Anatoly Korzhak, a pensioner and former engineer, died in Kiev on August 5, 2004. His body was picked up at 2 a.m. and taken to the forensic medicine institute in the Ukrainian capital. That same night, Korzhak's daughter, Lena Krat, received a telephone call and was asked to come to the institute as soon as possible the following morning, where she was told she would receive further information.
It was the first time Krat was confronted with the death of a close relative. "I was so upset that I couldn't think clearly," she recalls. When she arrived at the institute in the morning, a man there said something to her about skin transplants. He was an employee of a Ukrainian company that works hand-in-hand with forensic medicine experts. She said to the man: "Leave me alone. I don't understand what you're talking about, and I don't want to listen to you."
But the employee was persistent and eventually gave her a form to sign. He told her that if she consented to skin removal, she would be helping pediatric burn victims who needed transplants. Krat signed the form. "It was as if I had been hypnotized," she says.
But now Krat, a mother of two young girls, has learned from SPIEGEL that the Ukrainian company in question sends the body parts to a German company, Tutogen Medical GmbH, which in turn apparently supplies large numbers of such parts to the American tissue market.
In addition to strips of skin, tendons, bones and cartilage are removed from the bodies. "This shocks me," says Krat. "If I had known that so much is cut out, I would never have given my consent."
A Lucrative Industry
The incident in the Ukrainian capital is part of the secretive daily routine of a little-known but highly lucrative branch of the medical industry, in which companies use corpses to make medical spare parts. In doing so, they reuse almost everything the human body has to offer: bones, cartilage, tendons, muscle fascia, skin, corneas, pericardial sacs and heart valves. In the jargon of the profession, all of this is referred to as tissue.
Bones and tendons, the parts that interest Tutogen the most, are subjected to complex processing. The company degreases and cleans bones, cuts, saws or mills them into the desired shapes, then sterilizes, packages and sells the finished product in more than 40 countries around the world. With a prescription, it is even possible to order Tutogen's products through online pharmacies.
The market for tissue products is still small in Germany. When it comes to bones, for example, experts estimate that only about 30,000 transplants a year are used in hospitals nationwide, mainly for use in bone reconstruction for hip surgery and in spinal column surgery.
It's a completely different story in the United States. According to the American Academy of Orthopedic Surgeons, more than a million bone parts are used in transplants every year. In no other country is it possible to make so much money with body parts. If a body were disassembled into its individual parts, then processed and sold, the total proceeds could amount to $250,000 (€176,000). For a single corpse! The US tissue industry generates total revenues of about $1 billion a year, says journalist Martina Keller, a co-author of this article and the author of the German book, "Cannibalized: The Human Corpse as a Resource."
Legal and Ethical Questions
This raises the question of just how legal the process of obtaining raw materials is. And are bone products made from corpses even medically necessary? According to Klaus-Peter Günther, president of the German Society of Orthopedics and Orthopedic Surgery, they are often "not the first choice" in operations. "For us, the gold standard is still tissue taken directly from the patient in question."
Alternatives are only an option, says Günther, when the material from the patient's body is insufficient. Those alternatives include animal bones and artificial replacement parts made of ceramic material, for example -- or human donor bones.
Many hospitals collect and reuse bone fragments removed from patients who have received artificial hips. "For this reason," says Günther, "we have not had to resort to dead donors so far."
In the United States, doctors have fewer qualms about using body parts from corpses than their German counterparts -- in such areas as spinal surgery, sports injuries and cosmetic surgery. For instance, doctors used pulverized skin particles to enhance lips and smooth out wrinkles.
Should corpses be butchered to make cosmetic procedures possible? Ingrid Schneider is against the practice. For the past 15 years the Hamburg political scientist, a former member of the Investigative Commission on Law and Ethics in Modern Medicine in the German parliament, has been involved in the subject of recycling body substances. Schneider argues that the body is not a source of raw materials that can be sold at will. Given such concerns, it is not surprising that many people are deeply opposed to allowing the body of a family member to be reused, even for medical purposes.
Even if it is unrealistic to expect that all commercialization of the body could be ruled out in modern medicine, says Schneider, it is important to set boundaries. For that reason, she insists that human tissue ought to be used sparingly -- that is, only when such use is medically necessary and clearly superior to other forms of treatment.
The conviction that the body is much more than an object has also shaped the policies of the World Health Organization (WHO), the European Parliament and the European Council, the EU's body representing the leaders and ministers of the 27-member bloc. All of these bodies condemn the practice of trading in human body parts to turn a profit.
In Germany, the country's organ transplant act regulates the removal of tissue. Only those who have consented to organ and tissue harvesting are considered as donors. If a person dies and is not already a donor, his or her closest relatives can consent to donation. Paragraph 17 of the transplant act explicitly states: "Trading in organs or tissue intended for use in the medical treatment of others is prohibited." Physicians who remove tissue can only be paid suitable compensation for their efforts. The law calls for prison sentences of up to five years for violation of the trading prohibition.
A Booming Tissue Market
Tutogen paid its Ukrainian partners a fixed price for each body part. In January 2002, the company paid €42.90 for a complete femur, €42.90 for a humerus and €13.30 to €16.40 for a pericardial sac, depending on its size. Graduated prices were also arranged with the Ukrainians. Take, for example, the removal of patellar tendons with bone segments, known as "bond-tendon-bone," or BTB. When coroners supplied less than 40 BTBs on-site, Tutogen paid €14.30 apiece. For larger numbers of BTBs, the price went up: to €23 apiece for 40 or more BTBs and to €26.10 for 60 or more. For a coroner, who makes about €200 ($287) a month in Ukraine, such graduated prices must have been an incentive to remove as much body material as possible.
Thousands of pages of internal memos, faxes, supply lists and documents from the years 2000 to 2004, which SPIEGEL has obtained, suggest that not only did Tutogen process the Ukrainian body parts itself, but it also supplied the US tissue market.
Florida-based RTI Biologics, one of the US market leaders in the industry, generated $147 million in sales in 2008. The company describes itself as the "leading provider of sterile biological implants for surgeries around the world."
To that end, RTI acquired Tutogen Medical, Inc., the American parent company of the German company Tutogen Medical GmbH, last year. The acquisition was good news for RTI shareholders, because of Tutogen's large international donor network, says CEO Brian Hutchison. Put differently, Tutogen is a company that knows the ins and outs of gaining access to as many body parts as possible.
The body parts from Ukraine are shipped by air to Frankfurt or Nuremberg. From there, they are taken to Tutogen headquarters in Neunkirchen am Brand, a town of 8,000 people in northern Bavaria.
Tutogen's facilities in Neunkirchen, just a few kilometers north of Nuremberg, comprise several low, warehouse-like buildings, where about 140 employees work. All in all, it is an inconspicuous place for visitors who fly in regularly from Ukraine and the United States.
Company President Karl Koschatzky refused to respond to requests for an interview, and the company declined to answer a list of questions sent to its offices.
Tutogen uses a middleman to organize its deliveries from Ukraine. Dr. Igor Aleshenko, a coroner by training, manages the company's relationships with the various local forensic medicine institutes. He has been working for Tutogen in Ukraine for about 10 years.
In that time, Aleshenko has become a wealthy man, and he now divides his time between his two residences, one in Kiev and one in Moscow. In 2002, Tutogen described Aleshenko as a "cost-intensive person." He too was unavailable for an interview in Kiev, nor did he respond to written questions.
In Ukraine, Aleshenko is far more than Tutogen's local contact. He is the director of Bioimplant, a company that manages tissue removal. Because of its close ties to the Ukrainian Health Ministry, Bioimplant is practically immune to intrusive government inspections of bone shipments crossing the border.
Ukrainians are kept somewhat in the dark when it comes to Bioimplant's true business dealings. According to the company's Web site, its "primary activity" is the "production of bio-implants" for use in Ukrainian patients. But what does Bioimplant really do?
Kiev, on a summer's day in 2009. Anyone seeking to pay a visit to Bioimplant's headquarters would be inclined to head to the company's official address at Patrice Lumumba Street 4/6, an office building with a number of tenants -- where Bioimplant doesn't even have its own mailbox.
A guard and a doorman greet visitors and send them to the fourth floor, where Bioimplant's offices are supposedly located. Room 305 is in a long hallway of closed doors. There is not even a sign to identify the room as being associated with Bioimplant. A young man in a pinstriped suit opens the door. He says that he hasn't been working for Bioimplant for very long, and that most of his work consists of photocopying.
According to the young man, the company leases three rooms in the office complex, but Dr. Aleshenko is not in today. Tutogen brochures and packets of sterilized corpse bones are stacked in the next room. Instead of the expected production facility, the offices are nothing but a distribution site.
Tutogen developed its business relationship with Aleshenko about 10 years ago. During a trip to Tutogen headquarters in the Bavarian countryside in November 2001, Aleshenko met with Koschatzky at the Bayerischer Hof Hotel in Erlangen, near Nuremberg. The minutes of the meeting contain a list of "new pathologies" working for Tutogen in the eastern Ukrainian cities of Dnipropetrovsk, Poltava and Zhytomyr.
Aleshenko had apparently brought along a wish list to the meeting, and his German business partners were eager to comply. According to the minutes, "TTG (Tutogen) agreed to provide 5,000 deutsche marks for investment costs in Dnipropetrovsk (Ukraine). Dr. Aleshenko will send us the necessary payment instructions."
Some of the issues discussed at the meeting were less than kosher. For instance, the minutes state, "TTG is testing whether depilation of the corpse prior to skin removal could alleviate the hair problem (perhaps using the hot wax or cold wax method)."
A list of "pathologies currently providing (parts)," dated November 2001, already included abbreviations for 15 facilities in Ukraine. In the 2000-2001 fiscal year alone, 1,152 bodies in Ukraine were used to provide tissue for Tutogen.
But it still wasn't enough for the company, which needed more institutions to cooperate and more donors and more bone parts to supply a booming tissue market.
According to an internal planning document dated June 17, 2002 (the file is titled "Raw Tissue Requirements"), Tutogen needed the following parts for the coming fiscal year:
* 2,920 shafts of the femur,
* 3,000 iliac crests,
* 1,190 patellar tendons,
* 3,750 kneecaps,
* 10,200 femoral muscle fascia (or fascia lata),
* 50 cranial bones,
* 70 Achilles tendons.
Aleshenko, who Tutogen apparently paid directly for the tissue parts, is believed to have funneled part of the money to coroners in Dnipropetrovsk, Kiev, Kharkiv and other Ukrainian cities. According to an internal list of "paid incoming goods," Tutogen's Ukrainian partner received roughly €350,000 between January and August 2001.
The investment must have paid off. Online pharmacies charge between €367 and €854, depending on the size, for a Tutoplast Spongiosa Block (Bone Substance). According to the price lists used at the time, the Ukrainians received between €23 and €26.10 for the original body part, again depending on the size. Even if Tutogen were paying twice as much for the raw material today, it would still be a bargain.
Tissue and Organ Harvesting
Not surprisingly, Tutogen could afford to be generous to its Ukrainian partners. That generosity included large quantities of equipment the company routinely sent to its hardworking coroners.
According to the internal documents, in the 2000-2001 fiscal year Tutogen shipped 6,000 scalpels, 2,600 pairs of sterile gloves, 500 surgical gowns, 15 hacksaw blades for autopsies and many other items to Ukraine -- at a total cost of €40,000 in "donor expenses without tissue," as the Tutogen bookkeepers noted fastidiously. Tutogen paid its Ukrainian partners roughly €500,000 for the body parts during the same period.
The US Food and Drug Administration (FDA) currently lists 20 facilities in Ukraine that are authorized to supply body parts for the US market. But no matter which of these facilities one clicks on in the FDA database, all share the same contact information: the telephone number of Tutogen Medical GmbH in northern Bavaria.
One of the facilities on the list is the forensic medicine institute in Krivoy Rog, an industrial city in southeastern Ukraine, with a population of about 700,000. According to the FDA database, the Krivoy Rog site is authorized to supply bones, cartilage, fascia, ligaments, pericardial sacs, sclera (the white of the eye), skin and tendons.
Tissue and Organ Harvesting
The whitewashed, Spartan structure housing the forensic medicine institute is on the edge of the hospital grounds. Frosted glass windowpanes behind latticed windows discourage prying eyes. Visitors immediately notice the cloying odor of death upon entering the building. The director of the institute is unavailable, even though his car is parked on the hospital grounds. A doctor wearing a denim jacket assumes the task of getting rid of anyone inquiring about the institute's collaboration with the German company.
Instead, he tells the reporters to contact the district attorney's office and points to a sign above the door, which reads: "No Admittance without Authorization." Does that include Tutogen, the reporters ask? "No, Tutogen is not unauthorized here," the man says, indicating that the conversation is over.
The former director of the city's forensic medicine department, Vladimir Bondarenko, is slightly more forthcoming. A retiree, he meets with visitors at a street café. Tissue harvesting began at his department about 10 years ago, says Bondarenko.
"It was illegal," he says. "The family members should have been told about what was happening with the bodies," but they had no idea. "When the deceased is lying in the coffin, the family members see nothing but the face. What they don't see is that the bones of the legs or arms have been removed."
The Ukrainian tissue transplant act includes a provision stating that family members must consent to tissue donation if the deceased did not already do so while alive. However, there are indications that this was often not the case. Ukrainian authorities in Krivoy Rog and several other cities are conducting investigations into suspected illegal tissue and organ harvesting.
The case of the deceased father of Kiev resident Lena Krat, for example, was examined in connection with an investigation identified by the file number 50-3793, begun on Jan. 4, 2005. The investigation included all incidents that took place between May and September 2004. The names of 10 deceased persons are listed in the files. Their family members stated that they "did not consent to the removal of anatomical material."
According to the court order authorizing the proceedings, "family members were deceived, in that they were told that only a small part of the deceased would be removed, such as a bone or tissue fragment. In actual fact, almost all bones and tissue were removed. ... All of the material is taken to Germany."
A Legal Twist
Despite the evidence, the Kiev district attorney's office closed the proceedings in July 2005, "for lack of a statutory offense." Curiously, the document states, as grounds for dropping the case, that the Bioimplant employees had not violated the transplant act, because they had not transplanted material from corpses, but had merely removed it so that it could be processed into "bio-implants." As a result of this legal twist, the recycling of corpses has been allowed to continue to this day.
Kiev, the forensic medicine institute on Orangery Street: A long, brick building, from which doctors wearing light-green aprons occasionally emerge to smoke cigarettes outside the front door. Family members stand next to the entrance, waiting for the release of their dead relatives. There is a display of coffins and wreaths in front of a funeral parlor across the street.
Vladimir Yurchenko is the director of the institute. He points to the room where bodies are processed for Tutogen. It is on the ground floor and sealed off to outsiders. Why? "Because that's what the US health authorities require," says Yurchenko.
Kiev's senior forensic pathologist explains the process. Bioimplant obtains the relatives' consent, and company employees also come to the institute to harvest the body parts. Yurchenko's staff members assist in the process, for which they receive additional compensation. Once bones and other parts have been removed, wooden sticks are inserted into the body so that it retains its shape until the funeral.
The harvested bones, tendons and pieces of cartilage are stored in zinc-plated metal boxes in a refrigerated room in the basement. "The tissue parts are brought up once every few weeks, when a truck comes and takes them away," says Yurchenko. Karl Koschatzky, the secretive Tutogen executive from Bavarian, also turns up occasionally.
'A Source of Raw Materials'
According to Yurchenko, about 8,000 corpses a year are delivered to the forensic medicine department. Of that number, more than 5,000 are potential bone donors, but family members only consent to harvesting from about 150 bodies. If the two facilities in the capital already provide parts from about 150 bodies each, as Yurchenko says, and if a total of 20 facilities in Ukraine are registered with the FDA -- and, therefore, are collaborating with Tutogen -- it can be assumed that the German company obtains its body parts from large numbers of Ukrainian corpses. "All we are for the rich countries is a source of raw materials," says Yurchenko.
In May 2004, Tutogen signed a five-year contract with Bioimplant, which describes the process as follows: The Ukrainians transfer harvested tissue to Tutogen in Germany to have it processed into products. But this processing is costly. How does the Ukrainian company pay for the expensive processing? The answer is deceptively simple: with the bones, from Ukrainian corpses, that have been processed into products in Germany. This is the currency accepted by both parties to the arrangement.
What the agreement does not state is that the Germans were not producing products for Bioimplant, but were ordering substantial amounts of raw material from the Ukrainians every month.
At times, much larger numbers of body parts from Ukraine and other countries were arriving in Neunkirchen than Tutogen could even process. A document titled "Inventory, Raw Material Storage 1," dated March 2000, reveals the scope of this excess material. According to this inventory document, Tutogen warehouses already contained 688 patellar tendons, 1,831 kneecaps, 1,848 fibula, 2,114 fascia and 1,196 foot bones, or a total of more than 20,000 body parts.
In June 2002, Tutogen employees wrote the following comments in the minutes of a meeting: "Warehouse problems. More tissue than necessary continues to be delivered. Solutions are needed to address this problem."
The company documents also include references to the kinds of solutions Tutogen had in mind. According to an internal memo dated April 2002, a Ms. R. noted "that there is no longer any storage capacity in the deep freezers. Efforts must be stepped up to ship tissue to the USA."
According to a document dated June 2002, which lists the "Raw Tissue Requirements for USA Needs," the US partners required the following monthly supply:
* 119 iliac crests,
* 667 pieces of fascia lata,
* 267 kneecaps,
* 243 shafts of the femur.
Did Tutogen Break the Law?
Apparently, the deliveries to the United States were not only sent to the parent company in Florida, Tutogen Medical Inc., which could have been explained as a way of shifting the problem within the company, but also to RTI, the company's US competitor at the time.
In a table detailing a shipment from Lugansk in Ukraine, delivered on Dec. 7, 2001, a sum of €62,000 is quoted, but the recipient is identified as "TM/RTI."
If Tutogen was indeed shipping unprocessed tissue to the United States, this could constitute an act of engaging in illegal tissue trade, provided a profit was generated as a result.
In a memo dated April 4, 2002, a Tutogen employee issued the following cautionary statement: "We should avoid shipping unprocessed raw material to TMUS (Tutogen USA), so as not to create the impression of engaging in the tissue trade."
The German Institute for Cell and Tissue Replacement, another major bone producer, categorically rejects such practices. Director Hans-Joachim Mönig insists that "obtaining raw tissue from one country and passing it on to third parties is against the law. In our view, this constitutes the crime of trading in tissue."
To date, its collaboration with Aleshenko and the Kiev Health Ministry has worked exceedingly well for Tutogen. All investigations against Tutogen's Ukrainian partners in Krivoy Rog, Kiev and Dnipropetrovsk have been suspended.
But that could change. Last year, the public prosecutor's office in Krivoy Rog launched a new investigation.
Once again, forensic medicine employees, as the public prosecutor's office states in response to SPIEGEL's inquiry, are suspected of "having used coercion and fraud to obtain the consent of family members for the removal of tissue and other anatomical material for purposes of transplantation." Seventeen family members of the deceased have already testified.
On Jan. 9, 2009, the district attorney's office submitted the case to the relevant district court, where the case is still underway.
Lena Krat, the Kiev woman who was persuaded to release her father's body for tissue harvesting in 2004, would be pleased to see those responsible finally brought to justice. "Those people are truly guilty," she says, "and I am outraged that these terrible things are still taking place."