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

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

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

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

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

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

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

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

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

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

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

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

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