Compassionately Logical: Part II

This is the second part to Compassionately Logical: Part I.

Regulated kidney trade in Iran

In all developed countries, most living kidney donors are family members or spouses of the recipient. Commercial transactions involving the trade of human kidneys are strictly illegal and there is no compensation of any kind to the donor. Hence, it is extremely rare to find altruistic unrelated kidney donors apart from those with very strong unconventional religious convictions like the Jesus Christians in Australia. Because the pool of potential donors is effectively restricted, there are long lists of ESRF patients waiting for an available kidney. In America, about 3500 people on the waiting list die before receiving a kidney while only 16500 kidney transplants were performed in 2005. In a system which only allows kidneys from cadavers and related living donors, it is quite unlikely that the number of available kidneys will increase significantly to cover the shortfall.

In contrast, in Iran, there is no waiting list for kidneys. This is because most transplanted kidneys are taken from living donors, the majority of whom are unrelated to the recipient. Iran has a regulated system in which people can trade their kidneys - the recipient and the regulatory agency compensate the donor for his/her kidneys. According to this article,

"There are no private agencies or middlemen involved in the process of organ donation in Iran and all volunteer donors present themselves to the National Association for the Support of ESRD Patients. The sale of organs is legally and ideologically forbidden, but the concept of compensated donation is accepted."

In Iran, the middleman is a non-profit charitable organization, called the Dialysis and Transplant Patients Association (DATPA), which refers the donor to state hospitals where experts screen the donor physically and psychologically to ensure that the health and welfare of the donor is not compromised by the operation. It arranges for potential sellers to meet potential buyers. The donor receives a sum of US$1200 from the DATPA as well as health insurance coverage from the government for donating his/her kidney. The donor also receives a monetary 'gift' from the recipient, the quantum of which is agreed on by the two transacting parties. For more details, please see this article on the Iranian model of paid and regulated living-unrelated kidney donation.

For emphasis, I like to repeat this: there is no middleman, no risk of getting hepatitis from the transplanted kidney or surgical complications (unlike in India where the medical screening is dodgy), no coercion, etc. The donors are counselled about the risk and assessed for suitability in terms of physical and psychological health. I should also mention that both the donor and the recipient have to Iranian nationals. For foreign patients, the donor has to have the same nationality as the recipient.

As for concerns that the scheme might exploit the poor, I quote from the article:

"All transplant candidates who are poor receive renal transplantation. The elimination of renal transplant waiting lists means that all patients with ESRD, either rich or poor, have equal access to renal transplant facilities; otherwise, many poor patients would remain on the renal transplant waiting list. The main reason for this equal access is the active role of charitable organizations that pay for many expenses of renal transplantation that the poor patients cannot afford. One of the arguments against paid kidney donation is that the kidney donors are almost poor and illiterate, whereas the majority of recipients are educated and wealthy. We previously conducted a study on 500 renal transplant recipients and their living-unrelated donors to determine which socioeconomic classes are receiving transplants more from paid kidney donors (16). All of these donors and recipients were grouped according to their level of education, which showed no significant differences. In this study, 6.0% of living-unrelated donors were illiterate, 24.4% had elementary school education, 63.3% had a high school education, and 6.3% had university training. Corresponding levels in their 500 recipients were 18.0, 20.0, 50.8, and 11.2%, respectively. Then they were grouped according to whether they were poor, rich, or middle class. The results showed that 84% of paid kidney donors were poor and 16% were middle class, and of their recipients, 50.4% were poor, 36.2% were middle class, and 13.4% were rich. So >50% of kidneys from paid donors were transplanted into patients from poor socioeconomic class. This finding is a clue against commercialism in the Iranian model renal transplant program."

Of course, the Iranian model is not without its problems. Again, I quote:

"Because the amount of governmental donor award (approximately $1200 USD) is not enough to satisfy the majority of kidney donors, recipients provide rewarding gifts to donors. If the recipient is poor, then the rewarding gift is provided by charitable organizations. This also results in directed paid kidney donation, meaning that the transplant candidate and the volunteering kidney donor meet each other in a DATPA meeting for arrangement of rewarded gifting to be paid to the donor after transplantation. Providing sufficient financial incentives and some social benefits to each living-unrelated donor by the government will eliminate rewarding gifts and will make the Iranian model a nondirected paid kidney donation program whereby the donors and the recipients will not see and know each other at least before transplantation. All transactions for financial incentives will be carried out by organ procurement organizations (OPO). The OPO will receive all governmental donor award budgets as well as all charitable donations. The donor will donate a kidney to the OPO and will receive all defined financial incentives from the OPO. Because of lack of administrative expertise in health authorities, this approach has not yet been tested in the Iranian kidney donation model.

Unfortunately, the financial incentives to kidney donors in the Iranian model neither has enough life-changing potential nor has enough long-term compensatory effect, resulting in long-term dissatisfaction of some donors. However, providing adequate financial incentives to kidney donors and awarding some social benefits to them will eliminate almost all long-term dissatisfaction. Some opponents have sensationalized that the majority of Iranian paid kidney donors have been poor and have remained poor after kidney donation. As mentioned, in the Iranian model of paid kidney donation, not only the majority of donors (84%) but also the majority of transplant recipients (50.4%) also are from poor socioeconomic class. This national program is not adopted to upgrade the socioeconomic class of kidney donors and is very different from commercial transplants that are carried out in other countries."

Kidney transplant in Singapore

In Singapore, like most developed countries in which only deceased and living-related donors are allowed, there is a long waiting list and the average waiting time for kidney is roughly 7 years, despite the 'opt-out' system (as legislated in The Human Organ Transplant Act or HOTA) currently in place. We should also bear in mind that, as mentioned before, the longer the patient spends on dialysis, the lower the effectiveness of the renal transplant. The Ministry of Health acknowledges here that donor availability is a problem. Actually, what it is implicitly saying is that we don't have enough living donors.

Possible paid kidney transplant system in Singapore

I could envisage a system in Singapore similar (but not identical) to the Iran model in which living-unrelated kidney donors are paid for donating their kidneys. No point in reinventing the wheel. Such a system would have the following features:

1. A national regulatory body which screens potential donors physically and psychologically to assess their suitability for donating their kidneys. Potential donors are counselled about the risks.
   
2. Donors are paid a fixed sum by the government, say $20000, as compensation for the risk and loss of personal time. The exact quantum can be worked out later. This money would come from the patient or from charitable organizations. If the patient cannot afford the full amount, then we can have in place some kind of financial assistance to help him/her pay. The idea is that everyone pays the same amount for a kidney so that the wealthy have no advantage over the poor. There is no need for the recipient to know whom the donor is.
   
3. Priority in receiving the transplant is determined by the regulator body based on medical condition.
   
4. The donor receives free health insurance coverage/additional medical benefits from the government in recognition of his contribution. The national regulatory body should maintain a high level of post-operative care and the health of the donor is to be monitored over 10 years. Again, the duration of post-surgery monitoring is not set in stone.
   
5. The patient and the donor have to be Singaporeans.
   

I believe if we have such a system in place, donor availability will increase tremendously and the waiting list in Singapore will be eliminated.

Compassionately Logical: Part I

There are a couple of lively debates over organ trading, as suggested by an Assoc. Prof. Lee Wei Ling from the National Neuroscience Institute in a letter to the Straits Times forum, at the Kway Teow Man and nofearSingapore, where the majority of opinions have been against the sale of human organs. There seems to be some sort of instinctive revulsion towards the idea of trading human organs. The idea of regulated organ trade is fairly interesting and since I know next to nothing about the issue, so I decided to dig a little deeper. It turns out that there has been a flurry of discussion over the regulated trade of human organs.

Organ tranplant is a fairly complex issue so I decided to just look into kidney transplant since there seems to be much more information on it in general; also, there is some information on the regulated kidney trade in Iran which has been going on for some years. The following articles are quite informative, especially no. 7 to 10 which describe how the 'trade' in kidney transplants is managed in Iran.

1. Iran's market in human organs which was published on Nov 16 in the US print edition of The Economist. Sorry, it is available online only to subscribers of Economist.com and I don't want to violate copyrights on this website.
   
2. Organ transplant? which was also published in the same issue of The Economist.
3. Call to allow body organ selling, published in BBC online.
   
4. Experts warn against organ trade, published in BBC online.
5. What is a kidney worth? published in The Christian Science Monitor.
   
6. Kidney market, anyone? by Tan Hui Leng, published on Nov 24 in Today.
   
7. An organ is no different from a life-saving drug by Assoc. Prof. Lee Wei Ling, published on Feb 6 in the Straits Times forum. You can find the letter in the post by the Kway Teow Man.
   
8. Renal transplantation from living related and unrelated donors by I.Fazel ,MD, FACS.
9. Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation, by Ahad J. Ghods, and Shekoufeh Savaj, published in Clin J Am Soc Nephrol 1: 1136-1145, 2006.
10. About kidney transplants in Iran, by Firooz Fassihi M.D.
11. Iran's desperate kidney traders, by Nima Sarvestani, published in BBC online.
12. Iran kidney sale, published in BBC online.
13. Organ sales 'thriving' in China, published in BBC online.
14. Flesh trade, by Stephen J. Dubner and Steven D. Levitt, published in the N.Y.Times.
    
15. Living kidney donor FAQ from the University of Maryland Medical Center.
    
16. Living donor kidney donation from the University of Pittsburgh Medical Center.
    
17. Living with one kidney from the National Kidney Foundation, Inc in the United States of America.
18. Kidney transplant from Medline Plus.
    

With all due respect to Assoc. Prof. Lee, I will like to state that she did a rather poor job of selling the case for regulated human organ trade. Then again, the thrust of her letter was not that why we should have a regulated human organ trade but how we should approach the issue ("compassionately logical" in her own words).

What is a kidney?

It's more than an ingredient in kway chap, lah. According to the Wikipedia article on the kidneys,

In anatomy, the kidneys are bean-shaped excretory organs in vertebrates. Part of the urinary system, the kidneys filter wastes (such as urea) from the blood and excrete them, along with water, as urine. The medical field that studies the kidneys and diseases affecting the kidney is called nephrology, from the Ancient Greek name for kidney; the adjective meaning "kidney-related" is renal, from Latin.

In humans, the kidneys are located in the posterior part of the abdomen. There is one on each side of the spine; the right kidney sits just below the liver, the left below the diaphragm and adjacent to the spleen. Above each kidney is an adrenal gland (also called the suprarenal gland). The asymmetry within the abdominal cavity caused by the liver results in the right kidney being slightly lower than the left one.

...

In order not to bore people with the technical detail, our kidneys are our body's built-in sewage treatment plants which clean our blood, remove its waste and send it off as urine. In our daily lives, we produce a fairly large amount of metabolic waste and they are removed from our blood by our kidneys. Generally, the greater your muscle mass and the more protein you eat, the harder your kidneys have to work to remove the nitrogeneous waste.

Most humans have two kidneys (although it should be noted that 1 in 750 individuals is born with only one) which give us a high level of redundancy. Furthermore, modern humans generally have a far more sedentary lifestyle and consume less protein compared to our hunter-gatherer ancestors, which increases the level of redundancy. It must be noted that healthy kidneys can handle a very high level of nitrogeneous waste over prolonged periods; drug-free bodybuilders have a far higher level of muscle mass, exercise more and consume much more protein but don't have a higher incidence of renal failure than the general population. Also, there are no restrictions on healthy individuals with only one kidney from doing vigorous physical sports although they are usually advised not to take part in contact sports like rugby, football, boxing, etc since there is a chance that the kidney might get physically injured. They are more vulnerable to physical injury to the kidney since the one kidney usually grows bigger to deal with its increased workload.

On the other hand, if we are on medication - a benefit of modern civilization - our kidneys have to work harder to remove it from our blood and that is a problem that our hunter-gatherer ancestors didn't have. Having two kidneys in this case is an advantage in case you ingest something you're not suppose to. For example, in the rare case, some individuals can get renal failure from just ingesting aspirin.

Renal failure

There are many causes of renal failure. I am not a medical doctor and have the vaguest knowledge of nephrology. But in general, from what I know, renal failure can result from problems in your blood circulation (like getting hypotension), damage to your kidneys (like ingesting some kind of toxins or medication that you are allergic to) and/or problems with your urinary tract (e.g. kidney stones). If you are interested, see http://en.wikipedia.org/wiki/Renal_failure.

There are several stages of renal failure, which progresses with the level of loss of function of your kidneys and increasing use of hemodialysis (aka dialysis). End-Stage Renal Failure (ESRF) is the term doctors use to mean that the kidneys are gone-case. At that stage, the patient has to be hooked up to a dialysis machine until he/she has a renal transplant. Hemodialysis is only a stop-gap measure and is also expensive. Very expensive if you have to keep having it non-stop. Once the patient has ESRF, he/she is put on a waiting list for renal transplant until he/she finds a suitable donor or dies. There are others who do not have ESRF but can receive a renal transplant provided that they have a willing donor (who is usually a family member). It should be noted that not everyone with ESRF gets to be on the waiting list. There are age limits and some health restrictions. Basically, the qualifying condition is that the transplant procedure will not endanger you and getting the transplant will significantly improve your chances of survival. The medical authorities do not see any point in giving a kidney to a 90 year-old individual with ESRF and terminal lung cancer.

Kidney transplant

There's a relevant Wikipedia article here. I am not going to reproduce the article here in any form but will mention a few points that I think are rather salient.

1. Basically, there are two types of kidney donors - living and cadavers. In any case, donors and recipients are screened for compatibility before the operation. Studies seem to indicate that "overall, recipients of kidneys from live donors do exceedingly well in comparison to deceased donors".
   
2. Transplant patients should be under 69 and have no other other conditions apart from kidney disease. Obviously, the recipient and the donor have to be evaluated to ensure that they are fit for surgery.
   
3. "Some studies seem to suggest that the longer a patient is on dialysis before the transplant, the less time the kidney will last. It is not clear why this occurs, but it underscores the need for rapid referral to a transplant program. Ideally, a kidney transplant should take place before the patient starts on dialysis (pre-emptive.)"
4. "Recent studies have indicated that kidney transplantation is a life-extending procedure. The typical patient will live 10-15 years longer with a kidney transplant than if they stay on dialysis. The years of life gained is greater for younger patients, but even 75 year-olds (the oldest group for which there is data) gain an average of 4 years of life with a kidney transplant. People generally have more energy, a less restricted diet, and fewer complications with a kidney transplant than if they stay on dialysis."
5. Acute rejection occurs in 10% to 25% of people after transplant during the first 60 days. Rejection does not mean loss of the organ, but may require additional treatment.
   
6. Recipients have to take immunosuppressants for the rest of their lives to prevent rejection, unless the kidney is from a genetic twin (or clone if you've watched the movie The Island).
   

From the University of Maryland Medical Center's FAQ, I quote:

Death from kidney donation is extremely rare (about 3 in 10,000). Donating a kidney does not change your life expectancy nor does it increase your chance of kidney failure. The health effects of kidney donation have been and continue to be carefully studied by several research groups in the United States. This research has shown that kidney donation does not appear to put donors at any increased risk for future health problems.

Illegal kidney trade in India

Illegal kidney trade is a thriving unregulated business in India. Kidney transplants from living donors are illegal if they involve any kind of commercial transactions but not much has been done by the authorities. Kidneys are mostly obtained from poor people, who are usually impoverished rural villagers and paid a sum of money, and then transplanted into rich recipients. The transaction usually involves a middleman and the entire business is carried out with the connivance of doctors in India. There is minimal or no post-operative care for the donors and some of them seem to suffer from health problems following the operation but there has been no actual study on the extent of the problem. Most of the recipients are actually locals although India is regarded as an international centre for kidney trade. Many foreigners in need of renal transplant go to India to get their kidneys.

There are several factors contributing to the growth of the illegal kidney business in India. Firstly, dialysis is expensive and the country does not have enough dialysis facilities. It is much cheaper to get a kidney transplant than go on dialysis. Secondly, enforcement is weak and the punishment for selling an organ is rather light; it is punishable by up to seven years in prison and provides a fine of Rupees 10,000, about 300 U.S. dollars. Also, there is a loophole in the law that allows donors not related to the patient to donate in extreme circumstances on "compassionate" grounds. Thirdly, there is a ready supply of of willing sellers from the impoverished rural areas. Fourthly, the supply of kidneys from cadavers is too low and the country lacks the medical expertise to perform cadaveric kidney transplants. There is no law regulating the harvesting of kidneys from brain-dead patients which further restricts the supply of kidneys from deceased donors. Fifthly, kidney transplants have a higher rate of success given the availability of more effective immunosuppressants in recent years.

For further information, see:

1. Nepal's trade of doom.
2. India Kidney trade.
3. India: A Pound of Flesh. Selling kidneys to survive.
   

Playing with the big boys

My family just had dinner with my uncle and his family and I had a nice chat with him. It has been a good year for him. My uncle work for a GLC that builds oil rigs in Singapore. Given the spike in oil prices over the last year, the shipbuilding sector has been extremely busy. According to him, the orders for oil rigs are filled all the way to 2010 and labour is extremely tight with overtime being the norm now. Hence, wages are rising very fast in the shipbuilding industry. According to him, most people in the company expect a 6-month bonus this year... at least. To control the labour costs, his company has brought in a large number of foreign workers from China.

It is actually not at all difficult to bring in workers from overseas and actually a lot cheaper. One may ask, aren't there levies and quotas to control the number of foreign workers a company may have? Actually, no. It is not at all difficult to circumvent these rules. You see, although there are quotas associated with work and employment permits, a company actually has the right to bring in as many workers as it wants provided that they are on training permits. This is how it works. Firstly, the parent company must own 100 percent of its overseas branch. In my uncle's case, its owns shipyards in China. MOM allows Singapore companies to bring in workers from their overseas operations for 'training' in Singapore for up to two years. There is no quota and no levy although one can easily imagine the sort of training they really do. Ultra-realistic OJT, I suppose. When I asked my uncle if MOM knew anything about this, his response was something about the downward motion of skinfolds over one of the ocular organs.

According to my uncle, his industry is not the only industry that exploits this loophole. It is very well-known, at least to him, that major companies, the big boys, in the electronics, the IT and the hotel industries with overseas operations also have been doing that for some time even before the current economic boom. I'll leave it to the interested reader to guess whom the 'big boys' are and what their relation to the powers-that-be is. Indeed, one can just go to the electronics factories in Jurong and count the percentage of locals coming out of the gates of the factories or check out which major restaurants employ unusually high percentages of nonlocals. Small-scale companies without overseas operations are disadvantaged and have difficulty competing in terms of labour cost since they have to play strictly by the rules. No wonder the SME's in Singapore complain about being disadvantaged.

On a totally unrelated note, there was this enlightening and sympathetic response from MOM in the Zaobao today, in response to a letter from a Mr Lai, reassuring the readers that the authorities are closely monitoring the number of foreign workers in Singapore. Since Zaobao's online archive goes back only one week, I'll reproduce the MOM letter here for future reference with English translation in paratheses.

谨答复《联合早报·交流站》于12月22日刊登的黎少坤读者投函《我给外劳取代了》：

对黎先生的遭遇，我们感到非常遗憾。新加坡劳动力发展局将会同黎先生联系，帮助他寻找工作。

(With regards to Mr Lai's misfortune, we express our utmost sympathy. MOM will get in touch with him to provide him assistance in seeking employment.)

外来劳工可以增加新加坡的竞争力，也可以壮大我们的劳工队伍，维持我们的经济发展。他们也为新加坡人制造更多工作机会。

(Foreign labour can increase Singapore's competitiveness and can also augment our labour force and thus maintain our economic prosperity. They also help to increase the employment opportunities for Singaporeans.)

去年首九个月，我们增添了12万4500份新工作，这是自有纪录以来的最大增幅，其中有大约一半新工作是由国人获得。

(For the first 9 months of last year, Singapore added 124,500 jobs, which was the greatest absolute increase ever recorded. Half of the jobs went to Singaporeans.)

人力部一直密切注意外劳人数，也规定公司必须聘请足够的本地人后，才可以雇用S Pass或者工作准证的持有者。在必要的时候，我们也会调整劳工税。为了反映目前的经济状况，从今年1月1日起，人力部已经把熟练客工的劳工税从100元提高到150元。

(MOM has always closely monitored the size of the foreign labour population. It has required companies to hire enough locals before it can employ foreign workers on the S Pass or other work permits. When the need arises, MOM will adjust the levy. In keeping up with the current economic situation, from 1 Jan 2007, MOM has increased the levy on skilled workers from $100 to $150.)

我们了解黎先生的担忧，它其实反映了全球化的挑战，是全球许多低薪工人共同面对的问题。我们会继续为国人提供培训和协助他们寻找工作。其他政府措施如就业奖励计划，也可以让低薪工人从国家的经济增长中获益。

(We sympathise with Mr Lai's anxieties. They reflect the challenges of globalisation and are ubiquitous to low-income workers. We will continue to provide job-matching services and help them to find jobs. Other measures like the progress package can also allow low-income workers to reap the benefits of Singapore's economic growth.)

人力部常任秘书复

企业公关处长

陈丽娟代签

Tethering Students to Their States

Taken from Tethering Students to Their States:

New state scholarship programs proposed in Indiana and Wisconsin would offer funds to students attending in-state institutions, with strings attached — or, as the man behind the Wisconsin proposal puts it, “tethers.”

“If we can’t lure them here, let’s tether them here,” said Mark O’Connell, executive director of the Wisconsin Counties Association, a lobbying organization, and a member of the Commission on Enhancing the Mission of the Wisconsin Colleges, a group created to advise the network of 13 two-year colleges in the state.The commission, appointed by the chancellor of the University of Wisconsin Colleges in August, submitted a report late last month calling for an investment in new scholarships pegged to residency requirements post-graduation. “If we can’t lure people to our state, smart, young people, let’s give them education and then require them to stay here a certain number of years,” O’Connell said.

...

For those who do not know, similar schemes exists in Singapore. I have explained the working of such schemes here and also explained why it is a bad idea. The basic idea is that the government pays for some people's university education in return for the condition that they stay and work for a few years. In Singapore's case, the government offers subsidised or fully-sponsored university education to international students in return for a bond which obliges them to stay for 3 to 6 years after graduation in Singapore.

It's suppy-side economics in its purest form.

Singaporean come first (or so they say)

Taken from the CNA article Health and education ministries reviewing fees for PRs and foreigners.

SINGAPORE: Singapore citizens will always come first, before Permanent Residents and non-citizens, says Prime Minister Lee Hsien Loong.

That is why the health and education ministries are now working on changes to reduce fee subsidies for non-citizens, so that foreigners do not enjoy the same benefits as Singaporeans.

The next offset package for the GST increase will be for Singaporeans only, just like the Progress Package earlier this year, said Prime Minister Lee.

This is because the Government's responsibility is to Singaporeans first, although Permanent Residents and foreign workers will remain priorities.

"While we have non-citizens here, citizens always come first. We have to treat them as the best, we have to treat visitors well too but citizens have to be treated better," Mr Lee said.

"Right now, PRs enjoy the same subsidies as Singaporeans for education and healthcare, and in fact in healthcare, foreign workers also receive subsidised treatment. I think we should make a clear difference – PRs should pay more than Singaporeans but less than other foreigners, there is a distinction.

"If you are not a PR and not a citizen, you should be given good treatment but we will not give you special privileges."

For education, Mr Lee said there are plans to charge non-citizens more, but not to set fees so high that foreign students will not come.

While for healthcare, foreign workers will have to bear the full costs of their medical bills.

Halimah Yacob, Chairman of the GPC for Health, said that employers of foreign workers should do a proper costing to cover their full healthcare need so that Singaporeans would not end up paying for them. She also hopes that employers will not ignore the needs of these foreign workers.

"We got feedback from many Singaporeans and even from my own constituents that since everything's equal for Singaporeans, foreigners and PRs, what's so special about being Singaporean? To some extent, short of being nationalistic, PM's message of 'citizens first' is well overdue. It'll be much appreciated among Singaporeans who are wondering what's in it for me holding that red passport," said Zaqy Mohamad, MP of Hong Kah GRC.

More details about the review will be announced by the respective ministries over the next few months.

Fox says it's about bloody time.

If Singapore's hospitals and schools are as world-class as the government claims, then foreigners should still flock to them even when the rates are lowered for them. If local universities cannot attract enough foreign students, so what? It probably means that they are providing an overpriced service that only the locals can buy (with financial support from the state of course). In any case, why should Singapore subsidise a foreigner to get his or her undergraduate degree in Singapore? In the US, in any state, if a state-funded public university offers subsidised tuition rates to nonlocals, the governor and the state representatives will get lynched publicly.

On the other hand, the cost of medical care should not be made prohibitively expensive. If affordable healthcare is not made accessible to foreign workers, some of them may be skimp on that. Think SARS, TB, dengue, malaria, etc. Do people living in Singapore really want foreigners with these diseases to go untreated and mingle with them? One possible solution is to make it mandatory for employers to buy medical insurance and provide full healthcare coverage for their foreign workers.

Let's wait and see...