The Red Market (8 page)

One of Rani’s friends had sold her kidney a year earlier and told her that a broker named Dhanalakshmi ran a tea shop outside of Devaki Hospital in Chennai as a front for her real business: proffering organs on the black market. Dhanalakshmi gave Rani $900 up front to cover her daughter’s expenses and promised $2,600 more when the procedure was over. Dhanalakshmi made it clear that if Rani backed out, thugs on her payroll would sort out the situation with violence.

Before the transplant, Rani gave blood and urine to prove that she was a match for the buyer, who was a wealthy Muslim woman. When her blood work passed muster she was sent to the city’s General Hospital to pass an ethics review by the Transplant Authorization Committee.

Responsible for ensuring that all transplants are legal and unpaid for, the committee is authorized to oversee and stop kidney rackets from forming in the first place. Despite its noble aims, the committee rarely lives up to its charter and routinely approves illegal transplants through brokers. Its members are meticulous about covering their tracks, and give the procedures every appearance of legality. As long as the committee hearings proceed along a mutually understood pantomime between organ sellers and buyers, the committee can say that it did everything it could to ensure the transaction was ethical. After all, everyone who appears before the committee is under oath to tell the truth. Rani’s broker had coached her to speak only when spoken to, hand over a packet of forged papers, and then leave as quickly as possible. Rani said that sometime before the meeting, Dhanalakshmi paid a
2,000 bribe to be sure everything went smoothly.

Rani wasn’t alone in the committee’s waiting room; three other women were there to sell their kidneys.

“We went up one at a time and all [the committee] did was ask me if I was willing to donate my kidney and to sign a paper. It was very quick,” Rani said.

With the paperwork out of the way, she checked into Devaki Hospital for the surgery. The procedure went according to plan, but the recovery was more difficult than she had expected. Her neighbor who helped arrange an introduction to Dhanalakshmi sat by her bedside day and night. But after three days—with her wound still draining liquid—the hospital sent her home. When she went back to the hospital a week later for a checkup, the doctors pretended not to recognize her.

Meanwhile the broker predictably vanished during the time it took Rani to recover, and she realized she’d been cheated.

Now the pain in her side prevents her from getting the only work available: day labor on local construction sites. When I ask her whether it was worth it, she says, “The brokers should be stopped. My real problem is poverty—I shouldn’t have to sell my kidney to save my daughter’s life.”

In another case, Mallika, a thirty-three-year-old woman living a mile from Tsunami Nagar, says she made the decision to sell an organ to try to move beyond her meager existence doing laundry work. But the decision may have ended up costing the life of her son. I meet her in her one-room hut on a street that smells of rotting fish and open sewage. She is sweating profusely, which is something she doesn’t chalk up to Chennai’s unbearable heat but rather to the poor follow-up care she received after doctors removed and sold her kidney.

Just a handful of days before the tsunami a broker named Rajji, who now runs a tea stall near the docks, said he could help her out with her cash problems.
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His deal seemed straightforward: $3,000 for her kidney with $750 up front. Even now the thought of the cash makes her smile. Within days she was issued paperwork with a false name and, like Rani, cleared the bureaucratic hurdles without a problem. Soon she was packed away to Madurai, a smaller city in Tamil Nadu where members of Rajji’s network brought her to doctors at a branch of the internationally known Apollo Hospital. They removed her kidney and transplanted it into a wealthy Sri Lankan transplant tourist, whose police records indicate that he paid $14,000 for the operation. The recuperation took longer than she had expected, and she wasn’t able to return to Chennai for twenty days. The hospital refused to provide for her accommodation, and even the cost of postoperative drugs came out of her own pocket. When she returned to Chennai, Rajji said he wouldn’t pay her even one more rupee.

After two years of begging for cash, she filed a police complaint. She alleged that she had been defrauded of her organ. But the police saw it a different way. When they arrested Rajji under charges of organ trading, they also threatened to arrest her for agreeing to sell her kidney.

“Both of them broke the law,” says a plainclothes police investigator in the police headquarters. “If we prosecute one, we should also arrest the other.” A week later Rajji was back on the streets with only a warning. When I track him down from an address on the police report, he is manning his small tea stall. He tells me that he is really the victim as he boils a cup of sugary Nescafé.

“I am just trying to help people. I learned that someone was dying with kidney failure. I also know that there are many people here willing to sell. What is the problem with that? This should be legal,” he says. When I ask about the missing money, he denies ever offering Mallika more than $750. “I gave her only what it was worth.” Besides, he says, he shared his cut of the sale with several other tiers of brokers and doctors, netting only about $300 for himself.

While Mallika says that she never fully recovered from the surgery, she also tells me that her teenage son, Kannan, has contracted hepatitis B, which is now causing his kidneys to shut down. “Soon he is going to need a transplant, and I won’t have anything to give him,” she says. Even if she could find a hospital willing to donate medical services to her son, she would never be able to find the cash to buy a kidney. Flesh in India moves up the social hierarchy, not down.

The brokers who negotiated with Rani and Mallika were on the lowest rung in a series of intermediaries, each of whom took a cut of the $14,000 price tag for the transplant. Rajji claims that his cut was just a fraction of the total, the bulk of the commission going to a high-volume organ dealer in Madurai named Shankar.

While Shankar has since vanished without a trace, the identities of the higher-level people in the business are an open secret. Just a mile from Tsunami Nagar is K. Karppiah, who is widely considered one of the most active players in the kidney trade. His name is spoken in hushed whispers. And over the course of a month, dozens of kidney sellers fingered him, saying that he gets a cut of every kidney sold. As a kingpin broker he rarely makes contact directly with patients or vendors, but is a middleman who makes the entire system function. When I showed up at his house, he declined to be interviewed. But even the man outside laying asphalt knew what a powerful player he was. “Everyone knows Karppiah,” he said. “On this street, all the houses are his.”

Without the lucky break of someone coming forward with his or her story and a subsequent police investigation, it is almost impossible for an outsider to follow the story of an organ’s path as it travels from seller to buyer. Despite being housed at the same hospital, the patients who bought Rani’s and Mallika’s kidneys never introduced themselves to the sellers. The string of middlemen from Rajji, Dhanalakshmi, and Karppiah to the doctors who perform the operation keep the supply chain secret. After all, it’s in the middlemen’s best interest to never let the patient and seller negotiate directly. Secrecy is the key to maintaining the inflated fees they charge for a simple introduction.

While middlemen have a clear financial incentive to keep the specifics of the supply chain secret, hospitals and doctors use the sophisticated language of patients’ rights to keep the entire process behind closed doors. Even in legitimate cadaver donations in the West, hospitals argue that disclosing the name of the donor to the recipient harms the privacy of everyone involved.

Of the six hospitals I visited on a list of more than fifty that the Indian government claimed were performing illegal kidney transplants in Chennai, surgeon after surgeon told me that donors and recipients would come to great psychological harm if they were ever allowed to meet each other.

BUT THAT HASN’T ALWAYS
been the case. In her book
Strange Harvest,
about the cadaver donation system in the United States, anthropologist Leslie Sharp writes that anonymity between donors and recipients is a recent addition to medical ethics. In the 1950s, when transplants were first becoming popular in the United States, doctors argued that introducing donors’ families to recipients would enhance the clinical success of the operation by allowing the two to share medical histories and perhaps even bond over the transplant. As the transplant industry grew more profitable, organs started to get stripped of their human history. Anonymity was the new norm.

But by the time Sharp began her research in the early 1990s, “transplant professionals regarded written communication, and even more so, personal communication [between donors and recipients] as subversive acts.”
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Clinical staff went so far as to diagnose donors searching for their organ history as pathological.

Sharp’s research suggests that both donors and recipients generally want to know about each other, but are prevented by medical personnel. She writes that in public events where the transplant community comes together, “tales of personal encounters always generate spontaneous responses of joy and celebration from the audience.”
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And yet hospitals routinely seal records and keep the two sides apart. Sharp uses the word
biosentimentality,
the way donors and recipient families want to know the history of an organ for a sense of continuity between two living beings, to describe the unique relations created by transplant technology. However, despite this yearning there is a much more practical reason to do away with the notion of medical privacy.

In the context of international organ sales even when patients know they are buying an organ, doctors use the privacy ethic to trump any suspicion of exploitation along the supply chain. And yet what is worse: exposing the stories of people who sell their tissue under duress, or allowing brokers free and unfettered control of the organ supply? There is a clear conflict of interest when doctors and brokers are able to play the role of both profit-taking middleman and health-care provider. With total control of the supply chain, anonymity provides the perfect cover for extortion and criminal activity.

Since the early 1990s academics and journalists have been aware of the neocannibalistic demand for transplantable organs. Nancy Scheper-Hughes, an anthropologist at the University of California–Berkeley, has spent the better part of the last two decades researching and exposing the hypocrisies of international organ networks. In 2000 her landmark article “The Global Traffic in Human Organs” investigated organs being mined from Brazilian favelas, South African shantytowns, Indian slums, and Chinese prisons, and through Iranian state-funded programs.

Her most profound insight, however, is not to catalog the scale of organ trafficking but to question our bedrock assumptions about the nature of organ scarcity in the first place. She equates the insatiable demand for organs to our medical hubris in the face of mortality. She says that medical mythology promises the “unprecedented possibility of extending life indefinitely with the organs of others.” Transplant lists like the one perpetually updated by the United Network for Organ Sharing bloat as doctors tell dying patients that the only way to save their lives is to receive a functioning liver or kidney to replace the failing parts in their own bodies.

The reality is that while a transplanted organ is far preferable to being tethered to a dialysis machine or DeBakey heart pump, patients are merely trading a fatal disease for a chronic one. The new tissue often extends their lives for only a handful of additional years. Transplant programs frequently advertise that to sign up as an organ donor is to give a “gift of life” and that successful transplants are “miracles.” They rarely mention that posttransplant living generally falls short of a phoenixlike rebirth. Instead, recipients live on heavy regimens of antirejection drugs that lower their immune system and make them ideal hosts for fatal opportunistic infections.

Noting the ease with which brokers are able to locate human tissue, Scheper-Hughes writes, “the real scarcity is not of organs, but transplant patients of sufficient means to pay for them.” While it is very difficult to directly pay a person to sell a kidney in the United States, the transplant list creates a pressing sense of scarcity. It’s true that without paid donors most organs come from a limited supply in the United States, where we harvest organs from brain-dead patients, relatives, occasional spontaneous donations, and organ-sharing schemes. This limited amount of available tissue drastically falls short of demand and drives up the cost of transplants. The high prices support an entirely self-sufficient medical economy that involves special life-support suppliers, organ transporters, legal departments, doctors, nurses, social workers, and administrators who all have a financial stake in keeping the transplant business churning.