RAMAT GAN, Israel — Aside from the six-figure price tag, what was striking was just how easy it was for Ophira Dorin to buy a kidney.
Two years ago, as she faced the dispiriting prospect of spending years on dialysis, Ms. Dorin set out to find an organ broker who could help her bypass Israel’s lengthy transplant wait list. Only 36, she had a promising job at a software company and dreams of building a family. To a woman who raced cars for kicks, it seemed unthinkable that her best days might be tethered to a soul-sapping machine.
For five years, Ms. Dorin had managed her kidney disease by controlling her diet, but it had gradually overrun her resistance. Unable to find a matching donor among family and friends, she faced a daily battle against nausea, exhaustion and depression.
A broker who trades in human organs might seem a difficult thing to find. But Ms. Dorin’s mother began making inquiries around the hospital where she worked, and in short order the family came up with three names: Avigad Sandler, a former insurance agent long suspected of trafficking; Boris Volfman, a young Ukrainian émigré and Sandler protégé; and Yaacov Dayan, a wily businessman with interests in real estate and marketing.
The men were, The New York Times learned during an investigation of the global organ trade, among the central operators in Israel’s irrepressible underground kidney market. For years, they have pocketed enormous sums for arranging overseas transplants for patients who are paired with foreign donors, court filings and government documents show.
The brokers maintain they operate legally and do not directly help clients buy organs. Dodging international condemnation and tightening enforcement, they have nimbly shifted operations across the globe when any one destination closes its doors.
The supply of transplantable organs is estimated by the World Health Organization to meet no more than a tenth of the need. Although there is no reliable data, experts say thousands of patients most likely receive illicit transplants abroad each year. Almost always, the sellers are poor and ill-informed about the medical risks.
The vast marketplace includes the United States, where federal prosecutors in New Jersey won the first conviction for illegal brokering in 2011.
But a Times analysis of major trafficking cases since 2000 suggests that Israelis have played a disproportionate role. That is in part because of religious strictures regarding death and desecration that have kept deceased donation rates so low that some patients feel they must turn elsewhere.
“When someone needs an organ transplant, they’ll do everything in their power,” said Meir Broder, a top legal adviser to Israel’s Ministry of Health.
That desperation was evident in the workings of the transplant tourism pipeline that delivered Ms. Dorin and other foreign patients to Costa Rica from 2009 to 2012. Through more than 100 interviews and reviews of scores of documents, The Times traced the network from the barrios of San José, Costa Rica’s gritty capital, to the glass towers of Ramat Gan, a bustling commercial district near Tel Aviv.
The Costa Rican government is not sure how many foreigners received suspicious transplants there. But The Times identified 11 patients — six Israelis, three Greeks and two American residents — who traveled to San José for transplants using kidneys obtained from locals. Two other Israelis who were located brought donors from Israel with them for procedures that most likely would not have been approved in their own country.
The network was built by a cast that included high-rolling Israeli brokers, a prominent Costa Rican nephrologist and middlemen who recruited donors from the driver’s seat of a taxi and the front counter of a pizzeria. In interviews and documents, four Israeli patients or sources close to them identified Mr. Dayan, known as Koby, as their conduit to Costa Rica.
The authorities in Costa Rica have been investigating the operation for more than a year. But it is not clear that the police in either country have linked the transplants to Mr. Dayan or other Israeli brokers. None of the organ recipients contacted by The Times said they had been interviewed.
Ms. Dorin’s path through the organ bazaar was circuitous, taking her to multiple brokers doing business on opposite sides of the world.
The odyssey began when her family was referred to Avigad Sandler, who explained that he was sending clients to Sri Lanka for $200,000 in cash, Ms. Dorin said. Her co-workers staged a fund-raiser, and her parents mortgaged their house to cover the rest.
When Ms. Dorin’s mother went to convert her shekels into dollars, the money-changer told her that his uncle had received a kidney in Sri Lanka for far less. He offered to arrange an introduction.
The uncle’s broker, Boris Volfman, requested $10,000 down and told Ms. Dorin she would have to take the remaining $140,000 to Sri Lanka. He suggested she change her dollars into 500-euro notes to keep the wad thin, she said.
The timing was unfortunate. The next day, the Israel Police arrested Mr. Volfman, along with Mr. Sandler and others, on suspicions of organ trafficking unrelated to Ms. Dorin’s case.
The setback did not last long. When Ms. Dorin mentioned her plight to a client, he told her that his father had received a transplant in Turkey five years before. “Why didn’t you come to me earlier?” he asked.
A meeting was arranged with Mr. Dayan, who explained that a transplant in Costa Rica would cost $175,000, Ms. Dorin said. He was careful not to specify that the package would include a kidney. “But it was understood,” Ms. Dorin recalled, “that the payment was for everything, including the organ.”
She said that some of the money was wired to a hospital in San José, and that she delivered a payment to Dr. Francisco José Mora Palma, the kidney specialist who oversaw her transplant. Dr. Mora then paid the equivalent of $18,500 to an unemployed 37-year-old man for his kidney, according to a confidential Costa Rican court document.
Just hours after Ms. Dorin arrived in San José in June 2012, Dr. Mora met with her and the donor at her hotel. There, she said, they signed affidavits in Spanish, a language she could not read, swearing that money would not change hands.
Ms. Dorin said she had doubts about Mr. Dayan’s assurances that everything was legal, but did not feel she had much choice.
“My situation was critical,” she said. “I didn’t feel very good, and my condition was getting worse. Even if I knew it was illegal, I don’t think I would have done anything different. It’s important to understand that these people, although greedy, do save lives.”
A Growing Market
Because most people can live with only one kidney, that organ accounts for the vast majority of living-donor transplants. Laparoscopy has made the surgery to remove a kidney fairly routine, although it is not risk-free. Living donors account for about 40 percent of the roughly 80,000 kidney transplants performed worldwide each year, according to the W.H.O.
Patients fortunate enough to find a living donor with the right blood type and antigens can avoid the lengthy wait for an organ from a cadaver. Kidneys from living donors are also preferred because they tend to last longer.
Long criminalized across the globe, the organ trade was handed an unequivocal rebuke at a worldwide conference of transplant practitioners in 2008. The group’s manifesto, called the Declaration of Istanbul, asserted that trafficking violated “the principles of equity, justice and respect for human dignity and should be prohibited.”
And yet the prospective market for trafficked kidneys has grown unabated as the gap between supply and demand widens each year.
In the United States, the number of kidney transplants has remained static for a decade at 16,000 to 17,000 a year. During the same period, the waiting list for kidneys from deceased donors has nearly doubled, passing 100,000 this year. The median wait time for an adult is more than four years, and more than 4,000 die waiting each year.
Some physicians and ethicists question the relative morality of allowing thousands to die just because the means of saving them is considered repugnant. A regulated marketplace, they say, could all but eliminate the shortage. It is no accident, they argue, that the only country that allows compensation for donors — Iran — effectively has no waiting list.
Experts list China, Egypt, India, Pakistan, Sri Lanka, Turkey, Eastern Europe and the former Soviet republics as hot spots for organ trafficking. But illicit transplants usually go undetected unless there is a surgical mistake or a payment dispute. Prosecutions are thwarted by false affidavits, toothless laws and lack of international cooperation, particularly regarding extradition.
Over the last decade, the authorities have pursued only a handful of cases worldwide. Few have sidelined the brokers, who seem bolder than ever. Some, like Mr. Volfman, who leases office space atop a mirrored skyscraper in Ramat Gan, have moved out of the shadows. They brazenly ply their trade even while under police scrutiny, posting Facebook photos of the luxury cars and five-star hotel rooms they rent on the road.
The Times found that brokers in recent years typically have charged clients $100,000 to $200,000 to cover expenses associated with a transplant. As with other scarce luxuries, pricing can be elastic.