Death of a Financier

by John Francis Kinsella

  Amongst the crowd were the Rymans and the Parkins, sitting on their suitcases, wearily waiting in a seemingly static line to undergo the security and check-in procedures for their respective flights to Gatwick and Birmingham.

  More buses arrived at the airport, as officials in Kovalam pressed to complete the operation before night fall hurried the buses away without taking into consideration the pile up of waiting passengers at the airport.

  Delays in the departure from Kovalam had been aggravated by the general confusion with many people mistakenly or deliberately climbing into the wrong bus or any bus in their panic. Throughout the afternoon long lines of tired tourists wound their way around the carpark under the hot sun. People were hungry and thirsty, their water bottles trodden into the mud in the carpark or drunk during the long wait for the buses. A few enterprising hawkers were selling water at three and more times the going price, refusing to give change for large notes and refusing foreign currency.

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  Ajay was prepared for surgery prior to being moved to the operating theatre. First was an enema to clean out his intestines and prevent bowel problems after surgery, then his bodily hair was shaved off and he was given a sedative to sleep.

  Once in the theatre, an intravenous needle was inserted in his forearm for fluids and medications and he was ready for the transplant operation to commence. A nephrectomy was carried out on the donor in an adjacent operating room and the living kidney was quickly carried to Ajay's surgeon for grafting. It was placed in the lower abdomen where the renal artery and veins were connected and the urethra was linked directly to the bladder. His existing kidneys were untouched.

  The operation was completed in three hours without complication and Ajay was transported to the intensive care unit. The anonymous donor, after immediate post operatory care, was transferred to a secondary clinic in Kochi, not far from the slum area where he lived.

  The city's slums suffered from the same predicament as all Indian cities: poor sanitation, a lack of drinking water, industrial pollution, high unemployment and one of highest rates of crime in India.

  One of the problems was that organ transplantation had become associated with business and not healing, which meant that the health of donors - after donating a kidney - was a question of secondary concern to hospitals and clinics as there was no profit to be made.

  The length of time spent in the intensive care unit varied according to the patient and in Ajay's case he was soon sent to a special unit in the clinic that cared for post transplant patients, where his condition was closely monitored.

  The main danger faced by transplanted patients was rejection, a normal reaction by the body to the introduction of something foreign, which the body saw as a threat and the immune system developed antibodies to fight it. This reaction was countered by the use of immuno-suppressant drugs such as cyclosporine, which helped to prevent the rejection process.

  Before Ajay left the clinic he was provided with all the necessary information related to medication, post operational follow-up and diet. Living with a transplant was a life long process and the risks were important with many patients experiencing acute rejection within the first three months after the transplant, though after one year the risk fell considerably, providing anti-rejection drugs were regularly taken.

  During Ajay's hospitalization another drama was being enacted in New Delhi where the police had arrested a notorious kidney racketeer dubbed 'Doctor Horror' by the press. He had been tracked down by the Indian Central Bureau of Investigation and arrested in Nepal, where he had been in hiding in a wildlife resort with more than two hundred thousand dollars in cash in his possession.

  The authorities revealed that the doctor and his assistants had performed more than six hundred kidney transplants in recent times. What was shocking was he together with his anaesthesiologist had already been arrested on three previous occasions on charges of illegal human organ transplantation, but had been released on bail.

  His victims were the poor uneducated slum dwellers of Delhi and its surroundings whose kidneys had been bought and then transplanted into the doctor's clients, amongst whom were residents of the United States, England, Canada, Saudi Arabia and Greece. According to the police, the business had been going on for six or seven years.

  After the Indian government had introduced legislation banning the trade in human organs, more than a decade previously, it had simply gone underground, where the sordid business had continued to prosper. It was not difficult to understand the mechanics of the system, the demand was huge and ever growing with almost two hundred million people worldwide suffering from diabetes, a disease that often resulted in acute kidney failure - a figure that health authorities expected would double over the twenty years to come.

  The press reported that more than fifty Indian hospitals were under investigation by the Department of Medical Services, but only a one or two had had their licenses revoked.

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  In any surgical operation there are risks of post-operatory bleeding, infection, or respiratory problems. However, in Ajay's case everything had gone well with no complications. He awoke from his operation and apart from a floating feeling and a vague sensation of stiffness in his body everything seemed fine. He examined his immediate surroundings and discovered a number of tubes protruding from his body, besides the bed were what seemed like a mass of monitoring apparatus and drips. There was also a catheter, connected to a plastic bag, which was to remain in place for a few days to monitor his urine.

  After a while a nurse appeared. She smiled when she saw he was awake, then after checking the monitors she asked how he felt. He nodded and mumbled he felt fine though a little thirsty. The surgeon would be passing shortly she told him looking at her watch then allowed him to sip a little water.

  Later Ajay was told the operation had been successful and the new kidney had started to function correctly at once, producing urine without the least trouble and his blood was normal. Soon he would be out of bed and if all went well he could leave the hospital within a week.

  In effect the next morning, assisted by nursing assistants, he took his first steps, part of essential activity procedures designed to prevent complications such as pneumonia and the formation of blood clots.

  Two days later he was feeling considerably better, the only questions was had his parents arrived? He had informed them by telephone once the date for the operation had been fixed and before entering the clinic, on the eve of the transplant operation. His father had announced their flight would arrive late on the day of his operation.

  When he enquired to the nurse he was simply told there had not yet arrived, flights had been held up in London due to bad weather and there was nothing to worry about. He tried the phone, but the direct dialling was not working and the operator informed him that there was a temporary problem with international calls.

  He was soon eating almost normally in addition to taking an array of different medications necessary to prevent both organ rejection and infection.

  On the third day he finally received a call from his father who it seemed had been informed of his progress and recovery. He explained to his son their departure had been delayed due to bad weather and air traffic problems and they expected to arrive in Kochi in the next three or four days.

  What he did not tell Ajay was that all flights to Kerala from the UK had been suspended by the airlines following the cholera panic. He had however been in constant contact with the clinic who had advised him not to inform Ajay of the crisis as it would provoke unnecessary anxiety, which could possibly hamper his recovery.

  Three days later his parents arrived in Kochi and easily found an excellent room in one of the better guest houses. They accompanied him back to the apartment where he was booked for another week when he was scheduled to return to the hospital for his finally check-up before being allowed to travel.

  With his parents they de
cided to stay on at least until the end of the month, to ensure he was fully fit and there was no risk of complications, taking advantage of the time to do a little tourism and enjoy the good weather before confronting the winter back home.

  After looking at the different options for Ajay's convalescence they decide to spend a few days on a house boat in the Backwaters of Kerala. It would not be tiring and they could relax after Kochi, which was very limited in what it had to offer to the visitor.

  Through a travel agency in Fort Kochi, they hired a house boat that would take them eighty kilometres to the south on the Backwaters to Lake Vembanad. They were booked for three nights on the luxuriously appointed boat, disembarking in Alleppey from where they planned travel to Thekkady and the cool air of the Western Ghats.

  They were pleased to get away from the traffic of Kochi and its pollution, the endless traffic with it assortment of motorbikes, tuk-tuks, cars, buses, as well as just about every other kind of vehicle on wheels or on hooves. They abandoned the struggle with the crowds, cows, chickens and goats leaving the helpless traffic police behind them, who, in spite of their superhuman and somewhat authoritarian efforts, barely managed to put a semblance of order into the chaotic traffic and road system.

  The Ajays were filled with foreboding as they crossed the canals and rivers, and their chauffer driven car made its way to the south of the city. Many of the waterways in and around Kochi had once been a part of a vast navigable network, but they were now were filled to overflowing and the least shower of rain threatened the slums that lined their banks with a flood of raw sewage and the rubbish that accumulated all through the dry season. The canals were a constant threat to the health and wellbeing of Kochi's population with the mosquitoes that breed in their waters carrying malaria and chikungunya.

  The risks were enormous with over two hundred slum areas officially listed in Kochi and more than seventy thousand slum dwellings housing more than twenty percent of the city's population.

  To their relief as they finally approached the inland tourist port they found themselves in a much more pleasant landscape filled with rice fields and coconut palms. Once arrived they left the car in a rough and ready parking area and followed the driver on foot along a dirt road that led to the boat quay. The road was strewn with gravel and rubbish, around the ruts and potholes were piles of construction materials of every description: wood, bamboo, palm leaves, toilet fittings and tools.

  A long line of houseboats lay at the dock, the tourists had all but disappeared, it was evident even to the inexperienced eye that the season was a disaster for the operators, now using the time they had on their hands to carry out repairs and maintenance.

  Not since the tsunami had the region been so affected. The tsunami, though it had been unjust, was the work of nature, and in any case Kerala on the west coast of India, far from the zone struck by the waves, had been untouched. The real threat was the kind of epidemic that had struck Kovalam could strike again, and at any moment, unleashing not only cholera, but a multitude of other vector borne diseases.

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  Four days after the transplant, Anhil, the donor, was in a convalescence centre outside of Kochi to ensure full recovery before he returned home and resumed normal life, and apart from a little pain, whenever he turned at an awkward angle, he was recovering quickly.

  The removal of a kidney involves major surgery on the abdominal muscles, which excluded any donors who earned a living by manual labour. Anhil was more fortunate than many others, he was a small shop keeper, a business he had inherited from his father. He had sold his kidney for purely financial reasons, he had been paid the equivalent of ?1,500 for his kidney, a good price, which would enable him to buy a small piece of land he coveted adjoining his modest village commerce.

  He was not ignorant, as often were many who sold their kidneys, he had in fact volunteered as a donor and carefully discussed the subject with a medical representative, who had assured him he could continue a normal life after the operation if he took care.

  The fact was many donors knew full well the existence of the donor network, it was a subject of common knowledge in many Indian towns. Besides pharmaceutical distributors, medical representative worked with a number of clinics including the Aureolus Clinic, directing those who could either afford their care or whose costs were covered by religious organisations. In the case of kidney donors great care was taken to ensure the donors were willing and fully informed of the implications of being a donor, they were well paid, relatively speaking, and were given good post operatory care.

  The system was based on the altruist clause of the government act and in the vast majority of cases only Indians or those of Indian descent were transplanted, in order to avoid any possible accusations of fraud linked to the credibility of emotional links between donor and recipient.

  Many in the medical profession were in disaccord with the moral and philosophical arguments put forward by lawmakers and intellectuals, which resolved neither the problems of the needy or those of the sick. The eternal question was, should those suffering from terminal kidney failure be condemned to die a slow death because it was illegal for an unrelated person of sound mind to sell a kidney?

  In the meantime charlatans and unscrupulous agents went about their sordid business, often with donors, who though uneducated, were fully aware they were selling a vital organ for cash.

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  A vast number of potential donors lived in the third world slums of Kochi, where for decades the jobless had been forced to find work overseas in the Gulf States to support their families, returning home only once a year or less, providing their families with the means to survive by sacrificing their own lives in harsh working conditions on constructions sites for miserable wages and often in danger of their lives.

  The authorization committees were a fully legal part of the system, their duty included interviewing each legal donor to ascertain his or her willingness to donate a kidney and the donation was authorised only when the committee was entirely satisfied that the donation was voluntary. It was the old story of the sick and desperate in search of a cure, who had money, and unprincipled dealers and surgeons ready to sell them a cure at a price.

  Transplantation had become part of standard medical therapy for the treatment kidney diseases and tens of thousands of such transplants were carried out each year across the world, both legally and illegally.

  As a consequence low cost medical treatment linked with an unlimited supply of kidney donors made India a prime destination for the desperate, a source of profit for many and a vicious trap for bonded labourers, slum-dwellers and other poverty-stricken people, who were more than willing to sell part of the only thing they possessed: their bodies, and more precisely a kidney, for the survival of their large families.

  Nature had given man two kidneys and it was possible to remove one from a living person without endangering life. Since transplant operations involved a relatively low risk of major complications for the donor, a thriving and lucrative business had developed.

  In the developed world however, kidneys were mostly taken from clinically or brain dead donors, compared to India where transplants were carried out with organs bought from the poor by middlemen.

  It was not until a scandal involving Middle East Arabs coming to India to buy kidneys made international headlines did the government act, introducing the Human Organs Transplant Act in 1994, making trade in human organs a punishable offence, though it allowed the removal of organs from dead bodies after proper consent. The goal of the Act was to regulate the donation of organs from relatives.

  This did not prevent many doctors and intellectuals arguing in favour of the idea of a kidney market, saying that to help a dying person by selling a kidney was not morally wrong, especially when the donor could provide for his family by the sale of a kidney and that legalisation of the trade was desirable. After all even a former Indian prime min
ister had donated a kidney. Whatever the arguments, the trade in kidneys had thrived and in recent years the buying and selling of organs had taken on a new form.

  The law required unrelated donors and recipients to file a declaration with an authorisation committee stating that they were emotionally related and therefore a transplant should be allowed under the clause of altruistic donation. In other words, live donors, who were not blood relatives, such as adopted family members, spouses, or life long friends, who were willing to donate a kidney to the recipients were allowed to do so. The clause stated such donations were permitted by reason of affection or attachment towards the recipient or for any other special reasons, providing that the transplantations had the approval of the Authorisation Committee, as decreed by the Act.

  Marriage was one of the many ways to comply with law. Donors entered into a temporary marriage with a rich or middleclass recipient, thus fulfilling the obligations set out by the law and the Authorization Committees, who under the circumstances, approved donations between spouses.

  It was not surprising, because of the lack of state controlled monitoring agencies and wide spread corruption, the kidney business prospered given the number of persons suffering from severe renal deficiency, with hospitals and clinics regarding transplantation as a purely business transaction, and of course the vast reserve of willing and penniless donors.

  The situation was aggravated by the fact that the governments of many Indian states, including that of Kerala, openly supported and even promoted medical tourism, a huge foreign currency earning business. It was part of a growing Indian attitude towards the commercialisation of medicine, whereby many politicians, businessmen and intellectuals were convinced that the practice of medicine in general and transplantation in particular had not the obligation to conform to all conventional ethical principles.

  A new philosophical attitude had developed with India's conversion to globalisation, where modern technology was the order of the day, and as a consequence laws, perceived as outdated or out of step with new technological development, could be ignored, justified by the overriding needs of the bright new temples dedicated to progress and technology in health care that had sprung up on the outskirts of almost every large Indian city.