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On the 'Fast Buck' Trail: Kidneys on Sale

“Many have made a trade of delusions and false miracles, deceiving the stupid multitude”

……………. Leonardo da Vinci

The booming kidney trade in India is a cause of great concern due to its socio-economic, ethical and medico-legal overtones.

In the city of Chennai in South India, a nefarious trade has been evolving on par with the metropolis’ growing economy. The police had recently busted a flourishing racket, dealing in the most ‘sought –after’ transplant organ--Kidneys. The racket involved a wide network of brokers, possibly a few unscrupulous health care professionals and impoverished donors drawn from the poverty-ridden community of tsunami survivors. They were catering to patients across several hospitals in Tamil Nadu, many of whom came from other Indian states and some from abroad. This ‘one-way’ trade involving the poor, selling their kidneys to rich patients is undoubtedly a cause of great concern for this developing nation.

Kidney transplants are closely linked with exploitation and abuse, the world over. In another Asian country, Japan, some nationals were reported to have employed gangsters to ‘persuade’ people in neighboring countries to part with their kidneys. One such gang was even known to have established ties with a major medical centre in Boston in the US.

In China, organs are harvested from an ever-increasing number of executed prisoners, while in Brazil, Argentina and S.Africa organs are removed from the dead bodies of the poor with scant regard for the sentiments of their kin. If the wages of sin is death, then the wages of poverty is to sell one’s kidney

Kidney Vending For ‘Transplant Tourists’

Kidney donation began, for all intents and purposes, with altruistic considerations by close relatives of affected individuals. However, with time, the supply of organs through living, related donors o r cadavers failed to meet the burgeoning demand. Several studies have confirmed that the survival rate, after a kidney transplant from a living unrelated donor, far exceeded that from a cadaver .A combination of all these factors initiated the organ trade boom.

Kidney vending has a legal shroud in some nations, while in others it is illegal. Corruption is widespread in countries where kidney transplants are linked to commerce. In several countries there is an acute shortage of kidneys due to the existing laws and due to the high standards that prevail in the implementation of these laws. But such a situation is often transformed into a boom in the organ trade in the neighboring countries. People who need a kidney transplant are willing to travel great distances to acquire the organ, in order to add a few more years to their fading lives.

Therefore patients who are in dire need of a transplant, travel to developing countries such as India - where the kidney trade has prospered, thanks to the perilous combination of trained medical personnel who are willing to compromise on ethics, a large population living on the edge of poverty and a system that makes a mockery of the laws or the lack of it. All these features have blended well to make India the ‘Kidney Trade Center’ of the world. Other Asian countries such as Pakistan, Philippines, China and Taiwan too indulge in this organ trade.

Law and its Loopholes

Several kidney rackets have been busted in the past years after the media played a major role in highlighting the exploitation of the ignorant masses under dubious circumstances. The Indian Government banned kidney trafficking and passed an Act in 1994 whereby an unrelated individual may donate, provided there is no commercial angle to the donation. Sub Clause (3) under Clause 9, Chapter II of the Transplantation of Human Organ Act reads as follows :

‘If any donor authorizes the removal of any of his human organs before his death under sub-section (1) of section 3 for transplantation into the body of such recipient, not being a near relative as is specified by the donor, by reason of affection or attachment towards the recipient or for any other special reasons, such human organ shall not be removed and transplanted without the prior approval of the Authorization Committee.’

It is the highlighted part of the clause that creates the required loophole and allows exploitation of the donors by the middlemen. The act clearly defines that the final authority for any sanction rests with the government - constituted authorization committee.

However measures are taken, by vested interests, to work around the law. Affidavits are manipulated to affirm that the kidneys were donated out of ‘love and affection’ for the recipients whom, ironically, in most instances, the donors hardly know. When one area comes under public or police scrutiny the entire activity shifts its base from the ‘hot spot’ to more discreet locales to ensure that the kidney trade continues unabated. It certainly does not require a genius to understand the underlying currents that are now inherent to the trade.

Myth –Buster

It has been argued that paying the donor benefits both the recipient and the donor. The recipients are ensured of a steady supply of kidneys, while it is widely believed that the donors’ economic status receives a ‘shot in the arm’. What actually happens is, perhaps, more interesting than what is actually perceived.

Although the overall survival rate has increased significantly over the past decade, kidney transplantation is riddled with perils. A survey was conducted on a cross section of donors in Chennai, who had traded their kidneys six years before the study. Needless to say, all these individuals came from the economicall y –challenged strata of the society. Some interesting facts that emerged from this survey are featured below:

? The majority of the donors admitted that no altruism was involved in their kidney donation

? Average money received by a donor was equal to 1070 US dollars

? 96% of these donors donated their kidneys to pay off debts

? In many parts of India, kidneys are used as collateral to borrow money

? Besides debts, most of the money went to procure food and clothing

? Average family income plummeted by 1/3, after the nephrectomy

? Number of donors and their family members who lived below the poverty line increased

? Six years after the surgery, during the survey, these donors continued to live in poverty

? 86% of donors complained of deterioration in their health conditions

? 79% pointed out that they would not recommend that others donate their kidney

This study has indeed busted the myth that the economy of the donors received a boost after they were compensated financially for the kidney donation. The survey also points to the fact that the members of the authorization council failed miserably in their role of being the Government’s ‘watch dog’.

Similar problems haunt many developing countries in Asia, Europe, Africa and South America with the organ trade flourishing in violation of national laws, cultural and religious sanctions.

A survey conducted by Nancy Scheper-Hughes, an anthropologist, revealed that kidney vending has developed along the lines of class, gender and race. She refers to the global trade in human organs as the “new cannibalism."

Lawrence Cohen, a medical anthropologist from Berkeley, who worked in the south and western regions of India for his book on kidney trade found that, periodic kidney scandals involving doctors were mostly stories co ncocted by rival hospitals. The rumors were a part of the competitive commercialization that was an aspect of the trade. In fact, there was no need to ‘trick people’, since enough kidneys were readily available from the poor.

Vending ‘Blues’

This feature aims to draw the reader’s attention to the following issues that are now permanently associated with kidney vending:

? It is a public secret that the promised ransom never reaches the donor as a sizable portion goes to the middlemen

? When money becomes the motivating factor for the donation, crucial information may not be forthcoming and several guidelines may not be adhered to

? The medical history of the donors or their close relatives, high-risk sexual habits of the donor etc, are not satisfactorily considered

? As a result, reports are rampant on the rising incidents of health complications, such as HIV, Hepatitis or fungal infection, among recipients. This draws attention to the inefficiency of the existing screening and selection procedures

? The rate of infection is higher in Countries like India, China and Brazil which rely on live donors than in USA, Western Europe and Canada which depend on cadavers

? The high-cost of immuno-suppressant drugs like cyclosporine, which are quintessential to the recipient after a transplant, could be an economical burden on the them. Most often they are not fore- warned

? The donors are not forewarned of the intrinsic risks involved in kidney donation, even if the procedure is performed by the most competent surgeon

? There are no appropriate follow-up procedures for either the donors or the recipients

? The donors are discouraged from visiting the hospital after the surgery. Sadly, a high rate of morbidity is reported in these individuals, post surgery

? Several donors suffer from depre ssion, especially after their health deteriorates and the ‘new- found’ money runs out

? The health and social issues concerning the donors are not satisfactorily addressed

? Several instances have been reported of wives being coerced into selling kidneys, because their husbands have eyed the ‘booty’

? Due to the commercial overtone, many hospitals fail to produce relevant documents related to the kidney transplants

Silver Lining

A monitoring body called the ‘Organ Watch’ was kick started by University professors, two of whom are from UC at Berkley and the other two from the University of Columbia.

The main aim of this body is to act at a global level and investigate reports and rumors on kidney trafficking, and also to probe into the human rights issues associated with it. They will also be engaged in identifying ‘hot spots’, besides defining the line between an ethical transplant and an exploitative one.

These activists also hope to reform national and international laws governing organ transplant. They are funded by a 2-year grant of 230,000 US dollars provided by the Soros’Foundation Open Society Institute. An additional 160,000 US dollars has been granted by UC, Berkley.

Destination India-No pain, No Gain

While there is large-scale sympathy for those patients who die while waiting for a kidney transplant, it is vital to convert the sympathy into remedial measures by assessing the prevailing situation carefully. By banning kidney vending, the Indian government has lifted the lid off the Pandora’s box. It has failed, not only to stop the illegal trade of kidneys, but also to address the ethical, socio-economic, and health issues associated with it. Values have buckled under the pressure of desperacy and demand. In spite of this dismal scenario, six transplant centers have taken shape in southern India and the trade is better than never before.

Educating the general public, especially the donors, in all aspects of kidney donation is paramount to ushering in reforms in the practice of this medical procedure. It is also vital to screen and evaluate both the donor and the recipient carefully, to avoid post surgery ‘hiccups’. The Government must consider either legalizing the transactions related to kidney donations and take the rein of control from unscrupulous elements or ban it completely. There is an urgent need to plug the loopholes in the existing laws. Governmental ‘watch dogs’ must not ‘bark up the wrong tree’ and must be made accountable for every action or, rather, inaction.

The demand for kidneys and other solid organs in India can be met by the vastly untapped pool of brain- dead patients who are languishing in the critical care units. The high incidence of deaths due to road traffic accident only adds to the number of the brain- dead. The need of the hour is to explore the possibilities of tapping this pool of potential organ donors as is done in the western world. In the past decade, 1200 transplants have been performed in India from such brain- dead donors.

The American Medical Association (AMA) , is pondering over the possibilities of providing monetary incentive to encourage people to bequeath their organs to their heirs or for charity. This would no doubt widen the pool of potential donors, but serious study must examine the feasibility of this proposal against various socio-cultural and ethnic backgrounds.

At a time when India, with its vast repertoire of able professionals, is becoming a destination for medical tourism, caution must be exercised to nip unhealthy practices even as it sprouts, in order to avoid a situation that might get copletely out of hand.

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