Substantial efforts to prohibit human trafficking for organ removal (HTOR) in India via enhancements to the national transplant law have curbed the organ trade. Yet, the Coalition for Organ-Failure Solutions (COFS)–India has gathered evidence that this human rights abuse continues in various private transplant centers across the country, service to foreign patients is ongoing and victims’ consequences are long lasting.
Beginning in September 2010 until May 2012, COFS-India identified approximately 1000 victims of HTOR in India and conducted semistructured in-depth qualitative interviews with 153 of them. One hundred three victims in Erode and Chennai in Tamil Nadu are included in this study and were beneficiaries of a broader assistance project that included an additional 50 victims in West Bengal and Karnataka (1). Victims described their experiences in compelling detail, and each case involved the commercial removal of a kidney as evidenced by the medical follow-up examinations.
The findings presented here include information about demographics of victims interviewed, time and location of kidney removal, reasons for resorting to a kidney sale, awareness of how to arrange the sale, brokers, payment, and consequences for the victims.
Demographics of Victims Interviewed
Of the 103 trafficked persons interviewed, 56 (54%) are from Erode, and 47 (46%) are from Chennai. They ranged in age from 19 to 55 years at the time of the organ removal with an average age of 33 in Erode and 36 in Chennai. In the broader study of an additional 50 persons trafficked for an organ, 30 are from West Bengal, and 20 are from Karnataka. They ranged in age from 20 to 50 years at the time of the organ removal (average age of 35 in West Bengal and 35 in Karnataka). Fifty-seven percent of the victims in Erode are female, and 87% of the victims in Chennai are female (Table 1). Eighteen percent of the victims from West Bengal are female, and 50% of the victims from Karnataka are female.
Twelve percent of the individuals were widowed or abandoned, 79% were married, and 91% were parents with an average of two kids. Of those interviewed, 28% had no formal education, 19% had some primary schooling, 22% had some secondary schooling, and no individuals reported schooling above high school (Table 1). In the broader study, the majority of victims (72% in West Bengal and 71% in Karnataka) had no formal education. All victims interviewed lived in abject poverty with monthly income levels that reach well below the national average.
Time and Location of Kidney Removal
Persons trafficked for an organ in this study indicated that the organ removal occurred between 1981 and 2012. A sum of 14 cases (14%) from Chennai (9 cases) and Erode (5 cases) occurred between 2009 and May 2012 (the close of the study). From the broader study, an additional 20 cases (40%) from West Bengal (14 cases) and Karnataka (6 cases) occurred between 2009 and May 2012.
Reasons for Resorting to an Organ Sale
Individuals interviewed in this study reported that debt was the primary reason to sell a kidney (98%), and they resorted to the sale with the hope of eliminating debt and transcending poverty. In the broader study, 82% of victims in West Bengal and Karnataka gave debt as the primary reason. Wedding expenses, medical, food, and household expenses were the most common source of these debts in the 2002 study in Chennai (2). Related reasons for debt that victims reported in this study, over a decade later, include wedding expenses, family illness, being abandoned or widowed, children’s education, familial substance abuse, loss of job, and lack of income. It is noteworthy that victims provided numerous reasons for sale, and these categories are not mutually exclusive.
A small percentage of victims in this study (7% in Erode) identified the reason of “new opportunity.” No individuals in Chennai cited this reason. More individuals in West Bengal (34%) and Karnataka (12%), however, explained that the potential for a “new opportunity” was a reason for sale. These individual victims explained that the sale had represented an opportunity for personal and familial growth and stability. Purchasing a home, obtaining land, or realizing a business dream were among the noted potential opportunities for individuals. No matter the reason expressed for an organ sale, all victims reported that they would not have agreed to the organ removal if their economic circumstances were not so dire.
Awareness of How to Arrange the Sale
An overwhelming percentage of trafficked persons (93/90%) gained knowledge of organ sales from a member of the community, and 13 of these individuals (13%) made specific mention that this informant was also a victim. These data point to the occurrence of targeting of victims in specific impoverished areas, particularly in Chennai, where 95.3% of victims noted that the practice was common knowledge in their community. Brokers also played a significant role in the victim’s understanding and involvement in organ sales.
Trafficked persons from Erode collectively identified 17 brokers (3 women and 14 men) who were active offenders of HTOR. The majority of the brokers were from Coimbatore, but four brokers were from Bangalore. Several victims from Erode explained that a minimum of three of the brokers were victims of HTOR before brokering and four brokers pressured their own wives to sell a kidney. In Chennai, trafficked persons collectively identified 18 brokers (13 women and 5 men) who were active offenders of HTOR.
Reports on the price of a kidney in India vary, but it has been estimated that recipients pay approximately $25,000 U.S. dollars (USD), and the donors receive between $1250 and $2500 (3). In this study, one trafficked person reported that they received no payment, 67 received less than 900 USD (50,000 INR), 11 received 900 USD (50,000 INR), and 17 received more than 900 USD (50,000 INR), with the highest payment of 1400 USD (80,000 INR).
Knowledge About the Recipient
Most of the trafficked persons interviewed in this study had some information about the patient who received their kidney. In Erode, victims reported that three recipients were foreign (from Malaysia), and the remainder 53 recipients were from India and included 10 patients from Kerala, 1 from Andhra Pradesh, 2 from Karnataka, 1 from Bihar, and 39 from Tamil Nadu. In Chennai, victims reported that five recipients were foreign (three from Malaysia, one from Sri Lanka, and one unknown), and 42 recipients are Indian and include one patient from Kerala, one from Andhra Pradesh, one from Maharashtra, and 39 from Tamil Nadu. It is noteworthy that, although one of the victims knew the recipient of their kidney was foreign but the country was unknown, there was also a news report that a transplant tourist from the United States had purchased a kidney in Chennai in the same month with few barriers (3).
Consequences After the Commercial Kidney Removal
Victims in this study reported that their lives worsened after the nephrectomy. Eighty-nine percent expressed deterioration in their health. Their negative health consequences are likely a result of factors such as insufficient donor medical screening and preexisting compromised health conditions of this vulnerable population. Common experiences among individuals who have been trafficked for organ removal include pain and cramping at the site of the incision, an inability to lift heavy objects or do labor-intensive work, swelling of legs, loss of appetite, insomnia, and considerable fatigue. There were also consistent expressions of anxiety about the kidney removal including a guilt, depression, and ongoing fear that death would result from it.
A total of 30 victims (29%) expressed they had been seen by a physician since the kidney removal: 15 in Erode and 15 in Chennai. Of those who did see a doctor in Erode, most of these consultations were a result of a single follow-up that the transplant center provided. Of those who saw a physician in Chennai, it was never by the medical professional(s) who performed the kidney removal but instead was by a physician or nurse in local low-cost clinics when they sought treatment for pain and related health consequences. Thus, the majority (78%) of victims interviewed for this study did not receive medical follow-up care, and many reported fear of consulting a doctor and reliance upon pain medicine from local pharmacies.
Results from studies released in 2002 (2) and 2003 (4) as well as the findings in this study, indicate that a sale of a kidney in India has not been associated with an improvement in economic status and is associated with a subsequent decline in family income. Only four victims (4%) of those interviewed whose debt drove them to the kidney sale expressed that they were able to resolve the debt from the payment. The trafficked persons have predominantly worked in labor-intensive jobs in fishing and agriculture, construction, weaving mills, power loom factories, and domestic servants. Seventy of the 79 victims (89%) who disclosed details of their financial consequences of the organ removal reported that they could not return to labor-intensive jobs after the kidney removal; this compromised their ability to generate an income and led to further debt.
Victims of HTOR in this study also reported significant social consequences that resulted from the commercial kidney removal. Nearly half (43%) of the victims in this study (53% from Erode and 30% from Chennai) expressed that a loss of dignity accompanied the loss of their kidney when they became ridiculed by their family, friends, and community. The broader study included similar results as 60% of the victims from West Bengal and 40% of those from Karnataka reported such loss of dignity.
Individuals at each field site expressed frustration that media coverage heightened stigma for them within their communities and that the media attention also did not resulted in assistance for their hardships because of the experience. One hundred percent of those interviewed expressed that they need assistance to cope with these consequences. Finally, persons trafficked for organ removal unanimously regretted the commercial removal of a kidney and would advise others against it.
Human trafficking for organ removal continues in private hospitals in various centers throughout India. Persons are trafficked for an organ removal in India largely via deception, fraud, and a play of power on destitute conditions, and their consequences are long lasting. The majority of commercial transplants are for Indian nationals, but service to foreign patients is ongoing. This study recommends a rights-based response to HTOR (5). It is noteworthy that, although India has been considered the only country that hosts HTOR to have more female than male victims (6), the findings in this study reveal that this is not the case in all locations where HTOR operates in India. Although further research is required to better understand how this abuse targets women and men distinctly in India, it is important to highlight that only women trafficked for organ removal cited familial substance abuse (primarily alcoholism) as a reason for sale (Table 2). Approximately ten percent of the trafficked women explained that substance abuse had negatively affected the family unit and contributed to their decision to sell. These women almost exclusively explained that their husband’s substance abuse reduced their financial stability. Debt because of a lost relationship (abandoned or widowed) was a reason provided by nearly 12% of all women, where only 3% of men provided this reason. This could have been a result of unsettled debts, before the loss of a relationship, being posited on the women after this loss. This increased economic strain seems to have increased the instance of organ sales among women as a response. Although reported as “debt,” many women’s narratives also conveyed the pressures they felt from within the family, and especially from their husbands, to sell a kidney for the sake of the family.
The International Monetary Fund suggests that a third of the population in India lives below the government’s poverty line (7). The average Indian citizen’s monthly income is approximately 5000 INR or 90 USD (8). Persons trafficked for organ removal interviewed in this study fair worse than the average Indian with an average monthly income of 3119 INR or 59 USD.
With regard to the location of the kidney removal, all commercial transplants addressed in this study occurred in private, nongovernmental, transplant centers. However, each of these centers are recognized and licensed by state and federal level authorities of the Ministry of Health and Family Welfare Department. Table 3 indicates the place of residence of the trafficked person and the location of her/his kidney removal.
With regard to reasons for an organ sale, exploitative financial lending schemes have commonly resulted in insurmountable debt burdens that are especially harsh on India’s poor. In a report on kidney sales released in 2002, 96% of the 305 “kidney sellers” interviewed in Chennai sold a kidney because of debt (9).
With regard to awareness about an organ sale, it is likely that more of the victims’ family or community members who told them about organ selling were in fact victims themselves. The 13% captured here were only captured indirectly via an open-ended question.
In addition to the direct findings from victims in this study, interviewed victims and media reports indicate that the organ trade is ongoing in additional locations in India including Dharmapuri, Selam, and Tirunelveli in Tamilnadu; Bangalore, Osloor, Mandiya, and Mangalore in Karnataka; Uttar Dinajpur, Raiganj, and Kolkata in West Bengal; Hyderabad, Guntoor, and Vijayawada in Andhra Pradesh; Lucknow in Uttar Pradesh; and Mumbai in Maharashtra (10–13). Coalition for Organ-Failure Solutions does not engage in payments for interviews (as brokers requested). Information about brokers reported here is entirely provided by those interviewed as a part of the study (Table 4).
Negative health, economic, social, and psychological consequences for victims of organ trafficking have become evident from studies conducted in Egypt (14), India (15), Iran (16), Pakistan (17), and the Philippines (18). There were also reports of marriages broken when a spouse learned that their wife/husband sold a kidney, that relatives “disowned” the individual, and that a grown child’s fiancé and family cancelled a planned wedding when it was revealed that their parent sold a kidney.
Recognizing HTOR as a human rights abuse invokes a universal commitment to prevent, protect, and suppress its continued practice. State parties that have ratified the relevant human rights treaties are legally bound to ensure, respect, and fulfill their human rights obligations. The United Nations Trafficking Protocol is the key international instrument to address the trafficking of persons, including for organ removal. Article 2(b) affirms that the protection and assistance of trafficked persons “with full respect to their human rights” is one of the three major purposes of the Protocol. India has signed the UN Trafficking Protocol (19) and should ratify it to better address this form of human trafficking.
MATERIALS AND METHODS
The protocol for this study was approved by the internal review board of the University of Pennsylvania where the first author was a Visiting Research Associate at the UPenn Center for Bioethics.
The Coalition for Organ-Failure Solutions–India field researchers identified victims via local development and human rights organizations and via a snowball technique in which victims told COFS fieldworkers how other victims could be reached. All victims identified agreed to participate in the interview. The field researchers explained that the interview was to serve the purpose of gaining an understanding of their experiences of a commercial organ removal and to coordinate assistance services according to their needs that resulted from the commercial organ removal. Interviews were conducted in either the privacy of a home or in an office of a local development or human rights organization.
A consent form was read to all victims, and a COFS field researcher explained that participation was voluntary and that identities would remain confidential. Verbal consent was then obtained from each participant, and additional consent was obtained for several video recordings of testimonies. Compensation for travel to the interview site was provided, but no other monetary compensation was provided for an interview. Coalition for Organ-Failure Solutions field researchers also explained that because COFS’ commitment is to assist victims to deal with the abusive experience and its consequences, COFS provides assistance services, regardless of a victim’s decision to participate in the interview.
The instrument used to interview victims consisted of an oral questionnaire with closed-ended question to collect demographic and background data and open-ended questions to elicit narratives about their experiences and how these experiences have affected their lives. Field researchers conducted interviews in victims’ native language, and many interviews were arranged with COFS local partner organizations. In Erode, interviews were conducted with the assistance and at the office of a trade union that works as advocates for unemployed mill workers; in Chennai, interviews were conducted in the home of the lead local field researcher.
The fieldwork involved four of COFS-India field researchers, each of whom are Indian citizens and trained in social science research methods. Three have Masters degrees in Social Work, and one is a civil rights attorney. The lead researchers were certified by the Collaborative Institutional Training Initiative and included as research personnel on the protocol for the study. In addition to their research, the field researchers are also active social workers and victim advocates working to arrange ongoing medical follow-up and related outreach services to COFS beneficiaries.
Considering the clandestine nature of this activity, it is impossible to know a precise number of victims or to what extent the sample identified here represents the larger group of such victims. The relatively small number of participants in this study is a reflection of such clandestine operations, lack of victim protection, and limited resources to afford more extensive data collection. The findings nonetheless speak to the experience of being a victim of HTOR in India and the processes this crime entails, from victims’ points of view. Individuals are being systematically exploited based, in these cases, upon their destitute conditions. Thus, this sample size of interview subjects provides an important window into the secretive operations of HTOR that targets the poor and vulnerable.
COFS thanks the interviewed victims of organ trafficking in India who shared their testimonies with COFS-India field researchers. We especially thank our allies and friends in this mission in India, Drs. Sunil Shroff, Sumana Navin, and Mr. Raghuram Kuppuswamy of the MOHAN Foundation. The authors thank the leaders of the trade union in Erode for assisting us to identify and interview victims. In West Bengal, the authors thank Father Herman Kindo, Director of Social Welfare Institute of CARITAS and all of the staff of CARITAS and Forum for People’s Health (FPH) for their dedication and especially labor-intensive foot/fieldwork alongside our team. The authors also thank Vikasana Trust in Karnataka to assist us in building the informal networks that enabled us to identify the victims in the region. The authors also thank the many doctors and medical centers who assisted COFS to provide low-cost medical follow-up services to victims of HTOR where we could arrange this in Erode, Chennai, and West Bengal. COFS also thank Milbert Shin, Francis Delmonico, Gabriel Danovitch, and Ruchira Gupta who reviewed the broader report and discussed findings and advocacy routes.