Thirty-five years ago many patients used to buy blood because of a shortage of voluntary donors. Today, nearly all the blood used across India is received as replacement blood from relatives and as altruistic donations.

If attitudes can change to this extent for blood donation, the future could be just as bright for deceased-organ donation for transplants that could save thousands of lives mainly young people dying from failure of liver, kidneys, heart and lungs. The key is to educate the public, and even some doctors.

When kidney transplantation took off in India in the 1980s, it relied on paying poor people for their organs. Unfortunately this iniquitous practice was then well within the law. By the 1990s such practices resulted in India becoming a pariah in the international transplantation community. Paid-donor kidney transplants became known in the West as the `Bombay operations'.

It wasn't until 1994 that the law was changed. The new Transplantation of Human Organs Act aimed to stop organ trading and to make transplantation affordable for the poor and middle classes.

Over 95% of liver transplants are carried out in private hospitals where they cost between Rs 16-24 lakh. In public hospitals, where transplantations are infrequent, a liver transplant costs Rs 12 lakh. With post-transplant costs of around Rs 10,000 a month, for immunosuppressive drugs to prevent rejection of the new organ, such procedures remain inaccessible for the poor.

India today has one of the highest numbers of living donor transplants of kidneys and livers, mostly for rich recipients. Unlike in the West where over 80% of transplants are from deceased donors, in India this figure is less than 5%.

How can organ transplantation be made more accessible and less costly? By promoting deceased-organ donation. This is infrequent here mainly because of ignorance and, we dare say, an absence of altruism in society.

Even some doctors still don't understand the concept of brain death despite the law being in force since 1995. Many families believe their patient is alive if the heart is still beating and are reluctant to agree to organ donation. Studies show that people, especially in northern states, agree to donate organs for family but are reluctant to do the same to save lives of strangers.

Brain death, when the brain is damaged irreversibly, mainly results from road accidents. India has the world's largest number of traffic accident deaths per vehicle. At any given time, at least 5-10 patients could be brain dead across hospital ICUs in any given metro. But with no organised deceased organ transplantation system, these patients' organs go ‘waste’.

Developed countries maintain a transplantation registry to facilitate organ retrieval and transplantation. These are state funded and run by independent agencies. India relies mainly on living donors. A centralised registry is yet to take off. Government seems to have only now begun encouraging deceased-organ transplantation, with the National Organ and Tissue Transplant Organisation (NOTTO) based in Delhi's Safdarjang Hospital.

If it works, NOTTO will make organ allocation more transparent and fair. Allocation will be decided taking into account factors such as geographical distance, urgency for transplantation and preference for public hospitals. Government support is essential for a successful deceased donor programme. The public trusts the state system and its doctors much more than it does any private hospital.

Once trust grows, people donate much more willingly. Raising awareness and dispelling myths is key. This could be promoted through various media and by steps such as providing on driving licences an option regarding willingness to donate organs in case of death.

The optimal way forward is for organs from deceased donors to be the main source for transplantation. As the slogan goes “Don't take your organs to heaven with you, because heaven knows we need them here”.

-Dr Samiran Nundy heads the department of organ transplantation at Sir Ganga Ram Hospital.

(This is the abriged version of the article published in TOI)