Brisk Organ Trade Imperils Lives

Brisk Organ Trade Imperils Lives

Wednesday, 04 March 2009

{first of two parts}

Slightly after midnight on March 27, 2008 in Kasiglahan Village, a subdivision in San Jose, Rodriguez, Rizal, 27-year old Elmie Anchiola was trying to sleep on the floor of his tiny, mosquito-infested home when a figure approached him without warning and started stabbing him and his wife.

His wife Elna survived. Anchiola died of his injuries.

Their assailant, Jayson Araiz, who recently arrived from Samar and who had been living with the couple for three weeks, was in town for one reason: to sell one of his kidneys.

Anchiola, an agent who facilitates organ donation in Kasiglahan, was supposed to have helped him. After a failed interview, Araiz was declared unqualified to donate a kidney. Araiz, blinded with rage and desperation, turned on the Anchiolas.

The talk of the town for many months, the Anchiola murder highlighted a trade that has been going on in Kasiglahan and its neighboring villages for years.

Since the resettlement site was set up almost a decade ago, over a hundred residents here—women included—have had their kidneys extracted for quick bucks.

With the influx of many rich transplant patients from abroad who are willing to pay for new body spare parts, a brisk local trade in human organs has evolved that has not only led to one or possibly more heinous crimes, it is also putting the health and lives of many poor Filipinos at risk.

In most cases, the donors were assisted by entrepreneurs like Anchiola, who received commissions for referring them to the hospitals where very sick but well to do patients waited for new organs and a fresh lease in life.
Safe Procedure

Three decades ago, back in 1976, Teresita Marasigan Baesa donated one of her kidneys to her sister. The transplant operation was a success. Both Teresita, now 73, and her sister, now 65, are still alive.

Cases like that of the Marasigan are among the reasons why----whenever donors are available---doctors advice patients suffering from end-stage renal disease to resort to transplant operations.

Recipients in transplant operations---who otherwise would have to undergo regular and costly dialysis procedures---often enjoy a better quality of life after getting a new kidney.

It is generally safe for a living person to donate a kidney, says Benita Padilla, recently elected president of the Philippine Society of Nephrology. “There are many long term studies where donors did well.”

But unlike in Western settings where most living donors agree to give a part of their body to friends and relatives for altruistic reasons, material gratuity----not filial or emotional attachment to the recipient has become the primary reason motivating living individuals to donate organs.
Viral Marketing

Newsbreak talked to over a dozen individuals who “donated” their kidneys in exchange for cash in the towns of Calauag and Gumaca in Quezon Province as well as in Rodriguez (formerly known as Montalban), Rizal. We also talked to health officials and experts who are either involved in organ transplantation processes or have been observing and investigating this trade for years.

Our sources tell of cases of organ trade in different parts of the country----from Pangasinan and Northern Luzon to Davao City in Mindanao.

By various accounts, a vendor stands to earn from P110, 000 to P225, 000 from selling a kidney. What is worrisome is that the practice of selling organs is spreading like wildfire in the country. Like multi-level marketers, former donors often end up recruiting other donors for extra cash.

One can earn P2, 500 for every new donor one recruits, according to “Lito” (name changed upon request, a 23-year old donor from Gumaca, Quezon. A friend who is also an organ donor recruited Lito.

The huge amounts at stake---from P110, 000 to P225, 000 for a kidney is motivating prospective donors to lie about their health records, making the screening of organ donors more difficult and the nephrectomy operation (procedure done to extract a kidney) itself very dangerous for Filipino donors.

Earlier, Newsbreak reported on the case of 50-year old Dominador “Doming” Umandap, a resident of Calauag, Quezon, who died of heart attack months after donating.

Due to lack of access to Umandap's records, specialists are unable to determine with certainty if it was the kidney donation which triggered his heart failure. But what is clear is that, had all the medical requisites been followed, he should never have been allowed to donate at all.

The same Newsbreak report cited findings from a medical mission conducted by the Philippine Society of Nephrologists in Lopez, Quezon, where donors were found to have kidney abnormalities and hypertension.

These were early studies, according to Padilla, but the findings were not promising. It might very well mean that, years after donating, the donors themselves may eventually develop kidney disease.
Stricter Process?

Mike, a 40-year old barangay tanod was with 50 others in the room at the National Kidney and Transplant Insitute (NKTI) when he volunteered to undergo a screening process that will determine if he was qualified to donate a kidney. Most of them were not related to any potential organ beneficiary. Nor were they motivated by altruistic reasons.

Many secretly regarded the exercise as a mere transaction from which they expected to earn thousands of pesos in quick cash.

Mike, a resident of Rodriguez was earning only P1, 500 a month, barely enough to rent a room, let alone pay for food and daily expenses. With little prospects owing to lack of education and his girlfriend two months pregnant at that time with their first child, Mike mustered the courage to ask a neighbor who recently donated his kidneys for tips.

The going rate for selling a kidney, he was told, was P175, 000---enough to buy the rights to a small dwelling which at that time was around P50, 000. To donate, one can go directly to the NKTI, which holds regular seminars for would-be donors After the seminar, one fills out a form and is interviewed. Afterwards, a series of medical tests follow.

Mike attended the seminar back in April 2008. Later, during the interview, he was asked if there is a history of diabetes in his family. He told the interviewer that his grandmother had the disease when she was still alive.

This prompted the interviewer to have his blood sugar tested. “It came out high,” Mike recalled. He was rejected at that point. “Mahigpit sila,”he said, clearly very disappointed.

Mike’s experience might be proof that kidney transplant facilities are tightening up the way they screen organ donors following media reports concerning the increasingly rampant trade in human kidneys all over the country.

But our investigation shows that with so many patients waiting in line, the process of screening donors remain haphazard and suspect. Even reputable establishments in the country willingly cut corners and respected surgeons connive with syndicates acting as middlemen.

Contrary to health department regulations that stipulate that “health and health-related facilities and professionals shall not allow the trade of kidney vendors,” our investigation shows that doctors knew that money was changing hands. In a number of cases, it was the doctor that paid the donor. Interviews with donors who went through brokers also established that the doctors clearly personally knew the brokers.

From interviews with the donors themselves or persons privy to the donations of over a dozen individuals, a pattern emerged.

Donors often learned about the process from neighbors or friends who previously donated. Many went through brokers who were also typically former donors.

The more recent donors, however, went directly to the hospital---some of them ironically encouraged by television reports about the rampant trafficking in human organs.

Coercion is seldom necessary, at least in the initial stage. Widespread poverty in the country has ensured that there is no shortage of people willing to sell a body part for the right price. Oftentimes, it is the donors themselves who approached known brokers after hearing of the amounts that may be earned from the transactions.

But those who went through the brokers told Newsbreak, that after undergoing initial tests, they were required to stay in the quarters provided by the middlemen until the time of the operation.

There is no turning back at this point, Lito a 23-year old organ vendor from Gumaca,Quezon was told. Nobody is allowed to “escape” or change his mind. The reason given was that the brokers had to shoulder the costs of the initial tests and would lose their investment if the donor backs out.

Lito donated his kidney to a Japanese patient at St. Luke’s hospital in 2007.

Since each hospital keeps its own registry of patients waiting for donors, an agent may have to take one donor to different hospitals to find a matching recipient.

A new set of check-ups is done at each of hospitals. If, at any of the check-ups, it is found that the potential donor has an existing ailment that can disqualify him from donating, the broker shoulders the cost of “nursing” the individual back to health so that he will qualify in the future. Those with high-blood pressure may be given the medicines for hypertension.
Lax Screening process

Health regulations also require each facility engaged in kidney transplants to have an ethics committee which shall be “primarily responsible for resolving ethical issues and concerns relating to the act or process of donation.”

But by some accounts, the ethics committees in hospitals often tend to be nothing more than rubber stamps in the screening process.

Oftentimes, they only get to interview the donor a couple of days before the operation, a doctor who sits in the ethics committee of one Mindanao-based transplant facility told Newsbreak.

The source even threatened not to approve the transplant operation if the committee is not given the two-week grace period. “But their alibi is that the patient already needs it (the operation).”

All the ethics committee can do, the source said, is ensure that the doctors understand the process and that they were not coerced and or motivated by a debt of gratitude to the patient.
Hospitals have also been remiss in verifying the validity of medical and personal data given to them by donors. There were no procedures in place to establish true names, ages and addresses of donors.

As a result, attempts to conduct research on the health and other situation of the donors failed because of incomplete donor registries. A study led by Benita Padilla of the Philippine Society for Nephrology, for instance, noted that in some cases, 10 donors would give the same address.

Ages were also not verified properly, according to a hospital source, thus, there is a strong possibility of underage donors slipping through the screening process, according to Amihan Abueva, Regional Coordinator of Asia ACTs, a non-government organization which is involved in fighting trafficking in children.
Inadequate Long-term Care

Many Filipinos forced by poverty to sell their body parts cannot afford the standard of living and medical care needed to maintain one kidney, Newsbreak learned.

Teresita Marasigan attributes having remained healthy and active decades after donating a kidney to the proper medical care she has received all these years. “If you only have one kidney left, you just can’t eat or take anything,”Teresita explained. Oil and salty foods are particularly forbidden. One also cannot simply take over-the-counter medications without consulting a doctor.

The Marasigans are fairly well off. Three years after she donated her kidney, Teresita was able to migrate to the United States where---thanks to her health insurance----she was able to get regular quarterly check-ups.

Aware that she was a kidney donor, Teresita’s doctor monitored all medicines she took to guard against any side effects on her remaining kidney. And now that she is older, Teresita takes maintenance medicine on a daily basis to prevent kidney infections.

As in Teresita’s case, doctors usually advice donors to undergo regular medical check-ups. This is because there is no telling who will develop hypertension or diabetes in the future, Padilla said.

With only one kidney remaining, a donor has to be doubly on guard against such diseases, Roland Tiong Eng, a doctor at the Health Center of Gumaca, Quezon said. “Once you are hypertensive, you have to take care of all your organs because if your organs fail, your hypertension can worsen.”

All of the donors interviewed by Newsbreak in Quezon Province reported that they did not go back to their doctors for follow-up check-ups.

In most cases, the check-ups are free. What the donors cannot afford is the fare to Metro Manila, where most of the transplant centers are. The typical fare by bus from Calauag, Quezon to Cubao, Quezon City is almost P200 for a one way trip that takes over five hours. One still needs additional pocket money for food and in-city transportation going to the hospitals.

Typical of most organ donors, Lito and his family managed to enjoy tasty food only until a few months after he donated his kidney in 2007. But the money is long-gone. Now, his family is back to their usual fare of salty dried fish. “The money only lasted six months.”

“The very reason, you donated is because you are poor. How can you be expected to lead healthy life? Naturally, you can’t afford to eat healthy food,” says Gloria Cabangon, municipal administrator of Gumaca, one of the towns in Quezon Province where Newsbreak found many organ donors. – with research assistance from Anna Bueno

To be continued on Friday, March 6:
Part II - Organ trade continues despite ban on transplantation to foreigners

RELATED DOWNLOADS
• The Philippine Society of Nephrologists’ Presentation on AO 2008-004. The presentation shows rising trends on Filipinos needing kidney transplants, rising number of living non-related donors, and rising number of foreign organ recipients. It also presents problems and lapses of implementation in the previous AOs.
• Islas Isang Bato. The Philippines: Fifth Organ Trafficking Hotspot! A presentation by NGO Asia ACTS which gives the background, cites case studies, and analyzes how organ trafficking happens in the Philippines.
• Kidney Donation, from Redcop. Discusses the basics of organ donation and transplantation—definitions, kinds of donors, and FAQs.

This article was made possible with the generous support of the American people through the United States Department of State Office to Monitor and Combat trafficking in Persons and The Asia Foundation. The contents are the responsibility of the author(s) and do not necessarily reflect the views of Department of State of the United States or The Asia Foundation.

http://newsbreak.com.ph/index.php?option=com_content&task=view&id=5890&Itemid=88889458
............................... Part II follows .................

Organ trade continues despite ban on transplantation to foreigners

Written by Gemma Bagayaua
Friday, 06 March 2009

(second of two parts)

In recent years, transplant centers and establishments came under fire for their alleged involvement or complicity with middlemen in organ trafficking.

In early 2008, the health department’s Bureau of Health Facilities and Services (BHFS) issued cease and desist orders (CDOs) against the Capitol Medical Center and the Victor Potenciano Medical Center for violating the rule requiring hospitals to limit the number of foreign transplantees to only 10 percent of total kidney transplants they conduct for the year.

But beyond examining compliance to the 10 percent rule, Newsbreak has learned that the health department’s Bureau of Health Facilities and Services (BHFS) has no capability of its own to check if hospitals really comply with donor screening guidelines. It can only rely on professional organizations such as the Philippine Society for Nephrologists, the Philippine Society for Transplant Surgeons.

The two hospitals later submitted letters explaining why they exceeded the quota. After the ban, the CDOs against the two hospitals were subsequently lifted.

Beyond this, practically none of the transplant facilities or the surgeons was ever sanctioned for violating health guidelines.

Critics accused transplant institutions of facilitating a “repugnant” trade that preys on the vulnerabilities of the poor. They also accused health authorities of allowing wealthy individuals, health insurance companies and the governments of a number of rich countries to exploit the poor by dangling sums of cash they would not ordinarily see in their lifetime in exchange for their organs.

In 2008, the controversy prompted the President to order a ban in the transplantation of kidneys from Filipino non-related donors to foreigners. The ban was prompted by critics’ allegations attributing the boom in organ trading to the increasing numbers of foreigners coming into the country for organ transplants.

The criticism appears to have been valid.

Data from the Renal Disease Control Program (REDCOP), which is mandated by law to collect information on kidney transplant operations in the country, shows that only three of the 536 foreigners who visited the country in 2007 to get kidney transplant operations done sourced their new organs from blood relatives.

Two foreigners received kidneys from cadaver donors while the rest (531) benefited from living non-related donors (LNRDs).

The expertise of local surgeons was clearly not the only reason why the foreigners chose to get their transplant done in the Philippines. The more compelling reason appeared to have been the availability of kidney donors.

From 124 in 1996, the number of organ transplant operations in the country ballooned to 1046 in 2007.

Redcop only started collecting data concerning the ethnicity of transplant patients in 2006. But data available already indicates that the increase was indeed fueled, to a significant extent, by the influx of foreign transplant patients.

In 2006, 41.4 percent (286 of 690) of transplantation operations were done on foreign patients. The following year, the number of foreign patients in transplant operations outstripped the number of local transplant patients. 536 or 51.2 percent of 1046 recorded transplantations that year were done on foreign patients.

Kidneys used in 844 transplant operations undertaken by Philippine hospitals that year came from living donors who were not related by blood to their beneficiaries. Of this number, almost 63 percent (531 kidneys) went to foreign patients.
Lucrative business

The boom was partly attributed to the amounts desperate foreigners were willing to pay to get a transplant done.

Kidney transplant procedure costs average from $25,000 to $150,000, depending on the extent of kidney disease and whether the patient has a deceased or living donor transplant, according to the website of Emory Healthcare, the clinical arm of the Robert W. Woodruff Health Sciences Center of Emory University in Georgia, USA.

In the Philippines, medical community insiders say transplant surgeons typically charge each foreign patient around US$60,000 for the operation. Hope Foundation’s Manauis confirmed this during the Newsbreak interview.

The amount may seem like a big sum. But the benefits are huge. Kidney patients stand to enjoy a better quality of life post operation.

It is also a better and cheaper alternative to expensive dialysis—something patients suffering from end stage renal disease have to go through on a regular basis. The cost of kidney dialysis in the US averages about $44,000 per year per patient, using 1993 figures, according to a press statement of the University of Maryland Medical Center (UMMC).

Separate studies conducted by the UMMC and the Washington University School of Medicine in St. Louis both indicate that the "break even" cost of kidney transplants is shrinking. The Washington University School of Medicine study went so far as to state that, given reduced transplantation and post transplantation costs, society could pay each donor $90,000 and easily break even.

Better technology played a part. Oral anti-rejection medications are not only better now—they may also be taken by patients in the comfort of home, thus reducing the cost of hospitalization.

But the increased use of living donor kidneys also helped reduce costs. Kidneys from live donors tend to function better and sooner after transplant than those from cadaver donors, which often take days to function thus requiring the patient to still undergo dialysis post-operation.

And health insurance companies burdened by the cost of sustaining patients with kidney ailments through regular expensive dialysis are reportedly willing to foot the bill.

Health insurance coverage for kidney patients from the United Arab Emirates who were sent to the Philippines for a transplant, for example, can go as high as $95,000, according to Amihan Abueva, Regional Coordinator of Asia ACTs, a non-government organization which is involved in fighting trafficking in children. Of this amount, $10,000 goes to expenses for securing a donor.

It comes as no surprise then that Redcop data also shows that the number of transplant facilities also swelled from 14 in 2002 to 23 in 2007. All the new transplant facilities were privately owned.

Kidney transplantation is clearly a lucrative business and the ban on foreigners coming into the country for organ transplants has not changed this.

Some hospitals provided incomplete registries of transplants, which did not coincide with the operating room and anesthesiologist’s records, thus understating the total number of transplants involving foreigner recipients.
Inadequate Law

Gaps in existing law also played a role. Unlike in other countries, no law explicitly prohibits the sale of human organs from live donors in the Philippines.

To begin with, the Organ Donation Act of 1991 covers only brain dead donors and does not include acceptance and management of living donors.

The law against human trafficking (R.A. 9208) states the definition of human trafficking as “recruitment, transport, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation by the removal of organs, tissues or cells for transplantation.”

But while conceding that the rampant trade in human organs is indeed “morally repugnant,” Roland Argabioso, Chief of the Field Operations Division of the National Bureau of Investigation (NBI) said the way organ trafficking was defined in the law meant that the mere sale of organs is not enough for an activity to be considered a violation of the human trafficking law.

Other elements of the crime have to be present as well. These are: force, fraud, deceit, and coercion/intimidation. Given these conditionalities, it is not easy to file charges if it is shown that a person willingly donated his organ as is the case among most of the donors that Newsbreak interviewed.

This meant that, the NBI cannot on its own investigate such cases when there are no complainants.

The NBI was able to initiate operations and file charges against Rico Jusay, an organ broker, and his cohorts in Batangas because the “donors” complained that they were originally promised P300,000 for their kidneys only to be paid P100,000 after the operation. “They complained that they were deceived by the middle men.”

It also makes it difficult for the NBI to go after doctors and hospitals that are flagrantly violating the rules set by the DOH. The only way they can be punished at this point is if their license to operate is revoked by the BHFS.
Reforms Underway

By some accounts, things are much better now than when the whole program started.

Hospitals now require would be donors to submit identification papers such as birth certificates, donors interviewed by Newsbreak reported. In the past, all that was required were the laboratory tests.

The screening of potential donors has also become stricter. Of every 100 applicants, only 18 percent are accepted into the NKTI’s organ donation program, according to Nissan Manauis, a nurse working at the Human Organ Preservation Effort (HOPE).

HOPE, a foundation attached to the NKTI, screens would-be donors and determines who, in the long list of patients waiting for new kidneys, will have the new organs.

Doming, a resident of Rodriguez, Rizal who donated a kidney in 2006, says the more recent donors are enjoying more benefits than they did. “They have insurance now. We did not have that before.”

Last Christmas, some of the recent donors reported receiving cash gifts from a hospital where they donated.

Interviews of donors prior to donations are also a recent phenomenon, Doming recalled. “We did not have that before. We also did not pass through foundations.”

At the NKTI, Hope has partnered with the Kidney Foundation of the Philippines (KFP) to ensure that the health of donors is monitored years after donating. This is unlike before when the focus of the medical establishment has been on the recipients, Manauis said.

The health department has not been idle on the matter. Prior to issuing the order banning the transplantation of organs from Filipino living non-related donors to foreigners, the department also issued an order that supposedly seeks to revamp the way the donors are screened in hospitals in order to guard against “backdoor operations” that “defy ethical and medical standards in transplantation.”

The new guidelines provided for the creation of the Philippine Network for Organ Donation and Transplantation (PhilNetDaT), which shall be the implementing body of the organ donation and transplantation system of the country.
Stumbling Block

Among the functions of the PhilNetDaT is to monitor the compliance of transplant facilities to policies set forth by law.

A component of the PhilNetDaT will be the National Human Organ Preservation Effort (NHOPE) which, acting as the central clearing house for organ donations. NHOPE is supposed to keep three registries with data coming from different transplant facilities:

* registry of all kidney transplants performed in the country;
* registry of all placed LNRDs and those waiting to be placed; and
* registry of all patients seeking kidney transplantation.

Prior to this, hospitals only reported kidney transplants performed. Each hospital kept its own record of would be donors and patients.

To this date, however, the implementation of this new policy remains pending as the health department continues to dialogue with stakeholders on the implementing guidelines.

Sources privy to the issue said a primary stumbling block is the fear among private hospitals that Hope Foundation, which shall form the core of the proposed NHOPE, might be biased in favor of its parent institution, the NKTI.

“They are afraid that if they give their donors to Hope, then Hope will give those donors to the NKTI,” one source privy to discussions over the guidelines said.

Ernie de Vera of the Degenerative Disease Office of the DOH admits, “We are still in the infancy stage.” We are just in the process of setting up the mechanisms to improve the process.” De Vera’s office manages the Philippine Organ Donation Program.

De Vera said the health department is still addressing concerns raised by hospital owners concerning HOPE. Among the proposals is to move HOPE under the health department.

He pointed out however that the reason why HOPE was chosen to perform said tasks, despite its ties with NKTI, is the fact that it has already developed some expertise in the area. Moreover, he noted that the NKTI is a DOH specialty hospital, and should not be seen as competition.
The Trade Continues

While these issues remain pending, reports of organ trading continue, albeit, underground. De Vera confirmed receiving feedback that some hospitals are still conducting transplant operations on foreign patients using kidneys from local non-related donors. One particular case, he said, has already been referred to the National Ethics Committee.

In Kasiglahan Village, Rodriguez, Rizal, one resident became the talk of the neighborhood after he purchased a utility vehicle. Neighbors eventually learned that the man donated a kidney sometime in September 2008—months after the ban on foreigners.

The recipient, this time around, was a Filipino, Vilma, an officer of the local homeowners’ association said. “They don’t allow foreigners anymore,” she explained.

Asked if the man was compensated for the donation, Vilma responded, “of course he was.” Nobody in these parts, she said, would donate a kidney without getting paid. “Actually, I heard that the payment has increased already. They say it is now P225,000.”

RELATED DOWNLOADS
• Administrative Order 41 (2003) - Philippine Organ Donation Program under the Department of Health
• Administrative Order 81 (2003) - Rules and Regulations Governing Accreditation of Hospitals Engaged in the Conduct of Kidney Transplantation
• Administrative Order 124 (2002) - National Policy on Kidney Transplantation From Living Non Related Donors (LNRDs)
• Administrative Order 4 (2008) - Revised National Policy on Living Non Related Organ Donation and Transplantation and its Implementing Structures
• Administrative Order 4-A (2008) - Amendment to AO 4 on Revised National Policy on Living Non Related Organ Donation and Transplantation and its Implementing Structures
• Republic Act 7170 - Organ Donation Act of 1991
• Amendment to RA 7170

This article was made possible with the generous support of the American people through the United States Department of State Office to Monitor and Combat trafficking in Persons and The Asia Foundation. The contents are the responsibility of the author(s) and do not necessarily reflect the views of Department of State of the United States or The Asia Foundation.

http://newsbreak.com.ph/index.php?option=com_content&task=view&id=5900&Itemid=88889458