In Iran, people buy kidneys
The whirling hum of a dialysis machine could have been the soundtrack to the rest of Zahra Hajikarimi's life but for an unusual programme in Iran that allows people to buy a kidney from a living donor.
Iran's kidney programme stands apart from other organ donation systems around the world by openly allowing payments, typically of several thousand dollars. It has helped effectively eliminate the country's kidney transplant waiting list since 1999, the government says, in contrast to Western nations like the United States, where tens of thousands hope for an organ and thousands die waiting each year.
Critics warn the system can prey on the poor in Iran's long-sanctioned economy, with ads promising cash for kidneys. The World Health Organisation and other groups oppose "commercialising" organ transplants. Some argue such a paid system in the US or elsewhere could put those who cannot afford to pay at a disadvantage in securing a kidney if they need one.
But as black-market organ sales continue in countries like India, the Philippines and Pakistan and many die each year waiting for kidneys, some doctors and other experts have urged the US and other nations to consider adopting aspects of Iran's system to save lives.
"Some donors have financial motivations. We can't say they don't. If [those donors] didn't have financial motives, they wouldn't... donate a kidney," Hashem Ghasemi, the head of the patient-run Dialysis and Transplant Patients Association of Iran, said. "And some people just have charitable motivations."
As far as organ donations go, kidneys are unique. While people are born with two, most can live a full, healthy life with just one filtering waste from their blood. And although a donor and recipient must have a compatible blood type, transplants from unrelated donors are as successful as those from a close relative. In addition, kidneys from a living donor have a significantly better long-term survival rate than those from a deceased donor.
Iran started kidney transplants in 1967 but surgeries slowed after the 1979 Islamic Revolution and the storming of the US Embassy in Tehran, in part due to sanctions. Iran allowed patients to travel abroad through much of the 1980s for transplants -- including to the US. But high costs, an ever-growing waiting list of patients and Iran's grinding eight-year war with Iraq forced the country to abandon the travel-abroad programme.
In 1988, Iran created the programme it has today. A person needing a kidney is referred to the Dialysis and Transplant Patients Association, which matches those needing a kidney with a potential healthy adult donor. The government pays for the surgeries, while the donor gets health coverage for at least a year and reduced rates on health insurance for years after that from government hospitals.
Those who broker the connection receive no payment. They help negotiate whatever financial compensation the donor receives, usually the equivalent of US$4,500 (about 155,000 baht). They also help determine when Iranian charities or wealthy individuals cover the costs for those who cannot afford to pay for a kidney.
Today, more than 1,480 people receive a kidney transplant from a living donor in Iran each year, about 55% of the total of 2,700 transplants annually, according to government figures. Some 25,000 people undergo dialysis each year, but most don't seek transplants because they suffer other major health problems or are too old.
Some 8-10% of those who do apply are rejected due to poor health and other concerns. The average survival rate of those receiving a new kidney is seven to 10 years, though some live longer, according to Iranian reports.
In the United States, about a third of kidney donations come from living donors. The average kidney from a deceased donor lasts 10 years, while one from a living donor averages about 15 years, according to Dr David Klassen of the United Network for Organ Sharing, or Unos, which oversees the US transplant system. Recipients of living-donor kidneys in the US fare better in part because they haven't been on dialysis as long before their transplant.
For Ms Hajikarimi, a 52-year-old Iranian mother of two, a transplant can't come soon enough. Her kidneys failed, with doctors finding higher-than-normal protein levels in her urine, and she has been on dialysis for four months.
In that time, physicians determined Ms Hajikarimi can undergo a transplant and the nonprofit group managing her case began looking for a donor, a process that typically takes up to six months. Then the recipient and the donor meet to agree to the financial arrangements before the surgery.
Iran says its system safeguards against black-market organ sales by having the nonprofit groups handle all arrangements and hold money in escrow until after the surgery. The government's Health Department also must approve the surgeries, which take place in licensed and monitored hospitals. Foreigners are now largely banned from taking part, squelching the possibility of medical tourism.
However, it's clear that some donors are motivated by the cash payout. Inflation and unemployment remain high in Iran even after last year's nuclear deal with world powers that saw some sanctions lifted.
One man said he applied to sell one of his kidneys to pay off his debts. Debtors can be imprisoned in Iran.
"I am here because if I don't get the money my entire life will be ruined," said the man, who spoke on condition of anonymity for fear of ruining his professional image. "My life and my public face are in danger. This has driven me to do this."
Poverty around the world drives black market kidney sales, a lucrative business the WHO estimated represented at least 5% of all transplants in 2005, though it acknowledges that figure is only a guess. The UN health agency's guiding principles on organ transplantation call for banning organ sales, though it allows for "reimbursing reasonable and verifiable expenses", including the loss of income by a living donor.
In the US, there are more than 99,000 patients currently on the waiting list for a kidney transplant. Last year, there were 17,878 transplants, while 4,481 died waiting, according to Unos. A 1984 US law makes organ sales illegal.
A series of academic papers and opinion pieces in recent years by doctors and prominent economists like Nobel Prize winner Alvin Roth have explored the idea of allowing paid kidney donations in the US. An article in October's edition of the American Journal of Transplantation written by three physicians and an economist proposed a system in which the US government would pay $45,000 to a living kidney donor and $10,000 to the family of a deceased donor.
"Such compensation would be considered an expression of appreciation by society for someone who has given the gift of life to another," the paper said.
Some ethicists and doctors argue that compensating donors in the US would put the poor at a disadvantage of getting a transplant while also pressuring them to offer their organs for sale when they face financial trouble.
"We still think profiteering or someone making a profit from a sale and making this a commercial enterprise is a slippery slope," said Kevin Longino, the CEO of the National Kidney Foundation in the US. "It's still an easy way to exploit poor people and underprivileged people."