The decision to sell her kidney was easy for Ismat Bibi, a housewife in Pakistan’s Punjab province.
With four children to feed, a husband suffering from tuberculosis to look after, and a debt of 100,000 rupees ($950) to repay, she quickly offered herself up.
The deal seemed simple enough. She would go to a hospital in a nearby city, the organ would be removed and she would get 110,000 rupees ($1,000). No one needs two kidneys, Bibi was told by the middle man, her neighbor in the town of Kot Momin.
Twelve years on, not only have the debts mounted, she is grappling with her husband’s worsening health, a mentally disabled young daughter, and often insufferable abdominal pain due to the removal of her right kidney.
Worse still, her son, 15, plans to sell his kidney too.
“I am begging my son not to do this, but he is adamant,” said Bibi, 40, as she sat in her one-roomed mud home in a slum on the outskirts of Kot Momin in Punjab, northern Pakistan.
“I committed a mistake by selling the kidney, but I had no other option to feed my family.”
Punjab is Pakistan’s most prosperous region, but alongside thriving sectors from farming to textiles, another business is booming -- the illegal trade in human organs, say police, activists and victims.
Fueled by a cycle of poverty and debt, this black market has flourished for years with traffickers preying on the poorest - many of them laborers who have helped the region prosper but have been paid a pittance in return.
And with a shortage of organ donors globally, “transplant tourism” has taken off here with criminal networks, often influential people like doctors and businessmen, using their agents overseas to fly in foreigners needing organs.
There is no official data on the number of people who have sold their kidneys in Pakistan, but some officials estimate that there could be at least 1,000 victims every year.
Babar Nawaz Khan, Chairman of the National Assembly Standing Committee on Human Rights, says Pakistan is a hot spot for organ trafficking, but adds authorities are now cracking down.
“Until last year, Pakistan was the main hub of this trade,” Khan told the Thomson Reuters Foundation.
“According to some estimates, 85 percent of all organ trafficking cases were reported in Pakistan a few years back, but thank God, we are no longer in the top 10.”
Oranges, lemons and kidneys
Punjab is home to over 110 million people, around half of Pakistan’s population. Not only is it the country’s breadbasket - producing almost 60 percent of all agricultural output - it is also the most industrialized.
Fertile fields of green rice paddy, golden wheat and white cotton blooms are commonplace, alongside factories producing everything from textiles and cement to cricket bats and surgical equipment.
Punjab’s economy made up over 50 percent of Pakistan’s gross domestic product in 2016 and the poverty rate here is just over 20 percent -- the lowest among all its provinces.
But much of this prosperity is built off the backs of thousands of workers, who have for decades been exploited by feudal landlords, building contractors, brick kiln and factory owners who pay them as little as $5 daily, say campaigners.
Many borrow from their employers at interest rates as high as 60 percent. Before long, they are trapped in a cycle of debt.
In Kot Momin in Sargodha district - known as Pakistan’s “citrus region” due to its lush orchards of juicy oranges, mandarins, lemons and limes - hundreds have sold their kidneys.
“I have applications from around 250 people, who have sold their kidneys and who are now seeking government help,” said Zafar Iqbal, a social activist and victim of organ trafficking.
“They want authorities to provide jobs to them or their kids, as they can no longer do jobs like construction work.”
Iqbal, 45, sold his kidney in 2003. His brother had died and he needed the money to look after his brother’s wife and children as well as fund the weddings of his two sisters.
“We are small fries. We can’t confront these powerful people,” he said, as he served tea to customers at his run-down stall in Kot Momin’s main market.
The dusty town is surrounded by rows of citrus trees, interspersed with state-of-the-art fruit processing factories which export the world-famous orange, known as kinnow, to Europe and the United States.
Mohammad Zaheer, a worker at a sprawling orchard on the outskirts of Kot Momin, said he earns a daily wage of 500 rupees ($5). But he receives less than half after deductions made for a $950 loan he took from his employer.
“I sold my kidney five years ago to pay for my younger sister’s marriage,” said 43-year-old Zaheer. “She got married, but my ordeal did not end and I had to borrow money from my employer to feed my six children.”
Pakistan outlawed the commercial trade in human organs in 2010, imposing a jail term of up to 10 years and a maximum fine of one million rupees ($9,500) for doctors, middlemen, recipients and donors.
The law permits donors to give their organs to recipients who are relatives and for altruistic purposes, but bans the sale of human organs to foreigners.
But low wages and poor implementation of the law has hampered efforts to curb rising cases of organ trafficking.
Recipients from countries such as Britain, Saudi Arabia and South Africa travel to the Pakistani cities of Lahore or Karachi where they are operated on in private clinics in residential areas or houses with makeshift operating theaters in basements.
A kidney is sold to foreigners for between four to 10 million rupees ($38,000 to $95,000), but the donor gets less than 10 percent of that, say police officials.
In July, the Federal Investigation Agency raided a private clinic in an upscale neighborhood of Lahore, and arrested 14 people, including two Omani nationals suspected to be potential recipients.
Police admit the trafficking networks are difficult to break: They involve several players - from doctors, nurses and paramedics to hospital owners and businessmen - and many are influential and with political connections.
But authorities say they plan to strengthen the law by giving more power to the regulatory authority in charge of transplantations, upping surveillance at hospitals, and imposing stricter punishments.
“We are determined to clamp down this illegal trade,” Pakistan’s Health Minister Saira Afzal Tarar told the Thomson Reuters Foundation. “We are consulting all stakeholders to tighten laws to curb this inhumane business.”
These words however mean little to the victims who are left often still in debt and with health problems due to a lack of healthcare after their organs were removed.
“I have the option of either feeding my children or buying medicine for myself,” said brick kiln worker Sarfraz Ahmed, 30, pulling up his shirt to show a thin brown scar on the left side of his abdomen. “I have opted to feed my kids.”