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Eleni Dagiasi flew from Athens to Delhi in January 2008 on a mission to save her life. With her husband, Leonidas, she took a taxi from the airport past sparkling multiplexes and office buildings to a guesthouse in the booming exurb of Gurgaon. A kitchen staff was on hand, the rooms had cable, and there was a recreation area with billiards, providing patients with creature comforts while kidney transplants were arranged. Over the next week, as her operation was scheduled, Dagiasi went to a makeshift hospital for dialysis. Then one night, while she was watching TV with her husband, a chef turned off the lights and urged everyone to leave. Shortly afterward, 10 policemen stormed in. “We were too stunned to react,” says Leonidas Dagiasis, a former fisherman who borrowed money from his employer to finance the trip. The couple and other guests were hauled off for questioning. The Gurgaon hospital, it turned out, was the hub of a thriving black market in kidneys. The organs were harvested from poor Indian workers, many of whom had been tricked or forced into selling the organ for as little as $300.

The mastermind, India’s Central Bureau of Investigation (CBI) charged, was Amit Kumar—a man who performed the surgeries with no more formal training than a degree in ayurveda, the ancient Indian system of medicine. In a career spanning two decades, Kumar had established one of the world’s largest kidney trafficking rings, with a supply chain that extended deep into the Indian countryside. Some of his clients were from India. Many came from Greece, Turkey, the Middle East, Canada, and the United States.

At parties in India and abroad, Kumar introduced himself as one of India’s foremost kidney surgeons, said Rajiv Dwivedi, a CBI investigator based in Delhi. The claim wasn’t entirely illegitimate: Investigators estimate that Kumar has performed hundreds of successful transplants, a practice so lucrative that he was able to finance Bollywood movies and had to fend off extortion threats from the Mumbai mafia. Two weeks after the police crackdown in Gurgaon, Kumar was arrested at a wildlife resort in Nepal and brought back to India, where he now awaits trial.


Kumar’s operation was a microcosm of the vast, shadowy underworld of transplant trafficking that extends from the favelas of São Paulo to the slums of Manila. The tentacles of the trade crisscross the globe, leaving no country untouched, not even the United States, as evidenced by the July 2009 arrest of a New York rabbi who has been charged with arranging illegal transplants in this country by bringing in poor Israelis to supply kidneys.

In June 2008 I traveled to India to get an inside view of Kumar’s ring and examine the perverse enterprise that fueled its rise. How did Kumar build his organ empire, and how was he able to run it for so long? The answers, I learned, lay in the grinding poverty and entrenched corruption of India, the desperation of patients on dialysis, and the transnational nature of the black market transplant business—which, though dominated by the kidney exchange, includes livers and hearts as well. The factors at play in India allow the kidney trade to thrive around the world, despite efforts by various governments to stamp it out.

Life without a working kidney is harsh. We are born with two of these internal filters, located below the rib cage, to remove waste and excess water from our blood. Patients with kidney failure—often the result of diabetes and high blood pressure—can die within days from the buildup of toxins in the bloodstream and the bloating of organs. To avoid this outcome, modern medicine offers dialysis, a process in which blood is cleansed at least three times a week by pumping it through an external or internal filter. This grueling routine comes with dietary restrictions and side effects like itching, fatigue, and risk of infection. Theoretically you can live on dialysis for decades; in reality, though, risks are so great that without a new kidney, premature death is the frequent result.

No wonder that those needing a kidney vastly exceed the number of kidneys available from deceased donors. In the United States, some 88,000 individuals were on the waiting list as of early 2010, with 34,000 names typically added every year. The wait averages five years. The situation in Greece is similarly dire: Eleni Dagiasi put her name on a list around 2006 and expected a waiting period of five years or more. In the meantime, she needed dialysis three days a week—a treatment requiring that she live in Athens, more than 75 miles and three hours’ travel from her husband, who works on Andros Island as a caretaker of yachts. After Eleni learned of the India option through one of Kumar’s brokers, the couple saw it as a way out.

They could have gone elsewhere: to Pakistan, where entire villages are populated by men who have been stripped of a kidney; to China, where kidney harvesting from executed prisoners has supported a booming transplant industry; or to the Philippines, where transplant tourism flourished until May 2008, when the government banned the trade. Transplant tourism today accounts for as much as 10 percent of all donor kidneys transplanted, says Luc Noël, coordinator for Essential Health Technologies at the World Health Organization (WHO). Often lured by middlemen (or drugged, beaten, and other­wise coerced), donors end up with a few hundred to a few thousand dollars and a scar at the waist that has become an emblem of exploitation and human indignity.

The kidney trade has its origins not in the underworld but in the bright light of medical advancement and the globalization of health care. It began in a hospital in Boston in 1954, when a medical team led by plastic surgeon Joseph Murray conducted the first successful kidney transplant from one identical twin to the other. There was no immune rejection to contend with because the donor’s and recipient’s organs had coexisted happily in their mother’s womb. Through the 1950s and ’60s, researchers attempted to make transplants work in patients who were unrelated to their donors. To help the new organ withstand the assault from the recipient’s natural defenses, doctors developed tissue type matching, a technique to determine if the chemistry of the donor’s immune system, defined by antigens on the surface of cells, was similar to that of the recipient’s. Doctors also bombarded the recipient with X-rays and used a variety of drugs to beat the immune system into submission.

In the early 1980s transplants became feasible on a wider scale. What changed the scene was an immunosuppressant molecule called cyclosporin, developed by researchers at Sandoz, the Swiss pharmaceutical company. It became the foundation for new drugs that could counter organ rejection with unprecedented effectiveness.