Soon after Eidul Fitr, perhaps by end June, some 600 people (including 150 or so women) from six to seven villages around Kot Momin, Sargodha, will travel 200km to Islamabad for a sit-in in the federal capital.

This group of protesters all share a grim reality. Each has sold one of their kidneys, some as recent as 2016, six years after a law was passed criminalising organ transplantation for commercial purposes.

Leading them all is Zafar Iqbal. He has been living on one kidney since 2002 and is on a mission to fight against illicit organ trade. He was 24 and working in a textile mill bringing home 1,300 rupees a month, with family expenses becoming more and more difficult to meet. “It was just not enough to get my four sisters married off. The quicker option was to sell my kidney,” which fetched him 180,000 rupees (of which 50,000 rupees were taken by the middlemen), he told Eos over phone. Today, he runs his own tea stall in the small town but, after the death of his wife last year, is finding it difficult to take care of his five kids, the eldest being a 12-year-old son.

The sale of human organs continues on the black market despite stringent laws

“We have been left with no choice but to take our woes to Islamabad so that we are heard,” says Iqbal.

“I am unable to work as my health is not good,” he confesses. Living on one kidney means muscles on the right side of his body are not as strong anymore. “I am incapable of lifting heavy stuff,” he said.

Mariam, 23, sold her kidney in 2016 and is among the members of the Kot Momin union of kidney donors formed by Zafar Iqbal. “What is done is done. Now we want the state to help us get us out of the debt trap that we keep falling into, provide us with land, healthcare and education for our kids,” she says.

A mother of eight (her youngest is a year-and-a-half), Mariam sold her kidney in Rawalpindi to pay off part of the outstanding debt of 300,000 rupees. It was her husband Ansar’s idea that she sell her kidney. Though promised 200,000 rupees, she claims she received just 180,000 rupees against the promised sum.

“I work as a housemaid in Chaudhry sahib’s home whose land and livestock my husband tends,” she says. Her work starts at 6am and ends whenever the begum says so. In between, she comes home a couple of times to cook food for her kids or to see to them. The family lives in quarters given to them by the landlord for which they do not have to pay rent. “I earn 20 rupees a day and the day I don’t show up, I don’t get paid,” she says. Her husband gets paid when the crop is ready and sold. For anything they need, they keep borrowing from the landlord and the debt continues to mount. Since both husband and wife are completely uneducated they are clueless as to what is written in account books.

AN ACT OF DESPERATION

“Money was tight, and there was nothing to eat at home,” Mariam tells Eos over the phone from her village.

Ansar had already sold his kidney back in 2007, the year the ordinance on human organs and tissue transplantation was promulgated. It was not until 2010 that the ordinance became a law, after it was passed by both the upper and lower houses of the parliament.

“I was promised 110,000 rupees but, after paying the agent and his boss and procuring medicine, I came home with just 70,000 rupees. “I rested for three months and then was on my feet again,” he said.

The couple is thinking of selling the kidney of their 11-year-old first-born. “My husband had injured his leg and was in bed for six months and there was no income,” says Mariam. “We must have an outstanding debt of anywhere between 300,000 rupees to 400,000 rupees,” says Ansar anxiously.

“Our son is not very bright and cannot work. He himself volunteered his kidney,” both the parents insist, separately. “When he sees his father so worried and when he sees there is nothing to eat at home, naturally he will offer,” justifies the father.

“I was terrified before my operation; I had never ever set eyes on a hospital in my life but it was really no big deal,” says Mariam trying to make it sound like a simple procedure. “My mother and sister took care of my kids in our absence. I was back to my normal routine in a week or so,” she continues. Both insist that giving away the kidney has not made a difference to their health. “I am just fine!” says Mariam who gave birth to her youngest child after selling her kidney.

Both are aware it is a crime to sell kidneys but see no other way out. While their agent has long disappeared, they are confident they will find someone willing to help them find a recipient for their son’s kidney.

According to the law, not just relatives but also a living unrelated donor can donate organs, though under very stringent conditions.

Contravention of the transplantation law is punishable with up to 10 years’ imprisonment and a fine of up to one million rupees.

Jameel Ahmed Mayo, assistant director of Federal Investigation Agency (FIA), Punjab, acknowledges that the couple would be breaking the law in the event of selling their son’s kidney. “We will need to work with them, become their sympathisers instead of threatening them,” he says. “Once we gain their trust and gather information of the gang [organ traffickers], we carry out the operation against the traders.”

Hardly anyone escapes poverty by selling kidneys. In fact, those exploiting them get richer. “They charge between seven million to 12 million rupees from foreigners and up to two million rupees from Pakistanis for the package [including getting them the kidney and transplanting it],” says the assistant director of the FIA.

Nevertheless, Mayo says they show leniency towards these poor and vulnerable people. “They are already victims of their circumstances; the most we do is censure them, put them behind bars for a few days and then release them,” he says. In the last two decades since he started working on this issue, Mayo has hardly seen anyone escaping poverty by selling kidneys. In fact, those exploiting them get richer. “They charge between seven million to 12 million rupees from foreigners and up to two million rupees from Pakistanis for the package [including getting them the kidney and transplanting it],” he adds. “They are also the ones who can afford a good lawyer who will find lacunae in the law for the client so he can get them freed from behind the bars.”

A THRIVING TRADE AND EXPANDING NETWORK

Dr Mirza Naqi Zafar, General Secretary of the Transplant Society of Pakistan acknowledges that the trade has not completely abated. “Makeshift theatres” and “single-time clandestine activity” of extricating organs, he says, will continue until there is a need for human organs. And despite the existence of the law and the Human Organ Transplant Authority (HOTA) — a regulatory authority working to curb illegal trade of organs — the illicit practice continues. “HOTA itself is a powerless authority,” Zafar laments. 

In 2016, the law-enforcement agencies had raided a house in Bahria Town Phase VII, Rawalpindi, and rescued 24 people, including four women, some of whom had been held for up to four months and were to be operated upon without their will. The same year, a 60-year-old woman, having bought a kidney from Pakistan, fell ill on the flight home to Vancouver.

In 2017, the Chief Justice of Pakistan Mian Saqib Nisar took suo motu notice of the forceful removal of a kidney from a labourer, Irfan Ali, hailing from Sheikhupura. Irfan Ali claims he was drugged and his kidney removed.

The same year, three men were arrested from Murree Hills and a man from Gujranwala on suspicion of their involvement in organ trade.

Last year, the FIA raided and sealed a private hospital in Nowshera, owned by two officers of the provincial health department, involved in illicit kidney transplantation.

The trade has taken a much more sinister turn. Last week, Mayo busted a gang in Lahore that was taking both recipients and donors to India and China for transplant purposes. The FIA officer told Eos that the gang had taken some 40 recipients and donors, mostly for liver transplant, to New Delhi and Beijing in the last few years and the activity was being carried out in collusion with doctors on both sides of the border.

“Shopping for organs by visiting foreigners has been limited to a large extent but we know that locally the trade is still going on; what we do not know is the extent,” points out Zafar, professor of pathology at the Sindh Institute of Urology and Transplantation (SIUT), which was instrumental in getting the law passed and treats people suffering from kidney- and liver-related cancers and ethical transplant procedures, completely free of cost.

THE DECEASED DONOR PROGRAMME

According to Zafar, nearly 150,000 people in Pakistan die from end-stage organ failure. “Nearly 70,000 die of liver failure, 40,000 of kidney failure and 20,000 of heart failure.”

The 2010 law provides a way out of this — the deceased donor programme or using organs of people who have died. It is a programme whereby an organ from a dead person is extracted and transplanted into one who is dying because of that failed organ.

If Pakistan can breathe life into the deceased organ donor programme, says Zafar, it would turn things around. Muslim countries such as Iran, Saudi Arabia, UAE and now Jordan, Egypt and even Malaysia, are promoting cadaver donations.

In Pakistan, the programme has been met with stony silence.

In the last 20 years or since 1998, families of only five deceased people have come forward and donated organs — a “pathetic” score to be shared at international conferences, according to Zafar.

“To a large extent, though, Pakistan has successfully shed its label of being the foremost kidney bazaar, internationally, but the trade will not stop till the deceased donor programme finds traction,” he emphasises, adding: “All sections of society need to play an effective role to end this practice.”

In April, this year, the SIUT organised a conference, in Karachi, backed by the Law and Justice Department of the Supreme Court of Pakistan, for promoting the practice of ethical deceased organ donation. The conference was attended by the Chief Justice of Pakistan, who announced the donation of all his organs posthumously.

But experts agreed that not much effort has been made to reach out to the people and make them understand the programme.

But along with that, Zafar says the government needs to create world class intensive care units in government hospitals so that organ harvesting can take place. “We need trained transplant coordinators and doctors to declare brain death,” he said.

While more needs to be done to promote the deceased donor programme, Babar Nawaz Khan, former member of the National Assembly (PML-N), and chairman of the standing committee on human rights, says he is satisfied with the work carried out by legislators in the last one year in curbing the illicit trade.

For one thing, he says, HOTA has been “empowered” to some degree. This was corroborated by Zafar.

“At least in the Punjab and Sindh provinces,” he concedes reluctantly.

While HOTA cannot check hospital records, or raid or seal the premises, it can blow the whistle if they discover any nefarious activity taking place, after which the FIA can carry out arrests, says Khan.

Mayo has been in hot pursuit of gangs trafficking organs since 2008 and is behind many of the raids mentioned earlier. “Over the years,” he says, “we have managed to set up a permanent surveillance. But these are smart criminals and [they] keep shifting from one city to another, and now [have] even expanded their network abroad,” he says referring to the most recent arrests.

Just eight months back, in October 2017, a gang was busted in Lahore and a second one in Toba Tek Singh. The same year, six people, including two doctors were arrested in Lahore, red-handed, illegally transplanting kidneys into two Omani nationals having paid 7,000 dollars each for the operation.

To his mind, the transplant law can become more effective if it comes into the fold of the Pakistan Penal Code and made into a cognisable offence.

If that happens, he says, the law-enforcement agencies will have the authority to make arrests without a complaint first being registered with HOTA. “Sometimes, we get information at the eleventh hour and need to move immediately as time is of the essence but our hands are tied,” he adds.

Khan says the legislators have made recommendations to the effect that the transplant law may come under the PPC.

After the gangs were busted in Lahore and Rawalpindi, they moved to Gujrat, Jhelum, etc. Once they started getting arrested in Punjab, they moved to Topi in Khyber Pakhtunkhwa, so Punjab provided intelligence to the KP administration to nab them.

But now the gangs have moved to Pakistan-administered Kashmir region where the transplant law is not applicable. “Since they have moved away from our jurisdiction, we cannot do much so we’ve identified and alerted the AJK government to pursue these gangs. There were some arrests made earlier this year by the AJK police.”

As a recommending body, Khan said, the National Assembly’s standing committee had suggested increase in penalty for flouting the law, to up to 50 million rupees; that the licence of the doctor should stand cancelled and his/her property confiscated. Furthermore, the facility where the doctor performs (either a house or a private hospital) should be sealed and confiscated by the government.

In addition, recommendations have been made to stop foreigners from “shopping” for organs by placing visa restrictions on those seeking to visit Pakistan for healthcare purposes.

Khan says that the outgoing government succeeded in getting the interior ministry to direct the national data base and registration authority (Nadra) to add a column in the national ID card to allow for posthumous organ donation.

In Mayo’s opinion, the mafia will continue to operate unless “transplantation is made easier and people are convinced that the deceased donor programme is a good deed.”

The concerns of those who have been victims to organ trafficking remain largely unaddressed. Iqbal from Kot Momin says, “Over the years, many influential people have promised us all that we are demanding today; even the media has done stories but nothing seems to make a difference.” That is why he decided to organise a union so that they can “take matters into their own hands”. When countered that they may not be allowed to hold a sit-in, Iqbal replies, “What do we have to lose?”

He professes taking the drastic step of self-immolation if his union fails to get their protest registered.

Published in Dawn, EOS, June 15th, 2018