Introduction

Despite an almost worldwide prohibition (with the exception of Iran) of any form of organ trade, new reports on selling and buying organs continue to emerge (see, for example, Nossiter and Rahim 2021). In 2007, the World Health Organization estimated that 10% of all organ transplants were performed using organs that were retrieved by illegal means, i.e., from paid or trafficked donors (Shimazono 2007). This estimate has not been revised or updated. However, considering the upward trend of chronic kidney disease (CKD) across the world and the culture of impunity that contributes to “illicit organ removal,” there is a high probability that current estimates are considerably higher (ISN 2017; GODT 2021). At present, efforts to suppress the organ trade have centered around a loose set of penal measures and law enforcement strategies to identify, apprehend, and prosecute criminal perpetrators (see for example, UNODC 2008, 2015, 2018, FBI 2017). However, successful prosecutions remain limited to a number of high-profile cases with inconsistent outcomes (see, for example, The State v Netcare Kwa Zulu (Pty) Limited 2010; Medicus Clinic Case 2011; US v Rosenbaum 2012).

Notwithstanding the negligible impact of punitive measures, there continues to be a heavy reliance on criminal sanctions to deter and/or control the organ trade (see Council of Europe 2015). The overwhelming emphasis of current legislative approaches is to scale up existing law enforcement efforts and to increase criminal penalties to allow for the arrest and prosecution of criminal offenders within and between countries (WHO 2010; OSCE 2013; Council of Europe 2015; European Parliament 2018). The working assumption is that criminal groups and unscrupulous middlemen, in particular, control the illicit trade in organs. Evidence based studies, however, indicate that illegal transplants are organized by flexible networks of intermediaries with connections to legal institutions such as medical hospitals, transplant clinics, and dialysis centers (Scheper-Hughes 2004; Mendoza 2010; Yea 2015; Moniruzzaman 2018; Yousaf and Purkayastha 2015; Columb 2020). These legal actors, including medical staff, laboratory assistants, and hospital administrators actively participate in illicit transplants. Without the compliance of corrupt medical personnel, and other legal actors, such as law enforcement, members of the judiciary, and custom officials, illicit organ removal for transplantation would not be possible. Nevertheless, the role of corruption in facilitating illegal transplants, and human trafficking more generally, has received relatively little attention.

Corruption is pervasive and elusive, occurring in multiple forms and degrees at various levels, sectors, and ranks of society (Peters and Welch 1978; Von Lampe 2008; Rose-Ackerman and Palifka 2016). Subsequently, there are many ways to conceptualize corruption—which explains why it is relatively underexplored at the empirical level. The Oxford Dictionary defines corruption as “the action or effect of making someone or something morally depraved” and/or the “dishonest or fraudulent conduct by those in power, typically involving bribery.” Accordingly, some scholars define corruption as behavior that deviates from the public interest (Rogow and Lasswell 1963; Morris 1991). While others define corruption more narrowly, as the behavior of public officials that deviates from legal rules (Nye 1967; Klitgaard 1988). Legal interpretations of corruption broadly follow this public office centered approach. From a legal perspective, corruption is taken to denote irregular conduct(s), as specified in statutes and judicial interpretations, by government officials for private gain (see for example, UNCAC 2005: Art 2). For our purposes, we use the definition proposed by Zimring and Johnson (2005) that defines corruption as the unlawful abuse of power for personal gain, by state and non-state actors. We are interested in the causal relationship between corruption, inequality, and human development with regards to the organ trade (see Gupta et al. 2002; You and Khagram 2005; Treisman 2000). Hence, we understand corruption as a form of structural violence that denies some of the poorest people the means to sustain life and their right to constitutional justice (Galtung 1969; Gupta 2012). Adopting the view that support not punishment is integral to reducing crime (Braithwaithe 1989; Cullen 1994) we argue that enhancing social support would limit demand for illegal transplants and disrupt the symbiotic arrangements (Passas 2002) that underpin organ markets within and between countries, i.e., Egypt and Bangladesh.

Drawing on our combined ethnographic work we assess the impact of criminal measures on the organ trade in Egypt and Bangladesh. Several sources have identified Egypt as a major destination for transplant tourism and organ trafficking (Columb 2016; UNODC 2018; INTERPOL 2021). Egypt hosts the highest number of transplants for foreign patients in North Africa and the wider MENA region. Patients mainly travel from neighboring Gulf states, Europe, and the US (Koons et al. 2019). Although the Egyptian government has introduced strict measures prohibiting organ sales reports of a burgeoning trade in organs continue to surface (INTERPOL 2021). Attempts to regulate the organ trade in Bangladesh have been similarly underwhelming. Bangladesh has been identified as a key origin country for transplant tourism (Moniruzzaman 2012, 2016, 2018). Early reports indicated that Bangladeshi patients and organ sellers mainly travel overseas, to India, Pakistan, Thailand, Singapore, and China, for commercial transplants (Shimazono 2007). More recently, from 2011 onwards, there has been a shift towards illicit organ removal performed at public and private medical facilities in Bangladesh (Moniruzzaman 2019a, 2019b). We question why national transplant laws have been largely ineffective and why prosecution rates remain low, despite increased awareness of organ trading and related acts. In doing so, we explicate the role of corruption at institutions (e.g., public, and private hospitals, law enforcement agencies, the judiciary) and among individuals (e.g., organ brokers; medical personnel; customs officials; police officers) in facilitating illegal transplants and perpetuating organ sales.

This is the first cross-national comparative study of the organ trade based on ethnographic fieldwork and one of only a handful of studies that considers the linkage between corruption and trafficking in persons (see also, Zhang and Pineda 2008; Bales 2007; UNODC 2011). While this study is limited to the Egyptian and Bangladeshi context and should not be generalized to account for how the organ trade is organized and facilitated worldwide, a comparative perspective provides important insight into emerging trends and patterns that will serve as a valuable analytical counterpoint for further cross-national and regional studies of the organ trade and other illegal markets.

Narratives of corruption

There is a growing body of work examining the nature and extent of the global trade in organs (see for example, Cohen 1999; Lundin 2012; Efrat 2013; Ambagtsheer 2021; Orr 2022). Nevertheless, the organ trade remains a relatively under researched phenomenon. In comparison to research on other types of illicit trade there are relatively few empirical studies available. Existing studies provide insight into the social organization of organ trading networks, as well as the wider cultural, economic, and political factors that underpin this illicit business (Moniruzzaman 2012; Yousaf and Purkayastha 2015; Columb 2020). These studies largely focus on specific national contexts and inquire into the legal, ethical, and policy challenges that the organ trade presents. The presence of corruption within the organ trade has not, however, received adequate attention. Moreover, at the time of writing (August 2023) there is no comparative empirical research available. Cross-national comparisons are needed to assess the impact of regulatory measures established to prohibit organ sales. Comparative analysis can also help identify and contextualize the presence of corrupt actors and practices that sustain and perpetuate this illegal business (Zimring and Johnson 2005). For the purposes of this paper, we explore the nature of corruption in Egypt and Bangladesh and examine the role it plays in maintaining the state of the organ trade. We link our explanation of corruption to social support theory. The central proposition of social support theory is that the provision of social support, whether it is delivered by (inter)government agencies, communities, social networks, families, or through interpersonal relations, reduces criminal involvement (Braithwaite 1989; Cullen 1994). Hence, it follows that high levels of social support should be inversely related to corruption (Zhang et al. 2009). Our data supports this hypothesis, demonstrating how the misappropriation of public services (i.e., healthcare) for personal gain by corrupt actors (e.g., medical professionals, police, consulate officers, members of the judiciary) has allowed the organ trade to establish itself as an illegal subsystem of the transplant industry.

In reviewing our respective data, we realized that beyond individual comparisons between sellers, buyers, and brokers, the interview narratives that we collected were connected by a common theme: corruption. We identified several common characteristics in how the organ trade had emerged; how it was regulated; and how it was being facilitated. For example, organ sellers were invariably poor, uneducated, and disenfranchised. The surgeries (i.e., illicit organ removal) were largely performed in public and private hospitals with the support of trained medical staff. Strict laws prohibiting organ sales and/or trafficking in persons were introduced in both countries. Yet, successful prosecutions were limited or non-existent, despite reported arrests of “organ trafficking rings” in the media (Bangladesh Gazette 1999; BBC 2016, 2017; The Daily Star 2017). In state accounts of organ trafficking, criminal groups, unscrupulous doctors, and predatory brokers formed the collective imaginary of an “organ mafia” preying on the poor. In contrast, the personal accounts of the people that we interviewed were multi-layered, interconnected, and contextualized with experiences of corruption. From the issuance of consent forms by embassy staff to the tacit collusion of doctors and police who turned a blind eye or who were actively involved in organizing illegal transplants, official corruption was a key feature of their narratives. These “narratives of corruption” were inextricably linked to the violence of poverty, played out against the bodies of a political and social underclass who were systematically exploited for their kidneys and/or liver lobes.

The interview narratives presented in this paper cast a critical lens on the systemic corruption and structural violence that has shaped and distorted regulatory efforts to control the organ trade in Egypt and Bangladesh. Corrupt practices are implicated at every stage of the organ trading process, from the solicitation of organ sellers and recipients to the performance of illegal transplants, mediated by a system of kickbacks and payoffs to a range of beneficiaries who abuse their power for personal gain. To understand the dynamics of corruption it is necessary to consider the role that state institutions (i.e., medical committees; law enforcement; judiciary) play in the development and pervasiveness of corrupt practices that facilitate organ trading, amongst other things (Rose Akerman 1999; Sung 2002). To this end we have endeavored to bring into focus the institutional rules and conditions that enable corrupt actors to subvert otherwise legitimate procedures, i.e., organ transplantation. We frame our analyses of corruption around and from the narratives of people who have sold, bought, and brokered the sale of organs. In doing so, we explore how state level corruption influences public culture, shapes interpersonal relations, and effects the development of organ markets. Focusing on the discursive construction of organ markets from the situated perspective of people with first-hand experience of organ trading (i.e., kidney sellers, brokers, organ recipients, transplant professionals) brings into focus the contested moralities and symbiotic arrangements that underpin this illegal trade. At the same time, foregrounding subaltern voices and perspectives of kidney sellers and organ brokers challenges dominant (Western) modes of thinking around corruption, e.g., Transparency International’s Corruption Perceptions Index, and its relationship to illicit trade more generally.

Methodology

Data collection involved a combination of participant observation, informal conversations, and in-depth narrative interviews, largely arranged through personal connections and introductions. Interviews were completed by the first author with organ sellers, recipients, brokers, and medical professionals in Cairo, Egypt (63 respondents) between 2014 and 2020. The second author carried out interviews (70 respondents) with organ sellers, brokers, recipients, medical professionals, and journalists in Dhaka, Joypurhat, and Jessore in Bangladesh between 2012 and 2020. The analysis in this paper is developed from a subset of interviews (31 in total) that explicitly identify official corruption as a key variable influencing the dynamics of the organ trade. Respondents, across both datasets, were aged between 19 and 42 years of age. Most respondents who sold an organ (kidney or liver lobe) were male, with a median age of 28. Interviews by both authors were open-ended and narrative based. Approaching interviews in this way afforded the possibility of probing for additional information where necessary, without causing undue stress from repeated questioning. All interviews were conducted in the local language (Arabic in Egypt; Bengali in Bangladesh) sometimes with the assistance of an interpreter, at respondents’ homes and/or in public spaces, e.g., restaurants, bars, and cafés. The length of interviews varied between 1 and 2 h. Follow up interviews were arranged where possible, to allow respondents to think over different aspects of their experience that may have been withheld or simply forgotten during the initial interview. Comprehensive field notes were recorded after each interview and during periods of observation at different field sites. This allowed for the inclusion of additional context (e.g., body language; social interactions) and information that was revealed after the audio recording was turned off.

In Egypt, interviews with organ sellers and brokers were arranged through a process of snowball sampling (Goodman 1961). This “chain referral” method uses initial contacts to generate contexts and encounters that allow for an analysis of the different activities, actors, and relations that constitute the organ trade. In Bangladesh, the second author used the “key informant technique” to establish connections with organ brokers and to gain access to organ sellers (see Moniruzzaman 2016). In most cases, in Egypt and Bangladesh, personal introductions were arranged through preexisting contacts and/or with the assistance of a local gatekeeper or “key informant” (see for example, Bourgois 2003). At other times, respondents were approached directly after a period of observation or on the basis of information received from other respondents. For example, both authors observed individuals identified as organ brokers, by interview respondents, entering public and private hospitals in Dhaka and Cairo. The use of referrals helped to build trust and identify otherwise hard to reach populations (Polsky 1967). We are however aware that network-based recommendations can produce homogenous samples (Lee 1993). Nevertheless, comparing findings from across distinct data sets in Egypt and Bangladesh ensured that our overall sample was diverse. We analyzed our interview data separately, reviewing, reading, re-reading, thinking, and interpreting our respective fieldnotes, transcriptions and audio recordings. General themes and patterns of offending were identified by grouping together quotes and descriptions under three broad subheadings that included: demographic information; modus operandi of criminal actors; law enforcement responses (see Maxwell 2012). In doing so, we recognized the need to explicate and reflect on experiences of corruption at various levels. All interview data was transcribed and triangulated to identify commonalties and differences, between actors, organizational structure, and activities, and to cross-verify data between sources (Glaser and Strauss 1968). Supplementary sources of data included court transcripts, police reports, local newspapers, and online resources. This research was approved by the research ethics committee at the University of Liverpool and Michigan State University. Interviews were audio recorded or instantly handwritten with the consent of respondents and transcribed anonymously. Pseudonyms are used throughout.

The trade in living organs: Bangladesh

Prohibiting organ sales

In 1999, the state of Bangladesh passed the Organ Transplant Act, prohibiting the sale and purchase of human organs, tissues, and cells for transplantation. Organ donation is only permitted from "near family members" specified as children, parents, siblings, spouses, uncles, and aunts. Those found guilty of selling or buying organs, soliciting organ buyers or sellers, or assisting in such activities can face imprisonment between three to seven years. In addition to imprisonment, monetary fines are levied, with a prescribed amount of 300,000 Taka (approximately US $3,530) for violators. Despite the establishment of the Act in 1999, at the time of writing (April 2023) the Bangladesh Judicial Service is yet to prosecute a single case concerning illicit organ removal. In August 2011 the local police uncovered an “organ trafficking racket” in Joypurhat, a northern district in Bangladesh, where nearly fifty villagers sold their kidneys and liver lobes on the black market. The police arrested ten brokers who recruited the villagers for the purposes of organ removal (BBC 2013). This was the first, and only, case of illicit organ removal in Bangladesh to receive widespread media attention, nationally and internationally. Nevertheless, criminal proceedings have continued in the district court for more than ten years (discussed further below). The only major outcome from this case was the decision to amend the Organ Transplant Act in 2018.

The Transplantation of Human Organs (Amendment) Bill 2018 is broadly similar to the previous Act 1999, albeit with some additional provisions. Notably, it includes provisions to expand the donor pool; to reduce imprisonment terms and increase monetary penalties. Following the new act, grandparents, grandchildren, and first cousins are now permitted to donate their organs. The maximum penalty for violating this act is imprisonment for three years (reduced from seven years) and/or a fine of 1,000,000 Taka (US $11,765) (Dhaka Tribune 2018). In addition, the amended act stipulates the formation of a medical committee consisting of a state official, a transplant surgeon, and an anesthesiologist at each hospital performing organ transplants. The purpose of the medical committee is to certify whether the donors and the recipients are first degree relatives, as defined in the law, and based on a process of fact-checking it approves or rejects the cases. It is assumed that the medical committee will ensure that donors and recipients are related and will effectively end the recruitment of poor villagers for illicit organ removal. However, the amended act only requires the formation of a committee in private hospitals. This is a significant oversight. Organ transplants from commercial sellers are also performed in public hospitals in Bangladesh and overseas where unrelated recipients and commercial sellers travel for the purposes of illicit organ removal (Moniruzzaman 2012, 2016, 2018, 2019a, 2019b).

Symbiotic arrangements

Dipon, a 27-year-old middle-class Bengali fashion designer, purchased a kidney from a poor villager. Her husband explained that he was the only breadwinner in the family, “so I decided not to give away my kidney and gamble with my life”. He had a “family obligation” not to put any of his relatives at risk, as “organ donation can cause life-threatening health complications.” Desperate to save his wife’s life, he purchased a kidney from a young donor who, he reasoned, “needed the money.” Another respondent, Sudipta, a 32-year-old kidney transplant recipient, explained that paying a donor was the only way he could save his life. “My aunt was the only person whose tissue was matched with mine. However, she had diabetes so she could not donate her kidney. So, I ended up buying a kidney from a poor seller.” As cadaveric organ donation is virtually non-existent, the only way to obtain organs is through a living donor. Most impoverished patients cannot afford to buy an organ from a living donor; therefore, they rely on altruistic donations from family members. On the contrary, many wealthy and middle-class patients opt to pay brokers to facilitate commercial/illegal transplants in various countries, including Bangladesh, India, Pakistan, Singapore, Thailand, Taiwan, and China. There are a number of reasons for this: i) organs are readily available in the black market; ii) the price of an organ is affordable as there is a ready supply of poor sellers (the quoted price of a kidney is 150,000 Taka [US $1,700] and liver lobes is 400,000 [US $4,500] in Bangladesh; iii) the patients do not ask family members to donate an organ due to perceived health risks from the surgery; and iv) the patients do not want to carry the burden of accepting the “gift of life” from a family member.

To maintain ethical protocol, transplant professionals (acting as part of a medical board) are required to review legal documents confirming that the donation is altruistic and free of financial consideration. The necessary documents (e.g., passports, national identity cards, and notary certificates) can however be purchased for a nominal fee, effectively “papering over” illicit transactions and presenting them as altruistic donations (see also Columb 2016). Organ brokers, with longstanding connections to medical institutions hosting illegal transplants, often receive a commission from medical tourism agencies for recruiting client-patients and supplying would-be sellers to affiliated hospitals in Bangladesh, India, and abroad (Parvej 2013). Patients and donors are recruited via advertisements that appear in local newspapers and across social media platforms, such as Facebook, Instagram, and WhatsApp. Brokers also employ village recruiters who target poor rickshaw drivers, day laborers, and petty farmers, who agree to sell an organ to pay off debts and/or to generate some much-needed income. Whilst organ brokers play a key role in organizing illicit transplants and distributing profits, the criminal act of illicit organ removal necessitates the involvement of trained medical staff, including nephrologists, anesthesiologists, and transplant surgeons (see also Yousaf and Purkayastha 2015). Although most transplant professionals are supportive of laws prohibiting commercial transplants, personal interests often trump their professional ethics (see also Orr 2022; Ambagtsheer and Van Balen 2020).

A senior nephrologist working at a prominent hospital in Dhaka claimed that illegal transplants were not performed in Bangladesh. However, during an interview with the second author he was presented with evidence (i.e., recorded testimonies) to suggest the contrary. To which he responded: “We always maintain ethical protocol, but sometimes there might be very few cases that we are unaware of.” Pressed on the issue he concluded that, “nephrologists are not the police, and their role does not constitute spying on recipients. If the committee fails to authenticate the relationship, we should not be responsible for it. Our job is to provide medical care for patients, not to prove family ties of them.” While the role of transplant professionals may be limited to performing the surgery, many are willfully blind to the exploitation of impoverished donors: more transplants mean more profits (see also Mendoza 2010; Columb 2017). In some cases, transplant professionals actively collaborate with brokers to recruit donor-sellers and patient-buyers. Dalal, a prominent organ broker in Dhaka, claimed that over a 10-year period he brought more than “a few hundred kidney sellers”, often in small groups to transplant surgeons who performed the surgeries for large fees at select medical facilities. According to Dalal, additional payments are made to members of the medical committee(s), including hospital administrators and social workers, who approve the transplants without examining the requisite legal documents (e.g., consent forms) between the recipients and the donor-sellers.

Law enforcement

Following an investigation into the activities of a criminal group suspected of organ trafficking in Joypurhat (see above) 10 individuals were arrested on suspicion of soliciting and brokering organ sales (Karmaker 2011). The brokers were released on bail after serving only five months in custody. Organ brokers, interviewed as part of this study, reported that they regularly paid bribes to police officers to run their business without any intervention or disruption (see also Nawas 2012). One broker interviewed in Dhaka claimed that he bribed police officers, criminal lawyers, and court clerks to get a bail after he was arrested, as part of the Joypurhat investigation, on suspicion of brokering organ sales. He claimed that “the police know every dirty trick to extort money from us” implying that police protection could be secured for a fee. Routine payments were also made to state officials to obtain falsified papers, such as passports, national identity cards, and notary certificates, required by medical committees to legalize counterfeit identification documents between recipients and sellers. Bribes were accepted in lieu of a favor or fine, or as in the case above, in exchange for bail and/or impunity from criminal sanction. As a result, there has not been a single conviction for illicit organ removal in Bangladesh. Rather arrest has become a means to extort payments in exchange for the release suspected perpetrators.

Following the Joypurhat investigation, the police submitted a charge sheet (obtained by the second author from a court clerk) consisting of nearly one hundred pages of written testimonies gathered from the sellers, brokers, doctors, and recipients, the key actors of the organ trade. During the police interrogation, the sellers described how they had become victims of the organ trade and were brutally exploited by the brokers. Several organ sellers stated that they experienced bribery, intimidation, and arbitrary arrest in their encounters with law enforcement authorities, in particular the police. Those who paid a bribe were forced to do so when arrested, often without cause, or when requesting assistance, i.e., criminal investigation. Ainul, a kidney seller who was arrested as part of the raid in Joypurhat, claimed that he was forced to pay a bribe in exchange for his release: “The police arrested me from my home claiming that I had been brokering kidneys for several years. I told them that I sold my kidney, but never was I involved in organ brokering. The police threatened me” he said, claiming “if I did not pay the bribe, they would report me as an organ broker and file a charge sheet against me.” Ainul borrowed money from a moneylender and paid the police officer-in-charge 20,000 Taka (US $225) for his release. Like Ainul, other organ sellers explained that they were compelled to pay bribes to the police to avoid false arrest and/or to secure their release from custody.

In an interview with the second author, the defense lawyer representing the brokers argued that the defendants [organ brokers] were unaware of the Organ Transplant Act; therefore, they could not be found guilty under its provisions. The brokers named the doctors and hospitals where unlawful organ transplants were performed in Bangladesh and abroad. Nevertheless, the doctors denied knowledge of criminal misconduct insisting that they had to depend on the medical committee to verify the relationship between recipients and donors. The Bangladesh Medical Association supported the doctors and released a statement arguing that the doctors’ role is limited to performing transplant surgery and they [medical professionals] cannot be expected to verify counterfeit identities between recipients and donors. Similarly, the recipients claimed that they had no other choice but to buy an organ because they were unable to match tissues with their family members. The police only filed charges against the brokers. No doctors or recipients were indicted for their crime due to a perceived lack of evidence – despite the aforementioned testimonies. According to a report released by Transparency International (2018) bribes of between 200 Taka (US $2) and 1,000,000 Taka (US $10,000) are commonplace during legal proceedings in Bangladesh. Justice for ordinary citizens in Bangladesh, particularly for those who cannot afford to pay a bribe, has become an economic aspiration rather than a public entitlement. The pervasive nature of corruption in Bangladesh has prevented organ sellers from filing legal cases against brokers, recipients, or doctors, and has fundamentally diminished trust in the criminal justice system. Meanwhile, continued reliance on organ markets has undermined efforts to increase altruistic donations, limiting access to transplant services to paying recipients.

The business of selling organs: Egypt

Prohibiting organ sales

Following years of deliberation between medical, religious, and political leaders over the sanctity of the body and the permissibility of organ donation, the Egyptian government passed a national transplant law in March 2010. The Transplantation of Human Organs and Tissues Act (Law No 5/2010) made provision for the establishment of a deceased donor program and made it a formal requirement for organ donors and recipients to sign a consent form, attesting to the altruistic and consensual nature of the donation, before a select medical committee. Keeping in line with the World Health Organization Guiding Principles on Organ Transplantation (WHO 2010) the law introduced a range of criminal penalties to prohibit the sale and purchase of organs. Nevertheless, reports continued to emerge linking Egyptian hospitals with illegal transplants (BBC 2016, 2017). In contrast to the revised approach in Bangladesh, which focused on expanding the donor-pool to offset illegal demand, the Egyptian law was amended in 2017 to include higher penalties and longer jail terms. For example, intermediaries who facilitate commercial transactions between organ donors and recipients are subject to a maximum prison term of 10 years. As are medical professionals who knowingly perform a transplant that has been arranged by way of a commercial agreement. Medical facilities hosting illegal transplants (i.e., where there is evidence of financial exchange for personal gain) can be fined up to LE1 million (approx. US $52,863) and/or closed permanently. If a donor or recipient dies because of an illegal transplant those found responsible will be subject to life imprisonment, in addition to being fined between LE500,000 and LE1,000,000 (approx. US $26,431 and US $52,863). The death penalty can be applied where there is evidence of homicide, i.e., manslaughter or murder.

Speaking to the national press after Law No 5/2010 was approved by the Egyptian Parliament, the Assistant Health Minister Hamid Abaza proudly declared that “this law will bring the organ trade in Egypt down to a minimum…with a law like this, patients will not seek organs in an illegal manner” (The New Humanitarian 2011). The experiences of respondents would suggest otherwise. Hassam, a transplant surgeon based in Cairo, spoke candidly about the state’s efforts to regulate the organ trade. “They [doctors] do not care where the organ source comes from once, they have work to do. The middlemen [brokers] are also happy because they can make a lot of money from this business. This is why there is no pressure. Why bring in an alternative for the sake of ethics? The moral argument does not accommodate the reality.” Hassam was outspoken in his condemnation of organ “trafficking”, a phenomenon he distinguished from commercial transplants. However, he considered it unethical not to pay a donor. “How do you convince someone who has no employment, no access to education for their children, no support from the community or government to donate their organs for nothing? How can I ask them [living unrelated donors] to donate an organ and get nothing in return? If that person was to accept, they would not be sane. No rational person would do this.” Another transplant professional, Solomon, suggested that the health authorities in Egypt were in positive denial of the organ trade. “Global political pressure comes to nothing” he said. “The public here in Egypt are not upset about this. People go to the lab and arrange payment. They are happy that there is availability. Business is good for the medical community, so they are happy”.

Although transplantation is partly subsidized, two-thirds of the costs ($8,000) has to be paid out of pocket (Metwally et al. 2020). This effectively rules out most of the Egyptian population from having access to transplant services. The wider labor force working in informal sectors of the economy who are not covered by the social security system are even further marginalized (Roushdy and Selwaness 2019). People are unwilling to donate (altruistically) to a system that is viewed as institutionally corrupt, particularly when they are unlikely to benefit from or gain access to that system. This effectively rules out most of the Egyptian population from having access to transplant services. According to the WHO (2023) out of pocket spending on healthcare in Egypt has been fixed at 62% of total health expenditure over the past decade, more than double the average of other countries in the Middle East and North Africa. Like Bangladesh, patients (who can afford it) often prefer to purchase a kidney from a stranger rather than ask a family member to donate a kidney on their behalf. One patient receiving dialysis in Cairo explained: “People will not donate their kidney if there is an alternative. If my daughter needed a kidney, I would rather pay to get it from someone I don’t know rather than my other child.” Another patient commented: “I don’t want my family or anyone I know to donate their kidney. If I were to accept a donation from them, I would always be in their debt.” Other patients expressed concern for the long-term welfare of family members who donated a kidney. The same concern for bodily integrity was not however extended to the bodies of migrant donors who voluntarily sold a kidney, regardless of their personal circumstances. One patient, Ali, was openly looking for a commercial donor. “If someone is poor and they are offered money in return for saving a life then why not? I don’t see how this is a problem. Life is not easy here at the best of times. If someone wants to sell their kidney it is only fair that they are paid.” It was only in the context of “trafficking”, understood as a violent criminal act, that public attitudes were unequivocal in their condemnation of the organ trade (see also Mendoza 2010). This tension between international ethical standards and local norms is reflected in the legal ambiguity of Egypt’s transplant law and the symbiotic arrangements that subvert it.

Symbiotic arrangements

Dawitt, a young asylum seeker from Eritrea, agreed to a payment of $5000 in exchange for his kidney. Before the operation he was instructed to sign an affidavit claiming that he was a Sudanese national and that the donation was being made on a voluntary basis. Unlike Bangladesh, donation between non-relatives is allowed under exceptional circumstances, as determined by a “special committee” nominated by the Minister of Health in Egypt (Art 4). As the law does not include any guidance as to what these exceptional circumstances involve, the committee responsible for reviewing the documentation (i.e., letter from embassy, consent forms, passport, medical records) has wide discretion in making its decision. Dawitt was concerned that the operation would not go ahead because he was an Eritrean national and the recipient was from Sudan. He was also underage (19)—only persons over the age of 25 are permitted to donate an organ in Egypt. The broker assured him that there was no need to worry about identification papers: “It’s very easy, he [the broker] said. You just say you are Sudanese at the hospital, and then you are going to sign the papers and it’s done.” Corrupt embassy officials, he explained, provide “approval of kinship” forms for a nominal fee of $2,000, paid by or on behalf of the broker. When Law No 5/2010 was introduced, making it illegal to buy or sell an organ, the role of intermediaries (e.g., organ brokers) increased to act as a buffer against criminal investigation. Amir, a Sudanese national who sold his kidney in 2016 and was subsequently recruited into a criminal group to identify potential sellers, explained the extent of this symbiotic relationship. “There are a lot of different guys [brokers] working here (Cairo)” he said. “They work with all the hospitals and doctors. Some of the doctors are the famous ones here in Cairo, working in the best private hospitals…Without their brokers to bring them donors, nobody would come to them.”

Recruitment brokers connect the donor-seller to other intermediaries with established ties to one or more tissue typing labs or hospitals. The price that an organ seller receives depends on their ability to negotiate. Malik an organ broker interviewed in Cairo in 2017 explained: “For someone to sell his kidney…it depends on the person himself. If he is in the know, you will give him one price. If he doesn't know, then you will give him another [lower] price.” When a fee is agreed, the donor-seller undergoes tissue typing, a procedure in which the tissues of a prospective donor and recipient are tested for compatibility prior to transplantation. This usually takes place in several analytic labs to increase the probability of finding a suitable match in the shortest time possible. When a suitable match is found, the donor-seller is referred to a hospital or transplant center, where the nephrectomy is performed. “I took care of all the paperwork,” Malik explained. “I accompanied them [the donors] to get their papers approved by the official and then later I would bring them to the lab for health checks before the operation. The doctors don’t want to know anything. They take the money without question. This is their only concern. Once the papers are in order everything is legal.” Once an organ seller has been received with the requisite paperwork (i.e., letter from relevant consulate office approving donation, consent form, passport, medical records) the illegality of the transplant is concealed and rendered legitimate; normal procedure follows. In short, the illegal supply of organs is “laundered” by means of an arbitrary consent process, mediated by a segmented network of intermediaries working in partnership with corrupt medical staff (see also Moniruzzaman 2012). Medical facilities performing transplants are responsible for adhering to ethical standards but without any meaningful oversight mechanism self-regulated clinics are largely free to determine their own guiding principles. Only doctors with knowledge of a commercial agreement are prohibited from performing a transplant, meaning that if a doctor claims to be unaware of a commercial exchange a criminal investigation is unlikely (Ambagtsheer 2021).

Hana, a young asylum seeker from Sudan, was taken to an apartment where her kidney was forcibly removed. “They took my passport and clothes,” she said. “Then they drugged me. When I was awake, I found myself alone. I was in pain and there was blood on my side coming from a bandage. I had no idea what was happening.” Hana was afraid to go to the police. The broker told her that if she filed a report, she would be arrested for selling her kidney. Another woman, Hiba, threatened to report everyone involved, including the doctor who performed the surgery, to the police. She called the hospital to speak to the doctor, but he denied any knowledge of wrongdoing. “He took the documents I signed to a lawyer, so if I tell the police, they can prove I donated my kidney voluntarily. I was going to the police station, but people told me that if I report them, the police may arrest me as well.” If a consent form has been signed and approved by the Ministry of Health, the transplant is considered legitimate. The consent form that Hiba signed was used as evidence that she had donated her kidney voluntarily. If she was to say otherwise, she could have been liable for a criminal offence: selling a kidney. The fact that she was a foreign national living in Egypt without a valid residency permit meant that she was also at risk of deportation. Rather than deterring the trade, criminal sanctions have been used by criminal groups to silence their victims. Although it is unlikely that someone who has been trafficked for organ removal would be prosecuted, arrest and detention is a very real possibility for migrant workers and asylum seekers who are classified as “illegal” by immigration authorities (Columb 2020). Accordingly, there has been a shift in recruitment practices away from impoverished Egyptians towards migrant workers, asylum seekers and refugees excluded from state protection.

Law enforcement

In July 2018, a statement from the Egyptian Ministry of Health announced that 37 people, including doctors, nurses and middlemen, had been found guilty on charges related to illicit trading in human organs (BBC 2016, 2017). There was no mention of the victims. In 2016, millions of dollars were reportedly recovered from a private hospital during a raid as part of an investigation into illegal organ harvesting. The court records have never been released. Although there have been a number of arrests reported in the media actual convictions are yet to be confirmed, despite what appears to be a flourishing criminal enterprise. Several respondents claimed that “the business of selling organs” is being protected by corrupt officials. Okot, a Sudanese organ broker, suggested that doctors pay corruption money to protect themselves from police investigations. “The doctors,” he said, “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 [organ trade], otherwise, no doctor would be able to work.” When asked if he was referring to government officials, he simply replied, “they are people higher up.” The patronage of high-ranking officials cannot be confirmed from anecdotal evidence alone. Nevertheless, it does raise important considerations as to why so few cases are being investigated in Egypt, despite the introduction of strict laws regulating organ transplantation. According to Okot, the threat of arrest acts as a form of official extortion. Corrupt medical professionals, performing illegal transplants, who pay for protection will not be investigated. Whereas those who refuse to pay will be subject to arrest.

Political corruption and police brutality fueled the protests that led to the Egyptian Revolution in 2011 (Ketchley 2017; Rutherford and Sowers 2018). Studies suggest that police officials regularly solicit bribes in exchange for their discretion, e.g., dismissing traffic fines (Ghalwash 2014; Rutherford and Sowers 2018). The General Intelligence Service, known locally as the Mukhabarat, have been linked to reports of torture and the arbitrary arrest of “prisoners of conscience” (Magdi 2022). Since the military coup in 2013, under incumbent President Abdel Fattah al-Sisi, corruption among the military and their role in the country’s economy has caused further political instability and deepened mistrust in government institutions, including the Administrative Control Authority (ACA), the body responsible for fighting corruption (Transparency International Egypt 2021). Although the ACA is characterized as an independent body it works in close coordination with the central government. Therefore, the autonomy it has to investigate corruption among high-ranking officials is limited. Although Egyptian authorities claimed to have made several arrests of persons suspected of organ trafficking there are no convictions or testimonies recorded by the Egyptian judiciary. Critically, the law fails to address the underlying conditions behind the organ trade in any meaningful way. What it does do is provide legal clearance for medical facilities performing transplants in the event that a “consensual” donation results in explicit harm. However, impunity also depends on the selective discretion of legal authorities, which according to respondents can be purchased for a fee.

Discussion and conclusion

In Bangladesh, the organ trade developed as a corollary of an already corrupt medical system (Transparency International 2018). In Egypt, the organ trade emerged as an economic lifeline for impoverished communities living on the margins of society. In both countries, political indifference to the bodies of the poor and the non-enforcement of criminal penalties allowed the trade to establish itself as part of the supply chain for the transplant industry. In our respective fieldwork, interviews with transplant professionals, organ recipients, and law enforcement agents revealed a casual disregard for the business of organ sales. In a context of social inequality and endemic poverty selling or facilitating the sale of an organ was not seen as particularly corrupt. Organ sales were viewed as what Heidenheimer (1996) might describe as “gray corruption”, a morally reprehensible activity that does not elicit significant concern or public outrage. While some recipients considered it wrong to accept an organ from a family member, the conditions of poverty and indebtedness that compelled others to sell a kidney or a liver lobe were accepted as a fact of life. Meanwhile, brokers and medical professionals sought ways to rationalize objectively criminal acts as logical, if not inevitable, in a context of pervasive state corruption.

In both countries medical committees were established to oversee the ethical regulation and administration of all transplant activity. The establishment of medical committees have, however, added an extra layer of opacity by institutionalizing a superficial consent process that occludes ethical standards and protects transplant professionals from criminal scrutiny. In Egypt, medical committees were used as a means to legitimize and effectively launder illicit transplants (see also Manzano et al. 2014). Instead of protecting potential victims from “illicit organ removal” consent forms were presented as evidence of voluntary donations, regardless of the circumstances (see Hiba’s case above). In Bangladesh, medical professionals who were complicit in “illicit organ removal” denied any criminal misconduct by insisting that they were performing transplants that had been approved by committee members.

In addition to establishing medical committees to oversee ethical donations Egypt and Bangladesh introduced and amended criminal legislation in response to persistent reports of organ trading. Amendments to Egyptian law concentrated on increasing criminal penalties, without clearly specifying how or to who liability would be applied. In contrast to Egypt, Bangladesh amended its legislation to expand the organ donor pool by permitting extended family members to donate. Unlike Egypt, where unrelated donations are permitted between foreign patients of the same nationality, it remains illegal for an unrelated donor to donate an organ. Yet, regardless of legislative differences the impact of criminal legislation has been similarly ineffectual. In both countries, legal ambiguity with regards to criminal culpability has worked against the interests of organ sellers (see also Yea 2015; Mendoza 2010). In Egypt, rather than deterring the organ trade criminal sanctions were used by criminal groups to silence their victims. Migrant “donors” who reported criminal abuse to the Egyptian police were threatened with arrest and/or detention. In Bangladesh, organ sellers were solicited for bribes when arrested (for selling a kidney) or when requesting public services, i.e., criminal investigation into illicit organ removal. Bribes were also accepted in lieu of a fine or, in the case of brokers, in exchange for bail and/or impunity from criminal sanction. In general, laws intended to support victims of illicit organ removal served to conceal their abuse. In effect, prohibitionary measures have maintained the state of the organ trade rather than disrupt it.

Weak regulations, and procedural irregularities (e.g., regarding the admissibility of evidence) have been cited as the main reasons for poor conviction rates concerning illicit organ removal (Ambagtsheer 2021; Interpol 2021). Yet, as the above narratives indicate tightening laws does not necessarily act as a deterrent to organ trading. The failure to curb the organ trade, we suggest, is not so much a problem of legislation but is rather symptomatic of the unlawful abuse of power by state and non-state actors. The Corruption Perception Index (2022) from Transparency International ranks Egypt and Bangladesh as two of the most corrupt countries in the world with scores of 30 and 25 respectively, below the global median of 43 out of 100. According to a study by Zhang et al. (2009) increased social support, measured as public expenditure on healthcare, is associated with lower levels of corruption. Social support, they contend, is inversely related to corruption (see also Lin 1986; Cullen 1994). Our research supports these findings, illustrating how corrupt activities and how they are perceived is linked to the criminal divestment of social welfare (Hagan 1994). Hence, levels of public health expenditure, we suggest, are a good indication as to where organ markets might develop.

Although transplant services are available through public health care systems, access is often constrained by the availability of specialist physicians and surgeons, partial or inadequately subsidized medical coverage for transplant procedures, and a lack of altruistic donations (Cohen 2014). These constraints are particularly acute in low-to middle income countries where public expenditure is limited (Gupta et al. 2002). In comparison, the availability of (commercial) organs and the higher standard of care provided in the (globalized) private sector means that patients will pay out of pocket if and where they can afford it. Egypt and Bangladesh rank among the lowest countries for public health expenditure per capita in the world, along with other countries where cases of organ trading have been reported, i.e., India, Philippines, Afghanistan (WHO 2023). District hospitals in Egypt and Bangladesh are over-crowded, understaffed, and under resourced (McDevitt 2015; Hamdy 2012). As a result, 68 percent of patients pay privately for healthcare procedures in Bangladesh compared to 62% in Egypt (The New Age 2022; Khalifa, A. Y., et al. 2022). Those who cannot afford to pay out of pocket are effectively denied access to basic health care, not to mention costly transplant services.

In an institutionally corrupt environment where access to public services (i.e., healthcare) is determined by one’s ability to pay commercial transplants are inevitable. Prioritizing investment into impoverished communities and developing equitable transplant services would go a long way in reducing the commercial incentive for illegal transplants. The current (criminocentric) regulatory framework does not, however, acknowledge the structural conditions that underpin illicit organ removal. With a lack of altruistic donors and a failure to invest in the necessary infrastructure to develop deceased donation in support of a reciprocal organ sharing system, organ transplantation is dependent on illicit supply, invariably sourced from poor communities. Brokers are a by-product of systemic corruption in the transplant industry which has developed along commercial lines. Medical practitioners, for their part, are protected from criminal investigation by corrupt officials. A lack of economic opportunities is often the initial impetus behind organ sales and the exploitation that follows. However, in order for criminal groups to organize continuous operations, a regulatory or socio-legal environment conducive to illicit trade and related vice is necessary (Zhang and Pineda 2008). Thus far efforts to combat the trade in living organs have focused on increasing the altruistic supply of organs and expanding a framework of penal measures. The policy implication from this study clear – interventions to counter organ trading must recognize and address its symbiotic relationship with the regulatory environment.