High literacy, low compassion — Kerala’s paradox in organ donation

In Kerala, brain death certification is often delayed, or avoided. Many ICUs have no full-time transplant co-ordinator. Tamil Nadu offers a contrast. There, brain death certification is mandatory. Donor families are honoured publicly

In 2024, India performed a record 18,911 organ transplants. Yet, beneath this statistical achievement lies a stubborn truth: India’s organ donation rate remains under one per million population, placing us near the bottom of the global table despite being the world’s most populous nation.

Southern states, such as Tamil Nadu, Telangana, and Andhra Pradesh, have taken significant strides forward, building systems that make donation a predictable part of end-of-life care.

But Kerala, long held up as the exemplar of literacy, healthcare, and social development, finds itself in an inexplicable slump. The NOTTO Annual Report 2025 shows Kerala contributing just eleven deceased donors in the year, down from 76 in 2015. Even in voluntary registrations, the state lags far behind — fewer than 6,000 registered donors against Maharashtra’s 51,000.

This paradox cannot be dismissed as a matter of religion. Most major faiths practised in Kerala do not forbid organ donation. However, clerics who control the masses seem to have their own opinion that is trust upon the believers.

The barriers are not just imposed by the clerics, but they are also psychological, procedural, and cultural. Kerala’s life expectancy — among the highest in India at nearly 75 years — means more deaths occur in hospitals, often in ICUs and on ventilators. Added to this is the state’s grim record on road accidents, with over 4,000 fatalities reported in 2023 alone. In theory, this should give Kerala a natural advantage in identifying brain death cases suitable for organ retrieval. In reality, the advantage is squandered.

When a patient is declared brain dead, the window for organ retrieval is painfully short. It requires trained transplant co-ordinators to counsel grieving families, ICU teams to follow protocols without hesitation, and hospital leadership willing to own the process. In Kerala, brain death certification is often delayed, or avoided. Many ICUs have no full-time transplant co-ordinator. Doctors sometimes fear the backlash of initiating a donation conversation. The silence that follows wastes not just an organ, but a life that might have been saved.

Trust is another casualty. In a state where living kidney donations have risen even as cadaver donations have plummeted, suspicion festers. Sporadic reports of commercial middlemen, falsified kinship claims, and hospital complicity in illegal transplants have poisoned public perception.

Popular culture has only deepened this distrust. Malayalam cinema has long been fascinated with the dark world of the ‘organ mafia’. The 1995 film Nirnayam revolved around a respected surgeon uncovering an organ-smuggling ring within his own hospital, framing transplantation as institutional betrayal. More recently, Joseph (2018) portrayed a chilling organ racket in which victims were murdered in staged accidents to harvest their organs. The state’s own medical fraternity criticised the film for aggravating public suspicion, warning that such portrayals could dissuade families from making life-giving decisions in their most vulnerable moments.

These cinematic narratives, repeated over decades, have embedded themselves into the collective imagination. Even when individuals are aware of medical safeguards, the fear that ‘something shady is going on’ often triumphs over reason in the emotionally charged hours after a brain death declaration. Literacy and logic do not always travel together; grief and suspicion have their own stubborn momentum.

Tamil Nadu offers a contrast. There, brain death certification is mandatory. Police forces create green corridors at a moment’s notice. Donor families are honoured publicly. Hospitals are held accountable for missed opportunities. Transplant co-ordinators are embedded within ICUs. Kerala flirted with such a system in 2019, deploying trained transplant procurement managers in select hospitals, and the results were promising — but the initiative was never scaled.

Kerala’s failure is not the failure of its people, but of its process. Awareness campaigns alone will not fix this. The state must institutionalise transplant logistics as part of its healthcare system, make brain death audits routine, embed co-ordinators in every ICU, and rebuild public trust through transparency and visible recognition of donor families. It must also take a hard line against unethical practices that have corroded credibility.

Organ donation is not merely a matter of medical infrastructure — it is a moral question. Can we, as a society, accept death not just as an end, but as the beginning of another life? Kerala has led the nation in literacy, life expectancy, and public health. It must now find the courage to lead in the final mile of compassion. Let it be remembered not just for how long its people lived, but for how many lives they gave beyond their own.

Prasanth Nair is a civil servant and author. X: @PrasanthIAS.

Disclaimer: The views expressed above are the author's own. They do not necessarily reflect the views of DH.