Punjab's kidney industry

The arrest of three senior doctors and a search for more, bring into focus an exploitative and large-scale kidneys-for-cash trade in Punjab, abetted by a conniving system and driven by profiteering professionals. At least 30 of the paid donors are dead, but the kidney industry has used sections of the police to suppress the voices of the victims.

in Chandigarh

THREE years ago, Ravi Yadav left his home in Dehra Dun for Punjab, in a last-ditch attempt to raise money for the medical treatment of his father. He did not find the work he was looking for, but another opportunity came his way. Yadav was offered Rs.70,000 for one of his kidneys. There was no risk to his life, he was assured by an operator in the organ trade whom he knew as Tinku. He would not have to appear before the Authorisation Committee in Amritsar charged with approving transplant surgeries, he was told. He did not even read the affidavit in English that stated that he was donating his kidney purely because of love and affection for a person - a person whom he had never met. When Yadav left the hospital and asked for the money that he had been promised, Tinku, now identified as Yogesh Kumar, turned down his request. The man from Dehra Dun was arrested after he approached the police, charged with filing a false affidavit, and is now serving a two-year prison term. No action was taken against Kumar, the organ recipient, or the hospital that performed the procedure. Ravi Yadav's aged father meanwhile died.

Ravi Yadav was still one of the lucky ones: Punjab's kidney trade is now known to have cost some 30 paid donors their lives. While politicians and bureaucrats ensured that the lid was kept for years on one of the most sordid scandals in India's medical history, justice finally seems visible on the horizon. On January 11, the Punjab Police arrested Dr. P.K. Sareen, chief transplant surgeon at the Ram Saran Kakkar Hospital in Amritsar, Dr. O.P. Mahajan, the head of the city's Government Medical College and head of the Authorisation Committee, and his colleague, Dr. Jagdish Gargi. The first doctors ever to be arrested for trading in human organs, they are alleged to have been key players in a kidneys-for-cash trade that police officers believe generated over Rs.100 crores since the Transplantation of Human Organs Act began to be enforced in Punjab in 1997. The police are searching for four other doctors, P.K. Jain, Bhupinder Singh, Rajinder Kumar and K.K. Sharma, whose bail applications have been rejected by an Amritsar court.

The sheer scale of the trade in Punjab defies imagination. Since 1997, the four Authorisation Committees in the State cleared 2,384 kidney transplant procedures. Of these, 1,922 were carried out at the Kakkar Hospital, the only one in Amritsar registered for the purpose. Another 458 were done in Ludhiana, and four in Patiala. According to a report prepared by the Punjab Human Rights Organisation, 1,579 procedures were authorised in Amritsar after April 2000, a sign that the volume of the trade had grown dramatically in recent years. This figure stands in stark contrast to the 650 procedures authorised in New Delhi during the same period. Just 21 of the recipients in Amritsar were related to their respective donors. Thus, although the Act allows for unrelated donors to gift their organs only in exceptional circumstances, the Authorisation Committee in Amritsar allowed over 99 per cent of the procedures under this provision.

If officials of the Authorisation Committee made little effort to cover their tracks, the Kakkar Hospital was careful. Computer records of recipients and donors were allegedly fudged systematically. Investigators, it was claimed, found at least one case where the hospital allegedly doctored records to eliminate all traces of a donor who died after surgery, and was then cremated in a public facility. Investigators believe that the hospital's own legal counsel was among 30-odd lawyers involved in the preparation of the necessary affidavits. While the payments to donors were made by recipients and brokers, the hospital itself profited. Dr. Sareen charged Rs.5 lakhs for the transplant procedure, allegedly using the rest of the money to pay off certain elements in the police force and the Authorisation Committee. He is alleged to have kept Rs.75,000, in addition to the Rs.95,000 fee charged by the hospital, and passed on the rest. Police officers say that Dr. Sareen actively dissuaded patients from canvassing their relatives for the donation of organs, pointing to the risks involved. The surgeon had faced a raid on his premises by the income tax authorities in 1997, and proceedings in that connection are pending.

WHILE most recipients purchased up front the kidneys they received, there is some evidence that organs were sometimes pilfered. Batala resident Ashok Kumar's son Sumeet, for example, was admitted to the Kakkar Hospital after falling off the roof of his home. Kumar told the police that his son's kidney was removed without consent, on the grounds that it had been damaged in the fall. In other cases, the kidney industry used expressly brutal means. Bagicha Singh, 17, was kidnapped and threatened with execution if he did not offer a kidney for transplant. Most of the victims were labourers lured by the prospect of quick money. Doctors and hospital staff put patients in touch with `wholesalers'. Wholesalers such as Yogesh Kumar and Vicky Bhatia operated through a network of small-time touts. Chunni Lal, a tea-shop owner, used his business to make contact with desperate migrant workers. He also dealt in blood `donations', paying labourers at the rate of Rs.230 a bottle. The blood was sold to major city hospitals. At least one of these donors, Jammu resident Kailash Kumar, went on to sell a kidney as well.

Few of the organ donors received even minimal medical care after the procedure; no one knows how many may have died or have become chronically ill. In September last year, when the police raided the organ dealer Kumar, they discovered one donor, Raju, a resident of Milk village in Uttar Pradesh's Rampur district, being treated at his home. Raju, now in the Amritsar jail, remains unwell. The police's efforts to pin down both donors and recipients have had little success, since the names and addresses recorded in Amritsar are invariably fictitious.

Twelve teams despatched to four States to investigate at the addresses given of donors and recipients have so far come up with nothing. Sadly, the donors arrested in September remain in jail. Only one recipient has been arrested, while the police have acquired confirmed identification with regard to another. "It is tragic," admits a senior police officer, "but holding the donors is the only option we have. If the donors are out free, they will without doubt be paid off and silenced. Our only chance of successful prosecutions is the testimonies of the donors, and prosecutions are the only means of pressuring them to testify for the State.''

How did the organ traders operate for such a long time, and with seeming impunity? The Ram Saran Kakkar Hospital is no back-of-beyond operation. The 82-bed multi-specialty hospital has treated many of Punjab's best-known figures. Former Chief Minister Prakash Singh Badal was admitted here for emergency care of a fracture, before being flown abroad for further treatment. Congress leader Maninderjit Singh Bitta was treated here many years ago for injuries sustained in a bomb explosion, for which its administration was threatened by terrorist groups.

The hospital has had a close relationship with premier institutions elsewhere. A local branch of the New Delhi-based Escorts Heart Institute, backed among others by Dr. Sareen, was scheduled to be inaugurated on January 20. Dr. Sareen, like many of the Kakkar Hospital's senior staff members, was a prominent member of Amritsar's social circuit, and was a friend of top bureaucrats and politicians.

It is no surprise, then, that efforts to investigate the trade was no easy task. Four years ago, Kunwar Vijay Pratap Singh, a young Indian Police Service officer, arrived in Amritsar to serve out a mandatory stint of training as an Assistant Superintendent of Police (ASP). He made the mistake of starting to investigate complaints filed by some of the victims. Within days, Pratap Singh was transferred out. Last year, he was again posted to the city, this time as a full-fledged Superintendent of Police. His mind turned again to the cases he had begun to study as a trainee ASP.

In Ludhiana, three migrant workers from Nepal had provoked a furore by asserting that they had been denied payments promised for donating kidneys. The police and the Authorisation Committee blamed each other for failing to verify the donors' addresses, but no action was taken. In Amritsar itself, seven donors, all migrant workers, had been sentenced to two years in jail for submitting false affidavits. "We were beaten and told we would be punished for having dared to name the organ traders and doctors,'' says Vijay Kumar, who is serving an additional 10-month sentence because he could not pay a fine of Rs.10,000.

In other words, the kidney industry was using sections of the police to suppress the voices of the victims. In the Ludhiana instance, two relatives of the Patiala resident who received an organ were prosecuted for filing false affidavits, but the donor's allegations against organ traders were not even investigated. The then Inspector-General of Police, Rajan Gupta, apparently shot down efforts to proceed against doctors in the wake of the September arrests, claiming that he was convinced of Dr. Sareen's innocence.

Rajan Gupta even shot down efforts to investigative the Authorisation Committee, other doctors, lawyers and organ recipients. There is some suggestion that cash was the basis of the trade's immunity from the law. Rajan Gupta, for example, travelled with Dr. Sareen to Miami, United States, on a holiday allegedly sponsored by a multinational drug company. Frontline's investigation has shown that Gupta and his spouse had travelled on a two-for-one ticket scheme offered by Air-India, against purchases made by Dr. Sareen and his mother. There has so far been no explanation of why Dr. Sareen did not simply use his free ticket for his mother. Nor has the police officer been able to explain a minimum of 115 calls made by his personal security officer to Yogesh Kumar.

It was only after Chief Minister Amarinder Singh ordered Gupta's transfer that the investigation moved ahead. It is possible that political influence also helped shield the industry. Jalandhar Inspector-General of Police S.K. Sharma had gone on record to state that Dr. Sareen admitted to making a Rs.10-lakh donation to the election campaign of a person who has since become a Member of the Legislative Assembly. Amarinder Singh, for his part, has raised questions about Badal's silence on the issue. Health Minister R.C. Dogra has admitted to recommending the rapid clearance of a transplant for a friend, but asserts that the decision was based purely on humanitarian concerns.

The fact that the Minister initially criticised the police for harassing doctors, however, raised more than a few eyebrows. The Resident Editor of a prominent city newspaper, too, made several similar recommendations. Since almost all the donors at the Kakkar Hospital were paid ones, these recommendations were clearly unethical, if not criminal. Just how far the police will prove willing to go in tracking down the facilitators of the business, and their well-connected supporters, is far from clear.

So far, the Punjab government has backed the investigation down the line. Additional Director-General of Police A.A. Siddique has been charged with the day-to-day conduct of the investigation, which continues to be spearheaded by Superintendent of Police Pratap Singh. Securing prosecutions may well be a tough proposition: as police officers are painfully aware, buying over witnesses could prove only too easy in such a situation.

At least two issues are, however, evident. First, the Act is open to abuse. The Authorisation Committee in Amritsar did not even interview donors, and did not utilise the services of the police to verify their identities. In Ludhiana the police were initially involved, but the practice was discontinued after the 2001 fracas. In neither case was anybody monitoring the functioning of the Authorisation Committees, despite their extraordinary conduct.

Secondly, the medical community itself has proved unable to act against those indulging in criminal wrong-doing in its ranks. Indeed, the Punjab chapter of the Indian Medical Association (IMA) has come out in defence of the doctors, on the somewhat mystifying ground that their involvement was mitigated by the fact that politicians and police officers were hand-in-glove with them. In a January 15, 2003 press release, the IMA's Surinder Singla claimed that if persons from other categories were not arrested without delay, it might adversely affect the medical profession in general.

Attention needs to be paid also to the larger politics of the kidney trade in Punjab. Many of the Kakkar Hospital's transplant patients are believed to have been overseas Indians, mainly those from the United Kingdom. Last year, authorities in the U.K. debarred from practice a doctor of Indian origin, Bhagat Singh Makkar, who allegedly told some of his patients that he could purchase organs in Punjab for transplant candidates. Makkar allegedly offered jobs in the U.K. to potential donors.

But the kidney trade only represents the most macabre end of "globalised" medicine. Many hospitals in Punjab have been offering to perform procedures on patients suffering from conditions that are too expensive to be treated in their countries of residence. Even as high-end private medical facilities have proliferated, most of which ironically enough have the status of charitable institutions, Punjab's poor have had increasingly restricted access to healthcare. The State is currently in the midst of privatising its basic health services, which are now being run by the World Bank-funded Punjab Health Services Corporation. Although the Corporation has purchased expensive equipment, much of it is lying idle because there are not enough trained doctors to operate them. Poor patients find it difficult to access the Corporation's facilities because of the high user charges. Sadly enough, then, the kidney scandal is not the work of a few corrupt elements: it is just the broad edge of the wedge of the commercialisation of medicine.