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INDIA - The pain is hardest to take at night, says V. Kala, as she lifts the crumpled folds of her faded cotton sari to expose a 33cm scar across her midriff.
"I lie awake in agony scratching and clutching at the side of my body. Sometimes it
feels like it is still there, throbbing inside of me. It's at this time I feel most alone with what I've done.
"The doctors told me to expect that. I don't want sympathy or kind words. I want you to understand why I have put myself through this. It was my decision to sell my kidney. My family was drowning in debt."
Just over a month ago, Kala, 32, a mother of three, stood shaking with fear in Chennai's decrepit Kaliappa hospital. With her were an organ broker, a local advocate clutching her affidavit saying the recipient was a relative, a doctor and the elderly patient her kidney was destined for.
"The broker told me not to bring anyone close to me, in case they changed my mind. The only person in the room I could relate to was the dying woman lying on the bed.
"What struck me as surprising was her age," said Kala. "She was 80, from a Brahmin caste. She looked rich, like she'd had a good life. She told me she wanted to live longer to see her grandchildren in America.
"I wanted to help; now I feel betrayed. I've inherited her suffering."
Kala walks painfully back towards her dismal concrete hut in Ernavoor, a desolate fishing village an hour's drive north of the southern city of Chennai.
Trapped on a sliver of mud between the ocean and the Adyar river, it is one of many poor hamlets strung along the Bay of Bengal ravaged by the 2004 tsunami.
Behind the long rows of single dwellings, built by the Government to compensate fishermen who lost their homes, hunchback cows graze in vast, rotting piles of rubbish. The filthy sea estuary in the distance emits the sulphurous smells of poverty and sewage.
Here, in this ravaged community of 2500, we found 51 women who have sold kidneys in the past six months to escape the pressures of loan sharks who preyed on them after the tsunami. The majority of donors are women in their 20s. The recipients are both Western and Indian, and rich.
"At least 80 people we know of have given their organs in recent months, most are women, but the figure may be 10 times as much,' says S. Maria Silva, head of Ernavoor's tsunami fishermen's association.
"Our community is little more than a refugee camp, made up of eight tsunami-affected villages. After the tsunami we were moved to a temporary village known as Kargil Nagar, but it went up in flames and we were forced here, 14km from our boats.
"The fishermen are literally washed up; they can't afford the commute to their boats. Their wives put food on the table now. They either sell firewood and coconut husks from dawn to dusk and still starve, or sell their organs."
Before passing a series of laws attempting to ban the practice, India was the worst offender in the global organ trade. In cities such as Mumbai, foreigners could easily obtain transplants, although the level of medical care and likely success of the operation varied.
The Indian Government insists those days are gone, but the cash-for-kidneys business continues, mainly in small private hospitals where regulations are weak and technology plentiful.
A hospital needs only a blood supply, dialysis machine and post-operative care facilities to carry out a transplant.
According to Dr Ravindranath Seppan, of the Chennai Doctors' Association for Social Equality, the situation is desperate. "Although India banned commercial trading in human organs in 1994, it is clear a lucrative underground market has emerged in Chennai's suburbs. India's rich are turning to India's poor to live longer, and as the economy grows this abominable situation will also grow."
Seppan points to a study published in the Journal of the American Medical Association where researchers surveyed 305 Indians who had sold their kidneys, and found 96 per cent had done so to pay off debts, but three-quarters remained in debt and 86 per cent said their health had seriously declined since the operation.
The World Health Organisation issued guidelines in 1991 to avoid the exploitation of organ donors. They were endorsed by 192 countries, including Britain, but are not binding.
As health care increasingly becomes a marketplace transaction, a fierce debate about commercialising transplants has emerged. On one side are campaigners such as Seppan, who believe the poor suffer, and on the other side many who believe that payments can only help the dire shortage of organs for those who desperately need them.
One of the UK's top kidney consultants, Dr Andy Stein, of Walsgrave Hospital, Coventry, called last week for the organ trade to be legalised, claiming donors would suffer if it continued to go underground.
As people live longer, increasing the demand for organs, supplies diminish, thanks to increased survival rates in intensive care units. Better road safety has also cut the number of organs from car crash victims.
Frustrated by waiting lists in the tax-funded National Health Service (NHS), unknown numbers of sick Britons go abroad to find brokers, some of whom offer kidneys illicitly harvested from slums in countries such as China, India, the Philippines and those in eastern Europe.
But the internet offers the easiest solution. In 2004, bids for a human kidney reached US$5.7 million ($8.1 million) on eBay. The company classes such sales in the same category as people who try to sell rocket launchers, and closed down the site after informing the police.
Maria Silva and other women from Ernavoor, who complain of excruciating pain after the operations, are now taking matters into their own hands. A fortnight ago, dozens of residents marched on the house of Prakesh Babu, a local broker responsible for 15 sales in the past four months, demanding his arrest.
V. Mary, who sold her kidney through Babu, said: "We don't expect him to resurface. He fled when we went to his home."
Mary's hut is a cramped room with a dirt floor, shared by a family of five. It is suffocating in the heat. She admits her estranged husband frittered away most of what was left on drink after the moneylender was paid.
Mary's neighbour, S. Rani, 36, is clearly in pain. She sold her kidney to pay her 23-year-old daughter's debt to a local hospital. "My daughter had a Caesarean when she had my grandson and lost a lot of blood. She spent a month in hospital, running up a bill of 30,000 rupees. To make matters worse, my son-in-law's family was demanding a 20,000-rupee dowry debt and my husband had run away.
"I went to the hospital gates looking for a broker and I had the operation a month later in another hospital in Chennai. I woke up twice during the operation and was sent home after two days with a handful of sedatives."
In the fluorescent light of the dialysis ward of the Kaliappa hospital, feeble patients sit in armchairs hooked up to ancient fridge-sized machines that simulate the job of the kidney: it's a life-preserving process for people whose kidneys have failed, but they have to be connected three hours at a time, three days a week.
Outside the ward, Rana Vishnawatan, an elderly Indian businessman, says: "My kidney is failing and I don't want to be one of those people in there getting my blood changed in and out of the machine like a car going for an oil change.
"Nor can I afford dialysis. You tell me, what choice do I have? My family is looking for a broker. Either one comes to me or I make one come. I don't have much time.
"This system may seem horrendous to you, but it may not seem quite so bad when your family is starving in a gutter. The kidney business is not a trade - understand that - but a form of co-operation.
"It is not buying or selling. One person is dying of hunger. The other has money, but is on dialysis three or four times a week. If we all decide to co-operate, we can help save each other."
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