The Best American Science and Nature Writing 2011 (3 page)

The mastermind, India's Central Bureau of Investigation (CBI) charged, was Amit Kumar—a man who performed the surgeries with no more formal training than a degree in Ayurveda, the ancient Indian system of medicine. In a career spanning two decades, Kumar had established one of the world's largest kidney-trafficking rings, with a supply chain that extended deep into the Indian countryside. Some of his clients were from India. Many came from Greece, Turkey, the Middle East, Canada, and the United States.

At parties in India and abroad, Kumar introduced himself as one of India's foremost kidney surgeons, said Rajiv Dwivedi, a CBI investigator based in Delhi. The claim wasn't entirely illegitimate: investigators estimate that Kumar has performed hundreds of successful transplants, a practice so lucrative that he was able to finance Bollywood movies and had to fend off extortion threats from the Mumbai mafia. Two weeks after the police crackdown in Gurgaon, Kumar was arrested at a wildlife resort in Nepal and brought back to India, where he now awaits trial.

Kumar's operation was a microcosm of the vast, shadowy underworld of transplant trafficking that extends from the favelas of São Paulo to the slums of Manila. The tentacles of the trade crisscross the globe, leaving no country untouched, not even the United States, as evidenced by the July 2009 arrest of a New York rabbi who has been charged with arranging illegal transplants in this country by bringing in poor Israelis to supply kidneys.

In June 2008 I traveled to India to get an inside view of Kumar's ring and examine the perverse enterprise that fueled its rise. How did Kumar build his organ empire, and how was he able to run it for so long? The answers, I learned, lay in the grinding poverty and entrenched corruption of India, the desperation of patients on dialysis, and the transnational nature of the black-market transplant business—which, though dominated by the kidney exchange, includes livers and hearts as well. The factors at play in India allow the kidney trade to thrive around the world, despite efforts by various governments to stamp it out.

 

Life without a working kidney is harsh. We are born with two of these internal filters, located below the rib cage, to remove waste and excess water from our blood. Patients with kidney failure—often the result of diabetes and high blood pressure—can die within days from the buildup of toxins in the bloodstream and the bloating of organs. To avoid this outcome, modern medicine offers dialysis, a process in which blood is cleansed at least three times a week by pumping it through an external or internal filter. This grueling routine comes with dietary restrictions and side effects like itching, fatigue, and risk of infection. Theoretically you can live on dialysis for decades; in reality, though, the risks are so great that without a new kidney, premature death is the frequent result.

No wonder that those needing a kidney vastly exceed the number of kidneys available from deceased donors. In the United States, some 88,000 individuals were on the waiting list as of early 2010, with 34,000 names typically added every year. The wait averages five years. The situation in Greece is similarly dire: Eleni Dagiasi put her name on a list around 2006 and expected a waiting period of five years or more. In the meantime, she needed dialysis three days a week—a treatment requiring that she live in Athens, more than seventy-five miles and three hours' travel from her husband, who works on Andros Island as a caretaker of yachts. After Eleni learned of the India option through one of Kumar's brokers, the couple saw it as a way out.

They could have gone elsewhere: to Pakistan, where entire villages are populated by men who have been stripped of a kidney; to China, where kidney harvesting from executed prisoners has supported a booming transplant industry; or to the Philippines, where transplant tourism flourished until May 2008, when the government banned the trade. Transplant tourism today accounts for as much as 10 percent of all donor kidneys transplanted, says Luc Noël, coordinator for the Department of Essential Health Technologies at the World Health Organization (WHO). Often lured by middlemen (or drugged, beaten, and otherwise coerced), donors end up with a few hundred to a few thousand dollars and a scar at the waist that has become an emblem of exploitation and human indignity.

The kidney trade has its origins not in the underworld but in the bright light of medical advancement and the globalization of health care. It began in a hospital in Boston in 1954, when a medical team led by the plastic surgeon Joseph Murray conducted the first successful kidney transplant from one identical twin to the other. There was no immune rejection to contend with because the donor's and recipient's organs had coexisted happily in their mother's womb. Through the 1950s and '60s, researchers attempted to make transplants work in patients who were unrelated to their donors. To help the new organ withstand the assault from the recipient's natural defenses, doctors developed tissue-type matching, a technique to determine if the chemistry of the donor's immune system, defined by antigens on the surface of cells, was similar to that of the recipient's. Doctors also bombarded the recipient with X-rays and used a variety of drugs to beat the immune system into submission.

In the early 1980s, transplants became feasible on a wider scale. What changed the scene was an immunosuppressant molecule called cyclosporin, developed by researchers at the Swiss pharmaceutical company Sandoz. It became the foundation for new drugs that could counter organ rejection with unprecedented effectiveness.

The possibilities quickly became evident. "Doctors realized that with cyclosporin, you did not need a related donor," says Lawrence Cohen, an anthropologist at the University of California at Berkeley. Clinics were able to cast a wider net for donors, and kidney transplants became an established surgery around the world. Soon kidneys were a commodity. The first reports of kidney selling began to surface in India around 1985. With its large base of doctors and an expanding health care industry, India had already been attracting medical tourists from the rest of South Asia and the Middle East. Now there was a growing stream of patients from these countries checking into hospitals in Chennai, Mumbai, and Bangalore for kidney transplants. "There were lots and lots of sales," Cohen says.

In Southeast Asia another kidney-trading corridor had opened up, with the Philippines as the hub. Patients from Japan and elsewhere traveled to Manila to buy kidneys. The organs often came from jailed felons, according to Nancy Scheper-Hughes, an anthropologist at the University of California, Berkeley, who has documented the trade in various countries. "Guards would pick out the healthiest-looking prisoners," she says. Some reports allege that buyers negotiated with the prisoners' families, not the prisoners themselves. Meanwhile, China became the destination for patients from Singapore, Taiwan, and Korea. Under a rule approved by the Chinese government in 1984, kidneys and other organs were harvested from executed prisoners. Human rights activists became concerned that China might have been ramping up its executions through the 1980s and '90s in order to boost its organ supply.

The practice was gaining notoriety, but interventions urged by WHO and others often failed. India legislated its Transplantation of Human Organs Act, banning the buying and selling of organs, in 1994. But the law did not eliminate the practice; it simply drove it underground. By the end of the decade, the kidney trade was thriving, largely due to the Internet. Websites touting "transplant packages" priced from about $20,000 to $70,000 sent patients, many of them Americans, flocking to hospitals in the Philippines, Pakistan, and China. In 2001, when authorities apprehended a criminal syndicate trafficking kidneys from slum dwellers in Brazil and poor villagers in Moldova to Israelis, it became evident that the trade had spread far and wide.

 

When Kumar was arrested on February 7, 2008, he struck a defiant pose for the cameras as Nepalese officials prepared to escort him to Delhi. In the weeks that followed, he became a media celebrity, with investigators leaking stories about his flamboyant lifestyle. News reports alluded to Kumar's owning properties in India, Hong Kong, Australia, and Canada. Sher Bahadur Basnet, a Nepalese police official who apprehended Kumar, told me that he made frequent trips to nightclubs and casinos in Kathmandu. In an ironic twist, an Indian news channel discovered a clip from an obscure 1991 Hindi flick titled
Khooni Raat
("bloody night") in which Kumar—who harbored ambitions of becoming a movie star—plays a bit role as an upstanding police officer.

The first time I saw Kumar was in June 2008 at a court in Ambala, some 125 miles northwest of Delhi. The court had yet to open its doors when I arrived, and I sat outside on a bench. Two of the ring's employees—a driver named Harpal and a cook who worked at the guesthouse, Suresh—showed up, wiping their faces with handkerchiefs. They told me they had no idea that Kumar had been conducting illegal transplants.

A police van drove up carrying Kumar and his accomplices, including his youngest brother, Jeevan Raut (Kumar's original family name), who has a degree in homeopathy; a middleman named Gyasuddin; and a physician named Upender Dublish. Dressed in a beige shirt, Kumar waved at his lawyers from behind the vehicle's rusty iron-mesh window. He had shaved off his mustache, and his eyes looked bulbous. He glanced about furtively while talking with his lawyers.

I inched closer to the van under the gaze of policemen standing nearby, one of whom told me sternly that reporters were not allowed. Nonetheless, I introduced myself to Kumar, who responded with a nervous smile. "I never forced anybody to donate a kidney," he told me before a potbellied guard shooed me away. Inside the courtroom, Kumar kept primping his hair and smoothing out his shirt while the prosecutor, Ashok Singh, presented the charges, citing complaints by seven men alleging that they were tricked or forced into selling their kidneys. Kumar looked crestfallen as he was led back to the van, but his brother walked with a swagger, yelling out to me, "They have no case against us!"

 

At the start of their investigation, CBI officials found it difficult to believe Kumar had been conducting transplants on his own. "We thought his role was to provide donors and clients," Dwivedi told me. The agency assembled a panel comprising a surgeon, a nephrologist, and a forensic-medicine expert to probe Kumar's self-proclaimed expertise. In a two-hour interview not unlike a qualifying exam, the panelists asked Kumar to walk them through the steps involved in a transplant, from removing a kidney to hooking it up inside a recipient. By the end they were convinced. "Kumar had adequate theoretical knowledge about the surgical process" for kidney transplants, the panel said in a report filed in court.

Yet when Kumar entered the transplant business in the 1980s, it was not as a surgeon but as an entrepreneur. To understand how a leading organ dealer got his start, I visited Kumar's second-youngest brother, Ganesh Raut, a real estate developer who now lives in the same Mumbai apartment where Kumar set up a hospital in 1984. Although Ganesh has not always been on good terms with his brother, he has stood by him since the arrest, accompanying Kumar's lawyers to court hearings and meeting with Kumar in jail.

Nobody answered when I rang the bell, but the door was unlocked and I ventured in to find a friendly basset hound wagging its tail in the hallway. Ganesh, a portly, clean-shaven man, was in the middle of morning prayers in front of a miniature temple. I took in the smell of burning incense as he lit a diya and completed the ritual. Then he told me of Kumar's childhood ambitions.

"He would often tell us that he wanted to do something extraordinary in life," Ganesh said. After college in 1977, Kumar went to work at the M. A. Podar Ayurvedic Hospital in Mumbai. He began assisting with simple outpatient surgical procedures that Ayurvedic practitioners are licensed to handle, nothing more complicated than removing hemorrhoids, and later began freelancing as a surgical attendant at mainstream hospitals. Within a few years, he had made enough money and contacts to start his own hospital. Ganesh showed me the room that had once been the hospital's operation theater, where surgeons hired by Kumar performed head-and-neck and abdominal surgeries in the early years, before he turned it into more of a transplant center. Now it was a sitting area furnished with wicker chairs.

Ganesh was less forthcoming about Kumar's kidney venture, so I went to see Rakesh Maria, a top official of the Mumbai police, who shut down Kumar's first foray into transplants in 1995. By the late 1980s, Kumar (then using his birth name, Santosh Raut) had become well aware of medical tourists streaming in from the Middle East. "He knew at once that if he could tap this market, he would hit the jackpot," Maria said. To do so, he reached out to cab drivers at the city's international airport, paying them a commission to find clients.

There was no shortage of potential donors to Kumar's makeshift hospital in Mumbai. He targeted homeless beggars, handcart pullers, sweepers. He hired two men to scout the slums and offer anywhere from a paltry $300 to just over $1,000 for a kidney. Later he began paying the agents a fixed amount of a few thousand dollars per donor. To boost their cut, the agents started paying donors less and less.

Through the early 1990s, the business flourished, and the dozens of transplants performed at the hospital (many of them by a Mumbai Hospital surgeon named Yogesh Kothari) provided Kumar with the equivalent of a surgical residency. He attended conferences, read up on nephrology, and learned about different kinds of sutures and immunosuppressant drugs. In 1994 he performed his first transplant under Kothari's watch. But after a shortchanged donor filed a complaint, police raided Kumar's hospital that August, arresting eleven people on charges of cheating and criminal conspiracy. Kumar himself was charged with conducting illegal foreign-exchange transactions through two frontmen—a grocer and a silversmith—who had helped him receive payments from overseas clients to the tune of $60,000.

After four months in a Mumbai prison, Kumar was freed on bail. In 1995, after Maharashtra (the state that contains the city of Mumbai) banned organ selling, he was busted again and charged with conducting illegal transplants. Finally he fled to Jaipur, 800 miles to the north. There he assumed his new name and conducted thirteen illegal transplants before being arrested yet again, in 1996.