They travelled at night, for what seemed like hours, but it was difficult to tell. Yonas was blindfolded and drowsy from the Xanax he had been given. He wasn’t sure where he was, but he could smell salt in the air when the car stopped. Yonas heard Ali, the other passenger, wind down his window and light a cigarette. The driver sat motionless, breathing heavily. Several minutes passed in silence. Then Yonas heard a pinging noise. Someone’s phone had received a message.
The door next to Yonas was opened, and two men escorted him into a building. After they took off his blindfold, the men walked down a long corridor and took the stairs to the basement. There, Yonas entered a room where a man dressed in blue scrubs was talking to Ali, the broker who had brought him here. He assumed the other man was the doctor who would perform the surgery. Before Yonas could ask any questions, he was taken to another room where he was told to change into a surgical gown and wait for a medical attendant to prepare the anaesthetic.
As he waited, Yonas thought of his parents at home in Eritrea, his younger brother conscripted into military service, his sister destined to a life of servitude. He hoped his sacrifice would help them. The attendant came in. The needle scratched his arm; fluorescent lights gave way to darkness.
Yonas had made three attempts to reach Europe, twice from Libya and once from Egypt. But each time he was detained and forced to pay large sums of money – between $3,000 and $7,000 – for his release. Destitute and already heavily in debt, Yonas borrowed money from lenders in Cairo. He was under pressure from his creditors, who were threatening to call in their debts, with force if necessary. But above all else he was desperate to send money back to his family in Eritrea. Trapped in a spiral of debt, he traded the only thing of value that he had: one of his kidneys.
It is illegal to buy or sell an organ anywhere in the world, with the exception of Iran. Nevertheless, estimates suggest that around 10% of organs for transplantation come from illegal sources. Most cases, however, go unreported, so the true number is likely to be much higher.
Several countries, including Pakistan, Egypt, Bangladesh, India, Turkey, the Philippines and China, have been identified as centres of organ trafficking, but the trade in organs is a transnational operation. In its 2018 Global Report for Trafficking in Persons, the United Nations Office on Drugs and Crime identified more than 700 cases of organ trafficking, the majority in the Middle East and north Africa. A 2021 Interpol report claimed that organ trafficking was of particular concern in north and west Africa, “where impoverished communities and displaced populations are at greater risk of exploitation”.
According to the Global Observatory on Donation and Transplantation (GODT), only 10% of the global demand for transplants is met each year. Increased demand for kidney transplants, in particular, has been exacerbated by a shortage of altruistic donations and limited access to transplant services. This has led to an increased dependence on criminal networks that obtain organs from vulnerable individuals.
There is a black market for organs including kidneys, corneas and liver lobes. Rising demand for kidneys is partly a result of the spread of so-called diseases of affluence – diabetes, hypertension, obesity – and the subsequent rise in kidney failure. According to the charity Kidney Care, in the UK, the waiting list for a kidney transplant has increased dramatically since the pandemic. Consequently, more people are travelling overseas for transplant surgery. In many countries that attract transplant tourists, kidneys are sourced from the bodies of the poor and disenfranchised.
As a legal academic, I have been investigating the global trade in organs since 2014. Over the past 10 years, I have spoken to 43 people from Sudan, South Sudan and Eritrea who sold a kidney out of economic necessity. In most cases, people were targeted by criminal groups because of their precarious status as asylum seekers, refugees or undocumented migrants. Most were not paid what they were promised. Some were paid nothing. Doubly criminalised, as illegal migrants and organ sellers, they were in no position to negotiate a price, or to ensure they got paid the agreed amount. Because of their precarious legal status they were also less likely to report abuse to the authorities.
In the absence of legal pathways to migration, many had sold their kidneys after they had been arrested, detained and in some cases deported back to countries where their lives were under threat. Most had opted to avoid refugee camps, describing them as “prisons” and “death camps” where people go to die. They were disillusioned with the United Nations Refugee Agency (UNHCR). It was better to risk crossing the Sahara, Yonas told me, than to live under permanent surveillance, captive and dependent on a broken asylum system. Many, like Yonas, had expended all their resources trying to reach Europe and claim asylum. Categorised as illegal and pushed to the margins of society, they were exposed to exploitation of different kinds.
The illicit networks that supply organ markets depend on the close cooperation of medical doctors. Criminal intermediaries are involved in the negotiation of fees, and the preparation of official-looking paperwork presented as evidence of informed consent to an altruistic donation. These brokers, who connect sick patients with impoverished and vulnerable “donors”, also form long-term partnerships with medical professionals. Without the involvement of surgeons who perform illegal transplants for profit, the trade in organs would cease to exist.
In March 2023, the UK tried its first organ-trafficking case. A Nigerian politician, his wife and their broker were found guilty of conspiring to bring a man to the UK from Lagos to obtain his kidney for transplant. The judge said in sentencing: “The trafficking of people across international borders to harvest their organs is a form of slavery. It treats human beings, and their body parts, as commodities to be bought and sold. It is a trade that preys on human poverty, misery and desperation.” Unfortunately, as war and climate crisis displaces more people, there is no shortage of desperate people to prey on.
* * *
Yonas was conscripted into national service in Eritrea at the age of 14. He was sent for educational training at the Sawa Defence Training Centre, a sprawling military complex in western Eritrea notorious for its military-style discipline, physical punishments and forced labour. “My brother was with me,” Yonas recalled. “They tried to brainwash us. They don’t want people to have political ideas, thoughts. I had to escape that place.”
One night in September 2012, Yonas made a break for freedom. His family had paid a smuggler to take him across the border into Sudan, and there was a truck waiting for him on the far side of the compound. To reach it, Yonas had to crawl on his hands and knees, under wire fencing and across jagged rocks, avoiding the searchlights sweeping from above. He knew that if he was caught, he would be shot.
Outside an old garrison town close to the border, Yonas climbed on to another truck heading to the Sudanese capital, Khartoum. In Omdurman, the twin city of Khartoum on the opposite side of the Nile, he was introduced to a smuggler who, he was told, could organise transport across the Mediterranean.
The journey was expensive and dangerous, but Yonas felt he had nothing to lose. His family had given everything they had to help him escape Sawa; he was determined to make it to Europe and pay them back. Yonas had heard stories of kidnapping on migrant routes, but this smuggler had a good reputation, and Yonas was hopeful that he could make it.
After a long and difficult journey across the Sahara, between Sudan and Libya, Yonas was delivered to the Mediterranean coast, outside Tripoli, as agreed. In April 2018, he was shoved on to a small boat along with about 100 other migrants. They were from different parts of Africa – Eritrea, Somalia, Sudan, South Sudan, Chad and Nigeria. One of the passengers, with no experience of sailing, was handed the responsibility of manning the boat. After about an hour, the engine cut out.
Men, women and children sat helpless, dehydrated and fatigued, as the boat floated idly. Six hours passed before the Libyan Coast Guard intercepted the vessel and took them back to the African mainland for processing. They were told they would be detained for attempting to enter Europe illegally. After the engine had cut out, Yonas recalled, the passengers thought they might die. “And when the coastguard came,” he said, “some of us wished we had, because we knew where we were going.”
Libya’s immigration detention centres, which are partly funded by the EU, are notorious. Detainees have been subjected to torture, harassment, physical violence, sexual exploitation and forced labour, with no formal registration, no legal process and no access to lawyers or any judicial authorities. Yonas never spoke to anyone from the UNHCR or the International Organization for Migration (IOM) when he was detained. “I think someone like this came to visit,” he said, “but they just look around.”
In the absence of legal process, the only way to escape the punishing conditions of detention centres is to pay the officers a bribe. “When the guards receive the money, they leave you in the desert. Then you just try not to get picked up [arrested] again,” Yonas said.
Yonas had left some money with friends in Egypt in case of an emergency. He also had relatives living in Sweden, the Netherlands and the UK, who raised funds to help him pay his way out of detention in Libya. “The money was sent to a Libyan bank account via Western Union,” he said. He said he paid the prison guards around $7,000. After he was released, Yonas travelled to Cairo.
By the time he had bought his way out of detention in Libya, Yonas had exhausted the funds he received from friends and family. Once in Cairo, he borrowed 30,000 Egyptian pounds (around £470) from lenders – a temporary measure, he thought, to cover the cost of food and accommodation while he searched for work.
Two months went by. Yonas could not find reliable employment, and he was unable to make any repayments. He knew that if he missed his next payment, there would be serious consequences. “This guy [a debt collector] told me that he would take a tooth for every payment I missed.”
* * *
Yonas had all but given up hope of reaching European shores when he was approached by a Sudanese man, who gave his name as Ali, at a street market in Cairo. Yonas told him his story. Ali said that he knew a way that Yonas could pay back all his debts and secure a place on a more reliable fishing vessel crossing from Egypt to Italy. He told Yonas he could sell his kidney, make a lot of money and save a life in the process.
Yonas had his doubts. But he had amassed significant debts trying to cross the Mediterranean and he was coming under pressure to pay back friends, family and moneylenders. “This is the last thing you want to do,” he explained. “But for me there was no other way.” Ali, the broker, was personable and seemed genuine. Yonas agreed to the deal. He was promised $10,000 for his kidney. The money, he hoped, would be enough to cover his debts and pay for his onward journey across the Mediterranean.
The surgery took place at a medical facility near Alexandria in November 2018. “I remember waking up and feeling confused,” said Yonas. The first thing Yonas he was aware of was a buzzing noise coming from a loose lightbulb, like the sound of a trapped insect. Next came pain, then fear, panic, anger. “I was shouting as loud as I could. I just wanted to get out of there.” Yonas rolled over and vomited on to the floor.
Hours passed. Finally the door opened and a man holding a clipboard came in. The man told that Ali would be coming soon, at which point he could leave. He handed Yonas two painkillers and a glass of water, and slid out the door before Yonas could ask any questions.
When Ali finally appeared, he told Yonas to get dressed. His voice was hard, all his old charm now gone. A nurse removed the drip attached to Yonas’s hand and two heavy-set men escorted him back to the car. Yonas spent the next two weeks in an apartment in Cairo convalescing. He was closely monitored, in case he should decide to leave the apartment. They did not want him to attract attention. If someone were to see him, they might report his presence to the police. Best to keep him hidden while he healed.
Yonas had been promised $10,000, but he was given just $6,000 in notes. This would just about pay off his existing debts, but it was not enough to cover the cost of smugglers’ fees ($3,500) for the next stage of his journey, across the Mediterranean. Yonas went to the police and reported Ali for trafficking. He was trying to explain that he had been deceived into selling a kidney when another officer entered the room. The second officer informed Yonas that it was a criminal offence to sell a kidney. He took out a notebook and asked Yonas for his identification papers. Yonas fumbled in his pockets, searching for documents he knew he didn’t have.
The officers joked that Yonas didn’t look like an Egyptian, remarking on his dark skin and curly hair. If he was a refugee, they suggested, he should go and complain to the UNHCR. But maybe he wasn’t a refugee. Maybe he was an illegal migrant. The second officer reminded Yonas he could be arrested or deported for failing to produce his identification papers.
Yonas was regretting going to the police. He looked around, nervously waiting for someone to speak. The second officer smiled scornfully and told him to leave.
* * *
In my research, I wanted to learn more about how the trade in organs was organised, and how brokers rationalised what they were doing. As it turned out, certain brokers were aware of my work. Some of them wanted to meet me, to ask me about it, and to explain their perspective.
The brokers I interviewed did not necessarily see what they were doing as wrong. If anyone was to blame, they said, it was the doctors who knowingly performed illegal transplants. For the most part, they saw themselves as service providers, part of a supply chain for an already corrupt medical system. To them, it was just business.
I met Hakim in Egypt in February 2020. He had been introduced to the brokerage business after getting into financial difficulties. “My uncle took me under his wing,” Hakim told me. His family was from Khartoum, and his uncle was an established organ broker, with connections to doctors and transplant units in Egypt and overseas, mainly in Saudi Arabia, Oman and the UAE. Hakim said that his uncle introduced him “to all the top guys, the doctors and other mediators [brokers] who work with the clients”. The clients were transplant patients, some from Egypt, and others from across Europe, the Middle East and North America.
When I met him, Hakim was based in Cairo and was responsible for recruiting donors and referring them to his uncle. At the time, March 2004, the central government in Khartoum, supported by the Janjaweed militia, had launched a brutal counter-insurgency campaign against rebels in Darfur, killing hundreds of civilians and displacing thousands more. Amid the chaos, Hakim saw an opportunity for recruitment. He contacted smugglers in Khartoum, many of whom had connections with border officials on the Sudan-Egypt border, who had the power to let migrants through in exchange for payment. The brokers started to solicit people fleeing the fighting who might be desperate enough to sell a kidney. “I thought: they are in a very difficult position,” Hakim said. “Maybe they will sell a kidney for $5,000. Someone in Cairo will ask for more.”
Around the world, the cost of a transplant on the black market ranges from $20,000 to $200,000 – the higher price generally reflecting better treatment and care. The “donor” typically receives a fraction of this cost. The amount that they receive varies from country to country. In the Philippines and Colombia impoverished farmhands and bonded labourers have been documented as receiving less than $2,000 for a kidney. In contrast, kidneys have been sold for between $10,000 and $20,000 in Israel and Turkey.
In Egypt a kidney can sell for anywhere between $5,000 and $20,000. Patients, or “transplant tourists”, pay between $50,000 and $100,000 for a kidney transplant, including travel and accommodation. The price generally depends on market demand. For a kidney, the price paid to the seller can be anywhere between $5,000 and $20,000. Part of the broker’s job is to find out just how wealthy the buyer is, and to establish the absolute minimum the seller is prepared to accept. An impoverished, unemployed seller with no legal status is in no position to negotiate. For this reason, illegal migrants make valuable targets.
A series of drawn-out conflicts in the region have supplied a steady flow of people whose desperation can be commodified in different ways: bodies to be smuggled, sold or harvested. Hakim said that he referred between 20 and 30 sellers a week, who are themselves referred to him by his contacts in Khartoum. “They agree the deal [organ sale] in advance, and I call my uncle to receive them. After the operation, they continue to the coast to try and make the crossing,” he said. Most, he said, don’t make it across the Mediterranean.
I asked whether he felt any remorse for the people he was exploiting. “Yes, I feel bad for them. But I always give them their money. There are other brokers who would agree with you on a price, then disappear after the surgery without paying you,” Hakim said. “This happens at least 40% of the time.”
Most people are not paid what they are promised, but because it is illegal to sell a kidney there is little they can do. Brokers and the medical professionals they work with are aware of this, using the threat of criminal prosecution to silence their victims.
I met Hiba, a young single mother from Sudan, in Cairo in March 2020. She sold her kidney to help support her young daughter. She had been promised $10,000, but was paid $4,000. After she recovered from the surgery, she went back to the hospital to get her money. But prior to the surgery, she had signed documents that stated she was donating her kidney for free. This was enough to give those involved with the surgery legal cover. And now, if Hiba chose to report them to the police, she could be arrested for the criminal offence of selling a kidney. She was powerless to get the full fee she’d been promised.
One reason that worldwide convictions for illicit organ removal are so rare is that victims are reluctant to come forward. Another is systemic corruption. Hakim suggested that doctors pay bribes to protect themselves from police investigations. But he added, a little vaguely: “The doctors are not controlling the business. The people who control this business take a commission from the doctors. You don’t know them or what they do. You just know that those people take a commission from doctors, they control the business [the organ trade] – otherwise, no doctor would be able to work [performing transplants].”
When I asked Hakim if he meant government officials, he simply replied, “They are people higher up.” The threat of arrest, Hakim claimed, acts as a form of official extortion. Corrupt medical professionals, performing illegal transplants, who pay for protection will not be investigated, while those who refuse to pay could be arrested.
* * *
Three years later, in March 2023, I met Hakim again in Khartoum. I was following up on reports from contacts in Egypt who claimed that people, mostly from Darfur, were being trafficked from Khartoum to Cairo for organ removal. They were being promised safe passage across the Mediterranean, part of a “go now, pay later” scheme. But when they arrived in Cairo, they were forced to give up a kidney as the price for continuing their journey.
I wrote to Hakim on WhatsApp to see if he knew anything about this. He replied, “If you want to talk, I am in Khartoum now. I don’t speak about this on the phone.”
I don’t know if it was for dramatic effect, but he arranged to meet me at a graveyard close to Tuti Island, where the Nile divides. We discussed the mounting tension between the Sudanese army and the paramilitary Rapid Support Forces (RSF). The following month, violent street battles would break out between these two factions, a conflict that quickly exploded into a devastating civil war, which continues to this day. According to figures released by the IOM, more than 10 million people have been displaced in Sudan. All are in desperate need of humanitarian assistance.
“How has business been?” I asked Hakim.
“More people are coming now, with the fighting,” he said. “Some of these people will try to go to Libya. Others will try and make it [across the Mediterranean Sea] from Egypt, but this is more difficult. So, they can sell their kidneys,” he said. Hakim denied any knowledge of human trafficking for organ removal, saying that in times of conflict people are forced to do things they would normally never do.
The ongoing war in Sudan and the ensuing humanitarian crisis has pushed people to the brink. At the borders of conflict zones, selling a kidney is becoming a currency of last resort for people seeking refuge. In June 2023, I managed to contact two young Sudanese women who had fled the fighting in Khartoum. In April 2023, Rania was with her friend Fatima, both students at the University of Khartoum, when the RSF raided the main campus, on the banks of the Nile. “We were trying to hide from the fighting,” Rania told me on the phone. “There were a lot of [female] students there who were afraid to leave. We thought we would be safe, but they found us and forced us to have sex with them.”
Soon after that they packed up their belongings and took a bus heading towards the border with South Sudan. They had heard the route south was cheaper than trying to go north to Egypt, and Rania had a brother living in Kampala, Uganda, whom they hoped to join. It was a seven-day journey from Khartoum to Renk, a small town in South Sudan close to the border where thousands of people had set up temporary camps in bleak conditions. A lack of food, water, healthcare and sanitation had left people at increased risk of disease, malnutrition and violence. There were hundreds of new arrivals each day. “People are crammed together under tarpaulins,” Rania said. “There are mosquitoes everywhere. There’s not enough food, water, soap. Everyone is desperate for assistance. It’s chaos.”
When Rania and Fatima arrived at a makeshift camp on the outskirts of the town, they were approached by soldiers in plain clothes selling tickets for flights from a small airstrip outside Renk to South Sudan’s capital, Juba, and the city of Nimule. The flights, which should form part of the humanitarian corridor, are being controlled by armed militias charging exorbitant fees to board them. “They wanted a lot of money,” Rania said. “The price would go up every day. They said if we didn’t have any money we could have sex with them.”
When they refused, they were told there was something else they could sell: a kidney. “They said that this was the only way we were going to get a flight out of here,” Fatima said. “There were two men who had agreed to this [selling a kidney], but I don’t know what happened to them. I was worried that they would kill me and take my kidney.”
Two weeks after Rania and Fatima first arrived in Renk, they messaged me from Kampala. “We received some money from family members in Uganda. They paid a smuggler $500 to take us to Kampala.” Rania said. “There were no humanitarian agencies or government officials transporting people. The drivers, the militias, they are exploiting people every step of the journey.”
In Renk, they had watched as large trucks carried hundreds of people further south to transit camps that were rumoured to be less crowded and better resourced. Others boarded cramped and overcrowded boats down the Nile to the city of Malakal, from which they would attempt to reach Juba, 970km to the south. Each stage of the journey would come at a cost.
“We are telling you this for a reason,” Fatima said. “We desperately need more support for people trapped in Sudan. In Darfur, there is genocide. But no one is talking about it. Women are being raped every day. Children have been killed and abducted. People are desperate. This is when you sell your kidney.”
All names have been changed
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