May 23, 2004

Tracking the Sale of a Kidney on a Path of Poverty and Hope

RECIFE, Brazil — When Alberty José da Silva heard he could make money, lots of money, by selling his kidney, it seemed to him the opportunity of a lifetime. For a desperately ill 48-year-old woman in Brooklyn whose doctors had told her to get a kidney any way she could, it was.

At 38, Mr. da Silva, one of 23 children of a prostitute, lives in a slum near the airport here, in a flimsy two-room shack he shares with a sister and nine other people.

"As a child, I can remember seven of us sharing a single egg, or living for day after day on just a bit of manioc meal with salt," Mr. da Silva said in an interview.

He recalled his mother as a woman who "sold her flesh" to survive. Last year he decided that he would, too. Now, a long scar across his side marks the place where a kidney and a rib were removed in exchange for $6,000, paid by middlemen in an international organ trafficking ring.

Among poor men like Mr. da Silva and others who have migrated to slums here from Brazil's parched northeastern backlands, word of the market to sell their organs spread quickly.

Some who had done so were already buying houses, businesses, cars and refrigerators.

The sums being offered seemed a fortune. The minimum wage here is barely $80 a month, and work is hard to find. Many men struggle to exist on odd jobs that pay barely a dollar a day. Initially, the organ brokers paid as much as $10,000 for a kidney — more than a decade's wages.

Donors and recipients were not related, in contrast to the usual preference for legal and medical reasons. In fact, they did not even know each other. But they were linked by a trafficking ring that the authorities now say exploited two very different sets of needs — for money and for life itself — at opposite ends of a tangled chain thousands of miles long.

Tracing the journey of Mr. da Silva's kidney through that chain, which spanned four continents and ended in a one-bedroom apartment in Brooklyn, reveals the inner workings of a network that human rights groups say is by no means unique. Rather, they say, it is representative of a global black market for organs, including livers, kidneys and lungs, that touches dozens of countries and generates many millions of dollars a year.

In Alberty da Silva's case, the authorities here say, the organ's odyssey began with two middlemen based in this gritty port city of 1.5 million people: Gedalya Tauber, a former Israeli police officer, and his partner, Ivan Bonifacio da Silva, a retired Brazilian military police officer.

The pair, since jailed on organ trafficking charges, not only handed out cash payments, the authorities say, but also arranged for the medical exams to weed out unqualified donors. They then obtained passports and airline tickets for the donors to travel to South Africa, where the transplants took place. Both countries have laws against commercial trade in organs.

"Six grand is a lot of money, especially when you don't have any," Mr. da Silva said when asked why he had given up his kidney. "No one here warned us that what we were doing was illegal."

Get a Kidney, or Expect to Die

The American woman who received Mr. da Silva's kidney initially worried that what she was doing might be illegal. She described herself as deeply religious and concerned with the ethics of transplants.

But during an interview in April she also recalled the long years of suffering that made her take the risk of seeking an organ on the international market. The decision to go abroad for a kidney, she said at her third-floor walk-up apartment in Brooklyn, was not an easy one, but necessary nonetheless.

"I had been on dialysis for 15 years and on two transplant lists for 7," said the woman, who asked not to be identified by name, for fear of losing support payments vital to maintaining the health of her transplanted organ. "Nothing was happening, and my health was getting worse and worse." Finally, she said, "my doctors told me to get a kidney any way I could," or expect to die.

She took their warning seriously. The years of dialysis had left her with worsening heart and lung problems. She also suffered from severe osteoporosis. "I had seen four other ladies that I knew pass away" while they waited for kidney donors, she said.

More than 3,300 Americans died last year awaiting kidney transplants, and the Brooklyn woman was among 85,000 people on waiting lists in the United States, 60,000 of them in need of kidneys. The average wait can be five years, says the United Network for Organ Sharing, a nonprofit transplant information clearinghouse in Richmond, Va.

It is illegal in the United States to pay a donor for an organ. But Nancy Scheper-Hughes of Organs Watch, a human rights group in Berkeley, Calif., that has long tracked the illegal organ trade and denounced abuses, says irregularities still occur.

"It is a common practice of many larger clinics to advertise on the Internet for transplant tourists, so we're up to our necks in it," Dr. Scheper-Hughes said. Transplant doctors, she says, have developed a "don't ask, don't tell" policy.

The World Health Organization issued guidelines in 1991 to avoid the coercion or exploitation of organ donors. They were endorsed by 192 countries, including the United States, Brazil and South Africa. But the guidelines are not binding, and the recommendations have been widely ignored. At least one country, Iran, has a legally regulated system to trade organs.

As medical science advances and health care increasingly becomes a marketplace transaction, a fierce debate about commercializing transplants has emerged.

On one side, said Alexander M. Capron, the director of the ethics department of the World Health Organization, are "transplant surgeons who believe that a good way to remedy the shortage of organs would be to offer payments," and bioethicists and philosophers who see organ trade as an extension of the principle of autonomy.

But an opposing group, Mr. Capron said, "fears that the line between selling organs and actually selling people is a rather fine one" and that, as in sex trafficking, the marketplace is one in which coercion and exploitation may be unavoidable.

In the case of the Brooklyn woman, her husband had relatives in Israel who had heard of a syndicate that brokered transplants, and reached out to them. The woman and her husband said that relatives and the brokers reassured them that an operation abroad would be perfectly legal.

"I felt helpless, because she was going to die," said the woman's husband, who is in such fragile health himself that he receives disability payments. "Helping her get that kidney was the best thing that I have ever done for anyone in my entire life."

`Mr. Big' or `the Wrong Guy'?

The syndicate that organized the American woman's transplant, the authorities say, also arranged kidney transfers for at least 100 Israelis. It was led, they say, by a 52-year-old organ broker in Israel, Ilan Peri.

"He's Mr. Big, the one who started the whole thing," Johan Wessels, a forensic investigator in South Africa who works for the Department of Health in KwaZulu-Natal Province and has had access to hospital records there, said in Durban.

Mr. Peri works out of a Tel Aviv suburb through a company called TechCom. He faces charges of tax evasion in Israel, accused of improperly declaring nearly $4 million said to have been earned as an organ broker and is also under investigation in connection with inflating the invoices that he did submit to Israeli health care programs.

When reached by telephone in Tel Aviv and asked to comment on the charges, Mr. Peri said: "I have never been involved in kidney transplants. You are talking to the wrong guy." He eventually hung up the telephone, but not before amending his statement. "I'm not involved in that anymore, so I can't help you," he said.

To those who monitor organ trafficking, it was no surprise that Israel should emerge as the focal point of a syndicate. Organ donation rates in Israel are among the lowest in the developed world, about one-third the rate in Western Europe, in large part because of what Health Ministry officials and doctors describe as a widespread impression that Jewish religious law prohibits transplants as a "desecration of the body."

In reality, religious law is far more nuanced. But influential Orthodox rabbis have been reluctant to make public statements that would encourage either live donors or the harvesting of organs from the deceased.

Israelis needing transplants have suffered as a result. More than 1,000 people in a nation of about 6 million are on Israel's waiting list for organs, more than half of them for kidneys. The list grows by more than 20 percent each year, health officials say. In an average year, more than 80 people die waiting, proportionally a slightly higher rate than in the United States.

To meet Israeli's growing demand for organs, middlemen calling themselves brokers, from prominent doctors to a former spokesman for a health maintenance organization, have rushed into the market to set prices for a scarce product that can reach $150,000 for a kidney. Some advertise openly in Israeli newspapers and on radio stations, soliciting recipients and donors.

"As of today, there is no law in Israel that forbids trafficking in human organs," Meir Broder, a legal adviser to the Health Ministry, explained in an interview in Jerusalem. "There is no criminal aspect at all."

A bill drafted by the Health Ministry that would make trafficking illegal and forbid organ donations for money awaits action in the Parliament. But medical specialists say it faces strong opposition and may not pass.

For now, allowing the brokers to operate with few restrictions in effect benefits the state by exporting Israel's organ shortage overseas. The patients who do go abroad "save the country a lot of money," explained Dr. Michael Friedlaender, a kidney specialist at Hadassah Hospital in Jerusalem, "not only in terms of what doesn't have to be spent on dialysis, but also by opening places for other people who are on the list."

For operations in Israel, the Ministry of Health relies on elaborate procedures to ensure that donors and recipients act for "altruistic" motives and do not exchange money. But another ministry directive also allows Israelis who go abroad for transplants to be reimbursed as much as $80,000.

Much of the remaining costs can often be obtained from insurance plans, though Israeli health maintenance organizations are supposed to ask for proof when donors and recipients say they are related in "voluntary" operations.

Israeli doctors say those requirements are often ignored, and the government says it has no obligation to monitor operations done abroad. "In the end, a country can only be responsible for what happens within its own borders," said Mr. Broder, the Ministry of Health lawyer.

In the mid-1990's, many of the Israeli organ brokers took their patients to Turkey, flying in teams of Israeli surgeons and relying on donors from Moldova, Romania and Russia. But after some patients died and Dr. Scheper-Hughes of Organs Watch and the Turkish and European news media raised ethical questions, the brokers were forced to search for new locations.

For both the medical expertise available and its low costs, South Africa emerged as a logical alternative.

The South African Connection

It was there, in South Africa, the authorities say, that Mr. Peri's ring brought together Mr. da Silva and the woman who ultimately received his kidney.

After long negotiations in Israel, which she said were conducted by relatives of her husband, the Brooklyn woman flew to South Africa for a transplant. Because of her unusual circumstances, it cost her just over $60,000, which other kidney recipients who dealt with Mr. Peri said was less than half the price the syndicate usually charged.

Even so, that amount was 10 times the payment Mr. da Silva received, though organ recipients in Israel said Mr. Peri routinely told them that the Brazilian donors were being paid $25,000.

While money initially motivated Mr. da Silva to sell his kidney, he said he also came to be moved by the chance to help a stranger. The change, he said, occurred after he, too, arrived in South Africa, his first trip out of Brazil, in what he saw as an adventure that would allow him to see lions, giraffes and elephants.

Instead, after 10 hours of flying last August, Mr. da Silva found himself in Durban, a resort city of 1.4 million on the Indian Ocean, where he was shuttled to a safe house. Later, at St. Augustine's Hospital, he met the American woman and learned of her long ordeal.

"It's hard for me to imagine how a person might feel when a relative is about to die, so I don't blame anybody for trying anything to get a new kidney," Mr. da Silva said.

He said he also made friends with hospital orderlies and a nurse called Mama Tchuka. Mr. da Silva said hospital employees joked openly about the illegal nature of the transplants and the fact that he and the woman receiving his kidney were of different ethnic backgrounds and could not even speak each other's language.

"It was only when I got to South Africa and was told to sign a document saying that the recipient of my kidney was my cousin that I realized that something was wrong," Mr. da Silva said. "But by then it was too late to turn back."

In interviews, Mr. da Silva and several other of the Brazilian men who donated organs said they were treated well in South Africa. But investigators say the donors did not get the same quality of care as the Israelis who received their organs.

The Israelis, for example, like the American woman, were lodged in beachfront hotels before the operation and, afterward, kept under intense observation and given detailed records to be handed over to their doctors back home. The donors, by contrast, were monitored "for a maximum of three days," Mr. Wessels, the South African investigator, said. Some of that time, they were not even in the hospital, but at the safe house the syndicate rented.

"Then they were put on a plane without much further ado," he said.

Based on a detailed study of confiscated records, South African authorities say the kidney transfer between Mr. da Silva and the Brooklyn woman was one of more than 100 suspect transplants performed in less than two years at St. Augustine's.

Today, the director of the kidney transplant unit there, Lindy Dickson, and another employee, Melanie Azor, are among seven people arrested and charged with acting on behalf of the illegal organ ring. Government officials say more indictments are on the way. "Not all the invitation cards have been sent out yet," Barent Groen, the chief government prosecutor in the case, said in an interview in Durban.

Also arrested was Shushan Meir, an Israeli-born South African who authorities said acted as a middleman for Mr. Peri, the Israeli broker.

"He visited transplant clinics in Durban, Johannesburg and Cape Town," Mr. Wessels said of Mr. Peri, "and correspondence shows that he was in touch with the doctors and the transplant clinic staff here. The impression I get is that he was making sure his investment was running smoothly."

At a court hearing, Mr. Meir said that beyond the 100 or so transplants done in Durban, he had organized "probably about 35" more in Johannesburg. But South African investigators estimate that the actual number is probably closer to 200, divided among hospitals in Johannesburg and Cape Town.

All the hospitals under investigation belong to the same private health care chain, Netcare, which on its Web site boasts of "aiming to uphold South Africa's reputation as `the transplant capital of the world.' " Since the mid-1990's, the company has been buying up facilities like St. Augustine's, originally a Catholic missionary hospital, and demanding a strong bottom-line performance.

Netcare's chief executive officer, Michael Sacks, declined a request for an interview. Through a press spokeswoman, Martina Nicholson, Netcare has denied conscious involvement in any wrongdoing.

"We do not know of anything untoward having taken place at all," Ms. Nicholson said. "We still firmly believe that there has been no transgression at any of our hospitals or by any of our staff members."

With operatives of Mr. Peri's syndicate now jailed in Brazil and South Africa, and Mr. Peri under pressure in Israel, his ring has apparently been smashed. But the transplant waiting list in Israel continues to grow, and recent reports from kidney specialists say Israeli organ brokers have appeared in China, among other places.

"This is obviously a well-oiled syndicate that knows how to move from one country to another,' R. W. Green-Thompson, superintendent general of the KwaZulu-Natal provincial department of health, said in an interview in Durban. "I'm sure that this problem will pop up again in another country soon. The only question is which one."

Unexpected Consequences

These days, Mr. da Silva works 44 hours a week as a security guard, but still earns less than $175 a month, money that is the sole support for the 10 other people he lives with. Even that income was jeopardized when he and other kidney donors were arrested and briefly jailed early this year on suspicion of violating Brazilian laws against trading in human organs. He and more than a score of other donors still faced criminal charges here.

In the 18 months that ended last November, when the authorities shut down the ring, so many residents from the slums of Recife had volunteered that the middlemen had begun offering just $3,000 for a healthy kidney.

All told, the police in Brazil estimate that about 100 men, nearly all poor or unemployed, ages 20 to 40, agreed to sell kidneys. Though some would eventually be rejected for having an unusual blood type, frail health or signs of drug use, more than 60 men are believed to have gone to South Africa.

Recife and its slums had become so lucrative a source for organs, in fact, that Brazilian investigators believe that by late 2003, Israeli brokers, in an effort to swell their earnings further, were considering moving their operations to hospitals here and in other nearby cities.

With poverty offering up an unquenchable pool of volunteers, the local authorities say the ring had also begun inquiring about buying other vital organs from poor residents, including lungs, livers and corneas.

"Even after all of this fuss, I'd do it again," said Orley de Santana, a 26-year-old laborer, who went to South Africa but was unable to sell his kidney for $6,000 before the police broke up the ring. "In order not to have to steal or kill, I thought it better to sell my kidney."

Among the men who did give up a kidney, some say they have experienced health problems that no one warned them about.

"For me, the complications began almost immediately," said José Carlos da Conceicao da Silva, 24, a day laborer who hauls produce. He said he required a second operation in South Africa on a lung three days after his kidney was removed. Since returning to Brazil his health has worsened, he said.

"I'm tired all the time and can't lift heavy weights, which I have to be able to do if people are going to hire me," he said. "My blood pressure goes up and down, and I feel pain and numbness where the scar from the operation is."

Worse still, after his flight back to Brazil, Mr. da Silva, who is not related to Alberty da Silva, said he was robbed of nearly all of the $6,000 he was paid for his kidney when he went to São Paulo during a layover on his flight home. "I begged and pleaded for them not to take the money, telling them that I had sold my kidney abroad and showing them the scar," he recalled, near tears.

Another donor, Rogerio Bezerra da Silva, not related to the others, also lost his kidney and his cash, which South African authorities confiscated after the ring was exposed late last year, and is now the object of mockery in his slum neighborhood.

On occasion, Alberty da Silva says, he shows pictures of his trip to South Africa to the neighborhood children. During the interview, he showed them to a reporter, too, including some of him in Durban with the woman who received his kidney. He also displayed a letter she later wrote, thanking him for "the gift of life."

The American woman continues to correspond with him and, though hardly wealthy herself, says she intends to send cash gifts each Christmas and on his birthday.

"They never want you to see the donor," she said of the traffickers. "But I kept insisting that we meet because I know that he is now part of my being. I have a piece of him inside of me, so who wouldn't want that bond?"