Organ trade continues despite ban on transplantation to foreigners

By Gemma Bagayaua, Newsbreak

Posted at Mar 08 2009 12:30 PM | Updated as of Mar 08 2009 09:43 PM

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.”

_________________
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.