How are criminal organ trade networks organised? What are their similarities and differences and how can they be disrupted?
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Understanding the organization of the human organ trade

How are criminal organ trade networks organised? What are their similarities and differences and how can they be disrupted?

The human organ trade is a relatively new but neglected crime that is proliferating globally. It constitutes the sale and purchase of organs for financial or material gain. The World Health Organisation first prohibited payments for organs in 1987. Most countries have since laid down the prohibition in their national laws. Yet, the trade continues to take place across the globe.

Although reliable figures are lacking, the WHO estimated in 2008 that 5% of all transplants (~3000)     performed worldwide were illegal. Living donor kidneys are the most commonly traded organ.

The proliferation of the organ trade goes hand-in-hand with the ever-growing organ scarcity. Recent estimates suggest that 15 million organs are needed annually to meet organ demand. The total number of transplants performed worldwide is estimated to be less than 10% of the global need. Of all organs, the kidneys are the most in demand.

Chronic kidney disease has emerged as one of the most prominent causes of death and suffering, affecting roughly 10% of the world’s population today (~ 800 million people), leading to 2–7 million deaths annually. Given the projections that the prevalence of kidney disease and other types of organ failure will continue to rise, organ scarcity is likely to persist.

Under these circumstances, individuals needing organs resort to illegal means to acquire them from sources beyond their national borders. Rising organ values drive profit motives, motivating certain individuals to engage in organ trading and sales. Global developments and crises, including widening wealth disparities, conflicts, famine, climate change, and forced migration, heighten the vulnerability of populations to organ exploitation and sales.    

The gap between organ supply and demand for organs has led to a growing, global illegal organ market that converges with ‘legal’ organ procurement systems to meet the demand that altruistic organ donation systems fail to fulfill. 

Studying organ trade networks: The netcare and medicus case

An investigation into two global organ trafficking networks was conducted, employing crime script analysis to dissect their operations. This method breaks down the process of committing a crime into distinct steps, detailing the criminal activity, individuals involved, and locations. Approximately 1700 pages of law enforcement intelligence and interview transcripts from South Africa, Kosovo, and Israel were scrutinized. Through comparative analysis, differences and similarities between the cases were identified.

One of the networks, known as the Netcare case, orchestrated over 200 illegal kidney transplants in South African hospitals between 2001 and 2003. The network comprised recruiters, brokers, nephrologists, surgeons, lawyers, transplant coordinators, and a hospital CEO. These operations catered to Israeli kidney patients, who paid up to $120,000 for the transplants. Donors were recruited primarily from Brazil and received compensation of up to $20,000 for their kidneys.

Figure 1. Crime script of the Netcare case.
Credit. Author

Another case, referred to as the Medicus case, involved an international network comprising brokers, urologists, surgeons, notaries, anesthesiologists, and the head of the Medicus Clinic in Kosovo, among others. This network facilitated 24 illegal kidney transplants at the Medicus Clinic throughout 2008. Similar to the Netcare case, these transplants were arranged for Israeli kidney patients, who paid up to $108,000 for the procedures. Kidneys were primarily sourced from sellers in Eastern Europe. Israeli patients could afford these hefty sums as their health insurance companies reimbursed a significant portion of the transplant cost, aiming to avoid the high expenses associated with dialysis.    

Figure 2. Crime script of the Medicus case.
Credit. Author

Differences and similarities in the organisation of the organ trade networks

Both cases exhibited several similarities. They both featured a broad range of individuals in key roles, including surgeons, nephrologists, transplant coordinators, urologists, notaries, and lawyers. These individuals collaborated with brokers and recruiters to orchestrate and facilitate the illegal transplants. Crucially, the medical expertise and infrastructure provided by hospitals, clinics, and medical specialists were integral to the success of these operations.

The participants in these networks collaborated sophisticatedly across borders, utilizing legal loopholes to evade detection and arrest. The organization of these cross-border transplants required meticulous planning. For instance, in both cases, recipients and donors underwent initial blood group and tissue-typing tests in their respective countries of origin. These tests were then cross-matched to ensure compatibility between the donor and recipient pools.

In criminal organ trade networks, concealing and laundering illegal transplants (i.e., giving them the appearance of legality) is also crucial. In both cases, this was achieved by forging consent forms that falsely stated that donors and recipients were related and that donors were donating their kidneys voluntarily and without payment.  

Another concealment tactic was rapidly discharging donors and patients from the clinic/hospital to avoid detection. In both cases, but especially in the Medicus case, donors were discharged already after 2 days, which is much quicker than in standard medical practice.

In addition, both cases required the participants to ensure a steady supply of donors. In organized illegal living donor kidney trading schemes, donors are generally treated as expendable commodities after their kidney sale, leading to a continuous need for new recruitment cycles. In these instances, participants employed tactics such as withholding the full promised payment, offering it only upon successfully recruiting new prospective kidney sellers.

Credit. Midjourney

Risks and disparities in illicit organ transplant operations

The imperative for secrecy and profit maximization in illicit transplant operations heightens the risks of deception, fraud, and inadequate medical care for both patients and donors.

The cases diverge in terms of the transplant locations. While transplants in Kosovo were centralized in a single clinic lacking the necessary licensing, those in South Africa occurred across at least five hospitals duly authorized to perform transplants.

In Kosovo, the context of corruption and instability following the conflict provided fertile ground for illegal transplant activities. Conversely, in the Netcare case in South Africa, outdated and unclear legislation, coupled with lenient penalties and jurisdictional gaps, created an environment conducive to large-scale illegal transplants with minimal risk of prosecution.

Conclusion

Contrary to popular mythical depictions of the trade as an underground crime that takes place far away from legal, medical institutions and their staff, this study has shown that the trade can be deeply embedded within the medical sector. The findings point to locations where dubious activity can be recognized and disrupted, such as airports, hotels, and hospitals.

Moreover, the study highlights the urgent need for reporting mechanisms within medical facilities to detect and combat organ trafficking. However, such mechanisms are currently lacking in hospitals and other locations.

It’s worth noting a limitation of the research: it focused on only two historical cases, limiting its generalizability to other instances of organ trafficking. Additionally, changes in legislation over time may have reshaped the organization of organ trade networks.

Actionable recommendations

  • Medical staff, law enforcement, customs, airport –and hotel staff should be trained in recognizing dubious or illegal transplant activity. Organ trafficking indicators are a helpful tool to guide recognition and disruption.
  • Because organ sales are criminalised, organ sellers are reluctant to report abuses. Lawmakers and policymakers should consider decriminalising organ sales (removing penalties in the law) and offering organ sellers protection.
  • Countries should allow medical professionals to safely and anonymously report dubious transplant activity. This information can help the police and judiciary investigate, disrupt, and prosecute those who facilitate illegal organ transplants.

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Journal reference

Ambagtsheer, F., & Bugter, R. (2023). The organization of the human organ trade: a comparative crime script analysis. Crime, Law and Social Change80(1), 1-32. https://doi.org/10.1007/s10611-022-10068-5

Roos Bugter holds a degree in Criminology and completed her master’s thesis on the Medicus case during her internship at the Department of Nephrology and Kidney Transplantation of Erasmus MC’s Transplant Institute. Subsequently, she co-authored this article. Through this article, she aims to enhance understanding of human trafficking, particularly organ trafficking, and highlight the advantages of employing crime-scripting in this domain. She is presently employed at Triodos Bank as an analyst focusing on research into money laundering, terrorism financing, and human trafficking.

Frederike Ambagtsheer is an assistant professor and organ trafficking researcher at the Department of Nephrology and Kidney Transplantation of Erasmus MC’s Transplant Institute in Rotterdam, The Netherlands. Her ambition is to increase knowledge, raise awareness, and improve responses to the human organ trade. She coordinated the first EU-funded project on organ trafficking (2012-2015). Currently, she leads two projects funded by the Dutch Research Council: the first studies kidney sales by migrants in countries across the Mediterranean border. The second surveys European citizens’ opinions on removing financial disincentives and allowing incentives for deceased and living organ donation.