On her birthday on May 3 this year, a day she was supposed to receive presents, Hangzhou retiree Jiang Yaping, 60, decided to gift herself to others: She signed hospital forms pledging to donate her corneas and vital organs after her death.
Ms Jiang, who had retired in 2005 as a purchaser, told The Sunday Times that she felt obliged to do so after receiving government subsidies amounting to 80 per cent of the 100,000 yuan (S$22,000) needed for her breast cancer surgery in 2009.
She was also inspired by her late father, who chose to donate his organs after his death. He died in 1987.
"Society has been very kind to me and I want to give back. After reading reports about organ donors, I felt determined to do the same. How meaningful it must be to help people regain sight by donating an eye cornea," said Ms Jiang, who signed the forms in the presence of her supportive husband and son.
Acts like Ms Jiang's explain why China's organ donations are set to hit a record high this year.
Official figures as of Nov 16 show that 2,297 people have donated 6,428 organs, up from about 1,700 donors who donated some 4,548 organs last year, and 132 in 2011 who donated 347 organs.
China has depicted the spike as an achievement, in the light of the fact that its controversial policy of using organs from executed, death row convicts has ceased since Jan 1.
The policy change capped years of debate and efforts by China to enhance its organ transplant system to meet international standards.
A 2011 medical report said that about 65 per cent of transplants in China had involved organs from dead donors, of whom over 90 per cent were executed prisoners.
China puts more prisoners to death every year than the global combined total, with an estimated 2,400 people executed in 2013, according to San Francisco-based Chinese prisoners' rights group Dui Hua. China had been under international pressure to stop using prisoners' organs, a practice viewed as a potential violation of their rights as it is hard to ascertain if the donation was made out of coercion.
China first responded to the call in 2005, when then Vice-Health Minister Huang Jiefu said at a global health forum the country should reform its organ transplant system. China has taken steps since then, such as cutting down the number of hospitals licensed for organ transplants from 600 to 164 and issuing its first regulation on organ donation in 2007, stipulating all organs must come from voluntary donors.
Since 2010, when China began promoting public donations, it has attracted 40,162 to register as donors, and there have been 5,592 cases of successful organ donations that saved 15,354 patients.
China's organ donation numbers are now the highest in Asia, and third-highest globally behind Brazil and world leader the United States.
Dr Huang, who is now seen as the public face of China's human organ donation efforts, said the country is set to become the world's biggest organ donor in several years' time.
"As long as the donation system is transparent, most of the citizens will be willing to join the programme," he said at a health forum earlier this month.
Observers say the credit in part goes to volunteers like retiree Zhu Qiangrong, 61, who has been promoting organ donation since 2005.
He pledged in 1997 to give away his two corneas after he read that late Chinese patriarch Deng Xiao- ping had donated his corneas and vital organs after his death that year.
Mr Zhu recounted how tough it was in the earlier years when he went around distributing pamphlets in intensive-care wards in hospitals. "Some would tear the pamphlets in front of my face. Others would even point at my nose and scold me for even proposing such a taboo subject," he said.
Many in China believe in keeping the body intact after death.
But Mr Zhu, who is one of China's 1,154 organ donation coordinators, has noted an improvement in public perceptions since 2010 when China launched pilot schemes in some 10 cities to promote organ donation.
"The greater publicity has led to increased interest and keenness among many over this issue," he told The Sunday Times.
Ms Gao Min, 49, who has served as a full-time donation coordinator in southern Shenzhen city since 2005, cited rising education levels and the Internet as key factors.
"With greater access to information and knowledge, many people have changed their views on death," she told The Sunday Times, adding that people now view it as important to help others even in death.
It helped that the Communist Party had urged members to donate and instructed the media to step up calls for donations, said Chinese doctors quoted in local media.
Donations also rose amid fears of shortage after the cessation of the policy of harvesting from death row prisoners, said lung transplant specialist Chen Jingyu of the Wuxi People's Hospital near Shanghai.
"Getting rid of organ harvesting from prisoners forced us as a country - the hospitals, doctors, liaison people - to work really hard to promote organ donation," he was quoted as saying in an interview with The New York Times.
While China's donation rate has climbed in recent years, it remains one of the world's lowest.
Nearly two per million people in China donate their organs, up some 100 times from 0.2 in 2010 but still measly, compared with 25.9 per million in France, 25.8 per million in the US and 37 per million in Spain.
China has a ratio of one transplantable organ for every 150 patients in need, compared with 1:5 in the US.
A key factor for the organ shortage, which leaves some 300,000 people yearly awaiting organ transplants and many turning to the thriving black market, is the traditional belief of keeping the body intact after death. There is also an assumption that their organs would be misused by corrupt profiteers.
A 2012 poll in southern Guangzhou city found that 79 per cent of respondents believed organ donation was "noble". But 81 per cent were concerned the donations "inevitably feed the organ trade".
Another factor worsening the shortage is the delay in transporting the organs to transplant patients.
Dr Chen said in another interview that about 300 lungs were donated across China in the first nine months of this year, but about half were discarded because of poor quality, including 50 to 60 lungs that had deteriorated during delays in transport.
China does not have dedicated organ transport systems, and doctors must rely on commercial transport and race against time amid traffic jams and flight delays. The US reportedly saw 1,344 lung donors in the first eight months of this year, and 1,371 lung transplants.
Also, the shortage of transplant doctors is a bottleneck, with only some 100 in China qualified to do the operation. Experts have proposed expanding the number of hospitals allowed to do organ transplant to 300 and the number of doctors to 400 to meet the demand.
Ms Gao, who pledged in 2000 to give her organs away, said the often-tense relationship between doctors and patients in China also stops many hospital personnel from asking if a terminally ill person would be open to making an organ donation.
The lingering suspicion that China has continued using organs from executed prisoners may also affect the public's keenness in stepping forward, say observers.
Such distrust stems from Dr Huang's remarks in the Communist Party mouthpiece, People's Daily, earlier this year that "if death row prisoners are willing to donate their organs to atone for their crimes, then they should be encouraged".
Observers say it means China may have stopped its systemic use of prisoners' organs but continued using organs with consent from the prisoners and their families.
But Dr Huang has said he made the remarks "philosophically" and denied that the government was allowing it in practice.
Amid the controversy, there is support in China for the continued use of organs donated by prisoners.
Said Mr Zhu: "I feel aggrieved that death row prisoners are not allowed to donate their organs now. Letting them do so is also a respect of their human rights, as long as it is done with their consent."
Meanwhile, other steps are being taken to tackle the shortage.
The Health Ministry is setting up a centralised organ pool and distribution system modelled on those in the US. Lawmakers are pushing for transplant operation costs to be included in the state's medical insurance scheme to alleviate the burden on transplant patients. A kidney transplant operation costs at least 250,000 yuan and a liver transplant at least 600,000 yuan.
Several provinces have also rolled out new laws to regulate their organ transplant systems, such as stating that objections from family members cannot overrule a donor's pre-death donation pledge.
Ms Jiang believes the biggest factor in boosting China's organ donation lies in having more people step forward, just like how the late Deng had inspired Mr Zhu and others.
"There is a Chinese saying, that a train can move fast only with a strong engine. We need more people to set the right example and create a positive knock-on impact on others," she added.
Surprisingly short wait of 10 days for multiple-organ transplant
Guangzhou local Mr Zhang Ming-yuan, 57, who was diagnosed with liver cancer, diabetes and an intestinal illness in 2012, had mentally prepared himself for a long wait after he joined a waiting list in May for a multiple- organ transplant.
He was aware of the acute organ shortage in China, where some 300,000 people are awaiting organ transplants and only 10,000 get to undergo operations yearly.
Even though he was put on a priority queue as a multiple-transplant patient for liver, pancreas and a segment of the small intestine, he still thought he would have to wait at least half a year.
But 10 days later, Mr Zhang was informed by doctors that a 10-year-old boy and his father had died in a car accident and the family had donated the son's three organs to him.
Mr Zhang, who went for the operation at the Sun Yat-sen hospital in Guangzhou, capital of the southern Guangdong province, believes the improved public perception of organ donation had helped him.
"I was extremely lucky and I feel deeply grateful to the boy and his mother. Without their selfless act, I wouldn't be able to get the donated organs even if I had all the money in the world.
"Now, I feel like I'm as healthy as I was at age 40," Mr Zhang, who works in a private enterprise, told The Sunday Times.
Stories like Mr Zhang's and reports on rising organ donation rates have heartened a 53-year-old engineer in Inner Mongolia, who wanted to be known only as Mr Li.
Diagnosed with uraemia in 2008, Mr Li has been on the waiting list of the Chaoyang hospital in Beijing for a kidney transplant since 2010 and has spent 85,000 yuan (S$18,500) on medical fees.
"It is good news for me, but I don't know when my turn would come," he said.
In his desperation, Mr Li had thought about buying a kidney on the black market and was told that a transplant would cost about 700,000 yuan in all.
"I can afford at most 300,000 yuan. Now there's nothing I can do but wait for the life-saving phone call from the hospital," he said.
Additional reporting by Lina Miao.
This article was first published on December 27, 2015.
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