Indicators to Identify Trafficking in Human Beings for the Purpose of Organ Removal.

This article presents indicators to support transplant professionals, judicial and law enforcement authorities and victim support workers with the identification of trafficking in persons for the purpose of organ removal. It outlines the legal and illegal service providers that facilitate trafficking in human beings for the purpose of organ removal and guides the reader through the following criminal process: recruitment, transport, entrance, documents, housing, transplant, aftercare, and finance. Identification of illegal transplant activities by transplant professionals can support police and judiciary with the investigation, disruption, and prosecuting of trafficking networks.

This article presents indicators to help transplant professionals, law enforcement authorities and victim support workers identify trafficking in human beings for the purpose of organ removal (THBOR). THBOR is defined as “the recruitment, transportation, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include (…) the removal of organs”.[1]

The indicators are structured along a barrier model. This model identifies the legal and illegal service providers for each step (barrier) in the criminal process: recruitment, transport, entrance, documents, housing, transplant, aftercare, and finance (Figure 1).

FIGURE 1

Although the indicators are indicative of THBOR, they may point to other forms of organ trade as well, such as transplant tourism and transplant commercialism—forms of organ trade which do not necessarily involve THBOR. The indicators are not exhaustive; they should be extended or modified in response to changes in the modus operandi of traffickers and new research findings.

METHODOLOGY

The indicators are based on empirical research data that has been collected under the HOTT project, an EU-funded project against THBOR, titled combating trafficking in human beings for the purpose of organ removal (2012-2015). They are derived from the following sources: in-depth interviews with police, prosecutors, patients and transplant professionals, witness and victim testimonies, and judgments of prosecuted cases.

TARGET GROUPS

The indicators are for persons who may come into contact with (potential) recipients, donors, or facilitators who have retrieved or provided organs (or are planning to do so) by means of THBOR. These persons can be transplant professionals, judicial and law enforcement authorities (including border police and embassy officials), and victim-aid workers.

INDICATORS

Recruitment

Persons who are going to receive an organ through THBOR may:

leave for a transplant abroad without notifying their health caregivers;

refuse to accept local transplant solutions;

search the internet for transplant possibilities abroad;

be in (online) contact with a person and/or company that advertises/organizes transplants (abroad) and that does not provide information about the organ donors;

be in contact with a group of potentially suitable, but unknown donors abroad;

not know beforehand where the transplant will take place and/or who their prospective donors abroad will be;

have received a personal invitation from a transplant professional to be transplanted abroad;

have been asked to send medical test results abroad for review by a person/institution whose medical expertise lacks certification.

Persons who are going to supply an organ through THBOR may:

be in (online) contact with a person and/or company that advertises/organizes organ donations abroad,

not have received any or incorrect or misleading information about the pre- and postoperative risks and/or the duration of the operation,

not know who their prospective recipients abroad will be,

not have a (clear) motivation for their donation,

have a relative/acquaintance who has sold an organ before.

Transport/entrance

Persons who are going to receive/supply or have received/supplied an organ through THBOR may:

travel together with one or more persons, who do not appear to know each other, to the same destination;

be accompanied by someone with a medical background;

show signs of fear of someone who accompanies them, for example sweating, trembling, not speaking;

suffer from physical complaints, such as pain in the area where the organ was implanted or removed;

have not organized their own transport and/or do not know their destination;

be carrying a considerable amount of cash;

be carrying medical records and/or letters of invitation for medical treatment;

travel directly to a hospital or clinic upon arrival in a foreign country.

Documents

Persons who are going to receive/supply or have received/supplied an organ through THBOR may:

have received their travel and/or identity documents from someone else;

not carry their own travel or identity documents during the travel to or entrance in a foreign country;

carry identity documents that are very recently issued and/or appear to be forged;

carry travel documents that do not correspond with the purpose of their travel.

Housing

Persons who are going to receive/supply or have received/supplied an organ through THBOR may:

be housed in an accommodation owned by a medical professional or a hospital/clinic;

be housed together in the same accommodation;

not be allowed or able to leave the accommodation on their own

be escorted whenever they go to and return from the hospital/clinic;

not know the location of their accommodation;

undergo physical examinations, blood or other tests performed by doctors at their accommodation.

Transplant

Persons who are going to receive/supply or have received/supplied an organ through THBOR may:

not have received prior medical screening (in their home country);

undergo the transplant procedure abroad within a very short time frame (2 weeks to 2 months);

not know the location and/or name of the hospital/clinic and/or transplant professionals involved;

have not signed consent forms;

be illiterate and/or signed documents that were not written or explained in their native language;

have a group of potentially suitable, unknown donors;

have documents in which the donor-recipient relationship was changed from “unrelated” to “related”;

claim to know each other, but do not actually interact or show interest in one another before and/or after the transplant;

claim to be related to the donor or recipient, but have an inconsistent story about their relationship or give the impression that they were instructed to feign their relationship;

have not received any or incorrect or misleading information about the pre- and postoperatives risks and/or the duration of the operation;

have second thoughts and/or not have been given the opportunity to withdraw prior to the operation;

have seen other foreigners at the hospital/clinic (who arrived in groups);

have been accompanied by another person when visiting the hospital/clinic, who insisted to answer questions on their behalf and/or to translate all conversations with the medical staff;

have been operated at a hospital/clinic without the availability of a dialysis machine or other necessary medical equipment;

not have a (clear) motivation for their donation;

typically present as a donor/recipient pair consisting of a (foreign) younger donor and a (foreign) older recipient.

Aftercare

Persons who are going to receive/supply or have received/supplied an organ through THBOR may:

reappear unannounced at their local hospital with an implanted or removed organ;

have not received appropriate medical aftercare and/or necessary medication;

have received aftercare in another hospital/clinic than where the transplant took place;

lack discharge sheets and/or other information about the operation (abroad) in their medical records, for example, the name of the hospital/clinic, transplant professionals and/or source of the organ;

be reluctant to share information about where and how the operation took place;

be reluctant to share information about their relationship with the recipient or donor;

return from an operation abroad with infections, graft failure or other complications, recipients in particular may carry infections such as HBV, HBC, HCV,PCP, HIV, CMV, TB, Pyelonephritis, Aspergillosis, Sepsis, Malaria, liver cirrhosis, UTI, abscesses and meningitis and/or suffer from graft failure or graft loss and/or carry high doses of immunosuppressive regimen, wound drains and/or splints in their bodies;

show signs of emotional stress/complaints, such as shame, stigma, and regret, about the removal of their organ.

Finance

Persons who are going to receive/supply or have received/supplied an organ through THBOR may:

state that they will give/receive or have given/received payments in return for the organ;

have not received the agreed amount of money;

have paid fees for recruitment, transport and accommodation that were deducted directly from the person’s earnings in return for the organ donation;

have been told that they need to pay or will be paid in instalments (in advance of the operation);

have paid a donor, doctor and/or other facilitator (in cash) for an organ or an organ transplant;

not know the name of the person to whom they have paid or who received their payment;

have made payments through an intermediary person or institution;

have not received a receipt after payment.

CONCLUSIONS

Indicators are a helpful tool to support transplant professionals, judicial and law enforcement authorities, and victim support workers with the identification of THBOR. Such identification can encourage police and judiciary to investigate, disrupt, and prosecute trafficking networks. The infrastructure that allows transplant professionals to report such activity however may not yet exist in every country. We therefore encourage transplant professionals to follow the HOTT project's recommendations presented in this issue.[2-5] One example could involve liaising with government officials, lawyers, and police to establish national reporting codes that allow for the identification and disclosure of trafficking networks (ie, brokers, hospitals, hospital staff, and other individuals involved in trafficking) without revealing patients' identities.[6]