The Greek myth of the Hydra, a serpent with poisonous blood and many heads, is a fitting metaphor for the kidney trade in Pakistan. According to the legend when Hercules battled to vanquish this monster he found that whenever he cut off one of its heads two grew back in its place.

This is reminiscent of the recent reports suggesting resurgence in buying and selling of kidneys, a practice which exploits the impoverished of the land to act as organ vendors for transplants undertaken in affluent Pakistanis and foreigners who arrive from distant shores. Clearly the passage of the Transplantation of Organs and Tissues Law in 2010, with great fanfare, criminalising such practices may have amputated one head of this monster but it did not deliver the mortal blow. The Greek myth, however, also provides clues to how Hercules finally did succeed in killing the Hydra. Together with his nephew he developed a comprehensive, well thought out scheme that involved attacking the many heads of the serpent instead of focusing on only one. The organ trade monster in Pakistan also has many heads, and vanquishing this beast once and for all requires that all must be addressed.

The most powerful head sustaining the global organ trade, 70 per cent of which involves kidneys, is the insufficient number of organs available to meet transplantation needs of patients in kidney failure. Tackling this head requires not only steps to increase the number of altruistic donations from the living but also by initiating robust and sustainable deceased organ donor programmes in Pakistan. The reality is that although the number of kidneys donated by living related individuals has been steadily increasing every year in many countries, this has failed to keep pace with the far greater increase in the number of patients developing end stage renal failure and requiring transplantation.

In the absence of deceased donor programmes and sole reliance on living donors, Pakistan with a high prevalence of kidney disease can never meet this growing demand. Desperate patients and families and the presence of extreme poverty and socioeconomic disparities are a recipe for commodification of human “body parts”. Patients who have the money will always be able to find unethical physicians and hospitals willing to provide transplantation with kidneys bought from debt ridden labourers and kiln workers. Despite strong evidence that such illegal, surreptitiously undertaken transplants carry significant complications including failure of the transplanted kidney, serious infections and even death of the recipients, this collusion is likely to continue. But there is evidence that commercial transactions of kidneys can be reduced if the public is provided an alternative option for transplantation with organs from deceased donors.

In a study, conducted in Karachi, involving more than 100 members of the public, we found that an astonishing 70 per cent of the interviewees stated that they would buy a kidney if they could afford to do so rather than take one from a relative. This finding was both ironical and disturbing in a country that has criminalised this practice as was the fact that less than 10 per cent of those we interviewed knew of the existence of such a law. A promising finding, however, was that a significant number among them said that if kidneys did become available from deceased donors this would become their first choice.

The positive role of deceased donation in stemming kidney commerce has also been demonstrated in recent reports from two countries, India and Iran, where these practices are commonplace. By developing a private-public partnership promoting deceased donor transplantation the state of Tamil Nadu in India, with a population of 72 million, has effectively eliminated buying and selling of kidneys from the province. Similarly, through sustained efforts to increase deceased donation, physicians in the Shiraz Organ Transplant Centre in Iran have managed to completely eliminate transplantation undertaken with kidneys bought from living, unrelated individuals.

Pakistan can emulate these models, but this is only possible through organised efforts that can convince the public that kidney donation following death is permissible in Islam, that coming to the aid of fellow citizens devastated by renal failure is a collective social responsibility rather than individualised medical decisions, and that obtaining organs from the deceased is always more ethical as dead donors cannot be “harmed” in the sense that living donors can.

Another head of organ trade which must be tackled is the exponential global increase in the number of people developing renal disease with many ending up needing a transplant. Among the most important causes of what is now being termed as an “epidemic” of renal disease is the rise in obesity leading to diabetes, including in children, due to changes in life styles and eating habits — a global shift from sensible balanced diets to large “fast food” meals, from local bun kebabs to calorie laden, multinational franchise burgers. This dietary shift is rapidly making its way to developing countries, including Pakistan, as societies become more affluent. Due to this the global burden of renal disease is expected to double within the next few years.

Unfortunately, in the focus on increasing the supply of transplantable kidneys, public health measures for prevention and early diagnosis of kidney disease (never as ‘sexy’ a topic as tertiary medicine issues) have failed to garner the urgent attention and action they require. Pakistan is no exception to this. Without preventive measures, the pool of people suffering from end stage renal failure will continue to expand and there will never be enough kidneys to address this problem in this country or any other. This too will continue to expand the pool of people, particularly the affluent, seeking opportunities to buy a kidney for transplantation.

Another head of the monster is the failure of the government and its designated Human Organ Transplantation Authority (HOTA) to make the national law a reality on the ground. Passing laws against organ trade are doomed to failure in any country unless accompanied by vigorous state commitment to implement these through transparent oversight of all transplantation procedures undertaken in Pakistan, rigorous accountability of physicians and institutions providing these services, and even-handed punishments to all found to be involved in organ trade rather than merely the ‘middle men’ who seem the easiest to nab. This head works in tandem with another powerful one composed of well-connected, often highly placed physicians and their hospitals that provide the life blood to this exploitative practice. Despite media reports that they are flaunting the law, and clear knowledge that without them this exploitative practice would wither, there has been little will on the part of the state to strike a blow at this head of the monster.