Trading in transplants

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Organ transplantation may be a life saving procedure, but a worldwide shortage of donors is feeding a sinister black market in organ trafficking. Jo Hartley explores the situation in the Middle East and discovers a region in disarray.

In August a tabloid newspaper in the UK revealed that a leading London hospital had generated US$8 million last year by performing liver transplants on patients from the Gulf.

Over the past five years Kings College Hospital NHS Foundation Trust has carried out 22 such operations using spare livers on patients from the United Arab Emirates [UAE] and Kuwait.

Some patients received livers seemed unsuitable for European Union residents under clinical protocols. Most had liver parts donated by a relative transplants. A few had organs from people with hereditary liver disease transplanted when the original patient received a new organ .All involving about three months stay the UK at an average cost of AED262,000 (US$70,000) to the patient's government.

The practice is perfectly legal and above board But what it serves to highlight is the global shortage of organs, the level of unmet need in the Middle East, and the length and expense people in need of organs have to go to, in order to stay alive.

In terms of volume, the need for kidney transplants is highest. Dubai, for example, has 500 people waiting for a kidney at any one time, according to Dr Mustafa Ahmed, consultant nephrologist at the city's Welcare Hospital.

This figure is expected to rise alongside cases of end stage renal failure, spurred by the region's diabetes epidemic. This makes the need for a national cadaver transplant programme ever more urgent, adds Dr Ahmed. "It's in the country's interests to develop this programme."

In the past year just 11 patients from the UAE have received a kidney transplant in country, all with organs donated by living relatives. However, estimates suggest at least another 60 went abroad to undergo transplants with cadaver organs donated at death, or organs donated by living, unrelated people.

Of these, around half took the legal route while the other half - through choice or desperation - bought from the blackmarket, with the risks that entails. Dr Ahmed suggests one in 10 people taking this route will die following an infection, most commonly hepatitis C.

Back street surgeries

In May this year, 78 countries drafted the Declaration of Istanbul on Organ Trafficking and Transplant Tourism, which called for a worldwide end to the organ trade. The declaration was supported by key countries involved in transplant commercialism, including the Philippines, Pakistan, India and China that, until recently, sold on the body parts of executed prisoners to foreign recipients.

All have made moves to end the sale of human organs and tissues, but this has yet to filter down to the transplant tourists. Dr Abrar Khan, head of the multi-organ transplant programme at Sheikh Khalifa Medical City (SKMC) Abu Dhabi, notes the hospital regularly sees people who have undergone back street transplants.

"We are estimating that 35 to 50 people go abroad for transplants every year, to every part of the world, but mainly to Egypt, India and Pakistan. Around 50% of these are illegal," he tells MT. "I estimate in Pakistan alone there are two centres that do 100 to 150 transplants a year combined."

Dr Ahmed sees a similar number of patients following the blackmarket route. "I know about it, I told them not to do it. I will have nothing to do with the organ trade."

Live and let die

Ironically for a country with a shockingly high rate of road deaths, the UAE doesn't have an organ donation system. Although a law was passed in 1993 permitting cadaver transplants, none to date have been carried out.

This reluctance is blamed on a lack of national guidelines for the procedures and confusion over whether a Sharia-compliant definition of brain death has been agreed upon. Dr Ali Abdul Karim Al Obaidli, a consultant nephrologist at SKMC and acting clinical affairs director at Abu Dhabi Health Services Company, says the authorities are working to establish a national donor programme. "There is no need for more regulation but a need for policy and procedure that the health authority can issue on its own," he adds.

The move could see the country become self-sufficient in transplantation procedures, Dr Ahmed notes. "We have three road traffic accidents deaths every day and if we had a proper scheme here there would be enough organs for everyone."

"It costs AED140,000 ($38,000) a year to keep one person on dialysis and a transplant costs AED60,000 ($16,000) and then AED10,000 ($2,700) there after for medications, so with transplants we would be saving the government money."

As importantly, it would also help extract the UAE government from the grubby trade of transplant tourism. "What you have to remember with donation and transplantation is there's no grey area - it's black and white with no in-between," says Luc Noel, coordinator for essential health technologies at the World Health Organisation. "By putting money on the table you get what you need, and that (donor) gets the money, and then goodbye."

Money or morals

Other Arab states have set up cadaver schemes. Oman, Kuwait, Iran and Saudi Arabia all have established systems. However, these last two have also taken the controversial step of paying people to donate their kidneys.

The Tehran government made the move in 1988 and, within a year, the national waiting list had ceased to exist. By the close of 2005, 19,609 renal transplants had been performed largely through the paid scheme, with just 823 using kidneys from cadavers.

The price of the kidney is negotiated between buyer and seller and reportedly reaches AED22,000 ($6,000) a time. In March this year Saudi Arabia followed suit with a more restrictive scheme - no money changes hands between buyer and seller. Instead the government gives donors a 50,000 riyal ($13,350) lump sum to cover the loss of salary during recovery.

Full life insurance, a 50% discount on Saudi Airlines, free healthcare for life and a medal of honour awarded by the Prime Minister are also on offer. About 20 people have donated kidneys to date, according to the Saudi Centre for Organ Transplantation in Riyadh.

Both these schemes flout WHO advice, which recommends community schemes, which are stripped of financial incentives. The Iran programme, Noel believes, is particularly exploitive. "In Iran there are people in search of money, and those who are giving their kidneys are young people, students, single mothers and drug addicts," he says.

Countries need to change the way their societies think about organ donation, he argues. For some the choice to buy an organ from a stranger will always be preferable to asking a relative, or offending social beliefs about organ donation. "Do they think ‘we don't have to ask our only daughter because we can purchase one from a poor guy in a neighbouring country?" Noel concludes.

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