Joypurhat/Dhaka, Bangladesh, and New Delhi/Kolkata, India ? Under the mild afternoon sun, 45-year-old Safiruddin sits outside his incomplete brick-walled house in Baiguni village of Kalai Upazila in Bangladesh, nursing a dull ache in his side.

In the summer of 2024, he sold his kidney in India for 3.5 lakh taka ($2,900), hoping to lift his family out of poverty and build a house for his three children ? two daughters, aged five and seven, and an older 10-year-old son. That money is long gone, the house remains unfinished, and the pain in his body is a constant reminder of the price he paid.

He now toils as a daily labourer in a cold storage facility, as his health deteriorates ? the constant pain and fatigue make it hard for him to carry out even routine tasks.

?I gave my kidney so my family could have a better life. I did everything for my wife and children,? he said.

At the time, it didn?t seem like a dangerous choice. The brokers who approached him made it sound simple ? an opportunity rather than a risk. He was sceptical initially, but desperation eventually won over his doubts.

The brokers took him to India on a medical visa, with all arrangements ? flights, documents, and hospital formalities ? handled entirely by them. Once in India, although he travelled on his original Bangladeshi passport, other documents, such as certificates falsely showing a familial relationship with the intended recipient of his kidney, were forged.

His identity was altered, and his kidney was transplanted into an unknown recipient whom he had never met. ?I don?t know who got my kidney. They [the brokers] didn?t tell me anything,? Safiruddin said.

By law, organ donations in India are only permitted between close relatives or with special government approval, but traffickers manipulate everything ? family trees, hospital records, even DNA tests ? to bypass regulations.

?Typically, the seller?s name is changed, and a notary certificate ? stamped by a lawyer ? is produced to falsely establish a familial relationship with the recipient. Forged national IDs support the claim, making it appear as though the donor is a relative, such as a sister, daughter, or another family member, donating an organ out of compassion,? said Monir Moniruzzaman, a Michigan State University professor and a member of the World Health Organization?s Task Force on Organ Transplantation, who is researching organ trafficking in South Asia.

Safiruddin?s story isn?t unique. Kidney donations are so common in his village of Baiguni, that locals know the community of less than 6,000 people as the ?village of one kidney?. The Kalai Upazila region that Baiguni belongs to is the hotspot for the kidney trade industry: A 2023 study published in the British Medical Journal Global Health publication estimated one in 35 adults in the region has sold a kidney.

Kalai Upazila is one of Bangladesh?s poorest regions. Most donors are men in their early 30s lured by the promise of quick money. According to the study, 83 percent of those surveyed cited poverty as the main reason for selling a kidney, while others pointed to loan repayments, drug addiction or gambling.

Safiruddin said that the brokers ? who had taken his passport ? never returned it. He didn?t even get the medicines he had been prescribed after the surgery. ?They [the brokers] took everything.?Brokers often confiscate passports and medical prescriptions after the surgery, erasing any trail of the transplant and leaving donors without proof of the procedure or access to follow-up care.

The kidneys are sold to wealthy recipients in Bangladesh or India, many of whom seek to bypass long wait times and the strict regulations of legal transplants. In India, for example, only about 13,600 kidney transplants were performed in 2023 ? compared with an estimated 200,000 patients who develop end-stage kidney disease annually.

Al Jazeera spoke with more than a dozen kidney donors in Bangladesh, all of whom shared similar stories of being driven to sell their kidneys due to financial hardship. The trade is driven by a simple yet brutal equation: Poverty creates the supply, while long wait times, a massive shortage of legal donors, the willingness of wealthy patients to pay for quick transplants and a weak enforcement system ensure that the demand never ceases.

The cost of desperation

Josna Begum, 45, a widow from Binai village in Kalai Upazila, was struggling to raise her two daughters, 18 and 20 years old, after her husband died in 2012. She moved to Dhaka to work in a garment factory, where she met and married another man named Belal.

?In front of this gang?s gun?

In some cases, victims have become perpetrators of the kidney scam, too.

Mohammad Sajal (name changed), was once a businessman in Dhaka selling household items like pressure cookers, plastic containers and blenders through Evaly, a flashy e-commerce platform that promised big returns. But when Evaly collapsed following a 2021 scam, so did his savings ? and his livelihood.

Drowning in debt and under immense pressure to repay what he owed, he sold his kidney in 2022 at Venkateshwar Hospital in Delhi. But the promised 10 lakh taka ($8,200) never materialised. He received only 3.5 lakh taka ($2,900).

?They [the brokers] cheated me,? Sajal said. Venkateshwar Hospital has not responded to repeated requests from Al Jazeera for comment on the case.

There was only one way he could earn what he had thought he would get for his kidney, Sajal concluded at the time: by joining the brokers to dupe others. For months, he worked as a broker, arranging kidney transplants for several Bangladeshi donors in Indian hospitals. But after a financial dispute with his handlers, he left the trade, fearing for his life.

?I am now in front of this gang?s gun,? he said. The network he left behind operates with impunity, he said, stretching from Bangladeshi hospitals to the Indian medical system. ?Everyone from the doctors to recipients to the brokers on both sides of borders are involved,? he said.

Now, Sajal works as a ride-share driver in Dhaka, trying to escape the past. But the scars, both physical and emotional, remain. ?No one willingly gives a kidney out of hobby or desire,? he said. ?It is a simple calculation: desperation leads to this.?

Acknowledging the cross-border kidney trafficking trade, Bangladesh police say they are cracking down on those involved. Assistant Inspector General Enamul Haque Sagor of Bangladesh Police said that, in addition to uniformed officers, undercover investigators have been deployed to track organ trafficking networks and gather intelligence.

?This issue is under our watch, and we are taking action as required,? he said.

Sagor said that police have arrested multiple individuals linked to organ trafficking syndicates, including brokers. ?Many people get drawn into kidney sales through these networks, and we are working to catch them,? he added.

Across the border, Indian law enforcement agencies, too, have cracked down on some medical professionals accused of involvement in kidney trafficking. In July 2024, the Delhi Police arrested Dr Vijaya Rajakumari, a 50-year-old kidney transplant surgeon associated with a Delhi hospital. Investigations revealed that between 2021 and 2023, Dr Rajakumari performed approximately 15 transplant surgeries on Bangladeshi patients at a private hospital, Indian officials said.

But experts say that these arrests are too sporadic to seriously dent the business model that underpins the kidney trade.

And experts say Indian authorities face competing pressures ? upholding the law, but also promoting medical tourism, a sector that was worth $7.6bn in 2024. ?Instead of enforcing ethical standards, the focus is on the economic advantages of the industry, allowing illegal transplants to continue,? said Moniruzzaman.

?More transplants mean more revenue?

In India, the Transplantation of Human Organs Act (THOA) of 1994 regulates organ donations, permitting kidney transplants primarily between close relatives such as parents, siblings, children and spouses to prevent commercial exploitation. When the donor is not a near relative, the case must receive approval from a government-appointed body known as an authorisation committee to ensure the donation is altruistic and not financially motivated.

However, brokers involved in kidney trafficking circumvent these regulations by forging documents to establish fictitious familial relationships between donors and recipients. These fraudulent documents are then submitted to authorisation committees, which ? far too often, say experts ? approve the transplants.

Experts say the foundation of this illicit system lies in the ease with which brokers manipulate legal loopholes. ?They fabricate national IDs and notary certificates to create fictitious family ties between donors and recipients. These papers can be made quickly and cheaply,? said Moniruzzaman.

With these falsified identities, transplants are performed under the pretence of legal donations between relatives.In Dhaka, Shah Muhammad Tanvir Monsur, director general (consular) at Bangladesh?s Ministry of Foreign Affairs, said that the country?s government officials had no role in the document fraud, and that they ?duly followed? all legal procedures. He also denied any exchange of information between India and Bangladesh on cracking down on cross-border kidney trafficking.

Over in India, Amit Goel, deputy commissioner of police in Delhi, who has investigated several cases of kidney trafficking in the city, including that of Rajakumari, the doctor, said that hospital authorities often struggle to detect forged documents, allowing illegal transplants to proceed.

?In the cases I investigated, I found that the authorisation board approved those cases because they couldn?t identify the fake documents,? he said.

But Moniruzzaman pointed out that Indian hospitals also have a financial incentive to overlook discrepancies in documents.

?Hospitals turn a blind eye because organ donation [in general] is legal,? Moniruzzaman said. ?More transplants mean more revenue. Even when cases of fraud surface, hospitals deny responsibility, insisting that documentation appears legitimate. This pattern allows the trade to continue unchecked,? he added.

Mizanur Rahman, a broker who operates across multiple districts in Bangladesh, said that traffickers often target individual doctors or members of hospital review committees, offering bribes to facilitate these transplants.? ?Usually, brokers in Bangladesh are in touch with their counterparts in India who set up these doctors for them,? Rahman told Al Jazeera. ?These doctors often take a major chunk of the money involved.?

Dr Anil Kumar, director of the National Organ and Tissue Transplant Organisation (NOTTO) ? India?s central body overseeing organ donation and transplant coordination ? declined to comment on allegations of systemic discrepancies that have enabled rising cases of organ trafficking.

However, a former top official from NOTTO pointed out that hospitals often are up against not just brokers and seemingly willing donors with what appear to be legitimate documents, but also wealthier recipients. ?If the hospital board is not convinced, recipients often take the matter to higher authorities or challenge the decision in court. So they [hospitals] also want to avoid legal hassles and proceed with transplants,? this official said, speaking on condition of anonymity.

Meanwhile, organ trafficking networks continue to adapt their strategies. When police or official scrutiny increases in one location, the trade simply moves elsewhere. ?There is no single fixed hospital; the locations keep changing,? Moniruzzaman said. ?When police conduct a raid, the hospital stops performing transplants.

?Brokers and their network ? Bangladeshi and Indian brokers working together ? coordinate to select new hospitals at different times.?Porous borders and the fallout

For brokers and hospitals that are involved, there is big money at stake. Recipients often pay between $22,000 and $26,000 for a kidney.

But donors get only a tiny fraction of this money. ?The donors get three to five lakh taka [$2,500 to $4,000] usually,? said Mizanur Rahman, the broker. ?The rest of the money is shared with brokers, officials who forge documents, and doctors if they are involved. Some money is also spent on donors while they live in India.?

In some cases, the deception runs even deeper: traffickers lure Bangladeshi nationals with promises of well-paying jobs in India, only to coerce them into kidney donations.

Victims, often desperate for work, are taken to hospitals under false pretences, where they undergo surgery without fully understanding the consequences. In September last year, for instance, a network of traffickers in India held many Bangladeshi job seekers captive, either forced or deceived them into organ transplants, and abandoned them with minimal compensation. Last year, police in Bangladesh arrested three traffickers in Dhaka who smuggled at least 10 people to New Delhi under the guise of employment, only to have them forced into kidney transplants.

?Some people knowingly sell their kidneys due to extreme poverty, but a significant number are deceived,? said Shariful Hasan, associate director of the Migration Programme at BRAC, formerly the Bangladesh Rural Advancement Committee, one of the world?s largest nongovernmental development organisations. ?A rich patient in India needs a kidney, a middleman either finds a poor Bangladeshi donor or lures someone in the name of employment, and the cycle continues.?

Vasundhara Raghavan, CEO of the Kidney Warriors Foundation, a support group in India for patients with kidney diseases, said that a shortage of legal donors was a ?major challenge? that drove the demand for trafficked organs.

?Desperate patients turn to illicit means, fuelling a system that preys on the poor.?

She acknowledged that India?s legal framework was aimed at preventing organ transplants from turning into an exploitative industry. But in reality, she said, the law had only pushed organ trade underground.

?If organ trade cannot be entirely eliminated, a more systematic and regulated approach should be considered. This could involve ensuring that donors undergo mandatory health screenings, receive postoperative medical support for a fixed period, and are provided with financial security for their future wellbeing,? Raghavan said.

Back in Kalai Upazila, Safiruddin nowadays spends most of his time at home, his movements slower, his strength visibly diminished. ?I am not able to work properly,? he said.

He says there are nights when he lies awake, thinking of the promises the brokers made, and the dreams they shattered. He doesn?t know when, and if, he will be able to complete the construction of his house. He thought the surgery would bring his family a pot of cash to build a future. Instead, his children have been left with an ailing father ? and he with a sense of betrayal that Safiruddin can?t shake off. ?They took my kidney and vanished,? he said.

After their marriage, both Belal and Josna were lured by a broker into selling their kidneys in India in 2019.

?It was a mistake,? Josna said. She explained that the brokers first promised her five lakh taka (about $4,100), then raised the offer to seven lakh (around $5,700) to convince her. ?But after the operation, all I got was three lakh [$2,500].?

Josna said she and Belal were taken to Rabindranath Tagore International Institute of Cardiac Sciences in Kolkata, the capital of India?s West Bengal state, where they underwent surgery. ?We were taken by a bus through the Benapole border into India, where we were housed in a rented apartment near the hospital.?

To secure the transplant, the brokers fabricated documents claiming that she and the recipient were blood relatives. Like Safiruddin, she doesn?t know who received her kidney.

Despite repeated attempts, officials at Rabindranath Tagore International Institute of Cardiac Sciences have not responded to Al Jazeera?s request to comment on the case. Kolkata police have previously accused other brokers of facilitating illegal kidney transplants at the same hospital in 2017.

Josna said her passport and identification documents were handled entirely by the brokers. ?I was OK with them taking away the prescriptions. But I asked for my passport. They never gave it back,? she said.

She stayed in India for nearly two months before returning to Bangladesh ? escorted by the brokers who had her passport, and still held out the promise of paying her what they had committed to.

The brokers had also promised support for her family and even jobs for her children, but after the initial payment and a few token payments on Eid, they cut off contact.

Soon after he was paid ? also three lakh taka ($2,500) ? for his transplant, Belal abandoned Josna, later marrying another woman. ?My life was ruined,? she said.

Josna now suffers from chronic pain and struggles to afford medicines. ?I can?t do any heavy work,? she said. ?I have to survive, but I need medicine all the time.? (ALJAZEERA)

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