Department of Health & Human Services
Bureau of health Resources Development
Division of Transplantation
Rockville, MD 20857
May 2, 1996
Dear Mr. Marshall:
I'm writing to tell you how much I enjoy UpBeat. I was particularly interested in the two letters you published in the March issue in response to the Forbes article. Forbes itself printed a letter that described Brigid McMenamin's article as the "literary equivalent of a drive-by shooting."
We also wrote a response that was not printed. I have enclosed it.
I wish you continued success with UpBeat.
Director, Division of Transplantation
RE: "How a Government Monopoly Keeps the Transplant Organ Supply Low" (March 11)
This was an article with many misleading statements. Moreover, it is a disservice to patients on the organ transplantation waiting list to say that the reason for the organ shortage is government involvement. The reasons for the organ shortage are largely the relatively small number of potential donors (8,000-12,000) per year) and the intensity of the family grief accompanying the deaths of those persons who are potential donors. To permit physicians, hospitals and organ procurement organizations to approach those families, as your article proposes, and "bid" for organs would decrease not increase the supply of organs available for transplant. The article also faults the policy of offering recovered organs to patients in the area of the recovery first before offering them in a wider area. This is an incentive to local surgeons and hospitals to maximize organ procurement and at the same time to preserve organ viability. Importing foreign organs as the author suggests is not a realistic option. This country is not the only one with an organ shortage-it is a problem throughout the world.
Judith B. Braslow, Director
Division of Transplantation
TWENTY-THREE-YEAR SURVIVAL AFTER ORTHOTOPIC HEART TRANSPLANTATION
We wish to report the death of a patient who we believe was the longest surviving heart transplant recipient. The patient, Mr. Dirk van Zyl, underwent an orthotopic heart transplantation on May 10, 1971, for ischemic cardiomyopathy at the age of 44. He was the sixth patient to undergo heart transplantation at Groote Schuur Hospital by Professor Christiaan Barnard.
During induction of anesthesia ventricular fibrillation developed, and the patient required external cardiac massage while being supported by femorofemoral cardiopulmonary bypass under emergency and difficult conditions. The donor heart was from a 32-year-old man of mixed race. HLA typing showed a complete mismatch between donor and recipient. The patient made an uncomplicated postoperative recovery and was discharged home approximately 4 weeks later. Three months after the transplantation, he returned to full-time work as a warehouseman and did not miss a day's work because of illness until his retirement in 1982.
For the entire 23 years after transplantation he was maintained on immunosuppressive therapy consisting of azathioprine (200 mg daily for 15 years and later tapered to 50 mg. Daily) and prednisone (in tapering doses to a minimum of 5 mg twice daily). He was also maintained on the antiplatelet agent, sulfinpyrazone (Anturan, 200 mg three times a day). For the first few months after heart transplantation, he received monthly intravenous doses of methylprednisone 125 mg which was the policy of our unit at that time. Because of his excellent clinical course it was decided not to add cyclosporine to his regimen when it became available to us in 1983.
Function of his transplanted heart remained excellent, as confirmed by annual cardiac catheterization, coronary arteriography, and left ventriculography (until 1980) and radionucleide assessment of left ventricular function (until 1991). In that year his left ventricular ejection fraction was 57%. No detailed investigations of cardiac function were done after 1991.
His long-term complications included hypertension (requiring multidrug therapy), diabetes (which was controlled by diet and oral antidiabetic agents only), and moderate obesity. In 1986 ischemic changes developed in both legs, for which revascularization procedures were unsuccessful, necessitating below knee amputation of the left leg in 1986 and above knee amputation of the right leg in 1987. Despite his bilateral amputations, he remained positive and continued his active lifestyle in a wheelchair and performed regular exercise such as bowling and gardening.
In 1986 he also had a left-sided hemiplegia which resolved completely over the next few months, and in 1991 he had two transient episodes of cerebral ischemia, after which he received continuous aspirin therapy. In late 1993, after the sudden death of his wife, he had further cerebrovascular accidents, culminating in blindness of the right eye and, in 1994, a left hemiplegia.
After this, he required admission to a chronic care facility where he died on July 6, 1994.
He therefore survived for 23 years and 57 days after his heat transplantation. A necropsy confirmed the major cerebral infarct causing his hemiplegia and also showed severe and widespread ulcerated and calcific atherosclerosis, including the entire aorta, both carotid arteries, the mesenteric and coeliac arteries, and both common illiac arteries. There was also severe atherosclerosis of all three major arteries of the donor heart, with approximate 90% stenoses in each. Long segments of the coronary vessels showed concentric atherosclerosis (suggesting graft vascular disease), but many eccentric plaques were also noted, as in his native vessels. In addition, necropsy showed one unsuspected finding, which was the presence of a squamous cell carcinoma of the upper lobe of the left lung which had metastatsized to a left hilar lymph node. Death was considered to be due to cerbralvascular disease and bronchopneumonia.
In summary, therefore, this patient maintained an excellent quality of life for approximately 22 years despite widespread progression of his native atherosclerotic disease, which appeared to progress more rapidly that his graft vascular disease.
Of the first 16 consecutive heart transplantations performed by Professor Barnard at our institution between December 1967 and January 1976, seven patients survived at least 18 months, four survived more than 10 years, three more than 14 years, two more than 17 years, and one (Mr. van Zyl) more than 23 years. The longest surviving patient with a heterotropic heart transplant was Mr. William Fourie who underwent transplantation in December 1975 and died in July 1993, some 17 1/2 years later. Overall, land 10-year survival of these initial 16 patients was 44% and 25%, respectively. As 1 year survival of patients undergoing heart transplantation worldwide today is over 80%, we can reasonably anticipate a 50% survival at 10 years.
Our present longest surviving heart transplant recipient is Mr. Paul Thesen, who underwent heterotopic heart transplantation in January 1980 at the age of 14 years for idiopathic cardiomyopathy. Receiving azathioprine, cyclosphosphmide, and corticosterold therapy, he had graft atherosclerosis necessitating another transplantation in December, 1983. On this occasion, the poorly functioning heterotopic heart was left in situ, and the second heart was inserted in the orthotopic position. Since then he has received triple-drug therapy, including cyclosporine. Recent investigations have shown good function of the orthotopic heart with poor function of the heterotopic heart.
We have knowledge of five other recipients who have survived more than 20 years after heart transplantation. Roger Ejarque, transplantation performed June 9, 1973 at Hospital Foch, Paris, is according to a report in a lay magazine, alive and well. Arthur Gay, undergoing transplantation in 1973 at the Medical College of Virginia, died more than 20 years later on June 3, 1993, age 56 as reported in the Guinness Book of Records. Three Stanford University patients who underwent transplantation on July 1, 1974 (patient R.C.), April 6, 1975, (patient S.K.) and April 23, 1975, (patient M.G.) are also reported to be alive and well.
We would be interested in receiving further reports on long-term survivors after thoracic organ transplantation.
Johan Brink, MB, ChB, FCS(SA)
Department of Cardio-Thoracic Surgery
University of Cape Town Medical School
Private Bag Observatory 7925
Cape Town, South Africa
Journal of Heart & Lung Transplantation, April 1996, 430-31
This prospective study of 125 heart transplant patients demonstrates significant associations of several psychosocial predictor variables with a number of important outcomes after surgery. In particular the severity of compliance problems after surgery, as well as the number of rejection episodes experienced, and the early development of coronary lesions in the transplanted heart, were all associated with psychosocial factors that were determined before surgery, while the number of infections and survival were not.
Specific factors that contribute to the global assessment of risk but independently were associated with compliance problems were substance abuse, personality disorder, living arrangements, and support group attendance. Of these, the most powerful predictor, unexpectedly, was history of substance abuse. After substance abuse was taken into account, the significant effects of personality disorder and other independent variables were lost. Clinically, our experience suggests that patients whose substance abuse is not in long-standing remission, especially cases where substance abuse continued after developing heart disease and ceased only in the face of acute illness, are at especially high risk for poor compliance, especially if they also have other indicators of increased risk of psychosocial management problems, such as personality disorder or poor emotional support. Participation in substance abuse treatment, toxicology monitoring, prolonged abstinence for several months, and efforts to improve other aspects of the psychosocial situation are likely to be necessary to enhance the likelihood of a good outcome for such patients. Out transplant program did not maintain a fixed policy with regard to the duration of abstinence required of patients before listing for transplantation, in view of the fact that many patients are too ill to participate in this kind of treatment program; the results of this study illustrate the negative aspect of this policy in that more recent abuse was associated with higher risk of poor compliance. Above and beyond the power of discrete independent predictors, the study also illustrates the power of the psychiatrist's global clinical judgment of risk to predict postoperative problems with compliance.
The findings of coronary heart disease indicate that lower educational level was a risk factor for coronary disease. However, this result must be regarded as preliminary, since a substantial portion of the patient sample had not yet had their first annual angiogram at the end of the study follow-up period. Because of the small number of patients with sufficient follow-up to have undergone annual angiography, the number of these patients who had undergone the prospective rating of psychiatric data was only a quarter of the total patient sample. The failure to find an association of the psychiatric factors with transplant coronary disease may be due to inadequate power to address this particular outcome.
Likewise, no association was found between any of the predictor variables and survival. Since coronary disease and rejection episodes were associated with psychosocial predictor variables, it is conceivable that failure to find a similar association of psychosocial predictor variables with survival is due to inadequate power because of the limited sample size and the relatively short duration of follow-up. These limitations may be addressed with further study. It is clearly of fundamental importance to transplant programs to ascertain whether or not psychosocial predictors can be associated with a quantifiably increased mortality risk.
This study is consistent with and extends earlier observations of associations between personality disorder, substance abuse, and global psychosocial risk assessed before heart transplantation and subsequent problems of adjustment after transplantation. Another more recent study lends further convergent validation for the hypothesis that psychosocial variables predict compliance. Dew and colleagues prospectively studied 105 patients through the first year after heart transplantation. Poor family relationships and avoidant coping style were highly associated with noncompliance with smoking cessation, medication regiment, diet, blood work, blood pressure monitoring, and exercise. In contrast, Grady and colleagues evaluated compliance with annual diagnostic testing after heart transplantation, and found significant noncompliance rates that were not associated with demographic variables. This study lacked evaluation of any psychological or psychiatric variables.
If psychosocial evaluation can predict which patients are at increased risk of noncompliance, rejection episodes, and coronary disease after transplantation, what are the implications for transplant programs? Transplantation is an expensive and difficult process; organs for transplantation are a scarce resource; and decisions about organ allocation are complicated. As has been recently reviewed by Olbrisch and Levenson, philosophical views of the use of psychosocial screening in organ transplantation vary widely. If screening can identify patients at heightened risk for poor outcome, some might argue that it should be used to exclude such patients, to optimize the use of a scarce resource. On the other hand, so long as screening lacks perfect predictive power, patient exclusion on the basis of screening criteria might erroneously exclude a patient who would benefit from the surgery.
Olbrisch and Levenson note that the psychometric properties, such as test-retest and interrarer reliability and construct and predictive validity of transplant psychosocial evaluation instruments are for the most part poorly established. Moreover, Surman and Purtilo have described a number of different social and ethical agendas pursued by organ transplant programs, including not only the social utility of the transplant program but also the physician's duty to individual patients, the institutional needs of the transplant program itself, and the advancement of scientific knowledge. Given the current limitations of prediction, and the idea that an increased likelihood of a poor outcome does not vitiate the physician's ethical duty to help the patient, we would argue that the most appropriate inference to draw from our findings is that transplant programs should pay close attention to psychosocial screening information, and should use it to identify patients who need more than routine help with psychosocial problems in order to achieve good outcome after transplantation: Such attention is not different from that currently paid to concurrent medical problems that require stabilization in order to prepare patients for surgery. Structured inquiry combined with expert clinical judgment can lead to the development of individualized treatment plans to benefit difficult patients. Finally, transplant programs need to improve and standardize their predictive instruments, and to test the efficacy of psychosocial interventions for patients with heightened needs.
Transplantation, Vol. 60 No. 12 1462-66
We've mentioned Cliff Steer, The Heart Man of San Jose quite regularly here in UpBeat.
Cliff has been living with his transplanted heart since 1985. His was the 13th hear transplant surgery performed at San Francisco Presbyterian Medical Center. A recovered alcoholic for the last 20 years, and retiree of Pepsico, Cliff has worked extensively with young people to help them give up their addictions that eventually lead them to jail or worse.
"Heart Man" visits schools and brings his old diseased heart as a graphic example of what alcohol abuse and cigarette smoking can do to your body. In the last five years over 50,000 students have seen his presentation.
Recently, as reported here, Cliff's kidneys suffered cyclo-meltdown, and after a seemingly futile wait for a transplant it was found his wife tested out as a perfect donor and the switch was made successfully.
However, during the period of waiting Cliff became concerned about how to get his message across to "At Risk" kids if he should become physically unable to make the talks. This led him to make a professional video of his 'presentation' to enable his work with the kids to continue even if he couldn't. His old employer, Pepsico working through Cliff' s volunteer work with San Jose Neighbors That Care began doubling his monetary contribution to get this video produced.
This professional quality video has now been released and is being distributed free to any group that have "At Risk" kids to view it. The staff here at UpBeat ( 1 ) has reviewed the film and find it perfect for the situation, even to the point where they're holding up Cliff's piece of original equipment, a one and a half pound useless heart. The reason we're not absolutely effusive about the viewing was the old "there but for he go I syndrome", which makes the subject matter strike closer to home than is comfortable.
The tape may be obtained free for use with groups by contacting Cliff Steer -
The Heart Man
6404 Berwickshire Way,
San Jose, CA 92120
Okay, now no comments about the high cost of medicine, but I'll bet your transplant center doesn't have a Resident Cartoonist. Steve Brosnihan holds precisely that position with the Hasbro Children' s Hospital in Providence and has been there since 1991 drawing at bedside with patients. As such, the work has led him to meet patients awaiting transplants and their families. And, of course, as part of the package he has witnessed the tragedy of some dying while waiting for a needed transplant.
As a result, Steve became committed to the cause of donor awareness and joined the Rhode Island Organ Donor Awareness Coalition, hoping to help increase the odds for a happy ending for all people awaiting transplants.
Using his cartoon artistic abilities Steve designed a tee shirt around the message "Organ Donors Are Heroes in the Making." What he has done is put that excellent message on the front of the shirt for all to see, but on the back he's conjured up a rebus (Huh? A puzzle of pictures, letters, signs with a message.) that is sure to bring questions and as a result perhaps open discussion about organ donation. The shirts are available in ash gray or white, both with green print in S, M, L, XL and XXL. They are $10 each except XXL which are $11.50. There can be special prices for groups and organizations who would like to use the shirts for fund raisers.
To order contact:
Fly By Knight Designs,
P.O. Box 111, Bristol, RI 02809
or call 401-253-5909.
Tx A.C. Greene, professional writer and author of the early transplant recipient book, Taking Heart, writes with the following message from Salado, Texas:
"I can't think of anything more important to tell transplants, especially older ones, to make it a monthly/bimonthly habit of visiting a dermotologist. What appear to be innocent little 'skin places' can suddenly become cancers, and even when excised successfully, from surface views, can go inward with great speed. So follow up even the basal cells and non-cancerous conditions. We ain't got no first line of defense and the second line might be too late. I'm just one of several older transplants I know that it's happened to. This applies especially to the face and head, including bald pates. As for sun block -- surely we can take it for granted we all use it, whether we live in the sun belt or the snow belt."
No one would have planned it that way not even if Marge Schott was involved - The recent Virginia Transplant Council meeting was held on the same day, in the same hotel, at the same time and across the same hall from the Virginia Brain Injury Association.
1,000 and counting: Michael Boyer, 34, recently became the 1,000th patient to undergo a liver transplant at the University of Chicago. Boyer is tipping his hat to the patient who underwent the first liver transplant at the South Side medical center. He's says it's "comforting" to have been the 1,000th patient rather than the first. After all, he notes, "experience counts."
"One often hears expressions of concern that someone had to die in order for there to be a transplant. In reality the two are unrelated - the death over which no one had control has occurred and is irreversible, the transplantation is an entirely different action that takes place only after the death." Dr.Gerardo Mendez-Picon, Virginia Transplant Center, Henrico Doctors Hospital
"If you are waiting for a transplant and someone says you're at the 'top of the list', it's a lie. There's no such thing as the top of the list, every new donor generates a new list based on all the criterion of his or her organs." Peggy Schaffer, RN, CPTC; Director of Recovery Services; Washington Regional Transplant Consortium
By DR. LEWIS W. TEPERMAN, New York
University Medical Center, For AP Special Features
The success rate for liver transplant operations has been increasing steadily and now is higher than ever before.
Between 3,700 and 4,000 liver transplants are performed each year in the United States. At the best centers, the one-year survival rate for the transplants has reached 90 percent, with the five-year rate at 80 percent.
No single factor is responsible for the increased level of success. But one major reason is improvement in surgical techniques -- a living example of the maxim that practice makes perfect. The surgeons who do these operations are simply doing them better.
Postoperative care has also been improved, again an example of practice making perfect.
Better methods for preserving the organ for transplant are also available. Surgeons used to have only about eight hours to perform the operation before the organ began to deteriorate. Now organ quality remains high for at least 24 hours.
As a result, the rate of initial failure of transplants, immediately after the operation, has fallen sharply --to only 4 percent in the best institutions, compared to at least 20 percent in previous years.
At least equally important is the availability of excellent medications to fight rejection of the transplanted organ. These medications -- Neoral, Prograf, Cellcept -- reduce the reaction of the body's immune defense system to the foreign tissue.
Transplant patients must take such medications for the rest of their lives. And the drugs also reduce the defenses against infection, which means that the patients must be watched carefully for the early symptoms of infection.
A very few patients eventually can stop taking anti-rejection drugs. In rare cases, the body becomes tolerant of the foreign tissue.
A new anti-viral drug, Gancyclovir, has improved the treatment of infection with a virus called cytomegalovirus, which because of immunosuppression, is common in liver transplant recipients.
What has not changed is the demand for liver transplants. At any given time, 5,500 Americans are on the list for new organs.
The major reason is the liver-destroying infection, hepatitis C. The next biggest reason is alcohol-induced cirrhosis of the liver.
When alcohol is responsible, a transplant will not be performed unless the potential recipient can offer convincing evidence that drinking has been stopped for at least six months.
The limiting factor in liver transplants is the availability of organs. There is a continuing drive to encourage Americans to donate their organs for transplant.
MIAMI (Reuter 4/26/96) - Doctors at the University of Miami Medical Center said Friday they had performed the first so-called "domino" liver transplant, in which the healthy liver of a patient receiving a multi-organ transplant was used to save the life of a second person.
In the procedure, performed on April 11 but publicized only on Friday, the healthy liver of a 17-year-old Pennsylvania girl who underwent the transplant of several organs was given to a second patient, a woman who was near death with liver failure.
The two transplants were performed at the same time, in a measure that doctors said offered a real chance to make the best use of the limited supply of donor organs that become available each year.
In southern Florida alone, there are some 150 people now on waiting lists for liver transplants, and hundreds of others await other organs such as kidneys, hearts and lungs. There are more than 45,000 patients on the national transplant waiting list, with some 2,000 more added each month.
"Domino liver transplantation can utilize organs that would otherwise be wasted and maximize the benefits of modern technology for the greatest good," said Dr. Andreas Tzakis, chief of the division of liver and gastrointestinal transplantation at the University of Miami Medical School.
Seventeen-year-old Rondie Harris of Reading, Pennsylvania, had been unable to eat normally since birth because of a severe digestive disorder that kept her body from properly absorbing nutrients. Her condition had become so bad that doctors decided to attempt a multi-organ transplant.
But when a block of donor organs became available, they were from a younger child, which meant it would have been more complicated to attach the new organs to Harris' larger liver. By transplanting the liver, small and large intestines, stomach and pancreas as a block, the surgeons had to make fewer delicate connections, said Tzakis, who led the team that performed the transplants.
"The way the entire graft (block of organs) was transplanted, these connections were already made and we only had to connect to her body two vessels rather than several," he said.
He also noted transplant experts believe that transplanting the liver along with the block of other organs lessens the chances that the recipient's body will reject the new organ.
Tzakis said Harris, who spoke to reporters Friday, was doing well. She is out of intensive care and has been able to eat. The other patient, a woman who has not been identified, received only Hams' liver, and remains in intensive care although Tzakis said she also has done reasonably well since the operation.
Harris, a high school junior, who spoke from her hospital bed, looked pale and was shaking as she gave interviews, but said she felt good and felt excited to have been part of a big advancement in transplants. "I didn't know how big, but now I do," she said.
Doctors in Britain have performed successful "domino" heart transplants, in which a new heart and lungs were transplanted into lung disease sufferers, whose healthy hearts were then given to other patients.
WASHINGTON (AP 4/24/96) -- In October 1990, Thomas Hamilton lost his eldest son in a car crash. Three months later the Nashville businessman's second son also died in an auto accident. Within months after that, his wife Barbara was dying of kidney failure.
But out of that personal tragedy, and Hamilton's decision to donate organs and tissue from his sons, dozens of lives were saved. And in just reward, his wife received a life-saving kidney transplant.
Encouraging others to be organ donors "is my way of covering my grief," Meredith said Tuesday at a Senate Labor Committee hearing on organ donation awareness. Meredith said the organs and tissues from his two sons "improved the quality of life for 97 people and their families."
Senators had their own stories to tell.
Sen. Mike DeWine, R-Ohio, donated the eyes of his daughter, killed three years ago in a car accident. Sen. Strom Thurmond, R-S.C., lost his daughter to a drunk driver three years ago, and donated her organs. Rep. Joe Moakley, D-Mass, told the panel how doctors last year told him he had two months to live, but was given a second chance with a liver transplant.
Thurmond, the oldest man in Congress, was the first to sign up on a list of senators pledging to be donors. "If anybody wants my organs because I'm 93, they're welcome to them."
With medical advancements, more people have become candidates for transplants, but, despite donor check boxes on most driver's licenses, the number of potential donors has not kept pace.
According to the United Network for Organ Sharing, which operates a national donor network, organ donations from deceased people have crept up from 4,000 in 1988 to 5,300 last year. But in the same period the list of people waiting for a transplant jumped from 16,000 to 44,000.
"I have seen the sadness and sorrow of too few organs," said Sen. Bill Frist, R-Tenn., who was a heart and lung transplant surgeon before his election to the Senate two years ago.
To increase national awareness of the need for organ donations, Sen. Byron Dorgan, D-N.D., has attached to a health care bill now before Congress an amendment requiring the IRS to send out donor information with tax refunds.
"Of the 20,000 deaths each year that fulfill the medical criteria for becoming organ donors, only about one-fourth actually become donors," said Dorgan, who also lost a daughter two years ago to heart disease.
The Coalition on Donation, which represents some 100 groups involved in transplants, has recruited basketball star Michael Jordan to help publicize the need for increased donations.
Olympic track champion Carl Lewis, in televised remarks from Houston, told the hearing how he became active in the issue after a liver transplant saved the life of a friend, Wendy Marx.
The committee also heard from Clive Callender, founder of the National Minority Organ Tissue Transplant Education Program, who spoke of the struggle to get more blacks to become donors. African-Americans comprise 12 percent of the American population but make up one-third of those on transplant waiting lists.
BERKELEY, Calif.,(UPI 4/26/96) Researchers looking at the ethics of organ trafficking said Friday despite worldwide efforts to stop the practice, the sale of body parts is flourishing around the world.
From the organ bazaars of India to the morgues of South America, the world's poorest are at times so desperate, they sell organs to the rich, even if means ignoring cultural taboos and laws, said scientists so concerned about possible abuses they are holding a special conference to examine the issue.
To date, there has been no evidence of Americans engaging in black market organ sales, the researchers said, but the potential for abuse grows strong in life-and-death situations.
"The exchanges tend to be south to north, poor to rich," said Nancy Scheper-Hughes, medical anthropologist at the University of California, Berkeley. "I don't think it's a small practice. There are dozens of clinics in Bombay where it's happening. There are suggestions it's happening in parts of Southeast Asia and Korea."
Representatives of the U.S. transplant donor network shrug off such reports as more fiction than fact and say such hearsay stories do more harm than good.
"Stories about organ trafficking hurt the thousands of people in need of transplants," said Mary Ann Wirtz of the United Network for Organ Sharing in Richmond, Va. "Stories like that keep people from becoming donors because they feed misunderstanding."
At any moment, some 45,000 U.S. residents await available donor organs while countless others are not even placed on waiting lists because they are considered too old or otherwise unsuitable. One transplant-needing patient dies every three hours in the United States without getting the life-sustaining organ.
The situation is even worse elsewhere in the world, feeding the organ-for-sale market.
For example, in India, much of the body-organ commerce is linked to wealthy Arabs in Persian Gulf states and to the affluent of Southeast Asia, where religious and cultural taboos prohibit donating body organs even after death.
"Most of the commerce in organs is done elsewhere, but it will increasingly impact people in the United States," Scheper-Hughes said.
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