Asia's Kidney Bazaars

Posted January 6, 2009

After a stranger approached him for a job, Mohammad Salim told India’s NDTV Television he was escorted into a dark, paint-chipped room with gunmen who gave him an injection. He fainted and woke up with a pain in his side, a doctor standing over him. His kidney had been removed. The group paid him 50,000 rupees ($1,045) for the organ, but the crippling pain meant he was out of work—and in debt—for months.

That doctor, Amit Kumar, has since been arrested following a global manhunt, but the dark underworld of organ trafficking remains a big business in Asia. Kidneys around the continent fetch for between $25,000 and $60,000, and lungs and hearts are over $150,000. Yet unlike human or drug trafficking operations run by shady criminal warlords, organ trafficking operations are run by well-connected doctors in Chennai, Manila and Islamabad, and sophisticated middlemen who frequent the slums in those cities.

Medical advances, corruption, and growing poverty have all contributed to Asia’s booming organ markets, as “transplant tourists” increasingly jump waiting lists with ease to get organs in Pakistan, India, China and the Philippines. The World Health Organization suggests 10% of all transplants worldwide are trafficked. Before Pakistan passed a law in 2007 banning transplants to foreigners, the Sindh Institute of Urology and Transplantation estimated 75% of its 2000 yearly kidney transplants were to foreign medical tourists. And in China, shockingly, British medical journal The Lancet claims 90% of the organs for its 11,000 annual transplants come from executed prisoners. The government claimed in 2007 it had curbed the practice anticipating criticisms in the 2008 Beijing Olympics.

Poor people selling kidneys, or even having them taken, is nothing new. Many allegations stretch to the early 1990s, when police in Agra, India, found a clinic collecting and selling corneas and kidneys from lepers. Even in the aftermath of 2004 Banda Aceh tsunami, 150 residents claimed they had sold kidneys to escape debt and rebuild their homes. Yet their situation did not improve. Many residents, unable to work with pain in their sides, fell back into debt as post-surgery costs absorbed their kidney profits—contrary to the promises of the brokers.

With the arrests of Dr. Kumar in January, nicknamed in the press “Dr. Horror” for trafficking over 600 kidneys, and Singaporean tycoon Tang Wee Sung in September for trying to buy a $300,000 kidney, organ trafficking is no longer a sidebar on the WHO’s agenda. Its effects on communities can be devastating: the unregulated market leaves paid donors unable to work for months, without proper post-surgical treatment, and in a worse financial situation than before the operation. Many organ brokers do not follow through with their promises on payment, often leaving paid donors far less than their promised $2000, a common kidney fee.

With poor families sinking into debt, the economic crisis and last summer’s high food prices haven’t helped the situation. “Globally, dire conditions of poverty and debt are the key incentives to sell an organ,” said Debra Budiani, director of the Coalition for Organ-Failure Solutions (COFS) in Washington, D.C. “In Egypt last summer, the prices of bread more than doubled, which in tandem with unlicensed transplants, made the majority of transplants in Egypt commercial.”

Yet the coming threat may not only be a faltering economy, say doctors, but new legislation introduced in the U.S. to allow trials of financial incentive programs for donors. Under the bill, the Organ Clarification Act of 2008, organ donors could be reimbursed with anything from cash to free lifelong health insurance. And it has revived an age-old debate whether to legalize or ban organ sales, or do something in between.

“Think of it as one state like Pennsylvania adopting one measure and another state like Michigan adopting another. Would transplant donors flock to the state that provides the best sale for the donor and the cheapest price for the recipient?” said Dr. Francis Delmonico, professor of surgery at Harvard Medical School. “And in a global economy, why wouldn’t the same price differentials exist for sales in Asia or the Middle East? Why should Americans buy a kidney in Providence, if it is cheaper to purchase the kidney in Pakistan?”

A recent crackdown in Pakistan is halting the country’s once notorious kidney trafficking rings, and opponents of a regulated market point to that example. A year after the country outlawed transplants to foreigners in 2007, the total number of transplants in Pakistan fell to 700 from 2000 the previous year, said Dr. Farhat Moazam, head of the Center of Biomedical Ethics and Culture in Pakistan. “We now have only sporadic reports of unrelated, commercial transplants,” she claimed, adding that many hospitals are under investigation and one has been shut down.

Yet some physicians support U.S. trials despite events in Pakistan, claiming a regulated organ market in the developed world is the only realistic way to stop black markets in the developing world. “The legislation would send a strong message that the U.S. is opposed to organ trafficking, but also emphasizes that part of the impetus for organ trafficking is the failure of organ procurement policies to meet the growing demand,” said transplant nephrologist Dr. Ben Hippen. “When governments prohibit incentives for organ procurement, all that is accomplished is that the opportunity costs of participating in illegal, underground organ trafficking go up. But this doesn’t solve the essential problem, the shortage of organs, which is driving the demand.”

Regulated organ markets do exist. Iran can tout the world’s only regulated transplant market and abundant organ supply, with the government offering donors $1,200 and free health insurance. The government calls it organ “sharing” despite the money exchange. Middlemen and brokers are outlawed, and donors are not allowed to openly advertise their kidneys. Yet some donors, especially those with rarer blood types, still request under-the-table gifts of up to $10,000 from recipients, adding a black-market element.

Other countries, like Singapore, use presumed consent, an “opt-out of being a donor” policy different from most countries’ “opt-in” policy. Culturally speaking, Asia is prone to organ shortages, and therefore to larger black markets. Families often object to removing their deceased relatives’ organs—an interpretation of Buddhism and Islam in keeping the body whole after death. Singapore responded by adopting a presumed consent policy in its Human Organ Transplantation Act (HOTA) of 1987, meaning every citizen in a fatal accident is assumed a donor unless they opted out while alive.

Yet with its tiny population, Singaporean patients must still wait nine years for a kidney. That’s why a debate is raging in Singapore over whether to legalize organ sales, with many advocates taking a cue from the Iranian model. To some doctors, a regulated market is worrisome if the government targets the poor and vulnerable. “The Singapore initiative must be clarified as to who is the intended donor,” Dr. Delmonico said. “If it is immigrant Indonesians or Indians, that is unacceptable.”

Geoffrey Cain, a freelance journalist, followed this story for two years in Washington, D.C., and Southeast Asia.