The Red Market (15 page)

The child was delivered to the customer according to contract, and the fertility clinic denied any wrongdoing. But in a police complaint the husband suggested that the clinic had essentially dumped responsibility for his dying wife. The official investigation was perfunctory. When I contacted the clinic through e-mail, it took almost half a year to get a response. A doctor from the center wrote that Easwari “developed a severe disseminated intravascular clotting defect,” because the child’s head was too large. The doctor, who identified himself as Arun Muthuvel, added that the team was unable to save her life despite tearing through seven bottles of blood and calling in additional surgeons. Whether Easwari could have been saved remains a question that only a thorough investigation might hope to answer. However, nobody has the authority to examine such cases, which means that in instances of malpractice patients generally have to take the hospital’s word that everything happened according to the highest medical standards. India’s Parliament, however, is in the process of crafting legislation to address some of the concerns about surrogacy. The bill could be ready for formal consideration sometime around the end of 2011, but it is not clear which agency would be charged with enforcement.

Any regulatory oversight would likely fall to the states, yet pinning someone down in the government to comment on what department might be able to examine or regulate fertility clinics now is like playing a seemingly endless game of hot potato. It took six visits to different offices in Gujarat’s bureaucratic center and phoning three different ministers to get even half an answer: “At the state level, no one looks at surrogacy,” says Sunil Avasia, Gujarat’s deputy director of medical services, in a short interview.

When it comes to ethical conduct, it might as well be the Wild West. Forget laws, he says. “There are no rules.” That’s all he has to offer on the subject. “Perhaps you should talk to my boss,” Avasia says. Alas, the boss never returned my calls. Nor has there been an effort to regulate surrogacy contracts on the receiving end. So long as a surrogate infant has an exit permit from the Indian government, the process for getting the baby an American passport is straightforward.

FOR THEIR PART, PATEL’S
customers view the residency program as an insurance policy of sorts. “When I was told by my doctor they could get someone in Stockton, [California,] I don’t know what they’re eating, what they’re doing. Their physical environment would have been a concern for me,” says Ester Cohen, a forty-year-old from Berkeley who runs a catering company with her husband and teaches Jewish ethics lessons to children on weekends. “The way they have things set up here is that the surrogate’s sole purpose is to carry a healthy baby for someone.”

I met Cohen in the hallways of the Laksh Hotel, which caters to Akanksha’s surrogacy tourists. For many, this Indian excursion represents the final stage of an expensive and emotionally fraught quest for parenthood—their last, best option after a series of failed fertility treatments. Cohen tried for years to conceive, and after extensive testing was told she never would. Adoption didn’t appeal to her. Then she read a news article about Patel and knew immediately that she wanted to come to Anand. “Money was definitely one of the reasons, but it was like my gut feeling,” she says. “This is where I needed to be.” Cohen and her husband decided to keep their undertaking secret from friends and neighbors—at least until they returned home with a baby.

In the United States, a surrogate and her client must establish a relationship before coming to a fertility clinic, but Cohen has barely met Saroj, the woman Akanksha hired to carry her child. They connected just once at the clinic a few minutes after embryos from donor eggs fertilized with her husband’s sperm were implanted in Saroj’s uterus. That was nine months ago. Cohen has been back in Anand three days now but hasn’t gone to visit Saroj. “The clinic wants to keep a separation,” Cohen says. “They want it to be clear that this is what her job is: She’s the vessel.”

But this is where the ethos of commercial surrogacy becomes confusing. Cohen is quick to add that Saroj is giving her one of the most precious gifts one human can offer another. “The clinic won’t let someone be a surrogate more than twice, because they don’t want them to be just a vessel,” she says. “That shouldn’t be a job.”

Then how to view it? Oprah showcased Jennifer and Kendall, a childless couple who had tried everything else but couldn’t afford the American surrogacy system. With Patel’s help, Jennifer became a mom, and an Indian woman was lifted from poverty—a transaction that was part business and part sisterhood. The clinics also frame surrogacy this way, insisting that the women offer their wombs out of a sense of communal responsibility, not simply because they need a paycheck.

OVER $8 COFFEES AT
a swank hotel, Amit Karkhanis, one of Mumbai’s most prominent surrogacy lawyers, explains that this language of altruism gives clinics the upper hand in pay negotiations. Meanwhile, the contracts signed by clinic, client, and surrogate are vague about what type of service is being provided. “Is it work? Is it charity?” Karkhanis asks rhetorically, cocking one eyebrow before offering his own opinion: “Surrogacy is a type of employment, plain and simple. Foreigners are not coming here for their love of India. They are coming here to save money.” And if surrogacy is being treated as a job, then why aren’t women getting market rates for their time in the hospital?

While both cost of living and earning potential are far lower in India than in America, it is still possible to compare the relative pay for surrogates and clinics on either side of the globe: An American surrogate typically gets half to three-quarters of the total paid by the couple, while Akanksha’s surrogates receive one-quarter to one-third of the total. Lawyer Usha Smerdon, who runs Ethica, a US-based adoption reform group, told me in an e-mail: “Surrogacy is a form of labor. But it’s an exploitative one, similar to child labor and sweatshops driven by Western consumerism. . . . I challenge the notion that within these vastly different power dynamics surrogates are truly volunteering their services, that hospitals are operating aboveboard when driven by a profit motive.”

Besides India, only a handful of countries—the United States, Belgium, Canada, Israel, and Georgia—allow surrogacy for pay, and most of those have imposed strict regulations. France, Greece, and the Netherlands forbid even unpaid arrangements, and no country, not even India, recognizes surrogacy as a legitimate form of employment. America leaves regulation to the individual states: Eight recognize and support it, and have mandated health safeguards and counseling for surrogates. Six have banned it outright. And the rest have either deemed surrogacy contracts unenforceable, left surrogacy for the courts to deal with through case law, or simply ignored the practice. India’s Council on Medical Research has come up with proposed surrogacy guidelines that caution against some practices already in common use in Anand and elsewhere, such as allowing the clinics to broker surrogacy transactions. But these nonbinding rules, considered a starting point for national legislation, ignore other glaring ethical issues, such as whether it’s okay to impose C-sections on a surrogate. Or whether keeping surrogates cloistered under strict medical supervision violates a fundamental principle of personal liberty.

Implantation is another dicey issue. For healthy young women, the American Society for Reproductive Medicine advises American doctors to implant just one—and certainly no more than two—embryos in a woman’s uterus per attempt. The Indian guidelines recommend no more than three for surrogates. But Patel’s clinic routinely uses as many as five embryos at a time. Using more embryos boosts the success rate but also results in multiple births, which are far riskier for the woman and often lead to premature delivery (by C-section) and dire health problems in the infants. Although it’s impossible to verify, Akanksha claims an implantation success rate of 44 percent (similar to other Indian clinics), compared to a US norm of 31 percent. Several of the surrogates I met in Anand were pregnant with twins. In cases where three or more embryos take, the Akanksha clinic selectively aborts specific embryos to bring the total down to more manageable levels. They do this often without asking permission of the intended parents or the surrogates.

India’s surrogacy guidelines are also silent on the issue of locking down the women, a practice lawyer Karkhanis believes is illegal. “The Anand model is completely flawed,” he tells me. “Holding surrogates like that is unlawful confinement under the Indian Penal Code.”

While the guidelines clearly state that “the responsibility of finding a surrogate mother, through advertisement or otherwise, should rest with the couple,” Akanksha advertises far and wide for surrogates in local-language newspapers, and many hospitals have responded to demand by hiring headhunters.

AT MUMBAI’S IMPOSING HIRANANDANI
Hospital, physician Kedar Ganla introduces me to a gaunt woman named Chaya Pagari who is his direct line to the slums. The forty-year-old “medical social worker,” as Ganla calls her, sits uncomfortably in his office and meets my questions with hesitation. Given her sparse résumé, “recruiter” would be a more apt title. Ganla pays Pagari
75,000 (about $1,750) for each surrogate he accepts. He’s already accepted three this year, she tells me—meaning she’s making more than the women she recruits. “Between us brokers,” she adds, “there is near constant competition to find surrogates.”

Dr. Anoop Gupta does things a bit differently. He runs Delhi-IVF, the clinic where I met California customer Kristen Jordan, and where his waiting room is packed with chatty patients. Next to Akanksha’s Spartan vibe, it is night and day, with wood-paneled walls and a brightly lit aquarium exuding a sense of security and warmth usually lacking in Indian medical facilities.

Clad in green scrubs and a blue hairnet, Gupta is always on the move and has little time for questions. Instead, he has me observe a constant stream of patients who have come to him from as far away as Ireland and California, or from as close as a few blocks away. While most are here for routine fertility treatments, Gupta has at least seven surrogates on the rolls this month. “In India the government makes it difficult to arrange an adoption, while having your own genetic child through a surrogate is legal and easy,” the doctor says as he slathers a clear gel on the paddles of an ultrasound machine.
¹⁵
The only hurdle, as he sees it, is finding a surrogate who isn’t motivated by desperation. For this, he relies on Seema Jindal, his medical coordinator, who is a licensed social worker and registered nurse at the clinic. Her recruiting method has a twinge of evangelism: “I ask just about every woman I meet socially if she has thought about surrogacy.” She focuses on women who have completed college and are well-off enough not to have to rely on the clinic’s payments for basic needs. Otherwise, she says, “how do they know they are not being exploited?”

Several months before our interview, Jindal confides, she took a train to Gujarat to snoop on Patel’s operation firsthand, both to glean trade secrets that might make her own clinic more profitable and to scrutinize its flaws. In her view, the residency program treats women like livestock. For the entire length of their pregnancy they only do three things. “They sit, they talk, and they sleep,” she says. “It’s just not right.”

One of Jindal’s recruits, a thirty-two-year-old social worker named Sanju Rana, is here for her ultrasound. Unlike Patel’s surrogates, she is college-educated and plans to work full-time throughout her pregnancy. She’s been promised $7,500 for her services, and has Gupta’s direct phone number. During the procedure, Rana, already a mother of two, is surprised to learn that she is carrying twins. She’s worried, she tells me, but will most likely carry them to term. “They are good people and have been childless for so long,” she says of the American couple who hired her.

Like every other market in human tissue, surrogacy blends notions of altruism and humanistic donation with the bottom line of medical profitability. Expanding the market for surrogate mothers to India certainly allows more Western women to have access to a medical procedure that they would have otherwise been priced out of. However, the new market is simply passing the bill down the line. Before India, only the American upper classes could afford a surrogate. Now it’s almost within reach of the middle class. While surrogacy has always raised ethical questions, the increasing scale of the industry makes the issue far more urgent. With hundreds of new clinics poised to open, the economics of surrogate pregnancies are moving faster than our understanding of its implications.

The red market for new children spans the distance between questionable practices in adoption, egg donation, and surrogacy. All three businesses are tied together by our most basic desires for reproduction and raising a happy family. As customers, the intended parents are often unaware of the complexities of the supply chain and can easily enter into dangerous territory unintentionally. All three markets for children are expanding at unprecedented rates, making it easier than ever to buy a child on the red market.