Methodology

The methodology for this study took the form of a series of in-depth narrative interviews with Sudanese migrants involved in organ markets in Cairo, Egypt. Owing to its reputation as a “hotspot of organ trafficking” (COFS 2011; Reference McGrathMcGrath 2009; Reference ShimazonoShimazono 2007), Cairo was chosen as the key research site for this study. Furthermore, conducting research in Cairo provided an opportunity to assess the implications of criminalization, following the introduction of the Transplantation of Human Organs and Tissues Act (2010) which prohibits the sale or purchase of organs. After preliminary discussions and enquiries with local NGO groups,Footnote ¹ it became apparent that undocumented migrants, in particular, were being targeted for their organs. Having established a personal connection with a member of the Sudanese community, I was introduced to individuals who had sold and/or arranged for the sale of a kidney(s). The analysis that follows is grounded in, and developed from, the situated perspective(s) and experiences of these respondents.Footnote ²

Interviews with organ sellers were arranged via a process of snowball sampling. This “chain referral” method involved using initial contacts to generate contexts and encounters that would allow for an analysis of the different activities, actors, and relations that constitute organ trading networks (Reference Atkinson and FlintAtkinson and Flint 2001). In total, 27 in-depth interviews were carried out between the months of May and July 2014. The interview respondents consisted of thirteen organ sellers, four organ brokers, three medical professionals, and seven NGO staff.Footnote ³ Seven of the organ sellers were female; six were male. Of the organ brokers, three were male and one was female. Male respondents (organ sellers) were aged between 21 and 36. Female respondents (organ sellers) were aged between 19 and 42. Only one of the organ brokers confirmed his age. This particular individual was 28. The other organ brokers appeared to be older, possibly in their late 30s. All but one of the respondents had sold a kidney after the Transplantation of Human Organs and Tissues Act of 2010 (Egypt) was established to prohibit the sale or purchase of organs; adding further suggestion that the law has had little impact on organ trading, particularly amongst migrant groups (Reference HamdyHamdy 2012). Triangulation was used to cross-verify data between sources (Reference FramFram 2013; Reference Glaser and StraussGlaser and Strauss 2009/1967). The use of multiple methods helped avoid partial views, enhance research findings and meanings attached to the data.

Urbanization and Migration Patterns: Cairo

With the globalization of advanced capitalism, cities have taken on an increasingly dominant role in the global economy as both centers of production and consumption (Reference CastellsCastells 2011; Reference SassenSassen 2001). It is unsurprising then that there are now more people living in urban areas than at any other point in history (United Nations 2014), the vast majority of which are located in large cities, or urban agglomerations expanding outward from dominant metropolitan centers (Reference CohenCohen 2006; Davis 2008). According to a report by the United Nations Department of Economic and Social Affairs in 2014, approximately 54 percent of the global population reside in urban areas; a figure expected to increase to 66 percent by 2050. In the global South, the rate of urbanization is increasing at a much faster rate than in the global North (Reference DanielsDaniels 2004). For instance, 18 of the world's largest cities, or “mega-cities” with populations exceeding 10 million, are located in the global South (United Nations 2014). While there is an economic logic behind this accelerated rate of urbanization, insofar as cities provide an increasing share of job opportunities, many cities in the global South—particularly in Africa—are expanding in spite of poor macro-economic performance and without significant foreign direct investment (Reference CohenCohen 2006).Footnote ⁴

Part of the reason for this trend of urbanization is that policies of agricultural deregulation have generated an exodus of surplus rural labor, even as cities cease to offer employment opportunities (Reference BayatBayat 1997; Reference DavisDavis 2006). At the same time, civil wars uproot whole communities who migrate to urban centers to escape persecution and build new lives (Reference DavisDavis 2006).Footnote ⁵ These combined processes have played a significant role in the growth of Cairo's urban population and the expansion of its metropolitan periphery (Reference BayatBayat 1997). According to the United Nations World Urbanization Prospects (United Nations 2014), the Greater Cairo region has a population of over 18 million. The shift toward export-orientated commercial agriculture has had an adverse effect on subsistence farming and food production in local markets (Reference ZohryZohry 2002). Subsequently, rural peasants and smallholder farmers unable to compete with cheap foreign imports and the dominance of industrial-scale agribusiness have opted to migrate to urban areas, in search of other means of income production. Many of these internal-migrants end up in Cairo, or more specifically Greater Cairo, where already negligible resources are placed under additional pressure. This pressure is intensified by the arrival of foreign migrants.

In a context of prolonged civil unrest, constitutive of poor labor conditions and limited access to public services, there has been a mass exodus of Sudanese migrants, in particular, travelling to the greater Cairo region in search of better employment options and living conditions.Footnote ⁶ Many Sudanese migrants (from Sudan and South Sudan) travel to Cairo to seek employment, while others make the journey in order to register with the United Nations Refugee Agency (UNHCR).Footnote ⁷ Registering with the UNHCR allows migrants to apply for refugee status, in the hope of resettlement to a third country that would offer better living conditions and employment opportunities. However, the majority of individuals who register with the UNHCR remain in Cairo, joining the ranks of the urban poor occupying marginal spaces of the urban economy, with limited resources and opportunities for social mobility.

Sudanese Migrants: Legal Barriers to Citizenship

Sudanese migrants have historically shared a link with Egypt. Under the Wadi El Nil Treaty Footnote ⁸ (1976) Sudanese nationals could enter Egypt without a visa. Moreover, they were granted rights of residency, ownership, and employment, similar to Egyptian citizens. However, with increasing numbers of Sudanese nationals travelling to Egypt due to a succession of civil wars in the region, the Egyptian government made a request to the UNHCR in 1994 to begin processing “asylum seekers” (Reference GrabskaGrabska 2006; Reference Jacobsen, Ayoub and JohnsonJacobsen, Ayoub, and Johnson 2014). Further restrictions were imposed when the Wadi El Nil Treaty was revoked after a failed assassination attempt on President Mubarak, allegedly performed by Sudanese Islamists (Reference TurnerTurner 1995). Consequently, visa and residence permit requirements were introduced for all Sudanese nationals en-route to Egypt, regardless of their reasons for travel. These restrictions remained in force until the Four Freedoms Agreement (2004) was established.Footnote ⁹ Thought of as a partial return to the Wadi El Nil Treaty, the Four Freedoms Agreement accords Sudanese nationals “special status” which exempts them from visa requirements and guarantees reciprocal rights of residence, work, and ownership of property (Reference Jacobsen, Ayoub and JohnsonJacobsen, Ayoub, and Johnson 2014). However, there is an important caveat limiting the scope of the agreement to “Sudanese citizens.” Under the agreement “asylum seekers” are not extended the same privileges as “Sudanese citizens,” who are considered legal migrants. Their legal status and terms of residence remain subject to UNHCR registration.

It is unclear who exactly qualifies as a “citizen,” with the majority of Sudanese nationals in Egypt labelled by border officials as asylum seekers regardless of whether or not they are actually seeking asylum. Conceptually, forced migration refers to individuals or groups that have arrived at a country without formal documentation, having been compelled by an element of coercion (i.e., environmental disasters, political persecution) to seek asylum (International Organization Migration 2011). Such individuals are normatively classified as asylum seekers. In contrast, labor migration refers to those who leave home for economic reasons in search of employment (International Organization Migration 2011). In practice, however, the distinction between forced migration and labor migration is blurred (Reference Anderson and RogalyAnderson and Rogaly 2005). The conditions that propel either forced or labor migration are interconnected; they are co-effects of the same environment in which social inequality and political and economic instability are embedded. Nevertheless, labor migrants who do not possess the necessary travel documents can be perceived to have committed a criminal offence (illegal immigration), unless they are claiming asylum (Reference CoutinCoutin 2005; Reference DauvergneDauvergne 2008; Reference HamlinHamlin 2014; Reference ThomasThomas 2010). Therefore, migrants who are unable to obtain formal work or travel documents have a strong incentive to claim asylum, regardless of their purpose for travel. For example, for those fearing political persecution, it can be extremely difficult to obtain formal documents from the requisite consulate officers in Egypt. Hence, if there is any clear implication of the Four Freedoms Agreement, it is not the expansion of protections for migrant workers, but rather the reduction of legal protection for Sudanese asylum seekers who are formally excluded from its provisions (Reference ThomasThomas 2010). Formally excluded by the Egyptian administration, the majority of Sudanese migrants register with the UNHCR, to avail of whatever legal “entitlements” are available to them.

In order to secure permanent residency rights accorded via refugee status, an asylum seeker must first register with the UNHCR, who then schedule a refugee status determination (RSD) interview. Upon registering an asylum seeker is allocated a “yellow card.” The yellow card enables asylum seekers to stay in Egypt under the protection of the UNHCR until their RSD meeting takes place. However, this process can take several months to several years. Those rejected are entitled to appeal but if the appeal fails their file is closed permanently. They are no longer “people of concern” and are expected to depart the country (UNHCR 2014). However, the majority of migrant workers who have their files closed remain in Egypt, occupying a sort of legal limbo with “illegal” status and limited access to rights and services (Reference Anderson and RuhsAnderson and Ruhs 2010; Reference De GenovaDe Genova 2002; Reference GrabskaGrabska 2006; Reference Jacobsen, Ayoub and JohnsonJacobsen, Ayoub, and Johnson 2014; Reference Jones-Correa and de GraauwJones-Correa and de Graauw 2013). For those who qualify for a “blue card,” affording them recognized refugee status, the benefits are marginal. The main difference between a recognized refugee and an asylum seeker is that recognized refugees are eligible for UNHCR's “durable solutions”: local integration, voluntary repatriation, or resettlement (Reference Jacobsen, Ayoub and JohnsonJacobsen, Ayoub, and Johnson 2014). In practice, however, only the “most vulnerable cases” are deemed serious enough to satisfy a re-settlement request.Footnote ¹⁰ Therefore, for the majority of refugees, a sort of de facto local integration occurs, with no substantive rights to employment or housing. In this way, the laws regulating refugee status and immigration can be seen to produce illegality and thereby construct vulnerability (Reference Anderson and RuhsAnderson and Ruhs 2010; Reference CoutinCoutin 2005; Reference De GenovaDe Genova 2002; Reference Jones-Correa and de GraauwJones-Correa and de Graauw 2013). In Egypt, asylum seekers have come to represent unauthorized access, which has been branded as illegal. This ostensibly allows the state more control over admission and access to public services. However, in practice, the denial of access is not an effective deterrent: migrants stay and consequently occupy positions of “sub” citizenship (Reference AndersonAnderson 2013). Such “illegal” or “undocumentedFootnote ¹¹” migrants are socially, politically, and economically subjugated, existing external to formal legal rules, and are therefore vulnerable to various forms of exploitation. The organ trade is exemplary of this process.

Abido, a Sudanese migrant with aspirations to work in Europe, spoke about his experience registering with the UNHCR. According to Abido, he was given £300 LEFootnote ¹² ($33 USD) per month, for a period of two months. After two months had elapsed the payment was cancelled and his file was closed, without any explanation:

He continued:

Despite being signatories of the 1951 Convention Relating to the Status of Refugees, Egypt has placed several reservations on the implementation of the Convention, opting out of key provisions (Articles 12(1), 20, 22 (1), 23, 24) concerning personal status, access to education, labor rights, and social security. For example, refugees residing in Egypt are not eligible to apply for Egyptian nationality. According to the government, their residence is considered temporary, and thus no real integration occurs. Access to education is also limited. Refugee schools are not recognized by the Egyptian government. Therefore, refugees cannot progress to third level education. Rather Sudanese migrants, almost universally classified as asylum seekers/refugees regardless of their reason for travel, are encouraged to attend UNHCR workshops where the can learn “essential skills.” One respondent (female, Sudanese migrant, aged 36) commenting on the educational programs provided by the UNHCR claimed:

Although refugees can apply for a work permit, this is a difficult and costly procedure. To qualify for a work permit, a refugee must first demonstrate that they are uniquely qualified; in other words prove that an Egyptian could not perform the work in question. They must then convince a prospective employer to purchase a work permit on their behalf or cover the cost themselves. The cost of an annual work permit for a Sudanese refugee is £200 LE ($22 USD).Footnote ¹³ This may seem like an acceptable figure, but for someone with no viable source of income this can be a significant barrier to finding gainful employment. Consequently, many migrants have little choice but to find work in the informal economy (International Organization for Migration 2015).

Informalization, Precarious Labor, and Organ Sale

Following the deregulatory trend of advanced capitalism, formal employment options in Egypt—and indeed across the global North and South—are increasingly limited to only the highest skilled “professionals” with expertise in innovative sectors of the global economy, i.e., the bio-medical sector (Reference CastellsCastells 2011; Daniels 2001). Conversely, global competition for lower skilled jobs has meant that the diffusion of labor across borders has coincided with a process of informalization (Reference CastellsCastells 2011). In other words, with fewer employment options in the formal labor market low-skilled workers have no option but to accept conditions well below recognized labor standards (see Reference TatarynTataryn 2016). This has led to an expansion of informal labor practices, constitutive of the “informal economy,” as people look beyond institutional means of income production in an effort to sustain themselves. The activities that comprise the various sectors of the informal economy are unregulated by the social institutions that regulate similar activities in the formal economy (Reference Manuel, Alejandro and LaurenCastells, Portes, and Benton 1989). This absence of regulation affects the status of labor, lowering the costs of production by disregarding existing labor standards and regulations. In effect, workers’ rights and protections are surrendered in a trade-off for increased production. Shifts to limit access to workers’ rights and protections occur across all levels of employment and labor practices (Reference StandingStanding 2011). Yet migrants deemed “illegal,” “irregular,” or “undocumented” in informal economic arrangements are exposed and subjected to higher levels of exploitation (Reference Bloch and McKayBloch and McKay 2016; Reference TatarynTataryn 2016).

According to (Reference Manuel, Alejandro and LaurenCastells, Portes, and Benton 1989), the informalization of labor relations operates as a disguised form of wage labor which deprives workers of their bargaining power. Whereas jobs in the formal sector are relatively secure, informal workers lack access to formally recognized labor standards and protections, i.e., minimum wage, collective bargaining rights, safe working conditions, etc. (ILO 2012). Consequently, they are at greater risk of exploitation. Notwithstanding the probability of abuse, governments tolerate or even stimulate informal activities as a way to resolve potential social conflicts while maintaining broader economic interests (Reference Manuel, Alejandro and LaurenCastells, Portes, and Benton 1989; Daniels 2001). For example, permitting the growth of squatter communities and informal settlements in greater Cairo provides the government with a solution to the shortage of affordable housing, while freeing up resources to support the government's more vested interests, i.e., military power and consolidation of the security apparatus (Reference AdhamAdham 2005; Reference BayatBayat 1997). Similarly, excluding migrants (Sudanese or otherwise) from legal protection follows the logic of the state in reinforcing Egypt's migrant labor regime, supporting nascent sectors of its economy such as the transplant industry.

According to (ILO 2012) estimates, the informal economy accounts for approximately 69 percent of Egypt's GDP. Given the inherent difficulties in measuring, the economic impact of activities that are by definition “hidden” such estimates inevitably betray a certain level of inaccuracy. However, considering the informal economy largely consists of unreported income from the production of legal goods and services, the actual figure is likely to be even higher (Reference Buehn and SchneiderBuehn and Schneider 2012; Reference NordstromNordstrom 2000). Thus, from an economic governance perspective, it would be disingenuous to invest resources into the protection of migrant workers, as this would potentially compromise the economic aspirations of the State. Rather, the classification of Sudanese migrants entering Egypt as “asylum seekers” underpins a regime of strategic neglect, marked by legal barriers to citizenship that position migrants as a source of captive labor in the informal economy. In 2007, the Egyptian Initiative for Personal Rights reported that only about 13,000 of the estimated 2–5 million Sudanese nationals living in Egypt are officially recognized as refugees. Barred from entry into the formal labor market and with little chance of migrating beyond Cairo, undocumented migrants provide a source of captive labor, with little or no bargaining power to negotiate fair wages or acceptable working conditions.

Contrary to a common misperception of migrants as passive subjects or victims lacking agency and control over their lives, the narratives of Sudanese migrants interviewed as part of this study convey the experiences of resourceful people, willing to take risks and motivated beyond the norm to advance their life choices (see Reference AgustínAgustín 2007; Reference Isin and NielsenIsin and Nielsen 2008). Many had spent their life savings in order to get to Egypt, in the hope for a better life. The respondents in this study explained that their intention was to work, save money and move on to another country with better job opportunities and access to services. Yet, registered by the UNHCR as asylum seekers migrants cannot move beyond Egyptian territory. They have little choice but to remain and compete with Cairo's urban poor for limited employment opportunities, while they await a decision on their refugee status.Footnote ¹⁴ Eight of the respondents interviewed as part of this study had their files closed shortly after arriving, leaving them without legal protection and assistance. Speaking at length about her difficulties sustaining herself since emigrating from South Sudan, Nasrin (aged 28) explained:

Anita, a Sudanese migrant (aged 24) who travelled to Cairo to find work and advance her education, experienced similar difficulties:

With a lack of altruistic and deceased donations, the organ trade has emerged as an economic solution to the shortage of transplantable organs. For the majority of respondents interviewed as part of this study, organ sale represented an economic option of last resort. As the narratives below illustrate, respondents felt compelled to consider risky medical procedures carried out with little or no oversight, despite having no possibility of legal recourse should they be subject to any harm, be that medical or otherwise. Yet, in a context of legal marginalization and social exclusion, selling a kidney was widely considered the least bad option, notwithstanding the inherent risks involved.

Organ Markets

Globally, approximately 58 percent of kidneys used in transplantation come from deceased donors; live donations account for 41 percent (GODT 2014). In Egypt, however, kidney transplantation is almost completely reliant on live donations. Uncertainty over the legal and ethical parameters of cadaveric organ programs has meant that transplantation in Egypt has been dependent on living donations, usually from paid donors, since transplant technologies were first introduced in 1976 (Reference BarsoumBarsoum 1994). With a lack of altruistic and deceased donations, organ markets have been a constant feature of transplantation in Egypt. Propelled by the demands of industry, the development of transplant capabilities have continued unimpeded by social concerns. Consequently, Egypt is now the largest market for organ trading in North Africa, attracting buyers and sellers from neighboring states. This market trades on the bodies of the poor, the disenfranchised, and the undocumented.

For decades, legislators could not agree on how to provide a framework to regulate organ transplantation, due to divisions within the medical and religious communities over the legitimacy of cadaveric donation. From a medical perspective, it was argued that the procurement of organs from brain-dead patients was unethical because the patients were not yet dead; a patient could not be considered dead until all his/her organs had failed (Reference HamdyHamdy 2012). Religious organizations, such as the Muslim Brotherhood, argued that the soul of a brain-dead patient was still “lingering” and had not yet passed over to the other side (for further discussion, see Reference HamdyHamdy 2012). This belief was reinforced by the concern that the body could not pass over to the after-life “in-parts”; the body must leave this world the same way it had entered.

Providing a more novel perspective, one physician at a transplant clinic in Cairo suggested that Egyptians had a cultural attachment to the dead, going back to the time of the Pharaohs and the rituals associated with mummification, which might explain the cultural resistance to cadaveric donation in Egypt (personal correspondence 2014). Ironically, this attachment to the bodies of the dead does not apply to the bodies of paid living donors. Speaking to a number of patients at a dialysis clinic in Cairo, it was apparent that despite medical reports affirming the health of organ donors living with one kidney, patients continued to worry about the harm that might befall a close friend or family member, in the course of a kidney donation. They feared the disruption of family ties and the guilt that they would face for having accepted a kidney from a loved one. Persisting with dialysis or purchasing an organ from a stranger was the preferred option. A health-worker volunteering for a local NGO explained:

Given the significant cultural resistance to organ donation in Egypt, combined with logistical and infrastructural limitations inhibiting the successful operation of a nationally regulated organ donor program, the growth of the transplant industry will continue to depend on live donations, predominately sourced from organ markets. Although it is now illegal to sell or purchase a kidney in Egypt, since the establishment of the Transplantation of Human Organs and Tissues Act (2010), the experiences of organ sellers (discussed below) suggest that the introduction of criminal sanctions has had little bearing on the commercial supply of organs. Despite the establishment of legislation prohibiting organ sales, the continued reliance on organ markets would suggest that the substantive merit of the law rests on its symbolic value, in appeasing international standards. Notwithstanding the illegal nature of the organ trade, the sale of organs is tacitly accepted and rationalized as a mutually beneficial transaction, improving the economic situation of the organ provider whilst potentially saving the life of the organ recipient. Indeed, many consider it unethical not to pay a donor. As one transplant professional in Cairo put it:

In a further interview with the same respondent, it was suggested that the health authorities in Egypt were in positive denial of the organ trade. That is, while the organ trade is publically maligned, in practice organ markets are considered a solution to the surplus demand for organs. Moreover, ensuring a steady supply of organs maintains Egypt's economic aspirations of providing the best medical attention money can buy in North Africa:

In the same way informal networks free formally recognized firms from the constraints imposed upon them by regulatory controls and institutional norms, transplant clinics depend on informal networks to supply organs, invariably sourced by individuals in financial hardship. The conditions that compel individuals to sell are overlooked in the urgency to procure organs for transplantation. The lucrative promise that transplant medicine commands triumphs over any concern for the welfare of the donor-seller. There is little sympathy afforded to organ donors who are perceived to have participated in criminal activity. Their claim to corporeal sanctity is forfeit when they “decide” to sell a kidney. Ethical concerns are further removed when an organ is sourced from a foreign body discursively associated with criminality. Thus, while many poor Egyptians are involved in organ trading (Reference Budiani and KarimBudiani and Karim 2008; Reference HamdyHamdy 2013) undocumented migrants, in particular, represent a key source of supply for organ markets. Disqualified from the legal protection of the polity their bodies are rendered more “bio-available” than others.

Migrant “Donors” and the Selective Limits of State Protection

Migrants provide a preferential source of organs over local residents because of their perceived vulnerability. With expired passports, invalid visas, and no work permits, undocumented migrants, in particular, are at constant risk of arrest and detention, and are in no position to negotiate the terms of their employment. Opportunistic employers often take advantage of this vulnerability, compelling migrants to work long hours for a derisory wage. With no recognized rights or entitlements to work guaranteed under Egyptian law, migrants have no legal recourse for the harms committed against them, and are left little choice but to accept conditions that would otherwise be unacceptable. In other words, due to a lack of bargaining power migrants are particularly prone to exploitive labor conditions.

Each of the Sudanese respondents interviewed as part of this study reported working long hours for an insufficient wage. For those working as housekeepers, drivers and security guards, a typical working week consisted of twelve working hours per day, 6 days a week. The average wage for a female housekeeper was £800 LE, approximately $90 USD per month. Male respondents earned even less, earning on average £700 LE per month, approximately $78 USD.Footnote ¹⁵ Job security was also an issue. In total, seven respondents reported instances of arbitrary dismissal, lamenting their inability to challenge unfair working conditions. Malik, speaking about his experience working as a security guard in Alexandria, without a work permit, explained his dilemma:

Another respondent, Joyce, was dismissed from her position as a housekeeper, for attending a RSD meeting, which she had informed the “Madame” about, two weeks in advance. However, the Madame claimed that she had never been informed of this, and consequently dismissed Joyce, insisting that she could not be relied upon. Unable to depend on a stable wage, the majority of respondents had to supplement their income in other ways, engaging in multiple economic activities in an effort to cover rent and daily expenses. For example, some of the female participants supplemented their income earned as housekeepers by styling hair, applying henna tattoos or engaging in sex-work. Selling a kidney was another option. With limited opportunities to earn a living the promise of a substantial cash payment in return for a kidney was a significant incentive for migrants with ambitions to increase their social mobility.

Another reason why migrants are targeted for their kidneys is that procuring an organ from foreign migrants raises less suspicion. Despite the fact that under Egyptian transplant law, it is illegal to receive an organ from a foreign national (altruistically or otherwise) law enforcement officials are less likely to investigate a suspected organ sale involving Sudanese migrants. This investigative apathy into alleged criminal activity is sharpened by a cultural detachment to the affairs of foreign bodies, particularly asylum seekers and refugees who are not extended state protection. Owing to their precarious legal status, they are considered more expendable than other sections of the population. Therefore, absent any kind of public pressure to open an investigation, it is of little concern to the authorities whether or not a migrant has been coerced into selling his/her kidney. This selective indifference to the welfare of Sudanese migrants was a common theme in the narratives of organ sellers. Talia, a Sudanese migrant (aged 23) solicited for her kidney, revealed that she was subject to ongoing intimidation and threats from an organ broker, after she had informed him that she no longer wanted to proceed with the operation. Asked why she did not report this to the police she explained:

Experiences of hostility from the host community were interposed with reports of police brutality and state corruption. Tensions were evident between the Sudanese community and the domestic (Egyptian) poor, competing for work and opportunity in a context of social exclusion. From the interviews (and general conversation with local Egyptians), it was apparent that immigrants were blamed for the economic difficulties experienced by the urban poor; a convenient way to re-direct attention away from failed state polices (see Reference BayatBayat 1997). Stories of being robbed were common as were accusations of corruption amongst various Egyptian organizations, working under the auspices (and funding) of the government.

Experiences of sexual and gender-based violence were common amongst the female respondents; each of whom had reported feeling unsafe living in Cairo, and insisted that they were in need of protection. They argued that no one cared what happened to them. The police would not take their reports seriously and local Egyptians would always defend their “own,” regardless of the circumstances.

A number of respondents insisted that Egyptian nationals purchase refugee identity cards from UNHCR representatives in order to file a request for resettlement overseas, with Europe and the United States being the preferred destinations.

Another respondent, Patrick, claimed to have been solicited for his kidney by law enforcement officials, when arrested during a refugee protest outside the UNHCR in 2005.

Patrick had been arrested a number of times before this and claims to have been beaten on each occasion. On this instance, he described being stripped naked, beaten with a metal pipe, and burned with cigarettes. Another respondent who claimed to have been subject to arbitrary arrest, described the difficulties he faced after being released from prison. Mohammed (Sudanese migrant, aged 29) was arrested after getting into a confrontation with his employer over payment. Having no source of income upon release Mohammed soon found himself homeless:

Mohammed was reticent for some time before revealing that he was offered US$10,000 for his kidney. He claimed that the money he had received was taken from him by force shortly after the operation (from whom he did not say). Having lost his kidney, he expressed feeling a constant sense of shame and hopelessness:

After his transplant operation, Mohammed went to the UNHCR for assistance and was referred to its partner organization Caritas. He was prescribed sleeping pills and discharged without further inquiry. He claimed that the medical staff working for Caritas are not trained professionals and routinely prescribe the wrong medication for refugees. He alleged to know of a gentleman from Sudan whose leg was amputated as a result of misdiagnosis. Mohammed attributed much of his misfortune to his perceived lack of support. At the time the interview took place, he was sleeping in front of the UNHCR building in Cairo, in protest of an institution he feels betrayed by. He explained how he had believed that once he made contact with the UNHCR his problems would be over.Footnote ¹⁶ Mohammed was not alone in his condemnation. Five respondents complained about the treatment they received from Caritas, in particular:

In sum, with little trust in local authorities, migrants are less likely to report instances of abuse. Rather, they have to find ways to help themselves. Despite the many risks involved, selling a kidney is one such strategy.

The Social Determinants of Organ Sales

For the individuals interviewed as part of this study, selling a kidney was not so much a rational decision but rather a consequential imposition, informed by the everyday challenges to sustain oneself and/or one's family. It was one of many circumstantial outcomes related to a variable set of factors negotiating the migrant condition. In this regard, involvement in the organ trade was not causally linked to the criminal operations of traditional organized crime groups or organ trafficking rings, as suggested by numerous media reports (see, for example, Reference HolmesHolmes 2016; Reference PokharelPokharel 2015) but was rather symptomatic of a kind of circumstantial criminality, an irregular adaptation to a challenging market environment. In an environment with limited resources, kidneys were often the most valuable resource respondents had in their possession. With limited employment opportunities in either the formal or informal sectors, the organ trade was, for some, the only source of income available. For others, it represented an opportunity to enhance their labor market prospects.

One broker, speaking with his back turned, explained that he did not want to recruit people for organ sale. He was uncomfortable with being labelled a criminal or a broker explaining that he was “only trying to make money like anyone else.”

The majority of female participants who had sold one of their kidneys were single mothers. They described the challenges of raising children on a low budget. Despite working long hours as housekeepers their remuneration was wholly insufficient to meet the costs of running a household. The women that were interviewed had between two and five children, respectively. They explained that with their limited budget they could not afford to send all of their children to school, if any. Moreover, they could not pay for childcare. Often a number of families would live together in the same household, splitting costs and sharing responsibilities. Yet, there was not always someone available to watch over their children, which meant leaving them alone for extended periods of time. Hiba, a single mother working as a housekeeper, described an incident where a child who had been left on his own for the day had fallen from a balcony and died. Notwithstanding this apparent danger, Hiba insisted that she had little choice but to continue working, even when her children were unsupervised. Her immediate concern was the more probable risk of losing her job, falling deeper into arrears and being evicted from her home. Struggling to keep up with payments and concerned for the wellbeing of their children, the sale of a kidney represented an opportunity to transform their lives. Amirah, a Sudanese sex-worker, explained how she had hoped to use the money she received from selling her kidney to improve her life choices:

These respondents were motivated by a desire to advance their life chances. For the majority of female respondents, it was their hope that in selling one of their kidneys they could send their children to school, start up a business, or relocate to another country with better labor options and/or conditions.

The male respondents were similarly motivated. Three of the male participants described feeling emasculated by their joblessness (see, also, Reference JeffersonJefferson 2002; Yea 2015). They were uneasy staying at home with their children, while their wives were away working. Musa, commenting on his unemployment, explained that in South-Sudan “the man must provide for the family. You cannot have a wife unless you have something to give them.” For Musa, the sale of his kidney was the ultimate sacrifice, a way to re-establish and verify his male identity. It was better to be an “organ seller” than an impotent husband.

Unplanned events were also a factor, precipitating respondents toward the sale of one of their kidneys. Living on the margins of society, circumstances can change from bad to worse in an instance. After his mother was involved in an accident resulting in a severed spinal cord and a broken thighbone, Kamal sold his kidney in order to cover her medical expenses:

He added:

Others sold a kidney after losing their jobs, under circumstances beyond their control. Two of the respondents had fallen ill and were subsequently dismissed by their employers. Another had been arrested for driving without a license, and lost his job while in prison:

Najla travelled to Cairo in order to advance her education. She claimed to have purchased a visa from a contact with the Sudanese embassy prior to departing. But what little money she had when she arrived was stolen:

Najla received £40,000 Egyptian pounds upon completing the surgery, which when converted to US dollars amounts to around $4,500, significantly less than what she was promised. As soon as she received the payment, Najla was asked to leave, without receiving any information about the procedure or the type of aftercare that was needed.Footnote ¹⁷ Najla felt too ashamed to tell anyone about her experience, and spent a significant portion of the payment covering the costs of a hotel room while she recovered. Najla frequently experiences sharp pains in her lower abdomen and can no longer perform tasks that involve heavy-lifting.

While the majority of respondents were aware that they were “agreeing” to sell a kidney, some of them were coerced and/or deceived into having their kidneys removed. Two of the respondents had been taken to a local hospital on the pretense that they were receiving medical treatment. Zarif was suffering from a severe intestinal disorder and required urgent medical attention. He claimed that he could not find work until he received treatment. At the time, he was staying with the smuggler who had arranged for his entry into Egypt. The smuggler, known as Rashad, agreed to bring him to a clinic, provided he was compensated once he had started working. According to Zarif, Rashad brought him to a number of clinics where preliminary blood tests were conducted, which he understood were to diagnose his medical condition. After he went to four or five clinics (Zarif was quite vague on the details) he eventually spoke to a doctor who assured him that he could perform a successful operation. When he regained consciousness, he noticed a large scar across his abdominal area and his lower back. He was told by a nurse that this was where an endoscope entered to perform intestinal surgery. However, an ultrasound later confirmed that one of his kidneys was removed.

According to Zarif, he had no prior knowledge that his kidney would be removed. Yet, having revealed that his intestinal condition had also been treated, it would not be unreasonable to question whether Zarif had in fact traded his kidney in return for treatment; and more pertinently, for the services of Rashad. Considering that Zarif claims to have visited “three or four” clinics for blood tests prior to his donation, it seems rather dubious to conclude that his suspicions were not aroused at any point during this process. Other cases were however less ambiguous. Grace explained how she had been deceived by her then partner into selling her kidney:

Grace continued:

According to Grace, this particular man had sold his kidney on a previous occasion and was now working for the clinic as an organ broker. Subsequently, Grace had been informed that her former partner had moved in with another woman shortly after her operation. This woman had also, allegedly, had her kidney removed.

Experiencing Exploitation: The Failure of Crime and Immigration Controls

In 2010, the Transplantation of Human Organs and Tissues Act was established in Egypt, primarily out of concern that the sale of Egyptian kidneys and livers to foreign tourists was bringing “shame” and “humiliation” on the nation (Reference HamdyHamdy 2012). However, despite the legislative prohibition on the organ trade and the establishment of an oversight committee charged with enforcing the strict provisions of the Act, commercial transplants have persisted within Egypt. All of the respondents, interviewed as part of this study, had sold a kidney after this law was passed. In the same year, Law No. (64) of 2010 Regarding Combatting Human Trafficking included “the removal of organs” as a form of exploitation. Notwithstanding Egypt's reputation as a hot spot of organ “trafficking” (see WHO 2007) at the time of writing, no victims have been identified or assisted.

The respondents in this study had travelled to Egypt in search of better employment options and living conditions. Nevertheless, they were classified as asylum seekers and subject to the UNHCR registration process. With limited access to employment, residency, and/or education, they were left with little choice but to find ways to help themselves. In this context, selling or arranging the sale of a kidney was an option worth considering. It was their lack of bargaining power and inability to find gainful employment that ultimately led to their exploitation in organ markets. While the majority of respondents regretted selling a kidney, it was not the horror of organ sale that they wanted to communicate. Rather it was their lack of support in a precarious environment with little or no opportunity for social mobility. Each of the respondents decried their marginal status and inability to generate an income. Disenfranchised and relegated to the marginal spaces of the informal economy, they had limited or no access to housing, education, healthcare, or employment. Subject to their marginalized status their reports of abuse were not taken seriously. Reports of corruption and a lack of accountability were common, raising serious questions about the UNHCR registration process and the integrity of Egyptian law enforcement. As Mahmoud, a Sudanese construction worker, aged 21, explained:

Many of the respondents had taken great risks in order to come to Cairo. Large sums of money (i.e., $5,000 USD) were needed to pay smugglers and secure travel often under cramped and unsafe conditions, with some facing brutality, and hardship along the way. Selling a kidney was another aspect of this journey; part of a wider struggle to advance their life choices. While some of the respondents had their kidney's removed under fraudulent circumstances, the majority were under no illusion as to what is was they were doing. Some had even been prepared for the extremity of death, but were willing to forfeit their life if it meant helping their families. Considerations of legality or consent held little meaning for them.

Stripped of their agency, migrants can be redefined as refugees, “illegal” migrants, victims, and/or criminals, legitimizing mechanisms of control that put them at risk of exploitation. Classified into different migrant types and objectified as external agents their histories are unwritten and attention is focused elsewhere. With regard to the exploitation of migrants, political attention has largely focused on the activities of smuggling networks that are often conflated with human trafficking (Reference AronowitzAronowitz 2001; Reference SaltSalt 2000). There has been relatively less attention paid to the laws and policies of destination states where many individuals are ultimately exploited. In the Egyptian context, it seems clear that more services and support for housing, health, childcare, and education are needed for migrant groups. Especially given the current (2016) political climate across the Middle East and North Africa, the numbers of migrants in Cairo are increasing. More generally, increased labor informalization and the precarious working conditions that leave people exposed to exploitation of various kinds need to be addressed. As (Reference MeagherKatie Meagher 2014) points out clandestine trading activities are having an increasingly negative impact on local security and development. Furthermore, while there has been an emphasis on increasing organ supplies (see Declaration of Istanbul 2008; WHO 2010), there has been relatively less attention on limiting the risk of organ failure. At a minimum, re-focusing efforts on reducing demand for transplant services would seem more sensible than imposing ineffective criminal sanctions. If health care were to be supported more generally and broadly, then solutions for the prevention of organ failure would be the focus of medical intervention; not transplant programs with limited accessibility.

There is little to suggest that law enforcement measures are of any tangible benefit to individuals or groups exposed to exploitative practices, in various forms and degrees. Rather the rhetorical imaging of crime control policies, conveyed as a bulwark against a nefarious criminal order, act as a form of social control managing public expectations (see Reference CohenCohen 1985). Moreover, these policies relieve the state of pressure to address the types of social inequalities that subject people to exploitation. Organ markets have not produced an economic underclass; they are a condition of it. Selling a kidney is one aspect of a wider process of exploitation and a person's position in the social structure. While it is debatable as to whether or not the Egyptian state has either the capacity or interest to implement the relevant statutory provisions, it is unlikely that this will have any significant impact on the existence of organ markets.

The organ trade cannot be reduced to a singular criminal act. It is a particular expression of exploitation, linked to a process of social exclusion. Sudanese migrants, and indeed other migrant groups, experience this process through legal barriers to full citizenship embedded in the daily struggle to survive. Existing attention to immigration and crime control limit the existential scope of exploitation and re-orient critical attention away from the social and economic arrangements that perpetuate patterns of social exclusion. This social exclusion supports the emergence of organ markets. If the law is to have any impact on organ trading and indeed other forms of exploitation, it must first address the structural asymmetries that compel individuals to submit to the will of others. While it may prove impossible to eradicate organ markets, the legal barriers and policy decisions that predispose people toward organ sale can be addressed.

Conclusion

The empirical findings presented in this paper provide a contextual analysis of organ trading in Egypt, demonstrating how organ markets and the networks that supply them are embedded and implicated in local political cultures and socio-economic arrangements. From this analysis, it is clear that if policy makers are serious about preventing the organ trade the legal barriers, policy decisions, and economic conditions that stimulate organ markets will need to be addressed. The Sudanese migrants who participated in this study were compelled to sell a kidney due to economic pressures, intensified by precarious labor market conditions and exclusionary migrant policies. Existing criminal measures in response to the organ trade do not capture or respond to this empirical reality. For the majority of respondents, selling a kidney was a reaction to failed state policies (centered on public health, immigration, and crime control) and the social malaise that follows. This was evident in the narratives of various respondents who explained why or how they had agreed to sell one of their kidneys.

According to (Reference Mitra and Biller-AndornoMitra and Biller-Andorno 2013), exploitation is a way of taking advantage of vulnerabilities embedded within existing structural injustices. We must then look to the context in which vulnerability is grounded. There seems little sense in criminalizing individuals who are responding to challenging social conditions in a context of failed state policies. Limiting the level of exploitation organ sellers are exposed to will not be achieved by establishing more punitive measures; largely ignored in states lacking the resources or political will to arrest and prosecute suspected offenders. The organ trade is an effect of deeper structural causes, outside the scope of criminal intervention. For the respondents interviewed as part of this study, selling a kidney was an economic option of last resort. Morality or ethics played no part in their decision. More support is needed, not incrimination.