The possibilities quickly became evident. “Doctors realized that with cyclosporin, you did not need a related donor,” says Lawrence Cohen, an anthropologist at the University of California at Berkeley. Clinics were able to cast a wider net for donors, and kidney transplants became an established surgery around the world. Soon kidneys were a commodity. The first reports of kidney selling began to surface in India around 1985. With its large base of doctors and an expanding health care industry, India had already been attracting medical tourists from the rest of South Asia and the Middle East. Now there was a growing stream of patients from these countries checking into hospitals in Chennai, Mumbai, and Bangalore for kidney transplants. “There were lots and lots of sales,” Cohen says.

In Southeast Asia another kidney trading corridor had opened up, with the Philippines as the hub. Patients from Japan and elsewhere traveled to Manila to buy kidneys. The organs often came from jailed felons, according to Nancy Scheper-Hughes, a U.C. Berkeley anthropologist who has documented the trade in various countries. “Guards would pick out the healthiest-looking prisoners,” she says. Some reports allege that buyers negotiated with the prisoners’ families, not the prisoners themselves. Meanwhile, China became the destination for patients from Singapore, Taiwan, and Korea. Under a rule approved by the Chinese government in 1984, kidneys and other organs were harvested from executed prisoners. Human rights activists became concerned that China might have been ramping up its executions through the 1980s and ’90s in order to boost its organ supply.

The practice was gaining notoriety, but interventions urged by WHO and others often failed. India legislated its Transplantation of Human Organs Act, banning the buying and selling of organs, in 1994. But the law did not eliminate the practice; it simply drove it underground. By the end of the decade, the kidney trade was thriving, largely due to the Internet. Web sites touting “transplant packages” priced from about $20,000 to $70,000 sent patients, many of them Americans, flocking to hospitals in the Philippines, Pakistan, and China. In 2001, when authorities apprehended a criminal syndicate trafficking kidneys from slum dwellers in Brazil and poor villagers in Moldova to Israelis, it became evident that the trade had spread far and wide.

When Kumar was arrested on February 7, 2008, he struck a defiant pose for the cameras as Nepalese officials prepared to escort him to Delhi. In the weeks that followed, he became a media celebrity, with investigators leaking stories about his flamboyant lifestyle. News reports alluded to Kumar’s owning properties in India, Hong Kong, Australia, and Canada. Sher Bahadur Basnet, a Nepalese police official who apprehended Kumar, told me that he made frequent trips to nightclubs and casinos in Kathmandu. In an ironic twist, an Indian news channel discovered a clip from an obscure 1991 Hindi flick titled Khooni Raat (“bloody night”) in which Kumar—who harbored ambitions of becoming a movie star—plays a bit role as an upstanding police officer.

The first time I saw Kumar was in June 2008 at a court in Ambala, some 125 miles northwest of Delhi. The court had yet to open its doors when I arrived, and I sat outside on a bench. Two of the ring’s employees —a driver named Harpal and a cook who worked at the guesthouse, Suresh—showed up, wiping their faces with handkerchiefs. They told me they had no idea that Kumar had been conducting illegal transplants.

A police van drove up carrying Kumar and his accomplices, including his youngest brother, Jeevan Raut (Kumar’s original family name), who has a degree in homeo­pathy; a middleman named Gyasuddin; and a physician named Upender Dublish. Dressed in a beige shirt, Kumar waved at his lawyers from behind the vehicle’s rusty iron-mesh window. He had shaved off his mustache and his eyes looked bulbous. He glanced about furtively while talking with his lawyers.

I inched closer to the van under the gaze of policemen standing nearby, one of whom told me sternly that reporters were not allowed. Nonetheless, I introduced myself to Kumar, who responded with a nervous smile. “I never forced anybody to donate a kidney,” he told me before a potbellied guard shooed me away. Inside the courtroom, Kumar kept primping his hair and smoothing out his shirt while the prosecutor, Ashok Singh, presented the charges, citing complaints by seven men alleging that they were tricked or forced into selling their kidneys. Kumar looked crestfallen as he was led back to the van, but his brother walked with a swagger, yelling out to me, “They have no case against us!”

At the start of their investigation, CBI officials found it difficult to believe Kumar had been conducting transplants on his own. “We thought his role was to provide donors and clients,” Dwivedi told me. The agency assembled a panel comprising a surgeon, a nephrologist, and a forensic medicine expert to probe Kumar’s self-proclaimed expertise. In a two-hour interview not unlike a qualifying exam, the panelists asked Kumar to walk them through the steps involved in a transplant, from removing a kidney to hooking it up inside a recipient. By the end they were convinced. “Kumar had adequate theoretical knowledge about the surgical process” for kidney transplants, the panel said in a report filed in court.

Yet when Kumar entered the transplant business in the 1980s, it was not as a surgeon but as an entrepreneur. To understand how a leading organ dealer got his start, I visited Kumar’s second-youngest brother, Ganesh Raut, a real estate developer who now lives in the same Mumbai apartment where Kumar set up a hospital in 1984. Although Ganesh has not always been on good terms with his brother, he has stood by him since the arrest, accompanying Kumar’s lawyers to court hearings and meeting with Kumar in jail.

Nobody answered when I rang the bell, but the door was unlocked and I ventured in to find a friendly basset hound wagging its tail in the hallway. Ganesh, a portly, clean-shaven man, was in the middle of morning prayers in front of a miniature temple. I took in the smell of burning incense as he lit a diya and completed the ritual. Then he told me of Kumar’s childhood ambitions.

“He would often tell us that he wanted to do something extraordinary in life,” Ganesh said. After college in 1977, Kumar went to work at the M.A. Podar Ayurvedic Hospital in Mumbai. He began assisting with simple outpatient surgical procedures that ayurvedic practitioners are licensed to handle, nothing more complicated than removing hemorrhoids, and later began freelancing as a surgical attendant at mainstream hospitals. Within a few years, he had made enough money and contacts to start his own hospital. Ganesh showed me the room that had once been the hospital’s operation theater, where surgeons hired by Kumar performed head-and-neck and abdominal surgeries in the early years, before he turned it into more of a transplant center. Now it was a sitting area furnished with wicker chairs.

Ganesh was less forthcoming about Kumar’s kidney venture, so I went to see Rakesh Maria, a top official of the Mumbai Police who shut down Kumar’s first foray into transplants, in 1995. By the late 1980s, Kumar (then using his birth name, Santosh Raut) had become well aware of medical tourists streaming in from the Middle East. “He knew at once that if he could tap this market, he would hit the jackpot,” Maria said. To do so, he reached out to cab drivers at the city’s international airport, paying them a commission to find clients.

There was no shortage of potential donors to Kumar’s makeshift hospital in Mumbai. He targeted homeless beggars, handcart pullers, sweepers. He hired two men to scout the slums and offer anywhere from a paltry $300 to just over $1,000 for a kidney. Later he began paying the agents a fixed amount of a few thousand dollars per donor. To boost their cut, the agents started paying donors less and less.

Through the early 1990s, the business flourished, and the dozens of transplants performed at the hospital (many of them by a Mumbai Hospital surgeon named Yogesh Kothari) provided Kumar with the equivalent of a surgical residency. He attended conferences, read up on nephrology, and learned about different kinds of sutures and im­munosuppressant drugs. In 1994 he performed his first transplant under Kothari’s watch. But after a shortchanged donor filed a complaint, police raided Kumar’s hospital that August, arresting 11 people on charges of cheating and criminal conspiracy. Kumar himself was charged with conducting illegal foreign exchange transactions through two front men—a grocer and a silversmith—who had helped him receive payments from overseas clients to the tune of $60,000.

After four months in a Mumbai prison, Kumar was freed on bail. In 1995, after Maharashtra (the state that contains the city of Mumbai) banned organ selling, he was busted again and charged with conducting illegal transplants. Finally he fled to Jaipur, 800 miles to the north. There he assumed his new name and conducted 13 illegal transplants before being arrested yet again, in 1996. Released on bail, he disappeared from view and did not resurface until 1999, in Gurgaon. There Kumar built an empire bigger and more organized than ever as the Indian legal system churned sluggishly on.

While Kumar was setting up business in Gurgaon, Scheper-Hughes, Cohen, and two other academics were launching Organs Watch, a program to document exploitative organ transplantation worldwide. As Kumar’s business boomed, the researchers visited Brazil, Turkey, the Philippines, and elsewhere to interview hundreds of kidney sellers (including victims of coercion and fraud) along with buyers, doctors, and police.

As a result of new regulations, the climate for kidney dealers has gotten tougher. China implemented regulations in 2007 to stop the organ trade. Pakistan’s last president, Pervez Musharraf, issued an ordinance that same year to outlaw organ trafficking, which last April survived a legal challenge by a petitioner who called it un-Islamic. And in May 2008, the Philippines, which for years had promoted transplant tourism, followed suit. Yet, like a multiheaded hydra, the industry seems to be surviving legal onslaughts in countries like India and branching into newer, more vulnerable places such as Iraq and sub-Saharan Africa. “It gets snuffed out in one place and crops up in another,” Scheper-Hughes says.

The trade is adapting to the changing legal climate. One shift has been venue: Transplant surgeries seem to have moved out of large hospitals to small clinics away from the public eye. “We even have anecdotal reports of surgery being transferred to private homes,” WHO’s Noël says.

Another change is in marketing. Gone are the blatant online advertisements for transplant tours. Instead, dealers posing as private sellers post personal ads on Facebook. When the social networking site Orkut outlawed transplant-related communities, it saw a proliferation of user names containing the word kidney, such as “kidney4u.” The Orkut pages of these users are typically blank and presumably exist only as a place for potential buyers to leave a message.

Americans are not just buyers; some may be sellers as well. Scheper-Hughes discovered “an older brother in the Los Angeles area offering to sell his younger brother’s kidney online on Craigs­list.” The phenomenon has opened up a new form of trade, diffuse and fragmented, that has already increased the number of commercial transactions manifold and ushered in new kinds of abuse. And money is not the only inducement, says Monir Moniruzzaman, an anthropologist at Michigan State University in East Lansing. In a study of the organ trade, he has found numerous ads that promise jobs, visas, and even citizenship in the developed world.

Driving from Delhi to Gurgaon in June 2008, I glimpsed the soaring skyscrapers of Gurgaon’s economic boom, but shanties closer to the ground spoiled the glossy view. Finally I entered the gated residential community where Kumar’s hospital, sealed by the CBI, sat in a row of villas. It was enclosed by a wall and draped by bougainvillea vines whose pink flowers stirred in the muggy afternoon breeze. Peeking through the locked iron gate, I saw a stretcher left behind on the grounds. Having escaped from Mumbai and Jaipur, Kumar set up a clandestine facility here, putting up a sign advertising a lawyer’s services. “The idea was to keep nosy neighbors away,” CBI’s Dwivedi said.

Kumar did not work alone. One of his main accomplices, the physician Upender Dublish, ran a hospital in Ballabgarh, an industrial town about two hours away. Bald and rotund, Dublish projects the resigned air of a man terribly wronged but too beaten to protest. At the Ambala courtroom, he told me with a pained look that he needed medical attention for a heart ailment. Dublish ran Kumar’s supply chains, in which the more enterprising donors became middlemen themselves. The result was a pyramid scheme, which Scheper-Hughes says is common to kidney markets around the world. She has seen the pattern in Brazil and Moldova. “Middlemen will say to prospective donors, ‘I lived through it and made money; you can too.’” An early recruit was Gyasuddin, whom I saw with Kumar in Ambala. He told me he sold his kidney for $1,000 and became a node in Kumar’s network, earning about $110 “for every donor I could find.” He brought dozens of donors to Kumar from his hometown, Meerut, an old city about 40 miles from Delhi.

Even as old charges from past arrests slogged through the legal system, Kumar’s layers of protection grew. In 2004 he set up an in-house tissue-matching facility at the hospital to avoid dealing with external diagnostic labs, which he felt would draw the attention of law enforcement officials. But what really prevented exposure was corruption and lack of government oversight. In October 2003, a 55-year-old Turkish patient named Mehmet Bayzit died at the hospital. Bayzit’s relatives wanted the body flown back home, which meant that it had to be embalmed. There was a problem, though: Embalming centers need a death certificate, which in turn requires a doctor’s report.

The situation threatened to attract scrutiny of Kumar’s operations. Dublish came to the rescue. He wrote a report on his Ballabgarh hospital letterhead, stating that Bayzit came to his hospital after experiencing chest pains on his way back from a trip to see the Taj Mahal. The report, citing cardiac arrest as the cause of death, enabled Dublish to obtain a death certificate from local municipal authorities. When two more Turkish patients died, in 2004 and 2005, Dublish used the same story as a cover-up. Indian authorities started an investigation only in 2006, when the Turkish embassy in Delhi, prodded by the patients’ relatives, requested an inquiry. Still Kumar remained unscathed.

In fact, Kumar did not just evade the law; he turned to it for help. In his testimony to the CBI, he claimed that he received extortion threats from men working for Chota Shakeel, a Mumbai mobster. In 2007, after Kumar lodged a complaint, the Anti-Extortion Cell of the Mumbai Police arrested two men suspected of issuing threats on Shakeel’s behalf.

Official incompetence and corruption in Kumar’s case is too outrageous to believe. Since his wealth made him a target for income tax authorities, the government dispatched tax investigators to study his accounts in August 2006. They ignored the fact that the hospital was unlicensed and that it was a venue for illegal transplants. Instead, flabbergasted that Kumar had been paying no taxes for years, the Indian tax department sent him a notice that legal action would follow. Kumar promptly sent the tax department four checks totaling $1.4 million, but when the department tried cashing the checks, they bounced. In a further blow, Delhi police apprehended one of Kumar’s accomplices in January 2008. Kumar reportedly paid a bribe of about $40,000 to a group of police officers in exchange for the man’s release.

Kumar’s luck turned on January 24, 2008, when a constable in Moradabad, a town near Meerut, witnessed a fight between Gyasuddin, the middleman, and a donor named Vidya Prakash; Prakash charged that Gyasuddin had stolen his kidney. The two were taken to the nearby police station, where Gyasuddin directed police to the hospital and guesthouse, resulting in raids and, ultimately, Kumar’s arrest.

I went to Meerut to see Prakash, the man who brought down the ring. To get to his house, I walked through a quiet alley where barefoot children played cricket with a muddy tennis ball and a woman in a burka emerged to dump vegetable peels and eggshells into the street. I zigzagged through lanes that got progressively narrower, passing a dimly lit lathe shop, to finally arrive at a cluster of houses attached to one another like calcifications on a bone.

There, in a two-story structure, I found the Prakash home. Vidya once made a living repairing analog fare meters for auto-rickshaws. When digital meters came online he fell on hard times, he said, and had to sell his blood just to eat. One day he came down with a fever, and a local blood broker turned kidney hunter offered to take him to Gurgaon for treatment. After some lab tests at the Gurgaon hospital, he claims, he was taken for “stomach surgery.” When he regained consciousness, there was a scar on his waist. Prakash says that Kumar’s men, including Gyasuddin, threatened him physically when he complained.

But other kidney sellers in Meerut told me that Prakash had been a part of the pyramid. Among those he had allegedly lured was Mohan Lal (not his real name), a 16-year-old who had run away from his village after his father discovered his affair with a girl from a different caste. Lal was wandering through Meerut’s streets in search of work when, he claims, Prakash offered him a job as a dishwasher at the Gurgaon guesthouse. Once Lal reported for work, he says, he was taken for “free” medical tests and falsely diagnosed with a gallstone that Kumar’s assistants told him needed immediate surgery. (Piyush Anand, a senior CBI official who supervised the investigation, said a number of complainants were similarly misled.) After he was relieved of a kidney, Lal reluctantly accepted cash and continued to work at the guesthouse for several months.

According to Lal and two other kidney sellers, Prakash complained to the police in Moradabad only after a falling-out with Gyasuddin over commission. Prakash, a key witness in the case against Kumar, denies these allegations, but the irony is rich: Kumar’s operation may have been undone not by proactive law enforcement but by squabbling within the ranks.

“Being a good surgeon, that was always my dream,” he wrote. He explained his ayurveda degree: His high school exam scores had been just shy of what he needed to get into medical school. He bragged about his self-taught skills. “I helped recipients get well, and in turn they helped donors lead somewhat better lives.”

Kumar’s defense echoes arguments made by those proposing legalization of the kidney trade, such as Oxford ethicist and philosopher Janet Radcliffe Richards. In a 1996 paper in the Journal of Medicine and Philosophy, Richards wrote that it was a fallacy to view the trade in terms of the “greedy rich” and the “exploited poor.” Such misplaced moral indignation, she wrote, “leave[s] behind one trail of people dying who might have been saved, and another of people desperate enough to offer their organs thrust back into the wretchedness they were hoping to alleviate.”

The debate is not an easy one to settle, as I learned when I met with Govind Verma (not his real name), a father from Delhi whose 8-year-old son, Rahul, received a transplant from Kumar in January 2008. After I repeatedly rang the doorbell of his house one morning, Verma appeared on a second-floor balcony and nervously looked down at me, then reluctantly ushered me into his living room. In a tremulous voice tinged with guilt, he told me that his son’s kidneys had failed at age 5 from infections caused by urinary reflux. The boy hardly went to school. In the fall of 2007, Verma took him to Chennai in hopes of getting a transplant, but the surgeon was arrested, and kidney sales in that city were stopped. A family acquaintance sent him to Kumar, who, out of sympathy, charged a discount price of $12,000 for the job. Rahul no longer needed dialysis, Verma told me, and was seeing friends again. “I had no choice,” Verma said. As he led me out to the gate, his eyes shone with tears. “There were times when I thought of killing myself,” he said, motioning with his hand to suggest jumping from the balcony upstairs.

Rahul’s life may have improved, but none of the donors I met in Meerut or Mumbai seemed to have climbed out of poverty. Rakesh, a homeless man in Meerut, said the $1,000 he got after being tricked into giving up a kidney allowed him to buy drugs and alcohol for two months without having to work. Along with two other homeless donors, he was living in the compound of an abandoned government building. He told me that he was too ashamed to go back to his village.

What I found is borne out by Madhav Goyal, a Johns Hopkins doctor and bioethicist who interviewed more than 300 Indian men compelled to sell their kidneys in the mid-1990s. The bulk of their fees—an average of $1,070—was used to settle the debts that had driven them to make the sale in the first place. The rest was gobbled up by basic needs like food and clothing. Using the cash to start a small business, such as a tea stall or an auto-rickshaw service, remained a pipe dream.

Free-trade proponents argue that donors would fare much better under a government-regulated program, which could provide incentives such as lifelong health insurance or college tuition for the donor’s children. Scheper-Hughes counters that the concept amounts to a “kidney tax” on the poor, exacting an unfair price for basic services and opportunities. She points to Iran, which has allowed kidney donations for cash since 1988, virtually eliminating the waiting list for the organ. A survey of 500 Iranian donors who received $1,200 and a year of medical insurance from the government found that their quality of life, as measured by factors like financial condition and psychological health, remained poor three to six months after the donation. “Nobody denies that most donors live in extreme poverty; many are drug addicts,” says WHO’s Noël. “There is candid recognition in Iran now that the scheme is working well only for the recipients.”

Indian officials find it hard to imagine a financially compensated donor program that would be free of exploitation. Singh, the CBI lawyer, says that initially, recipients might pay the price set by the government, but soon they would start looking for bargains. It would amount to giving the likes of Kumar a hunting license, he argues.

Sale of an organ will always be “an unequal transaction,” CBI director Vijay Shankar, who has since retired, told me. Legalizing the trade would further institutionalize India’s glaring social inequalities while providing an unfair advantage to rich nations like the United States (see “A Transplant Tourist,” below). His words echoed in my head the next morning when I stepped outside my hotel in Gurgaon, where guests were eating a breakfast of aloo parathas, omelets, and juice. At the hotel gate, a man from the shantytown across the street was sharpening knives for the hotel’s kitchen, a weekly assignment that earned him $3. As sparks flew from his grindstone, he told me that even with Gurgaon’s booming economy, he was struggling to feed his family. When he rode off, I imagined how life would change for him if he sold a kidney.

A TRANSPLANT TOURIST

When H. Q., a 46-year-old accountant, was diagnosed with end-stage liver failure at Mt. Sinai Medical Center in New York City, he was given a single option: Wait for a new liver in the United States, where thousands of others were already queued up ahead of him. A year later H. Q.’s illness had worsened, but no donor had emerged. That is when friends suggested he pay for a transplant without the wait, by going to China.

Desperate, H. Q. became a transplant tourist, securing a liver—probably from an executed prisoner—in 2004. Yet the procedure left him with a bacterial infection so severe that the new liver, too, was irreparably damaged. Ultimately, H. Q. needed a second transplant to survive.

In all, more than 100,000 Americans are waiting for transplants across the range of organs—heart, lung, kidney, intestine, pancreas, and liver; some 12 percent will die before their turn arrives. As a result, hundreds of Americans underwent transplants abroad between 2004 and 2006, according to the Scientific Registry of Transplant Recipients.

“Transplant tourism from the United States is growing in direct correlation to the organ shortage,” says Mt. Sinai liver doctor Thomas Schiano, who published H. Q.’s case in Liver Transplantation in 2010. “The bottom line is that governments have to find solutions to provide transplants to those who need them,” Luc Noël of the World Health Organization says.

H. Q.’s botched procedure highlights the murky ethics involved. Did his Chinese donor give permission? Did the lure of profit from an organ sale hasten an execution? Doctors at Mt. Sinai had to decide whether to provide a precious replacement organ to someone who had already bought one under this kind of cloud.

“It’s a tough call, but we were dealing with a patient who was going to die,” Schiano says. “The ethics committee decided it would be wrong to withhold the standard of care that we would normally provide, so we proceeded.”