Transplantation in the Context of Migration - Ethical and Practical Challenges

0:22 hi everybody welcome to this episode of transplant talks I'm Rachel Davis uh psychiatrist and living liver donor and here with my co-host Anastasia Henry who is executive director of the American transplant foundation and today we have the pleasure of talking with Dr sio Dy and this is his second time on our podcast um we're going to talk about the fascinating topic of transplantation in the context of migration but before we get into that Sixto can you tell us a little bit about your background and um why you were interested in nephology uh of course uh first of all thank you for having me it's a it's a great pleasure to to be here and and talk about this interesting topic so um initially what red me in uh to nephology or transplant nephology was a combination of events uh in college I had took a Immunology course which I found fascinating at the same time my roommate um one of my best friends had fsgs and required a transplant so I saw the whole Spectrum from him being super healthy at 20 years old to all of a sudden uh having a big change change in his health and and obviously uh not doing so well and then being able to recover back his life with a living donor guine transplant which that definitely was uh uh one of the turning points then uh in in med school my favorite uh course in the first year was renal physiology I was very uh uh driven or drawn to it by the complexity

1:53 and and and how well it function and then ultimately my residency Internal Medicine Residency my favorite Mentor was in a project so that was the icing on the cake so that combination of factors led me to uh pursue a career in academic transplant neology well what I didn't say in the beginning is that you're an associate professor of medicine at the University of Colorado anuts and also director of the Hispanic transplant clinic yep that's one of my uh uh babies or passions as well that that i' like to do and we have a very good team uh here uh tackling uh the healthcare dispares that Hispanics face in in in this country in particularly uh when talking about kidney transplantation and I imagine that's a topic that probably will weave throughout our dialogue today yes ma'am so tell us why you want to talk about this topic transplantation in the context of migration first of all what does that mean and why is it important so uh as part of the of the the role that we have with the Hispanic transfer program we see a a decent number of undocu dou umented citizens that uh that come to this country for work Mo mostly for work and then for for x or y reason they end up in kidney failure so uh most of these patients before they were not able to receive any any type of care and end up just either going back to their country uh of origin to just die or try to get some help there so with the Hispanic trans uh uh program we try to

3:25 uh help these patients that otherwise don't have like an alternative uh with the provisions that the states put in place uh the state of Colorado back in 2018 or 2019 some of these patients now were able to get dialysis and eventually transplant so once that happened we were able to help this uh patient population that was otherwise unattended or or were not receiving the appropriate care so that's my first connection to uh talking about undocumented citizens uh receiving organ transplantation uh in in last year in 2024 Dr Peter Scott which is a a transplant surgeon at the University of of California in San Francisco uh gave a gave a talk about this same topic so he was part of a of a group of leaders which will talk about that met back in 2022 to talk about the same talk about uh transplanting the uh in the context of migration refugees so that talk definitely spark more interest in me in trying to get to know more about the topic and now I feel like I'm in a position to try to uh spread the word out and try to make sure that more people are aware uh of the findings and the things that play here so I'm I'm curious to hear a little bit more could you tell us before legislation was passed in you said 2017 or 2018 what was this status for people who are undocumented and in kidney failure what what did that look like for them so not

4:56 so good uh as you're aware we have a friend in common Dr Cervantes CIA cantes so she was the master of the one that fear hit that here uh in in the state of Colorado and she has the big example of what happened she had a a patient that she identified with and that patient unfortunately didn't have insurance and was just getting emergency dialysis on a on regular basis and unfortunately had to just go back to her country of origin to die so there they did not have many options unfortunately well just to clarify for our listeners who may not be aware of what emergency dialysis it means basically someone has to wait until they're so sick that they're at risk of death before they can get dialysis and before that legislation was passed that's how people who were undocumented that was the only way they could get dialysis so that's a terrible way to live it's a terrible way to live and also like let's talk about the cost of emergency dialysis yes so uh Dr Cervantes has a very nice study that was uh published around four or five years ago tackling the same topic so first of all as you as Dr Davis was mentioning it's not a good thing for patient from like mortality or quality of life perspective usually uh standard uh in Center dialysis patients go three times a week to get their treatment to a center outside of the emergency facility on a control scenario where they're more comfortable and they they get adequate dialysis uh this patient population that

6:29 have or insure and have kidney failure as Dr Davis said they have to go to the emergency room and pray that they're very sick or even have to fake symptoms to be able to get the life- saving treatment of dialysis that means a huge cost to to the state and and and that's something that people are might not be aware of so although yes we're talking about somebody who is undocumented by providing regular dialysis to this patient population we actually save money and and to the other perspective too like the we are improving the patients quality of life and their life expectancy and as we're going to talk about later these are are individuals that come here to work and are able to provide way more in terms of uh money to the economy than they take out so it's at least for me having that information seems like an orb brainage right to help uh these patients yeah exactly so just to clarify like if a person you know receiving regular dialysis treatment they are able to work you know not everything will be available but they still like we know police officers that are still working while on dialysis or they can just have completely no resources to survive and once they literally on the edge of dying they getting this emergency dialysis like it's just such a no-brainer can you go back for a second Sixto to that particular legislation was it just Colorado specific or what was the name of it or was it national can you tell us

8:01 more about that so um in terms so uh in general so what's what's the access of kidney care for undocumented immigrants across the United States so we have a nice study from Dr isolo that was published in 2023 and that study look at the whole landscape of that same question across the US so as of 2023 there were 20 States and DC that provided Statewide coverage for standard outpatient hemodialysis for undocumented immigrants um so these patients if they meet certain criteria including working and having lived in in the states for x amount of year they were able to be included in this thanks to the 1972 uh Medicare ESRD uh program that show that tell us that US citizens and lawfully present immigrant populations with access to care should be able to receive dialysis as well so in terms of transplant as of 2023 there were five stat including the state of Colorado California Massachusetts that offer transplant access uh through like state state funding so obviously the um Nationwide covered is still not accepted but at least in in their certain pockets and states that do have Provisions uh through their own phone to try to offer uh these patients uh insurance so they can uh get um dialysis and Transplant so the legislation that passed was not not only dialysis but it extended to transplant or was that a

9:32 separate legislation it's not a it's not a legislation it's an interpretation of the existing group so that was already put in place back in 1972 we were just or like Dr santes was just smart about it going through through the uh trying to interpret the actual existing law differently so and this is something that is Statewide we don't use uh National Funds which is uh I think it's the key um so we use State funds or Statewide funds uh to allocate for this patient ation okay do you have any statistics since that legislation um what are the trends like are you seeing the difference just on a personal level somebody who grew up in Puerto Rica like what are you seeing so uh what what we did saw which we when when that started after 2019 and forward we see like a big uh pool of patients that were sitting 10 or plus years in dialysis and now all of a sudden they were able to get transplanted um so we saw like a big bat or a big number of patients at least in our Center probably from the range about 50 to 75 during those 2019 and 2020 period they were waiting uh on emergency dialysis and and once they were able to uh get insurance they were able to uh get transplanted and I still follow many of those patients and they're doing great um they're uh citizens that are contributing they're working they're all happy they're raising their families and contributing to the economy but I think it's a it's a great thing that we able to do so uh and we we're going to talk

11:03 about it later but uh we have our own internal and National Data that shows that these patients in terms of outcome they do better than any other population so if given the opportunity they're going to do great Thrive and and and be able to continue contributing to to our society so why do why do you think they do better so it's a combination of um there might be some sele ction bias meaning that the patients that get through the transplant list or even get refer are usually younger and healthier and uh one one of the other theories is like all these sicker older individuals don't tend don't tend to go take the risk and migrate to another country looking for better opportunities the vast majority are young healthy uh individuals uh that are ready to work and unfortunately uh get sequel being here and and end up needing dialysis so I think that was that's one of the key factors why why they do so well uh there there are other potential uh theories including like for example Hispanics have like a big family Lee so they have like a strong family support to get them through it um once they are able to trust or establish a report with the provider or the physician they do very well and they're very good patients in terms of like following instructions and doing what what they ask them to but I think that the main reason is what we are seeing the patient that actually getting to the transplant list other the cream of the prop or the healthiest of that sub group and that's why I think they're doing so

12:34 well I want to ask you Sixto so were you the one who studied Hispanic transplant program initiative at the University of Colorado say again were you the one who studied Hispanic transpant program the idea came about by Dr grafals and Dr Elizabeth P so um both of them they're no longer working here but they met back in Boston and Monica which is from Puerto Rico she's the one that recruited me to help with the Hispanic program she noticed that need back in in in the hospital in Boston and then when Dr Pomfrey came here and saw a bigger number of Hispanic IR population got Monica here to to Kickstart the program and then two years after when the program kept growing that's when they recruited me to try to help and then uh they both end up leaving and and I took the Von and took over how many transplant centers across the country have Hispanic transplant program or initiative so I I said that the number is increasing it's very hard to say because most of them will portray that they do have a Hispanic transplant program but at the same time might not have the whole the whole key component but I said that at least half of the transplant programs now have some form of initiative of whether having interpreters with the information in Spanish or having most of the key pieces needed to for you to call like a Hispanic transer program per se so the number is increasing I know that your program your

14:04 team you very much focus on cultural education and also cultural education related to living donation as I'm thinking about different cultures I'm thinking like Eastern European culture for so many people to ask to donate a kidney it's basically like asking like hey can you give me like cut out your hands right so can you talk about that like how what do you how can we address that so I think uh education is the key to success uh in Hispanics which I can uh foresee in other different cultures as well the same living donation is kind of a taboo and if you as a patient 99% of the time from they get go they're going to say like no are you crazy no of course not but once you start educating about what living donation entails what are their actual risks to the donor which in theory if you have a healthy donor that qualifies those those risks are minimal so when when when patients start understanding what is the actual risk versus benefit how the process go through and once they are well educated they tend to come around and and seem way more open to the idea and and and one of the key uh pieces from from this is that the vast majority of immigrants so I would say so from statistics 60% of undocumented immigrants might have a viable living donor so their family members their close family members are ready to donate but

15:34 obviously for uh because of citizenship status most of them are not able to so I've had the cases here in which we have a viable living donor undocumented but I'm not sure about their followup so sometimes we are not eager to accept those because yes although the patient is healthy we are concerned about that potential donors in the future if they are not able to uh have proper medical uh uh uh care afterwards so how do you make that decision so for the most part I ultimately try to steer them through uh how to get care so in here up until I mean as of now I know that obviously things might be changing in the country but taking that into a side the state of Colorado does does offer uh so far like 12,000 spots a year for uh medical insurance for anybody including undocumented citizens so if I have a case similar to that I try to steer those patients uh for them to get insurance so they can actually get proper care after and and and I feel like comfortable saying okay right now you're a good donor and then I am comfortable after you have insurance or have established medical care you can have some for of followup after that first year post donation and you should be okay and in the current state are they usually able to get insurance through that so as of now yes so obviously the the spots for for example the omnis Salud or the initiative the Colorado

17:05 State initiative should have already filled the spots by uh January 1 before like the change in um in in in policy and in government so those spots are filled and they're going to be uh fulfilled at least for the next year things can change but I I don't forese seee that changing in our state so I'm hopeful that that provision will stay in place now you were part of a workshop looking at this topic right can you tell us about that workshop and what the point of that Workshop was so at least I participated in the in the state initiative uh and Dr Cervantes also spoke and we just trying to advocate for our patient population so the insurance uh you had to renew each each year and then you started from zero next year so My my point was like hey we are transplanting these patients if they don't have insurance they and they cannot pay their medications they're going to lose their their transplant their transplant so they're they're going to be back probably worse than they uh than they started because they're going to be sensitized they're going to be harder for them to get like a second transplant center might say like oh you're non compliant so my ask was for make to give priority to these patients and uh we were successful and as of this year all of our transplant patients and patients with chronic disease like cancer as well were given priority on the opportunity to to get reinsured without having to uh wait in the que online or RIS not getting Insurance the the other important like

18:38 uh at least like on a on a nationwide perspective which was like the uh the topic that uh doctors uh stock talked about the the veil controversies meeting so it was like a a a world meeting for different countries uh people from from the States from Poland Colombia Spain Australia Qatar Lebanon they the all uh experts in organ transplantation they met in Argentina in 2022 um the meeting was called the Declaration of Istanbul uh or organ traffic and Transplant tourism so that Workshop they try to focus on on discussing the the vulnerability of these migrant and refugees in terms of trafficking organs and then the finan financial coercion that some of them were suffering they also discussed like the access of care for migrants and refugees and and particularly for those with endstage organ disease needing transplant for transplant recipients and then ultimately they try to discuss about potential strategies about the Fallout of offering transplant to these migrant refugees on uh take it into account that they were potentially using the resources of availability of available organs um to local citizens and try to mitigate that follow so um overall so in in that in that Workshop each of the repres from each country gave like a quick overview of what were the status of their country to try to compare um so the big big picture of the meeting is

20:08 that they realize that yeah there's a disparate access to transplant Service uh for these migrants and but it was dependent on the resources and access to transplant for care citizen in each region so region with greater resources had potentially more willingness to allocate organs to these migrants and refugees uh compared to others that don't have the the resource But ultimately that willingness was compromised by the natural concerns that the citizens might be negatively impacted uh because of the scarce resources that we talked about and then also regions where the access uh was scare scarce um and in some places even the the natives were not able to pursue organ transplantation so in those cases we actually uh not feasible uh the best example and most relevant I would say is like the Poland which was uh Dr jolanta malis spoke about so they they received um as of 2022 uh more than 8 million Ukrainian uh citizens across the Polish border um so ultimately like about six six more million were able to return but in Poland at least 2 million arcan refugees uh remain so uh Poland did something very nice and generous and they were able to provide like a Polish uh polish ID identification um number which gave them access to the basic drugs and and health care and ultimately

21:40 the Polish national health established a fund which were able uh which helped these patients cover for dialysis service in public and nonpublic units and be able to provide reimbursements of renal replacement therapy and Transplant for these refugees so that's Quon call like a great model about what about how how we should we should do things um to put in contrast for example in Colombia which you have close to three million Venezuelan immigrants um in 2004 there was a a a law or a decree called number 2493 um that made it almost impossible for a foreigner to get a deceased donor transplant but living organ donation was still permitted uh now the caveat is that um if you're able to stay or live there long enough event eventually you would become um a legal resident so of close of the 3 million immigrants from Venezuela to Colombia after three to four years close to 70% of them were legal residents and they were able to actually after enter the the local pool for deceased uh donation so with that being said Dr Mercia which gave the talk about Colombia did says that uh the Colombia was facing like major Healthcare reform and he was not certain that this organ transplantation was going to be able to continue um other places spoke like from Lebanon for example in Lebanon there was like a from the C Syrian Civil War in 2011 to multiple conflicts made like a

23:12 disaster uh or kind of like um overall like a pretty bad picture H most more than half of this transplant centers closed uh they were able to um to not do as many transplant they were doing about 80 transplant per year in terms of across the the number so that's that's that's a typical case scenario of of things not going well when there's ongoing conflict uh other places like Australia and Qatar which had decent number of immigrants to were able to have some provisions and then another good example was Spain uh they also had like a royal degree back in 200 18 that provided universal access to the National healthc care system as long long as they were able to live three months there or to prove that they were there in Spain for at least three months they were able to get this uh health insurance and be able to provide care so uh that's another great example of things uh that can go well great you um you briefly mentioned organ trafficking and I think for most people that's something they've only heard about like in a bad movie or something and so can you tell us more about the reality of that and the implications so the so the reality is that at least in um third world countries it it it's way more common than than we would think and and and and for example the in in Lebanon which is like a humanitarian

24:44 crisis we're talking about people that don't have resources to eat and live and then you have wealthy individuals going to these places to try to buy some some some organs so Lebanon went from being called a s land of Middle East a place where the same Dr barbari mentioned that he doesn't see like any U any Improvement in the foreseeable uh future and it's like a he called it like hopeless human tragedy and at least in Lebanon there was a pretty high propensity of of people being taken advantage of and and and getting paid for Gan donation so it's not about the payment per se but obviously taking advantage of somebody in need who is donating uh which for example in the state that's something I've heard of or something that we're very Sous and the living donor Advocate is looking for that always but these patients don't have their proper followup after donation and they're taking advantage of and so it's a sad situation very sad and on the subject of organ trafficking usually does it take place at some proper medical facility or it's not even under yeah yeah that that's another great point it's not in the in the cleanest place or or in a place where um you should get ever operated on so another another potential risk for that uh for that potential donor in which you are doing a major medical procedure in a place where you should not be dealing

26:16 with with with human life and livelihood like that definitely so another good point yeah you might get some money but then you will end up dying for there's so many complications so so much that can go wrong it's just terrible as we were preparing for the podcast you send us some research information I thought it was very interesting um when it says that noncitizen organ donors in the United States of America the number of non-citizen organ donors far exceeds the number of non-citizen recipients so more people donate organs versus receive can you like explain and when you mean non-citizens versus is non-documented that also would be great of course so um to start with as of 2012 the United Network for organ sharing or unas which is the uh um agency that is in charge of regulating and overseeing transplant in the US as so 201 12 they actually started asking citizenship for all potential um organ recipients that were listed in the states and and the classifications were US citizen non- US citizen us resident non US citizen non- us resident uh that traveled for the US for reason other than transplant and then ultimately non US citizen non- us resident that travel to the US for for transplant and and and at least the last one for those who who

27:47 come here for organ transplantation it's like a different story they require it's like a a different requirement uh they need to put their country of origin and that's the the least of the cases so but for the most part we have citizenship citizenship classification since then and we were able to distinguish if they're US citizens or non non US citizens so um in terms of um how many undocumented cases in the US So based on the organ OPN which stands for organ procurement and Transplant Network they did a study back in 2018 and they estimated that approximately 1% of the of the kiny transplant res iens in the US were non-citizens and and and and they were comp composed most of them from undocumented immigrants and permanent residents with legal uh with legal visas meaning non uh US citizen but us residents so in terms of the waiting list there was an average of s% uh non US citizens that compromised the waiting list as of 2021 so most importantly they contribute close to three 3.3% at least uh of the organ pool so meaning of all the organ donors that we have uh on the United States at the very least 3.3% of them are considered non us uh US citizens or undocumented uh citizens and we think that that number is bigger because there's 10% of organ

29:19 donors that don't have citizen ship uh status in place I thought that that's that's a really high number 10% like we don't know the citizenship setup so we assume that at least half of them probably also that category when as when the opo procurements were asked about why is that they thought that they were like non US citizen and they feel comfortable asking because of fear that people might decide not to donate or that the actual uh family of the potential uh donor would say like hey I don't want to I don't want so yes we estimate that the percentage of of of organs that come from non- US citizen is more but at the very least documented 3.3% so that's a surplus of organs if they're taking close to 1% and and they they're donating close to 4% they're actually contributing more toan pool than than they're taking and is that both deceased and living donors that's that's only deceased only deceased wellow yes don't deceased so yeah as I said there's a big chunk of of of non uh US citizens that are willing to donate we do have multiple cases but the vast majority are constrained by the lack of insurance and proper followup so if we're able to accept this patient we even have more donors so they contribute to both to to the living donor pool and the diseased donor pool but that statistics are mainly from the disease donors I'm reading this book it's called

30:51 the elephant in the room so I'm challenging myself it's like my experiment like in every conversation and every podcast like what's the elant in the room and how can I ask that question without being you know thrown stones in my face but you know at the American transplant Foundation we work with just people of all walks of life from all over the world and sometimes like we do ask we are ask this question my mom has been waiting for kidney transplant for five years we are concerned that if it will be easier for undocumented immigrants to get a kidney transplant like she will never get a transplant it will be even worse like what would be your response to that so uh my response would be that uh undocumented citizens will not affect their waiting time or their chances of uh of receiving a transplant so everybody will have to wait the same in terms of so the same criteria for somebody waiting so it's going to be the same either you're a citizen or a non- US citizen so with that being said we have to take it into account that yeah there there is like a said 7% of of patients being um be being on the weight list that are non- US citizen so you would say like oh but that 7% might affect my chance but if you take into account the removal of those patients on the waiting list you will also take take out those 3.3% of of

32:22 organs that are being donated so at least three point and it's more so if you take one you're going to the other so I think that is better if this uh if this if we are allowed for non US citizen to participate in the Oregon pool because they're going to yes take some more guns but they're actually giving more so it's better for them to participate so I I don't think it it takes into effect having non- US citizen on on our weight list just for those reasons um and more importantly which is a topic that when I discuss it most of the people are like what is like one of the other arguments against people are like on documented citizens receiving transplant is that they say like oh but um if if the if non us if non-citizens don't contribute economically to the system why should they get access and there's multiple studies tackling this uh but there was a nice study uh published by Salman and it was back in 2013 that that studied how much immigrants contributed to for example the Medicaid Trust F and what we found is actually they contribute more they have an excess or Surplus so uh they actually contribute more to the to the medic trust fund than than us born people so they actually leave a surplus the the immigrants because as many people might not be aware these immigrants pay taxes they work and and

33:53 they pay pay taxes and most of them are young and healthy so they actually don't use as much from that Medicare funding so that explains why they actually have a surplus so H in 2009 the immigrants made close to 15% of the Medicaid trust fund contribution but only accounted for 7% of the expenditures and that led to a net surplus of close to4 billion if you put that in contrast with the US born people they actually generated a 30 billion deficit so these immigrants have a Surplus and one of the uh key points of of this study says like hey uh we need policies that restrict uh so that help immigrants because if we keep putting policies that will restrict this IM that immigrant from participating we might deplete uh Medicare Financial Resources so it's actually better for us to have these people working and pay taxes because they're contributing more which is something that if you think about it it's like oh okay this makes sense why why we should consider this uh these patients in transplant and another like important point that I find very interesting is that 95% of these undocumented immigrants are working citizens so we're talking about that they the vast majority of them come here to work and another point that came out is like oh and what if the people come here just to get transplant and that was this proven by uh

35:23 also a study from pediatric K transplant recipients that show that on average patients are here in the state for more than five years be before they seek medical care for kidneys so they're not moving here because they need a transplant or medical here they're they're moving for because they're looking for a better life they're looking for work they want to be able to provide for their families and unfortunately they get sick while being here so if if someone is an undocumented immigrant and they have kidney problems and they're not connected with healthc care what would would be your general advice say across the United States I know that's hard to answer generally but so it it's hard so ideally I try to to look for some way where we can get insurance so in the ideal scenario if you're not able to qualify for some form of like state funded initiative or state funded insurance I would try to get private insurance but that's very expensive but uh ideally just try to get some form of insurance to try to get uh transplanted so for example in here we have the hospital care discount which we use for patients that we know that don't don't have insurance and don't qualified uh for the state approv the state funding initiative but we still try to help them out for the same reason knowing that it's going to be more expensive for the state to keep these patients on dialysis and it's going to be better for them because they're going to go back to work and contribute to society so ideally try to uh move to a state where you can get

36:55 provided better care as we're talking about like long-term Solutions it's obvious that we need more living donors what needs to happen that more undocumented living donors are able to step forward knowing that there are certain guarantees for them in the future if they need medical followup if they have medical complications that they're not going to be just left alone struggling so that's a very uh complex or or hard question to to to answer my my simplistic answer would be like we have to do better as a medical community what can we do to try to help the steing donors can we try to uh push for the recipient insurance to cover this patient for longer because right now the recipients insurance cover you for like basic complications for that first month to a year but what if we offer coverage for at least three years or or what if try to uh legislate for potential living donors if you're a living donor then might then then after that you might be able to qualify for Medicare and Medicaid so we have to work through the system with the ongoing resources to make it easier for them to donate so I think it's not on them it's it's on us like as a medical community what can we do and obviously from a simplistic way that will be one of the things that I would consider like how how can we get

38:25 these patients better care how can we ensure that they have proper followup after which is the main limiting factor that I see right now happening yeah and as an immigrant just the the cultural barriers the language barriers let alone insurance right just like to trying to put the system of really sophisticated us transplant system it's overwhelming so I just want to to remind everyone that at the American transplant Foundation we have an incredible mentorship program that is available in 12 languages and like that is such a great resource to be connected to someone who can be there and just like explain the basics and then take you like through the Journey and help you out with different resources that's a great Point yeah I think that you guys do a very good job in education and and advocating uh for potential donors which we need more so definitely that's a very good point Anastasia and and the the reason you know that our founder Steve Farber when he was going through his transplant Journey uh right next to him there was this Hispanic family and he was looking at them like it's so hard for me and and they have to jump through even all these additional barriers and that is simply not fair so that was one of the one of the reasons to even start the American trustman Foundation 20 years ago which is like a very very valid point and that similar or in line to what we try to do with our Hispanic trans program uh that we're actually

39:58 trying to expand to uh to like different cultures as well like under the same umbrella so we're hopeful that over the next um three to four years we can roll out as well and we are doing the same We're translating um all of our educational material in the top like top five language spoken one of them is Russian uh in in our hospital so having having this initiative will definitely help our population our patient population and speaking of new initiative like are there any research projects or like any new initiatives that you personally excited about so um yes so part of our work in terms of uh investigation and research is trying to prove that these patients do well so on another very good reason which is in the same line of why we should consider these patients like I mentioned they do their outcomes are great so we have pediatric kidney adult kidney uh an adults heart liver and lung all of these organ recipients have excellent outcome they have comparable to actually better outcomes in terms of uh how well that organ does and how long this patient live when compared to the typical US citizen so one of the ongoing uh uh research that we have that the manuscript is on the revision is tackling the same we're proving uh that the Hispanic uh recipient irrespectively of the citizenship status which we included 30% non US citizen did better

41:29 than the typical uh non-h hispanic white on that same analysis we did found that they were more propense to being lost to followup so now we're trying to uh come up with ideas of how we can improve the post transplant followup on this patient population uh uh working with with Dr uh Cervantes she has also several ongoing projects which I'm trying to help her the same trying to improve access to care uh for this uh undocumented Hispanic in uh recipients that are looking for dialysis care and Transplant care so um we also have like data from from like a Statewide initiative this is like something new or something novel we're used to uh using like National Data like the srtr which is stands for the scientific transplant recipient registry so we have now Statewide data that we're trying to compare on the same trying to look for uh what are the cost resources of these patients that are not getting proper care which similar to what we talked about we know that if we provide the appropriate gear it's going to be cheaper for us as a society and it's going to be better for patient we're trying to to model the same on a Statewide uh analysis well you've certainly covered a lot of things today that are I think very interesting and eye opening are there other points that you would hope to get across or share with our audience so um basically so I think like more or less like in a summary we know that uh

42:59 just try to educate people for example like we said like hey why we should consider these patients when uh they don't contribute we know that the actual non-citizens provide a surplus to the Medicaid trust fund and then they provide more money than they take same as like the organs important to say people say like how why why we should include this uh non-citizens in the organ pool they actually provide more more organs than they take they have better out outcomes as we said so it's very uh so it's not like we're wasting organs away and we know that these patients are not coming here just to get transplanted they're coming here to work and be able to uh to be part of like a productive Society so I think those are the main key points that that I wanted to uh drive across today particularly in the ongoing uh climate which again things might change but we have very good data stating otherwise that it's actually better for them to stay and it's it's actually very feasible and realistic to to to get these patients transplanted I really appreciate your willingness to talk about a topic that might be difficult and controversial to some but so important and um really grateful for your time today so thank you thank you thank you thank you it was a pleasure and thank you for having me