Kidneys in Cairo

Seán Columb, a senior lecturer in law at the School of Law and Social Justice at the University of Liverpool, has been investigating the illegal trade in kidneys and other used human body parts for many years. In his recent book Trading Life, Columb provides insight into a world of despair, dependency and economic hardship.

FairPlanet: What is the current legal status of organ trade worldwide?

Seán Columb: It’s a criminal offence to buy or sell a kidney everywhere, except for Iran, where there’s a regulated market. A transplant is illegal if there is money exchanged between the donor and the recipient or a third party. Basically, if anyone other than the hospital gets paid for facilitating a transplant, or if there is a lack of informed consent -  it’s illegal. What this actually means is open to interpretation.

Can you elaborate? 

Depending on how the law is interpreted, someone who consents to sell a kidney can be charged with a criminal offence. So, we have a bizarre situation where people who are compelled to sell a kidney out of economic necessity can be considered complicit in their own exploitation. Unless they can somehow prove that they have been physically coerced or trafficked for organ removal. 

No one should ever be in a position where they have to consider selling a kidney. But the reasons why people are compelled to sell are not recognised by current legislation. A big part of the book is about drawing attention to the socio-economic conditions that position people in exploitative relations, where selling a kidney is something that people are forced to consider as a matter of survival. No one I spoke to wanted to sell a kidney. Some people were physically coerced. But with no means of subsistence, selling a kidney was sometimes the least bad option. 

There are two approaches to organ transplant - altruistic and commercial. Is there also a clear cut between western societies and the Global South?

Yes, because poor people don’t have the privilege of being altruistic. Morality shifts depending on the context. In most countries organ transplants are only available on a quid-pro-quo basis, meaning the average person cannot access transplant services. An altruistic system doesn’t necessarily make sense in an environment that is defined by social malaise and political instability. 

Also, many people are still not convinced that it is safe to donate. Some patients that I spoke to explained that they would prefer to purchase a kidney from a stranger than risk the health of a loved one. One patient made the point that it is more cost effective to make a one-off payment to a stranger as opposed to owing a lifetime of debt and gratitude to a family member. Some people argued that it would be immoral not to give the donors money for their kidney. 

It’s worth pointing out that most people who sell a kidney would not be able to access transplant services themselves. Until more equitable health systems are developed there will continue to be demand for commercial transplants, inevitably supplied by poor and marginalised people.  

'complicit' in their own exploitation

Cairo seems to be one of the main global hubs for organ transplants. Why is that?

Egypt has an established medical infrastructure, a surplus of skilled surgeons, relatively low costs for transplants and an abundance of donors, mainly from poor and marginalised communities. 

Many refugees living in Cairo have been waiting to be resettled for years and are struggling to maintain a livelihood. There’s a huge backlog of people who have been cut off from support services, which were limited to begin with. It’s difficult for ordinary Egyptians to find work, let alone migrant workers and refugees. So, brokers know who to target. 

Foreign patients mainly travel from neighbouring Gulf states, but also from Europe and the US. 

How many hospitals in Cairo are capable of conducting a transplant operation?

I don’t know exactly, but there are quite a few. One study suggests that there are over 500 transplants per year. I would say that this is a conservative estimate at best. And, you know, not all transplants are being done in hospitals. Some take place in unlicensed premisses.

And how many illegal transplants are taking place in Cairo per week?

That’s difficult to say. A broker I spoke to told me that he’s bringing at least thirty to forty donors per week to hospitals for illegal transplants and he could easily bring double that if he wanted to. 

How would you characterise a typical organ donor like the ones you met in Cairo?

Most people I spoke to were asylum seekers and refugees from Sudan, South Sudan, Ethiopia, Eritrea and Somalia. But there are poor and marginalised people all over who are solicited for their kidneys because of their economic circumstances and lack of options to support themselves. 

They are told by brokers that donating an organ is a good and honourable thing to do. They will save someone’s life and with the money they receive they can help their families. And that’s what most people want, to find a way to help themselves and their families. 

An abundance of donors from poor and marginalised communities

Given their situation and legal status, those people are perfect targets for organ brokers, because when it comes to any confrontation, they are ultimately powerless, especially if they don’t have any papers?

That’s right. I remember, there was a 19-year-old man from Eritrea whom I interviewed. He went to the authorities after his operation. He sold his kidney, and he was promised $6,000, but he was given only $2,000 instead. So, when he reported what happened to the police he was asked for his passport, and he said he didn’t have it - he’s a refugee.

They said 'fine, go to the UN, you’re not our concern, we only deal with Egyptian nationals'. But he persisted, so he was threatened with arrest. He was told that what he has done is illegal, selling a kidney is illegal. Also, you shouldn’t be here, without your papers - we could arrest you. And that’s the reason migrant workers, refugees and asylum seekers are being targeted: because of their perceived vulnerability. With or without refugee status, they don’t have legal protection. 

Do you think it was a good idea to criminalise organ sales?

No. You know, the organ trade is something of an open secret. It’s publicly condemned, of course, but it happens in the background. 

There’s a real lack of transparency. And by making it illegal to sell a kidney, the whole process is pushed further underground. To be clear, I’m not advocating a legal system for selling and buying organs. However, I do think organ sales should be decriminalised. The focus of criminal investigations should be the hospitals performing the transplants and the brokers who facilitate them.

I’ve looked into several criminal cases of organ trafficking in different countries. It’s much easier to prosecute and find evidence against an organ seller than it is against the network involved, the brokers or the hospital.

Like I said earlier, people are being held liable for being complicit in their own exploitation, which is kind of ridiculous, really, as it goes against the objectives of what the law is supposed to be doing, in terms of protecting potential victims. 

One thing that came out in the interviews I conducted, that people really wanted to communicate to me, was how they got to the point of selling a kidney to begin with. They explained that if the UNHCR were functioning as it was supposed to, if people received support in emergency situations, to feed their families and put a roof over their heads, they would never find themselves in that position - where they had to consider selling a kidney or taking a hazardous sea journey that they know will put their lives at risk

"By making it illegal to sell a kidney, the whole process is pushed further underground."

In your book you describe the phenomenon of organ laundering as a process of turning illegal organ trade into a legal one. Could you tell us how that works?

Sure. You know, a transplant in and of itself is perfectly legitimate. It is only considered illegal when there is evidence that the donation was commercially motivated or if there were a lack of informed consent. But that is kind of a woolly term. What is informed consent? It’s not very well defined. 

So, basically, all that is needed is paperwork, like an affidavit, a sworn statement saying that the transplant is approved by the relevant authorities. The donor and the recipient declare that they are fully informed about the procedure and are happy to donate on an altruistic basis. And assuming the patient is a foreign national, a passport, visa and a letter of approval from the patient’s embassy is presented.

Once the paperwork is in order - the medical team performing the surgery can claim that as far as they know the transplant is legal.    

The situation has changed in recent years, as you explain in your book, as more organised mafia-like criminal gangs are getting involved in the organ trade. How did this phenomenon come about?

It developed as an informal economic activity, but over time partnerships developed and criminal groups were established. So I guess it became a bit more competitive. People figured out that you can make money through organ trade, and they wanted to protect their interests. In some cases, this resulted in more violent means of recruitment. 

For example, there was one group that I present in my book that were recruiting people outside Egypt, in Khartoum, Sudan. This group was involved in human trafficking in the most extreme sense of the term. They offered jobs to people in Cairo and then coerced them into selling their organs. Some of these transplants took place in unlicensed premisses. But this was one specific group. In most cases, illegal transplants take place at legitimate hospitals using forged or counterfeit documentation.  

What, in your view, should be done to get the problem under control?

There is no silver bullet, obviously. Organ trade is not going away anytime soon unless we get rid of poverty and income inequality. So a long-term approach is needed.

But, first of all, I think [organ trade] should be decriminalised. I know decriminalisation won’t change much, but it would at least open up a space for dialogue beyond criminal sanction. At the very least, people could come forward to assist with criminal investigations without fear of punishment. 

But, really, legal reform and political action need to look beyond prohibitive measures and address the social and economic conditions that underpin the organ trade. Prioritising investment in impoverished communities and developing equitable transplant services within and between countries would go a long way in reducing the commercial incentive for illegal transplants.      

Seán Columb, PhD (Queen's University, Belfast), is a Senior Lecturer in Law at the School of Law and Social Justice, University of Liverpool. His research interests include human trafficking, extra-legal migration and transnational crime. His current research examines how the organ trade fits into the anti-trafficking framework, its link to organised crime and the wider political economy. He has published numerous articles on this topic in peer leading journals, including the British Journal of Criminology and Law and Society Review. His book “Trading Life: Organ Trafficking, Illicit Networks, and Exploitation” was published with Stanford University Press in July 2020.

Image by Dr Seán Columb