The kidney trade in Kerala

A Frontline investigation into the kidney trade in Kerala highlights the failure of institutional mechanisms in place to enforce the law, a political cover-up, the role of intermediaries and the fragility of medical ethics.

THE logical assumption that Kerala, with its high levels of literacy and general public awareness, would not allow transplantation of donated human organs to stray off legal and ethical boundaries was shattered in May by the revelation that a major kidney business centred around middlemen was operating in some hospitals in the northern districts. However, after the initial flurry of activity that included the ordering of a succession of inquiries by the State government following news reports about the racket, it is hush-hush in the State.

It is now three months since the `secret' police inquiry report was submitted to the government and the Health Department closed the chapter after satisfying itself with a cursory inquiry which suggested that ``there is nothing legally wrong in the case records in the hospitals in Kozhikode'' where the controversial transplants were alleged to have taken place. State Health Minister P. Sankaran told Frontline: ``Middlemen may have been involved, money may have changed hands, but how can it be proved? They [the hospitals] have all the records [affidavits from the donors and the recipients, certificates from the village officers concerned, and so on] required under the law.''

Clearly, the State government took care to keep the inquiries separate and independent of one another so that the conclusions arrived at by the Health Department were only about the records provided by the hospitals; that of the Department of Welfare of the Backward and Scheduled Communities were only based on the statements made by a few donors from Methotti village in Idukki district from where the largest number of `donor-victims' hailed; and that of the police, who on their own have no authority under the organ transplant law to inquire into such cases, could be brushed aside as mere ``fact finding'' and kept a carefully guarded secret.

The Appropriate Authority (the Director of Medical Education) is the only agency that, under the Transplantation of Human Organs Act, 1994 (a Central law adopted by the State in April 1996), is responsible for ensuring that no buying and selling of human organs take place; to conduct inquiries; and to initiate action in cases of a breach of the Act's provisions. In this case it did not budge until well after the middle of August. Eventually, it half-heartedly ordered an inquiry by the Principal of the Government Medical College, Thrissur. For all intents and purposes, according to official sources, the inquiry merely meant ``another look at the records'' which, the Health Minister had already concluded, were ``legally without flaws''.

It is, therefore, once again a conspiracy of silence in the health sector in Kerala, a re-run of the stonewalling the State government resorted to when confronted with serious allegations with regard to the Johns Hopkins-Regional Cancer Centre (Thiruvananthapuram) `drug' trial, which had caught international attention in 2001 (Frontline Cover Story, August 31, 2001).

However, Deputy Inspector-General Of Police (Central Range) Muhammed Yaseen, the officer who led the police inquiry ordered by Chief Minister A.K. Antony, told Frontline: ``The police team has completed its task well on time. We have done a comprehensive inquiry into the allegations. It is a precise, clinical and in-depth inquiry report. We do not want to save anybody.'' But he would not divulge the details of the report.

Director-General of Police (DGP) K.J. Joseph too would give only a similar answer: ``Under the Act, the police cannot take any action unless specifically asked by the authorities entrusted to do so by the law. What the police did was merely a fact-finding exercise. That was what we were asked to do. The report is with the government and it is up to it to divulge its details or not or to decide whether any action should be taken based on it.''

Frontline spoke in detail to three donors in Idukki district, including K.J. George, who from all indications was probably one of the first persons from the district to respond to a newspaper advertisement with a telephone number seeking a kidney donor and, in what was to become a pattern later, ``find'' that it was placed by a middleman named `Reji'.

George admits that he later ``introduced'' some others from Methotti village to Reji and that all of them sold their kidneys for varying remunerations to patients in two hospitals in Kozhikode. Through Reji's mediation, George donated his kidney to Saidalavi Karadan, a native of Malappuram district, at the Baby Memorial Hospital in Kozhikode on August 17, 2001 (transplant serial number 22 in the hospital records). Muhammed, the uncle of Saidalavi, told Frontline in a telephonic interview that the first few persons who responded to their advertisement in the newspapers were found to be unsuitable as donors, because of poor health. He said that they came to know about Reji through some other patients at the Baby Memorial Hospital.

Asked about the deal in particular, Muhammed said that they paid ``Rs.1 lakh, in all'' to Reji. Before the operation, he took about Rs.25,000 in instalments and soon after the operation, in George's room, in the presence of George, his wife and son and some other people, Reji was paid Rs.75,000 (the amount George says he got). ``All money transactions were with Reji. We had no dealings with George, except that we met his medical and hospital expenses,'' Muhammed said.

AT Methotti village, labourers Damodaran Ooraali, a tribal person, and Mathai (alias `Kunju'), who now owns a paan shop that he bought with the money he got by donating a kidney, had similar stories to tell. Both of them faced financial difficulties when they decided to sell their kidneys. Damodaran said that he responded to an advertisement and somebody called from the central Kerala town of Kottayam and directed him to contact Reji. He was eventually introduced to Reji by George, who took him to the National Hospital in Kozhikode, which seems to have later become the middleman's favourite haunt. (Doctors at the Baby Memorial Hospital claimed that Reji was told never to step into the hospital once they realised that he was an agent.) Mathai said he wanted to sell his kidney as he was in dire straits and had sought the help of an ``earlier donor'' from his village to seek out Reji in Kozhikode. Both had their surgical procedures at the National Hospital Damodaran on January 22 (Hospital Registration No. 224757, according to his documents) and Mathai on May 13 (Hospital Registration No. 23212, according to his documents).

In all the three cases, the donors being willing and needy, the middleman seemed to have been careful not to promise them a fixed amount and yet mention what appeared to be a fantastic figure. After the operation, Mathai, who claims he was given the hope of getting up to Rs.3 lakhs, was paid Rs.60,000; Damodaran, who donated his kidney under the impression that it would fetch Rs.1.5 lakhs, was paid Rs.50,000; and George, the first donor, who ``had no idea'' how much a kidney was worth, got Rs.75,000.

For the first time, from Muhammed's statement, in George's case at least, the middleman's commission in the days when he seemed to have been establishing himself in Kozhikode was Rs.25,000. However, later donors appear to have been fleeced.

That the three donors chose to speak in detail and confess to their having donated their kidneys for money shows their ignorance of the law, which prohibits the buying and selling of human organs. From their statements, it was not clear how deeply the doctors were involved, though they indicated some involvement and awareness of the transplant doctors that the trade was going on. Both Mathai and Damodaran said that they were not sure whether the doctors were involved. However, according to Damodaran, the doctors at the National Hospital knew Reji who, he said, was a familiar face in the hospital.

Informed sources told Frontline on condition of anonymity that the police inquiry report had ``justified many of the allegations regarding the kidney racket as reported in the media''. According to the sources, the following conclusions can be drawn from the police inquiry report, which the State government is keeping under wraps:

* Nearly 20 persons (``16 to 20'', the majority of them poor and uneducated, have traded their kidneys for money in the past two years in the incidents inquired into by the police. Only a few of them are tribal people. Others belong to various communities, including the Scheduled Castes. The majority of them are from Idukki district. Three or four of them are from Ernakulam district.

* Most of them had contacted a middleman known as `Reji', through whom the transactions were discussed and finalised. It was the middleman who eventually paid them. (According to other information available, the amounts ranged from Rs.47,000 to Rs.75,000. Other inquiries suggested that more than one middleman was involved.)

* All of them were ready-to-sell donors, ``except, maybe, one or two''. The majority of them were badly in need of money and saw selling a kidney as an option that would get them out of immediate financial difficulties. A few did it ``to improve their lives further''.

* The transplants involving the middleman and donors who sold their kidneys had taken place in two prominent hospitals in Kozhikode, the National Hospital and the Baby Memorial Hospital. While the majority of these transplants took place at the National Hospital, the Baby Memorial Hospital also ``had a few cases''.

* There is evidence to show the ``involvement'' of a ``few, not all doctors in the two hospitals''. (One of the sources said: ``Only a few of the transplant doctors were involved. Not all of them. Especially, some senior and reputed doctors do not seem to be involved.'') One doctor seemed to have an important role and ``belonged to Idukki or some nearby areas'' and ``that probably is a reason why so many people from a central district came all the way to Kozhikode to donate''.

* However, it is not clear whether the doctors had a role in the money transactions. There is no evidence that they sought a share of the donor's remuneration.

* There is no evidence to show the involvement of the hospital authorities, though they may have known about the middleman and that transactions are indeed taking place in their premises.

* Although all the cases were approved by the Authorisation Committee, there was no evidence of the involvement of any of the three members of the committee. (Under the Act, every transplant from a live donor who is not a relative of the patient has to be screened by the Authorisation Committee to ensure that there is no payment involved and that the donor is acting with altruistic motives.)

* The police have made a positive identification of the middleman known as Reji, but no further action has been taken. (Frontline's efforts to contact Reji were not successful.)

The doctors and the authorities of both the hospitals deny having known Reji personally, but agree that ``he may have been there'' and that ``money may have changed hands''. In general, they argue that their primary responsibility is for their patients, that screening donors can never become their duty; and that it is the responsibility of the Authorisation Committee to accept or reject the claims of the donors.

Dr. Ruben George, Consultant Nephrologist, National Hospital, told Frontline: ``I do not know this person named Reji, although it is possible that he may have been in the hospital three or four times, as a bystander or in some such role. I speak only to the patient and the donor and always in the presence of another doctor in the hospital, Dr. Elizabeth Joseph. In my conversations with my patients and their relatives I have, however, come to know that whenever they give an advertisement in the newspapers seeking donors, it is middlemen like Reji who would contact them first. The first three or four calls are always from people like him. So they [donors] may be contacting them [the middlemen] directly.''

Dr. Lalitha, a member of the transplant surgery team in the hospital, told Frontline that though the doctors may not have known Reji, the nursing and theatre staff in the hospital knew him.

According to Dr. K.M. Mehboob, Medical Director of the National Hospital, though the hospital's stress is on doing related transplants, where the donor is a first-degree relative as defined in the Act, every day it has to face the problem of patients who cannot find suitable donors among their relatives or of those whose relatives are not willing to donate. Dr. Mehboob said: ``So the next thing that we tell them is that we will do an unrelated transplant provided the government-authorised people approve of it. We just put them all before the Authorisation Committee.'' However, according to Dr. Ruben George, out of a total of 183 transplants done in the hospital so far, only 48 involved live-related donors. Dr. Mehboob argues that it is important that people understand the difference between the kind of kidney trade that was prevalent in places like Bangalore in the past and what allegedly happened in his hospital. He said: ``Here a patient with a problem comes to the doctor and he/she is put before the screening committee duly authorised by the government, an expert committee of people widely known for their integrity. They have rejected many cases we sent from here, and once they do it they do not reconsider it and the patient loses his chance.''

However, Dr. Sreedharan Unni, Consultant Urologist at the hospital, said that it was the doctors in the hospitals who were better-placed to decide the genuineness of a donor. He said: ``But we don't look at it in a hair-splitting way. That is one of the reasons why this happened. We cannot also discount the possibility of patients themselves helping each other find donors.''

Dr. Sunil George, a nephrologist at the Baby Memorial Hospital, claimed that the allegations made by the donor George against him were ``politically motivated''. He alleged that George was ``a person with a dubious record''. He said he had only a vague recollection of seeing Reji in the hospital about a year and a half ago. Dr. George said: ``It is usual for such middlemen to make claims to patients that they know such and such a doctor or such and such a [Authorisation] Committee member in order to serve their own purpose. Then, before us, they would pretend to be a relative or a friend or a bystander who is assisting the patient and his family. How do we know who these people are? Only when they come repeatedly with several patients do we begin to suspect. Then we send them out.''

Dr. K.G. Alexander, director of the Baby Memorial Hospital, said that in the two years since the transplant programme started in his hospital, only 54 operations were conducted in the hospital. According to him, despite the fact that there were only one or two cases of donors from Idukki being in the list of 54, the media had projected his hospital's name in a bad light. He said that his hospital's policy was to keep the unrelated transplant procedure in every single case well documented and legally correct. He added: ``In spite of all this, how can we bother about whether there is any transaction between them [the donor and the recipient]? How can we conduct an inquiry? We do not have a mechanism to do it.''

About Reji, Dr. Alexander said: ``It is said that it was Reji who brought George the donor to this hospital. After that we saw that he started coming here with one or two other patients. At that time Dr. Sunil George had sent him away. That is when Dr. Sunil understood that he was a broker or that he had some third party role. He was then told very strictly that he should not step into this hospital. After that we don't know about Reji. Only when the scandal broke out did we come to know of it. None of us have any contact with him.''

On the important question of involvement of doctors, a member of one of the (on-going) inquiry teams told Frontline on condition of anonymity that ``some of the young nephrologists in both the hospitals seem to have shown some over-enthusiasm in the whole affair''. He said that it was more or less clear that these young nephrologists may not have been after money, but were definitely after prestige, in their competition, perhaps even with their senior colleagues, for more and more patients.

The day this correspondent visited Methotti, most of the donors were not available for an interview. Some had ``gone into hiding'', others were ``not in station'', a few had ``just left their homes''. One donor, Mohanan, in his petition to several authorities, including the Chief Minister, has alleged that he was forced into donating his kidney by some local financiers from whom he had borrowed Rs.15,000. When he failed to repay the amount, it was the financiers who suggested that he sell his kidney to repay the loan and, in the process, make some money for himself. He was introduced to Reji, who arranged his operation at the National Hospital. The rest of his story is similar to that of the others, except that he alleges that the Rs.60,000 he got for his kidney was taken away by the financiers.

Frontline contacted the patient to whom Mohanan donated his kidney, Safia, who belongs to Payyannur in Kannur district. Speaking on her behalf, her husband Muhammed Kunju told Frontline over telephone: ``I am a trader and my wife was detected as having renal disease about two and a half years ago. Financially we are ruined now, having had to spend nearly Rs.3.5 lakhs for her treatment. I did not meet this man Reji. Mohanan contacted us directly and donated his kidney out of his own free will.'' Asked why a tribal labourer from Idukki had come all the way to Kozhikode to donate his kidney, he said Mohanan had come to Kozhikode on the recommendation of someone from his village who had already been there.

Asked how much money he gave Mohanan, a cautious Mohammed Kunju, already aware of the legal implications of buying a kidney, would only repeat that ``Mohanan had donated his kidney out of his own free will''. However, in reply to another question, he said that out of a total expenditure of Rs.3.5 lakhs made in over two and a half years, they had spent Rs.2.5 lakhs for the `transplant procedures' alone, out of which the hospital charges came to about Rs.80,000, including the cost for medicines. In addition, he said as an after-thought, he had also spent nearly ``Rs.80,000 extra, from his pocket''.

HOW did all such dubious cases pass the Authorisation Committee's scrutiny? In over 35 interviews that Frontline conducted for this feature, with transplant doctors, hospital authorities, officials, donors and recipients, except George (who claimed that Reji had some link with the committee, and that otherwise it would not have passed the seven or eight cases from the Idukki village) all others vouched for the personal integrity of the committee members. But from the response of the donors about their experiences at the committee, it appears that the committee members may be guilty of remaining mute spectators to the illegal donations.

The Authoristaion Committee Chairman, Dr. M.R. Chandran, who is also the Principal of Kozhikode Medical College, told Frontline: ``There was no occasion when the committee had reason to suspect that there was money transaction. Yet we know invariably there will be money transaction. But the committee has no way of finding out.''

He said: ``Maybe the doctors know that there is money transaction and middlemen may be taking advantage. I do not exclude completely the possibility of rackets. But the Authorisation Committee does not have a mechanism to find out these. Primarily the hospitals should be careful.'' Asked why the committee had approved the donation of seven or eight persons from the same village in Idukki, which surely suggested the working of a racket, Dr. Chandrtan said: ``They came on different occasions. After the first one, the next person comes four months later. How do we connect that person to that particular locality? It is completely gone from our minds, that particular place. We don't go by place names... It is eight or nine cases over a period of 10 months. One case comes and the next one comes four months later, the next, two months later. So that when the second one comes the first is totally forgotten... Unless a computer is used and a search is made... how do you find out otherwise''

An on-going inquiry that offers hope of corroborating the above conclusions, including that of the police, is the one being done by the Kerala Chapter of the Indian Medical Association (IMA). A five-member IMA committee led by Dr. M. Bhaskaran held sittings in Idukki and Kozhikode to hear the donors, doctors, patients and others. After the last sitting in Kozhikode on August 25, the chairman of the committee told mediapersons that preliminary conclusions indicated that a large-scale kidney racket was operating in Kerala involving, significantly, ``not a single middleman but several agents''.

State Health Secretary K. Ramamurthy said: ``If any hospital has conducted transplants not approved by the Authorisation Committee, that institution is going to be in trouble.'' Or, in other words (in the absence of reliable data with the government), the Secretary's contention seemed to be that all the transplants had the approval of the Committee and that nothing could be done against them. Minister Sankaran told Frontline, in the context of the hospitals having all the legally required case documents: ``Here, the eagerness of the hospitals is not to take care that wrongs are not committed, but to cover up such mistakes.''

From these responses, it is more or less clear that the government has no intention to go ahead with its inquiry or to initiate any action on what has been revealed so far. Interestingly, the Minister himself is facing a vigilance inquiry for using a car belonging to the owner of the National Hopsital while on an official tour in Kozhikode district. However, Sankaran told Frontline: ``That will have no bearing on the government's response to the allegations. I am yet to recover from a serious car accident and needed a comfortable car to travel to the interior regions of Kozhikode.''