For nearly 18 years Sameer Kiran lived in fear of an impending renal failure. The Karachi-based physician was diagnosed with an incurable congenital renal disease at the age of 24, and an early detection allowed him to arrange for a life-saving transplant procedure in time. Today, he lives to tell the tale of his battle with the silent disease, not knowing whether his donor was as fortunate.My doctors said there was nothing I could do and that I just have to wait and watch until the kidneys fail. And they eventually did in 2011,” says Kiran. Unlike the great majority of renal failure cases in Pakistan, Kiran was put on dialysis well before the complete collapse of his kidneys. In the three years that followed, he endured the morbidities of dialysis while searching for a family donor, and came close to death twice. When things started to look bleak, he decided to expand his pool of donors in a desperate attempt to find a match. “Dialysis is a painful process and the outcome is not good either. I was living on a day-to-day basis,” he says. At this point, Kiran says, he was willing to take any measures necessary to secure a kidney as his family was dependent on his income.In his quest for a donor, Kiran learnt about hospitals in Islamabad and Rawalpindi offering complete packages for transplants, including surgery, follow-ups and, intriguingly, an organ in case one is unsuccessful in securing a family donor. Although suspicious about the legality of this all-inclusive package, he decided to approach one such hospital in the capital and further probe the matter. “I knew the hospital was not conducting secret operations in narrow lanes,” says Kiran. It is a prominent building that enjoys main road exposure and has been operational since 30 years, explains Kiran. “They furnish all the legal documents and [the hospital] has never been raided but still, I was reluctant.”It was not until a fellow colleague, who had also been a mentor, confirmed the above by narrating his personal experience of getting a transplant at the hospital that Kiran finally decided to opt for the procedure. According to the law on transplantation in Pakistan, donation to a non-relative is allowed only if it is voluntary. And that is what the hospital claims to do: finding people willing to give away their vital organs for free to patients they have never met. “When the hospital draws up transplant documents, they ask the vendor to write he gave his organ for free, but of course he/she is paid extra money,” says Kiran. Hospitals charge an additional amount for the organ if they are asked to arrange for one and this amount is offered to the vendor, he explains. “This way all the legalities are followed and the transplant is not deemed illegal,” he concludes.Under the Transplantation of Human Organs and Tissues Act 2010, buying and selling of human organs for transplants is prohibited in Pakistan, and donations from living donors are strictly restricted to blood relatives. In case of a donation to a non-relative, the law calls for strict evaluation of the case to determine if it is being done purely for altruistic reasons and no coercion or monetary benefits are involved. But despite the sentence for up to 10 years and a fine for up to one million for anyone involved in facilitating an illegal transplant, the business of illegal organ trade has attracted many because of its lucrative nature. As a result, five members of a ring of doctors and clinical staff operating an illegal organ transplant racket were arrested in Lahore in August this year and in October, Islamabad Police unearthed a kidney smuggling gang and arrested two people from the capital’s outskirts. Peshawar was also rife with rumours of organ trade when bodies of kidnapped children started turning up early this year.Kiran’s story is just one side of this multifaceted trade that continues to flourish. From the bottom of society, right up to the top, everyone is involved: the poor donors who are willing to donate a kidney in return for some quick cash to either pay of debts or support their family, the brokers who exploit the impoverished into selling their organs, the rich foreign recipients who travel to Pakistan for a transplant, the surgeons who cut through the ethics of the medical profession and retrieve kidneys, and the powers that facilitate and protect this illegal business. Everyone wants a piece of the pie.Before the law was passed in 2010, Pakistan was the destination for ‘transplant tourism’ with hundreds of renal failure patients from the Middle East and the West travelling to the country for the gift of life. “More than 1,500 foreigners were coming to Pakistan for transplants from all over the world each year. There was no law [prohibiting it back then] and people could get transplants in Lahore, Rawalpindi... basically everywhere,” reveals Dr Mirza Naqi Zafar, general secretary of the Transplantation Society of Pakistan (TSP).In a study conducted by the Sindh Institute of Urology and Transplantation (SIUT) on kidney vendors near Sargodha, it was discovered that they all come from impoverished backgrounds, most of them being bonded labourers. “The sellers were promised a certain amount of money to get out of their debt — between Rs0.1 million to Rs0.2 million — but they never got it as the agents siphoned the payment,” adds Dr Zafar.Labour rights activist Syeda Ghulam Fatima, who is the general secretary of the Bonded Labour Liberation Front Pakistan (BLLF), says the issue first came to her notice in 2006 when a boy, originally from Hyderabad, ran away from a brick kiln in Lahore and came to her. “The boy and his family were visiting Punjab when a kiln owner captured them saying their relative owed him money and that they should work at his kiln to repay the debt. In reality the family was sold by their Sindh kiln owner to the one in Punjab,” Fatima recalls. Desperate for freedom, the family asked for a quicker solution and the kiln owner told them to sell their organs. They agreed and the organ trade gang extracted kidneys of two of the family members when the boy got cold feet and ran away. Fatima petitioned for the boy and his family and over the course of several hearings, found that the son of the Punjab kiln owner was part of the organ trade and all this had been part of their plan. “Landlords and kiln owners realised this was a good way of recovering their money and so they encouraged, coordinated and supported these organ hunters,” says Fatima.The case didn’t lead to any conviction but Fatima took it as a stepping stone for a campaign against organ trade in Pakistan. Narrating some of the most harrowing stories of victims, Fatima says, “We targeted Hafizabad in Punjab and found out around 5,000 people had sold their kidneys and were still bonded to their owners. In Kasur, a man went to the hospital for a check-up and woke up with one kidney. I know another person who was forced to sell his organs but managed to escape only to join the gang later as a broker.”While the majority of vendors are male, researches show a big number of women are also part of the trade. SIUT’s study in Sargodha also included a number of women who had sold their kidneys for various reasons, including duty to family. “After the law was passed, there was a time in Lahore when ‘love transplants’ were common; men would meet young women near Ravi river and marry them only to get their organs legally,” Dr Zafar shares. Co-founder of Organs Watch — an international organisation monitoring the trade — Lawrence Cohen also says, scholars who study transplantation have pointed out that despite the presence of a black market, many organ transactions are among family relations and community members where duty, love, coercion and money all play a role.With Pakistan at the centre of the global organ trade in 2007, the government took measures towards curbing it and introduced an ordinance, which was later passed as a law. Dr Zafar, who is also a professor at SIUT, says there was uproar by certain elements when the government was in the process of declaring organ trade illegal. “Those involved in buying and selling of organs tried to get the law upturned by going to the Shariat Court. They said it was un-Islamic to ban organ trade which ‘benefited’ renal failure patients coming from rich Arab countries,” Dr Zafar says. Fortunately, the court declared the trade against the spirit of Islam; the law was passed in both houses without any opposition and blatant buying and selling of organs stopped.Dr Zafar, however, acknowledges clandestine deals are still going on due to weak implementation of the law. “It was a big racket with so many people and so much money involved. The infrastructure and the agents are still there and so they find different ways to continue with their business,” he says, mentioning an instance when a foreigner from east Africa came to Pakistan, sold his kidney and left. “They are so powerful and so well-connected that they can even bring vendors from abroad,” he notes.The TSP general secretary says the number of transplants have reduced since the law declared it illegal but the sum of money has gone up due to reduction in supply of organs. “The gangs may be organising less transplants but they must be making more money,” he estimates. Fatima also keeps hearing stories of people getting organ donations from outside their family. A close friend of hers recently had an illegal organ transplant in Islamabad for Rs2.5 million.Since Kiran’s transplant was ‘legal’ on papers, there was no need for secrecy. But most illegal transplants are done under the cover of darkness in shady buildings on the outskirts of cities where vendors and recipients meet their surgeons only under the influence of anaesthesia. “From what we have learnt in the past, vendors are incarcerated in one house and recipients are kept in another. Both of them are then taken to a different place for the transplant,” says Dr Zafar. People who have been part of illegal transplants visit SIUT for check-ups but never divulge the details of the operation, he adds. “Some don’t give us that information out of fear, but most of the time they don’t have that information,” he says. “If I pay for an illegal transplant, I would not know where I will be taken for the transplant, who will be my surgeon — this information is not available to them,” he explains.Dr Zafar also doubts organ trafficking gangs follow stringent criteria for transplants to ensure a perfect match. “I don’t think they care about tissue typing; they would use any vendor — healthy or not — for the transplant,” he says, sharing the findings of an international study which focused on recipients who travelled to Pakistan for transplants. According to the research, the recipients had post-transplant complications because the organs they received were not healthy. Also, of the 120 vendors SIUT interviewed in Sargodha, Dr Zafar says many of them were medically unfit to donate a kidney.Though Kiran has not had any complication since the transplant, he also does not know how well his body matched that of his ‘donor’. “I don’t know if the match was a 100%, 70% or 50%. It all comes down to putting your trust in the doctors,” he says. According to Dr Zafar, few doctors who do get tissue typing done to find the best match do it perhaps for the recipient’s goodwill. “If the match is good and the recipient is satisfied, he will become an ambassador for their work and bring in more customers,” he speculates.Like many countries worldwide, Cohen says Pakistan faces considerable challenges with regards to the impact of an illegal organs market on poor, indebted farmers, labourers and urban slum-dwellers. As per the Human Organs Transplantation Authority (HOTA) guidelines, doctors must tell recipients and donors about the effects, complications and hazards related to organ removal but when the transplant falls outside the law, the human body is left at the mercy of surgeons whose only concern is money. “The vendors are desperate, poor people. If you offer Rs100,000 to a person who cannot even afford to feed himself, it’s a windfall!” Dr Zafar explains. “The brokers often make prospective vendors meet previous vendors to convince them that quality of life doesn’t change after donation,” he adds.While vendors take the risk for monetary gains, the motivation for recipients is to avoid the regular struggles of being on dialysis and increase the chances of survival, says Dr Zafar. “In the US, chances of five-year survival on dialysis are 35% and 85% with a transplant.”The global hotspots of organ trade keep changing as new laws are introduced and enforced. However, the trend of organs supplied from the poor to the rich remains the same. Nancy Scheper-Hughes, director of Organs Watch and a renowned expert in organ trafficking, once said the organ trade “follows the modern routes of capital; from south to north, from Third World to First World, from poor to rich.”In early 2000s, India was supplying thousands of organs to foreign recipients but the trade shifted to Pakistan when the Indian government started a crackdown against the organ gangs, says Dr Zafar. Pakistan became a hub for transplant tourism in 2006 and when the government introduced laws prohibited buying and selling of organs in 2010, recipients began to travel to Iraq, Eqypt and Philippines. “The trade is still going on in Philippines and now there are reports coming in from Bangladesh,” he states. “We got to know about Pakistan’s role in the trade when TSP received reports from recipient countries saying their citizens had undergone transplant surgery in Pakistan,” he says. Countries detected this when their dialysis patients began disappearing from organ waiting lists, he explains.There is an argument against criminalising organ trade which calls for regulating the business through strict guidelines because in the end, both vendor and recipient gain something. As a kidney patient, Kiran says he favours purchase of organs. “There are people who have no family donors. I know cases where mothers refused to donate their kidney to their children. One cannot force anyone to donate,” he says. Such patients should be given this privilege, he explains.But Dr Zafar disagrees. Is prostitution legal, he asks. If today we allow people to sell their kidneys, tomorrow there will be a demand for livers and then some other body part, he argues. “We fight for human dignity even when it is for a person who is in jail for committing a crime,” he adds. “What do we live for? Are we going to commercialise everything? Human life doesn’t revolve around buying and selling; you cannot buy and sell everything.”With a huge chunk of the country’s population living below the poverty line, organ trade is likely to continue in secret operation theatres and at known hospitals with strong political connections. Criminals have their ways and work around the loopholes in our system, says Fatima. “Ending poverty, unemployment and forced labour will be the first step towards ending this evil,” she advises. The labour activist believes a single conviction with a severe punishment will put a stop to this.For curbing the international trade, Dr Zafar says there is always a pressure on developing countries to stop people from selling their organs but why can’t the rich countries stop their citizens from coming to us for transplants? “At international forums, head of SIUT, Dr Adeeb Rizvi, asks recipient countries to not send their citizens here and if they do get a transplant, then don’t entertain them when they come back,” he says.The answer to ending this organs market is self-sufficiency through deceased organ donation, stresses Dr Zafar. “The more living and deceased donors you have, the better chances of patients not dying on waiting lists or travelling abroad for a transplant,” he insists. The trend of living donors — family and friends who donate willingly — is already catching up in the US and UK as well as Europe while deceased donation is rising in KSA, Iran, Kuwait, Bahrain, Oman, Qatar and UAE.