Slavery is such an atrocious debasement of human nature, that its very extirpation, if not performed with solicitous care, may sometimes open a source of serious evils.
—Benjamin Franklin
SHROUDED IN SECRECY
NO FORM OF human trafficking proved more challenging to research than human trafficking for organ removal, also known as organ trafficking.1 The trade is shrouded in secrecy and is most often the province of dangerous organized crime groups, such as the Zetas and the Sinaloa cartel in Mexico, the Nigerian mafia, the Albanian mafia, and organized crime groups across South Asia. The issue is mired in complex ethical quandaries, and many upstanding physicians and even religious leaders feel that facilitating the sale of organs for transplantation is a noble deed that saves lives on both sides of the transaction: the recipient, who needs the organ to survive, and the donor, who is able to lift his or her family out of poverty by selling an organ (usually a kidney). Individuals who promote a market for buying and selling organs typically ask the following question: “Is selling a kidney any different from an individual’s selling sexual services to make ends meet or a young woman selling her eggs to couples struggling with infertility?” Indeed, the trade in human bodies and body parts for economic consideration raises numerous moral questions without easy answers. When is it okay to sell oneself, or parts of oneself, if ever? Would not any loving parent sell a kidney if it meant his or her children could have food, an education, and enjoy better lives? If we are all owners of our bodies, can we not transact with them as we choose? Or are there broader social contaminations that invariably fester and spread when we allow individuals this freedom? Is there a categorical difference between selling an organ and selling sexual services, and if so, why? Why do only two countries at present—Iran and Singapore—allow the legal sale of organs, whereas numerous countries allow the legal sale of sex?
In search of answers to these questions, and to understand exactly how human trafficking for organ removal functions from one region to another, I conducted research in several countries, including Moldova, Kosovo, India, Nepal, Bangladesh, Singapore, Mexico, and the United States. In none of the cases I documented did I find a single instance in which the full theoretical benefits to the seller were realized. As with prostitution, the theories of self-determination and open markets for transactions suggest that in the right circumstances the transaction can be a win-win for all parties and that people should have the right to sell whatever parts they wish, but these theories did not bear out in the real-world cases I encountered.
I should note at the outset that a foundational question is whether organ trafficking is a form of slavery. It is certainly a form of human trafficking as specified in the Palermo Protocol (but not in the U.S. Trafficking Victim Protection Act), and many cases of organ trafficking are born out of debt bondage. Whether it is slavery—the condition or status of a person who is treated like property—is a separate question that can have opposing answers. I believe the phenomenon is too intricately linked to other phenomena we label as “slavery” to categorize it separately, but I appreciate the argument that this violation may not amount to forcing a person into a condition of slavery even though it may be a gross and unconscionable violation of human rights. The cases of organ trafficking I have documented are not included in the summary metrics on slavery I present in chapter 1 and in the appendixes because the economic data were insufficient and inconsistent. Nevertheless, I do consider organ trafficking to be a form slavery that is every bit as dehumanizing, exploitative, and ruinous as any other.
I conducted a modest amount of research on human trafficking for organ removal in the Balkans and in East Asia; however, the majority of my research on this issue focused on South Asia and North America. Trying to track down and trace cases of organ trafficking and document each participant in the organ chain proved arduous, debilitating, and dangerous. There was no way to avoid brushing perilously close to major organized crime networks, and the exceedingly clandestine nature of the crime made it all the more difficult to collect comprehensive economic data on cases or piece together the nature of the organ trafficking networks from one region to another. Finding victims alive to tell the tale was also a significant obstacle to the research. The cases I managed to document have sharply influenced my thinking about the ethical questions related to organ sales and have reinforced the general thesis of my broader research on slavery—the poor, vulnerable, disadvantaged, and outcaste people of the world are chewed up and sold for parts by those with power, rights, and resources, with little consequence. Organ trafficking took this thesis to the extreme.
SOUTH ASIA: HARVESTED AND DISCARDED
Organ Villages in West Bengal
South Asia is ground zero for most forms of slavery, and organ trafficking is no exception. My first encounter with the phenomenon was during research I conducted in the summer of 2001. I traveled to several villages in West Bengal where adivasis (tribal people) had been recruited by dalals (traffickers) to sell kidneys. The people in the villages were beyond poor and almost completely disenfranchised from mainstream Indian society. A soft-spoken man named Debjeet described his experience:
The dalals come to our villages and offer 50,000 rupees [~$1,100] if we donate a kidney. We have almost nothing in this place, so many people accept these offers. I was only paid 10,000 rupees [~$222] after they took my kidney. The dalal said I will have medicine and the doctors will care for me, but no one gave me any care or helped me when I became ill. They left me here to die. I am always sick, and I cannot work. Now my wife must sell her kidney or we cannot eat. I knew there was a risk they will not pay me the full amount, but even 10,000 rupees is more money than I have seen. I am tired all the time. I have so much pain. I know I will die soon.
Debjeet was very unwell when I met him—gaunt, weak, and huddled under a tree, scarcely able to move. He had been continuously ill since his kidney was removed the previous year, and he had received virtually no postoperative care. He looked old beyond his years, as did many of the other young men in his village, and a few of the women, too. It felt as if his entire village had been systematically harvested for kidneys. Debjeet’s surgery took place at a hospital in Kolkata. I asked him if he could tell me which hospital it was, but he did not know and could only describe it as a large building with hundreds of rooms for patients. After his kidney was removed, he was stitched up and sent on a bus to return home the following day. The bus only took him part of the way; he had to walk the final twelve kilometers under the baking sun, just one day after his kidney was removed. His life had been a bleak ordeal every since. He did, however, receive a lavish dinner the one night he spent in the hospital, “They gave me daal, aloo-gobi (potato and cauliflower), baingan (eggplant), luchi (puri), and for sweets I had two pieces of sandesh. It was the most food I ate in my life.”
After Debjeet made it home, he was left to fend for himself. He had basically been used for his kidney then discarded like so much refuse. He showed me the nine-inch scar on his left abdomen where the surgery had been performed. The kidney had not been removed laproscopically, which added to his pain and left a glaring reminder of the loss he had suffered.
I documented a total of fifteen men and women in Debjeet’s village who had undergone the same nightmare. Their misery left me infuriated. They had been carved up one by one and left to die. These were not one-off cases but part of a well-developed system of organ trafficking that stretched from remote villages straight into major hospitals in some of the largest cities in India. Unfortunately, the tales of impoverished villagers in India being carved up and sent packing with a handful of rupees did not end there. Across northern India I documented the same scenario time and again. Desperate, poor villagers were promised life-changing amounts of money for kidneys, paid only 10 to 30 percent of what was promised,2 then discarded to suffer a slow and agonizing demise. I documented a handful of cases of partial liver transplants, but most of the cases involved kidneys. The majority of the organ harvesting surgeries took place in what the victims described as proper hospitals, but some took place in small, nondescript clinic settings as well. A few hospitals were identified by name, including one of the largest hospital chains in the country—Apollo. I spoke to personnel at a few of the Apollo hospital branches in India, and they described the situations I documented as rarities and more the fault of predatory brokers who dupe everyone, including the hospital. My conversations at Apollo in New Delhi were just a few months before the hospital was in the local news for being used in a major organized crime organ trafficking operation that included two hospital employees who forged papers to facilitate the harvesting of organs from exploited peasants for use in transplant procedures in the hospital.3 Despite increasing awareness of the risks and likelihood of fraud, many peasants still accept the offers out of desperation for any amount of money they might receive. Many peasants told me they were aware they would not live very long after the organ donation should they not receive adequate care, but even 10 percent of the promised payment would help their families in ways they could not otherwise provide. Such is the moribund calculus of the poor—sell a body part for ten cents on the dollar and know you will suffer an agonizing death, because this outcome may still be preferable to the alternative.
A second scenario I documented across India with alarming frequency was the offer to discharge a debt in exchange for a kidney. Many bonded laborers had become so indebted that they felt no hope of ever being able to repay their debts no matter how hard or how long their families worked. In Uttar Pradesh, Punjab, and Rajasthan, I encountered numerous families working in brick-making, carpet weaving, agriculture, mining, and construction who had been attempting for several years to work off loans that ranged from fifty dollars to a few hundred dollars. The debts grew year after year, no matter how hard they worked, then a crisis struck and the landowner or contractor told them they could not extend additional loans, but they could extinguish most or all of their debts if the debtor parted with a kidney. This barter was almost always accepted, and the debts were largely extinguished, but within a few years the family was back in debt because the male head of household who parted with the kidney could no longer work due to illness or death. The wife of one such man who had died just a few weeks after selling his kidney beat her chest and wailed as she described her pain:
See what they did to my husband! They cut him like an animal. He came home, and he knew he was going to die. He was vomiting all night. He told me he was sorry he did this because he knew he made me a widow. See my two children there. They are sick. We have no food. I cannot buy medicine. They have killed us!
Somewhere, an upper-middle class Indian had received a new lease on life in exchange for the destruction of a peasant family. I have no doubt that the wealthy Indian was unaware of the harm to his poorer countrymen that resulted from saving his life, but I am not convinced that he, or the system that facilitated the transaction, really wanted to be aware.
The phenomenon of bonded laborers parting with organs to discharge their debts took an even more disturbing turn in Bangladesh.
Organs and Loans in Bangladesh
Deep in the southwestern fringes of Bangladesh, just above the Sundarban mangroves, waterlogged villages are perpetually at risk of flooding and of devastation by cyclones. It is a highly impoverished region that was once rich farmland. However, landowners saw more profit in saltwater shrimp than in farming and transformed hundreds of thousands of hectares into saline shrimp farms, devastating the local agricultural economy and displacing hundreds of thousands of peasants.4 Many of the villagers who remained behind entered into debt bondage with their landowners, taking loans to operate the shrimp farms with the idea of repaying the debts with each year’s shrimp harvest. The economics predictably disfavored the debtors, and they entered into cycles of perpetual debt. This drove many peasants to other moneylenders such as microcredit institutions, which operate extensively across Bangladesh. Peasants took loans from microcredit banks to repay other loans from landowners, or to supplement the original loans because they were unable to maintain basic survival. Traversing the rural reaches of southwestern Bangladesh, I encountered scores of families that had taken two or three microcredit loans each. The repayment requirements for these loans are strict, and in some cases debt collectors can be aggressive in pursuing outstanding payments. When peasants are unable to discharge their debts (either to the landowner or to the microcredit institution), many resort to selling organs to repay the loans that were supposed to lift them out of poverty. M. Hossein’s story was typical:
I took my first loan from Grameen Bank5 three years ago. I was not able to pay the loan, so I took another loan from BRAC.6 Then I was not able to pay this loan, and I had to keep taking loans because the interest was too much and I did not make enough income from my fishing business. When my loans passed one lakh taka [~$1,430], I became desperate. The debt collectors would harass me, and one of them beat me because I could not repay my loans. Some time later a man came to our village and promised we will be paid four lakh taka [~$5,720] for a kidney. I did not know what a kidney was, but this man told us we could live a very long time after the operation and that we would be doing a noble act to save another man’s life. I did not know what else I can do, so I agreed. They took me to a hospital in Dhaka and removed my kidney. I have this long scar here. I was very sick after the operation and could not see out of one eye. My left arm is paralyzed. I cannot work at all. I was only paid fifty thousand taka [~$715] after the operation, so I still have debts. I wish I had never done this operation. It ruined my life.
Like so many organ trafficking victims I documented, M. Hossein looked like a skeleton, old beyond his years, barely surviving. His breathing was labored, and his face was shrouded in anguish. He was twenty-eight.
Other men in M. Hossein’s village had made deals with the same recruiter, all to repay microcredit loans. Most had their operations in Dhaka, but others were sent to India and three were flown to Singapore. I was astonished at the level of coordination in the network of recruiting desperate and indebted Bangladeshis for organ transplants being conducted by doctors in hospitals in several countries. It was one of the most polished human trafficking networks I came across in South Asia, and I wanted to trace it in more detail. To do so, I needed to speak with the organ recruiters directly.
The organ-trafficking victims with whom I spoke offered a handful of names and phone numbers for the recruiters, all of whom were based in Dhaka. When I returned to the capital, I rang nine recruiters and managed to speak with three. I told them I was an Indian in need of a transplant and heard they could help me. Two of the three were willing to meet with me, Hasan and Iqbal.
Hasan asked me to meet him at the Radisson Blu hotel at six in the evening three days after we spoke. I arrived on time and waited in the lobby. After twenty minutes, Hasan had not arrived. I rang his number, but it went straight to a busy signal. I thought that perhaps he had arrived at the hotel, seen me, and decided something was amiss. I was preparing to leave when a man approached me and asked, “Siddharth?”
“Yes,” I replied.
“I take you Hasan.”
“He’s not coming here?”
“Please.”
The man headed out of the lobby. I surmised that he worked for Hasan and was probably taking me to meet him at a less public place. Perhaps this was part of his security process, or perhaps I was being set up. Either way, I had a choice to make. I could pass on the meeting with Hasan and try my luck with Iqbal, but that might lead to a similar result. For all I knew, Hasan and Iqbal were known to each other, and word could get around that I was not to be trusted.
I followed the man out of the hotel to a car. As we drove through the manic streets of Dhaka, I was not able to keep track of our course and was unsure to which part of town he was taking me. The driver spoke virtually no English, so there was little I could gain by trying to converse with him. I sipped on my water bottle and worked through a possible escape plan should the evening go in the wrong direction. Eventually, we arrived near a dimly lit alley between fairly dilapidated residential buildings. The driver parked the car and pointed toward the far end of the alley at a man. I could see that the man in the alley was chatting on a cell phone, smoking. There did not appear to be anyone else with him. There was no way out of the alley once I walked into it. I considered canceling the meeting because there was a good chance this was an ambush. As I ran through the possible outcomes in my mind, the driver pointed again to the man in the alley and said, “Hasan.” I surveyed the alley and deduced that there were bound to be people in the residential buildings, should I need to call for help, but that was no guarantee that help would arrive, or would arrive in time. I had to make a decision.
I walked toward Hasan with a firm gait. He was well groomed and well dressed. He also spoke perfect English.
“You are Siddharth?” he asked.
“Yes. Why are we meeting here?”
“You need a kidney?”
“I was told you could help me.”
“You look healthy.”
“Can you help me or not?”
“You are Indian, why are you in Bangladesh?”
“I tried in India for a few months,” I replied, “I was told it would be quicker here.”
Hasan took a long look at me, then started typing on his cell phone.
“If you can’t help me, just say so,” I told Hasan, “I have other options.”
I heard footsteps from the far side of the alley. Two men were walking in my direction.
“What’s going on?” I asked.
“I don’t think you need a kidney,” Hasan replied, “I want to know why you are here.”
Within moments I was surrounded. I stayed calm.
“This is very unkind,” I told Hasan, “I don’t know what you think you will accomplish by trying to frighten me.”
“Tell me who you are,” Hasan commanded.
“I told you already.”
Hasan smirked. His men closed in. They stank of cheap booze.
“Are you a journalist?” Hasan asked.
“Tell your men to back away, and I will walk out without any trouble.”
“You will not go anywhere until you tell me who you are.”
Hasan spoke to his men in Bengali. One of them shoved me.
“Speak,” Hasan said.
“Okay,” I replied, “Before I stepped out of that car, I took a photo of you with my cell phone and sent it to my wife. If I do not check in with her every twenty-four hours, she will contact my friends at the U.S. Embassy in Dhaka. Let me go, or you will be hunted.”
Hasan took a moment to process my statement.
“Show me your phone,” he said.
“If you touch me, you will be sorry. Your choice.”
Hasan locked eyes with me. I locked back. He muttered at his men, and they backed off. Hasan spat on the ground not far from my feet, “I know all the brokers in Dhaka. No one will talk with you.”
Hasan and his men left in the car that brought me. I was fortunate he did not call my bluff because there was no picture of him on my phone. I collected myself and started walking toward the nearest main road to hail a taxi. I was upset that I had put myself in a dangerous situation, but I had also been researching human trafficking long enough to know which traffickers were to be feared and which were petty thugs who would back down with a show of strength. I knew Hasan was a coward the moment I saw him. Despite his warnings, I was even more committed to getting a meeting with Iqbal.
My meeting with Iqbal was more informative, although not terribly satisfying. We met near the Sadarghat Ferry Terminal and found a relatively quiet place to talk. Iqbal was from Dhaka and had studied medicine in India before returning home to be a doctor. For reasons he did not explain, his medical career did not work out, so he found another way to help patients. He told me that most of his patients were Bangladeshis who lived abroad and came back for kidney transplants because the waiting lists abroad were too long. He explained that the longer they wait while on dialysis, the more damage is done to their bodies, so they are eager to have their transplants arranged more quickly. I asked Iqbal how patients from abroad found someone like him. He told me that prospective patients could find him through numerous informal channels, including social media and word of mouth. Once a patient decided to employ his services, several surgeons he worked with in Dhaka could perform the operation. The patient paid $75,000 to $100,000 for the procedure. Upon arrival in Dhaka, all of the patient’s needs were met: accommodation in a nice hotel, surgical pretesting, transplant surgery, full recuperation, and discharge to travel home. I asked Iqbal how much he gets paid, and he told me he received 5 percent of the fee. He said he typically arranges two or three procedures a year, sometime more. I asked him how much he pays the donors, and he said they receive a fixed fee of one lakh taka (~$1,430). I told Iqbal that I had documented numerous peasants who were promised a certain payment but only received a fraction of it. Iqbal said he always paid his donors in full. I asked him about aftercare for the donors, and he said this was a problem because they usually returned to their villages soon after the operation and not many physicians traveled to rural areas to provide adequate care for them.
“You realize that even if these donors receive all the money they are promised but do not receive proper after care, their lives are ruined,” I explained.
Iqbal did not respond.
“Do you think it is it fair to exploit poor people in this manner, just so the rich can survive?” I asked.
“Some people are worth less,” Iqbal responded, “That is the reality in our world.”
I was taken aback by Iqbal’s harsh statement and asked him if he really felt that way.
“It’s not my feeling, it’s the truth. If you don’t see this, that is your pity.”
I wanted to argue with Iqbal to persuade him that the worth of all human beings is equal despite their life circumstances, but I knew it would be a pointless discussion. One of the great frustrations of my research has been continually encountering the reality that, for all practical purposes, the disadvantageous circumstances of billions of people in the world make them worth less than the rest of us. Add cultural and religious biases relating to gender, caste, ethnicity—all of which have for centuries reinforced the devaluation of certain groups of people around the world—and there is little practical merit in a philosophical argument for the theoretical equality of all people, especially in a country such as Bangladesh were it is painfully obvious that people are not at all equal. The real-world devaluation of the poorest people in the world provides logic for their exploitation, which in turn perpetuates their devaluation. Iqbal was simply the mouthpiece of an ancient system of human stratification based on arbitrary allocations of resources, rights, and type (gender, caste, etc.), which somehow persist into the modern age. This randomness was at the heart of almost every case of slavery I encountered, and it is perhaps the chief quality that makes the system so challenging to eradicate.
The numerous cases of organ trafficking I documented in Bangladesh that were catalyzed by the seller’s need to repay microcredit loans led me to speak with the two largest microcredit lenders in the country: Grameen Bank and BRAC. Officials at both banks informed me that they were aware of the issues. They stated that they always endeavored to ensure that their prospective loan recipients did not have other loans outstanding. However, there was no centralized system for microloans in Bangladesh, so it was challenging to determine the debt load of a prospective recipient. I asked about local agents who pressure or intimidate debtors into repaying their debts, which can cause them to take desperate measures, but officials at Grameen and BRAC said that their agents never resorted to any sort of aggressive tactics. They argued instead that these practices were more an issue with smaller, unlicensed lenders who prey on the poor, although this is not consistent with many of the cases I documented.
After several months of research, it was clear to me that the organ recruiters in South Asia were the glue that made the system work. The process began and ended with them; they were the link between hospitals and patients on one end and vulnerable donors on the other. The recruiters were supposed to pay the donors out of the fees they received, but they typically pocketed most of the cash and paid the seller a fraction of what was promised. As near as I could piece together, if a patient in Dhaka paid a hospital between $75,000 and $100,000 for the transplant, roughly $7,500 to $10,000 of this went to the recruiter, and perhaps $400 to $500 to the organ seller, or 0.5 percent to 1 percent of the total amount paid by the patient for the transplant. The ratios in India were closer to 1 percent to 2 percent. Transplant surgeons did not occupy themselves with securing donors (nor should they), and wealthy recipients did not really wish to know the details of the donor beyond assurances that the organ was disease-free and a proper match. The organ brokers made the system work across India and Bangladesh, allowing everyone else to look the other way. These brokers were even more crucial to the system I uncovered in Nepal.
Preying on the Oppressed in Nepal
The first time I visited the National Kidney Center in Kathmandu several people were outside the main entry begging for kidneys, either for themselves or for loved ones. Their faces were drawn with fear and desperation. Inside the center, patients were hooked up for dialysis in a relatively clean and modern facility. The mood was somber, but some of the patients kept a cheerful demeanor and believed their prayers for a kidney would be answered.
“I believe God will help me,” a forty-year-old father of three named Madhav told me. “If I pray and do penance every day, God will help me.”
Supriya had been undergoing dialysis for four years, since the age of fifty, due to renal failure attributed to type 2 diabetes. Her husband passed away several years earlier. She had two daughters, both were a match for donation, but Supriya refused to accept organs from them. “They are just starting their lives and have to take care of their children,” Supriya explained, “I will not sentence them to an early demise by taking a kidney from them. Maybe their husband or children will need it one day. I would give all my organs to keep my children alive, but I will never take from them.”
Although she spoke in a calm and reflective voice, I could sense the pain of Supriya’s predicament deeper within her. I could well imagine that her children were exceedingly desperate to save her life, just as desperate as she was to preserve theirs. It was not hard to see why, in similar situations, some may resort to less orthodox measures to obtain a kidney.
Staff at the center informed me that patients like Supriya can expect to wait ten to twelve years for a kidney transplant in Nepal. Similar to most countries, demand for kidneys far outstrips supply. A nurse at the center named Rupa explained, “Because Nepal has fewer transplant physicians per patient population than other countries, our patients must wait longer for their transplant procedures and many cannot survive this long.” Rupa told me that many patients who can afford to do so travel to India where they can secure a transplant more quickly. I was sure that in these cases the swiftness of the procedure was facilitated by duping peasant donors such as Debjeet. However, Nepalese patients like Madhav and Supriya cannot afford this option, so they wait … and pray.
Insufficient organ supply and a lower per capita level of transplant physicians are among the primary factors that create a flourishing black market for organs in Nepal. A sophisticated network of organ brokers has developed to recruit donors from the country’s poorest areas for donation in hospitals in Kathmandu, as well as across the border in India. I spoke with staff at the Human Organ Transplant Center and the Grande International Hospital in Kathmandu, both of which had reasonable, albeit easily circumvented, checks in place to ensure organs had not been purchased or coerced from vulnerable peasants. The transplant teams seemed understandably focused on availing of any healthy organ that was donated to save their ailing patients. Some of the most disheartening cases I documented involved donors from the Makwanpur district of Nepal.
Makwanpur is a poor, rural district southwest of Kathmandu. Research in this area is arduous, as roads can only take one so far. I traveled by foot to get from one village to the next, usually several hours or a full day’s hike up one side of a mountain and down the other. During the monsoon season, flash floods and rockslides can cut off travel for days. The region is isolated and poor, but given its proximity to the capital (as the crow flies), it is heavily sourced by sex traffickers, labor traffickers, and organ traffickers. The recruiters who travel to Makwanpur meet with villagers and promise more money for their organs than they can earn in several years. The villagers I met in Makwanpur were especially ignorant of what it meant to donate a kidney, and it was clear that the recruiters fully exploited this ignorance.
Raj, a weary and listless man, invited me into his small wooden hut and explained, “The recruiter told me my kidney would grow back.” Raj showed me a 10-inch scar on his abdomen. “He lied to me. Nothing grew back. I am sick all the time. My family is in a very bad condition because I cannot work.”
Vishal, from the same village, said, “They kept saying ‘kidney,’ ‘kidney,’ I had no idea what this was. I thought they would take some flesh from my stomach. If I had known what they were doing, I would not have agreed.”
Vishal and Raj were both paid about 20 percent of what they were promised (~$450 each). Neither received any postoperative care after their kidneys were removed, and they were both sent back to their villages within two days of their operations. The harvesting of their organs, however, did not take place in Nepal. Both men were trafficked to India to have their organs harvested for transplant into Indian patients. I knew quite well how sex and labor trafficking from Nepal to India worked, but I was curious to learn how Nepali men were brought to hospitals in India and had organs removed and transplanted into Indian recipients without anyone raising concerns. Out of twenty cases of organ trafficking (all males) I documented in Makwanpur district, thirteen had gone to India and seven to Kathmandu. I followed the trail of these thirteen men to find out how the system worked.
One of the pitches used by the Nepali organ traffickers is that the donors will receive better medical care in India after their kidneys are removed than they would in Nepal. They are told the procedures will use the latest technology, that many of the surgeons have been trained abroad, and that they will be well taken care of at the hospital until they are strong enough to return home. Most of the Nepali donors are taken by bus across the border to Kolkata for the transplants. A smaller number are taken to Delhi. I did not document any victims who were taken to other cities, but I am sure they exist. Prior to the journey, the traffickers arrange a “No Objection Certificate” through the Nepali embassy in New Delhi. This certificate states that the Nepali donor is a relative of the recipient in India and has made the altruistic choice to donate an organ, without duress or payment. The certificate is provided to the hospital in India where the transplant will take place. Policy requires that a picture of the donor be included with the certificate, but photos are often not included. Either way, the procedures continue. Once at the hospital, the Nepali donor presents himself as a relative of the recipient. In none of the cases that I documented did the donor actually meet his supposed relative. A victim named Gopal told me what happened when he arrived at the hospital in India:
The night before the procedure I was given new clothes and taken for a very nice meal. There was so much food I wish I could take some to my family. I remember I thought that with the money they will pay me we can eat like this for the rest of our lives. The next morning I went for the procedure. The man who brought me from Nepal was named Hitesh. He spoke to the doctors in Hindi, so I did not understand them. They told me I would go to sleep, and when I woke up the procedure would be finished. After the procedure, I was in too much pain. Hitesh was gone. He left 18,000 rupees [~$360] for me, not 100,000 rupees [~$2,000] that he promised. The hospital discharged me that same day and told me where I could find a bus to take me home. I was very confused. I thought, what has God done to me? I had to urinate constantly, so it was impossible for me to sit in the bus for long periods. It took me four days to return home. I confronted Hitesh when he came back to my village, but he told me the hospital charged fees and that is why I received less money. Now I am so ashamed. I tell others not to give their kidneys, but people are so poor they will do anything.
When I followed up with hospitals in India about the Nepali cases I documented, the transplant units informed me that they relied on the Nepali embassy in New Delhi to verify that the donor is a relative of the recipient and is making an informed and altruistic choice. I asked the hospitals why they did not bother to have the supposed relatives meet each other prior to the procedures, just to be sure they were actually relatives. I was told that this can lead to stress, and it is better to keep the donor and recipient apart. I tried to speak with officials in the Nepali embassy in New Delhi, but I was brushed off. I also tried to speak with personnel at the Organ Retrieval Banking Organisation (ORBO) in India, but they too were not terribly sympathetic to my inquiries. I received an official statement that read:
We are aware of the shortage of organs for transplant in India and are actively trying to address the same. The Indian Health Ministry has recently implemented a new systematic allocation system of cadaver organs to counter abuses. Allocation of cadaver organs shall be based on a city waiting list, followed by the state, followed by other states through a Regional Organ and Tissue Transplant Organization. We are taking additional steps to set parameters for kidney allocation across India and rule out the illegal trade involving organs.
Beyond this technocratic jargon, no one in India or Nepal was willing to answer my questions. Hospitals, embassies, and regulatory bodies all pointed their fingers at each other as being responsible for properly vetting each donor. They also seemed to have the impression that the exploitative scenarios I described were uncommon; hence, there is no pressing need to address them. After several years of research, it was clear to me that far more must be done across South Asia to screen supposedly altruistic donors more effectively, be they Indians or Nepalis or Bangladeshis, to ensure that they are not being exploited for their body parts. Once they are carved up and sent packing, their fates are sealed.
As Gopal from Makwanpur district told me, “After they took my kidney, my heart became too heavy to bear. I wish they had taken it instead.”
Summary of Organ Trafficking Cases Documented in South Asia
Although I cannot provide precise estimates and prevalence rates, I am confident that there are thousands of victims of organ trafficking in South Asia each year. Many are trafficked for organ removal inside national borders, and others are trafficked across borders (primarily to India). Patients also cross borders in significant numbers, seeking the quickest and most reliable possible transplant rather than abiding by the excruciatingly long waitlists that often extend well past their ability to survive. The poor also are desperate to survive, and the meager income they receive can be the difference between life and death for their families, at least in the short run. Enter the traffickers, who prey on the desperations of both parties and bridge the transaction between them. Because patients are being saved and the harms against the donors are pitched to be minimal, hospitals and regulators look the other way. In cases of organ trafficking, victims can do little to nothing to seek redress. Most are weak, unwell, and stigmatized; they are simply biding their time until death.
The following data summarizes some of the key metrics from the organ trafficking cases in South Asia that I documented:
• 104 cases of organ trafficking: 41 in India, 33 in Nepal, 30 in Bangladesh
• 91 cases of male victims; 13 cases of female victims
• 100 percent of victims belonged to low-caste or minority ethnic communities
• 63 percent of cases involved sale of a kidney to discharge a debt
• 42 percent of cases involved transnational trafficking
• $355: average sum received by victims
• 21 percent: average sum received as a percent of promised payment
• 1.18 days: average number of days after organ removal to discharge
• 24.5 years: average age of victim at time of organ removal
Beneath these numbers resides immense misery and the destruction of peasant families. The system of organ trafficking in South Asia thrives in the shadows of regulatory and enforcement loopholes at the grave expense of the poorest and most downtrodden people of the region. However, this kind of predatory viciousness is not found solely in poorer regions of the world. I found it thriving in the West as well, including in the United States, despite robust regulations meant to prevent any such abuses from taking place.
ORGAN TRAFFICKING AND THE UNITED STATES
Understanding the System: Cadavers and Live Donors
The United States has numerous laws and regulations relating to organ donation; nevertheless, human trafficking for organ removal is a serious and potentially growing problem in the country. I assumed it would be very challenging for anyone to introduce trafficked organs into the transplant system in the United States, but my investigation uncovered the loopholes traffickers are able to exploit.
As with all countries, there are two sources of organs for transplant in the United States: cadaver organs and living donors. Cadaver organs constitute roughly three-fourths of all transplant surgeries in the United States.7 Harvesting and transporting cadaver organs for transplant is strictly governed by fifty-nine Organ Procurement Organizations (OPOs) spread across the country. Each OPO is required to be a member of the national Organ Procurement and Transplantation Network (OPTN), which was created by the National Organ Transplantation Act of 1984 and administers the national organ recipient waitlist. As of May 2017, approximately 120,000 Americans were waiting for an organ transplant, 97,000 of whom were waiting for a kidney.8 When a patient in a hospital becomes brain dead and is a candidate for organ donation, the local OPO is contacted and goes to the hospital to make an assessment. They attempt to secure consent from the patient’s family, but consent is typically secured in only half the cases.9 If consent is received, the organs are tested for contagions and infections diseases. Once the organs are approved, all data are uploaded to a national computerized system called UNET, which is operated by the United Network for Organ Sharing (UNOS). A list of potential recipients, called a “closed sheet,” is generated by an algorithm, and the organ is allocated first locally, then regionally, then nationally until a match is found. This is akin to the new procedures described to me in the official statement I received from the ORBO in India. Data are sent to the recipient’s physician for the first potential match, and if accepted, the OPO transports the organ to the recipient’s hospital. Considerable coordination between donor and recipient hospitals is required. Hearts require the most coordination because the extraction and transplant must be performed by two teams in the same place, one right after the other. Lung, liver, and pancreas can last up to twelve hours outside the body; and if properly cared for, a kidney can last up to twenty hours, providing more flexibility between extraction and implantation. Because the OPO manages and monitors the entire process from donor to recipient, it is very difficult to introduce a trafficked organ into the cadaver organ system in the domestic United States. I conducted interviews at several hospitals, OPO offices, and with UNOS, and there was no reasonable way for a trafficked organ to enter the cadaver transplant system. At most, there could be one-off cases involving egregious levels of corruption either at an OPO office or by a transplant team.
Unlike cadaver organs, the living donor system opens a few loopholes through which trafficked organs can enter the system. The process of living organ donation in the United States is regulated by the Revised Uniform Anatomical Gift Act of 2006 (the original act was passed in 1968). The law outlines the mechanisms through which individuals can altruistically donate their organs and the processes hospitals should undertake to ensure the donation is truly altruistic. The process can be manipulated, however, and I documented several cases in which the “living donor” turned out to be an exploited migrant across the border in Mexico.
The process of altruistic organ donation in the United States is fairly straightforward. First, if an individual indicates that he or she would like to make an altruistic donation of an organ (usually a kidney) to another person, the person goes through a rigorous intake process at the recipient’s hospital to ensure that the individual is making a fully informed decision, is not being paid, and is not under any form of duress. Duress can be particularly tricky when it comes to family members donating to each other. Would a child or a spouse donating to a family member out of love not also possibly be doing so out of a sense of obligation or pressure? As with sex trafficking, the line between “willing” and “coerced” can become quite gray. To minimize these scenarios, the altruistic donor is assigned a separate screening team from that of the recipient. This team is headed by an intake coordinator who is charged with ensuring that family members are not making the donation unwillingly. However, it is rare for a hospital to turn down an altruistic donor from within the family. Assuming the donor passes the intake process (as most do), they are tested to see if they are tissue and blood type matches for the recipient, followed by independent counseling leading up to the procedure. Most hospitals in the United States follow both the donor and recipient with regular medical checkups for at least two years to ensure optimal health after their respective procedures.
Despite their best efforts, the transplant units at several hospitals in Boston, Los Angeles, New York, Chicago, San Diego, Dallas, San Antonio, and Houston acknowledged that it is possible for a donor to pass the intake scrutiny and still be offering an organ out of duress or because of a financial payment. Websites such as ineedakidneynow.org and matchingdonors.com and Facebook pages such as Facebook.com/findakidneycentral create marketplaces for donors and recipients to transact with each other. These and dozens of other online marketplaces have sprouted up in recent years, and many of the sites specifically offer tips on how to pass the intake process at hospitals. These cases typically do not involve organ trafficking but rather illicit markets in organ selling. However, another category of living donor case is more likely to involve trafficked organs—those in which the living donor is (allegedly) a relative or dear friend living across the border in Mexico. This is the most common scenario used to introduce trafficked organs into transplant hospitals in the United States, especially in Texas, Arizona, and California, all of which are within reach for transporting a kidney via vehicle in the viability time frame.
On the Trail of Trafficked Organs
In my efforts to investigate organ trafficking in the United States, I followed two leads to identify hospitals that might be using trafficked organs from Mexico: (1) hospitals that consistently show a higher than 40 percent proportion of living donor transplants (25 percent or less is the norm) and (2) hospitals with disproportionate insurance billing for codes CPT 50547 and 50320, indicating that a higher number of transplants were performed than the number of organs they could possibly access. I followed these threads of investigation and found several hospitals in South Texas and a few in the San Diego area that appeared suspicious. I visited each of them in person.
The first thing I noticed at most of these hospitals was that organ brokers were operating outside the dialysis units. The brokers were well-dressed and respectfully solicited patients who were leaving after their dialysis sessions with offers that they could arrange a transplant in a short time frame. Most of the solicitations fell on deaf ears. I had detailed discussions with the nurses at several transplant units in hospitals across Texas and in San Diego. Only one transplant team, at the largest transplant unit in South Texas in McAllen, just a few miles from the U.S.-Mexico border, was unwilling to speak with me.
The nurses and coordinators with whom I spoke at the hospitals in Texas and San Diego were all well aware that there were organ brokers outside their dialysis units who promised they could arrange transplants within a few weeks. “Those brokers work with surgeons in private clinics on either side of the border,” one nurse at Houston Methodist Hospital explained to me.
I asked about the issue of fake altruistic donors who are either under coercion or are being paid, and each unit told me they screened heavily against this, but they also said that other hospitals looked the other way. “They want to save lives,” one nurse at the Christus Transplant Institute in San Antonio told me. “So as long as they have someone who says they want to donate, they proceed.” Another nurse told me, “Just do a Google search for ‘I need a kidney’; you will see a ton of sites that promise transplants for the right price. Most of those people go across the border, but some of them have the procedures in the United States. I’m pretty sure you would find organ trafficking with those cases.”
One scenario described to me repeatedly in Texas and California was an alleged family member who lived across the border in Mexico and was said not to have immigration papers. This alleged family member would indicate that he wished to donate to the recipient at the U.S. hospital. In these cases, the U.S. hospital relies on a hospital in Mexico to perform the necessary testing, screening, and matching, and to send a letter attesting that the donor is not being paid or under duress. Once these formalities are accomplished, the organ is driven across the border for implantation. The system is very similar to the “No Objection Certificate” provided by the Nepali Embassy in New Delhi that attests that the Nepalese migrant is a willing donor or relative of the recipient. Unlike in India and Nepal (which share an open border), in the United States and Mexico the migrant does not cross the border because he claims not to have valid immigration papers that would allow him to do so. Without a border crossing, it is impossible for the intake team at a U.S. hospital to determine if something is amiss. Several transplant nurses told me candidly that they had no idea where the organs really came from in these situations and that they could possibly be cases of organ trafficking. As long as the tissue and communicable disease testing is performed at reputable hospitals across the border and the results are acceptable, they proceed. Assuming that many or most of these cases could involve organs that are fraudulently or coercively harvested, I wanted to understand exactly where the organs were coming from.
To probe the circumstances behind the alleged cross-border altruistic donations, I conducted interviews at migrant shelters in the border towns of Matamoros, Reynosa, Nuevo Laredo, Mexicali, Tecate, and Tijuana, as well as at the corresponding border towns on the U.S. side. In several shelters, I found individuals who had suffered fraudulent organ extractions and lived to tell about it. All of these Mexican border towns also have extensive medical, dental, and pharmacological clinics for Americans who prefer to cross the border for cheaper procedures and prescription drugs. The welcome centers in these cities provide maps with listings and locations of all the available medical facilities. There are also rumored to be off-book medical clinics that offer quick, but expensive, organ transplants. I was not able to track any of these down, primarily due to limits on the amount of time I could spend in Mexican border cities due to security issues.
Arranging for a security team was compulsory due to the risks of abduction by drug cartels. The Gulf cartel controls the border in the South Texas region; the Zetas own Central Mexico and portions of the Texas border; La Familia controls the border between Guatemala and Mexico; and the Sinaloa cartel owns territory between Baja California and California. The Gulf, Zetas, and Sinaloa cartels were of primary concern to me because I was conducting research in their territories. Each cartel operates sophisticated drug, human, and organ trafficking networks, and abduction of high-value targets for ransom is a key component of their business models. The brutality of these cartels needs little discussion; they skin people alive, behead them, dismember and scatter the body parts of politicians and informants across city streets, and dissolve bodies in acid. No one is off limits, least of all investigators poking around in cartel business. Because of the high level of risk, the only security teams willing to cross the border with me were private military contractors, typically veterans of the U.S. military involvements in Iraq and Afghanistan. Their main source of income following their tours of duty was to provide security for U.S. businessmen who cross the border for meetings or to inspect manufacturing facilities. The price for this kind of security is steep, but I was able to arrange a “human rights” discount with each of the teams that assisted me.
Each team had its particular operational style, but the basics were similar. Defensive tactics were of paramount importance because it is illegal to take firearms into Mexico. If we were arrested for having done so, we would probably spend the rest of our lives in a Mexican prison. Each team consisted of a primary vehicle (PV) and a chase vehicle (CV). The PV carried the executive protector (EP) and me. The chase vehicle consisted of two additional security personnel. The PV was typically a jeep, and the CV was usually a sedan. Each vehicle carried a first aid kit, trauma bag, and IV kit. The security teams developed specific driving tactics to avoid being boxed in or disabled. If the PV suffered an attack, the role of the EP was to get me to the CV for an immediate retreat across the border. I met with my security team to go over the tactical plan for the day each morning that we intended to cross the border. The latest cartel movements were reviewed, and if the team received intelligence that there was going to be too much attention near the border, that day of research was called off.
I made a total of nine forays across the border for interviews in shelters with my security teams in Texas and California. Three times we called off the trips the morning of departure due to security concerns. I was treated with the utmost respect by my teams, and I developed deep admiration for their professionalism and courage. At no point were we in serious danger (as far as I could tell), although on two occasions we had to return to the United States earlier than planned to avoid cartel movements. The security teams taught me how to spot the cartel halcons (hawks) just across the border. They were usually young males operating a taco stand, or just circling around on their bicycles looking for high-value targets for abduction. They used handheld radios to communicate through a private system of thousands of antennas and repeaters across Mexico to avoid tapping by the government on a cellular network. I was the only noncorporate client my teams had protected, so they were intrigued by my research. The days ended with a few drinks and dinner, during which I described the work I had been doing around the world, the kinds of tragedies I had documented, and some of the slaves I had met. The security teams had harrowing stories to share about their experiences in Iraq and but the tales that most astounded me related to the cartels. The EP with whom I most bonded, Rodriguez, told me “What you see in the media is just a fraction of what really happens down here.” “This place is worse than Iraq.”
The stories my security teams shared about cartel violence did not help calm my nerves when it was time to cross the border. With each foray, I felt that I was stepping into a highly unpredictable, hyperviolent world, which exceeded anything in my previous experience. Repetition eased my anxieties, but each trip was an excruciating experience, with senses heightened and an irrepressible feeling of dread. The first trip was one of the most stressful days of all my research, surpassed perhaps only by the anxiety I felt stepping into GT’s lair in Edo State. Every minute that we were across the border, I was convinced we would be attacked. Every car that swerved near us felt like an attempt at abduction; every awkward glance was a possible assessment of me as a target; and everything I did not see and hear filled my imagination with scenarios of impending disaster. Why were that car’s windows so tinted? Is that shifty fellow on his phone reporting me as a target? The steel nerves of my teams helped ease my stress when we crossed the border, and thanks to them I gathered invaluable information from the people I met in the border town migrant shelters.
At a shelter in Nuevo Laredo in 2011, a nineteen-year-old girl named Juanita told me a jarring story of migration and exploitation that began when she left her home in central Mexico:
By the time I came to Nuevo Laredo I had already been raped several times. At the bus station in Nuevo Laredo the police arrested me. I did not understand the charges. After three nights in prison they sent me with a man named Alfredo. He was with the Zetas. They locked me in a house with other migrants. They told us if we wanted to cross the border we had to pay $600. No one had that money, but some people had relatives in the United States who sent money for them. The rest of us had to work for the cartel. The women were raped by the guards every night. I saw two people killed in that house for no reason. The cartel sent me to Boys Town for prostitution. After a few weeks, they sent a doctor to the house, and I thought he would give us medicine because we were sick, but he did tests on us. After a few weeks they took eight of the migrants to remove their kidneys. They were in a lot of pain when they came back. One of them died. Thank God they did not take my kidney. They made me take drugs across the border. I could not believe I made it to America, then they forced me to come back and bring drugs again. When we crossed, we were in groups of three or four, that way if one group was caught the others got through. My life was like this for more than a year. The cartel would not let us go. One day there was a police raid. We were arrested. I cannot explain what happened. After two weeks in prison they sent me to this shelter. The cartel comes here to recruit the migrants, but I will never go with them.
I heard numerous stories like Juanita’s at the shelters I visited. Migrants from across central Mexico and Central America survived the journey to the U.S. border but were then raped, killed, exploited as drug mules, had organs harvested, or worse. I met a few migrants whose organs were forcibly removed, but most people I interviewed could only report that they saw this happening to other migrants, as many of the unwilling donors did not survive. Several of the migrants from Guatemala also reported seeing or hearing about large numbers of bodies turning up along the Guatemala-Mexico border with their organs removed. As many stories as I documented, and as many people as I interviewed who had organs forcibly removed, it was impossible for me to trace where these organs ended up. The cases were in the past, and I discovered no leads to how or where the organs were used. The organs might have been used in living donor transplants in Texas from alleged altruistic donors in Mexico or for transplants in medical clinics in Mexico for transplant tourists who traveled south for their procedures, or they might have been sold to hospitals for medical testing. I realized I was never going to be able to follow an actual trafficked organ from the point of harvesting to the point of implantation, so the only remaining avenue I could explore to try to piece together more of the network would be to engage directly with an organ broker, such as those I saw operating outside the dialysis units of the hospitals I visited.
Meeting an Organ Broker
To go undercover as a prospective transplant patient and engage with an organ broker, I needed a credible cover story. For this, I turned to a few transplant surgeons who had been advising me throughout my organ trafficking research. They told me that I would need to indicate that I had just discovered that my kidneys were failing, but that I had not yet started dialysis. If I were to say I had already begun dialysis, the brokers could investigate to determine whether this was or was not the case. As a generally healthy young man, I could also explain to the brokers that I did not go for regular medical checkups and that the first time my problem was discovered was when I felt sick and went to the emergency room with nausea and vomiting, at which point I was told I had renal failure. I was also advised to pick a kidney disease that typically left most patients appearing to be otherwise healthy, such as focal segmental glomerulosclerosis (FSGS), the same kidney disease suffered by NBA players Alonzo Mourning and Sean Elliot. This disease would allow me to appear to function somewhat normally up to a few months before a transplant was required, and many FSGS patients attempt to secure a transplant before they have to begin dialysis, which also fit with my cover story. I was advised further that I would need to tell the brokers that I had no viable living donor, that my family members suffered high blood pressure and other ailments that disqualified them, and that I had the financial means to work with them if they could find me a kidney match. Luckily, my blood type is A-positive, which is the easiest to match. Finally, I was advised that the broker would ask for my glomurelar filtration rate (GFR), which is a measure of kidney function. A reading between 15 and 20 meant I could live without dialysis for a short period of time, so I was told to say that my reading was right around 20 and that the doctor was not able to tell me yet how fast my disease was progressing.
Armed with this information, I prepared to approach the organ brokers. Before doing so, I took some time to consider the moral legitimacy of what I was planning to do. People in my family had suffered terminal renal failure, and I knew all too well how debilitating the disease could be, including dialysis treatment and the daily anxiety of wondering how long one has to live. I felt revulsion at the prospect of pretending to be someone in this position, a feeling similar to times I feigned to be a customer in search of young girls to purchase during my sex trafficking research. But something about this was different. It cut right to the fundamental desire to live, to be forced to come to terms with the reality that your body had failed you, and the desperation to do whatever it took to survive. I spent some time reflecting on whether I was crossing lines that I would later regret, and whether I was justified in proceeding simply to conduct my research. In the end, I made the difficult decision to proceed.
As unpalatable as the research was going to be, I wanted to understand as much as possible about this grotesque trade in human body parts. I was told to be confident, to insist on being told from where my kidney was being sourced, the age of the donor, the full medical history, where the surgery would be conducted, and how I could be certain that the kidney being implanted was the one I asked for. “Be demanding,” one transplant surgeon in Chicago advised me. “You are theoretically going to pay up to $200,000 to save your life. Act entitled. That’s how someone in your shoes would behave.”
During the course of my explorations as a prospective kidney transplant patient, I spoke to six organ brokers outside hospitals in South Texas and San Diego. Transplants were promised at “private clinics” on the U.S. side of the border or at hospitals in Monterrey or Tijuana. The furthest I pursued the process was with a broker in San Diego, Juan. He and I first exchanged emails, then spoke on the phone, then set a meeting in San Diego—all within three days. Juan wore a suit and tie to our meeting and spoke professionally. I kept to my story of a recent FSGS diagnosis and a GFR of around 20. Juan advised me that he could arrange a transplant in Tijuana with the same standard of care and sophistication as any hospital in the United States. He showed me glossy pamphlets with testimonials and said I could speak to previous patients. I told him I would prefer to have the procedure done in the United States, and he said he could arrange the same operation at a private clinic, but it would cost more. I asked him how much? “In Tijuana, the price is $200,000. In the United States we charge $300,000.”
I asked Juan the important questions about the donor, matching, viral testing, and assurances that I would be getting the exact organ I purchased. Juan gave me all the right answers. He said that the organ transplant system was “broken” and that his network was trying to save lives. I told Juan I wanted to see the clinic before the transplant, but he said this was not possible.
“Why not?” I asked.
“That’s the policy.”
“I’m putting my life in your hands. I need to see the clinic, and I want to speak with the donor.”
These were nonstarters for Juan (and every other organ broker I spoke to).
“Then what’s the next step?” I asked.
“You wire half the funds into an escrow account. Once we know the funds are clear, we will proceed with your match. If anything goes wrong, you may withdraw the funds at any time up to the surgery. The day before the procedure, you pay the second half, and we proceed with the transplant.”
“What about after care?”
“The fee includes two years of postoperative care.”
“Does the donor receive postoperative care as well?”
“Of course.”
“And there is no way I can speak to him or meet him?
“I’m sorry, no.”
I had to decide how much further I was going to push down this path. Obviously, I was not going to put $150,000 into an escrow account just to see how far my research would go, and it was clear that Juan was not going to let me meet my supposed donor or visit the clinic or even meet the doctors until the last minute.
I told Juan that I had heard stories that some of the organs used in clinics are taken from migrants under false pretenses. I asked him how I could be sure this would not be the case with my surgery. “You are paying money so that you don’t have to worry about these things,” Juan replied. “I promise the donor will be paid fully. His life will be better. So will yours.” In those few sentences, Juan encapsulated the essence of the contemporary organ trafficking phenomenon. Those who can afford to do so pay money to save their lives, and so they do not have to worry about the (human) costs associated with the transaction.
I was unable to proceed any further with my research into organ trafficking in the United States and Mexico. In total, I documented seventeen migrants whose kidneys had been forcibly or fraudulently removed, and I heard stories of scores of other migrants to whom the same had happened but who did not survive. I identified the loopholes in the altruistic donation regime that were evidently being used to introduce trafficked organs into the system, and I went as far as I could with an organ broker to explore how an actual case worked. I was unable to trace the networks from the point of organ harvesting to the point of transplantation in any particular case. Limited resources were one constraint, but untenable levels of risk presented a greater obstacle.
As I found in South Asia, vulnerable people in the Americas are being carved up for parts so that the wealthy can survive. As long as the severe market imbalances between supply and demand in transplant organs persist, the organ trafficking market is likely to thrive. Therefore, one must ask, “Are there any policies that might help rebalance the system and abrogate some of the pressures that lead to these exploitative black markets?”
CLEAR POLICIES, UNCLEAR RESULTS
The severe market imbalances between the supply and demand for transplant organs that give rise to illicit organ sales and human trafficking for organ removal have received the clearest policy response of any facet of human trafficking. Only two countries in the world—Iran and Singapore—have responded to these market imbalances by legalizing the sale of kidneys. No other countries sanction organ sales, and numerous international conventions and policy instruments staunchly advocate against legalized organ sales being a valid response to the crisis. The results of this near-unanimous policy approach do not, however, appear to have helped remedy the imbalances that motivate black markets in organs and organ trafficking.
The “Guiding Principles on Human Cell, Tissue and Organ Transplantation” was issued by the World Health Organization (WHO) in 1991, and it includes nine principles intended to prevent abuses in the organ transplant system that can lead to illicit organ markets and organ trafficking.10 Article 3 of the Palermo Protocol includes organ removal as one of the forms of exploitation captured by the definition of human trafficking. Article 3 of the United Nations Optional Protocol on the Sale of Children, Child Prostitution and Child Pornography was added in 2000 to the UN Convention on the Rights of the Child and states that the sale of children for the purpose of transferring their organs for profit should be a criminal offense. In 2000, the World Medical Association issued a statement that financial incentives for organ donation should in all cases be prohibited.11 Article 22 of the European Convention on Human Rights and Biomedicine, ratified in 2002, prohibits organ and tissue trafficking, and Article 21 of the convention prohibits financial gain from the selling of organs. Organ trafficking was most directly addressed by the Declaration of Istanbul on Organ Trafficking and Transplant Tourism in 2009,12 which outlined four principles to help address the supply–demand imbalances that lead to organ trafficking, including: (1) maximizing the use of deceased donor organs, (2) encouraging countries with established deceased or living donor programs to share their knowledge with countries that lack these programs, (3) protecting vulnerable populations from abusive acts, and (4) ensuring the equitable allocation of donor organs based on sound ethical principles. Article 6 of the declaration also specifically states that “organ trafficking and transplant tourism violate the principles of equity, justice and respect for human dignity and should be prohibited.” Despite these and other conventions and guidelines, illicit organ sales and organ trafficking remain serious issues around the world.
As a result of the deplorable levels of exploitation and abuse in many organ transplant markets, some scholars have argued that a regulated system of organ sales would help eliminate exploitative practices, akin to those who call for legalizing and regulating prostitution as a way to eliminate abuses.13 These scholars typically argue that bringing organ sales out into the open with careful monitoring and strict regulation will allow sellers to benefit financially without being exploited. Monitoring and regulation also will help ensure that poor sellers of organs receive adequate postoperative care. Proponents of regulation further argue that a transparent system that is carefully monitored to prevent deception and coercion will remove pernicious brokers and traffickers from the equation and ensure that the donors are not exploited. In the end, financial incentives, strict monitoring, and proper postoperative care for sellers will increase supply and help balance the transplant market. Not to be overlooked, a more balanced system will save more lives.
On the other side of the debate, scholars argue that regulation will not work because it is impossible to achieve adequate levels of monitoring and postoperative care, primarily due to funding deficiencies and corruption.14 Black markets will inevitably arise to exploit a legalized organ sale system. The sellers will disproportionately be poor and vulnerable, and as a consequence they will inevitably suffer exploitation, will not be paid the promised sums, and will have little access to justice to enforce their rights. In addition to negative health results, they will suffer stigmatization and early demise that perpetuate cycles of poverty and exploitation. Finally, placing a market value on the body parts of the poor dehumanizes them and will reinforce the legitimacy of society’s monetization of the labor, bodies, services, and body parts of the downtrodden. One study in India has confirmed many of these statements; researchers found that 86 percent of organ sellers suffered a decline in health, 36 percent suffered a decrease in income, and 79 percent stated they would not recommend selling a kidney to others because of the ill effects they suffered.15
What about Iran and Singapore? Do the regulated systems of organ sales in these countries work? Research in Singapore is limited because the country only legalized organ sales in 2008. In Iran, organ sales have been legal since 1988. Two studies in Iran found that 85 percent of sellers said they would not sell their kidney if they could go back and reconsider the decision, primarily due to ill health and lack of postoperative care.16 The studies also found that 80 percent of donors suffered negative health effects after the donation and that 76 percent strongly discouraged others from selling.17 With more resources and better enforcement, Iran or other countries that create legal systems of organ sales might be able to achieve better results, but the available evidence does not appear promising.
The research I have conducted in almost every aspect of slavery leads me to conclude that systems that legalize and attempt to regulate markets that involve the purchase of the bodies or body parts of the poor will inevitably lead to exploitation and misery for the sellers. Whatever is being sold—be it commercial sex, cheap labor, or body parts—the poor are inexorably reduced to expendable and dispensable resources for the wealthy. Theoretical enforcement of protective regulations and punishment of abuses consistently fail because of one glaring truth—we don’t really care about the poor as much as we care about ourselves. They are “those” people from “those” communities, and that makes them disposable.
At the end of the first chapter, I offered ten initiatives that I feel provide the optimum opportunity to eradicate slavery. Most of these initiatives would also address the issues that underpin the organ trafficking market. Specific supply–demand dynamics promote organ trafficking, however, and powerful forces feed into these black markets, such as profit (for traffickers) and the will to live (for sellers via income, and for buyers via an organ). Policy responses customized to organ trafficking issues must accompany the ten broader initiatives I outlined in the first chapter. Some of these policies could include:
1. An organ draft—all cadavers can be harvested for organs unless there is a specific religious objection by the family of the deceased. This is an aggressive policy proposal, but it would help alleviate some of the supply–demand imbalances by increasing the available supply of cadaver organs.
2. Presumed consent—all individuals at death are donors unless they actively state otherwise before perishing. This policy is similar to the organ draft but provides individuals with an opportunity to opt out of being a candidate for organ donation at death, whether for religious or other reasons. This policy also increases the supply of available cadaver organs.
3. Limited compensation—the deceased’s family members are given a small financial benefit for allowing organs to be used for transplantation. This may help alleviate some of the financial strain on the deceased’s family and motivate an increase in cadaver organ supply. The exact amount of the financial benefit would need to be determined so that it does not amount to the same as purchasing a human organ.
4. Futures markets—provide a small financial benefit today to an individual who agrees to make his or her organs available at death. Again, the compensation would need to be thought through so that it does not amount to the same as purchasing an organ, but a modest financial benefit could help increase cadaver organ supply.
These and similar policies might help attenuate the supply–demand imbalances in the transplant organ system, but they will probably not succeed in balancing the market fully. The most promising effort to do so may come from 3-D printing technology. Forecasts are that 3-D printing technology should be able to produce human organs for transplantation by around 2030,18 and if so, this might very well mean the end of black markets in organ trade or organ trafficking, assuming it is financially feasible for, and accessible to, all patients.
For the time being, the market imbalances that lead to organ trafficking continue to widen. Organized crime groups are heavily involved in organ trafficking from Asia to the Americas, primarily because of the substantial profits they are able to generate from the illicit harvesting and sale of body parts. These groups have developed highly organized systems that rely heavily on brokers to facilitate the transactions between sellers and buyers. Disrupting the operations of these brokers is one important step to take to combat organ trafficking markets, but it will not solve the broader problem. Data on organ trafficking is difficult to come by, in no small part because of the clandestine nature of the offense and the heightened perils associated with conducting research in this area. Nevertheless, research must be done, and new preventions and interventions must be attempted, or the poor, migrant, indebted, disenfranchised populations of the world will continue to be pressured, duped, and harvested for their organs, with just the shell of a person remaining.
BORDERS AND BLOOD
Borders play an important role in many aspects of slavery, and they are particularly enmeshed with the phenomenon of organ trafficking. Patients cross borders as transplant tourists in search of quick procedures, sellers are trafficked across borders to have organs removed for wealthy recipients, and migrants make their way to the borders of more affluent countries in search of a better life, only to be chewed up by cartels for sex, labor, and organs. In every case, the borders involved in organ trafficking networks are painted with blood, including the southern border of the United States.
On what turned out to be the last day of my research along the Texas-Mexico border, Rodriguez told me at our morning briefing that I had garnered the interest of at least one cartel. He advised that it would be too risky for me to cross the border. I called off our research that day, and I never conducted additional research along the border in that area. It was not, however, a completely unproductive day. Rodriguez told me that he had been working on a lead and managed to track down a surgeon who had conducted four transplants for high-ranking cartel members. The doctor was not willing to meet, but he had agreed to speak on the phone.
I rang the number the doctor gave Rodriguez several times, and he finally answered in the afternoon. I asked him if he was willing to answer a few questions. He sounded jittery but agreed. The doctor confirmed that in the last three years he had performed four transplants for high-ranking cartel members at two different clinics. He was not willing to disclose the locations of the clinics, or even the cities in which they were located. He had a team of physicians and nurses who assisted him with the harvesting and transplanting procedures.
“Where did the organs come from?” I asked.
“Migrants,” he answered.
“All four?”
“Sí.”
“Did the migrants offer the kidneys willingly?”
“I am sure.”
“Were they paid?”
“I don’t know.”
“Do you know where they are from?”
“Mexico.”
“Are they still alive?”
No answer.
“Were they alive when you took the organs from them?”
No answer.
“Okay, maybe you can tell my why you did these surgeries for the cartel members?”
“I have no choice.”
“Why not?”
“When they ask, you do it.”
“Did the migrants have a choice, or were they pressured as well?”
“This is all I can tell you. Good luck.”
The surgeon hung up. This was the only conversation I had with a physician who appears to have conducted transplants with trafficked organs from migrants. Though I could not confirm the details, I was reasonably certain the migrants whose organs were removed had not offered them willingly and were probably no longer alive. I wondered why the surgeon was open to speaking with me if he really was not going to answer any of my questions, but I appreciated that I probably pushed too hard too quickly. Rodriguez told me that he had leads on where the surgeon operated, but he warned me it was deep across the border. I was not willing to put myself or Rodriguez’s team at risk, and I was left frustrated that I was not going to be able to gather more research across this part of the border.
Before I left South Texas, I spent the day driving around the area, taking it all in one last time—the white sun, the feverish breeze, the restless desert dust that tastes bitter in the mouth. About an hour northwest of Laredo along Mines Road, I found a dirt path that led to the Rio Grande. I parked my car and went for a walk. There was no border fence—just the United States on one side of the river, and maybe a hundred feet across, Mexico. It was a searing, inhospitable day, so I veered toward the sparse shade offered by scattered trees. Dry brush crunched under my feet. I came to an area of tree cover and took a seat. The river was still, and the air was stagnant. I thought about my conversation with the surgeon and wondered how many more there were like him, working not just for cartels but at major hospitals across the border for transplant tourists. The disappeared migrants used in these surgeries were as silent as the border river in front of me, the river they were so desperate to cross. I could not comprehend the absurdity that this narrow ribbon of water separated such extremes—hope from despair, dreams from nightmares, life from death.
I wandered further down the river, listening to the crunch under my feet, to the anemic whisper of the breeze. After a few minutes, I came across a tattered sneaker. I looked around, and about twenty feet away, I found its pair, under some bushes. Two feet from the second shoe, I saw a torn pair of trousers, a shirt, a broken pair of glasses, and a large area of dried blood. There was no telling how long the clothes and blood had been there. All borders have blood on their hands, but the U.S.-Mexico border may have the most blood of all. Had I continued walking, it would not have been long before I came upon another remnant of the border’s butchery. But I was too tired and too disheartened that day to forge forward in search of more remnants of the border’s body count.
That night, I ate fish tacos with Rodriguez and his crew. We talked about sports and cars. It was a distraction for all of us from the darkness we kept buried behind our public faces—theirs born of the blood of war; mine of the blood of slaves.