correct thank whatever it wouldn't be the town manager that declares the property surplus he would request the council declare the property surplus and he would be providing the council with all of the materials listed in the policy along with that request so we have the final say the count if it's the council's authority to declare the property surplus and then if you wanted to place other requirements on disposing of the policy property just to complicate things we don't own school buildings they have to be given back to us first okay all right are there any other questions on this particular thing then we're moving on the next motion is regarding a letter on behalf of the council supporting a senate 1836 and a house 2963 uh of relative act relative to payment and move taxation for organizations exempt from property tax the motion I'm seeking second for is to authorize the council president to sign a letter on behalf of the council in support of s 1836 h 2963 an act relative to payments and rule taxation by organizations exempt from property taxes their second change seconds thank you I have sent a let me just this is the second time actually something like this is coming for this council we continue to want to support legislation that would benefit us with regard to pilots I've remained in touch with a group that's predominantly eastern boston based or eastern mass based and they alerted me to the fact recently that this legislation is has been left open and still made something may happen with it I doubt it but I hope between now and the end of April and so I crafted a memo and a letter and since then have given to Athena another version which only has some edits in it based on some feedback I've received from counselors I had I had already made some changes so you might want to show that on the screen one was from a counselor who pointed out correctly that Amherst college does pay taxes on boat the end of boatwood and they pay taxes on the houses that they own and so in the letter I nuanced the issue of that so I believe the changes from this the last draft that were posted are shown in purple here that's correct and then there were some other changes that I also received from another counselor that basically helps with the grammar George so if by some legislative miracle this actually were to be passed it would not apply to UMass is that correct that is correct that is a different payment in lieu of taxes that I've also been following that's the one that Joe Comerford Senator Joe Comerford has weighed in on but largely with regard to the amount of acreage and we've had more than one discussion about the fact that you can talk about acreage but I want to talk about what's built on it and how many people come to it and that one doesn't appear to be going anywhere except that last year when it did come up they put more money into it at least that's a good thing but anyway that's been part of it and Anna you've been following some of these as well so please jump in thank you George any other question no Jennifer I just want to say thank you for writing it okay all right if there's any other changes I do want to get it off tomorrow and but we need to vote that I'm allowed to do this so we'll begin with I think we're up to counselor Ryan hi Kathy Shane yes Andy Steinberg yes Jennifer top yes Councillor Walker yes Pat d'Angelo's hi Anna Devin Gotham hi Councillor Ate hi Lynn Griesma is an eye Councillor Hanna key is now absent uh Bob Hegner yes Councillor Lord Lord I 12 in favor with one absent oh sir did you call in really me I'm sorry thank you did I miss somebody I'm so sorry oh I'm sorry Pam Rooney was an eye thank you how did I miss that oh I see okay all right that's getting late that's the last motion oh no it's not no it's not we are now moving on to appointments and I'm going to call on CRC chair we have appointments for the ZBA and so Pam do you want to speak to do you want to place it in motion or would you like me to place it in motion I'd like you to place the motion because you have it written in front of you I'm sure great zoning this is regarding zoning board of appeals appointments and the motion is to appoint the following residents to the zoning board of appeals full member effective July 1 2024 for a three-year term expiring on June 30th 20 27 Craig Meadows full member effective immediately for a term expiring on June 30th 2025 David Sloveter associate member effective immediately for a term expiring on June 30th 2024 David Alfeld Alfeld and John Barner associate members effective July 1 2024 for a one-year term expiring on January the June 30th 2025 David Alfeld John Barner held a greener bomb and Rizwan.com is there a second second Ryan thank you Pam would you like to speak to the motion yes it sounded complicated but it is simply because there are several existing vacancies and as well as one person who moved from being an associate member to a full member leaving another associate spot that we felt we could fill immediately so it's a little bit convoluted but I would appreciate support for these fine candidates who are willing to contribute to the town serving on the ZBA thank you are there any questions or comments seeing none we're going to move to a vote uh we are going to start with Kathy Shane yes Andy Steinberg yes Jennifer top yes Councillor Walker yes Pat DeAndreyes aye Anna Devin got here aye Councillor Ette aye Lynn Griezmer is an aye Councillor Hannake is absent Bob Hagner aye Councillor Lord Lord aye Pam Rooney yes Councillor Ryan aye did I get everybody this time thank you it's unanimous with one absent uh we are now going to move to non-voting liaisons Anna this is wild um all right so in your packet from last week there was a list of um liaison appointment recommendations based on feedback that folks had sent in so as a reminder GOL had put forward one two three four five six I think one two three four five six seven ten am I counting right yeah ten committees that um had requested liaisons as priority to be approved for liaison I then sought feedback from the council on what you might want to liaise who you might want to liaise for um and so there are a couple areas that you'll see um have multiple people that expressed interest um I tried to stay if folks did say you know if someone else is interested I don't need to need to do this one I tried not to make judgments based on what you said in an email and you can say that again now and we can take your name off but uh I thought that I wanted to make sure everybody was was on the list I didn't want to accidentally interpret something incorrectly so um everyone is is on there with what you indicated interest in um and then I I figured in this meeting you can say oh I see someone else is into that I will take my name off which is likely why hands are going up um I think that's about it please remind please refresh yourself on the role of liaisons I have linked it in past memos and I'm happy to email it to anyone who's who's interested but it's in our roles procedure and I'll take questions and also please note there's three committees we're still looking for liaisons correct okay I'll start I'll take my name off Jennifer top yes so George and I conferred and um George we agreed if everyone agrees that George would be the liaison to the transportation advisory committee and also make sense he's a member of the of TSO and then it would just leave me for council on aging okay resolve that one just to confirm because I'm keeping notes here so you said George would be transportation advisory and you would be council on aging okay thank you okay um Kathy I have I have a question it's why my hand is up no one said they want community preservation at committee that's correct and I just want to speak to I think it needs someone and I'm trying to figure out whether I'm going to volunteer but you get to see the proposals when they come in and you can make comments and get questions answered as a liaison you don't have an official role so it's a really early look where hopefully most years they have more proposals than they can fund and they spend about two million dollars a year so I'll wait as people sort out all the other committees but I think it would be I I did it for two years in a row which is why I didn't put my name on it yeah Pat T. Angeles yes I am I think you lost your mic I thank you my finger was not in the right place I would like to stay as the liaison to the disability access advisory committee I've been serving on it for several years and established some really good relationships if Hala would uh once it very badly I would step aside but I would like to keep it the other thing is I did not put my name down for community preservation conservation or energy climate action because I can't attend the meetings and I know we don't have to that we can watch the videos but I find that it's very beneficial to be sitting in the audience and attending the meetings when possible if no one else signs up for conservation commission I would be willing to do that even though I can't make the meetings okay are you um one of you is keeping track of this got it I've got it yeah and I think Athena does uh Andy oh I'm sorry pardon me would you please call on counselor lord because um counselor D'Angelo has just suggested that they swap it might be nice to tidy that up sure counselor lord um yes part of what I was going to say was please take me off of that I'm happy to and then I was going to remove myself from the HRC since there were multiple names and one of my committees only had my name on it so I'm happy to so we have you both on pssjc and HRC correct and we're saying do we serve on one should you take me off the HRC if you want to serve on two that's great okay I'll hold that thought well Andy uh who there was somebody else for HRC Andy who hand us up okay Andy yeah I thought I was removing my name from that one uh because I said either that or board of health but not both so take me off I think of the the one sorry just stay with board of health okay Andy's going with board of health and then that means that Hala would go to human rights commission yeah we're gonna need some clarity because I think everyone has just taken themselves off of human rights commission I'm still there I'm still there you are still there sorry to speak out of turn right okay uh so that we have affordable housing trust uh dpac uh conservation commission um I had a question yes George did you want to stay on the affordable housing trust as well as the okay thank you okay the answer is uh freka you have your hand up so I'm gonna go to you for a moment how do I miss Jennifer now you go I I've been a guy frek I'm sorry counselor at the I think the energy is that still up energy and climate action committee yes I would express interest for that great it's a really good one Anna has served in that role okay uh so we uh Jennifer so I want to ask for the CPA committee does that only meet a few times a year meets it meets it meets just in the fall so they get that you know okay all right Jennifer job for CPA and then that leaves us with conservation commission okay fine I'll do it yep okay you were like you were like doing this to me like Anna yes I will do conservation commission she's going back home Anna used to serve on the conservation commission before she came on the council can I confirm the finalist I think Athena has it up on the board as well but I just want to read through it if that's okay okay why don't you do it as a motion please all right I who appoint the following council I understand I moved to appoint the following counselors to the following committees as uh council liaisons for 2024 to the affordable to the Amherst affordable housing trust did I mess it up you're looking at me to the Amherst affordable housing trust George Ryan to the board of health Andy Steinberg to the community safety and social justice committee hollow lord to the council on aging Jennifer Taub to the disability access advisory committee pat de Angelis to the human rights commission hollow lord to the transportation advisory committee George Ryan to the community preservation act committee Jennifer Taub to the conservation commission Anna Devlin got there and to the energy and climate action committee freka ate second may I make a slight change in the motion and it would be for the remainder of the council's term so we would do this for this year and next year okay is that acceptable to you as the person who made the motion yes okay it's acceptable to me as the person who cited just sorry just as a note though our rules of procedure do say that they indicate the liaison preferences annually so that's why I said for 2024 um so we have to overwrite our rules first can I suggest that we keep it for 2024 and in this 2024 and then you're you're right correct thank you I have my moments every okay once so the motion's been made and seconded are there any questions comments okay um Kathy Shane now did I start with you before they what yeah did I start with you before you you did start with me before you you could start with me again if you'd like I'm up to Andy Steinberg yes Jennifer Taub yes Councillor Walker yes pat de Angelis I Anna Devlin got your eye Councillor Ate aye Lynn Griesma is an aye Councillor Hanna is absent Bob Hegner aye Councillor Lord aye Anne Burnie yes Councillor Ryan aye Kathy Shane yes it's 12 in favor and one absent thank you Anna for finally getting us through that one we've had to delay it so often all right um we're approaching the witching uh Councillor uh committee and liaison reports and let me just say that uh before we start this this is the point in time where we will also now include the committees that we have liaisons to you don't have to report every week or every time we meet but if you have something you need to bring up please make that's the time you bring it up okay uh CRC Pam Rooney Jennifer Taub thank you yeah I'm opening my I'm slowly I think you've heard enough from us tonight um appreciated the vote to finalize the vote on rental registration um but we did especially want to say thank you for the vote tonight on ZBA members we met in a special session on April 2 to uh interview and and then put forward our recommendation um so that really was the gist of it uh and then just to remind people that the town manager did have the nuisance by law reviewed by KP law and that is sitting with GLL which they may report on we don't know but they will not be discussing it until April 18 thank you Jennifer thank you Pam the only thing I'd add is tomorrow we have we will be discussing at our meeting um planning board applications and vacancies there will be two so just if people want to we're low on caps right now so if people want to start getting the word out that would be appreciated um elementary school building committee uh our next meeting is April 26 we're only meeting once a month uh but the design team is uh actively working on the 90 percent cost estimates um so we are moving along and the plan is still to put this out to bid um by June so with the town manager opting to put additional solar they're also doing some additional design work on that so we can get a cost estimate and have some idea how much solar we can put on I think that's the main thing it's a pretty exciting time so um when the cost estimates come in at 90 percent the let I think everyone knows the early site past which came in well underneath what we had estimated and our estimates have been holding which means we've got a really big cushion of contingency money which is very I think excellent news for the taxpayers great elementary um I'm sorry framing this committee Bob uh yeah we um we had a meeting last week uh to just do initial discussions of the regional school budget and the town audit we want to wrap up our discussion of the town audit uh at our meeting next week and we have prepared some questions to the superintendent schools uh on the school budget regional school budget that we'll discuss uh at our next meeting next week and then there's the public hearing which is later on Thursday of next of next week okay um GL Anna so as mentioned before GL currently has in front of it the nuisance bylaw I think there were more comments coming back from legal than GL anticipated we were hoping to get it through it in one meeting but there was there was more there so um we will be continuing to to address that at our coming meeting next week uh right yeah next week um we are waiting on the ahra report folks have been asking some questions on that there is no delay in acting on it we just don't have it yet so soon as we have it we'll be able to slot that in um we did our our attempt to get more caps for the charter review committee by talking about it a lot at a council meeting was helpful because we did get a few more um caps in after that meeting and we were able to vote the charter um the charter review committee pool sufficient at our last meeting so we'll be moving ahead with that process in um making recommendations to the council we do however still as Jennifer mentioned um first uh did you mention this who mentioned about caps two seconds ago yeah thank you okay for planning board um we also need caps for finding an ants committee um for the resident non-voting member um so if you are thinking about your ways you might get engaged that's a really good one as well as planning board um and then the other thing that GL is working on right now is our examination of the town manager evaluation process so GLL members are looking at other towns and their processes and bringing those back to discuss with the committee to see what merit we might pull um forward and and how we do our own process here GLL meets again next week on thursday uh john's library Pam Rooney oh i'm sorry george you had your hand up just a small note on um the charter review we have 16 um current caps so and that we still can take more so please don't stop in an effort you're making to encourage people to apply thank you jennifer you had your hand up is this a time to ask a question about um so the jones library building committee should i wait till uh i was going to ask whether there's any update from pam shaking her head no the report that there has been no meeting um and what we were told by paul bachelman last last meeting is that they have signed a contract with 101 university drive for a new a new active library site for the interim uh during construction and that they were out to bid for um transportation of books to the to the new site and that that that's actually what i read in the paper so the committee itself has not met jennifer so i had a question maybe it's directed to dave um it we're supposed the bids for construction are supposed to be back by june we're supposed to have select the town is supposed to have selected a contractor by june 30th is that part of the massachusetts board of library commissioners requirement i don't think i'm going to wait into that one tonight i'm just not prepared with those dates or that product i'm happy to get those answers from maybe at the next yeah meeting thank you um tso and yes tso um i mentioned earlier that the uh report that is in the packet today's meeting should not be drafted should be considered the final report and uh we've already discussed one major item out of it and acted on it which was the uh north plizzen street um proposal the other one where there is an actual recommendation that's been made by tso which we will have to come back to as a prior meeting was the emerson college sign and i think that the report is complete there's not much i can add to the report right now um but um i want to point to to acknowledge that we were asked to review that we did we spent some time on it and uh we consulted the consultation and it's all reported that the other thing is that at the last meeting there were four road projects that were referred to us um belchertown road heather stone um being the first two that we dealt with and then the section of pomer lane and the the proposal to have a roundabout at the corner of amity and university drive those two uh we did not give the priority to because the belchertown road proposal is funded by a very generous mass works grant and that needs action um in um may uh in order to have the contrary the work done um during the summer season and both the town manager and the dpw superintendent made a very strong point of that um on that one and heather stone road the decision of the committee was is that we really needed to have the advice of two committees of the disability access advisory committee and the transportation advisory committee regarding those two because the question of pedestrian and bike safety um was um an issue in both and um we felt that it was important that we hear from the committees that um really think deeply on those issues of bicycle and traffic safety and safety of pedestrians uh which is very much of always a daac concern um the last thing that i'm saying and want to say is about heather stone road that we had something that i think is extraordinary in all of my years in tso and that is a tremendous turnout of residents of an area where something we were considering was being discussed and not only was it a large number people um who were addressing a large number of issues but quite frankly i found that they weren't always in agreement with each other but they all spoke very passionately about what their concerns were for a roadway that is very essential to uh either the street they live on if they live on heather stone or to their neighborhood and as a consequence um there was also pointed out that we had not um had scheduled our meeting at a time that was accessible to all um of the residents of the neighborhood or the street because we meet during the day there were a lot of people who work in the evening and are very concerned about um the same set of issues so that our conclusion was given what we know to be a large community input that we want to schedule a listening session in which we can hear from people on heather stone and in the neighborhood echo hill about um the same set of issues or other issues that they might raise so that we are fully informed in addition to getting da c and tack input on um the project and uh it will and i talked to lin about this i've not had a chance to talk with pat because it is their district and um they will have a strong presumably a strong interest in it and might be very helpful in outreach um to neighbors that we might not otherwise reach in telling that we want to hold this listening session is a consequence of the five members of our committee and two district counselors we already have a quorum of the council president so it may be that we have to request that this um meeting also be scheduled as a council meeting um because of the fact that we could have the quorum of the council present anyway so i just wanted to emphasize those points i think uh that in the written report conclude the report for tonight kathy and he largely answered the question i was going to ask on heather stone there is i assume you know there is an association um yes and and i know lin and pat know but it's a very active association so i was struck when i saw that proposal that the there was going to be a reaction and i didn't know what the reaction would be and i didn't know whether they'd been informed so it sounds like you're going a terrific route to uh find out what the people who live on the road think that's great yeah there there's been lots of conversations with people on heather stone um are there any other questions counselors on their committee reports we have no minutes did any special words i'm very pat um lid i just have one um there's a committee that's not normally on which i think is fine but jcpc the joint capital planning committee so it we're finishing our work this thursday um i'm assuming we're finishing our work because we have to finish our work and so this is a committee that reviews capital projects within the budget that the town has and then we make a recommendation to the town manager but the council will get a copy of that as it's going forward so it's the early look at the capital plan and um we have a very tight budget that we were working within so you'll be able to see we had to move some things around and the staff was fantastic um including athena who uh got us organized against all odds so thank you athena let me also just mention that is not the large capital projects it's the small capital project yeah it's it's building repairs roads sidewalks buying uh new stuff like it and playgrounds yeah so the the big projects are one of the reasons we have a tight budget david lin very quickly um and i'm sure paul will have more updates when he returns but it is april it is it is time to get going full bore on construction projects um i'm sure the council is well aware of the north common underway um we are very pleased with the progress to date that has a june 30th deadline so our contractor caracas construction is moving daily out there it's kind of interesting to see their progress and um i know gilford mooring and his team are out there every day managing the project and hopefully you know we'll we'll have a ribbon cutting scheduled at some point down the down the road apiece we will also have a ribbon cutting at the trails at hickory at the appropriate time those are a little bit farther out one should be done by the end of june and i would imagine the other trail will be done september october and then i did want to let the council know and paul will have more information on this you know in four to five weeks but um from time to time the council does hear about the condition of the dam and dyke at puffers pond and i just wanted to let the council know that we are aggressively seeking funds for to address some of the issues up there we just submitted a $250,000 design assessment and design grant for the dyke and dam at puffers pond which will really help us look at the condition of both those structures the dyke is in poor condition the dam is in fair condition almost every dam in massachusetts gets a fair very few get better than that um we're more concerned actually about the dyke and so this will allow us to hire uh engineers dam engineers who specialize in this uh if we're successful to come in and um assess the dams and then propose uh fixes for both the dam and the dyke and i do have some capital money we have some capital money that we set aside and i've asked for more in the capital budget for fy 25 so i'm hopeful about that because we will need construction funds obviously in the future if we get the design done so just wanted to let you know we are beginning to address those issues and we should know more in four to five months once the grant comes back and then we get some engineers on the ground so we'll keep our fingers crossed on that okay andy i think you're going to ask the question i am but go ahead uh well my question is uh you didn't say anything about dredging the pound yes so um in light of all the earlier conversation about um what things cost so uh this grant will get us a little more than just design it will also get us bathymetry of the pond in other words how deep is the water it will also get us the depth of sediment in the pond it will also get if we're successful it will pay for um sediment cores to take a look at what is in the sediment in puffer's pond it will also get us some some um way forward with regard to um uh surveying up at the pond so it does move it does move the needle um andy on dredging from that information we should be able to extrapolate the volume of sediment that needs to be removed from the pond and then that will be another choice that the town has to make do we want to dredge the pond we we must do the repairs to the dyke and dam honestly choosing whether to dredge the pond will be a community decision that will come through the council um via a funding request again we'll go out and do the very best we can if we get to that point and try to leverage local funds into state and federal funds but we'll cross that bridge when we come to it so yes we are thinking about dredging finally and we will get some relative cost estimates out of this work thank you andy you saved me from asking the question are there any other comments um our questions of dave uh then uh let me just mention ana and i both agreed that we would do our uh presidents and vice presidents report for the 29th and uh on the future agenda items i just want to mention on the 29th this is what we know is on the agenda the first reading is for the surplus property the amherst college sign the planning board report for him amherst hills um the potentially the nuisance bylaw and uh we hope belcher town road okay uh are there any council comments or requests is there a i'm making a motion to adjourn is there a second quickly we got to go through it uh i don't care pat yes hi ana hi eti councillor eti hi lindy greaseman is an i andy johannity sapson bob hegner hi councillor hi ham rooney yes councillor ryan hi gathie shane yes andy steinberg yes jennifer tov yes councillor walker yes we're joined adjourned at 9 59 that's why i was doing


All right it's um okay quick quick one on New York and San Francisco um just some good news uh so I've talked about in the past the district attorney of New York not wanting to prosecute crimes not wanting people to go to jail uh on robbery not being a offense that he was going to ask for jail time for pretty spooky ridiculous stuff mugging was not going to be an offense that they were going to ask for jail time for this guy was a product of the nutty left the mayor of New York is not is a former cop he's much more rational when it comes to law enforcement he's much better when it comes to issues of crime uh he is basically overridden the district attorney put him into a corner and it looks like we'll have a saner situation in New York than what we thought uh it looks much better than the worst case scenario people don't want the nuttiness they don't want it when they faced actually with it they don't want it they might want it in theory they might think it sounds nice they might appease their guilt it might make them feel a little bit better but they don't actually want to live it and then what happened today in San Francisco is very exciting so uh I I don't know if you remember we did the story on the show uh I don't know about a year ago that in the midst of COVID with the school shut down and the hysteria in San Francisco about COVID San Francisco uh not only shut down at schools but decided to rename them they didn't want schools named after racists like Lincoln or you know uh what's her name the senator from uh from California uh Feinstein they didn't want schools named after these people because they were beyond the pale now you could make the argument that Feinstein was beyond the pale but not by their standards they had 50 schools they wanted to rename their names then they decided that they were gonna shut down or or not shut down change there were the two schools in San Francisco that accept students based on merit and they the school board decided that they were going to um basically stop accepting students by merit and have a lottery and this infuriated Asian parents in particular because I think three quarters of the kids in those schools are Asian so over the last year parents have organized and they organized a recall a recall movement to recall three of the members of the school board the president the vice president one other woman and they succeeded they voted them out the recall one they're out the mayor who supported the recall the mayor of San Francisco is a leftist herself supported the recall because even she realized that this was insane oh she realized that her constituency thought it was insane and the fact is that if you add this up to what happened in november and you add this up to other aspects what you see is a rejection of the crazy lefts educational agenda what you see is parents rising up to fight these leftists to reject them to to to kick them out of positions of power and I think this uh this vote a recall which is pretty rare this recall in california is really really good news so we've got a popular uprising electoral uprising against the worst elements in our educational system and I think as a consequence the schools are not going to be renamed and more importantly I think even the new renaming the two schools that function based on merit today will continue to function based on merit they will not be shifted to a lottery system uh and yes there's still a lot of work to be done particularly in place like San Francisco but these little steps matter particularly when it comes to education the most important place where we have to have change thank you for listening or watching the Iran book show if you'd like to support the show we make it as easy as possible for you to trade with me you get value from listening you get value from watching show your appreciation you can do that by going to iranbookshow.com slash support by going to patreon subscribe star locals and just making a appropriate contribution on any one of those uh any one of those channels also if you'd like to see the Iran book show grow please consider sharing our content and of course subscribe press that little bell button right down there on youtube so that you get an announcement when we go live and for you those of you who are already subscribers and those of you who already supporters of the show thank you I very much appreciate it


Now the Gambia has declared a public health emergency after two cases of polio virus were found in environmental sewage samples. A new sampling policy was put in place in the Gambia in May, or the support of the World Health Organization. Gambia declared a public health emergency on Wednesday after traces of the polio virus were found in sewage water samples. The sewage water in which the virus was detected was collected from the capital, Banjul, and the tourist hub of Kottu. Gambia's Minister of Health, Ahmadullah Minh Samate, said no case of polio had been confirmed among the population in the country. He said the government is also planning at least two mass vaccination campaigns targeting children under five. A new sampling policy was put in place in Gambia in May, with the support of the World Health Organization. The country routinely tests sewage waste for any traces of the virus. The Gambia was declared polio-free in 2004, according to the ministry. In August 2020, the WHO announced that polio had been eradicated from Africa after four consecutive years without reported cases, calling it a historic moment. Don't forget to hit the notification button so you get notified about fresh news updates.


I'm delighted to welcome you to this session in our seminar series on ethical issues in organ transplantation. The speaker today is going to be Mike Millis, who will be talking about ethical issues and transplantation in China. As many of you know, Mike is a professor of surgery, the director of the transplant center here, and also the medical director of transplantation services at the university. He trained in medical school at Tennessee and residency and fellowship at UCLA. His research in recent years has been closely related to health policy and ethics, particularly working with the vice minister of health of China, J-Fu Wang, himself a transplant surgeon to try to modify and change transplantation policies in China. I think that will be the topic that Mike is going to discuss today. It's wonderful to welcome you, a member of the American College of Surgeons, Mary Sider Transplant Surgeons, et cetera. Michael, welcome. It's a great honor to be asked to speak in the faculty series following such great talks that we've had all this year. And hopefully this will live up to the standard, and the rest of the talks from the rest of our speakers for the rest of the year will be similarly as good as at least our past ones. So with that, as Mark said, over the last several years worked very closely with the vice minister of health in China to enact some reforms that have improved the field of transplantation in China. And I'll be talking about that. I have to obviously start off with a conflict of interest statement, and I don't think I have any conflict of interests. The work that I've done has been supported by a grant from the China Medical Board, which is to improve the practice and policy of transplantation in China. It was originally funded in 2007 and renewed in 2011. When people find out that I'm a transplant surgeon and that I do work in China, the first thing that people ask me is, oh, so do you go over and do transplants in China? And I quickly respond that I do not. And I mention this at the conflict of interest slide because frequently those activities have been associated with a high compensation for those surgeons who have gone to other countries and done transplants like this. And so I can assure you I have never done a transplant in China, much less gotten any money from doing them in China if I were to go. So then the follow-up question is, then, well, what do you do? And so I had a hard time answering that up until the McLean Fellows Conference when Peter Singer introduced me, at least, to the term of social entrepreneur. And I think that really does describe what I'm trying to do. And this is a picture of Bill Drayton, who is a founder of an organization that funds and supports social entrepreneurs. And in the quote, it says that social entrepreneurs are not content to just give a fish or to teach how to fish. They will not rest until they have revolutionized the fishing industry. And so putting that into what I do in China, my goal is not to just do a transplant or to teach the Chinese how to perform transplants, but to revolutionize the transplant system. And so we'll kind of use that as the benchmark of what I'm trying to do and how successful I may have been or not have been, as your opinion may vary on that. So the first thing we have to really discuss is, why does transplant need policies and regulations? We certainly know that if many of the physicians in this room were in their lab working on their research and had developed a small molecule that they wanted to try to test in humans, they would have to go through a rigorous FDA approval process in order to do the clinical trials much less than get approval to do them. However, if a surgeon develops an operation either in his lab or even in his mind and wants to try it on a patient, probably at most he needs an IRB approval and informed consent for that. So surgery is remarkably absent of regulatory oversight. That the surgeon-patient relationship is one of the most sacred in medicine. We have individualized pre-op planning of unique operations and intraoperative decisions that we cannot discuss with the patient. And so the care between a surgeon and a patient is very personalized and very much lacking of regulation. So in general in the hospital, if you just take it out to the hospital, non-transplant medical care, there's regulation on general hospital care, drugs, diagnostics, things like that, that the FDA and JCAH, et cetera, goes through. But regulation is absent on process, priorities, resource allocation, et cetera. So if a patient with a pancreatic cancer with a minimal chance of survival really wants a Whipple operation, then as long as the risks and benefits are described to the patient, then more than likely that patient will receive the operation. But transplant surgeons are, by their nature, conflicted in our practice. We have the care of the patient and the care of the potential donor simultaneously. And so regulations must be provided. And for transplant care, regulation, in fact, drives all processes, priorities, allocation decisions, and quality assessments. It's not just up to the doctor and the patient. So this is obviously Michelangelo's depiction of the gift of life from God to man, Sandy. I think that's right. Your husband, the art history. Sandy here? No. Oh, she's not here today. Okay. I certainly know Michelangelo in terms of art. I was able to connect this mother and her daughter through the gift of an organ. And this is indeed why we have to, transplantation is different and why we have to be concerned both about the donor and the recipient. And in fact, I say that transplantation and the regulatory aspects that we deal with the most is because of the concern for that third party, for that donor. And we have to protect the rights and concerns of that donor before and after donation, and that's whether they are a living donor or a deceased donor. We have to protect their gift, and that drives much of the regulation on the recipient side. Patient selection is part of the decision-making process, is determined if the recipient will be able to take care of the graft, the program quality. If we don't have guidelines for the quality aspects of the program, then the gift will be wasted as well. And once the aspect of an equitable allocation system we know is part and parcel to a society that will support organ donation in the long term. So now we change a little bit, hopefully having provided you the background and reasons why transplantation has to be regulated. And we can see, in fact, that when transplantation grows up in an unregulated fashion as it did in China, there are many abuses and problems. And these were finally started to be addressed in 2006 by Jaifu at a WHO conference in 2006 in which the first public and then subsequently scientific recognition of the problems of transplantation in China occurred. The press focused, of course, on the organs from executed prisoners of which is certainly a problem, but there were also many other problems, quality, lack of a database, lack of transparency at every level, transplant tourism, and payment of organs were in fact just a few of the additional problems that needed to be addressed in order to try to clean up the transplant system in China. So the bottom line in China, having transplantation grown up in a nonregulated fashion, were that patients who needed transplants were getting harmed, living donors were being harmed, transplantation's reputation worldwide was being harmed, patients were not receiving maximal benefits from their transplant because of physician compensation systems and feudal transplants were performed just in order to get the compensation. Organizations were not provided adequate informed consent either on the donor, the recipient, or the payer. There was no transparency. Centers had exclusive relationships with prisons and centers could do whatever they wanted to with the organ, eliminating any appearance of equity. And there was also concerns that the need for organs would drive executions at least the time of the execution. And at least at that level, if not at potentially even at the judicial level of someone being paid off to, a judge being paid off to sentence someone to death in order to receive ultimately the organs from that person. So this is, so now we're kind of switching now to what we've gotten to in 2012. And a recognition by China and Jaifu, both in April and May at two different talks that the reliance on deceased donors, organs from executed prisoners will stop. And that the reason for that is that the death rope inmates in his words may feel oppressed to become a donor. So transplant tourism is driven by profits. Some hospitals trade with illegal organ agencies and forged identifications in order to sell organs to foreigners. Transplant tourism has made the sale of organs even more lucrative. And unfortunately this practice continues in China, although regulation has been established to ban transplant tourism. And that really talks about the lack of the rule of law overall in China, and not just within transplant or health care in general. If you talk to enough people from China who know about China, the whole rule of law aspect and pushing down regulations to the individual level is frequently a problem. But the commercialization of transplant services with organ trafficking and agencies is a huge problem and it violates the principles of equity and the goal of establishing a harmonious society. So one of the things that we've seen with the regulations is a dramatic decrease in the number of transplants performed. You see the curve of transplants going up and it really peaked in in 04. And then soon after that in 06 is when the regulation started and you're seeing a drop. And today, well the most recent data that we have, 2010, it's essentially at the same level as this for kidneys and this for liver. So one could certainly say that we haven't been successful in terms of providing transplant services to those Chinese who need it. And I think that we would all have to agree that that is true. But the issue is that we have to go through a period of time in which to get into a more ethical scenario and a sustainable ethical scenario that fewer transplants are being performed. And ultimately the greater good of a better system that ultimately will provide more organs for China will be developed. Even at the most extreme estimates of the number of executed prisoners that have been postulated out there, there's no way that that number, even if they were able to use all of them as organ donors, would be able to satisfy the demand. And a citizen-based system would be much more likely to get to a closer scenario of demand and supply. So if we look at the world activity in organ transplantation, those are the numbers. China does approximately 10% of those. And those are the numbers there for each organ with kidney a little lower and liver at 9.9% and heart and lung in very small amounts. So once again, in 06, if we go back to that point in time, we had over 95% of the donors were from executed prisoners. Transplant tourism was widespread. There were over 600 hospitals performing transplants, and then there were no regulations. The vice-minister called all the programs that were operating at that time to Guangzhou for a meeting in which all the transplant centers were notified that they must apply to the Ministry of Health in order to continue to perform transplants in general. And they provided the criterion which programs would be judged. And they are very similar in fact to FDA and UNOS regulations regarding transplant centers as well. Experience of primary surgeon, the center volume, institutional support, and the field strength of the institution in order to be able to provide transplant services. And on the donor side, there was regulations that the prisoners and or the prisoners family must sign the consent. There were four principal areas of focus, regulating quality, regulating transplantable organs, regulating transplant tourism, and regulating the source and rights of the organ donor. So in 06, the interim provisions on the clinical application and management of human organ transplantation was promulgated from the Ministry of Health and that those once again now codified those areas of criteria of ethics, medical and surgical expertise, ICU, care, et cetera. And in April of 06, the Committee of Organ Transplantation was established. And in November of 06, the National Summit was to announce all these changes. This is the regulation that came out in 07 that from the State Council and then the decree which was adopted by the legislature. So the impact of these regulations decreased the number of transplant centers from over 600 to 161. They had 18 months to fully comply with the Ministry of Health regulations. And currently there are 161 fully approved Ministry of Health transplant centers. There were applications that were turned down because they didn't want to increase that number and they were still reviewing the first group. All provinces in China have at least one transplant center. So I go through the liver regulations just as a highlight, basically all the other organs have similar regulations. You must have a Ministry of Health license to perform, in this case liver transplantation. Only they have different levels of hospitals, the highest level is a 3A hospital. So you must be a 3A hospital. You must have departments of surgery, gastroenterology and ICU. The facility requirements you have to have more than 80 beds, 10 years of experience in hepatobiliary surgery, over 500 hepatobiliary or pancreatic operations per year. And that you have to have a separate liver transplant OR and a liver transplant ward. Surgery requirements, three senior surgeons, greater than 10 years of experience and five years, greater than five years of experience in liver transplantation and the volume requirements as well. So you can see that those of us who are very familiar with the requirements for CMS and for UNOS, in general they are in the same flavor as those regulations. So how have they tried to enforce the regulations? As I mentioned before, there are issues regarding the rule of law and enforcement of any regulation in China. And this slide is just documenting too, but there have been others with similar consequences. The vice minister was informed of two cases of transplant tourism back in 08. The response was after a full investigation that confirmed these cases. Each of the hospitals was not allowed to perform the transplant that they transplanted a transplant tourist on for a year. So it found out at least the penalties are severe. The issue is once again how to kind of police that as they don't really have the manpower to do audits, UNOS audits like we see here, CMS audits, or even an ability to track each organ that is procured at the current time. So one of the issues is living donation and as the number of organs from executed prisoners has decreased, the number of living donors has increased, the Ministry of Health does not officially condone or support living donation, but it does address it in regulation and has become even more prescriptive than the U.S. in this area in terms of who should be accepted for donors, including BMI, hypertension and anatomy issues that get down to who can and cannot be a living donor. And part of that is that the Ministry of Health feels that China's legal, social, economic and health systems are not yet mature enough to support living donation in the way that Western countries have been able to support it. So these regulations were published in The Lancet by Jaifu, myself, and Eli Mao, who is Jaifu's kind of right-hand man back in 08. And then, soon after that, the registry was formed, and the key people for the registry are ST Fan here and Haibo here. Both ST is a transplant surgeon in Hong Kong and chairman of the Department of Surgery, and Haibo, I don't know what kind of physician he is, but he's also getting his Master's of Public Health currently in the States and has been instrumental in developing and working with the registry to make it as efficient as possible. And it is a post-transplant registry, so Ministry of Health approved hospitals have to provide information regarding their transplants to the registry. And if you have access to it, you can get your own data. It is certainly not the same as you know those of us who, in transplant, you know, we can go to SRTR and find out not only your stats, but stats for every other program that you, in the country, it is not that robust. It is not that transparent at the current time. Something that we'll certainly be working on, but there's a lot, just as it was when the U.S. started that, there's a lot of apprehension of putting your own data out publicly. So brain death has been a big issue in Asia in general, and it has not been particularly effective or embraced by any of the Asian cultures. That, however, didn't stop us from at least trying. As we know that in the U.S. it's been the standard since 69, it's the standard in Europe. The primary criteria are established in the etiology of the disease causing brain death, excluding other potentially reversible syndromes, demonstrating clinical signs of brain death, and all of these were, in fact, generally accepted by this conference that I was at by the medical community, but because of issues regarding kind of the Ministry of Health, the Justice Ministry, et cetera, there was no way to get a law passed. And so we have, as of today still, have failed in getting a brain death law happening in China. At the same time, I show this, at the same time that the brain death meeting was occurring, I think a couple of days before, there was a meeting in the Chinese Organ Transplant Council. I think I was the only Westerner that has been a part of that, but that is not the significant part. The significant part is this person here who's in military garb, and it was the first time, in fact, that the military had attended a Chinese Organ Transplant Council meeting. And that is significant because in China there are at least two different hospital systems. There's the Ministry of Health system, which is the larger, and then there's a military system. Military system essentially does not have to abide by the Ministry of Health policies, rules, and regulations. And so just by them joining the Organ Transplant Council meeting is at least a first step in the process of them understanding that hopefully they will get into a similar type of regulatory environment in the future. So what do we do when we're trying to develop a citizen-based voluntary system of organ donation without a brain death law? So this is the standard Western and our current way of looking at the deceased owner pool. We have the blue ones, the brain death ones, and the salmon color that are depicting the donation of cardiac death. And we think of them as different groups, and we treat them in a totally different manner in terms of their workup, the ethical underpinnings, et cetera. And when you don't have a brain death law, it's really hard to kind of move forward in a deceased owner pool. So what we had to do was think of an innovative way to reclassify things. And so what we did was we redefined deceased organ donation in China. And so now we have this whole pool and we have those blue donors who are brain dead donors, but we will treat them like the salmon, the donation after cardiac death donors. And that way every donor will be treated the same way, just like a DCD donor. Some of them will be brain dead, but will not be necessarily classified as brain dead, but they will obviously die more quickly than those that in our traditional fashion of looking at a donation after cardiac death. And so we looked at this innovative way of redefining deceased organ donation in China. We published that once again on Lancet Article in 2012 and also noted that we were going to begin a pilot project of donation utilizing these types of terms and processes. And so as I mentioned, we will treat all potential donors as DCDs and especially at first because in fact many of the hospital's ICUs, they would have brain dead donors just hanging around because they had nothing else that they could do with them.  And so they just had these people taking up and at the brain death meeting it was estimated that up to I think 10% of the healthcare costs in China were programmed for these types of patients who were in ICUs just hanging out as brain dead but not being able to do anything about them. And so we also wanted to establish a national organ donation system with an allocation system, etc., moving towards what would be closer to be considered to be a Western type of scenario. So we were treating everyone as a DCD donor. The demonstration project ran from April of 11th to January of 12th and 26 OPOs were utilized slash established and 292 organs went to 31 hospitals and 50% were occurred in the last six months of the project. An update from that is now that there's up to 546 organs from 207 donors in 16 regions. And for the first time under this system organs were actually allocated in a transparent way and a sharing policy was established. As I mentioned before previously there was a one-to-one relationship between prisoners and hospitals which allowed the hospitals to transplant whoever they wished. And now there's a sharing policy and an allocation system. If a donor was identified in one of the transplant hospitals the transplant hospital was guaranteed to get at least one kidney out of that donor similar to the early stages of UNOS in which there was some feeling of propriety in an organ and a donor within your organization. So the essentially UNOS type of system, the China organ transplant response system was launched in April of 11th and there were 26 OPOs, etc. And this is how they signed in and there was a decision made on how to allocate and prioritize candidates with transparency. And this is how the system looks when you open it up with a donor. Very similar to how we would see a donor and recipient characteristics with melds of 40 down to melds of 22 although in our UNOS systems they're not Chinese characters. So one of the aspects that was truly remarkable at the meeting that really summarized the experience of the pilot project was the donor story. And although I've been to China several dozens of times and spent anywhere from a couple of days to a month there in one trip I've learned very little Chinese. I'm generally tone deaf, it's a tonal language, I'm terrible at languages and I'm fortunate and they always are able to provide me with an interpreter so the need is not there to learn either. But at this meeting with the donor story you didn't need to know the language. It's the same that we hear from our own donor stories with this was a migrant worker who lost his son and was fortunate enough in his terms to be able to allow his son to be a donor. I had always thought that the cities like Shanghai would be the leaders in developing a voluntary deceased donor program because there's a more youth-oriented culture with less reliance on the traditional cultures. But this was a man who in fact proved that wrong. Like I say he was a migrant worker of little means and really was very emotional in being able to provide his story and his son's organs to other people. So some of the things that are moving on since then there's a manuscript under current review utilizing ECMO and Will and I were talking about ECMO and other scenarios today and they have started using ECMO for their DCDs so they pronounce someone dead after the usual five minutes and then initiate ECMO in order to improve the preservation system of the organs while they're doing now a more standard organ procurement. They were initially concerned that the heart might reanimate after initiation of ECMO but at least as of the last I spoke with them they had not seen any reanimations of the heart with ECMO and that they are you know worrying about whether to try to move up go from five minutes to four minutes but also the concern that that would be in terms of reanimating the heart. So but this is a nice step in terms of trying to improve the quality of the organs that they receive from their donors. So let's kind of encapsulate what we've seen already in terms of social changes when I first started going over to China and really talking about transplantation and thinking about their system the general sense was not only from the physicians but even from people that I talked with you know cab drivers etc that there was nothing wrong with using executed prisoners as donors. Transplant tourism was good for the system and that Chinese would never embrace living donor transplantation because they wanted to have their body whole up until the time of burial. Well now in 2010 the government wants to eliminate the death penalty recognition that transplanted tourism and payment for organs is unacceptable living donation is increasing and deceased donor donation is definitely on the agenda and being executed now in many projects. So this is just one of the many stories that are in the press in China the idea of donating one kidney to my daughter had been lingering with me for some time and he was you know in the new system more willing and able to do that. A quote from Jaifu in recent meetings the evolution of organ transplantation provides one of the best windows through which to view contemporary Chinese society while it struggles with the search for a cultural identity and late modernity. And that the deepest significance of organ transplantation lies in its gift exchange dimension and the nature and magnitude of what is given taken and received. There's a feeling that organ donation will help China and its constant quest for a harmonious society and that having a fair ethical organ transplant system is part and parcel to that harmonious society. So how have we done in the last six years? We've improved the quality of patients so patients are not getting harmed by setting the standards for being a Ministry of Health approved transplant center. Transplantation's reputation is improving and that we're trying to address these problems and that's globally. China's organ transplant committee has provided clinical guidelines regarding candidacy, perioperative and postoperative care. We've improved informed consent to the patients and donors including the prisoner donors and develop strategies and voluntary deceased donor systems with transparent allocations. In terms of a social entrepreneur, I think that we're about halfway there to a sustainable social entrepreneurial success with entrepreneurship, innovation and social change. What we need to accelerate it, I think number one is some time, obviously funding that's going to take a lot of money to really broaden this out and to extend the rule of law in China. And so our goals, my goals at least for the next five years in regarding this aspect is to make a voluntary deceased donor program robust enough to eliminate the use of prisoners as organ donors, improve the enforcement of regulations, provide on-site audits of transplant activities, expand the policies and procedures to non-ministry of health hospitals such as the military hospital. So one of my goals as you saw was to eliminate the need for, eliminate the use of donors from executed prisoners. So the recent notice from the Ministry of Health says that they want to eliminate this use of organs from prisoners in 2013. So in the year that we are currently in, they want to eliminate it. And I highlight Haibo's name here who's quoted significantly in this article so that we really see that this is a truly a Chinese effort. I have, I think, provided some assistance, counseling, guidance and consultation to the Ministry of Health as well as others in order to try to guide them through both their own issues as well as the issues in terms of international acceptance. Frank Delmonico, who was our first speaker in this series, sometimes has been very vocal and animated regarding the use of, the use of executed prisoners in the whole transplant system in China and kind of maneuvering through all of those types of concerns and critics and still keeping China on a path that is sustainable. At times has been a challenge and many phone calls to all people but I'm really encouraged at the process that China has gone through and the progress that they are making and will continue to make. So once again, Mark, thank you very much for inviting me. Thank you, Mike. The paper is open for questions. I'm going to ask Dr. Chapman. Would you introduce yourself as you start? Please. Sure, thank you. My name is Will Chapman. I'm a transplant surgeon at Washington University in St. Louis head up the Transplant Center and abdominal transplant programs there. Mike, that's a great summary of the problems that have existed. One area I'd be curious about for you to comment on is term transplant tourism and the elimination and punishment of centers that have been, that have engaged in any transplant tourism. I guess I'd like you to define it a little more because I'd have to say we practice transplant tourism very commonly. In fact, centers work to have transplant tourism in the U.S. We think it's good. And United Network for Organ Sharing is established that you can have as much transplant tourism for living donation as you like. You're restricted to 5% of your transplant volume annually for cat of Eric donation. There's some really busy centers. There's some not so busy. But I've never had the view that that was something that shouldn't be done in the United States. Right. So I think it's an excellent point. And I've had that same concern regarding transplant tourism and how we allow it here and its banned in China. And I think that the difference is that when patients go to China to get an organ, they are paying a broker a lot of money. Would they have to? Yes. That has been the system. Now, yes. I mean, in a different system in which there is not payment for organs, then I think you at least have to readdress the concept of whether transplant tourism is allowable or not. But in the U.S., there is no difference. So when Wash U and the University of Chicago performs a transplant on someone who specifically came to the U.S. for their transplant, they are getting charged the same amount, at least their charged bill, as any other patient in the U.S. In China, that is not true. The foreigners are charged more. In addition to, they are paying for an organ. And I think those two differences make the ethical practice of transplant tourism in China a real challenge right now. If we were 10 years, 15 years, whatever, in the future and the payment of organs has gone away in China, there is a transparent system, all that other stuff, then I think at least we can readdress it. You know, if we were to fully utilize the potential of deceased donors in China, it would probably overwhelm currently the number of patients who can at least afford transplantation in China. And so then you'd have to think, well, what should you do with those organs? You know, should the government, you know, provide more insurance to get, allow more Chinese people to get organs, or should you open that up to transplant tourism? I think that those are reasonable things to think about 10 or 15 years from now. How did Vice Minister Wang do in the recent reshuffling? He did fine. So there's a mandatory retirement age of 65, and similar to what I talked about with the rule of law, that doesn't apply. Jaifu is 70 or so, I think, something like that, certainly over 65. And in the previous power shift before the most recent one, one of the ways they got around the Ministry of Health, the governmental age restriction was, is that they defined him as the personal physician for all the leaders. And so I think that that continues. And he has continued to be Vice Minister even with the new power shift. Wow, lots of questions. Well, Mark came with a microphone first. Perhaps I'm a little dense, but I'm having a hard time understanding your blue and the salmon with the cardiac death and being ready. Do they preline these people ready to go get on ECMO? Yes. And so how do they anticipate that? I mean, how much, there must be a lot of manipulation there as to who's going to have a cardiac death. Tell me who, you know, if you can predict within... No, no, no. So it's, so it's just as, in that system, it's just the way the same way that we do it, right? It's just that someone, you know, is on life support, has no chance of survival, etc. So the organ procurement organization goes to the family and says, would you like to be able to provide organs for donation? And they say yes. And they, so they, they withdraw life support. Okay. And once the heart stops for five minutes, they're declared dead. So, but if there's no brain dead, how do they, they're still allowed to withdraw life support? Yeah. Yeah. Right. Okay. And once their heart stops, then they're declared dead. So before you do that, you line them up with an echo. Yeah. But it sounds like a little manipulation as far as, it's just not really a brain dead, just still disconnecting. Well, there, there are patients who have been identified as, as, and their families have identified that they want to withdraw life support. Is there an EEG on one of these individuals? What's that for? No. Well, the EEG wouldn't make it a difference in China. There's no brain death. They're basing it on the cessation of circulatory function. Well, if they're re-establishing circulatory function, they're bypassing the heart. Right. They may block it. They do it. Mike. Shola. Yeah, Mike, as declared social entrepreneur now, and with some of the successes that you've had in China. I'm curious as to what you intend to do next, since issues related to transplant tourism and all of those issues actually prey on the unexplored vulnerable populations. Since you're so close to India, have you ventured to actually look at what operates there? I've never been to India. India is far away from China, actually. But there are a lot of vulnerable populations in between the two, too. I thought actually the elimination of executed prisoners would pretty much take the rest of my professional career. I'm really amazed at how quickly it seemingly is coming around. It does bring up the issue, well, what am I going to do next? I think there's still a lot to do in China, and I want to continue to work in that area. I'm open to looking at other areas as well. I think that the experience has been a learning experience, and it's very gratifying that it's moving along so quickly. I'm going to raise two, I hope, controversial issues. That's the intent. The first is about the use of ECMO to prepare a donor for donation post-cardiac death. As it's practiced in China, do they prevent cerebral re-blood flow, or as it's done in the United States, do we prevent cerebral re-blood flow? My understanding in both of those scenarios is that they do not. So there's no blockage of it, but there's also no retesting of whether... That's correct. That's my understanding. As far as I know, there's a balloon catheter that's put in the aorta to prevent re-flow to the heart, but not flow to the brain. And that's how this is practiced in the U.S. and in some areas of Europe. So I think it's the same. The second issue has to do with the somewhat... I'm going to label it disingenuous stance that transplant tourism is practiced in a wide-open completely transplant mechanism in the United States. While I am certainly part of it, we must recognize the fact that there isn't... While there may not be a difference in charges established for transplants for foreign visitors, there is certainly a difference in revenue generated. No question about that. Huge difference. So that individual programs may survive on doing as few as one foreign national on an annual basis, because that's the difference between losing money and... Making money. Can you comment further on that? Yeah, so that's absolutely true. And there's more transparency coming in terms of transplant tourism, with UNOS regulations requiring public dissemination of the number of transplants that you've done on patients that are non-U.S. nationals. So there's more transparency in the numbers. In terms of the financial aspect, you're absolutely right. Programs get a lot more money from doing transplant tourism than they do for doing transplants on Medicaid patients. No question about it. Or Medicare. Or Medicare. Or any other private payer. Yes. But the charges are the same. Charges are the same. So Mike, I wonder if you can tell us a little bit more about your own personal story of how you got from being a professor at University of Chicago to advise the United States government and maybe what lessons you've learned about how to be effective in that situation and maybe pitfalls to avoid. Repeat the question. So I think this got that, right? So the question is how did I get involved in moving from a professor of surgery at the University of Chicago to advising the Ministry of Health and doing this and then how kind of some lessons about why I've been so successful perhaps. So my first experience with China and transplantation was a self-preservation experience. I was a fellow at UCLA and we were doing 250 liver transplants a year and I was the only fellow. And so C.M. Lowe, who is ST Fan's junior person, came over for a year starting in January of my first year of my fellowship. And as bad as the first year of the fellowship was going to be, the second year of the fellowship was going to be worse. Because during the second year of the fellowship, you go out on all the procurements with the first year fellow and teach them how to procure. And I was going to have to go out every night with the first year fellow and that was going to be just a killer. And so when C.M. Lowe came over for a year starting in January, my first order of business for self-preservation was to teach him how to procure so that he could go out some of the nights with the first year fellows instead of me. And so C.M. Lowe and I became very close and then he went back to Hong Kong after he finished and helped ST Fan with the liver transplant program there. And he would invite me over fairly frequently to Hong Kong and I started not only going to Hong Kong but to some areas of China giving talks and all that, as I said, not doing transplants. And so I got fairly familiar with the transplant system there and many of the transplant surgeons. And then in the old six time period, and Mark will know this very well, Roy Schwartz, who at that time was the head of the China Medical Board and also the head of the visiting committee of the dean of the University of Chicago here was talking with Jaifu regarding the need for transplant reform in China. Jaifu agreed and they said that they needed a U.S. partner to help them with and so Roy being on the visiting committee here said, well, we've got a great transplant program at the University of Chicago, why don't you talk with them? And it was through then that relationship that I got involved and helped write the grant ultimately to get, they got China Medical Board funding and then the renewal in 11. And so it was through that specific relationship. The broader picture of that relationship is that Jaifu, in addition to being vice minister of health, is also head of the liver surgery section at Peking Union Medical College, which is the most prestigious and best medical school in China. And that PUMC was established by Rockefeller, which the China Medical Board was as well and obviously the University of Chicago. So we all have Rockefeller roots as well. So I think that helped cement a relationship. And so how I've been successful, I think that one thing is that you always have to recognize that it's not about you. It's about them and getting them to improve. And I think that I think your question about being a professor is really important. I'm not sure that an assistant professor could do that but an assistant professor is looking at ways to promote his career and would probably look at that more, can I be a first author, can I be a last author, can I do this, can I get this published, etc. And having already been a professor, it was less important for me to feel that any of these specific steps along the way were attributed to me, but the fact that I really wanted to help China and to be a social entrepreneur and get that established. It always has to be a Chinese initiative. It has to have Chinese roots and a Chinese flavor. My contribution has been to make sure that they understand what's ethically acceptable, how to maneuver from sometimes Frank's extreme thoughts and comments about the executed prisoners and payment for organs and this and that and the other and where they want to go and to try to find that ground that doesn't hit the third rail on either side. I know there are more questions, but I always think that that answer is an effective place to stop. I mean it is quite remarkable as you think about how much you and J-Fu and the Chinese transplant programs have accomplished and changed in six or seven years to think about moving a major system in the largest population base in the world in a relatively short time. And even though there are still critics out there like Frank, Lady mentioned Art Kaplan's article, which he doesn't think anything has changed, I think things are really different now from when you started. Of course, in a very selfish way, I think your background in ethics, you know, beginning with the Broch program here and including that critique of living donors for right hepatectomies in the New England Journal in 2000 gave you a certain perspective on some of the ethical problems that are associated with Chinese transplant policy before you and J-Fu began to work. Of course, having a helper like J-Fu, who is safe and secure in the Chinese system, was fabulous. Well, I want to thank you. It was fabulous. Thank you.