Saturday, February 23, 2008

Health: South Asia hub of international trade in human organs

By Sandhya Srinivasan (IPS)

The arrest of ‘Doctor Kidney’ Amit Kumar for running a sizeable racket in live kidneys has highlighted the role that South Asia plays as the hub of an international trade in human organs.

A sophisticated but unregulated healthcare industry, a "donor pool" of desperately poor people ready to sell a kidney and a corrupt monitoring system have combined to create a special brand of ‘medical tourism’ in the region, especially in India and neighbouring Pakistan.

While India's Transplantation of Human Organs Act (THOA), 1994, is observed mostly in the breach, the impact of Pakistan's Transplantation of Human Organs and Tissues Ordinance passed in 2007, is yet to be gauged. Till last year, the organ trade was legal and flourished openly in that country.

Top transplant surgeons are collaborating with criminal organ trafficking networks to target the desperate, noted Nancy Scheper-Hughes, founding director of Organs Watch, an academic research project at the University of California, Berkeley, United States while speaking at the Vienna Forum to Fight Human Trafficking in February.

"The latest arrests reveal a global network larger in scale than any other one," said Dr Samiran Nundy, gastroenterological surgeon at the prestigious Sir Gangaram Hospital in New Delhi. Nundy was one of the architects of India’s transplantation laws that should have put an end to paid transplants in this country. The THOA was the result of activism by a small group of conscientious medical professionals appalled by the trade.

Kumar is accused of luring poor labourers to his ‘hospital’ in the New Delhi suburb of Gurgaon with promises of job offers or large sums of money. Typically, they were promised Rs 300,000 (7,500 US dollars) but paid only Rs 30,000 (750 dollars) after the surgery, police said.

He is alleged to have conducted more than 500 transplants over an unspecified period, charging up to Rs two million (50,000 dollars) for each operation. Investigators say his patients came from Britain, the United States, Turkey, Nepal, Dubai, Syria and Saudi Arabia.

The racket first came to light on Jan. 24 when police raided Kumar's hospital following a complaint by a ‘donor’ who had been paid less than the amount promised. At his hospital police found recipients recovering from surgery and arrested a number of doctors, nurses and support staff.

"Under the THOA, the powers to investigate and take action lie with the authorisation committee," says Chennai-based surgeon Dr George Thomas, editor of the Indian Journal of Medical Ethics, who has campaigned against the kidney trade. "However, this usually consists of government doctors without the infrastructure to investigate infringements. Many hospitals where these transplants take place are linked to politicians. And members of the authorisation committee never complain to the police."

A series of investigations by the newsmagazine ‘Frontline’ has documented the extent of kidney trade in various states of India, with "donors" drawn from the poorest parts of the country. State authorisation committees have approved almost all the hundreds of applications for unrelated donations for "reasons of affection" despite clear evidence that money had changed hands.

"But Amit Kumar did not even use the legal loophole of pretending that the donors were donating out of affection for the patient," says Thomas. "He did not even bother to seek permission from the authorisation committee to perform these unrelated transplants as required by THOA."

The kidney trade requires the collusion of highly trained surgeons. Kumar was the organiser of the enterprise and seems to have either hired or partnered with surgeons and other medical personnel. He had contacts all over the world who directed patients needing transplants to him, and a network of brokers all over India who ensnared poor people into parting with a kidney with promises of large rewards.

THOA was meant to stop kidney trading, and is "one of the most important pieces of medical legislation in India," said Nundy. But "to a certain extent it has been a failure though trading is much less than it was before the law."

Pakistan’s laws, passed last year, has been criticised by some as inadequate.

"The ordinance came about after a struggle by professionals, civil society and the media for almost two decades against a strong pro-organ trade lobby," explained Dr Farhat Moazam, professor and chairperson of the Centre of Biomedical Ethics and Culture at the Sind Institute for Urology and Transplantation (SIUT), Karachi.

Moazam was part of the campaign to get the law passed against what she prefers to call organ "trafficking" rather than the more neutral "trade". "I believe it is a step in the right direction. But it needs to be strengthened in some areas and also implemented honestly and transparently if it is to work,'' she said in an e-mail interview with IPS. She notes that the Indian law was ''a moral victory, an important statement by (Indian) society, and it has given the teeth to go after those involved in this racket. Of course, no law completely eliminates the practice''.

In 2003, SIUT estimated that a little over 2,000 kidney transplants were done in Pakistan every year, said Moazam. Eighty percent were from unrelated donors, and, of these, almost two-thirds were done on patients from outside Pakistan.

The 2007 ordinance makes it mandatory for institutions doing transplants to register and be monitored, prohibits and provides punishments for commercial dealings in human organs as well as donation by Pakistani citizens to 'citizens of other countries'.

However, 'donation' by non-related individuals is permitted if it is 'voluntary', a term Moazam views as "vague" and prone to abuse. She also notes that since spouses may donate "sham marriages are inevitable in an androcentric society." Finally, the same problems of corruption in giving permission for non-related "donations" exist as in the Indian law.

Though India's THOA permitted the transplant of organs from cadavers by recognising brain death, doctors estimated that fewer than 600 organ transplants between 1994 and 2003 were cadaver-based. On average 2,000 transplants are recorded in India annually.

One reason that the cadaver transplant programme has not developed in India is that the lucrative trade in live "donations" has not been checked. Other reasons are a lack of infrastructure and public awareness. "We need the infrastructure and regulations to harvest organs from smaller hospitals, we need more publicity about cadaver donation, people don't know what brain death is, and that organs can be harvested from the brain dead," says Nundy.

"There is a poor understanding of brain death even among medical professionals," says Thomas. "We also need a system to seek and obtain consent from relatives of brain dead people. What is needed is a social movement for organ donation."

One option to increase the number of cadaver organs is the "presumed consent" policy followed by Spain, which has 31.5 donors per million population (compared to 21.2 in the U.S., 16.9 in France and 16.7 in Portugal). Every citizen is considered a donor unless he or she specifically opts out. "I would prefer the 'opt in' policy in India at present because the poor and less literate will not know that they can opt out," says Thomas.

"Development of deceased donor programmes at least in some of the major institutions to supplement living organ donation is absolutely essential to address the needs in Pakistan," said Moazam. "But this will require raising public and professional awareness, and education."

In Pakistan, only the SIUT has carried out deceased, or cadaver donor, kidney transplants, and of the 20 such transplants only six were from deceased Pakistanis. The rest were flown in from the Netherlands through a special arrangement with a transplant association there.

In 2007 the World Health Organisation estimated that 10 percent of all transplants involved patients from developed countries travelling to poor countries to buy organs. They depended on local agents who "sourced" kidneys and arranged the transplant. At least 15,000 kidneys are believed to be trafficked in this way each year. While there is evidence of people being forcibly deprived of a kidney, clearly most "donors" are people in desperate need for money.

"In my opinion, organ trafficking involves societal and global issues that must be discussed within the broader paradigm of global injustices," said Moazam. "It must be a debate about communities of one kind of people being systematically exploited by communities of other kinds, both internationally and intranationally."

"This is exploitation of the worst kind, where you want to remove a body part of the poor to help a rich man survive,’’ said Nundy.

Original article: HEALTH-SOUTH ASIA: Hub For Global Organ Trade
Reproduced with permission of and www.ipsnews.netCopyright © 2008 IPS-Inter Press Service