Transplanting problems

Even as Southasians watched in disbelief the crossborder chase of Amit Kumar, the disgraced transplant doctor, as he fled from his Gurgaon office to the Chitwan jungles of southern Nepal (and, allegedly, planned to move on surreptitiously to Canada), the people of Pakistan have breathed something of a collective sigh of relief. It is a sigh that still holds some trepidation, however. After decades of deliberation, and having long been a centre of illegal transplants of kidneys and other organs, in late 2007 Pakistani legislators won wide approval for finally promulgating a law regulating the transplants of human organs and tissues. The "Transplantation of Human Organs and Human Tissue Ordinance" now prescribes punishments of up to 10 years imprisonment and fines of PKR 1 million (USD 15,900) for those dealing 'unlawfully' in organs, and those who remove these organs without the victim's consent.

Perhaps most importantly, the new ordinance explicitly bans the 'donation' of organs to foreigners, clearly the most well-to-do of clients throughout the region. At Dr Kumar's Gurgaon office, for instance, a kidney transplant used to cost up to USD 2500; when he was arrested by Nepali security forces, the doctor was found with packets of money worth about USD 150,000. For transplant services in Pakistan, foreign clients generally came from the US, Europe and West Asia, thronging the country largely due to lax or non-existent regulatory control. (Pakistan and Bangladesh had long been the only two countries in Asia without any organ-transplant legislation.) Arab patients to Pakistan generally numbered the highest, partially due to the wealth on the peninsula, and partially due to the fact that the Islamabad government had given them special treatment as 'close friends' of the state.

The 2007 ordinance gained particular praise for allowing 'cadaver transplantation', or the transplantation of organs from those who had been declared brain dead, if they had indicated their approval of such a procedure while alive. This was a major break with older legislation, as for decades the only legal transplantation in Pakistan had been from living donors. This had not only dramatically reduced the number of transplant possibilities for Pakistanis themselves, but hiked up the costs.

Ghoulishly, pre-existing legal stipulation had also led to the creation of a thriving underground trade in 'living organs'. Oftentimes these came from poor labourers hoping to settle debts, though stories continue to circulate of people being drugged and outright 'robbed' of their organs. At one point, an estimated 2000 kidneys were being transplanted every year in Pakistan; and, in what was described as a flourishing 'kidney tourism', half of those were for patients from outside of the country. The World Health Organisation said that an average of around 1500 tourists were coming to Pakistan every year for transplants of various kinds, though others have placed that number significantly higher.

A dead body's rights
Pakistan evolved as a hub of illegal organ transplants during the early 1980s, at a time when India was the main centre for the regional organ trade. But after 1994, when New Delhi imposed a countrywide ban on transplants from donors unrelated by blood to the patient, the vast majority of the trade shifted to Pakistan. Since then, the rate of 'unrelated' kidney transplants being performed in Pakistan has increased massively, from around 25 percent of total transplants in 1999 to 85 percent in 2007.

Of course, India's existing law books contain many provisions similar to Pakistan's new ordinance, and those have clearly not been able to stamp out this black market entirely, as is evident from the recently exposed racket led by the Gurgaon doctor. While many of the elements of Pakistan's new ordinance look good on paper, implementation inevitably remains an onerous task, particularly given the country's socio-economic realities. Two of the most significant obstacles come from opposite sides of the spectrum: from the religious conservatives, who disapprove of the removal of human organs from a deceased person's body; and from doctors themselves, who suggest that continuing to outlaw non-related donations does a disservice to patients, even while allowing for the continuation of a black market.

It is largely due to pressure from religious quarters, and fears of backlash, that Islamabad took so long in promulgating the transplant legislation in the first place. (All along, though, there seems to have been little consideration given to the fact that Muslim countries around the world allowed for such operations, and that patients from Arab countries were making up much of Pakistan's transplant business.) As such, Dr Najib ul-Haq, the dean of the medical faculty at Peshawar Medical College, believes that the "rights of the dead body" could soon prove to be a crucial ethical and religious issue, one that policymakers will soon be forced to wrestle with again. He warns that going back to an outright ban on live donors, in the absence of a cadaver organ bank, could raise a series of new uncertainties in decision-making – for instance, as to who would decide which transplant patient is to be prioritised for receiving a kidney.

The reason for the hurried legislation can be traced to the previously deposed chief justice of Pakistan, Iftikhar Chaudhry. Almost immediately after being reinstated to his position for the first time, on 20 July 2007, the chief justice reprimanded the federal government for having failed to draft an ordinance on organ transplantation despite years of debate. Chaudhry's brief gave the government just a three-month deadline with which to come up with such a law – which the government then, perhaps surprisingly, succeeded in meeting. "But if you do something in weeks that you have not been able to do over decades," one urologist notes, on condition of anonymity, "you are bound to leave gaping loopholes." More onerous, the urologist feels, is the ordinance's continued ban on non-related donors. "What's wrong is the exploitation of the donors by middlemen," he says. "But when you don't get a donor in the family, you have to rely on a non-related one."

The issue, of course, remains far from black and white. In a poor country such as Pakistan, problems inevitably arise involving vulnerable donors-to-be being taken advantage of, often for paltry sums of money. Ghulam Ahmed Raza, a philanthropist, recalls seeing kidney donors in immense pain and misery, due either to unsatisfactory post-operative care, or simply because of the tiny compensation they had received. Raza says that the draft law had originally included a clause regarding the required compensation for non-related donors, but that this was removed on severe criticism from different quarters. NGOs, social workers, doctors, human-rights activists and the like were the main opponents of the proposal, warning that monetary rewards would always lead to exploitation. In addition, one-time-only payment means that no one would take responsibility for post-operative care for poor donors.

But Raza says that he knows many kiln workers who have sold their kidneys for just a couple thousand rupees, and that such legalities could have proved crucial in helping the situation, while also ameliorating the worries of lawmakers intent on outlawing non-related donors. Indeed, Raza says that, upon asking to see affidavits signed by some donors, hospital staff members have told him that the patients in question have given their kidneys free of cost – purportedly just to "win god's blessings". But such reasoning does not stack up for Raza. "Why is it," he asks, "that only the poor have the courage to donate their organs, and an obsession to win God's blessings?"

Gift of life
In fact, under the new law, some non-related transplants will be allowed, though only in very particular circumstances. With all of the surrounding controversies still on the boil, in January 2008 the Sindh Institute of Urology and Transplantation (SIUT), in Karachi, did just this, carrying out Pakistan's first non-related cadaver transplant. SIUT's director, Adibul Hasan Rizvi, says that the operation involved the kidneys of a recently deceased doctor named Abdul Razzak Memon. The organs, Rizvi continues, proved to be a "gift of life" for two patients, Zarina and Kashmala. Rizvi says that SIUT's staff initially had no idea how to inform Dr Memon's family about the donations, but adds that the family members knew about the will and ultimately allowed the transplantations to go forward.

But though notable, the fact is that the first non-related cadaver transplant in Pakistan took place more than full four months after the promulgation of the ordinance. Clearly this process needs to be massively streamlined if this new legislation is to have any hope of having an effect on the ground for emergency patients. Much of the problem appears to be that lawmakers understood the need both to safeguard Pakistan's poor, while also allowing for the possibility of non-related donors – but had little idea how to efficiently bring the two together.

In the case of SIUT's non-related transplantation, this was only made possible through a lengthy bureaucratic process, currently the only way that such an operation can be legally undertaken. Dr Nawaz Chughtai, professor of Urology at King Edward Medical University, in Lahore, says that new law stipulates the creation of a series of evaluation and monitoring committees. These, he hopes, will curb certain instances of malpractice, particularly cases in which poor donors are taken advantage of for the transplant purposes of wealthy patients.

Dr Chughtai says that only under special circumstances will these evaluation committees allow for the donation of an organ by a non-relative, and only after satisfying itself that such a donation has been done on a truly voluntary basis. Evaluation committees are now to be established for every recognised medical institution and hospital in Pakistan where at least 25 transplants are being carried out annually. Similarly, a high-profile monitoring body is also to be formed, and tasked with inspecting hospitals where transplants are being carried out.

Their inherent bureaucracy notwithstanding, Dr Chughtai says that he is confident that the new committees will do much to cut down on cases of transplant malfeasance. At the same time, however, he emphasises that there remains a dire need to create greater awareness among the people of Pakistan regarding cadaver transplants in general. Many people, he says, including a significant segment of the clergy, continue to believe that operating on the body of a deceased person is tantamount to disrespecting that person. Though the promulgation of the new ordinance is clearly an important step forward, it is now incumbent on the government to launch an aggressive awareness exercise, asking people to enrol themselves as potential donors. In the current absence of such a basic step, it appears that lawmakers feel that simply making a law to be enough of a panacea for the people of Pakistan for now.

~ Shahzada Irfan Ahmed works for The News on Sunday.