Government Gives Green Light to Kidney Racket

The government has dropped the charges against 13 hospitals after a four month investigation into the kidney racket citing "the welfare of the patients" waiting for organ transplants as the reason. In the last two years over 2000 the hospitals have preformed over 2000 illegal kidney transplants and have colluded with criminal gangs of organ brokers to steal organs from the state's poor and destitute. I have been covering the story for WIRED News and in this blog since the story first broke and this seems an appropriate coda for my investigation in light of the rampant corruption and lack of ethics that permeates ever corner of the medical administration here.

The Directorate of Medical Services, the organization in charge of the investigation, is trying what it calls a "humanitarian approach" that favors wealthy people with renal failure over the poor who must sacrifice their own health for another person's treatment.

Dropping the charges means opening up the flood gates to more illegal surgeries as the DMS has effectively admitted that it will not enforce the rule of law even under extreme instances of medical negligence. The DMS has let the worst offenders completely off the hook (Devaki Hospital, and Madurai Meenakshi Mission Hospital) after asking them to abide by the rules in the future.

This excerpt from the Indian Express yesterday says it all:

"The hospitals had committed only simple mistakes like discrepancies in forms and HLA matching. We have kept in mind the suffering of patients waiting for transplants. Many of them are on dialysis ans need to undergo surgery. The hospitals have agreed to follow the rules and regulations. They will submit an undertaking and obey the rules [in the future]" an official said. (My guess is that the official was Bava Fathurudeen who I have written about earlier)

This is an outright lie that goes to show exactly how high the corruption rises in the administration. A month ago I went to the police and told them I had hard evidence on Devaki hospital that they were preforming illegal kidney transplants. I had uncovered records of the procedure with signatures of doctors (Thiagarajan and Reddy) on one person in Ernavoor and if I searched a little more I could easily have uncovered hundreds of similar documents. However when I went to the police station the Assistant Commissioner only looked at me blankly and said "we are not interested in prosecuting the case."

For Bava Fathurudeen to say that hospitals have only made "simple mistakes" is a bald faced like. The hospitals have knowingly been providing illegal services and have gotten the government to tow the line with them. It's already an established fact that the ethic board that approves transplants knows that 90% of the donors who apply for permission to undergo a transplant are unrelated and being paid by brokers.

So in light of the now defacto legalization of unrelated live-donor transplants why doesn't the government take the more radical step and push for formal legalization? Call me crazy, but I don't think that dozens of hospitals who have been actively pursing criminal transplants are going to stop business as usual after only a slap on their wrists. The honor system isn't going to keep things in check.

Chennai through a Camera's Lens

For the last few weeks I've been trying to get the most out of my camera. After seeing someone's gallery on Flickr I've decided to rediscover black and white photography and spent a couple hours yesterday shooting portraits.

This is is a picture of my wife, Padma Govindan. I think she is the cat's meow.

Padma's mother, Indira Govindan is visiting from the USA for a few more weeks.

The gate to my apartment.

Mallika, my wife's cousin who is in town from Delhi. I took this photo while she was snarfing down potato chips in a local mall. She looks cute when her mouth isn't masticating huge lumps of processed root vegetable.

Passports, Phone Bills and Bureaucrats

For almost ten years I've marveled at the pleasant ideosyncraces of India's bureaucracy, but it wasn't until today that I finally realized that I will never truly penetrate very far into the government mindset. This morning Padma, her mother and I went to our local Hyundai dealership to purchase our first car in India, laid down a cash for the down payment and set up a plan for picking it up in the next few days. Everything seemed in order until the dealer told us to fill out a set of forms that would allow us to register the car in our names. This shouldn't have been a problem. We've registered several motorcycles in the country, have a valid lease, photos, and resident status, but the dealer balked when we proposed to use our government issued Person of Indian Origin (PIO) cards as proof of identity.

The PIO card is the Indian equivalent of an American green card and gives the bearer the same basic rights as a citizen minus voting privledges and the ability to acquire vast tracks of farmland. It looks just like a passport and allows us to come and go from the country as we please. I qualify as a PIO because of my wife, which is sort of funny, but another story entirely.

The dealer looked at our cards and said that it didn't prove our identity and demanded that we produce something a little more authentic. Did we have a ration card? No. How about an Indian driver's license with our local address on it? No. We suggested that we show our lease to prove our address. That wouldn't work either.

"Well, how about a phone bill?", he asked.

Yes, that's right. He asked if we had a phone bill after rejecting our passports and apartment lease as valid identification.

Padma fished through a a sheif of papers and produced a slightly over-due phone bill from AirTel. The dealer smiled, clapped his hands, and said that this would prove who we were nicely.

At this moment I wish there had been a camera on me because I'm sure that my jaw dropped.

In order to get a Person of Indian Origin card person needs to fly to an Indian consulate in another nation, produce thirty different documents attesting to Indian heritage, a dozen passport sized photographs and an Interpol security check. To hook up a land line phone all you have to do is show up at an AirTel office with a passport sized photo, and an address where you want to connect the phone service.

While in theory the AirTel bill does say who we are, it is by no means as rigorous a form of identification as a triple checked ID issued at an Indian consulate. Nor is it as obvious a proof of residence as an active rental agreement. Yet the dealer insisted that the Regional Transportation Office (RTO) wouldn't accept our government issued documents, and would rather rely on a telephone company to verify identity.

While this works out for us perfectly well, we will have the car by the middle of next week, this experience shows me that there is something deeply wrong with the way the Indian government chooses to track it's population. Since when should private carriers bear the burden of censusing the population? Shouldn't the government accept it's own IDs? If the document is good enough to let you in and out of the country, shouldn't it be enough to register a car?

How I quit the crowds and learned to love late fees

For the last year I have been at war with the electricity board of Tamil Nadu. I chalk it up to cultural miscommunication, they chalk it up to me being an all around non-bill paying delinquent. Every two months on the 15th a meterman drops by my apartment snoops around the electrical box and makes a note of how much electricity that I have used. He is supposed to write it down on an government issued electricity ration card so that I have a record of the reading, but more often than not I am not home to give it to him and my aging and mostly blind guardsman never picks it up from me. The ration card stands in for a what I consider a normal electricity bill--the kind that arrives in the mail--and without a notation there is nothing to tell you when you actually have to pay. And I usually don't. At least not on time.

Instead of bill dates, everyone just seems to know that you need to run across town to the electricity board building and pay them in cash before the 15th of the next month. If you don't the next time the meter man drops by he will cut your power. This happened to me in September (and every month thereafter) when my first fights with the electric company began.

Paying the bill at the electricity board is no easy task. Invariably when I show up there is a line that stretches around the block and it can easily take four house in the hot sun just to give a man behind a glass window money.

So after about six months of trial and error I've finally figured out the trick for paying the electricity bill with as little hassle as possible. It involves a few late charges, a little expertise as an electrician and a sneaky way to avoid the insurmountably long lines.

While I am never able to catch the meter man when he is on the premisis, I am invariably home when he ends up cutting my power. Since power outs are common in this part of town I usually don't think much of it, but after the power has been out over an hour (or if I hear my neighbor's TV) I march down to my power box to fix the problem. In the United States when the electricity company shuts down your power they usually do so by pressing a button on some centralized computer in another part of the country. Here in Tamil Nadu it's not quite that sophisticated. In stead of a person at a call center managing your power, the meterman simply disconnects one of the yellow wires at the bottom of my meter (usually the one on the far right side--see photo) and flips the main power switch for the apartment.

To reconnect the power I just wait for the meter man to leave and then plug the lead wire back in. Presto. The lights are back on and I have two more months of power.

Of course, I don't want to steal electricity, I just want to have a way of knowing when to pay the bill. So after a bit of procrastinating (usually about a month) I make my way down the the electricity board which sits on a busy intersection about a mile from my house. Most times of the month there are dozens, if not hundreds, of people holding their electricity ration cards in their hands and waiting to pay their bills. I've waited in those lines before and it can take a very long time before the men and women behind the window stop jabbering with one another, finish their twelfth tea break and finally get around to processing payments. It makes paying a electricity bill the same as a monthly visit to the DMV.
Not wanting to wait in the nightmare line (see photo above) I have come up with a way to skirt the whole issue. Like everything in this country, there are several levels of bureaucracy that you have to deal with when interacting with the government. And despite the huge lines, there are three or four workers behind the glass counters who sit around and do nothing all day because no one needs their specific bureaucratic skills. There are three lines for paying your bill on time, a line for fines, a line for late bills and a line for general inquiries.

That majority of people have come to pay their bills on time and thus have to wait around forever to get processed. However, as a delinquent bill payer I have the luxury of scooting ahead of everyone and going to my own delinquent bill payer window.
So while everyone of India's upstanding citiziens gets to stand in lengthy lines, I get to scoot past them all and pay a nominal (60 rupee) fine for not paying on time and get away from the bloody mess in just a few minutes.

Now I'm sure that this is not the system that the Indian government intended to create for bill payment, but it is by far the easiest one that I have come by yet. Not only do I avoid lines, but I don't need to wait around my house for three days in the middle of the month to catch the meterman as he threatens to turn off my power.

Today I paid my last two month's bill for 1800 rupees, and still had time to write this post. I think the people in the photographs above as still waiting for their agent to finish their tea.

Organ Trade Story in Wired News

After three months of investigation, rewrites, and new information my series on the kidney trade in Tamil Nadu and the rest of the world finally came out on WIRED News. It's a five part series that covers the extent of what happened here in Chennai, the economics of organ sales, the stories of donors who were cheated by brokers and a possible controversial solution to the whole mess.

Check out the stories here:

Part 1: Black-Market Scandal Shakes India's Ban on Organ Sales

Part 2: Inside 'Kidneyville': Rani's Story

Part 3: Why a Kidney (Street Value $3000) Sells for $85000

Part 4: The Case for Mandatory Organ Donation

Portrait: A Land Ravaged by a Tsunami and Kidney Brokers

Spelling Bee Kid aims to Bring Back Deported VHP Rowdy

Today the New York Times is running a story about a thirteen year old scripps national spelling bee contestant Kunal Sah who aims to win the competition to raise awareness of his parent's stalled immigration case. It's the sort of quirky story that immediately pulled on my heartstrings because I have known many people to get stuck in an oppressive US immigration bureaucracy, humiliated and eventually deported back to their home countries.

Kunal's parents were Bihar natives who were seeking asylum in the states on the basis of what they perceived as persecution from their neighbors. See, Mr. Sah had been a rowdy for Vishwa Hindu Parishad (VHP), a fundamentalist Hindu outfit known around the world for its deep pockets and regressively conservative agenda.

Mr. Sah acknowledged in his application that he had been active in organizing a campaign against Babri Mosque, in northern India, because it was “built on our sacred land” and that he “actively participated” in riots intended to demolish.

After several years pursuing his case in courts and in front of immigration officials the Times reports that:

In denying him haven, immigration officials noted that Mr. Sah “had participated in the persecution of non-Hindus and thus was ineligible for asylum.”

While I feel for the son who has been separated from his parents by State powers, I basically agree with the decision. Why should the United States allow violent anti-muslim groups into the the country. This is the same outfit that helped plan and execute the riots in Gujarat, demolished the Babri mosque and continues a direct lineage of colonial "divide and rule" strategy as it sets one community against another.

Sah says he feels that Muslims in his community may target him for retaliation for his involvement in the VHP. I find this unlikely in itself, but while it could be true, I see no reason that America should protect perpetrators of hate crimes from other countries.

While the story has a premises with a good hook: "thirteen year old spells to get his family un-deported", the Times should think twice about running articles that are sympathetic to the struggles of violent fundamentalists from other countries. No matter how cute their sons' story's may be.

Flight of the Repairmen

He came in the morning and began drilling holes in my wall. The bits for his drill we at least an inch thick and a few feet long and the perfect tool for breaching the concrete slabs that make up my apartment building. Three days before this moment I bought an air conditioner to keep my wife's office cool while the rest of the city heats up like an oven. This particular AC design isn't the sort that just hangs out of a window, instead the cooling unit is separate from the grill and is generally perched on balconies outside every apartment. When the workman took his first look at the project he groaned.

In order to access the ledge he would have to rappel down the side of my building holding a clutch full of hemp rope in one hand and the air conditioner in the other. It is a fascinating process to watch. And it is as dangerous as it sounds. The day before his colleague fell from the second story and spent the night in the hospital. Thankfully he wasn't seriously injured, but the jolt was enough to make even my repairman to return home and get a harness and a yellow hardhat. Though in his defense, the hardhat just laid on the floor during the operation.

So for the last five hours he and one or two of his accomplices have been swinging on ropes outside my window, taking water breaks while a five story abyss hangs below their feet. When they go home they get the company rate of $30 for installation and I will have a nice cool room to relax in.

The Problem With Selling Organs

Yesterday morning Francis Delmonico, the Director of Medical Affairs for the Transplant Society and an advisory to the WHO Transplant Committee, phoned me because he had seen some of the articles I have been writing on the kidney racket here in Chennai on this blog and in Wired News. He had included several of my posts on the subject at a recent convention of nephrologists in Rio last week and wanted to know more about the information I had gathered in my three months researching the subject.

What strikes me most about the paying for organs issue is that the conversation is still very narrowly defined. In the comments sections of other blogs I have been accused of not truly understanding the situation and sensationalizing medical procedures that ultimately aim to benefit both the donor (with cash) and a patient who has to endure a painful existence on dialysis. Many people believe that what is happening in Chennai is basically a well maintained free-market that is ultimately tailored to the needs of patients. The assumption that many people make is that the trade should be made legal.

But what I have seen in case after case on the streets of this city is that everyone--doctors, brokers, news people, administrators, NGO workers and dialysis patients--are exclusively focused on the plight of the patients paying for an organ. They don't seem concerned in the least for people who supposedly willingly sold their flesh to an underworld gang.

The truth on the streets of Chennai--and the world at large--is that the trade in human organs is organized by a criminal underground that systematically cheats and mishandles donor and patient interests. The people who sell their kidneys get no good aftercare and often develop health problems as a result of their surgery. Brokers and doctors them off out of the majority of the income from the procedure and once they have left the hospital premises they are no better off then when they signed up for the surgery. No one escapes poverty from selling an organ. In Chennai, organ brokers pay between 30,000 and 60,000 ($700-$1500) for a kidney. A patient will pay between 300,000 and 600,000 rupees ($7,000-$14,000) for the surgery. The rest of the money gets divvied up between the broker, the doctor, official bribes, and hospital administrators).

One woman I met recently named Mallika (see photo) was paid on the low end for her kidney. She made $700 and had to stay in a hospital for three weeks for testing. The broker absconded with the cash that he made. Then, two weeks ago, her 16 year old son was diagnosed with an advanced case of jaundice that caused his kidneys to fail. At the moment he is at Stanley hospital getting dialysis treatments but it is unlikely that she will be able to afford the treatment for long. In a month he will die.

Mallika's case illustraites the inherent inequality of the system. She's poor and a member of the city's organ farm. While she has been a health care provider to a wealthy Indian patient, she has no access to care for her son. She can't donate an organ to her son to save his life because the underworld has already stolen the only commodity that she had access to.

According to the WHO for the last decade China has executed 5000 prisoners annually in order to harvest organs. The organs they provide account for upwards of 11,000 heart, liver and kidney transplants. Can you imagine being a prisoner in China knowing that your only value to the government is to be a host for organs? It is sort of like being a live fish in a tank at a sushi restaurant. And while the Health Minister has vowed to end the practice (on behalf of the upcoming Olympics) it most likely continues to today.

But what happens if China does cut off this steady supply of transplant organs? There will still be a market for them and somehow wealthy sick people will engage brokers and organized criminals to provide them. They will come from people like Mallika.

In my opinion, in an article that will be published in Wired News this week or next, I argue that the only way to solve the problem is to drive the price of organs down by increasing the supply of cadaver organs. And the only way to do that is to harvest organs from every possible brain dead organ donor without regard to consent. The technology is in place to make it possible to harvest organs from you, me and anyone else who gets killed in an auto accident. Organs can be flown around the world in less than 24 hours and transplants made available to anyone at a fraction of the live-donor costs. But the sad state of the present is that live-donor transplants are logistically easier to manage. The donor can find their own way to the hospital and the negotiations only involve one person (rather than a whole family for a brain-dead organ).

Inevitably, efforts to regulate the organ market just don't work. In places like Iran and the Phillipines where selling organs is basically legal you find that the state has taken over the role of brokers and rarely looks out for the welfare of patients. And even if one country regulates the trade in transparent way, it will most likely be more expensive than unregulated--illegal markets--and patients will seek shady transplants abroad.

So when this article appears in a couple days on Wired News, I expect that dozens of people will levy the charge at me that I just don't understand the free market. That I'm sensationalizing the stories of donors and not adequately looking at the levels of despair of a person on dialysis. To this, I can only think about the countless conversations I have had with people who have given their organs, been cheated, and are worse off than they were before.

In the words of Nancy Schper-Hughes, the founder of Organs Watch, "Why should the poor have to pay the body tax?"

click here to see other photos from my thee month investigation.