“Organ transplantation (OT) is one of most successful advances in modern medicine; for patients with end stage disease, transplantation often provides their only chance for survival.”
Illegal organ transplantation is estimated to account for 5-10% of all global organ transplants, generating between USD$840 million to USD$1.7 billion annually, and is another form of human exploitation on the rise. Operating on a global scale, it uses a series of professional “middlemen”, specialist medical personnel, specialist blood & tissue testing laboratories, public and private medical & surgical facilities (on occasion, “popup” surgical theatres), travel and facilitation companies, and front companies to hide the activity, particularly the payments. Few compliance professionals are aware of the size and scale of the crime, and the elements of the crime that may leave a signature in the financial system which is used to facilitate this illicit trade.
Desperation and greed drive the illegal organ trade.
The sums involved are significant – an illicit transplant costs between USD$50,000 (kidney) and USD$290,000 (lung), of which the source (“donor”) gets very little; typically it is the intermediaries (broker, surgeons) that benefit the most, paying a pittance to the source (“donor”) while charging the recipient an exorbitant fee. The “markup” varies between 500% to nearly 2,000%.
The recipient, generally middle-to-high income individuals from developed countries, often face certain death unless they get a transplant. The source (“donor”), often from poor and developing countries, often seeking to alleviate debt and/or escape poverty, or as a refugee willing to exchange an organ for the promise of passage to a new life. The outcomes for the donor are often negative, left with a lifetime of impaired health and debt from medical costs, resulting from the procedure; the recipient may also be infected with disease, accompanied by reliance on expensive immunosuppressive drugs, due to poor donor matching.
Only certain countries have the medical skills and infrastructure to offer organ transplantation – these are targeted by the organ trafficking networks. Additionally some countries have a preference for living donations (rather than organs from deceased donors); this may predispose such jurisdictions towards illicit organ transplantation from living, paid donors. The International Registry in Organ Donation and Transplantation (IRODaT) publish regular lists of transplantations by geography.
In 2013, OSCE published its findings representing those found to be involved in illegsl organ trafficking, which included a number of key stakeholders involved in arranging and facilitating international organ transplantation – highlighting the role of coordinators / brokers, as well as the role of a range of medical professionals. Often the stakeholders may be in different countries, thereby adding further complexity to law enforcement investigation.
Key stakeholders involved in arranging and facilitating international organ transplantation (OSCE)
It is important for the AML compliance professional to note that this network of stakeholders may operate within normal businesses i.e. hospitals, laboratories, clinics, etc and that there will be co-mingling of payments for illicit activity within normal business activity. However illegal activity often happens outside of normal business hours i.e. evenings, weekends, public holidays – so not to draw attention to the illicit activity.
Case Studies of Organ Trafficking Networks
To assist AML compliance professionals understand how such networks operate, three previous cases will be examined to show how they operated.
Case 1 – Netcare (South Africa)
“Israeli citizens in need of kidney transplants would be brought to South Africa for transplants at St Augustine’s Hospital. They paid kidney suppliers for these operations . [the kidneys] were initially sourced from Israeli citizens, but later Romanian and Brazilian citizens were recruited as their kidneys were obtainable at a much lower cost than those of the Israeli suppliers”
In 2010, one of the leading private hospital groups in South Africa, listed on the JSE, its chief executive, and five leading surgeons in Durban, South Africa were charged with their alleged roles in an international “kidneys for sale” syndicate. This was in response to the state’s investigation into over 100 illegal transplants between 2001 and 2003. The hospital group admitted receiving ZAR3.8m (USD$542,000) from an illegal organ trafficking syndicate in a scam that included the removal of kidneys from five minors. The company’s Durban subsidiary, trading as St Augustine’s Hospital, pleaded guilty in a plea bargain, paying a fine of ZAR7.8m (USD$1m) in November 2010. As part of the plea bargain the charges against the CEO and the group were withdrawn; allegations that a significant number of transplants had been made at associated group facilities in Johannesburg and Cape Town were not investigated nor pursued.
A prominent kidney specialist (JK), specialist surgeons (JR and AH) and doctors (NC, MN, KS), transplant unit staff, and an Israeli interpreter (SZ) were accused of involvement in an “illegal scheme” to give kidney transplants to wealthy Israelis, using organs donated by poor Brazilians, Romanians and Israelis, with the procedures carried out in South Africa. To legitimise the surgery, documents were allegedly forged to show that the donor and the recipient were related – a requirement for organ transplants in South Africa.
Initially, kidney suppliers from Israel were paid approximately USD$20,000; however later, cheaper kidney suppliers were sourced among Romanian and Brazilian citizens, who were paid, on average, about USD$6,000 for their kidneys.
Two of the alleged syndicate’s South African “co-ordinators” (RK and SM) pleaded guilty to related charges. Separately, a Brazilian court sentenced kidney-donor recruiters (IdS and GT),as well as other intermediaries, to imprisonment for their roles in the syndicate.
Key was the involvement of an Israeli “organ broker” (IP), an Israeli business person with a background in medical insurance, who allegedly was involved in setting up a global transplant scheme involving the global trafficking of paid organ donors and patients. Transplant recipients (from Israel) were alleged to have paid IP between USD$100,000 and USD$120,000 to arrange a kidney transplant in South Africa. IP’s company, UDG Medical Services, or its agents, are alleged to have paid St Augustine’s Hospital before each transplant operation.
“Netcare and Netcare KwaZulu-Natal, trading as St Augustine’s Hospital, would receive payments from UDG or IP and would disburse the money received to other accused and service providers, including the surgeons, for their services”.
Allegedly, IP has links with other networks involved in illicit organ transplantation – Dr ZS and Dr YS, two of the world’s most notorious illicit transplant surgeons (see case Study 2) and IR, an alleged organ trafficker from Brooklyn, New York (see Case Study 3) .
Payments to nephrologist JK, who was allegedly instrumental in the scheme, and fled to Canada, were believed to have been made into his Canadian bank account. He eventually pled guilty and was fined ZAR150 000 (USD$20,000)
A key point in this case was that, until 2008, it was common practice for health insurance companies in Israel to reimburse for transplants performed abroad, irregardless of their legitimacy. [NOTE: This may still be the case in other jurisdictions whereby medical insurance may be inadvertently supporting illicit organ transplantations on clients having a transplant procedure overseas, outside of the national organ transplant network]
In Dec 2012, a permanent stay of prosecution was given to four surgeons and two clinic staff implicated in the “cash for kidneys scandal” citing undue delay in the prosecution. Further details on this case may be found in the UNODC Sherloc Case Law Database
Visualisation / Further Information
Case details, available from the public domain, were searched against company registries and adverse media databases, using Quantexa advanced network analytics and visualisation capabilities, to provide an overview of the extensive corporate networks & associations, that are linked to the main entities involved in the case.
The visualisation for Case 1 outlines a significant number of corporate entities operating in South Africa – with property holdings, medical and surgical hospitals, business consulting services, ambulatory health care services, and medical clinics – as well as associated corporate entities & networks operating in the UK, BVI, and Lesotho. In many instances the organisations are still operating; undoubtedly, some or all of them are using the financial system.
Case 1 Netcare Visualisation (created using Quantexa software)
Case 2 – Medicus (Kosovo)
In 2005, a respected urologist (LD) established a relationship with a Turkish surgeon (Dr YS), an infamous transplant surgeon, to perform organ transplants at the Medicus clinic, in Pristina, Kosovo, which at that time were strictly controlled.
Subsequently LD, his son (AD), Dr YS and an Israeli organ broker (MH) allegedly planned to bring donors and recipients to Kosovo for kidney transplantation. An anaesthesiologist (SH) and several other surgeons (Dr KD and Dr ZS) were also co-opted.
Between March to November 2008, 24 “donors” from Israel, Turkey, Russia, Ukraine, Kazakhstan, Belarus, and Moldova were brought to Kosovo for the removal of their organs for transplant into “recipients” from Israel, Poland, Turkey, Canada, Germany. The donors were promised payments of up to USD$20,000; some received partial amounts, whilst others left empty-handed. The recipients had paid upto USD$132,000 for kidney transplants. The operations carried out in 2008 earned the Pristina-based clinic around 679,000 euros (@ USD$900,000).
LD, AD and SH were convicted in 2013 and sentenced to substantial prison sentences that were amended on appeal in 2016 and 2018. Dr YS and MH remain fugitives – although MH was arrested in Cyprus in 2018 and subject to extradition proceedings to Russia.
Dr YS, “the Organ Mafia Doctor” who operates “underground” on wealthy patients from Israel, Turkey, Russia is allegedly a key player in the unscrupulous organ market for more than 10 years, linked to clinics across the world; he has admitted to doing thousands of transplants. Investigators have placed in him in several locations, notorious for illicit transplants, including Azerbaijan, South Africa, Kosovo, Kazakhstan, Turkey. It is believed that he has amassed USD$20m to 30m from illegal organ transplants, located in a Swiss bank account.
Visualisation / Further Information
Case details, available from the public domain, were searched against company registries and adverse media databases, using Quantexa advanced network analytics and visualisation capabilities, to provide an overview of the extensive corporate networks & associations, that are linked to the main entities involved in the case. The visualisation for Case 2 highlights a different story – the illicit transplants happened in Kosovo – however it is part of much larger network of corporate entities, mainly registered and operating in Turkey – including various types of medical and surgical clinics, but interestingly international transport & logistics, publishing, tourism, import & export companies – as well as associated corporate entities & networks operating in Azerbaijan, and Albania. In many instances the organisations are still operating; undoubtedly, some or all of them are using the financial system.
Case 2 Medicare Visualisation (created using Quantexa software)
Case 3 – United Lifeline (US)
In 2011, an Israeli citizen (IR) living in Brooklyn, N.Y., US admitted that from January 2006 through February 2009, he conspired with others to provide a service to individuals seeking kidney transplants, in exchange for large payments, to obtain kidneys from paid donors. Specifically, IR, the self-styled ‘Robin Hood of kidneys,’ admitted to arranging three transplants that took place in December 2006, September 2008 and February 2009; for which he was paid $120,000, $150,000 and $140,000. IR pleaded guilty to three transactions, although “authorities said he brokered many more kidney transplants and made millions from the deals”.
IR admitted to an undercover agent that he had associate in Israel to find suitable donors, who were brought to the US for the procedure after matching, facilitated via IR’s organisation, United Lifeline. IR claimed that he fabricated cover stories in order to fool hospital employees into believing that the transplants were altruistic donations. He further claimed that he had been arranging kidney transplants for a period of 10 years.
In the process of arranging a donor for the UC’s relative IR accepted four blank cheques totalling $10,000 as a down payment, to be paid to a “charitable organization”, later deposited in an account held at a branch of Wachovia Bank, Brooklyn, NY. Of note is that several of the finest private hospitals in the East Coast were allegedly used for the procedure
Case Visualisation / Further Information
Case details, available from the public domain, were searched against company registries and adverse media databases, using Quantexa advanced network analytics and visualisation capabilities, to provide an overview of the extensive corporate networks & associations, that are linked to the main entities involved in the case. The visualisation for Case 3 highlights a different story – the “arranged” (illicit) transplants took place in private hospitals; the defendant (IR) was convicted for facilitating 3 transplants. However, as this visualisation shows, IR was associated with a large network of associated businesses, with a series of companies under the same name (United Lifeline), providing medical equipment for elderly / infirm patients in & around New York. In many instances the organisations are still operating; undoubtedly, some or all of them are using the financial system.
Case 3 United Lifeline Visualisation (created using Quantexa software)
Resources for AML Professionals
As highlighted, the illicit organ transplantation business is highly lucrative and commands large sums of money from the recipients, much of the profits going to the brokers (and surgeons) who facilitate this trade. The case visualisations have shown that often there is a sophisticated network of corporate entities associated with the network, that may be directly involved in facilitation, or indirectly used for laundering proceeds.
The HOTT Project conducting scientific, empirical research on THBOR across the globe, provides a Barrier Model for THBOR – useful in showing the various roles, across a range of logistics and actions, potentially associated with illicit organ transplantation.
- The HOTT Project identified, from surveying recipients, several key aspects, notably * in some cases, payment of the fees were made by family members or relatives, on behalf of the recipient
- payment was made to the surgeon (50% of cases), broker (30% of cases), bank transfer (10% of cases), or directly to the medical facility (10% of cases) on receipt of invoice
- in some cases, the recipient was partially reimbursed by their insurance providers for their overseas organ transplantation, on submission of official stamped invoice
- in one case, the transplantation reimbursement was arranged directly between the coordinator of the hospital and the health insurance company.
From the above, financial investigators may want to look at activity
- Surgeons – receiving large amounts in foreign currency from individuals (with limited supporting documents / explanation of purpose)
- Anaesthetists / Nurses – receiving unusual amounts in foreign currency from individuals (with limited supporting documents / explanation of purpose)
- Brokers (individuals) – with transaction activity disproportionate from their declared occupation including transfers from individuals or charities overseas in foreign currency
- Laboratories / Medical Facilities – – receiving large amounts in foreign currency from individuals (with limited supporting documents / explanation of purpose)
The role of health insurance companies in identifying suspicious transplantation activity can not be understated; some countries have legislated to stop the use of health insurance to pay for illegal transplants overseas with profound effect.
Bain et al identified a number of potential red flag indicators that financial investigators could include into their monitoring regime to identify potentially suspicious behaviour:
- Wire transfers to entities in high-risk jurisdictions with names that include a variation of medical.i.e “Medicus”
- Methods of payment such as wires payment, email money transfer, and bulk cash withdrawal – for amounts that correspond with payments for organ donation or organ recipient amounts (see tables in GFI report)
- Payments between charities and medical tourism sites
- First-line banking staff indication of potentially ill customers moving large amounts of funds to numbered companies or charities prior to travel
- Medical tourism websites that offer transplant services abroad that recommend utilising their own trusted domestic doctors prior to traveling
“Unscrupulous individuals and organisations are profiteering from this situation.
The stakes are so big, the profit that can be made so huge, that the temptation is
One of the recommendations from a panel of experts convened under the HOTT project was the importance of parallel financial investigations; this is especially true in THBOR cases, where reliance on the victim testimony can be precarious, however use of financial investigations to identify payments, combined with analysis of financial transactions associated with the activity can play a powerful role in substantiating the allegations.
This article has outlined, in brief, some of the issues, cases, and resources available for compliance professionals to engage and use the power of financial investigations; undoubtedly AML compliance professionals have a key role to play in combating this “crime of crimes.”
Appreciation: The author would like to thank the following for their significant help in developing this article, the team at Quantexa (https://www.quantexa.com), Frederike Ambagtsheer (Erasmus MC / HOTT Project), Jonathan Ratel (EU Special Prosecutor and Head of Special Prosecutions Office Republic of Kosovo SPRK)
Steve Farrer has been, for the past 5 years, actively involved in working with the financial services sector, under the anti money laundering (AML) framework, to help identify and mitigate the illicit proceeds from human trafficking (modern slavery). Previously the head of global Non Government Organization (NGO) team collating information on large-scale trafficking incidences, to proactively inform financial institutions of those individuals and entities that are either directly facilitating or indirectly financially benefiting from human (and other forms of) trafficking. In recognition of his knowledge and expertise, Mr Farrer has been involved in plenary sessions and working groups of the Financial Action TaskForce (FATF), the Egmont Group of Financial Intelligence Units (Egmont) and the AsiaPacific Group on Money Laundering (APGML), on the use of AML to combat the illicit proceeds from human trafficking and related criminal activities..
Prior to this, Mr. Farrer was the regional head of intelligence for a global financial institution, covering Greater China and North & East Asia, leading a world-class team, pioneering the use of open source intelligence & techniques to proactively identify & mitigate anti money laundering risk. With over 25 years of experience, he has enjoyed a number of senior management roles in both small specialist advisory firms and major multinational corporations, focusing on anti money laundering & fraud risk mitigation, through the innovative use of technological solutions and use of intelligence, in making risk-based decisions.
Institutions seeking to enhance their response to human trafficking can contact him on firstname.lastname@example.org