On June 24, Mukesh Chaddwa died of kidney failure in Mumbai. His name featured in a waiting list maintained by Mumbai’s Zonal Transplant Coordination committee for people requiring a life-saving kidney transplant. The patients registered by the committee are allotted a kidney when the family of a brain-dead patient consents to donate his or her organs.

In Mumbai, around 3,105 people are on the waiting list for cadaver donations. Over the past three months, seven people on the list have lost the battle against death while waiting for their turns.

Chaddwa was one of them. He had been on the waiting list for four years.

“Nothing was in our hands,” said his son Hardik Chaddwa. “We were waiting patiently for a donated organ.”

Hardik is proud of the fact that his family did not once consider buying a kidney from the illegal organ market that allegedly thrives in Indian hospitals.

A recent case has brought the illegal market into the spotlight.

The Hiranandani case

On July 15, the Mumbai police claimed to have busted a kidney racket where a patient who was on dialysis for six years was allegedly buying a kidney for a transplant. According to the police, Brijkishore Jaiswal, a resident of Surat, produced fake documents to establish that Shobha Thakur, a woman unrelated to him, was his wife.

Family members can donate organs with the approval of a hospital authorisation committee. But buying or selling of an organ is in contravention of the Transplantation of Human Organs and Tissues Act, a central legislation that governs organ transplants in the country.

The police claims Thakur, a resident of Gujarat, was selling her kidney to Jaiswal in exchange for money.

The alleged donor and recipient were the first to be arrested in the case. They were subsequently granted bail, though Thakur, who does not have the money to pay surety, is yet to be released from women’s jail in Byculla in Mumbai.

Defending Jaiswal, his laywer Pradeep Shetty said: “A reputed doctor suggested this and my client decided to do it to save his life.”

Last week, the investigation moved into high-gear when the police arrested five doctors attached to LH Hiranandani Hospital where the transplant was scheduled to take place.

A three-member committee of the Maharashtra’s health department found the doctors negligent in performing their duties and authorised the police to initiate action against the doctors including Dr Sujit Chatterjee, the Chief Executive Officer of the hospital CEO.

The arrests have shaken the medical community in Mumbai and associations of nephrologists and urologists have threatened to stop carrying out transplants.

Doctors say they should not be held responsible for vetting the identification documents of the donor and recipient. They blame the illegal organ trade on other factors.

Desperate patients

A senior doctor working with the Tamil Nadu government’s organ transplant program said the trade will continue “until the gap between the demand and supply of organs is bridged”.

India does not have a national registry of patients waiting for cadaveric organs. But doctors said that about 3 lakh-3.5 lakh patients need transplants in India at any given time.

Tamil Nadu alone account for around 3,500 patients with end-stage organ failure registered in the waiting list for a kidney transplant. Another 400 patients with end-stage liver failure are registered for receiving a liver transplant. “The patient is a drowning man and he will do anything to save his life, while the donor is someone fighting poverty and would use any means to provide for himself and his family,” explained the doctor who requested anonymity. “We cannot eliminate poverty but what we can do is make cadaveric organs available and bring down the waiting list.”

Echoing the sentiment, Dr Sanjay Agarwal, the head of the department of Nephrology at the All India Institute for Medical Sciences in Delhi, said: “If plenty of cadavers are available as a source of kidney transplant, even the rich will not try to buy kidneys.”

Experts working in Tamil Nadu recalled how the state had become the hub for illegal kidney transplant rackets some years ago. “Now such illegal trade is non-existent,” said a doctor requesting anonymity. He attributed the change to a rise in the number of cadaver donations.

Since October 2008, around 1,525 cadaver kidneys have been donated in Tamil Nadu hospitals. But doctors say the rise in donations has not kept pace with the growing demand, visible in an ever increasing waiting list of patients.

Unequal and unethical

But many believe the factors driving organ trade in India are more complex.

Vivekanand Jha, executive director of the George Institute of Global Health and professor of Nephrology at the University of Oxford, said it wasn’t always that a patient considered buying a kidney out of desperation. “In some instances there are rich people who have potential donors at home but they would prefer buying the kidney because they have the money and do not want to put their loved ones under the stress of donation,” he said. “It’s like saying it’s okay to steal if you don’t have it.”

Dr Barry who is helping the Rajasthan government to set its cadaver transplant program blamed the corruption in India for the illegal sale of organs. “The illicit organ trade is more prevalent in India because it’s easier to get away with it in this country,” he said. “The culture of bribery and corruption, the acceptance of profiteering over ethical considerations and the belief that desperately poor people would be willing to sell their organs to desperately rich people in an attempt to escape poverty are all unfortunate assumptions and, hence, realities.”

A bulletin released by the World Health Organisation in 2007 described India as a “commonly known organ-exporting country”. It said organs from local donors are regularly transplanted to foreigners through sale and purchase. Although the number of foreign recipients seems to have decreased after the enactment of a law banning the organ trade (the Human Organ Transplantation Act of 1994), the bulletin claimed the underground organ market remained active in India.

Growing burden of disease

The debate is likely to deepen as the number of Indians needing an organ transplant rises.

According to a study conducted by Agarwal at AIIMS in Delhi, approximately 1,500 in a million people in India have chronic kidney diseases and around 350 to 400 people per million population have end stage renal disease. “Not only are the patients of chronic kidney diseases increasing in number, but also more patients are being diagnosed due to greater awareness and more facilities for diagnosis,” said Agarwal.

“The actual burden of the disease is also increasing because of the rising magnitude of diabetes and hypertension, two of the common causes of chronic kidney diseases,” he added.

Explaining the association between diabetes and kidney diseases, Dr Christopher Barry, a transplant expert from United states, said, “Diabetes rates are increasing globally as a result of lack of exercise and obesity from overeating and poor food choices.”

Diabetes is a major cause of kidney failure, which ultimately results in the need for dialysis. Indians appear to be more genetically prone to diabetes and other complications of the “metabolic syndrome” such as heart disease, hypertension and fatty liver disease, Barry added.

Unlike end stage liver failure patients where the only treatment is a liver transplant, patients with end-stage kidney failure can survive on dialysis. However, end-stage kidney failure patient needs to undergo dialysis at least thrice a week for almost five to six hours. This makes the process not only strenuous but expensive, said doctors.

“Dialysis involves double the cost of regular transplant maintenance. It needs to be repeated,” said Agarwal. “It does not correct all the function of failed kidneys and it does not increase survival and quality of life as transplant does.” In addition, dialysis facilities are not available widely in India.

Trade or donations?

Concerns over the rise in the incidence of chronic kidney diseases have prompted Iran to allow the sale of organs. It is one of the few countries that allows this. Though the system is criticised by advocacy groups, some research papers hint that that more countries might have to consider the Iran model if the incidence of kidney diseases climbs further.

Many doctors in India support this.

A senior doctor from Delhi compared the sale of organs to surrogacy. “If a woman is allowed to rent her womb and undergo a major surgery (for delivery someone else’s child) in exchange of money,” said the doctor, “why can’t someone be allowed to sell an organ to save another human being?”

“A woman can die during labour but it is almost impossible that a person donating kidney will suffer any such harm,” he added.

But public health experts say legitimising the buying and selling of organs in an unequal society will introduce greater disparities in health care. As it is, even in cadaver donations, there is a popular belief that the donated organs are directed to rich patients first.

“We have to get rid of the system where the poor donates organs at a public hospital and the rich receives the organ at a private five-star hospital,” said the doctor from Tamil Nadu.

An end to the VIP culture in waiting lists would encourage more people to donate, he argued. If the poor are assured that donated organs are not just meant for the rich, more people might come forward, increasing the availability of cadaveric donations. The doctor said the government should provide free transplants to the poor to prove this.