Kidney Transplantation And Poverty

The situation is dire and pathetic as on the one hand patients needs kidneys and donors have nothing to sell but body parts- due to poverty.

In a country where more than 40 per cent of the population lives below poverty line and 13 per cent (or 20 million) suffer from kidney diseases, the link between kidney trade and poverty is not very difficult to establish. The recent incidents of kidney trade by some unscrupulous ‘brokers’ buying kidneys from poor people for transplantation within and outside the country has raised serious concern among general public and also among medical practitioners. The poor people who have ‘sold’ their kidneys have become impaired for the rest of their lives due to the extraction of an organ from their body. They can perhaps solve some problems with the cash received from the trader but may also become disabled, because they may not be a productive member of society due to a lack of proper medical care both preceding and following the removal of an organ and may have to spend money for continuous ailments.

Among other indicators of poverty, the direct calorie intake method measures poverty incidence using the minimum level of food energy (calorie) per capita/day to maintain normal health. For those who are in absolute poverty it is below 2,122 kcal while the ‘hardcore poor’ have a calorie intake of less than 1,805 kcal. In terms of the upper poverty line based on calorie intake, there were 41.2 million poor in rural areas and 14.8 million poor in urban areas in 2005. The number of hardcore poor was 18.7 million in rural areas and 8.3 million in urban areas in 2005. The per capita income of people in the lower poverty line was Tk 630.53 in rural areas, and Tk 741.52 in urban areas in 2005 [http://foodsecurityatlas.org/bgd/country/access/poverty].

Now the offer to sell kidneys made to these poor people who are poor and, at the same time, indebted can make them vulnerable to fall into the trap. Although such a trade has been going on for a long time, the media reporting on Kalai upazila of Jaipurhat has drawn attention of the people in a very serious way. The police have uncovered a major organ trafficking ring that is believed to have persuaded up to 200 people to sell their kidneys for cash in the remote Kalai area, 300 kilometers northwest of Dhaka. These poor villagers have sold their kidneys for Tk 150,000 to Tk 200,000 ($2,000 to $3,000). It is also alleged that the promised amount was not delivered to all these who sold their kidney. Will this money help them get out of poverty or make them disabled forever? Will a new category be identified for the poor people, ‘to see the scar on the belly’ which shows that the person has sold his/her kidney?

It is very unfortunate that more than 18 million people suffer from kidney diseases and 40,000 of them die every year in Bangladesh. Due to the lack of treatment facilities, 90 per cent of these patients remain untreated. Hardly 5 per cent of those who have such disease can afford to the costly treatment including dialysis and transplantation. Rising trend of high blood pressure, diabetes and indiscriminate use of drugs contra-indicated for kidneys are causing increasing number of kidney patients. High use of pesticides and food contamination are also important causes of kidney diseases. Since treatment of kidney disease is costly, many patients die every year. Poor people can hardly think of proper treatment; transplantation of kidneys will remain a dream for them.

Dialysis is often seen as the end-treatment and a kidney patient reportedly needs about Tk 250,000 to Tk 300,000 ($4,166 to $5,000) each year for dialysis. On the other hand, about Tk 250,000 is required for kidney transplantation and for meeting immediate medical expenses and this costly treatment is out of reach of 95 per cent of the patients. Both dialysis and kidney transplantation is out of the reach of the majority of the patients. According to medical experts, ‘People with chronic kidney diseases are more likely to die of heart attacks and strokes than any other normal person.’ The patient does not necessarily always die of kidney failure but can also become vulnerable to stroke and heart attacks. It is nothing but a silent killer. The patients are the worst sufferers as they cannot live a normal life.

Kidney disease is linked to an organ of the body. Although this organ is affected by other health problems such as diabetes and hypertension, ultimately the organ becomes the centre of attention for treatment. While very little is done to prevent kidney diseases which are caused by use of pesticides, unsafe and contra-indicated medicine, polluted environment, etc, prevention of the disease never became an issue in the healthcare policies and programmes. On the other hand, kidney transplantation as a treatment has drawn attention. Organ transplantation is an effective therapy for end-stage organ failure and is widely practiced around the world. According to the World Health Organization, kidney transplants are carried out in 91 countries. Around 66,000 kidney transplants, 21,000 liver transplants and 6,000 heart transplants were performed globally in 2005. The access of patients to organ transplantation, however, varies according to their national situations, and is partly determined by the cost of health care, the level of technical capacity and, most importantly, the availability of organs. Bangladeshi patients are traveling to Singapore and India for kidney transplantation taking along the ‘donors/sellers’ on the trip overseas. Although transplantation in a foreign country is much higher than in Bangladesh, the main reason for Bangladeshi patients’ kidney transplantation in hospitals abroad is to bypass the law. They can make false papers to prove that the kidney donor is a relative of the recipient.

In Bangladesh the Human Organ Transplantation Act 1999 stipulates that only close relatives and blood relations can donate organs voluntarily. The law allows father, mother, son, daughter, maternal and paternal uncles and aunts, husband and wife to donate their organs. Unknown people can in no way donate organs for others, as per the law. Anyone, even doctors, involved in influencing others to donate human organs, will face a maximum of seven years and a minimum of three years in prison or a fine of Tk 300,000 or both. From the legal point of view, there cannot be any trade, i.e. buying and selling of kidney from external sources but can only be ‘donated’. Kidney is not a commodity produced by anybody; it is a body part of a person and cannot be reproduced in the body and ‘donated’.

However, the shortage of organs is virtually a universal problem. In some countries, the development of a deceased organ donation programme is hampered by sociology-cultural, legal and other factors. Even in developed countries, where rates of deceased organ donation tend to be higher than in other countries, organs from this source fail to meet the increasing demand. The use of live donors for kidney and liver transplantation is also practiced, but the purchase and sale of transplant organs from live donors are prohibited in many countries.

Kidney transplantation was first done in the Institute of Post-Graduate Medical Research Hospital (now Bangabandhu Sheikh Mujib Medical University) in 1981; it has also been done in other hospitals such as BIRDEM (2004), the Kidney Foundation (2006), and the Institute of Neurology (2008). Besides, a number of private hospitals such as United Hospital, Lab Aid and AL-Markazul Islam Hospital also conduct kidney transplantation. All these have been done after the law on organ transplantation was enacted in 1999. It is learnt from newspaper reports that the need for law arose because of a kidney ‘donation’ by a poor person to a Japanese citizen in exchange for money occurred, which raised ethical concerns among medical profession. As per law, there is no scope for trade over transplantation. So far, the number of kidney transplantation performed within the country is 700 and outside the country 300.

According to chairman of the Kidney Foundation and a kidney specialist, the number of kidney transplantation performed in different government and private hospitals over the past five years is 421 in BSMMU, 220 in Kidney Foundation, 60-70 in BIRDEM and 20-30 in United. Besides, a few kidney transplantation were done in LAB Aid and Apollo Hospital. The cost for transplantation varies from hospital to hospital, Tk 1 lakh in BSMMU, Tk 2.2 lakh in Kidney Foundation, Tk 4-5 lakh in BIRDEM and Tk 6-8 lakh in private hospitals such as United, Lab Aid and Apollo . That is, the cost of transplantation is six times higher in private hospitals than in public hospitals. The reason for the higher price in the private clinics is not clear. The patients also need to be under constant care and spend about Tk 15 to 20 thousand every month for the rest of the life.

The precondition for kidney transplantation is to have a ‘living donor’ almost lying side by side in a bed parallel to the kidney patient in the operation theater while donating the organ. So whether the donation is from a close relative such as siblings, children, spouses, uncles and aunts, etc or from a person unknown and unrelated to the recipient ‘selling’ the organ at an agreed price hardly matters, if it really fits medically. So far, only 700 kidneys have been transplanted in about 23 years (since 1988), which is very insignificant compared to the demand for transplantation. It is not recorded whether all the 700 transplantation were carried out by kidney donation from relatives or arranged through brokers in exchange for money. Newspaper reports about Kalai upazila show that kidney donation has turned into an organised and criminal trade taking advantage of poverty and indebtedness of the village people and these kidneys were supplied to national hospitals or taken abroad. This trade started secretly in a village named Bahuti five years ago and has since spread into 20 villages of three unions. More than 200 persons from 150 families have sold their kidneys because they needed the money to overcome economic hardship.

The kidney sellers are both men and women. In some cases, both the husband and the wife sold one kidney each to get more money. The final price given to the seller ranges from Tk 30,000 to Tk 1 lakh. The brokers in kidney trade have violated the agreement between the seller and doctor at a price of Tk 6 lakh for the couple’s kidneys as the husband received Tk 30,000 while the wife received Tk 15k only. Kidney selling is occurring through a Broker gang a gang of brokers who resort to various forms of deception, allurements and even false certificates to prove that the seller is a close relative as indicated in the Human Organ Transplantation Act 1999.

Why do people sell kidneys? The main two causes reported are poverty and indebtedness. In Kalai particularly, couples and other members of the same family sold kidney because they needed money to maintain the family and also to repay micro-credits taken from a number of NGOs in their area. The broker gang took advantage of the ‘helpless’ situation of the poor people and motivated them to sell an organ of their body and told them that it is alright for them to have one kidney. People can easily survive with one kidney, as if one of the two kidneys is a spare part in the body. But what happened to the sellers afterwards? Could they get out of poverty? On follow-up investigation by newspaper journalists in the Kalai village, it was found that most of the sellers are suffering from various health problems. They cannot do any heavy work, feel pain in the abdomen and suffer from ailments that they did not have before. The money received by selling kidney is going back to the doctors for treatment (Prothom Alo, August 30).

The kidney sellers are supposed to be a healthy person, but once they decide to sell or donate the kidney they are also on the operation table in the same way as the recipients of kidney (i.e. the patients in need of transplantation). After the kidney is taken out of the body the donor/seller also falls in the category of a patient, who needs further support of health care. Unfortunately, when it becomes a case of trade, there is no option for such care after the payment for the organ is made. The organ has been commodified and whatever happens to the ‘seller’ is no more a concern of the ‘buyer’. No record is kept so no one can come back and claim compensation for the health hazard caused by donation. On the other hand, in the case of ‘donors’ as described in the law, there could have been protection and ensured follow-up care.

It is time to think about the responsibilities of all the related stakeholders to protect the rights of poor people for proper health care and the right of the kidney patients to have treatment, including transplantation, without causing threat to the life of the poor people. The necessary amendment of the law which ensures protection and proper care must be made.

However, poor people must be brought out of the deception, allurement and the trap of organ trade. Kidney selling is not a way out of poverty, it will rather enhance poverty.

Tags: Kidney Transplant, Kidney Selling, Poverty, Bangladesh