Scars – Ruined Lives and Deaths of Kidney Trafficking Victims
Paper presented at
The Pontifical Academy of Social Sciences
Human Trafficking: Issues Beyond Criminalization
17 – 21 April, 2015
Casina Pio IV, Vatican City
Prologue – Sacrificial Violence
A persistent theme that has defined my lifework as a barefoot anthropologist is derived from a tradition of critical theory, a concern with the invisible violences of everyday life. In my long-term study of mother love and child death in Northeast Brazil during and after the military dictatorship years (1964-1990) I used “everyday violence” to refer to the normalization of violence through institutions, bureaucracies and professionals – the agents of the social consensus – including politicians, teachers, agronomic engineers, urban planners, sugar plantation managers, civil servants, physicians and surgeons, municipal coffin makers. When the populist mayor, Jacques, produced hundreds of plywood coffins for free distribution to the hungry and afflicted families of the shantytown of Alto do Cruzeiro, the structural violence of the post-slave sugarcane plantation economy was amplified by its symbolic violence. “Here they are, take them away, the gift of coffins for your children are ready and waiting”. And when doctors in the municipal clinic prescribed tranquilizers for hungry and wasted babies, we enter the moral and ethical grey zone, the collusions between socially abandoned mothers desirous of the drugs that silenced their mewing infants and the doctors who were more than happy to supply them.
The structures of violence that produced premature death, slow starvation, infectious disease, and the despair and humiliation of making one’s little accommodations to it destroyed their spirits as well. Dom Helder Camara, the “little red archbishop” of Recife, railed against military police attacks on the few dissenting landless peasants by reminding those in power of the violence of hunger and the bombs of sickness and destitution. It was almost fifty years ago that I first walked up, slowly and fearfully, to the top of the Alto do Cruzeiro, in Timbauba, Pernambuco with a hammock and a plastic suitcase. It was the beginning of an anthropologist’s life’s work, somewhere between an obsession, a trauma, and a romance with the shantytown, home to 5,000 dispossessed sugarcane cutters expulsed from their homes in one of several plantations and usinas, industrialized sugar mills, where they had lived and worked, and turned into migratory seasonal contract workers, earning roughly a dollar a day to cut and sack cane. Impoverished, hungry, disoriented, they threw together homes made of straw, of mud and sticks, and found scrap material. They threw together families in the same bowdlerized fashion, taking whatever was available and making do, like the bricaleurs described by Claude Levi-Strauss. They circulated husbands and children among neighbors who would take them in, they were forced by scarcity and need to let their older children “go the streets”, where many loose street children were murdered by local death squads. “Well, after all,” my next shack over neighbor on the Alto do Cruzeiro, a classic favela, Biu commented after the police mowed her 17-year-old last-born child, her caçula, down, “Gilvan was no angel”.
Structural violence determines the timing of death and the depth of one’s grave. Structural violence begins with body counts and is often preceded by soul murders, the forms of symbolic violence that make victims complicit with their perpetrators, turning them into their own executioners. James Gilligan defines structural violence as “the increased rates of death, disease, and disability suffered by those who occupy the bottom rungs of society”. Structural violence is invisible and can only be recognized through its consequences. What is buried with these anonymous deaths is the enormous weight of useless suffering and premature death that might have been captured in the “dash” on the tombstone: “Here Lies Xoxinha, 1964- [dash] 1966”. Rest in peace little angel. Except, there were no tombstones, and no incriminating dash to memorialize the death. There was only the borrowed coffin and the pauper’s grave, the deposito de osos, the bone depository. No wonder the people of the Alto loved the prefeito imperfeito, Seu Jacques, for giving them free coffins. The act of “Christian” kindness solidified the perverse and pernicious patron-client relations that kept the people of the Alto in line. For dependency is like a drug.
Good enough ethnography requires a good enough method, one that I called, drawing on the language of Brazilian liberation theology, antropologia-pé-no-chão – anthropology “with its feet on the ground”, a barefoot anthropology, a grounded ethnography, grounded in the everyday realities, everyday violence and the little spaces of resistance to it. My research on love and death in the Alto do Cruzeiro was inspired by the Brazilian geographer Josué de Castro, by Paulo Freyre’s Pedagogy for the Oppressed, by Gustavo Gutiérrez’s “preferential option for the poor”, and by Ivan Illich’s “tools for conviviality” and by the writings of the Czech philosopher, Jan Patočka, whose work has been anthologized in Heretical Essays, in which he called for a solidarity of the shaken, as a basic starting point for all those involved in moral, cultural, political conflicts. In anthropological research this means balancing our conflicting roles, and allowing ourselves the freedom to take stands and to take sides in our particular corners of the global ethnographic world. The barefoot anthropologist “accompanies”, is side by side in the luta, as a dedicated friend and a follower.
In the decade of the 1980s life on the Alto do Cruzeiro resembled a refugee camp or the emergency room of an inner city hospital. The recently late Eduardo Galeano (1998) described Northeast Brazil as a concentration camp for more than 40 million people. Decades of nutritional studies of sugar cane cutters and their families in Pernambuco, showed evidence of slow starvation and inter-generational stunting. These Brazilian nanicos, nutritional dwarfs, were surviving on a daily caloric intake – camp rations – similar to the inmates of Buchenwald death camp. The camp analogy was a subtext in my account of mother love and child death on the Alto do Cruzeiro. Life on the Alto resembled prison camp culture with a moral ethic-based triage and an ethics of survival. Scarcity made mother love a fragile emotion, postponed until the newborn displayed a will to live, a taste (gusto) and a knack (jeito) or a talent for life. Infants died, mothers said, because they had no desire to live, they were elusive creatures, more like birds – here today, gone tomorrow, it was all the same to them, I was told. It was best to help them “go” quickly. The angel-babies of the Alto were “transitional objects” neither of this earth nor yet fully spirits. In appearance they were ghost-like: pale, wispy haired, their arms and legs stripped of flesh, their bellies grossly extended, their eyes blank and staring, their faces wizened, a cross between startled primate and wise old sorcerer. These supernumerary babies were kept at arm’s length by their mothers.
Primo Levi (1988) might have called those babies miniature “Musselman”, a reference to the cadaverous “living dead” in Auschwitz known in camp argot as “Muslems”. These were victims whose state of exhaustion was so great, whose despair was so palpable, whose collapse so complete, that they looked and behaved like walking mummies. Sometimes unable to stand of two feet these “given up” inmates were said to resemble Muslims at prayer. Their lethal passivity and indifference seemed to announce an “availability for death/execution”. Thus, they were isolated and reviled by those in the camps who still clung, however absurdly, to hope, and to life itself. The given up babies were described as “ready” for death. “Dead or alive”, an Alto mother said, “it’s all the same to them”. When Alto mothers cried they cried for themselves, for those left behind to continue the luta, the struggle that was life. They cried hardest of all for their children who almost died, but who surprised everyone by surviving against the odds. Mothers would speak with deep feeling of the child who, once given up for dead – “the candle already burning round his little hammock” – suddenly beat back death by displaying a fierce desire, a desejo and a gusto – a real taste, for life. Ah, these tough and stubborn children – you couldn’t kill them if you tried – were loved above all others. And they were raised to be fierce and wild, brabo, to know when they had to “eat shit” in the favela (be self-effacing and obedient) and when they could lash out and spit in the eye of the oppressor, whoever that person was defined.
The “gray zone” is populated by a thousand little betrayals in the desperate, covert, and continuous struggle to survive. The poor residents of the Alto do Cruzeiro knew that the “good” die young and the survivors are not always the best exemplars – survival tactics are rarely morally edifying. If there is a lesson here for physicians, it is surely one about knowing the material and moral grounds that define sickness and death. Life – survival at all costs – is not always better than death. A “liberation medicine” is a modest medicine, with scaled back expectations, and based on an understanding that life, by its very nature is scarce, and triage is inevitable, whether it is the triage of the battlefield, saving the salvageable, or the triage of the emergency room, or saving the sickest.
Sacrificial Violence and Kidney Selling
My organs watch project began, once again, in the hillside slum, the favela, of the Alto do Cruzeiro, within the context of rumors and allegations of foreigners in yellow vans kidnapping street children for their organs amidst scarcity, unmet needs and a multitude of moral and ethical gray zones. Those early rumors circulating in the mid 1980s were untrue, but the disappearances of street kids was true, and the illegal removal of organs from the bodies of paupers and unidentified persons in the Medical-Legal institutes of Brazil was not uncommon, and what else could mothers think when they came to claim their dead children? But another and more insidious form of kidney theft began to appear in the medical files of a large, private hospital in Recife, where living, unrelated kidney transplants accounted for a third of the transplants. I found that the traditional force of patron-client relations, similar in its intensity to master-slave relations, had created certain new labor agreements between plantation owners and their sugar cane workers, and between the wealthy Donas da casa and their domestic workers: to provide their patron or their patroa a “spare” kidney as needed. For generations sugar plantation owners had extracted cute babies from their fertile rural workers, saying “you have enough already, give your little blond daughter to me”. Demanding an extra kidney was only the next logical step. Kids and kidneys are linked in more ways than one.
In the meantime global demands and markets in kidneys were being introduced to transplant candidates stuck on waiting lists as a viable option through national and international organized crime syndicates. Purchased fresh kidneys were so much more appealing than brain dead kidneys on ice. The idea that I could improve my life, attain a higher quality of life, meant time off the dialysis machine which one kidney patient described to me as his “time on the cross”. Eventually, by 2001 the international kidney hunters and transplant traffickers came to Northeast Brazil, to Recife, drawn there by the Berkeley Organs Watch website (since taken down), that had listed the hot spots where human trafficking for kidneys was prevalent.
On a field research trip to Tel Aviv in 2001 an active international transplant coordinator (i.e., a kidney broker), told me that she had moved her base of operations from Israel, Russia, and Turkey to South Africa and Brazil having noted that the website explained that foreigners were trickling into private and even academic hospitals in South Africa after the fall of apartheid and the realignment of public health to primary health care. South African transplant surgeons needed new customers who could pay them. Brazil, described on my web page, had an internal kidney trade and poor people who advertised in local newspapers their willingness to sell “any organ of which I have two, and the removal of which will not cause my immediate death”. And so, one location of the Netcare Corporation Kidney Scandal derived from the medical human rights activist. As Brazilians like to say, “No one is innocent”, but I would add, “but some are very naive”.
Just as debt peonage drove the global illicit international adoption networks in Brazil (and Eastern Europe where both kid and kidney theft are just as entangled), debt peonage drives the kidney selling cartels that enforce a new tax on the bodies of the poor, a kidney tax. When Alberty Alfonso da Silva from a slum close to the international airport in Recife could not pay the debt on a used car and was physically threatened, he sold his kidney to cancel the debt. When Viorel was hunted by his debt brokers in Chisinau, Moldova, the tough guys put a gun on the bar table. “Pay up or your body will be floating somewhere”. They gave Viorel a way out – a bus trip to Istanbul to sell his kidney to an international tourist.
We ought to think twice about the words we use in describing human organ and tissue harvesting replete with financial and banking metaphors: organs stocks, tissue, organ and sperm banks, organ scarcities, kidney short-falls, supply and demand are dominant. These terms are accompanied by the commodification of organs in the language of spare parts. A kidney (that is sold) is always described by the brokers and even the surgeons (who know better) as a “spare” kidney, a “spare part, a commodity, detachable from the body, the owners” reliable “kidney” bank. No wonder the frightened people of the Alto do Cruzeiro told me that “the rich look at us and they see only one thing: a sack of spare parts”.
At a lecture some years ago for Catholic-identified Berkeley law faculty at Newman Hall, Holy Spirit Chapel, on the intriguing title, “The Unknown Sin”, emeritus professor John T. Noonan broke the suspense by immediately identifying the referent as human slavery which the world at large, and Christianity in particular, was slow to recognize as morally, ethically, and spiritually repugnant. It took a rather secular branch of Christianity, the Quakers in the 1830s, to develop a sin-based perspective on slavery and to lead an abolitionist movement to eradicate it. The Quakers were moved by the publication of slave narratives and the eloquence of men like Frederick Douglas whose words began to chip away at the thoughtless reification of slaves as property, mere things to be bartered, sold and disposed of at the owner’s will.
Until the mid-19th century slavery was simply accepted as a sad, lamentable, even tragic but nonetheless inescapable fact of Western civilization, as taken for granted as the air they breathed. It is true that Bartolomé de las Casas protested the enslavement of Indians in the New World but only because as indigenous residents of colonial New Spain they fell under Spanish laws and protections. Las Casas did not protest the enslavement of Africans or condemn the institution of slavery itself. The gospels do not quote Jesus speaking to or about slaves, although his spiritual mission was to lead an oppressed people out of one kind of slavery into a spiritual form of human liberation.
In his History of the English Church and People, written in 731 AD, the Venerable Bede explained Pope Gregory’s deep desire for the conversion of the British Isles: “We are told that some merchants recently arrived in Rome displayed their many wares in the market place. Among the crowd who thronged to buy was Gregory, who saw among other merchandise some boys exposed for sale. These had fair complexions, fine-cut features, and beautiful [flaxen] hair... Gregory inquired from what country and what part of the world they came. “They are from the island of Britain”, he was told, “where all the people have this appearance”. [Bede] then asked whether the islands were Christians or still heathen. “They are pagans”, he was told. “Alas!” replied Gregory with a heart-felt sigh: “How sad that such bright-faced folk are still in the grasp of the Author of Darkness and that such graceful features conceal minds void of God’s grace!” (pp. 99-100). The chains of ignorance, not the chains of human bondage inspired compassion in the man who would later become known as Gregory the Great. When told that the young slaves were from a race known as “Angles” the future Pope found the name most fitting. For indeed, “the boys had such angelic faces”.
I introduce this historical anecdote to address the late modern moral blindness with respect to the traffic in humans for their organs and tissues. I refer to the failure to see in the frank buying, selling, and trafficking in bodies in the zealous pursuit of organs for transplant, slavery in a new and distressing form. What is different about these transactions that might differentiate them from other forms of human trafficking – in sex, in smuggled workers, in third-world babies for international adoption – is that the traffic in humans, dead, brain dead or alive, for usable organs and tissues requires the skills and consent of society’s designated healers and guardians of the body: physicians, surgeons, and forensic pathologists among them.
Like slavery before abolition, the contemporary traffic in bodies is still generally not seen as morally repugnant, not seriously reckoned with as a medical human rights abuse, nor seen as a crisis in medical ethics, nor even as a pressing social problem about which “something must be done”. To the contrary, the brokering of organs from weak and fragile populations – the homeless, the unemployed, debtors, prisoners, political and economic refugees, street kids, the mentally ill and the mentally deficient – most of whom are pressured into selling – is still defended today by some of the world’s leading transplant surgeons, bio-ethicists and economists, and even by a few well-known medical anthropologists as a rational, sensible, and even as an ethical solution to the needs of transplant patients and their surgeons, and as a final solution to the global “scarcity of deceased donor and living related donor organs”. The global traffic in organs has clearly clouded the moral vision of some of the world’s most gifted transplant surgeons who are willing to prolong or improve the quality of their patient’s lives at almost any human cost. When confronted with moral quandaries they often respond that it is too complex, they are, after all just “technicians” or to “let the philosophers figure that one out”.
The Terror of the Gift – The Body Torn Asunder
"I know quite well that back there is only darkness crammed with organs”
Merleau-Ponty, 1973, The Prose of the World
In an attempt to lift the curtain on that “darkness crammed with organs” as Merleau-Ponty described the secret interior of the human body, I present a normative case of living donor transplant in a private hospital in Recife in July 2006. The following vignette is taken directly from my field notes at the Royal Portuguese Hospital (Real Hospital Português). The transplant candidate is not rich, but very poor. Adriano Rodrigo, from a working-class neighborhood of Recife, a venerable but decaying port city on the coast of Northeast Brazil, was twenty-eight years old and mortally ill with end-stage kidney disease. He is lying bare-chested and stretched out on a rusty metal gurney, next to his sheet-draped mother, Adriana, her son’s namesake and his lifeline to a new existence, unfettered to the dialysis machine on which he was fading fast. Only death, the joker, was in his cards. The young man’s “dirty blond” hair was tied back with a piece of leather string into a mass of tight springy curls, his thin arms and shoulders were alive with a tattooed garden of creeping vines, turtles, serpents and dragons.
At Portuguese Hospital 70% of kidney transplants there rely on living donors, some loving relatives, others from strangers or from one’s agricultural or household workers, following the rules of patron-client relations. But buying and selling kidneys had become so normalized, so normalized at the Portuguese Hospital that the transplant manager gave me a computer printout of all the transplants that had ever taken place there including the names of the patients and their living donors and their relationship – mother, brother, daughter, husband, cousin (questionable), or simply unrelated (meaning in this hospital a solicited and paid donor).
This pattern of kidney selling in the zona da mata, the traditional sugar plantation region, derives from the deadly trio of paternalismo, latifundismo, and clientelismo (patron-client relations) (see Scheper-Hughes 1993) made it easy for international transplant brokers to infiltrate a poor barrio on the outskirts of Recife, euphemistically named Jardim Sao Paulo, evoking the bright lights of Brazil’s largest city where these men hoped sometime in the lives to migrate.
Between 2001-2003 an international trafficking scheme led by two retired military men, one a Brazilian, Captain Ivan, the other, an international organs trafficking broker from Israel, Captain Gaddy Tauber, put out feelers into the bars, back alleys, and open air markets and curbside car repair to recruit young mostly Afro-Brazilian young men to travel to Durban, South Africa to provide a spare kidney to one of the 101 Israeli transplant tourists who arrived in groups, week after week, filling the hospital beds at the private NETCARE Corp clinic at the old and prestigious St. Augustine’s hospital.
On arrival from their countries, the elderly and sick Israeli patients, some in wheelchairs, were housed in large and comfortable suites with windows facing the ocean at the Holiday Inn on the luxurious Durban Parade. On arrival, the meninos do Brazil – The Boys from Brazil – were housed in a dark and dreary flat with bunk beds (a “safe house”) shared with kidney sellers trafficked in from rural Moldova and Romania. The Brazilian guys were incensed to learn that a handful of Israeli sellers were housed at the Holiday Inn with the Israeli transplant tourists and were paid $20,000 while the Brazilians were kept in a “kidney hostel” and were paid only $10,000 and some, like Alberty da Silva, got only $6,000, the same amount paid to the Romanians. Soon fights broke out among the kidney sellers.
One of the meninos complained to the police after he returned to Recife saying that he had been cheated by the brokers who made promises that were broken. They were mistreated and sent home before they had recuperated, their bandages seeping with blood and pus, as they were dropped off at the airport and told to shut their mouths because what they had done was a crime for which they could be arrested and sent to prison for many years. Gervasio asked the Brazilian police two questions: “Aren’t I the owner of my own body?” “Isn’t my body, my organs worth the same as the others?” It wasn’t long before Brazilian and South African police waged police stings – “operation scalpel” in Brazil, and “operation life” in Durban, resulting in arrests and prosecutions that are continuing to this day. Dr. Williams, Adriano’s surgeon, had informally contracted with the Israeli broker, Gaddy Tauber, about whom I published a three-part series in the Anthropology Newsletter. The scheme was to deliver Israeli patients to the Hospital Real who would be provided (through Gaddy Tauber) with young men from neighboring slums who were “clamoring”, or so it was said, to provide kidneys. But just before the first group of Israeli transplant tourists came to the Hospital Real, the police cracked down on the transplant scheme and prosecuted their case using the Palermo convention against international human trafficking.
The Bisturi – the Knife
Torn between the adjacent donor-recipient operating rooms, I entered the donor’s OR first. Adriana, unconscious, was rolled over to her left side with her right arm lifted high over her head in an awkward position and taped to a metal swing, fully exposing her right flank where the incision would take place. The old woman’s body was a marvel, even her breasts, following eight births, were still firm and her skin (except for her face) unwrinkled. “Hard workers, like these, keep their shape”, the nephrologists-surgeon commented approvingly, giving the donor’s rump a friendly thwack. Thank heavens she wasn’t a fatty (gordinha) he said, which makes rubber gloves and scalpel slippery.
The surgical instruments were arranged in a precise order by the scrub nurse so that the surgeon, even without looking up from the operating table could instantly take what he needed. The bisturi, the scalpel, occupies place of honor. Handle and blade, fitted together, the scalpel is just six inches from tip to tip. The handle has a notched prong into which the sharp blade is snapped into place. Now the knife springs to life, almost like a switchblade. “To hold the scalpel above the belly”, writes Richard Selzer (1974) “is to know the knife’s force – as though, were you to give it the slightest free reign, it would pursue an intent of its own, driving into the flesh with wild energy”. The surgeon’s power over life and death, writes Selzer, separates him from the murderer by only a thin line. “Now the scalpel sings along the flesh… a barracuda spurt, a rip of embedded talon… the whine – nasal, high, delivered through the gleaming metallic snout. The flesh splits open with its own kind of moan. It is like the penetration of rape” (p. 104).
The first sharp slice into the kidney donor’s side sends shivers down my spine. The layers of flesh are sliced and drawn back like heavy curtains, and secured with hard metal clamps. The electric cauterizing knife is brought out and the surgeon sets to work severing the old woman’s ribs. Like Eve, Adriano’s Mum will be permanently missing a rib or two. The smell of smoke and burnt flesh, and the squeal of bone, fills the room. Now the surgeon reaches down deeply into Adriana’s soft, warm, dark, pulsating inner sanctum followed by the tinkling sound of ice and ice water poured into her abdominal cavity and then suctioned out with a loud slurp.
I steel myself to go next door into the transplant theatre where Adriano, the son, is being prepped to receive his mother’s kidney. Dr. Williams and his team are hard at work. I navigate the edges of the table, trying to find a space where I can see and not be in the way until the female anesthesiologist pulls over a high stool and positions it at the head of the operating table telling me to hop up on it. From my parrot’s perch, with Adriano’s head just slightly butting into my stomach, I can, indeed, see everything.
Using what look like giant metal shoehorns, the surgeons pull back Adriano’s flesh back and secure it with metal clasps. A large round metal brace, that looks like it was lifted from a curbside auto repair shop, encircles and holds open the patient’s cavernous abdomen. The crater I am staring down into is a huge, red, gaping hole, large enough, as the surgical joke goes, to drop an alley cat (or two) into. At one point there are three pairs of surgical gloves and several pieces of “heavy metal” inside or at the rim of Adriano’s abdominal well. From time to time I pat the young man’s head softly and wish him courage, couragem.
The nephrologists-surgeon sends word to the transplant theatre that that he is ready to remove the old woman’s kidney. For now, it is sitting in its owner’s “pocket” detached from everything except its blood supply. Dr. Williams is surprised. “That was quick!” he says and sends word back that his team is not yet ready to receive the organ and he and his team redouble their efforts so that in anther twenty minutes they are ready. I follow the transplant team into the donor’s operating room and we hover around the operating table as the surgeon and his assistants begin the final severing and removal of the kidney, taking care that the arteries are properly tied off so that the donor doesn’t bleed to death. There is some coaxing: “Tira, Tira!” “E Isso! E Isso!” “Grab it! Take it!” “That’s it! That’s it!” And a cautionary “Hold it – not just yet, not now”.
The “delivery” of the kidney from Adriana’s kidney resembles a childbirth, and old lady’s kidney is “caught” in the surgeon’s hands and delivered to her son’s expectant body. She is giving birth to her son for a second time! The “newborn” kidney is gently lifted and placed into its kidney shaped pan and sprinkled with ice water, a baptism of sorts, before more ice water is poured on it. Dr. Williams is the first to have a long look at the little fellow which he lifts it out of the pan to examine it in his gloved hands. Something is not right and he shakes his leonine head. The visiting surgeons from rural Paraiba also have a look, pulling on its connective veins and arteries. They inject the kidney with a chemical solution, cover it with ice and sterile pads. The surgical team makes a solemn procession carrying the kidney into the adjacent operating room where Adriano waits, his body inert, his abdomen flayed and exposed like the caucus of a cow hanging from a meat hook.
Now five people, the surgeon and his assistants, are examining the little pink fellow, anxiously, as if a listless neonate had come into the world. It is “muito pekeno”, they cluck, awfully little. But I am not sure if they are referring to the kidney or to an artery. Williams criticizes the handiwork of his colleague in the next room, who is busy suturing up Adriana’s abdomen with her lone kidney, behind her second-class kidney, the one that atrophied and “wasn’t worth anything”. “Take the best one”, she had insisted before being put down to sleep.
The most delicate part of the operation begins, as the kidney is introduced into Adriano’s organ well and the laborious task of attaching it begins. There is a great deal of snipping and sewing. The OR is turned into a tailor’s shop and the seamstress-surgeons adopt a fussy, maternal air. The delicate, fine stitching requires sharp eyes and nimble fingers. “Williams”, a man in his sixties, is sweating profusely and struggling with the needlepoint; his large hands shake perceptibly. When a younger colleagues tries to direct his fingers, Williams brushes his hand away. Another calms the senior surgeon down: “OK, go easy, go easy now”. Finally, the stitching is completed and the coaxing and prodding of the pale little fellow begins:
“Come on, come on, wake up, wake up!”
“It’s lazy and soft”.
“It’s not working”.
“Look, (says Williams) he works OK when he’s sitting up”
“But he has to lie down!”
Williams pulls the kidney up, rubs it, pats it, encourages it:
“Come on, now. Wake up!”
“Is it any better?”
“I think he’s improving!”
“But he’s still not making chi-chi (pee-pee)”.
(Adriano’s head, still at my fingertips: “Hang on, hang on”, I whisper).
“Look, it’s beginning to pink-up!”
“Yes, it looks a bit better!”
(But hanging in the air is the question: Is it good enough, is it going to do the trick?)
Throughout the afternoon the mood in the OR has shifted back and forth from loud and playful, alegre and boisterous, to quiet, tense, sharp, tired, frustrated, abusado, critical, almost angry, until now when things seem to be going downhill, it is silent. Williams is exhausted, and another surgeon takes over for a bit and he tells Williams to take a break. A nurse comes over to help him remove his gloves and blood-splattered apron covering his surgical pants. As the surgeon walks out of the room, his head bowed, I see a large wet stain between his legs. A very depressed looking Williams walks dejectedly out of his operating room.
While Williams washes and rests up, the visiting surgeons continue to struggle inside Adriano’s abdomen for another endless forty-five minutes. When Williams returns there is a heavy air hanging thickly over the room. The newborn kidney is still not up and kicking. When probed, it is soft. Williams wants to leave the kidney “sitting up” for a while longer. The others disagree saying that the time has come to let him go. “Tuck it in”, they say. The time has also come to close Adriano up. “It’s over. Let’s go”, says Dr. Williams, in English, again taking command, as he claps his hand on Dr. Marcelo’s shoulder. “Vamos ver”, “We’ll see what happens”. Then he apologizes to me saying that the transplant that was not “bem-bonita”, not real pretty. “There were problems… I’ll stay up all night thinking about it”. And so will I, reflecting for many days on the failed transplant and the inherent terror of the gift.
My paper is the beginning of an anthropological/ethnographic/ethno-theological reflection on the body as a “perfectly made” corporeal assemblage that is dismantled, at great cost. While there are organs that are universally perceived as indispensable to the sense of self/personhood (heart, face, hands, legs, trunk, brain, lungs, stomach) other body parts and organs (pancreas, liver, heart valves) invisible, mute, and “absent” to the self (Leder 1990) are disguised and concealed from the individual’s anatomical schemata or body image. While injured limbs and diseased organs are removed through amputation or other life-saving surgeries they are not easily forgotten.
Fears of the fragmentation and disintegration of bodies are expressed in religious traditions from Egyptian mummification to medieval Christianity to contemporary burial practices across the world’s great religions. This under-examined and under theorized topic in the anthropology of bodies – what I am calling body-love – refers to an intuitive, existentially given, appreciation of the body’s design and the inalienability of its parts, both manifest and obvious head, trunk, limbs, and skin, and the silent and “absent” organs and tissues that make their presence known through disease, wounding, and excision.
Body love has a long history in early Christianity, in Kant’s philosophy of the inalienability of body parts (Morelli 2002) as well as in modern phenomenology. During the Catholic sacrament for the dying, a medieval rite originally called Extreme Unction (or final blessing) the priest tenderly anoints with holy oil each of the sensory organs of the dying person, the eyes, ears, nostrils, lips, hands and feet, and, (for men only) the loins. Pausing at each body-site the priest recites the benediction: “Through this holy anointing… may the Lord pardon whatever sins or faults thou hast committed by sight” [or by hearing, smell, taste, touch, walking, or sexual excess or dereliction]. Sin, pleasure, and carnal love are conjoined in a fond farewell to the flesh, organ by organ. In the medieval Christian world, the wounded body was an image of the godhead. To be vulnerable meant to be open, to embrace and to venerate the sacred wounds, a reflection on Christ’s passion – the nails to hands and feet, the crown of thorns to the head, the spear (like a scalpel) to the side.
“They have numbered all my bones” Psalm 22
At birth the newborn’s fingers, toes and other appendages are identified, numbered, and inspected by the midwife or the doula. “It’s all there” she announces to the relief of the parents. The dead, too, want to be buried intact, no missing limbs, brain, heart, liver, eyes. How else will they be able to navigate the river Styx, see the ancestors, or stand on their two feet before their Maker?
While studying infant mortality in Brazil in the 1980s I spent a good deal of time in the municipio of Timbauba/Bom Jesus da Mata graveyard. Dead infants arrived steadily, most carried in their little blue and silver lightweight coffins by a procession of children, although some neonates arrived in cardboard shoeboxes balanced on the head of the midwife or friend the family, Timbauba being a center of small-scale shoe factories. Sometimes baby coffins arrived tucked casually, like a Christmas gift, under the arm of its grieving father. So, I was not totally surprised to pass a small circle of sugar mill (usina) workers in their workaday attire, rubber boots, sackcloth pants held up with belts of rope. They must have come directly from the mill to bury a companheiro’s infant. The tiny coffin was just being gently put down into its shallow grave. I joined the group for a few “Hail Marys” and a “Glory Be” and then asked, as delicately as possible, whose child it was. “Criança, nada” – “What child?” one of the men replied. “It’s our companheiro Severino’s foot!” The foot had been mangled in the jaws of the sugar mill and amputated at the local hospital. Severino’s coworkers were charged with making sure the foot was given a proper burial, so that it would be waiting for the rest of his body when his time came.
In his autobiography, The Spirit of St. Louis, Charles Lindbergh (1953) tells the story of his grandfather who stumbled against a spinning saw at the sawmill. The saw’s teeth cut into his arm near the shoulder and ripped open his back. The gash was so deep that his coworkers could see their friend’s heart beating. They bound up his wounds, laid him on top of straw in an oxcart and carried him home to the family. The nearest doctor in St. Cloud took three days to arrive. By then there was nothing for it but to amputate the arm and stitch together the hole in his grandfather’s back. Lying on his bed in great pain, Lindbergh’s grandfather asked to see his severed arm before it was buried in the garden. It was brought to him in a small, rough-hewn coffin. The man took its fingers into the palm of his good, right hand and said in halting, broken English: “You have been good and faithful friend to me for fifty years. But you can’t be with me any longer. So good-bye, good-bye my friend” (p. 221-222).
Similar sentiments are expressed by the families of the victims of 9/11 that all body parts and fragments unearthed by construction workers at Ground Zero be carefully recovered and identified, as described by Chip Colwell-Chanthaphonh. Family members have staged protests while cranes and bulldozers turned up debris that might contain fragments of their loved ones. Fearing that human remains mixed in with the debris would be used to fill New York City potholes, family members of the victims called for an interruption of construction work at the “sacred site” until military forensic specialists were called in to comb the area for any human remains.
One thinks also of the Israeli orthodox religious organization, Zaka, comprised of observant Jews who train as forensic volunteers and who are called upon to gather at the scenes of traffic accidents, terrorist attacks, and suicide bombs (Stadler, 2005). Dressed in distinctive bright yellow lifejackets and plastic gloves Zaka team members hover at the scenes of mass violence until ambulances and police leave and they are left to scour the streets and scrape the walls of buildings, trees, busses, and sidewalks retrieving the tiniest bits of flesh and blood which they put in plastic containers so that they can be buried in accordance with orthodox tradition along with the rest of the dead body. But before burial, all the fragments assembled, classified, and matched by the volunteers are required by law to be dispatched to the secular professionals at the National Forensic Institute at Abu Kabir, a neighborhood in Tel Aviv. Ironically, the Institute was involved in a very different obsession: the illicit harvesting and stockpiling of the organs and tissues of Israeli citizens, Palestinians, tourists, political activists and even the victims of terrorist attacks inside Israel (Scheper-Hughes 2010, Scheper-Hughes and Bostrom 2013).
The 4th Body
Some years ago I wrote an essay on the “three bodies” – existential, social/representational, and the political body (Scheper-Hughes and Lock 1987). But is there another body, a 4th body, a body that goes without saying? A body unmediated by language or representation? If so it resonates with Wittgensteinian perception that all knowledge and all certainty begin with the “unquestionability” of the body. “If you know that here is one hand”, Wittegenstein began his last book, “we’ll grant you all the rest”. This generative perception on the “givenness” of the body as a natural tool or a natural symbol with which to “think” the world, came to Wittgenstein while he was working as a volunteer with patients hospitalized during the War. Wittgenstein’s essay is a reflection on the circumstances or the situations which might take away one’s unconscious certainty of the body and all that this implies. (“If here you know there is no hand... no leg... or eye... no kidney”?) The result is a profound sense of malaise, of loss, of grief, of existential insecurity in one’s body and in the world.
The history and distribution of body modification, scarification, tattooing, genital, plastic, and sexual reassignment surgeries might be seen as a deviation from what I am describing. But rather they are the most cogent expression of individual and/or cultural (and therefore diverse) internalized “anatomical schema” (de Preester and Knockaert, eds. 2005) conforming to the given body-image. There are pathological conditions – anorexias, “wanna-be amputees” (Elliott 2003), self-cuttings, etc. based on distortions of body image and design. And to be sure traumatic injury can upset the body scheme to the extent that one can temporarily dis-identify with the damaged body part. Although Oliver Sacks (1998) miraculously saved himself by inching his way down a mountainside after severely damaging his leg in an encounter with a bull on a solitary stretch of Norway, in hospital he suddenly refused to accept the injured leg as belonging to him. The experience was transitory and his normal body-sense was restored, including the alienated limb.
Merleau-Ponty’s (1962) description of the “phantom limb” stands as the most cogent description of the attachment of individuals to an existentially given and complete anatomical schemata in those who have suddenly experienced an amputation. The ghost limb – the limb that is gone – returns to haunt the body with its ethereal but deeply felt and intact presence. The phantom limb – arm, foot, leg or finger – retains the position of the original body part at the moment of the injury or trauma. The pain can be unbearable but even “anesthesia with cocaine does not do away with [it]” (p. 66). The clinical and psychological literature contains many cases of phantom limbs without amputation, resulting from a brain injury, and people who suffer the absence of limbs who were born without them. Phantom limbs appear in paraplegics and in those who have suffered a complete break in the spinal cord and who nonetheless insist that they experience feeling in their legs and lower body.
For Merleau-Ponty the body is not a mechanical object but a lived embodied subjectivity: “To have a phantom arm is to remain open to all the action of which the arm alone is capable; it is to retain the practical field which one enjoyed before mutilation… The body is one’s vehicle in the world and having a body is, for a living creature, to be intervolved in a definitive environment, to identify oneself with certain projects, and to be continually committed to them” (p. 71). Thus, even when a limb is suddenly gone forever the person retains the memory and possibilities for its use even though they can never again be taken up as a project in the world. The phantom limb is a symbol of corporeal intactness and of the person’s “total awareness of their posture in the inter-sensory world” (p. 86) akin to Bourdieu’s “habitus”.
Against this view, however, are equally gripping narratives of naturalized (born) or traumatized amputees who, like 28-year-old Diane deVries, initially described by Geyla Frank as “a woman born with all the physical equipment she would need to live comfortably in our society – except arms and legs (Venus on Wheels) and Albie Sachs (Soft Vengeance of a Freedom Fighter) who express an equally intuitive and passionate attachment to their truncated bodies, the missing limbs seen (in the first instance) not only as natural to the self but as a sign of freedom, beauty and agility (despite all) or (in the second instance) as a manifest symbol of one’s political love and embodied commitment to the anti-apartheid struggle and the beloved community. In the case of Diane, Frank noted the frequent verbal references to her presumptive legs (made present even by mention of their absence) – as in friends teasing, “If you don’t have a drink, I’ll sit on your legs”, and Diane’s own dream experiences and faith-based experience of the “restoration” of her legs, thus conforming to the notion of a given anatomical schema. According to Frank, Diane claimed that she taught her sister to dance because there was a Diane within her own body who was born, although legless and armless, already knowing how to dance.
Buried in the thicket of annotated and translated field notes and interviews with kidney sellers in/from Brazil, Moldova, Israel, Syria, Egypt, Turkey, the Philippines and the United States I discovered a variation of the phantom limb, the phantom kidney. What distinguishes the phantom kidney is the sudden apparition and presence of what was, prior to the nephrectomy (kidney removal) an invisible, absent, even covert organ. I have argued (without success) that the “Phantom Kidney Syndrome” deserves a special notation in the latest revision of the DSM-IV. It belongs under the broader category of “Somatoform Disorders”, physical symptoms that are disabling and even occasionally life-threatening but that cannot be explained by organic/medical conditions. Thus, they are categorized as pathological mind-body-social (I would add, political and economic) relations.
Prior to surgical removal, kidney sellers often dismiss the kidney of last resort as a thing of little value of worth, as a supernumerary, “stupid”, “dirty”, “little thing” until the “redundant” kidney is excised and the “empty nest” or “empty pocket” suddenly becomes the locus and explanation for everything that has gone wrong in the lives of the vendor. The “phantom kidney” acts up. Some young men in rural Moldova described an absent kidney that wiggles or hops, itches or stings, contracts or expands. The phantom kidney is described as bloated and needing to urinate. The missing kidney inflicts pain, turns one’s eyes or skin yellow, and is attributed by some villagers as a cause of premature death. (“He sold the organ that makes the urine flow”). The lonely remaining kidney also suffers. It is described by some kidney sellers as “old before its time”, “used up” or simply as “tired” as consequence of being forced to do the work of two, to work overtime.
Among agricultural workers in Moldova the allusion to overwork and overtime and to doing the work of others is a critique of a diseased individual within an ailing collective and collectivist body in villages where the kholkhoz, or model collectivist farm system, is still the local mode of production and highly valued. “I never knew how much the little thing (coisinha) meant to me, until he was gone”, a kidney seller, Paulo, from Recife, Brazil told me. “That damn kidney keeps me up at night. I can feel it drumming inside the empty pocket”. Niculae Bardan of Mingir, Moldova expressed his fear of imminent death, wiping a tear from his eye with dirt-encrusted fingers. “What if I die for the loss of my kidney?”, a fear complicated by the village agricultural cooperative’s critique that if so, he would have died “for naught”, for “nothing”, for a mere payment of $2,700. A “stupid peasant” he took his “kidney” to the market and had it exchanged for a “basket of rotten apples”. “Stupid donkey” Dom Vasile upbraided his sick-to-death son, Validimir, who did, in fact, die of an infection following his illicit kidney removal surgery in Istanbul. “You came home weak and yellow like a wax candle. You have lost your strength. How will you work in our vineyards? Who will want to marry a half man such as you are?” “The kidney belongs to God”, chastised the local Eastern Orthodox prelate in Mingir, hinting at Divine retribution.
Monir Moniruzzaman described something similar among the 33 kidney sellers he interviewed in Bangladesh, an extreme form of what I have called “kidney seller’s regret”, focusing on the ruination of one’s body. Prior to the nephrectomy surgery Bangladeshi sellers surrendered their bodies to repeated clinical pre-screening of their blood, tissue and urine. On the day of the operation they were washed down like animals, shaved of their body hair, and trussed and bound to their surgical gurneys “like cows strapped down for the slaughter”. Dildar, a 32-year-old kidney seller, told Monir: “When a fox catches a chicken, the little one cries. I was the chicken, and the buyer was the fox. In the dawn of the operation my tears were dropping so frenziedly that the shower could not even wash away those eye drops. I felt like a kurbanir goru, sacrificed cow purchased for slaughtering on the day of Eid, the biggest celebration in Bangladesh” (The Seller’s Odyssey). The Bangladeshi sellers asked themselves the question that I heard from kidney sellers in several languages, Spanish, Portuguese, Romanian, Hebrew and English: “What have I done to myself?”
The Kid and the Kidney – Strange Symmetries
Kidleys, kiddies or kittys – as kidneys are variously described by organ sellers who are not primarily English speakers but who use the English word or some variant of it to describe a global commodity that is sold for American dollars, for “greenbacks”, “paid in green”. Sellers who suddenly became aware of its existence describe their kidney as a kid-ly, looking something like an embryo or an aborted fetus. I think this analogy also occurs to those who support the right of an individual to “abort” and sell a spare kidney?
The symbolic association between kidneys and kids was foremost in the conversations I had with a woman I’ll call Ariel Dove, a Good Samaritan kidney donor from northern California, who freely gave her kidney to a stranger she met through a plea on the Internet, “I am begging you for the gift of life”. The recipient was described by two of the supplicant’s “friends”, who contacted Ariel, as a young man in his 30s, the father of two little children, healthy and hard-working, but suffering from irreversible kidney failure. “I imagined myself as an angel of mercy, rescuing an entire family”, Ariel said. Divorced, unemployed, a woman who took care of stray cats, Ariel said she had “failed” at everything – marriage, career, fertility, and fertility treatments (including IVF). The kidney donation represented a path to personal fulfillment. She imagined her kidney donation as a kind of virgin birth until she met the elderly man at the University of South Carolina transplant unit who would be receiving her gift of life. She had been duped, fallen into the hands of Internet organs brokers. The recipient was not the man she hoped would take home her kid/kidney. Trapped by the transplant team celebrating her as a heroine, Ariel went through with the procedure but a year later she had become a reclusive invalid, living at home in the country, nursing her cats and her missing kidney, certain that the pain and itching she felt at the site of her wound could only be healed by a return of the missing organ, which I assured her was quite impossible.
In the Organs Watch archives are many narratives of kidney harvesting and sharing as reproductive work, as men giving birth, which, in a way, it is, even when the kidney sharing was coerced or based on fraud and deception. I have never met a kidney seller who wished ill to the anonymous buyer, or the recognized and known buyer. They might wish ill to the “butcher of a surgeon” or to the “bastard” of a broker, but for the other person who now holds their kidney inside the strangers” body there is concern for the buyer and for the kidney which still “belongs” to the seller. “He has my kidney inside him. I hope to God that he lives well with it, takes care of it, eats well, and avoids alcohol. My kidney deserves all this and more. The little guy is a hero kidney and I want him to survive”.
In the watery slum of Banong Lupa, Manila, a site of active kidney selling, I stumbled on a troubling phenomenon – family obligations and normal household pressures that gradually turned every adult body in the household into a living kidney bank. At first the obligation to sell a kidney to supplement low wages and to provide for the basic necessities for one’s family fell initially on male heads of households. Over time, kidney selling became routine and was generally perceived as a meritorious act of self-sacrifice, demonstrating the lengths to which a good husband and father would go to protect his family. On a second, follow-up fieldtrip to Manila in 2003 as part of a documentary film team, I observed many more scarred bodies among young men and boys, even underage teenagers, who had lied about their age to be accepted as paid kidney donors in both public and private hospitals in Manila.
Sixteen-year-old Faustino was recruited by his maternal uncle, Ray Arcela, a former kidney seller. “It’s your turn”, Ray told the boy reminding him that Faustino’s father and his two older brothers had already sold a kidney. The $2000 earned per kidney never got these large families out of trouble. Similarly, Andreas was 17 when his mother begged him to sell a kidney so she could purchase the cases of beer, cokes and hard liquor she sold out of her shack. A good son, Andreas could not refuse his mother’s request. Kidney selling had become a rite of passage among adolescents, and the pronounced kidney scar across the torso of a teen in Banong Lupa was as common as a decorative tattoo. Just as tattoos signified membership in a youth subculture, the long saber-like scar across the young men’s torso symbolized machismo, courage and family loyalty, indicating the boy’s attempt to support his parents. Leonardo de Castro, a bio-ethicist at Manila’s Jesuit University, originally defended kidney selling in Manila’s slums as providing an opportunity for penance. He referred to Roman Catholic practices of self-flagellation during Holy Week, common among the poor in the Philippines:
“Self-flagellation [is] a culturally prescribed way of making up for past mistakes by [showing that] one is willing to go to the extreme to manifest one’s sincerity. Organ donation (even with selling) fits this penitential mode of Catholicism. We should reserve the individual’s freedom to make decisions regarding his body or parts, while recognizing that even radical acts of self-mortification are safely anchored in religious and cultural traditions”.
In the kidney-villes in South Asia (as described by Lawrence Cohen) and in the Middle East (the Gulf States and Israel) that I have documented, the possibility of purchasing a kidney relieves family members of the obligation to give. The kidney patient no longer needs to ask a relative for an organ, but can arrange to pay a third party to locate a seller. It is also a great relief to the transplant patients who state, often quite bluntly, a preference for a paid donor so as to be a guilt-free recipient. Or Milech, an Israeli woman who traveled to Durban where she was transplanted with the kidney purchased from a Romanian peasant told me: “To ask someone from inside your own family, it’s too difficult. It’s like you owe him your life, so it’s always a big problem, always hanging like a weight on you. If I would have to see my donor everyday, I would have to be thanking him all the time and that would be awful. I didn’t want to see the face of the kidney seller, so that I would never have to think about him again. I paid for it. He accepted it. It’s done, over. His kidney inside me belongs to me now, the same as if it were a cadaver kidney”.
Another transplant tourist put it more bluntly: “It is better to buy from a stranger than to harm a family member”. This is not always the case, however. Because “sharing organs” among the living is such an intimate exchange even when the organs are shared among strangers from far-flung places and for money, kidney buyers and sellers do make claims on each other. Kidney buyers (consumers) fear they may “reject” a kidney that was purchased from an angry or resentful seller who could, in turn, wish them ill after the transplant. They often seek to meet with the sellers, even briefly and in the hospital, after the transplant, to thank them for their precious gift. This, however, sets up the most common expectation for a return gift, even in the context of a frank sale.
What’s a Kidney?
“What is a kidney?” I asked Dov Rosen, a seller of wholesale electronic parts as he tinkered away in his cluttered little shop in a working-class mall in downtown Jerusalem in October (2003). Dov had recently returned from Romania (rural Transylvania, in fact) where, with the help of a local broker, he purchased a kidney from a “miserable wretch”, of a peasant, a man from a family so low-down, so destroyed, Dov said, that the seller’s wife had sold one of her kidneys and his brother had sold two of his six children, two little girls, to an international adoption ring. “People like these will stop at nothing”, Rosen said sadly, shaking his head. Forced by circumstances – too old for a deceased donor organ and too poor to go through established organ broker firms in Israel – Dov had to be his own advocate, his own “international transplant co-coordinator”. “I had a do-it yourself transplant. I was stranded on a waiting list for 5 years. This is absurd. Here we are living in a country where almost every day a bomb explodes, cars crash, people drop dead on the street, but nobody wants to give up an organ. People care more about the dead than the living”.
Dov arranged a trip to rural Romania, the country he had left behind as a 17-year-old, and where he still had family connections. There he found a kidney seller, a 36-year-old ethnic minority and a transplant in a rural clinic in Oradia, a hospital so “primitive”, he said, that he feared he was playing a game of Russian roulette: “The same nurse who assisted at my surgery was cleaning up my hospital room!”
The following dialogue, part playful, part dead serious, ensued:
So, What’s a kidney?
What kind of question is that?
Well some people say that you can’t put a price tag on a living person’s organ. Some people feel that the body is special, sacred. A rabbi told me about prayers that are recited for every part of the body, every organ and every orifice. There is even a prayer, he said, to give thanks for peeing. It’s one he recites first thing every morning.
Well, I am not a religious person. What’s a kidney? What’s a chicken? Why can people kill and eat a chicken? Isn’t a chicken also a life? Nobody cares. They just kill it, make it kosher, and we eat it. Taking a kidney from somebody doesn’t finish that person’s life. It may even make his life better, for all we know.
Your donor could be dead by now and how would you know?
Why are you asking me if you aren’t judging me? I can live pretty well with just one kidney, so why can’t he, also, the one who sold it to me? We’re even. Half and half. It was his choice, his consideration. I’m a shopkeeper, not a philosopher. When I was younger, I sold cars, Fiats. Good cars, some new, some used. I made a lot of money in those days. It was like this: I want to sell, he wants to buy. We talk it over. We make a deal. Now I want to buy. And he wants to sell. We talk it over, he says more, I say less and in the end we agree. So, what’s the big deal?
So, a kidney is like anything you can buy and sell off a shelf or a used car lot. You can just buy some guy’s kidney right from under him?”
Look, Nancy, the strong are always going to eat the weak. It’s the way of things. Besides, the people we are talking about [the sellers] are from the lowest rungs of society. They are the under class, primitive people: drifters, wife-beaters, thieves, drunks, debtors, Gypsies, baby-sellers. I’m not going to worry about their dignity. I only hope my seller stays away from the bars and the drinking he’s used to because alcohol can wash away his second kidney. He now has to act responsibly.
So, the kidney is nothing?
I never said that. For me, a kidney is life. And a man – if he’s worthy of the name – will do anything to save his own life. The kidney that I bought, it’s given me wings. Today I can come and go as I please. I want to come to my shop at 10 am and leave at 4 pm, I can do it. I want to take a drive to the beach in Tel Aviv with my wife, I can do it. I want to go to Jerusalem and see my grandchild, I can do it. My new kidney is like a bird, it’s like freedom itself.
For buyers the purchase of a kidney removes the recipient from the demands of the gift economy – it is a choice, as Dov’s puts it, for a kind of total uninhibited freedom. For the kidney sellers, however, the kidney remains a gift and a debt. “How can you sell what doesn’t belong to you? The body belongs to God”, a Moldovan kidney seller told me. Kidney sellers tend to feel that they are related to the recipient after the fact and as “kidney kin” they have the right to ask help, often phrased as “a life for a life”, a “rim por rim” – “a kidney for a kidney” as Alberty da Silva, a 38-year-old night watchman from Recife, Brazil, put it. Alberty asked my help in locating Luanne Higgs, the middle-aged woman from Brooklyn, New York who had purchased Alberty’s kidney in a transplant transfer that brought both of them across the Atlantic to Durban, South Africa where the kidney removal and transplant took place at a private, formerly Catholic hospital: St. Augustine’s.
When I met Alberty in the mud hut he shared with several other unemployed relatives and children, he defended his honor saying that although he was given a little something ($3,000 for his kidney), it was still a priceless “gift”. “Isn’t a human life worth much more than a few thousand dollars?” he asked. Luanne, in turn, sent Alberty a Christmas card explaining that she was herself a poor sick woman and unable to repay him for his precious gift of life:
“Dear Alberty: How are you feeling? I hope and pray that all is well with you and your family. My husband and myself are doing well and putting our faith in God to keep us well. I hope you haven’t forgotten me, because I’ll never forget you for giving me my life back. I was close to death and you gave me your kidney. I wish I could send you a little gift for Christmas but I am not sure this is even your correct address… God Bless you, Luanne…”
Luanne wrote the card in English which I translated for Alberty, then living in a mud hut behind his aunt’s house in Recife. Alberty dictated the following response which I hand delivered to Luanne and her husband in Brooklyn, New York:
“Dear Luanne, I hope that you are happy and safe among your family. I am here rooting for your happiness. I am well and my life is normal despite the disruptions caused by this donation of my kidney. I am trying to get out of my present difficulties as best as I can. My greatest happiness is to know that you are well. I hope that one day we will see each other again now that we are one. I miss you and when I see you again we will share a meal together. I will never forget the short time we spent together. If I had it to do all over again I would do it. I believe that by the grace of God I will be reunited with you. We will blow out the torch of the Statue of Liberty together. We will walk hand in hand through the forest of Central Park like two children without a care in the world. May God be with you and may you have health and peace for you and your husband.
Please write back to me at this address:
Alberty Jose da Silva
Rua da Cacamba, 42
Although he never did hear back from Luanne, Alberty was philosophical. “That woman was very sick”, he confided. Kidney providers never, in my experience, never wish ill to the recipient, even a recipient they do not know, when the transaction was of the cloak and dagger sort. Instead, as in the case of Alberty (above) they shrug it off and wish them health and happiness. I puzzled over this for a while until it was confirmed by another trafficked kidney seller, Niculae from a devastated village in Moldova. I asked him why, given all his disappointment and suffering following the sale of his kidney he still spoke well of the recipient of his body part. Niculae replied: “My kidney saved his life. Now I want both him AND my kidney to have a long life!”
The death of one’s dearly disposed kidney is, in a sense, a death of ones self.
Almost twenty years into the organs watch project there are no easy answers to the basic questions: How do kidney sellers, trafficked or self-trafficked, view their position in illicit transplants? As victims? As survivors? As heroes? In the economically demolished villages, slums, and shantytowns of the “third world” that provide the more affluent world with surplus kidneys, the meanings of buying and selling an organ are, of course, always context specific. A kidney is never just a kidney. And, the large, disfiguring saber-like scar running across the torsos of kidney sellers worldwide – some who line up for a photo ops or for those who refuse to display it – can be a sign of weakness or strength, of shiftlessness or hard work, greed or generosity. It can signify a prodigal son or a good daughter, a bad woman or the dutiful wife, or a foolish, dumb, exploited, worthless, or adventuresome and enterprising person. The sellers of Mingir, Moldova still suffer the consequences of their bio-availability: they are stigmatized and shamed, excluded from marriage, and prone to a psychological and medical disorders.
The Brazilian meninos who were recruited by the international organs trafficking syndicate defended themselves before Judge Amanda in the federal court of Recife in 2004, saying that if they had been trafficked, they had “chosen” to “traffic themselves”. The “boys from Brazil” were macho, and did not want to be treated as if they were trafficked sex workers who were mostly women. They wanted to be seen as strong, competent, and adventuresome, which they were. As for whether he had been “fooled”, deceived, or exploited, Joao Cavalcanti, like his circle of his kidney selling neighbors in the slum known as Jardim Sao Paulo defended himself as a free agent and as a dono de seu corpo, the owner of his body before the courts and before the Brazilian CPI (Congressional Hearings) that investigated the trafficking scheme. They admitted that they were recruited, that they had been deceived about the legality of what they were doing, that they had been misinformed about the medical demands and possible risks of the surgery they would undergo, transported with visas and plane tickets purchased by brokers, told to keep silent and to sign any papers they were given at the hospital, and that they had been held virtual prisoners in a safe house in Durban, their passports confiscated by the local brokers. All that was true they said, but they refused the label. The judge tried to sway them saying that if they were trafficked by brokers and deceived, they would not be culpable, they would not have to go to prison. But the men persisted in their self-evaluation.
“Yes, your honor”, I answered a question put to me by Dr. Raimundo Pimentel, the state deputado (senator) of Parliamentary Commission. “Yes, the men from Jardim de Sao Paulo were classic victims of human trafficking”. Pedro begged to disagree: “No way! No matter what that woman, Dona Nanci, has to say, it was me, my choice. I, Pedro Gervasio, I trafficked myself! To me trafficking means that somebody with a mask kidnaps you, puts a hood over your head, and stuffs you in the back of a car, and takes you to a secret place where you are cut up and have your kidney or liver taken without your consent. Nobody put a knife to my throat, nobody forced me to get on that plane. I did it freely and I would do it again even if I had to spend the rest of my life in jail, because now I can rest easy knowing that with my kidney I was able to buy this little house so that my wife and children can have some security. I will die satisfied, no matter what happens to me now. I had an opportunity offered to me and I took it”.
A few years later I returned to Recife to check in on the meninos: Geremias, Pedro, Paulo, Alberty, Joao, Gerson, Hernani and a dozen other of the kidney sellers who had gotten caught up in the same trans-Atlantic human trafficking scheme and who were now trying to sort out some of the consequences. They blamed their financial troubles on the police sting, Operation Scalpel (Bisturi). They talked about organizing an NGO, a non- governmental organization, an Association of Disillusioned (or Disenchanted) Organ Donors – Associacao de Doadores Disilusionados (or Disencantados). The name was in debate. At their first meeting, the disenchanted sellers aired their complaints: loss of work, loss of income, loss of strength, and worst of all, a loss of honor, of social standing. They reported chronic pain, weakness, anxiety, depression, family discord, and personal rejection, as well as medical problems, attributed (by them) to their missing kidney.
They returned from their “kidney safari” weaker, but wiser. They had learned a few things about the world. They found South Africa Black people to be different than Afro- Brazilians like most of themselves. The Blacks in South Africa were bigger and stronger because they were closer to their roots. “They had never been slaves”, said Alberty Alfonso, which opened up a conversation on how they had been manipulated almost like slaves, debt slaves. “None of us were told how hard it would go for us”, Cicero said. Paulo agreed: “The pain was so bad that for three days in the hospital I was praying to be the next one to die”. Geremias said that they were treated OK until the doctors got what they wanted and then they were thrown out like lixo, garbage and put back on a plane, with their cash stuffed under their bandages, and warned by Roddy the Durban broker not to show they were in pain because the customs/immigration people might be suspicious.
The displaced agricultural workers of Moldova who were trafficked to Turkey and Russia to sell a kidney understand their bodies differently than the “boys” from Brazil. Some had come of age under the old Soviet state and they put their agricultural cooperatives and their coworkers above their own individual desires and saw their body as belonging to the village collective. The body was not theirs to mutilate or to weaken, for it would harm the whole body of the village. Older villagers used that argument to punish them when they returned after selling a kidney, a social-economic system that many of them still mourn to this day. The young men avoided public places, they visited with each other in their home or in their small, dark wine cellars. They felt that they could not go to Church. They hid their story from the confessional just as they hid it from their friends for as long as they could. In fact, they knew that everyone in the village knew who had sold a kidney, and it was seen as disgraceful, a moral failing, and a mortal sin. During a Sunday Mass in Mingir the local Russian orthodox priest, Andreas, gave a homily about the sacredness of the body and the importance of keeping one’s body clean inside and out. He scolded his parishioners (mostly old women, grandmothers likely).
“Health is the goodness that God has given us. Certain of our brothers have sold their body and committed a very serious sin. By selling their body, they are also selling their soul, because by this action they are ignoring God’s existence and they have turned toward evil. Many of our young men in this village have sold a kidney. Do they ever think about the future and the suffering they will have to face? They hoped to get rich, but now they are poorer because they have lost their good health. By losing their health they have also lost their redemption because they think they can no longer pray. I do not judge or condemn them because they were trying to provide for their families and for their children. But what will their children think when they will have to take care of a sick parent who is still young? The people who buy kidneys are motivated to hurt Christianity and Christians [a reference to the surgeons who were Turkish Moslems]. I pray for those who have committed this sin in ignorance and error. May God protect you! May God protect us all and give us force to fight against this evil. May God protect our children so that no others will fall into the same trap? In the name of the Father, the Son, and the Holy Ghost. Amen”.
After the Mass I spoke with Father Antoine [not his real name]. He told me that he understood that the men wanted to find work abroad and that some did not even know what work they would be doing. When I asked who owned the body, Father Antoine replied that the body belonged to God, to God alone. He wishes that the men would come to Church and be forgiven, but they did not come. They hid themselves. He feared that some might commit suicide, because they are unused to the isolation in which they were now forced to live.
The trafficked Brazilian men were raised as Roman Catholic, some of whom converted to Protestant Evangelicalism. But whether identified as Catholic or Evangelical Christians, religious teaching stopped at the body. As they saw it their body was theirs to do with and to dispose of as they saw fit. Pedro and Paulo and Joao used a familiar Brazilian idiom in stating their subject/object relationship to their body as: “I am the owner, the master of my body!” Nonetheless, Paulo chided himself long after the nephrectomy for selling his kidney. He did not know how attached he was to the “little thing” (coisinha) until it was gone and began to announce its absence as a constant itching at the site of his wound, even three years later. “I’ve learned one thing”, he said. “Even though I have two of them, I will never sell one of my hands”.
Alberty lost his job in the open-air market of Jardim SP and he took an inferior job as a night watchman. The job in the market required too much heavy lifting, and he could not do that any longer. The night watchman job gave him lots of time to think and to worry. “My health has declined”, he told me. “What if those doctors in Durban took more than just my kidney?” This was a common fear among kidney sellers in all the sites I visited. Alberty badgered me so much that we went together to a local public hospital and waited on lines all day so that Alberty could have an X-ray to determine if the “rest of him” inside was in tact. The X-Ray technician told him that everything looked OK to him but he had to come back the following week to get the doctor’s diagnosis. Alberty was relieved for a few days until we returned to the clinic for the results and found after several hours of waiting that his medical file had gone missing. On the way back to his shack in Jardim de Sao Paulo Alberty raised a new concern: whether his orphaned kidney, now that it had to do the work of two kidneys, could affect his sexual potency or his fertility. I reminded Alberty that he had two “wives” and several children who needed all of his support. “And isn’t that why I sold my kidney?” “Alberty, you told me that you sold the kidney to pay off a car debt”. “Well, that’s also true, but the mothers of my children got to me first, and I had nothing left except enough to buy a used bicycle”.
The question of what kidney sellers hoped to get out selling a kidney and what they ended up with is a topic I have engaged with kidney sellers from the Philippines, Brazil, Turkey, Israel, Palestine, Egypt, Moldova, and the United States. Kidney sellers hope to (in order of frequency) clear a debt, buy or fix up a house, move to a safer community, to be able to marry, to have food and clothing and toys for the children, etc. What did they end up with: a car, a karaoke machine, a cell phone, running shoes, a pig feast, an electric fan, a fridge, gold-looking chains of jewelry, clothing, a casket for a dead child, among the photos in my file marked: Kidney Loot. A few of the lucky ones did manage to get out of their slum, did manage to get medical care for a sick child, did manage to convince a young woman to marry them.
Elsewhere, I have described in greater depth the particular and often peculiar symptoms that kidney sellers attribute to their missing kidney: weakness, depression, sense of emptiness, evacuation, of regret, desire for revenge, self-hatred, sense of emasculation, of stigma, of stupidity, of disloyalty, loss of honor. These symptoms could be dismissed as “merely” psychosomatic events, the result of a real trauma that the body remembers but that the person cannot share with his family or neighbors. Other post-traumatic kidney removal consequences are tragic and mortal, including the many unexplained and undiagnosed premature deaths of kidney sellers. There were 5 deaths among the 40 kidney sellers from several villages and the capital city of Moldova: 1 suicide, 1 death from kidney failure, 1 homicide by local vigilantes for having shamed the community, and 2 who died without any diagnosis. All were young and were rural workers. These are not deaths that would ever be reported in medical journals or statistical studies, but I can assure you that in the narratives told by the dying person himself, or by his relatives or doctors or by a village prelate, the deaths were the result of kidney selling. Among the others who are still alive are many who fear death, who have been diagnosed with hypertension or other diseases that can affect their one kidney. Some are alcoholics, some have lost their families, but few have ended up as criminals, except for one Moldovan kidney seller who was beaten up for being a chicken thief.
In going over the police charts of the Brazilian men who were identified by the South African police not one of the kidney sellers had a background police record in Brazil, amazing given the drug-ridden and violent slums they came from. Captain Louis Helberg said, “I’ve been a police detective all my working life, and I was never involved in a case like this in which the men who were trafficked by the two brokers, Captain Ivan and Captain Gaddy Tauber, were just ordinary poor people. A few of the sellers were rejected by the Netcare clinic because they tested positive for HIV or had traces of drugs in their blood. But none were criminals. Five of the 38 were minors under 18 years old. The indictment sheet noted 5 counts of trafficking in children. One of the 38 sellers had only one functioning kidney and it was removed and transplanted into the body of a paying transplant tourist. The Durban police charge sheet included one culpable homicide by the South African surgeon who removed the seller’s kidney of last resort”.
Kidney trafficking casts light on the dark underbelly of neo-liberal globalization, on the rapacious demands it creates and the predatory claims it makes on the bodies of the “bio-disposable”, but also the dreams it engenders about a better life and a mobile existence, mobility being the root metaphor of organized kidney selling through transplant tourism. For patients it signifies a release from the corporal entombment of dialysis machines. For kidney sellers it signifies a release of the red balloons from the slum, the favela, the shantytown and a chance to see the world, or at least, a chance to visit the shopping mall with a wad of dough in one’s pocket.
I finally got out to the distant rural suburb of Janga in July 2006 to visit Geremias’ new home and to meet his family. While the house was not nearly so fine as the mansion imagined by the fellows he had left behind in the slums near Boa Viagem airport and was just a concrete slab with four barn like rooms with unfinished cement floors and a muddy backyard, Geremias was still proud of it and he smiled broadly as he ushered me inside the gate and quieted the skinny puppy yapping at my heels. Geremias pulled himself up to his full 5”4” height as he motioned for me to sit down on a hard kitchen chair: “Bem-vinda!” he said. "Welcome inside my kidney".
What about your scar, Geremias, I dared to ask, as the young man had fussed so about the wound saying that his wife found his body less attractive because of it. “I have the solution”, he said. “I’m going to have a tattoo artist weave a beautiful Amazonian snake all around it so that this, [pointing to one end] will be the head, and this [pointing to the other end] will be the tail. It will be an expensive tattoo, in multi-color, but it will be worth it, nao eh? After all, Eu sou meu corpo!
Modes of Bodily Commitment
People “commit” their bodies in a myriad of ways – in wage labor, in sex (including prostitution and rape), in childbirth, in military conscription, and in extreme sports, body-building exercise and in religious discipleship. We submit our bodies to clinical exams – (blood and urine tests) – we circumcise our male infants, and we surrender our bodies to all kinds of surgeries that sometimes require the removal of tissues, organs, and other body parts.
In death our bodies are “committed” to autopsy, dissection, tissue and organ removal, burial and (even) exhumation. So, living donor transplant needs to be seen as part of a larger spectrum of what Lawrence Cohen calls bodily “modes of commitment”. However, the kidney trade pushes the envelope of medical ethics, social justice, fairness, and human decency toward vulnerable people – buyers and sellers – who are desperate and will do whatever is necessary – even break the law – to solve their problems in living under extreme duress.
For most bioethicists the “slippery slope” in transplant began with the emergence of unregulated black market in organs and tissue sales. For critical medical anthropologists like ourselves the slide down the proverbial “slippery slope” begins the first time one ailing person gazes longingly at another, realizing that inside that other body is organic medical material capable of prolonging their own life. In the post-human era, ancient prescriptions for grace in the face of suffering and equanimity in the art of dying can only appear absurd. But the transformation of a person into a “life” that must be prolonged, enhanced, or saved at any cost – even by borrowing time and strength from the bodies of the destitute, the indebted, or from the bodies of one’s own children and grandchildren –renders “life itself” into a fetishized commodity.
An absolute value placed on a single human life saved, perfected, or prolonged at any cost, erases any possibility of a social ethic, and brings us into that impossible ethical and moral gray zone that Primo Levi described.
References and Related Readings
Bakdash, T. and N. Scheper-Hughes (2006) “Is It Ethical for Patients with Renal Disease to Purchase Kidneys from the World’s Poor?” PLoS Medicine 3(10): e349.
Basch, S.H. 1973. The intraphysic integration of a new organ. The Psychoanalytic Quarterly 42, 364-384.
Bramstedt, K.A. and J. Xu (2007) “Checklist: Passport, Plane Ticket, Organ Transplant”, American Journal of Transplant 7: 1698-701.
Budiani-Saberil, D.A. and F. Delmonico (2008) “Organ Trafficking and Transplant Tourism: A Commentary on the Global Realities”, American Journal of Transplantation 8(5): 925-8.
Bunzel, B. et al. 1992. Does changing the heart mean changing personality?: A retrospective inquiry on 47 heart transplant patients. Quality of Life Research 1, 251-256.
Castelnuovo-Tedesco, P. 1973. Transplant, body image, psychosis. The Psychoanalytic Quarterly 42, 349-363.
_______1978. Ego vicissitudes in response to replacement or loss of body parts. Certain analogies to events during psychoanalytic treatment. The Psychoanalytic Quarterly 47, 381-397.
Cherry, Mark J. (2005) Kidney for Sale by Owner: Human Organs, Transplantation, and the Market. Washington, DC: Georgetown University Press.
Daly, M. (2009) “Anthropologist’s “Dick Tracy Moment” Plays Role in Arrest of Suspected Kidney Trafficker”, New York Daily News 24 July.
Eulex Kosovo (2010) “Indictment in MEDICUS Clinic Case”, press release, 15 October, URL (consulted March 2011): http://www.eulex-kosovo.eu/en/pressreleases/0098.php
Finkel, M. (2001) “Complications”, New York Times 27 May, URL (consulted March 2011): www.nytimes.com/2001/05/27/.../complications.html
Fox, R. and J.P. Swazey. 1992. Spare parts: organ replacement in American society. Oxford: Oxford University Press.
Goodwin, Michelle (2006) Black Markets: The Supply and Demand of Body Parts. Cambridge: Cambridge University Press.
Hamdy, Sherine. (2012) Our Bodies Belong to God: Organ Transplants, Islam, and the Struggle for Human Dignity in Egypt. University of California Press.
Goyal, M., R.L. Mehta, L.J. Schneiderman and A.R. Seghal (2002) “Economic and Health Consequences of Selling a Kidney in India”, Journal of the American Medical Association 286(13): 1589-93.
Jimenez, M. and N. Scheper-Hughes (2002) “Doctor Vulture: The Unholy Business of the Organ Trade”, National Post (Canada) 30 March: B1, 4, 5.
Leder, D. 1990. The Absent Body. Chicago: The University of Chicago Press.
Levi, Primo. (1998) “The Grey Zone”, in The Drowned and the Saved, chapter 2. New York: Vintage.
Levinas, E. 1961. Totality and Infinity: an essay on exteriority (trans.) A. Lingis. Pittsburgh: Duquesne University Press.
Merleau-Ponty, M. 1968. The visible and the invisible. Evanston: Northwestern University Press.
Merleau-Ponty, M. 2002. Phenomenology of Perception. London: Routledge. Moore, F.D. 1955. A Miracle and a Privilege: Recounting a Half-Century of Surgical Advance. Washington, D. C.: Joseph Henry Press.
Scheper-Hughes, N. (1993) Death without Weeping: The Violence of Everyday Life in Brazil. Berkeley, CA: University of California Press.
Scheper-Hughes, N. (2000) “The Global Traffic in Organs”, Current Anthropology 41(2): 191-224.
Scheper-Hughes, N. (2002) “Min(d)ing the Body: On the Trail of Organ Stealing Rumors”, pp. 33-63 in J. MacClancy (ed.) Exotic No More: Anthropology on the Front Lines. Chicago, IL: University of Chicago Press.
Scheper-Hughes, N. (2003) “Rotten Trade: Millennial Capitalism, Human Values, and Global Justice in Organs Trafficking”, Special Issue on Human Frailty, Journal of Human Rights 2(2): 197-226.
Scheper-Hughes, N. (2004a) “The Last Commodity: Post-human Ethics and the Global Traffic in ‘Fresh’ Organs”, in A. Ong and S. Collier (eds) Global Assemblages. London: Basil Blackwell.
Scheper-Hughes, N. (2004b) “Parts Unknown: Undercover Ethnography of the Organs-Trafficking Underworld”, Ethnography 5(1): 29-73.
Scheper-Hughes, N. (2006a) “Organs Trafficking: The Real, the Unreal and the Uncanny”, Annals of Transplantation 11(3): 16-30.
Scheper-Hughes, N. (2006b) “Kidney Kin: Inside the Transatlantic Kidney Trade”, Harvard International Review winter: 62-5.
Scheper-Hughes, Nancy and M. Ferreira. (2007). Domba’s Spirit Kidney: Transplant Medicine and Suya Indian Cosmology. In Be. Ingstad and S. Reynolds, ed. Disability in Local and Global Worlds. University of California Press.
Scheper-Hughes, N. (2007) “The Tyranny of the Gift: Sacrificial Violence in Living Donor Transplants”, American Journal of Transplant 7: 1-5.
Scheper-Hughes, N. (2008) “Illegal Organ Trade: Global Justice and the Traffic in Human Organs”, pp. 106-21 in R. Grussner and E. Bedeti (eds) Living Donor Organ Transplants. New York: McGraw-Hill.
Scheper-Hughes, N. (2009) “The Ethics of Engaged Ethnography: Applying a Militant Anthropology to Organs Trafficking Research”, Anthropology News September: 13-14.
Scheper-Hughes, N. (2010) “Is There a Right to Buy a Kidney from a Stranger from Another Country?”, in S. Schicktanz, C. Wiesemann (eds) Teaching Ethics in Transplantation Medicine: Cases and Movies, UNESCO Chair in Bioethics.
Selzer, Richard. 1974. Mortal Lessons. New York: Simon & Schuster.
Sharp, Lesley. (2015). The Transplant Imaginary. University of California Press.
Shimazono, Yosuke. (2013). Accommodating a “Foreign” Organ Inside the Body: Post-Transplant Bodily Experiences of Filipino Kidney Recipients. Ars Vivendi Journal No. 3 (February): 24-50.
Taylor, James S. (2005) Stakes and Kidneys: Why Markets in Human Body Parts are Morally Imperative. Aldershot: Ashgate.
Young, Katherine. (1997). Present in the Flesh: the Body in Medicine. Harvard University Press.
Zaner, R.M. 1981. The Context of Self. Athens, Ohio: Ohio University Press.
Zargooshi, J. (2001) “Iranian Kidney Donors: Motivations and Relations with Recipients”, Journal of Urology 165: 386-92.
 “Somatoform Disorders” are described in the Diagnostic and Statistic Manual, 4th edition (DSM-IV) as a group of physical symptoms that cannot be fully explained by a neurological or standardized medical (“organic”) condition. Scheper-Hughes and Lock (1987) have tried to destabilize the medical and psychosomatic interpretation of somatoform states of bodies that are mindful, and minds that are embodied in particular cultural and historical ways.
 This is a reference to the film, Dirty Pretty Things, which captures the spirit, sense, and sensibilities that surround kidney selling by undocumented workers in the immigrant underworlds of London – hotel kitchen and cleaning staff, doormen, taxi drivers, morgue workers.
 I wondered whether the term “bio-disposal” had any salience outside medical anthropological circles. A Google search came up with these top three references: “Bio-disposable bag-type liner for bedpans and the like”; “bio-disposable Chinese tableware”; and “bio-disposable plastic cups”.