Desperate Arrangements

Desperate Arrangements

Richard C. Morais 01.29.07
Forbes.com

The demand for transplants can't be met by altruistic organ banks, so Internet brokers are stepping into the breach. It's not a pretty picture.

From his modest ranch home in the hills of Sun Valley, Calif., filled with didgeridoos picked up in Australia and German shepherd puppies, James Cohan, 66, sells organ transplant brokering services to the desperate. His customers face certain death if their diseased organs aren't quickly swapped out. They find him on the Internet; his stated fee--$140,000 for a kidney and $290,000 for a heart, liver or lung--includes hospital and surgeon charges, and flights and accommodation for a fellow traveler, such as a nurse or spouse.

Cohan's sales pitch: The quality of the organ is more important than the choice of the doctor performing the transplant, and I know how to get you a fresh organ--quickly--if you've got the money. "If you keep putting a broken engine into your car, you're going to keep on having the same problem, no matter how good the mechanic is," he says.

Cohan spent several months in an Italian jail in the late 1990s on ultimately unsubstantiated allegations that he was buying and selling organs. What he is doing, he says, is entirely legal; he does not buy or sell organs but merely brings clients to hospitals that are equipped to provide them. He claims that his customers come in at the rate of one a week from all over the world, and he finds them new "engines" in a network of 15 or so transplant hospitals he has cultivated in China, India, the Philippines, South Africa, Singapore, Pakistan and South America.

Does "transplant coordinator" Cohan have dozens of satisfied clients? Where do they live? How long have they survived their operations? He doesn't answer question like these clearly; transparency is not a feature of the international organ trade. But this much is clear: There are a lot of people doing, or trying to do, what Cohan says he does. These underground travel agents use the World Wide Web to act as middlemen between deathly ill patients in wealthy countries and hospitals in developing countries where ethical scruples about organ sources don't rise to Western levels.

According to a recent hearing in Taiwan's parliament, 450 of Taiwan's 787 transplant recipients in 2005 had their operations performed in China. The World Health Organization in Geneva estimates that 10% of the 61,000 kidney transplants performed globally in 2004 were cases of transplant tourism. Pakistan is a global hub for live kidney purchases; Aadil Hospital in Lahore offers transplant patient testimonials from Italy, Norway, Britain, Bulgaria, Uzbekistan, Sudan and Yemen. Says Dr. Luc Noel, head of the transplant unit at WHO: "Organ transplant tourism has clearly blossomed in the last five years."

In September 2005 a small tumor showed up on the liver of Kevin Scott, already suffering from hepatitis C and cirrhosis. His VA hospital took 11 months to conclude all the required transplant criteria tests, he says, and by that time the tumor had grown to 2.5 inches. "No longer has any traditional options available for survival," the medical authorities wrote in his file in August 2006. "Not a candidate for liver transplant." So Scott, 49, was on the the official liver wait list only a week before he was cut and directed to a hospice to die. But Scott and his family are fighters, and they immediately began researching transplant options in India, Germany and Mexico, before narrowing it down to China.

Yeson Healthcare Services Network, a firm in Taiwan run by one Tung-Chieh (Tony) Lee, offered the Scott family two options: a liver transplant at the Shanghai International Transplant Center for $120,000 or an $80,000 version at a no-frills provincial hospital in Nanjing. The Yeson packages include the transplant surgery; translation services; all drugs and hospital care; and up to 40 days of post-op treatment. Despite the difficulty finding an O-positive donor, "we try and control the waiting time to be within two to four weeks after arrive to our center," Lee wrote in October during e-mail exchanges with the Scott family.

The Scotts didn't have the money for Yeson's packages, so they got quotes from rival brokers. Tx-Bridge, situated in Beijing and Shanghai, bid $60,000 to $70,000 for the Scott business and even threw in a two-to-three- day "cultural experience" with its transplant packages at Wuhan and Nanjing hospitals. But when a Scott family member had the temerity to ask precisely which hospitals were involved, Tx-Bridge's Lily Huang wrote back, "Sorry, but I think your following question is wrong. Tx-Bridge center is saving life and only provides the best High Quality service package to patient. Please kindly understand that our further talking needs to be based on this."

The Scott family stopped writing to Huang and quickly got a glimpse of how the underground network of Internet transplant brokers really works. According to an organizational chart FORBES found, Shanghai's Tx-Bridge is affiliated with Alberta's Overseas Medical Services Canada, which, in turn, is represented by a retired U.S. Navy maintenance officer in Florida, Dan Adcock. "Be aware that this case has progressed as far as it can through our Chinese counterparts and from this point onward I must make all arrangements and therefore must have all communications and information," the take-charge Adcock wrote the family.

FORBES has seen transplant quotes from Internet brokers that suggest they are offering their services at markups of between 60% and 400% over costs. The resourceful Scott family ultimately used the Internet to bypass the brokers and cut a deal directly with the First Affiliated Hospital at the College of Medicine of the Zhejiang University in Hangzhou. They had to pay only an initial $2,500 for tests once they were in China, and the final bill, depending on complications, would be between $60,000 and $70,000, paid as the bills came in. According to one family member, having raided their pension funds, raised donations at their church and hosted a Web site (newliver forkevin.blogspot.com) urging members of the public to mail in $1 for Kevin's $70,000 transplant, "we simply had to find another approach" to the "prohibitive" brokerage fees.

So Kevin and family flew to the Hangzhou hospital in November, but this decent man was not entirely sure he had made the right decision. "I had a bad episode last night. I have an important friend back home, and I wish she was here," he told FORBES.

Looking to Christmas, Kevin bought little presents for Chinese patients on the ward and had his mate, Sherry, bring him a Santa Claus outfit from the U.S. for the festive day. But soon Kevin's mother, Connie Carpenter, was e-mailing loved ones, "How do I begin to write the most difficult letter of my life?" Kevin was in a coma and on life support in his hospital room. A liver that arrived at the last moment, much to the family's elation, turned out to be hiv-positive. The family had by then discovered the legal difficulties of repatriating Kevin's remains, should the worst happen, and they began battling Chinese and U.S. bureaucracies. On Dec. 22 Kevin died, Sherry and Mom at his side. The two grief-stricken women donned the Santa outfit on Christmas day and handed out the presents, fulfilling Kevin's last wish, before finally bringing him home.

There are no easy answers in this troubled corner of medicine--just heartache. Governments across the globe have almost universally outlawed the commercial trade in organs. The core principle of America's 1984 National Organ Transplant Act and the legislation of other nations: no meat markets. It's inhumane and exploitative, the authorities reason, for the rich to buy organs harvested from the poor or the imprisoned. So organ trade is mostly illegal and underground, greased along by daisy chains of brokers. By the time Nepalese authorities caught up with Hari Narayan Lam in 2003, this organ broker had convinced 50 dirt-poor Nepalese to part with a kidney. He sold their organs for $2,000 to $3,500 for transplants performed in India, and it's likely he kept the bulk of the profits. Organ sellers can get as little as $800 for their sacrifice.

"If you set a price for components of the human body, then it inevitably leads to extremes, where respect for human rights is destroyed," says Dr. Noel. "None of the brokers ever mention the costs--long-term health issues, chronic pain, inability to perform manual labor--that are borne by these poor organ vendors. And once you make organs a commercial commodity, you could conceivably go down the path where you say, 'Kill a young person and you could extend your life by 20 years.'"

Iran is the only state in the world today that operates, controversially, a legal, commercial market in organs and then only for the benefit of its citizens. This might be changing: Saudi Arabia passed a law in October that allows up to $13,000 to change hands between unrelated donors and organ recipients. China, meanwhile, has been attracting large numbers of transplant tourists like Kevin Scott by using its massive prison population as a ready organ bank. (Click here for more.)

Most nations have instead adopted highly regulated donation systems like the United Network of Organ Sharing in the U.S. UNOS monitors each kidney, lung, heart or liver available from a deceased donor going to a patient on a wait list. The problem: The wait list for organs in the U.S. has doubled in the last decade, to 94,000. People on the wait list die (or, like Scott, get forced off, for various reasons) at the rate of 12,000 a year. The lucky recipients of a kidney, say, have been waiting, on average, 3.2 years (latest figure, from 2001). The wait time for a kidney in western Europe is also three years, notes the Council of Europe, but it is expected to rise to ten years by 2010.

The reason for the shortfall: A decline in supply occasioned by the long-term fall in the car accident death rate has coincided with a growth in demand occasioned by aging demographics and breakthroughs in medicine. Better antirejection drugs and surgery techniques make more patients good candidates for transplants. "There's no question that transplants not only improve the quality of life, they also improve the quantity of life," says Dr. Brian Pereira, former president of the U.S.' National Kidney Foundation.

If state-run organ banks can't deliver enough organs, then the terminally ill will take risks and, if necessary, break laws to stay alive, even for just a few more months.

It's a Faustian bargain tailor-made for the Internet age. In 2003 a police sting at South Africa's St. Augustine's Hospital busted a global ring: Slum-dwellers from Brazil and Moldova were selling their organs to an Israeli-led broker network, which then used the Internet to pull together over 100 willing kidney transplant patients from Israel, Europe and the U.S. Donors and recipients, posing as relatives, were flown to South Africa and operated on by elite doctors in Durban. By 2004 dozens of the schemes' participants--doctors, insurance agents, medical technicians, Internet brokers and nephrologists--were arrested and charged. Some players are today serving ten-year prison sentences; others are still on trial.

Nancy Scheper-Hughes, a medical anthropologist and founding director of Organs Watch, a UC, Berkeley-based research project, played a role in this case and noticed that the Israeli broker and his Brazilian partner set up shop in Recife's barrio, initially offering to buy kidneys at $10,000. As willing sellers rushed in, however, prices fell steadily, so in the end they paid the desperate slum dwellers only $3,000 for their vital organ. According to Organs Watch, a live-donor kidney typically trades hands for $1,500 in the Philippines, $2,700 in Moldova and Romania, $7,500 in Turkey, $10,000 in Peru and $30,000 in the U.S.

Such price differentials are arbitraged by Internet brokers, and, like all modern markets, it's a fast-shifting business. Turkey, India and Iraq were the big centers for underground organ transplants until public outrage--or war--curtailed the business. So the hot action shifted to Pakistan, Brazil, Colombia, Montenegro, the Philippines, South Africa and China.

The Shanghai-based New Life Global Medical Service Ltd. is typical. It distances itself from illegal activities by offering to "coordinate" kidney, liver and lung transplants. But its Web site still manages to convey what is going on behind the scenes: "If you are simply seeking political correctness or media value, please look no further. Our service do not involve organ donation. We do not have detail regarding source of organs."

Israel's medical authorities recently tightened the guidelines on funding overseas transplants: State medical insurance will now reimburse overseas transplants only if donor and recipient swear, and the hospital confirms, the transplant was done for altruistic reasons. But if the patient can get by without insurance that rule doesn't mean anything. Ventex Management Medical Services Ltd., a firm with an Israel-based Web address, has "specialized in sending Israeli citizens for transplants in Medellin, Colombia." Its Web site is partly in Hebrew, partly in English and includes grainy head shots of the two Colombian doctors in Medellin who will be performing the transplant services. When FORBES contacted Ventex, asking if it would work with U.S. patients, broker "Oliver" (first names only, please) wrote back that Ventex was set up for Israelis only but urged us to contact a U.S. broker called Glohus Inc.

Incorporated in 2004 in Pennsylvania by an attorney outside Pittsburgh, this Internet broker is impossible to locate. Its current Web site gives no information, but its archived Web pages provide addresses and telephone/fax numbers in New York and Pittsburgh, all untraceable dead ends. The company and the attorney declined to talk with us, but FORBES has seen evidence Glohus is still actively matching transplant patients with overseas hospitals.

Early in 2006 Eric De Leon, of San Mateo, Calif., was stricken from the UNOS list because of cancer. Eric and his wife, Lori, turned to Liver4you.org in Manila. The cost of a Philippine liver transplant, says the broker's Web site, is around $100,000.

Liver4you's Dr. Mitch Michaelson and Alberto Gomez said, in their correspondence with Lori, that "we have a surplus of cadaver livers" and that they could "arrange a live partial liver transplant within less than a month, with our donor or yours." But first they needed $60,000 wired to their New York bank account. "How do I know this will be a sure thing and not a $60,000 lesson?" Lori shot back.

Dr. Michaelson then proposed that the De Leons fly to Manila, where he personally would take them to meet the first of several candidates for the job of transplant surgeon. "But do not tell him that you have three more transplant surgeons to meet," Michaelson instructed in his e-mail. "After the meeting you can tell him you and Eric will sleep on it and call him for the next visit. After meeting this transplant surgeon you can give me the $60,000, then we can get the appointments with the other surgeons." The De Leons didn't like the sound of this and passed.

Eric refinanced his house and in the end paid Yeson Healthcare--the same broker that the Scott family passed on--$110,000 for a liver transplant. Eric arrived in China in March and two weeks later Shanghai surgeons were removing his diseased liver in a five-hour operation, replacing it with a liver taken from what he was told was a 19-year-old executed drug smuggler. The antirejection drugs made Eric a little paranoid, but he recovered nicely on hospital dinners of "stewed shredded eel," and the elated couple returned home in April. Alas, in late August Eric's U.S. doctors found, as predicted, a tumor on his new liver. He is self-publishing his story. "I would have to do it again," Eric says. "I had no other choice."

This underground business, involving as it does hungry sellers and desperate buyers, is a fecund breeding ground for scoundrels and scam artists, despite the high-minded claims of saving lives. "The brokers are only motivated by greediness," says Noel. Fee-fronting appears to be a common way less reputable brokers help the desperately ill part with their money.

Consider Jim Cohan, the Internet broker in Sun Valley. Cohan couldn't produce a single satisfied customer for FORBES, and we were unable to prove or disprove his many claims. But we note the wily Californian requires customers to front a $1,000 "application fee" and then, once accepted, another $10,000 payment to get the search started. Cohan told us he does what he does for the sake of humanity. "We are all one family," he says in a choked voice, his eyes suddenly tear-filled.

Perhaps. The contract De Leon signed with Yeson, however, did not require the fronting of fees and primly provided for a sliding-scale refund, depending on the length of the hospital stay, if the surgery was unsuccessful. Only once Eric was in China did he pay an initial $10,000, the funds wired to Citibank, Shanghai, in the name of the broker, Tung-Chieh Lee.

After the FBI raided Cohan's office in 1998 on behalf of Italian authorities, the investigating officer stated in an affidavit that the agency suspected Cohan was defrauding the public with false claims he could broker organ transplants. There was no evidence he had arranged a transplant, the investigators said. "[The allegations] were untrue," Cohan says today. "And they never gave me a chance to respond."

Nor, it must be noted, did the U.S. authorities subsequently charge Cohan with fraud or any other illegality--they couldn't find a victim.

URL: http://www.forbes.com/free_forbes/2007/0129/072_2.html
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