In total desperation, Tupa contemplates selling one of her kidneys on Dubai’s black market in order to make some quick cash to return home. The trafficking of human organs may be a lesser known aspect of human trafficking more generally, but the two are increasingly interconnected in places like Dubai.
Few things capture the growing disparities between the haves and have nots in a more macabre manner than the trafficking of human organs. The idea of trolling humanity’s poorest and most vulnerable communities to harvest spare body parts for the benefit of our wealthier and more privileged members is the stuff of science fiction movies like Comaor books like Kasuo Ishiguro’s Never Let Me Goand Ninni Homqvist’s The Unit. But does it actually happen? It not only happens, but it has become a significant global problem underpinned by a sophisticated and highly resilient network of players including organized crime members, tour group operators, professional organ hunters, rogue surgeons, and more ‘legitimate’ but unwitting (some would say naïve) biomedical professionals working at some of the West’s finest hospitals and medical research institutions around the world (including the U.S.). Perhaps the biggest fault associated with fictionalized depictions of the black market in human organs is an inability to capture the true diversity of players and how so many operate in the open or under the guise of professional legitimacy. The issues are strikingly similar to those involving human trafficking and the sex trade, including transactions that range from the consensual to the coerced, multiple forms of violence ranging from the direct use of force to insidious forms of structural violence that restrict individual freedom and choice, and the commodification of bodies (and body parts) against the backdrop of a globalized economy and the unquestioned neoliberal ideals of free trade, privatization, and limited public oversight.
When it comes to the actual global pathways of human organs, much of the emphasis has been at the global, geo-political level. Nancy Scheper-Hughes, a medical anthropologist who has conducted extensive research on the illicit trade in organs and serves as Director of Organs Watch, has gone to great lengths to trace an elaborate network of nation-states that fall on either the supply or demand side of the equation. She paints a broad picture where those in need of human body parts include wealthy countries like the United States and a large swath of Middle Eastern states (including the UAE). Meanwhile, the supply-side is made up of comparatively less wealthy countries with large populations of people living in shantytown settings, such as the Philippines, India, and Thailand. Scheper-Hughes also describes a pattern in which it is mostly men who supply organs. While there may not be any reason to question this picture at a general, world-systems level, there are reasons to believe that the UAE – and Dubai in particular – is in a unique position to buck this trend, if it has not done so already.
Since organ trafficking emerged from the shadows and as something more than just the plot of a science fiction novel, the UAE has been consistently pegged as a country where human organs are in high demand. In fact, the first high profile article involving the black market in human organs – which appeared in a 1990 issue of the prestigious medical journal The Lancet –documented the experiences of 131 renal patients from three dialysis units in the UAE and Oman as they travelled to the slums and shantytowns of India in search of individuals willing to donate a kidney. As the article highlighted the murky line between willing donors and the outright exploitation of the desperately poor, there at center stage were the privileged citizens of the UAE, who were clearly benefiting from an ethical muddle that no matter how you rationalized it had an air of repugnance and sleaziness to it that was impossible to shake.
Since The Lancet article, UAE’s demand for human organs has only grown, though now the most prized organ of all is the kidney. Why the kidney? The answer has to do with a bevy of lifestyle factors that are all too familiar to Americans: poor nutrition, lack of exercise, and a serious obesity epidemic. These are the key ingredients for Type 2 diabetes and, ultimately, chronic kidney disease leading to kidney failure.
The UAE has quickly progressed to the top of the charts when it comes to prevalence rates for Type 2 Diabetes. While getting accurate data can be a challenge, most reports put the prevalence rate of Type 2 Diabetes among UAE citizens at around 20%, with another 20% at high risk of developing the condition in the near future. And with an estimated growth rate of 10-15% per year, it is entirely possible that well over half of Emirati will be diabetic or pre-diabetic in a very short time. These kinds of numbers easily put the UAE in the top 10 with respect to countries having the highest rates of diabetes in the world, with many experts placing it as high as number two. An oft-repeated anecdote is that the country would be number one if it were not for the Republic of Nauru, a tiny speck of an island in the middle of the Pacific where almost every resident is overweight and three-quarters are obese following a truly unique and tragic set of circumstances that led to a government-sponsored lifestyle essentially dedicated to getting fat.
But what happened in Nauru is not entirely dissimilar to the situation in the UAE. Both countries became fabulously and rapidly wealthy by encouraging outside investment in their natural resources (or in the specific case of Dubai, its brand), relied almost exclusively on outside labor to do all the dirty work, and then proceeded to coddle and spread the wealth among its citizens for doing next to nothing, all of which resulted in the widespread adoption of a sedentary lifestyle. In the UAE, Emirati packed on the pounds as they hired maids and other household servants to do all the chores, gorged themselves on a Western fast-food diet of pizza and hamburgers, drove their new cars everywhere (except to the gym), and generally embraced a lifestyle of hyper-consumerism filled with TV and computer games. As early as 2000, the World Health Organization was reporting that over 50% of Emirati were overweight or obese. In 2008, the Department of Nutrition and Health at UAE University reported that about a quarter of children between the ages of 8 and 12 were overweight. Currently, the country ranks among the top 10 worldwide in terms of obesity rates. The extent of the problem is even more pronounced when one keeps in mind that less then half a century ago, the region was inhabited almost exclusively by nomadic Bedouin who subsisted on a balanced diet of fish, rice, bread, dates, yogurt, and meat from their livestock.
The health care system in the UAE is unable to address the many nuanced issues involved when it comes to diabetes, modeled as it is on the West and a largely curative rather than prevention-oriented approach to disease and illness. In other words, it is the exact opposite of what is needed to combat a ‘lifestyle disease’ like Type 2 Diabetes. The number of health professionals who focus on diabetes care and prevention are limited, including – most importantly – health educators. Their absence translates into an increasing number of misdiagnoses and people who are unaware that they even have diabetes until they experience kidney disease and a transplant. Yet the first kidney transplant was not even performed in the UAE until 2013. Prior to that, individuals had to leave the country to get a kidney as well as to have it installed (as it were). As the situation matters approaches crisis levels, the Health Authority of Abu Dhabi (HAAD) has been forced to acknowledge the need for drastic health care reform.
They better move fast, given that future projections for diabetes in the Middle East do not look good. Most experts agree that over the coming years the region will face the greatest increase in Type 2 Diabetes in the world and a 32% increase in treatment demand for diabetes-related ailments. The UAE already spends more in diabetes than any other country in the Middle East, but HAAD forecasts an unprecedented fourfold increase in healthcare costs related to diabetes over the next 15 years.
Future projections for diabetes translate into a huge demand for anything kidney-related, including dialysis equipment. The Middle East is already the fourth largest importer of kidney dialysis equipment, but it is on pace to become number one in just a few short years. Companies aggressively market their products throughout the region and the UAE specifically, pitching oddball items like kidney dialysis chairs with all the overbearing shrewdness of used car salesmen. They know their audience and artfully promote products with the overweight and obese in mind: “…comfort foam, phlebotomy arm rests…able to lift 225 kg from its lowest height, full choice of accessories and colors…” Combine obesity with a culture of hyper-consumerism, and the UAE represents a diabetic cash cow for biomedicine and a slew of support industries, interested parties, and hangers-on. There is a notable fervor and buzz among entrepreneurs and others who see the massive profits to be made from the UAE’s diabetes epidemic, all of which translates into the perfect environment for a thriving black market.
But exposing Dubai’s black market in kidneys is another matter altogether. The supply side of the human organ trade can be ugly, filled with unpleasant images of shantytowns, back-alley kidney hotels, makeshift operating rooms, and even discarded bodies with their organs cut out. No place wants to be associated with such scenes, especially Dubai, which protects and polices its image as zealously and aggressively as any place on Earth. Dubai is not just a place – it is also a brand – so it works overtime to protect its image and the enormous amount of wealth and benefits that come with it. The last thing it needs is any hint of an association with the human organ trade – especially the supply side of the equation. The entire issue also speaks to its treatment of migrant laborers, something Dubai’s leaders are already hypersensitive about.
In fact, Dubai’s multi-pronged public relations machine has gone into overdrive in recent years in order to quash nagging rumors that a thriving black market supply in human organs exists within its borders. In 2014, reports circulated on social media that a Dubai-based gang had been kidnapping children in order to sell their internal organs. While the story was never proven true, Dubai’s highest police officials saw fit to launch a massive media campaign to denounce the story as “rumor” while threatening anybody linked to it with legal action, warning that spreading such a rumor would be “committing a crime against the society by instilling fear in them.” They reacted similarly when news spread of a man who was being held in one of Dubai’s debtor prisons placed an ad on a classifieds website offering to sell his kidney in order to pay off his debt. Articles refuting that such a thing could happen in Dubai quickly appeared in the media, many with direct quotes and assurances from Dubai’s leading physicians. The ad was quickly taken down amidst extensive warnings of disciplinary and legal reprisal. Yet within weeks, other ads appeared on the very same website, one from an individual in financial distress advertising a human kidney in “flawless” condition. Dubai’s media mill churned into action once again, mocking the ads and dubbing them as “bizarre,” even likening them to other oddball things for sale like cheetahs and parrot eggs. One article even provided its readers with a list of “the 10 weirdest eBay auctions, followed by 10 of the most bizarre personals ads posted on Craigslist” – anything to deflect attention from the underlying conditions that might prompt Dubai’s desperately poor to sell their organs. In other words: move along people, there is nothing to see here.
Meanwhile, Emirate continue their search for healthy kidneys, and expeditions in search of the elusive organ have only broadened and become more sophisticated. There are now numerous reports in both the scientific literature and the popular press documenting the experiences of UAE citizens as they scour the world’s slums in places like Thailand, the Philippines, Egypt, India, and Pakistan in search of black market kidneys for transplant. Another popular destination is China, where the organs of executed prisoners are openly offered for sale. A growing number of UAE nationals who experience renal and liver failure are turning to illegal transplant brokers, and almost every doctor in the country has a story of being approached by one of these shady middlemen. Some even operate ‘transplant tour agencies’ that organize travel, passports, visas, and all the logistics related to the surgery. As Scheper-Hughes notes, the Middle East is replete with such services, often creating or using religious organizations, charitable trusts, and patient advocacy groups as fronts.
Countries on the supply side of the equation often conduct their transplant services in the open. In the Philippines, for example, the idea of selling a spare body part is almost as ordinary as any other business transaction, and there are entire communities whose residents are so anxious to sell their kidneys or livers that they will actually haggle with one another on street corners to offer you the best price. In other countries, such as those in Eastern Europe, the deals go down in hidden settings that are notably dark and ominous, where many individuals who supply their body parts spiral downward into an abyss of shame, regret, and public humiliation, unable to shake the sense that selling an organ represents an unforgiveable sin.
Individuals who buy kidneys on the international black market have their own set of problems, many of which involve the inevitable complications that arise as a result of botched surgeries. The UAE has seen a steady rise in complications due to kidney transplants performed in other countries; some hospitals estimate that they see as many as 30-40 patients each year as a result of transplant surgeries gone horribly wrong, and the numbers are on the rise. Some patients lose their transplanted kidneys as a result of such complications, forcing them into an even more desperate life and death search.
Dubai recognizes it has a problem on its hands, but addressing the underlying lifestyle issues associated with obesity, poor nutrition, and lack of exercise can be challenging. Dubai is not exactly known for its exercise culture; until recently the only health clubs to be found in the entire emirate were located in hotels. Abu Dhabi and Dubai city, an urban planning strategy that did not exactly go out of its way to promote physical activity did not help matters. Health promotion events are a relatively new phenomenon and their strategies to motivate people to exercise can seem somewhat perplexing. For example, the “Yalla Walk” (“Let’s Walk”) initiative offered cars as prizes to those who lost weight by walking in one of Dubai’s parks, while another program challenged citizens to lose weight by giving them a gram of gold for every kilogram shed over the course of a month. One story that made headlines in 2010 involved the annual Abu Dhabi half-marathon, where not one citizen from the UAE managed to be among the hundreds who actually finished the race. In fact, there is a general perception among Emirati that being overweight is a sign of both wealth and health (a popular belief in Nauru as well). One easy fix that many people have discovered is gastric bypass surgery or what is more commonly known as stomach reduction surgery. The procedure has proven so popular that some hospitals in Dubai are carrying out as many as 40 each month. Not surprisingly, the surgery does not necessarily kick start people into adopting a healthy lifestyle. For some, the procedure is a license to jump right back into a life of hedonism and excess. As one patient reported to a local newspaper following his surgery: “Because of my weight, I could not sit in the car of my dreams. Now I feel my Lamborghini is approaching.” Such a mindset contributes to a general situation in the UAE where awareness of diabetes is high but public perception of its importance is low. Why worry about or change your behavior when you can have the government subsidize your stomach reduction surgery and jump right back into your luxury sports car?
Dubai is also putting a lot of marbles behind its new national cadaver donation scheme that allows people to donate organs upon their death. Until 2010, when the law was changed, only transplants from living donors could be performed. Prior to that time, a tangled web of religious and cultural precepts combined with a series of vague and poorly written laws prevented the UAE from establishing a national donor system. Now, a person can choose to donate a kidney to a registered patient on a donor waiting list, which Dubai’s leaders and medical professionals frequently highlight as a cure-all, implying that it should put a stop once and for all to its citizen’s participation in black market organ activities. They even point to the strong potential for donors due to the high number of deaths from traffic accidents, which stems from its dependency on automobiles and the penchant among Emirati for luxury sports cars.
But the existence of a national donor system is no guarantee that demand for human organs will be satisfied. An obvious case in point is the United States. Despite having a donor system in place for decades now, the list of people in need of a transplant has grown exponentially over the years while the number of organ donors has barely budged. The number of people waiting for a donor organ who actually receive one gets fewer each year, which is why researchers like Scheper-Hughes can easily trace black market organs to the finest public, academic, and private hospitals in the United States. There are other reasons why the black market persists, including advances in medicine that keep us alive longer (and when it comes to kidney-related issues, this contributes to a larger pool of obese patients with Type 2 diabetes), the robust and resilient nature of underground criminal rings themselves, and a climate of denial within the biomedical industry and among transplant surgeons who until recently did not even seriously consider that a black market existed. In fact, many rogue transplant surgeons see themselves as saviors and mavericks who actively subvert unrealistic, outdated laws for the benefit of those in need. Patients tend to agree with this perspective, especially those who need a kidney and consider the endless waiting and dialysis treatments as an unnecessary, state-imposed form of suffering. And taking a kidney from a healthy, living person will always be preferable to receiving one from some collective repository of mysterious corpses. All of these factors are whey transplant surgeons agree that demand for organs from living donors will only continue to grow.
In the end, a national cadaver donation scheme can only go so far, especially in Dubai, where there is a ready-made population of vulnerable people from around the world right at its doorstep. Why get a kidney from a dead person when you can get one from the living? And why travel to far-away countries for something you can just as easily get it at home? When it comes to the UAE and Dubai in particular, one has to wonder why these questions are not asked more often. If there is one place in the world that does not fit the mold of mutually exclusive points of supply and demand, it is Dubai. The Emirate’s unique population structure – consisting as it does of a wealthy minority of increasingly obese and diabetic citizens who surround themselves with a sea of marginalized, indebted servants – could not be a better recipe for the black market trade in kidneys. And many if not most of its marginalized majority just happen to come from countries that are the biggest suppliers of human organs. When it comes to kidneys – the most coveted of all human organs – Dubai represents the ultimate overlap between supply and demand. That is significant in a place where money buys everything.
There are some signs that a thriving but highly secretive supply-side black market in kidneys exists among Dubai’s migrant laborers. But the Emirate has been particularly successful at hiding what life is like inside its massive migrant labor camps, most of which are placed in the desert on the outskirts of town or squeezed in among it’s desolate, post-apocalyptic industrial areas. The migrant labor camps are exactly where to start if you want to hear whispered stories of individuals who, in such dire straits, are compelled to have a kidney carved out of them. But whispers are all that you are likely to hear, especially if you are a journalist, researcher, rights activist of some kind, or anybody ‘from the outside.’ Everybody knows that talking openly about illegal kidney surgeries is a taboo subject that could lead to serious trouble. The stories are there, however, and most highlight surreptitious deals put together stealthy brokers who seek the most desperate individuals: migrant workers yearning to go home but cannot due to massive debt. Such individuals make up a fairly large pool in Dubai, which allows brokers to hone in on the most extreme cases, as well as meet the more specific demands of their clients, such as Emirati women who seek kidneys from other women (this would make Dubai unique since black market suppliers around the world are almost always male). Whether the supplier is a man or a woman, offering up a kidney will pay off debts and possibly leave them with a wad of cash that would take several years to earn as a migrant worker. It is a win-win situation for everyone involved and, as an extra bonus, all the evidence is literally shipped out of the country since the supplier is given a ticket home as part of the deal. You would be hard pressed to find bodies with the telltale scars of kidney sellers in Dubai.