaborative arrangements, and bring Western organ specialists—that is, people who are involved in organ procurement, technical training, administrative training and ethical training—into China to run courses and develop programs collaboratively with certain Chinese hospitals. That is what we've been doing.

So we know there's a problem. We know that there are still certain hospitals in China that we have not been able to get access to. We know that there was this Korean documentary. We're quite aware of that and we're certainly looking into that. I have actually visited the hospital where that video was filmed, and we're still trying to get a lot of information about that. So we are by no means saying that there's not a problem in China—not at all. What we are saying is that, compared with where we were three or four years ago, we're now in totally different realm.

We now have in China a group of champions—doctors, particularly surgeons, and some government administrators—who we believe genuinely want change to happen in China. They have actually taken a lot of personal risk. They have been really courageous in standing up and saying, 'We do not want to have that reliance on executed prisoner organs.' And they have been very active in developing deceased donation systems that are now in place. The deceased donation system that is in place is very small in comparison with what we enjoy here in Australia and what other developed countries enjoy—but it's a start. We believe that, by continuing that engagement, we are actually going to make it a lot more difficult for China to go back to the old ways. It has to be said that there are still some surgeons in China who probably could find their way to be going back to those old ways. So we've really got to try and build capacity in China to have ethical transplantation.

We are also seeing a number of Chinese surgeons who are now presenting papers at international conferences. We had the major organ procurement conference in Geneva last year, and a number of Chinese hospitals were presenting papers—that were peer reviewed by Western academics—that were accepted for presentation. That is a big jump on what we had before. Next month we will have a really big conference, the Transplantation Society conference in Madrid and, again, Chinese scholars and surgeons will be coming and engaging with us there.

What we believe—or my perception of what is happening now—is that our policy of engagement is very slowly but surely coming through what's happening in China. We certainly don't know everything that's going on in China, but we know an awful lot more than we did in the past and we believe that, just by slowly chipping away at this, we will eventually get to a point where we can look at China as having robust systems in place. We're not there yet, but we're getting there. That's my take on it, but it might be useful if Professor O'Connell, who has also been involved in this, gives his view on it.

CHAIR: Would you like to add to that, Professor O'Connell?

Prof. O'Connell : I guess so. I broadly support what has just been said. What I would say is that in around 2007 in particular, in that era, there was a big problem in China where they were using organs taken from executed prisoners and then selling those organs to foreigners to make money. This system was due to a large amount of corruption within the health system in China at the time and working with governments and prison officials to do it. This was common knowledge. Ultimately, one of the people who was part of the reforms in China acknowledged publicly what we all knew was happening: that they were doing this. As a result, China was ostracised from the international transplant community. They were not allowed to present clinical papers at meetings. They were barred from membership of the Transplantation Society, and as much external pressure as we could bring to bear was brought upon them.

The issue I would like to emphasise is that, although there was international condemnation, which did hurt, the reform process was an internal reform process. The people who reformed the system were from inside China. They worked closely with the government crackdown on corruption and were able to successfully link reform of organ donation to that initiative. It also helped that one of the reformers had a close personal relationship with President Xi Jinping and was able to bring about reform of that process. It's widely accepted now that they are not using organs from executed prisoners. There are other issues for a developing country with relatively small numbers of organ donors and, having had an institutionalised system of corruption, you're not going to get rid of all those surgeons in one go. They do have ongoing issues, but that problem's largely been resolved.

We had a meeting at the Pontifical Academy of Sciences, and every expert from around the world was able to show the best data we could of where people had travelled for transplantation. In 2007, a peak number of people travelled to China, and that has essentially dropped off to not zero but near that. A lot of the people who are travelling to China now for transplant are often dual nationals and have nationalities in a Western country and in China and are going back to China. For instance, in Australia, 20 people travelled overseas to China and other destinations for transplantation. Some of those were legitimate. In 2015, that number was seven. I understand 2016 data, as best as we can ascertain, was less than five.

China used to be the biggest destination, and it's essentially disappeared and our data mirrors exactly data from all other places where you'd expect to see it, particularly Middle Eastern countries such as Saudi Arabia where they are have a big problem with their citizens travelling overseas to purchase organs. I would say, looking at the terms of reference for today's meeting, that there are other areas that we have concerns about—in particular, Egypt, Pakistan, parts of India, Sri Lanka and the Philippines. These places suffer from wide disparities in the population in terms of income, with a very large number of very poor people in desperate circumstances. There is poor law enforcement and unscrupulous doctors are able to get away with appalling practices where they're putting both the donor and the recipient at risk. But desperate people will do desperate things. Most Australians do not travel to those places unless they are a citizen of that country—in other words, they're dual citizens. Patients that I've seen who have been to Sri Lanka are normally Sri Lankan by birth. People who go to the Philippines are largely Philippine by birth, although occasionally we'll see Westerners going there who are married to Filipinos. They are largely going back to their country of origin because they think they can avoid the waiting times in Australia.

Having said that, the other positive from an Australian perspective is that the government have put a large investment in our organ procurement agency, the AOTA, the Australian Organ and Tissue Authority. By investing in that, they've doubled Australia's organ donation rate and have halved our waiting times. People know that they can get a transplant here with some of the best results in the world in a reasonable time and it won't cost them anything because it's paid through the national healthcare system. That, more than anything, has taken the pressure off desperate Australian patients heading overseas, regardless of what their country of origin is. I'll leave it there, and I'm happy to answer any questions.

CHAIR: Thank you. Do you want to add something, Dr Fraser?

Dr Fraser : Just to build on what Professor O'Connell has said, one of the big misconceptions about organ trafficking is that it is patients from rich countries going to poor countries for transplantation. The bulk of patients purchasing organs in a country other than their own tend to be wealthy people in poorer countries. They're wealthy people who do not have access to deceased donation in their own country because a deceased donation system doesn't really exist. For example, I have seen many patients from Malaysia who were previously going to China for transplantation, because a large percentage of the Malaysian population are of Chinese origin. They are all wealthy individuals who cannot obtain transplantation in their own country because there's no deceased donation system or it's just in its infancy. The automatic choice at one point, if you go back six or seven years ago, was that, if you needed an organ transplant in Malaysia, your physician would refer you to China for transplantation. That was the norm. Here in Australia, this was not the norm at all—anything but. In a number of developing countries where there are patients with the financial means to do that, they are the ones going to China; they are the ones going to other countries.

Particularly in my capacity as a patient talking to patient groups, I found that in Malaysia, although there are still patients travelling overseas and talking to their doctors who are providing referrals, they are no longer able to provide referrals to China because China has essentially closed down the market to foreigners. There are now a number of South-East Asians who, instead of going to China, are now going to Pakistan and Egypt and in smaller numbers to a few other countries. We're now seeing major problems, particularly in northern Pakistan. I don't like saying just 'Pakistan', because in certain regions of Pakistan they've got very high ethical standards. But certainly in the Punjab area, in Lahore, in Islamabad, there are major issues with organ trafficking with foreigners who are now being redirected away from China to where there are organs available and to Egypt as well. I'm seeing a lot of South-East Asians who are now going to Egypt for transplantation.

This is one of the really interesting things about organ trafficking. When one market gets closed down, whether it's by enforcement or by pressure from outside, then unfortunately another one seems to open. I find myself that it's like playing that game Whac-A-Mole. You close down one market and another one pops up somewhere else. This is something that we've seen happen a lot. For example, if you went back to 2008, the Philippines was the country to go to for transplantation. Through a number of initiatives, the Philippines market closed down, but unfortunately we're starting to see patients starting to go back to the Philippines now. In fact, I'll be going to the Philippines shortly to investigate that. So this is one of the other things that we've got to be careful about. China at the moment is not a country where foreigners generally go to unless they are Chinese speakers of Chinese ethnic background and have family connections there. What we've got to be really careful about is that, yes, we can maybe be successful in closing the Chinese market down to foreigners, but in five years or 10 years from now there might be a problem there again, because that has happened in so many other countries. What we really want to be thinking about is: how do you break that cycle? It's not a matter of closing a market down for five years; that market has got to be closed down forever. That's what we've got to try and do.

Australia has been really successful in stopping Australians going overseas, not by having laws against doing that. It's been about education. It's about clinicians making it very clear to patients that travelling overseas is really risky. The chances, for a patient travelling overseas to receive transplantation, of that being a successful transplantation are significantly less than they would be here in Australia. I know there is no hard and fast data about that, but the anecdotal data that I have got from patients I have met, patients I know personally, is that a one-year graphed survival rate here in Australia is 97 per cent or so—Professor O'Connell will be able to clarify that—but certainly, from patients who have travelled overseas, anecdotally, I would say that most of them are going to be coming back with significant complications. It may well result in severe infection that may cause death. It's very likely to cause loss of the organ and leave that patient in a worse state than they were in before they went for that transplant and significantly in debt for having paid for that organ.

By educating patients about the risks of doing that, yes, we can tell them about the ethical issues, but the best thing we can be doing is saying: 'This is not an answer. You could die by doing this.' In fact, I met a patient—this was a Cambodian patient who went to India for a transplant—when she came back. She had a serious infection. I talked to her about the process she went through, and she died the next day. That thought will stay with me for the rest of my life.

What we are doing now by increasing organ donation here, by developing that and making patients understand that they will get the organ they need—if you tell a patient, 'You're almost certainly going to get an organ within a certain amount of time, and it's not just going to be this indefinite waiting list'—is that there's a much higher chance that they're not going to want to go and spend $100,000 rolling the dice on something that might not actually work with them. If we look at Spain, in Spain, with a common blood type, a patient can be expected to receive that transplant probably—I'm hearing the latest from them is—in 18 months. If you tell a patient, 'Yes, it's going to be 18 months on dialysis; it's not going to be pleasant, but 18 months from now you'll get a transplant,' none of them are going to go overseas and roll the dice to try and get that transplant. They'll sit and wait.

And that's what I would like to see us get to here in Australia: have patients understanding that it's their best interests; it's in their health's best interests. If you want to get back to good health, just sit and wait, stay on dialysis, if it's a kidney, and be compliant with the dialysis regulations—special diet, limited fluid intake. It's not going to be pleasant, but we'll get there in the end. I think that is going to be far more effective than putting in punishment, putting in any form of criminal proceedings, against very sick people. I think education is the answer, and I think most clinicians are actually doing that. Maybe Professor O'Connell would like to build on that.

Prof. O'Connell : As I understand it, the one thing that the parliamentary committee is considering is how we can help prevent organ trafficking and what we can do as a country, or what our response to this issue can be. I see that in several ways. We have professional organisations such as the Transplantation Society of Australia and New Zealand, which cooperates closely with the Transplantation Society, and we've made strong statements and public statements that we're against this practice. Most of our people who train in transplantation are aware of organ trafficking, aware of how to approach that with a patient and, as has been stated, to educate a patient about the benefits of staying here and in fact to reassure them that they will receive a transplant. Not only that but the technology involved, the sophistication in transplanting people who are difficult to transplant, is far superior than they're going to get in a country such as Pakistan. So at one level it's about education and reassurance and about a medical system that provides government national self-sufficiency. In that area, we've improved remarkably since 2007 or 2008. We were never bad by international standards, but we've improved markedly in that time.

The next issue is cooperation at a global level, and I think the Australian government could look closely at how they can cooperate with international agencies. The real issue is that we need to put pressure on governments to act, so there needs to be pressure put on the Sri Lankan government, the Pakistani government, the Egyptian government and the Philippine government so that they will enforce the laws that they have that allow them to close these practices down. It also would help if we were able to provide information to those authorities internationally about where patients travel to, the institutions they go to—because many of these are done in hospitals—and maybe even the names of the doctors or the cities that they're in so that we can assist their authorities in identifying these practices within their own country and put pressure on them to close them down.

There are international instruments that we could be signatories to. The Australian government could consider signing the EU convention on organ trafficking, which is open to signatories for countries outside the EU, which documents a very strong emphasis that countries are against this and are doing all that cooperatively to stop human trafficking for organ transplantation, which is a problem that will keep going, as has just been pointed out; it will just vary from where it's occurring. I think that's another level that the Australian government could work at a government-to-government level.

The next issue, I suppose—and I know it's been discussed in certain circles—is about whether we can modify our laws to prosecute people for crimes that are committed outside our jurisdiction. Largely, the way I see this, this would mean us prosecuting patients, and they're the easy target because these are desperate people. It would rely on doctors who have people come back dobbing them in to the authorities because they suspect they've purchased an organ overseas. Now, the problem I know from patients that I know personally that have gone overseas for transplant, where I suspect heavily that they've purchased this organ, and I know the countries they've been to, is that proving that is particularly difficult, especially if, for instance, you're of Sri Lankan origin and you've gone back to your family and have come back with a transplant. It's very hard to say that that didn't occur legally in that country. When people were going to China and purchasing an executed prisoner organ, with the fact that this was occurring in national hospitals and in the army hospitals, so this was occurring officially within China, you could argue that they weren't breaking a law in China, although morally and ethically we considered the practice repugnant.

So, that, I think, could prove to be counterproductive because those patients come from countries where corruption is rife. They're used to dealing with corrupt police departments. They have an innate suspicion of authority. If they felt that they came back here and they couldn't trust their doctor, then we would be putting their health at risk. Really, I suspect that we wouldn't get a conviction, and we'd lose the trust of the people who could help identify the brokers and the corrupt doctors who are doing these transplants. My suspicion is that, given the low number of people and—I suspect, not being a law enforcement person—the low likelihood of getting a conviction and obtaining evidence from overseas, we ought to focus more on gaining their cooperation and trying to identify the process in which they achieved it.

Certainly, I'm not an expert on the Australian law for prosecuting people who are trying to broker a transplant, but I'd certainly make sure that, if there were Australian citizens who were brokering transplants overseas, they were punished severely for that. Maybe a review of the laws in that aspect would be warranted—though, as I said, I'm not a legal expert, and I'm not sure how robust our laws are there. In fact, I'm not aware of any broker systems that have been ever identified in Australia. My suspicion has been that brokers are overseas and these are patients who have contacts within the host country.

That is how I would see the situation at the moment. I think international cooperation; obtaining the trust and the cooperation of patients who've travelled, to try and identify where this is occurring; collecting that data and using that data to force host countries to enforce their own laws would probably be the most beneficial way of dealing with this.

CHAIR: Thanks, Professor O'Connell. This morning, Professor Coates in his evidence said a couple of things that either of you might wish to comment on. Firstly, on the basis of the survey which is currently being conducted by the Transplantation Society of Australia and New Zealand, the number of people travelling overseas for transplants is probably three to four times the number that the ANZDATA officially reports, and the indication is that there's a significant underreporting in the official data. Secondly, he was of the view that Australia should ratify the Council of Europe declaration and that we should endorse mandatory reporting in Australia. I just wonder if you have any comments on that.

Prof. O'Connell : Yes, I would agree. If you look at the ANZDATA numbers, I think they're reflective of the true nature of things, but there is underreporting. ANZDATA has very complete data about transplants in this country. We also capture people who are on dialysis in this country. So, if you start with dialysis in this country, the process within hospitals is that you're put onto the register and, if you get a transplant, when you fill out the annual review of the data that gets put in and you put in the overseas numbers. The issue comes when patients know they're going to need a transplant, haven't yet started dialysis and get a transplant overseas. When they come back, the doctors are then relied on to sort of remember that that's occurred. It's not that they're blase or trying to hide it; I think it's more that the systems we have set up to capture patients skips that, and therefore there is a degree of underreporting. I know Professor Coates is collecting the data. I don't know exactly the process or how accurate it is, and it would be good to do some further case studies and look at particular institutions to try and get an estimate. But I do agree that there is underreporting.

I agree: we should ratify the EU convention, which is the same thing that I was talking about. Excuse me, I don't have all those documents in front of me, but I'm very much aware of the EU convention and believe it would be good to do that, and that would be part of the international cooperation.

I believe there should be mandatory reporting, but I guess what I would be cautious about is what gets done with that data in terms of the individual patient. What you don't want is the individual patient not seeking care and attention at the best place. In a sense, the easy person to persecute is the patient because they're at the end of the chain, yet they're the ones who've got a life-threatening illness, are in a desperate situation and often have family members overseas encouraging them to go back and get that transplant. So, in terms of stamping out the practice and relative justice, I don't think they're the group we should be focusing on in a punitive sense, but we should have better ways. At the hospital level and at the physician level, it would be easy to report those transplants and capture that data in ANZDATA or in a separate registry—it would probably be easier in ANZDATA.

The thing about ANZDATA is that it collects the data and says, for instance, in 2015 there were seven people who travelled overseas for transplantation. One got a deceased donor, five got a living donor and one was not stated. Of those live donors, some of those are completely legitimate, and you can often tell where they are. For instance, some people travel to the United Kingdom or even to the United States or to Europe, and that's because they have a brother or a sister there who's willing to give them a kidney and they go there for completely legitimate reasons and come back. They're normally easy to capture. If someone goes to the Philippines, Sri Lanka or India and you ask them, 'Where did you go for your transplant and who was the donor?' and they can't say, 'It was my brother or sister'—and normally they can't—then you're very highly suspicious that that is a case of organ trafficking. I don't know if that's clarified the situation, but there are things we can do in a very positive way to do that. Mandatory reporting is one thing we can do, but at what level you do that and what you do with that information are very important. I think a lot of physicians would feel uncomfortable if that were then going to bring their patient into the full gaze of law enforcement. If it were identifying practices that could be eliminated, and prosecutions further up the chain, then I think you would have the full endorsement of the transplant medical professionals.

Senator MOORE: The issue of a register was brought up this morning in evidence. Certainly there's support for mandatory reporting, but there is also the issue that if there were a centralised transplant register that covered everybody then that might be a way of getting information and data without necessarily exposing individuals. Has that issue been raised with either of you?

Prof. O'Connell : It has. We've already got a register, and it's called ANZDATA. The federal government does support it and it provides fantastic data to the Australian government for workforce planning and for expenditure on end-stage renal failure. It's a unique resource and it's highly regarded overseas; in fact, it's the envy of everywhere in the world.

Senator MOORE: Yes, and my understanding is that it's very good for domestic data but there is the issue of people going overseas. Certainly the data that we received, from the very preliminary stages of the survey that the Transplantation Society have done, shows figures significantly different to what are on ANZDATA.

Prof. O'Connell : Yes. Earlier in my evidence I identified that I think there are reasons for that which are more to do with the way we currently capture the data. What I would propose, rather than making a new register for which people have to capture and report data, is that we emphasise it within ANZDATA and make it clear that we want to do that. If we do that, we will get better capture of that data. In other words, although ANZDATA is technically voluntary, no-one misses out. I think we could improve the data capture within ANZDATA, which would give you the information much more effectively and at much less cost. The first step is to identify whether there are deficiencies and then plug those deficiencies within ANZDATA. You will then get very good data from there.

There are now ways through other data capture measures, by data exchange—maybe looking through Medicare and scripts for immunosuppression—to check to see whether people have gone missing. I think you will get much more complete data that way. Also, we've just started—and this has been an initiative of the profession; it wasn't from government mandate—reporting people who get transplanted overseas. Before, that was captured but it wasn't put in the ANZDATA report. Now that's being put in every report. Once that starts to be put in every report, it's brought much more to the forefront of people. If we then highlight that and have to report back to the government, say, from ANZDATA then that will again bring it to the forefront of everyone in the profession and make sure that all these patients are being captured. I guess what I'm saying is that it would be much more cost-effective and much better if that were done through ANZDATA, by strengthening the capture mechanisms within it, rather than by setting up another registry separate to that.

Senator MOORE: Just as long as there's trust in it. Certainly in the number of questions we've had about ANZDATA there seem to be various levels of trust.

Prof. O'Connell : I think the level of trust in ANZDATA within the profession is 120 per cent. You look at the trust in our data in the United States and it's 100 per cent. You look at the trust in our data in Europe and it's 100 per cent. I don't know what's been put forward to your committee, but it's the most highly regarded data we capture. If you did a survey of ANZDATA as a data-capture mechanism, you'd find it's completely trusted.

So, in this particular thing, are they underreported? That's probably true but it's not that people are purposely trying to hide things; it's probably that they've come through systems that normally capture them. For instance, at my hospital, if you start dialysis, we've got dialysis nursing staff and you are automatically captured within the system as starting dialysis. When a patient gets transplanted, their sheet comes back to us every year; that's for every patient, and we're talking some 800 patients. We then fill that out. If they've got a transplant and no longer get dialysis, we put that down. We then have to put down the donor information. Because the donor was overseas, we have to tick a box to say they were overseas and then we state the country of origin. If the patient doesn't end up in the dialysis bit or doesn't get a transplant in Australia, which means that the system automatically collects the data, then the doctor, when some of those people turn up to his rooms, may then forget when it comes to filling out the form that, out of his 100 patients, there is that one. However, if we have reminders that they have to report the data of people who have it done overseas—we may ask more specific questions within ANZDATA—I think you've got a better mechanism for picking up the patients. I would argue the claim that the data isn't trusted very strongly. I'd say it's the most trustworthy data that the Commonwealth government gets from a registry, and it's been that way since the 1960s.

Senator MOORE: We had a number of people talking to us this morning about their concerns about what's happening in China. Their concerns are, whatever processes are put in place about visitation to China and from talking to people who are over there, that there can be no information that can be fully trustworthy and that that creates a problem where, when you're looking at a situation, you're reliant on a situation where you're not getting accurate information either through the government or any of the medical facilities. Dr Fraser, you gave evidence just now about the ways that you're trying to get into the system: working with WHO; trying to visit as many places as you can; talking to people at every level. There just seems to be a huge gap between the work that you're doing in trying to find that information and the perception of people who are concerned about the whole system in China. The gap is so large. I'm just wondering whether you have any ideas of how we can make sure people are talking to each other?

Dr Fraser : We want to try and expand engagement as far as we can to try, initially, to make it as hard as possible for the Chinese system to continue using executed-prisoner organs. The first thing that we're trying to do there is see whether an ethical model exists at all in China; have we got the seeds of something? We've seen that we do have that. We have now had access to the computer systems of the organ procurement organisations, where we can see that there are systems in place for organs from trauma victims to be identified in intensive care units. We can see that there is a system in place for finding the surgeons who will remove those organs, and for transportation; we've seen organs being delivered. We've seen surgery taking place. It's a start. It's certainly nowhere near the end. What we now want to do is try and expand that. In a number of locations in China there are some highly respected transplant professionals, particularly from Europe; a number of Spanish transplant professionals have gone there. They're running training sessions, and they believe that they are making progress in that.

So, yes, there's a long way to go. What we feel is that, yes, we could just stand outside China with all the others who are outside China saying, 'China's doing all these terrible things,' and do nothing about it. Here in Australia, we're very aware of China's ambitions and propaganda that's coming out of China. We know about that. We cannot change the law in China. China is a sovereign state. But what we can do is keep going with that engagement to try to educate and champion the ethical practice that we have there.

There are people in China that we do really trust. There are a number of doctors and a number of hospitals that we have built up close relationships with, and we do trust them. There are a number of transplant professionals in China who we don't know. We know who they are, but we don't have a relationship with them. But every time any of us go there we build a new relationship when we're introduced to somebody else. We find out more. We're peeling it back bit by bit. This is going to take years to do. This is not something that's going to happen quickly. Personally, I can't think of any better way of doing it than that. I agree: there is a lot we don't know about China. It's not just transplantation but everything in China. If you look at the news, there's always the question, 'What are China's ambitions?' We don't know. All we as people involved in the international transplant community can do is do the best we can with the resources that we've got.

I honestly believe that we are making progress. Things are happening. Things are changing. We are not seeing anything like the number of foreigners going to China. We are seeing far more Chinese transplant professionals engaging with the international community. I think that is a really worthwhile exercise. We're doing that with significant opposition from a number of groups that feel that we should not be engaging with China and should not be engaging with people who have previously been involved in executions. And, yes, I regularly talk with surgeons in China who have been involved in the use of executed prisoner organs. That is not something that's easy to deal with. I often go to those meetings and come out of it thinking, 'What have I done?' But, when we think about it, we believe it's the best way. A lot of people don't believe that we're doing that in the best way, and we receive numerous complaints. I spend probably a day a week responding to complaints over doing that but, in my heart, I believe that this is the best way forward for that.

Senator MOORE: Doctor, I just want you to have a look at one of the pieces of evidence we got. There are so many. It's data captured from the organ donation administrative centre under the heading 'Red Cross Society of China'. It particularly refers to a date in 2015 when there was an enormous jump in a one-day period in the number of registered donors. I know it's just one piece of information, but it was used in a submission to indicate that the data we're getting from China is completely untrustworthy. It's part of a much wider, very well-documented submission that talked about the issues in dealing with China. But this piece of evidence has been particularly highlighted. I'm just wondering whether you would like to have a look at it and, on notice, see whether this is a piece of information you know about and whether you know the background to this sheet.

Dr Fraser : I don't personally know the background to that sheet, but on notice I would be very happy to review that and review any other documentation. Any recommendations or any evidence that is presented, I'm always very happy to look at. But I'm always very cautious of any data that's coming out of China or anywhere else. We take it for what it is and try to correlate that with what other information we've got. But we never put full trust in one particular document or one particular set of figures.

Senator MOORE: This submission didn't do that at all. They had a whole lot of information—it was just one particular segment that interested me.

Dr Fraser : There is just this mass of information.

Senator MOORE: Sure.

Dr Fraser : And there's a mass of conflicting information. We just try to play with what we've got and make the best of it. That's the best we can do.

CHAIR: On that note, Dr Fraser and Professor O'Connell, I'll draw this segment to a close. Can I again thank you for your participation in the inquiry, and any further information you're able to provide will obviously be useful for the committee. Thank you both very much for your participation.

Dr Fraser : Thank you for the opportunity.

Prof. O'Connell : Yes, thank you for the opportunity to speak. The one thing I would say about issues regarding China and, at least, the transplantation of foreigners is that the information we do have that's more reliable, you might say, or less opaque, is that, when people start coming back from China to other countries, we can capture that information. The data is that that's not happening, whereas the data beforehand was that it was. So it's much easier to get a hold of that information. It doesn't mean that unethical practices aren't happening there or that data isn't opaque or things inexplicable aren't happening, but what is clear is that things are changing. What our policy has been is to engage very positively with those bringing about reform, because they are combating entrenched interests in China. I'm sure there are people in China who would be happy to see them go. If those people are not supported and they're ignored then that's playing right into the hands of those who want to return to the old ways. I just think that needs to be weighed up in whatever the response is to China. Thank you.

CHAIR: Thanks, Professor O'Connell. Thanks, Dr Fraser.