Your part or mine?

AS MARKETS in human organs go, the one which flourishes on Tehran's Vali Asr street, where Iran's main transplant hospital is located, is not the cruellest—and there is no lack of people willing to discuss their transactions. Gholamreza, a 44-year-old man from northern Iran, explains what he did when his dialysis started to fail. “I put an advertisement in the paper for a kidney, and a donor came straight to me. We reached an agreement on the price quite quickly. In these cases, the recipient usually takes care of the donor afterwards. So I still visit my donor and help him out.”

Another man wandering round the district, aged around 30 and wearing torn, cheap clothing, is hoping he can find a buyer as decent as Gholamreza claims to be. He expects to get between $3,000 and $4,000 for one of his kidneys. “I need the money because I lost out in a pyramid investment scam. After the operation I won't be able to lift heavy things, but I can still live with only one kidney.”

Iran's Association of Kidney Patients, a non-government organisation which obviously enjoys official favour, is responsible for all legal kidney transplants: it insists that commercial deals are the exception, not the rule. For one thing, it says, the religious authorities encourage voluntary gifts: in other words, cases where a patient receives a kidney freely offered by a friend or relative. Pious Muslims may also offer up a kidney to anyone who needs it.

With 27,000 road deaths a year, Iran has a tragically plentiful supply of young corpses, the association adds. “We're against kidney sales, we discourage them,” says Daryush Arman, its deputy head. But in practice, lots of “bargains” take place; in other words, recipients top up the $1,200 that the association pays all donors.

Although there is little information on how donors ultimately fare, Iran can claim to have solved a problem which in most Western countries is growing more acute: a rapid increase in the number of people whose lives could be extended, or improved in quality, by kidney transplants—and a failure of the supply of kidneys to keep pace. In America, the average waiting time for a kidney is now five years, up from less than a year in the 1980s. In Britain, there are around 6,000 people who need a transplant—and less than 2,000 such operations take place a year.

Some countries—Spain, Austria, Belgium and Singapore—have tried to increase the supply of kidneys and other body parts by passing laws that authorise the re-use of organs from dead bodies unless the individuals, or their families, have made formal objections. But even in those places, waiting-lists have not disappeared.

For surgeons, patients and medical economists alike, the shortage of kidneys seems frustrating, because no organ lends itself better to transplant. As long as they receive decent after-care, kidney donors suffer only the tiniest increase in their own risk of dying of kidney disease. And transplants make economic sense: the cost of one kidney operation and a lifetime's supply of anti-rejection drugs equals that of three years' dialysis. Kidneys donated by a living person last for a median 22 years in another body; when they are taken from a fresh corpse, the figure is 14 years.

Whatever solution they propose to the shortage of kidneys, nobody doubts that the black market, as it now works, has grotesque effects, both for donors and recipients. Rich westerners who go to South Asia or Africa in search of kidneys often receive organs that are diseased or unsuitable.

Fresh details of a huge, illegal kidney-trading operation—in which poor Brazilians were brought to Durban where their kidneys were transferred to paying customers, mostly Israelis—may well emerge from a forthcoming trial in South Africa. Ilan Perry, a Israeli businessman, has been charged with masterminding a syndicate that arranged at least 100 illegal kidney swaps at a top Durban hospital. Senior medical staff there have been accused of fraud, assault and trading illegally in human organs. Their trial was halted during the summer because a key suspect was missing; the arrest of Mr Perry, who is now in Germany awaiting possible extradition, may allow proceedings to restart.

Nancy Scheper-Hughes, an American professor of medical anthropology and campaigner against organ trading, says the way poor Brazilians were induced to travel to South Africa is typical of the abuses a market in body parts, especially an international one, is bound to cause. She says donors in the Brazilian slums were given false promises about the money they would make, the care they would receive and the after-effects of the operation.

Some senior figures in the medical world draw a different conclusion: as long as some people are determined to obtain kidneys and others are desperate enough to sell them, the trade will be impossible to stop—so it makes better sense to regulate the business than drive it underground.

In Canada, where 4,000 people are waiting for organ transplants and some go to India or the Philippines in the hope of buying body parts, one specialist argues that a regulated system of compensation poses fewer problems than an illicit trade. “If you have buying and selling taking place in a country, and you can't stop it, then it's immoral not to regulate the trade, since so much harm occurs in a black market,” says Abdallah Daar of the University of Toronto, who has visited Iran and thinks it may have lessons for others.

As a member of what America calls the “axis of evil”, Iran is not often held up as a model in the West. But its approach to a desperate, and growing, medical need may yet find some imitators.