China's organ-transplant system was once a cause of international scorn and outrage, as doctors harvested organs from prisoners condemned to death by criminal courts and transplanted them into patients who often paid dearly for the privilege.
After years of denials, China now acknowledges that history and has declared that the practice no longer occurs — largely thanks to the perseverance of a health official who, with the quiet backing of an American transplant surgeon, turned the system around over the span of a decade.
That official, Huang Jiefu, built a register of voluntary donors, overcoming both entrenched interests that profited from the old ways and a traditional Chinese aversion to dismemberment after death. In true modern Chinese fashion, donors can sign up through a link and app available through the ubiquitous Alipay online payment system. More than 230,000 people have done so, and a computerized database matches donors with compatible potential recipients, alerting doctors by text message as soon as organs become available.
Leading transplant experts outside China, including once-severe critics, have slowly been won over.
"There has been a substantial change in China which has been in the right direction," said Jeremy Chapman, a leading Australian physician and former president of the Transplantation Society who in the past had harshly censured Chinese transplantation practices.
Yet skeptics still abound, and a darkly sinister accusation continues to be heard.
Just last year, the U.S. House of Representatives passed a resolution condemning "state-sanctioned forced organ harvesting" in China, and accusing the Communist Party of killing prisoners of conscience — held in secret, outside the usual criminal prisons — to feed the transplant industry.
Huang and his allies in the transplant industry around the world dismiss those allegations. In their eyes, the China that has emerged on the world stage as a financial and technological power, with a rising and increasingly sophisticated middle class, has successfully done away with a wicked practice from the past.
The use of prisoners' organs had left China a global pariah in the transplant field. Relying on prisoners caught in a corrupt and inhumane legal system, China had built the world's second-largest transplant industry after the United States'. It was effectively an unregulated system in which organs were being delivered not to the most deserving recipients but to the highest bidders. Vast profits were generated as medical ethics were set aside.
"Financial interests were driving malpractice," Huang said. "The allocation of organs had become a game of wealth and power, with no social justice."
Thousands of organs were being harvested from executed prisoners every year, but over the course of a decade, Huang has garnered support at the highest levels of government and succeeded in pushing China's medical establishment into dropping the often-lucrative practice.
Since 2010, Huang has slowly built the register of voluntary donors, who now meet the needs of patients who require transplants. Such a register is a breakthrough for China.
The turn toward reform began in 2006, when Huang was the first to publicly acknowledge an open secret in the medical industry — that prisoners' organs were the basis of the nation's fast-growing transplant industry.
Huang's efforts to clean up the system, with the quiet backing of University of Chicago transplant surgeon Michael Millis, surmounted stiff resistance — and met with skepticism and sometimes lurid allegations that continue to dog their work.
"It has been very tough going over 10 years," Huang said in an interview in his office in Beijing, as he described his battle against powerful vested interests.
Huang and Millis both work for medical centers with close links to the Rockefeller Foundation and its spinoff the China Medical Board (CMB). They met at a Rockefeller-CMB-sponsored meeting nearly a decade ago. They discovered a shared concern about the workings of China's transplant industry.
The pair agreed that an abrupt end to the use of prisoners' organs was not feasible and would only create a black market. Instead, they resolved to work for gradual change. With a grant from the CMB, and with Millis as Huang's main consultant, they began to investigate alternative approaches.
China had more than 600 organ transplant centers in a sprawling, unregulated system. That number was whittled down to about 160 registered and approved centers in 2007, when legislation was also introduced to outlaw organ trafficking and ban foreigners from coming to the country to receive Chinese organs.
The public was brought on board with the help of the Chinese Red Cross, and skeptics in China's medical profession were gradually won over by Huang's persistence and his ability to secure official support.
Last year, Huang said, 4,080 donors supplied organs after their deaths, and 2,201 living donors gave organs to relatives. In total, China performed 13,238 organ transplant operations, mostly of kidneys and livers, but a few hundred hearts and lungs, too. None of those came from prisoners, Huang said.
"Our system is transparent and traceable," he said. "We know where every organ comes from and where every organ goes."
That may overstate the reality, but Huang's allies say that irregularities are now the exception rather than the rule.
Chinese law does not explicitly rule out using organs of prisoners condemned to death by the criminal courts, and Huang himself was quoted in Chinese media in late 2014 and early 2015 as saying prisoners could "voluntarily" donate organs.
Huang now disavows those comments, insisting there is "zero tolerance" for using any prisoners' organs in the hospital system. But in a country of 1.3 billion people, he said at a Vatican conference in February, "I am sure, definitely, there is some violation of the law."
Lawyer Yu Wensheng said that one of his clients had shared a Beijing prison cell with a man facing the death penalty last November and that the condemned man was given a form to sign to "voluntarily" donate his organs.
Death-row prisoners, he said, were "given the choice not to sign the forms, but they would receive much more mistreatment and suffer much more. If they sign, their last days of life would pass more easily."
Yet the supply of organs from executed prisoners seems to have been drying up because the number of death sentences appears to have fallen dramatically after a 2007 mandate requiring the Supreme Court to review all capital cases.
When she introduced the House resolution condemning China's organ-transplant system, Rep. Ileana Ros-Lehtinen (R-Fla.) declared, "We cannot allow these crimes to continue." She accused the "ruthless dictatorship" running China of persecuting peaceful practitioners of the Falun Gong spiritual movement, and of the "sickening and unethical practice" of harvesting organs without consent.
The basis for this allegation is research compiled over many years by David Matas, a Canadian human rights lawyer, David Kilgour, a former Canadian politician, and Ethan Gutmann, a journalist, who assert that China is secretly carrying out 60,000 to 100,000 organ transplants a year, mostly with organs taken from Falun Gong practitioners held in secret detention since a crackdown on the movement in 1999.
But research and reporting by The Washington Post undercut these allegations.
Transplant patients must take immunosuppressant drugs for life to prevent their bodies from rejecting their transplanted organs. Data compiled by Quintiles IMS, an American health-care-information company, and supplied to The Post, shows China's share of global demand for immunosuppressants is roughly in line with the proportion of the world's transplants China says it carries out.
Xu Jiapeng, an account manager at Quintiles IMS in Beijing, said the data included Chinese generic drugs. It was "unthinkable," he said, that China was operating a clandestine system that the data did not pick up.
Critics counter that China may also be secretly serving large numbers of foreign transplant tourists, whose use of immunosuppressant drugs would not appear in Chinese data. But this assertion does not stand up to scrutiny.
Jose Nuñez, head of the transplantation program at the World Health Organization, which collects information on transplants worldwide, says that in 2015 the number of foreigners going to China for transplants was "really very low," compared with the traffic to India, Pakistan or the United States, or in comparison with transplant-visitor numbers in China's past.
Chapman and Millis say it is "not plausible" that China could be doing many times more transplants than, for instance, the United States, where about 24,000 transplants take place every year, without that information leaking out as it did when China used condemned prisoners' organs.
And lawyers who have defended Falun Gong practitioners also reject allegations that those prisoners' organs are being harvested.
"I have never heard of organs being taken from live prisoners," said Liang Xiaojun, who said he had defended 300 to 400 Falun Gong practitioners in civil cases and knew of only three or four deaths in prison.
In China, despite state repression, family members can be determined in speaking out and seeking justice when relatives vanish.
If tens of thousands of Falun Gong practitioners were being executed every year, that information would emerge, experts say.
A U.S. congressional commission on China, the State Department and the Falun Gong community website have separately tried to estimate the number of political prisoners in China, and the figures range from 1,397 to "tens of thousands" — and even that upper number is significantly lower than the 500,000 to 1 million claimed by Gutmann and others.
The symbolic focal point of China's organ transplant industry is the Oriental Organ Transplant Center, a gleaming 14-story building in the northeastern city of Tianjin that is the largest of its kind in Asia.
In the lobby, a sleek promotional video advertises the center's expertise in supplying livers, lungs, hearts and pancreases to save thousands of lives every year.
On a recent visit, a handful of patients from Pakistan, Libya and the Middle East were observed in transplant wards. Two Pakistani families said they had brought their own donors with them, although one admitted that the donor was not related to the recipient, in breach of Chinese law.
The families said they were paying $70,000 to $80,000 each for the operations.
Wei Guoxin, public relations director at Tianjin First Center Hospital, which runs the transplant center, said accusations that China used organs from Falun Gong practitioners were "ridiculous" and part of a conspiracy against the country. But she did not respond to subsequent requests for data on the transplants carried out at the center or the number of foreign patients served.
But in Beijing, doctors say a steady stream of organs is flowing in from voluntary sources.
When 72-year-old Lu Wen suffered a brain hemorrhage on New Year's Eve and was put on life support, her husband, Zhao Hongxi, had no hesitation in agreeing that her organs be used to save others' lives.
"She always liked to help others and wanted to contribute," said Zhao, a retired engineer in the People's Liberation Army and a loyal Communist Party member. "If the organs are usable, they should be used to help others, as a way of lengthening her life."
His two daughters soon agreed, although 47-year-old Zhao Wei said she hesitated at first: She had imagined holding her mother's hand when the life support system was turned off, but the need to swiftly remove her organs made that impossible. Still, she said, she soon came around to the idea, her Christian faith helping her to accept her family's decision.
"While I waited downstairs in the hospital for my mother to die, I felt huge love," she said.
Congcong Zhang contributed to this report.