Poverty Trap and the Kidney trade

Sale of body parts for overcoming poverty and indebtedness!

In a country where over 40% of the population lives below poverty line and 13% (or 20 million) of the total population suffer from kidney diseases, the link between kidney trade and poverty is not very difficult to establish. The recent incidents of kidney trade, by some unscrupulous ‘brokers’ buying the kidneys from the poor people for transplantation within and outside the country, has raised serious concern among the general public and also among the medical profession. The poor people who have ‘sold’ their kidneys have become impaired due to the extraction of an organ from their body for the rest of their lives. They can perhaps solve some problems with the cash money received from the trader but may also become disabled, because they may not a productive member of society due to a lack of proper medical care both preceding and following the removal of an organ and may have to spend money for the continuous ailments.

Among the other indicators of poverty the Direct Calorie Intake (DCI) method measures poverty incidence using the minimum level of food energy (calorie) per capita/day to maintain normal health. Those who are in absolute poverty it is below 2,122 kcal, while “hardcore poor” have a calorie intake of less than 1,805 kcal/capita/day. In terms of the upper poverty line based on calorie intake, there are 41.2 million poor in rural areas and 14.8 million poor in urban areas in 2005. The numbers of hardcore poor was 18.7 million in rural areas and 8.3 million in urban areas in 2005. The per capita income of people in the lower poverty line was Tk. 630.53 in rural areas, and Tk. 741.52 in urban areas in 2005 [http://foodsecurityatlas.org/bgd/country/access/poverty].

Now that the offer to sell kidneys is made to these poor people who are poor at the same time indebted can make them vulnerable to fall into the trap. Although such trade was going on for a long time, the media reporting on Kalai upazila of Joypurhat district has drawn attention of the people in a very serious way. The Police have uncovered a major organ trafficking ring that is believed to have persuaded up to 200 people to sell their kidneys for cash in the remote Kalai area, 300 kilometers northwest of Dhaka. These poor villagers have sold their kidneys for 150,000 to 200,000 taka (2,000 to 3,000 dollars). It is also alleged that the promised amount was not delivered to all those who sold their kidneys. Will this money help them get out of poverty or make them disabled forever? Will a new category be identified for the poor people, ‘to see the scar on the belly’ which shows that the person has sold kidney?

Twenty-three-year old Mehdi Hasan from Bamongram in Kalai upazila had been lured into selling his kidney but ended up losing a part of his liver. courtesy The Daily Star 11 Sept. 2011

It is very unfortunate that over 18 million patients suffering from kidney diseases and 40 thousand are dying every year in Bangladesh. Due to lack of treatment facilities, 90% of the patients remain untreated. Hardly 5% of those who have the disease can afford to the costly treatment including dialysis and transplantation. Rising trend of high blood pressure, diabetes and indiscriminate use of drugs contra-indicated for kidneys are causing increasing number of kidney patients. High use of pesticides and food contamination are also important causes of kidney diseases. Since the treatment of kidney disease is costly, many patients die every year. Poor people can hardly think of proper treatment; transplantation of kidneys will remain a dream for them.

Dialysis is often seen as the end-treatment and a kidney patient reportedly needs about 250,000 taka to 300,000 taka (4,166 to 5,000 US dollars) each year for dialysis. On the other hand, about 250,000 taka is required for kidney transplantation and for meeting immediate medical expenses and this costly treatment is out of reach of the 95 percent of the patients. Both dialysis and kidney transplantation is out of the reach of the majority of the patients. According to medical experts, ‘People with chronic kidney diseases are more likely to die of heart attacks and strokes than any other normal person’. The patient does not necessarily always die of kidney failure but can also become vulnerable to die of stroke and heart attacks. It is nothing but a silent killer. The patients are the worst sufferers as they cannot live a normal life.

Kidney disease is linked to an organ of the body. Although this organ is affected by other health problems such as diabetes and hypertension, ultimately the organ becomes the centre of attention for treatment. While very little is done to prevent kidney diseases which are caused by use of pesticides, unsafe and contra-indicated medicine, polluted environment etc. prevention of the disease never became an issue in the healthcare policies and programmes. On the other hand, the kidney transplantation as a treatment has drawn attention. Organ transplantation is an effective therapy for end-stage organ failure and is widely practiced around the world. According to WHO, kidney transplants are carried out in 91 countries. Around 66 000 kidney transplants, 21 000 liver transplants and 6000 heart transplants were performed globally in 2005. The access of patients to organ transplantation, however, varies according to their national situations, and is partly determined by the cost of health care, the level of technical capacity and, most importantly, the availability of organs. Bangladeshi patients are travelling to Singapore and India for kidney transplantation taking along the ‘donors/sellers’ in the foreign trip. Although the transplantation in a foreign country is much higher than in Bangladesh, the main reason for Bangladeshi patients’ kidney transplantation in hospitals abroad is to by pass the law. They can make false papers to prove that the kidney donor is a relative of the recipient.

In Bangladesh, the Human Organ Transplantation Act-1999 stipulates that only close relatives and blood-relations can only donate organs voluntarily. The law allows father, mother, son, daughter, maternal and paternal uncles and aunts, husband and wife to donate their organs. Unknown people can no way donate organs for others, as per the law. Anyone, even the doctors, involved in influencing others to donate human organs will face maximum seven years and minimum three years of imprisonment or a fine of Tk 300,000 or both. From the law point of view, there cannot be any trade, i.e., buying and selling of kidney from external sources, but can only be ‘donated’. Kidney is not a commodity produced by anybody, it is a body part of a human person and cannot be reproduced in the body and is being ‘donated’

However, the shortage of organs is virtually a universal problem. In some countries, the development of a deceased organ donation programme is hampered by socio-cultural, legal and other factors. Even in developed countries, where rates of deceased organ donation tend to be higher than in other countries, organs from this source fail to meet the increasing demand. The use of live donors for kidney and liver transplantation is also practiced, but the purchase and sale of transplant organs from live donors are prohibited in many countries.

The kidney transplantation started in the Institute of Post-graduate Medical College Hospital (now Bangobandhu Sheikh Mujib Medical University, BSMMU) since 1981, and has been done in other hospitals such as BIRDEM (2004), Kidney Foundation (2006) Institute of Neurology (2008). Besides a number of private hospitals such as United hospital, Lab Aid, al-Markazul Islam Hospital are also conducting kidney transplantation (Amar Desh 12 September, 2011). All these are done after the law on organ transplantation has been enacted in 1999. It is learnt from the newspaper reports that the need for law arose because of a kidney ‘donation’ by a poor person to a Japanese citizen in exchange of money occurred, which raised ethical concerns among medical profession. As a result, the law was enacted. As per law, there is no scope for trade over the transplantation. So far, the number of kidney transplantation within the country is 700 and outside the country is 300.

According to Dr. Harun-ur-Rashid, Chairman of Kidney Foundation and Kidney specialist, the number of kidney transplantation occurred in different government and private hospitals during last 5 years is 421 in BSMMU, 220 in Kidney Foundation, 6- - 70 in BIRDEM, 20 – 30 in United Hospital. Besides few kidney transplantations were done in LAB Aid and Apollo Hospital. The cost for each transplantation varies by hospital, Tk. 1 lakh in BSMMU, Tk. 2 lakh and 20 thousand in Kidney Foundation,  Tk. 4 – 5 lakh in BIRDEM and Tk. 6 – 8 lakhs in the private hospitals such as United, Lab Aid and Apollo. (Jugantar, 11 September, 2011). That is, the cost of transplantation is 6 times higher in the private hospitals. The reason for the higher price in the private clinics is not clear. The patients also need to be under constant care and has to spend about Tk. 15 to 20 thousand every month for the rest of the life.

The pre-condition for kidney transplantation is to have a ‘living donor’ almost lying side by side in a bed parallel to the kidney patient in the operation theatre while donating the organ. So whether the donation is from a close relative such as brother-sister, children, spouse, uncle-aunt, etc. or from a person unknown and un-related to the recipient ‘selling’ the organ at an agreed price hardly matters, if it really fits medically. So far, only 700 kidneys have been transplanted in about 23 years (since 1988), which is very insignificant compared to the demand for transplantation. It is not recorded whether all the 700 transplantations were carried out by kidney donation from the relatives or arranged through brokers in exchange of money. The newspaper reports about Kalai Upazila of Joypurhat show that kidney donation has turned into an organized and criminal trade taking advantage of poverty and indebtedness of the village people and these kidneys were supplied both to the national hospitals and taken abroad. In the village named Bahuti this trade has started secretly during past five years and has spread into 20 villages of three unions. Over 200 persons from 150 families have sold their kidneys because they needed money to overcome economic hardships. (Shokaler Khobor, 4 September, 2011)

The kidney sellers are both men and women. Sometime both husband and wife sold one kidney each to get more money. The final price given to the seller ranges from Tk.30 thousand to Tk. 1 lakh. The brokers of the kidney trade have violated the agreement between the seller and doctor at a price of Tk. 6 lakh for the couple’s kidneys, but husband received Tk. 30 thousand and wife received 1 lakh 50 thousand only (Prothom Alo, 30 August, 2011). Kidney selling is occurring through a ‘Dalal Chakra’ – the gang of traders, who take various forms of deception, allurements and even creating False Certificates to prove that the seller is a close relative as indicated in the Human Organ Transplantation Act of 1999.

Why people sell kidneys? The main two causes reported are poverty and indebtedness. In Kalai particularly couples and other members of the same family sold kidney because they needed money to maintain the family and also to repay the micro-credits taken from a number of NGOs in their area.  The Dalal Chakra took advantage of the ‘helpless’ situation of the poor people and motivated them to sell an organ of their body and told them that it is alright for them to have one kidney. People can easily survive with one kidney, as if one of the two kidneys is a spare part in the body. But what happened to the sellers afterwards? Could they get out of poverty? On follow up investigation by the newspapers journalists in the Kalai village most of the sellers are suffering from various health problems. They cannot do any heavy work, feel pain in the abdomen and suffer from ailments that they did not have before. The money received by selling kidney is going back to the doctors for treatment (Prothom Alo, 30 August, 2011).  

The kidney sellers are supposed to be a healthy person, but once they decide to sell or donate the kidney they are also on the operation table in the same way as the recipients of kidney (i.e. the patients in need of transplantation). After the kidney is taken out of the body the donor/seller also falls in the category of a patient, who needs further support of health care. Unfortunately, when it becomes a case of trade, there is no option for such care after the payment for the organ is made. The organ has been commodified and whatever happens to the ‘seller’ is no more a concern of the ‘buyer’. No record is kept so no one can come back and claim compensation of the health hazard caused by donation.  On the other in the case of ‘donors’ as described in the law, there could have been protection and ensured follow up care.

It is time to think about the responsibilities of all the related stakeholders to protect the rights of poor people for proper health care and the right of the kidney patients to have treatment, including transplantation, without causing threat to the life of the poor people. The necessary amendment of the law which ensures protection and proper care must be made.

However, poor people must be brought out of the deception, allurement and the trap of organ trade. Kidney selling is not a way out of poverty, it will rather enhance poverty.  

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