More and more Westerners - including Australians, it appears - are travelling abroad to get transplants, particularly kidneys - currently the world's most sought-after organ.
REPORTER: Elizabeth Tadic
Northern Pakistan has a timeless beauty but poverty runs deep. I'm heading into the Punjab's Sargodha region, an area notorious for its role in the human kidney trade. There are thousands of poor villagers here who have sold their kidney in order to escape crippling debt. Like Munira and Mohammed Aslam, from the village of Sultan Pur. They work from dawn till dusk with little to show for it. Even the chickens don't belong to them.
MOHAMMED ASLAM, (Translation): I was in debt and that's why I sold my kidney. I owed the landlord money. I'm a labourer. I was helpless. I had to sell my kidney.
Mohammed's kidney was his only valuable possession. Several years ago he borrowed money from his landlord to buy medicine for his first wife who was sick. After she died the debt spiralled out of control. So last year Mohammed's second wife, Munira - a 36-year-old mother of four - was also forced to sell one of her kidneys.
MUNIRA ASLAM, (Translation): It hurts because it's a recent operation but I have these young children so I have to work.
MOHAMMED ASLAM, (Translation): The money I got for my wife's kidney went toward the debt. Now I just do labouring jobs and eat what I can. There's a difference - I can't work as much.
Praying is part of their daily ritual but it doesn't lessen their humiliation.
MOHAMMED ASLAM, (Translation): It's shameful that we've sold the body that God gave us.
They feel like they've dishonoured their god by desecrating part of their body. But they're not alone - nearly every neighbour who's come to visit them today is also surviving on one kidney. Mohammed shows me his wife's discharge papers from the clinic which removed her kidney. I'm curious because even though she was paid for her kidney, the certificate says she donated it on humanitarian grounds. It's about a 4-hour drive from the village to bustling Rawalpindi and the privately owned Kidney Centre where Munira's operation took place.
DR MUKHTAR HAMID SHAH, EX-ARMY SURGEON AND CEO RAWALPINDI KIDNEY CENTRE: The donors are not a problem in this country or any other country. It is the patients who are suffering and who are dying.
Dr Mukhtar Hamid Shah, an ex-army surgeon, opened the first transplant centre in 1979. He's known as the founding father of kidney transplants in Pakistan.
DR MUKHTAR HAMID SHAH: Patients have blood tests and testing drug levels right in here.
I tell him about my visit to the village of Sultan Pur and he's not happy.
DR MUKHTAR HAMID SHAH: Why you went there? Why you went there? Why did you not first come to me? Why did you go to Sultan pur several days ago? I don't know that village. But I have been told by my friend yesterday. Why did you go there? What for?
REPORTER: To get all sides to the story.
DR MUKHTAR HAMID SHAH: Everybody is talking of the donors, nobody is worried about the patients. This is the dialysis, the main thing is done here.
Dr Shah is concerned about those suffering from kidney disease and in need of a transplant but he's also under pressure from the World Health Organisation, or WHO, which wants to stop the unregulated kidney trade.
DR MUKHTAR HAMID SHAH: The WHO pressures poor countries and sponsors these projects to restrict unrelated transplantation, putting pressure to stop trafficking. They're the people who do not worry about the 15,000 people who are dying each year.
Dr Shah is intent on putting a positive spin on his work
REPORTER: What's happening?
Without warning a kidney recipient is wheeled in, saying all the right things.
KIDNEY RECIPIENT: I pray for my donor because he gave me sacrifice not for money - he gave me sacrifice. Many people can donate kidney without money. Don't totally stop. Please don't totally stop this hope because we only have one life, one chance, one hope.
By the time another two kidney recipients and one potential donor, prepared to give his kidney for free, come in - I can't help thinking this is a set-up.
MAN, (Translation): I did it for Allah. No money taken or given.
Meanwhile, Dr Shah's tour continues. He believes it's a win-win situation where the patient gets a fresh kidney and saves money on dialysis and the donors solve their financial problems.
DR MUKHTAR HAMID SHAH: Nobody is worried about their financial health. The conscience of the world is sleeping.
REPORTER: But some argue that this is an exploitation of the poor people.
DR MUKHTAR HAMID SHAH: I say this is an exploitation of my patients. Who is going to decide?
Back in the village, impoverished donors have no choice - dire poverty determines all decisions. I'd even heard that labourers were shackled by their landlords, and this is confirmed by Zulfikar Ahmed.
ZULFIKAR AHMED, (Translation): In the evening they tie you up. They demand money and tie you up. Those circumstances made me sell my kidney.
Ahmed says he's so deeply in debt to his employer, even the money from his kidney wasn't enough to pay off his debt.
ZULFIKAR AHMED (Translation): My kids are dying of hunger. I have no land. I have no income. I'm paid 300, 400 rupees. How do I feed my kids on this?
400 rupees is about A$10 a month - not even a dollar a day. Zulfikar works at a brick kiln like this one. These are bonded labourers, so deeply in debt to their employer, they've become modern-day slaves. Bonded labour is supposed to be illegal but it's rampant in the Punjab.
MANZOOR AHMED (Translation): I work at the brick kiln, I sit and make bricks. I thought I'd pay my debts. The brick kiln owner pressured me and in those circumstances you have to do it. Now I've lost a kidney and I'm still in debt.
Manzoor Ahmed and his family of seven live in this 1-room mud house without electricity on his employer's land. Like many, Manzoor has post-operative problems. He borrowed more money from his landlord to pay for medicine, putting him further in debt.
MANZOOR AHMED, (Translation): My health is in bad shape. A single injection can cost up to 5,000 rupees. I have to borrow money from the landlords again. The Kidney Center in Rawalpindi that's where I sold my kidney. Dr Mukhtar Ahmed's hospital. He took out my kidney and when I went back to get medicine they told me I'd have to pay for it.
DR MUKHTAR HAMID SHAH: We supply free treatment to the donors if they have any problem. I feel my own obligation, my own internal feeling, like Hippocrates, that they, the poor man must be helped, the man who has saved a life, who has not given anything wrong.
REPORTER: Then why are they saying that they're worse off and they've got to pay all this money for medicine? Why would they claim this?
DR MUKHTAR HAMID SHAH: I don't know.
Dr Shah's response seems implausible. These people are living proof of this nasty trade. And there's a nagging question - what's a kidney worth? I've been told the patient pays 400,000 rupees - about A$10,000 - of which 125,000 rupees - or A$3,000 - is supposed to go to the donor. But there are greedy middlemen or 'agents' who allegedly work for the hospitals, trawling this area looking for fresh kidneys. Not 1 of the 20 or so villagers I spoke to said they received the full 125,000 rupees.
MOHAMMED ASLAM, (Translation): The agent takes 15,000 or 20,000. He always takes some pay-off. That's his profession.
MOH (Translation): He's the agent for the hospital.
QASIM (Translation): The doctor employed him. He's a big dark man. Without a moustache.
MOHAMMED ASLAM, (Translation): He often keeps 50,000, more than half what they're paid. They're just cheating the poor.
REPORTER: Do you have a middleman at the moment?
DR MUKHTAR HAMID SHAH: No, I don't have. Why should I have? I have the hospital.
REPORTER: How come the donors, though, told us that they only got..
DR MUKHTAR HAMID SHAH: Who?
REPORTER: The donors said they would get around 80,000 to 90,000 rupees. Is that the middleman taking a cut?
DR MUKHTAR HAMID SHAH: No, the patient pays 125,000 rupees.
The kidney trade has become controversial in Pakistan and the nation's lawmakers are aware of the plight of the rural poor. A bill to regulate the industry has been drawn up, but remains stalled before being passed into law.
DR FAROOQ SATTAR, MQM PARTY: There are people who are playing intrigue, who are trying to derail this whole thing.
Dr Farooq Sattar is the leader of MQM, the Government's key coalition partner. He says the bill doesn't go far enough, and wants a complete ban on kidney donors other than from relatives of the recipients.
DR FAROOQ SATTAR: This bill should in no way legitimise or even legalise whatever unethical and immoral practices going on.
Dr Sattar disagrees with the argument that there isn't any exploitation because the poor benefit financially.
DR FAROOQ SATTAR: I think those people who have an interest in this - and I think they are an immoral practice - I think they would always like to advance such arguments to justify what they are doing. But I think this cannot be condoned. It's an oversimplification of a very complex and very complicated issue.
Naeem Yar Gondal is a lawyer from the Sargodha district where many of the kidney donors come from. He says legislation to ban the trade has been blocked by an all-powerful lobby group of professionals he calls "the mafia".
NAEEM YAR GONDAL: These people are highly educated and professional people. They are the doctors, they are businessmen, they are traders, these mafia people. These are pressure groups in fact.
LT COLONEL SHAHID UL HASSAN, MANAGER, ARMY HPSPITAL RAWALPINDI: No. No, no. In fact nobody's powerful in Pakistan except the government.
Lieutenant Colonel Shahid Ul Hassan manages the Army Hospital in Rawalpindi. It's a prestigious role in Pakistan's military-led dictatorship. I asked him why if MQM had tabled the bill in parliament seven years ago, the government has done nothing about it.
LT COLONEL SHAHID UL HASSAN: The fact is that this problem was not so much serious earlier. The seriousness of this cruel business has just come to the knowledge of government and the political parties.
Contrary to what the lieutenant colonel says the bill has been on hold for seven years. And now the kidney business is booming. This hospital has added nine floors just to accommodate the influx of foreigners coming to Pakistan for kidney transplants. So-called transplant tourists from Europe, the Middle East, the US and Australia are flocking to private hospitals, frustrated after spending years on waiting lists back home.
JOHN DAVID HORNE: I would recommend this to any person that was in dire need of a transplant.
John David Horne, or JD, as he prefers to be called, is a semiretired businessman from Australia's Gold Coast. He was told by his doctor that without dialysis he had six months to live but didn't like the idea of being hooked up to a machine.
JOHN DAVID HORNE: I said, "It's not my lifestyle." It's not something that I want to be involved with.
With up to seven years wait in Australia for a kidney, JD decided to look elsewhere.
JOHN DAVID HORNE: So I hopped the net and I found and I went through four or five different places. Yeah, there was the Philippines where they have a very big kidney research transplant clinic there. Costs in there finished up around about $120... A$120,000. Or there was China, you could go to China. But basically from what I'm told, and from a good source, they kill the Falun Gong until they find a match for you.
JD settled on Pakistan - also the cheapest option - where a new kidney costs $18,000. He set off with his best mate, Noel Oliver, as a carer.
NOEL OLIVER: In the first 24 hours I spoke to two Bulgarians, a Russian and a Pakistani who had had the operation and I was more confident then.
JOHN DAVID HORNE: Yeah, because you didn't have to have to have it.
NOEL OLIVER: I didn't have to have it. It was my job if JD carked it to organise the box and get him home.
In the end JD's condition improved and he didn't have the transplant operation, but he knows the system well. He doesn't believe the poor are being exploited.
JOHN DAVID HORNE: We used to give blood for money when I was in the navy for a drink, we used to get $10 for that, which was a lot of money. I mean, these people are doing basically the same thing.
REPORTER: Some of the donors are now complaining that they're no better off than they were before they sold their kidney.
JOHN DAVID HORNE: I don't know of any. We spoke with donors. We spoke with some going in and those coming out and some that had been done for quite a long while. There was no complacency about them at all, whatsoever. I suppose there's always that chance of someone getting it and blowing the money and doing what they do.
Like many desperate foreigners, JD and Noel came here to the Aadil Hospital in Lahore. Waheed Sheikh is the chief executive and he reluctantly agrees to show me around.
WAHEED SHEIKH: Here's someone from CBC, 'New York Times', or whatever. Would you like to speak with her?
WAHEED SHEIKH: Oh, SBS. Would you like to talk to her?
This man is a US citizen, here with carer from his family.
WOMAN: In the world, we say there's no place where this is happening. It is this place where this miracle is happening. It's a life-giving place for us.
Although many countries allow the donation of a kidney from a relative, few permit the purchase of a kidney from a non-related donor.
DRAGAN: You cannot find anything in Serbia, anything like this.
Waheed introduces me to patients from Serbia, Canada and the US.
WAHEED SHEIKH: As far as this patient is concerned, this patient has come from Trinidad and Tobago.
This woman has only recently received a kidney. I'm not allowed to record a transplant operation but I'm allowed to film the empty theatre.
WAHEED SHEIKH: You're an unwanted creature here.
Dr Waheed is happy for me to talk to patients but I'm not given access to any of the donors. He claims his donors are not motivated by money.
WAHEED SHEIKH: We don't pay anything to the donor at all. And every recipient family is satisfied that this person is donating on humanitarian grounds and they're satisfied about that because people from the Western hemisphere, they attach a lot of values on such things.
REPORTER: But I just don't understand - why would someone want to give up one of their kidneys? I mean, would you donate a kidney?
WAHEED SHEIKH: No, I wouldn't donate a kidney. Possibly I'm not motivated to that extent but people who are motivated would like to donate their kidney.
REPORTER: What are the motivations?
WAHEED SHEIKH: It is basically religious motivations. You've got to be a Muslim to understand what religious motivations is all about.
But according to JD, who was here earlier this year, the hospital does purchase live kidneys.
JOHN DAVID HORNE: I met the donor. Yeah, I met the donor. You meet your donor.
REPORTER: Do you?
JOHN DAVID HORNE: Yes.
REPORTER: Who was your donor. Was it a man or a woman? Can you tell me about your donor?
JOHN DAVID HORNE: Male, young man, actually.
REPORTER: Do you know how old?
JOHN DAVID HORNE: 26.
REPORTER: Where was he from?
JOHN DAVID HORNE: He was from Lahore. He was from Lahore?
REPORTER: He was from Lahore. And why was he doing it?
JOHN DAVID HORNE: For the money.
REPORTER: How much was he getting?
JOHN DAVID HORNE: He gets about a third. About US$3,500, US$4,000, which is enough to last him for 10 to 15 years on their money over there. That's big money to them.
JD obviously hasn't been to the Sargodha district. Perhaps these poor peasants may have benefited from money they received but I didn't find any who were happy with what they'd done. Most have paid a terrible price and are sick of telling their story.
WOMAN, (Translation): They film us, we wait for aid. Why don't you just get your photos taken so you can look at them whenever you like? Nobody's helped us and nobody will help us. And yet every time, you all gather here and go through this ordeal.
With no way out of poverty, the destiny of these children may also lie in the hands of the kidney traders.
MOHAMMED ASLAM, (Translation): The kids may have to do it too when they grow up.
Field Producer / Translator