COLUMN ONE : For Sale: The Poor’s Body Parts : Vast market in kidneys, skin and reportedly even eyes stretches from the Mideast to Hong Kong. Slum dwellers line up to sell what they can--for a brief break from poverty.

Ganapathy Thiagarajan earns less than $20 a month scavenging garbage. He lives in a mud and thatch house on a rutted dirt road and has no electricity, fairly typical of countless thousands of poor in the overcrowded slums of Madras.

So, when he heard of an easy way to make $700--almost three years’ income--he leaped at the chance. He sold one of his kidneys at a transplantation clinic in Madras.

His neighborhood is home to more than 350 commercial kidney donors--including his two wives--who live in the cramped, squalid homes of Madras’ poor. It is so infamous as a bazaar of human body parts that Second Road, Villivakkam, is now informally known simply as “Kidney Street.”

“Everything is still the same,” Ganapathy said, surveying the poverty around him. “We’re rich for a few weeks and then go back to our normal lives.”

Villivakkam is only a small but highly visible part of a vast, gray market in human organs that stretches from the Middle East to Hong Kong. The market deals mainly in human kidneys, more than 1,000 a year. But there is also talk of skin for sale to burn victims, and an ophthalmologist in Madras said he was appalled that virtually every day he received offers from poor people who wanted to sell an eye.

“It’s immoral, ethically objectionable and socially degrading,” said Dr. B. N. Colabawallah, a Bombay urologist who is one of the few doctors in India to publicly condemn the sale of kidneys. “Many times, these operations are carried out in a way-out place where I’d be scared to have my toenail removed.”

Typically, the market transfers health from the poor people of India, China, Thailand and the Philippines to the relatively affluent but infirm patients--not only the well-to-do in their homelands but also those from oil-rich Arab states, Malaysia, Singapore and Hong Kong.

The wealthy are motivated by the fact that dialysis treatments, which can replace malfunctioning kidneys, are often prohibitively expensive and can severely restrict a patient’s lifestyle.

They have no relatives willing to offer them a kidney. At the same time, cultural taboos in many Third World countries have largely inhibited hospitals from receiving free donations of kidneys from accident victims, as is the case in the United States.

In addition to the moral and ethical concerns raised by the commercialization of kidney transplants, doctors in the region have reported a significant number of botched operations in which the transplants have been rejected. There are also complaints about poor screening of donors before operations, many performed in unsanitary conditions. That has resulted in the deaths of recipients due to hepatitis and AIDS. One facility in southern China, which performs transplants by day, is a disco at night.

“This is big business. The people involved are absolutely ruthless,” said Dr. Hugh Wood, medical director of Singapore’s National Kidney Foundation. While sale of kidneys takes place in most poor Asian countries, the majority of known transplants are carried out in India.

Last week, the Indian government announced that it was introducing legislation to ban kidney sales after a drug addict in New Delhi admitted selling a kidney for $1,000 and trying to sell an eye. But many are concerned that such a law would simply drive the trade in kidneys underground; already some donors are signing legal documents, swearing to be distant relatives of recipients.

Since the operations started in the mid-1980s, Bombay also has been plagued by a series of kidnapings in which the victims have regained consciousness on a back street with a large incision across their abdomen--a sign that a kidney has been removed while they were drugged.

Initially, middlemen combed the slums of India’s cities looking for donors. But doctors in Madras said that they now have far more people offering their kidneys for sale than there are paying patients, so they no longer have to use the services of commission agents.

Dr. K. C. Reddy, a Madras urologist who performs two transplants a week, is one of the most outspoken advocates for the continuation of the sale of kidneys. “You’re not buying a kidney, but buying a life,” he said in his cramped office at Madras’ Pandalai Clinic, where he was interviewing potential donors. “The patient’s life is at stake. What can he do? You’ve got to put yourself in his place.”

Reddy said that, in addition to using a qualified team of urologists and nephrologists (kidney specialists) to carry out the transplant, he offers three years of free follow-up care to the donors to ensure that they have no unexpected health problems. It is a measure of Reddy’s high reputation in places like Villivakkam that potential organ donors throng his offices.

“You cross the ethical Rubicon when you ask, ‘Is it justified to subject a human being to a risk, however negligible, to save the life of another person?’ ” Reddy said. “If it’s ethical on altruistic grounds, does it change if money changes hands? Why does payment of money make the act unethical?”

Reddy said there are 100,000 to 120,000 cases of renal failure in India each year, and without paid-for kidney transplants, most patients would be condemned to an early death. About 15% of Reddy’s patients are from abroad.

“No one wants a trade in human organs, but one has to be very practical,” said Dr. Raj Yadav, a transplant specialist in New Delhi. “There is no cadaver program in India and no free dialysis treatment. So long as the safety of the donor is ensured, I don’t see anything wrong with it.”

Outside Reddy’s offices on a recent weekday morning, more than 150 people were lined up in neat rows seeking blood tests to show they would make good donors. Nearly all hoped to use the money they would be paid to pay off debts or to pay a dowry in hopes of marrying off a spinster sister. The current market price for a kidney is around $1,100.

“We make only 500 rupees ($18) a month, so there is very little money for food,” said Selvi Veerabadran, 32, who has five children. With the proceeds of her kidney sale, she plans to buy a motorized rickshaw, a kind of motorcycle taxi, for her husband.

Vijay Kumar, a 27-year-old mechanic who has brought his wife so she could sell her kidney, too, observed of the surgery: “It’s not easy money, it’s a matter of survival for me. We just can’t survive on the money I make.”

Most patients seeking kidneys pay about $2,000 for the operation and to recuperate in the hospital. They also must pay the donor directly for the kidney; in this way the doctor is not directly involved in a commercial transaction and distances himself from the ethical problems that might create. For a year after the operation, the patient must take an anti-rejection drug called cyclosporin that costs $200 a month.

In contrast, a patient on dialysis in a private clinic can expect to pay more than $700 a month for his lifetime, which in India often is less than 18 months.

“The question for me was how to live and live nicely,” said Dwarakadeshi Bhasin, a 52-year-old New Delhi systems analyst who bought a kidney in Madras. “It was either death or a transplant.”

Bhasin said he could no longer walk after two years on dialysis. He could barely lift his head. Now, a month after the transplant, he is walking around barking orders through a surgical mask to repairmen fixing the air conditioning of his borrowed home. “I studied over the whole problem,” Bhasin said. “It is not that you are snatching away someone else’s life. They also live. It’s a world of difference.”

Although the transplant operations have become fairly routine, it is still a relatively complicated procedure in which the condition of a recipient must be carefully evaluated before undergoing the stress of surgery.

Last year, two general surgeons in Madras were arrested by the police after both the donor and the recipient died within days of the transplant operation. Following an outcry among the medical community, however, the charges were dropped and both doctors are still performing transplants.

Even an advocate of kidney sales, such as Reddy, acknowledged that kidney transplantation has become what he terms a “cottage industry” in many small clinics throughout India. “It’s the mavericks who give the business a bad name,” Reddy said. “Some kind of regulation is necessary.”

Prof. C. L. Ashok Kumar, a Madras urologist, said he used to perform a transplant a week involving so-called unrelated donor transplants but has stopped doing the operations unless a relative was involved. “It’s a big racket now,” Kumar said. “Transplants are going on in Madras at a hectic speed and with hectic jealousy among doctors. People were asking me to do operations that I was just not comfortable with.”

A study published in the respected British medical publication the Lancet found that, of 122 patients from Oman and the United Arab Emirates who went to Bombay for transplants, 25 had died within a year--which it said was unacceptable by standards in the West; in the United States, experts say that 90% survival rates are common for a comparable period.

The Lancet study noted that: “The patients who died had multiple complications but infection was the (most common) known cause of death. Patients were not properly instructed about their treatment, and little or no information was given to doctors following up the patients, criteria of suitability for transplantation were not strict and patients were exposed to serious infections (including human immunodeficiency virus infections).”

Ong Soo Ghee, a Singaporean kidney patient, said he spent $15,000 receiving a new kidney in Madras this January but had to have the organ removed three months later because of a fungal infection. Ong, one of 10 Singaporeans who lost a transplanted kidney in recent years, said he didn’t want other patients “to go through the hell I went through.”

Wood of the Singapore Kidney Foundation said seven Singaporean recipients had died in China after botched operations, which usually involve kidneys from executed prisoners.

In China, many still hold to traditional beliefs about the sanctity of the body, which they believe must be buried intact; these beliefs, however, contribute to a shortage of organs for transplanting, a regional scarcity that leads the wealthy but ailing in nearby Hong Kong to try to buy organs from the poor but healthy in China.

In India, the biggest enemy of a free system of cadaver transplants is ignorance. The kidney must be taken from the body of an accident victim while the heart is still beating but after “brain death.” But doctors say that India’s simple poor cannot grasp the idea that a person is dead, even while his heart still beats; relatives, thus, refuse to allow transplants from their hospitalized, critically injured relatives.

One Kuwaiti study said that the availability of cheap organs for sale in India made it almost impossible to persuade relatives of patients in the Middle East to offer to help their brothers and sisters by donating a kidney.

“It’s unfortunate poor people give up a kidney, but they are the people with the need,” Madras’ Reddy said. “If you stop kidney sales, you will be depriving the segment of society who most need the money.”