Monday, April 21, 2014

Vulnerable Bodies


The ideas that "age" can be defined in a number of ways:
  • chronological
  • biological development
  • social development
Vulnerability of the body is based on our conception of "stages of life" and the qualities and conditions associated with these stages in culture

When I look back on my own childhood in the 1970s and 80s and compare it with children today, it reminds me of that famous sentence ‘The past is a foreign country: they do things differently there’ (from L. P. Hartley’s novel The Go-Between). Even in a relatively short period of time, I can see the enormous transformations that have taken place in children’s lives and in the ways they are thought about and treated.
  • Today, children have few responsibilities, their lives are characterized by play not work, school not paid labor, family rather than public life and consumption instead of production.
  • Yet this is all relatively recent. A hundred years ago, a twelve-year-old working in a factory would have been perfectly acceptable. Now, it would cause social services' intervention and the prosecution of both parents and factory owner.

American colonial families: Industrious girls treated with respect

The differences between the expectations placed on children today and those placed on them in the past are neatly summed up by two American writers, Barbara Ehrenreich and Deirdre English. Comparing childhoods in America today with those of the American Colonial period (1600-1775), they have written:

‘Today, a four year-old who can tie his or her shoes is impressive. In colonial times, four-year-old girls knitted stockings and mittens and could produce intricate embroidery: at age six they spun wool. A good, industrious little girl was called 'Mrs.' instead of 'Miss' in appreciation of her contribution to the family economy: she was not, strictly speaking, a child’.

Childhood: A social construction?

These changing ideas about children have led many social scientists to claim that childhood is a ‘social construction’. Social anthropologists have shown this in their studies of peoples with very different understandings of the world to Western ones.

  • Canadian Arctic: Acquiring understanding

    • Jean Briggs has worked with the Inuit of the Canadian Arctic and has described how, within these communities, growing up is largely seen as a process of acquiring thought, reason and understanding (known in Inuit as ihuma).
    • Young children don’t possess these qualities and are easily angered, cry frequently and are incapable of understanding the external difficulties facing the community, such as shortages of food.
    • Because they can’t be reasoned with, and don’t understand, parents treat them with a great deal of tolerance and leniency. It’s only when they are older and begin to acquire thought that parents attempt to teach them or discipline them.

  • Tonga: Closer to insanity than adulthood

Royal New Zealand Navy Petty Officer Richard Boyd dances with school children during a Pacific Partnership 2009 community service project at Faleloa Primary School 
Royal New Zealand Navy Petty Officer Richard Boyd dances with school children during a Pacific Partnership 2009 community service project at Faleloa Primary School, Tonga. But some chilldren have a tougher time of it on the island.
    • In contrast, children on the Pacific island of Tonga, studied by Helen Morton, are regularly beaten by their parents and older siblings.
    • They are seen as being closer to 'mad' people than adults because they lack the highly prized quality of social competence (or poto as the Tongans call it).
    • They are regularly told off for being clumsy and a child who falls over may be laughed at, shouted at, or beaten. Children are thought of as mischievous; they cry or want to feed simply because they are naughty, and beatings are at their most severe between the ages of three and five when children are seen as particularly wilful.
    • Parents believe that social competence can only be achieved through discipline and physical punishment, and treat their children in ways that have seemed very harsh to outsiders.

  • The Beng: Arrivals from a spirit world

    • In other cases, ideas about children are radically different. For example, the Beng, a small ethnic group in West Africa, assume that very young children know and understand everything that is said to them, in whatever language they are addressed.
    • The Beng, who’ve been extensively studied by another anthropologist, Alma Gottleib, believe in a spirit world where children live before they are born and where they know all human languages and understand all cultures.
    • Life in the spirit world is very pleasant and the children have many friends there and are often very reluctant to leave it for an earthly family (a fictional account of a spirit child’s journey between the spirit and the earthly world is given in Ben Okri’s novel, The Famished Road).
    • When they are born, they remain in contact with this other world for several years, and may decide to return there if they are not properly looked after. So parents treat young children with great care so that they’re not tempted to return, and also with some reverence, because they’re in contact with the spirit world in a way that adults aren’t.

  • The West: Dependency

    • There’s a tendency to view children in the West, and in the Western world in general, as incompetent and dependent. But this isn’t the case throughout the world. In many societies children work and contribute to the family in whatever way that can from a very early age.
    • A good example of this is child care. In the West, it is illegal for a child under the age of fourteen to look after another child unsupervised, because they’re deemed incompetent and irresponsible.

  • The Fulani: Working by the age of four

    • In other cultures, this is not the case. Michelle Johnson has written about the Fulani of West Africa describing how by the age of four, girls are expected to be able to care for their younger siblings, fetch water and firewood and by the age of six will be pounding grain, producing milk and butter and selling these alongside their mothers in the market.

  • The Yanamamö: Girls marry earlier than boys

Yanomami children [Image by Ambar under CC-BY-SA licence] 
Yanomami children
    • Across the world, among the Yanamamö of the Amazonian rainforest, another anthropologist, Napoleon Chagnon, has shown how different these children’s childhoods are from Western ones, and also how differently boys and girls grow up in comparison with other parts of the world.
    • He has written how a Yanamamö girl is expected to help her mother from a young age and by the age of ten will be running a house. By the age of twelve or thirteen she is probably married and will have started to have babies.
    • Boys on the other hand, have far fewer responsibilities. They don’t marry until later than girls and are allowed to play well into their teens. Western notions of childhood simply do not ‘fit’ in these cases, where children’s competence and responsibilities are understood very differently.

  • Studying very different communities

    • Social anthropologists ask questions about how childhood, and the role of children, is seen within the communities they study, rather than how it fits into Western ideas about childhood.
    • By doing this they seek to avoid imposing outside ideas onto people with very different understandings of the world or of making value judgments on other people’s ways of raising their children.
    • While Westerners might take exception to eight-year-old girls working or to twelve-year-old girls marrying, within their own communities such activities are seen as a normal and positive part of childhood. Indeed, seen through the eyes of non-Westerners, many ‘normal’ Western childcare practices are seen as extremely bizarre and possibly harmful to children.
    • Placing children in rooms of their own, refusing to feed them on demand, or letting them cry rather than immediately tending to them, are viewed very negatively in many societies and lead some to think that Westerners don’t know how to look after children properly.

  • A changing phenomenon

    • Childhood is a changing social phenomenon, of continual fascination and concern. Looking at it from a cross-cultural perspective shows the wide variety of childhoods that exist across the world and warns against interfering in or criticizing people whose lives, and understandings of the world, are very different to our own.
    • All societies recognize that children are different to adults and have particular qualities and needs; what anthropologists and other social scientists are interested in are the ideas that each society has about the nature of childhood and the impact these views have on children’s lives.

The Middle Ages & Europe

  • During the five hundred years between the Norman Conquest of 1066 and the dawn of the Reformation, there were many different emphases in thinking about childhood. But there was one dominant and enduring institution, the Catholic Church, which set the tone for all such thinking. In the ceremony of baptism a child was received into the Church and freed from the burden of original sin. Babies, said one preacher, "are symple, withowt gyle, innocent, wythout harme, and all pure wythowt corruption."
    • The Church had inherited from Greek and Roman authorities ideas of the stages of life. Infancy lasted up to the age of seven, pueritia or childhood up to fourteen, to be succeeded by adolescence.
    • These ages were in some senses building blocks to enable you to reach the peak of life which came with young adulthood: childhood was not thought to be as important as we now consider it in the formation of personality and character. That said, there was nevertheless room for debate as to how best to bring up a child.
St Anselm [Image: Lawrence OP - CC-BY-NC-ND] Creative commons image
St Anslem depicted in stained glass at Our Lady and the English Martyrs, Cambridge.
  • "Spare the rod and spoil the child" echoes through most centuries of Western history.
  • But whatever else this debate about child-rearing shows, it puts paid to the idea, frequently cited, that in the Middle Ages, and beyond them, children were seen simply as ‘little adults’. They were not. Childhood was clearly recognized as a distinct time of life.

The Protestant Reformation

  • The Reformation of the sixteenth century replaced the Catholic Church and its rituals with a sterner faith. Children and their parents no longer had the comfort of knowing that, once baptized, they would be spared the pains of hell should they die – an all too frequent occurrence. Godly parents, urged on by their preachers, tried to bring their children to an awareness of their sins and of the need for salvation.
  • Parents, if not children, lived in a state of anxiety unparalleled until our own time.
James Janeway
James Janeway
  • Janeway was a Protestant minister in London. He’d experienced the terrible plague of 1665, children most vulnerable to its ravages. "Did you never hear of a little Child that died?" he asked. "And if other Children die, why may not you be sick and die? And what will you do then, Child, if you should have no grace in your heart, and be found like other naughty Children?"
  • On the positive side, parents were told not to resort too easily to corporal punishment, and to aim at a happy medium, in the words of one advice book, ‘so as I neither make my child to despise me through too-much lenity, nor to hate me through too-much severity’.

The Enlightenment

  • In 1693 the great philosopher John Locke (1632-1704) published Some Thoughts Concerning Education, probably the most influential British book on childhood. Its origins hardly suggested this. Locke had been tutor to a number of aristocratic children, and on the basis of this experience wrote some letters to a relative on child rearing. These circulated, and eventually Locke was persuaded to publish them.
  • Locke, unlike the Puritans of the sixteenth and seventeenth centuries, does not seem at all concerned about the child’s salvation. His interest, rather, is to suggest ways of instilling good habits into a child that will last a lifetime. 
    • (civilizing rather than saving)  
    •  The way to do this was not through corporal punishment, not through frightening them, as servants were inclined to with stories of ghosts and hobgoblins, but to take reason as your guide.
    • Body of a child is to be protected from HARM
  • REASON---(civilizing ingredient) The first thing babies should learn is that they shouldn’t have something because they like it, but because it is thought good for them. Locke is full of sensible advice on clothing and food for children, and on not buying them too many toys.
John Locke
John Locke
    • He also thinks that learning should be made fun, and that children should "be tenderly used … and have Play-things". 
    • And he recognizes that each child will have its own ‘natural Genius and Constitution’. 
    • Parents fell on Locke’s book in much the same way as they would fall on Dr Spock in the mid-twentieth century: he relieved them of many anxieties, and set them a clear agenda, for, he claimed, nine-tenths of how a child turns out as an adult, "Good or Evil, useful or not", will be the result of its education.(DISCIPLINING)

The Romantics

  • For Rousseau (1762 publication), the problem with Locke lay in his obsession with the adult to be, rather than with the child. Rousseau was perhaps the first thinker to be truly child-centered. "Don’t reason with children... Let them learn from things, from nature, not from teachers".
  • Child should learn from nature to suggesting that a child might have access to the natural world in a way denied to world-weary adults.(their bodies are more NATURAL)
Jean Jacques Rousseau
Jean Jacques Rousseau
  • Childhood, for the first time, became the most privileged, enviable, phase of life. 
  • Children, were not only innocent, but could also have much to teach adults about truth and beauty. As Charles Dickens was to reiterate, if you let the child in you die, you were in effect dead, like Scrooge in A Christmas Carol.

The Victorians

  •  For the Austrian-born philosopher RUDOLF STEINER (1861–1925), childhood was a state of physical and spiritual being roughly between the ages of seven and fourteen years, indicated initially by certain physiological changes such as the loss of the milk teeth.
  • Some Victorian children were allowed to live out the dream of a romantic childhood. But for all too many, conditions of life in industrializing and urbanizing West made it seem to observers that they were ‘children without childhood’, condemned to long hours of work and far from the nature that the Romantics so prized.
    • Reformers set themselves the task of restoring childhood to these children who were missing out on it. 
    • Children, it came to be thought, should be protected from the adult world of work and responsibility. 
    • They should be dependent on adults, and their time divided between home and school. 
    • And ideally they should be happy, a state of happiness coming to be particularly associated with childhood.
    • Compulsory schooling, from the 1870s onwards, had to be imposed by force of law.

The Century of the Child

  • The twentieth century was loudly proclaimed at its outset to be ‘the century of the child’. 
    • the future of any nation was dependent on its children. 
    • The health of children began to receive serious attention, as did their education.  
    • There was much fear of a ‘degeneration of the race’ and of halting it by discouraging unsuitable parents from breeding. Science seemed to hold the key to the future, and if, as the prominent child psychologist, Cyril Burt, claimed, ‘superintending the growth of human beings is as scientific a business as cultivating plants or training a race horse’, then many parents seemed ill-equipped for the task. In the 1920s and 1930s behaviorism dominated as a mode of child rearing, the emphasis on producing an obedient child.
    • By the end of the century children in many families could expect parental support up to their twenties, something unimaginable in previous centuries. 
    •  At the same time, from the 1970s onwards, children began to acquire new rights in relation to the state and to their families: 
      • the right not to be beaten in school (1982), 
      • the right to be consulted in the event of parental divorce, and so on. 
      •  Childhood itself had in many ways become prolonged, and children had gained a higher status both within the family and in society at large.

IMAGES OF "CHILDHOOD" AND THE BODY
  • The concept of "childhood" is new in the West -- there was little differentiation between a child and adult and any markings of their lives through the Medieval period in Europe. Cultures throughout the word all define life stages, but in different ways. Childhood tends to be a short is differentiated at all. Transition from child to adult is seen as a progression rather than a stage change.
  • Contemporary images of childhood in the West
    • viewed as a time of innocence and joy (Oprah)
    • children are dissimilar to adults in biological, psychological and moral terms
    • the bodies of children are seen as "unfinished" and the institutions in our culture are designed to complete this transition to adulthood through CIVILIZING the body and regulating "unruly selves"
      • learn to control ones body and to and learn important forms of bodily conduct in particular places and contexts
    •  Discourses on children's bodies:
      • Child labor laws of the late 18th century- children are vulnerable and physically unsuited to labor which is dangerous 
Childhood is generally considered to be either a natural biological stage of development or a modern idea or invention. Theories of childhood are concerned with:
    •  what a child is
    • the nature of childhood
    • the purpose or function of childhood
    •  how the notion of the child or childhood is used in society.
    • The necessity of formulating a precise legal definition of childhood grew out of demographic, economic, and related social and attitudinal changes in the industrialized world that together forged a new recognition of the significance of childhood at the end of the nineteenth century and the beginning of the twentieth. 
      • Before this time, children had been defined in strict relation to their status as the biological offspring of fathers who also were considered by law to own any of the child's possessions and to whom they were obliged to offer their services. 
    • The social historian Viviana Zelizer has described what she terms a "sacralization" (investing objects with religious or sentimental meaning) of childhood that occurred at this time, creating a transition in the way children were regarded, from a position of economic value to one of emotional price-lessness.
      • Thus, the notion of the economically useful child began to be replaced by the notion of the incalculable emotional value of each child. 
      • The traditional Western notion of childhood, which had held from about the 1850s to the 1950s, was implied in its absence by notions such as "the disappearance of childhood" or David Elkind's "the hurried child."
    • Children are now more DEPENDENT on adults and images of childhood and the child's body are more POTENT
      • children are now conceptualized as "other", "pre-social", "non-adult"
      • learn how to BECOME ADULTS in their bodies which are highly regulated and disciplined in institutions like school.
        • schooling has become mandatory and regulated by the state as a way of regulating and managing children's bodies
        • laws regulating child labor
        • laws regulating child/adult interactions
        • contributes to the recognition of BODY DIFFERENCES in terms of GENDER
    IMAGES and AGING
    • culture provides images of bodies which we measure ourselves against as we age.
      • changes in physical appearance are part of this process
      • aging bodies are generally imagined in culture as as social problem
        • aging bodies are in the process of deterioration and are subject to sickness whcih must be cared for
        • welfare and pensions are also an issue for society (how to care for nonproductive bodies)
        • aging bodies are not beautiful


    Images of the aging body are highly gendered and their abilities and meanings are gendered as well.
    • Generally
      • loss of productivity
      • increased dependence
      • increased vulnerability
      • loss of status-infantalization
      • senility
      • liminal
        • loss of function that leads to "leaking" and "inability to keep body boundaries" (DOUGLAS)
          • lack of privacy and impenetrable boundaries of ones body as it may be:
            • incontinent
            • subject to probing and observation
            • physically assisted
            • exposed to nonintimates
    • gendered differences
      • women
        • desexualized
        • judged on appearance of beauty (lack of)
      • men
        • distingusihed
        • wise
    • Experience of Aging in the Body
      • Focus has always been on the experience of LOSS of bodily function and ability over time in recent Western culture
        • internalization of stereotypes leads to an internalization of the embodied experience
      • New: focus on FITNESS and "aging well" has created a new conception of the aging body and a new standard for embodiment
        • consequence to some extent of new technologies 
          • hormone replacement
          • viagra
          • plastic surgery
          • etc.
      • Sense of Self
        • many report that they do not experience themselves as an aging body
          • may report tiredness or loss of stamina rather than experience of being in an aging body---how do negative constructions of aging in our culture contribute to the experience of embodiment in aging? (we could ask the same question we did about adolescence or puberty!)
        • Importance of TOUCH (direct contact with the body) in Therapies of wellness in aging
          • the body is an important focal point for relational networks that allow people to see themselves as whole beings. (Massage, beauty therapies, yoga, etc.)
          • Wellness for the aging has to do with the feeling of BEING IN THE BODY
    • Death and the Body
      • The dead body as contaminating
      • dead body as public image
        • Power of the state
    stoning

    hanging

        • viewings
    Lenin's Tomb
        • display as medical curiosity
    Mutter Museum (exhibitions link)

      • The dead body as dehumanized
      • The dead body as a commodity
        • body parts
        • experimentation
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    Tuesday, April 15, 2014

    Organs For Sale: Organ Donation and Trade

    Organs for sale 1

    Organs for Sale 2


    ORGAN TRAFFICING AND TRANSPLANT TOURISM
    • Medical ethics;
    • organ markets;
    • organ trafficking

    Abstract

    The extent of organ sales from commercial living donors (CLDs) or vendors has now become evident. At the Second Global Consultation on Human Transplantation of the World Health Organization's (WHO) in March 2007, it was estimated that organ trafficking accounts for 5–10% of the kidney transplants performed annually throughout the world. Patients with sufficient resources in need of organs may travel from one country to another to purchase a kidney (or liver) mainly from a poor person. Transplant centers in ‘destination’ countries have been well known to encourage the sale of organs to ‘tourist’ recipients from the ‘client’ countries.
    Organ trafficking brings little regard for the well being of the donor. Who cares for the donor in the early period following transplantation or in the long term, especially if complications arise? This report will describe the organ trafficking known to the authors by their visits to many countries on behalf of The Transplantation Society (TTS) and the World Health Organization and by the field research and advocacy work with commercial living donors (CLDs) of the Coalition for Organ-Failure Solutions (COFS). It introduces alternative approaches that must be addressed by each country to combat organ trafficking.
    The buying and selling of organs in the global markets has become an ethical issue for transplant clinicians everywhere in the world. Even physicians who would have no part in the organ trade now bear a responsibility for the medical care of those recipients who return to their home countries having undergone organ transplantation from an unknown vendor. These recipients arrive at physician offices in widespread locations such as Tel Aviv, Toronto and Trinidad. Some patients return home with inadequate reports of operative events and unknown risks of donor-transmitted infection (such as hepatitis or tuberculosis) or a donor-transmitted malignancy. The source of their allografts is mainly from the poor and vulnerable in the developing world. These vendors or commercial living donors resort to an organ sale because they have virtually no other means to provide support for themselves or their families. Selling kidneys may be a consideration of ‘autonomy’ in academic debate but it is not the coercive reality of experience when a kidney sale is a desperate alternative available to the poor (1).
    This report describes the characteristics and extent of the global trafficking in human organs. It includes the experience of the authors' personal visits to numerous countries on behalf of TTS and WHO. This report is also fashioned by the extensive field research of COFS. Finally, this commentary proposes an alternative approach that must be addressed by each country to alleviate the shortage of organs for transplantation and combat the exploitative practices of organ trafficking.

    Definition of Organ Trafficking and Transplant Tourism

    The discourse on the market of organs has used various terms to describe the commercialism at the core of organ trafficking. The seller of a kidney is not only the donor source of an organ but a vendor whose motivation is monetary gain. The following definition of organ trafficking is derived from the United Nations Trafficking in Persons (2). Organ trafficking entails the 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, of a position of vulnerability, 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. The reason to oppose organ trafficking is the global injustice of using a vulnerable segment of a country or population as a source of organs (vulnerable defined by social status, ethnicity, gender or age).
    This definition of organ trafficking captures the various exploitative measures used in the processes of soliciting a donor in a commercial transplant. Exploitation is the threat or use of force or other forms of coercion, abduction, fraud, deception, abuse of power or position of vulnerability. The commercial transaction is a central aspect of organ trafficking; the organ becomes a commodity and financial considerations become the priority for the involved parties instead of the health and well-being of the donors and recipients.
    Transplant Tourism has become a connotation for organ trafficking. The United Network for Organ Sharing (UNOS), recently defined transplant tourism as ‘the purchase of a transplant organ abroad that includes access to an organ while bypassing laws, rules, or processes of any or all countries involved’ (3). However, not all medical tourism that entails the travel of transplant recipients or donors across national borders is organ trafficking. Transplant tourism may be legal and appropriate. Examples include, when travel of a related donor and recipient pair is from countries without transplant services to countries where organ transplantation is performed or if an individual travels across borders to donate or receive a transplant via a relative. Any official regulated bilateral or multi-lateral organ sharing program is not considered transplant tourism if it is based on a reciprocated organ sharing programs among jurisdictions.
    The modes of illicit transplant tourism were recently illustrated by Yosuke Shimazono at the Second Global Consultation on Human Transplantation at the WHO headquarters in Geneva in 2007 (Figure 1) and capture the various ways recipients, CLDs, and transplant centers may be coordinated for such a transplant (4). In addition to these modes that occur across national borders, organ trafficking may also occur at transplant centers within the same country of residence of the CLD and recipient.
    image
    Figure 1. In this figure, Shimazono (2007) illustrates four modes of transplant tourism. Mode 1 entails a recipient traveling from Country B to Country A where the donor and transplant center are located, Mode 2 entails a donor from Country A traveling to Country B where the recipient and transplant center are located, Mode 3 entails a donor and recipient from Country A traveling to Country B where the transplant center is located, and Mode 4 entails a donor from Country A and a recipient from Country B traveling to Country C where the transplant center is located.

    The Extent of Organ Trafficking

    Countries that have facilitated organ trafficking such as Pakistan and the Philippines do not release precise data (not surprisingly) regarding the numbers of foreign patients that travel to these countries for transplants. In the Philippines, a quota of foreign nationals was intended but there has been no report of data to indicate that such a stipulation has been fulfilled. Despite its clandestine nature and the difficulties in obtaining national data, the extent of organ trafficking has become evident by our visits to many countries around the world and by reports prepared for presentation at the WHO.
    According to data from the Sindh Institute of Urology and Transplantation (SIUT), at least 2000 kidney transplants have been performed in Pakistan to transplant tourists (source: Delmonico visit to Karachi Pakistan January 2007). The widespread dimension of these practices becomes particularly evident, when a highly regarded nephrologist in Port of Spain Trinidad reports that a series of 80 patients had gone from Trinidad to Pakistan to buy organs (source: Delmonico visit with Dr. Leslie Ann Roberts in Trinidad).
    In the Philippines, a February 2007 newspaper account of the number of kidney sales reveals over 3000 have been performed (5). The WHO held a regional consultation in Manila to call attention to its objection to the rampant commercialism (source: Delmonico participation). The Cebu Province of the Philippines is now reported to be seeking transplant tourists to increase Philippine commercial transplants (6).
    It is estimated by Egyptian transplant professionals that we both have visited (source: Egyptian Society of Nephrology, Cairo June 2007) that Egypt performs at least 500 kidney transplants annually (7). A majority of these transplants are performed from CLDs.
    Scott Carney reports (source: conversations with Delmonico and by Carney publications) that transplant tourists have undergone kidney transplantation from tsunami victims in Chennai, India (8).
    At the WHO regional consultation in Slovenia, the representative from Moldova reported the request of Israeli physicians to set up a transplantation practice in that country. The request was denied but there is no current penalty being imposed upon the insurance companies that are systematically enabling these transplants to occur outside of Israel. As many as 20 patients from Israel may currently undergo kidney transplantation in the Philippines each month. The consequence for Israel is that the expertise in performing organ transplantation within Israel may be lost (9). Hopefully, the pending legislation in the Knesset on organ transplantation will address this issue (see below).
    At the Second Global Consultation on Human Transplantation at the WHO headquarters in Geneva in 2007, Shimazono also assembled a sampling of the trafficking by an analysis of databases such as Lexis/Nexis, MEDLINE and Pubmed academic journal articles, and Google searches that included media sources, transplant tourism websites, renal and transplant registries and reports from health authorities. Shimazono estimated that 5–10% of kidney transplants performed annually around the globe are currently via organ trade. The credibility of this estimate is given by the following data: at least 100 nationals from countries such as Saudi Arabia (700 in 2005), Taiwan (450 in 2005), Malaysia (131 in 2004) and South Korea (124 in the first 8 months of 2004) went abroad annually for a commercial kidney transplant. At least 20 nationals from other countries such as the Australia, Japan, Oman, Morocco, India, Canada and the United States traveled as transplant tourists for trafficked organs. But the more striking observation comes from the revelation of data in a visit to China in the summer of 2007. In 2006, 11 000 transplants were performed in China from executed prisoners. There were 8000 kidney transplants, 3000 liver transplants and approximately 200 hundred heart transplants. The 8000 kidney transplants alone in China in 2006 would account for at least 10% of the total number of annual organ transplants done in programs of organ trafficking. It should be noted that since China's recently adopted Human Transplantation Act that bans commercialism was adopted in May 2007, China has reduced the number of transplants to foreign patients by 50% in 2007. Nevertheless, the reduction in Chinese activity has presumably been supplanted by an increase in Philippine organ trafficking.
    Merion et al. have reported the initial US experience that includes some patients whose transplants were not obtained from CLDs (10). One hundred nineteen US citizens and resident aliens from 55 transplant centers in 26 states were recorded as having received kidney transplants in 18 foreign countries after a median of 1.5 years (range 21 days to 8.5 years) on the US waiting list. HRSA officials who collaborated with Dr. Merion are now aware of this practice and should be following it closely. There is a public hazard for patients to return from out of country was potential transmissible infection such as avian flu, tuberculosis, Schistosomiasis, acute hepatitis and/or HIV infection.
    Recipients of commercial transplants abroad should not be denied the provision of follow-up care; yet there is no justification to condone illegal transplants outside United States if the purchase of a kidney (that could result in Medicare benefits to be received for immunosuppressive medications) is illegal within the borders of the United States. The legislation that is being considered by the Knesset in Israel would prohibit the insurance reimbursement of transplant costs for Israelis that undergo a purchased organ transplant in countries where the buying and selling of organs is illegal.
    Insurance companies may be influencing practices: for example, Bramstedt and Xu reveal ‘US medical insurance programs are taking steps to address the problems of organ availability, long waiting times, and high medical and surgical costs by promoting transplant tourism’ (11).

    The Consequence to the Vendors

    What then of this emerging worldwide population of live kidney vendors? In Pakistan, the SIUT group has carefully detailed a sample cohort of (n = 239) vendors in a follow-up—the outcome all very troubling (12). The majority of these CLDs (93%) who sold a kidney to repay a debt and (85%) reported no economic improvement in their lives, as they were either still in debt or were unable to achieve their objective in selling the kidney. The disturbing report by the SIUT group becomes not only an accounting of the Pakistani experience but an indictment of the international transplant community because it overlooks the plight of the donor whose interests are just as valid as the recipients.
    Egypt is one of the few countries that prohibits organ donation from deceased donors. In the absence of an entity to govern allocation or standards for transplants, the market has become the distribution mechanism. Egypt is also one of the countries in which COFS has conducted extensive field research and long-term outreach service programs for victims of the organ trade. In-depth longitudinal interviews conducted by Budiani reveal that 78% of the CLDs (n = 50) reported a deterioration in their health condition. This is likely a result of factors such as insufficient donor medical screening for a donation, pre-existing compromised health conditions of CLD groups and that the majority of employed CLDs reported working in labor-intensive jobs. A kidney sale does not solve the most frequently given reason for being a CLD, 81% spent the money within 5 months of the nephrectomy, mostly to pay off financial debts rather than investing in quality of life enhancements. CLDs are not eager to reveal their identity; 91% expressed social isolation about their donation and 85% were unwilling to be known publicly as an organ vendor. Ninety-four percent regretted their donation (13).
    The studies in Pakistan and Egypt are consistent with findings in India (14), Iran (15) and the Philippines (16) that revealed deterioration in the health condition of the CLDs. A long-term financial disadvantage is evident following nephrectomy from a compromised ability to generate a prior income level. The common experience also entails a social rejection and regret about their commercial donation. These reports are consistent with the COFS experience in the CLD interviews; a cash payment does not solve the destitution of the vendor.

    What Are the Alternatives?

    As an international community we need to fulfill the goals of the Amsterdam Forum and provide ethical protocols for donor selection and longitudinal care for the live kidney donor (17). We collectively need to dispel the unrealistic notion that these cash payments can be regulated without the influence of brokers. The cash payment system targets the poor, privileges those who can afford the purchase, undermines altruistic donation and it has escaped governmental regulation. The Iranians are to be commended for their candor at a recent Transplantation Society Key Opinion Leader meeting in Turkey in which Professor Ahad Ghods and his colleague Dr. Shokoufeh Savaj acknowledged limitations of the Iranian Model, which included the lack of medical coverage for the donor beyond one year following transplantation. But it is also widely known that unregulated payments may be imposed upon the recipient.
    Transplants conducted in countries with loose or no legal frameworks such as that of Pakistan, the Philippines and Egypt accommodate the organ market and the transplant tourists that drive the demand. Engaging governments to play a central role in establishing laws on transplants and for the Ministry of Health to carry out oversight of transplant practices is an essential component to improve the global situation of organ trafficking/transplant tourism. This has been the gratifying experience of TTS interaction with the Chinese Ministry of Health, but it remains to be determined if MOH regulatory oversight will be sustained after the 2008 Beijing Olympics. An alliance of TTS and the International Society of Nephrology (ISN) and other professional societies, all working with the WHO to influence health authorities at the World Health Assembly is now needed to combat organ trafficking.
    Each country should establish a system of deceased organ donation. At a WHO Regional Consultation on Developing Organ Donation from deceased donors, held in Kuwait City last year, transplant professionals from Bahrain, Iran, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen supported the development and expansion of organ and tissue donation from deceased donors. They opposed commercialism and transplant tourism, including brokerage and medical professionals seeking monetary profit as a result of the vendor sale or coerced donation of an organ or tissue. The Kuwait Statement was crafted with an eye towards the following goals:
    • • 
      Each country must develop a legal framework and national self-sufficiency in organ donation and transplantation;
    • • 
      Each country must have a transparency of transplantation practice that is accountable to the health authorities and whose authority is derived from national legislation;
    • • 
      Countries in which the buying and selling of organs is outlawed must not permit their citizens to travel to destination countries and return for insured health care in the client country and
    • • 
      Insurance companies should not support illegal practices as they are doing preferentially in some countries.
    This list is not exhaustive of approaches that can improve the care of the live donor consistent with the recommendations of the Amsterdam Forum. Proposals are now being made to address additional measures to improve donor safety (18). These aims of the Kuwait Statement are also elaborated in the drafted and updated WHO Guiding Principles. This document is a product of the recommendations from global experts who participated in several WHO regional consultations hosted in diverse locations such as Khartoum, Manila, Slovenia and Geneva. The WHO guiding principles emphasize that ‘organs, tissues and cells should only be donated freely and without monetary reward. The sale of organs, tissues and cells for transplantation by living persons, or by the next of kin for deceased persons, should be banned. However, the prohibition of sale or purchase of cells, tissue and organs does not affect reimbursing for reasonable expenses incurred by the donor, including loss of income, or the payment of other expenses relating to the costs of recovering, processing, preserving and supplying human cells, tissues or organs for transplantation’.
    Additionally, corporations such as pharmaceutical companies involved in transplants and insurance companies should also be made accountable for their engagement in processes, which prioritize profit generation at the disregard of social justice. TTS has addressed each of the major pharmaceutical representatives involved in transplantation (Delmonico Sydney Australia August 2007) to solicit support for its global mission to combat organ trafficking. Further, various insurance programs (both public and private) in countries as diverse in resources as the US, Israel, Yemen and Saudi Arabia, should not encourage patients to seek a transplant abroad without regard to the source of the organ (11,19). These countries cannot overlook the plight of the donor and condemn organ sales within the country and condone the commercialism outside its borders. There is precedent in international law to prohibit illegal practices irrespective of national borders, for example, in the bribery of public officials (20).
    The international transplant community must deliver a concerted message that organ markets that exploit the poor and vulnerable are not acceptable, but programs must be developed alternatively that assure donor safety and provide social benefits that address donor needs. These needs are the legitimate consequences of living organ donation and must be addressed in each country with Ministry of Health oversight, authorized by national legislation and guided by the World Health Assembly resolution.

    References

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