The gift of life denied

HEALTH: WHY IMMIGRANT KIDNEY PATIENTS ARE AT A DISADVANTAGE
The gift of life denied
Toronto's Tong Tep thought the government would be thrilled when his Cambodian nephew offered to donate an organ. Wrong

MARINA JIMÉNEZ

February 21, 2009

For 25 years, Tong Tep, a devout Buddhist and Cambodian refugee, worked as a crane operator in Toronto. He saved enough to buy two small houses in the east end, and to send money to relatives back home.

But Mr. Tep, who suffers from diabetes, suddenly found himself in ill health three years ago when his kidneys failed and his left leg had to be amputated.

A 25-year-old nephew from his homeland came forward and offered to donate his kidney to the kind uncle who had helped put him through school.

However, much to Mr. Tep's surprise and devastation, Citizenship and Immigration Canada denied his nephew a visa to fly from Phnom Penh to Toronto for the operation.
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"I can't understand it. It would save the government money, and it would save my life," said Mr. Tep, 60, shrugging as he sat in his home watching his two-year-old grandson play with his walker. A gold Buddha smiled down from the top of a large-screen television.

His plight has emerged as a major issue in the field of kidney transplantation. According to nephrologists at the three largest kidney-transplant centres in Toronto and Vancouver, CIC often denies visas to donors from developing countries.

"In our experience, Canadian embassies often deny visas to potential kidney donors from some developing countries out of concern that these donors [might] remain in Canada after having donated their kidney," said Jeffrey Zaltzman, medical director of the renal-transplant program at St. Michael's Hospital in Toronto.

This puts immigrant kidney patients - who often only have relatives overseas - at a disadvantage. Not only is pre-surgical testing and screening more complicated for a foreign donor, but it isn't covered by Canada's health-care system, notes John Gill, president of the Canadian Organ Replacement Register.

Dr. Gill, who also works as a transplant nephrologist at St. Paul's Hospital in Vancouver, says he has noticed a bias against donors from India and Pakistan. Every year, St. Mike's, Toronto General Hospital and St. Paul's in Vancouver each send out letters on behalf of about two dozen kidney patients who have willing donors living in Sri Lanka, Brazil, Vietnam, India and Pakistan. Often, CIC rejects their visa requests, though six overseas donors have come to St. Mike's recently.

In 2007, 146 Canadians died while on the organ wait list, which numbered 4,167. Two-thirds of the patients are waiting for kidneys.

Transplant specialists say there has been a dramatic shift in recent years toward living donors, who can give up a kidney with no long-term impact on their health. In 2006, 40 per cent of all 1,202 kidney transplants in Canada were from living donors, versus 28 per cent in 1996. The wait list for a kidney from a deceased donor in Canada is as long as seven years, and in Mr. Tep's case, a decade. His blood type, B, is harder to match.

CIC's overly rigorous screening may indirectly contribute to transplant tourism because it encourages disappointed patients to go shopping for a kidney in the black market in body parts, Dr. Gill says.

Buying or selling a kidney is illegal in Canada. At an international conference in Istanbul last May, transplant professionals from 78 countries signed a declaration prohibiting the practice. However, it still thrives in Pakistan, China and the Philippines.

Replacing a faulty kidney actually saves the health-care system $300,000 - and also gets the person back to work, says Dr. Scott Klarenbach, a nephrologist and health-care economist at the University of Alberta: "It's very rare in medicine that you have a treatment that both reduces costs and improves outcomes."

With a new kidney, the patient no longer has to be hooked up to a dialysis machine for 12 hours a week to remove excess water and waste from his blood - as Mr. Tep must do, leaving him fatigued.

"It's not an easy thing to ask someone for a kidney. Usually a family member volunteers, and for people born elsewhere, they often turn to relatives overseas," says Dr. Edward Cole, program director of nephrology at the University Health Network in Toronto.

In Toronto, half of all residents were born somewhere else. Diabetes and high blood pressure, both of which can lead to kidney failure, are more common among certain ethnicities, including Indian and Caribbean.

Mr. Tep paid $5,000 for tests in Phnom Penh to ensure his nephew was a match. After several months, a letter arrived from CIC saying it had reviewed the financial assets of his nephew, as well as his ties to Cambodia, and was unsatisfied he would return home. They would consider issuing a special minister's permit for him to travel to Toronto if Mr. Tep could "prove there is no other relative in Canada who can be a kidney donor," the letter noted.

Mr. Tep says his wife and two sons cannot be donors because they all have diabetes. "My nephew is the only person," he says. "In our culture, families help one another."

His living-room walls are decorated with paintings of his parents and his grandchildren. His younger son, wife and child live with him, and his older son occupies the house he owns down the street.

Doctors say they understand that CIC - which couldn't comment on Mr. Tep's case because of privacy legislation - must uphold the integrity of Canada's immigration program. But they want to improve the overseas screening policy. CIC guidelines note that overseas donors must be medically compatible with recipients, must not be paid and must be able to convince the visa officer they will leave Canada at the end of their stay.

Physicians are working with sister hospitals in developing countries so that donors can be evaluated before the operation, and cared for when they return.

A recent study in a prestigious medical journal, Transplantation, found that patients recover much more quickly if they undergo transplant surgery in Canada. The paper tracked the outcomes of 20 Canadian patients who travelled abroad and purchased live kidney donations. "Many patients were very ill upon arrival [back in Canada], requiring very intensive medical treatment," noted Dr. Zaltzman, the study's author.

Mr. Tep would like a chance to be helped by his family, as he has helped them all these years. "Maybe it was bad karma. The visa officer was in a bad mood that day," he says, shaking his head in dismay and rubbing his prosthetic leg.

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