Conversations with kidney vendors in Pakistan: An ethnographic study

Hastings Center Report

Volumn 39, Issue 3, 2009, Pages 29-44

  Moazam, Farhat ^a   Zaman, Riffat Moazam ^a   Jafarey, Aamir M ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; BIOETHICS; ETHNOGRAPHIC RESEARCH; FINANCIAL MANAGEMENT; HEALTH HAZARD; HUMAN; KIDNEY DONOR; KIDNEY TRANSPLANTATION; LIVING DONOR; PAKISTAN; SOCIAL STATUS; SURVIVAL RATE; ADULT; COMMERCIAL PHENOMENA; CULTURAL ANTHROPOLOGY; ECONOMICS; ETHICS; FEMALE; INTERVIEW; MALE; POVERTY; PSYCHOLOGICAL ASPECT; QUESTIONNAIRE;

ADULT; ANTHROPOLOGY, CULTURAL; COMMERCE; FEMALE; HUMANS; INTERVIEWS AS TOPIC; KIDNEY TRANSPLANTATION; LIVING DONORS; MALE; PAKISTAN; POVERTY; QUESTIONNAIRES; YOUNG ADULT;

EID: 67651175982     PISSN: 00930334     EISSN: 1552146X     Source Type: Journal    
DOI: 10.1353/hcr.0.0136     Document Type: Article

References (69)

1. A.L Friedman, "Payment for Living Organ Donation Should Be Legalized," British Medical Journal 333 (2006): 746-48;
2. A.J. Matas and M. Schnitzler, "Payment for Living Donor (Vendor) Kidneys: A Cost-Effectiveness Analysis," American Journal of Transplantation 4 (2004): 216-21;
3. C.A. Erin and J. Harris, "An Ethical Market in Human Organs," Journal of Medical Ethics 29 (2003): 137-38;
4. M.M. Friedlaender, "The Right to Sell or Buy a Kidney: Are We Failing Our Patients?" Lancet 359 (2002): 971-73;
5. E.A. Friedman and A.L. Friedman, "Payment for Donor Kidneys: Pros and Cons," Kidney International 69 (2006): 960-62;
6. also see "Demand Soars on Kidney Transplant Market," NewsMax.com Wires, April 3, 2007, http://archive.newsmax.com/ archives/articles/2007/4/3/143617.shtml,
7. and "Your Part or Mine?" Economist, November 18, 2006, 65-66.
8. J. Radcliffe-Richards et al., "The Case for Allowing Kidney Sales," Lancet 351 (1998): 1950-1952
9. S.M. Rothman and D.J. Rothman, "The Hidden Cost of Organ Sale," American Journal of Transplantation 6 (2006): 1524-28;
10. F.L. Delmonico et al., "Ethical Incentives - Not Payment - for Organ Donation," New England Journal of Medicine 346 (2002): 2002-5;
11. G.M. Danovitch and A.B. Leichtman, "Kidney Vending: The 'Trojan Horse' of Organ Transplantation," Clinical Journal of the American Society of Nephrology 1 (2006): 1133-1135
12. For some examples from India, the Philippines, and China, see S.S. Chattopadhyay, "A Kidney Racket in West Bengal," Frontline 20, no.15 (2003);
13. "Discount Kidneys for Sale in Living Donor Hotspot," Gulf News, April 19, 2008;
14. Y. Yun and J. Da, "Illegal Kidney Transplant in Mainland Hospital," Epoch Times, http://en.epoch times.com/news/6325/39692.html.
15. Y. Shimazona, "The State of the International Organ Trade: A Provisional Picture Based on Integration of Available Information," WHO Bulletin, http://www.who.int/bulletin/volumes/85/12/06-039370/en/print/html.
16. N. Scheper-Hughes, "The Global Traffic in Human Organs," Current Anthropology 41, no.2 (2000): 191-211;
17. also see N. Scheper-Hughes, "Keeping an Eye on the Global Traffic in Human Organs," Lancet 361 (2003): 1645-1648
18. A handful of surveys related to health and economic conditions of kidney sellers can be found in medical journals, but ethnographic studies involving in-depth interviews are a rarity. For examples of the former see M. Goyal et al., "Economic and Health Consequences of Selling a Kidney in India," Journal of the American Medical Association 288 (2002): 1589-1593,
19. and A.J. Ghods, S. Ossareh, and P. Khosravani, "Comparison of Some Socioeconomic Characteristics of Donors and Recipients in a Controlled Living Unrelated Donor Renal Transplantation Program," Transplantation Proceedings 33 (2001): 2626-2627
20. The few academic publications about kidney vendors based on ethnographic field research include L. Cohen, "Where It Hurts: Indian Material for an Ethics of Organ Transplantation," Daedalus 128, no.4 (1999): 135-66;
21. J. Zargooshi, "Quality of Life of Iranian Kidney 'Donors,'" Journal of Urology 166 (2001): 1790-1799, (Pubitemid 32953413)
22. and J. Zargooshi, "Iranian Kidney Donors: Motivations and Relations with Recipients," Journal of Urology 165 (2001): 386-392 (Pubitemid 32060419)
23. S.A. Rizvi and S.A. Naqvi, "Kidney Transplantation in Pakistan," Clinical Trans plantation (2000): 381-82;
24. S.A. Naqvi, "Community Involvement in Increasing Transplant Activity," Transplantation Proceedings 31 (1999): 3280-81;
25. F. Jawad et al., "Problems of Donor Selection in a Living, Related Renal Transplant Program," Transplantation Proceedings 30 (1998): 3643. (Pubitemid 128712773)
26. S.A.A. Naqvi et al., "A Socioeconomic Survey of Kidney Vendors in Pakistan," Transplant International 20 (2007): 934-939
27. This is a questionnaire-based study, the only one to be undertaken by a team of health care professionals in the country. In comparison, the national press and media have been very active in reporting news stories based on meetings and interviews with vendors. See A. Mehdi, "Jobless Youths Offer Kidneys for Sale," Dawn, June 2, 2005;
28. Z. Tahir, "Hundreds Deprived of Kidneys in Punjab," Dawn, May 27, 2007;
29. A. Ansari, "Kidney Donor Has the Worst of Both Worlds," Dawn, July 10, 2007.
30. F. Moazam, Bioethics and Organ Transplantation in a Muslim Society: A Study in Culture, Ethnography, and Religion, Bioethics and Humanities, ed. E.M. Meslin and R.B. Miller (Bloomington: Indiana University Press, 2006), 28-30.
31. C. Geertz, "Thick Description: Towards an Interpretive Theory of Culture," The Interpretation of Cultures (New York: Basic Books, 2000), 3-32.
32. On September 4, 2007, after years of pressure, the government of Pakistan finally passed the Human Organs and Tissue Transplantation Ordinance, 2007. The ordinance requires all institutions, private and public, to register with and provide annual data to a national oversight committee, whose functions include periodic inspections of all transplant hospitals. See B.S. Syed, "Organs Trade Ordinance Issued," Dawn, September 4, 2007.
33. F. Moazam, "Organ(ised) Crime," Dawn, magazine section, August 27, 2006. This article gives an overview of the Pakistan kidney trade and lists some of the Web sites of hospitals in Punjab advertising "transplant packages" for foreigners at that time.
34. See Naqvi, "Socioeconomic Survey of Vendors," 936. Among the 239 vendors surveyed, kidneys from 69 percent were used to transplant non-Pakistanis. At the WHO Regional Consultation Meeting on Cell and Organ Transplantation held in Karachi in November 2005, nephrologist Nabil Mohsin presented data showing that following the drop in kidney tourism to India (with passage of the Indian Transplant Law in 1995) and then to Iraq (due to the Gulf war), patients from the Middle East were traveling increasingly to Pakistan for transplants; "Trend of Renal Transplant Operations - Living Related, Cadaver and Unrelated from Outside the Saudi Kingdom."
35. "Surgeon Accused of Kidney Theft Still at Large," Dawn, July 8, 2006;
36. "Kidney Theft Victim Seeks Compensation," Dawn, July 30, 2006.
37. The Sindh Institute of Urology and Transplantation provides free care and has a good reputation. For a breakdown by provinces of kidney transplants done by SIUT, see M. Alam, "SIUT Set to Become Region's Biggest Transplant Center," Dawn, August 6, 2008. Of the 2,030 patient transplants done to date, 1,194 were from Sindh, 641 from Punjab, 127 from Balochistan, 57 from NWFP, and 11 from Azad Kashmir.
38. P.R. Ulin et al., Qualitative Methods: A Field Guide for Applied Research in Sexual and Reproductive Health (Durham, N.C.: Family Health International, 2002), 59-61.
39. Our primary contact was Ali, a young man born and raised in a dera near Sargodha and active in social work within local communities. A landowner who knew several vendors but employed none was also helpful. During our first visit to Sargodha we also contacted the Naib Nazim (deputy mayor) about our study due to safety concerns, as a few months earlier a member of our institution was assaulted while making inquiries about vendors. A general practitioner and a psychiatrist were also contacted for follow-up for vendors we judged to require medical attention.
40. The study was carried out during three field visits in April, June, and November, with each visit lasting from four to five days. Our second visit was delayed twice. The first delay occurred when Ali called to say that the harvest season in Punjab was not over and that vendors would have difficulty taking time away from work. The second delay was due to the May 12 face-off between lawyers and the government in Karachi, leading to violence that spread to other provinces, including Punjab.
41. For use of the SRQ in Pakistan, see K. Saeed, S.S. Mubashar, and I. Dogar, "Comparison of Self Reporting Questionnaire and Bradford Somatic Inventory as Screening Instruments for Psychiatric Morbidity in Community Settings in Pakistan," Journal of College of Physicians and Surgeons of Pakistan 11, no.4 (2000): 229-31;
42. D.B. Mumford et al., "Stress and Psychiatric Disorder in Rural Punjab: A Community Survey," British Journal of Psychiatry 170 (1997): 473-78;
43. S. Ahmer, R.F. Faruqui, and A. Aijaz, "Psychiatric Rating Scales in Urdu: A Systematic Review," BMC Psychiatry 7 (2007): 59, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2186345.
44. B. Glacer and A. Strauss, The Discovery of Grounded Theory (Chicago, Ill.: Aldine Publishers, 1967).
45. Moazam, Bioethics and Organ Transplantation in a Muslim Society, 164-67. Moazam's ethnographic research revealed that the reasons for reluctance to donate a kidney include a belief that the loss of one kidney somehow reduces an individual to adha insan (half a person). This "halfness" is believed to make one kamzor (weak) physically and sexually and make childbearing difficult for women. This is felt to be particularly problematic if the potential donor is unmarried, as it results in not getting an ideal "match" for marriage. In some cases, the fact that one has donated a kidney is not revealed to anyone beyond the immediate household.
46. This clarified a conversation we had had in Karachi with a man who said he was planning to have a transplant done in one of the Rawalpindi hospitals. He said the hospitals ran a "one-window operation": all you had to do was give a blood sample and they did the rest. According to him it was like a gurda piri (kidney market) there. The man was drawing an analogy to a bakra piri (goat market), where there are milling herds of goats that may be purchased for sacrifice.
47. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision (Arlington, Va.: American Psychiatric Association, 2004), 492-98. The seizure variety of conversion disorders presents as voluntary motor or sensory symptoms, suggesting a neurological condition as a result of stress or conflicts being experienced by an individual. Conversion reactions are "a way of expressing distress but, unlike malingering, are not produced intentionally by the subject." This variety is "more commonly reported in rural populations, [and] individuals of lower socioeconomic status." DSM notes that "The form of the symptoms reflects local cultural ideas and acceptable ways of expressing distress."
48. For the lack of economic improvement following the sale of kidneys by Iranians, see P. Khajehdehi, "Living Non-Related versus Related Renal Transplantation - Its Relationship to the Social Status, Age and Gender of Recipients and Donors," Nephrology, Dialysis, Transplantation 14 (1999): 2621-2624,
49. and A. Griffin, "Kidneys on Demand," British Medical Journal 334 (2007): 502-5. Khajehdehi found that 87 percent of the living unrelated donors remained in "economic deadlock" due to debt, unemployment, illness, and drug abuse. Griffin offers a good overview of reports about the transplant system in Iran and notes that despite inconsistent data, what is "true" is that "nearly all the donors are desperately poor men who do not want to be identified" due to fear of social stigma.
50. For studies about quality of life and psychosocial repercussions on those who have sold a kidney in Iran, see Zargooshi, "Quality of Life of Iranian Kidney 'Donors,'"
51. and "Iranian Kidney Donors: Motivations and Relations with Recipients."
52. For a report on Indian vendors, see Goyal et al., "Economic and Health Consequences of Selling a Kidney in India."
53. A recent newspaper article reports an interview of 109 kidney vendors by the Philippine Society of Nephrology, revealing that "almost 80% of the villagers were just as poor as they were" before they sold a kidney. See J. Gomez, "Philippines: No Kidneys for Foreigners?" Associated Press, April 1, 2008.
54. See Moazam, Bioethics and Organ Transplantation in a Muslim Society, 137-145.
55. A. Kleinman, "Moral Experience and Ethical Reflection: Can Ethnography Reconcile Them? A Quandary for 'The New Bioethics,'" Daedalus 128, no.4 (1999): 69-97.
56. For a landmark study on the economic conditions of laborers in rural Punjab, see M. Darling, The Punjab Peasant in Prosperity and Debt (Oxford, U.K.: Oxford University Press, 1925).
57. For literature on the psychology of the oppressed in the context of male-female relationships, see J.B. Miller, Toward a New Psychology of Women (Boston, Mass.: Beacon Press, 1986).
58. A.J. Matas, "Should We Pay Donors to Increase the Supply of Organs for Transplantation? Yes," British Medical Journal 336 (2008): 1342-1343
59. Friedman and Friedman, "Payment for Donor Kidneys."
60. R.C. Fox and J. Swazey, Spare Parts: Organ Replacement in American Society (New York: Oxford University Press, 1992): 207-8;
61. R.C. Fox, "Afterthoughts: Continuing Reflections on Organ Transplantation," Organ Transplantation, Meanings and Realities, ed. S. Younger, R.C. Fox, and L.J. O'Connell (Madison: University of Wisconsin Press, 1996), 252-272
62. M. Lock, "Transcending Mortality: Organ Transplants and the Practice of Contradictions," Medical Anthropology Quarterly, New Series 9, no.3 (1995): 390-393
63. I. Sajjad et al., "Commercialization of Kidney Transplants: A Systemic Review of Outcomes in Recipients and Donors," American Journal of Nephrology 28 (2008): 744-754
64. In this literature search, the authors could find studies on vendor outcomes only from India, Pakistan, and Iran, all suggesting poor "medical, socioeconomic and emotional outcomes." Along the same lines, also see review article by V. Jha and K.S. Chugh, "The Case against a Regulated System of Living Kidney Sales," http://www.medscape. com/viewarticle/ 543585.
65. Danovitch and Leichtman, "Kidney Vending."
66. G.M. Danovitch, "Cultural Barriers to Kidney Transplantation: A New Frontier," Transplantation 84, no.4 (2007): 462-463 (Pubitemid 47312154)
67. L.D. de Castro, "Commodification and Exploitation: Arguments in Favor of Compensated Organ Donation," Journal of Medical Ethics 29 (2003): 142-146
68. Castro, who is from the Philippines, argues for a market that "will freely determine the price of human organs in a market economy" that can, among other things, "monitor developments," "protect donors" against middlemen, and ensure that "organs are sourced legitimately." Also see A. Bagheri, "Compensated Kidney Donation: An Ethical Review of the Iranian Model," Kennedy Institute of Ethics Journal 16. no.3 (2006): 269-282
69. A.M. Capron, "What Contributions Have Social Science and the Law Made to the Development of Policy on Bioethics?" Daedalus 128, no.4 (1999): 295-297