Why kidney rackets in India flourish with impunity
Three major kidney trafficking rackets spanning several states and neighbouring Nepal were busted in India since June 2016. Two of them involved staff of important private hospitals in Delhi, and the third a fake doctor and his family who operated India’s biggest and longest such racket.
Each year, approximately 210,000 new people need new kidneys, but barely around 8,000 get them. The demand-supply mismatch creates a ripe space for organ rackets. Fake doctors carry out fly-by-night surgeries and documents are systematically forged to show donors and recipients as family — attempts to beat India’s tough restrictions meant to prevent trafficking.
The lynchpin of the most unprecedented racket was Amit Kumar, 65, who has no training in medicine or surgery. He has instead shown skill in evading the law, changing names and moving cities several times each time he secured bail after an arrest. Kumar’s thriving illegal kidney transplantation empire began two decades ago in Mumbai and spread to Delhi, Rajasthan, Andhra Pradesh, Gujarat, Haryana, other parts of Maharashtra and Uttarakhand. He was finally arrested in Gangotri along with his brother Jeevan in September. The pair did around 50 illegal transplantations in the three months before they were caught.
Earlier in June, Delhi Police busted an unrelated racket spanning operating in Maharashtra, Gujarat, Punjab, Uttarakhand and Nepal. A sting operation that exposed the operation showed meticulous planning: Fake Aadhaar cards, election identity cards, bank passbooks and birth- and high school-certificates were created; donors were made to spend time with the family of the recipient to get the history, mannerisms and accent right; and family pictures were photoshopped to show them as related.
Last year, in June 2016, police arrested 13 people, including assistants to doctors at Delhi’s Indraprastha Hospitals, for buying and selling organs. Five doctors — four from Apollo and one from Holy Family Hospital — on the Ethics Committee that vets documents to authorise transplantation were questioned for ostensibly failing to spot fake documents.
Diabetes and hypertension are the biggest cause of kidney failure in the country, accounting for 40-60% of chronic kidney disease https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4446915/ that leads to kidney-function failure.
With life expectancy increasing and lifestyle diseases affecting people at younger ages, prevalence of chronic kidney disease is steadily rising. “The average age of a person needing transplantation is less than 50 years,” says Dr Sandeep Mahajan, professor of nephrology, at the All India Institute of Medical Sciences in New Delhi.
In order to prevent trafficking, India has severe restrictions on who can be a kidney donor. The Transplantation of Human Organs (Amendment) Act 2011 allows only a “near relative”— parents, children, siblings, spouse, grandparents and grandchildren — to be a living donor. It also allows “swap’ donations, where a pair of incompatible donor-recipient pair can swap with another incompatible pair, so that each donor gives a kidney to the other person’s intended recipient.
The law also permits donation from “affection or attachment towards the recipient or for any other special reason”, but such donations are closely screened for commercial motives by hospital ethics committee and the state authorisation committee. The checks are meant to ensure donations are not made under duress or for money.
The black market flourishes despite these safeguards since it is often a matter of life and death.
“The donor pool is shrinking and the number of people with end-stage chronic kidney disease is going up. People want to live and unfortunately, social reality and economics dictate that very often the recipient is the breadwinner with dependents, so people are ready to risk a jail to live,” said Dr Harsh Jauhari, chairman, kidney transplantation surgery, Sir Ganga Ram Hospital.
Swapping organs between incompatible donor-recipient pairs and ABO-incompatible renal transplantation to cross the blood group barrier has somewhat widened the donor pool, but cases are rare and not enough to meet the acute shortage.
Living donation in India is often driven by gender, with the odds stacked against women. “Less than 20% recipients are women, while 55-60% donors are women from the family — sisters, wife or mother. And if the son wants to donate, parents always refuse,” said Dr Jauhari, who heads a team that does 220-230 transplantations in a year. “Since the law permits donation driven by affection and the hand of friendship always extends from the poor to the rich, the authorisation committee must also rule out wide disparity in the social and financial status of the donor and recipient,” says Dr Jauhari.
India’s dubious position as being the leader in road accident fatalities presents an opportunity to widen the organ pool. More than 146,000 people die annually, of them close to 65% are from severe head injuries leading. This translates to around 90,000 people in hospitals with “brain death” each year. Given that two kidneys can be retrieved from each, the potential of lives saved is massive.
India could borrow from the Spanish system of organ donations. Spain leads the world with 35 organ donors per million people, compared to Britain’s 27, US’s 26 and Australia’s 11 donor per million. India 0.16.
What works for Spain is the Organizacion Nacional de Trasplantes, a centralised waiting list and registry, and a rule that all citizen after death are organ donors unless they exercise their right to exclusion. Those who refuse deny themselves the right to receive organs from the donor pool.
But it is not as simply for India.
“India cannot have a similar law because there are issues of informed consent due to low awareness and education levels,” says a health ministry official who does not want to be named.
“With cadaveric donations, which are the biggest donor pool to be harvested given the high number of road accident deaths, not catching up to expectations, and with families getting smaller and many siblings ineligible to donate because they have the same lifestyle diseases (diabetes, hypertension) as the patient, the donor pool is shrinking rapidly,” says Dr Mahajan, who is part of the transplantation team that did external affairs minister Sushma Swaraj’s kidney transplantation at AIIMS in 2016.
Dialysis is an option, but it’s expensive: costing anywhere upwards of Rs 20,000 a month with medicines. “It’s expensive and time consuming — patients spend half or a full day in hospital — which makes people unemployable. People begin dialysis late and don’t go regularly because of inconvenience or expense, which damages kidneys and brings down survival rates.
“The unfortunate reality is that for most patients, it’s a choice between transplantation or death. At good centres, people on average live for more than 15 years on dialysis, but you live tethered to a hospital. With immunosuppressant medicines, life after transplantation is normal, and that is what touts exploit,” says Dr Mahajan.