The slide on the screen showed several skinny, dark Filipino men lined up, displaying their sacred wound, the kidney scar, long as a sabre slice across their convex torsos. More than 150 representatives of scientific and medical bodies from 78 countries stared solemnly at the photo during the Istanbul Summit of 2008, the defining moment in the global recognition of human trafficking for ‘fresh’ kidneys. ‘Is this why we began as transplant surgeons?’ one of the convenors, US surgeon Francis Delmonico, asked. ‘Are we comfortable with this? Is this fair? Do we want to participate in this?’
The man sitting next to me, a Hindu surgeon in white robes, reminiscent of Hippocrates, was moved. When I asked what he was thinking, he replied: ‘This is too late. Kidney selling is no longer a strange or exotic act. It is normal, everyday, and entrenched. We in the South can agree that it is a tragic turn of events, but the demand comes from outside.’
In the early 1980s a new form of human trafficking, a global trade in kidneys from living persons to supply the needs and demands of ‘transplant tourists’, emerged in the Middle East, Latin America and Asia. The first scientific report on the phenomenon, published in The Lancet in 1990, documented the transplant odysseys of 131 renal patients from three dialysis units in the United Arab Emirates and Oman. They travelled with their private doctors to Bombay (now Mumbai), India, where they were transplanted with kidneys from living ‘suppliers’ organized by local brokers trolling slums and shantytowns. The sellers were paid between $2,000 and $3,000 for a ‘spare’ organ. On return, these transplant tourists suffered an alarming rate of post-operative complications and mortalities resulting from mismatched organs, and infections including HIV and Hepatitis C. There was no data on, or discussion of, the possible adverse effects on the kidney sellers, who were still an invisible population of anonymous supplier bodies, similar to deceased donors.
In 1997, I co-founded Organs Watch, specifically to draw attention to the then invisible population of kidney ‘suppliers’.1 Today human trafficking for organs is a small, vibrant and extremely lucrative business that involves some 50 nations.2
No cadavers wanted
In the summer of 2009 I received a phone call that unnerved me.
‘Are you the Organs Lady?’ a young man I’ll call Jim Deal* asked me with a slight tremor in his voice.
‘Perhaps,’ I replied. ‘How can I help you?’
‘I just found out that my kidneys are failing and my doctor wants me to start dialysis immediately.’
‘Yes?’
‘Well, I can’t attach myself to a machine three days a week. I’ve just started a new company and I can’t lose a minute. I need a kidney now. Where can I go to get one? I have the resources. Money is not an object.’
My suggestions to ask his relatives (which included several siblings) were rejected – they were all busy with their careers and families. Would he be willing to take the ‘Steve Jobs option’, registering in multiple transplant centres in different regions of the US, increasing the possibility that his number would be called – Bingo!
The demand for organs outstrips supply
Advances in medicine that keep us alive longer, coupled with rising levels of type-2 diabetes and heart disease, mean that the pool of patients waiting for organs is growing. In any given year, fewer than 1 in 10 waiting for a donor organ will receive one.
At the same time, there are fewer organs from young, healthy people – who make the best deceased donors – due to the life-saving influence of car seat belts. Prolonged end-of-life medical care can also mean fewer usable organs upon death.
Nevertheless, the WHO believes national self-sufficiency through deceased donor organs is possible – efforts to retrieve usable organs from the deceased need to be maximized. Progress in stem cell research, the creation of workable artificial organs and xenotransplantation could help towards meeting the demand in the future.
‘No cadavers,’ Jim said. It would have to be a kidney purchased from a living stranger. Could I recommend a surgeon or a broker who could help? Given his family genealogy, which included a grandparent from Iran, I told Jim that he might be in luck. Iran had the only legalized and regulated kidney selling programme, but it was reserved for Iranian citizens and diaspora.
‘I’m not going to go to Iran, if that’s what you are saying,’ Jim countered. ‘I want First World medicine.’
There was no use trying to convince Jim that Iran had ‘First World’ surgeons. Some weeks later he called to tell me that his family had found several local, willing kidney providers online through Craigslist. He chose the least expensive ‘option’: a kidney from 19-year-old community college student Ji-Hun*, an immigrant from South Korea who could not afford his tuition, books, room and board, and who feared deportation if he dropped out.
The deal was secured for $20,000. The night before the transplant, two very nervous Korean brothers met with Jim’s relatives in an upscale suburb of Los Angeles to count the kidney loot in crisp one hundred dollar bills. An armed guard oversaw the encounter. The seller requested half in advance. The family refused, but they agreed to hand over the money to the seller’s older brother as soon as both parties were under anaesthesia but before they knew the outcome of the organ transfer.
‘Kidney selling is no longer a strange or exotic act. It is normal, everyday, and entrenched’
By the time I arrived at the famous ‘hospital for the Hollywood stars’ in Beverly Hills, the surgery was over and Jim was out of the recovery room and surrounded by well-wishers. His private room was festive with flowers, gifts, smiles and prayers for Jim’s recovery. Nurses popped their heads in and out to see if everything was going well.
It took some sleuthing to locate Ji-Hun, who was tucked away in a corner room several flights above the regular post-op recovery rooms. He was a delicate young man, weighing no more than 55 kilos. He was doubled over with pain, and blushed with shame when I introduced myself to him as an informal ‘kidney donor’ advocate. The nurses tittered anxiously when I presented my calling card with its Organs Watch logo. They told me that Ji-Hun would be released that same day, although he had not yet seen a doctor following his kidney removal. He was worried about returning to his one-room bedsitter apartment in a dodgy section of Los Angeles. Before leaving the hospital Ji-Hun gave me his cell-phone number.
A few days later Ji-Hun reported that he was still in bed, immobilized with pain, and unable to eat, urinate or defecate. His older brother, a surly young man who worked as a dish washer in a fast-food restaurant, was angry with him. He had no medical insurance, and the $20,000, which had been handed over to his brother in a public toilet on the surgical ward, was already all but gone after settling unpaid bills along with student tuition and remittances for their parents in Korea. After a few brief calls, Ji-Hun’s phone went dead.
Jim, anxious about disclosure, emigrated to another country and on last report was married and able to work. The head of the surgical staff of the complicit hospital refused to discuss the case, citing patient confidentiality. The consulting nephrologist who worked shifts at the private hospital contacted me to say that he had seen many other instances of bartered kidneys, but was loath to be a ‘whistleblower’.
While most illicit kidney transplants take place in the so-called developing world – India, Pakistan, Bangladesh, Egypt, the Philippines, and more recently Central Asia and Central America – future transactions are likely to resemble the above story. Facilitated by the internet, organ ‘suppliers’ will be drawn locally from the large pool of new immigrants, refugees and undocumented workers. The transplants will be arranged in private hospitals where the transactions are reported as altruistic, emotionally related donations.
Organized crime
That is the future. For now, transplant tours are more usual. They can bring together actors from as many as four or five different countries, with a buyer from one place, the brokers from two other countries, the mobile surgeons travelling from one nation to another where the kidney operations actually take place. In these instances, and the case of a private clinic in Kosovo is perhaps the best example (see ‘The Medicus affair’), the participants appear and disappear quickly, with the guilty parties, including the surgeons, taking with them any incriminating data. When the police finally arrive at the scene, they discover the bloody remains of a black-market clinic, with traces of forensic evidence, but the key players long since disappeared.
Over the course of more than 17 years of dogged field research, my Organs Watch colleagues and I had realized that we were not dealing with a question of medical ethics. Rather, we had gained entry into the world of international organized crime. Following fieldwork in Turkey, Moldova, the US, Israel, Brazil, Argentina, the Philippines and South Africa, it became apparent that organ brokers were human traffickers involved in cut-throat deals that were enforced with violence, if needed. Many of the ‘kidney hunters’ who seek out new candidates in poor localities are former sellers, recruited by crime bosses.
The transplant and organ procurement traffic is far-flung, sophisticated and extremely lucrative. Although trafficking in human organs is illegal in almost every nation, the specifics of the laws differ, making prosecutions that can involve three or more nations a judicial nightmare. In some countries it is illegal to sell a kidney but not to purchase one. In others it is illegal to buy and sell within the country but not to buy and/or sell abroad.
Organ trafficking made its début as a much-contested add-on to the 2000 United Nations Palermo Protocol on Human Trafficking, which recognizes that even willing participants in underworld illicit kidney schemes can be counted as victims. Indeed, most are coerced by need, not physical threats or force. Some even pay significant amounts of money to be trafficked.
As it is covert behaviour, it is difficult to know with any degree of certainty how many people are actually trafficked for their kidneys, but a conservative estimate, based on original research by Organs Watch, is that at least 10,000 kidneys are sold each year. Human trafficking for organs is a relatively small and contained problem, one that could be dealt with efficiently with the political will to do so.
Complex co-ordination
Unlike other forms of trafficking that unite people from shady backgrounds, the organ trade involves those at the highest – or at least middle-class – levels of society: surgeons, doctors, laboratory technicians, travel agents, as well as criminals and outcasts from the lowest.
Transplant professionals are reluctant to ‘name and shame’ those of their colleagues involved in the trade, thereby creating a screen that conceals and even protects the human traffickers who supply the surgeons. And because trafficking living donors for organs is a traffic in ‘goods’ (life-saving ‘fresh kidneys’) not traffic in ‘bads’ (drugs or guns) there is reluctance, even on the part of the justice system, to recognize the ‘collateral damage’ it inflicts on vulnerable bodies – and the harm to society and the profession of medicine itself.
Organ brokers are the linchpins of these criminal networks, which handle an onerous feat of logistics. They co-ordinate three key populations: (1) kidney patients willing to travel great distances and face considerable risk and insecurity; (2) kidney sellers recruited and trafficked from the urban slums and collapsed villages of the poor world; (3) outlaw surgeons willing to break the law and violate professional codes of ethics. Well-connected brokers have access to the necessary infrastructure such as hospitals, transplant centres and medical insurance companies, as well as to local kidney hunters, and brutal enforcers who make sure that ‘willing’ sellers actually get up on the operating table once they realize what the operation actually entails. They can count on both government indifference and police protection.
Unlike other forms of trafficking that unite people from shady backgrounds, the organ trade involves those at the highest levels of society, like surgeons
The complicit medical professionals perform expert teamwork – technicians in the blood and tissue laboratories, dual surgical teams working in tandem, nephrologists and post-operative nurses.
There are ‘transplant tour agencies’ that can organize travel, passports and visas.
In the Middle East and in the US, religious organizations, charitable trusts and patient advocacy groups are often fronts for such international networks.
Tactics of persuasion
Some brokers in Moldova used underhand tactics that had already been honed in recruiting naïve Moldovan women into sex work. They offered the opportunity of work abroad to unemployed youth, or household heads in debt or in need of cash to support sick spouses or children.
On arrival, the young men were kept in safe houses, had their passports confiscated, and were reduced to total dependency on the brokers (women were exceptions, see ‘My heart weeps inside me’). A few days later, the brokers would break the news that it was not painting or ironing trousers that was needed from the illegal ‘guest workers’ but their kidneys. Those who refused outright were threatened or beaten. One young man, Vladimir*, explained the stark ‘choice’ that faced him in Istanbul: ‘If I hadn’t given up my kidney to that dog of a surgeon, my body would be floating somewhere in the Bosphorus Strait.’
Most brokers, however, offer themselves as altruistic intermediaries promising a better life to donors and recipients. The commonest scenario is of vulnerable individuals easily recruited and convinced to participate in the trade. The pressures are subtle; the coercion hidden.
In Baseco, a dockside slum and notorious ‘kidney-ville’ in Manila, brokers recruit young men (and a small number of women) who are distant kin, related by blood or marriage or informal fosterage.
Ray Arcella, a famous broker from the area, could often be seen with his arm slung loosely around the shoulders of his young recruits, some of whom referred to Ray as their uncle or their godfather. Ray’s less than avuncular advice to his many ‘cousins’ and ‘nephews’ was that kidney selling was the best way of helping out one’s family – since mechanized containers had rendered dock work, once Baseco’s main source of employment, obsolete.
Brokers will hire local kidney hunters – often former sellers – to do the dirty work of recruiting their neighbours and extended family members. In these seemingly consensual transactions, controlling behaviour, fraud and manipulation are well hidden.
The sellers
Kidney sellers are predictably poor and vulnerable: the displaced, the disgraced or the dispossessed. They are the debtors, ex-prisoners or mental patients, the stranded Eastern European peasants, the Turkish junk dealers, Palestinian refugees, runaway soldiers from Iraq and Afghanistan, Afro-Brazilians from the favelas and slums of northeast Brazil, and Andean Indians.
Most enter willingly into a ‘transaction’ in which they agree to the terms, which are verbal, but only realize later how they have been deceived, defrauded or cheated. Few are informed enough to give consent. They do not understand the seriousness of the surgery, the conditions under which they will be detained before and after the operation, or what they are likely to face with respect to the discomfort or immediate inability to resume their normally physically demanding jobs.
Some in the slums of Manila, as in the slums of Brazil, were underage teens who were counselled by brokers to fabricate names and add a few years to their age to make them ‘acceptable’ to the surgeons. Many of those trafficked deny the ‘sale’, saying that what they were paid was too small to constitute a sale for something as ‘priceless’ as a non-renewable body part. In these unconventional transactions, the boundaries between gift, commodity and theft are decidedly blurred.
‘If I hadn’t given up my kidney to that dog of a surgeon, my body would be floating somewhere in the sea’
Male kidney sellers tend to minimize the trauma they experienced to protect their pride. But their reserve often crumbles under gentle but probing questioning of how their lives have been affected. Some male sellers in Moldova denied that they were ‘trafficked’ because the language of trafficking made them sound like female ‘prostitutes’, a stigma they could not live with. Others become obsessed with the kidney sale and attribute all the misfortunes that occurred before or since to that one act of ‘stupidity’.
Among a group of 40 Moldovan kidney sellers we followed from 2001 to 2009, there were deaths from suicide, failure of the remaining kidney, and even from battering by angry villagers who felt that the sellers had disgraced their village. Some were banished from their homes and disappeared.
The brokers
The brokers, who may be transplant surgeons, or organized crime figures, co-ordinate transplant tour junkets that bring together relatively affluent kidney patients from Japan, Italy, Israel, Canada, Taiwan, the United States and Saudi Arabia with the impoverished sellers of healthy organs.
Transplant brokers and organ traffickers are ever more sophisticated, changing their modus operandi, realizing that their engagements with public and private hospitals in foreign locations are severely time-limited. Israeli brokers, for example, recently confided that they either have to pay to gain access to deceased donor pools in Russia or Latin America (Colombia, Peru and Panama in particular), or they have to set up new temporary sites and locations (Cyprus, Azerbaijan and Costa Rica) for facilitating illicit transplants quickly and for a short period of time, already anticipating police, government and/or international interventions. They are always prepared to move quickly to new locations where they have established links to clandestine transplant units, some of them no more sophisticated than a walk-in medical clinic or a rented ward in a public hospital.
The buyers
Transplant tourists are a varied but determined and risk-taking population, willing to travel to ‘parts unknown’ to purchase a stranger’s kidney. They pay for a package deal; they do not know – nor do they want to know – the exact price that will be paid to the person who will deliver their fresh kidney. They do want to know whether the purchased organ will come from a healthy person, an educated person, a person of acceptable race and ethnicity. (Ethnicity matters to them because it might signify a ‘closer’ or a ‘better’ match.) They want a kidney that has not had to work hard for a living, and they want their surgeon to make sure they get access to the seller’s healthiest kidney.
There is a preference for male donors between the ages of 20-30 years. Transplant tourists are asked to pay a great deal of money – normally somewhere between $100,000 and $180,000 – of which the sellers receive a mere fraction.
Some buyers refuse kidneys from women, expressing a kind of old-fashioned chivalry, others an old-fashioned sexism. Men are by far the greatest purchasers.
In 2010, I was paid a visit by a sixty-something man from southern California who insisted on setting me straight on certain matters. David* wanted me to know what it felt like to be in his shoes. ‘Dialysis is like a living death,’ he said. ‘You get cataracts, problems in your gut, you can hardly eat. You lose your libido, you lose the ability to relieve yourself until finally you stop urinating altogether. You lose your energy, you become anaemic, and you are cold all the time. You get deeply depressed.’
He was put into contact with a surgeon and his broker in Tel Aviv, who required him to settle the entire package – $150,000 – in advance for a transplant at an undisclosed location. Putting his fate in their hands, David travelled to Israel, and following cursory medical exams, he flew with the Israeli surgeon and his broker on to Istanbul where they picked up a second surgeon. ‘One takes out and the other puts in,’ was the simple explanation. Only in Istanbul was David told that his transplant would take place in Kosovo, a country he knew nothing about. The day before flying there, the broker announced that police had broken into the Medicus Clinic in Pristina, and that the planned transplant there was now unavailable. However, he was willing to offer, at a cut-price rate, another option that had opened up in Baku, Azerbaijan. And that is where David finally received his kidney, from a seller from Central Asia.
The new generation
Following the Istanbul Summit in 2008, the Declaration of Istanbul Custodian Group was instituted. For the last eight years, it has been working closely with The Transplantation Society, the World Health Organization (WHO), and a vast network of transplant professionals to negotiate with public health and other government officials to create new laws to encourage deceased donor programmes, promote transplant self-sufficiency within nations, and discourage transplant tourism. It has also exerted pressure on hospitals to stop sheltering the outlier surgeons who perform transplants involving foreign patients and trafficked kidney suppliers.
But illicit transplant trafficking schemes remain robust, exceedingly mobile, resilient and generally one step ahead of the game.
The new generation of organ traffickers is also more ruthless. During the Beijing Olympics, brokers had their supply cut off after foreign access to organs harvested from executed Chinese prisoners was shut down. Undeterred, they began to pursue transplants from living donors, some of them trafficked Vietnamese, others naïve villagers in parts of China where blood-selling programmes had groomed people to accept kidney selling as another possibility.
The sites of illicit transplants have expanded within Asia, the Middle East, Central Asia, Eastern Europe, Central and Latin America, Europe and the United States. As for the recruitment of kidney sellers, they can be found in almost any nation. One crisis after another has supplied the market with countless political and economic refugees who fall like ripe, low-hanging fruit into the hands of the human traffickers.
Prosecutions are difficult. In most instances a few culprits, usually lower-ranking brokers and kidney sellers, are convicted. The surgeons, without whom no organ trafficking crimes can be facilitated, and the hospital administrators often escape, pleading ignorance.
The famous Netcare case in Durban, South Africa, is a case in point. A total of 109 illicit transplants were performed at Saint Augustine’s Hospital, including five in which the donors were minors. A police sting resulted in several plea bargains from various brokers and their accomplices. Netcare, the largest medical corporation in South Africa, pleaded guilty to having facilitated the transplants. The immediate result was the plummeting of Netcare stocks.
The four surgeons and two transplant co-ordinators who were indicted held fast to their not-guilty plea. Their defence was that they had been deceived by the company and its lawyers, who had stated these international surgeries were legal. In December 2012, they were given a permanent stay of prosecution and the state was ordered to pay their legal costs. It is fair to state that rogue transplant surgeons operate with considerable immunity. This is unfortunate because they constitute the primary link in the transplant-trafficking business.
A victimless crime?
Because human trafficking for organs is seen to benefit some very sick people at the expense of other, less visible or dispensable people, some prosecutors and judges have treated it as a victimless crime.
When New Jersey federal agents caught Levy Izhak Rosenbaum, a hyperactive international kidney trafficker who had sold transplant packages for upwards of $180,000, the FBI had no idea what a ‘kidney salesman’ was. The prosecutors could not believe that prestigious US hospitals and surgeons had been complicit with the scheme, or that the trafficked sellers had been deceived and at times coerced. The federal case ended in a plea bargain in 2011 in which Rosenbaum admitted guilt for just three incidents of brokering kidneys for payment, although he acknowledged having been in the business for over a decade.
At the sentencing in July 2012, the judge was impressed by the powerful show of support from the transplant patients who arrived to praise the trafficker and beg that he be shown mercy. The one kidney-selling victim, Elhan Quick, presented as a surprise witness by the prosecution, was a young black Israeli, who had been recruited to travel to a hospital in Minnesota to sell his kidney to a 70-year-old man from Brooklyn. Although Mr Cohen had 11 adult children, not one was disposed to donate a life-saving organ to their father. They were, however, willing to pay $20,000 to a stranger.
Transplant tourists are a varied but determined and risk-taking population, willing to travel to ‘parts unknown’ to purchase a stranger’s kidney
Quick testified that he agreed to the donation because he was unemployed at the time, alienated from his community and hoped to do a meritorious act that would improve his social standing. On arrival at the transplant unit, however, he had misgivings and asked his ‘minder’, Ito, the Israeli enforcer for the trafficking network, if he could get out of the deal as he had changed his mind. These were the last words he uttered before going under anaesthesia.
His testimony had no impact. The judge concluded that it was a sorry case. She hated to send Rosenbaum to a low-security prison in New Jersey for two-and-a-half years as she was convinced that deep down he was a ‘good man’. She argued that Elhan Quick had not been defrauded; he was paid what he was promised. ‘Everyone,’ she said, ‘got something out of this deal.’
Closing down the networks
Convicted brokers and their kidney hunters are easily replaced by other criminals – the rewards of their crimes ensure that. Prosecuting transplant professionals, on the other hand, would definitely interrupt the networks. Professional sanctions – such as loss of licence to practice – could be very effective. Outlaw surgeons and their colleagues co-operate within a code of silence equal to that of the Vatican. International bodies like the UN and the EU need to take concerted action on the legal framework in order to prosecute these international crimes.
Prosecutors look kindly on kidney buyers because they are sick and looking to save their lives. But buyers have no qualms about taking a kidney from deprived persons without any medical insurance, any future, and sometimes no home. They have to be made accountable.
Until we can revolutionize the practice of transplantation, a case needs to be made for a more modest medicine that realizes our lives are not limitless. This is a difficult message to convey when transplant patient advocacy groups and religious organizations have sprung up demanding unobstructed access to transplants and to the life-saving ‘spare’ organs of ‘the other’, as if this were a moral crusade.
The kidney is the blood diamond of our times. The organ trade is one of the more egregious examples of late capitalism where poor bodies are on the market in the service of rich bodies.
Organs Watch was co-founded with Lawrence Cohen. They are both professors of medical anthropology at the University of California, Berkeley, who had made initial anthropological forays into the various sites where illicit transplant operations were arranged. Over the years they have been joined by a number of independent medical human rights activists from the countries in which they have worked. ↩
As identified by Organs Watch, WHO, The UN Office on Drugs and Crime and the Declaration of Istanbul Custodian Group. ↩
