"When I tell my colleagues I have not urinated for more than three years, they think I am making excuses to shirk work. They do not understand how painful dialysis is. It leaves me terribly weak. But then I cannot afford to miss work. My monthly expense on medication and dialysis exceeds Rs 30,000," says Nozer H Canteenwalla, who suffers from end-stage renal disease (ESRD). Three times a week, the 42-year-old development officer at a Mumbai-based insurance firm leaves office early for a dialysis session at the city's Lilavati Hospital. A kidney transplant could have brought an end to his travails but Canteenwalla hasn't found a donor in five years.

"Getting an unrelated donor is extremely difficult in India. Cadaver organ donations are extremely rare in the country. Dialysis just delays the inevitable," says Meeta Shah of the Narmada Kidney Foundation in Mumbai, an institution Canteenwalla visits often to get information on ESRD. Vatsala Trivedi, secretary of Zonal Transplant Coordination Committee (ZTCC)-an organization that coordinates between hospitals to improve organ donations and transplantation system in Mumbai-concurs. "There are barely 15 kidney donations in a year in Mumbai, while 100 people are added to the list of patients requiring a transplant.

Eight hundred and fifty people are listed with us for a kidney transplant in the city," she says. Trivedi notes that only half of the organs donated in the city come from cadavers.

Exact figures of ESRD patients in the country are not easy to come by. Conservative estimates put their numbers at several hundreds of thousands. "Every year an estimated 400,000 Indians develop ESRD. Of these, barely 15,000 receive regular dialysis. And there are not more than 4,000 transplants in a year. So, about 380,000 patients remain outside the pale of the formal healthcare system. Where do they go? It's anybody's guess. It's no surprise illegal organ trade flourishes in India," says Bharat V Shah, a consultant nephrologist with Lilavati Hospital, Mumbai.

The government's estimates are somewhat conservative. But even they betray the enormity of the problem. "There are about 400,000 organ failure cases in India every year. 150,000 of them are ESRD patients. But only 35,000 organ transplants have taken place since 1994, when the Transplantation of Human Organs Act was passed," says a source at the Directorate General of Health Services (DGHS).

Most doctors blame the demand supply hiatus on the organ transplant act. It does not put any fetter on "near relatives"-spouse, son, daughter, father, mother, brother or sister above the age of 18-donating orgaans. But things get extremelydifficult if the donor is not a close kin. Such a person has to establish "a case of love and affection" with the recipient. Distant relatives find it difficult to donate organs. "My sister wanted to donate a kidney to my daughter Shabana, who suffers from ESRD. But she wasn't allowed. Medical reasons don't permit my husband and me to donate," says Shamima Khatun of east Delhi's Welcome Colony.

In the aftermath of the Amit Kumar scandal, doctors seem to have become extra cautious about the kinship angle. In many cases, donors have been asked to undergo DNA tests, which mean an additional cost of Rs 3,000 to Rs 4,000. "We don't want to take chances," says Harsha Jauhari, chairperson of the department of renal surgery, Sir Ganga Ram Hospital, New Delhi.

Organ donors have to prove their "affection" for the intended recipient before an authorization committee. Some doctors say that it's often hard to find the committee members when emergencies strike. But R R Katti, assistant director of DGHS Maharashtra and member of Mumbai's authorization committee, refutes these charges: "We meet on the first and third Tuesday of each month" he says. But then he acknowledges the problem: "There should be eight authorization committees in Maharashtra but only five have been formed." Many states, including Punjab and Haryana-where the Amit Kumar racket was unearthed-do not have a single authorization committee.

Katti is no supporter of the affection clause. "It's absurd. One surely can't expect the donor to slit his/her wrist to prove affection. The committee has no way but to take recourse to crude subjective methods," he says.

Illicit operators find it easy to work around this loophole. The organ transplant act is unequivocal that no money should change hands between the recipient and the unrelated donor. But experts find it hard to believe that this is always the case.

"Why is it always that a poor labourer has affection for a rich man?" asks M S Kamath, a medico-legal expert in Mumbai.

The organ transplant act stresses on transplants from cadavers. But according to DGHS, only 1,000 of the 35,000 transplants performed after the act came into force have used organs from cadavers. A 2006 article in the Indian Journal of Urology notes that 233 of the 8,428 transplants in 13 hospitals across the country used organs from a cadaver.

Why hasn't cadaver organ transplant made much headway in India? The reasons are various. "A team of four doctors is required to declare a person brain dead. It includes a neurosurgeon and a neurophysician who do not benefit-professionally or financially-from a transplant. This means that brain death declarations are rare," says an official with DGHS.

Some doctors say the medical establishment works to the detriment of transplants from cadavers. "Transplants from live donors mean use of more drugs. There is always a junket or two in the offing from pharma majors. So why get into their bad books by doing transplants from cadavers?" asks a senior doctor from Mumbai who did not wish to be named.