Human traffic: exposing the brutal organ trade

Men with scars

Men from Baseco, a slum in the port area of Manila, the Philippines, show their scars from kidney sales in a photograph from 1999. © Pat Roque/AP/Press Association Images

The slide on the screen showed several skinny, dark Filipino men lined up, displaying their sacred wound, the kidney scar, long as a sabre slice across their convex torsos. More than 150 representatives of scientific and medical bodies from 78 countries stared solemnly at the photo during the Istanbul Summit of 2008, the defining moment in the global recognition of human trafficking for ‘fresh’ kidneys. ‘Is this why we began as transplant surgeons?’ one of the convenors, US surgeon Francis Delmonico, asked. ‘Are we comfortable with this? Is this fair? Do we want to participate in this?’

The man sitting next to me, a Hindu surgeon in white robes, reminiscent of Hippocrates, was moved. When I asked what he was thinking, he replied: ‘This is too late. Kidney selling is no longer a strange or exotic act. It is normal, everyday, and entrenched. We in the South can agree that it is a tragic turn of events, but the demand comes from outside.’

In the early 1980s a new form of human trafficking, a global trade in kidneys from living persons to supply the needs and demands of ‘transplant tourists’, emerged in the Middle East, Latin America and Asia. The first scientific report on the phenomenon, published in The Lancet in 1990, documented the transplant odysseys of 131 renal patients from three dialysis units in the United Arab Emirates and Oman. They travelled with their private doctors to Bombay (now Mumbai), India, where they were transplanted with kidneys from living ‘suppliers’ organized by local brokers trolling slums and shantytowns. The sellers were paid between $2,000 and $3,000 for a ‘spare’ organ. On return, these transplant tourists suffered an alarming rate of post-operative complications and mortalities resulting from mismatched organs, and infections including HIV and Hepatitis C. There was no data on, or discussion of, the possible adverse effects on the kidney sellers, who were still an invisible population of anonymous supplier bodies, similar to deceased donors.

In 1997, I co-founded Organs Watch, specifically to draw attention to the then invisible population of kidney ‘suppliers’.1 Today human trafficking for organs is a small, vibrant and extremely lucrative business that involves some 50 nations.2

No cadavers wanted

In the summer of 2009 I received a phone call that unnerved me.

‘Are you the Organs Lady?’ a young man I’ll call Jim Deal* asked me with a slight tremor in his voice.

‘Perhaps,’ I replied. ‘How can I help you?’

‘I just found out that my kidneys are failing and my doctor wants me to start dialysis immediately.’

‘Yes?’

‘Well, I can’t attach myself to a machine three days a week. I’ve just started a new company and I can’t lose a minute. I need a kidney now. Where can I go to get one? I have the resources. Money is not an object.’

My suggestions to ask his relatives (which included several siblings) were rejected – they were all busy with their careers and families. Would he be willing to take the ‘Steve Jobs option’, registering in multiple transplant centres in different regions of the US, increasing the possibility that his number would be called – Bingo!

‘No cadavers,’ Jim said. It would have to be a kidney purchased from a living stranger. Could I recommend a surgeon or a broker who could help? Given his family genealogy, which included a grandparent from Iran, I told Jim that he might be in luck. Iran had the only legalized and regulated kidney selling programme, but it was reserved for Iranian citizens and diaspora.

‘I’m not going to go to Iran, if that’s what you are saying,’ Jim countered. ‘I want First World medicine.’

There was no use trying to convince Jim that Iran had ‘First World’ surgeons. Some weeks later he called to tell me that his family had found several local, willing kidney providers online through Craigslist. He chose the least expensive ‘option’: a kidney from 19-year-old community college student Ji-Hun*, an immigrant from South Korea who could not afford his tuition, books, room and board, and who feared deportation if he dropped out.

The deal was secured for $20,000. The night before the transplant, two very nervous Korean brothers met with Jim’s relatives in an upscale suburb of Los Angeles to count the kidney loot in crisp one hundred dollar bills. An armed guard oversaw the encounter. The seller requested half in advance. The family refused, but they agreed to hand over the money to the seller’s older brother as soon as both parties were under anaesthesia but before they knew the outcome of the organ transfer.

‘Kidney selling is no longer a strange or exotic act. It is normal, everyday, and entrenched’

By the time I arrived at the famous ‘hospital for the Hollywood stars’ in Beverly Hills, the surgery was over and Jim was out of the recovery room and surrounded by well-wishers. His private room was festive with flowers, gifts, smiles and prayers for Jim’s recovery. Nurses popped their heads in and out to see if everything was going well.

Nicolae, a father of three children, suffers from chronic hypertension. He fears he will not see them grow up.

Nancy Scheper-Hughes

It took some sleuthing to locate Ji-Hun, who was tucked away in a corner room several flights above the regular post-op recovery rooms. He was a delicate young man, weighing no more than 55 kilos. He was doubled over with pain, and blushed with shame when I introduced myself to him as an informal ‘kidney donor’ advocate. The nurses tittered anxiously when I presented my calling card with its Organs Watch logo. They told me that Ji-Hun would be released that same day, although he had not yet seen a doctor following his kidney removal. He was worried about returning to his one-room bedsitter apartment in a dodgy section of Los Angeles. Before leaving the hospital Ji-Hun gave me his cell-phone number.

A few days later Ji-Hun reported that he was still in bed, immobilized with pain, and unable to eat, urinate or defecate. His older brother, a surly young man who worked as a dish washer in a fast-food restaurant, was angry with him. He had no medical insurance, and the $20,000, which had been handed over to his brother in a public toilet on the surgical ward, was already all but gone after settling unpaid bills along with student tuition and remittances for their parents in Korea. After a few brief calls, Ji-Hun’s phone went dead.

Vladiumir, recruited at 18, died from post-surgical infection and kidney failure on return from botched surgery in Turkey.

Nancy Scheper-Hughes

Jim, anxious about disclosure, emigrated to another country and on last report was married and able to work. The head of the surgical staff of the complicit hospital refused to discuss the case, citing patient confidentiality. The consulting nephrologist who worked shifts at the private hospital contacted me to say that he had seen many other instances of bartered kidneys, but was loath to be a ‘whistleblower’.

While most illicit kidney transplants take place in the so-called developing world – India, Pakistan, Bangladesh, Egypt, the Philippines, and more recently Central Asia and Central America – future transactions are likely to resemble the above story. Facilitated by the internet, organ ‘suppliers’ will be drawn locally from the large pool of new immigrants, refugees and undocumented workers. The transplants will be arranged in private hospitals where the transactions are reported as altruistic, emotionally related donations.

Organized crime

That is the future. For now, transplant tours are more usual. They can bring together actors from as many as four or five different countries, with a buyer from one place, the brokers from two other countries, the mobile surgeons travelling from one nation to another where the kidney operations actually take place. In these instances, and the case of a private clinic in Kosovo is perhaps the best example (see ‘The Medicus affair’), the participants appear and disappear quickly, with the guilty parties, including the surgeons, taking with them any incriminating data. When the police finally arrive at the scene, they discover the bloody remains of a black-market clinic, with traces of forensic evidence, but the key players long since disappeared.

Viorel is furious because his kidney was removed under duress. Both he and Vladiumir were operated upon by the prolific Turkish outlaw surgeon Yusuf Sonmez.

Nancy Scheper-Hughes

Over the course of more than 17 years of dogged field research, my Organs Watch colleagues and I had realized that we were not dealing with a question of medical ethics. Rather, we had gained entry into the world of international organized crime. Following fieldwork in Turkey, Moldova, the US, Israel, Brazil, Argentina, the Philippines and South Africa, it became apparent that organ brokers were human traffickers involved in cut-throat deals that were enforced with violence, if needed. Many of the ‘kidney hunters’ who seek out new candidates in poor localities are former sellers, recruited by crime bosses.

The transplant and organ procurement traffic is far-flung, sophisticated and extremely lucrative. Although trafficking in human organs is illegal in almost every nation, the specifics of the laws differ, making prosecutions that can involve three or more nations a judicial nightmare. In some countries it is illegal to sell a kidney but not to purchase one. In others it is illegal to buy and sell within the country but not to buy and/or sell abroad.

Organ trafficking made its début as a much-contested add-on to the 2000 United Nations Palermo Protocol on Human Trafficking, which recognizes that even willing participants in underworld illicit kidney schemes can be counted as victims. Indeed, most are coerced by need, not physical threats or force. Some even pay significant amounts of money to be trafficked.

As it is covert behaviour, it is difficult to know with any degree of certainty how many people are actually trafficked for their kidneys, but a conservative estimate, based on original research by Organs Watch, is that at least 10,000 kidneys are sold each year. Human trafficking for organs is a relatively small and contained problem, one that could be dealt with efficiently with the political will to do so.

Complex co-ordination

Unlike other forms of trafficking that unite people from shady backgrounds, the organ trade involves those at the highest – or at least middle-class – levels of society: surgeons, doctors, laboratory technicians, travel agents, as well as criminals and outcasts from the lowest.

Unlike other forms of trafficking that unite people from shady backgrounds, the organ trade involves those at the highest levels of society, like surgeons

Transplant professionals are reluctant to ‘name and shame’ those of their colleagues involved in the trade, thereby creating a screen that conceals and even protects the human traffickers who supply the surgeons. And because trafficking living donors for organs is a traffic in ‘goods’ (life-saving ‘fresh kidneys’) not traffic in ‘bads’ (drugs or guns) there is reluctance, even on the part of the justice system, to recognize the ‘collateral damage’ it inflicts on vulnerable bodies – and the harm to society and the profession of medicine itself.

Organ brokers are the linchpins of these criminal networks, which handle an onerous feat of logistics. They co-ordinate three key populations: (1) kidney patients willing to travel great distances and face considerable risk and insecurity; (2) kidney sellers recruited and trafficked from the urban slums and collapsed villages of the poor world; (3) outlaw surgeons willing to break the law and violate professional codes of ethics. Well-connected brokers have access to the necessary infrastructure such as hospitals, transplant centres and medical insurance companies, as well as to local kidney hunters, and brutal enforcers who make sure that ‘willing’ sellers actually get up on the operating table once they realize what the operation actually entails. They can count on both government indifference and police protection.

The complicit medical professionals perform expert teamwork – technicians in the blood and tissue laboratories, dual surgical teams working in tandem, nephrologists and post-operative nurses.

There are ‘transplant tour agencies’ that can organize travel, passports and visas.

In the Middle East and in the US, religious organizations, charitable trusts and patient advocacy groups are often fronts for such international networks.

Tactics of persuasion

Some brokers in Moldova used underhand tactics that had already been honed in recruiting naïve Moldovan women into sex work. They offered the opportunity of work abroad to unemployed youth, or household heads in debt or in need of cash to support sick spouses or children.

On arrival, the young men were kept in safe houses, had their passports confiscated, and were reduced to total dependency on the brokers (women were exceptions, see ‘My heart weeps inside me’). A few days later, the brokers would break the news that it was not painting or ironing trousers that was needed from the illegal ‘guest workers’ but their kidneys. Those who refused outright were threatened or beaten. One young man, Vladimir*, explained the stark ‘choice’ that faced him in Istanbul: ‘If I hadn’t given up my kidney to that dog of a surgeon, my body would be floating somewhere in the Bosphorus Strait.’

Nancy Scheper-Hughes with Alberty Alfonso da Silva, who was recruited from a Brazilian slum to provide an organ to an American woman from New York City.

Nancy Scheper-Hughes

Most brokers, however, offer themselves as altruistic intermediaries promising a better life to donors and recipients. The commonest scenario is of vulnerable individuals easily recruited and convinced to participate in the trade. The pressures are subtle; the coercion hidden.

In Baseco, a dockside slum and notorious ‘kidney-ville’ in Manila, brokers recruit young men (and a small number of women) who are distant kin, related by blood or marriage or informal fosterage.

Ray Arcella, a famous broker from the area, could often be seen with his arm slung loosely around the shoulders of his young recruits, some of whom referred to Ray as their uncle or their godfather. Ray’s less than avuncular advice to his many ‘cousins’ and ‘nephews’ was that kidney selling was the best way of helping out one’s family – since mechanized containers had rendered dock work, once Baseco’s main source of employment, obsolete.

Brokers will hire local kidney hunters – often former sellers – to do the dirty work of recruiting their neighbours and extended family members. In these seemingly consensual transactions, controlling behaviour, fraud and manipulation are well hidden.

The sellers

Kidney sellers are predictably poor and vulnerable: the displaced, the disgraced or the dispossessed. They are the debtors, ex-prisoners or mental patients, the stranded Eastern European peasants, the Turkish junk dealers, Palestinian refugees, runaway soldiers from Iraq and Afghanistan, Afro-Brazilians from the favelas and slums of northeast Brazil, and Andean Indians.

Most enter willingly into a ‘transaction’ in which they agree to the terms, which are verbal, but only realize later how they have been deceived, defrauded or cheated. Few are informed enough to give consent. They do not under­stand the seriousness of the surgery, the conditions under which they will be detained before and after the operation, or what they are likely to face with respect to the discomfort or immediate inability to resume their normally physically demanding jobs.

Some in the slums of Manila, as in the slums of Brazil, were underage teens who were counselled by brokers to fabricate names and add a few years to their age to make them ‘acceptable’ to the surgeons. Many of those trafficked deny the ‘sale’, saying that what they were paid was too small to constitute a sale for something as ‘priceless’ as a non-renewable body part. In these unconventional transactions, the boundaries between gift, commodity and theft are decidedly blurred.

‘If I hadn’t given up my kidney to that dog of a surgeon, my body would be floating some­where in the sea’

Male kidney sellers tend to minimize the trauma they experienced to protect their pride. But their reserve often crumbles under gentle but probing questioning of how their lives have been affected. Some male sellers in Moldova denied that they were ‘trafficked’ because the language of trafficking made them sound like female ‘prostitutes’, a stigma they could not live with. Others become obsessed with the kidney sale and attribute all the misfortunes that occurred before or since to that one act of ‘stupidity’.

Among a group of 40 Moldovan kidney sellers we followed from 2001 to 2009, there were deaths from suicide, failure of the remaining kidney, and even from battering by angry villagers who felt that the sellers had disgraced their village. Some were banished from their homes and disappeared.

The brokers

The brokers, who may be transplant surgeons, or organized crime figures, co-ordinate transplant tour junkets that bring together relatively affluent kidney patients from Japan, Italy, Israel, Canada, Taiwan, the United States and Saudi Arabia with the impoverished sellers of healthy organs.

Transplant brokers and organ traffickers are ever more sophisticated, changing their modus operandi, realizing that their engage­ments with public and private hospitals in foreign locations are severely time-limited. Israeli brokers, for example, recently confided that they either have to pay to gain access to deceased donor pools in Russia or Latin America (Colombia, Peru and Panama in particular), or they have to set up new temporary sites and locations (Cyprus, Azerbaijan and Costa Rica) for facilitating illicit transplants quickly and for a short period of time, already anticipating police, government and/or international interventions. They are always prepared to move quickly to new locations where they have established links to clandestine transplant units, some of them no more sophisticated than a walk-in medical clinic or a rented ward in a public hospital.

The buyers

Transplant tourists are a varied but determined and risk-taking population, willing to travel to ‘parts unknown’ to purchase a stranger’s kidney. They pay for a package deal; they do not know – nor do they want to know – the exact price that will be paid to the person who will deliver their fresh kidney. They do want to know whether the purchased organ will come from a healthy person, an educated person, a person of acceptable race and ethnicity. (Ethnicity matters to them because it might signify a ‘closer’ or a ‘better’ match.) They want a kidney that has not had to work hard for a living, and they want their surgeon to make sure they get access to the seller’s healthiest kidney.

There is a preference for male donors between the ages of 20-30 years. Transplant tourists are asked to pay a great deal of money – normally somewhere between $100,000 and $180,000 – of which the sellers receive a mere fraction.

Some buyers refuse kidneys from women, expressing a kind of old-fashioned chivalry, others an old-fashioned sexism. Men are by far the greatest purchasers.

In 2010, I was paid a visit by a sixty-something man from southern California who insisted on setting me straight on certain matters. David* wanted me to know what it felt like to be in his shoes. ‘Dialysis is like a living death,’ he said. ‘You get cataracts, problems in your gut, you can hardly eat. You lose your libido, you lose the ability to relieve yourself until finally you stop urinating altogether. You lose your energy, you become anaemic, and you are cold all the time. You get deeply depressed.’

He was put into contact with a surgeon and his broker in Tel Aviv, who required him to settle the entire package – $150,000 – in advance for a transplant at an undisclosed location. Putting his fate in their hands, David travelled to Israel, and following cursory medical exams, he flew with the Israeli surgeon and his broker on to Istanbul where they picked up a second surgeon. ‘One takes out and the other puts in,’ was the simple explanation. Only in Istanbul was David told that his transplant would take place in Kosovo, a country he knew nothing about. The day before flying there, the broker announced that police had broken into the Medicus Clinic in Pristina, and that the planned transplant there was now unavailable. However, he was willing to offer, at a cut-price rate, another option that had opened up in Baku, Azerbaijan. And that is where David finally received his kidney, from a seller from Central Asia.

The new generation

Following the Istanbul Summit in 2008, the Declaration of Istanbul Custodian Group was instituted. For the last eight years, it has been working closely with The Transplantation Society, the World Health Organization (WHO), and a vast network of transplant professionals to negotiate with public health and other government officials to create new laws to encourage deceased donor programmes, promote transplant self-sufficiency within nations, and discourage transplant tourism. It has also exerted pressure on hospitals to stop sheltering the outlier surgeons who perform transplants involving foreign patients and trafficked kidney suppliers.

Kidney transplants by numbers

But illicit transplant trafficking schemes remain robust, exceedingly mobile, resilient and generally one step ahead of the game.

The new generation of organ traffickers is also more ruthless. During the Beijing Olympics, brokers had their supply cut off after foreign access to organs harvested from executed Chinese prisoners was shut down. Undeterred, they began to pursue transplants from living donors, some of them trafficked Vietnamese, others naïve villagers in parts of China where blood-selling programmes had groomed people to accept kidney selling as another possibility.

The sites of illicit transplants have expanded within Asia, the Middle East, Central Asia, Eastern Europe, Central and Latin America, Europe and the United States. As for the recruitment of kidney sellers, they can be found in almost any nation. One crisis after another has supplied the market with countless political and economic refugees who fall like ripe, low-hanging fruit into the hands of the human traffickers.

Prosecutions are difficult. In most instances a few culprits, usually lower-ranking brokers and kidney sellers, are convicted. The surgeons, without whom no organ trafficking crimes can be facilitated, and the hospital administrators often escape, pleading ignorance.

Donor lifespan graphic

The famous Netcare case in Durban, South Africa, is a case in point. A total of 109 illicit transplants were performed at Saint Augustine’s Hospital, including five in which the donors were minors. A police sting resulted in several plea bargains from various brokers and their accomplices. Netcare, the largest medical corporation in South Africa, pleaded guilty to having facilitated the transplants. The immediate result was the plummeting of Netcare stocks.

The four surgeons and two transplant co-ordinators who were indicted held fast to their not-guilty plea. Their defence was that they had been deceived by the company and its lawyers, who had stated these international surgeries were legal. In December 2012, they were given a permanent stay of prosecution and the state was ordered to pay their legal costs. It is fair to state that rogue transplant surgeons operate with considerable immunity. This is unfortunate because they constitute the primary link in the transplant-trafficking business.

A victimless crime?

Because human trafficking for organs is seen to benefit some very sick people at the expense of other, less visible or dispensable people, some prosecutors and judges have treated it as a victimless crime.

Global demand graphic

When New Jersey federal agents caught Levy Izhak Rosenbaum, a hyperactive inter­national kidney trafficker who had sold transplant packages for upwards of $180,000, the FBI had no idea what a ‘kidney salesman’ was. The prosecutors could not believe that prestigious US hospitals and surgeons had been complicit with the scheme, or that the trafficked sellers had been deceived and at times coerced. The federal case ended in a plea bargain in 2011 in which Rosenbaum admitted guilt for just three incidents of brokering kidneys for payment, although he acknowledged having been in the business for over a decade.

At the sentencing in July 2012, the judge was impressed by the powerful show of support from the transplant patients who arrived to praise the trafficker and beg that he be shown mercy. The one kidney-selling victim, Elhan Quick, presented as a surprise witness by the prosecution, was a young black Israeli, who had been recruited to travel to a hospital in Minnesota to sell his kidney to a 70-year-old man from Brooklyn. Although Mr Cohen had 11 adult children, not one was disposed to donate a life-saving organ to their father. They were, however, willing to pay $20,000 to a stranger.

Transplant tourists are a varied but determined and risk-taking population, willing to travel to ‘parts unknown’ to purchase a stranger’s kidney

Quick testified that he agreed to the donation because he was unemployed at the time, alienated from his community and hoped to do a meritorious act that would improve his social standing. On arrival at the transplant unit, however, he had misgivings and asked his ‘minder’, Ito, the Israeli enforcer for the trafficking network, if he could get out of the deal as he had changed his mind. These were the last words he uttered before going under anaesthesia.

His testimony had no impact. The judge concluded that it was a sorry case. She hated to send Rosenbaum to a low-security prison in New Jersey for two-and-a-half years as she was convinced that deep down he was a ‘good man’. She argued that Elhan Quick had not been defrauded; he was paid what he was promised. ‘Everyone,’ she said, ‘got something out of this deal.’

Closing down the networks

Donor countries

Convicted brokers and their kidney hunters are easily replaced by other criminals – the rewards of their crimes ensure that. Prosecuting transplant professionals, on the other hand, would definitely interrupt the networks. Professional sanctions – such as loss of licence to practice – could be very effective. Outlaw surgeons and their colleagues co-operate within a code of silence equal to that of the Vatican. International bodies like the UN and the EU need to take concerted action on the legal framework in order to prosecute these international crimes.

Prosecutors look kindly on kidney buyers because they are sick and looking to save their lives. But buyers have no qualms about taking a kidney from deprived persons without any medical insurance, any future, and sometimes no home. They have to be made accountable.

Until we can revolutionize the practice of transplantation, a case needs to be made for a more modest medicine that realizes our lives are not limitless. This is a difficult message to convey when transplant patient advocacy groups and religious organizations have sprung up demanding unobstructed access to transplants and to the life-saving ‘spare’ organs of ‘the other’, as if this were a moral crusade.

The kidney is the blood diamond of our times. The organ trade is one of the more egregious examples of late capitalism where poor bodies are on the market in the service of rich bodies.

Nancy Scheper-Hughes is Professor of Medical Anthropology at the University of California, Berkeley, and an activist in many social movements. Her classic 1993 study Death without Weeping: the Violence of Everyday Life in Brazil was the basis, 20 years ago, for an edition of New Internationalist.
* Names marked by an asterisk are pseudonyms.

  1. Organs Watch was co-founded with Lawrence Cohen. They are both professors of medical anthropology at the University of California, Berkeley, who had made initial anthropological forays into the various sites where illicit transplant operations were arranged. Over the years they have been joined by a number of independent medical human rights activists from the countries in which they have worked.

  2. As identified by Organs Watch, WHO, The UN Office on Drugs and Crime and the Declaration of Istanbul Custodian Group.

The Organ Donors' Bill of Rights

To help combat the illegal trade in body parts, I have written a Bill of Rights which has been distributed in several languages in villages and urban slums which are being targeted by organs brokers.

Article 1. All humans have the right to bodily integrity. Organs are every person’s birthright, their bodily patrimony. Humans both are and have a body. (A post-Cartesian notion of the person is not ‘cogito ergo sum’ but rather ‘I am embodied, therefore I am’.)

Article 2. There are no ‘spare’ kidneys, lungs, or part-livers. To share these human parts is a sacrifice not to be normalized, routinized, or taken lightly.

Article 3. Although living donation is honorable and ethical, it is never to be presented by the recipient or his surgeons as an obligation.

Article 4. Green donation (deceased donors) should be the default system. Red donation (living donors) should be viewed as the exception, not the rule.

Article 5. Acknowledge that vulnerable populations – young people, the unemployed, prisoners, the mentally ill, the mentally deficient, guest workers, the uninsured, economic and political refugees, those in debt – are exploitable and that the ‘choice’ to sell a kidney is often coerced.

Article 6. Recognize the role of relative power/powerlessness based on gender, race, class, education, citizenship, nationality in organ selling, transplant tour, internet brokering schemes.

Article 7. Establish a principle of solidarity with the weak, the frail, the sick and the economically and existentially shaken.

Article 8. Recognize that the medical, psychological, social and political consequences of kidney selling, like the scars themselves, are often kept hidden from view.

Article 9. Revise hospital protocol to increase surveillance of living donation to include a ‘donor’s doula’, a guardian-advocate at the bedside, independent of and un-beholding to, or financially dependent on the transplant team, to represent the living donor during screening, surgery, and post-surgical follow up.

Article 10. No living organ donation from the unemployed or medically uninsured.

If you’re willing to ask a living person, a total stranger, to rescue you from the queue of those patiently waiting for a deceased donor organ, or from the onus of asking a relative or close friend to rescue you from dialysis, be aware that you entering a moral, social, ethical, and political grey zone. You’re putting the seller and yourself at risk. Be aware of the collateral damage to the families of kidney sellers and to the economically battered communities where kidney brokering and selling has destroyed trust, broken homes, eroded agricultural, fishing, construction and other work opportunities. In some hard-hit villages and slums from Latin America to Eastern Europe to Asia, the obligation to sell a kidney to save the family is being passed down from the father to his wife to oldest sons and even to underage children whose bodies are now seen as the family piggy-bank.

If you were able, as I have been, to talk to kidney sellers the world over, you would find that even years after the operation, the sellers are still suffering from its effects on their bodies, minds, social status, intimate relations, and working lives

Despite what you may have heard from some surgeons or from transplant brokers, the kidney is not a ‘spare’ organ. If you were able, as I have been, to talk to kidney sellers the world over, you would find that even years after the operation, the sellers are still suffering from its effects on their bodies, minds, social status, intimate relations, and working lives. Medical journals do not report on the invisible and long-term consequences of kidney selling, which include: decreased physical and mental well-being, chronic pain, depression and suicide, self-hatred, distorted body image (‘half-man’ syndrome), anger, social rejection, isolation, physical abuse, battering, and forced exile from their native communities. There are new syndromes that don’t appear in medical textbooks: phantom kidneys, kidney regret, kidney-impotence, bodily evacuation (the body without organs), chronic pain at the site of the surgical scar, empty burning space, and the attribution of all subsequent troubles to the ‘missing kidney’. Economically, kidney sellers are worse off a year after selling their kidney. Because most kidney sellers are poorly educated and are unskilled labourers who rely on the strength of their bodies, many are excluded from work that requires them to lift heavy objects, to leap and jump, to be fearless and unconcerned about the effects of ordinarily rigorous work on their bodies. They fear death. In Bangladesh and Pakistan, kidney sellers refer to their kidney removal as ‘the day I died’, a reference to their economic, psychological, spiritual, and social death. Many seem to have lost their already tenuous existential niche in the world.

Underground markets run by organs brokers and kidney hunters trawling poor communities exploit the desperation of both buyers and sellers. If your rational reply is: ‘Don’t criticize. Legalize the sale of organs’ then we need an organ sellers’ bill of rights to assure that sellers know the broader risks, and so that they won’t be treated as living cadavers, as containers of recyclable biological and medical material and energy to be siphoned off to the highest bidder. Even a regulated system will have to rely on ‘match makers’ and intermediaries. Hospitals and transplant teams cannot be left with the responsibility to monitor legally mandated paid donation of living people’s organs. Transplant teams in the US have failed to identify cases in which force, coercion, and fraud have motivated seemingly willing and informed consent to forfeit an organ. We need independent living donor/seller advocates – guardians of the body of the donor who have nothing to do with the medical or financial elements of the transplant who can verify that the ‘deal’ cut is fair, un-coerced, and that there are no other social or medical or psychological reasons for prohibiting the sale. Kidney sellers require unions and collective bargaining because as a potential labour force they constitute the poorest, weakest, and most vulnerable people on the face of the earth. Finally, if you’re going to plunge into the bodies of the poor, who appear to be (but may not in the long-term prove to be) healthy people, make sure that no-one becomes a kidney seller who does not have access to adequate medical insurance for the rest of their lives.

But in the final analysis, if you are able and willing to pay someone for a kidney (or a liver lobe) to save your life, please make sure that the money is paid to someone you know, even to someone you love, someone who you will be able to watch out for over the long term should their health fail and, turning the tables, they may need you to give them a helping hand. You can’t put a price on life, but you can exchange money with a promise of mutual trust and care. We do it all the time in our families and friendships. It’s called open-ended reciprocity and it is what makes social life possible in the first instance.

Joining the witch–hunt

Harvesting hope: more than 2,000 people have told their stories to the TRC.

PAUL WEINBERG / PANOS

As a very small girl, I was impressed by the story a nun told to our catechism class. It was about an old woman who went to her priest asking forgiveness for a sin of gossip that had harmed the reputation of a neighbor. The priest accepted the woman’s expression of remorse, gave her ‘conditional’ absolution, told her to mend her ways, and gave her the following penance. He ordered the old woman to climb the belfry of the parish church, where she was to cut a small hole in a feather pillow and then shake the feathers loose onto the streets below. Then she was told to go about the village collecting the feathers until she had enough to sew back into the pillow. ‘But Father,’ the woman protested, ‘that would be impossible!’ To which the good priest sadly replied: ‘Yes, and so, too, is it impossible to undo the damage caused by malicious acts.’

Wise words – but counterintuitive to the received wisdom of the day. For the romance with remorse and with reparation, memory and healing – of both the individual and groups – has emerged as a master narrative of the late twentieth century, as individuals and entire nations struggle to overcome the legacies of suffering ranging from rape and domestic violence to state-sponsored dirty wars and ‘ethnic cleansing’. Lawrence Weschler has hit upon an appropriate metaphor for looking at the present contexts of national recovery: ‘getting over’.

'Getting over it'

Just what needs to be ‘gotten over’ if South Africa and South Africans are to get safely to the other side? Surely, as many have argued, a first step towards reconciliation is learning exactly what happened to whom, by whom, and why.

‘I sometimes wonder,’ said Father Lapsley, who received a letter bomb from the apartheid regime, ‘who that man or woman was who typed my name on the envelope that was supposed to kill me. I wonder – what did they tell their spouses or children that night at supper time about what they did in the office that day? Either they are so dehumanized that they don’t care or else they have learned to live comfortably with their guilt. I don’t want vengeance but I think that the names and faces of these people should be known.’

The official vehicle to facilitate ‘getting over’ is the Truth and Reconciliation Commission, the TRC. More than 2,000 victims of apartheid-era brutality have told their stories to the independent Commission and a smaller number of perpetrators of the violence have come forward to confess the details of their attacks on civilians, in exchange for political amnesty.

Those seeking truth in South Africa today do not want the partial, indeterminate, shifting ‘truths’ of the post-modern but rather the single, sweet, ‘objective’ truth of the moralist and, with it, a restored sense of wholeness and a taste of justice. But, as Justice Albie Sachs has noted, South Africans are willing to settle for a ‘good enough’ truth – a narrative that will at least place black and white South Africans, Afrikaners and English speakers, Xhosas and Zulus, African National Congress and PanAfrican Congress members, on the same map rather than living in different nations across the road from each other.

It seems that a great number of white people in South Africa still fail to get the point behind the TRC

There are, of course, many critics of the TRC ‘process’. Some worry about the focus on the ‘exceptional’, the ‘extreme’, and on the ‘gross’ acts of human-rights violation, which runs the risk of obscuring or, worse, of normalizing the daily acts of apartheid’s structural violence – the legal, medical, economic, bureaucratic and commercial violations of human rights that alienated millions of South Africans from their property, their homes, their families, their labor, their citizenship and even from their own bodies.

Still others – most of the ‘ordinary’ South African whites I have spoken to – worry about witch-hunting, scapegoating, and persecution. Indeed, it seems that a great many white people in South Africa still fail to get the point behind the TRC. So, time and again, I was told that if General Malan ordered these tortures or that massacre, it was because he had to do it for the national security. Those who were detained, tortured and killed were not innocent, after all, they were terrorists. And, I was reminded, Communists were poised to take over all of Southern Africa.

As for the ‘higher ups’, their defences are well fortified. Wynand Breytenbach, for example, a former Deputy Defence Minister under both Presidents Botha and De Klerk, is now comfortably retired on a government pension and living out his days as a recovering heart-transplant patient in a luxurious, well-tended and gate-secured community in Sun Valley. He remains unrepentant as he comments on the revelations of torture and murder by the apartheid regime: ‘You know, I sat in at all the top executive meetings of the Defence Force, which is where all the decisions were taken... and I swear to you that never, ever were these sorts of things discussed. OK, we said that we must try and achieve something in this area [ie torture] to get stability. But these characters went out and slaughtered people like cattle.’

‘Does that mean that discipline had broken down in the security forces?’ I asked.

‘I wouldn’t say that discipline had broken down so much as… If you read that book _The Sword and the Swastika_, you can see what the Germans did in the past war to the Jews. You just can’t believe it. And there, too, you find the same thing as happened here. It all boils down to a few individuals, a few rotten apples, small people sitting in big jobs who suddenly think that they can play God… But nowhere and at no time were these things ever discussed or hinted at during the executive meetings.’

In his extraordinary narrative, Breytenbach both manages to deny and to assert his knowledge of, and responsibility for, the state-level atrocities, to attribute blame both above and below him, and to take comfort in the knowledge that the kinds of atrocities committed by the apartheid state are not unique to South Africa but have taken place before (as in Nazi Germany). And now, he says, the real ‘bad guys’ are the ‘disadvantaged’ black criminals who have no respect for law and order, and so corrupt the morals of white people who violently respond to the country’s rising crime.

Like most whites I have encountered since 1992, Breytenbach fails to recognize the enormous grace by which he and all white South Africans have been spared. In the light of the aberrant behavior coming to light through the TRC amnesty hearings, one is inclined to feel that perhaps the ‘witch-hunting’ metaphor is not such a bad one. The apartheid state was filthy with ‘witches’ at all levels of power and authority and a little ‘witch-hunting’ could clear the air.

Witchcraft and popular justice

Allow me, then, to play devil’s advocate in suggesting that witch-hunting might not only be a fitting metaphor for the collective recovery and healing of South Africa, but that certain aspects of this kind of popular justice have been incorporated into the curiously hybrid formulas and rituals of the TRC.

Confession is, of course, a central dynamic in all witchcraft-believing societies from the Navajo and Pueblo peoples of the American south-west to highland Papua New Guinea, from vast stretches of indigenous Africa to the Bocage region of modern France. Conventional insight suggests that witch-hunts are aberrant and dysfunctional institutions which choose the ‘witch’ as the surrogate ritual scapegoat who represents the group’s worst collective nightmare. The processes of fact-finding, guilt determination, the ritualized expressions of remorse and the demand for immediate, though often symbolic, reparation strike liberal, bourgeois sensibilities as weak, irrational and unjust. But a great many anthropologists have challenged the Western stereotype by showing the positive uses of witchcraft in restoring health to troubled communities.

The apartheid state was filthy with 'witches' at all levels of power and authority and a a little 'witch–hunting' could clear the air

In South Africa, the power of traditional Zulu medicine resides in the _sangoma’s_ (healer’s) skill in identifying the social tensions, ‘hard feelings’ and anti-social hostilities that can congeal into sickness, misfortune and death in the community. ‘Witches’ are asked to identify themselves, to come forward and to ‘speak out’ their ‘bottled up’ envy, hatred and guilt. And a great many ‘witches’ do – confessions are said to be a means of ‘emptying themselves’ of the burden of evil and restoring feelings of lightness and emptiness which signify balance, health and good relations.

Rarely, however, do such public confessions result in amnesty and even the most repentant ‘witches’ can be punished by fines, forced labor and public floggings. Miscarriages of popular justice can result in outbreaks of indiscriminate witch-hunting hysteria and witchburnings, such as the much-publicized spate of recent witch-hunts in Venda, northern Transvaal. But these incidents are anomalies compared to the more common and judicious applications of ‘counter-sorcery’ as a traditional form of popular justice. During the anti-apartheid struggle years, some of these older practices were transformed into newer institutions of popular justice, including the people’s courts, security committees and discipline committees put into place by ‘the comrades’ in urban townships and squatter camps. People’s courts meted out a rough sort of popular, revolutionary justice using apologies and fines, public lashings and at times suspected or confessed police collaborators were punished or even killed as ‘witches’.

But in my work in a new and desperately poor squatter camp outside Cape Town during 1993-94, and during a return study in 1996, I was impressed by the generally responsible manner of those involved in community policing and in administering the organs of popular justice. For example, in the Chris Hani squatter camp, several young ANC and PAC members intervened when an angry mob gathered around three local unemployed teenage boys who were caught stealing 400 rand from a local shebeen (bar). The crowd wanted the boys ‘necklaced’ (burned to death) but these few youth leaders, waving the then-draft ANC Bill of Rights, raised their voices in protest and argued for public whippings rather than the death penalty. The floggings were laid on ‘collectively’ by several older men of the community.

Afterwards I visited the boys and they were not a pretty sight. Their eyes were dull with fever, they had trouble bending their legs, sitting and urinating. But following the incident many open-air meetings took place in the squatter camp at which the future of people’s courts and popular justice were endlessly debated Only one of the boys could not get over his anger at the floggers. He was advised to leave the squatter camp and was given help in locating a new home. The other two boys accepted their punishment and were reintegrated into the camp. Nothing more was said about their crime. The last time I saw one of them he boasted that his circumcision ‘cut’ hurt very badly, much worse, he maintained, than his whipping.

The strength of these institutions of popular justice is that they are immediate, public, collective, face-to-face and relatively transparent. They are based on traditional notions of _ubuntu_ (people are people through the eyes of others), and the power of shame within a context of codes of personal honor and dignity.

Of course, popular justice and people’s courts are vulnerable on many counts. They depend on volunteers and have a high turnover following any criticism of their activities or decisions. Many township and squatter-camp residents are afraid to serve on people’s courts, fearing intimidation by relatives of those accused and/or punished; paving the way for ‘strongmen’ with vigilante or police connections to usurp these roles. But in the main, these grassroots institutions operate judiciously. And, elements of both traditional and popular justice have made their way into the uniquely South African version of the idea of the ‘truth commission’.

Witch–hunting and the TRC

Like traditional witch-hunting and the people’s courts, the TRC is not terribly concerned with fact-checking and relies more on the power of the dramaturgical moment – public enactments of suffering, confession, remorse and forgiveness. The TRC places a high premium on apologies offered in person by the perpetrators, who are asked to give ‘eye contact’ to those who were hurt and wronged. At the close of each amnesty hearing, the commissioners and trained ‘briefers’ expedite a ‘closing’ ritual by inviting the survivors to come forward and address their former tormentors, raising with them any final, unanswered questions.

Perpetrators are asked to give 'eye–contact' to those who were hurt and wronged

And so Dawie Ackerman, who lost his wife when shooting broke out in a church in an incident known as the St James Massacre, comes forward. He tells the young men who killed his wife how he had to step over dead bodies in order to get to her, still sitting bolt upright in the front-row pew, and how all the while he was hoping against hope that Marita might just be shell-shocked but still alive, until he finally crossed that endless expanse and reached her. But just as he touched her back, her body rolled over and fell with a dull thud to the floor, her special Sunday clothes splattered with blood.

Dawie continues, his composure now broken, his voice cracking and trembling with tears that have been, he said, a very long time – five years, in fact – in coming: ‘I’ve never cried since I lost my wife other than to have silent cries. I’ve never had an emotional outburst till now. When. . . when Mr Makoma here [the young man who was 17 at the time he took part in the church attack] was testifying, he talked about his own tortures in prison, and that he was suicidal at times, but that he never once cried. I thought to myself – and I passed the TRC lawyer a note – to please bring your cross-examination to an end. Because what are we doing here? The truth, yes. But then I looked at the way in which he, Makoma, answered you. All his anger. And I thought that he cannot be reconciled.’

Then, in a final and painfully wrenching scene Dawie Ackerman, now openly weeping, asks the three young applicants to turn their averted faces to look at him directly and remember which of them shot Marita in her long blue coat. Makoma looks terrified, as if he is seeing Hamlet’s father’s ghost. He nervously bites his lower lip and slowly shakes his head. No, he cannot remember – neither Marita nor her long, b1ue coat. But all three young men apologize to Dawie. Makoma is the most affected: ‘We are truly sorry for what we have done. But it was not intentional. It was the situation in South Africa. Although people died we did not do that out of our own will. It was the situation we were living under. And now we are asking you please, do forgive us.’

Dawie Ackerman did give Makoma his forgiveness and he withdrew his formal, legal objection to the young men’s receiving amnesty from the state. But while some seem to have experienced a real catharsis through the TRC process, young Makoma has yet to find any such emotional relief. He said to the girl whose mother he had killed about the attack: ‘Yah, I had feelings then. It was bad. But no matter how I feel now, at this moment, that what I did was bad, there is nothing I can do. The people are dead. How I feel cannot change anything.’ As a ‘strong’ and ‘disciplined’ PAC militant, Makoma still feels that all these emotional performances are unseemly and just a little bit beside the point.

Albie Sachs expressed the wish that there could be more ‘felt emotion’ by the perpetrators of political violence. He referred to those who seem unmoved by the TRC process, who (like PW Botha and Winnie Mandela) have refused the new history, and who remain frozen in the past. But the TRC process has in fact opened up new emotional spaces where conversations and actions that were once impossible, even unthinkable, are now happening. The unlikely encounters between perpetrators and victims, who are beginning to empathize with each other’s situation, is an extraordinary case in point. And I think of the ordinary Afrikaner couple with very concerned looks on their faces who approached me one day on the steps of St. George’s Cathedral in Cape Town (Archbishop Tutu’s church). ‘Where can we find the Bishop?’ they asked.

‘Oh, he’s a very busy man,’ I said. ‘I’m sure he’s not here now.’ They both looked crestfallen.

‘What did you want to see him about?’

‘We want to confess to the Truth Commission. We did not treat black people very well and now we want to make a fresh start.’

I explained that the TRC was a very formal process ‘with lawyers and official papers’ and that it was meant for murderers and torturers and not for ordinary people who could have behaved better. But the real effects of the TRC will perhaps be felt in small ripple effects like these and, hopefully, in various community circles. As part of Father Lapsley’s ‘Healing the Memories’ forums, some of these healing retreats are reserved for those who were neither victims nor perpetrators, but people who, all the same, were hurt, diminished, traumatized and/or compromised by the apartheid state and the violent struggle against it.

And some have been redeemed, such as Hennie, an Afrikaner and a private security guard. I ran into Hennie in the streets of Cape Town during a spontaneous celebration of South Africa’s victory in the All-Africa Soccer Cup in February 1996. Hennie was very excited, almost emotionally overwrought, and he didn’t know quite how to explain to me the magnitude and significance of that magical moment. ‘Did you see the game?’ he asked. I did, I said, on a big screen in a packed bar.

‘Both goals?’

‘Yes, indeed’

‘And did you see our President right there out on the field?’

‘Yes.’

‘Can you possibly know what this means for us?’ And without waiting for an answer, Hennie told me: ‘It means we are not 100-per-cent bad. It means God is willing to forgive us. That He would give to us – of all people – such great heroes! It is a sign that we are going in a good way now. We are not hated any more. Oh, how can I explain this? It’s like before we were Fat Elvis: sick, disgusting, ugly. Now we are like skinny Elvis: young, handsome, healthy. In the New South Africa we have all been reborn.’

_*Nancy Scheper-Hughes* is a professor of anthropology at the University of California, Berkeley. She is a frequent contributor to the *NI*._