It’s 2024, and people are still dying from ... consumption.

This ancient disease, known today as tuberculosis or TB, has plagued humanity for thousands of years, and as recently as a few hundred years ago, was thought to be responsible for some 25 percent of all deaths in Europe and North America.

Today, TB is both preventable and treatable — there’s a century-old vaccine, effective antibiotics, and known behavioral and sanitation safeguards that disrupt transmission. Yet in 2022, more than 10 million people globally still fell ill from TB and 1.3 million died, making it the second deadliest infectious disease that year. (More people die from TB generally, but Covid-19 temporarily outpaced it.) More than 80 percent of those TB cases and deaths occur in low- and middle-income countries.

That’s largely because people in those countries are more likely to suffer from contributing risk factors to TB, such as malnourishment and HIV.

But beyond those factors, when it comes to preventing illness and death in these regions, physicians, researchers, and public health officials say that the available vaccine and treatments don’t do enough: The vaccine is given to infants and only offers protection in the first few years of life, leaving large swaths of people at risk, while antibiotic treatments take months to cure the disease.

“TB is a disease of poverty,” explained Helen McShane, professor of vaccinology at the University of Oxford, where she and her team are developing a new TB vaccine among other TB research. “There have been decades of neglect where there was no funding for new drugs or new vaccines for TB.”

But for the first time, promising new vaccines are now in the pipeline and may help prevent TB in adolescents and adults who currently have no such protection. These vaccines might also be more effective than what we have right now. Several are undergoing phase 3 trials — the last step before vaccine makers can apply to international and national agencies for approval.

“It is excellent news,” said Matteo Zignol, unit head of the WHO’s Global Tuberculosis Programme. The success of the first wave of vaccines has helped usher in more support and funding to the field, but many researchers say we will need more than just a few effective vaccines. “We all wish [the M72/AS01E vaccine trial] is going to be a successful trial, but in any case, this is going to be like a first generation sort of new vaccine, and we really need more candidates to be able to help the epidemic.”

It’ll likely still take years for the vaccines to be rolled out, but if approved, the new vaccines have the potential to save hundreds of thousands of lives, making an enormous dent in a disease that has killed humans for millennia.

Why do we need another TB vaccine?

One of the strange things about tuberculosis is that having the bacterium that causes TB doesn’t mean you have the disease. In a 2016 paper published in PLOS Medicine, researchers estimated that nearly 25 percent of the world’s population has a latent TB infection. For most people, though, the bacteria remain dormant and never go on to cause disease.

Basic preventative measures — such as improving sanitation, ensuring proper ventilation in hospitals and laboratories, and proactively identifying and treating high-risk patients — helped greatly reduce TB cases in developed countries like the US, where there were around 8,000 TB cases reported in 2022. Many lower-income countries, unfortunately, still have underdeveloped public health systems and lack the resources to implement the multipronged approach necessary to stamp out TB. That is where vaccination can be a critical tool.

The world’s first and only available TB vaccine, the Bacille Calmette-Guérin (BCG) vaccine, was created in 1921. Given the low burden of TB in the US, BCG is not routinely given to infants, but it is commonly used in many other countries. In Africa and Southeast Asia — the regions with the highest TB burden — 80 and 91 percent of 1-year-olds received the BCG vaccine in 2022, respectively, according to estimates by the WHO.

The BCG vaccine is considered safe with rare side effects, but it’s not very effective. One meta-analysis of 26 studies reported that when the BCG vaccine was given during infancy, it was 37 percent effective against all forms of TB during the first five years of life, but did not offer protection among adolescents and adults.

The way TB infects someone also plays a role in how contagious the disease can be and limits the vaccine’s ability to prevent disease. Usually, TB infects the lungs — that’s pulmonary TB. But Mycobacterium tuberculosis can infect the liver, bones, spinal cord, brain, urinary tract, bladder, kidneys, and even the intestines. When TB infects organs other than the lungs, it’s called extrapulmonary TB. Individuals with extrapulmonary disease don’t usually infect others, while those with TB in their lungs can more easily spread the bacterium to others by breathing, coughing, or sneezing.

Pulmonary infections account for the majority of TB morbidity and mortality. Exact percentages vary by country, but globally around 63 percent of all TB cases were pulmonary in 2021, according to the WHO. BCG vaccine efficacy against pulmonary TB infections still remains a bit of a mystery as studies have reported efficacy rates ranging from 0 to 80 percent and efficacy tends to be lowest in high-burden countries close to the equator.

Researchers are not quite sure why this is. One theory is that those who live closer to the equator are more likely to be exposed to non-tuberculous mycobacteria, which are similar to the pathogen that causes TB. This exposure confers preexisting immunity which may actually hinder the BCG vaccine from doing its job, McShane said.

All in all, researchers estimate that the BCG vaccine prevents only 5 percent of all vaccine-preventable deaths due to TB. For comparison, vaccines for measles, smallpox, and polio are 93, 95, and 90 percent effective in preventing disease, respectively.

So why now? What can a new TB vaccine actually accomplish?

Despite the limitations of the BCG vaccine, no new vaccine candidates have emerged in the past 100 years. M. tuberculosis is notoriously difficult to make a vaccine for because the bacterium has an adept ability to evade the human immune system. As Vox’s Dylan Matthews reported last year, “TB is a hard disease to vaccinate against. While most vaccines target viruses, TB is a bacterium, and one with a strange lifecycle.”

Economic and political factors play a role as well. After many high-income countries made huge strides in reducing TB in the late 1990s and early 2000s, they allocated few resources to further research and development of new vaccines and treatments, focusing instead on other health threats such as cancer and cardiovascular disease. TB fell into the category of neglected diseases.

McShane recalled when her team conducted the first trials of a new generation TB vaccine in 2002. “At the time, there were about 50 candidate vaccines being tested for malaria and about 50 for HIV,” she said. “Of course, for both of those pathogens, there is a Western market. There is no Western market for a TB vaccine.”

Since then, however, there have been renewed efforts to eradicate TB. The emergence of drug-resistant TB has threatened to reverse what global gains against TB have been made and may even cause a TB resurgence in the US and other low-burden countries, spurring more attention and funding to the disease. The Global Fund and the Stop TB Partnership have also launched major advocacy campaigns to bring more attention to the epidemic.

Additionally, in 2016, the World Health Organization set a goal to end the TB epidemic by 2030. The US government has also ramped up investments in global TB eradication efforts. In the 2023 fiscal year, the US contributed more than $400 million to the cause, nearly double its total investments for global TB in fiscal year 2013.

As of last year, there are 16 new TB vaccine candidates in development, four of which are in phase 3 clinical trials — which, if successful, would likely be the last phase of trials before FDA or WHO approval. Some vaccines aim to replace the BCG vaccine altogether while other candidates will serve as boosters to the BCG vaccine among adolescents and adults, McShane explained.

One vaccine, M72/AS01E, seems to be the most promising candidate, buoyed by support and funding from the Bill and Melinda Gates Foundation. In a phase 2B clinical trial conducted in South Africa, Kenya, and Zambia, more than 3,500 adults with latent TB were randomly assigned to receive either two doses of the M72/AS01E vaccine or a placebo. Initial vaccine efficacy was 54 percent. Three years later, a follow-up analysis revealed that the vaccine had prevented active TB cases in 49.7 percent of people who received the vaccine.

Most other TB vaccine candidates have demonstrated similar efficacy rates. “It’s unlikely that we’re going to get a vaccine against tuberculosis that is 100 percent effective anytime soon,” McShane said.

But even a TB vaccine with low efficacy can have profound global implications. If the M72/AS01E vaccine demonstrates safety and efficacy in the ongoing phase 3 trial, then for the first time, the world could prevent at least a good portion of infections among adolescents and adults.

“One of the big issues is that even if we’ll have a vaccine, it’ll be a game changer, but the effectiveness is around 50 percent. So it’s not one of the best, but it is something,” said Eliud Wandwalo, head of TB at the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Given the relatively low efficacy rates, these new TB vaccines are not a silver bullet for eradicating TB globally. For most of the world, improvements in sanitation, infrastructure, and medication are also urgently needed. Currently, it takes six months of ongoing therapy to cure TB, and as drug-resistant strains of TB become more common, existing antibiotics will become less and less useful. The vaccine will be just one of the tools in the toolbox, Wandwalo said.

“If you look at the trajectory and projections, if we continue the same pace with the same tools, we’ll be ending TB in the next 180 years,” he said. “It’s a dire projection. But I think with a vaccine, we are likely to be able to end TB in our lifetime.”

Is Israel a “settler colonial” state?

That charge has been the subject of fierce debate in recent months amid the continuing Israeli assault on Gaza after the October 7 attacks by Hamas.

Colonialism is a system in which one people dominates another and uses the subjugated group’s resources for its own benefit (the British Raj in India is a classic example). Colonial projects take many forms, but Israel is accused of being the result of a specific variety: settler colonialism.

According to the Cornell Law School Legal Information Institute, settler colonialism has “an additional criterion that is the complete destruction and replacement of indigenous people and their cultures by the settler’s own in order to establish themselves as the rightful inhabitants.”

Settler colonialism does not have a definition under international humanitarian law (unlike many other terms used during this latest war), although Article 49 of the Geneva Convention prohibits certain actions often associated with that term; it is instead a concept that historians use to describe the system of replacing an existing population with a new one through land theft and exploitation, which is enabled by occupation, apartheid, forced assimilation, or genocide.

Historians often apply the term to the projects that founded the United States, Canada, South Africa, and others.

Within that cohort, there are scholars who apply the term to Israel’s founding, too. The argument begins with the 30-year period during which the British Empire controlled historic Palestine and facilitated the mass migration of Jews, particularly those persecuted in Europe before the Holocaust and in the wake of it. That migration, they argue, displaced the existing Arab population and launched a conflict that continues to this day.

But critics of the argument view accusing Israel of settler colonialism as a distortion of the term, in large part because of Judaism’s deep historical ties to present-day Israel. Many Jewish people who migrated from around the world and became citizens of Israel use the word “return” to describe making their home there.

The debate has echoed from college campuses to the halls of Congress. In the United States, “colonialism” is, at times, viewed as a popular buzzword used to vilify the Jewish state and a means of casting Jewish refugees as agents of empire. Among pro-Palestinian activists and in many formerly colonized communities, the term is a historical prism linking much of the Global South and through which the Palestinian struggle can be understood.

The argument might seem academic. But it is important for understanding pro-Palestinian groups’ grievances with the international community — for failing to prevent Israel from engaging in what they view as an established settler colonial pattern of eliminating a native population through expulsion and genocide to annex Palestinian land.

Palestine’s short but critical history as a British colony, briefly explained

Both the United States and Canada, widely viewed by historians as states founded as settler colonial projects, relied heavily on British patronage. Israel’s foundations are similar, some scholars argue.

In 1917, the British colonial period, or British Mandate, began in historic Palestine. Zionism, the ideology that Jews are both a religious group and nation whose spiritual homeland is Israel, was extant for decades before then, driven in large part by violent antisemitism in Europe.

Daily Express/Hulton Archive/Getty Images

But that year, British Foreign Secretary Arthur James Balfour wrote what he considered a declaration of sympathy with the aspirations of Zionism.

“His Majesty’s Government view with favour the establishment in Palestine of a national home for the Jewish people,” he wrote in what came to be known as the Balfour Declaration. The declaration also stated, “nothing shall be done which may prejudice the civil and religious rights of existing non-Jewish communities in Palestine” — though, as my colleague Nicole Narea wrote, there was no specification of what those protections would be or who they would apply to.

The letter was a powerful endorsement of the establishment of a Jewish home where the biblical kingdoms of David and Solomon once were. Priya Satia, a historian of the British Empire and professor at Stanford University, said it also marked another British foray into colonial enterprise.

“You’ve got to remember, this is against the backdrop of ongoing British settler movement into Rhodesia, into Kenya, into South Africa,” she said. “That is what the architects thought they were doing when they started this process.”

Historians argue that the British Empire backed the Zionist movement for myriad reasons, including anxieties about Jewish migration to Britain, the search for new allies in World War I, and to maintain control of the nearby Suez Canal.

“The British, before they decided to take Zionism under their wing with the Balfour Declaration in 1917, for more than a decade had decided for strategic reasons that they must control Palestine,” Rashid Khalidi, a professor at Columbia University and author of The Hundred Years’ War on Palestine, told Vox. “They needed it to defend the eastern frontiers of Egypt. They needed it because it constituted the Mediterranean terminus of the shortest land route between the Mediterranean and the Gulf.”

After the Balfour Declaration, the British facilitated the mass immigration of European Jews to historic Palestine. Per a League of Nations mandate, the British would maintain economic, political, and administrative authority of the region until a Jewish “national home” was established.

Were Zionism and the founding of Israel inherently colonial projects? The debate, explained.

That long, tangled history planted the seeds for today’s strife — and the debate over what to call the Israeli project.

“Zionism, of course, has a national aspect, but as early Zionists all understood and accepted and were not ashamed of, it was a colonial project,” Khalidi said. “It was a settler-colonial movement to bring persecuted Jews from Europe to Palestine, where they would establish a Jewish majority state.”

But others dispute that view. That includes scholars like Benny Morris, a member of the Israeli New Historian movement that challenges official Israeli history, who argues that Zionism is rooted in the aspirations and ideals of a persecuted group, instead of the interests of a mother country. “Colonialism is commonly defined as the policy and practice of an imperial power acquiring political control over another country, settling it with its sons, and exploiting it economically,” Morris writes. “By any objective standard, Zionism fails to fit this definition.”

Derek Penslar, a history professor at Harvard University, writes in his book Zionism: An Emotional State about the various taxonomies of Zionism and that some of its early visionaries were critical of political Zionism’s aims.

“The most famous Zionist intellectual of the early 20th century, Asher Ginsberg, who went under the pen name of Ahad Ha-am, was against the establishment of a Jewish state,” Penslar told Vox. “He was very well aware of the Arab population of Palestine, and he said, ‘look, you know, we basically can’t get these people against us. We can’t anger them, we have to live with these people.’ And so he advocated forming much smaller communities that would not antagonize the Arab populations.”

The man who came to be known as the ideological father of Israel, however, was the political Zionist Theodor Herzl. A journalist from Vienna in the late 1800s, he witnessed the rise of populist, antisemitic politicians in his city and remarked on the pervasiveness of antisemitism in Europe in a play and later his pamphlet, The Jewish State.

Imagno/Getty Images

Credited for galvanizing an international movement for Jewish statehood in Palestine, Herzl sought a more dignified existence for European Jews like himself and espoused a vision of the Jewish state that included universal suffrage and equal rights for the Arab population. But in private, he wrote of Arab expropriation, and in public, he placed Zionists like himself within the colonial order of the time.

“We should there form a portion of a rampart of Europe against Asia, an outpost of civilization as opposed to barbarism,” he wrote. “We should as a neutral State remain in contact with all Europe, which would have to guarantee our existence.”

While under British control, Palestine saw violent clashes between Zionists and Arabs, and its demography changed rapidly, with the Jewish population increasing from 6 percent to 33 percent. In the eyes of Arab nationalists, the argument was a simple one: A foreign power took control of Arab land and promised it to another foreign group.

“For the Zionists and for Israel, it’s a lot more complicated,” said Penslar, whose work links post-colonial studies with the history of Zionism. “They wanted to be free, they wanted self-determination, and they wanted the kinds of things that colonized people in the world wanted. And the consensus was that they would realize their freedom in the Jews’ historic, biblical, and spiritual homeland in the land of Israel, which is the same thing as historic Palestine.”

(In a sign of how contentious the discussion over Zionism and antisemitism is, as part of a broader criticism of Harvard’s handling of antisemitism on campus, critics also protested Penslar’s heading of a university task force to combat antisemitism, pointing to his criticism of Israel as disqualifying — this despite Penslar’s own critiques of Harvard’s handling of antisemitism and his distinguished academic reputation.)

Judaism’s ties to the Middle East, mentioned in both the Bible and the Quran, the Hebrew language’s origins in ancient Palestine, and the Jewish ties to the region as a motherland motivate arguments that Jews are a native group in present-day Israel. It’s why groups supportive of Israel argue that it does not fit into the settler colonialism framework.

Universal Images Group via Getty

“Jews, like Palestinians, are native and indigenous to the land,” writes the Anti-Defamation League, a mainstream Jewish pro-Israel group and also one of the US’s leading anti-extremism organizations. “The Land of Israel is integral to the Jewish religion and culture, the connection between Jews and the land is a constant in the Bible, and is embedded throughout Jewish rituals and texts. The Europeans who settled in colonies in the Middle East and North Africa were not indigenous or native to the land in any way.”

To scholars like Khalidi, who comes from a family of Palestinian civil servants dating back to the 17th century, the connection doesn’t justify the creation of a majority Jewish state under international law.

“Does that mean that the people who arrive from Eastern Europe are indigenous to the land? No, they’re not indigenous. Their religion comes from there. Maybe or maybe not their ancestors came from there,” said Khalidi. “That doesn’t give you a 20th-century right — that’s a biblical land deed that nobody believes except people who are religious. And in modern international law, that just doesn’t hold.”

By the mid-20th century, the British, recovering from World War II and facing anti-colonial agitation from Zionists and Arabs in Palestine — not to mention from other corners of their empire — handed control of Palestine to the United Nations. In 1947, the General Assembly passed Resolution 181 to partition Palestine.

“Even though Arabs constituted a two-thirds majority of the country, more than 56 percent of it was to be given to the Jewish state and the rest was to be given to an Arab state,” said Khalidi.

For Israel, the birth of a Jewish state was a triumphant defiance of odds in the face of the Holocaust, and victory against military units from Transjordan, Iraq, Syria, and Egypt who were defeated the following year. It also occasioned the expulsion or voluntary exodus of hundreds of thousands of Jews from Arab countries. Israel soon established a Law of Return that would grant any Jew from any country the right to move to Israel and gain citizenship.

In Palestinian memory, the establishment of Israel entailed an ethnic cleansing campaign known as the Nakba, or “catastrophe” in Arabic. Fearing violence by Zionist forces or actively expelled by them, an estimated 750,000 Palestinians were displaced from their homes in present-day Israel. According to a 1948 Israeli Defense Forces intelligence report, “without a doubt, hostilities were the main factor in the population movement.” No Law of Return exists for Palestinians who were displaced by the Nakba.

History/Universal Images Group via Getty Images

The Nakba took place as independence movements in Africa, Asia, and the Caribbean gained traction. To scholars like Satia, who studies the empire that once colonized a quarter of the world, Palestine became a global touchpoint in an era of decolonization.

“All these other places do eventually get some kind of decolonization process. And in Palestine, there isn’t one,” she said. “It becomes the last bastion along with South Africa.”

The present-day charges of settler colonialism and demands to decolonize

Settler colonialism is hardly a thing of the past nor is it an exclusively Western enterprise. China is arguably practicing it by incentivizing Han Chinese migration to Xinjiang and Tibet. India’s revocation of Kashmir’s autonomous status is criticized as a Hindu nationalist effort to transform the demographics of its only majority Muslim state.

And Israel’s continued occupation of Palestinian territories motivates charges of present-day colonialism. This includes continued settlement construction in the West Bank and control of the ingress and egress of people and goods (most notably humanitarian aid) into the Gaza Strip.

In the West Bank, almost 700,000 Israelis are living in settlements scattered throughout the territory, which are protected by the Israeli military and often subsidized by the government.

“It’s pretty fair to say that the Palestinians are an occupied people. And there’s no question that the settlements that Israel has set up in the West Bank since 1967 are a kind of colonialism,” said Penslar.

As Vox’s Zack Beauchamp explained, “Most international lawyers (including one asked by Israel to review them in 1967) believe settlements violate the Fourth Geneva Convention, which prohibits the transfer of population into occupied territories.” Israel’s government disputes that its settlements violate any international law.

The settlements obstruct the contiguity of Palestinian land and movement. Palestinians are barred from certain Israeli-only roads and forced to navigate a network of checkpoints, which invokes comparisons to apartheid South Africa.

“The contiguity of the territory of the West Bank has been completely broken up,” said Satia. “You can use analogies like ‘Bantustans,’ which comes from the South African context.”

Menahem Khana/AFP via Getty Images

South African politicians, including its first post-apartheid president, Nelson Mandela, argued that Palestinians were engaged in a parallel struggle. In the wake of Hamas’s October 7 attack on Israel and Israel’s subsequent siege of Gaza, South Africa is accusing Israel of committing genocide in the International Court of Justice. Israel vehemently denies the charge, calling it “blood libel,” and says it has a duty to protect its citizens from Hamas.

As the world watches the deadliest war in the history of the Palestinian-Israeli conflict unfold on their screens, activists and academics rely on the term “settler colonialism” to explain a decades-long cycle of violence that has killed over 30,000 Palestinians and over 1,400 Israelis in the last six months.

To Penslar, who lived in Israel through two intifadas, today’s cycle of violence won’t change by identifying Israel as a settler-colonial state.

“Even if we do go through all of this and decide Israel is a settler-colonial state, it doesn’t really mean very much, because at the end of the day we have to come up with a solution which involves either Israeli Jews dominating Arabs, or Arabs dominating Jews, or the two people sharing the land or two states,” he said. “And whether you call Israel a settler-colonial state or not, it doesn’t really help us a whole lot.”

The call for decolonization is criticized by some for lacking achievable goals and denounced by others as a euphemism for expelling or killing Israelis in the name of anti-colonial resistance. Immediately after the October 7 attacks, Hamas leader Ismail Haniyeh said, “the enemy has had a political, military, intelligence, security and moral defeat inflicted upon it, and we shall crown it, with the grace of God, with a crushing defeat that will expel it from our lands.”

But academic proponents of the settler-colonial thesis say that expulsion is not a natural consequence of accepting that settler colonialism is foundational to a country.

“You can have that conversation and acknowledge that historical reality without implying that everyone needs to leave,” said Satia, citing Australia, New Zealand, and Canada — countries that have formally apologized to their indigenous peoples for colonial atrocities and pledged reparations to certain groups.

If the First Aliyah, or migration of the Jewish diaspora to historic Palestine, began in the late 19th century, then the descendants of those people living in Israel today are tied to the land not only because of Judaism’s history but also because of several generations living there in recent memory.

“Those are people who now have not just a presence but certain rights,” said Khalidi, adding that Israel fits into a pattern seen in other settler-colonial enterprises.

“You look at South Africa, or you look at Ireland, or you look at Kenya, or you look at what is now Zimbabwe — a very large proportion of the populations that were settled there by colonial powers … are now part of those populations. They have rights there. They should live there,” he said. “Now, how the relationship between them is to be worked out. That’s a question that’s not going to be easy to solve.”

What if I told you there was a way that the US could prevent 60,000 deaths, save American taxpayers $25 billion, and pay a deserving group of people $50,000 each? Would you be interested? Would you wonder why I’m pitching this to you like I’m the host of a late-night basic cable infomercial?

I am not a spokesman. I am simply a fan and supporter of the End Kidney Deaths Act, a bill put together by a group of kidney policy experts and living donors that would represent the single biggest step forward for US policy on kidneys since … well, ever.

The plan is simple: Every nondirected donor (that is, any kidney donor who gives to a stranger rather than a family member) would be eligible under the law for a tax credit of $10,000 per year for the first five years after they donate. That $50,000 in total benefits is fully refundable, meaning even people who don’t owe taxes get the full benefit.

Elaine Perlman, a kidney donor who leads the Coalition to Modify NOTA, which is advocating for the act, based the plan on a 2019 paper that estimated the current disincentives to giving a kidney (from travel expenses to lost income while recovering from surgery to pain and discomfort) amounted to about $38,000. That’s almost $50,000 in current dollars, after the past few years’ inflation.

The paper also found that removing disincentives by paying this amount to donors would increase the number of living donors by 11,500 a year. Because the law would presumably take a while to encourage more donations, Perlman downgrades that to about 60,000 over the first 10 years, with more donations toward the end as people become aware of the new incentives. But 60,000 is still nothing to sneeze at.

Due to a law signed by Richard Nixon, the US has single-payer health care for only one condition: kidney failure. Medicare picks up the bill for most patients with kidney failure, including for the main treatment of dialysis, in which an external machine replicates the functions of a kidney.

Dialysis is not only worse for patients than a transplant, for reasons we’ll get into in a moment; it’s more expensive too. In 2021, Medicare spent $33.4 billion, or almost 7 percent of its overall budget, on patients with kidney failure, much of it on dialysis treatment. Getting people transplants saves both lives and money: At about $416,000 in estimated savings each, those 60,000 transplants made possible by donor incentives over the first 10 years would save taxpayers about $25 billion.

I write about a lot of government programs, and usually there’s a tradeoff: You can do more good, but you’re going to have to spend a lot more money. Win-win scenarios where the government saves money while saving lives are virtually unheard of. We’d be foolish not to leap at this one.

The kidney problem, explained

The End Kidney Deaths Act is trying to solve a fundamental problem: Not nearly enough people are donating their kidneys.

In 2021, some 135,972 Americans were diagnosed with end-stage renal disease, meaning they would need either dialysis or a transplant to survive. That year saw only 25,549 transplants. The remaining 110,000 people needed to rely on dialysis.

Dialysis is a miraculous technology, but compared to transplants, it’s awful. Over 60 percent of patients who started traditional dialysis in 2017 were dead within five years. Of patients diagnosed with kidney failure in 2017 who subsequently got a transplant from a living donor, only 13 percent were dead five years later.

Life on dialysis is also dreadful to experience. It usually requires thrice-weekly four-hour sessions sitting by a machine, having your blood processed. You can’t travel for any real length of time, since you have to be close to the machine. More critically, even part-time work is difficult because dialysis is physically extremely draining.

Most people who do get kidney transplants get them from deceased donors. There’s more we can do to promote that: One study found that about 28,000 organs annually, including about 17,000 kidneys, could be recovered from deceased donors but are not, largely because organ procurement groups and surgeons have strong incentives to reject less-than-perfect organs. People are working hard on fixing that problem, but they’d be the first to tell you we need more living donors too.

The gap between kidneys needed and kidneys available is about 10 times larger than that 17,000-a-year figure. Kidneys from living donors also last longer than those from deceased donors, and the vast majority of those who die (96.7 percent by one study’s estimate) are not even eligible to donate their organs, usually because the prospective donor is too sick or too old.

So we should be recovering the organs that are eligible. But it won’t get us all the way. We need living donors too.

But we don’t have enough — particularly enough nondirected donors. These are donors giving to a stranger, and thus donors whose kidneys can be directed to the person with the most need. While I and others have done our best to evangelize for nondirected donation, our ranks are pretty thin. In 2023, only 407 people donated a kidney to a stranger.

The End Kidney Deaths Act would aim to increase that number nearly thirtyfold. Perlman told me the Coalition to Modify NOTA is open to supporting donors who give to family or friends as well, or even providing benefits to families of deceased donors. But in part because nondirected donations are so rare, starting out by just subsidizing them saves money upfront. The act is meant as a first step toward a system of more broadly compensating donors; if it proves this approach can work, we can always expand eligibility.

The moral case for compensating kidney donors

The most common objection to compensating kidney donors is that it amounts to letting people “sell” their kidneys, a phrasing that even some proponents of compensation adopt. For opponents, this feels dystopian and disturbing, violating their sense that the human body is sacred and should not be sold for parts.

But “selling kidneys” in this case is just a metaphor, and a bad one at that. The End Kidney Deaths Act would not in any sense legalize the selling of organs. Rich people would not be able to outbid poor people to get organs first. There would be no kidney marketplace or kidney auctions of any kind.

What the proposal would do is pay kidney donors for their labor. It’s a payment for a service — that of donation — not a purchase of an asset. It’s a service that puts some strain on our bodies, but that’s hardly unusual. We pay a premium to people in jobs like logging and roofing precisely because they risk bodily harm; this is no different.

When you think of donor compensation as payment for work done, the injustice of the current system gets a lot clearer.

When I donated my kidney, many dozens of people got paid. My transplant surgeon got paid; my recipient’s surgeon got paid. My anesthesiologist got paid; his anesthesiologist got paid. My nephrologist and nurses and support staff all got paid; so did his. My recipient didn’t get paid, but hey — he got a kidney. The only person who was expected to perform their labor with no reward or compensation whatsoever was me, the donor.

This would outrage me less if the system weren’t also leading to tens of thousands of people dying unnecessarily every year. But a system that refuses to pay people for their work, and in the process leads to needless mass death, is truly indefensible.

A version of this story originally appeared in the Future Perfect newsletter. Sign up here!