Once a fishing village, the Ernavoor slum is now a refugee hutment – and an easy hunting ground for kidney brokers. View Slideshow CHENNAI, India – For two years, Maria Selvam was the most respected man in Tsunami Nagar, a desperately poor refugee camp for tsunami survivors in India's Tamil Nadu province.

As the village's only elected official, he was the closest thing they had to a celebrity. His photograph was plastered on the sides of buildings and the entrances to the community. But lately his popularity has been on the wane. Rocks have been thrown through most of his posters and local youths have carved away his eyeballs from the images on their walls.

"It used to be that only one woman a month would sell a kidney to a broker, but lately it has gotten a lot worse," Selvam said. "Before the meeting, it was two women a week and I knew I had to do something."

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In the last three months, 52 Indian hospitals have come under investigation by the Department of Medical Services in one of the country's broadest crackdowns yet on illegal organ sales. Of those facilities, two have had their licenses revoked, and 13 remain under investigation.

Selvam is at the center of the firestorm.

After the 2004 Indian Ocean tsunami, it fell to him to represent his village in front of high courts that determined how much aid his community of 2,500 survivors was entitled to. But for the most part, he says, the government did nothing. He campaigned tirelessly for what he thought were basics. He wanted fishing nets so the men of the community could start earning a living again and a small three-wheeled rickshaw to haul the community's catch to market.

His pleas fell on deaf ears and in January – two years after the tsunami – Selvam decided to play the only card he had left at a meeting scheduled to take place in front of one of Chennai's most powerful high court justices.

Kidney brokers had long preyed on Tsunami Nagar, and he planned to use the testimony of poor women who were forced to sell their organs to shame the court into finally administering aid. Even though kidney brokers had plagued his community since before the tsunami, he was sure members of the court would empathize when they heard the stories.

Things didn't go according to plan. The judge listened carefully, but said he didn't have any aid to distribute. To make matters worse, the 500 men and women in the audience nearly rioted when they realized that Selvam had betrayed their secret. Youths shouted that he had dishonored the women of his community by exposing what should have been a private matter.

When he came back to Tsunami Nagar, a gang of young men assaulted him and his son and told him he would never be safe in the town again. The situation got worse when teams of reporters descended on the village and photos of the women's scars began to appear on TV.

Some villagers have accused Selvam of taking bribes to arrange the visits. Regardless of his denials, every television appearance set off a new round of beatings. Last month, he was forced to flee.

"In other parts of India, people say that they are going to Malaysia or the United States with a glimmer of hope in their eyes," he told Wired News in a recent interview. "In Tsunami Nagar people speak that way about selling their kidneys."

Little more than a decade after enacting a toughly worded ban on human organ sales, India is rethinking its transplant stance amid one of the nation's worst organ scandals.

The police crackdown in January, instigated in part by Selvam's charges, has thrown a spotlight on the enormous economic incentives that have kept the kidney farms open, despite all efforts at reform. And now, the threat of prosecutions has spurred a political backlash from Tamil Nadu's wealthy and politically connected medical class – many of whom are under investigation – giving new life to long-standing calls for legalization.

It's too early to read the chances of a significant policy swing. But, in 13 years, the battle has never been more public, and medical ethicists around the world are watching the political situation closely. A shift in organ-sale policy here could send shock waves through the international kidney black markets, where prices already appear to be falling in some regions thanks to increased global competition among a growing number of donors eager to escape poverty. (See our related story on international organ markets.)

Early gains for the legalization side came last month, when the Ministry of Health convened doctors from around the state to offer a solution to the problem. The majority of doctors who attended were transplant surgeons under investigation for facilitating organ brokering. The unsurprising – if controversial – resolution was to legalize paid organ donations and hamstring future police efforts to curb organ trafficking.

The stark failures of the current system are partly driving the legalization push. But not everyone believes opening up kidney sales is the right course, and a bitter fight over the issue is shaping up.

In a recent meeting of the state assembly, Health Minister Ramachandran seemed ambivalent, reiterating his agency's commitment to enforcing the law, while hinting that greater permissiveness might be desirable. "While the government is taking all steps to prevent illegal operations, it should also keep in mind the conditions of the patients who badly require kidneys for transplantation," he said.

Others take a harder stance. "The argument that law is not able to curb organ trafficking is no justification for allowing organ sale," said R.R. Kishore, an advocate on the Supreme Court of India and Delhi High Court who helped sign the Transplantation of Human Organs Act into law in 1994.

The legalization fight comes as India wrestles to contain an organ scandal that has rocked the medical establishment and drawn worldwide attention.

In February, Wired News reported that more than 500 people across Tamil Nadu were allegedly cheated by kidney brokers who promised to pay several thousand dollars for a kidney, but absconded with the profits after the surgeries. The news received widespread media coverage when 90 women in Ernavoor, the town where the tsunami refugee camp is located, came forward to tell their tales of poor medical care and exploitation.

A member of the Transplant Authorization Committee, which is in charge of enforcing the ban on commercial transplants, admitted to Wired News on condition of anonymity that the government colluded with brokers to circumvent the laws and authorize thousands of illegal transplants. He claimed it was the only way to save lives.

Identifying herself only as Rani in a Wired News interview, a woman said her surgery was performed at Devaki Hospital, a major transplant center currently under investigation. The hospital is expected to escape punishment. She still keeps all her medical records from the transplant in a chest by her bed – each piece of paper signed by doctors at the hospital.

The facility is run by transplant surgeon K.C. Reddy, one of the most renowned critics of the ban on paid organ donations. Before the ban was enacted, Reddy ran a clinic that was famous for performing thousands of kidney transplants and making sure donors were well compensated and cared for after the operation.

He has written about overturning the ban on paid donors in scholarly journals and in The Economist (subscription required). But since police ordered him in January to hand over his transplant records from the previous decade, he has become media shy – he declined to comment for this story. (In the past he has been quoted as saying: "It is far better to accept, regulate and contain the malpractice in the organ trade rather than to legislate against it – this will only drive the business underground to the ultimate detriment of the donor and the patient.")

Regardless of the long-term prospects for legalization, few here believe the recent police crackdown will dent live donor sales for long. Quite simply, the legal supply of organs is woefully inadequate to meet demand.

In Chennai alone, hospitals performed some 2,000 live-donor transplants in 2006, observers estimate. Of those, at least 50 involved foreign nationals buying cheap donor organs and paying on average $7,000 for a transplant according to the Indian news site Tehelka that cited an unnamed source in the health ministry.

By contrast, a representative of one of the country's biggest legal cadaver donor programs says the group is hard-pressed to procure more than a dozen organs per year.

"In the long term there is just no doubt that we need to rely more heavily on cadaver donations, but the truth of the current situation is that we are a long way from establishing a system that will work," said Sumana Sundaram, project coordinator at the Mohan Foundation. "The supply (of legal organs) isn't even close to the demand." (See our (https://www.wired.com/medtech/health/news/2007/05/india_transplants_donorpolicy).)

Even after the police crackdown, some brokers have continued to arrange organ sales with impunity, running high-profile rackets and even maintaining websites advertising their services.

Deeraj Bojwani runs an all-inclusive kidney brokering service out of Mumbai that boasts a smoothly designed service that can circumvent any ethics committee.

Part of why it's so easy for Bojwani and others to get around the law is because some states stipulate that only relatives or individuals with "love and affection" for the recipient can donate an organ. So while it's a stretch to imagine that's the case between an American from Oklahoma receiving a kidney from a slum dweller in Mumbai, it could also be difficult to prove otherwise.

That ambiguity seems to serve both sides of the debate, offering public approbation while keeping open wide legal loopholes to serve the needs of a lucrative and growing – albeit ostensibly illegal – industry.

As a result, the status quo could well survive intact after a few public trials for the sake of appearances.

"The kidney rackets have been operating in this community for a long time," admitted V.K. Subburaj, deputy secretary of health and family welfare, in his inaugural address. "Ninety percent of the donors we know about come from below the poverty line, and 90 percent of those donate for money."

Meanwhile, Selvam says the government has still given no word about his fishing nets and rickshaw.

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Scott Carney is an investigative journalist based in Chennai, India.

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