Editor’s Note: If you or someone you know is struggling with suicidal thoughts or mental health matters, please call the 988 Suicide & Crisis Lifeline by dialing 988 to connect with a trained counselor, or visit the 988 Lifeline website.

Delivery driver Maung Maung’s wife and young daughter hadn’t eaten in three days, he recalled, when he walked into an internet cafe in his hometown of Mandalay, Myanmar, in late 2022.

He had recently been detained and tortured by the country’s military junta for weeks, he said, on suspicion of transporting goods for opposition forces, during which time his wife had been forced to take out loans to support the family.

When he was finally released, he had lost his job and the family found themselves penniless and ridden with debt. Desperate, Maung Maung went on Facebook and offered to sell his kidney.

“In that moment, I felt life was so harsh. There is no other way I could survive other than to rob or kill people for money,” he said. “My wife was the same, she didn’t want to stay in this world anymore. But only for the sake of our daughter we stayed.”

Months later in July 2023, Maung Maung, who asked to use a pseudonym for safety reasons, traveled to India for the transplant surgery. A wealthy Chinese-Burmese businessman had bought his kidney for 10 million Burmese kyat ($3,079), nearly twice the annual average urban household income in Myanmar, according to 2019 data from UN affiliated Myanmar Information Management Unit.

Maung Maung is not the only one.

When asked for comment, Meta, Facebook’s owner, said one online group had been removed, but the company declined to give further details or comment further. Facebook’s own rules do not allow content that lets users buy, sell or trade human body parts and breaches can be reported for review.

Coup sends poverty soaring

Three years since Myanmar’s military took power in a coup, nearly half of the country’s 54 million people live below the poverty line. That figure has doubled since 2017, researchers with the United Nations Development Programme (UNDP) has found.

As various armed groups fought against junta control, violence spread across the country. Foreign investment dropped, unemployment skyrocketed and the cost of basic goods increased at a rate most people couldn’t keep up with. While sellers are poor and buyers relatively rich, both sides are in the illegal organ market because they find themselves in dire straits.

“To sell a part of your body is a difficult decision for everyone. Nobody wants to do it,” April, 26, who asked to go by a pseudonym, said shortly after advertising her kidney on Facebook in February. “The only reason I am doing this is because I have no choice.”

April said she abandoned her dreams of becoming a nurse and moved to Myanmar’s commercial capital Yangon when she was 18 to work in a garment factory and help support her family. But her monthly salary of $100 was not enough to keep up with rising costs exacerbated by the political crisis and medical bills that kept piling up as her aunt suffered from cancer.

A person can still live a healthy life with one kidney, which makes this trade possible, but it’s a major surgery that can have lasting consequences. The biggest risk is not having a backup in case anything happens to the remaining kidney, according to the National Kidney Foundation.

April quickly wrote up her own post: “I want to donate my kidney. My blood type is O. I need money for my aunt who has cancer and needs an operation. I’m 26 years old and I don’t drink. DM me.”

An illegal but accessible industry

In the online organ trade, buyers and sellers often work with agents, middlemen who match donors with recipients, to forge the necessary documents and arrange surgery.

Because the sale of organs is illegal in India and donations are permitted only among relatives, with a few rare exceptions, agents often forge household records, family trees and other documents with the help of lawyers and notaries. Myanmar’s embassy in New Delhi has to review the paperwork in order to pass the case to the state or hospital authorization committee.

The authorization committee is the final line of defense. It’s designed to catch anyone trying to cheat the system. Documents, family photos and bank statements are checked, and interviews conducted to expose strangers posing as family members or anyone trafficking organs.

Thiri Khine, who asked to use a pseudonym so she could speak safely, became a widow when her husband died eight years ago. Six years later, ravaged by kidney disease, she posed for new wedding photos. This time, the groom smiling next to her was the man whose kidney she was buying for 12 million kyat ($3,695).

Thiri Khine tried to get a transplant by getting on the official transplant waitlist, but said the process would’ve taken years, at which point she may have already died from her illness.

Between 1995 and 2022, there were only 308 successful kidney transplants in Myanmar, according to ruling junta chief Min Aung Hlaing’s office.

Since the coronavirus pandemic and the coup, transplants can only be performed at military hospitals, with a few exceptions, according to one current and one former doctor in Yangon who asked to remain anonymous out of fear for their safety.

The war has also created a shortage of doctors.

In the early days of the military takeover, doctors were often at the forefront of the resistance movement, treating injured protesters and staging strikes. For this, they paid a high price, with many medical professionals arrested or forced to flee the country, leaving Myanmar’s already fragile healthcare system on the brink of collapse.

‘Family photos’, a trip to India

In the weeks leading up to the surgery, Thiri Khine and her pretend husband practiced for the authorization committee interview, finding answers to questions such as how they met, each other’s favorite foods and their license plate number.

“It’s an interrogation to confirm whether we are a real couple or not. But the thing is they know that we are lying,” Thiri Khine says. “The law by definition is strict, and so are the hospital’s rules. However they make it possible for us to get the treatment by ignoring the red flags and forged documents.”

Scared and far from home, Maung Maung went through a number of medical tests and interviews in the days before his transplant surgery. He had never left Myanmar before, but now he found himself posing for photos in front of New Delhi’s famous Lotus Temple next to the family of the man who would soon have his kidney.

“If I die, I hope this money could help my wife and daughter for their food and survival, even if it would not last their whole lifetime.”

Myanmar’s military has a long and well-documented track record of rights abuses, and the civil war has unleashed new levels of violence on both civilians and rebel forces alike.

‘Saving a life’

One Yangon-based agent, who asked to remain anonymous due to the illicit nature of his work, said both the Burmese embassy in India as well as the authorization committees are aware that the document presented are forged.

“It is an act of saving a life. It is not a bad thing,” he says, having received a kidney transplant himself in a similar way last year.

Dr Sunil Shroff, a transplant surgeon and founder of the Multi Organ Harvesting Aid Network, a non-profit which promotes organ donation in India, said the issue of organ donation is complex.

“It is not an easy job for the (authorization) committee either. Then again, they’re not policing it. They’re looking at each case individually with some sympathy because there is a recipient suffering who needs an organ,” he said.

This is complicated by the fact that documents produced in another country are extremely difficult to authenticate.

“Once the embassy signs, what happens is that the local authorization committee thinks the responsibility was on the embassy. They might be coming with an unrelated donor we don’t know,” Dr Shroff said.

A ward filled with Burmese patients

A few days after the transplant surgery in August 2023, Maung Maung sat on the edge of his hospital bed and lifted his shirt to reveal a fresh scar on his left side.

“It seems it is healing from inside, but it still hurts on the outside,” he said, touching the purple mark.

As he walked through the hospital, he pointed out other Burmese patients in the recovery ward, each with the same four-inch scar on their abdomen.

“When you go to the toilet, you see Myanmar people and when you go somewhere nearby you see Myanmar people again,” he said.

For those trapped in a never-ending cycle of poverty, selling a body part often appears as a quick way to escape. It’s been a last resort taken by people in many other countries from Afghanistan to Nepal, but it’s one that comes with serious and sometimes fatal health consequences.

“The quality of life after selling the kidney is not good because once the money runs out, they’re back to square one. And then there’s a scar to see. They look at it, so they’re depressed,” Dr Shroff says.

Maung Maung predicts that with only one kidney left “the most I can live is 15 to 20 years and then I will be gone.”

Yet, he doesn’t regret his decision.

“If I had not done this at this moment, my life would be in chaos. No job, no food. My wife, my kid didn’t have anything to eat. All three of us could have been dead or gone crazy.” he says.

He has since returned home to Mandalay but hasn’t recovered enough to work. He spends most of his days at home, in pain, as the money he got for selling his kidney slowly runs out.

Documents were forged, family photos showing April as the man’s eldest daughter taken — the only thing left was the surgery.

As the transplant neared, April worried she might die on the operating table, but felt it was too late to back out.

April’s family still did not know about her plan to sell her kidney.

For mental health support outside of the US, a worldwide directory of resources and international hotlines is provided by the International Association for Suicide Prevention. You can also turn to Befrienders Worldwide.