Stephen Frears’ film Dirty Pretty Things treats the traffic in human frailty and vulnerability in the shadowy underworld of immigrant London. In one poignant scene, Okwe, a politically framed, sleepless, haunted Nigerian doctor-refugee, hiding out as a hotel receptionist, delivers a freshly purloined human kidney in a Styrofoam cooler to a sleazy body-parts broker waiting in the underground parking lot of the hotel.
“How come I’ve never seen you before?” the tight-lipped, white English broker asks Okwe before gingerly accepting the strangely animate and “priceless” parcel. Barely concealing his rage, Okwe replies between clenched teeth in finely accented Nigerian English: “Because we are the people you do not see. We are the invisible people, the ones who clean your looms, who drive your cabs and suck your cocks.” And now, he could have added, the ones who are even asked to provide you with our “spare” body parts.
Little did the London-based scriptwriter of Dirty Pretty Things realize how close to the mark his fictive portrayal of the global transplant underworld struck. But the film is a social thriller, not a documentary, and it toys with the theme of organ theft, blending elements of fantasy with realist scenes of human trafficking for kidneys. When Senay, a pretty Turkish waif, pledges her kidney for a passport and visa to New York City, the filmmakers capture a real dilemma among illegal workers from the Third World jockeying for a toehold in the North. Filipina domestic workers overseas, for example, are often lured into selling a kidney in exchange for help with their legal status.
The Berkeley Organs Watch project had its origins in bizarre rumors of body snatching and organ theft that circulated wildly in the urban shantytowns of Brazil in the mid-1980s. The residents of Alto do Cruzeiro, site of my long-term anthropological research in Northeast Brazil, reported yellow vans scouring poor neighborhoods looking for street kids and other social marginals whose bodies would not be missed. The drivers were described as U.S. or Japanese medical agents working for large hospitals abroad. The abducted bodies, they said, would appear later on the sides of country roads or in hospital dumpsters missing vital parts, especially eyes, kidneys, hearts and livers. “You may think this is nonsense,” my ordinarily trustworthy field assistant Irene da Silva said, “but we have seen things with our own eyes in public hospitals and in police morgues, and we know better.” Irene’s neighbor, Beatrice, agreed: “In these days, when the rich look at us, they are eyeing us greedily as a reservoir of spare parts.” Edite Cosmos added: “So many of the rich are having transplants and plastic surgeries today we hardly know anymore to whose body we are talking. Where do you think they are getting all those body parts?”
The rumors of organ theft, often embellished with outlandish details, were all too easily discredited by the medical profession, who like the medical director of the police morgue in Rio de Janeiro, dismissed the charges as the ignorance of the poor who imagined that even their penises and uteruses might be taken to serve the needs of the rich. But altogether credible stories like the following, told to me by a washerwoman from Recife, illustrate the material grounds for the profound sense of insecurity experienced by shantytown residents who are sure that almost anything can happen to themselves and to their bodies:
When I was working in Recife, I became the lover of a man who had a large, ugly ulcer on his leg. I felt sorry for him and I would go to his house and wash his clothes for him, and he would visit me from time to time. We were lovers for several years when all of a sudden he died. The city sent for his body. I decided to follow and make sure that his body wouldn’t get lost in the bureaucracy. My partner didn’t own a single document, so I was going to serve as his witness and as his identification papers. But, by the time I got to the morgue, it was too late; they had already sent his body to the medical school for the students to practice on. So I followed him there and what I saw happening I could not allow. They had his body, and they were already cutting off little pieces of him. I demanded his body back, and after a lot of arguing they let me take it home with me.
It was unfair that ordinary peoples’ fears and narratives of body tampering and organ theft were scoffed at, and I realized that there were research questions that needed to be pursued ethnographically. In 1997, with funding from the Open Society Institute, I began following the rumors and then, inevitably, following the bodies of the dead and of the living. Before the Organs Watch project came to an end in 2005, I had traveled to 12 countries and visited more than 50 backdoor settings and scenes of illicit organs and tissues procurement. Following new paths in the global economy, I discovered several active circuits of tissues and organs trade that circulated human bodies—whole and in parts, living as well as dead—for the purpose of organs procurement and sales. I found that strange rumors sometimes hardened into facts. And I learned that organ theft jokes, science fiction novels, surreal films and urban legends deflected attention from the “really real” traffic in humans and their body parts.
Where once the idea of buying and selling human tissues evoked shock and revulsion bordering on nausea, today the international marketing of human tissue is a fait accompli—an accepted medical fact defended on pragmatic grounds. At a 2003 World Health Organization (WHO) panel—of which I was a member—on “Ethics, Access and Safety in Tissue and Organ Transplant,” a director of a private eye bank in the Third World defended the “necessary” commercialization of tissue banks in the developing world. He argued that in the absence of government subsidized tissue banking, the only recourse in poor countries was through international trading/selling. Bone, organs and tissues not being utilized locally, he said, could be exported through informal agreements to the First World, where they are in great demand for orthopedic and other high- tech surgeries. In exchange, the poor donor-institutions could receive a steady supply of scarce corneas. While seemingly rational, this kind of informal global networking and trade in body parts ignores the cruel realities of such practices for vulnerable donor communities.
Organs Watch uncovered a large, unregulated, multi-million dollar business in human tissues, taken without consent or procured from the naïve family members of brain-dead donors who believe that their “gifts” would be used altruistically to save lives and reduce human suffering. All too often, however, these gifts of life changed hands many times and were bought, sold, processed and transported, picking up value at every port of call. In many parts of the United States, bone and skin grafts are sold and processed by private biotech firms into expensive commercial products for dentistry, orthopedics and plastic surgery.
The special WHO panel—while not particularly concerned with the sensibilities of grieving family members and local cultural “taboos” regarding the treatment of the dead body—was very concerned about the medical safety issues of unregulated tissue procurement, distribution and sales. One member of the panel referred to the present situation as “a ticking time bomb waiting to explode.” The final report adopted the term “Tissues Without Passports” to refer to the inherent risks and dangers of a free trade (or global free-for-all) in human body parts.
The director of an experimental research unit of a large public medical school in South Africa showed me official documents allowing the transfer of human heart valves taken without consent from the bodies of poor blacks in the local police mortuary and shipped for “handling costs” to medical centers in Germany and Austria. These allowable “handling” fees helped support the unit’s research program in the face of austerities and the downsizing of advanced medical research facilities in the new South Africa. Although one can understand the frustration of the cash-strapped South African research scientists, the leeway afforded to them contributed to widespread corruption in the country.
In 2002 I contacted the South African Ministry of Health to report a scheme originating at a national tissue bank involving the transfer of hundreds of Achilles tendons that were removed without consent from the bodies of the victims of township violence and shipped by the director of the tissues bank to a corrupt U.S. businessman who paid $200 for each tendon. The tendons, used in sports medicine procedures, were shipped to the United States via South Korea, arriving at the free trade zone of the Tampa international airport where the South African tissues were repackaged as U.S. products. The tendons were then sold internationally and domestically to private medical firms and biotech companies for $1,200 each, generating a tidy profit for every party concerned, except for the poor chaps and their families who were the unsuspecting donors.
For Rosemary Tandiwe Sishetshe, speaking from her little concrete slab house in Gugutelu Township, the illicit harvesting of the body of her only son, 17-year-old Andrew, was biopiracy and plunder pure and simple. Andrew, caught by a stray bullet to his chest during a gang shootout, was taken by ambulance, still breathing, to a police mortuary in Cape Town where his eyes, heart valves and other body parts were removed by the state pathologist while Rosemary and her family members sat in the corridor waiting to receive the body for burial. When Rosemary was finally allowed to identify Andrew, she was shocked to find his body laid out on newspaper comic strips “like a gutted fish,” and covered by a blood-soaked blanket. Andrew’s eyes were stored in the refrigerator of the South African eye bank, which refused to return them for Andrew’s burial. Sitsheshe complained to the South African Truth and Reconciliation Commission on behalf of thousands of other black South Africans like herself, who were also the victims of an institutionalized medical human rights abuse: “Although my son is buried, is it good that his flesh is here, there and everywhere, that part and parcel of his body are still floating around? I stand up and condemn this act in the strongest terms. Those who are guilty must be punished. Are we to be stripped of every comfort as well as our dignity?” Rosemary Sitshetshe has since joined with others in Guguletu Township in a campaign to end the unauthorized body parts harvesting of poor people in state mortuaries.
For Paulo Pavesi of Brazil, there was no such entity as the Truth and Reconciliation Commission to which he could turn. His 10-year-old son’s organs were removed before the child was officially declared brain dead at a small hospital in the town of Poços de Caldas in the state of Minas Gerais. His son, Paulinho (little Paulo), fell from the verandah of the apartment complex where he lived and was taken to a small provincial hospital nearby where he was treated in an intensive care unit (ICU) and then transferred, still alive, to the larger Santa Casa Hospital. The next day, his solid organs and cornea were removed without following the established protocol for diagnosing the child as officially brain dead. The unresolved question that has destroyed Paulo senior’s life is whether his son’s death resulted naturally from the cranial injuries sustained from the fall, or whether he died as a consequence of the untimely and premature surgical removal of his organs. Paulo wants to know just how dead his little boy was when he was wheeled, heavily sedated, onto the operating table at Santa Casa Hospital where his kidneys, cornea, heart, liver and lungs were removed.
The purloined organs were distributed illegally to unauthorized transplant centers and were transplanted to private patients not listed on the official regional organs waiting list. Paulo believes that his son was the victim of a regional traffic in organs organized by a “medical mafia” operating with impunity. His appeals to the Ministry of Health and the Ministry of the Pubic fell on deaf ears until media and Organs Watch revelations of international organs trafficking in the slums of Recife in 2003-2004 led to a federal investigation of organs trafficking held in Brasília, during which Paulo’s case was discussed. While “irregularities” in the designation of brain death and the illicit distribution of some of his son’s tissues and organs were acknowledged, the Brazilian doctors were not held culpable because malicious intent could not be proven. The parliamentary investigation in Brasília was far more eager to ferret out and condemn the international criminals involved in the organs trafficking ring between Brazil, Israel and South Africa, than to investigate and prosecute criminal corruption within Brazil’s own transplant and organs procurement centers.
The dead, at least, have always had their protectors and defenders, like Rosemary Sitshetshe, Paulo Pavesi and the Recife washerwoman. The living, however, who are prey to a new class of organs brokers and dealers, must often fend for themselves.
During the summer of 1998, I sat at a sidewalk café in downtown São Paulo with Laudicéia Cristina da Silva, a young mother and office receptionist who had just legally requested an investigation of the large public hospital where in June 1997, during a routine operation to remove an ovarian cyst, she had “lost” a kidney. That she was missing a kidney was discovered soon after the operation by her family doctor during a routine follow-up examination. When confronted with the information, the hospital representative told a highly improbable story: Laudicéia’s missing kidney was embedded in the large “mass” that had accumulated around her ovarian cyst. But the hospital refused to produce either their medical records or the evidence. The diseased ovary and the kidney had been “discarded,” she was told, along with some of her medical records. The regional Medical Ethics Board refused to review the case. Laudicéia believes that her valuable kidney was taken to serve the needs of another, wealthier patient in the same hospital. “Poor people like ourselves are losing our organs to the state, one by one,” Laudicéia concluded with a deep sigh as she rose to catch her bus home.
A few years later, I traveled to Buenos Aires to meet with another victim of alleged kidney theft: Liliana Goffi, a 50-year-old woman whose freak (or freakish) medical event, similar to Laodicéia’s, is bogged down in a criminal and civil lawsuit against the private hospital and the elderly surgeon who removed her kidney, without her consent or her knowledge, during a minor operation that she did not need. Liliana’s case, like several others I have investigated remains in legal and prosecutorial limbo. Massive evidence of multiple tomographies (a method of producing three-dimensional images of internal structures), sonograms, X-rays and clinical examinations, including those conducted at Johns Hopkins Medical Center by three specialists in radiology, nephrology and surgery, all indicate that Liliana’s kidney was most certainly and inexplicably surgically removed. But Argentina’s highest tribunal of forensic experts has argued, with its own panel of paid medical consultants, even in the face of the diagnostic evidence, that Liliana’s missing kidney is present, but that it atrophied to the size of an olive pit following her surgery. Their conclusions caused at least one U.S. specialist who independently reviewed the clinical and radiography records to laugh aloud. But when I asked him why surgeons might have removed Liliana’s kidney, he immediately became sober: “I am a surgeon, not a detective,” he replied.
Like Laudicéia, Liliana is a likely victim of a rare, isolated and largely invisible, medical crime, a crime without a name, without medical legal standing, without victims support groups and without public recognition. In making a claim of “organ theft,” the mental status of the victim is cast into doubt: is she or he psychotically depressed, delusional, menopausal or otherwise mentally unbalanced? It is no wonder that the aggrieved victims of organ theft are oppositional, obsessed and defensive, their lives reduced to a single-hearted pursuit of justice or vindication for a crime that exists beneath the radar of normative medical knowledge and practice.
Like jailhouse lawyers, the victims of organ theft read every new medical text, journal and pharmaceutical reference book they can lay their hands on, and they review every legal precedent. They become experts in every technical and medical-legal aspect of their injury. They arrive for meetings in hotel rooms, restaurants, lawyers offices and medical clinics, carrying bags bulging with notarized legal and medical documents, scientific articles, newspaper clippings, letters signed by experts, sonograms, x-rays and tomographies, binders with copies of illegible and contested medical records that may have been altered or “falsified” by hospital and medical staff. The victims of this unacknowledged medical crime lift up their shirts or blouses to show you their scar: “Let me show you what they did to me.” And they ask you to run your fingers across the angry, red scar so that seeing and feeling you may believe and reach into their pain and to their existential anxiety: the body without organs.
Organ theft rumors and organ stealing scandals did nothing to curtail the growth of illegal transplant tourism, a polite term for human organs trafficking that I coined several years ago. The transplant trade developed to meet an insatiable demand for organ transplants that rises exponentially against a flat supply of organs donated through traditional and regulated means. In the United States, for example, kidney donations from brain-dead donors increased only 33% between 1990 and 2003. During that same period, the number of kidney transplant-patients on the national waiting list increased by 236%. Whereas transplants were once necessarily rationed, the free market ethos of the present day has allowed sick individuals to demand that they be wait-listed for an organ, even if their prospects of surviving a transplant are exceedingly slim, and even if they are over 75 years of age. Organ “scarcity” is what cultural critic Ivan Illich would call an artificially created need, invented by transplant technicians and dangled before the eyes of an ever-expanding sick, aging and dying population.
Worse, with an out of control and inflated waiting list of hopeful and demanding organ transplant recipients, questionable practices of organs harvesting have emerged as a solution to the shortage of organs. The demand has given rise to doctors acting as organ brokers; fierce competition between public and private hospitals; and, ultimately, to medical human rights abuses in ICUs and mortuaries. What has emerged is the active recruitment and entrapment of the world’s poor as kidney sellers to supply the needs of affluent patients willing to travel a great distance and to violate national laws and international medical regulations to get the organs and medical procedures they need. The confluence in the flows of immigrant workers and itinerant kidney sellers who fall into the hands of unscrupulous organ brokers is a distressing subtext in the story of globalization.
Finding an available supply of organ vendors was only a partial solution to the new scarcities produced by transplant technologies. The tempting “bio-availability” of poor bodies has been a primary stimulus to the “fresh organs” trade. Today, a great many eager and willing kidney sellers wait outside transplant units; others check themselves into special wards of surgical units that resemble “kidney motels,” where they lie on mats or in hospital beds for days, even weeks, watching TV, eating chips and waiting for the “lucky number” that will turn them into the day’s winner of the kidney transplant lottery. Entire neighborhoods, cities and regions are known in transplant circles as “kidney belts,” because so many people there have entered the kidney trade.
New transplant-patient advocacy groups have sprung up in many parts of the world, from Brazil to Israel and Iran to the United States, demanding unobstructed access to transplant and to the lifesaving “spare” organs of “the Other,” for which they are willing to pay a negotiable, market-determined price. They justify the means by recourse to the mantra that it will “save a life.” But many kidney patients reject the option of hemodialysis, weakening the “lifesaving” argument. Sophisticated kidney activists increasingly view dialysis—even as a bridge while waiting for transplant—as unacceptable suffering.
In September 2000, a 23-year-old university student from Jerusalem flew to New York City for a kidney transplant with an organ purchased from a local “donor” arranged through a broker in Brooklyn. Israeli “sick funds”—medical insurance that is guaranteed to all Israeli citizens—paid the $200,000 bill of the surgery. Noteworthy in his narrative is an almost seamless “naturalization” of living donation and the rejection of the artificiality of the dialysis machine: “Kidney transplant from a living person is the most natural solution because you are free of the [dialysis] machine. With transplant you don’t have to go to the hospital three times a week to waste your time, for three or four hours,” said the student. “Look, it isn’t a normal life. And also you are limited to certain foods. You are not allowed to eat a lot of meat, salt, fruits, vegetables. Every month you do tests to see that the calcium level is OK, and even so your skin becomes yellow. Aesthetically, it isn’t very nice. So, a kidney transplant from a living donor is the best, and the most natural solution.”
Today, many well-informed kidney patients reject conventional “waiting lists” for organs as archaic vestiges of wartime triage and rationing, or reminiscent of hated socialist bread lines and petrol “queues.” In the present climate of biotechnological optimism and biomedical triumphalism, any shortage, even of body parts, is viewed as a basic management, marketing or policy failure. The ideology of the global economy is one of unlimited and freely circulating goods.
These new commodities are evaluated, like any other, in terms of their quality, durability and market value. In today’s organs market, a kidney purchased from a Filipino costs as little as $1,200, one from a Moldovan peasant about $2,700 and one from a Turkish worker up to $8,000. A kidney purchased from a slum dweller in Recife, from 2003 to 2004, began at $10,000 and rapidly decreased to $6,000 and then $3,000, when police interrupted an aggressive trafficking scheme. The ring involved more than a hundred kidney patients from Israel, Europe and the United States, with recruited kidney sellers from the slums of Brazil for illicit transplant transactions that took place in a private Netcare clinic of Durban’s premier private medical center, St. Augustine Hospital.
Among the Brazilian kidney sellers coaxed to South Africa in 2003 were dozens of undernourished and unemployed men who dreamed of finding a way out of their economic difficulties. When Gaddy Tauber, a lean and mean-looking ex-Israeli Defense Force broker, and his Brazilian sidekick, Captain Ivan, a retired military policeman, set loose rumors of $10,000 to be made in South Africa by parting with a “spare” kidney, a stampede of willing “donors” lined up to sell an “inert” part of themselves they had never thought much about. The Brazilians figured they would be able “to see the world,” even if it was no more than a “safe house” in Durban where they were kept as virtual prisoners and a shared hospital room at St. Augustine’s Hospital where they tossed and turned with the agony of post-operative pain. Later, the hapless kidney sellers, who were actually paid between $6,000 and $3,000, grieved the loss of the “little thing” (the missing kidney) that constantly announced its absence with a tingling or itching at the site of their ugly wound. “What have I done to myself?” Paulo, a house painter in a slum of Recife, asked himself aloud. Today, depressed and disgruntled, the disillusioned kidney sellers of Recife meet among themselves to share their anxieties about their loss of work, of reputation, their strength and their health.
But at least the trans-Atlantic trafficking scheme was interrupted in 2004 by a Brazilian Federal Police sting called “Operation Scalpel,” which put the key brokers, Gaddy Tauber and Captain Ivan, away in military brigs in Recife where they are serving long sentences (10+ years) for their crimes: fraud, organs selling and organized crime. Taking a drag on his cigarette during Sunday visiting hours in July 2005, Gaddy was resigned and philosophical. “I broke the law,” he told me in his thickly accented Israeli-English. “I deserve to be here. But in my defense I saved many Israeli lives with the kidneys the guys sold of their own free will. Did I torture them? Did I beat them up? No! Did I force them to get up on the operating table? No! They did it to themselves. So I ask: who was the victim of this victimless crime?”
Captain Ivan, housed in a small cell in another military battalion headquarters, denies involvement in the trafficking scheme. He angrily claims that he was a fall guy and a minor figure, duped by Gaddy Tauber and betrayed by some of the kidney sellers who, he said, became active brokers and kidney bounty hunters themselves, later turning on him to protect their own skin.
The South African surgeons and transplant coordinators in Durban are free on bail, awaiting the medical trial of the century to be held in a South African court before the end of 2006. The surgeons and their associates have been charged with three crimes: fraud, contravening the 1983 South African Organs and Tissues Act—which prohibits the buying and selling of human body parts—and “assault to do grievous bodily harm” on the bodies of the vulnerable kidney sellers. The latter charge took them and the transplant world by surprise. As Geremias, a Brazilian kidney-seller, put it, “They took what they wanted from us and then threw us away like garbage.”
The trans-Atlantic organ trade triangle that brought together an unlikely bunch of Israeli and U.S. buyers, Brazilian and Moldovan kidney sellers, South African doctors and transnational brokers from Israel, the United States, Brazil and South Africa may prove to be the ultimate Achilles heel—one that can determine the fate of commerce in living peoples’ organs and whether it will be judged as something the neoliberal world can live with or as the ultimate form of human exploitation. But one fact is indisputable: it took two countries to the south—Brazil and South Africa—to challenge the power of transplant outlaws and their kidney bounty hunters. And they did so in the name of protecting and defending the vulnerable bodies of the world’s socially disadvantaged.
About the Author
Nancy Scheper-Hughes, professor of medical anthropology at the University of California, Berkeley, is co-founder and director of Organs Watch.
