Monday, March 23, 2009

A Bloody Harvest

How much is your kidney worth?
In Turkey the prized organ fetches about €2,300, while an Indian or Iraqi kidney enriches its former owner by a mere €800. And the World Health Organisation estimates the going price on the black market to be about €4,000. When you consider that wealthy clients will later pay more than €100,000 for the kidney, this massive profit margin would appear to guarantee a lucrative future for the international trade in human organs, if it continues to be left unchecked.
Laudable developments in biotechnology and organ transplantation are becoming tarnished by shades of questionable conduct ranging from buying and selling organs to trafficking in humans for their valuable body-parts and outright bodysnatching. Our organs, cells, tissues, and bones are now the raw material for new commercial products, and the simple laws of supply and demand has given rise to a thriving black market.
While primarily the circulation of organs flows from South to North, East to West, from third to first world, and from poor to affluent, increasingly ordinary folks are finding themselves caught up in the macabre body shopping business. And the Irish are no exception.
Late last year Irish journalist and author Mary Kenny learned that the man behind an illicit trade in body parts in the US, which included the remains of her sister Ursula and British broadcaster Alistair Cooke, was sentenced to 18 to 54 years in prison.
Disgraced Dental surgeon Michael Mastromarino’s multimillion-dollar enterprise, Bio-Medical Tissue Services, harvested tissue and bone - many that regulations deemed too old or diseased to use – without permission from more than 1,000 cadavers between 2001 and 2005, using funeral homes in Brooklyn, Manhattan, Newark, Rochester and Philadelphia.
Although revelations about this gruesome, greedy scheme has prompted more than 900 lawsuits in the US, Mary Kenny says she doesn’t resent that her sister’s body was dissected, only that it was done without express permission. “I don't think that Ursula would have minded. If she had been asked, I think she'd have given permission for her remains to be used in medical transplants,” she says.
“But there is one disturbing question for me: are the remaining ashes that I have in an urn on the mantelpiece those of my sister at all?”
The true scale of the grisly market in body parts has only surfaced in recent years with the WHO, Human Rights Watch, Interpol and many transplant surgeons speaking out publicly against the growing problems of organ sales, transplant tourism and trafficking in organ donors in the context of the global shortage of organs.
And with those precious few organs going to patients most likely to survive and thrive following transplantation, it’s not surprising that some hopelessly ill people don’t play by the rules.
The WHO estimates that the average wait time for a kidney in Europe is expected to increase to 10 years by 2010. Most dialysis patients won’t last half that time, and the desperate are faced with a Hobson’s choice; find a replacement organ or die.
At least 10 percent of all transplants in 2007 involved patients from developed countries travelling to poor countries to buy organs, a WHO spokesperson explains. They depend on local agents who "source" kidneys and arrange the transplant. An estimated 15,000 kidneys (the bulk of the black market in human organs) are being trafficked in this way each year.
Scope magazine has learned that at least one Irish person travelled recently to Pakistan for a kidney transplant. The organ was sourced in Pakistan and the transplantation carried out by a local surgeon. It is documented that foreigners receive two-thirds of the 2000 kidney transplants performed annually in Pakistan.
Given his global connections as former Director of the International Federation of Kidney Foundations, Mr Mark Murphy, CEO of the Irish Kidney Association is in an excellent position to know if other Irish patients are travelling outside Europe for transplant surgery.
“I don’t know of any others, just this one person, and up to now we wouldn’t have considered this a potential problem in Ireland. Irish patients have had a reasonable chance of getting kidney transplants. We have almost 50 percent more organ donations than in the UK,” he says, quickly adding that there is a complacency developing in Ireland arising from this favourable comparison with our closest neighbour. Britain has one of the worst organ donor rates in Europe, he stresses.
“We’d have about 1,700 people getting dialysis treatment at the moment, of which about 500 are on the kidney transplant list and 800 ultimately would at some stage be ready for transplantation. But there were only 146 kidney transplants in 2008 and a similar number the previous year and the year before that.
“The real horror is when you look at the heart and lung transplant programmes in Ireland. There are serious issues there. We did four heart and four lung transplants in this country last year and none of those lungs were for Cystic Fibrosis patients,” he points out.
“Norway is a similar country with 4.7 million people but a more proactive organ procurement and transplant programme compared to us. They did 29 lung transplants, out of a similar amount of donors last year.
“There’s no doubt people are focusing on the Mater Hospital (Heart and Lung Transplant Programme) at the moment, particularly the Cystic Fibrosis Association wondering where are the lungs that were promised for transplantation? We have one of the highest rates of CF in the world. While good treatment is better for young Cystic Fibrosis sufferers, it will get them into their 40s, they may need lung transplantation in the last three years of their expected life at the time, giving them possibly a two-year window before they are beyond transplantation, and that’s a desperately hard situation to be in, particularly when they’re still so young.”
Mark maintains that Ireland is performing well with regard to liver transplants at St Vincent’s University Hospital – 59 in 2007. However, a scathing article in the journal ‘Liver Transplantation’ in 2004 exposed a significant inequity in liver transplant allocation in Ireland with patients holding private health insurance three times more likely to receive a transplant than those without insurance.
“I don’t believe there is a problem with Irish people going abroad for organ transplantation, they would show up, it’s too small a country to be honest, they’d present to the medical profession because they’d be looking for immunosuppression drugs. We might have the odd one who is, I don’t know, I only know of the one, but I don’t think it’s an Irish problem, yet,” he emphasises. “It will become an Irish problem if our organ donor levels or our transplantation programmes cannot keep up with demand, it will drive us in that direction because patients who need a new lung or heart don’t have the ‘luxury’ of dialysis to keep them alive. If I were put on a heart transplant list here I’d be sorting out my affairs and not expecting it.”
Mark was invited along with Mr David Hickey, one of Ireland’s top transplant surgeons and Director of Transplantation at Beaumont Hospital, to participate in the International Summit on Transplant Tourism and Organ Trafficking convened by The Transplantation Society and International Society of Nephrology in Istanbul, Turkey, in May last year. There they joined more than 150 healthcare professionals, scientists, ethicists and legal scholars from 78 countries in drafting the groundbreaking Declaration of Istanbul on Organ Trafficking and Transplant Tourism, which was published in November 2008.
This document proclaims that the poor who sell their organs are being exploited, whether by richer people within their own countries or by transplant tourists from abroad. Moreover, transplant tourists risk physical harm by unregulated and illegal transplantation.
Participants in the Istanbul Summit agreed that transplant commercialism and tourism and organ trafficking should be prohibited. And they also urged their fellow transplant professionals, individually and through their organisations, to put an end to these unethical activities and foster safe, accountable practices that meet the needs of transplant recipients while protecting donors.
The broad representation at the Istanbul Summit indicates the importance of international collaboration and global consensus to improve donation and transplantation practices. A vital network of ‘informants’ also sprang from the Protocol groups with the objective of communicating any illegal or suspicious practices among the medical profession and others.
“At the moment I am watching the tracking of a particular doctor in Turkey who appears to be organising organ donors for people who want them. He would be removing the organ from the donor and making the money. It’s the hospital he works at as well but he’s the ring leader,” says Mark, who is an active member of this informal grapevine. “If I saw something untoward in this country I’d be letting them know and they’d be letting Interpol know.”
When contacted by Scope, Interpol declined to release its Report into Human Organ Trafficking (2006), however an officer confirmed that reliable intelligence of these international black market operations is thin on the ground.
“Interpol has very little concrete information about organ theft or trafficking and we would appeal to the authorities in each country, and the medical profession, to keep us informed of any suspicious activities in this area,” she appealed.
She confirmed that doctors and other medical staff are often part of the criminal networks involved in this crime, and she highlighted a high-profile case of a doctor apprehended at a jungle resort in southern Nepal in February 2008 for “illegal transplanting of kidneys, cheating and criminal conspiracy” – according to the arrest notice issued by Interpol.
The fugitive doctor, Amit Kumar was the alleged mastermind of a shadowy organ transplant operation in India that illegally removed hundreds of kidneys - sometimes from unwilling donors.
"It is believed that during the past eight years around 500 people were forcibly operated on and their kidneys transplanted to foreign patients in a secret operating theatre," the global police body said.
The arrest was an important coup for those trying to combat this criminal trade but, as the WHO points out, while there is “assumed complicity in illegal organ trafficking of a minority of trained physicians and surgeons”, they have been identified in only a small number of cases “as there is extreme difficulty in documenting illegal trafficking events reliably and either substantiating or refuting rumour”.
This difficulty is compounded by the fact that many countries and professional associations may simply reject organ trafficking as immoral and illegal without taking further active steps.
Print and electronic news services are peppered with scant accounts of formal investigations into organ trading in several countries, few resulting in legal proceedings and even less securing convictions. Ireland is noticeably absent from these efforts and for good reason – no legal provision exists in this country prohibiting the sale or the purchase of an organ here or abroad. Our Government admitted as much to the Secretary General of the Council of Europe in a 2004 survey of 44 countries, prompted by concerns over organ trafficking. Ireland was among only four countries not to have legislated against this practice.
At a push, Irish legal eagles could dust off the 1832 Human Anatomy Act, which was introduced to stop people robbing bodies from graveyards for medical school dissection tables.
Albeit belated, the Department of Health’s recent public consultation into consent for the donation of organs after death for transplantation has been welcomed by various interest groups, the medical profession and the public at large.
This consultation process, which closed to submissions at the end of February this year, will feed into the preparation of the Human Tissue Bill to regulate the removal, retention, storage, use and disposal of human tissue from cadavers, including the issue of consent for donation of organs after death for transplantation. The Department is examining the case for the ‘opt-in’, ‘opt-out’ and ‘mandated choice’ systems of consent for organ donors.
Ms Ruth-Gaby Vermot-Mangold, President of the Human Trafficking Commission of the Council of Europe, recently appealed to Governments in the “rich countries” of Western Europe to vigorously promote the donation of organs in their own countries and thus begin to erode the black market demand.
In Ireland this donor drive could include the training of donor co-coordinators in hospital intensive care unit – a recommendation anticipated in an eagerly awaited National ICU audit by the HSE to identify the reasons for Ireland’s low organ retrieval rate.
Another popular option is an education and public awareness campaign blitz to boost, in particular, live donor transplants, although Ireland has yet to regulate the transplantation of organs removed from living donors. There is also a conspicuous absence of an independent Transplantation Authority in this country, and this must also be addressed.
Organ trafficking and transplant tourism is a serious 21st century problem for health service providers and governments. There is no doubt that a worldwide shortage of organs is being exploited by unscrupulous operators, and is putting donors and recipients at risk. Commercialised organ transplantation ensures the middlemen become rich, the sick get bad treatment and the poor suffer the consequences.
“Organ theft and trafficking it is not a myth or urban legend: It happens at an alarming rate in some countries. If we want to ensure that it doesn’t become a problem in this country we need to get active now, get out donor rates up and our transplantation programmes busy,” says Mark.

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