The widespread organ trade in Asia

Have you ever thought about selling your kidney? A piece of your liver? For many people in Asia, these difficult questions are a daily reality.

The global demand for organs is growing rapidly, with more than 100,000 people on the U.S. national organ waiting list in 2023, more than 13,000 on the European waiting list in 2023, and thousands more in other countries. The limited supply of legal organs is not meeting this high demand. Although more than 150,000 transplants took place worldwide in 2022, noticeable shortages mean people are still waiting for years. Because the sale of organs is illegal in most parts of the world, a growing black market has emerged to meet the global demand for organs.

Organ trafficking is a huge industry. Including illegal organ transplants, the trade is estimated to generate between US$840 million and US$1.7 billion per year. About 10 percent of all transplants, a total of 12,000 per year, are considered illegal.

Compared to labor or sex trafficking, trafficking in both organs and people for organ removal is particularly difficult to track because of the involvement of professional medical professionals. Organ transplant procedures require a high level of technical knowledge, so traffickers use legitimate medical providers, such as board-certified physicians and hospitals. These medical professionals, who include nephrologists (kidney specialists), anesthesiologists, and transplant surgeons, are rarely convicted for their involvement in illegal organ trafficking.

Nowhere is this elusive black market for organs more prevalent than in Asia. The largest currently active illegal organ market in the world includes India, Nepal, Bangladesh, Pakistan, Sri Lanka and Iran. In addition, China, India, the Philippines and Pakistan were the top destinations for transplant tourism, where people travel abroad to obtain organs. This problem is exacerbated by poor economic conditions and inadequate law enforcement.

Nepal’s “Kidney Valley” and Other Illegal Operations in Vietnam and Indonesia

Organ suppliers primarily come from countries where a large portion of the population lives below the poverty line. These suppliers come from poor economic and educational backgrounds and often see selling their organs as an important way to earn money. One Nepalese organ seller referred to selling his kidney as a “job.” The perceived need for illegal organ donations is exacerbated by the lack of law enforcement and oversight in countries where transplant tourism takes place to prohibit and monitor illegal organ transactions.

In Nepal, poverty has forced people to sell their kidneys to traffickers for decades, who then profit on the black market. The Kavre District in central Nepal is specifically known as the “Kidney Bank of Nepal” or the “Kidney Valley.” For the past 20 years, the villagers of Kavre have been the primary source of kidneys for the entire country, and dozens of men from these villages have traveled to India to sell their kidneys, both willingly and involuntarily—trafficked, coerced, and tricked into undergoing organ removal procedures. Vendors are often paid far less than originally promised; other lies include promises of no medical complications and that the removed kidney will grow back.

The volume of transactions in this area is extremely high. In Jamdi village alone, located in Kavre district, financial need has driven at least one person from every house to sell a kidney. These cases are also underreported. According to the Nepal National Commission for Human Rights, at least 150 people from an undisclosed village in Kavre district have sold their kidneys, although only three cases have been reported. Although reports mention 300 people from Kavre district as victims of kidney trafficking in the past five years, the actual number of victims could be much higher.

Nepal is not the only country experiencing this phenomenon; Vietnam is facing a similar situation. In April 2023, the Vietnamese Ministry of Public Security discovered and disbanded an organ trafficking network in Hanoi, Vietnam. Organ recipients who purchased livers through this network paid approximately US$50,000. Sellers, however, received just under US$20,000. This recent case highlights another tragedy of the illegal organ market: even when individuals voluntarily sell their organs illegally, they rarely receive full payments, with much of the money going to the recruiters.

A similar case was reported in July 2023 in another Southeast Asian country: Indonesia. Police and immigration officials worked with traffickers to send 122 Indonesians to Cambodia, where their kidneys were harvested for sale. An investigation into the scheme arrested 12 people, nine of whom were former organ trafficking victims who became recruiters. The ring had been active since 2019 and had generated about $1.6 billion over the years. Each victim was promised just $9,000 for a kidney.

Catfishing for organs and the surprising presence of social media

To recruit potential organ sellers, recruiters use methods common to other forms of human trafficking. These include false promises of overseas employment, passport withholding, threats, and physical violence. Recruiters may also emphasize the buyer’s desperation as a manipulative mechanism, telling donors that they cannot withdraw their consent once the buyer commits to the transaction.

Organ brokers have also taken advantage of social media, which has increased the illegal organ trade. Recruiters create numerous Facebook pages under the guise of transplant support groups looking for potential organ donors. Hiring their true identities, buyers also pose as family members in urgent need of an organ transplant or as foreigners to make themselves appear more trustworthy, as victims often believe that foreigners will pay more. Outreach via social media also allows brokers to change their identities frequently to avoid being tracked by law enforcement.

Transplant tourism

Illegal organ trafficking also exacerbates international inequality. “Transplant tourism” is a term used to describe typically wealthier individuals who travel abroad to obtain organ transplants from poorer destination countries. The participation of foreigners is motivated by organ shortages in their home countries or severe domestic restrictions on organ transplantation. In addition to fueling illegal and unethical organ transplants, transplant tourism has a negative impact on areas of social justice, poverty reduction, and equality, thereby reinforcing and deepening economic disparities between countries.

Explanations and failed solutions

To address these unethical practices, the World Health Assembly held a summit of over 150 medical professionals, government officials, and social scientists in Istanbul, Turkey from April 30 to May 2, 2008. The meeting culminated in the creation of the Istanbul Declaration on Organ Trafficking and Transplant Tourism. The Declaration, which was updated in 2018, aims to establish international standards, guidelines, and support for organ transplantation, in collaboration with other intergovernmental organizations such as the World Health Organization, the UN, and the Council of Europe.

Although the Declaration still exists, it has not deterred organ trafficking and transplant tourism. Dr. Sanjay Nagral, co-chair of the Declaration of Istanbul Custodian Group, said there is “a lot of money” in organ transplants and that there is a supply of wealthy individuals who need organs and are willing to pay whatever it takes to get them.

Looking ahead: strengthening legal frameworks and raising awareness

In addition to the Istanbul Declaration, countries are trying to take various measures to tackle the illegal organ trade. China, another affected country, has taken a series of legal steps in recent years. In 2014, the government announced a monitoring system to counter and prevent the “private” sale of donor organs. While the new rules, published in December 2023, are strong, analysts worry that the involvement of institutions such as military hospitals in illegal operations could hamper the effectiveness of the rules. Canadian human rights lawyer David Matas described the rules as “a big smokescreen” because there is a lack of information about where the organs come from and what part of the population benefits from them.

Indonesia has also taken measures to combat organ trafficking. In 2009, Indonesia signed the Palermo Convention, also known as the United Nations Convention against Transnational Organized Crime, a 2000 multilateral treaty that covers organized crime related to organ trafficking. In 2015, Indonesia also signed the Association of Southeast Asian Nations Convention against Trafficking in Persons, Especially Women and Children, a regional and legally binding agreement that aims to provide action plans and international obligations to its member states regarding victim protection and prevention of human trafficking. Even with all of these measures, many of which date back decades, Indonesia remains a major player in the illegal organ trade. Several officials are calling for more organized and focused task forces to enforce anti-trafficking laws, rather than relying solely on non-binding international treaties that are largely symbolic.

Other critics have called for information campaigns to raise awareness—both by governments and humanitarian NGOs—of this overlooked but ubiquitous illicit market. Increased awareness would strengthen communication to detect illicit surgeries, create mechanisms to increase transparency between organ donors and recipients, and combat the misconceptions that lead many victims to donate their organs (for example, the misconception that victims will be paid what they were promised).

There are several possible solutions to the crisis of the illegal organ market. A first step would be to establish a better organ distribution system for high-income countries, to ensure equality among organ recipients. More research into regulating donations and waiting lists in a fair and efficient way could alleviate the lack of available organs. This step would directly help to combat organ transplant tourism and divert some of the attention from poorer countries and their ready supply.

At the same time, there can be no quick and hard solution to combating such a debated problem as long as the root causes of donor supply exist. The illicit trade will continue to flourish if the underlying economic and educational conditions that catalyze the market are not addressed.