The Rise of the Red Market

How the best intentions of the medical community accidentally created an international organ-trafficking underground.

On the night of Jan. 11, Turkish police officers burst into a villa in Istanbul's Asian quarter and arrested a 53-year-old transplant surgeon named Yusuf Sonmez. Interpol had been looking for Sonmez since 2008, when a Turkish man collapsed in the airport in Pristina, Kosovo, and reported that his kidney had been stolen. The incident led to an investigation by European Union prosecutors, who uncovered an international organ-stealing and smuggling ring of alarming scope. Sonmez and eight co-conspirators, prosecutors alleged in December, had lured poor people from Central Asia and Europe to Pristina, harvested their organs, and sold them at up to $100,000 a pop to medical tourists from Canada, Germany, Israel, and Poland. The clinic where Sonmez did his work, a separate report by the Council of Europe alleged, was part of an even vaster organ-smuggling network -- one which, incredibly, even involved Kosovo's prime minister, Hashim Thaci.

The trafficking operation was grisly, but hardly unusual. The World Health Organization estimates that approximately 10 percent of the world's organ transplants originate on the black market; as a rule of thumb, that figure seems to hold true across the trade in human body parts. And while occasional law enforcement successes like Sonmez's arrest do happen, for the most part no one is really seriously attempting to shut down a market that is not just lucrative, but, many would argue, inevitable.

It would be an understatement to say that the last century has been a golden age for medical science. The average human life span today is almost a 30 years longer than it was in 1900. We've seen the advent of once-unthinkable innovations such as antibiotics, blood transfusions, and the surgical wizardry of organ transplants. These once-miraculous feats depend on a supply infrastructure that those of us outside the medical profession rarely think about. We take it for granted that if we get into a car accident that the local hospital will have blood on hand for a lifesaving transfusion. If our kidneys fail, we expect a spot on the transplant list. If we are infertile, we expect to have access to someone else's sperm or eggs, or -- if we can afford it -- the services of a surrogate mother to bring a child to term.

Of course, every kidney, cornea, or pint of blood has to come from somewhere -- or, more precisely, someone. Forget the image of grass-skirt-wearing cannibals on tropical islands; no society has had as insatiable an appetite for human flesh as the developed world of the 21st century.

Because the idea of a marketplace in which body parts are bought and sold makes us squeamish, the growth in demand for human materials has been accompanied by an effort to build an ethically justifiable system for supplying them. Organs aren't supposed to be bought and sold; rather, they are donated by altruistic individuals, and we pay for the services necessary to acquire them rather than for the organ itself.

There's just one problem with this picture: It's a fiction. Regulation of the supply of human tissue is haphazard at best; in most cases, people looking to acquire an organ have only the assurances of doctors and social workers to persuade them that everything is aboveboard and ethical. And the very provisions we've built into the system to bring it in line with the ethical norms of medicine and charity have made it easy for criminals to reap outlandish profits buying and selling human flesh.

Half a century ago, the world was relatively comfortable with open commerce in human products. The rollback of that business, and the institution of the system we have today, began with blood. As of the mid-1960s, blood-collection clinics in the United States were amassing 6 million pints of blood a year, for which they paid about $25 apiece at the time to donors. The model was a holdover from World War II, when blood was badly needed for the war effort. But as the collecting centers became as common as cash-for-gold franchises in skid rows across the United States, they began to present problems for the medical system. Because poorer and accordingly less healthy people were more likely to sell their blood for a quick buck, paid blood collection led to higher rates of hepatitis transmission.

In the 1970s, a British social anthropologist named Richard Titmuss proposed a new system, one that would remove the risk of coercion and problematic incentives by eliminating payments to blood donors. In addition, the blood would be depersonalized -- marked with an identifying bar code rather than a name -- so that the recipient would feel indebted to the overall system of blood donation rather than a single individual. Officially, at least, blood was transformed from a product into a gift.

It was a revolutionary idea at the time, and it succeeded wildly, helping create one of the most robust and safe blood supplies in the world. Today, Americans donate so much blood in excess of the country's needs that the United States is the No. 1 blood exporter on the planet. It sends almost 1.5 million gallons of blood plasma abroad every year, enough to fill two and a half Olympic swimming pools.

Titmuss's model also applied to acquiring and selling body parts -- which has since become the gold standard throughout medicine. In 1984, the U.S. Congress passed the National Organ Transplant Act, forbidding the sale of body parts and effectively requiring an altruism-based system for acquiring them. Anonymity, too, has become the rule. In the 1960s, it was still possible for organ recipients to learn who donated the organ that saved their life. Now we take it as a given that such knowledge should be protected by the strictest standards of medical privacy. The prevailing logic has been that making it possible to connect the dots between donor and recipient could compromise the entire system, maybe even stopping people from donating their tissue in the first place.

Unfortunately, the anonymous, altruistic system has produced unintended consequences. Even Congress couldn't get rid of the market for body parts entirely: Individuals can't directly buy and sell bodies, but doctors, nurses, ambulance drivers, lawyers, and hospital administrators can all bill for their services. (You may not pay for a heart, but you definitely pay for a heart transplant.) And the flip side of anonymity is opacity: Although confidentiality provisions are meant to protect the interests of the donor, they also obscure the supply chain.

The result is a system whose best intentions create ample opportunities for criminally minded entrepreneurs. There are huge profits to be made by middlemen dealing in everything from kidneys to human eggs to sight-unseen surrogate pregnancies. In the age of globalization the brokers are adept at exploiting the knowledge and legal gaps between national jurisdictions to arrange just about any sort of organ acquisition, and advances in anti-rejection drugs allow people with widely diverse genetic backgrounds to swap organs. In Romania, Moldova, Turkey, and Egypt, brokers can easily acquire kidneys for $3,000 and sell them for $50,000 or more. In 2008, an Indian broker was arrested for kidnapping people from New Delhi slums and literally stealing their kidneys to sell to foreign transplant patients. In China, selling the organs of executed prisoners continues to be an official state policy.

Law and economics recognize three types of markets with varying degrees of legality: white, gray, and black. The trade in human flesh has evolved into its own category of commercial activity, what you might call the "red market" -- a market whose economic characteristics are complicated by the fact that customers owe their lives and family relationships to the supply chain, yet know perilously little about it. I spent the past six years tracking the red market across South Asia, Europe, and the United States, exploring the business practices of kidney traders, skeleton thieves, blood pirates, and child kidnappers. In every case, I was astonished to find that most people who bought a piece of a human being had no idea what series of events had to have occurred to make that body part available.

Obscuring the source of raw materials for any market is almost always a bad idea. We would never allow an oil company to hide the locations of their oil rigs or not disclose their environmental policies. And when an oil rig fails and leaks millions of barrels of petroleum into the ocean we demand accountability. Transparency is capitalism's most basic safety feature.

Solutions to the problem are hard to come by, however, and will likely require a wholesale revamp of the tissue donations system. Economists have argued that a commercial system similar to the one that exists in Iran for kidneys -- in which the state pays donors a modest sum for the organ -- could allow the market to regulate the human tissue supply. Others argue that it is possible to increase actual altruistic donation rates -- and cadaver donations for internal organs -- to the point at which supply and demand will be balanced, reducing the need for a red market.

In my view, neither is likely to work until we answer a simple question: At what point is one person entitled to use the flesh of another? The central problem with the human supply chain is that it has been dehumanized -- its very opacity allows us to elide the fact that we aren't just buying tissue, but a piece of a person, and one that comes with a history. Perhaps then we can accept that people are not commodities and our own lives are often predicated on the sacrifices of others.



China's Port in Pakistan?

China's dream of Indian Ocean ports -- the so-called string of pearls -- is heightening geopolitical tensions in a rough neighborhood.

Pakistani officials have announced that the Chinese look favorably on taking over the operation of the Arabian Sea port of Gwadar close to the entrance of the Strait of Hormuz, and perhaps building a naval base for the Pakistanis there as well. The Chinese have apparently contradicted these claims, indicating that they have made no such decisions on these matters.

The fact that Pakistan should want deeper Chinese involvement with this strategically located port, even as the Chinese are hesitant to do just that, should surprise no one. Gwadar is where dreams clash with reality.

The Chinese have already invested $200 million in building a modern port in Gwadar. Furthermore, a presence of some sort at Gwadar makes estimable sense for Beijing in the abstract. China faces what has been called a "Malacca dilemma." It is too dependent on the narrow and congested Strait of Malacca between Indonesia and Malaysia for its oil and natural gas shipments from the Middle East to Chinese ports.

Thus, China has been engaged in port-building projects in Pakistan and Burma, which, someday, may be linked by roads and energy pipelines directly to China. Besides offering an alternative route for energy supplies, such new ports will be the 21st-century equivalent of 19th-century British coaling stations for China's budding maritime empire spanning the Indian Ocean. Once China has developed a blue-water navy to protect its sea lines of communications, it will require port access along the global energy interstate that is the Indian Ocean. For Pakistan's part, a robust Chinese presence at Gwadar would serve to check India's own strategic ambitions, as Islamabad leverages Beijing against New Delhi.

The problem is that these are all long-range plans -- and dreams. They conflict with messy ground-level realities. Visiting Gwadar for a week in 2008, I was struck not only by how isolated it was, between pounding sea and bleak desert, but how unstable was the region of Baluchistan, which lies immediately beyond the port in all landward directions. Ethnic Baluchi rebel leaders told me that they would never permit roads and pipelines to be built there, until their grievances with the Pakistani government in faraway Islamabad were settled.

The security situation is indeed fraught with peril. The Chinese know this. They know that a pipeline network from Gwadar into Central Asia and China must await the political stabilization of Afghanistan -- and Pakistan, too. Until such a day, Gwadar, while a potentially useful coaling station for a budding Chinese navy, constitutes, in essence, a road to nowhere.

Bottom line: The Chinese may be as frustrated and aghast at the dysfunction of the Pakistani state as are the Americans. Yes, they built the port, with hopes of using it someday. But it seems from their latest statements that they have reservations for the moment. True, they seem to have moved closer to Pakistan to take advantage of Islamabad's estrangement from Washington in the wake of the killing of Osama bin Laden, but they are nevertheless still being cautious. And the caution, I believe, comes not from a lack of geopolitical ambition regarding Gwadar, but from the present security situation in Pakistan, with a government that frankly cannot control its own territory, whether it be the lawless frontier with Afghanistan, or Baluchistan.

Furthermore, just as the Pakistanis want to use China as a bulwark against India, China -- while not shying away from strategic competition with India -- must at the same time be careful not to unduly antagonize India. For China is building or upgrading ports not only in Pakistan and Burma, but in Bangladesh and Sri Lanka, too. The point must be emphasized that it is unclear exactly what China intends for these Indian Ocean ports -- China's so-called "String of Pearls." India already feels surrounded by China and has greatly enlarged its own naval base at Karwar, in the country's south, partly in response to Chinese construction work in Gwadar. Given that India and China may soon constitute the world's largest bilateral trading relationship, China must tread carefully. After all, it has always claimed to its neighbors that its rise is benevolent and non-hegemonic.

Indeed, Gwadar is important: not for what it is today, but for what it will indicate about Beijing's intentions in the coming years and decades.

Jason Lee-Pool/Getty Images