Chinese surgeons extracting vital organs from condemned prisoners.
Indian villagers selling a kidney for a dowry.
And all to feed the booming global traffic in human organs for transplant.
A shocking report from Nancy Scheper-Hughes.

George Soros is best known as a world-class billionaire financier. But in a recent issue of Atlantic Monthly he finds himself analyzing some of the deficiencies of the global capitalist economy. It's a fairly elementary exercise but since it comes from someone in his position we tend to sit up and take notice.

What bothers Mr Soros most is the erosion of social values in the face of anti-social, market values. Not that markets are to be blamed, of course. By their very nature markets are indiscriminate, promiscuous and inclined to reduce everything - including human beings, their labor and even their reproductive capacity - to the status of commodities.

But while a market economy is generally a good thing, says Mr Soros, we cannot live by markets alone. And the real dilemma, he points out, is that the global market has far outstripped the development of a mediating global society.

Indeed, there is nothing stable or sacrosanct about the 'commodity candidacy' of things. And nowhere is this more dramatically illustrated than in the booming market in human organs from both living and dead donors.

These organs are used for transplant surgery, a business driven by the simple market calculus of supply and demand. With desperation built in on both sides of the equation - deathly ill 'buyers' and desperately needy 'sellers' - local and religious beliefs in the sanctity of the body have collapsed under the weight of market demands.

These demands are amplified by medical talk about the scarcity of organs. In the US, for example, there are close to 50,000 people currently on various organ waiting lists.

But the very idea of organ scarcity has to be questioned. It's an artificially created need, invented by transplant technicians and dangled before the eyes of an ever-expanding sick, ageing, and dying population. And it's a scarcity that can never under any circumstances be satisfied, for underlying the need is the quintessentially human denial and refusal of death.

Japanese sociologist T Awaya describes the trend more bluntly: 'We are now eyeing each others' bodies greedily, as a potential source of detachable spare parts with which to extend our lives.' And he calls it a form of 'social or "friendly" cannibalism'.

While unwilling to condemn it outright, Awaya does want organ donors and recipients to face squarely just what kind of social exchange they are engaged in.

Global flow

Over the past 30 years, organ trans- plantation has developed from being an experimental procedure performed in a few advanced medical centers, to being a fairly common therapeutic one carried out in hospitals and clinics throughout the world.

Kidney transplantation is now conducted in the US, in most European and Asian countries, in several South American and Middle Eastern countries, and four African nations. Survival rates have increased markedly over the past decade, although rates of infection are higher in Brazil, India and China, which rely more on living donors, than in the US, Canada and Western Europe.

The gap between supply and demand is wider in countries where there are strong religious sanctions or cultural inhibitions with respect to 'brain death' or the improper handling of the dead body. But sanctions in one country may stimulate organ sales in a neighbouring one. Wealthy patients have shown willingness to travel great distances to secure a transplant, even in areas where survival rates are quite poor. And with the globalization of the economy, the circulation of bodies and body parts increasingly transcends national boundaries.

In general, the movement and flow of living donor organs - mostly kidneys - is from South to North, from poor to rich, from black and brown to white, and from female to male bodies. For many years desperate Japanese nationals have used intermediaries with connections to the underworld of organized crime - the so-called 'body mafia' - to locate paid kidney donors in other countries. One ring of yakuza gangsters, operating through connections at a major medical center in Boston, US, was uncovered by journalists and broken up by police a decade ago.

More recently, Japanese kidney patients travelled to Taiwan and Singapore to purchase organs obtained - without consent - from executed prisoners. This practice was roundly condemned by the World Medical Association and prohibited in 1994.

China's 'killing-machine'

But today, China stands alone in continuing to use organs of executed prisoners for transplant surgery. Because China enacted a rule in 1984 stipulating that 'the use of corpses or organs of executed criminals must be kept strictly secret, and attention must be paid to avoid negative repercussions', most doctors and public officials in China deny any knowledge of the practice.

David Rothman, head of the Bellagio Task Force now investigating allegations of traffic in organs worldwide, visited major hospitals in Beijing and Shanghai in 1995. There he interviewed surgeons and others about the technical and the social dimensions of transplant surgery as practised at their units.

While the surgeons and hospital administrators answered the technical questions freely and accurately they responded with blank stares to inquiries such as: 'Where do donated organs come from?', 'How many foreigners come to the medical institutions seeking transplants?', 'How much do the hospitals charge for various transplant operations?' No-one would break the official code of silence on this delicate topic.

Checking the lists of the dead. Chinese executions increased to 4,367 in 1996, in line with rising demand for organs PHOTO: J.C. CALLOW / PANOS

But Mr Lin of San Francisco, California tells a disturbing story - one that is repeated by many other recent Chinese immigrants to the US. Just before coming to live in California two years ago he visited a friend at the same medical center in Shanghai visited by Professor Rothman. In the bed next to his friend was a wealthy and politically well-situated professional man who told Mr Lin that he was waiting for a kidney transplant later that day. His new kidney would arrive, he said, as soon as a prisoner was executed that morning. Minutes after the condemned prisoner was shot in the head, doctors present at the execution would quickly extract his kidneys and rush them to the hospital where two transplant-surgery teams would be assembled and waiting.

Human-rights activists report that in China the state systematically takes kidneys, cornea, liver tissue and heart valves from executed prisoners. While these precious organs are sometimes given to reward politically well-connected Chinese, often they are sold to medical 'visitors' from Hong Kong, Taiwan or Singapore who will pay up to $30,000 for an organ.

Harry Wu, the Chinese human-rights activist, was among the first to reveal this. At a conference at Berkeley's Department of Anthropology Wu said: 'I interviewed a doctor who routinely participated in removing kidneys from condemned prisoners. In one case she said, breaking down in the telling, that she had even participated in a surgery in which two kidneys were removed from a living, anaesthetized prisoner late at night. The following morning the prisoner was executed by a bullet to the head.'

In this chilling case, brain death followed, rather than preceded, the harvesting of vital organs. Wu and others claim that the Chinese Government takes organs from 2,000 executed prisoners each year. That number is growing because the list of capital crimes in China has been expanded to accommodate the demand for organs. Amnesty International has recently reported that a new 'strike hard' anti-crime campaign has led to a sharp increase in the number of people executed, among them petty thieves and tax cheaters. In 1996 alone at least 6,100 death sentences were handed out and at least 4,367 confirmed executions took place.

David Rothman, among others, believes that what lies behind the draconian anti-crime campaign is a 'thriving medical business' that relies on prisoners' organs. The state is sponsoring, he says, an 'insatiable killing machine', driven by the rapacious need for fresh and healthy organs.

Organs bazaar

But nowhere more openly and flagrantly than in India has the 'shortage' encouraged a sale of kidneys. There a veritable organs bazaar is operated out of private clinics, especially in Bombay and Madras.

Until a new law last year prohibited the sale of living donor organs, patients from the Gulf States - Kuwait, Saudi Arabia, Oman and the United Arab Emirates - travelled to India to purchase a kidney. Now that market has been driven underground. Recent reports by human-rights activists, journalists and medical anthropologists in-dicate that the international kidney trade has declined but left in its wake an even larger underground market controlled and organized by cash-rich crime gangs expanding out from the heroin trade into the organs trade.

In some cases they have the backing of local political leaders. Organ 'donors' are recruited by 'agents' to sell a spare organ in order to cancel crippling debts, to pay for a necessary operation, or to cover large family expenses. And where there is an illegal market there are likely to be other criminal practices as well.

Professor Veena Das of the University of New Delhi has come across stories, from reliable sources, of 'organ theft'. She told the story of a young woman with stomach pains who went to a small clinic where she was told by the doctor: 'It looks like you have a bladder stone and we had better remove it.' But in fact the doctor used it as a pretext to operate and remove a kidney which he had contracted to deliver to an intermediary for an undisclosed third party.

Lawrence Cohen, a medical anthropologist from Berkeley who has worked in the south and western regions of India, reports that in a very brief period the idea of trading 'a kidney for a dowry' has caught on and become a fairly common strategy for poor parents. Cohen notes that ten years ago, when villagers and townspeople first heard through newspaper reports of kidney sales occurring in the big cities of Bombay and Madras, they responded with predictable alarm and revulsion. Today, some of these same villagers speak matter-of-factly about when it might be necessary to sell a 'spare' organ. Some village parents say they can no longer complain about the fate of a dowry-less daughter. 'Haven't you got a spare kidney?' one unsympathetic neighbour or another is likely to respond.

'Compensated gifting'

Meanwhile, in Brazil, there are over 100 medically certified centers for kidney transplant, 21 centers for heart transplant and 13 centers for liver transplant. The medical demand for organs to keep these clinics operating has meant tolerance toward various unofficial incentives to encourage donation.

Rather than rampant commercialism the more ambiguous concept of 'compensated gifting' is passively accepted by many transplant surgeons as an ethically 'neutral' practice.

As one Rio doctor explained: 'I don't want to know what kinds of private exchanges have taken place between my [kidney] patients and their [living] donors. But obviously you do have to suspect something when the patient is a wealthy Rio socialite and her "donor" is a poor, barefoot "cousin" from the country.'

The compensations can be modest - a lump sum of $1,000 for example - or extravagant. In one incident a niece agreed to donate a kidney to her wealthy uncle in exchange for a suburban house complete with amenities. Even though the operation failed the niece still got her part of the bargain. 'Wouldn't you say that was a fair deal?' the surgeon asked.

These sentiments are shared with transplant surgeons and bio-ethicists in other countries. Labor is sold, sex is sold, sperm and ova are sold, even babies are sold in international adoption. 'What makes kidneys so special, so exempt?' asks Dr Abdullah Daar from Oman.

Meanwhile, the American Medical Association is currently considering financial incentives to enable people to bequeath organs to their heirs or to charity. One proposal is for a 'futures market' in cadaveric organs that would operate through contracts. These would provide that if, at the time of the seller's death, organs are successfully transplanted a substantial sum would be paid to the seller's designee. A sum of $5,000 per major organ utilized is suggested. The proposal is based on the idea that pure gifting can be expected among family members, but financial inducements might be necessary to provide organs for strangers.

At present the AMA is exploring several options. One is a fixed price per organ. Another is to let market forces - supply and demand - set the price. The idea still makes a lot of doctors in the US uncomfortable but the AMA is pushing to get a state-run pilot project off the ground this year.

While some 'transplant surgeons are not alarmed by such commercial exchanges, in Brazil a large coalition of civil-rights activists, lawyers and public officials are. They have mobilized support in passing a radical new law which went into effect on 1 January this year. The ruling - similar to laws in Belgium and Spain - makes all Brazilian adults into universal organ-donors at death unless the individual officially declares themselves a 'non-donor'. Behind the law, I was told by key legislators, was the desire to eliminate any possibility of 'organ trafficking' in Brazil, by mass producing a surfeit of freely-available organs for transplant surgery.

The law was also intended to 'educate' the poor who had, for many years, been terrorized by rumours of kidnapping and murder with the aim of extracting organs. 'If everyone is a potential donor we have the basis for building a truly democratic society,' said one academic bio-ethicist.

But to the 'average' man and woman on the streets of Rio, Recife and Salvador the new law was yet another unwelcome bureaucratic assault on their bodies. The only way to exempt oneself was for adults to request new identity cards or drivers licences stamped with the logo: 'I am not a donor of organs or tissues.'

Last August I visited various civil offices in large and small cities where long lines of anxious people, most of them poor and from Brazil's notorious favelas, were seeking to opt out of compulsory donation before the law came into force. 'God forbid,' whispered Rosa, a young Black school-cafeteria assistant who had taken her own lunch break to get the stamp that, as she saw it, would save her body from greedy doctors or over-zealous mortuary police wanting to transfer her young organs to some 'wealthy old so-and-so'.

Variants of the same story were repeated up and down the line of those waiting at the Felix Pacheco institute in LeBlon, Rio, not far from Copacabana Beach. House-painter and pedestrian Seu Jose said: 'Now we are doubly afraid of being hit by a car. We were always afraid of crazy drivers. Now we have to worry about ambulance workers who may be paid on the side to declare us "dead" before our time is really up.'

Since August the momentum against the new law is growing, evidenced in angry television talk-shows, tabloid editorials, radio reports and on-the-spot interviews with frightened residents of Brazil's giant urban shantytowns.

While to transplant surgeons an organ is just an organ, a heart is just a pump and a kidney is just a filter, a thing, a commodity better used than wasted, to vast numbers of ordinary people an organ is something else - a lively, animate, spiritualized part of the self that most would still like to take with them when they die.

Nancy Scheper-Hughes is an anthropologist and a member and co-author of the Bellagio Task Force Report on Transplantation, Bodily Integrity and the International Traffic in Organs, 1997.