Organ trading remains a mushrooming business around the world, as human organs, tissues or other body parts are sold and bought for transplantation. As the word trading suggests, monetary values are attached to the donors' organs, giving rise to societal problems. The problem of organ trading is often attributed to poverty, but much deeper issues are linked to it. Only a systematic investigation will unearth why and how organ trading occurs in a particular community.

In a recent research published in PloS Global Public Health, interdisciplinary experts, including those involved in the study of anthropology, social sciences, public health, demography and clinical sciences, came together to explore why kidney trafficking has entrapped a village in Kavrepalanchowk called Hokse. Hokse is often referred to as a village with a single kidney.

Before moving into the village with a single kidney, let me discuss why and how organ trading occurs. Human organs traded in the organ trade market include the heart, pancreas, skin, kidney, and eyes. The kidney remains the most traded organ globally.

As intricate and visceral a kidney is, so are the mechanisms of trading attached to it. Kidney trading has roots and causes unique to the context and circumstances. For instance, low- and middle-income countries (LMICs) are mostly sellers, thus banks for kidneys for customers in high-income countries. Nepal, one of the LMICs of South Asia, is a developing economy where a considerable section of the people lives in poverty. With high unemployment and underpaid jobs, Nepal has been a hot spot for kidney harvesting for the last two decades.

Among all the places of Nepal, Hokse village of Kavrepalanchowk district, just 50 kilometres from the capital city Kathmandu, is infamous for the trade of kidneys. More than 100 people in the village have sold their kidneys. Considering the population density and geographic landscape of the village, it is appalling to learn that every alternate resident of Hokse suffers from the mutilation of kidneys.

Kidney trade is often carried out by the trafficking of humans and/or their body parts. The victims of trafficking are not identified until they are found with brutal mutilations of their body parts. The victims are recruited through deception and are uninformed about the reality of the procedure and the impact of kidney removal. The kidney trade is facilitated by the highly efficient skills of brokers who know how to exploit the vulnerability and evade the laws. Organ brokers are, therefore, the catalyst for initiating and accomplishing the transaction between the people who need kidneys and those who need money. Often, wealthy clients who are in end-stage renal disease demand kidneys. Conversely, people desperate to fulfil the necessities of their lives sell their kidneys.

Anthropologists have cautioned about underreporting the facts and reasons for kidney selling, alluding that the kidney trade is not merely a result of poverty. There are social, cultural and individual layers to its survival. Anthropologist Lawrence Cohen narrates the story of poor Indian slum dwellers who sold their organs to raise money for the dowry of their daughters. Adding to the stories from the poor slum dweller, she quotes one of the females who regretted having only two kidneys in her body; basically, she wished she could have more to sustain her living.

In Hokse village, poor and unemployed people have been lured into selling their kidneys. Brokers show big dreams of huge payoffs and debt-free lives to the victims and trap them by offering high hopes. Often, the brokers study the situation of the community people and build connections on a personal level. The brokers often form relationships of “mitjyu”, or kin friends, with the community people who are in dire poverty. The brokers then deceive their new friends and take them to a destination for selling their kidneys.

Similarly, with the buyers of kidneys, the brokers again negotiate for a higher price depending on the desperation level of the buyers. Following the mutilation of kidneys, the brokers again find new victims, and teach them the "easy" way to earn money, and a vicious cycle of kidney trade continues. Various factors sustain this trade: poverty, unemployment, imitation of others, policy loopholes, involvement of medical personnel, rising technology and, above all, the participation of brokers to meet the demand and supply.

Although brokers are the key players in the kidney trade in Hokse village, previous reports also highlight the role of poverty, and in particular, the role of the earthquakes in pushing families into poverty, which ultimately prompted them to resort to selling their kidneys. Nevertheless, attributing the kidney-selling tendency only to poverty sketches an incomplete story. It requires a thorough exploration of social dynamics and mechanisms that underpin the kidney selling from Hokse village. For instance, many villages are identically poorer and inaccessible, but they do not resort to kidney selling, making Hokse a unique case.

Brokers and their roles in kidney trafficking can be scrutinised through simple measures, although they look smart for a number of reasons. Their knowledge of bureaucratic processes, documentation, connections, and networks with clinicians, hospitals, and authorities is incredibly well-established. More importantly, there are clear legal loopholes that brokers take advantage of. For instance, doctors performing kidney transplantations are provided with perfectly normal documents and fully informed consent; thus, the doctors cannot refuse to undertake the operation.

The question is, when, if at all, will brokers be scrutinised and penalised for what they have already done to Hokse? The answer lies in the fact that the brokers smooth over the loopholes so meticulously that it is hard to disentangle the kidney trade from the transplantation procedure. And though the transplantation was first carried out in 1954 with an altruistic gesture, the evolvement of the trafficking and trade through the brokers has painted such a noble cause as one of the heinous crimes.

A number of measures can help resolve and tackle the issues of brokerage. A massive public awareness campaign against the kidney trade should be launched. With awareness, authorities should address people's basic needs, such as employment, education, and health. The medical fraternity should adhere to its professional ethics.

Moreover, to maintain transparency in the medical profession, there should be unanimous approval of the team to decide the transplantation. This will bring down unethical practices. Regulations against fake documentation must be strictly enforced so that the government can hold the people involved accountable. Transnational coordination should be applied to curtail kidney trafficking between Nepal and India. Lastly, the role of brokers should not be underestimated, and they should be made accountable for the extent of harm they have inflicted on their victims.