The great and bloody organs bazaar
THE notification of the Transplantation of Human Organs Act, 1994, finally announced by the Union government in the first week of February, had long been promised as a sharp, surgical strike against the practitioners of the human organs trade in the country. Going by the reception it has been accorded, however, the scalpel may miss the point entirely.
There are signs that the unscrupulous wheeling and dealing in human organs may well survive intact with just a few precautionary responses. Voluntary as well as official agencies***(name?), concerned with monitoring such trade in Bombay, reported 2 related trends within 3 weeks of the notification.
First, there were signs that the transplant operations were shifting to safer bases. A high powered cell of Maharashtra police, based in Bombay, had received details from its informants among "gurda-dalals" (kidney-brokers) of 47 donors being taken to nearby Surat and Vadodara. Both cities have witnessed a remarkable proliferation of unregistered medical clinics in recent years.
Second, exploiting a quickly spotted loophole in the Act, enterprising kidney brokers in the city have begun to organise package tours of willing donors to countries where their body parts. Says Deputy Commissioner R Thambe, who heads the Maharashtra Police tracking cell, "The organ-traders are obviously taking advantage of the law which prohibits commercial trade in human parts within the country, but does nothing to prevent Indians in doing so abroad." The destinations are Sri Lanka, Yemen, Oman, Turkey, Syria and Saudi Arabia, countries which have been known to send ailing organ-seekers to India.
The prices of human-organs in Bombay have increased only marginally since the notification. Before the bill, a live-donor kidney was available for Rs 40-50,000. Now it has been notched up by only an additional Rs 8-10,000. Other human parts such as corneas and skin patches have also gone up by only 8-15 per cent (see table). Says Aftab Nadiadwala, a tout who claims regular deals brokered by him at clinics in Khar and Andheri suburbs of Bombay, "The demand for our trade is so high that mere laws can hardly check us."
Warped confidence This confidence is shared by organ traders at other trading centres, including Bangalore, where a largescale kidney trading scandal exploded just days before the notification of the Organ Transplant Act. A fortnight on, when a government-appointed committee began to investigate the involvement of several doctors of the state medical service in kidney transplants from poor donors at several private clinics in the city, it started receiving threatening telephone calls. By mid-February, the number of calls and their content became alarming enough for the state government to order police protection to several members of the committee, including S Kantha, state director of medical education. Kantha says that the callers repeated, "Nothing will come out of the enquiry. We have made contacts at the highest level. You had better lay off or face the consequences."
In Hyderabad, soon after the notification, some doctors decided to temporarily restrict their lucrative transplant practices to cases where the organ was forthcoming from close relatives of the patients, as permitted by the current law.
So delicate is the matter of transplants that the government had not envisaged protests from an unlikely quarter: the patients. Many patients with end-stage kidney failure who had journeyed to the Andhra Pradesh capital in February in search of unrelated donors felt their futures close shop. On February 18, insisting that they had already invested too much time and money to go anywhere else, almost 100 kidney-seekers threatened to go on a hunger strike unless the state government directed the clinics to go ahead with their transplants.
It seemed to have worked: on February 23, the Andhra Pradesh authorities announced that they were considering a temporary arrangement to facilitate unrelated kidney donations, but have been unable to reach a mutually satisfactory cutoff date. Says Union health secretary M S Dayal in New Delhi, "How do we really prevail upon people who are determined to break the law?"
The gist of explanations that the Union health ministry is busy brandishing about the Act's ineffectiveness is that since health legislation is a state subject under the Constitution, the Act is really a model legislation for the states. So far, it has come into force -- mildly -- only the states of Maharashtra, Goa and Himachal Pradesh, apart from the Union Territories. There is nothing to stop illegal organ transplants in the rest of the country.
While the government has incomplete statistics on the extent of the trade, NGOs like the Voluntary Health Association of India (VHAI) have made reasonable estimates which are endorsed by the government as well. As in the rest of the world, the demand for live human organs clearly outstrips supply by a conservative factor of 2:1. There are about 4,000 kidney transplants in India every year, and 8,000 join the waiting list annually. An estimated 100,000 Indians suffer from end-stage kidney problems.
As for other organs: at any given time, the market for bone marrow transplants is believed to be 4 to 5 times the supply. The demand-supply gap is believed to be even bigger for small organs like eyes and ears. A study*** this February by the Union health ministry estimates that nearly 1 million Indians require corneal transplants; less than 30,000 eye donations were recorded by all the eyebanks in the country in 1992.
A large proportion of transplant patients are from the upper and middle classes, and there is no shortage of money to keep a nexus of agents and health professionals raking it in. Profits are stupendous because most donors, driven to the act by poverty, sell cheap and without bargaining. Says Mira Shiva of the VHAI, "A kidney donor rarely gets even Rs 10,000." According to Nadiadwala, a rule-of-the-thumb is that "donors get 6-8 per cent of the amount paid by the organ-seekers." The preliminary findings of a confidential report of the Union health ministry, submitted in the second week of February, show that the human organs trade in the country is worth Rs 55-60 crore.
It's enough money to turn the heads of even medical professionals. The lynchpin of the Bangalore kidney scandal was K S Siddaraju, head of the department of nephrology at the city's prestigious state-run Victoria Hospital. Using his clout, Siddaraju's associates influenced the state government as well as the city police to release him "on administrative grounds" barely 36 hours after his arrest. The only other punitive action against medical personnel involved has come from the Karnataka Medical Council, a professional registration association, which removed 2 other doctors, S A Ahmed and D Ramachandrappa, from its membership.
The involvement of doctors was confirmed by the police in Bombay in the second week of February when they responded to a request by the Karnataka state authorities for details of the organ trade's linkages. Says joint police commissioner of Bombay, M N Singh, "It is no secret that illegal kidney transplants are done in almost every hospital in the city, and every surgeon is aware of this."
This is confirmed by N Colabawala, one of Bombay's leading urologists. "There are doctors in this city, as well as in Madras and Bangalore, who have each performed more than 500 illegal transplants," he says. "There is even an informal ranking system of this dubious expertise." Ashok Kriplani, surgeon at Bombay Hospital, reveals what he asserts is a common practise: that of duping innocent patients to go in for surgical operations, using "parts which have already been committed in a sort of forward-trading system".
Both doctors and police officials in Bombay claim that they know of routes through which the traffic of organ-seekers is directed to the city. Says Singh, "There is a well-established chain from hotels to hospitals, with taxi drivers and touts at your service if you want a kidney or any other human organ. He also points to a steady "tourist" traffic of organ-seekers from West Asia and even Europe. "We know for certain that an Indian travel agent based in Turkey has made millions from this trade. We are also reasonably certain that the staff of a number of consulates in Bombay receive regular commissions for bringing in tourists seeking kidneys, in particular," he says.
Kriplani feels that this traffic will probably increase with the advanced medical treatment that has recently become available in India. A major problem faced by organ-seekers earlier was incompatibility with donated organs, acute where the donor was genetically unrelated to the seeker. Kidney transplants, in particular, have now become safer because of immunosuppressants such as cyclosporine, which enables receivers to overcome temporary incompatibility problems. Says Kriplani, "Just 5 years ago, immunosuppressants had to be imported and would cost a kidney receiver as much Rs 5,000 a month. Ever since the drug began to be manufactured in India, this has come down by nearly half."
Experts like Colabawala and K K Aggarwal of the Delhi-based Indian Medical Association fear that the Organ Transplant Act has insufficient teeth. Says Aggarwal, "Instead of specifying that donors be restricted to genetic relatives of the patient, the lawmakers have gone in for vague language which provides loopholes to the practitioners of the organ trade." He is referring to clauses in the Act which allow organ donations by persons influenced by "reason of affection or attachment". Asks Aggarwal, "How can legitmacy on this count be determined by any regulatory body?"
O P Nigam, joint secretary in the Union health ministry, retorts that the Act is only a beginning of the process of using cadaver derived organs for transplants. As part of its move to encourage cadaver donations, the Act recognises only brain stem death as the legal definition of death. This is the stage where all functions related to the brain cease permanently and irreversibly, but various body organs can still be sustained on external life-support systems to facilitate their removal. The Act also allows for the removal of organs from braindead persons.
Colabawala, Aggarwal and others who have campaigned for years for adequate and effective organ transplant laws in India agree that this is a significant provision. They point out, however, that its implementation will probably be a protracted affair, simply because both government and private hospitals have inadequate facilities for processing cadavers efficiently. Cadaver donations are essentially premised on quick ambulance reactions to transport cadavers to hospitals. Even after this, hospitals need to have expensive life-support facilities for organ removal. Says Aggarwal, "The number of such hospitals can be counted on your fingertips."
But the wishes of the living paralyse even adequately equipped hospitals. New Delhi's Ganga Ram hospital has 14 ventilator-support units which are always overbooked by the relatives of patients, anxious to keep the bodies of their beloved ones breathing as long as possible. They give brain-death no cognisance. Says Harsh Johri, senior nephrologist at Ganga Ram, "The pressure is too much for any doctor to even consider detaching the ventilator-support units."
It was this consideration that influenced the Delhi health minister, Harsh Vardhan, to give substantial thought to the Act before recommending a parallel legislation by his state government. "I have asked the Union government for financial support for cadaver operation clinics," he said in the last week of February.
The infrastructural requirements go on: the excised organs have to cryogenically preserved until compatible recipients are found. This means storage systems, computerised databanks and medical information networks between organ banks and hospitals of a sophistication alien to India today.
Doubts about the efficacy of the Organs Transplant Act are also raised by those who have a more holistic and social view of health. Aggarwal is keen that the Act be backed up by other programmes which will combat, in the first place, the rising incidence of kidney and lung diseases. "In particular, the tendency of doctors to prescribe erroneous treatment or harmful drugs, which easily leads to serious kidney problems, must be monitored and curbed," he says.
Mira Shiva calls for reviewing poverty eradication programmes which have created "organ depots of impoverished donors in many parts of the country." One pocket is the Pallipalayam-Kumarapalayam belt in Tamil Nadu, which sends a regular stream of donors to Madras, Bangalore and Bombay. This belt's malady is rampant unemployment; in the organ trade parlance, the area is known as "kidneypalayam".
Union health officials seem to be confident of the legislation's eventual success. They point out that in the first week of March, the West Bengal and Karnataka governments intimated the Centre of their willingness to introduce similar legislative schemes.
---With inputs from Rahul Shrivastava in Bombay.