What is the Evidence of ‘Forced Organ Harvesting’ in China?

Journal of Political Risk, Vol. 7, No. 7, July 2019

Tianjin First Center Hospital, left, and the Oriental Organ Transplant Center, right, seen in Tianjin, 2018. Data from official records about the hospital, and admissions by medical staff, suggest it performs thousands of transplants annually. Source: Wikimedia commons.

Matthew Robertson
Victims of Communism Memorial Foundation

On June 17 in London a “people’s tribunal” chaired by Sir Geoffrey Nice QC, prosecutor of Slobodan Milosevic at The Hague, issued a judgement stating that “forced organ harvesting” has taken place in China for over 20 years, and continues to this day. It concluded that practitioners of Falun Gong have been “probably the main” source of organ supply, adding that the violent persecution and medical testing of Uyghurs make it likely that they too are victims, or at least are highly vulnerable targets for organ harvesting now and in the future. The findings have been widely reported.

The tribunal has thus reaffirmed a long-standing allegation: that the Chinese security services and military, working with transplant surgeons in hospitals, use prisoners of conscience as a living organ bank — blood and tissue-typing them, entering their biometric data into databases, and killing them on demand (or removing their organs before they die, as some Chinese medical papers suggest, and as testified to by the Uyghur former surgeon Enver Tohti) for paying recipients. Transplant surgeries typically cost hundreds of thousands of yuan (or hundreds of thousands of dollars for tourists), and recipients then take immunosuppressants for the rest of their lives. Depending on the scale of the practice, this would make it a multi-billion dollar industry.

The tribunal’s conclusion is the highest-profile statement on these allegations since they emerged in somewhat dubious circumstances 13 years ago. It appears that the long association with Falun Gong activism (a marginalized identity group in mainstream media representations and scholarship), coupled with the novel horror of the claims, has meant that they have largely been avoided by the wider China studies and international human rights establishments.

The gravity of the allegations, however, demands that they be engaged. If they are false, they should be refuted and set aside. If they are true, the implications must be explored, and their renewed relevance given current circumstances in Xinjiang fully considered. In either case, their awkward, unresolved status in the China field and beyond must come to an end.

Extraordinary claims require extraordinary evidence. We must ask, then: what evidence and inference is the conclusion based on? Has a major figure in international human rights and a committee of legal and medical experts — after consulting roughly 150 submissions and a large body of background reading material — made an awful mistake, or should informed observers of China, after examining the evidence for themselves, come to the same conclusion?

The inferential logic followed by the tribunal, based on the summary findings, appears to be roughly as follows.

The Logic of the Claim

China’s organ transplantation system began a period of enormous national growth, concurrent with central policies and research funding, in the year 2000. This included training of new doctors, significant expansion in the number of hospitals performing transplant operations (from 91 in 2000 to up to 1000 by 2006), and growth in the type of transplants performed from almost exclusively kidney transplants to livers, hearts, and lungs. This latter development necessitates closer interaction between judicial and medical authorities in coordinating death and organ extraction, as the other organs are highly sensitive to ischemic damage and must be removed much more promptly upon donor death.

Throughout the 2000s, according to available estimates, death penalty sentences have been in decline, despite China still being the largest executer in the world. Estimated figures begin at 12,000 in the early 2000s, and decline to just a couple of thousand by 2013.

This decline accelerated in 2007, according to judicial sources and scholars, with the Supreme People’s Court recentralizing review of death penalty cases. Reliable local data, in Guangdong, for instance, shows a clear trajectory of decline.

There was no system of voluntary organ donation during this period, and the number of voluntary deceased donations was only about 120 or 130 by 2009. Subsequent data about voluntary donations from 2010-2017 is highly unreliable, as it appears to have been falsified based on a simple mathematical formula (the paper making this claim, of which I am lead author, is under review with a medical ethics journal). In any case, the official figures of claimed deceased donors only exceeded 2,000 annually in 2015. This means that from 2000-2015, the only major official source of organs was death row prisoners.

The actual number of transplants performed in Chinese hospitals is considered a secret, and said to be “too sensitive” for disclosure. Official numbers made public are incomplete and often contradictory. Estimates of actual transplant volume, however, using such measures as dedicated transplant beds, occupancy rates, lengths of stay, as well as careless admissions by Chinese doctors in official publications, lead to estimates of figures in the tens of thousands annually.

Another unusual change takes place in the post-2000 era: a move to organ availability on demand. The co-author of the medical ethics paper referenced above, the Israeli cardiac transplant surgeon Dr. Jacob Lavee, was told by a patient in 2005 that his insurance company had arranged for him to receive a new heart in two weeks time, on a specific date. “Do you listen to yourself?” Dr. Lavee asked the patient. “How can they schedule a heart transplant ahead of time, two weeks?” The patient responded: “I didn’t bother to ask.” He indeed received the transplant. There are numerous data points showing that this is not an extraordinary case. Chinese hospitals advertised waiting times of one to four weeks for transplants (in the US, waiting times are often measured in years); official transplant registries stated that a third and a quarter of all liver transplants (for which time was recorded) in 2005 and 2006 respectively were performed on an “emergency” basis — meaning that after the recipient presented at the hospital with liver failure, the donor liver was matched, extracted, and transplanted within 24-72 hours. This is strong prima facie evidence of a pool of blood-typed donors whose livers were extracted on demand. Of course, this results in the death of the donor.

Much of the growth in the transplant sector took place even after the 2007 death penalty reforms. This included, for example, the construction of China’s largest transplant center in Tianjin, which operated at full capacity for years afterwards, as well as the Beijing 309 military hospital adding 71 transplant beds from 2010 to 2012, and boosting revenue from its transplant ward by a factor of 8 from 2006-2010.

All of the foregoing indicates, at least, that the official story of organ sourcing does not explain the observable growth of the system. If death penalty prisoners were the sole or primary source of organ supply, the transplant system would also have begun to decline through the 2000s and in particular in 2007 — yet it exhibited the opposite tendency. (Indeed, one wonders whether the death penalty reforms would have been put in place at all were such prisoners the primary source of organs.)

It is the above constellation of facts that forces researchers, and appears to have forced the tribunal, to consider alternative populations that could have provided the organ supply. Transplant organs must come from either the living or very recently deceased. The question then becomes: which population may have been able to satisfy this demand for organs?

One key indicator noted by the tribunal is the timing of the explosion of transplant activity: the year 2000, around six months after the Party’s anti-Falun Gong campaign began in July 1999. Like the campaign taking place against Uyghurs today, Chinese authorities used the tools of mass incarceration, torture, and thought reform in an attempt to eradicate the group. It is likely that within the first year, hundreds of thousands at least had been placed in the detention system, including re-education through labor camps, prisons, and a range of other extralegal facilities. These were the contemporary predecessors to the re-education camps in which perhaps 1.5 million Uyghurs find themselves today, and were developed by some of the same officials.

Falun Gong witnesses attest to unusual blood, urine, and physical examinations. It is not possible to know the purpose of these tests, though they are consistent with those required to assess the health and function of the abdominal and thoracic organs, and sometimes the cornea. Multiple blood withdrawals over a period of weeks are consistent with cross-matching necessary prior to kidney transplantation. Urine tests are used to evaluate kidney health prior to transplantation. Similarly, ultrasounds are used to determine liver and kidney health, X-rays the health of the lungs, and EKGs that of the heart. Some witnesses attest to only the Falun Gong detainees being called out for the tests. Others note that the examinations are performed by outside medical personnel, who drive a specially outfitted bus into the courtyard and march the prisoners through their tests in silence. The same prisoners are malnourished, beaten, and severely tortured in custody, so it would be unusual if such extensive medical examinations were for their benefit. The targeted nature of the testing also raises questions — if they were aimed at detecting communicable diseases, presumably the entire prison population would be examined, not only the political prisoners. Prisoners speak of inmates then disappearing afterwards. (About 20 Falun Gong testimonies speaking to the above are collected in the submissions section of the tribunal’s website.)

There are an unknown number of disappearances of Falun Gong practitioners, who are arrested but never heard from again. There is also one well documented case of a number of sisters (among whom Jiang Li gave testimony at the tribunal) in Chongqing, 2009, seeing their dead father Jiang Xiqing with scars consistent with those that would have been made due to organ removal. In this instance, even the police admitted the organs had been taken — though they claimed that they were turned into medical specimens (标本), not transplanted.

One unorthodox piece of evidence considered by the tribunal — and the subject of a forthcoming report by Victims of Communism Memorial Foundation — are the undercover cold calls made by activist-investigators to hospitals around the country.  The investigators pose as relatives of potential patients, other doctors, or security officials, and make enquiries about organ availability and sourcing. The investigators have obtained numerous admissions that the organs come from Falun Gong — and also many where, when they reach this line of questioning, the callee denies it or hangs up. Typically organs are claimed to be available within weeks, or at the most a month or two. In attempting to establish the authenticity of these calls, VOC examined telephone logs, compared them to the audio files for call length, and redialled the numbers to confirm they belonged to the hospitals stated. We also personally observed a number of the calls, and believe they are what they purport to be.

Finally, there are cases of double duty between some of the personnel involved in the anti-Falun Gong campaign and the organ transplant sector. Dr. Zheng Shusen, a leading surgeon and administrator at Zhejiang University’s First Affiliated Hospital for instance, is one of China’s most prominent liver surgeons — yet he is, or was, the director of the China Anti-Cult Association in the province of Zhejiang. CACA is a PONGO (Party-organized NGO) established in 2000 to devise and promulgate the official propaganda against Falun Gong. In the preface to a 2009 anti-Falun Gong book, he wrote: “‘Falun Gong’ and similar evil religions are like viruses corroding the organism of humanity, warping the souls of believers, destroying social order, disrupting economic development, and have become a public nuisance to mankind and a cancer on society.” Why a liver transplant surgeon should be so deeply involved in the anti-Falun Gong struggle is, on the surface, something of a puzzle. Incidentally, Zheng reports performing dozens of “emergency” liver transplants from 2000-2004 (key years of the Party’s anti-Falun Gong campaign). Similarly, Wang Lijun, the deposed former police chief of Chongqing, ran an organ transplantation research laboratory in the same building as the Public Security Bureau when he was police chief of Jinzhou, Liaoning Province, where he was involved in anti-Falun Gong security activities. In an internal speech, he boasted of performing “thousands” of transplant trials in Jinzhou alone over a period of a few years. This is far more than any reasonable estimate of Jinzhou’s share of capital executions.[1] The alliance between the Party and the transplant profession is also clear from, for instance, the fact that over 90% of the transplant personnel at a major Shanghai hospital are Party members, or the apparent ubiquity of Party cells in hospitals and transplant wards. The top transplant official in China, Huang Jiefu, is or was director of the Party’s Healthcare Committee Office (中央保健委员会办公室).

Is the above sequence of claims dispositive of the case? Is there sufficient evidence buttressing each of them, and no countervailing evidence sufficient to show that some other population (not death row, not prisoners of conscience) could have been used on demand and at scale? There are media reports in China about criminal gangs working with hospitals to traffic organs from living donors, and even killing beggars and other vulnerable people on the margins — but this hardly appears adequate to explain the industry that has developed. Other possible objections might be that China’s real transplant volume is far lower than researchers have estimated, or that, somehow, the death penalty system has operated for 20 years at a scale over ten times greater than all available literature suggests. Yet, the evidence of significant hospital transplant volume is clear and comes from numerous official sources; and China’s death penalty system has been under sustained scrutiny from scholars for decades, making the complexity of that conspiracy far greater than the alternative.

This is where the collection and evaluation of complex strands of evidence becomes so crucial, and why the topic must be engaged in with thought and care.

Gathering and Evaluating the Evidence

To readers who have followed the in-text links, it will be clear that each data point or item of evidence is like a puzzle piece, drawn from a wide variety of sources: hospital websites, medical journals, clinical studies, transplant registries (also purged), internal speeches, media reports, surgeon biographies, and more. Many hospital websites were purged or stopped updating data, while others retroactively altered transplant figures downward. Apart from such documentary sources, there are the investigative phone calls, and witnesses testifying to blood tests and physical examinations.

None of these sources are by themselves perfectly reliable or complete — but when so many different sources all point in the same direction, despite none by themselves being unimpeachable, one’s conclusions are much stronger.

In the case of China’s transplant system, many of the arguments in the above narrative are indeed open to dispute, or demand careful substantiation. For instance, what method should we use to derive estimates of transplant volume? Western doctors intent on shepherding China’s purported transplant reforms have criticized the authors of the Kilgour-Matas-Gutmann report of 2016 for claiming that China may have performed 60,000-100,000 transplants annually. Part of these figures were estimated based on official mandated minimums for transplant beds and surgeries, and the authors make assumptions about transplant bed occupancy and the proportion of new patients versus readmitted patients. This then requires careful analysis of medical papers discussing readmissions, lengths of stay, and infection rates. (It turns out that even using a highly conservative estimate of 50% occupancy of beds by new recipients, transplant volume still outstrips death penalty numbers by at least an order of magnitude.)

Chinese officials do not release national death penalty figures. Could they be an order of magnitude greater than the entire body of scholarship on China’s death penalty suggests? Given the quantity, access, depth, and care of this work, this seems extraordinarily unlikely — though there is no way to definitively disprove it. On the other hand, there is an abundance of evidence pointing to the panoply of reforms and attesting to their effect in reducing sentences. The coverup of ten times as many executions as estimated would require a conspiracy more elaborate than the simple exploitation of another organ source, captive alongside death row prisoners. There is also the question of high rates of infection of prisoners with blood-borne diseases, disqualifying them from being forced donors.

Often, the real objection to the argument is simply that it seems so unbelievable (or “hard to believe” as a documentary on the subject was titled.) This concern was best presented in a Washington Post article of 2017, where the reporter argued that if this had really gone on, we’d have heard about it by now. Yet the only new hard data in the story was the claim that China’s consumption of immunosuppressants (measured in dollars, not doses) did not match the reports of such large transplant volumes. Immunosuppressant drugs must be taken by transplant recipients for the rest of their lives, to prevent rejection of the foreign genetic material. This argument, however, which first appeared in the official Chinese press, was the product of a basic error in statistical inference: it is impossible to establish a statistical relationship between a country’s dollar amount of immunosuppressant consumption as a share of the global total and its transplants as a share of the global total, without data for all (or the major) countries on both measures. Specifically, the argument breaks down when looking at Japan and the U.S.: their share of global immunosuppressant sales are much higher than their share of global transplants; thus, other countries must exhibit the opposite relationship. Moreover, immunosuppressants are between 2.5-4 times cheaper in China than the U.S., the proportion of transplant tourists to domestic recipients is unknown, and there is a large (and government-subsidized) domestic immunosuppressant industry which operates largely through “grey” pharmacies that aren’t captured by foreign data sources. These four confounding variables might change the calculation by many times over. Nevertheless, the Post cited the claim as strong evidence of the veracity of official transplant figures, which authorities go to great lengths to falsify and conceal.

Proof and Social Proof

Given the controversial and emotive nature of the alleged crime, it seems the primary obstacle to forming consensus on the issue has been less about what the evidence actually says, than in having key constituencies attend to the evidence in the first place.

Even then, assuming that raw evidence for each of the synthetic claims is substantiated, another, more complex question arises: is the matter ‘proven’? What constitutes ‘proof’ of such a crime?

When a suspect is charged with homicide in the United States, police and forensic investigators gather and analyze evidence, and a prosecutor brings an indictment. The defendant retains counsel, and if the case goes to trial a jury decides on the matter of guilt. The ‘truth’ of whether or not the suspect committed the crime is thus decided by a group of peers, and the verdict (assuming it is not overturned), is generally taken as ‘real’ by the wider society. The guilty party is imprisoned or worse.

The matter is clearly different in the current case, where a state, or regime actor, is the suspect. The people’s tribunal in London effectively acted as a jury, taking in the evidence, evaluating it, and drawing conclusions as to guilt. It invited all relevant stakeholders to present evidence (the PRC and international doctors supportive of reforms declined), published online all evidence it evaluated, and provided a lengthy explanation of the reasoning behind its decision.

At the present stage, this appears to be the furthest any outside party can go in attempting to prove whether or not forced organ harvesting of prisoners of conscience has taken place in China. The extent of the recognition of claim, and the greater the repute of those who affirm it, the more the matter’s truth status will change from rumor to fact. This is what Robert Cialdini called “social proof,” whereby “we determine what is correct by finding out what other people think is correct.” It is too much to expect that every member of the public examine the evidence for themselves and reach a conclusion, which is why we rely on institutions in positions of public trust.

If, for instance, The Transplantation Society or the World Health Organization had, a decade ago, assembled a group of eminent experts to gather and assess the evidence, and they had come to the same conclusion as the tribunal, using the same inferential logic, the question would be considered settled. Subsequent data about China’s transplantation system would have then been interpreted within the framework of an established crime against humanity, and the claims of reform met with a much more skeptical eye. It’s likely that demands for a reckoning with past abuses would have been a precondition of any acceptance of such reform claims.

Yet a breakdown in the process of social consensus formation took place instead: the raw evidence behind the claim is complex and voluminous, and the key constituencies that would traditionally be expected to evaluate it and pronounce definitive opinions failed to do so. Western governments made an “easy surrender to… the uncertainty of proof that then allows them to avoid finding an ‘inconvenient truth’,” as the tribunal charged. They were speaking about the U.K.’s Foreign & Commonwealth Office, but the same could be said about the U.S. State Department and Australia’s Department of Foreign Affairs and Trade. In 2012 a senior Amnesty International China researcher gave credence to the claims at the European Parliament (“there are many groups that these organs may be taken from, the Falun Gong being one of the main groups”), but the organization has subsequently been silent. Human Rights Watch attempted to thread the needle by stating that it “has not substantiated claims that any one community is particularly targeted for this treatment, partly as a result of government-imposed restrictions on research.” The New York Times discouraged journalist Didi Kirsten Tatlow from pursuing the story in 2017, and declined to promote her possibly due to her expressed interest in the issue; she subsequently left the newspaper. (She testified to the tribunal that, based on a verbal exchange she witnessed between surgeons in 2017, the use of prisoners of conscience as an organ source appeared to be “common knowledge, at least among some medical specialists.”) Freedom House, in a February 2017 report on religious freedom in China, said it found “credible evidence suggesting that beginning in the early 2000s, Falun Gong detainees were killed for their organs on a large scale,” though this does not appear to have been enough to shift the debate.

Indeed, it is quite possible that in a world without ready access to satellite data and deep, on-the-ground reporting, current events in Xinjiang may have come to languish in a truth zone somewhere closer to awful rumor than the grim reality they now occupy.

The question now is whether continued temporizing will be considered adequate for the volume and strength of the evidence, the persistence of the allegations, and their newly found high-level sponsorship. Those concerned with their veracity might hope that such a strong conclusion by an eminent figure in international criminal law will prompt a reconsideration of the matter, and a deeper engagement with the evidence and inference, by the institutions that shape public beliefs.

Current Concerns

Events unfolding in Xinjiang may add an urgent impetus for such a reassessment. The Chinese security apparatus is in the process of creating a biometric database of the entire Xinjiang population, in particular targeting Uyghur Muslims. Blood-typing is a prerequisite for organ matching, and DNA analysis can lead to more accurate organ matching and thus lower rejection rates. Uyghurs are being transported to the Chinese interior by train, another prerequisite for their use as organ sources. The tribunal heard four testimonies from Uyghurs and Kazakhs (1, 2, 3, 4) who described the same types of unusual physical examinations necessary for evaluating organ health, but otherwise out of place in a context of extralegal incarceration occasioning widespread violence and abuse. Undercover footage from six Beijing military hospitals in November and December 2018, recorded by an activist now in the United States and reviewed by VOC, shows bustling transplant wards, with fresh livers available in weeks, or sooner if the right bribes are paid. A November 2017 documentary by undercover South Korean journalists showed the same thing in Tianjin. Meanwhile, Chinese officials speak of a growing transplant sector performing about 18000 transplants from 6000 donors (i.e. a claim of three organs per donor) in 2018, and the need to expand the hospitals performing transplants from 173 to 300 by 2020. The official explanation for organ sourcing this time is no longer death row prisoners, but voluntary, hospital-based donors. Yet given that the numbers underlying that growth appear to have been centrally falsified based on a simple formula, the question again arises: Who are the organs really coming from?

Casual observers of the organ harvesting issue often seem to experience a primal rejection of the hypothesis — that the crime is so obscene, heinous, and of an almost science-fiction quality, it cannot possibly be true. To a large degree this perspective fails to take into account the peculiar capacity for revolutionary violence that has been an important feature of PRC history. While the post-Mao era has not been characterized by the same campaigns of public, mass violence as the first few decades of the PRC, it is clear that the Party’s antireligious campaigns against both Falun Gong practitioners and Uyghur Muslims draw closely from that earlier model of political-ideological violence. Scenes from struggle sessions in Xinjiang recorded in 2017 by a documentary filmmaker, shown privately in New York recently, closely resemble the CCP’s land reform movement of the 1940s and 1950s. That campaign alone may have led to millions of deaths. Though the outright killing of political enemies may seem out of step with our wishes and hopes for a modernizing China, it is far from clear that the Chinese Communist Party feels the same way. There is a sense in which the marriage of ‘Mao’ and ‘market’ exemplified by the literal commodification of political enemies follows its own sort of logic. Every regime justifies its actions through its own vision of the good. If the revolutionary destruction of enemies of the people — Uyghurs are detained so that their “ideological viruses” can be forcibly wiped away, and Falun Gong is a “cancer on society” (presumably to be excised clinically) —  may profitably coincide with the healing and longevity of Party cadres and other upstanding (and paying) citizens, the only obstacles to the realization of that project would be medical ethics and legal safeguards. In China, both are absent. The Chinese Communist Party may be many things, but it has never stood accused of being unpragmatic.

The tribunal stopped short of calling organ harvesting a “genocide” — but they dealt with the evidence they received, at a specific point in history, where we appear to be at the beginning stages of the Uyghur persecution. Given the racial overtones of the Party’s campaign against Uyghurs, and its clear willingness to use medicine as a tool of coercion and destruction, we may wish to consider whether five years hence the CCP will have fairly earned the “genocide” label.

Matthew Robertson is a research fellow in China Studies at the Victims of Communism Memorial Foundation and a PhD student in political science at the Australian National University. His thesis examines the development of organ transplantation in China. JPR status: working paper.

[1] Assume, for example, 12000 executions in China in 2004 (an extremely high estimate). If they were equally distributed per population (they do not appear to be, in fact, but the inference holds nevertheless) this would mean that Jinzhou’s population of roughly 3 million would comprise 0.25% of the country’s executions, meaning there should be about 30 there. Wang’s reference to “thousands” is two orders of magnitude greater than this figure.