INVESTIGATION

Kidney commerce in Tamil Nadu

A recent arrest in Chennai highlights the fact that the city continues to be centre of the trade in organs though Tamil Nadu has adopted the Transplantation of Organs Act.

ASHA KRISHNAKUMAR

A COMPLAINT of cheating and an arrest. An everyday occurrence at police stations. But the August 13 arrest by the Chennai police of Mahalingam was not a routine one. The complaint was made by Dhileep, who alleged that Mahalingam had not delivered on his promise of supplying a kidney. Mahalingam, it turned out, was a long-time broker dealing with the procurement of kidneys for those in need of them for medical reasons. The police, it appeared, had stumbled on an organ trade racket.

That there is in Chennai a thriving kidney market, with an active doctor-broker-patient nexus, has been brought out time and again in the media and by independent investigators since the Transplantation of Human Organs Act was adopted by the State in 1995, making trade in human organs illegal. (A selection of Frontline's investigative articles on kidney commerce can be read at www.flonnet.com.) Frontline has now in its possession evidence of the trade and of a cover-up in Tamil Nadu by the Authorisation Committee set up under the Act to prevent trade in human organs.

Confirmation of the existence of the trade in kidneys in Chennai has come even from the chairpersons of the Authorisation Committee. In 1997, when Frontline first investigated the trade, Dr. V. Rajappa, who headed the committee then, said: "It is clear that the donors are tutored to say things they say to the committee. There is a trade and there are kidney brokers. We cannot stop it." Five years and several media investigations later, the Authorisation Committee chairman, Dr. V. Anil Kumar, admitted to this correspondent: "There are kidney brokers and there may be monetary considerations. Most donor addresses are false. In several cases the addresses of the donor and the recipient are the same as the former works for the latter. But we cannot do anything as the documents are all there."

Chennai thus continues to be one of the main centres for live unrelated renal transplantation in India, attracting patients from all over the country and abroad. Beyond adopting the Transplantation of Human Organs Act to "provide for the regulation of removal, storage and transplantation of human organs for therapeutic purposes and for the prevention of commercial dealing in human organs" and making the trade in kidneys illegal by declaring cash-for-kidney transactions a criminal offence, the State appears to have done little to stop the trade.

If by the Authorisation Committee's own admission, the trade has been thriving in violation of the Act and because of its own inability to perform its functions under Chapter IV, Section 13 of the Act, why did it not make a criminal complaint to the Appropriate Authority set up to monitor the implementation of the Act, ask informed observers. (The offences covered by the Act are non-cognisable. In consequence, the police can take action against the offenders only if the Appropriate Authority or an officer authorised by it or an individual who has given notice of not less than 60 days to the Appropriate Authority make a complaint.)

The reply to this point by a key member of the Authorisation Committee was contradictory. First he said that "there is no provision under the Act to make a complaint". But when it was pointed out that there is indeed such a provision, and that a list relating to live unrelated kidney donation that went before the Authorisation Committee in Karnataka for approval since 1995 was made public only on a complaint to the police to verify the documents produced by a recipient-donor (Frontline, April 12, 2002), he said: "My higher authorities were not willing [to complain]."

That a booming trade in kidneys is on in Tamil Nadu is clear from the number of live unrelated transplants that come up for approval before the Authorisation Committee. If in Karnataka there were 1,012 such cases in six years (from January 1996 to March 2002; the list is available with Frontline), in Tamil Nadu the committee, according to Dr. Anil Kumar, gets on an average 800 cases a year. According to him, in 2001, there were 860 cases and 400 were rejected. A reasonable estimate is that some 5,000 cases have come up to the Authorisation Committee in Tamil Nadu since 1995 (when it was set up).

According to Frontline's 1997 investigation (issue of December 26, 1997), 1,243 cases came up before the Authorisation Committee between June 1995 and July 1997. Subsequent investigations identified several donors from the city's slums. Recently, a probe in the Chennai suburb of Villivakkam found at least a dozen donors who had "sold" their kidneys since 2000.

All the donors this correspondent met had gone through brokers (Vijaya, Lakshmi or Shanti) from the same area. Each one had got not more than Rs. 40,000 for a kidney. The investigations also point to a few hospitals in Chennai that regularly perform live unrelated kidney transplants.

In 1998, when this correspondent approached one such hospital seeking details about obtaining a kidney, the receptionist said: "We do not arrange kidneys. But we can put you on to the brokers." It is reliably learnt that another hospital, which does only kidney transplants, offers "package deals" - from providing dialysis to arranging a donor and doing the transplantation. In 1999, Frontline met a broker (Madan) and his deputy (Edward) in a Chennai hospital. The broker was willing to arrange a kidney provided the patient shifted to one of the hospitals he recommended. Recently, the same broker was seen negotiating a "kidney deal" at another Chennai hospital, which is known to perform live unrelated kidney transplants on a regular basis. Interestingly, some super-speciality hospitals whose area of specialisation is not nephrology have set up kidney transplantation centres and are performing live unrelated transplants.

In July 1998, investigations revealed the hospital-doctor-agent nexus. By way of investigative follow-up, Egmont R. Koch (a television producer based in Bremen, Germany) e-mailed a nephrologist practising in a now-closed Chennai hospital (the nephrologist has since shifted to another hospital where he does live unrelated transplants) asking for help in procuring a kidney for his company's managing director. Egmont got a reply from the doctor informing him that it could be done but he would have to come to India to "discuss" the matter. Egmont came and met the doctor who had with him an agent. The transplantation, the doctor said, would cost $30,000, and the kidney another $8,000. The broker was confident that "we can fabricate a story to get through the Authorisation Committee." The meeting was video-taped by Egmont "to help his managing director decide." Egmont's story on the "kidney trade in Tamil Nadu" was telecast on German television.

With evidence in hand on a thriving kidney trade in Chennai, Frontline sought to obtain the list of names, addresses, occupations and other particulars of the donors and recipients who have gone before the Authorisation Committee since 1995. In January 2001, the Authorisation Committee members were approached for details. Dr. A. Parvathavarthini, the then Dean of the Madras Medical College, when approached first, directed this correspondent to Dr. M. Palaniappan, Director, Medical and Rural Health Services. Dr. Palaniappan pointed to Dr. Anil Kumar, Deputy Director, Department of Medical Education, who turned this correspondent back to Dr. Parvathavarthini. After this runaround, the search did not yield any worthwhile information.

In March 2002, Frontline wrote to each member of the Authorisation Committee seeking the full list of recipients and donors, with particulars, from 1995. Only Dr. C. Ravindranath, Dean, Madras Medical College, responded saying that Dr. Anil Kumar, Chairperson of the Authorisation Committee, would be able to give the information. But as Dr. Anil Kumar did not respond to telephone calls, a letter was addressed to Dr. Munir Hoda, Tamil Nadu Health Secretary (now Home Secretary), on March 30, seeking his intervention. On April 5, Hoda replied saying that we could get the information from Dr. Anil Kumar, who would be told about the request.

After several phone calls Dr. Anil Kumar informed this correspondent that his section "did not have" the entire list but would provide the names and addresses of recipients (and only the names of donors) who had approached the Authorisation Committee in January-February 2002. (The list of names and addresses of 87 recipients and the names of donors approved by the Authorisation Committee in January-February 2002 is with Frontline.) Interestingly, Dr. Anil Kumar maintained that "we do not have the donor addresses." The question arises how the Authorisation Committee monitors, as mandated by the Act, the health of those whose kidneys are removed for non-therapeutic purposes.

On June 4, when this correspondent met Dr. Anil Kumar at his office, he gave a different story. About the donor addresses, he first said: "We are not supposed to give the details." After much persuasion, he said: "Most donor addresses may be false. Many donor addresses would be the same as of the recipients' as the former may be working for the latter." Despite the suspiciously large number of live unrelated transplants and journalistic investigations of the kidney trade, no criminal complaint has been lodged with the police by the Appropriate Authority.

If the government is indeed keen to end the trade, it must act now on the complaint made by Dhileep to the Chennai Commissioner of Police, K. Vijay Kumar. Mahalingam, who had 'sold' one of his kidneys about a decade ago, has since been an agent, making a large sum each month by persuading poor people from the slums to 'sell' their kidneys. According to Assistant Commissioner of Police M. Murugesan who is investigating the case, Mahalingam and his accomplice Moorthy were arrested on the charge of cheating under Section 384 of the Indian Penal Code and remanded to 15 days' police custody. During interrogation, Mahalingam revealed that he sourced kidneys from slum-dwellers. He preferred women donors because the kidneys of many men were medically rejected on account of alcohol abuses. Working with Moorthy and Fazilbai, Mahalingam allegedly arranged at least three kidneys per month for patients admitted in specified hospitals. He generally charged Rs.1 lakh for a kidney.

Admitted to a city hospital with end-stage renal disease, Dhileep was approached by Mahalingam. A deal was struck and Dhileep paid an advance of Rs.17,500 to 'arrange' a kidney. When Mahalingam did not come up with a donor, Dhileep made an oral complaint to Commissioner Vijay Kumar, which led to the arrest of Mahalingam and Moorthy. According to Murugesan, this is obviously part of an extensive kidney racket exploiting the poor. But the police cannot take up the case under the Transplantation of Human Organs Act as Dhileep has not made a written complaint. For the police to register a case under the Act, the complaint has to be made by the Appropriate Authority. According to a leading lawyer in Chennai, the Appropriate Authority can suo motu take up the case based on Mahalingam's statement and make a complaint to the police.

According to Chapter VI Section 19 (c) of the Act, "Whoever offers to supply any human organ for payment, shall be punishable with imprisonment" for two to seven years "and shall be liable for fine" of Rs.10,000 to Rs.20,000. Section 22 (1a) says that "No court shall take cognizance of an offence under this Act except on a complaint made by the Appropriate Authority concerned..." Says MOHAN Foundation director and renal transplant surgeon at the Sri Ramachandra Medical College and Research Institute Dr. Sunil Shroff: "It is unfortunate that a city that leads the country in cadaver transplants is involved in such a racket. The kidney trade, by all accounts, seems extensive and deeply entrenched. We have to put our resources and minds together to wipe it out." A strong political will is needed to crack down on the racket as it appears to be extensive, notes Dr. Shroff, who has been championing the cause of cadaver-based transplants.

According to him, the cadaver-based transplant programme is doing well in Tamil Nadu. In the last two months seven transplant procedures have been done from brain dead persons at the Christian Medical College, Vellore. In the last two years, Kovai Medical College, Coimbatore, has done 36 such transplants. "If the government is keen on ending the kidney trade, it should encourage cadaver-based transplants in a big way," Dr. Shroff emphasises.

Whether the Appropriate Authority can be prodded to act now is uncertain. If the State government is serious about ending kidney commerce in Tamil Nadu, it can make the Appropriate Authority act decisively. If the Central government is serious in putting an end to the kidney trade, it must plug the escape clause, Section 9(3) of the Act. This permits live unrelated donors for reasons of "affection and attachment towards the recipient or for any other special reasons". Only, the Authorisation Committee needs to be convinced that it is donation and not a "sale". The committee's willingness to be persuaded that donations are being made on the basis of "affection and attachment" or for some other "special reason" - and not money - is seen to be at the root of the thriving trade in kidneys. The government can perhaps think of placing a moratorium on live unrelated transplants till safeguards are built into the 'altruistic' provision for donations.