Two-Bean Harvesters

Operation Exploitation

• Amit Kumar, a doctor with an organ-­trade history of 21 years, was arrested again this end-July, but he ‘escaped’ while being escorted to Anand, Gujarat

• Apollo in Delhi and Mumbai’s Hiranandani are two hospitals accused of facilitating kidney trade

• India has 2 lakh people in need of kidney transplant every year; only 5,000 get it. The country logged 21,395 transplants in past 45 years; only 5 in 1971.

• Legal organ transplants involve a lot of formalities. Minister Sushma Swaraj, e.g, is waiting for a right kidney match.

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Indian Railways has  always had its ticket reservation forms asking whether the passenger is a doctor. The idea, obviously, is to know if help can come in case of a medical emergency during travel. From Amit Kumar, though, authorities expected no such mercy: he was alre­ady known as Dr Horror for his role in a Gurgaon kidney racket case. Just south of Delhi, Kumar headed an illegal organ transplant operation, eventually prompting the pol­ice in early 2008 to arrest the linchpin from Nepal to where he had escaped. A CBI court sentenced the “quack” to seven years’ imprisonment, but that did not lead to his punishment. The middle-aged man kept fighting multiple cases. This monsoon, Kumar was nabbed again—on identical complaints that came from Gujarat. After a round of probe in the national capital, the police were escorting him on Ahmedabad-bound Swarna Jayanti express back to Anand on August 9 when he gave the cops a slip.

This wasn’t the first time Kumar esca­ped while in custody. The earliest case against the man from Maharashtra’s Akola was registered in Mumbai in 1995. He simply moved to different cities and set up shop again. His international kidney trafficking operation involved harvesting organs from poor donors and transplanting them very often in foreign recipients, including those from the US, Europe and Nepal. So, once again, Amit Kumar roams around, portending danger for people’s vital organs.

Kumar ran no hospital. That way, the case of Apollo kidney racket is perhaps more stunning. To say the crime was carried out at the doorstep of the Delhi police is no exaggeration. The super-specialty facility, with 718 beds, is directly opposite the Sarita Vihar police station that also houses a deputy commissioner. On its website, Apollo Indraprastha says it has “one of the busiest Liver Kidney transplant programs in the country”. The police  discovered just what all kept the hospital schedule packed in recent times.

In June this year, cops attended to a call regarding a woman who claimed she had not been paid for an organ she ‘donated’ at Apollo. The police raided the plush hospital to find a large number of forged ID documents that they say were being used to create a fake organ donor-recipient relationship. Indian law dubs sale of org­ans illegal. There is no way this woman merited remuneration. Also, only immediate relatives can sign up to be a living donor for a patient in need of an organ, unless the transplant is permitted by a government-appointed body. But in their search, the team seized several fake documents such as marriage proofs, Aadhaar and voter ID cards. The organ recipients always brought genuine documents, but the relatives’ photos would be replaced with that of the donors.

A dozen km from Apollo, external affairs minister Sushma Swaraj is waiting at AIIMS for a kidney match so that she can have a transplant. From the autonomous institution last month, she tweeted about her condition—with transparency and confidence: “I am in AIIMS because of kidney failure. Presently, I am on dialysis. I am undergoing tests for a Kidney transplant. Lord Krishna will bless.” The reaction has been overwhelming. People from all over the country—from parliamentarians to traffic cops—have come forward to donate the bean-shaped organ. It’s a critical phase—even if the patient is a public figure. For instance, in 2012, Vilasrao Deshmukh died as a union minister, waiting for a liver. Three years bef­ore that, Samajwadi Party leader Amar Singh flew to Singapore for a kidney implant that turned out to be successful. India has designed the law with an eye on checking organ trafficking. So much so, even if these well-wishers are a match, it will be a hard, if possible, process for Swaraj to take the kidneys. She continues to wait in hospital.

Last week, Union health minister J.P. Nadda pledged his organs for donation, calling them a “national resource” that should not be wasted. He has been pushing a campaign to increase pledges on the organ registry. The result is showing: the National Organ & Tissue Transplant Organisation now has one lakh pledges—ten times more than what it was till this June. “I fix a target of 20 lakh by next year,” Nadda said. The government is now working to resolve infrastructural and organisational issues in order to ramp up organ donation. Ominously for Swaraj, the health ministry tweeted this week, “For people who suffer from failure of an organ, transplantation is often the only possibility to get a second chance of survival.”

Five months have passed since the Delhi police raided Apollo, yet no arrest has been made of three nephrologists believed to be part of these dubious transplants. Cops apprehended 17 others—the doctors’ assistants, three employees of the hospital, donors, recipients, touts and the kingpin—and filed a charge sheet against them. The doctors have only been quizzed. They have been “assi­sting” the police in their investigations, and continue to see patients, the hospital said in an email reply to Outlook. “False and forged documents were used to misguide the hospital in order to pass unrelated persons as related donors and recipients,” it added. This suggests that illegal organ transplantation did occur in the two-decade-old hospital; only, they were not aware of its illegality. Apollo says it followed the law and none of its employees was involved in the racket. But the Delhi police explain that two of those arrested were working as personal assistants to the hospital’s doctors for close to four years. So what is happening at this hospital that is regularly ranked as one of the best in the country?

The police are now investigating 10 cases of possible illegal transplants at Apollo Indraprastha, spread over nine months. They say the donors were receiving Rs 3-4 lakh for each kidney. Donors from around India were put up in Delhi hotels; their operations were done at Apollo after tests to check compatibility. The donors were mainly from Uttar Pradesh’s Kanpur and West Bengal whereas the recipients were from Nagpur, Gwalior, Jammu and Kashmir and Delhi. The touts were mostly from West Bengal. Many of them formed part of the racket on personal and professional levels. One of them had himself donated a kidney in 2014, following which he began soliciting other donors for the racket. Another tout made his wife donate her kidney this year.

A senior police officer explains how Apollo bypassed an overseeing system, which is mandatory as per the Transplant of Human Organs Act (THOA). All donors, recipients and their documents are app­roved only after a screening process by a five-member team. These are in-person interviews. The pol­ice have been reviewing their videos. “We can see the panel doubted the donors’ legitimacy. They did ask her questions about how come she was married to the recipient who she claimed was her husband. It struck them as suspicious,” he says. “But they ignored the doubts. Everyone is now hiding behind pap­erwork, saying they filled up the necessary forms.” The screening committee consisted of two Delhi government officials, one retired director of education, and doctors from Apollo Indraprastha and Holy Family Hospital. The police are not pursuing any case against this panel, although they looked for evidence of intentional malpractice.

DCP (southeast Delhi) Romil Baaniya says the police have been able to explore the culpability of all accused with no exception for the doctors. “A supplementary charge sheet naming the doctors could be filed soon. Our probe into their actions is ongoing,” he adds.

The complication and delay in the case came from the police’s discretion to charge people under the Indian Penal Code, but not under the THOA. The 1994 Act prescribes any prosecution be approved by an “appropriate” authority. In Delhi, it is the health secretary. The senior police officer explains that they had sent their application to the home department, seeking permission to investigate and prosecute the doctors. “A bare reading of the case and its evidence shows forgery in the documents. So we presented all the matter to the authorities in our request for prosecution of the doctors too,” he says. Seventeen people were charged under IPC sections for cheating, forgery and conspiracy.

Documents the home ministry’s despatched took time to reach the Delhi health department, and permission for prosecution was given on October 17. A Delhi government source said a five-­member committee was set up on June 6 to “re-­examine the documentation and interview process by the authorisation committee of the hospital”. Another official source explains that a tussle between the lieutenant governor and the Delhi government contributed to the holding up of files. A massive bureaucratic reshuffle led to an August 31 change of the health secretary, who did not reply to Outlook’s requests for an interview.

Shortly after the Delhi raid, the famous Hiranandani Hospital in Mumbai, too, faced a similar operation. This, after a Maharashtra-based BSP leader alerted the police on an alleged racket in the commercial capital. “Many months ago, our workers here met a man, who said he had been cheated of money after donating his organs,” recalls the politician, Mahesh Tanna. “He later began working at the same hospital. Around 5 a.m on the day of the raid, we received papers about an illegal transplant that was to take place by noon.”

Tanna called the police and the media, but neither paid much attention. He went in himself with two junior cops and caught the doctors just before they were to begin—and videotaped his conversations. That’s when the police took the matter seriously and landed up at the hospital. Unlike in the Delhi case, an inquiry report from the dire­ctorate of health services found guilty eight doctors who approved the transplant. They—including the hospital CEO and medical director—were charged with negligence. All are now out on bail.

The red market continues to prosper. The demand-supply imbalance makes the risks negligible and the gains lucrative. Stories of poor fishermen in Tamil Nadu selling their organs following the 2004 tsunami horrified the country. The model of organ trafficking in India has come a long way—from its early days in shady clinics with several casualties, to its modern form, happening in big city hospitals. Its current mode betrays a pattern: posh private hospitals, senior doctors, poor donors (some of them cheated of their money), rich patients and forged documents.

Even talks about legal transplant cannot be divorced from its evil brother, organ trafficking. To combat it, Tamil Nadu started a massive organ donation and transplant programme in 2008. Today the state is considered to have the country’s most successful organ donation and transplant system with 1.8 donors per million people. Maharashtra (0.26) is the lowest. Tamil Nadu has seen 3,000 legal transplants in the last eight years.

J. Amalorpavanathan, a former member-secretary of the Transplant Authority of Tamil Nadu, speaks about the evolution of the organ trafficking model in India. “In 2008, big hospitals were not doing many transplants. Donor numbers were anyway low. Thus, illegal market thrived in places like Coimbatore and Madurai,” he says. “Our programme became successful, and private hospitals began to realise the fin­ancial gain from transplants—especially in liver and heart that are more complicated than kidney transplants.”

This also explains how scandals moved from smaller hospitals to big ones like Apollo and Hiranandani. “Big hospitals know they have the wherewithal to resist the law, but small ones know they will be finished if caught,” Dr Amalorpavanathan says. This may mean that harvesting and transplants are now safer, with fewer casualties. But it hasn’t changed one thing: poor donors still give up their organs for rich patients while poor patients cannot access organ transplants in the same way. Reasons: high demand and prohibitive costs. “It’s a misnomer we have a national programme for organ transplant,” he says. “All this celebration of national organ donation week is window-dressing.”

Dr Harsha Jauhari is an advisor to the central government on organ transplantation. He says diabetes, TB or hypertension per se don’t kill anyone. “People die due to damage to their target organs. You can repl­ace organs and save people. But this also means that organ transplantation will form more than a third of our burden in the next 15 years.” But given the demand-supply gap, is monetisation an incentive to boost legal organ donation? A country like Iran has tried it—and found some success in closing the gap. Dr Jauhari cautions against such a move “We are not ready for monetisation. The need is so high and desperate here that the use and abuse of any plan for monetisation will be unfathomable.” This knot points to the divergent tensions inherent in the system—between the need to increase legal organ donations and decrease illegal organ trafficking.

At present, nearly two lakh people need a kidney transplant every year but the odds are against them. Only  about 5,000 are successful in getting one. The Indian Transplant Registry shows India having carried out 21,395 kidney transplants since 1971. From the low point of only five that year, the country peaked in 2004 with 1,214 transplants. The numbers have been falling since. There’s also a stark male-female bias with men more likely to get a transplant than women. Even in the good year of 2004, males who got a living kidney transplant totalled 887, whereas females formed less than a third of it. “There will always be a global shortage between demand and supply of organs,” says Dr Amalorpavanathan. “Illegality creeps in when this is  imbalanced. But an audited system will help genuine patients and kill the black market.”

Back in Delhi’s AIIMS, Swaraj continues to stay upbeat, writing wittily but also meaningfully. “Thank you very much brothers. I am sure, kidney has no religious labels,” she replied to a Muslim donor who was concerned about his religion being a ground for rejecting his kidney. A team of top AIIMS doctors looks after her. One of them says the minister is doing fine. “If she doesn’t get the transplant, she can still go back to work, carrying on with dialysis every week,” he says. “Transplant is not the only option; it is the best option for her.”

The time that it’s taking to find her a donor exemplifies the problem. At some level, the concern to decrease the illegal trade interferes also with the ease of getting legal transplants. No matter Swaraj’s status and donor offers, it would involve discretion of the law for any of them to be accepted. In the meantime, one only hopes the minister would get her payback for those assurances she gave to people facing medical issues by telling them, “We are with you”.