EXCAVATING THE ORGAN TRADE: AN EMPIRICAL STUDY OF ORGAN TRADING NETWORKS IN CAIRO, EGYPT

Legislative action in response to the organ trade has centred on the prohibition of organ sales and the enforcement of criminal sanctions targeting ‘trafficking’ offences. This paper argues that the existing law enforcement response is not only inadequate but harmful. The analysis is based on empirical data gathered in Cairo, Egypt, among members of the Sudanese population who have either sold or arranged for the sale of kidneys. The data suggest that prohibition has pushed the organ trade further underground increasing the role of organ brokers and reducing the bargaining position of organ sellers, leaving them exposed to greater levels of exploitation.


Introduction
Defined in terms of human trafficking the organ trade is nominally described as a feature of organized crime.Consequently, anti-trafficking measures supported by an ethical discourse prohibiting organ sales have become the focal point of legal intervention, in response to a phenomenon embedded in social, political and economic malaise.Conceptualized as a human trafficking offence the organ trade has been framed within a narrow criminal paradigm (see UNODC 2008;2010;OSCE 2013;COE 2014) underpinning a regime of punitive justice, which does nothing to address the structural conditions that produce demand for organ markets and/or the policy decisions that circumscribe the social mobility of the populations that service this demand.Conversely, the implementation of criminal sanctions targeting transnational organized crime groups, associated with trafficking in persons for select 'criminal' purposes (i.e.sexual exploitation, forced labour, the removal of organs, etc.), serves to further disenfranchise already marginalized populations, whose livelihood struggles are rendered insignificant in comparison to the suffering of trafficked victims (see Andrijasevic 2007).The majority of individuals, who due to their poor socio-economic status have little choice but to consider an organ sale, are bypassed and effectively discriminated by anti-trafficking polices attentive to selective elements of 'trafficking in persons' that correspond and reinforce the punitive logic behind policing and immigration controls (for additional critiques, see Agustín 2007;Chuang 2010).In short, the social context in which vulnerability is produced is hidden behind a symbolic call for justice, targeting elusive criminal organizations operating at the transnational level.This emphasis on the transnational shifts the critical focus away from the legal and political processes that engender and sustain exploitative relations within borders.
This paper redirects analysis to the domestic level, challenging the interpretative bias that informs the current transnational legal framework regulating the organ trade.While much has been written about the operations of 'criminal syndicates' and 'criminal enterprises' that are alleged to be responsible for the 'global traffic of organs' (see, e.g., Scheper-Hughes 2000;OSCE 2013), there has been a critical deficit of empirical research into the social organization of organ trading networks in countries identified (see Shimazono 2007) as having an active organ trade.Rather tangential and generalized claims have been reproduced from a select number of cases at the judicial level (Medicus Clinic Case 2013; U.S. v. Rosenbaum 2012; The State v. Netcare Kwa-Zulu (Pty) Limited; Allain 2011), reinforcing a partial conception of organized crime and organ trafficking at odds with the diverse experiences of individuals engaged, at various levels, with organ trading networks.Contrary to official reports of organized crime groups recruiting donors from overseas and coercing them into organ sale (primarily in countries with weak border controls), this paper presents an alternative contextual insight into organ trading, grounded in empirical research undertaken in Cairo, Egypt.
Owing to its reputation as one of world's largest organ bazaars (Shimazono 2007;McGrath 2009), 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 establishment of the Transplantation of Human Organs and Tissues Act 2010, which prohibits the commercial exchange of organs (EIPR 2010).The activities of Sudanese migrants engaged in organ trading provide the empirical basis for this study.That is, while this research is illustrative of the social context that underpins migrant organ trading networks amongst Cairo's Sudanese population, the findings should not be extrapolated to describe the organ trade as a whole, nor the situation as it exists outside Egypt.Rather the point of this study is to forge insight into the contextual expression of organ trading networks, which are comprised of different relations and activities depending on the particular environment and circumstances in which it is situated.At the time of writing (2016) this is the first study to consider the perspectives of organ brokers and organ sellers.

Methodology
The methodology for this study took the form of a series of in-depth narrative interviews, with Sudanese migrants who have either sold or arranged for the sale of an organ, in Cairo.The analysis that follows is grounded in and developed from the situated perspective(s) and experiences of the respondents.The interviews were conducted in accordance with the Economic and Social Research Council (2015) guidelines, the author's university policy and with the consent of all respondents.All of the interviews were audio recorded and transcribed anonymously.Accordingly, pseudonyms are used throughout.
Interviews with organ sellers and brokers 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 (Atkinson and Flint 2001).In total, twenty-seven 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.All of the organs sellers and brokers interviewed were Sudanese.Seven of the organs 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.Interestingly, all but one of the respondents had sold a kidney after the Transplantation of Human Organs and Tissues Act of 2010 was enacted into the Egyptian penal code, adding further suggestion that the law has had little impact on organ trading, particularly amongst migrant groups (Hamdy 2012).Triangulation was used to cross-verify data between sources (Glaser andStrauss 2009/1967;Fram 2013).

Narrating the Threat of Transnational Organized Crime
The threat of transnational organized crime underpins the rationale behind the antitrafficking framework.This threat is conveyed in various reports, academic commentaries and media sources, which attest to the virulence and menace of an international criminal order, threatening to undermine the integrity and survival of democratic governments (see, e.g., Sterling 1994;Shelley 1995;UNODC 2015).In this contemporary narration of organized crime, the conventional representation of criminal organizations, as hierarchically structured homogenous groups, has been revised with the addendum of transnationality, suggestive of a widening domain of criminality under the control of a new 'global mafia' (see, e.g., Nicaso and Lamothe 1995;Galeotti 2014).Admonishing against the common threat to nation states presented by transnational organized crime, the preamble to the United Nations Convention against Transnational Organised Crime (2000) declares: …If crime crosses borders, so must law enforcement.If the rule of law is undermined not only in one country, but in many, then those who defend it cannot limit themselves to purely national means.If the enemies of progress and human rights seek to exploit the openness and opportunities of globalization for their purposes, then we must exploit those very same factors to defend human rights and defeat the forces of crime, corruption and trafficking in human beings.(UNODC 2000: Preamble) The language of risk and security associated with traditional organized crime has been augmented with an emphasis on the transnational, creating a sense of urgency around interventions targeting the mobility of suspected criminals.Terms such as 'transnational' and 'cross border' are indicative of an 'alien conspiracy' with designs to infiltrate and corrupt the integrity of the nation state (Ruggiero 2000).Problematized in this way organized crime is conveyed as an external threat, acting upon the state rather than within it.
Transnational criminal organizations are said to be responsible for all manner of social ills, resulting in the victimization of millions of innocent people (UNODC 2015).However, it is the moral outrage associated with human trafficking that has elevated transnational crime to the forefront of the global political agenda.Allied to the transnational discourse of organized crime, the narration of threat advanced by the metanarrative of human trafficking (for further discussion, see Weitzer 2011;Snajdr 2013) is conveyed through the victimization of trafficked persons.
Human trafficking is a global problem and one of the world's most shameful crimes, affecting the lives of millions of people around the world and robbing them of their dignity.Traffickers deceive women, men and children from all corners of the world and force them into exploitative situations every day.(UNODC 2015) A populist vernacular is composed through the suffering of idealized victims, exemplified in sensational accounts of human trafficking, i.e. defenceless women being sold into sexual slavery or young children being kidnapped for their organs by unscrupulous traffickers.Yet as Weitzer (2011), Ellison (2015) and Steinfatt (2011) demonstrate in their studies of the sex trade, such macabre accounts only apply to a fraction of the reported millions of people who are trafficked.This singular emphasis on violent crime constructs a belief system at odds with the diverse experience(s) of individuals who are engaged in criminal activities and/or exploited for various purposes, obscuring the social context and relations within which criminality is situated.Critically, the perceived threat that this meta-narrative represents lends credibility to policy interventions centred on cross border policing and the apprehension of criminal perpetrators; policies which paradoxically contribute to the exploitation of the very people they ostensibly protect.
The definition of trafficking outlined under Article 3 of the United Nations (2000) Protocol, to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children (henceforth the Trafficking Protocol) advances a formulaic understanding of exploitation, comprised of three elements: an action (i.e.recruitment), means (i.e. the threat or use of force) and purpose (i.e. the removal of organs).Supplementing the United Nations Convention against Transnational Crime (2000), states are encouraged to adopt a 'common definition' around trafficking, in an effort to promote cooperation to 'prevent and combat, transnational organised crime, more effectively' (UNODC 2000: Preamble).However, in practice, it is not always clear when someone has been trafficked (in regards to human smuggling, see Campana and Varese 2016).For instance, individuals who sell an organ but do not clearly satisfy all three elements required to establish the offence of 'trafficking in persons' are unlikely to be recognized as victims of trafficking (Yea 2010;Mendoza 2011).This might explain why there have been relatively few cases concerning trafficking in persons for organ removal to appear at the judicial level.Moreover, in the majority of states where it is a criminal offence to buy or sell an organ (Iran being the exception), organ sellers who do not identify as trafficked victims are liable for prosecution.Hence, individuals who have been exploited for their organs are unlikely to report any instances of abuse that they may have experienced as a consequence of their involvement in organ markets, making it difficult to determine the actual nature and extent of organ trading.

Organ trafficking
While the traditional/mob-boss model, discussed above, has been systematically challenged by a number of scholars (see Block and Chambliss 1981;Hobbs 1998), it remains central to the working assumptions of many legal practitioners and law enforcement agencies (Klerks 2001;Farrell et al. 2014).Subscribing to a rigid crime-fighting doctrine, law enforcement strategies concentrate on the arrest and prosecution of professional criminals, the disruption of criminal networks, the policing of borders and the seizure of assets (Klerks 2001;Ruggiero 2001;Chuang 2010).Yet, despite significant investment into 'zero-tolerance' policies and the development of international agreements (i.e. the United Nations Convention against Transnational Crime and the Protocols thereto) to coordinate efforts against transnational crime, available evidence suggests that the operational capacity of these investigative methods is significantly limited (Chuang 2010;Weitzer 2011;Farrell et al. 2014).Moreover, there is little evidence to suggest that 'victims' actually benefit from this approach.Rather it would seem that this instrumental search for perpetrators is a way of managing public concerns, by rendering organized crime as something material, identifiable and predictable; something that can be controlled and countered (Garland 2001).
This consequentialist response to organized crime relieves the state of its responsibility for the social inequalities that engender modes of criminality, deflecting critical attention away from failed state policies (i.e.migration, public health, labour, crime control) towards a narrow pursuit of criminal justice.The framing of the organ trade as a human trafficking issue orchestrated by sophisticated criminal organizations is a key example of this political misdirection.Public anxieties over organ harvesting have been diffused into a moralistic debate over organ sales (see, e.g., Delmonico and Scheper-Hughes 2003;Caplan 2013) collapsing a complex humanitarian issue into a narrow bioethical calculus, negotiating the ethical parameters of what can be considered good transplant practice (i.e. using organs sourced from altruistic donors) versus bad transplant practice (i.e. using organs sourced from commercial donors).Organ trafficking rings (typified in a recent high profile case in Kosovo-Medicus clinic ( 2011)) are understood to be responsible for driving the trade in organs, recruiting individuals from poor countries and 'trafficking' them into various destinations for organ removal (Shimazono 2007;OHCHR 2013).Such destinations or organ trafficking 'hotspots' are encouraged to increase their altruistic supply of organs, or risk infiltration by organized crime groups specializing in organ trafficking (see, e.g., Kishore 2004;Declaration of Istanbul 2008;Council of Europe and United Nations 2009;WHO 2010).
Essentially the organ trade is conceptualized as a perversely criminal phenomenon, a social aberration far removed from the ethical domain of transplant medicine.This unambiguous representation is, however, a false dichotomy.There is no clear illegal/ legal divide.Organ markets exist to service the surplus demand for organs generated by the commercial expansion of the transplant industry.The transfer of transplant technologies is contingent on the supply of organs (Cohen 2001;Yea 2010;Mendoza 2011).When this supply cannot be satisfied by legal channels, organs are sourced from commercial donors, or in some instances from individuals who have been coerced into having one or more of their organs removed (see Yea 2010;Hamdy 2012).The informal networks that support the organ trade are not isolated units possessing a purely criminal modus operandi. 1These networks cross various divides: legal, quasi-legal and the blatantly illegal (Bruinsma and Bernasco 2004).The individuals who assume different roles in informal networks are rarely specialists in a particular criminal enterprise; rather they respond to relative opportunities in a given context (Nordstrom 2000;Castells 2011).For instance, the majority of organ brokers interviewed as part of this study were involved in organ trading on a temporary basis.Their participation in organ markets was viewed as a part-time occupation, a way to supplement their income.
In 2010, the Transplantation of Human Organs and Tissues Act was established in Egypt, making it a criminal offence to buy or sell an organ.In accordance with the Law of Trafficking in Persons (2010), individuals who are implicated in organ sales are liable for trafficking offences (EIPR 2010).2Yet, despite the legislative prohibition of organ trading and the establishment of an oversight committee charged with enforcing the strict provisions of the Act, commercial transplants have persisted within Egypt.Significant cultural resistance to organ donation combined with logistical and infrastructural limitations inhibiting the successful operation of a nationally regulated organ donor programme, continue to place an over-reliance on live donors, the majority of whom require payment (see El-Katatney 2009;Hamdy 2012).While organ sales remain public knowledge, the process has become more hidden.Private clinics and analytic labs (where the majority of sellers are matched with buyers) have proliferated, making it increasingly difficult to monitor the treatment of organ recipients and organ sellers.Furthermore, owing to their precarious legal status, undocumented migrants have become a key source of organ supplies in Egypt, with no legal recourse for harms committed against them.Although the majority of respondents in this study who have sold a kidney have been exploited, they are not recognized as trafficking 'victims' by the Egyptian authorities.Neither do they identify themselves as victims of trafficking.Rather their exploitation is bound up in their migrant status and a lack of opportunities to generate an income.

Migrant Organ Trading Networks
Migrant populations provide a key source of organs for Cairo's burgeoning transplant industry (see COFS 2011).Barred from access to the formal labour markets, migrants have little choice but to accept precarious labour conditions.Furthermore, migrants compete with locals for limited job opportunities in an unregulated, uncertain and often hostile environment (see Grabska 2006;Thomas 2010;Jacobsen et al. 2014).Excluded from state protection migrants rely on the strength of their social relations to gain access to job opportunities (Jacobsen et al. 2014).While Sudanese migrants have strong social ties in Egypt, owing to a tradition of shared migration between the two countries, employment options remain limited and working conditions fall well below what might be considered 'reasonable' standards (Grabska 2006).Faced with occupational barriers in both the formal and informal sectors, Sudanese migrants have to achieve a level of labour flexibility beyond recognized norms, responding to available market opportunities, legal or otherwise (Kleemans and Van De Bunt 1999).
In other words, the legality of their activities is shaped according to existing opportunities and demands.
Informal street markets are important sites of economic production for marginalized populations disconnected from the official labour market, providing a shared space to pool resources and organize economic activities.These markets consist of internally differentiated groups of stakeholders who routinely enter into associations, bargains and partnerships, identifying demand and establishing supply chains (Kotiswaran 2008).Responding to the surplus demand for organs, the organ trade has been identified as an alternative source of income generation for various stakeholders operating from Cairo's Sudanese street markets.Those who participate in one or more of the variegated activities that constitute organ trading networks are not professional criminals, in the sense that they do not specialize in criminal activity.Neither do they cater to a specific market.Indeed, this group represents an entrepreneurial core of migrants adapting to a challenging market environment, who 'commute from illegality to legality and back again', in order to advance their own life choices (Ruggiero 2001).
There are numerous stakeholders involved in the organ trade, each with different roles, functions and identities that often overlap, i.e. transplant professionals, hospitals, brokers, service providers, law enforcement, etc. (Ambagtsheer et al. 2013).Intermediaries/brokers, however, play a key role in organizing and connecting the diverse networks that facilitate the continued expansion of the transplant industry.Critically, they occupy a strategic bridging position, linking up the various market players across the legal/illegal divide.A number of brokers involved in the recruitment of organ donors were interviewed and observed as part of this study.The brokers explained how they worked in cooperation with other agents operating in Cairo's informal economy, through a series of subcontracting arrangements and joint ventures, akin to formal capitalist structures discussed by Castells (2011).Furthermore, it was explained how they routinely exchanged services and knowledge with individuals or organizations 'represented' in the official economy; renegotiating and revising the boundaries of legitimate economic practice, along lines of mutual entrepreneurial promotion.

Broker network
In much of the literature on organ trafficking, organ brokers are represented as nefarious gangsters preying on the weak and helpless (see, e.g., Scheper-Hughes 2000; Kumar 2003).These elusive criminals coerce passive victims into selling their organs, or in more fatalistic circumstances they butcher and harvest body parts from innocent bystanders (Gutmann 2014).The overall image that is constructed is one of categorical deviance, inculcating an unambiguous image of brokers linked to criminal networks.This study however reveals a less sensational account of organ brokers, in sharp contrast to the one-dimensional caricature portrayed in the populist discourse framed around this issue.The Sudanese brokers interviewed formed part of a network of brokers/intermediaries, with connections in the both the informal and formal economy.These intermediaries perform a number of different functions instrumental to the operation of organ markets.They are involved in the recruitment of organ sellers, the negotiation of fees, preparing 'official' paperwork and crucially they are responsible for connecting buyers with sellers.The Sudanese brokers were generally involved in the recruitment of Sudanese migrants (discussed below).However, depending on their relative skills and experience they adopted more roles or functions that increased their level of involvement, and subsequently their earning potential.Interestingly, tissue typing/analytic labs emerged as the key nodes of activity linking up the various brokers in the network(s), as will be discussed in more detail below.Representatives from the labs formed partnerships with recruitment brokers who operated both locally and transnationally.Organ sellers were recruited from the migrant community, in this case Sudanese migrants, while recipients were recruited domestically and internationally.When suitable donors/sellers were matched with recipients/customers, they were referred to hospitals/clinics where the surgery was performed.
This combination of flexible networking between local actors is more indicative of the organ trade than the hierarchical structure of organized crime groups typified by the anti-trafficking discourse.It should be noted however that the local networks of brokers involved in the recruitment of Sudanese migrants for organ sale can and do intersect with transnational networks, via intermediaries recruiting buyers/recipients from overseas.It is this combination of flexible networking between local and global actors, within and between countries, which explains the transnational reach of the organ trade.

Recruitment of Sudanese Organ Sellers
In Cairo, Sudanese recruitment brokers operate in and around informal street markets spatially divided across different districts (i.e.Maadi, Downtown Cairo, Dokki, Heliopolis, Nasr City) where they have links, either directly or indirectly via another intermediary, with tissue typing labs and/or hospitals with transplant facilities.Rather than competing for predominance over local territories, the various brokers or clusters of brokers are interconnected, exchanging information and adapting their activities accordingly.For example, brokers keep each other informed of the current market value of a kidney and exchange information on potential targets considered more open to persuasion, due to their precarious circumstances.They also refer sellers to other intermediaries when they are preoccupied with their 'regular' occupations (security guards, street vendors, translators, etc.).The majority of Sudanese brokers interviewed were primarily involved in the recruitment of Sudanese migrants and only engaged with the trade on a temporary basis.Shaker, a musician (male, aged 28) originally from Darfur, worked with a team of brokers recruiting organ sellers from Sudanese street markets in different locations around Cairo.He explained how he got involved in the recruitment process, after finding it difficult to secure employment: I'm a musician but this work does not pay well.I needed to find another way to make money.I had a girlfriend but she left me, because I had nothing to give her.So I started to ask people about their kidneys.I worked with some other guys in different places.One guy would stand by the corner every day asking about people, to know their situation and to see if they needed to find a way to get money.And then I would talk to them to see if they were interested in selling their kidney.If they were happy, I would bring them to get their papers stamped and then to a clinic for health checks.Maybe 10 people a week…But, I don't do this anymore.
Shaker was quick to point out that he had done nothing wrong, explaining that he was ' just trying to get by, like everybody else'.He was uncomfortable referring to himself as a broker, insisting that he was merely providing a service: This is just a service.If they want to sell that is for them to decide.It is no problem to find people, but no one wants to talk about this.People want things.Sometimes this is the only way.They get paid what they are promised and they are happy.Some of the people are stupid.I know one guy who sold his kidney because he wanted to buy a laptop and some speakers.
According to Shaker, most of the individuals that he referred to tissue typing labs had in fact sought out his services.He explained: You cannot go to a clinic by yourself.You have to be brought there by someone connected.This is the only way.Otherwise people will get suspicious, and that could cause some problems.Also, if people could go by themselves we [the recruitment brokers] would lose business.
Kalib, a (male) restaurant owner from Sudan, who occasionally connected recruitment brokers with tissue typing labs looking to increase their organ supply, provided a similar account: Brokers have their own territories [local street markets] and work with specific labs and hospitals.There is no need to recruit people outside of Egypt as there is a plentiful supply of donors.But a lot of the buyers come from the Gulf. 3owever, while some of these respondents had actively sought out the services of organ brokers, the majority had only agreed to sell a kidney after a period of persistent solicitation, or, as outlined below, in cases of intimidation.Elaborating on Shaker's account of the recruitment process, a number of respondents (NGO representatives and organ sellers) commented on how brokers collude with other 'market dwellers' or 'scouts' exchanging information on different individuals, particularly Sudanese asylum seekers who have recently arrived in Cairo.
Whenever you come to Egypt people know that you are suffering.The brokers watch you and learn about your suffering.The Egyptian cannot come to you but the Sudanese can approach you.He might say that we want to give you an idea to improve your situation; you will not lose anything.Then they offer you money.He offered me £30,000 LE (approx.£2,339 GBP).(Ali, male, Sudanese migrant, aged 22) These 'scouts' were usually Sudanese and had close ties to the community, working as street vendors, restaurants owners, housing agents or hotel staff.In some cases they also acted as recruitment brokers.Hiba, a single mother with two children, was repeatedly solicited for her kidney while staying at a hotel, shortly after arriving in Cairo.The hotel had been recommended by the smuggler(s) who had organized her transport into Egypt.According to Hiba, hotel staff members had enquired over her circumstances before she had been solicited.After she had left the hotel she was pursued for over three months by two brokers, until she eventually relented and 'agreed' to sell her kidney.
They don't give you time to think about what you want to do.They keep asking you, reassuring you.They say it is OK; it is going to be fine; this is good for you and your family.They introduced me to some guy who had already sold his kidney.They wanted me to see that he was happy.He said he was Ok and that this was safe.But he did not look OK.
Other respondents who had sold a kidney reported similar experiences.Discussing his encounter(s) with different recruitment brokers (Egyptian and Sudanese), Ahmed (male, aged 26) reflected on their unyielding perseverance: I met these people in a coffee shop in Giza.They approached me several times.The first time I refused and after that they were talking to me and talking to me until I agreed.I almost felt guilty for not doing it…We met in different coffee shops.It was one guy from Sudan who convinced me.As soon as I agreed he brought me to the lab for a health check and then I went for the operation.

Negotiating Fees
Once an individual indicates that he/she is willing to sell one of their kidneys, the negotiation process begins.This usually takes place in an informal setting, a coffee shop or a restaurant, where a valuation for the kidney is deliberated between the prospective 'donor' and the recruiter(s).Often there is another intermediary present, who has connections with a particular tissue typing lab/transplant clinic.The initial recruiter will negotiate a price directly with the 'donor' before escorting him/her to a lab for preliminary testing.Interestingly, five respondents revealed that prior to any negotiation over a fee they had consulted with an 'adviser', to ascertain the current market value of a kidney.According to one respondent: There is a lady here [in Dokki] who tells people what they need to get paid.The price can change from year to year.It is going down now, as there are more and more donors.It is normal to donate your kidney this way.I met the brokers (two Egyptian and one Sudanese) in a coffee shop in Dokki to negotiate the price.One of them was from the lab; I think he was the secretary.After about an hour of talking, I negotiated a payment of $10,000 USD.They tried to lower the price but I knew what my kidney is worth.(Mohammed, Sudanese migrant, aged 28) The level of remuneration an organ seller receives, or more pertinently is 'offered', is contingent on his/her knowledge of the organ market.Depending on the 'donor's' informational basis and subsequent ability to negotiate, there can be significant discrepancies in the level of payment received.For instance, the organ sellers interviewed in this study were paid between £30,000 LE (approx.£2,339 GBP) and £200,000 LE (approx.£15,595 GBP).That is a difference of £170,000 LE (approx.£13,300), suggesting there was a substantial divergence in market knowledge shared between respondents.Notably, the individuals who were paid the least were all relatively new to Cairo.Whereas the individuals who received the most had been living in Cairo for a number of years.Asylum seekers who have recently arrived in Cairo are not privy to this information nexus.Moreover, given the urgency of their particular set of circumstances, they do not possess the same bargaining power as individuals who have had more time to adapt to their migrant status.Disconnected from this local knowledge economy, they are at greater risk of exploitation.As one informant working for a local Sudanese run NGO explained: When people come to Cairo, they go to the markets and talk to each other.They ask where they can go for assistance; how to register with the UN or where to go to look for work.But some people take advantage of their position.Let me give you an example: there is a hotel in Ataba where many people stay when they first come off the boat.I know what happens here.After they stay in this place, for one or two weeks, the people there convince them to sell a kidney.They say this is the only way they can pay them.
Other intermediaries involved in negotiations used their connections with various networks to influence proceedings.For instance, Kariem revealed how sex workers had been used to 'sweeten the deal' in some of the negotiations that he was involved in.According to Kariem, the majority of Sudanese migrants who sell a kidney are male.It is more difficult for them to find employment (Grabska 2006;Jacobsen et al. 2014); and without employment it is difficult to sustain a relationship.Kariem (male), who worked primarily as a pimp, used the services of sex workers as leverage when negotiating fees with both sellers and buyers.A night with a sex worker was offered as an extra inducement to sell.'Serviced' accommodation was arranged for organ donors after their operation.
After the operation they [organ sellers] are taken to an apartment for their recovery, for a number of weeks.The apartment is unfurnished, so they must pay for the rent and furniture.They are sent a caretaker to make them food and they are brought women to make them feel good, but when they are ready they must pay for this service.All of this is taken from their fee.
Kariem did not comment on whether or not the sellers were made aware of these 'hidden charges' during negotiations.Rather he promoted the merits of his services, particularly his negotiation skills.
I help negotiate the price.There was a girl from France [who needed a kidney] whose father contacted me.I saved him a lot of money.He got the kidney for £45,000 GBP.Without me he could have paid more than £100,000 GBP.
Asked how he made contact with potential recipients Kariem declined to answer, simply stating that it was 'a secret process'.However, he did reveal (unintentionally) the name of one of the tissue/typing labs that he was associated with.After searching for this particular lab online, via Google-Egypt, a number of forum pages were located.On one of these pages, a user posted a comment referring to the aforementioned lab and thanked an unnamed intermediary for his services.The recipient was from Saudi Arabia.

Matching 'Donors' and Enforced Compliance
It was common for organ sellers to undergo tissue typing and diagnostic testing in different labs before being matched with a suitable recipient.Such testing involves an ultrasound to determine the size and function of the kidney, followed by blood and urine tests (Thiruchelvam et al. 2011;Ming and John 2014).For the majority of respondents who had sold a kidney, this process was conducted over a period of two weeks.It is probable that donors were taken to multiple labs to expedite the tissue typing/matching process.Another possible explanation is that the broker(s) were looking to negotiate a higher recruitment fee, exhibiting their 'merchandise' to different labs in order to elicit a higher price for their services.Furthermore, it is likely that the various tissue typing labs were working in partnership with different hospitals/transplant centres, which can pay more or less depending on the availability of donors, as discussed above.Certainly, the alleged payment structure of this illegal/legal interface would support such an inference.Kalib, a broker with links to a number of labs, explained how payment was allocated between the different stakeholders4 : The hospital gets paid from the recipient via an intermediary, and then the money is allocated to different medical staff.The recipient can pay from $40,000 to $100,000 USD.The hospital pays the lab around $6,000 USD.Sometimes labs are separate from the hospital.Sometimes the hospitals and labs are one, so the payment can depend on this.The broker(s) gets paid around $3000US from the lab and another $2000USD commission is taken from the donor.Most of the brokers work in teams so this money can be allocated amongst them.
All of the respondents who had sold a kidney were accompanied by a broker(s) while attending the clinics.Apart from collecting their recruitment fee, the presence of the broker(s) ensured that the donors did not reconsider their 'donation'.While the majority of respondents did not experience any overt violence compelling them to donate, it was clear that once they had agreed to sell a kidney they had little choice but to proceed with the operation.Asked whether a donor could in fact change their mind, Shaker bluntly affirmed that this was not possible: 'They cannot change their mind.This is not an option.Once they agree it is done'.Pressed as to how exactly consent was maintained, given the probability that a donor may wish to reconsider, he curtly restated that it was not possible.The comments of some of the other respondents were more revealing.Six of the respondents, who had sold a kidney, had expressed serious concerns prior to the operation.They had heard rumours that both of their kidneys would be taken; or that other organs (i.e.heart, lungs, liver, cornea) would be removed while they were under anaesthetic.These fears were escalated by the high volume of health checks that were performed in different clinics.Consequently, they had expressed doubts as to whether or not they should proceed with the operation.These doubts were firmly dismissed by an entourage of threats and warnings over the consequences that would follow, if they were 'dishonourable' and reneged on their agreement.Talia's narrative gives some context to the insidious nature of such threats.
Talia had decided that she no longer wanted to proceed with the operation, after being warned by a friend that she might lose both her kidneys.She informed the brokers (Egyptian and Sudanese) of her decision not to go ahead with the operation, but they insisted that it was too late for her to reconsider, as the health checks and surgery had already been paid for.They explained that Talia was now in their debt and that she would have to reimburse them for their medical expenses if she changed her mind.Further, she was warned that it was better for her to come by her own volition.Despite such threats, Talia did not go through with the operation.
I was going to do it but I was worried when they would not let me take someone with me.I am afraid.People are talking about me now.They all think that I sold my kidney.I cannot walk around freely anymore because they will find me.These people have eyes everywhere.I did not take any money from them.I just did the tests because I wanted to help my kids.They told me that it is better you come yourself.They said: "all the people they know that you already sold your kidney so if we come and take your kidney nobody will care and you will get nothing.The rumour is already out there." Talia was forced to move house and change her phone number after her door was kicked in several times in an apparent attempt to unsettle her.At the time of the interview, she was afraid to leave her house for fear of a reprisal.She would not go to the police as she does not trust them.
The police don't care about you.They just file a report but no one investigates.My door was broken because I am staying alone, and they [the brokers] know this.So I went to the police to file a report but they never even came to look at my house.What can I do?I just lock myself in my room and hope they go away.A lot of people donated their kidneys and they didn't even get paid.That's the problem.You can wake up with nothing and nobody knows you.You just ask for £20 LE fro transportation to get back.I worry about my kids.I want to help them but I am worried that if I do this [sell kidney] I might be killed.They might take both my kidneys and then there will be no one here for my kids.
While Talia's narrative should not be generalized, other respondents reported similar experiences.According to Patrick: They [the brokers] told me that they would never let me change my mind.They said, if you change your mind you will pay for all the health checks, and we will never leave you alone.We will take your money and your passport.We will never let you go.Every day they paid me 50 or 150 LE.They told me that I owe them now.I couldn't pay them back so I had no choice but to continue.

He continued:
I was in the hospital for one day and then I left.They told me they had somewhere I could stay.But I said I wanted to go home.The doctor's secretary paid me cash, in an envelope, before I left.Before the operation he asked me how much I agreed with the broker.He paid me $10,000 USD as promised.I asked for it in dollars.They wanted to pay me in Egyptian pound but I would not accept it.The money did not last long.I had to pay for my sister's funeral expenses and to help my family…I have not had any contact with them [brokers] since.But I went to the hospital to get my wound cleaned.I was bleeding.
One of the respondents mentioned above, Hiba, had a particularly harrowing encounter when she was brought to a hospital, hosting its own tissue typing lab, for diagnostic testing.When Hiba arrived at the clinic, she was welcomed by a member of the medical staff, Dr Hakim, who conducted some blood tests to determine compatibility with the organ recipient.After the blood tests were completed, Dr Hakim informed Hiba that she would receive £40,000 LE, significantly less than the $40,000 US that she had been promised by her broker, Ali.Hiba did not accept this and refused to 'donate' her kidney.However, she was prevented from leaving the hospital: They would not let me leave.He [Dr Hakim] had my passport.They put me into a room, where they do the surgery, and locked me in.There were guards outside, so that I could not leave.After some time, the Doctor gave me some medicine.I do not remember much after this.I was there for maybe four days.Then Ali [the broker] gave me £40,000 LE and asked me to leave.I spent most of this money staying at a hotel.I didn't want anyone to know what happened.
Hiba is adamant that security officials stood guard at the door of the operating theatre preventing her from leaving.The transplant was completed without her consent.Hiba never met the recipient and does not know anything about him/her.She was not provided with any information about the operation, before being discharged from the clinic.As a consequence of the operation, Hiba suffers from sharp pains in her abdomen and cannot perform tasks that involve heavy lifting.She explained that because of this she can only find work in nightclubs (i.e. as a sex worker).
These narratives are indicative of the coercive nature of 'consensual' organ sales, illustrating the thin line between a seemingly consensual agreement to sell a kidney and trafficking in persons for organ removal.However, while such cases underline the more nefarious elements of the organ trade, they should not be considered as typical.Contrary to the above accounts, other respondents experienced more favourable treatment.According to Kamal: The doctor told me I could change my mind if I wanted.He asked me again before the operation.He said I am free to go at any time.I was not obliged to do this.(Sudanese migrant, aged 21) It is worth noting that such positive experiences were observed in transplant centres, as opposed to the tissue typing labs where donors were treated with a general sense of apathy and in some cases, disdain.The majority of respondents had little if any direct correspondence with the medical staff at the labs.They were taken directly to a waiting room, while the broker(s) spoke to a representative from the lab before undertaking the requisite medical tests.Nonetheless, experiences in the transplant centres were also variable, as Hiba's narrative confirms.In general, the female respondents reported the most negative experiences.According to Mohamed, a Sudanese community leader, this is because: 'women are easier to intimidate; the brokers use fear and shame to enforce their compliance'.

Organ Laundering and the Limitations of Criminal Investigation
It is important here to reconsider the division of labour between the different agents that constitute the organ trading network.While there is no fixed system binding the movements of the various stakeholders, there was a general pattern of activity evident from the interview data.In summary, recruitment brokers connect the donor(s) to another intermediary, usually with ties to one or more tissue typing labs or hospitals, who negotiates a price with the donor.Once a fee is agreed the donor undergoes tissue typing.This usually takes place in a number of labs to increase the probability of finding a suitable match, in the shortest time possible.This also means that the donor has less time to reconsider his/her donation.When a suitable match is found, the donor is referred to a hospital or transplant centre, where the nephrectomy is performed.Crucially, however, before the donor is referred to the hospital/transplant centre, the necessary paperwork alluding to the donors 'informed consent' is completed.Once a donor has been received with the requisite paperwork (i.e.consent form, passport, medical-records, etc.), the illegality of the transplant is concealed and rendered legitimate; normal procedure follows.In short, the illegal supply of organs is laundered via an arbitrary consent process, mediated by a segmented network of intermediaries, which transforms what was an illegal transaction into a legitimate procedure.This process of 'organ laundering'5 disassociates the transplant centre from any 'criminal' activity and negates any wrong doing on behalf of the recipient. 6 According to Egyptian regulations established under the professional code of ethics and conduct, 7 and reaffirmed and codified into domestic legislation under Article V of the recently established Transplantation of Human Organs and Tissues Act (2010), all transplants performed in Egypt must first be approved by the Egyptian Medical Syndicate, via a special committee.Ostensibly this is to ensure that the integrity of the transplant procedure is upheld in accordance with internationally recognized guidelines (WHO 2010).Before a transplant is referred for approval the lab/clinic must submit the relevant paperwork to the committee, providing information on the patient and the donor, specifying the altruistic character of the donation, the age, nationality and sex of the donor, the health status of donor/recipient, as well as establishing that the donor has indeed given his/her consent.Furthermore, an affidavit is signed, before a special committee comprised of an unspecified number of technical and legal experts confirm that 'informed' consent has been given.In the context of an illegal organ transplant, however, the affidavit is usually signed under the instruction of the broker(s).The affidavit is then brought to a Ministry office where it is stamped and officially approved by a 'select' ministry official(s).As Shaker, a recruitment broker mentioned above, explained: I accompanied them to the Ministry (of health) to get their papers stamped and then later I would bring them to the lab for health checks before the operation.The doctors don't want to know anything.They take the money without question.This is their only concern.Once the papers are in order everything is legal.
When the affidavit is signed and the necessary health checks are performed, the lab forwards the 'official' documentation to the transplant centre.The centre's acting physician then makes a submission to the Egyptian Medical Syndicate to obtain overall approval for the procedure.Further, the donor signs a second consent form at the clinic where the procedure will be performed.This is to protect the clinic against any accusations of organ theft.Finally, according to Article 50 of the Professional Code of Ethics, the acting physician is obliged to confirm the donor's consent verbally, giving him/her the option to reconsider 'donating'.The donor should also be informed of the medical consequences and risks to which he/she may be exposed to, as a result of the transplant operation.
On an evidential level the physician is fulfilling his/her professional duties, provided consent has been confirmed.It should be noted however that the physician is under no legal obligation to ensure the consent of the donor, after a transplant has been approved by the Egyptian Medical Syndicate; this is merely a matter of professional ethics.That is, while a physician or transplant professional may be subject to disapproval amongst peers, he/she will not be held liable under law if he/she fails in his/her professional obligations (Ambagtsheer et al. 2013).Moreover, should a transplant professional suspect that an organ has been donated illegally there is no legal duty to report this to the relevant authorities.According to the Hippocratic Oath (adhered to on an international level), medical professionals have a duty to uphold confidentiality of information shared by the patient/donor (Edelstein 1943).This requirement grants transplant professionals the privilege of non-disclosure, meaning they cannot be held to account for failing to disclose information related to a suspected organ sale, which may or may not have been sourced from a victim of human trafficking.While in some jurisdictions doctors have a judicial requirement to report 'violent crimes', such as child abuse and crimes that could result in the death of the patient, no guidelines or bodies exist in Egypt, or anywhere else for the that matter, for the reporting of organ purchases or sales (Ambagtsheer et al. 2013).Without the testimony of transplant professionals, it is difficult to establish that an illegal organ sale has occurred.

Investigative limitations
In addition to a professional reticence to provide information that could lead to a successful prosecution, the organ laundering process presents a further challenge to the investigation and prosecution of organ 'trafficking' cases.For instance, while it is illegal to buy or sell an organ, transplantation is a legitimate procedure.Therefore, the proceeds of an illegal organ sale are reinvested without difficulty, into what is prima facie a lawful service.According to the information provided in interviews with organ brokers, the recipient's payment is, in general, allocated directly to the transplant centre where the transplant surgery (nephrectomy) is performed and accounted for against the medical expenses a recipient might be expected to pay for a transplant procedure.The surplus payment that is received is allocated to the various agents involved in supplying the organ(s).Segmented in this way it is difficult to trace the proceeds back to any one organization 'existing for a period of time and acting in concert with the aim of committing one or more serious crimes or offences' in order 'to obtain, directly or indirectly, a financial or other material benefit' (UNODC 2000: Art 3).Further, the fact that there is no single structured group responsible for the illegal supply of organs makes it difficult for law enforcement agencies to investigate a human trafficking case, where evidence of the method and means in conjunction with an illegal purpose need to be established.Consequently, the majority of 'trafficking' suspects are charged individually with lesser crimes associated with human trafficking, i.e. illicit organ sale, assault, battery, fraud, forgery, extortion, rape, fraud, kidnapping, etc. (Farrell et al. 2014;Netcare Case, 2003in Allain 2011;U.S. v. Rosenbaum, 2012).New laws create problems for prosecutors because the elements of the crime that are needed to establish a prima facie case are unclear until tested in court (Farrell et al. 2014).Moreover, given the complications involved in establishing a human trafficking case, organ sellers are more likely to be prosecuted for an organ sale than recognized as victims of human trafficking.Subsequently, the majority of cases that would correspond to the legal elements of 'trafficking in persons' are not reported.Hiba and Talia's experiences (see above) are indicative of this.It is unsurprising then that at the time of writing (2016) prosecutors are yet to file criminal charges against any perpetrators suspected of organ trafficking in Egypt, despite its reputation as an organ trafficking hotspot (Shimazono 2007).

Conclusion
The data gathered as part of this study suggest that the criminal sanctions introduced in response to reports of organ 'trafficking' in Egypt have pushed the trade further underground.This has increased the role of intermediaries and reduced the bargaining position of organ sellers, leaving them exposed to a greater risk of harm.While organ markets continue to operate, the process of organ trading has become more hidden, making it more difficult to assess the extent of the problem and identify individuals targeted for organ sale.Interestingly, analytic labs were the key nodal points of activity, linking up actors in both the formal and informal sectors of the economy.Reversing the logic behind prevailing attitudes on organized crime, that proceed from the assumption that crime infiltrates legitimate business, this study revealed how analytic labs formed strategic partnerships with various intermediaries/organ brokers to recruit individuals, usually from select ethnic backgrounds (in this case Sudanese), to meet a demand for organ supplies that could not be achieved by altruistic means.In other words, the 'criminal' aspects (i.e.recruiting donors/sellers) associated with the organ trade were outsourced from legitimate businesses to individuals operating in the informal economy.Once a donor(s) had been recruited a process of 'organ laundering' followed, disassociating the transplant clinic where the surgery was performed from any criminal liability.
The organ brokers and organ sellers interviewed as part of this study were responding to the same set of circumstances and conditions.With limited access to employment, residency and/or education respondents 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.Contrary to popularized reports that link organ trafficking to the operations of transnational crime groups, the informal/formal relations that underpin Cairo's organ markets are based on modern modes of collaboration, trading and communication, across the illegal/legal divide.In this sense, the organ trade is better understood as an emerging sector of the informal economy, as opposed to a trafficking offence.Yet, sensationalized global media accounts continue to overshadow a more nuanced analysis, that considers the negotiated practice of organ trading, reorienting attention towards the macabre spectacle of organ 'trafficking'.Rather than targeting the alleged criminal operations of transnational crime groups and suspected 'traffickers', legislative action needs to focus on addressing the legal barriers and policy decisions that position individuals in positions of vulnerability, leaving them exposed to exploitation of various kinds.In order to do this exploitation needs to be resituated in its broader context, and addressed at the domestic level where the effects of 'criminal' behaviour are experienced.From a law enforcement perspective resources would be better served by targeting the operations of private labs and investigating the 'organ laundering' process.
Sometimes I get a call and then I go to help people agree on a price.It can be difficult to come to an agreement.So I offer them something more…Some of these people I have seen in the nightclubs.I know what they want.They want to live the good life.They want to experience what they see [sex workers].But this is not free…If you come to the nightclub you will understand.