* the owner of the lab that realized the tests (PCS Lab Saleme) is the cousin of the former secretary of health from Rio, Dr.Luizinho.
* Anvisa (brazil health regulatory agency) alleges the lab didn't have the kits to realize the blood exams and didn't present the receipts proving their purchases, leading to the suspicion
they didn't do the tests at all and forged the results.
* Since many hospitals outsourced donor organ tests to the 3rd party lab, there is a precedent for more cases of infected organs, so the stored material of 286 donors will be retested by HemoRio, a state health unity.
No. That is just naive pattern-matching against a hot-button issue that you read a lot about on HN. For both this story AND Boeing, the explanation is more complicated than “outsourcing bad!”
It's also an example of the really irksome thing that happens on American sites where people will quickly steer the conversation away from non-America stuff to America stuff because they feel more comfortable talking about something that they know about than just not participating in the conversation and watching other people talk about stuff that they are knowledgeable of.
Which is kinda silly because if they just sat back and listened they could learn more about the thing that other people are talking about so that the next time this topic comes up they won't feel uncomfortable and can jump in and add something to the conversation instead of just nervously pivoting to talking about Alatucky or Boeing or the number of street poops in SF.
I for one look forward to learning more about the medical system of Brazil from this post.
It is noticeable but this seems a bit circular though.
If the user-base is predominantly American then of course if you tally up the random nonsense comments on any given day, they will also be predominantly made by Americans, due to probability.
I think the issue is that some people ( and this may be HN-specific ) think that medicine in general, and maybe even diagnostics in particular, is almost exactly like software testing. In a lot of ways, it really isn't. Some reasons get a little esoteric, but the more important one is rather simple: until more recently, software did not have a direct impact on life and as such was mostly given a pass on some otherwise heavy blunders. That is slowly changing, but missing something during quality control is not likely to have the same impact.
But this brings me to the other important reason, statistical check can only get you so far and that is assuming we can now trust it was even done. Some people do rely on being able to say, 'this was false positive once, you know what are the odds of it being false positive twice'? Now, we add variable of uncertainty into the system in the form of 'well, it was outsourced so there is a non-zero chance it is bs anyway'.
In this particular case you're saying you need to test the organs once at the outsource place and then again at the hospital? Why not just get rid of outsourcing then?
No, that is not what the parent said. "Check an verfiy" can come in diffrent forms and tastes eg. having some samples (not all) checked by another lab, asking for standards and inspection performed by 3rd parties, asking and checking for documentation...the hell how do you think anybody could work with suppliers?
> eg. having some samples (not all) checked by another lab,
I don't think that is useful at all in case of rare diseases. You would just get two reports saying that the random sample is free of HIV.
Much better would be to send some known control samples. Making sure that some of the samples is known HIV+, and then check if the supplier can tell which ones are those.
You can still do this kind of audit, but you need to test a statistically significant number of samples in your "spot check" such that you know you some of them will be infected. The number will vary depending on the incidence of a particular type of infection present, but this is data that should be available.
I agree that sending control samples can also be effective, though. But if you need to send the whole organ to the test lab (and not just a small tissue sample), you probably don't want to be wasting healthy organs by infecting them. Better to just wait until you have an organ that's known to be infected already.
> But if you need to send the whole organ to the test lab
Why would you need to do that? Realistically the sample needed here is a small vial of blood from the organ donor’s body.
> You can still do this kind of audit, but you need to test a statistically significant number of samples in your "spot check" such that you know you some of them will be infected.
Nah. It really doesn’t work. The problem is that HIV is very rare. (HIV incidence per 1000 population adults 15-49 in Brazil is between 0.34 - 0.45[1])
Let’s be ultra conservative and set the “spot check” rate at 100%. That is you are sending samples from every single body to two labs. Because of the low incidence rates you would still expect hundreds and hundreds of those samples to return as negative from both labs. This might work if you would somehow have a “gold standard” lab you trust and an other “less trusted lab”. But in reality there is no such a thing as a “gold standard” lab you can trust without QA. (And if there would be you would just use them, instead of the other lab.) Even with that ridiculously high “spot check ratio” you wouldn’t know if you are getting negative results because they are in fact negative, or because both of your labs are falling for some reason and giving you constant false negatives.
In conclusion spot checking the results with a second lab simply doesn’t work. Even if you spot check every single organ donor you would be still blind for even the most basic error cases for unacceptably long times.
On the other hand if you intermingle a control sample into every single batch that changes the game. Lets say they run the tests on batches of 10 and you make sure that a random one of those is always known to be positive. Now if something goes wrong and they don’t detect the sample you can straight away reject the whole batch of tests as faulty. And it only costs you an 11% extra over not doing any QA.
So with the “spot checking” test you can pay as much as 100% extra and still not know if the tests are having the most elementary kind of fault for hundreds and hundreds of organ donors. Or you can go with the “control sample” strategy and have a reasonably high confidence for every batch right away at much less of a cost. Yeah you can do the “spot check” audits but it is ridiculously bad at catching issues even if you spend a lot of money on it.
I agree with you, also the bogus argument of "since most people are HIV free..." assumes direct testing instead of pooled testing (using modern information theoretic optimized pooled testing).
A bit of data is most informative if the entropy is 1 bit as well. A signal that is true most of the time, or a different signal that is false most of the time is less informative. Use pooled testing such that the result is true or false half of the time.
Had information theoretically justified pooled testing been applied from the start, then:
* 1) control-testing the testing contractors would have been straightforward and passing 10 control samples by chance would have a likelihood of 1 over 1024.
* 2) it would have made obvious that saving money on control-testing the contractors would hardly save any money
* 3) even in the bad scenario that control testing was skipped, the issue of contractors cheating would have surfaced much faster, since combining the pooled tests to identify which patient tests positive would constantly result in mysteries, meaning control-testing needs to be enabled, not the mathematics of pooled testing brought in doubt.
* 4) testing pharma industry hates pooled testing, as it means technological competition instead of sales growth by abusing the naive but false "common sense" that you need as many tests as patients tested.
on a side note: assuming tests with different operating point on the RoC curves (having different false positive vs false negative ratios) have different prices, do we know if the operators blatantly provided fabricated results, or if they blatantly ignored basic mathematics and thought the more expensive tests could be substituted by the cheaper ones even if intended for a different purpose?
consider a test designed for telling a patient that we diagnosed HIV, and then consider a test designed for screening an organ to be inserted into a patient.
do you think they should both use the same test? or do you think it wiser to have the diagnosis test have lower false positive rates, and the organ screening test to have lower false negative rates?
Yes, why not? You don't re-test every single one, though: you spot-check a statistically significant percentage of them. Or maybe you do check all of them, but only for a one month period every year (a month that changes every year, and isn't known to the testing lab, so they can't game the system).
Another option is to send "control samples" to the testing lab, something you know already is infected with something they should be testing for. Do this enough times, and you'll know if they're accurately reporting the bad samples.
This type of thing is the only way for anyone in any kind of organization to verify that their outsourcing is effective and they're getting the result they want.
Outsourced companies deal similar issues internally while also forcing you to trust their management. Internally this kind of corruption is more difficult because you have more control, and fewer people are going to cooperate. Similar to how companies can regularly use untrustworthy low level employees handle cash.
You can still get rogue employees in ether case, but an outsourcing company is like a ready made conspiracy where any corners cut automatically turns into money.
> Internally this kind of corruption is more difficult because you have more control
If we anthropomorphise the regulatory body, sure. In reality, there isn’t evidence either way. Corrupt governments handing work to the private sector is a proven efficiency booster. Meanwhile, competent governments Severn Trenting everything is textbook (on the political left).
Outsourcing and corruption isn’t limited to government agencies. Quite a lot of it is from companies to other companies or governments to company A and then from company A to company B where the subcontractors are at issue.
Outsource to 2+ contractors, use pooled testing, and use control tests to steer that percentage of tests towards those contractors that score better on the control tests. Obviously the contractor should not be allowed to know which samples are control tests.
If your reaction is that Apple’s core competency is in marketing and design and not manufacturing then i will ask if the same pattern couldn’t be applied to Boeing.
Further context: In Brazil since we have universal health care provided by the government, generally speaking non outsourced or contractors becomes public servants.
The issue is: Public service in Brazil is expensive and is virtually impossible to fire anyone. On top of that the cost of public service has second order effects in the public balance sheet for the municipalities plus it has a huge burden in the public retirement system.
Not saying that is right or wrong, but this is very common in the Brazilian heath system.
You don’t check the organs. You check the process by intermingling known HIV+ samples and check if they are being detected.
> Checking means re-testing, so might as well get rid of outsourcing.
Thing is you need to do QA on the testing system no matter what. Doesn’t matter if it is performed by contractors, in house staff or little grey aliens. If you are not doing QA you won’t know if the testing is done correctly or not.
At some point, your recursive watchers of watchers watching watchers has to have a base case of "we trust this entity" (or maybe, "you, the public, trust this entity").
Outsourcing only matters for this if it provides a break in the chain of responsibility. That is, if the person selecting the outsource provider can (successfully) say "hey, not my fault" by pointing to... some entity that whoever they answer to doesn't already trust.
I agree provided that "checks" isn't just the narrow sense of "verification upon receipt of the product", but also the supporting framework of "violators will get punished."
Nothing wrong with outsourcing as long as it doesn't allow the user of the third-party operation to escape legal liability for failures and fraud committed by said third party that affect the user's clients.
Why? If you have HIV you need to be on antiretroviral drugs. They keep your viral load to undetectable levels, so your immune system does not need to fight it.
Yep, if HIV progresses to the point of AIDS, suppressing your already-suppressed immune system would be bad. But with today's treatment regimens HIV won't progress anywhere near that point. Which is borderline miraculous, really.
HIV is the virus that makes you develop (or "acquire") AIDS; AIDS is the condition that weakens and kills you. If you pump the breaks as soon as possible, HIV on its own won't have catastrophic health implications, although it's obviously better not to have it at all.
That may have been true decades ago, but is no longer the case. Of course nothing is risk-free, but current drugs can get HIV viral loads down to undetectable levels, and if your drug treatment is successful, it's considered reasonably safe for you to swap fluids with others (with their knowledge of your medical history, and consent, of course), as well as become pregnant. Sexual partners should be on PrEP too, to further reduce the risk.
This isn't "living a normal life" completely, and the retrovirals have side effects and the regimen needs to be maintained, but the state of things for people with HIV is so much better than it was back in the 90s.
I don’t know why you are getting downvoted but I’m guessing that a lot of people don’t know about/understand that undetectable = untransmittable. It is generally seen as safe to have unprotected sex with someone whose viral load is suppressed to the point of being undetectable. Of course you need to believe that’s the case, informed consent is still important, and it’s probably a good idea for the negative party to be on prep, but the fact that the likelihood of transmission is so low if someone is undetectable is widely accepted in medicine and widely known in the LGBTQ+ community at this point.
Just because your condition has catastrophic consequences, particularly if not _properly_ managed, doesn't mean you have to live your life in a catastrophic way.
Pretending that should be ignored benefits no one.
Antiretrovirals have significant risks and adverse effects. Uninfected people don't take antiretrovirals unless they have been exposed to the virus. They protect against exposure instead.
The chance of both condoms and antiretroviral therapy failing to prevent transmission simultaneously is always going to be lower than the chance of either failing independently. In practice, many couples decide that the risk of transmission associated with antiretroviral therapy is low enough for them.
Not true at all! You can absolutely get pregnant with HIV, and there are a number of steps you can take to prevent transmission to an unborn child.
Similarly, if you take antivirals to get your viral load down to undetectable levels, the risk of sexual transmission is very, very low. The risk is even lower if your partner takes PrEP as well.
You certainly need to take precautions, but people with HIV can live full, normal lives.
AIDS is the immune deficiency-causing virus, and that begins (usually) way after an HIV infection takes place — months, years. So until then, they’d still need to take immunosuppressants.
to be clear, I believe modern antiretrovirals can prevent the virus from replicating for an entire lifetime. They bring the viral load down to undetectable levels.
Rio de Janeiro is by far the most corrupt Brazilian state. Its hard to explain how bad it is if you are not Brazilian, but imagine that every single former state governor and many of the mayors have been sent to prison for corruption after their term ended.
So what usually happens is that someone from the public sector opens up a public bidding for some service to be done by the private sector, and usually who wins is someone who has ties with the local government.
Most of the time whoever wins the bid (usually some shell company) is going to barely offer the service, and share most of the profits with their associates in the local gov.
This is one of such cases: The private lab doing the tests is owned by the cousin of the former state secretary of health Dr.Luizinho. Its very likely that they just did not do the tests at all (yes, that how bad it is)
Interesting perspective on the impact of corruption across different countries. It's striking how two countries with similar levels of corruption can have vastly different outcomes in specific areas. Take Argentina as an example: while it's highly corrupt, organ transplants are remarkably well-organized under a single entity, INCUCAI [1]. You can even see crystal clear stats there.
Corruption is not a single axis, for example college entrance exams and voting in brazil are very trustworthy in my opinion.
Institutions are corrupt, not a whole country. Sure there is some level of infection between institutions but there is still a lot of a single one can do.
Because the supreme court judge has decreed that the voting machines are UNQUESTIONABLE. That's all there is to it. Not even our elected representatives get to doubt these things:
Fun fact: brazilians commonly express feelings of superiority towards civilized developed world nations because of these voting machines. They think americans, germans and everyone else in the world are living in the literal stone age due to their "archaic" voting processes just because it takes time to count the votes.
Brazil is way more decentralized in that way, especially health care, so health care quality will greatly change depending on your city even.
That said, organ transplants in Brazil are managed by the Federal Government (lists, etc), but the clinics and hospitals will usually be state or city made...
Brazil is pretty good at organ transplants, surprisingly.
Similarly to the Mongolian government, except that only major cases are targeted, and instead of the actual culprits, people who were just doing their jobs under them end up in prison. Case closed.
I usually direct people to watch the movies Elite Squad 1 and 2. They're entertaining and pretty much explain why Rio is so violent and so corrupt and how both things feed off each other.
I'd like to note that Brazil is not at all unique in being corrupt or even in the methods used. For example, watch HBO's The Wire and you'll find the police and politicians playing the exact same numbers game. It seems to be inherent to democracy, a side effect of reelection.
The films do a wondeful job depicting the poverty of Brazil, and the way it attracts people to organized crime. It attracts so many of them, they form a nation unto themselves. Complete with their own army, territory, laws, tribunals... It gets to the point it's a silent secession.
Not uniquely corrupt but uniquely violent (before the Ukraine invasion one in eight violent homicides happened in Brazil... not South America, Brazil).
Besides, I don't know great movies that explain the corruption and violence on each metropolis, just this one (and The Wire for Baltimore, which is by the way great television).
I'd recommend also watching the Vice piece on how Brazilian gangs are fueling violence in Paraguay. It's quite jarring to see the slang of street criminals of Rio and SP spoken across the border in what is a war like situation.
Tangentially related, but when i lived in Rio I would always tell people I thought it was the most beautiful city in the world. Then, a visiting exec asked me: "Well, have you been to Cape Town?"
How free do people feel to speak up against corruption? Like could they go public on Twitter/X and call out the issues they see? Or would they face legal retribution or physical violence?
It really depends. Locally, factions like criminal associations and retired cops mafias (militias), who always have city councelors and mayors in their pockets, may retaliate if someone with an audience is being too annoying (see Marielle Franco's case).
Nationally, not all politicians enjoy any protection from the supreme court against critiscism, only the best connected ones and the supreme court itself. Recently, a former YouTuber who lost all his social accounts and had to self-exile to the US for some disrespectful comments against the supreme court was sentenced to 1.5 years in jail for calling the newest supreme court judge a "fatty".
Except for the supreme court itself, the average Brazilian can voice their concerns and speak up against corruption with very low chances of repercussions if they don't display wholly anti-democratic discourse, like wishing the military to execute a coup.
He merely observed that the extreme left has a lot more space in politics than the extreme right. Why is it that nazism is banned while we have so many literal proud self-admitted socialists and communists in this country who not only walk this soil completely unpunished but also form organized parties, get elected, get appointed to the supreme court? The judge who held him guilty for calling him a "fatty" is the perfect example of one.
Anti-nazism laws are unconstitutional. Constitution says that "any and all" censorship of political nature is prohibited. Nazism is a political party. Therefore censorship of nazism is prohibited. It's that simple.
So why is it that nazism is literal thought crime while socialism and communism, far more harmful ideologies, are allowed to flourish with complete impunity? If they're gonna ban nazis, I demand that they also ban communists and socialists. It should be a literal thought crime to advocate for anything related to that nonsense. And any form of socialist organization should get all involved sent straight to jail.
That's the point that was made. Allowing that crap while simultaneously banning nazism is a contradiction. His only "crime" here was trying to resolve the contradiction by arguing that nazis should be allowed to organize. That's not what we really want. What we actually want is these socialists and communists in jail.
> Anti-nazism laws are unconstitutional. Constitution says that "any and all" censorship of political nature is prohibited. Nazism is a political party. Therefore censorship of nazism is prohibited. It's that simple.
There’s no censorship. You are allowed to say your mind and nobody can prevent you from doing it. Freedom to do something doesn’t imply impunity for committing crimes in the process of expressing your political beliefs.
> the extreme left
Brazil had a far-right president for four years. There’s zero far-left in mainstream politics in Brazil, unless you slide the Overton window so far to the right social democrats (such as PT) looks far-left and Bolsonaro looks like a moderate right-winger.
> Freedom to do something doesn’t imply impunity for committing crimes in the process of expressing your political beliefs.
Those two statements contradict each other. One can't criminalize political beliefs and simultaneously claim that there is no censorship of political beliefs.
The man had his social media presence blocked for his wrongthink. That is censorship.
> There’s zero far-left in mainstream politics in Brazil
There must be dozens of political parties with communism and socialism right in the name. Not social-democracy, not social-anything. Straight up socialist and communist parties. Why is this allowed?
And it's not just the names either, as is often claimed. They are very much socialists in their proposals and public policies. Why are these ideas allowed to spread and proliferate?
Freedom of expression is guaranteed in Brazil. In general people feel free to speak and that hasn't changed.
What has become a crime is the spread of misinformation in the form of fake news. For the most part these are still legislated fairly IMHO. But the precedent feels a bit dangerous
Yes, incredible. When HIV/AIDS emerged, dentists were among the first professionals to adopt protective measures.
I don't have more details than what's mentioned in the article, but situations like this can sometimes reflect a deeper issue within the underlying professional and organizational structures, almost as if they're "calcifying", not just negligence, but a symptom of how things are functioning beneath the surface. On the other hand, it might simply be a case of individual malpractice, though I think the latter will be rare in the context of transplants.
Isn't the window period large enough for the HIV test that it could slip through that way, i.e. you get infected on Friday, die and organs get harvested/get tested on Monday (or possibly longer) but you have not been infected long enough for the test to detect it? I had to sign a waiver acknowledging this possibility when I had some dental procedure last year.
It is but the test isn’t fully considered accurate for the first 30 days (45-90 days to be conclusive). That’s a long window of time for the virus to spread.
Organ transplants are "ooh, shiny" headline grabbing medicine. Better healthcare to try to keep your original equipment is boring and gets dismissed as "just lucky." It's hard to prove a connection between x, y z and not needing a transplant.
Any criticism or critique of this paradigm gets hated on without anyone really listening or wondering what might motivate someone to be not crazy about our "we are borg" trends in medical care.
Everyone I've ever talked to dealing with conditions that often end in transplant knows and shares that they're big-deal, serious-business, forever-life-altering treatments that are ultimate last resorts. But for some things we simply don't have any alternatives.
And for some of those - for instance one of the super-obvious ones is alchoholism-induced cirrhosis - "don't drink so much that you kill your liver" is VERY discussed, not just considered "lucky." You might even get yourself disqualified from a transplant if you can't get it under control. Everyone would MUCH rather you not need it.
Where are you seeing "get a transplant" pushed as a shiny panacea? They aren't even new anymore... lots of newer-shinies out there.
Sure, reducing the conditions that lead people to need transplants is a great idea, and should be done more. But I don't see how that's relevant to this discussion.
What happens if someone contracts HIV and dies over the next 2 weeks before the virus is detectable in tests. Would it propagate even in a dead body? Using an organ from this donor would cause HIV either ways and so is honestly a risk factor for US donors as well.
For those who watch medical shows, this is somewhat reminiscent of a case of several patients who contracted rabies through organ transplants - a story that was portrayed in Scrubs season 5 episode 20, "My Lunch".
> laboratory responsible for conducting tests on donated organs had been suspended after the organs from two donors were transplanted into six people
So they missed the same thing twice, presumably at around the same time.
> and all stored organs from donors are being tested back to December 2023 when the lab was hired
I had the impression that there was a very short time limit, like maybe as long as a couple days. Is this just wrong, or does it only apply to same things?
Just for additional note:
* the owner of the lab that realized the tests (PCS Lab Saleme) is the cousin of the former secretary of health from Rio, Dr.Luizinho.
* Anvisa (brazil health regulatory agency) alleges the lab didn't have the kits to realize the blood exams and didn't present the receipts proving their purchases, leading to the suspicion they didn't do the tests at all and forged the results.
* Since many hospitals outsourced donor organ tests to the 3rd party lab, there is a precedent for more cases of infected organs, so the stored material of 286 donors will be retested by HemoRio, a state health unity.
> Dr.Luizinho.
He was also short listed to take over the Ministry of Health under Bolsonaro’s government.
[flagged]
No. That is just naive pattern-matching against a hot-button issue that you read a lot about on HN. For both this story AND Boeing, the explanation is more complicated than “outsourcing bad!”
It's also an example of the really irksome thing that happens on American sites where people will quickly steer the conversation away from non-America stuff to America stuff because they feel more comfortable talking about something that they know about than just not participating in the conversation and watching other people talk about stuff that they are knowledgeable of.
Which is kinda silly because if they just sat back and listened they could learn more about the thing that other people are talking about so that the next time this topic comes up they won't feel uncomfortable and can jump in and add something to the conversation instead of just nervously pivoting to talking about Alatucky or Boeing or the number of street poops in SF.
I for one look forward to learning more about the medical system of Brazil from this post.
It is noticeable but this seems a bit circular though.
If the user-base is predominantly American then of course if you tally up the random nonsense comments on any given day, they will also be predominantly made by Americans, due to probability.
Yeah, it's more about the failure of the checks and balances in both cases. Old school corruption really.
Okay — what makes it more complicated?
Because you can have solid outsourced work, as long as you bother to check and verify that work.
I think the issue is that some people ( and this may be HN-specific ) think that medicine in general, and maybe even diagnostics in particular, is almost exactly like software testing. In a lot of ways, it really isn't. Some reasons get a little esoteric, but the more important one is rather simple: until more recently, software did not have a direct impact on life and as such was mostly given a pass on some otherwise heavy blunders. That is slowly changing, but missing something during quality control is not likely to have the same impact.
But this brings me to the other important reason, statistical check can only get you so far and that is assuming we can now trust it was even done. Some people do rely on being able to say, 'this was false positive once, you know what are the odds of it being false positive twice'? Now, we add variable of uncertainty into the system in the form of 'well, it was outsourced so there is a non-zero chance it is bs anyway'.
Not exactly a recipe for success.
In this particular case you're saying you need to test the organs once at the outsource place and then again at the hospital? Why not just get rid of outsourcing then?
No, that is not what the parent said. "Check an verfiy" can come in diffrent forms and tastes eg. having some samples (not all) checked by another lab, asking for standards and inspection performed by 3rd parties, asking and checking for documentation...the hell how do you think anybody could work with suppliers?
> eg. having some samples (not all) checked by another lab,
I don't think that is useful at all in case of rare diseases. You would just get two reports saying that the random sample is free of HIV.
Much better would be to send some known control samples. Making sure that some of the samples is known HIV+, and then check if the supplier can tell which ones are those.
You can still do this kind of audit, but you need to test a statistically significant number of samples in your "spot check" such that you know you some of them will be infected. The number will vary depending on the incidence of a particular type of infection present, but this is data that should be available.
I agree that sending control samples can also be effective, though. But if you need to send the whole organ to the test lab (and not just a small tissue sample), you probably don't want to be wasting healthy organs by infecting them. Better to just wait until you have an organ that's known to be infected already.
> But if you need to send the whole organ to the test lab
Why would you need to do that? Realistically the sample needed here is a small vial of blood from the organ donor’s body.
> You can still do this kind of audit, but you need to test a statistically significant number of samples in your "spot check" such that you know you some of them will be infected.
Nah. It really doesn’t work. The problem is that HIV is very rare. (HIV incidence per 1000 population adults 15-49 in Brazil is between 0.34 - 0.45[1])
Let’s be ultra conservative and set the “spot check” rate at 100%. That is you are sending samples from every single body to two labs. Because of the low incidence rates you would still expect hundreds and hundreds of those samples to return as negative from both labs. This might work if you would somehow have a “gold standard” lab you trust and an other “less trusted lab”. But in reality there is no such a thing as a “gold standard” lab you can trust without QA. (And if there would be you would just use them, instead of the other lab.) Even with that ridiculously high “spot check ratio” you wouldn’t know if you are getting negative results because they are in fact negative, or because both of your labs are falling for some reason and giving you constant false negatives.
In conclusion spot checking the results with a second lab simply doesn’t work. Even if you spot check every single organ donor you would be still blind for even the most basic error cases for unacceptably long times.
On the other hand if you intermingle a control sample into every single batch that changes the game. Lets say they run the tests on batches of 10 and you make sure that a random one of those is always known to be positive. Now if something goes wrong and they don’t detect the sample you can straight away reject the whole batch of tests as faulty. And it only costs you an 11% extra over not doing any QA.
So with the “spot checking” test you can pay as much as 100% extra and still not know if the tests are having the most elementary kind of fault for hundreds and hundreds of organ donors. Or you can go with the “control sample” strategy and have a reasonably high confidence for every batch right away at much less of a cost. Yeah you can do the “spot check” audits but it is ridiculously bad at catching issues even if you spend a lot of money on it.
1: https://www.unaids.org/en/regionscountries/countries/brazil
I agree with you, also the bogus argument of "since most people are HIV free..." assumes direct testing instead of pooled testing (using modern information theoretic optimized pooled testing).
A bit of data is most informative if the entropy is 1 bit as well. A signal that is true most of the time, or a different signal that is false most of the time is less informative. Use pooled testing such that the result is true or false half of the time.
Had information theoretically justified pooled testing been applied from the start, then:
* 1) control-testing the testing contractors would have been straightforward and passing 10 control samples by chance would have a likelihood of 1 over 1024.
* 2) it would have made obvious that saving money on control-testing the contractors would hardly save any money
* 3) even in the bad scenario that control testing was skipped, the issue of contractors cheating would have surfaced much faster, since combining the pooled tests to identify which patient tests positive would constantly result in mysteries, meaning control-testing needs to be enabled, not the mathematics of pooled testing brought in doubt.
* 4) testing pharma industry hates pooled testing, as it means technological competition instead of sales growth by abusing the naive but false "common sense" that you need as many tests as patients tested.
on a side note: assuming tests with different operating point on the RoC curves (having different false positive vs false negative ratios) have different prices, do we know if the operators blatantly provided fabricated results, or if they blatantly ignored basic mathematics and thought the more expensive tests could be substituted by the cheaper ones even if intended for a different purpose?
consider a test designed for telling a patient that we diagnosed HIV, and then consider a test designed for screening an organ to be inserted into a patient.
do you think they should both use the same test? or do you think it wiser to have the diagnosis test have lower false positive rates, and the organ screening test to have lower false negative rates?
Yes, why not? You don't re-test every single one, though: you spot-check a statistically significant percentage of them. Or maybe you do check all of them, but only for a one month period every year (a month that changes every year, and isn't known to the testing lab, so they can't game the system).
Another option is to send "control samples" to the testing lab, something you know already is infected with something they should be testing for. Do this enough times, and you'll know if they're accurately reporting the bad samples.
This type of thing is the only way for anyone in any kind of organization to verify that their outsourcing is effective and they're getting the result they want.
> Why not just get rid of outsourcing then?
The problem is corruption. I don't see why you think that wouldn't plague internal operations.
Outsourced companies deal similar issues internally while also forcing you to trust their management. Internally this kind of corruption is more difficult because you have more control, and fewer people are going to cooperate. Similar to how companies can regularly use untrustworthy low level employees handle cash.
You can still get rogue employees in ether case, but an outsourcing company is like a ready made conspiracy where any corners cut automatically turns into money.
> Internally this kind of corruption is more difficult because you have more control
If we anthropomorphise the regulatory body, sure. In reality, there isn’t evidence either way. Corrupt governments handing work to the private sector is a proven efficiency booster. Meanwhile, competent governments Severn Trenting everything is textbook (on the political left).
Outsourcing and corruption isn’t limited to government agencies. Quite a lot of it is from companies to other companies or governments to company A and then from company A to company B where the subcontractors are at issue.
Outsource to 2+ contractors, use pooled testing, and use control tests to steer that percentage of tests towards those contractors that score better on the control tests. Obviously the contractor should not be allowed to know which samples are control tests.
I haven’t seen a company outsource a core competency and succeed, eg Boeing outsourcing airplane manufacturing.
How about Apple and Foxconn?
If your reaction is that Apple’s core competency is in marketing and design and not manufacturing then i will ask if the same pattern couldn’t be applied to Boeing.
Apple is higher up the descent than Boeing — but I’d argue that their lackluster iPhone 16 is precisely that they’re on the same slope.
Further context: In Brazil since we have universal health care provided by the government, generally speaking non outsourced or contractors becomes public servants.
The issue is: Public service in Brazil is expensive and is virtually impossible to fire anyone. On top of that the cost of public service has second order effects in the public balance sheet for the municipalities plus it has a huge burden in the public retirement system.
Not saying that is right or wrong, but this is very common in the Brazilian heath system.
Outsourcing isn't a problem, people don't make their own clothes. It's inadequate checks relative to the risk of the component.
How are you gonna check the organs? You can't see HIV on the organs by eye. Checking means re-testing, so might as well get rid of outsourcing.
> How are you gonna check the organs?
You don’t check the organs. You check the process by intermingling known HIV+ samples and check if they are being detected.
> Checking means re-testing, so might as well get rid of outsourcing.
Thing is you need to do QA on the testing system no matter what. Doesn’t matter if it is performed by contractors, in house staff or little grey aliens. If you are not doing QA you won’t know if the testing is done correctly or not.
In-house workers can phone it in as well.
At some point, your recursive watchers of watchers watching watchers has to have a base case of "we trust this entity" (or maybe, "you, the public, trust this entity").
Outsourcing only matters for this if it provides a break in the chain of responsibility. That is, if the person selecting the outsource provider can (successfully) say "hey, not my fault" by pointing to... some entity that whoever they answer to doesn't already trust.
> It's inadequate checks
I agree provided that "checks" isn't just the narrow sense of "verification upon receipt of the product", but also the supporting framework of "violators will get punished."
Nothing wrong with outsourcing as long as it doesn't allow the user of the third-party operation to escape legal liability for failures and fraud committed by said third party that affect the user's clients.
Shades of the UK infected blood scandal of the 1970s -- 1990s:
<https://en.wikipedia.org/wiki/Infected_blood_scandal_in_the_...>
the same thing happened in the states and France among other countries, it was a global thing
At the bottom of the Wikipedia article I'd linked are references to similar scandals in France as you note, Arkansas, Libya, Italy, and Scotland.
That’s rough cause transplants usually mean immunosuppressants which is precisely what you don’t want for hiv
Why? If you have HIV you need to be on antiretroviral drugs. They keep your viral load to undetectable levels, so your immune system does not need to fight it.
Yep, if HIV progresses to the point of AIDS, suppressing your already-suppressed immune system would be bad. But with today's treatment regimens HIV won't progress anywhere near that point. Which is borderline miraculous, really.
HIV is the virus that makes you develop (or "acquire") AIDS; AIDS is the condition that weakens and kills you. If you pump the breaks as soon as possible, HIV on its own won't have catastrophic health implications, although it's obviously better not to have it at all.
> HIV on its own won't have catastrophic health implications
Yes it does.
You can never let your blood or sexual fluids come in contact with another uninfected person and you can also never be a mother.
Your lifespan probably won't be impacted all that much.
These are two wildly different things.
That may have been true decades ago, but is no longer the case. Of course nothing is risk-free, but current drugs can get HIV viral loads down to undetectable levels, and if your drug treatment is successful, it's considered reasonably safe for you to swap fluids with others (with their knowledge of your medical history, and consent, of course), as well as become pregnant. Sexual partners should be on PrEP too, to further reduce the risk.
This isn't "living a normal life" completely, and the retrovirals have side effects and the regimen needs to be maintained, but the state of things for people with HIV is so much better than it was back in the 90s.
I don’t know why you are getting downvoted but I’m guessing that a lot of people don’t know about/understand that undetectable = untransmittable. It is generally seen as safe to have unprotected sex with someone whose viral load is suppressed to the point of being undetectable. Of course you need to believe that’s the case, informed consent is still important, and it’s probably a good idea for the negative party to be on prep, but the fact that the likelihood of transmission is so low if someone is undetectable is widely accepted in medicine and widely known in the LGBTQ+ community at this point.
Just because your condition has catastrophic consequences, particularly if not _properly_ managed, doesn't mean you have to live your life in a catastrophic way.
Pretending that should be ignored benefits no one.
Not quite, the proper course of action is that both you AND your partner take drugs to prevent transmission
Antiretrovirals have significant risks and adverse effects. Uninfected people don't take antiretrovirals unless they have been exposed to the virus. They protect against exposure instead.
The chance of both condoms and antiretroviral therapy failing to prevent transmission simultaneously is always going to be lower than the chance of either failing independently. In practice, many couples decide that the risk of transmission associated with antiretroviral therapy is low enough for them.
Yes you’re right. I was wrong. I confused it with the case where you both have HIV since they can be different strains.
Not true at all! You can absolutely get pregnant with HIV, and there are a number of steps you can take to prevent transmission to an unborn child.
Similarly, if you take antivirals to get your viral load down to undetectable levels, the risk of sexual transmission is very, very low. The risk is even lower if your partner takes PrEP as well.
You certainly need to take precautions, but people with HIV can live full, normal lives.
Normal lives is not exactly the correct term. Like any drugs, HIV medication come with their own bagage of side effects.
Let's say people with HIV can live like most people receiving treatment for a chronic disease.
The rest of your points stands.
> You can never let your blood or sexual fluids come in contact with another uninfected person and you can also never be a mother.
Completely false. Treatment is quite effective at preventing transmission in both cases.
The drugs have lifelong costs and side effects, and patients have lower life expectancy than the general population.
Massive improvement to what came before but it's still much worse than most health outcomes people take pains to avoid.
https://www.webmd.com/hiv-aids/aids-hiv-medication-side-effe...
So dumb question, but if you have HIV, does that mean you won't have transplant rejection? Or are there two different mechanisms of immunity here?
(Disclaimer: not a doctor)
AIDS is the immune deficiency-causing virus, and that begins (usually) way after an HIV infection takes place — months, years. So until then, they’d still need to take immunosuppressants.
> AIDS is the immune deficiency-causing virus
AIDS (Acquired Immune Deficiency Syndrome) the illness, whereas a HIV infection (Human Immunodeficiency Virus) is its cause.
That's what I meant but I accidentally used the term virus, thanks.
to be clear, I believe modern antiretrovirals can prevent the virus from replicating for an entire lifetime. They bring the viral load down to undetectable levels.
They're miracle drugs, but they aren't panaceas.
Hopefully they are administered before too much damage to the immune system is done.
And hopefully the treatment regimen is adhered to, because the virus can become resistant.
It is so much better to not have the virus in the first place.
Oh of course, I just meant to emphasize that it isn't HIV that causes immune system deficiency, therefore, transplant rejection can still occur.
But after AIDS sets in, you don't?
A little bit more context:
Rio de Janeiro is by far the most corrupt Brazilian state. Its hard to explain how bad it is if you are not Brazilian, but imagine that every single former state governor and many of the mayors have been sent to prison for corruption after their term ended.
So what usually happens is that someone from the public sector opens up a public bidding for some service to be done by the private sector, and usually who wins is someone who has ties with the local government.
Most of the time whoever wins the bid (usually some shell company) is going to barely offer the service, and share most of the profits with their associates in the local gov.
This is one of such cases: The private lab doing the tests is owned by the cousin of the former state secretary of health Dr.Luizinho. Its very likely that they just did not do the tests at all (yes, that how bad it is)
Just another normal day in Rio de Janeiro.
Interesting perspective on the impact of corruption across different countries. It's striking how two countries with similar levels of corruption can have vastly different outcomes in specific areas. Take Argentina as an example: while it's highly corrupt, organ transplants are remarkably well-organized under a single entity, INCUCAI [1]. You can even see crystal clear stats there.
[1] https://www.argentina.gob.ar/salud/incucai
Corruption is not a single axis, for example college entrance exams and voting in brazil are very trustworthy in my opinion.
Institutions are corrupt, not a whole country. Sure there is some level of infection between institutions but there is still a lot of a single one can do.
One thing you don't see in Brazil is traffic police or bureaucrats asking for petty bribes, something which is quite common in neighbouring countries.
Corruption is a problem for sure, but I think incompetence and lack of initiative are far worse issues in the Brazilian executive.
> voting in brazil are very trustworthy
How can a closed system that cannot be audited be considered trustworthy? After the voting happens, there's no physical proof of the vote.
Highly recommend reading this: https://dfaranha.github.io/project/evoting/
Because the supreme court judge has decreed that the voting machines are UNQUESTIONABLE. That's all there is to it. Not even our elected representatives get to doubt these things:
https://news.ycombinator.com/item?id=36543423
Fun fact: brazilians commonly express feelings of superiority towards civilized developed world nations because of these voting machines. They think americans, germans and everyone else in the world are living in the literal stone age due to their "archaic" voting processes just because it takes time to count the votes.
Brazil is way more decentralized in that way, especially health care, so health care quality will greatly change depending on your city even.
That said, organ transplants in Brazil are managed by the Federal Government (lists, etc), but the clinics and hospitals will usually be state or city made...
Brazil is pretty good at organ transplants, surprisingly.
Rio de Janeiro is corrupt, but it is far from the most corrupt in relative terms. Contrary to popular perception is not even one of the most violent.
> but imagine that every single former state governor and many of the mayors have been sent to prison for corruption after their term ended
Sounds similar to Illinois
Similarly to the Mongolian government, except that only major cases are targeted, and instead of the actual culprits, people who were just doing their jobs under them end up in prison. Case closed.
I usually direct people to watch the movies Elite Squad 1 and 2. They're entertaining and pretty much explain why Rio is so violent and so corrupt and how both things feed off each other.
Incredible movie. And, the backstory is incredible as well: https://en.wikipedia.org/wiki/Elite_Squad
I'd like to note that Brazil is not at all unique in being corrupt or even in the methods used. For example, watch HBO's The Wire and you'll find the police and politicians playing the exact same numbers game. It seems to be inherent to democracy, a side effect of reelection.
The films do a wondeful job depicting the poverty of Brazil, and the way it attracts people to organized crime. It attracts so many of them, they form a nation unto themselves. Complete with their own army, territory, laws, tribunals... It gets to the point it's a silent secession.
Not uniquely corrupt but uniquely violent (before the Ukraine invasion one in eight violent homicides happened in Brazil... not South America, Brazil).
Besides, I don't know great movies that explain the corruption and violence on each metropolis, just this one (and The Wire for Baltimore, which is by the way great television).
I'd recommend also watching the Vice piece on how Brazilian gangs are fueling violence in Paraguay. It's quite jarring to see the slang of street criminals of Rio and SP spoken across the border in what is a war like situation.
> Its hard to explain how bad it is if you are not Brazilian
It's hard to explain to most Brazilians too.
People go there expecting the worst. I don't think I've met anyone that wasn't still surprised.
Huh, as a South African, now I'm quite intrigued to visit it.
As a tourist you won't get yourself in situations like people throwing threats at you because you obeyed traffic laws.
Tangentially related, but when i lived in Rio I would always tell people I thought it was the most beautiful city in the world. Then, a visiting exec asked me: "Well, have you been to Cape Town?"
How free do people feel to speak up against corruption? Like could they go public on Twitter/X and call out the issues they see? Or would they face legal retribution or physical violence?
It really depends. Locally, factions like criminal associations and retired cops mafias (militias), who always have city councelors and mayors in their pockets, may retaliate if someone with an audience is being too annoying (see Marielle Franco's case).
Nationally, not all politicians enjoy any protection from the supreme court against critiscism, only the best connected ones and the supreme court itself. Recently, a former YouTuber who lost all his social accounts and had to self-exile to the US for some disrespectful comments against the supreme court was sentenced to 1.5 years in jail for calling the newest supreme court judge a "fatty".
Except for the supreme court itself, the average Brazilian can voice their concerns and speak up against corruption with very low chances of repercussions if they don't display wholly anti-democratic discourse, like wishing the military to execute a coup.
About the "fatty" one... This is more how richer/powerful people have more resources to sue. The case would be a clearly win for everyone who sue it.
Brazil's penal code criminalize any "Injury" and "defemation"
> Art. 139 - To defame someone, attributing to them a fact that is offensive to their reputation:
> Penalty - detention from three months to one year, and a fine.
> Art. 140 - To insult someone, offending their dignity or decency:
> Penalty - detention from one to six months, or a fine.
> a former YouTuber
Remember he also committed the crime, live, on YouTube, of advocating for the creation of a Nazi party.
Thought crime, huh.
He merely observed that the extreme left has a lot more space in politics than the extreme right. Why is it that nazism is banned while we have so many literal proud self-admitted socialists and communists in this country who not only walk this soil completely unpunished but also form organized parties, get elected, get appointed to the supreme court? The judge who held him guilty for calling him a "fatty" is the perfect example of one.
Anti-nazism laws are unconstitutional. Constitution says that "any and all" censorship of political nature is prohibited. Nazism is a political party. Therefore censorship of nazism is prohibited. It's that simple.
So why is it that nazism is literal thought crime while socialism and communism, far more harmful ideologies, are allowed to flourish with complete impunity? If they're gonna ban nazis, I demand that they also ban communists and socialists. It should be a literal thought crime to advocate for anything related to that nonsense. And any form of socialist organization should get all involved sent straight to jail.
That's the point that was made. Allowing that crap while simultaneously banning nazism is a contradiction. His only "crime" here was trying to resolve the contradiction by arguing that nazis should be allowed to organize. That's not what we really want. What we actually want is these socialists and communists in jail.
> Anti-nazism laws are unconstitutional. Constitution says that "any and all" censorship of political nature is prohibited. Nazism is a political party. Therefore censorship of nazism is prohibited. It's that simple.
There’s no censorship. You are allowed to say your mind and nobody can prevent you from doing it. Freedom to do something doesn’t imply impunity for committing crimes in the process of expressing your political beliefs.
> the extreme left
Brazil had a far-right president for four years. There’s zero far-left in mainstream politics in Brazil, unless you slide the Overton window so far to the right social democrats (such as PT) looks far-left and Bolsonaro looks like a moderate right-winger.
> There’s no censorship.
> Freedom to do something doesn’t imply impunity for committing crimes in the process of expressing your political beliefs.
Those two statements contradict each other. One can't criminalize political beliefs and simultaneously claim that there is no censorship of political beliefs.
The man had his social media presence blocked for his wrongthink. That is censorship.
> There’s zero far-left in mainstream politics in Brazil
There must be dozens of political parties with communism and socialism right in the name. Not social-democracy, not social-anything. Straight up socialist and communist parties. Why is this allowed?
And it's not just the names either, as is often claimed. They are very much socialists in their proposals and public policies. Why are these ideas allowed to spread and proliferate?
Freedom of expression is guaranteed in Brazil. In general people feel free to speak and that hasn't changed.
What has become a crime is the spread of misinformation in the form of fake news. For the most part these are still legislated fairly IMHO. But the precedent feels a bit dangerous
There are zero laws against "fake news" currently in effect in Brazil. One was proposed and Google even campaigned against it but it has yet to pass.
See the recent spat between the Brazilian supreme court and Twitter for your answer there
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Its just bizarre to me how simple this is to avoid.
Its one of the most common place tests in the world.
Yes, incredible. When HIV/AIDS emerged, dentists were among the first professionals to adopt protective measures.
I don't have more details than what's mentioned in the article, but situations like this can sometimes reflect a deeper issue within the underlying professional and organizational structures, almost as if they're "calcifying", not just negligence, but a symptom of how things are functioning beneath the surface. On the other hand, it might simply be a case of individual malpractice, though I think the latter will be rare in the context of transplants.
Rio isn't exactly known for its solid institutions or sanitary excellence.
Isn't the window period large enough for the HIV test that it could slip through that way, i.e. you get infected on Friday, die and organs get harvested/get tested on Monday (or possibly longer) but you have not been infected long enough for the test to detect it? I had to sign a waiver acknowledging this possibility when I had some dental procedure last year.
Sounds reasonable, but why would they have you sign that before having a dental procedure?
Is it in case one of the doctors or nurses infects you?
Cadaver allografts (for dental bone implants) can transfer HIV.
It is but the test isn’t fully considered accurate for the first 30 days (45-90 days to be conclusive). That’s a long window of time for the virus to spread.
Organ transplants are "ooh, shiny" headline grabbing medicine. Better healthcare to try to keep your original equipment is boring and gets dismissed as "just lucky." It's hard to prove a connection between x, y z and not needing a transplant.
Any criticism or critique of this paradigm gets hated on without anyone really listening or wondering what might motivate someone to be not crazy about our "we are borg" trends in medical care.
Everyone I've ever talked to dealing with conditions that often end in transplant knows and shares that they're big-deal, serious-business, forever-life-altering treatments that are ultimate last resorts. But for some things we simply don't have any alternatives.
And for some of those - for instance one of the super-obvious ones is alchoholism-induced cirrhosis - "don't drink so much that you kill your liver" is VERY discussed, not just considered "lucky." You might even get yourself disqualified from a transplant if you can't get it under control. Everyone would MUCH rather you not need it.
Where are you seeing "get a transplant" pushed as a shiny panacea? They aren't even new anymore... lots of newer-shinies out there.
>>> Any criticism or critique of this paradigm gets hated on without anyone really listening
I'm having a hard time following this. Could you perhaps reference some examples to illustrate what you mean here?
Sure, reducing the conditions that lead people to need transplants is a great idea, and should be done more. But I don't see how that's relevant to this discussion.
What happens if someone contracts HIV and dies over the next 2 weeks before the virus is detectable in tests. Would it propagate even in a dead body? Using an organ from this donor would cause HIV either ways and so is honestly a risk factor for US donors as well.
Maybe people with HIV just shouldn't donate blood or organs...
It's possible they didn't know they were infected.
Oh my god, why didn't anyone think of that!
Do you think people are doing it intentionally?
I wonder what HIV tests cost.
Also, if I were dying of organ failure, getting (treatable) HIV to get a transplant might be a good deal. This is not 1988. HIV is treatable today.
Note: There are 3 kinds of illness: curable, treatable, and terminal.
Curable illnesses can (generally) be cured.
Treatable illnesses will be with the patient for the rest of their life, but are treatable so the patient does not have to die from them.
Terminal illnesses kill the patient.
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For those who watch medical shows, this is somewhat reminiscent of a case of several patients who contracted rabies through organ transplants - a story that was portrayed in Scrubs season 5 episode 20, "My Lunch".
> laboratory responsible for conducting tests on donated organs had been suspended after the organs from two donors were transplanted into six people
So they missed the same thing twice, presumably at around the same time.
> and all stored organs from donors are being tested back to December 2023 when the lab was hired
I had the impression that there was a very short time limit, like maybe as long as a couple days. Is this just wrong, or does it only apply to same things?