The mixture of science and religion—so spicy, so impossible to emulsify—has also, this year, drawn in the immense talents of Jill Sisson Quinn. "Sign Here If You Exist" begins with a description of the surreally complex egg-laying behavior of the ichneumon wasp. Had Quinn written about nothing more than that, the beauty of her phrasings would still have left me speechless. But her musings on the ichneumon led her to reframe her views on God and afterlife. She comes to see body, not soul, as immortal. "I got my elements from stars: mass from water, muscles from beans, thoughts from fish and olives. When Edward Abbey died, his body was buried in nothing more than an old sleeping bag in the southern Arizona desert. He said, 'If my decomposing carcass helps nourish the roots of a juniper tree or the wings of a vulture—that is immortality enough for me.'"
First-rate essays like Quinn's tempt the nonbeliever to adopt science as a kind of God stand-in—infallible, omniscient, eternal, good. "Lies, Damned Lies, and Medical Science" is a bucket of ice water to the face. David H. Freedman profiles the Greek gadfly and meta-researcher John Ioannidis. In a 2005 Journal of the American Medical Association article, Ioannidis looked at forty-five of the most often cited and highly regarded medical research papers of the past thirteen years: among them, studies recommending hormone replacement therapy for menopausal women, vitamin E to reduce the risk of heart disease, and daily low-dose aspirin to prevent heart attacks and strokes. Forty-one percent of these, Ioannidis found, "had been convincingly shown to be wrong or significantly exaggerated."
Science writing regularly honors the accomplishments of science, but it is equally important to expose its shortcomings. Atul Gawande's "Letting Go" profiles the American physician's overcommitment to preserving life. There is a tendency among surgeons and oncologists to equate death with failure. Death is someone else's job. Too often, Gawande argues, doctors do not merely shy away from death. They get in the way of it, and by their obfuscation or omissions, their rosy-hued prognoses, they deprive patients of a dignified death.
Gawande's and Freedman's articles happened to be back to back in the stack by my bed. Happily, Jon Cohen's piece on how to collect semen from a chimpanzee was next on the pile.
In simpler times, good, careful writing about the natural world fostered awe and wonder, the necessary starting points for good stewardship. Today's nature writing, more and more, fosters disquiet and concern. Much of this year's best nature writing is a call to action, the writers' work artfully spotlighting environmental atrocities both within and far outside our normal gaze. If not for their work, I would not have realized the extent to which broken space hardware clutters our heavens and jellyfish clog our oceans. The plight of songbirds on Cyprus netted by the thousands for diners would have remained distant and abstract.
Two of my favorite pieces manage to impart urgency without sowing despair. The authors use fine narrative writing, humor even, to draw readers in and quietly open their eyes to the direness of the situation. In "New Dog in Town," Christopher Ketcham charms the reader with his opening description of coyotes on the Van Cortlandt Park Golf Course in the Bronx. "They apparently like to watch the players tee off among the Canada geese. They hunt squirrels and rabbits and wild turkeys along the edge of the forest surrounding the course, where there are big old hardwoods and ivy that looks like it could strangle a man—good habitat in which to den, skulk, plan. Sometimes in summer the coyotes emerge from the steam of the woods to chew golf balls and spit them onto the grass in disgust." Ketcham meets a golfer who describes a coyote trotting alongside his golf cart, stopping and starting when he does. The man mimes the coyote watching the golf balls fly—"following with his head the coyote-tracked ball's trajectory up and up, along the fairway, then its long arc down." Ketcham goes on to explain how, over millennia, the coyote's "elasticity" has allowed it to expand its range, while the less adaptable wolf has dwindled. The coyote has no need for a pack or for cover of woods. It sleeps anywhere, eats anything ("garbage, darkness, rats, air"). Coyotes have been around since North America teemed with saber-toothed cats, mastodons, and the glyptodon, "a turtle as big as a Volkswagen." All but the coyote perished in a mysterious mass extinction.
By the end of Ketcham's essay, we realize that the coyote on the golf course, the coyote who howls along with the ambulance sirens, is a wily portent of doom. Another massive die-off is underway. Nothing loud or catastrophic, no asteroids, just the slow, expanding vacuum of habitat loss. The "weed species" thrive as thousands of others blink out, all but unnoticed, year upon year. One day, millennia from now, scientists will ponder the massive die-off of the late Holocene. Whatever could have happened?
In "Fish Out of Water"—so titled for the Asian carp's alarm response of leaping fifteen feet into the air, "knocking boaters' glasses off and breaking their noses and chipping their teeth and leaving body bruises in the shape of fish"—Ian Frazier charts the well-meaning, largely ineffectual, occasionally comical efforts to brake the spread of this swiftly invasive, ecologically disastrous species. These efforts include exporting them to China ("Rick Smith belongs to the very small number of motorcycle-rally food vendors who also ink multimillion-dollar deals with the Chinese"), erecting electric fish barriers, and attempting to legislate them out of existence. (The Obama administration has a "zero tolerance policy" for Asian carp.)
The hardest science in Frazier's piece is the DNA analysis being used to track carpal creep through Illinois's waterways. "I did not follow all the science of it," Frazier admits. He tends to spend his word count on the places that make for better reading. Had this piece run in a science magazine rather than The New Yorker, I suspect the explanation of the DNA work would have been expanded and we would probably not have read about the Redneck Fishing Tournament (prizes awarded for most carp taken in a two-day period, and costumes). That would be a shame. Readers would have missed "the smell of ketchup and mud," the sound of "crushed blue and white Busch beer cans disappearing into the mud, crinkling underfoot," and the winning costumes—"devils from Greenview, Illinois, and cavemen from Michigan."
There is nothing wrong with an article on the intricacies of DNA analysis for monitoring invasive species. But you risk missing the waterways for the fish. Environmental science happens in a context. Frazier handily captures the complexities of the challenge—logistical and political—and the flavor of the grass-roots creativity being applied to overcome it. Explaining DNA science clearly to readers is a laudable skill, but equally so is reporting the issue in a way that roots the science in a place—in people and their situations. That can be, in its way, even more complex than sequencing DNA. "Through waving weedbeds of bureaucracy and human cross-purposes," writes Frazier, "the fish swims."
When your characters are galaxies or subatomic particles, different standards apply. If your topic is "time" or "the elusive theory of everything," simply helping the reader to understand will more than suffice. Stephen Hawking and Leonard Mlodinow got me all the way to the top of the second column before they lost me. ("According to quantum physics, the past, like the future, is indefinite and exists only as a spectrum of possibilities.") This was long before they dropped the bomb that there are no less than five different string theories, and that all five are about to be scrapped for a network of theories collectively known as M-theory. It may make you feel better to know that although physicists are on the verge of assembling a unifying network of theories to explain the workings of the universe, none of them "seems to know what the M stands for."
Hawking and Mlodinow's central metaphor is the goldfish in the glass bowl, believing its view of reality to be an accurate representation of the external world. He has the reader imagine the goldfish as they "formulate scientific laws from their distorted frame of reference that would always hold true and that would enable them to make predictions about the future motion of objects outside the bowl." This was a good year for fish humor in science writing.
MARY ROACH
The Organ Dealer
Yudhijit Bhattac
harjee
FROM Discover
ELENI DAGIASI FLEW from Athens to Delhi in January 2008 on a mission to save her life. With her husband, Leonidas, she took a taxi from the airport past sparkling multiplexes and office buildings to a guesthouse in the booming exurb of Gurgaon. A kitchen staff was on hand, the rooms had cable, and there was a recreation area with billiards, providing patients with creature comforts while kidney transplants were arranged. Over the next week, as her operation was scheduled, Dagiasi went to a makeshift hospital for dialysis. Then one night, while she was watching TV with her husband, a chef turned off the lights and urged everyone to leave. Shortly afterward, ten policemen stormed in. "We were too stunned to react," says Leonidas Dagiasi, a former fisherman who borrowed money from his employer to finance the trip. The couple and other guests were hauled off for questioning. The Gurgaon hospital, it turned out, was the hub of a thriving black market in kidneys. The organs were harvested from poor Indian workers, many of whom had been tricked or forced into selling the organ for as little as $300.
The mastermind, India's Central Bureau of Investigation (CBI) charged, was Amit Kumar—a man who performed the surgeries with no more formal training than a degree in Ayurveda, the ancient Indian system of medicine. In a career spanning two decades, Kumar had established one of the world's largest kidney-trafficking rings, with a supply chain that extended deep into the Indian countryside. Some of his clients were from India. Many came from Greece, Turkey, the Middle East, Canada, and the United States.
At parties in India and abroad, Kumar introduced himself as one of India's foremost kidney surgeons, said Rajiv Dwivedi, a CBI investigator based in Delhi. The claim wasn't entirely illegitimate: investigators estimate that Kumar has performed hundreds of successful transplants, a practice so lucrative that he was able to finance Bollywood movies and had to fend off extortion threats from the Mumbai mafia. Two weeks after the police crackdown in Gurgaon, Kumar was arrested at a wildlife resort in Nepal and brought back to India, where he now awaits trial.
Kumar's operation was a microcosm of the vast, shadowy underworld of transplant trafficking that extends from the favelas of São Paulo to the slums of Manila. The tentacles of the trade crisscross the globe, leaving no country untouched, not even the United States, as evidenced by the July 2009 arrest of a New York rabbi who has been charged with arranging illegal transplants in this country by bringing in poor Israelis to supply kidneys.
In June 2008 I traveled to India to get an inside view of Kumar's ring and examine the perverse enterprise that fueled its rise. How did Kumar build his organ empire, and how was he able to run it for so long? The answers, I learned, lay in the grinding poverty and entrenched corruption of India, the desperation of patients on dialysis, and the transnational nature of the black-market transplant business—which, though dominated by the kidney exchange, includes livers and hearts as well. The factors at play in India allow the kidney trade to thrive around the world, despite efforts by various governments to stamp it out.
Life without a working kidney is harsh. We are born with two of these internal filters, located below the rib cage, to remove waste and excess water from our blood. Patients with kidney failure—often the result of diabetes and high blood pressure—can die within days from the buildup of toxins in the bloodstream and the bloating of organs. To avoid this outcome, modern medicine offers dialysis, a process in which blood is cleansed at least three times a week by pumping it through an external or internal filter. This grueling routine comes with dietary restrictions and side effects like itching, fatigue, and risk of infection. Theoretically you can live on dialysis for decades; in reality, though, the risks are so great that without a new kidney, premature death is the frequent result.
No wonder that those needing a kidney vastly exceed the number of kidneys available from deceased donors. In the United States, some 88,000 individuals were on the waiting list as of early 2010, with 34,000 names typically added every year. The wait averages five years. The situation in Greece is similarly dire: Eleni Dagiasi put her name on a list around 2006 and expected a waiting period of five years or more. In the meantime, she needed dialysis three days a week—a treatment requiring that she live in Athens, more than seventy-five miles and three hours' travel from her husband, who works on Andros Island as a caretaker of yachts. After Eleni learned of the India option through one of Kumar's brokers, the couple saw it as a way out.
They could have gone elsewhere: to Pakistan, where entire villages are populated by men who have been stripped of a kidney; to China, where kidney harvesting from executed prisoners has supported a booming transplant industry; or to the Philippines, where transplant tourism flourished until May 2008, when the government banned the trade. Transplant tourism today accounts for as much as 10 percent of all donor kidneys transplanted, says Luc Noël, coordinator for the Department of Essential Health Technologies at the World Health Organization (WHO). Often lured by middlemen (or drugged, beaten, and otherwise coerced), donors end up with a few hundred to a few thousand dollars and a scar at the waist that has become an emblem of exploitation and human indignity.
The kidney trade has its origins not in the underworld but in the bright light of medical advancement and the globalization of health care. It began in a hospital in Boston in 1954, when a medical team led by the plastic surgeon Joseph Murray conducted the first successful kidney transplant from one identical twin to the other. There was no immune rejection to contend with because the donor's and recipient's organs had coexisted happily in their mother's womb. Through the 1950s and '60s, researchers attempted to make transplants work in patients who were unrelated to their donors. To help the new organ withstand the assault from the recipient's natural defenses, doctors developed tissue-type matching, a technique to determine if the chemistry of the donor's immune system, defined by antigens on the surface of cells, was similar to that of the recipient's. Doctors also bombarded the recipient with X-rays and used a variety of drugs to beat the immune system into submission.
In the early 1980s, transplants became feasible on a wider scale. What changed the scene was an immunosuppressant molecule called cyclosporin, developed by researchers at the Swiss pharmaceutical company Sandoz. It became the foundation for new drugs that could counter organ rejection with unprecedented effectiveness.
The possibilities quickly became evident. "Doctors realized that with cyclosporin, you did not need a related donor," says Lawrence Cohen, an anthropologist at the University of California at Berkeley. Clinics were able to cast a wider net for donors, and kidney transplants became an established surgery around the world. Soon kidneys were a commodity. The first reports of kidney selling began to surface in India around 1985. With its large base of doctors and an expanding health care industry, India had already been attracting medical tourists from the rest of South Asia and the Middle East. Now there was a growing stream of patients from these countries checking into hospitals in Chennai, Mumbai, and Bangalore for kidney transplants. "There were lots and lots of sales," Cohen says.
In Southeast Asia another kidney-trading corridor had opened up, with the Philippines as the hub. Patients from Japan and elsewhere traveled to Manila to buy kidneys. The organs often came from jailed felons, according to Nancy Scheper-Hughes, an anthropologist at the University of California, Berkeley, who has documented the trade in various countries. "Guards would pick out the healthiest-looking prisoners," she says. Some reports allege that buyers negotiated with the prisoners' families, not the prisoners themselves. Meanwhile, China became the destination for patients from Singapore, Taiwan, and Korea. Under a rule approved by the Chinese government in 1984, kidneys and other organs were harvested from executed prisoners. Human rights activists became concerned that China might have been ramping up its executions through the 1980s and '90s in order to boost its organ supply.
The practice was gaining notoriety, but interventions urged by WHO and others often failed. India legislated its Transplantation of Human Organs
Act, banning the buying and selling of organs, in 1994. But the law did not eliminate the practice; it simply drove it underground. By the end of the decade, the kidney trade was thriving, largely due to the Internet. Websites touting "transplant packages" priced from about $20,000 to $70,000 sent patients, many of them Americans, flocking to hospitals in the Philippines, Pakistan, and China. In 2001, when authorities apprehended a criminal syndicate trafficking kidneys from slum dwellers in Brazil and poor villagers in Moldova to Israelis, it became evident that the trade had spread far and wide.
When Kumar was arrested on February 7, 2008, he struck a defiant pose for the cameras as Nepalese officials prepared to escort him to Delhi. In the weeks that followed, he became a media celebrity, with investigators leaking stories about his flamboyant lifestyle. News reports alluded to Kumar's owning properties in India, Hong Kong, Australia, and Canada. Sher Bahadur Basnet, a Nepalese police official who apprehended Kumar, told me that he made frequent trips to nightclubs and casinos in Kathmandu. In an ironic twist, an Indian news channel discovered a clip from an obscure 1991 Hindi flick titled Khooni Raat ("bloody night") in which Kumar—who harbored ambitions of becoming a movie star—plays a bit role as an upstanding police officer.
The first time I saw Kumar was in June 2008 at a court in Ambala, some 125 miles northwest of Delhi. The court had yet to open its doors when I arrived, and I sat outside on a bench. Two of the ring's employees—a driver named Harpal and a cook who worked at the guesthouse, Suresh—showed up, wiping their faces with handkerchiefs. They told me they had no idea that Kumar had been conducting illegal transplants.