China’s Execution-Transplantation System and International Institutions:
A Too-Sticky Wicket?
by Kirk C. Allison
The nexus of transplantation and execution in China and professional association responses highlight tensions between disciplinary standards and self-regulation. While not wholly autonomous, characteristics justifying professions’ unique legal standing include specialized expertise, self-regulation (practice standards and discipline), and serving the public interest including protecting “against bungling and extortion.”(1) Thus, “it alone must exercise discipline over its members, and with due regard to basic human rights, remove delinquents from its lists.”(2) What response should follow when an entire context of professional practice shows no regard to basic human rights, even relying on execution for its materials?
After years of denial, in 2005, Vice Minister of Health and liver transplant surgeon Huang Jiefu admitted executees were China’s primary organ source.(3) The confluence of Falun Gong persecution, launched in 1999, and an exponential increase in organs with a peak in 2004 (see Fig. 1)(4)has had little acknowledgment in professional society discourse, despite increasing recognition among medical professionals and ethicists.(5) (6)
Professor Shi Bingyi (Transplantation Director, 309th People’s Liberation Army Hospital Beijing), stated transplants peaked at 20,000 in one year—2006, not 2004, thus if accurate contradicting MOH presented data.(7)
Evidence of Falun Gong sources has led to European Parliament Resolution 2013/2981, (December 2013),(8) and, with 215 cosponsors, House Resolution 281 has been approved unanimously by the U.S. House Committee on Foreign Affairs in July 2014, “Expressing concern over persistent and credible reports of systematic, state-sanctioned organ harvesting from non-consenting prisoners of conscience, in the People’s Republic of China, including from large numbers of Falun Gong practitioners imprisoned for their religious beliefs and members of other religious and ethnic minority groups.”(9)
The pattern characterizes a supply-driven market, not merely capacity increase; a supply glut processed down (2004-2005), servicing the lucrative transplant tourist flow.(10) In 2005, the China International Transplantation Network Assistance Center’s homepage boasted: “Viscera providers can be found immediately!”(11) Whence such ‘providers’?
Liver transplants lagged kidney, negligible before 2000 (< 350), peaking in 2005 (3,500+), before dropping in 2006 below 2004 levels. This reflects numerous hospitals entering the more lucrative liver transplant market after the kidney peak. By 2006, 500+ Chinese hospitals performed liver transplants, compared to about 100 in the U.S.(12)
Hao Wang’s 2007 time-series study (data 1993-2005) indicates confirmed Falun Gong detention death trends (2,773 between 1999-2005) predict liver transplant trends highly significantly (t=10.16, p<.00001), while Chinese media execution reports did not (t=0.57, p=.5792). The study points beyond the official explanation of judicial executions being the main source of the ‘surplus’ organ explosion. Non gratas tortured to death have little transplant value; however, a Falun Gong practitioner refusing to recant or identify him/her self in detention could generate several hundred thousand dollars. Preparatory examinations (blood draws, x-rays, etc.) are multiply attested.(13) In 2006, 120 calls to hospitals and 36 to detention centers and courts yielded 19 acknowledgments of available Falun Gong organs. Many skirted the sourcing question as a sensitive secret.(14)
Given disciplinary and commercial cognizance of China’s execution-transplantation system, this chapter examines two institutional documents and material supporting services:
The Transplantation Society member letter of November 6, 2006 (hereafter “member letter”).(15)
Declaration of Istanbul on Organ Trafficking and Transplant Tourism (2008).(16)
Pharmaceutical and diagnostic interests and supports.
Beside China‘s vacillating ethical self-assessments, execution- based transplantation has been termed unethical, immoral, evil, barbaric or genocidal depending on the context. International transplant societies’ primary strategy has been mostly ‘constructive engagement’, not isolation. Are those efforts or actions by market seekers licit or complicit? Has proximity to China enabled continuance?
Cooperation in evil? A heuristic framework
While terms of opprobrium are fitting, a more differentiating structure may clarify proximity and culpability: cooperation in evil (borrowing a Catholic taxonomy). One may use another term than “evil” however which will indicate the gravity accorded to what is at stake.
Cooperation concerns an act, here procuring/transplanting executee organs. The agent performs; cooperators assist. Either may be personal or institutional. Cooperation devolves at three levels: intentional (Formal) or practical (Material) cooperation; the nature of material support (Immediate or Mediate); and the level of proximity to the act (Proximate or Remote).(17)
Formal cooperation concerns intent (transplant tourist approving source). Immediate material cooperation involves an integral contribution necessary for the act (training). Mediate contributions are involved contextually, but not integrally. Proximate ones may lead to the act (agreeing to attend an academic transplant demonstration); a remote one does not per se (selling surgical drapes to a hospital). One could triply intend, provide necessary material, and proximately contribute. Unless an act is intrinsically evil, context is determining. Hence a good in one context (transplantation) may represent an evil in another (execution- transplantation). Intent, an act’s moral nature, and consequences are each in play.
In China, physicians, (i.e., principal agents) co-effect execution in transplant selection and scheduling(18) (19) (if not taking organs alive), raising the question whether organ availability is a ‘byproduct’ (aftermarket, value-added) or prisoners are executed for organs.
The Transplantation Society member letter of November 6, 2006 — generating change through proximity?
The Transplantation Society (TTS) is a “NGO in official relations with the World Health Organization—WHO.”(20) Transplantation, the official journal, “the most cited and influential journal in the field” with a vision to “provide the focus for global leadership in transplantation” in “development of the science and clinical practice,” “scientific communication,” “continuing education,” and “guidance on the ethical practice.” TTS boasts 6500+ members in 100+ countries and a biennial congress of 5,000+ participants.
On November 6, 2006, TTS issued a 3-page member letter on China and other countries not conforming to its Policy & Ethics or Membership statements. It announced work with WHO and Chinese government agencies, “to develop a legal framework that achieves TTS standards of practice” and WHO guiding principles.(21) For this, “interaction with Chinese officials is the only true route to effect long term change” and “must be derived from Chinese Governmental policies;” suggesting other routes would be ‘false’. Further, TTS endorsed a recent MOH statement of “new ethical standards.”
Before 2006, no centralized oversight was attempted; a well- connected military medical system outside the MOH drove the lucrative transplant tourism boom (bing shang–soldiers in business) with few organs for ordinary Chinese. A decentralized death penalty system allowed broad discretion with 68 capital crimes as did seasonal “strike hard” campaigns until capital punishment review returned to Beijing in November, 2005. Capital crimes reduced to 55 in 2011, with reduction to 46 proposed in 2014.(22)
The TTS member letter presents four “realities and principles”; 1) China’s prominence (11,000+ transplants in 2005). 2) “Almost all organs are likely to have been obtained from executed prisoners.” 3) “As a professional society, TTS cannot dictate to China that its practice regarding capital punishment is unethical” — despite the documented arbitrary nature. Rather, “TTS should express concern that recovery of organs from executed prisoners has resulted in rampant commercialism and transplant tourism.” 4) MOH intent to create national oversight, establish credentials, ban organ commerce, prevent trafficking/tourism, establish deceased donation (brain death criteria) and self-sufficiency with deceased and living donors. Strongly emphasizing unlikelihood of free consent by prisoners, “financial incentive for recovering organs from executed prisoners may become an incentive to increase the number of such organs available for transplantation.”
For China the letter welcomes TTS membership for anyone signing the membership statement; TTS meeting attendees can include personnel transplanting executee organs (for dialogue/ promoting alternatives); scientific presentations from China not involving executees and research collaborations, when IRB/ Helsinki Declaration-compliant, welcome. Member lectures and expertise may support China’s program if, “as far as possible,” not promoting executee use; and international registries may accept duly noted executee sourced transplant data for transparency/ demographics, but not aggregate outcome reporting.
By 2005, China International Transplant Network Assistance Center attributed its capacity almost entirely to Western training (eleven surgeons and two physicians).(23) Astonishingly the TTS letter encourages Western institutions to accept new transplantation trainees from executee-using programs, if ensuring, “as far as possible,” intent to follow TTS guidelines in the future. Some institutions, however, took a radically different tact: In December 2006, transplant centers in Queensland, Australia, banned further training of Chinese surgeons and related joint research.(24)
While TTS intends no executee use (no ‘formal cooperation in evil’ nor complicity in membership or registry tracking, if compliant), research discussions provide mediate support on return to China; meeting contents (new techniques) make integral contributions; and new training increases capacity for any organ source.
Did the TTS member letter’s approach work? — Seven years later, (February 27, 2014) TTS and the Declaration of Istanbul Custodian Group published an Open Letter to Xi Jinping President of China, President of the People’s Republic of China: China’s Fight against Corruption in Organ Transplantation.(25) Advocating “a culture of human rights,” urging Xi to address still ongoing unethical transplant practices, “to rid Chinese society of corruption,” including coerced consent, “notorious transactions between transplant surgeons and local judicial and penal officials,” “clandestine organ transplants,” and continuing transplant tourism marketing; in sum, “decades-long malpractice.” Among the standards cited is the 2008 Declaration of Istanbul on Organ Trafficking and Transplant Tourism.
The Declaration of Istanbul on Organ Trafficking and Transplant Tourism
April 30 – May 2, 2008, a Summit convened in Istanbul to “assemble a final declaration that could achieve consensus” on organ trafficking and transplant tourism. A Steering Committee (TTS and International Society of Nephrology leadership) provided a working draft. Some 170 invited potential participants represented diverse countries and interests; 160 participants accepted (four from China) and 152 attended. A worksheet assigned PRC participants to Governing Principles and Communication Plan and MOH representative Zhao Minggang to Transplant Tourism.(26)
Declaration Principle six addressed organ trafficking/transplant tourism, referencing World Health Assembly (WHA) Resolution
44.25 Human Organ Transplantation (1991).(27)
Principle 6a) calls for advertising, soliciting and brokering bans; 6b) for penalties for related screening, transplanting, and acts “that aid, encourage, or use the products of, organ trafficking or transplant tourism.” Pharmaceuticals or other supports are unmentioned save acknowledging Summit funding from Astellas Pharmaceuticals — the major supplier of anti-rejection drugs in China.
Principle 6c) broaches prisoners, first and last …
“Practices that induce vulnerable individuals or groups (such as illiterate and impoverished persons, undocumented immigrants, prisoners, and political or economic refugees) to become living donors are incompatible with the aim of combating organ trafficking, transplant tourism, and transplant commercialism.”
… only as living donors, not executees (unless killed by organ removal). By April 2008, all Summit participants knew China’s ongoing organ source: hundreds of executees monthly. Was mentioning this considered unnecessary given reform promises or blocked by China’s representatives?(28)
In 2008, TTS awarded Huang Jiefu its President’s International Award for “the favorable changes and good progress in the regulatory development related to organ transplantation in China …”(29) Surprisingly, at the end of 2008, Vice Minister of Health Huang, responsible for organ procurement practices on the civilian side, still cited executee sourcing at 90%.(30)
The Declaration of Istanbul Custodian Group (DICG) was established in 2010 to promote Declaration principles; participants and organizers subsequently spoke out on China’s ongoing execution-transplantation reality.(31) Yet the Declaration’s silence—unregistered as a category of concern—remains a remarkable event in disciplinary self-censorship.
Supporting Services and Vested Interests
Each TTS webpage acknowledges four corporate sponsors: Japan-based Astellas Pharma, U.S.-based One Lambda (Thermo Fisher Scientific), Swiss-based Roche, and Paris-based Sanofi. Each has significant involvements in China not indifferent to TTS policies.
Astellas Pharma China, Inc. notes use of immunosuppressive Prograf® (tacrolimus) to prevent liver and kidney graft rejection in China since 1999.(32) This predates Wang Guoqi‘s 2001 landmark Congressional testimony on organ harvesting, including from still living executees. The webpage identifies tacrolimus use in China in over 20,000 cases and 20 million worldwide, China patients comprising 0.1%. Not surprisingly, www.astellas.com.cn fails to mention that physicians prescribing and patients receiving Prograf® rely chiefly on executee organs.
Astellas commenced drug trials in China statistically requiring executees after the TTS member letter; March 2007 (42 livers), July 2007 (240 kidneys) and January 2008 (172 livers).(33) Prograf® study site, First People’s Hospital (Shanghai) acknowledged Falun Gong sources on March 3, 2006.(34)
In 2011, prominent ethicists and transplant surgeons declared, “Time for a boycott of Chinese science and medicine pertaining to organ transplantation”(35) noting “pharmaceutical companies continue their marketing efforts and engage in sponsoring research involving various aspects of transplantation in China.“ In 2011 Astellas introduced Advagraf® to the PRC (“New Prograf extended release capsules”).(36)Despite well-known execution-transplantation, Astellas aims for monopoly claiming “application of other immunosuppressive drugs cannot control graft rejection.”(37)
Immunosuppressive therapy is downstream from selecting and killing prisoners, yet without this, fewer near matches would be used. In 1999, Astellas was likely unaware, but now expanding in such a system is culpable. Astellas could declare a moratorium date and exert significant pressure rather than continuing cooperation. Immunosuppressive therapy is not integrally tied to execution, but supporting the organs-through-execution market is.
Whether a company foreswears a lucrative market position may come down to public exposure and what company leadership, and shareholders, can stomach after recognition.
Roche began anti-rejection drug trials in China during April, 2006; 36 hearts, 90 livers and by September, 2008, 210 kidneys.(38) On March 16, 2006, one Roche trial involved Shanghai Jiaotong University Hospital’s Liver Transplant Centre, where a Dr. Dai identified organs available within a week, including Falun Gong sources.(39)
In September 2009, Arne Schwarz queried a Roche compliance officer. The response: “Roche is, as mentioned above, neither in China nor in any other country of the world in charge of the supply of organs. Anonymity and privacy of the most highly personal donor data are protected by law. Roche is not entitled to know from where or from which donors the transplanted organs come.”(40) Transplant journals now require executee-free source certification, why not Roche? Where the vast majority of organs are sourced unethically, corporate responsibilities cannot hide behind a foil of respecting anonymity and privacy. Here, both serve complicity with a lethal system and endanger prisoners of conscience, chiefly, but not limited to, Falun Gong.
In 2010, Roche rightly received two unwanted “Public Eye Awards” in Davos, Switzerland, for Cell Cept® trials, without verifying organ sources.
One Lambda (Thermo Fisher Scientific)
One Lambda is a world leader in HLA tissue typing, HLA antibody detection, transplant monitoring and diagnostic products. Acquired in 2012, such “complement our existing immunosuppressant assays, which are used to monitor the level of drugs in transplant patients,” an opportunity to accelerate growth faster than U.S. rates.(41) Roche’s 2012 Annual Report reflects $700M China sales (up 22%), primarily lab consumables well aligned with China’s Five-Year Plan.(42)
In 2013, Paris-based Sanofi celebrated 30 years in China with a new 3.5B capacity pill plant in Hangzhou.(43) In 2009, it had China’s first international biotech R&D hub.(44) Acquiring Genzyme Corp., Sanofi entered the transplantation field in April 2011, including an “immune-suppressive and immune-modulating agent that aids in the prevention and treatment of acute rejection.” It also distributes anti-thymocyte globulin against bone marrow rejection. The China Bone Marrow Donor Program and database are under the Red Cross Society of China. Prisoner sourcing has not yet been identified.(45)
The cooperation/complicity analysis of TTS sponsors is left as an exercise for the reader.
The intersections of China’s execution-transplantation system with the persecution of Falun Gong; professional and commercial responses, responsibilities, and contradictions, while reflection on the nature of culpable cooperation even in the midst of well-meaning engagements, invite several conclusions and a more effective response.
For professions to foreswear the legitimacy of their practice is difficult even in unethical (in this case homicidal) contexts, particularly when promoting an intrinsic good (i.e., health); likewise for companies to give up expanding markets given ethical contraindications.
TTS acknowledges no prima facie right to an organ. A few licit sources do not redeem the majority of illicit ones. ‘Constructive engagement’ has been selectively accepted by China, resulting in an increase of capacity (training surgeons) and unimpeded continuation also after the use of prisoners organs were admitted to by hospitals surgeons and detention centers.
In summer 2005, law professor Qu Xinjiu (Political Science and Law University, Beijing) addressed China’s “transplantation bank” pointing out lack of consent and danger that health officials’ organ demand would influence sentencing. He called for immediate moratorium.(46)
Prudence is the virtue of attaining morally laudable ends by morally consonant means. There is no prudent path to an immoral end nor prudent complicity in immoral means. Both China’s medical establishment and population are addicted to sourcing organs from prisoners, including prisoners of conscience.
Ending even indirect support of a lethal organ procurement system is likely the most efficient path to the good while avoiding complicity; compelling populace, politicians and medical functionaries to make a choice.
In 2013, Huang, et al. errantly stated, “the need of the Chinese people for high-quality organ transplant services is our obligatory mission.”(47) If China’s population does not highly value transplantation, with their own organs voluntarily in the game, no transplant would be the logical, ethically obligatory consequence.
Formerly Vice Minister Huang called prisoner sourcing “variously improper, unethical, violating standards, and vulnerable to death penalty reform.” In a 2014 China Times interview he offers instead a final, but only semantic solution:
“Executed prisoners can voluntarily donate organs. Given the willingness of death row prisoners to donate organs, once entered into our unified allocation system they are counted as voluntary citizens – the so-called death row organ donation doesn’t exist any longer.”(48)
Here the China Organ Transplant Response System (COTRS) performs as immediate efficient sanitizer. China’s medical system and population continue to rely on execution; physicians codetermine execution; Western institutions enable continuance. All except prisoners, especially prisoners of conscience, have a choice.
COTRS Director Wang Haibo: “The question is, indeed, when can China solve the deficit in donor organs? I wished we could stop with that tomorrow. But it requires a process. Many things evade our control. Therefore we cannot name any timetable.”(49) Clearly, it is well past the time for Western entities to stop enabling and align action with moral responsibilities.
 Klass, A.A., “What is a profession?” Canadian Medical Association Journal, 85(1961):698-701.
 Caplan A.L., “Polluted sources: Trafficking, selling and the use of executed prisoners to obtain organs for transplantation.” In: Matas, D. and T. Trey (eds.) State Organs (Woodstock ON: Seraphim, 2012), pp. 27-34.
 Xu, Y. 供体短缺是制约器官移植事业发展的瓶颈 (“Donor shortage is a bottleneck restricting the development of organ transplantation”). Science Times, 6/15/2007. http://paper.sciencenet.cn/html/showsbnews1.aspx?id=182075. Comparative graphs: http://www.stoporganharvesting.org/quantity-skyrocketed.
 European Parliament resolution of 12 December 2013 on organ harvesting in China. (2013/2981(RSP)) http://www.europarl.europa.eu/sides/getDoc.dotype=TA&reference=P7-TA-2013-0603&language=EN&ring=P7-RC-2013-0562.
 H.Res.281 – 113th Congress (2013-2014). https://www.congress.gov/bill/113th-congress/house-resolution/281.
 Wang, H. “China’s Organ Transplant Industry and Falun Gong Organ Harvesting: An Economic Analysis.” Thesis. Yale University, 2007. See pp. 16-18. http://organharvestinvestigation.net/events/YALE0407.pdf. Also Gutmann E. The Slaughter: Mass Killings, Organ Harvesting and China’s Secret Solution to its Dissident Problem (New York: Prometheus Books, 2014), pp. 217-253.
 China International Transplantation Network Assistance Center, “Introduction to China International Transplantation Network Assistance Center.” ©2004-2005. http://en.zoukiishoku.com. (Website down. Author’s screenshot available.)
 Zhang Feng, “New rule to regulate organ transplants.” China Daily, 5/5/2006. http://www.chinadaily.com.cn/china/2006-05/05/content_582847.html.
 Gutmann, pp. 29, 186-187, 233-237, 239-240 (also ‘Eastern Lightning’ Christians), 244 (Tibetan monk report), 282 (Uighurs), 320-321 (16 of 50 FG interviewees in Thailand recounting exams). 364 (indexing exam types).
 The Transplantation Society. “To TTS members,” 11/6/2006. [No longer on TTS website.] http://transplantation.graydesign.com.au/files/StatementMembsChineseTXProg.pdf
 Archdiocese of Philadelphia. “Cooperation in Evil” [chart]. s.d. http://archphila.org/HHS/pdf/CoopEvilChart.pdf. Typo edited.
 Laogai Research Foundation, Involuntary Donors: A Comprehensive Report on the Practice of Using Organs of Executed Prisoners for Transplant in China (January 2104), pp. 119-120. The report, however, does not remark on evidence of Falun Gong and other prisoners of conscience as sources.
 The Transplantation Society. “About TTS.” http://www.tts.org/about-tts-5.
 Letterhead lists TTS President/Historian Nicholas L. Tilney; Director of Medical Affairs Francis L. Delmonico. Ethics Committee under Annika Tibell composed the guidelines also for consideration by Global Alliance for Transplantation organizations.
 AP. “China considers ending death penalty for 9 crimes,” 10/29/2014. http://bigstory.ap.org/article/1c1950e80db54763ab82232d88ee7cd8/china-considers-ending-death-penalty-9-crimes.
 Listed: University of Nebraska, Emory, Toronto, Hong Kong, Hanoverian University, Minnesota, Tokyo, Kumamoto, Queensland and Flinder Center. China International Transplantation Network Assistance Center, “Introduction to Doctors.” http://en.zoukiishoku.com/list/doctors.htm. Update 7/20/2006. Website down. Author’s screenshot available.
 “Hospitals ban Chinese surgeon training.” Sydney Morning Herald, 12/5/2006. http://www.smh.com.au/news/National/Hospitals-ban-Chinese-surgeon-training/2006/12/05/1165080933418.html.
 The Transplantation Society & Declaration of Istanbul Custodian Group, “Open Letter to President of China,” 2/27/14. https://www.tts.org/home-660/newletters/past-newletters/2014-volume-11-issue-1/1585-open-letter-to-president-of-china.
 See related resolutions at http://www.who.int/transplantation/publications/en.
 “The content of the Declaration is derived from the consensus that was reached by the participants at the Summit in the plenary sessions.” Clinical Journal of the American Society of Nephrology, 3 (2008):1230.
 See articles at http://www.declarationofistanbul.org/articles/articles-relevant-to-the-declaration.
 Astellas, 移植免疫: 普乐可复 (他克莫司胶囊、注射液) [“Transplant Immunology: Prograf (tacrolimus capsules, injection).] http://www.astellas.com.cn/?productshow/pid/197/tp/198/id/2.
 Matas D, “Antirejection Drug Trials and Sales in China,” American Society of International Law Annual International Conference on Law, Regulations and Public Policy (LRPP 2012), Hotel Fort Canning, Singapore, July 8 [sic! 9], 2012, pp. 3-5.
 Caplan A.L., G. Danovitch, M. Shapiro, J. Lavee, and M. Epstein. [Same title]. Lancet 378(9798):1218. http://www.thelancet.com/journals/lancet/ article/PIIS0140-6736%2811%2961536-5/fulltext.
 Astellas, 移植免疫: 新普乐可复 (他克莫司缓释胶囊) [“Transplant Immunology: New Prograf (tacrolimus extended release capsules)”.] http://www.astellas.com.cn/?productshow/pid/197/tp/198/id/3.
 Matas D, “Antirejection Drug Trials and Sales in China,” American Society of International Law Annual International Conference on Law, Regulations and Public Policy (LRPP 2012), Hotel Fort Canning, Singapore, July 8 [sic! 9], 2012, pp. 3-5.
 Thomson Reuters Street Events. “TMO – Thermo Fisher to Acquire One Lambda Conference Call,” 7/16/2012. http://ir.thermofisher.com/files/events/2012/TMO-Transcript-2012-07-16.pdf
 Sanofi. “Annual Review 2013: Protecting Life, Giving Hope.” http://www.sanofi.co.za/l/za/en/layout.jsp?scat=86ABAAB0-44B1-4769-8D9A-6BA1C270B3C5.
 Pharmaceutical-technology.com. “Genzyme R&D Facility, China,” s.d. http://www.pharmaceutical-technology.com/projects/genzyme-facility/
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 Huang, J., S.-S. Zheng, L. Yong-Feng, H.-B. Wang, J. Chapman, P. O’Connell, M. Millis, J. Fung, and F. Delmonico. “China organ donation and transplantation update: the Hangzhou Resolution.” Hepatobiliary Pancreatic Dis. Int. 13,2(2014):122-124.
 Sharif, Fiatarone Singh, Trey, and Lavee, p. 4; Dailynews.sina.com. 黄洁夫：内地已有38家医院停用死囚器 [Huang Jiefu: Mainland has 38 hospitals stop using prisoner organs.] 3/4/2014. http://dailynews.sina.com/gb/chn/chnpolitics/phoenixtv/20140304/12205515629.html.
 Kirchner, R. “Keine Organe mehr von Hingerichteten?“ Tageschau, 4/14/2014. http://www.tagesschau.de/ausland/china2158.html. URLs accessed 11/24/2014.